ROUGHLY EDITED COPY
EHDI - STOPHER
‘Alternative Methods of Testing Hearing in Children’
Casey Judd
March 10, 2015
11:30a-12:00p ET
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"This text is being provided in a rough draft format.
Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings."
>> All right, good morning, my name is Jon Douglas, I'm a
Clinical Professor at the University of Wisconsin and audiologist at the Waisman Center. I'm here with Bridget
Shanahan and Amy Hartman. We have no relevant or financial or non-financial relationships.
So what we're going to talk about today is some various projects with students that I've been working with in the doctoral program. Specifically we're going to look at video, visual reinforcement in audiometry versus traditional audiometry and
VRA in the home setting and Reaching for Sound, another way to test kids in the two to three-year-old range. The really difficult age to test.
And so, this is a project that Megan Costanzo spearheaded. I worked with her on this project, looking at visual reinforcement audiometry and compared it to video, visual reinforcement audiometry in kids with developmental disabilities.
Before I get into the VRA set-up, they, unfortunately didn't update our slides, but I wanted to comment. There were three different studies that were done before this, comparing video
VRA and traditional VRA, and so, one of the studies looked at two-year-olds and found no significant difference. There were

about 15 head turns with the video VRA group and 11 head turns with the traditional VRA group.
A study in 2009 looked at a group of kids, 7 to 16 months of age and found that about 25, 26 head turns, so again, no significant difference between video and traditional VRA.
And then the third study published a year later looked at more of the clinical aspect of video VRA versus traditional. They looked at a number of thresholds. Using toys for a reinforcer.
So, this kind of finds -- they postulated, because they had a lot of reinforcers to toys. That's kind of why they might have gotten more reinforcers with the animated set-up.
So...as far as our set-up, I had a picture, so, it was just, for those who don't know VRA and maybe some do, but there's a child that sits in the center, on their mom's lap or in a high chair, if they're older, in a chair. We present sounds and we train them to turn their head, either directly to the right or left in response to sounds. We do, we, they are given various toys. I have a bunny and dog in our booth, little bit older toys, but they're nice and they work. And so, then, with the video VRA set-up, when we present, we present different movies. There was an article published, in the ASHA Leader and looking at how to test kids with autism and one of the points was you know, to include their interests and one of the, you know, include video as such. This was a good way for us to include that and videos are, you can download them, pay for them online, they're pretty easy to access these days. We created a set-up on our own, we had a, an extra PC and some monitors and mounted it and was able to do this, I'm Scottish, I'm cheap, I was able to do it pretty cheap.
And...so, participants that we had in the study, so it was a pilot study, and it was children referred to the Waisman Center in the Autism and Developmental Disabilities Clinic. They were suspected of having autism or other developmental disabilities.
Their children from six months to six years of age, we included the wider age range, a lot of kids may be six or five, but think more like a one or two-year-old. The VRA protocol test method was appropriate for that age.
And then, if the child couldn't be conditioned to VRA or if we had to do play audiometry, we wouldn't include them in the study.

So the kids ranged typically from 21 months to about five years of age and there was six participants in each of the groups for the pilot study. And the disabilities ranged anywhere from like
Autism Spectrum Disorder, apraxia of speech, developmental delays, those types of things.
And so, the response consistency is looking at the percentage of correct head turns before habituation. These are results from
Megan's study. So, we have VRA, there it is. So the VRA and the video VRA. Then we have, for the VRA group, the response consistency was about 60% and the video VRA was about 67%. So, then, Megan compared it to previous study done by Lowry et al..
That was done in 2009. So, they found similarities, so they got about 70% or so. And so, in, in addition, I was able to compare it to the first study in 2003 and similar results about 70% or so response consistency.
And so, the number of head turns that we got were also kind of right in the middle of the two other studies. So we had the study with the 2-year-olds that were sitting around 11 to 15 head turns and ours were a little more than that, but we also had a wider range of ages and we were looking at kids with intellectual differences or Autism Spectrum Disorder that can kind of skew that as well.
And so, the findings from our study there, wasn't a significant difference between VRA and video VRA. That's not necessarily a bad thing, we know that we can use this tool in kids with autism and other development disabilities. As we collect more data, specifically with kids with autism, we can start looking at you know, is there differences in kind of their ADA scores, language scores, those things, how we can measure thresholds in sound field. And another thing to note is with video VRA, we didn't see any negative reactions and we still haven't seen negative reactions. A lot of times, we'll ask parents what videos the child likes or prefers and sometimes with the toys, you know, if they're animated or if you forget to turn off the animation, they can get a little scared. There was actually one kid in the animated toys that we had to exclude from the study, because they started to cry during the tests, so...yeah, and so what
I'll do, I'll turn it over to Bridget who will talk about the
VRA in the home setting.
>> Thank you. Is this good? Okay...so, my name is Bridget
Shanahan. I'm the second year audiology graduate student at
University of Wisconsin, Madison. I'm a Wisconsin trainee.

