Pediatric Audiology: Interview with Jane R. Madell, PhD
Interview with Jane R. Madell, PhD
Director Hearing Learning Center, Co-Director Cochlear Implant Center, The Ear Institute at the New York Eye and Ear Infirmary
Professor of Clinical Otolaryngology, Albert Einstein College of Medicine
New York City, New York
Co-Author of Pediatric Audiology: Diagnosis, Technology and Management
By: Jane R. Madell and Carol Flexer
2008, www.thieme.com ISBN978-1-60406-001-0
By: Douglas L. Beck, AuD
Board Certified in Audiology
Web Content Editor
American Academy of Audiology
Academy/Beck: Hi, Jane. Thanks for taking the time to meet with me, and congratulations on the new book.
Madell: Hi, Doug. Thanks very much for your interest.
Academy/Beck: Let’s start with… Why write a new book on pediatrics?
Madell: Well, there are many reasons, but the most important is that the profession has changed so much in such a short time, and we urgently need to make sure we stay abreast of the changes, while holding on to the tried-and-true basics.
Academy/Beck: I recall your previous book from 1998 (Behavioral Evaluation of Hearing in Infants, Thieme) and I noticed some of the same very important trends in the new book. For instance, despite modern and cutting-edge chapters on topics such as cochlear implants, genetics, newborn hearing screenings, otoacoustic emissions, middle-ear measurement, and auditory-evoked responses, you maintain and updated information about behavioral testing and protocols.
Madell: Exactly. Behavioral audiometry is quite often the backbone of what we do, and it has to be studied, explored, and practiced to do it well. Unfortunately, behavioral testing is not as “sexy” as some of the extraordinary bio-electric techniques we use in audiology, and so it’s easy for some programs and professionals to dismiss it. So we do indeed maintain a healthy respect and exploration of behavioral techniques and interpretation. While ABR can identify a hearing loss in an infant, we cannot monitor performance of babies with hearing aids using ABR. If we develop good behavioral skills we are going to be able to monitor how they are doing with their hearing aids so we know if and when changes need to be made to the amplification.
Academy/Beck: I should add that the accompanying DVD shows multiple examples in real time, with and without narration, so the audiologist or student can observe the newborn’s responses, and try to figure out if the change in behavior was real or not and if it was an auditory response.
Madell: Yes, we spent a lot of time assembling those video loops so as to allow practice and increase the depth of the experience for the reader, whether it’s a student or a professional. In other words, the book allows a clinical experience.
Academy/Beck: Well said. And your book is less of a “survey book” and more of a “how-to” approach.
Madell: Right, that was one of the goals. Carol and I wanted to show how to do what we do, and to provide references for students and pediatric audiologists practicing in the real world.
Academy/Beck: And to me, this is a concern that needs more attention. I often hear people involved with pediatrics say that behavioral testing on newborns and infants is a bit of an oxymoron, and although I must admit, it’s not as easy as acquiring otoacoustic emissions on sleeping babies, it can be done with a high degree of accuracy and repeatability.
Madell: Of course, and for many people in the profession, who have not been exposed to good test protocols and interpretation, it probably seems like we cannot do reliable behavioral tests on infants, but the opposite is true. We can do behavioral and it is very accurate. In the book, we show audiograms of the same kids over time comparing behavioral observation, visual reinforcement and play audiomtetry demonstrating that it can be very reliable.
Academy/Beck: Didn’t you speak at the Academy AudiologyNOW!® Pediatric Grand Rounds last year with respect to behavioral testing of infants?
Madell: Yes, that was a great event. The audience has a million questions and they were very excited about the topics. It was exciting to present these thoughts and techniques to so many interested professionals.
Academy/Beck: And so in the book, in addition to the other 29 chapters, you have three chapters authored specifically on behavioral tests. Chapter 6 is titled “Using Behavioral Observation Audiomety to Evaluate Hearing in Infants from Birth to 6 months,” chapter 7 is titled “Using Visual Reinforcement Audiology to Evaluate Hearing in Infants from 5 to 36 Months,” and chapter 8 is titled “Using Conditioned Play Audiometry to Test Hearing in Children Older Than 2.5 Years.” I think that when you put these chapters together with the DVD, one really can experience the techniques and the success likely with good behavioral techniques. And so now that I’ve revealed some of the chapter titles, and there’s less mystery left—what do you recommend as the starting point for audiologists trying to develop their behavioral testing skills?
Madell: That’s a great question. I think the place to start is “assisting” and there’s a chapter in the book on being a good test assistant, too (Chapter 12). Any audiologist can learn to turn the dials and manage the technical work, that’s no surprise, audiologists are highly technical people. But learning to interpret human movement, behavior, and activities in tandem with the test situation is a skill that requires lots of time and practice. It can be highly accurate and scientific, but it takes more practicum-based experience to learn, that is, we cannot learn to observe through reading chapters, we have to actually do it. So you need to observe time and time again, and to do so in context we really learn what it’s all about and the DVD provides that opportunity.
Academy/Beck: Yes, I understand. I’m really good at learning to ski while reading books and magazines about skiing, but I’m not quite as talented while negotiating the slopes! Jane, what can you tell me regarding the purpose and the goals of audiologic management of the pediatric patient?
Madell: Carol Flexer, my co-author, and I had that discussion before we started to write and assemble the book. Our goal was to make each child a star, so they could each achieve all they can with the hearing they have. We want all children to be able to acquire speech and language through audition because when they do, their language and vocabulary will be as good as possible. Children who learn through audition acquire knowledge more readily, easier and faster than children who cannot acquire knowledge through auditory channels and their literacy clearly shows this. So maybe the bottom line is children need excellent auditory access through appropriate technology and through auditory therapy to perceive and acquire auditory-based speech and language therapy to allow children to be the best they can be. Further, we want to enhance the reception of clear and intact acoustic signals to access, develop and organize the auditory centers of the brain.
Academy/Beck: That’s great…because we all know that human brains are plastic. In fact, the most recent research shows that neurogenesis continues throughout the lifetime when the brain is appropriately stimulated, but neuroplasticity is more robust and active in childhood, and indeed, auditory stimulation clearly impacts the anatomy and physiology of the brain.
Madell: Exactly, and that’s key to fitting children with amplification or implants as soon as possible. The vast majority of children that receive cochlear implants at about one year of age will be mainstreamed by the time they’re in first grade. That is just remarkable.
Academy/Beck: Jane, what about the percentage of newborns screened in 2008? What are the latest numbers?
Madell: In Karl White’s chapter he talks about how in 1993, fewer than 5 percent of all children were screened for hearing loss. In 2008, across the United States, now it’s about 95 percent of all newborns are screened, so the numbers have flipped dramatically.
Academy/Beck: What are your thoughts regarding fitting amplification on babies, based on ABR, OAE, and perhaps middle-ear reflexes?
Madell: ABR is the way to start but my thought is that it’s just so much better to base the fitting on behavioral testing. I think we’re all so much more comfortable fitting technology with behavioral data, and that’s usually the best way to go. Of course I am not saying I wouldn’t fit the child if all I had was physiologically derived data. That data is fine, but it is not as comprehensive as what we can get behaviorally—(if we acquire the skills to do just that.) and behavioral testing allows us to verify how the child is doing with the technology. I am concerned about using only electrophysiological information (ABR) to diagnosis hearing loss and then using only real ear to fit the hearing aids. Without behavioral testing, we do not know how the baby is hearing.
Academy/Beck: And if you’re really competent and skilled, you can test the kids with and without technology, and you can monitor how the kids are doing with their technology, and if you are skilled at this, you can do this quite rapidly, right?
Madell: Yes, and that’s another issue. Indeed, for a skilled tester, it’s very quick…and this makes it so much easier later to test the child with their hearing aids or cochlear implant up and running.
Academy/Beck: But I can just see so many readers saying “yes, sure, but what about uncooperative kids?”
Madell: Doug, you know my mantra on this. There is no such thing as a child that is “un-testable.” There are indeed audiologists who cannot test particular children, but all children are testable. I remember when I was getting my training at Emerson College and David Luterman was my professor. I remember I said to him, “Dr. Luterman, this child cannot be tested.” He wisely replied “What you mean is, you do not know how to test this child.” And he was right. I didn’t know how to test that child, and I didn’t know what else to do. So I’ve been there, too.
Academy/Beck: Jane, if I may, I’ll just finish up here by asking you for some quick thoughts and opinions on a few topics, and then I’ll let you go.
Madell: Okay, fair enough. Shoot.
Academy/Beck: Monitored live voice (MLV) versus recorded tests?
Madell: MLV has only a very little place in audiology. The data is very clear that recorded tests are the tests of choice. With very young children, you may need to do some MLV , but you should always use recorded tests as soon as possible—and it’s surprising for many, but it’s possible most of the time.
Academy/Beck: Okay, next topic, for children with severe-to-profound sensorineural hearing loss, compression, or linear hearing aids?
Madell: Children with severe-to-profound hearing loss need much more high-tech hearing aids than do adults. It’s very simple, their needs are greater because they are learning speech and language and they are learning academics and they need to hear it all. So bottom line, compression is the technology of choice for children with hearing loss.
Academy/Beck: Okay, next topic, tell me more about noise-reduction circuits in pediatric hearing aid fittings?
Madell: Absolutely. Yes, I believe in this technology and I endorse noise-reduction circuits to make sound more pleasant.
Academy/Beck: Directional microphones in hearing aids?
Madell: Well, I like directional microphones and they make sense and they provide a signal-to-noise ratio benefit. But the issue is, as Harvey Dillon and colleagues wrote in their chapter, that directional should be turned on once the child consistently turns their head to face the person speaking. So maybe for the first year or two the directional circuit is off, but is enabled once the child is watching the sound source consistently.
Academy/Beck: Okay, Jane. As always, I’m delighted and honored to speak with you. I know I have taken way too much of your time. I absolutely enjoyed reading the book. I believe it offers multiple advantages and I would certainly recommend it as an extraordinary text for students and professionals alike, with a real-world passion and orientation. Thanks so much.
Madell: Thank you, too, Doug.