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Chapter

The Frequency Following

Response: Evaluations in Different
Age Groups
Milaine Dominici Sanfins, Michele Vargas Garcia,
Eliara Pinto Vieira Biaggio and Piotr Henryk Skarzynski

Abstract

In this chapter, recent data on the clinical application of the frequency follow-
ing response (FFR) in different age groups will be presented. The chapter begins
with the importance of using speech sounds in electrophysiological assessments.
Then the FFR methodology is presented, giving normative data and the expected
responses in different age groups: infants and young children, children and adoles-
cents, and adults and the elderly. Finally, the unique responses of each age group are
presented in order to show how this new technology can be an extremely useful tool
for diagnosing hearing dysfunction.

Keywords: electrophysiology, frequency following response, speech perception,

hearing, auditory evoked potential

1. Introduction

Until recently, electrophysiological evaluations were performed exclusively with

nonverbal stimuli such as clicks and tone bursts which allow rapid and synchronous
stimulation of neurons. However, the use of verbal stimuli, such as speech sounds,
allows a more accurate analysis of the auditory system, especially if the aim is to
investigate how the system decodes speech sounds involved in daily communica-
tion. Verbal and nonverbal stimuli are decoded in different ways and follow differ-
ent trajectories through the central auditory nervous system.
Human communication consists predominantly of verbal stimuli, and it is
important to understand how verbal sounds are coded at various levels of the audi-
tory system. The need to develop research methods that are objective and accurately
represent daily listening led to the development early this century of electrophysi-
ological tests for measuring how speech sounds are perceived [1, 2]. Subsequently, a
number of research groups have focused their efforts on using complex stimuli such
as speech for diagnostic purposes [3–10].
The initial studies were performed in animal models [11] aiming to evaluate how
the temporal and spectral properties of verbal stimuli were coded, and later human
responses were also analyzed [12]. Among the electrophysiological procedures for
investigating the processing and coding of verbal sounds, we highlight the fre-
quency following response (FFR).

1
The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy

2. Frequency following response

Acquisition of an FFR is very similar to collecting an ABR with a click stimu-

lus. However, interpretation of an FFR requires that the audiologist has a more
sophisticated knowledge base. Speech stimuli allow a more complex analysis of the
responses, such as their:

• timing;

• magnitude;

• frequency content and magnitude;

• frequency tracking;

• phase consistency;

• intrinsic factors; and

• difference between individual responses.

An FFR evaluation can be performed on different clinical populations and age

groups, and below we give details of how the procedure varies depending on the
patient’s age. Because FFR is a relatively new procedure, initial work was done on
adult subjects. Afterward, researchers turned their interest to the study of responses
in infants and young children, children and adolescents, and the elderly.
In order for an FFR assessment to be useful in identifying auditory disorders at
an early stage, normative values using different equipment and recording param-
eters need to be established and compared with language acquisition markers.
The distinctive features of FFRs in different age groups will be presented in
three parts:

• evaluation in infants;

• evaluation in children and adolescents;

• evaluation in adults and the elderly.

3. Frequency following response: evaluation in infants

In clinical practice, a comprehensive hearing evaluation for infants and young

children is essential, since the integrity of their auditory system is the basis for
acquiring oral language. In this context, if one measures only the functioning of
the peripheral auditory pathway, perhaps by recording and analyzing otoacoustic
emissions and/or auditory brainstem evoked potentials, it significantly constrains
one’s knowledge of the patient’s hearing status. Moreover, behavioral assessments of
hearing in very young children are often inconclusive, considering the diversity of
neuropsychomotor development in this age group.
The perception of speech is important for the development of receptive and
expressive language [13]. Through auditory experiences, infants and toddlers acquire
and master the linguistic elements necessary for effective communication. The
experiences are associated with information from the other senses, and together

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The Frequency Following Response: Evaluations in Different Age Groups
DOI: http://dx.doi.org/10.5772/intechopen.85076