This is my Capstone project. It's Visual Reinforcement
Audiometry in the Home. Okay, so they didn't update our slides,
I'll talk a lot more than show a lot more. The purpose of my
Capstone project is to evaluate the effectiveness of screening children ages six months to three years old using a portable VRA system, in sound field in their homes. I want to look at if it can be done, and how good are the results? If it's proven successful, then, the portable VRA can be used to screen children with developmental delays and other various disabilities in their home, in a comfortable setting, least restrictive environment which could be their homes.
This might be also beneficial for families that are in rural communities and are unable to get to audiology clinics. Right now, it's only being used as a screening tool and not a diagnostic tool.
Okay...so my participants are typically developing children ages
6 months to 3 years. Many of them come from our outreach clinics at UW-Madison. From Headstart and early Headstart programs. These are perfect settings, we can test them at daycare centers or in their homes and out of the booth.
All children are required to pass otoacoustic emissions in both ears before participating in my study. You might be asking why wouldn't I just look at the results of an OAE screening, which is appropriate during ASHA screening guidelines. Well, as we know, behavioral results give us additional testing results and it is the preferred method of testing. It can be done through
VRA, conditioned play or conventional audiometry. Otoacoustic emissions are not a test of hearing, they just look at the function of the outer hair cells in the inner ear. VRA, or in my case, portal VRA is looking at the behavioral responses outside of the booth to determine if we can get reliable and accurate results that fall under ASHA screening guidelines.
So ASHA screening guidelines, their suggested stimulus level is
30 dB for VRA. Okay, so my equipment. There's a lot of the words on the screen, but I'll talk you through them. I used a loudspeaker, reinforcement toy like a switch toy where you can hit the button and it's a frog bubble machine, an animated picture, an external computer monitor we set up a good six feet away from me that will display that picture. A sound level meter and the laptop that runs my audiometer software and I also use a test assistant.

The software I use follows the standards, but there's no standards for the dimensions in the room. Ideally you want to be an in a quiet space, no other noise and the child in the center of the room surrounded by the speaker.
Okay...so...this is a screen shot of what the audiometer software on my laptop looks like. It was created by Corey
Stoelb. He's also a software programmer. He built this. So starting here on the left, you can change the stimulus from the right and left ear or in sound field. This drop down menu here will offer you narrow band noise, warble tones, FM tones and speech stimulus. We have it as like animal noises. Whoops.
Okay and then here, you can change the duration that you want that stimulus to present. So it's anywhere from one second to five seconds.
The big blue or purple buttons. You can change the intensity up or down and change the frequency and then here in the center, you present your stimulus and you can save it as you go. So it will plot on the audiogram. It will do an S for sound field, red circle for the right ear and blue X for the left ear. Up here, this kind of bluish box is where I go to calibrate the equipment. The yellow here is my reinforcement. I've downloaded a couple of animated files. The most popular is Elsa from Frozen singing Let It Go. It plays for about three seconds.
So, Corey has it programmed that those pictures will just automatically go to the external monitor and I don't need to drag it over or turn the screen on and off, it will just do it.
A really great feature of having my classmate who can design this, he created a bunch of shortcut keys for me on my laptop so the child doesn't hear me clicking the mouse and moving it around. I'm ready to go. Whoop.
Okay, so my initial impressions, I tested a handful of children so far, it's proven successful. I've been able to get thresholds from 1,000, 2,000 and 4,000, between 20 and 30 decibels HL. In sound field.
However, I do need more data and more test subjects. Down the road, I see this project, if it's successful, passing it on to future audiology graduate students and they can look at testing children with developmental disabilities and autism and screening them in their home where they're in a comfortable environment.

