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Published on: December 5, 2014
The distraction test: the last word?
Shirley A Russ1, Zeffie Poulakis, Melissa Wake
1Centre for Community Child Health, Royal Children's Hospital, Victoria, Australia.
Insights
The distraction test in newborn hearing screening programs results in many false positives and negatives, failing to meet diagnostic goals. This method is not suitable for population-based infant hearing screening.
Area of Science:
- Audiology
- Public Health
- Pediatrics
Background:
- Universal Newborn Hearing Screening (UNHS) programs are widespread but require rigorous evaluation of their cost-effectiveness and logistical efficiency.
- Few studies have rigorously assessed alternative screening strategies for infant hearing loss.
Purpose of the Study:
- To evaluate the performance of the distraction test, a key component of the Victorian Infant Hearing Screening Program (VIHSP).
Main Methods:
- A 1993 birth cohort in Victoria, Australia, was screened for hearing loss risk factors.
- At-risk infants received Auditory Brainstem Evoked Response (ABR) screening; others underwent a modified distraction test at 7-9 months.
- The cohort was followed to age 6 to diagnose congenital hearing loss and determine aid fitting, calculating screen performance metrics.
Main Results:
- The distraction test showed a sensitivity of 65%, specificity of 91%, and a positive predictive value (PPV) of 0.3%.
- It yielded 8 false-negatives (0.02%) and an estimated 4265 false-positives (99%) for moderate or greater hearing losses.
- Mean age at diagnosis was 23 months and at aid fitting was 26 months for screen failures.
Conclusions:
- The distraction test generated numerous false positives and significant false negatives, particularly for moderate hearing losses.
- Diagnosis and aid fitting ages for screen failures significantly exceeded established goals.
- Evidence suggests the distraction test is not an acceptable population-based screening method for infant hearing.
Objective:
Universal Newborn Hearing Screening (UNHS) programmes have been widely implemented, but their costs, benefits and long-term logistics remain to be clearly defined. There are few rigorous evaluations of alternative strategies. In this paper, we evaluate the performance of the distraction test component of the two-tiered Victorian Infant Hearing Screening Program (VIHSP).
Methods:
All babies born in the State of Victoria, Australia in 1993 who survived the neonatal period were screened for the presence of risk factors for hearing loss. Those at-risk were referred for Auditory Brainstem Evoked Response (ABR) screening by a professional audiologist. All others were screened by modified distraction test at age 7-9 months. This birth cohort was followed through age 6 for diagnoses of congenital hearing loss resulting in fitting of hearing aids. Estimates of false-positives, false-negatives, sensitivity, specificity and positive predictive values were determined for the distraction test as a population screen. Ages at diagnosis and aid fitting for screen failures with hearing loss were compared with current goals.
Results:
For targeted (moderate or greater-aided) losses, the distraction test yielded eight (0.02%) documented false-negatives (one severe and seven moderate) and an estimated 4265 (99%) false-positives. Distraction test sensitivity was 65%, specificity 91% and PPV 0.3%. Mean age at diagnosis for distraction test failures across all severities, including mild losses, was 23 (SD 18) months with a mean age at aid fitting of 26 (SD 20) months.
Conclusions:
The distraction test screen generated large numbers of false-positives and a significant number of false-negatives, performing particularly poorly with moderate losses. Ages at diagnosis and aid fitting for screen failures were far older than currently accepted goals. There is little evidence that the distraction test can be made to work acceptably as a population-based screen.
