American Speech-Language-Hearing Association

Technical Report

Audiologic Screening

Ad Hoc Committee on Screening for Impairment, Handicap, and Middle Ear Disorders


About this Document

The Report on Audiologic Screening was developed by the American Speech-Language-Hearing Association (ASHA) Ad Hoc Committee on Screening for Impairment, Handicap, and Middle Ear Disorders and was approved by the Executive Board (EB 182-93) in December 1993. Members of the committee include Robert Nozza, chair; Judith Gravel; Joan Martilla; Michael Nerbonne; Diane Scott; Thayne Smedley; and Jo Williams, ex officio. The report was completed under the guidance of Jean Lovrinic, vice president for governmental and social policies.


Table of Contents


Executive Summary

Introduction

The American Speech-Language-Hearing Association (ASHA) is strongly committed to the prevention and early identification of audiologic disorders in people of all ages. According to the ASHA Position Statement on Prevention of Communication Disorders (1988), secondary prevention is “the early detection and treatment of communication disorders,” and audiologists and speech-language pathologists are urged to “demonstrate the ability to…provide early identification and early intervention services for communication disorders occurring at any time during the life span.” The implications of this Association position for screening are clear. Guidelines for screening should be available for all conditions related to hearing disfunction and for all ages.

The Ad Hoc Committee on Screening for Hearing Impairment, Handicap, and Middle Ear Disorders determined that in order for the Association to develop a comprehensive and progressive set of guidelines in a proactive manner, the first step was to establish an organizational framework for screening for all audiologic conditions across the life span. This framework would facilitate identification of areas for which no guidelines exist and would help in the analysis of existing guidelines. Consolidating and/or developing screening guidelines according to condition (hearing impairment, disability, and middle ear disorder) and age group (newborns, infants and toddlers, preschool children, school-age children, adults, and adults/elderly) is necessary, but cannot begin until a framework for all guidelines is in place.

Accordingly, the committee report provides a point of departure for the ultimate development and organization of a comprehensive set of guidelines for screening in audiology. Report objectives reflect the important preliminary steps in that process.

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Report Objectives

1. Definitions and use of terms, such as disorder, impairment, disability, and handicap, vary across disciplines and across international boundaries. It is important to use terminology consistently in our policy documents. Therefore, this report defines terms for the various levels of auditory disfunction for which we might screen.

  • Disorder: Any anatomic abnormality; pathology. May or may not result in a change in function of a given organ or organ system (e.g., sensory system).

  • Impairment: Any loss or abnormality of psychological or physiological function. Auditory impairment implies that a dimension of the auditory system is outside the normal range, but it does not necessarily imply any restrictions in the level of performance of the individual in activities involving that dimension.

  • Disability: Any restriction of lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. That is, disability relates to performance of the individual.

  • Handicap: The difficulty an individual experiences as a result of an impairment/disability, and as a function of barriers (e.g., structural, communication, architectural, attitudinal), lack of accommodations, and/or lack of appropriate auxiliary aids and services (e.g., amplified telephone handset, assistive listening device) necessary for effective communication.

2. A summary of screening principles is presented to provide the appropriate context within which to consider screening guidelines. The essential elements to be considered for any screening program are:

  1. Purposes of screening,

  2. Importance of the disease,

  3. Diagnostic criteria,

  4. Treatment,

  5. Reaching those who could benefit,

  6. Resource and compliance considerations,

  7. Test appropriateness, and

  8. Screening program evaluation.

3. Existing ASHA guidelines and reports on audiologic screening were critically reviewed for terminology and adherence to basic screening principles. Conditions and age groups not covered by guidelines were determined.

4. Recommendations for future efforts by the Association related to screening guidelines in audiology were presented.

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General Recommendations:

  • Establish an ongoing mechanism (e.g., standing committee) within the Association to monitor and develop screening guidelines and protocols for hearing impairment, disability, and middle ear disorders.

  • Develop a comprehensive and systematic method for development of Association screening guidelines for all ages and all conditions (disorder, impairment, and disability).

