Communication Screening Instrument (IRC-36) for auditory-linguistic monitoring of babies with risk indicators for hearing impairment

ABSTRACT

Purpose:  to describe the results of objective and behavioral auditory tests and the Communication Screening Instrument from zero to 36 months of age in children with risk indicators for hearing loss in an auditory-linguistic monitoring program.

Methods:  a quantitative, cross-sectional, observational study, surveying the medical records of 34 children aged zero to 21 months, both sexes, with risk indicators for hearing loss.

Results:  all children had "pass" results on bilateral Transient Otoacoustic Emissions and Brainstem Auditory Evoked Potentials, consistent with auditory pathway maturation. In the behavioral auditory assessment, results incompatible with age were observed in 5.9% of the medical records, while the Communication Screening Instrument showed scores corresponding to possible communication disorders in 50%. Fisher's exact test did not show a significant association (p>0.05) between the behavioral auditory assessment and the Screening Instrument.

Conclusion:  the data analyzed indicated that the presence of normal results in objective auditory monitoring tests may not be sufficient to exclude atypicality in the communication development process, revealing the need for studies applying the Communication Screening Instrument as a clinical marker in auditory-linguistic monitoring of children presenting risk factors.

Keywords:
Speech-Therapy; Child Health; Communication; Public Policy; Hearing

RESUMO

Objetivo:  descrever os resultados dos exames auditivos objetivos e comportamentais e do Instrumento de Rastreio da Comunicação de zero a 36 meses em crianças com indicadores de risco para deficiência auditiva de um programa de monitoramento auditivo-linguístico.

Métodos:  trata-se de um estudo quantitativo, transversal e observacional. Foram observados 34 prontuários de crianças entre zero e 21 meses, de ambos os sexos, com indicador de risco para deficiência auditiva.

Resultados:  todas as crianças tiveram resultados “passa” nas Emissões Otoacústicas Transientes bilateralmente e Potenciais Evocados Auditivos de Tronco encefálico compatíveis com a maturação da via auditiva. Na avaliação auditiva comportamental, foram observados resultados incompatíveis com a idade em 5,9% dos prontuários, enquanto o Instrumento de Rastreio da Comunicação apresentou 50% dos resultados com pontuação correspondente a possíveis alterações na comunicação. O Teste Exato de Fisher não registrou associação significativa (p>0,05) entre a avaliação auditiva comportamental e Instrumento de Rastreio.

Conclusão:  os dados observados apontam que a presença de resultados considerados normais nos exames auditivos objetivos do monitoramento pode não ser suficiente para excluir atipicidades no processo de desenvolvimento de comunicação, revelando a necessidade de estudos que apliquem o Instrumento de rastreio da comunicação como marcador clínico no monitoramento auditivo-linguístico em crianças com indicadores de risco.

Descritores:
Fonoaudiologia; Saúde da Criança; Comunicação; Política Pública; Audição

INTRODUCTION

The universal newborn hearing screening (UNHS) aims at health promotion. All newborns with or without risk indicators for hearing loss (RIHL) should undergo the examinations recommended by the Comitê Multiprofissional da Saúde Auditiva (COMUSA) [Multiprofessional Committee on Hearing Health (COMUSA)] within the first 24 to 48 hours of life¹. An infant’s hearing system can be evaluated using electroacoustic measurements such as the Otoacoustic Emissions (OAE) test and through electrophysiological tests such as the Auditory Brainstem Response (ABR) test².

Through the performance of OAE, cochlear function is evaluated, while ABR assesses the electrophysiological activity of the auditory system, from the vestibulocochlear nerve (VIII cranial nerve pair) to the brainstem. The ABR can identify retrocochlear lesions and study the maturation of the auditory pathway when applied to the newborn population. This population presents a higher occurrence of this type of hearing loss, which cannot be identified when only OAE results are considered^1,3,4.

Hearing plays a fundamental role in the development of oral language and is considered a relevant factor in communication, neuropsychological maturation and cognitive development since these factors interfere in the development process of speech and hearing skills^5-7. When hearing is altered, it might affect oral language acquisition and result in the child’s social and emotional harm^8,9.

For children presenting RIHL the Joint Committee on Infant Hearing (JCIH) recommends conducting acoustic and electrophysiological measurements. Furthermore, the Speech-Language Pathology Council recommends combining objective procedures with behavioral assessments, such as auditory behavior tests for calibrated sounds^3,10.