they allow the acquisition and development of oral language. Through listening,
the subject understands oral language and creates concepts, finally inter-relating them
and expressing them through speech [14]. Thus, the importance of hearing for the
acquisition and development of language is vital, and any disturbance to the auditory
pathway has implications for oral communication as a whole [14].
FFR testing can be used with infants and young children as a predictor of the
extent of future language appropriation—in other words as a way of identifying
children who are at risk of deficits in oral language acquisition [2, 15]. Assessment
by FFR of infants and young children is relatively recent, and published studies
of its potential have only been done over the last decade. Before discussing what
is known about FFR in this population, it is first necessary to clarify an important
factor: maturation of the auditory pathway.
It is known that peripheral hearing is functional even before birth, whereas
myelination and the organization of neural connections keep developing after
birth [16, 17]. Indeed, the central structures, such as the subcortex and cortex,
develop throughout the early years of human life. There is an ascending myelina-
tion of the auditory pathway, evidenced by magnetic resonance imaging. Up to
the 13th week of life, there is an increase in myelination density of the cochlear
nucleus, the superior olivary complex, and the lateral lemniscus, with the inferior
colliculus demonstrating an increase in density around the 39th week of life [18].
This continuous process of myelination of the higher structures of the auditory
pathway during the first year of life must be considered when evaluating the FFR,
for it means that the lower the age of the evaluated subject, the greater the latency
of the FFR waves [19, 20]. This increase in latency can also be seen in other auditory
evoked potentials [21]. An FFR can be recorded from a neonate, but the responses
only become readily apparent from the third month of age [15]. The existence of a
series of FFR waves—V, A, C, D, E, F, and O—in neonates has been pointed out by
several researchers [15, 19, 22–26]. FFR evaluations have been performed with the
vowel /i/ [15, 24], the syllables /ba/ and /ga/ [26], and the syllable /da/ [23].
The FFR has been studied in neonates of different nationalities (Chinese,
American) during the first days after birth, and the FFRs were nearly the same. This
finding makes it possible to infer that, independent of the mother tongue, there is
an innate capacity for speech coding in neonates at the subcortical level [22].
The evaluation of subcortical representation of speech coding was studied by
evaluating FFRs in 28 healthy North American infants, 3–10 months of age. The
study focused on the fundamental frequency (F0), the response time of the FFR,
and the representation of harmonics. To analyze the data in the frequency domain,
spectral amplitudes were calculated by fast Fourier transform (FFT) and divided
into three frequency ranges: F0, 103–125 Hz; first formant (F1), 220–720 Hz; and
high harmonics (HH), 720–1120 Hz. The F0 responses were more robust in infants
3 months of age and the amplitude of F0 did not show significant changes over the
entire 6 months. For the F1 and HH frequencies, there was a rapid and systematic
increase of amplitude from 3 to 6 months of age.
To analyze the data in the time domain, the peaks were identified manually and
confirmed by a second observer. Waves I, III, and V were first identified in response to
a click, and then, in the FFR, the same peak and following valley (V and A), the peaks
(D, E, and F), and the displacement peak (O). Non-detectable peaks were marked
as missing data points and were excluded from analysis. The latencies and ampli-
tudes (baseline to peak) were extracted from the identified waves. The time domain
analysis demonstrated a decrease in neural conduction time and an improvement in
amplitude with increasing age. The latencies of A and O, the time interval between
A and O, and the slope between V and A were shown to have a negative correlation
between latency and age. In addition, there was an improvement in the morphology

3
The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy

of all waves as age increased. It was also observed that infants 3–5 months of age had
longer latencies, smaller intervals between A and O, and a lower V/A slope compared
to those 6–10 months of age. This negative correlation between the latencies and the
age of the infants, as well as the decrease of slope in the smaller children, is due to a
maturational process occurring in the subcortical auditory system and shows that
there is less neural synchrony in younger infants [23]. The authors also note that
these findings indicate that at approximately 6 months of age, the coding of speech
characteristics, both spectrally and temporally, becomes more like those of an adult,
although the changes continue through to school age. These findings indicate that
FFR evaluation can detect early disorders in the perception of speech sounds.
The researchers also investigated the development of subcortical speech pro-
cessing in Chinese infants born in households in which the mother tongue was
Mandarin. They recorded FFRs at two ages: 1–3 days of life and at 3 months. This
prospective-longitudinal design study included only infants who had undergone
auditory screening at birth, who had no obvious neurological disorders, and did
not have any risk indicator for hearing loss. Initially, 44 newborns were tested by
FFR during natural sleep. After that, the sample was divided into groups. For each
group, the researchers selected different speech stimuli for the evaluation of FFR
(monosyllables contrasting with Mandarin). Only 13 infants completed the follow-
up protocol at the third month. The processing and tracking of the fundamental
frequencies of human speech at the subcortical level, evidenced by the FFR, showed
more robust responses when the babies were 3 months old. Researchers acknowl-
edged the limitations of the study, including statistical analysis and data interpreta-
tion. A research weakness was the relatively low completion rate (i.e., 17/44 infants
or 38.64%). This factor undermined the power of the conclusions and prevented the
possibility of performing statistical analyses for each Mandarin tone used. Despite
the limitations of the study, the findings fill a gap in understanding the develop-
mental trajectory of subcortical processing during the first 3 months of life [25].
From the theoretical assumptions highlighted in the previous reference, it
should be noted that the linguistic environment of a newborn has a substantial
effect on the development of its speech perception. Even at birth, children are able
to detect subtle differences in verbal sounds. Newborns can effectively differentiate
all the features of human speech and most infants who participated in an FFR fol-
low-up showed improvement in pitch tracking and response amplitudes at 3 months
of age [25]. Such neural refinements observed by FFR are often highlighted in the
literature for both infants [22, 24] and young infants [15, 23]. For example, in a
longitudinal case report of one infant, the researchers obtained FFR records when
the infant was 1, 3, 5, 7, and 10 months old. The results showed an evolving trajec-
tory of development with a transition point of about 3 months [15].
Using FFR evaluation in preterm infants may also be an alternative for the early
diagnosis of auditory disorders in this population related to the perception of speech
sounds. Premature babies are at high risk of developing language disorders, so using
FFR may be a way of measuring immature neural activity and predicting possible
changes in the processing of verbal sounds. In order to do so, one study evaluated 12
premature Indian infants through FFR with the aim of exploring how an immature
auditory system responds to complex acoustic stimuli such as speech [27]. Peaks V, A,
C, D, E, and F were detected in almost all babies and with latencies and amplitudes
similar to those reported in the literature. The waves could be replicated. The authors
conclude that FFR may be a way of understanding how the human brain-stem
receives speech signals and that such an assessment might be important for all high-
risk babies. Although the findings of this study cannot be generalized, mainly due to
the limited data (small sample and absence of a controls, among others), they point
out the potential of FFR in evaluating infants from neonatal intensive care units.

