Unit 1: Early Identification of Hearing Loss: Need and Strategies

1.1 Need for early identification of hearing loss

1.2 Overview to behavioral test and objective techniques in screening for hearing loss

1.3 Team members involved in hearing screening and their role

1.4 Use of checklists and behavioral observation in early identification of hearing loss by school teachers (congenital and acquired)

1.5 Referral of children based on symptoms of hearing loss













1.1 Need for early identification of hearing loss


Identifying hearing loss at a very early age is important because children with hearing loss often fall behind their peers in speech and language development, cognitive skills and social skills.  If the hearing loss isn’t treated these deficits can lead to adult issues such as reduced socio-economic status, poor socialization skills, depression, etc.  Obviously, the earlier we can identify hearing loss the sooner we can begin with the intervention for the better outcomes of that individual.

Early intervention can radically improve outcomes for children with hearing impairment.

Undiagnosed or late-diagnosed hearing loss in young children can have substantial negative consequences: not only in terms of its impact on a child’s language and communication development, but also on social and emotional development and mental health, family relationships, educational opportunity and achievement and later economic contribution to society.

Many high-income countries have implemented early hearing detection and intervention. There is now compelling evidence from established programmes that when hearing screening in early life is followed up by appropriate assessment, management and support for both child and family, the developmental outcomes for a child with hearing impairment can be radically improved.

Around 90% of the world’s hearing-impaired children live in countries where limited resources are likely to present a significant challenge to the implementation of new born hearing screening. However, novel pilot or emerging programmes in some low- and middle-income countries have already demonstrated that it is feasible to implement hearing screening whilst taking into account not only the societal, cultural and economic conditions but also existing health structures and patterns of care. One of the lessons from such programmes is that even where follow-up services are under-developed, parents benefit from knowing early the status of their child’s hearing and can modify their communication style to facilitate essential effective parent-child interactions. The opportunity to develop language through a positive approach rather than focusing on a defi cit not only enhances the child’s social development, but enables proper access to education and increases life chances.

The development of competent and fluent language and communication is central to children achieving their full potential. Considerations of the cost-effectiveness of new born hearing screening have tended to focus on numbers of cases detected rather than on the long-term impact of hearing screening on the health, quality of life and productivity of children identified as having a hearing impairment. However, the cost of lifelong disability to society is substantial, and failure to identify hearing loss early when there is a possibility to do so may be deemed not only a failure to address the economic issue but also a denial of the rights of the child. It is in this context that any reservations about the ethics, appropriateness or cost-effectiveness of implementing early hearing screening should be challenged.


        The child can undergo intervention before the age of six months.

        The child will achieve better speech and language and educational success.

        The cause of hearing loss can be identified early and managed appropriately.

        Associated medical conditions can be identified and managed early.

        The child’s auditory system will develop better.

        The burden of stress within the family will be reduced.

        Parents can be offered genetic counselling (if relevant), especially if they are planning for more children.

        The child will continue reaping benefits in the long term: social, psychological, educational and professional.



1.2 Overview to behavioral test and objective techniques in screening for hearing loss


Behavioral Hearing Tests 

Once a child is approximately 6 months old, the audiologist will start to introduce behavioral testing.  There are different types of tests based on the age and capabilities of the child. 

A regular (behavioral) audiological evaluation measures degrees of hearing for different tones. This test is performed in a sound-treated room to find out whether your child can hear soft sounds at all of the important levels for hearing spoken words clearly.

     Visual Reinforcement Audiometry (VRA) is typically used for children ranging from 6 months to 2 years of age. The child is trained to turn toward a reward (puppet, video) when he or she hears a sound. 

     Conditioned Play Audiometry (CPA) is used for children between 2 and 5 years of age.  The child is taught to play a listening game such as putting a block in a bucket when he or she hears a sound. 

     Conventional Audiometry is used for children 5 and older. The child is asked to raise his or her hand, push a button, or say “I hear it” when he or she hears a sound.

Children with suspected hearing loss should be evaluated as soon as possible.  Audiologists are able to provide reliable information about hearing loss for children of any age. 

