Identifying reduced hearing in children who have developmental disabilities: Insights for inclusive research practices with electronic health records.

Introduction: Recent advancements in big data analytics and the formation of large-scale clinical data repositories provide a unique opportunity to determine the current state of pediatric hearing health care for children who have developmental disabilities. Before answering unresolved questions about diagnostic practice, it is paramount to determine a standard and reliable method for identifying children who have reduced hearing because clinical management is affected by hearing status. The purpose of this study was to compare 5 different methods for identifying cases of reduced hearing from pure-tone thresholds based on developmental disability status. Methods: Using retrospective clinical data from 100,960 children (0-18 years), hearing status was determined for a total of 226,580 encounters from three clinical sites. 9% of the children had a diagnosis of intellectual disability, autism spectrum disorder, Down syndrome, or cerebral palsy. Results: Results revealed that encounters from children who have developmental disabilities were more likely to have insufficient data to allow hearing status to be determined. Moreover, methods with higher data demands (i.e., number of thresholds and ear-specific thresholds) resulted in fewer classifiable encounters. The average child age when hearing status was classified for the first time was older for children who have developmental disabilities than for children in the comparison group. Allowing thresholds to build up over multiple test sessions did result in more children who have developmental disabilities being classified than for single-encounter methods, but a meaningful decrease in child age at the time of classification was not seen for this strategy. Compared to the comparison group, children who have developmental disabilities were more likely to have reduced hearing that was stable over time, yet their hearing status was determined at older ages. Discussion: Results provide key guidance to researchers for how to determine hearing status in children for big data applications using electronic health records. Furthermore, several assessment disparities are spotlighted for children who have developmental disabilities that warrant further investigation.

Visual Reinforcers Designed for Children with Developmental Disabilities.

A library of visual reinforcers has been created to facilitate visual reinforcement audiometry (VRA) testing in children with developmental disabilities. The library includes 45 reinforcer sets-photos or videos grouped by a common theme-that were created based on commonly reported interests of children with developmental disabilities. Each reinforce set contains a minimum of 20 unique photo or video files that can be downloaded in two formats: one for commercially available VRA reinforcement systems and another for a custom setup. The library is freely available for download online under a Creative Commons License (Creative Commons Attribution-NonCommercial 4.0 International License). Use of these materials has the potential to improve behavioral testing outcomes for children with developmental disabilities, including children with restricted interests. Future research is needed to determine the effectiveness of implementing these materials in clinical settings.

Development of Masked Speech Detection Thresholds in 2- to 15-year-old Children: Speech-Shaped Noise and Two-Talker Speech Maskers.

OBJECTIVES: On the basis of the data from school-aged children, there is consistent evidence that there is a prolonged course of auditory development for perceiving speech embedded in competing background sounds. Furthermore, age-related differences are prolonged and pronounced for a two-talker speech masker compared to a speech-shaped noise masker. However, little is known about the course of development during the toddler and preschool years because it is difficult to collect reliable behavioral data from this age range. The goal of this study was to extend our lower age limit to include toddlers and preschoolers to characterize the developmental trajectory for masked speech detection thresholds across childhood. DESIGN: Participants were 2- to 15-year-old children (n = 67) and adults (n = 17), all with normal hearing. Thresholds (71%) were measured for detecting a two-syllable word embedded in one of two maskers: speech-shaped noise or two-talker speech. The masker was presented at 55 dB SPL throughout testing. Stimuli were presented to the left ear via a lightweight headphone. Data were collected using an observer-based testing method in which the participant's behavior was judged by an experimenter using a two-interval, two-alternative testing paradigm. The participant's response to the stimulus was shaped by training him/her to perform a conditioned play-based response to the sound. For children, receptive vocabulary and working memory were measured. Data were fitted with a linear regression model to establish the course of development for each masker condition. Appropriateness of the test method was also evaluated by determining if there were age-related differences in training data, inter-rater reliability, or slope or upper asymptote estimates from pooled psychometric functions across different age groups. RESULTS: Child and adult speech detection thresholds were poorer in the two-talker masker than in the speech-shaped noise masker, but different developmental trajectories were seen for the two masker conditions. For the speech-shaped noise masker, threshold improved by about 5 dB across the age span tested, with adult-like performance being reached around 10 years of age. For the two-talker masker condition, thresholds improved by about 7 dB between 2.5 and 15 years. However, the linear fit for this condition failed to achieve adult-like performance because of limited data from teenagers. No significant age-related differences were seen in training data, probe hit rate, or inter-rater reliability. Furthermore, slope and upper asymptote estimates from pooled psychometric functions were similar across different child age groups. CONCLUSIONS: Different developmental patterns were seen across the two maskers, with more pronounced child-adult differences and prolonged immaturity during childhood for the two-talker masker relative to the speech-shaped noise masker. Our data do not support the idea that there is rapid improvement of masked speech detection thresholds between 2.5 and 5 years of age. This study also highlights that our observer-based method can be used to collect reliable behavioral data from toddlers and preschoolers-a time period where we know little about auditory development.