Now we'll pass this over to Dr. Hartman.
>> Okay, I'm the last one here, so then you guys get lunch.
Can you hear me okay? In the back? Yeah...okay, excellent.
So...I'm Amy Hartman. I'm a clinical professor at UW-Madison
AUD program and I'm an audiologist. Reaching for Sound is a project we're working on, I'm working with Kaitlin O'Brien who isn't here today, so I'll be doing this for both of us.
So, why are we talking about alternative methods to testing children. What's wrong with our current methods? The answer is really nothing, in the vast majority of cases, our current behavioral methods really work. Visual reinforcement audiometry, conditioned reinforcement audiometry. There are children that even when we use all of our good tricks and tools, we cannot get good behavioral measures. That's either because the child is afraid, the child maybe has different cognitive function, they have not, they're not attending or they're not interested. This little guy is an actual child that we tested and he just didn't like those guys. He'd be like no guys, no guys, whenever we take them into the booth. This is an example of one that didn't like that.
In particular, let's talk about those 2-year-olds, right? All of us know those 2-year-olds, they're the best, we love them, they're fun, but they can be challenging, right? They're not quite ready, sometimes, maybe to do conditioned play. Maybe they're like, I'm not ready to do this, I don't want to wear headphones or not going to pay attention this long. The VRA might not be interesting to them.
So...some of the limitations of VRA, why it might not be interesting, we can only get a limited number of responses doing
VRA. This is true of every child we test. The number decreases as children get older.
With VRA we use simple reinforcers. Even using video VRA and adding those in, there are still reinforcers, a toy, a video, that's what they get. As I mentioned kids just don't like VRA.
One day I was in clinic can Kaitlin O'Brien and another student and we were talking about this. Erica is getting her Ph.D. as well and they look a lot at reaching and Erica said, what about reaching? Kids will reach all day long. What about reaching?
Let's look at it. So that's where that idea came from. I love my job, you get clinical and research melding all the time.

So a little background on reaching. Reaching has typically been used to evaluate localization skills. So, it was first looked at in 1988 by Paris and Clifton. They looked at 7-month-old children who, normal hearing children, looked to see if they could reach when they heard a sound. They had a rattle that elicited a narrow band noise and the children would reach toward it when they heard it.
Hailier et al. 92 looked at a similar study with four, six and eight months old. They looked at reaching in the dark. To see if children would do the same type of task when they were in a dark setting.
And these studies showed that reaching tasks are interesting to infants with normal hearing and they can maintain infant's attention long enough to determine their localization abilities.
So...next, when we see reaching, as I mentioned, Dr. Latufski is in our group as well. Her group looked at a novel reaching method for two to three-year-olds. What they did, they set up an apparatus for Reaching for Sound method and the apparatus was like a large semicircular apparatus with a curtain and it had nine holes around and then each hole, there was a speaker in the hole. And what happens is, when the child would here the sound, they would reach into the correct hole of where they heard the sound coming from. Then they are given a tangible reinforcer.
And what they found is that children with bilateral cochlear implants and normal hearing were actually able to do this task.
They found that the use of these tasks, in research, really has resulted in little to no habituation and provided experimenters with sufficient trials to determine localization abilities in infants and toddlers.
So, what did we want to do? We wanted to to something different. We wanted to see, can we do this when it's soft sound, right? All these other tests were done at super threshold level. They were not looking at very soft sounds. So we wanted to see first, would this work? When we tested children to try and test their hearing?
So our participants were children between the ages of 24 and 47 months. And the reason we used this age is because we specifically wanted to look at the same age group that they have looked at in the localization task.

