BEHAVIORAL OBSERVATION AUDIOMETRY

Prior to the advent of immittance measures, ABR, and OAE,

audiologists had to rely on their observations of a young
infant's responses to sound to estimate the audiogram.
Called behaviour observation audiometry (BOA).
This procedure required an observer to judge if a behavioural
response (i.e., a change of state such as a startle, eye
widening, a grimace, cessation or initiation of sucking) was
related to the presentation of an auditory stimulus. If the
observed behaviour was time-locked with the presentation, it
implied that the infant was responding to the sound.
Observers noted systematic behaviours that tended to occur in
response to different stimulus types (speech, noisemakers,
tones) and different stimulus levels at different ages.
Responses ranged from arousal from sleep in the newborn
period to rather precise localization of sound by 2 years of
age.
Younger infants required greater sound levels to elicit
responses than did older infants.
And, speech was the most effective signal at eliciting
responses at low levels.
These observations culminated in the Auditory Behaviour
Index. Illustrations from every edition of Hearing in Children
by Northern and Downs have become the hallmark of the
index. Copies of the figures and the index can be found taped
to the walls of sound-treated test booths across the country.
What's important to remember about the index is that it is a
developmental index of responsiveness to sound, not
sensitivity to sound. The levels included in the index are not
norms for audiometric threshold.
Numerous investigators have noted other limitations of BOA.
First, babies with normal hearing range vary greatly in their
responsiveness.
For example, at 3 months of age, some normally hearing
babies will respond at levels as low as 20 dB HL and others
not until levels of 80 dB HL.
This range of normal hearing effectively eliminates the
possibility of detecting mild and moderate degrees of hearing
loss.
Another problem is the wide range in responsiveness within
individual babies, depending on state of the baby, alertness,
and attention.
Also, the responses are prone to habituation.
That is, an infant may respond to the presentation of a
stimulus, but subsequent presentations are less likely to evoke
a response, especially at low levels.
Another problem is that infants respond differently to
different types of stimuli.
Speech signals are the most evocative; they will typically
elicit the most responses at the lowest levels.
In order of likelihood to evoke infant responses are broad-
band complex noises, narrow bands of noise, and pure tones.
Thus, the most frequency-specific signals, those used for
audiometry, especially at low stimulus levels (near threshold),
are the ones least likely to result in responses from infants.
A final limitation on the clinical use of BOA is that our
judgment of responses tends to be colored by our
expectations.
If we know the stimulus level is high, we're more likely to
expect, and thus to perceive, a baby's behavioural response.
If we know the child has previously failed a hearing
screening, we're less likely to expect a response.
These expectations can result in underestimating or
overestimating hearing loss.
Many audiologists have abandoned the use of BOA in any
formal sense.
Others report good agreement between BOA and later
audiograms.
Those who do use BOA have added considerable, needed
restrictions to the protocol.
They require that the evaluation be done when the baby is
hungry, awake, and quiet-a rare occurrence!
They limit the acceptable response to one: only a sucking
response, either cessation or initiation.
They require that two observers agree on the responses, and
that there must be three responses noted at one level for an
interpretation of minimal response level (MRL).
Behavioural Observation Audiometry
Purpose
Assesses hearing using unconditioned responses to sound (i.e.,
reflexive and orienting behaviours).
Appropriate for children from birth through age 7 months.
Procedure
The infant is observed for changes in behaviour after
presentation of an acoustic stimulus in the sound field
(through speakers) or with noisemakers.
Results
This screening test provides information about age-
appropriateness of an infant's response to sound. Can rule out
significant hearing loss.
Limitations
This method relies solely on the audiologist's observations to
determine when a response to sound has occurred. Cannot be
used to define auditory thresholds.