Behavioral observation audiometry is a test of hearing loss waged for your new born babies and infants where their counteraction to sound is gauged during breastfeeding or bottle feeding. This test entails rendering sounds to your babies and heeding their counterstand in order to test hearing.This test is often fixed for infants less than six months of age or who are progressively not able to turn their head towards a sound. It not only helps to sink in the presence of hearing loss, but also perceives which hearing aid is recommended for your baby. This test examines the behavioural shift in reactive to different sounds in your babies. Your child’s counteraction to each sound is kept on record and your baby’s hearing potency is analysed.

Behavioural tests are based on reckling a change in behaviour in counteraction to a sound. The behavioral observation audiometry test is featured in order to evaluate the reactance of auditory child when opting a hearing aid or to appraise the boons of the hearing aid for your new born. As the name signifies it is based on the perusal of behavioral and involuntary mirror of your child. This is a pattern for testing hearing in infants before they can manifest the systematic reactive to sounds. The aim of this test is to scrutinize the accuracy of unconditioned behavioral observation audiometry in anticipating the hearing acuity in babies and check the esteem of test upshots at various frequencies.

Behavior observation audiometry is an audiometric test for hearing level estimation in BABIES as young as 6-9 months. In this test the baby is seated with caregiver in a sound proof room and an audiologist is presenting various calibrated or measured sounds through speakers .The babies response to sounds presented is then OBSERVED and noted and measured. An estimation of babies hearing loss is made through this audiometric test.

        BOA is a time consuming test as it is difficult to get a reliable & repeatable response from babies as young as 6 months for the same test stimulus.

        BOA can take sometimes days & weeks to establish reliable hearings thresholds across various frequencies.

        BOA cannot be ear specific test as we are presenting sound in a free field setup, hence always a better ear will response & in case of asymmetric hearing loss, we cannot establish each ear hearing levels.

        Parents needs to understand that this test may need immense patience to establish reliable response from their babies & this may require several repeats

        BOA is generally used to augment or add value to other objective tests. Therefore, this test should not be treated or interpreted as a standalone test to confirm diagnosis of hearing loss & also to fit amplification device.


Objective Hearing Tests 

Objective hearing tests are done for those who cannot reliably respond on their own during a behavioral hearing test. Behavioral testing is typically used with older infants and small children. There are two types of common objective hearing tests: Otoacoustic Emissions (OAEs) and Auditory Brainstem Response (ABR). Either of these may have been done in the hospital after your child was born as his or her newborn hearing screen.  

     Otoacoustic emissions are sounds recorded from the ear. The tester puts a small probe in the ear and the child hears a series of sounds. The test equipment records the response from the ear without the child having to respond. An abnormal otoacoustic emissions test indicates either a hearing loss or perhaps fluid in the ear (such as an ear infection). 

     Auditory brainstem responses record the neural response to sound. Sticker electrodes are placed on the child’s head and a sound is played in the ears. The audiologist records the brain’s response to this sound and can provide an estimate of the child’s hearing loss 

It is important to remember that objective hearing tests do not tell audiologists what the child actually hears, but confirms that the pathways needed to understand sound are functioning.  Once a child is old enough, he or she will be tested using behavioral tests. 



1.3 Team members involved in hearing screening and their role


Early childhood screening is also common as not all hearing loss can be identified at birth. Screening during early childhood or beyond the newborn period is critical because hearing loss is an invisible condition. Between birth and age five, the incidence of hearing loss doubles.  Just because a newborn passed their hearing screening at birth, it is not a guarantee that a late onset and/or progressive hearing loss won’t develop. As a result, early childhood programs, such as Early Head Start, require hearing screening with all new enrollments.

When people hear the words “early detection” they think it means screening at a young age, but a hearing loss can occur at any age. It is about detecting the problem at the earliest possible time. The sooner you can detect hearing loss, the better the outcome for the person with the loss. Hearing loss can occur at any age and hearing screening plays a vital role to ensure that patients can avoid communication roadblocks and potentially have a better quality of life.

The Parent

You are the first and most important member of the team. No one knows your baby as well as you.


The audiologist is a very important member of the team. This individual:

Educational Team Members

Speech/Language Pathologist (SLP)

Teacher of the Deaf/Hard of hearing

Listening and Spoken Language Specialist (LSLS)

Medical Team Members

Otolaryngologist (Ear, Nose, & Throat (ENT) Physician)

A Primary Care Physician




1.4 Use of checklists and behavioral observation in early identification of hearing loss by school teachers (congenital and acquired)


Even in the earliest months of life, babies begin learning how to communicate by listening to and imitating the sounds they hear around them. But if your baby has a hearing problem, his or her ability to speak and understand language could be affected. That’s why it’s important for parents to recognize the signs of hearing impairment early. Roughly half of children with hearing impairments have no risk factors for it.

