The National Center for Evidence-Based Practice
in Communication Disorders
Home      PCHL-Assessment-Audiologic-Behavioral-Measures

Permanent Childhood Hearing Loss
Audiologic Assessment

Behavioral Measures



External Scientific Evidence

Evidence-Based Practice Guidelines
New York State Department of Health, Early Intervention Program; U.S. Department of Education

Clinical Practice Guideline: Report of the Recommendations. Hearing Loss, Assessment and Intervention for Young Children (Age 0-3 Years)
New York State Department of Health, Early Intervention Program. (2007).
Albany (NY): NYS Department of Health, Publication No. 4967, 354 pages.
Added: July 2012

This evidence-based and consensus-based guideline provides recommendations for the assessment and intervention of hearing loss for young children ages birth to three. The guideline targets parents and professionals. Recommendations of interest to audiologists and speech-language pathologists include screening, assessment, and management of hearing and assessment of communication. Each recommendation is provided with a strength of evidence rating defined as Level A (strong evidence), Level B (moderate evidence), Level C (limited evidence), Level D1 (consensus panel opinion based on topics where a systematic review has been conducted), and Level D2 (consensus panel opinion not based on findings from a systematic review).


  • Behavioral observation audiometry (using an unconditioned response procedure) should not be the sole method of hearing assessment in infants and young children (Level D1 Evidence).

» See full summary and quality ratings

Evidence-Based Systematic Reviews
Diagnostic Challenges and Safety Considerations in Cochlear Implantation Under the Age of 12 Months
Vlastarakos, P. V., Candiloros, D., et al. (2010).
International Journal of Pediatric Otorhinolaryngology, 74(2), 127-32.
Added: July 2012

This is a systematic review of the literature examining the diagnostic, surgical, and anesthetic challenges associated with cochlear implantation in children before the age of 12 months.

“Visual reinforcement audiomentry (VRA) which may be used for behavioral testing in late infancy, is not applicable in young infants, due to their inability to make reliable direct head-turn responses towards sound sources. In addition, children with additional disorders as well as prematurity may also not be able to complete VRA testing. Objective audiometric tests (OAE, ABR, and ASSR) may be the only method of assessing candidacy for early cochlear implantation…” (p. 128).

» See full summary and quality ratings

Clinical Expertise/Expert Opinion

Consensus Guidelines
American Academy of Audiology

Audiologic Guidelines for the Assessment of Hearing in Infants and Young Children
Retrieved from
Added: May 2013

This guideline provides recommendations for the assessment of auditory function in infants and young children. The target audience of this guideline is audiologists. Select recommendations are provided below; for the full set of recommendations, please review the guideline document.


  • A pediatric audiologic assessment test battery includes a case history, otoscopy, behavioral observation, visual reinforcement audiometry, conditioned play audiometry, physiologic assessments (e.g., tympanometry, otoacoustic emission testing), and electrophysiologic audiometry (e.g., auditory brainstem response, auditory steady state response).

  • Behavioral responses to auditory stimuli may provide information on the child's global auditory skill development but should not be used for hearing screening, determining auditory thresholds, or determining amplification needs.

  • Visual reinforcement audiometry (VRA) is intended for children with a developmental age between 5-24 months and provides an "estimation of hearing thresholds based on minimum response levels (MRLs) that have a close relationship with perceptual thresholds" (p. 12).

  • In VRA, begin testing after two consecutive correct responses have been elicited. Obtain MRLs for speech stimuli first, "followed by tonal stimuli with center frequencies of 0.5, 1.0, 2.0, and 4.0 kHz; order of stimulus presentation will depend on the focus of the evaluation" (p. 13).

  • Conditioned play audiometry (CPA) is intended for children with a developmental age between two and five years and is used to determine ear- and frequency-specific hearing sensitivity and quantifies the type and configuration of hearing status.

  • As part of CPA, conditioning to stimuli should be completed to ensure the child understands the task. If the child does not respond to air-conducted stimuli then a bone vibrator should be used for conditioning. "...if the child does not condition with the bone vibrator, the task might not be developmentally appropriate or appealing, and visual reinforcement audiometry should be utilized" (p. 19).

  • Play tasks for obtaining thresholds may include stacking or tossing blocks or other game-like activities. Tangible or visual reinforced audiometry are also acceptable options (instead of CPA).

  • Speech audiometry is used to quantify bilateral speech perception ability in children with a developmental age of at least 6 months. The purpose of speech audiometry is "to determine ability to perceive speech or speech-like stimuli; to aid in determination of pure tone threshold reliability; includes speech awareness, speech discrimination, and speech recognition determinations" (p. 21).

  • In supra-threshold speech perception assessment, either open-set tasks (word/sentence repetition) or closed-set tasks  (picture pointing) can be used depending on which is most appropriate.

» See full summary and quality ratings

Joint Committee on Infant Hearing

Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs
Joint Committee on Infant Hearing (2007).
Pediatrics, 120(4), 898-921.
Added: July 2012

This consensus-based guideline provides recommendations for screening infants for hearing loss, assessing infants identified as at-risk for hearing impairment, and providing appropriate early intervention for infants with hearing impairment. The intended audience of these guidelines is not specified, however they are relevant to all professionals involved in the screening, assessment or treatment of hearing in infants.


  • For infants birth through a developmental age of 6 months, the test battery should include:

» See full summary and quality ratings

NHS Newborn Hearing Screening Programme Clinical Group (UK)

Newborn Hearing Screening and Assessment: Guidelines for the Early Audiological Assessment and Management of Babies Referred from the Newborn Hearing Screening Programme
Stevens, J., Sutton, G., et al. (2011).
England: NHS Newborn Hearing Screening Programme Clinical Group, 41 pages.
Added: July 2012

This consensus-based guideline provides recommendation for the early audiologic assessment of infants referred from the newborn hearing screening program.

An audiologic assessment should include the following:

  • OAEs

  • Air conduction tone pip ABR

  • Bone conduction ABR

  • ASSR

  • Tympanometry – A high frequency probe tone of 1 kHz should always be used for babies less than 6 months of age.

  • Reactions to stimuli

» See full summary and quality ratings

Client/Patient/Caregiver Perspectives

No information was found pertaining to client/patient/caregiver perspectives.


Use the images below to navigate to other sections of the Permanent Childhood Hearing Loss evidence map.