1. Behavioral tests are used to evaluate hearing in infants and young children, including behavioral observation audiometry for infants under 6 months and condition orientation reflex audiometry (CORA) for children 6 months to 1 year old. 2. CORA uses operant conditioning to teach the child to orient towards a sound source to receive a visual reinforcement from a lighted toy. 3. Visual reinforcement audiometry (VRA) and tangible reinforcement operant conditioning audiometry (TROCA) build on CORA principles to test older children using reinforcement strategies. 4. Conditioned play audiometry (CPA) teaches children ages 2-4 to perform tasks after hearing tones to make the

1. Behavioural Test in
Pediatric Audiology
By Sakshi Gupta

2. Behavioral Observation Audiometry
• Age Range: 0 to 6 months
• Used to monitor auditory response when infant is in light sleep.
• Are accomplished without any reinforcement.
• Stimuli used: sudden onset of speech signal, narrow band noise
• Transducers: soundfield speakers.
• Presentation levels: 60 to 90 dBHL.
• Duration: 3 to 4 sec.
• Responses: eye blinking, eye widening, slight shudder of whole body, arm
and body movements.
• Responses are true if are seen within 2 sec. of stimulus presentation.

3. Condition Orient Reflex Audiometry
• Given by: Suzuki and Ogiba
• Based on operant conditioning theory.
• Child is conditioned to correctly orient to sound presented from
one of the two speakers.
• Child’s head turn is reinforced by blinking lighted toy.
• Age range: 6m to 1yr.
• Localization required

4. Equipment and procedure in CORA
• Place child between speaker and adjacent visual stimuli within a sound
treated room.
• Initially toy draws attention of child which is unconditional.
• Once conditioning is achieved, the illumination provides reinforcement.
• Procedure:
The test tone is presented through one of the speakers at an intensity level of
approximately 30dB above the estimated threshold of the child followed
immediately by the illumination of the toy on the same side.
The child will instinctively orient or turn toward the source of the tone/light
presentation.
Once the child has turned toward the source of the sound, the toy is
illuminated as reinforcement.

5. Procedure cont.
• The second step involves measurement of threshold.
• reducing the intensity of the test tone to near the estimated
threshold of the child, and presenting the tone from one side.
• The intensity of the test tone is then reduced and the process
repeated until the child fails to respond. Using this procedure, the
child's hearing threshold for a given frequency can be obtained.

6. CORA Setup

7. Visual Reinforcement Audiometry
• Term coined By Liden and Kankkonen(1969).
• Same as CORA but utilizes only single sound field speaker.
• Transducers: insert earphones, loudspeakers, Earphones.
• Presentation level: 75dB or above
• Reinforcement should be placed 90 degree.
• Equipment and procedure same as CORA.
• The key difference between COR and VRA is that COR is dependent
on the child to have the ability to detect and localize the sound,
whereas VRA only requires the child to have a head turn response
after the auditory stimulus is presented, they do not need to
accurately localize the sound as well.

8. VRA Setup

9. TROCA
• Tangible reinforcement operant conditioning Audiometry
• In this test Child will be provided with a positive or tangible
reinforcement whenever he/she responses for auditory stimuli.
• Items such as candy, cereal, trinket etc. can be given.
• For false positive response negative reinforcement such as time
out can be used.
• Age range: 2 to 4 yrs.
• Transducers: headphone, inserts, bone vibrator, loud speaker

10. TROCA Procedure
• Typically the child’s response behavior is conditioned to push a
response button whenever sound is perceived.
• Tangible Reinforcement is usually accompanied by social
Reinforcement.

11. Condition play Audiometry
• Condition play audiometry is a preferred behavioral technique to
determine ear specific and frequency specific hearing thresholds.
• Age range: 2 to 4 yrs.
• CPA is a kind of audiometry is a form of operant conditioning in which
child is taught to wait and listen carefully for a pure tone, Nbn,
speech stimulus and then perform a task that is actually a sort of
child’s game in response to presentation of stimuli.
• The conditioning phase includes review of planned task which require
gross motor response from child
• Eg: dropping marbles into can, putting pegs in peg board, building
tower etc.

12. CPA cond.
• Presentation level: 40 to 50 dB above expected threshold level.
• 3 to 4 trials before testing.
• Decrease the intensity till last response is present.

13. Speech Audiometry
1. Speech Detection Threshold:
The awareness or detection level is recorded as lowest decibel level at which
child makes a response.
During this test child just listen to the sound(speech stimulus).
Responses can be eye widening, head movement, head turn, facial expression,
hand raising, even sometimes babbling can be observed as response.
Stimulus: Any speech stimulus like Papapa, bababa, aa, mamama, etc can be
used.(Live voice is preffered)
Correlation with PTA should be within 6 to 8dB.
Presentation level: Pta+20.

14. Speech Audiometry
2. Speech reception threshold:
• Used to validate pure tone thresholds.
• Correlation within +- 12 dB with pta
• Presentation level = pta+20dB. And reduce by 10 dB steps. {bracketing method}
• Stimulus type: Spondee words.[baseball, football, handwash, hotdog]
• For young child use pictures of spondee words with which child is familiar with and ask to point the
picture which he herd.
• For toddlers directly use pointing objects that are named. Eg. Pointing body part which is named.
• A 3 to 4 yr child may repeat the words verbally.

15. Speech Audiometry
3. Speech perception Testing
• Purpose: To determine chil’s auditory recognition of words presented at
conversational and supra threshold level.
• Presentation level: Srt+40dB.
• Testing Young children: Use some form of pictures identification pointing response
to a picture board. Child hears a word and attempts to identify correct picture.
• Speech perception can be 2 types:
a. Open Set
b. Closed Set

16. Speech Audiometry
• Closed set: Picture pointing technique.
• Open Set: Various word list are made
i. PBK(phonetically balanced kindergarden)- given via live voice
and consist of list of pb words which are in vocabulary of
children.
• Tangible reinforcement (Smith and Hodgson, 1970).
• Other test: Discrimination by identification pictures(DIP), Word
intelligibility by picture identification (WIPI) etc.