The behavioral auditory test does not substitute electrophysiological and objective measurements. However, it might provide complementary information contributing to the diagnostic conclusions. Aiming to investigate how peripheral hearing works, it verifies the detection and discrimination of sounds at different intensities and frequencies¹¹. It must be planned according to the chronological age, level of development and the child’s expected responses, also considering the hearing system maturation and the behavioral profile since the response is not purely reflexive but involves attention and auditory-behavioral integration^11,12.

The JCIH¹³ emphasizes the importance of both hearing monitoring and communication development monitoring of children presenting risk indicators for hearing loss. In 2012, the Health Ministry¹⁴ recommended monthly monitoring of hearing and speech of children up to one year old without RIHL, suggesting the use of hearing and language development milestones as reference¹⁴. The American Pediatric Association¹⁵ proposes the use of questionnaires applied to the parents during the screening to identify development alterations combined with the pediatrician’s clinical observation, for later referral to specialist evaluations¹⁵.

The Communication Screening Instrument from 0 to 36 months of age (IRC-36) is a validated and user-friendly protocol divided into nine age groups, each one containing ten questions which include aspects of social development, cognition, hearing, receptive and expressive language⁵. The IRC-36 is a questionnaire that identifies, based on family report, the everyday development of skills such as hearing, receptive and expressive language, as well as cognitive and social aspects within the family environment^5,16.

Within this perspective, this study aimed to use the IRC-36 as a protocol for monitoring the communication of children up to 36 months of age⁵.

The hypothesis of this study is that the IRC-36 can be considered an ancillary marker in the hearing health program since its objective is to identify possible delays and/or alterations in hearing and communication development milestones.

This study aimed at describing the results of objective and behavioral hearing tests and the Communication Screening Instrument from zero to 36 months of age in children with risk indicators for hearing loss in an auditory-linguistic monitoring program.

METHODS

This is a quantitative, cross-sectional and observational study submitted to and approved by the Research Ethics Committee (CEP) of the Federal University of Pernambuco - UFPE, PE, Brazil, with opinion number 6.071.305 and CAAE 67740223.2.0000.5208, for being in compliance with the standards recognized by Resolution 466/2012 by the National Health Council, Health Ministry, Brazil. All participants’ parents/guardians were informed about the objectives and collection procedures. After having agreed with the children’s participation in the research, they signed the Free and Informed Consent form- FICF.

The data were collected at the Serviço de Monitoramento Auditivo e de Linguagem (SeMAL) [Hearing and Speech Monitoring Service] at the Speech-Language Pathology Clinic of a Public University. The service aims at diagnosing and monitoring the development of children referred by partner public maternity hospitals who presented absent and/or present responses in the OAE test and who presented some type of RIHL in the auditory screening protocol. That service is linked to a scientific research project that manages the database for this extension. For evaluation and monitoring, data from Transient Otoacoustic Emissions (TOAE) tests, ABR, auditory behavior assessment, and the application of the IRC-36 were used^5,16.

The initial database contained 50 medical records. However, 16 were excluded for not presenting all the information needed. Therefore, 34 babies were included in the study. The participants’ age ranged between one and 21 months, there were boys and girls, born at term or preterm, all presented bilateral transient otoacoustic emissions and one or more RIHL. Only those cases where it was not possible to carry out the aforementioned procedures for any reason were excluded.

The IRC-36 application consisted of carrying out an interview with one of the child’s parents/guardians, preferably the one who spent more time with the child, with questions about the child’s hearing, expressive and receptive language, cognitive and social skills. As responses, the interviewees could use the following options: “yes”, “no” or “sometimes”. The analysis of results was carried out using a quantitative approach, considering zero (0) for “no”, one (01) for “sometimes” and two (02) for “yes” answers. The minimum score expected for each age group was from zero (00) to twenty (20) points^5,16.

A score below 10 points indicated that the baby might be “at risk” for alterations in language development. If the score obtained was between 11 and 14 points, the baby would require “attention”, that is, close monitoring. If the score was over 15 points, it indicates that the baby had no alterations or delays, and its performance was considered out of risk^5,13.

In the ABR, neurodiagnosis was performed using the Contronic Evokadus equipment, adopting the execution parameters based on the description by Griz et al.¹⁷, namely, stimulus: click, intensity: 80 dB NAn, presentation rate: 21.1 estimuli/s, polarity: rarefied, transducer: insert earphone, pass filters in 150-3.000Hz frequencies, 2000 averages, 20ms window, and four electrodes: Ground at Fpz, non-inverted electrode (+) on the upper midline of the forehead (Fz) and inverted electrodes (-) on the right and left mastoid processes (M1 and M2).