Early detection and treatment of hearing impairment can help avoid speech delays and other communication problems. But experts say many hearing-impaired children aren’t diagnosed early enough. This could be because many parents don't know the signs of hearing loss. Hearing loss can also accompany other disabilities and could be overlooked.

The National Institute on Deafness and Other Communication Disorders offers this checklist to help you recognize signs of a hearing problem at various stages throughout your baby’s first year.

Birth to 3 months

At birth to 3 months, does your child:

·       React to loud sounds?

·       Seem soothed by your voice?

·       Turn his or her head when you speak?

·       Smile when spoken to?

3 to 6 months

At 3 to 6 months, does your child:

·       Look up or turn toward a new sound?

·       Respond to “no” and changes in tone of voice?

·       Imitate his or her own voice?

·       Enjoy rattles and other sound-making toys?

·       Begin to repeat sounds (like “ooh” and “ba-ba”)?

·       Seem scared by loud sounds?

6 to 10 months

At 6 to 10 months, does your child:

·       Respond to his or her name, a ringing phone, or someone’s soft voice?

·       Know words for common things (“cup,” “shoe”) and sayings (“bye-bye”)?

·       Make babbling sounds, even if alone?

·       Start to respond to requests such as “come here”?

·       Look at things or pictures when someone talks about them?

10 to 15 months

At 10 to 15 months, does your child:

·       Play with his or her voice, enjoying the sound and feel of it?

·       Point to or look at familiar objects or people when asked to do so?

·       Imitate simple words and sounds, and use a few single words meaningfully?

·       Enjoy games like peek-a-boo?

If you answered no to any of these questions, talk with your pediatrician. Even if it’s not a hearing loss issue, there may be another medical problem that is hindering your child’s development.

Observation by School teachers

Classroom observation is a critical part of assessment and performance monitoring. It provides the opportunity to collect data on how the student with hearing loss is functioning in the classroom in comparison to typical peers. Specifically, we need to observe behavior using what we know about how the hearing loss impacts speech perception, listening, learning, language, participation, behavior and overall social interaction.

Teachers of the deaf/hard of hearing, educational audiologists, and speech language pathologists with a specialty in DHH all bring the following ‘lenses’ to their observations. In some places this input by the student’s classroom interpreter or transliterator is also sought. These “lenses” of observation are different from others on the assessment/IEP team.

Communication Lens

Participation and Social Language Lens

Curriculum Lens:

This focus of student assessment is different from other school staff that do not have DHH expertise.

What needs to be observed?

The information under each of the “lenses” provide a good start to what the observer needs to have in mind when beginning the classroom observation.

It is critical to not only note behaviors, but to collect specific data. The following are examples:

FREQUENCY – number of times, or how often a student behavior occurs

DURATION – total amount of time a student is engaged in a specific behavior

LATENCY – elapsed time between an event and the expected behavioral response


Students with hearing loss have access issues, as hearing technology does not ‘restore’ normal hearing ability, especially when listening at a distance, in noise, and to softly spoken or quickly spoken speech. Functional information by means of classroom observation, teacher checklists, and student checklists, will often reveal that students with hearing loss:

1)     Hesitate in starting work after instruction

2)     Participate less in the classroom (less often, less appropriately)

3)     Have challenges comprehending verbal instruction, class discussions, small group work, and partner projects as compared to peers.

4)     May interact less and/or more immaturely with peers

In grades preschool through fourth grade this translates into the need to develop awareness of

(a) when information is being missed (he doesn’t know what he didn’t hear because he didn’t hear it – but he is continually held accountable for knowing this information anyway),

(b) different ways to respond when information is missed (communication repair),

(c) appropriate ways and when to self-advocate, and then

(d) in the tween/teen years, how to apply problem-solving to challenging situations for self-determination.