  • Develop a standard format for all guidelines that incorporates all aspects of screening (as outlined in the report).

  • Use consistent terminology in screening guidelines and reports and use the terminology as put forth in this report.

  • Define clearly what is being screened (e.g., disorder, impairment, or disability), the definition of the terms as they apply to the population (e.g., designed to make decisions about educational placement), and whether the guidelines apply exclusively to a high-risk population.

  • Make issues and research related to screening a priority for the Association. And continue to promote ways to estimate screening program costs.

  • Address personnel issues and the education and training needs regarding screening in audiology.

Personnel: Any audiologic screening program or program component that calls for screening for hearing impairment, disability, or outer and middle ear disorders should be under the direction of a certified audiologist. All screening testing should be done as part of a comprehensive screening program. Association policy should be changed to distinguish certified speech-language pathologists from “support personnel” with respect to performing acoustic immittance screening procedures.

Education and Training: All audiologists and speech-language pathologists should further their education with respect to epidemiology of disease and screening principles. Those who perform screening tests for disorders of the auditory system, hearing impairment, and hearing disability should undergo a minimum amount of training under the supervision of a certified audiologist.

  • Direct the efforts of future committees to define high-risk groups and determine the efficacy of screening such groups.

  • Continue efforts to educate the general public and professionals about the importance of communication and the importance of early identification of communication disorders.

  • Develop guidelines for infants (29 days to 3 years) and adults/older persons.

  • Consider discussing unacceptable screening methods as well as those methods that are recommended in future guidelines.

  • Incorporate ASHA policy on ethical professional practice and any existing national (e.g., ANSI) standards on test procedures and test environments into guidelines.

A copy of the complete report and recommendations of the ad hoc committee is available to ASHA members. The report will be published in a future issue of the American Journal of Audiology: A Journal of Clinical Practice. (Editor's Note: Complete report follows below.)

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Technical Report

Prepared by the Ad Hoc Committee on Screening for Hearing Impairment, Handicap, and Middle Ear Disorders: Judith S. Gravel, Joan Marttila, Michael A. Nerbonne, Robert J. Nozza (chair), Diane M. Scott, Thayne Smedley, Jo Williams (ex officio), Jean H. Lovrinic (monitoring vice president).

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Introduction

The American Speech-Language-Hearing Association (ASHA) is strongly committed to the prevention and early identification of audiologic disorders in people of all ages. The Association Position Statement on Prevention of Communication Disorders (1988a) states that “speech-language pathologists and audiologists should…play a significant role in the development and application of prevention strategies.” Prevention, according to the position statement, includes not only “the elimination or inhibition of the onset and development of a communication disorder” (primary prevention), but also “the early detection and treatment of communication disorders” (secondary prevention). In that regard, the position statement goes on to state that audiologists and speech-language pathologists should “demonstrate the ability to… provide early identification and early intervention services for communication disorders occurring at any time during the life span.” The implications of this Association position for screening are clear. Guidelines for screening should be available for all conditions related to hearing disfunction and for all ages.

Numerous Association guidelines, tutorials, reports, and other documents on screening have been developed over the past 20 years. These documents reflect the efforts of a number of different committees and, in many cases, have provided much-needed information and guidance. Documents have addressed a variety of conditions that affect auditory function and various age groups. For the most part, audiologic screening guidelines have been developed to address only very specific and sometimes very narrowly focused areas. In some instances, documents overlap on certain issues and areas have not been addressed, either because of omission or because of new information that has become available since publication of the document. In addition, the committees that developed ASHA documents were active at different times over a span of many years. The various guidelines and position statements differ in content and style. Some documents do not reflect current perspectives because policy changes, such as new federal legislation, occurred after the documents were prepared.

Screening guidelines developed by ASHA become official policy of the Association. As such, they are used not only by professional members of ASHA but also by others interested in learning of ASHA's position on certain practices. For example, school administrators, physicians and nurses, educators, and others might refer to ASHA guidelines to make decisions regarding development of hearing screening protocols. Because of their multipurpose design, ASHA guidelines must be clear and comprehensive, must reflect current knowledge, and must be easily accessible.

In the committee's efforts to complete its charge, it became apparent that updating existing guidelines, consolidating them into one document, and filling in where no screening guidelines existed was not the appropriate way to proceed. Rather, it was determined that in order for the Association to develop a comprehensive and progressive set of guidelines in a proactive way, the first step was to establish an organizational framework for screening for all audiologic conditions across the life span. This framework would facilitate identification of areas for which no guidelines exist and help in the analysis of existing guidelines. Consolidating and/or developing screening guidelines according to condition (hearing impairment, disability, and middle ear disorder) and age group (newborns, infants and toddlers, preschool children, school-age children, adults, and adult/elderly) is necessary, but cannot begin until a framework for all guidelines is in place.

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Report Objectives

This report is designed to provide a point of departure for the ultimate development and organization of a comprehensive set of guidelines for screening in audiology. The specific objectives of this report reflect the important preliminary steps in that process.

Objective 1. Definitions and use of terms, such as disorder, impairment, disability, and handicap, vary across disciplines and across international boundaries. It is important to use terminology consistently in our policy documents. Therefore, the first objective of this report is to define terms for the various levels of auditory disfunction for which we might screen.

Objective 2. The second objective is to present a summary of the principles of screening to provide the appropriate context within which to consider screening guidelines. The guidelines for screening cannot be interpreted and applied properly without an understanding of why we screen for disease and the wellestablished principles related to the factors that must be considered in developing screening programs. Implied in this presentation of screening principles is the notion that all screening for hearing impairment, disability, and middle ear disorders should be done in the context of a program that includes not only methods for identification but also resources for follow-up and means for measuring outcomes. This notion was well-established in past screening documents adopted by ASHA, as well as in the prevention literature.

Objective 3. The third objective is to review existing Association guidelines and reports for audiologic screening. The critical review is not intended necessarily to criticize the guidelines with respect to the degree to which they met specific charges. Peer review was done at the time the documents were prepared, so the present ad hoc committee need not repeat that exercise. The primary objective of reviewing documents in this report is to evaluate existing guidelines within a broad and comprehensive conceptual framework. This review identifies gaps and limitations of existing guidelines in the need for fitting guidelines into a comprehensive plan, rather than in the specific issue the guidelines were originally designed to address.

Objective 4. The fourth objective of this report is to present recommendations for consideration by the Association with regard to future efforts related to screening guidelines in audiology.

Finally, because of a special request of the Executive Board, the ad hoc committee also considered the issue of the use of speech-language pathologists in screening for middle ear disorders using aural acoustic immittance measures. The response to the Executive Board is summarized in the present report.

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Terminology

Among the issues that add to the complexity and, in some cases, confusion regarding screening is the inconsistent use of terminology both within our profession and in the health care community in general. It is important that we bring consistency to the use of terms that are important to our understanding of diseases and conditions and their effect on people and society. As a national professional association, ASHA should provide leadership and use its influence to help achieve agreement on terminology across disciplines and across international boundaries.

People with disabilities have strong feelings about the terminology that applies to them. People with disabilities do not favor the use of the term handicapped in reference to a person or persons with a disability. Congress deliberately omitted the term handicap in the Americans with Disabilities Act (ADA) and, instead, defined the effects of a disorder in terms of impairment and/or disability. In this way, the ADA signals a radical shift in public policy regarding people with disabilities.

The following definitions are recommended for use in all relevant documents:

  • Disorder. Any anatomic abnormality; pathology. May or may not result in a change in function of a given organ or organ system (e.g., sensory system).

  • Impairment. Any loss or abnormality of psychological or physiological function. Auditory impairment implies that there is a dimension of the auditory system that is outside the normal range, but does not necessarily imply any restrictions in the level of performance of the individual in activities involving that dimension. This definition has been used in the Prevention of Disorders Tutorial (ASHA, 1991b) and is similar to that used in the ADA.