Also regarding ABR, different absolute latency analysis parameters were employed. The first parameter used was for infants aged 0 to 18 months, due to the maturation process of the auditory pathway, according to the reference value for normality described in Rosa et al.¹⁸ (i) Absolute latency of the V wave = around up to 7.0ms.

As a parameter of analysis of absolute latency and interpeak intervals for babies from 19 to 36 months, the following reference values were considered for normality as described by Soares et al.¹⁹: (ii) Absolute latency: wave I = around 1.38 ms; wave III = around 3.5ms; wave V = close to 5.4 ms; (iii) Interpeak intervals: waves I-III = around 2.08ms; and III-V = around 1.86 ms; waves I-V = around 3.92 ms.

The OAE was carried out with the TITAN equipment by Interacustic - ABRIS440. To perform the test, an ear tip connected to a probe was inserted into the external auditory canal, through which the stability of the stimulus was verified, which had to be equal to or greater than 70%. The emissions were tested in the frequency bands of 1,000Hz, 1,410Hz, 2,000Hz, 2,830Hz, and 4,000Hz. Infants and/or neonates would have a "pass" result in the test when the signal-to-noise ratio was greater than 6 dB in at least three frequency bands and the reproducibility equal to or greater than 70%.

For behavioral evaluation of auditory skills, non-verbal stimulus sound instruments (rattle, bell, drum, shaker, and agogô), whose frequencies are between 500 and 8000 Hz, were used following the protocol introduced by Azevedo²⁰, analyzing the maturation of the peripheral auditory system across different frequency bands. Responses were classified considering the compatibility of skills with chronological age. Instruments were tested according to the following criteria: 0 to 3 months, attention or orientation to the sound, 03 to 06 months, lateral localization and search for the sound source, 06 to 09 months, indirect localization upwards and downwards, 09 to 12 months, direct localization downwards and indirect upwards, and 12 to 15 months, direct localization downwards and upwards²¹.

The data collected were entered into an Excel spreadsheet for descriptive and inferential statistical analysis. The data analyzed were: (i) results of the OAE, behavioral auditory assessment, ABR, and IRC-36 of the infants; (ii) mean, median, and standard deviation values ​​of the absolute latencies and interpeak intervals of the ABR tests performed on the infants; (iii) cross-referencing of the IRC-36 results with those of the behavioral auditory assessment.

For the statistical analysis, mean, median, standard deviation and Fisher’s Exact test were employed and considered significant when p ≤ 0.05.

RESULTS

Table 1 shows that 100% of the OAE results presented bilateral pass. The behavioral auditory evaluation showed only two (5.9%) babies with inadequate results, 100% of absolute latencies and interpeak intervals were within normality for the auditory pathway maturation, according to age group, and IRC-36 showed 17 (50%) babies with normal results and 17 (50%) with altered results (attention or risk) for communication development.

Table 1
Distribution of Transient Otoacoustic Emissions, Behavioral Auditory Evaluation, Brainstem Auditory Evoked Potentials and Communication Screening Instrument in babies from zero to 36 months. Recife, PE, Brazil, 2024

EOAT
Ears	PASS N (%)	FAIL N (%)
Right	34 (100%)	00 (0.0%)
Left	34 (100%)	00 (0.0%)
Behavioral Auditory Evaluation
Classification	N (%)
Adequate	32 (94.1%)
Inadequate	02 (5.9%)
NEURODIAGNOSTIC - ABR
Classification	N (%)
Normal	34 (100.0%)
Altered	00 (0.0%)
IRC-36
Classification	N (%)
Risk	05 (14.7%)
Attention	12 (35.3%)
Normal	17 (50.0%)

• Source: elaborated by the authors 2024
• Captions: EOAT - Transient Otoacoustic Emissions; PEATE - Brainstem Auditory Evoked Potential; IRC-36 - Communication Screening Instrument from zero to 36 months.

Table 2 presents results of absolute latencies of waves I, III and V and interpeak intervals within expected standards. Regarding neurodiagnostic ABR, all exams presented result of absolute latencies of waves I, III and V and interpeak intervals I-III, III-V and I-V within expected values for the age group and auditory pathway maturation process.

