Pediatric Hearing Assessment


Testing children, particularly those under the age of three years, is both challenging and rewarding.  At Evergreen Speech & Hearing Clinic, Inc. the doctors and staff strive to make the experience both fun for the child, and productive for the referral.  Once a detailed history has been taken, the child’s ear canals are examined for obstruction and patency.  During the actual test process we allow the child to lead the way, but guide the process to ensure that we obtain the most information possible. Our goal in a pediatric evaluation is to gain information as close to an adult model as possible, including frequency specific, ear specific and site of lesion information whenever possible.  Most commonly, the process can be broken down as follows.

Children 0-4 months typically do not respond well behaviorally, so we focus on objective measures of hearing and ear health such as Otoacoustic Emissions (OAE)Brainstem Auditory Evoked Response (BAER), and Immittance.

Children 4-18 months will typically respond well to acoustic stimuli in the sound field.  Utilizing a procedure known as Visual Reinforcement Audiometry (VRA), a child is taught to turn in response to sound by presenting a lit and animated toy simultaneously with a high level signal.  Once the behavior has been conditioned, the intensity of the signal can be decreased, and a threshold determined.  This is a highly reliable procedure which gives a good estimate of hearing across a frequency range desirable for speech and language development.

Children 18-24 months can often wear headphones while completing play-oriented activities in response to sounds (e.g. picture identification, blocks in a can in response to sounds, etc.).  When cooperative, these children will give adult like audiologic responses and complete procedures including Pure Tone Air and Bone Conduction, SRTs, and Speech Discrimination.


Since fully one third of school aged children suffer from some degree of hearing loss (either temporary conductive problems or permanent sensorineural loss) on a given day, our Audiologists support universal newborn hearing screening, as well as regular annual hearing tests.  At minimum, any child who suffers from middle ear problems, has a family history of hearing loss, has suffered any form of pre- or perinatal complication, or experiences speech/language or developmental delays, should be referred for testing.

Significant Findings/Impact on Development
Normal Hearing is defined as pure tone thresholds of 15dBHL or better for the frequencies 250-8000Hz with normal speech discrimination ability in both ears.  When sound field-testing is required, disallowing for ear specific analysis, we accept hearing as adequate for speech and language development, if head turn responses for speech and warble pure tones (500-4KHz) are grossly within normal limits.  In these cases, however, we strongly advocate follow-up testing before entering school to rule out any frequency specific or asymmetrical hearing loss.

Minimal Hearing Loss (thresholds 16-25dBHL)
Speech/Language Impact: These children may have difficulty hearing faint or distant speech. At 15dBHL students can miss up to 10% of speech, when the teacher is at a distance of greater than 3 feet, and when the classroom is noisy, especially in the elementary grades when verbal instruction predominates.

Possible Psychosocial Impact: These children may miss subtle conversational cues causing the child to be viewed as awkward or inappropriate. They may miss portions of fast-paced peer interactions which could impact socialization and self concept. They may have immature behavior patterns. The child may be more fatigued than classmates, due to listening effort needed.

Potential Education Needs:

  • Use a sound-field amplification system or personal FM system in the classroom
  • Seek favorable seating in the classroom
  • Special attention to vocabulary and speech
  • Close medical monitoring of any middle ear problems
  • Instruct the teacher as to potential impact

Mild Hearing Loss (thresholds 26-40dBHL)
Speech/Language Impact: At 30dB, the child can miss 25-40% of the speech signal. The degree of difficulty experienced in school will depend upon the noise level in the classroom, distance from the teacher, and configuration of the loss. Without amplification, the child with a 35-40dBHL loss may miss 50% of classroom discussion.

Possible Psychosocial Impact: This child may be accused of daydreaming or not paying attention which can impact self esteem. The child begins to lose ability for selective hearing and has increasing difficulty suppressing background noise which makes the learning environment stressful. Increased effort results in the child being more fatigued than classmates.

Potential Education Needs:

  • Needs hearing instruments and either a sound-field amplification or personal FM system
  • Requires favorable seating and lighting in the classroom
  • May need special help with speech, language, reading, auditory skill building, vocabulary, and self esteem
  • A teacher should receive training as to appropriate classroom management of child

Moderate Hearing Loss (thresholds 41-55dBHL)
Speech/Language Impact: This child will understand conversational speech at a distance of three to five feet only if structure and vocabulary are controlled.  The amount of speech missed can be 50-75% with a 40dBHL hearing loss, and up to 100% for losses above 50dBHL.  Without help, the child will likely have delays in syntax, limited vocabulary, and imperfect speech.

Possible Psychosocial Impact: Communication is often significantly affected, and socialization with peers becomes increasingly difficult.  Without full time use of hearing aids and classroom amplification systems, the child may be judged as a less competent learner.  There is an increasing impact on self esteem.

Potential Education Needs:

  • Amplification is essential (hearing instruments and sound-field or personal FM systems)
  • Refer for special education follow-up
  • Teacher training is a must
  • Attention to oral language development, reading, and written language
  • Speech therapy is normally needed

More Severe or Profound Hearing Loss (thresholds in excess of 56dBHL) Can have a dramatic impact on the child’s life and development in our culture.   Please refer this child for immediate and individual attention.


As with vision or dental, prevention and early intervention is the best approach toward detecting and treating hearing problems.  We recommend universal screening of newborns as well as routine annual screenings throughout the school years.  Many physicians are also incorporating hearing screenings into their routine physical examinations.  If you would like more information about these options, please contact one of our audiologists today at 425-899-5050 or E-mail


Northern, J.L., Downs, M.P.; Hearing In Children. The Williams & Wilkins Co., Baltimore MD, 1984.
Martin, F.N.; Pediatric Audiology. Prentice-Hall Publishing, Englewood Cliffs NJ, 1978.
Jerger, J.; Pediatric Audiology – Current Trends. College-Hill Press, San Diego, CA, 1984.
Katz, J.; Handbook of Clinical Audiology, 2nd. The Williams & Wilkins Co., Baltimore, MD, 1978.
Bluestone, C.D., Klein, J.O.; Otitis Media In Infants and Children. W.B. Saunders Co., Philadelphia, PA, 1988.