August 2, 2021
Authors from the Center for Audiology at Hackensack Meridian JFK Johnson Rehabilitation Institute present case of young boy with normal hearing who had difficulties in real-world listening conditions
“Incorporating Speech-in-Noise Testing in the Pediatric Test Battery,” supports the need to include a signal-to-noise ratio loss screening tool as part of standard pediatric hearing testing. In the article, audiologists from Hackensack Meridian JFK Johnson Rehabilitation Institute’s Center for Audiology present the case of a boy with normal hearing who had difficulties in how he performed in complex, realistic listening conditions over the course of several years while his hearing and other abilities were being evaluated.
Signal-to-noise ratio (SNR) is the measurement used to describe how much desired sound is present, as opposed to unwanted sound, in the environment. The “routine” audiological battery administered by audiologists does not typically include a screening tool to identify SNR loss, which can lead to further evaluation. The child in this case did not initially get screened for SNR ratio.
“One such screening tool, the BKB-SIN, detected an SNR abnormality in a child with normal hearing who was tested at our Center,” said Karissa Gavin, AuD, CCC-A, the article’s lead author. “Although the traditional pediatric hearing tests allow the audiologist to diagnose a hearing impairment using an ideal listening environment, adding the BKB-SIN easily provides objective measurements of how a child is performing in complex, realistic listening conditions. Abnormal findings not only trigger recommendations for further testing but they also support the need for an assistive listening device or environmental modifications.”
Although it’s well documented that the signal-to-noise ratio (SNR) impacts those with hearing impairment, the impact of a reduced SNR is also significant to a child with normal hearing. This is especially true for children who may have an auditory processing disorder (APD), which is difficulty hearing small sound differences in words.
“A favorable SNR aids auditory figure-ground discrimination, which is the ability to identify sounds in the presence of background noise,” said Dr. Gavin. “A child who has normal hearing but struggles with auditory figure-ground discrimination may be unable to filter background noises to focus on important speech cues, which can potentially lead to learning difficulties.”
The article states that combining auditory difficulties and poor classroom acoustics with other higher-level challenges, such as a language delay, attentional weakness, reduced intellectual function, or any other learning disability, creates even more of a challenge for a child.
Furthermore, it states that if the pediatric audiologic test battery does not include a hearing in noise screening tool, there is a high probability that auditory discrimination problems can go undetected. An abnormal score on a speech in noise screening score may indicate possible auditory problems, which would then trigger a recommendation for further evaluation, as well as strategies to manage the child’s particular situation.
A five-year-old boy was evaluated at the Center for Audiology at JFK Johnson Rehabilitation Institute for an audiologic assessment. His parents reported that he had difficulty hearing from a distance, localizing sounds, and regulating the loudness of his voice. They also reported that the child was receiving therapy due to a language delay. Audiologic testing indicated normal hearing and excellent word recognition in each ear. At that time, an auditory processing disorder evaluation was deferred in view of factors that may have contributed to the low scores such as low cognitive ability, developmental factors, and other non-auditory processing influences. It was therefore recommended that he continue with language therapy and return in one year for audiologic monitoring.
The child returned at age 6 years and 10 months for a follow-up audiologic evaluation. Per the parental report, therapy was discontinued as he no longer met eligibility for in-school services, though it was reported that he continued to have difficulties with language and hearing from a distance, especially when background noise was present. Audiologic testing remained unremarkable with one exception; the BKB-SIN, demonstrated a mild degree of SNR loss. Noting his parental case history and the BKB-SIN score, an auditory processing disorder evaluation was recommended.
Results of the auditory processing disorder test battery demonstrated a global deficit. Specifically, deficits were seen in four out of the five subtests. In addition, a Clinical Evaluation of Language Fundamentals screening was performed as part of the Center’s standard battery of tests. The child scored borderline low in the areas of concepts, following directions, and understanding spoken paragraphs. This deficit pattern suggested that the weaknesses identified in the test battery were likely secondary to the previously identified language delay and/or a combined auditory processing disorder/language delay.
Based on the results of the evaluation, recommendations were categorized under environmental modifications, remediation activities, and compensatory strategies. Additionally, a repeat comprehensive language evaluation was recommended. Lastly, it was advised that the child return to the Center for repeat testing in one year to monitor for maturation and/or effects of remediation.
“We believe it is important for audiologists to begin including a signal-to-noise ratio loss screening tool as part of the initial standard pediatric hearing testing, to prevent further developmental impairment in children who may have either language delay, auditory processing disorder, or both,” said Anne, Eckert, AuD, MBA, CCA-A, an author of the article and audiologist at the Center for Audiology at JFK Johnson Rehabilitation Institute.
1The Hearing Journal: July 2021 – Volume 74 – Issue 7 – p 16
doi: 10.1097/01.HJ.0000766232.27845.d4 Gavin, Karissa AuD, CCC-A; Eckert, Anne AuD, MBA, CCC-A; Gural-Toth, Virginia AuD, CCC-A