Table 2
Distribution of the mean, median and standard deviation values of absolute latencies and interpeak intervals of the Brainstem Auditory Evoked Potential exams in babies. Recife, PE, Brazil, 2024

Latencies and interpeaks		Normal (n = 34) Mean ± SD (Median)
Right ear	Wave I	1.54 ± 0.15 (1.52)
	Wave III	4.10 ± 0.39 (4.00)
	Wave V	6.30 ± 0.55 (6.25)
	Interpeaks I-III	2.56 ± 0.36 (2.49)
	Interpeaks III-V	3.42 ± 1.18 (3.18)
	Interpeaks I-V	3.55 ± 1.52 (3.20)
Left ear	Wave I	1.60 ± 0.18 (1.55)
	Wave III	4.29 ± 0.61 (4.11)
	Wave V	6.38 ± 0.57 (6.29)
	Interpeaks I-III	2.64 ± 0.44 (2.60)
	Interpeaks III-V	2.16 ± 0.41 (2.45)
	Interpeaks I-V	4.71 ± 0.63 (4.18)

• Source: elaborated by the authors 2024
• Caption: SD - Standard deviation.

Finally, Table 3 shows the distribution of results of the behavioral auditory evaluation according to IRC-36. Fisher’s Exact Test was carried out, and no significant (p > 0.05) association was observed between the behavioral auditory evaluation and the IRC-36 results.

Table 3
Description of behavioral auditory evaluation results, according to the Communication Screening Instrument in babies from zero to 36 months old. Recife, PE, Brazil, 2024

Behavioral Auditory Evaluation
Variable	Compatible	Incompatible	p-value
	n (%)	N (%)
Total group	32 (94.1%)	02 (5.9%)
IRC-36			p(1) = 0.279
Risk	05 (14.7%)	01 (50.0%)
Attention	12 (35.3%)	00 (0.0%)
Normal	17 (50.0%)	01 (50.0%)

• (1) Fisher’s Exact Test.

DISCUSSION

The presence of risk indicators, mainly permanence in ICU for over five days might increase the likelihood of auditory alterations since babies who underwent such treatment show a health history with prevalence of hearing impairment which ranges between 0.3% and 20.6%. Therefore, hearing monitoring in the first years of life of those babies is essential. These data justify the need for monitoring in the population investigated since 62.2% of the participant babies showed this risk indicator for hearing loss (IRDA). Although the presence of hearing loss was not identified in this study, 50% of the babies obtained results indicating need for attention and risk in IRC-36, which justifies auditory monitoring up to three years old, considering the possibility of progressive alterations in communication, including progressive hearing loss²².

Among risk indicators for hearing loss, permanence in ICU for over five days stands out and requires auditory monitoring since procedures performed at the ICU involve invasive mechanisms that might lead to the appearance of alterations, factors that might provoke alterations in the cochlea and vestibule²².

According to the research inclusion criteria, 100% of OAE exams present bilateral responses. In addition, their results reveal that 100% of those children present absolute latencies and interpeak intervals in neurodiagnostic ABR compatible with the maturational development of their age group bilaterally. These data show that the diagnostic methods chosen for this research did not show alterations related to the hearing development of this population, even though the babies present risk indicators for hearing impairment.

It seems relevant to emphasize the importance of carrying out behavioral auditory evaluation in the hearing and speech monitoring process. The behavioral auditory evaluation carried out in the first years of life, enables the verification of the child’s auditory development and the identification of delay in the acquisition of hearing skills since the communication acquisition and/or development process might be hampered if the hearing skills are altered²³. Auditory monitoring is fundamental for hearing and linguistic development since it aims to evaluate and monitor de hearing maturation and speech acquisition processes^24-26. In this study, even if 100% of the babies presented the expected objective evaluation results, 5.9% presented inadequate subjective responses in the behavioral auditory evaluation, thus requiring greater attention in their auditory monitoring.

This study offers a new complementary tool for the investigation of children’s communication development since only isolated exams might result in a gap in the efficacy of auditory health programs^27-29.

It was also observed that the IRC-36 application in auditory monitoring was a sensitive instrument regarding aspects of children’s development in babies with RIHL and that its application might be considered a strategy in the early identification of risks of development delay in that population.

Araújo et al.²⁹ demonstrated that babies with RIHL showed development of speech, motor and cognitive skills below the expected average for that age group. The age group investigated in this study showed relevant data regarding speech development after the IRC-36 application.