Typically developing native English speakers with no known hearing loss. And, besides looking at the idea of, can they do it? We also wanted to look at, what does this look like compared to traditional VRA? So, are we getting the same results?
Okay, so here is a little bit about the set-up. The children would come in for two visits and they're randomized to eliminate any order effects, so they'd come in one time and have traditional VRA and come in another time, reaching for sound.
Traditional VRA, I'm not going into how that's done and Dr.
Douglas briefly explained that. It's done conducted according to clinical standards.
And Reaching for Sound, we're going back, this is the set-up for
Reaching for Sound. You see, we made a different apparatus, it has two holes on each side and what happens is, we condition the child to actually reach and, reach for the hole, either side, doesn't matter, we'll reinforce either way when they hear the sound. Back here. Okay...so we have the child in midline, we have two speakers on either side, this is that apparatus, that I just showed you earlier and then, we actually have, this takes three testers. This is one of our limitations, we have to have the person at the booth, the person that is the midline distracter test assistant here and the person I call Oz, the man or woman behind the curtain giving the reinforcers.
And this is a picture of that person looking from behind. That person is using an FM that talks with the tester because they can't see if they should be reinforcing or not. So that's how that works.
Okay...so testing. As I mentioned, the kids are conditioned to this reaching for sound task. They're only reinforced when they hear a sound, but it doesn't matter which side and then what we're looking at, we're recording their thresholds, we're tracking the number of responses, as well as their total time.
So, this is a picture of a child actually doing the reaching and that's a child of the little hand coming through the hole.
Preliminary results, as I mentioned, this is very early, we have tested a handful of kids. This is a pilot study, so, I don't have a ton of information for you all today, but what we do know is that we are able to test children this way. This is like exciting, we're very excited about this. So, in the kids that we've been able to test, we've been able to get thresholds for

all six frequencies, going from 250, 500, 1,000, 2,000, 4 and 8.
We seem to have a fewer number of false-positives using this method compared to traditional VRA. We're having very few false-positives with this. Traditional VRA, we're averaging about 10 to 12 per child. Thank you. Okay...
One other thing to note, it is taking longer. It's definitely a limitation. It takes quite a bit longer, test time, compared to traditional VRA, you know, the kids are like, I hear it and sometimes they get up and walk to the hole. It's a slower process as we look at results.
Anecdotally, I don't know if you noticed, this guy here was our same crime guy from the beginning. So, in his case, when he would go in to do VRA, he was like, no, guys, no, guys, he didn't like VRA. When we were doing reaching, he was saying, "I so -cited." "I want to do more." It was exciting to see the differences between the child's behavior.
So, discussion, as I mentioned, we need more data. We have very limited data at this time. So we want to test a lot more kids.
If this is working, we'd also like to see how this looks with children with hearing loss. Children with other development delays, younger children. As you notice we did this all in sound field. How it would look with individual ear testing.
These are all areas we'd love to explore more.
Limitations, as I mentioned, it requires our three testers, versus traditionally one or two. It does require the apparatus, although I will tell you, the apparatus, our third year student made, it was, it's like PVC pipe and some curtains and felt.
Probably cost, I think she said like $15 at Home Depot. Not a huge expense. It does require more tangible reinforcers. As you can imagine, lots of stickers, little dinosaurs, little animals, cars, the kids leave with a bag of goodies. They're pretty excited about that, but that's another limitation, it requires more of those. However, even with all these limitations, we're thinking this might be a viable option, another tool in our tool box when we're looking at testing these children. Maybe it's something we choose to do before we have them go for an auditory brainstem response test, especially if we sedate the child. We're just thinking that maybe it might be a good option for people.
All right...so we're at the end. I did it. All right, questions? For any of us? You guys are ready for lunch. Thank

you so much and have a wonderful conference.
[applause]
"This text is being provided in a rough draft format.
Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings."