September 4, 2007 Feature

Assessing Auditory Milestones in Children

Clinical Tools for Pediatric Audiologists

see also

The following article is excerpted from the March 2007 issue (Vol. 17, No. 1, pp. 8-11) of Perspectives on Hearing and Hearing Disorders in Childhood, the publication of ASHA Special Interest Division 9, Hearing and Hearing Disorders in Childhood. This first of two articles focuses on clinical tools to assess the development of auditory milestones in children with hearing loss. A Sept. 25 article will focus on fostering the psychosocial development of children with hearing loss.

Audiologists have at their disposal both auditory (Palmer & Mormer, 1999) and speech and language milestones to use as benchmarks for monitoring aspects of communication development. One of our first challenges in measuring functional benefit with amplification is assessing these earliest auditory milestones. The Developmental Index of Audition and Listening (DIAL), developed by Palmer and Mormer, is a tool that gives audiologists a "systematic way of evaluating the current abilities and need of the child as related to the range of auditory signals that are used in day-to-day life" (p. 63).

This list of auditory milestones from birth through early adulthood provides audiologists a means of assessing auditory development across childhood. DIAL provides audiologists with expected milestones, so that if a young child does not demonstrate auditory behaviors typical for his/her developmental age, the clinician can work with the family to set goals for enhancing auditory access. Palmer and Mormer have developed two other tools to accomplish this task.

The Pediatric Hearing Demand, Ability and Need Profile (PHDANP) provides clinicians with the ability to chart the milestones that should have been mastered at a particular developmental age level and to explore potential roadblocks that may be interfering with achieving these milestones. The Family Expectation Worksheet (FEW), the final tool in this series, helps set
goals with the child and his/her family by defining skills and the interventions needed to accomplish these tasks. This trio of worksheets/charts provides an invaluable clinical tool for defining typical development and how audiologists can support our patients and their families in achieving their goals.

Once a young child starts demonstrating some consistent alerting responses—around 5 months of age—the Early Listening Function (ELF) evaluation developed by Karen Anderson (2002) becomes an essential tool in the clinical setting. The ELF teaches families to observe auditory behaviors and then suggests activities to stimulate alerting responses in their young child. These activities, completed in the home with the parents presenting different auditory signals at varying distances, help families systematically observe auditory awareness and measure improvements in skills with amplification. With this information, the audiologist validates that the amplification system is improving access to auditory signals and providing functional benefit.

Tools for Preschoolers

Once a child reaches 3 years of age, a different type of validation tool can be used by families: the Children's Home Inventory of Listening Difficulties (CHILD) developed by Anderson and Smaldino (2000). CHILD asks parents to rate their child's abilities for 15 different listening situations in the home/family environment. Activities observed range from waking/alerting to an alarm clock to understanding speech in a crowded store. The authors of this tool suggest several applications: 

  • To assist parents in identifying or confirming areas of concern 
  • To serve as a pre- and post- test with amplification fitting 
  • To assist in counseling parents regarding the communication difficulties that a child with hearing loss can experience 
  • To help assess the need for assistive listening devices 
  • To monitor auditory function with amplification and assistive devices over time

Significant Hearing Losses

For children who have severe-to-profound hearing loss, the Infant-Toddler: Meaningful Auditory Integration Scale is a useful tool for assessing auditory function with amplification. This 10-question scale was developed by Zimmerman-Phillips, Osberger, and Robbins (1997). Through a guided parent interview, the audiologist is able to assess device bonding and auditory function with amplification systems. Parents are asked to provide specific examples of auditory behaviors from "responding to his/her name in the presence of background noise" to "associating vocal tone with its meaning." This tool is commonly used for assessing functional benefit of amplification and has been incorporated into cochlear implant candidacy evaluations.

Although other measures are available for use with this young population and their families, the tools suggested here fit easily into daily clinical practice, and have been found by the author to be particularly useful for measuring/validating interventions for patients seen in our clinic.  

Eileen Rall, is an audiologist at the Center for Childhood Communication, The Children's Hospital of Philadelphia.

cite as: Rall, E. (2007, September 04). Assessing Auditory Milestones in Children : Clinical Tools for Pediatric Audiologists. The ASHA Leader.


Anderson, K. L. (2002). ELF: Early listening function. Tampa, FL: Educational Audiology Association.

Anderson, K. L.,& Smaldino, J. J. (2000). Children’s Home Inventory of Listening Difficulties (CHILD). Tampa, FL: Educational Audiology Association.

Berger, K. S. (2003). The Developing person through childhood and adolescence (6th ed.). New York: Worth Publishers.

Dowd, T., & Tierney, J. (1995). Teaching social skills to youth: A curriculum for child-care providers. Girls and Boys Town, NE: Girls and Boys Town Press.

Gresham, F. M. (1994). Best practices in social skills training. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology—II (pp. 695-709). Washington, DC: The National Association of School Psychologists.

Hodgdon, L. A. (2000). Visual strategies for improving communication: Practical supports for school and home. Troy, MI: Quirk Roberts Publishing.

Palmer, C. V., Butts, S. L., Lindley IV, G. A., & Snyder, S. E. (1996). Time out! I didn’t hear you. Pittsburgh, PA: Sports Support Syndicate. Also available from [PDF]. 

Palmer, C., & Mormer, E. (1999). Goals and expectations of the hearing aid fitting. Trends in Amplification, 4(2), 61–71.

Zimmerman-Phillips, A., Osberger, M. & Robbins, A. (1997). Infant-Toddler Meaningful Auditory Inte-gration Scale. Retrieved January 22, 2007, from [PDF].


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