The first years of life are highly relevant for the development of hearing and speech skills, since it is in this period that most of the maturation process of the central auditory system and the neuronal plasticity of the auditory pathway occurs alongside the development of brain structures and connections^30-33. For this reason, the application of the IRC-36 as a complementary screening tool to the electrophysiological and behavioral auditory assessment is fundamental for monitoring infants with hearing loss, since it is a sensitive instrument for detecting possible alterations and/or delays in auditory skills and language development.

As regards the behavioral auditory evaluation, of the 32 (94.1%) babies presenting compatible results for their age group, 17 (50%) obtained a score that indicated risk and the need for attention in the IRC-36. Therefore, those children required monitoring even having obtained the expected result for their age group in the behavioral auditory evaluation.

It is believed that those babies completed the auditory skills maturation process²⁵ but still need to be stimulated regarding language. The IRC-36 application might contribute to the parents’ increased knowledge about hearing and language development and guide them on how to provide their child with stimuli on an everyday basis.

The same was inferred about the ABR. In this study, 100% presented responses compatible with the auditory pathway maturation according to their age group. However, the number of babies at risk or in need of attention according to the IRC-36 raised greater concern about the monitoring required. Therefore, further studies correlating ABR development and responses from the IRC-36 different categories must be carried out.

Although the statistical analysis did not present significance between the IRC-36 and the behavioral auditory evaluation, it seems important to emphasize the need to carry them out together, since they can provide important information about the development of such skills^20,34 since the evaluation of auditory skills is essential to monitor children at risk. In addition, behavioral auditory evaluation allied to electrophysiological assessment provides data on the maturation of the peripheral and central auditory systems³⁵.

This study observed that the IRC-36 application as a complementary tool in the analysis of the tests carried out in auditory monitoring of babies with RIHL enabled the early identification of possible delays and/or alterations in communicative skills⁵. Thus, it can be considered a clinical marker in the monitoring of children’s hearing and speech development^2,5.

Monitoring babies with RIHL is fundamental since it seeks to monitor main development markers, enabling their early detection, if necessary, for referral to specialist care³⁶.

One of the limitations of this study was the reduced sample size due to the fact that 16 medical records did not contain all the information. Furthermore, further investigations should explore the distinct evaluation dimensions of the IRC-36 in isolation, since this research did not establish which of the skills analyzed - hearing, cognition, socialization, expressive and comprehensive language - were affected according to the RIHL results.

Finally, to evaluate IRC-36 when compared to other standard auditory tests in auditory health programs, other studies are needed with greater sample control and evaluation of intra-subject outcomes over their maturation process.

CONCLUSION

The data observed in this investigation pointed out that the presence of results considered normal in objective auditory exams, such as OAE and ABR in the context of auditory monitoring might not be enough to rule out atypicality in the communication development process. This reveals the need to develop studies that use the IRC-36 as a clinical marker in auditory-linguistic monitoring.

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• A study developed at the Federal University of Pernambuco, Recife, PE, Brazil.
• Financial support
  Nothing to declare
• Data sharing statement
  The data collected in this study were secondary data from a data base of babies who took part in an extension project “Implementation of a referral service for the diagnosis and auditory monitoring of children with results “FAILED” in the newborn auditory screening with or without risk indicators for hearing loss developed at a Speech-Language Pathology Clinic of a public university. Therefore, the research data that can be shared are protocols of collection to researchers who provide a methodologically solid proposal, immediately after publication and ending three months after this article’s publication. To gain access to the collection protocols, send proposals to [e-mail]
• Artificial Intelligence tool use statement
  No Artificial Intelligence tool was used to elaborate the article.

Edited by

• Chief Editor
  Erissandra Gomes

• Associate Editor
  Adriane Teixeira

Data availability

The data collected in this study were secondary data from a data base of babies who took part in an extension project “Implementation of a referral service for the diagnosis and auditory monitoring of children with results “FAILED” in the newborn auditory screening with or without risk indicators for hearing loss developed at a Speech-Language Pathology Clinic of a public university. Therefore, the research data that can be shared are protocols of collection to researchers who provide a methodologically solid proposal, immediately after publication and ending three months after this article’s publication. To gain access to the collection protocols, send proposals to [e-mail]

Publication Dates

• Publication in this collection
  20 July 2026
• Date of issue
  2026

History

• Received
  06 May 2025
• Reviewed
  17 Sept 2025
• Accepted
  11 Mar 2026