1.5 Referral of children based on symptoms of hearing loss


Hearing loss in children can be present at birth (congenital) or develop later in childhood (acquired). Congenital hearing loss can be hereditary (genetic) or caused by infections during pregnancy, including infection with cytomegalovirus or rubella. Hearing loss is more common in babies who are in the neonatal intensive care unit (NICU). Hearing loss can be an isolated condition or a feature of a syndrome that causes additional symptoms. Genetic testing can help determine the cause of hearing loss in some cases. Acquired hearing loss can be caused by infectious diseases, such as meningitis or recurrent ear infections, as well as trauma and certain medications.

Sign and symptoms of hearing loss

Signs and symptoms of hearing loss in infants and toddlers vary and may include the following:

Signs and symptoms of hearing loss in children may include the following:

If you are concerned about your hearing and are experiencing any of the symptoms of hearing loss, see an audiologist for a hearing test. A hearing test can check the type of hearing loss you have and how severe it is. You can make an appointment at an audiology clinic without a referral from a doctor. 

If your child is entering school with special learning needs or if you and/or the classroom teacher find that your child is having difficulty learning, certain areas need to be considered to plan appropriately. To find out more about your child and how he or she learns, a teacher may look at the following areas:

        social or behavioural skills

        communication skills

        cognitive/learning skills

        physical or sensory skills

A doctor’s diagnosis of a specific condition or disability does not provide enough information for planning for your child’s individual needs. No two children are exactly alike. Children identified with the same diagnosis often have different abilities and learning needs, and require different supports. For example, two children could be diagnosed as having fetal alcohol syndrome, but each child could have very different learning needs. One child might function quite well in the classroom with the regular curriculum and need a little support to be successful, while the other child might have severe difficulties and need programming outside the curriculum as well as close supervision at all times.

If you feel your child is having difficulty learning, the first step is to talk with the classroom teacher. To identify your child’s learning needs, the teacher may

        talk with your child

        observe your child during classroom activities

        analyze your child’s class work

        assess your child’s abilities in areas such as mathematics, reading, and so on

As a parent, you can also gather information that may be useful in the assessment process. This information could include medical reports and observations you have made about your child’s learning needs and recent behavioural changes outside of school.

After taking these steps in assessing a student’s needs, the teacher, in consultation with the parents, may decide that a referral to a specialist for support or further assessment is necessary. Written parental consent is recommended before any referral to other teaching or clinical resources within the school/division is made. Each school/division has different assessment procedures, so talk to your child’s teacher or the school principal about what kind of assessment or referral will take place and how long it will take.

After you give consent to the school for referral of your child to a resource teacher or clinician, an assessment plan will be developed. Parents can be involved in the assessment process in various ways.

There are 5 stages in the Early Intervention process:

1.     Initial Referral and Identification
When an EI program receives a referral, information about the reason(s) for the referral and the results of any screening or assessment(s) will be collected. A special educator/counsellor is then assigned to contact the family to

o   Provide information about the program,

o   Gather familiy concern and child information, and

o   Determine interest in scheduling an intial visit.

2.     Intake and Family Assessment 
A special educator/counsellor meets with family to

o   Explain the program,

o   Conduct developmental screening (if appropriate),

o   Determine with family whether other evaluation is needed, and

o   Identify any concerns and availability of resources, and set priorities.

3.     Child Assessment

The EI program determines eligibility to be enrolled in the early intervention program, and coordinates with an evaluation team to determine if further evaluation is needed.

o   If found eligible, the EI program will contact the family to schedule and Individual Family Service Plan (IFSP) meeting

4.     Individual Family Service Plan (IFSP) Development
The EI program team develops and IFSP with the family that integrates the following:

o   Parents; concern and priorities

o   Functional and measurable outcomes for the child

o   Service identification and establishment of timeline for the services

5.     Service Delivery and Transition
The service coordinator ensures that providers are timely in delivering services specified in the IFSP. The coordinator also ensures

o   Transition services are provided when child reaches 3 years of age, and

Even if the family is found to be ineligible for services, the EI case coordinator will be able to share other resources with the family.

Depending on your child’s needs, a number of specialists may be involved in the assessment plan. These specialists could include a resource teacher, reading clinician, speech-language pathologist, psychologist, occupational therapist, or others. Different professionals are qualified to assess different areas of your child’s development. For example, a psychologist assesses a child’s cognitive ability or potential. A classroom teacher or resource teacher can assess children’s learning skills or how they learn. Talk to your child’s classroom teacher about who will assess what.