Interrater Reliability for a Two-Interval, Observer-Based Procedure for Measuring Hearing in Young Children.

Purpose To overcome methodology limitations for studying auditory development in young children, we have recently developed an observer-based procedure that uses a conditioned, play-based, motor response (see Bonino & Leibold, 2017). The purpose of this article was to examine interrater reliability for the method. Method Video recordings of test sessions of 2- to 4-year-old children (n = 17) were examined. Detection of a 1000-Hz warble tone was measured with the Play Observer-Based, Two-Interval (PlayO2I) method in each of two conditions: for a fixed intensity level (30 dB SPL) or for a variable intensity level signal (0-30 dB SPL). All test sessions were scored independently by three observers (one real-time, two offline). Observer consensus was evaluated with Fleiss' kappa statistic. To determine if summary data were similar across the observers of each test session, the proportion of correct trials (fixed-level condition) or threshold (variable-level condition) were computed. Results The strength of observer consensus was classified as "almost perfect" and "substantial" for the fixed-level and variable-level conditions, respectively. Follow-up analysis of the variable-level data indicated that differences in observer consensus were seen based on the signal level, the type of response behavior provided by the child, and the confidence level of the real-time observer. Resulting summary data were similar across the three observers of each test session: no significant differences for estimates of the proportion of correct trials or threshold. Conclusions Results from this study confirm strong interrater reliability for the method. The PlayO2I method is a powerful tool for measuring detection and discrimination abilities in young children. Supplemental Material https://doi.org/10.23641/asha.12978197.

Measuring open-set, word recognition in school-aged children: Corpus of monosyllabic target words and speech maskers.

A corpus of stimuli has been collected to support the use of common materials across research laboratories to examine school-aged children's word recognition in speech maskers. The corpus includes (1) 773 monosyllabic words that are known to be in the lexicon of 5- and 6-year-olds and (2) seven masker passages that are based on a first-grade child's writing samples. Materials were recorded by a total of 13 talkers (8 women; 5 men). All talkers recorded two masker passages; 3 talkers (2 women; 1 man) also recorded the target words. The annotated corpus is freely available online for research purposes.

Using Visual Supports to Facilitate Audiological Testing for Children With Autism Spectrum Disorder.

Purpose One in 59 children is diagnosed with autism spectrum disorder (ASD). Due to overlapping symptoms between hearing loss and ASD, children who are suspected of having ASD require an audiological evaluation to determine their hearing status for the purpose of differential diagnosis. The purpose of this article is twofold: (a) to increase audiologists' knowledge of ASD by discussing the challenges associated with testing and interpreting clinical data for children with ASD or suspected ASD and (b) to provide visual supports that can be used to facilitate audiological assessment. Method Eight children (ages 4-12 years) were recruited as video model participants. Videos were filmed using scripts that used concise and concrete language while portraying common clinical procedures. Using the video models, corresponding visual schedules were also created. Conclusion Although obtaining reliable hearing data from children with ASD is challenging, incorporating visual supports may facilitate testing. Video models and visual schedules have been created and made freely available for download online under a Creative Commons License (Creative Commons-Attribution-NonCommercial-ShareAlike 4.0 International License). Incorporating visual supports during clinical testing has the potential to reduce the child's and family's stress, as well as to increase the probability of obtaining a reliable and comprehensive audiological evaluation. Future research is warranted to determine the effectiveness and feasibility of implementing these tools in audiology clinics. Supplemental Material https://doi.org/10.23641/asha.10086434.

Behavioral Assessment of Hearing in 2- to 7-Year-Old Children: Evaluation of a Two-Interval, Observer-Based Procedure Using Conditioned Play-Based Responses.

Purpose It is challenging to collect reliable behavioral data from toddlers and preschoolers. Consequently, we have significant gaps in our understanding of how auditory development unfolds during this time period. One method that appears to be promising is an observer-based procedure that uses conditioned, play-based responses (Bonino & Leibold, 2017). In order to evaluate the quality of data obtained with this method, this study presented a suprathreshold signal to determine the number of trials 2- to 7-year-old children could complete, as well as the associated hit rate and observer confidence. Method Participants were 23 children (2-7 years old). Children were taught to perform a play-based motor response when they detected the 1000-Hz warble tone signal (at 30 dB SPL). An observer evaluated children's behavior using a 2-interval, 2-alternative testing paradigm. Testing was terminated after 100 trials or earlier, if signs of habituation were observed. Results Data were successfully collected from 22 of the 23 children. Of the 22 children, all but 1 child completed 100 trials. Overall hit rate was high (0.88-1.0; M = 0.94) and improved with listener age. Hit rate was stable across the test session. Strong agreement was seen between the correctness of the response and the observer's confidence in the judgment. Conclusion Results of this study confirm that the 2-interval, observer-based procedure described in this article is a powerful tool for measuring detection and discrimination abilities in young children. Future research will (a) evaluate coder reliability and (b) examine stability of performance across a test session when the signal intensity is manipulated. Supplemental Material https://doi.org/10.23641/asha.8309273.

Behavioral Assessment of Hearing in 2 to 4 Year-old Children: A Two-interval, Observer-based Procedure Using Conditioned Play-based Responses.

Collecting reliable behavioral data from toddlers and preschoolers is challenging. As a result, there are significant gaps in our understanding of human auditory development for these age groups. This paper describes an observer-based procedure for measuring hearing sensitivity with a two-interval, two-alternative forced-choice paradigm. Young children are trained to perform a play-based, motor response (e.g., putting a block in a bucket) whenever they hear a target signal. An experimenter observes the child's behavior and makes a judgment about whether the signal was presented during the first or second observation interval; the experimenter is blinded to the true signal interval, so this judgment is based solely on the child's behavior. These procedures were used to test 2 to 4 year-olds (n = 33) with no known hearing problems. The signal was a 1,000 Hz warble tone presented in quiet, and the signal level was adjusted to estimate a threshold corresponding to 71%-correct detection. A valid threshold was obtained for 82% of children. These results indicate that the two-interval procedure is both feasible and reliable for use with toddlers and preschoolers. The two-interval, observer-based procedure described in this paper is a powerful tool for evaluating hearing in young children because it guards against response bias on the part of the experimenter.

Development of Open-Set Word Recognition in Children: Speech-Shaped Noise and Two-Talker Speech Maskers.

OBJECTIVE: The goal of this study was to establish the developmental trajectories for children's open-set recognition of monosyllabic words in each of two maskers: two-talker speech and speech-shaped noise. DESIGN: Listeners were 56 children (5 to 16 years) and 16 adults, all with normal hearing. Thresholds for 50% correct recognition of monosyllabic words were measured in a two-talker speech or a speech-shaped noise masker in the sound field using an open-set task. Target words were presented at a fixed level of 65 dB SPL throughout testing, while the masker level was adapted. A repeated-measures design was used to compare the performance of three age groups of children (5 to 7 years, 8 to 12 years, and 13 to 16 years) and a group of adults. The pattern of age-related changes during childhood was also compared between the two masker conditions. RESULTS: Listeners in all four age groups performed more poorly in the two-talker speech than the speech-shaped noise masker, but the developmental trajectories differed for the two masker conditions. For the speech-shaped noise masker, children's performance improved with age until about 10 years of age, with little systematic child-adult differences thereafter. In contrast, for the two-talker speech masker, children's thresholds gradually improved between 5 and 13 years of age, followed by an abrupt improvement in performance to adult-like levels. Children's thresholds in the two masker conditions were uncorrelated. CONCLUSIONS: Younger children require a more advantageous signal-to-noise ratio than older children and adults to achieve 50% correct word recognition in both masker conditions. However, children's ability to recognize words appears to take longer to mature and follows a different developmental trajectory for the two-talker speech masker than the speech-shaped noise masker. These findings highlight the importance of considering both age and masker type when evaluating children's masked speech perception abilities.

Adults, but not children, benefit from a pretrial signal cue in a random-frequency, two-tone masker.

This study examined the benefit of a pretrial cue, a preview of the signal, on children's (5-10 years) and adults' detection of a 1000-Hz pure-tone signal in a broadband noise or a random-frequency, two-tone masker. No cuing effect was observed with the noise masker, regardless of listener age. In contrast, all but one adult benefited from the cue with the two-tone masker (average = 9.4 dB). Most children showed no cuing effect (average = 0.1 dB) with the two-tone masker. These results suggest that, unlike adults, the provision of a pretrial cue does not promote frequency-selective listening during detection for 5- to 10-year-olds.

Effect of signal-temporal uncertainty in children and adults: tone detection in noise or a random-frequency masker.

A cue indicating when in time to listen can improve adults' tone detection thresholds, particularly for conditions that produce substantial informational masking. The purpose of this study was to determine if 5- to 13-yr-old children likewise benefit from a light cue indicating when in time to listen for a masked pure-tone signal. Each listener was tested in one of two continuous maskers: Broadband noise (low informational masking) or a random-frequency, two-tone masker (high informational masking). Using a single-interval method of constant stimuli, detection thresholds were measured for two temporal conditions: (1) Temporally-defined, with the listening interval defined by a light cue, and (2) temporally-uncertain, with no light cue. Thresholds estimated from psychometric functions fitted to the data indicated that children and adults benefited to the same degree from the visual cue. Across listeners, the average benefit of a defined listening interval was 1.8 dB in the broadband noise and 8.6 dB in the random-frequency, two-tone masker. Thus, the benefit of knowing when in time to listen was more robust for conditions believed to be dominated by informational masking. An unexpected finding of this study was that children's thresholds were comparable to adults' in the random-frequency, two-tone masker.