4
The Frequency Following Response: Evaluations in Different Age Groups
DOI: http://dx.doi.org/10.5772/intechopen.85076

More recently, studies that record FFRs in the presence of background noise
have been published. It is known that competing noise can make speech compre-
hension more difficult in people of all ages. Speech-in-noise tests are clinically
available but cannot be given to infants. Thus, the use of FFRs in noise may be an
alternative for evaluating impaired speech perception in young children who are
unable to respond to behavioral tests.
In this context, with the objective of examining the electrophysiological
responses in the presence of noise, researchers have evaluated the FFR in 30
children with typical development under conditions with and without noise (a
signal-to-noise ratio of +10 dB in the former) [28]. Babies were divided into two age
groups: 7–12 and 18–24 months. For all infants, frequency analysis of the FFR with
a Fourier transform was performed, analyzing the latency and amplitude of waves
V, A, D, E, and F, and correlation tests were carried out. In both groups, the mean
latency of all recorded waves was higher in the presence of noise. According to the
authors, this suggests that, at least for infants up to 24 months, the presence of noise
causes a delay in the appearance of FFR waves independent of age. In addition,
they observed a greater amplitude of F0 in the noise condition in the group of older
babies; this difference was not seen in the silent condition. Thus, the authors point
out that, at 2 years of age, infants are less vulnerable to the degrading effects of
noise compared to children younger than 12 months.
The development of phase lock and frequency representation has also been
evaluated in infants. This was the focus of a study that included an initial sample
of 56 typical babies, aged between 2 and 12 months, and evaluated the FFR with /
ba/ and /ga/ stimuli presented in the right ear using the SmartEP equipment from
Intelligent Hearing Systems [26]. These responses were also obtained in young
adults to provide a reference for the course of development of neural synchrony
(represented by phase lock) and response amplitude (represented by spectral
magnitude). The results obtained in this study demonstrate that the strength of
phase-lock in the fine structure at CV transition is higher in young adults com-
pared to infants. However, phase lock for F0 was equivalent between adults and
infants. The frequency of F0 was found to be higher in older infants compared to
younger infants and adults. Thus, these data demonstrate that speech coding can
be evaluated in infants from 2 months of age and that such data are of value in
a clinical setting, since it is known that performing electrophysiological evalua-
tion of hearing in young children is difficult because they are less able to remain
still during a test. The data indicate that the FFR may be a way of testing babies
who are at risk of developing a language disorder, examining the auditory coding
mainly of the midbrain, but also reflecting contributions from the auditory nerve,
brain stem, and cortex.
The most commonly used parameters in FFR evaluations are: monoaural stimu-
lus, right ear stimulation, intensity of 80 dB SPL, syllable /da/ speech stimulus,
alternating polarity, presentation rate of 10.9 stimuli per second, vertical placement
of electrodes, insert headphones, and the subject sitting distracted or awake during
recording [29].
Regarding the latency parameters, when FFR is done with the Navigator Pro
AEP System (Natus Medical, Inc.) and a syllable stimulus, one group of researchers
[19] pointed out that in 23 normal-hearing babies (0–12 months) the wave latencies
were on average: V = 7.22 ms, A = 8.22 ms, D = 23.14 ms, E = 31.5 ms, F = 39.91 ms,
and O = 49.64 ms. FFR wave latencies were also investigated in 53 children aged
3–5 years (Tables 1 and 2).
Parameters of FFR evaluation in infants and young children used in the Hearing
Electrophysiology Service of the Federal University of Santa Maria, Brazil, are
presented in Table 3.

5
The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy

Waves

V A D E F O

Lat Lat Lat Lat Lat Lat

∑ 7.22 8.22 23.14 31.51 39.91 49.64

SD 0.42 0.43 0.66 0.49 0.45 1.32

Detect (%) 86.9 86.96 91.30 91.30 82.61 65.22

∑: average (ms), SD: standard deviation, Detect: the percent detectability for each peak.
Sample: 23 babies (0–1 years old).

Table 1.
FFR latency values using syllable /da/of 40-ms duration performed on babies with normal hearing
(silent background) [19].

Waves

V A D E F O

Lat Lat Lat Lat Lat Lat

∑ 6.59 7.56 22.36 30.90 39.34 48.14
SD 0.26 0.35 0.38 0.37 0.32 0.42

Detect 100 100 88.67 98.11 100 90.57

∑: average (ms), SD: standard deviation, Detect: the percent detectability for each peak.
Sample: 53 children (3–5 years old).

Table 2.
FFR latency values using syllable /da/ of 40-ms duration performed in children with normal hearing (in silence) [19].

Presentation parameters Setting

Equipment SmartEP, Intelligent Hearing Systems (IHS)
Transducer Insert phones
Electrodes Fz; Fpz; M1; M2 or Cz, M1, M2
Stimulation Right ear
Stimulus Syllable /da/
Duration of stimulus 40 ms
Presentation rate 10.9/s
Window 80–100 ms
Filter Low pass of 100 Hz and high pass of 2000 Hz
Low pass of 100 Hz and high pass of 3000 Hz
Polarity Alternating
Intensity 80 dBnHL
Number of stimuli 6000
Reproducibility 2 × 3000 stimuli
Condition of evaluation Awake and quiet
Impedance 3k Ohms
Artifact rejection Acceptance if <10%
ms, millisecond; s, second; Hz, hertz; dB, decibel; HL, hearing level.

Table 3.
Parameters of FFR in infants and young children.

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The Frequency Following Response: Evaluations in Different Age Groups
DOI: http://dx.doi.org/10.5772/intechopen.85076

Source Latency (ms) Amplitude (μV) VA measures

∑ SD ∑ SD ∑ SD
V 6.61 0.25 0.31 0.15
A 7.51 0.34 0.65 0.19
C 17.69 0.48 0.36 0.09
F 39.73 0.61 0.43 0.19
Slope VA (μV/ms) 0.13 0.05
Area VA (μV × ms) 1.70 1.23

∑: average, SD: standard deviation.

Sample: 36 and 38 children and adolescents (8–12 years old) with normal hearing.

Table 4.
FFR latency and amplitude values using the syllable/da/of 40-ms duration, performed in children with normal
hearing on the right ear (silent conditions) [12].

Waves
V A C D E F O

Sex Lat Amp Lat Amp Lat Amp Lat Amp Lat Amp Lat Amp Lat Amp
∑ M 6.53 0.10 7.53 0.19 18.43 0.08 22.29 0.17 30.86 0.21 39.31 0.17 48.02 0.13
F 6.49 0.13 7.43 0.23 18.33 0.12 22.28 0.15 30.81 0.29 39.27 0.24 47.95 0.21
Med M 6.49 0.10 7.53 0.18 18.28 0.07 22.24 0.09 30.86 0.21 39.28 0.7 48.11 0.13
F 6.49 0.12 7.37 0.22 18.37 0.09 22.11 0.13 30.78 0.22 39.11 0.24 47.86 0.21
SD M 0.19 0.05 0.32 0.04 0.44 0.05 0.32 0.07 0.53 0.07 0.44 0.08 0.45 0.07
F 0.22 0.07 0.35 0.90 0.44 0.11 0.67 0.09 0.58 0.35 0.56 0.26 0.75 0.28

∑: average, Med: median, SD: standard deviation, M: male, F: female.

Sample: 40 children and adolescents (8–16 years old).

Table 5.
FFR latency and amplitude values for males and females using syllable /da/ of 40-ms duration performed in children
with normal hearing (silent conditions) [30].

Complex VA

Sex Slope VA (ms/μV) Area VA (ms × μV)

∑ M 0.31 0.29
F 0.39 0.34
Med M 0.29 0.31
F 0.36 0.31
SD M 0.11 0.09
F 0.14 0.14

∑: average, Med: median, SD: standard deviation, M: male, F: female.

Sample: 40 children and adolescents (8–16 years old).

Table 6.
Complex VA (slope and area) values for males and females using syllable/da/of 40-ms duration performed in
children with normal hearing (silent conditions) [30].

The early identification of hearing disorders through FFR evaluation allows a

speech-language pathologist to intervene, lessening the damage that this disorder
can have on the development of speech skills in early childhood [2, 20, 22, 31]. This

7
The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy

Waves

V A C D E F O

Ear Lat Amp Lat Amp Lat Amp Lat Amp Lat Amp Lat Amp Lat Amp
∑ R 6.50 0.12 7.46 0.22 18.33 0.10 22.21 0.14 30.89 0.30 39.37 0.24 48.00 0.21

L 6.51 0.11 7.48 0.21 18.41 0.11 22.36 0.13 30.78 0.23 39.20 0.19 47.95 0.16

Med R 6.45 0.12 7.45 0.21 18.33 0.08 22.12 0.14 30.86 0.23 39.24 0.19 47.99 0.15
L 6.53 0.11 7.41 0.21 18.33 0.09 22.28 0.11 30.78 0.21 39.07 0.18 48.03 0.15

SD R 0.21 0.06 0.33 0.09 0.42 0.08 0.66 0.09 0.50 0.39 0.55 0.29 0.75 0.30

L 0.21 0.06 0.36 0.07 0.46 0.10 0.44 0.08 0.61 0.09 0.47 0.09 0.54 0.12

∑: average, Med: median, SD: standard deviation, R: right, L: left.

Sample: 40 children and adolescents (8–16 years old).

Table 7.
FFR latency and amplitude values for right and left ears using syllable/da/of 40-ms duration performed on
children with normal hearing (silent conditions) [30].

Complex VA

Ear Slope VA (ms/μV) Area VA (ms × μV)

∑ R 0.37 0.33

L 0.34 0.31

Med R 0.32 0.31

L 0.32 0.31

SD R 0.14 0.13

L 0.13 0.13

∑: average, Med: median, SD: standard deviation, R: right, L: left.

Sample: 40 children and adolescents (8–16 years old).

Table 8.
Complex VA (slope and area) values for right and left ears using syllable/da/of 40 ms duration performed on
children with normal hearing (silent conditions) [30].

Waves
V A C D E F O

Age Lat Amp Lat Amp Lat Amp Lat Amp Lat Amp Lat Amp Lat Amp
range
∑ 8–11 6.53 0.12 7.44 0.22 18.37 0.11 22.26 0.15 30.80 0.25 39.34 0.21 47.95 0.17
12–16 6.46 0.11 7.51 0.21 18.36 0.10 22.32 0.10 30.89 0.28 39.19 0.21 48.02 0.21
Med 8–11 6.53 0.11 7.45 0.21 18.37 0.09 22.20 0.14 30.78 0.23 39.28 0.20 47.95 0.15
12–16 6.45 0.12 7.45 0.17 18.28 0.08 22.20 0.09 30.86 0.20 39.11 0.15 48.03 0.13
SD 8–11 0.23 0.06 0.32 0.10 0.46 0.09 0.53 0.08 0.62 0.19 0.56 0.11 0.75 0.14
12–16 0.17 0.06 0.37 0.07 0.41 0.08 0.63 0.45 0.43 0.22 0.42 0.32 0.46 0.33

∑: average, Med: median, SD: standard deviation, R: right, L: left.

Sample: 40 children and adolescents (8–16 years old).

Table 9.
FFR latency and amplitude values for various age ranges using syllable/da/of 40-ms duration performed on
children with normal hearing (silent conditions) [30].

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The Frequency Following Response: Evaluations in Different Age Groups
DOI: http://dx.doi.org/10.5772/intechopen.85076

assertion can be understood by appreciating the relationship between language

development and the presence of stimulating auditory experiences in the first few
months of life.
Future studies evaluating FFRs in infants will no doubt benefit from interdis-
ciplinary collaboration which seeks to deepen understanding of the underlying
mechanisms involved in the typical and atypical development of the auditory
system during early childhood.

4. Frequency following response: evaluation in children and adolescents

Auditory impairment is almost invariably associated with language and commu-

nication deficits. Learning a spoken language depends on assimilating the acoustic
and phonetic elements of a language [32]. The development of the central auditory
nervous system begins in intrauterine life and continues until adolescence, over
which time hearing abilities become more complex and elaborate.
Because of the close relationship between hearing, language, and learning, it is
extremely important to monitor hearing over the course of life. Especially in children,
be it pre-school or school age, the aim should be to monitor auditory function, either
through behavioral or electrophysiological assessments. The ideal would be a combi-
nation of both behavioral and electrophysiological methods, so that with numerous
evaluations there are crosschecks which allow a more accurate diagnosis to be made.
The electrophysiological procedure traditionally used in clinical practice is the
click ABR. However, in evaluating children with language deficits, this type of sound
stimulus is not ideal for making diagnoses. Assessments using verbal sound stimuli,
such as used in FFR, appear to be more effective and reliable in cases of learning
problems or school difficulties [6]. Evaluation via an FFR allows a detailed analysis
of how verbal stimuli are encoded in the central auditory nervous system to be done.
The FFR allows fine-grained auditory processing deficits associated with real-
world communication skills to be identified. As well as being used for the early iden-
tification of auditory processing, it can also be used to assess hearing across different
clinical populations [33, 34]. This electrophysiological procedure can provide reliable
and objective information about acoustic patterns such as timing, pitch, and timbre
[35]. These three elements can be evaluated using different parts of the FFR, as follows:

• timing—via analysis of the onset and offset portions;

• pitch—by analysis of the fundamental frequency (F0);

• timbre—from analysis of the harmonics of F0.

Simplistically, it can be said that the FFR helps in understanding which speech
sounds were spoken (their timing and harmonic cues) and who said it (pitch cues)
[36]. In addition, an FFR test can be performed under two conditions: (i) in silence
(presentation of verbal stimuli only), and (ii) in noise (presentation of verbal
stimuli plus background noise).
In children and adolescents, studies have shown that FFRs change in latency as
age increases. FFRs of children aged around 5 years appear to be very similar to the
responses of children aged 8–12. However, the FFR pattern of children under 5 years
has a somewhat different morphology and latency. According to Johnson et al. [33],
the differences in children younger than 3 years are more evident in the initial por-
tion of the responses (the onset), while in older children the change is more evident
in the final portion (the offset) [3, 37].

9
The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy

Initial studies have focused on understanding the FFRs in children and adoles-
cents under silent conditions and in subjects who have normal hearing and typical
development. For the benefit of clinical audiologists, some of these studies are
summarized below (Tables 4–9).
Table 10 shows the parameters used in children and adolescents at the
Electrophysiology Department of the State University of Campinas using Biologic
equipment and BioMARK software.
Because FFR is a new procedure, unstudied pathologies are gradually being
added and, little by little, we are gaining new information about what effects the
pathologies have on the responses of affected children and adolescents.
The FFRs of children diagnosed as poor readers frequently present as altera-
tions in the timing and magnitude of timbre components [38]. The perception of
the duration of a sound stimulus is essential for proficient reading, and the FFR
can evaluate or monitor a decline in temporal and spectral precision. Children
and adolescents with dyslexia commonly have difficulty perceiving speech sounds
either in silence or in competing noise backgrounds. If a child has difficulty in
perceiving speech sounds, their reading can be severely impaired [39]. Recently,
Sanfins et al. [6] highlighted the importance of FFR as a biological marker in
scholastic difficulties.
FFR evaluation in children who have suffered from secretory otitis media in the
first 6 years of life, and who have undergone myringotomy for bilateral ventilation
tube placement, exhibit changes in their FFR compared to normal children [5]. This
study found that evaluating the FFR seems to be a promising method of identifying

Parameter Settings
Equipment Biologic Navigator Pro
Software BioMARK
Electrode montage Cz, M1, and M2
Stimulated ear Right ear
Stimulus Speech
Stimulus type Syllable /da/
Stimulus duration 40 ms
Stimulus polarity Alternating
Stimulus intensity 80 dB SPL
Stimulus rate 10.9/s
Number of sweeps 6000
Replicability Twice for 3000 sweeps
Transducer Insert
Assessment condition Watching a movie
Impedance 1k Ohms
Window 85.33 ms 85.33 ms
Filter 100–2000 Hz
Artifact rejection >10%
Cz: vertex, M1: left mastoid, M2: right mastoid, ms: millisecond, dB: decibel, SPL: sound pressure level, s: second, Hz:
hertz.

Table 10.
Parameters of FFR in children and adolescents.

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The Frequency Following Response: Evaluations in Different Age Groups
DOI: http://dx.doi.org/10.5772/intechopen.85076

changes in the coding of speech stimuli in these children which might be undetected
using traditional electrophysiological evaluation. The changes in their electrophysi-
ological responses might serve as an alert to parents and educators, who can then
adopt strategies to minimize the negative consequences on language development
and academic achievement.
Another possibility for using FFR assessment may be in monitoring an auditory
training program or even tracking the effect of therapeutic interventions. Studies
have shown that children with learning disabilities can benefit from an auditory
remediation program, and it might therefore be usefully accompanied by FFR
examinations (because FFRs have good repeatability in test and retest) [40, 41].
In addition, bilingual children can also be monitored through FFR assessment.
Researchers have confirmed that neural perception of speech seems to be more
consistent in bilinguals than in monolinguals [42, 43]. Bilingual experience dur-
ing childhood may favor plasticity in the neuronal coding of sound and improve
fundamental frequency perception (F0).
Recently, the neurophysiological aspects of speech perception have been investi-
gated in cases of autism spectrum disorder (ASD). The results showed that children
with ASD tend to have changes in the sensation of pitch (frequency), which might
explain a withdrawal from speech reception. The fundamental frequency (F0) and
its harmonics contain speech information which is essential in conveying affect
[44], so changes in FFRs are consistent with a defect in perceiving prosody. The
inference is that prosody deficits in some ASD patients may derive from an inability
to encode and transmit auditory information in the brainstem [45].
Traditionally, FFR testing is done by presenting verbal stimuli through an insert
earphone with a silent background. However, the perception of speech in a noisy
background is a much discussed topic. In the presence of noise, normally hearing
individuals need to make constant adjustments in their central auditory nervous
system to satisfactorily understand and process speech information. Of course,
there are others who, in the presence of competing noise, experience great difficulty
in understanding speech [46].
The evaluation of FFR in the presence of noise can be effectively used to
diagnose children with learning disabilities [47]. Thus, identification of such
children could lead to improvements in their reading and writing skills and in daily
communication.

5. Frequency following response: evaluation in adults and the elderly

In the adult and elderly population, the need for detailed audiological investiga-
tion increases when the patient complains of hearing difficulties, even if auditory
thresholds appear normal.
The evaluation of the FFR first involves time and prosody recordings, which
provide important information about consonant and vowel discrimination and also
aid in the perception of intonation [48]. For adults, but especially in the elderly,
participation in these sorts of tests can assist in rehabilitation, either using a hearing
aid or auditory training (or both).
The clinical usefulness of the FFR in gauging how well auditory information
is being processed is unquestionable. In adults and the elderly, many studies have
already been done to identify how the FFR can help in diagnosing complaints
related to central auditory processing, thereby allowing better rehabilitation.
The latencies (mean and standard deviation) for adults and the elderly are
presented in Table 11. The values come from Skoe et al. [19] who used Biologic and

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The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy

Complex VA

Age range Slope VA (ms/μV) Area VA (ms × μV)

∑ 8–11 0.38 0.31

12–16 0.33 0.34

Med 8–11 0.37 0.31

12–16 0.28 0.31

SD 8–11 0.12 0.11

12–16 0.16 0.16

∑: average, Med: median, SD: standard deviation, R: right, L: left.

Sample: 40 children and adolescents (8–16 years old).

Table 11.
Complex VA (slope and area) values for age range using syllable/da/of 40-ms duration performed in children
with normal hearing (silent conditions) [30].

Age (years) Number Latencies (maximum in milliseconds + 2 SD)

V A D E F O
17–21 54 7.04 8.15 23.21 31.9 39.50 48.94

21–30 143 7.17 8.28 23.4 32.54 40.84 49.79

30–40 32 7.27 8.39 23.64 32.09 40.38 49.13

40–50 11 7.05 8.22 24.26 31.86 39.93 49.6

50–60 26 7.5 8.77 24.5 32.97 41.46 50.72

60–73 24 7.68 8.81 24.27 32.47 40.60 50.02

Data from [19].

SD: standard deviation.

Table 12.
FFR latency values based on mean values in Table 11 plus two standard deviations.

Navigator Pro equipment. In this study, subjects aged between 18 and 72 years and
distributed in 6 age brackets were used. In the case of adults, the authors list values
for subjects aged 21–30 years (n = 143) and found that latency values tended to
increase with age. Thus, the researchers emphasized the importance of conducting
research on FFRs in different age groups, since normative values can be modified
with the aging process.
In Table 12 the maximum values of each wave are listed by adding two standard
deviations to those in Table 13. Assuming the distribution is Gaussian means that
this measure will cover 95% of the population.
Undoubtedly, the largest number of FFR studies have been performed using the
Navigator Pro model from Biologic. Researchers tend to use this equipment together
with the Intelligent Hearing Systems and SmartEP software [7, 49, 50].
One study aimed to assess the processing of auditory information in those with
hearing loss through an evaluation of eight individuals, aged 46–58 years, with
hearing loss [7]. FFRs (collected by SmartEP) were correlated with results from two
auditory processing behavioral tests—the masking level difference test and the ran-
dom gap detection test. No correlation was found between FFR and these tests. The
researchers found that the generation of this potential is extremely complex and
could encompass several functions and does not depend on just temporal resolution

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The Frequency Following Response: Evaluations in Different Age Groups
Age Number Latency ∑ (mean in milliseconds) Standard deviation

V A D E F O V % A % D % E (SD) % F (SD) % O %
(SD) (SD) (SD) (SD)
117–21 54 6.58 7.53 22.41 31.02 39.50 48.26 0.23 100 0.31 96.30 0.40 92.6 0.44 94.44 0.46 98.15 0.34 98.15

221–30 143 6.65 7.60 22.60 31.12 39.61 48.33 0.26 100 0.34 100 0.67 95.8 0.71 100 0.62 99.30 0.73 97.90

330–40 32 6.61 7.53 22.52 31.09 39.54 48.21 0.33 100 0.43 100 0.56 96.88 0.50 96.88 0.42 96.88 0.46 93.75
440–50 11 6.67 7.64 22.84 31.26 39.49 48.30 0.19 100 0.29 100 0.71 90.90 0.30 100 0.22 100 0.65 90.90

550–60 26 6.86 7.89 23.08 31.57 39.92 48.72 0.32 92.31 0.44 92.31 0.71 76.92 0.70 96.15 0.77 92.31 1.00 88.46

660–73 24 6.92 7.89 23.05 31.37 39.68 48.84 0.38 91.67 0.46 91.67 0.61 83.33 0.55 83.33 0.46 83.33 0.59 100
∑: Average (ms), SD: standard deviation, %: percent detectability for each peak.

Table 13.
FFR latency values for syllable /da/ of 40-ms duration, (silence) performed in adults and the elderly with normal hearing [19].
The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy

or selective attention [7]. Also seeking to correlate FFRs with hearing loss, Peixe
et al. [49] evaluated 11 individuals, aged 23–59 years, with moderately severe hear-
ing loss. They concluded that hearing loss may cause an increase in the FFR wave
latency, but the waves are still present so long as the stimulus intensity is adjusted.
In other words, the presence of FFR waves is related to the audibility of the signal.
Another interesting study was conducted with 30 young Indian adults aged
18–25 years [50]. The evaluation was carried out with the SmartEP equipment,
and FFRs were present in all subjects evaluated. The latency and amplitude values
of the analyzed elements were: wave V (lat = 6.81 ms and amp = 0.19 μV), wave C
(lat = 16.82 ms and amp = 0.24 μV), wave D (lat = 24.75 ms and amp = 0.32 μV),
wave E (lat = 31.36 ms and amp = 0.37 μV), and wave F (lat = 40.04 ms and
amp = 0.29 μV).
Worldwide, there is a large increase in the number of elderly people. This entails
providing better care for the elderly in all aspects of their health. With aging, there
are structural changes in the peripheral and central auditory system which can lead
to a decline in hearing. This, in turn, causes complaints of difficulty in understand-
ing speech, especially in unfavorable environments [51, 52]. These impairments
have a great impact on the life of the elderly, since in addition to causing social
isolation, it can also lead to a depression and reduce cognitive function [53].
Only a few studies have focused on FFR in the elderly, with the most
reported population being young adults [54]. Some researchers have pointed
to the clinical applicability of FFR in different populations and with different
pathologies [7, 19, 37, 55].
The effects of presbycusis on FFRs have been investigated in 18 individuals aged
61–78 years with hearing loss at frequencies of 2, 4, and 8 kHz (and compared with
the responses of a control group of 19 young adults aged 20–26 years with normal
hearing) [37]. The elderly group had lower amplitudes and increased latencies com-
pared to the control group, demonstrating that the FFR can be affected by aging as
well as hearing loss, but in different ways.
The effects of hearing loss on FFRs were described in a sample of 30 elderly
individuals aged 60–71 years who were divided into two groups matched by gender
and intelligence quotient: (i) normal hearing, and (ii) mild to moderate hearing
loss [35]. With ABR clicks, all subjects had normal responses. FFR testing indicated
that individuals with hearing loss could be assessed with this procedure, but there
were changes in the frequency responses. In the elderly with hearing loss, there was
a breakdown in the perception of the speech signal, which resulted in differences in
signal parameters compared to the group with normal thresholds. This breakdown
in neural synchrony may explain the greater difficulty subjects with hearing loss
have in speech perception.
The evaluation of FFR in noisy environments is becoming more widespread,
Thus, one study was carried out with 111 individuals between 45 and 78 years
of age (mean 61.1 years) with normal to moderate hearing loss [56]. All subjects
presented values within normal limits for the Montreal Cognitive Assessment
(MoCA) and click ABR. In addition, they were tested on the SSQ (Speech, Spatial,
and Qualities of Hearing Scale) which relates to auditory quality, as well as to the
Quick Speech-in-Noise test (QuickSIN), in which phrases are presented binaurally
with a verbal background babble. The FFR assessment demonstrated an increase
in O-wave latency associated with speech comprehension difficulty in competing
noise environments.
Supporting the observation that FFR traces are affected by increasing age, research
on 34 individuals aged 22–77 years with normal hearing [57] found a decrease of the
amplitude was associated with an increase in latency (Figures 1 and 2).

