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Assistant Professor
University of Central Arkansas
Patti F. Martin, M.S., CCC-A
Director of Audiology and Speech-Language Pathology
Arkansas Children’s Hospital
Dee M. Lance, Ph.D., CCC-SLP
Assistant Professor
University of Central Arkansas
Introduction:
It seems that in our high-tech world, many of us believe we must have a piece of equipment with tons of bells and whistles to perform almost any kind of assessment. In our continuing effort to obtain the biggest, best, and most powerful assessment instruments, it’s easy to overlook tried and true procedures.
The Ling Six Sound Test (Ling 1976, 1989) is one procedure that, in our experience, is often overlooked. One of its many benefits is that it can be used by anyone; audiologists, speech language pathologists, teachers and parents. The Ling Six Sound Test will truly get to the “nuts and bolts” of speech and hearing without all the “bells and whistles.” It can be used with hearing aids, cochlear implants, or no amplification at all. It’s a good “low tech” tool to keep handy for quick and accurate assessment of essential communication abilities of adults and children.
Historical Perspectives:
The concept behind Daniel Ling’s Six Sound Test was to select familiar speech sounds that would broadly represent the speech spectrum from 250-8000 Hz. This spectral range is the same range tested by conventional audiometry. Ling used isolated phonemes to target low, middle and high frequency sounds.
The phonemes for the Ling Six Sound Test are [m], [ah], [oo], [ee], [sh] and [s]. There are many ways to use this test to assess functional listening skills. A short review of the hierarchy of auditory skills will be helpful in thinking of ways to use the Ling Six Sound Test.
Erber (1982) described a four level hierarchy of auditory skills with respect to sounds: detection, discrimination, identification and comprehension. Additionally, some of these same topics have been addressed in the psychoacoustics literature (Small, 1973).
Detection is the most basic auditory skill (Tye-Murray, 1998). Detection is the awareness of the presence or absence of sound. It is the most basic level of sound perception. Detection is probably best illustrated by a comprehensive audiologic evaluation. Pure tone testing is accomplished by asking a person to respond to sound when they hear it. Their response can take many different forms. Infants and young children may respond by turning their head towards the sound. A pre-schooler may respond by using a play task (i.e. dropping a block in a bucket when they hear a sound). Raising your hand or saying “yes” when you hear a sound such as an adult would do, is also a form of sound detection.
Discrimination is the ability to tell if two sounds are the same or different. In many discrimination tasks, the goal is to identify the smallest difference between two sounds, which the listener can perceive. To discriminate between two sounds, the listener must first be able to detect the two sounds. Therefore, discrimination is a “higher level” task than is detection.
Identification involves being able to label or name the sound that is heard. Identification tasks require that the listener be able to detect and discriminate the stimuli and then to uniquely identify it. Identification is a “higher level” task than is detection and/or discrimination.
Comprehension is the most complicated auditory skill, as it requires the listener to detect, discriminate, identify and understand the meaning of the sound or the message. Comprehension is the highest of the four levels as it bridges the auditory perception with cognitive and/or language abilities.
The Ling Six Sound Test is useful for addressing the skills of detection, discrimination and identification, but it is not a test of comprehension.
Applications:
When using the Ling Six Sound Test, the clinician starts at the level at which the client is functioning and works toward a higher level. For example, if a child with hearing impairment can repeat the sounds (identification level) in the Ling Six Sound Test, the clinician might address identification and comprehension issues. Using a lower level skill such as detection or discrimination would be inappropriate as the child has already obtained and demonstrated those prerequisite skills, prior to achieving identification.
The Ling Six Sound Test can be used in the same way as pure tone stimuli for the person whose auditory skills are at the detection level (Yoshinaga-Itano, 2000). The Ling Six Sound Test can be presented and the person can respond to the presence of the sounds. The responses could be as varied as those discussed earlier regarding the audiologic evaluation.
For example, if you are working with a 3 year old boy who is at the detection stage of auditory development, you might use the Ling Six Sound Test to quickly obtain information relative to what he is hearing with respect to aided versus unaided perception. A play task, such as throwing toy blocks into a bucket when he hears the sound, could be used as the response mode. Again, for the purpose of detection, the child does not need to know the difference in the sounds, nor does it require him to repeat the sound. However, if he can respond via detection, to the six sounds in the test, then the clinician knows he is grossly hearing the sounds across the speech spectrum range. If he does not respond to one or more of the sounds in the test, then you have potentially acquired information about frequency regions that need to be targeted for auditory training. Additionally, if the responses obtained represent different hearing acuity than that which was previously obtained, an audiologic evaluation may be in order. Therefore, although the Ling Six Sound Test is not a diagnostic audiometric evaluation, it is a tool which can help provide information analogous or similar to threshold testing, in the appropriate circumstance.