Release from perceptual masking for children and adults: benefit of a carrier phrase.

OBJECTIVES: The purpose of this study was to test the hypothesis that a carrier phrase can improve word recognition performance for both children and adults by providing an auditory grouping cue. It was hypothesized that the carrier phrase would benefit listeners under conditions in which they have difficulty in perceptually separating the target word from the competing background. To test this hypothesis, word recognition was examined for maskers that were believed to vary in their ability to create perceptual masking. In addition to determining the conditions under which a carrier-phrase benefit is obtained, age-related differences in both susceptibility to masking and carrier-phrase benefit were examined. DESIGN: Two experiments were conducted to characterize developmental effects in the ability to benefit from a carrier phrase (i.e., "say the word") before the target word. Using an open-set task, word recognition performance was measured for three listener age groups: 5- to 7-year-old children, 8- to 10-year-old children, and adults (18-30 years). For all experiments, target words were presented in each of two carrier-phrase conditions: (1) carrier-present and (2) carrier-absent. Across experiments, word recognition performance was assessed in the presence of multi-talker babble (Experiment 1), two-talker speech (Experiment 2), or speech-shaped noise (Experiment 2). RESULTS: Children's word recognition performance was generally poorer than that of adults for all three masker conditions. Differences between the two age groups of children were seen for both speech-shaped noise and multi-talker babble, with 5- to 7-year-olds performing more poorly than 8- to 10-year-olds. However, 5- to 7-year-olds and 8- to 10-year-olds performed similarly for the two-talker masker. Despite developmental effects in susceptibility to masking, both groups of children and adults showed a carrier-phrase benefit in multi-talker babble (Experiment 1) and in the two-talker masker (Experiment 2). The magnitude of the carrier-phrase benefit was similar for a given masker type across age groups, but the carrier-phrase benefit was greater in the presence of the two-talker masker than in multi-talker babble. Specifically, the children's average carrier-phrase benefit was 7.1% for multi-talker and 16.8% for the two-talker masker condition. No carrier-phrase benefit was observed for any age group in the presence of speech-shaped noise. CONCLUSIONS: Effects of auditory masking on word recognition performance were greater for children than for adults. The time course of development for susceptibility to masking seems to be more prolonged for a two-talker speech masker than for multi-talker babble or speech-shaped noise. Unique to the present study, this work suggests that a carrier phrase can provide an effective auditory grouping cue for both children and adults under conditions expected to produce substantial perceptual masking.

Release from informational masking in children: effect of multiple signal bursts.

This study examined the degree to which increasing the number of signal presentations provides children with a release from informational masking. Listeners were younger children (5-7 years), older children (8-10 years), and adults. Detection thresholds were measured for a sequence of repeating 50-ms bursts of a 1000-Hz pure-tone signal embedded in a sequence of 10- and 50-ms bursts of a random-frequency, two-tone masker. Masker bursts were played at an overall level of 60-dB sound pressure level in each interval of a two-interval, forced choice adaptive procedure. Performance was examined for conditions with two, four, five, and six signal bursts. Regardless of the number of signal bursts, thresholds for most children were higher than thresholds for most adults. Despite developmental effects in informational masking, however, masked threshold decreased with additional signal bursts by a similar amount for younger children, older children, and adults. The magnitude of masking release for both groups of children and for adults was inconsistent with absolute energy detection. Instead, increasing the number of signal bursts appears to aid children in the perceptual segregation of the fixed-frequency signal from the random-frequency masker as has been previously reported for adults [Kidd, G., et al. (2003). J. Acoust. Soc. Am. 114, 2835-2845].

The effect of signal-temporal uncertainty on detection in bursts of noise or a random-frequency complex.

This study examined the effect of signal-temporal uncertainty on detection of a 120-ms, 1-kHz tone in the presence of a continuous sequence of 120-ms bursts of either a broadband noise or a random-frequency, two-tone complex. Using the method of constant stimuli, signal-temporal uncertainty was defined as the difference in threshold across temporally uncertain and temporally defined listening conditions. Results indicted an average effect of signal-temporal uncertainty of 2 dB for the noise masker compared to 9 dB for the random-frequency, two-tone masker. These results suggest that signal-temporal uncertainty may be more detrimental for conditions in which informational masking dominates performance.