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Figure 1.
FFRs of an infant 13 days old. Authors’ data with FFR performed using SmartEP.

Figure 2.
FFRs of two 9-year-old-children. The top trace represents a normal response and the second represents an
abnormal response. Authors’ data using BioMARK software and Biologic equipment.

Figure 3 shows an FFR done on an adult aged 25 and on one aged 70. The shape
of the FFR is similar in both, but there is an increase in latencies and some waves
appear to be absent.
In these FFR tracings, it can be seen that the elderly subject had an increase in
latency of all waves compared to the younger adult. Aging causes a progressive loss
of structure or functioning of neurons, which can be seen as decreased auditory
evoked potentials. Through the FFR, it is seen that there is also a reduction in the
speed of neural activation from brainstem to cortical structures.
Our FFR evaluation in adults and the elderly used IHS equipment and the
parameters are shown in Table 14.

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The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy

Figure 3.
FFRs of an adult aged 25 years (top) and another aged 70 (bottom). Note the increase in latency of the waves.
Authors’ data using SmartEP equipment.

Presentation parameters Setting

Equipment SmartEP Intelligent Hearing Systems (IHS)
Transducer Insert phones
Electrodes Fz, Fpz, M1, M2 or Cz, M1, M2
Stimulation Right ear
Stimulus Syllable /da/
Stimulus duration 40 ms
Presentation rate 10.9/s
Window 80–100 ms
Filter Low pass of 100 Hz and high pass of 2000 Hz
Low pass of 100 Hz and high pass of 3000 Hz
Polarity Alternating
Intensity 80 dBnHL
Number of stimuli 6000
Reproducibility 2 × 3000 stimuli
Condition of evaluation awake and quiet
Impedance 3k Ohms
Artifact rejection >10%

Table 14.
Parameters of FFR in adults and the elderly.

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DOI: http://dx.doi.org/10.5772/intechopen.85076

6. Conclusion

FFR evaluations can be included as an extra examination in diagnostic test-

ing and have an important role in crosschecking the results. It can also greatly
assist making differential diagnoses in different clinical populations. However,
each age group has FFRs with specific characteristics, so it is important that
the audiologist has access to good normative values for the different age groups
(infants and toddlers, young children, children and adolescents, adults and the
elderly).

Terminology

10–20 International System a standard system for electrode location

ABR auditory brainstem response
AEP auditory evoked potential. Evoked potential when
using an auditory stimulus
BioMARK Biological Marker of Auditory Processing is software
that compares responses from a click to those from a
synthetic syllable (usually /da/)
CANS central auditory nervous system
CAP central auditory processing
CAPD central auditory processing disorder
CNS central nervous system
CV syllable a phoneme produced by a consonant and a vowel
FFR frequency following response
Onset portion the first part of an FFR that reflects the consonant
SAB Scale of Auditory Behavior, a questionnaire for
monitoring auditory processing skills
Sustained portion the second part of an FFR that reflects the vowel
Synthesized speech
Artificial human speech produced by a computer

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The Human Auditory System - Basic Features and Updates on Audiological Diagnosis and Therapy

Author details

Milaine Dominici Sanfins1,2*, Michele Vargas Garcia3, Eliara Pinto Vieira Biaggio3
and Piotr Henryk Skarzynski4,5,6

1 Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas,

Brazil

2 Centro de Eletrofisiologia e Neuroaudiologia Avançada, São Paulo, Brazil

3 Departamento de Fonoaudiologia, Universidade Federal de Santa Maria,

Santa Maria, Brazil

4 Department of Teleaudiology and Hearing Screening, World Hearing Center,

Institute of Physiology and Pathology of Hearing, Warsaw/Kajetany, Poland

5 Department of Heart Failure and Cardiac Rehabilitation, Medical University of

Warsaw, Poland

6 Institute of Sensory Organs, Kajetany, Poland

*Address all correspondence to: [email protected]

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/
by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

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The Frequency Following Response: Evaluations in Different Age Groups
DOI: http://dx.doi.org/10.5772/intechopen.85076

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