Discrimination, the second level skill in the hierarchy, can also be addressed with the Ling Six Sound Test. The clinician can present two sounds from the test and ask the person with hearing impairment to indicate whether the sounds are the same or different. If an individual is in the early phase of development of this skill, sounds that are very different could be used, for example [ah] and [s]. However, as the person progresses in the development of this skill, sounds that are similar could be used for discrimination skill building, for example [sh] and [s].
The skill of identification would require that the individual with hearing impairment say, or otherwise indicate, the sound they hear. If the clinician says [s], then it would be expected that the person with hearing impairment would repeat that sound. However, errors in repeating the sounds can provide useful information to the clinician. If a person cannot repeat the sound with auditory input only, then the clinician could add visual input. Once the person was able to repeat the sound with visual and auditory input, the visual cue could be eliminated.
Another application of the identification task using the Ling Six Sound Test is related to duration. The goal of this task is for the person with hearing impairment to be able to repeat a sound with progressively shorter presentation times by the clinician (Leach, 2003). This most closely approximates how the person will hear the sound in connected speech. However, if the hearing impaired individual needs a longer presentation to hear and repeat the target sound, the clinician knows that the sound needs to be targeted for work. Of course, it is also possible that the amplification system (hearing aids, FM, sound field etc.) needs to be adjusted.
Another application of the Ling Six Sound Test has to do with signal-to-noise and figure-ground relationships. This can be accomplished by presenting the Ling Six Sound Test at a normal conversational loudness, and at a comfortable listening distance, perhaps 3 or 4 feet. Then, while maintaining the same vocal effort, systematically increase the distance between the speaker and the listener. This will help to increase “distance listening skills” as the primary signal becomes less dominant and gradually approaches the lesser loudness levels of the background noise.
The Ling Six Sound Test has previously been useful in the early detection of middle ear pathology (Laughton & Hasenstab, 2000). For example, Tyler was a 4 year old child with a moderate to moderately severe sensorineural hearing loss. He had been wearing hearing aids for approximately 2 years. At the beginning of Tyler’s speech language therapy sessions, his speech language pathologist listened to his hearing aids with a hearing aid stethoscope. In addition, she used the Ling Six Sound Test as a quick check of functional listening skills. Tyler had previously been able to repeat all six sounds, as a first level task, identification (see above). One day he had trouble repeating some of the sounds. Immediately, his clinician was alerted to the fact that something was different for Tyler. She knew his hearing aids were working because she listened to them herself. The speech language pathologist spoke with Tyler’s mother, noted the inconsistency, and recommended further evaluation. Tyler’s physician confirmed an ear infection.
Similar observations could apply to new ear molds, new hearing aids, recently reprogrammed hearing aids, dead batteries, cochlear implant troubleshooting and malfunction identification etc.
Conclusion:
Many clinicians are familiar with the Ling Six Sound Test. The Ling Six Sound Test is very low tech, very easy to learn, and has a variety of pragmatic applications. Unfortunately, the test is often restricted to detection tasks. The Ling Six Sound Test can provide quick and easy verification of auditory abilities, can establish continuity and preparedness for training and development of additional listening skills, can serve as a guide for setting auditory training goals, and can serve as a “red flag” for problems related to hearing, hearing loss and hearing amplification systems.
References:
Erber, N. (1982). Auditory training. Washington, DC: Alexander Graham Bell Association for the Deaf.
Laughton, J., & Hasenstab, S.M. (2000). Auditory learning assessment, and intervention with school-age students who are deaf or hard-of-hearing. In Alpiner, J.G., & McCarthy, P.A. (Eds.), Rehabilitative audiology: Children and adults (pp. 178-225). Philadelphia, PA: Lippincott Williams & Wilkins.
Leach, M. (2003, October). Tips from the toy box. Paper presented the annual meeting of the Arkansas Speech-Language-Hearing Association, Hot Springs, Arkansas.
Ling, D. (1976). Speech and the hearing-impaired child: Theory and practice. Washington, DC: Alexander Graham Bell Association for the Deaf.
Ling, D. (1989). Foundations of spoken language for the hearing-impaired child. Washington, DC: Alexander Graham Bell Association for the Deaf.
Small, A. M. (1973). Psychoacoustics. in Minifie, F.D., Hixon, T.J. and Williams, F. (Eds.), Normal Aspects of Speech, Hearing, and Language (pp. 347). Englewood Cliffs, NJ: Prentice-Hall, Inc.
Tye-Murray, N. (1998). Foundations of aural rehabilitation. San Diego, CA: Singular Publishing Group.
Yoshinaga-Itano, C. (2000). Assessment and intervention with preschool children who are deaf and hard-of-hearing. In Alpiner, J.G., & McCarthy, P.A. (Eds.), Rehabilitative audiology: Children and adults (pp. 140-177). Philadelphia, PA: Lippincott Williams & Wilkins.
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