The standard behavioral procedures used to assess the hearing of very young children are powerful tools. Yet, even in the hands of a skilled clinician, they are nearly worthless unless the child is ready to be tested. Thus, it is helpful—indeed necessary—to draw on techniques that get the child to do what we want the child to do.
Behavior-changing methodology can help in selecting tactics that increase the chances of obtaining a child’s compliance. These methods shape behavior in a desired direction using established techniques: reinforcing desired behaviors, not reinforcing undesired behaviors, modeling the desired response, desensitizing to aversive stimuli, and successive approximations (Peck, 2007). Combining behavior-altering strategies with principles of child psychology can guide us in making a child more amenable to testing.
This article offers practical ways to increase a child’s acceptance of audiological interactions. The intention is to blend various elements into an overall manner of clinician behavior.
Naturally, what children will accept is influenced by their personalities and age. If a child’s body language indicates comfort, there may be no need for these techniques. However, even if things are going well, one does not know at what juncture a child may become noncompliant, perhaps torpedoing the rest of the session.
Whether to cultivate cooperation or to maintain it, it is advisable to adopt a path of likely acceptance. In behavioral terms, proceed with activities that are presumably less aversive to the child. If resistance appears probable, there may be merit in deferring for the moment a procedure you deem paramount in favor of a different one that the child is more apt to accept.
Commonly, young children are apprehensive when they are brought to unfamiliar people and situations. Yet, adults ask or tell a child to do something, which often results in a blank stare and failure to perform the behavior. Examples are: “Tell the doctor your brother’s name,” or “Can’t you talk?” Thus, instead of eliciting the behavior, they actually inhibit it. Clinicians and parents are well advised to avoid making demands.
A related rule that can reduce complications is: Never ask if a child wants to do something if you don’t want “No” for an answer. For adults, asking is often a polite directive or invitation. To children, yes-or-no questions are literal and concrete.
Suppose you ask, “Do you want to play with my game?” and the child answers “No.” This has unnecessarily set up an opposition. The adult means it as in invitation; the child hears it as a choice. Instead, state the request in the affirmative: “Let’s play with this game.”
For the most part, avoid wearing a white lab coat, given that children may have a negative reaction due to previous experiences with physicians or other professionals wearing white coats.
Space and Time
Generally, young children need some space and time to feel comfortable around unfamiliar people and settings. This is a normal caution on their part. Several factors can be manipulated to get through that caution and foster trust.
Height. Approaching more or less at eye level reduces tension. Similarly, items such as earphones or immittance probes, and sometimes even toys, are best introduced no higher than the child’s torso.
Personal Space. From a very early age, people have a strong sense of their personal space. The range of that area correlates to about the distance of an arm’s reach. A clinician should remain cognizant of space, gauging the child’s acceptance and being ready to withdraw immediately.
Time. Having a potentially disconcerting object or person near a child momentarily is less threatening than having it or the individual close for several seconds. By carefully adjusting the duration, one can help desensitize the child and increase acceptance of the proximity.
By their nature, slow movements are less menacing than quicker ones.
Eye contact is a robust form of communication, whether to express positive or negative emotions. Because of the possible aversive effects, watch for the child’s reactions to eye contact and be ready to fall back either to no contact or to briefer moments of eye contact. As acceptance grows, eye contact can be resumed and the time lengthened.
Insofar as possible, give a child some degree of control. One way to do so is to present options. A good example is offering two choices, such as which toy to play with, either one of which is acceptable to the clinician.
For the most part, people tend to behave in the direction in which they are expected to behave. By presuming cooperation and radiating the expectation of it, cooperation is more likely.
Appraise the child’s posture. Sitting up tends to signal acceptance, whereas slouching back against an adult may suggest insecurity.
Facial expressions can be telling as to relaxation versus wariness. Watch particularly for very subtle movements of the eyes or fingers, or of a limb away from the examiner.
Audiologists frequently need to get a child to look where they want the child to look and, perhaps more importantly, not to look where they do not want the child to look. At times, that means steering the child’s attention away from one thing to something else. Having a child not look at something or keeping something out of sight or unnoticed can be accomplished by borrowing sleight-of-hand tactics.
One might infer from all the above that interacting with young children is dicey and that the clinician has to proceed with trepidation. Such is not the case, as many children are fairly amenable to most audiological procedures or can be induced to comply using the suggested techniques. Furthermore, concerns can be allayed by the clinician displaying relaxed confidence and assuming a matter-of-fact manner.
Ear Canal Inserts
A child may not welcome having an otoscope speculum or ear tip put in the ear canals. Here are some ways to reduce a child’s resistance (desensitization).
When using an otoscope, consider starting without a speculum and having the child help put the speculum on the otoscope. Turn the light on and off. Shine the light on the child’s leg or arm, moving in successive steps toward the head. Shine it on the ears of a puppet, doll, parent, or sibling, or on your own ear.
Allow the child to hold the otoscope and do these same things. Next, the examiner can put the tip in a doll’s or parent’s ear. Perhaps, let the child look through the otoscope in the examiner’s ear. Then, the examiner can move to looking in the child’s ear.
As for insert tips (immittance, otoacoustic emissions (OAE), earphones), encourage the child to choose one or hand the child an ear tip to feel. Anticipate the possibility of a young child putting the tip in the mouth and be ready to block such movement.
Enlist the child’s help in putting the ear tip on the tube. Hold the ear tip near the child’s head or ear or to another person’s ear to demonstrate. If the child objects, accept the rejection and move on in the same positive manner that presumes participation.
During immittance or OAE testing, divert attention away from the probe. Invite the child to press equipment buttons using “approach” language: “You can touch the button. I’ll let you…”
If the child seems agreeable, perhaps tell the child to put the probe in his own ear (again conferring a degree of control on the child). Every now and then, a child may even get a good fit.
Either way, the clinician can then offer to “help” and insert the tip in the ear canal. Point to the screen as results are displayed or to some object. If tympanometry is successful on one side, let the child “make a picture” to take home to the family, i.e., print out the results, and offer the same for the other ear (reinforcement).
The ideal situation during visual-reinforcement audiometry, whether by sound field or earphones, is having the child sitting still and looking forward in quiet. If the child is calm and alert and not looking toward the reinforcer light, there is little or nothing that the clinician needs to do.
However, if the child stares at the reinforcer or becomes restless, then the clinician must become more active to manage the situation. For the child who stares at or frequently turns to look at the reinforcer after the light is turned off, there are two tactics: extinction and distraction.
Extinction means not reinforcing an undesired behavior in order to decrease that behavior. By withholding the visual reinforcement, the staring or frequent turning behavior will tend to diminish and eventually disappear.
Allowing a child to stare or to keep turning toward the unlit reinforcer can be exasperating to the clinician. However, extinction can occur fairly promptly if the clinician can be patient. Persistent looking can also be managed by directing visual attention elsewhere through distraction.
There are three modes to distract a child from gazing at the reinforcer: acoustic, tactile, and visual. Sound in general, including calling the child’s name, should be used sparingly.
If the clinician calls the name and the child looks to the clinician but nothing happens, the child will probably look back at the reinforcer and be more liable to ignore the clinician next time (habituation). Moreover, any sound used to distract can compete with the acoustic test signal and also interrupt the quiet that makes very soft sounds more salient.
Touching is also not an efficient distracter. A touch may prompt the child to face front, but lacking some agreeable consequence (reinforcement), the child will likely turn back to watch for the light (habituation).
Using sound or touch to draw attention away from a visual stimulus is not as effective as presenting an alternative visual stimulus. Put another way, cross-modality distraction is much less efficient than distracting within the same sensory modality.
If you do not want a child to look at A, you must entice the child to look at B. However, a caution—keep any article beyond a child’s reach. Once in the hand, an item may take precedence over the sound signal and also create a situation of having to take something away from a child, which may be disruptive.
There is a tendency to feel a need to have a large selection of toys. An abundance of them may give more comfort to the uneasy clinician than they help control behavior. For example, when the target behavior of looking away from the reinforcer is not met, a clinician may keep pulling out toys in hopes that the right one will be successful.
Almost without exception, a child not sufficiently distracted by the first few toys will not be distracted by the fourth or fifth one, either. Also, after two or three toys are taken out of a box in succession, the child may realize that there is a supply of playthings and want to see more. It is crucial to remember that it is not the toy or item, but the clinician’s behavior that determines whether a child is brought under control.
In reality, one does not need to use a lot of toys, although it is good to have a variety available. This examiner tended to use few props, such as just playing with a block, removing and putting on glasses, and handling a pen, wristwatch, or ID badge.
Motion is attention-getting. Examples are touching the tip of each finger in sequence and running a finger up and down between the fingers of the other hand. Merely dropping something (on purpose) or standing up evokes immediate attention.
A remarkably good visual distracter—and one that is always handy—is the face. Young children are “wired” to look at faces and mouths. Simply opening the mouth or pretending to put something in the mouth are strong attention-getters. Moreover, all of these visual distracters can easily be faded to neutral so as not to decrease responsiveness to the acoustic signal.
These tactics may seem silly and nonsensical to adults, but they raise curiosity in most young children. In the final analysis, the proper criterion is not how strange it seems to the clinician, but how well any object or action produces the desired behavior in the child.
Finally, minimize room clutter. Insofar as possible, keep toys, equipment, and any distractions out of sight. In behavioral terms, those things can be competing stimuli in that they might compete for attention with the test signals.
Two good response activities are dropping blocks into a container and placing pegs in a pegboard. Choose objects that are easy to handle so there is less chance of dropping them on the floor. Children usually feel compelled to pick up anything dropped, thereby interrupting the flow and focus of the activity.
Also, select objects that are not too alluring, so they don’t invite play by themselves. Generally speaking, the simpler, the better. Toys that entail some additional task, such as matching an object’s shape to an opening, might add a layer of difficulty with no offsetting benefit. (However, a reluctant child might like finding the object’s correct opening.)
If it seems unlikely that the child will accept a headset (whether for air- or bone-conduction) or insert earphone, begin by placing it on a table in front of the child. Present a signal that is likely to be audible.
Alternatively, the bone-conduction transducer can eventually be put in the child’s hand to feel a vibratory stimulus. The clinician can then teach the child, either verbally or by pantomime, in whatever task has been planned and model the desired response. Next, it is the child’s turn.
Once trained to task, reduce the signal to obtain responses at lower levels as part of pretesting. When the time seems right, transfer the headset or insert earphone to the child.
If the child balks, withdraw the headset and direct attention elsewhere. The clinician could don the air- or bone-conduction headset (or hold an insert earphone tip to the ear), act as though hearing the signal, and model the target response. Or, one could put the headset/insert earphone again on the table and move it in steps nearer the child’s personal zone, head, or ear, as acceptance allows (successive approximations).
In the case of a headset, unsnap an earphone and hold it as close as the child will tolerate. Successively, move it closer to the point of touching the child’s ear. One can manipulate not only distance but also time from briefer to longer moments.
The clinician can feign a need for help. “Would you please hold this on your ear?” and move the child’s hand with the phone to the ear. Eventually, one can say, “Let’s put the phone in the holder,” snap it into place, and put the headset on the child.
Be ready to continue promptly with the activity so as to direct attention away from the headset. If the child accepts it momentarily, but then protests or pulls it off, do not resist or argue. Instead, reapply the above principles, presume acceptance, and put the headset on again. Usually tolerance grows.
Making intentional errors is a good way of diverting attention away from being tested. For example, suppose the chosen game is dropping blocks, and the child is to have the red ones and the clinician the blue ones.
Clinician: “OK, you got the blue ones, I got the red ones.”
Child: “No, I got the red ones.”
Clinician: “Oops, right. Sorry, you got the red ones. I get the blue ones.”
Another example is, knowing that a child is four years old, the clinician says: “Now that you are three, you’re a big girl.”
Child: “I’m not three. I’m four.”
Clinician: “Oh, right. I forgot.”
In these contrived cases, the issue to the child is not the ears, the strange equipment, or anything else other than setting the record straight as to who gets the red ones or how old the child is.
Applying behavior-shaping techniques and principles from child psychology can maximize compliance in the young child undergoing an audiological evaluation. This implies that the audiologist continuously assesses the child’s behavior throughout the session.
None of these techniques may be necessary every time, but a few can be beneficial some of the time. If a child readily complies with the clinician’s wishes, one can proceed directly with the tasks at hand.
There are secondary benefits to having a command of these techniques. Parents will feel confident that the clinician is knowledgeable and effective with young children. Also, it is more probable that, at follow-up visits, the child will be accepting of the process because of a favorable first encounter.
Finally, a sedated auditory brainstem response (ABR) evaluation might be avoided by satisfactory behavioral testing, even if it takes more than one session to obtain sufficient results.
Peck JE. (2007) Behavioral principles for pediatric audiologists. Audiol Today 19(4):39–42.