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Updated: Jun 8, 2026
Behavioral Assessment of Hearing in 2 to 4 Year-old Children: A Two-interval, Observer-based Procedure Using Conditioned Play-based Responses
Published on: January 23, 2017
Comparison of two hearing screening programs in the same population: oto-acoustic emissions (OAE) screening in
Miriam Geal-Dor1, Cahtia Adelman, Haya Levi
1Audiology and Speech Pathology Clinic, Hadassah University Medical Center and Department of Communication Disorders, Hadassah Academic College, Jerusalem, Israel. miriam112@bezeqint.net
Insights
Newborn hearing screening and later behavioral tests are complementary. A two-step approach combining both methods ensures comprehensive early identification of infant hearing impairment.
Area of Science:
- Pediatrics
- Audiology
- Public Health
Background:
- Infant hearing screening is crucial for early identification of hearing impairment.
- Common programs use either neonatal objective tests (oto-acoustic emissions or automatic auditory brainstem responses) or behavioral screening at 7-9 months.
- Most countries utilize only one screening method.
Purpose of the Study:
- To compare the effectiveness of neonatal objective hearing screening with behavioral screening at 7-9 months in the same group of children.
- To evaluate the agreement and discrepancies between the two screening methods.
- To recommend an optimal hearing screening strategy for infants.
Main Methods:
- A cohort of 1545 infants born between 1999-2003 in Jerusalem were prospectively followed.
- Infants underwent transient oto-acoustic emissions (TEOAE) testing before hospital discharge.
- At 7-9 months, infants received a behavioral hearing screening test.
Main Results:
- Compliance was significantly higher for neonatal testing (99.7%) compared to behavioral testing (83%).
- Failure rates were similar (4-6%), but the nature of failure differed (unilateral in newborns, bilateral at 7-9 months).
- An 11.2% disagreement was observed between the two screening methods, highlighting their complementary roles.
Conclusions:
- Newborn hearing screening offers objectivity, early detection, and high compliance.
- Behavioral screening at 7-9 months identifies later-onset or progressive hearing loss and auditory neuropathy spectrum disorder.
- A comprehensive two-step hearing screening plan, combining newborn and later behavioral tests, is recommended for optimal infant hearing assessment.
Objective:
Hearing screening programs in infancy should identify hearing impairment as early as possible. The two common programs utilize either objective neonatal tests (oto-acoustic emissions (OAE) or automatic auditory brainstem responses (aABR)) or behavioral screening at 7-9 months of age. Most countries employ only one of these options. The uniqueness of this study is the comparison of both hearing screening programs on the same group of children.
Methods:
The study was conducted on 1545 children born between the years 1999 and 2003 who were followed up in public well baby clinics in the Jerusalem district. The children were tested with transient oto-acoustic emissions (TEOAE) before discharge from the neonatal ward, and later, at the age of 7-9 months, underwent a behavioral hearing screening test in a public well baby clinic. The results of both hearing screening programs were compared.
Results:
The compliance rates were 99.7% for the neonatal testing and 83% for the 7-9 months behavioral testing (p=0.0001). The failure rate was 4-6% in both screening programs; failure of OAE testing was unilateral in 65% of newborns; at 7-9 months bilateral failure was more common (56%). There was an 11.2% disagreement (kappa coefficient 0.03) between the outcomes of both tests. In another group of 49 known hearing-impaired children, 27 who had undergone newborn screening were diagnosed before the age of behavioral testing. Twelve children had failed either both tests or the only test they underwent. In nine cases, the children had passed one of the hearing screening tests and had failed the other, and one child had passed both tests.
Conclusions:
Newborn hearing screening has the advantages of objectivity, early identification, and higher compliance. The major advantage of the later behavioral test is identification of later onset or progressive hearing impairment as well as auditory neuropathy spectrum disorder. Each screening test is testing different entities; hence they are complementary and not interchangeable or superfluous. We recommend a comprehensive two-step hearing screening plan (newborn and later behavioral) with close cooperation between the health care providers involved.