  • Disability. Any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being. According to the World Health Organization (WHO, 1980), “disability represents a departure from the norm in terms of performance of the individual, as opposed to that of the organ or mechanism” (p. 28). That is, disability relates to performance of the individual.

  • Handicap. The difficulty experienced by an individual as a result of an impairment/disability, and as a function of barriers (e.g., structural, communication, architectural, attitudinal), lack of accommodations, and/or lack of appropriate auxiliary aids and services (e.g., amplified telephone handset, assistive listening device) necessary for effective communication. The term handicap has been redefined in recent years, largely as a result of a movement to improve attitudes toward and conditions for people with disabilities. In this country, people are no longer considered to be handicapped. Rather, people with disabilities are sometimes placed in situations that are handicapping to them, the point of reference being the environmental or social restrictions. The definition of handicap provided by WHO (1980) is not the same as the one offered here, but, according to WHO (1980), “handicap is characterized by a discordance between the individual's performance or status and the expectations of the particular group of which he [sic] is a member.” Although the definition offered by WHO is slightly different from the one given above, we interpret the WHO definition as being consistent with the above definition as well as the usage in the ADA, whereby the expectations of others defines the “handicap.”

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Principles of Screening

To understand, critique, and, ultimately, apply the information in the screening guidelines, it is essential to know the principles of screening. Further, ASHA documents that represent the official policy of the Association should adhere to the generally acknowledged guiding principles of screening for a disease. With those concepts in mind, a brief treatment on screening principles has been included here. A list of selected references, which is not intended to be comprehensive, is included for the interested reader (Cadman, Chambers, Feldman, & Sackett, 1984; Frankenburg, 1974; Swets, 1988; Thorner & Remein, 1982, Turner, 1991; Weinstein & Feinberg, 1980). Information related to screening principles can be organized in a number of ways. The following outline covers the essential elements to be considered regarding any screening program.

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A. Purposes of Screening

The purposes of screening are to separate from among apparently healthy individuals those for whom there is a greater probability of having a disease or condition and then to refer them for appropriate diagnostic testing. That is, those screened are separated into a “pass” group and a “refer” group.

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B. Importance of the Disease

Each disease has a cost to society; the greater the burden to society, the greater the reason to screen for the disease. Evaluating the cost of a given disease to society in general is not easy. Factors that must be considered, however, include the prevalence, morbidity, and duration of the disease, as well as the cost of screening, diagnosis, and treatment.

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C. Diagnostic Criteria

For a screening program to be successful, there must be a clear and measurable definition of the disease one is attempting to identify through screening. In this regard the definitions of impairment, disability, and handicap are critical to our understanding of the purpose of screening and the kind of test(s) that should be used. In addition, measurable and acceptable criteria for diagnosis must be available. Application of the diagnostic procedures must differentiate between those with the disease and those without the disease.

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D. Treatment

Before a screening program is implemented, it is necessary to demonstrate that treatments are available, effective, and shown to alter the natural history of the disease. This must be done through research, preferably through randomized, controlled clinical trials. It should also be shown that treatment early in the disease process (i.e., before symptoms appear) results in greater benefits than when treatment is begun in the symptomatic patient. There is no need to find the asymptomatic patient if treatment is no more effective at that stage than when the disease declares itself through symptoms.

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E. The Program Must Reach Those Who Could Benefit

It is important that screening programs be administered so that those who would most likely benefit from early identification are included easily. Mechanisms for outreach to the targeted population should be in place. Education and public policy can influence how well screening programs succeed in reaching those it should reach.

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F. Availability of Resources and Compliance of Those Identified

Diagnostic and treatment resources appropriate for the population being served must be available before a screening program can be managed successfully. After identification, those identified must comply with follow-up components of the screening program. A screening program without willing participants will not endure. There is little advantage to identifying disease through a screening program without the capability to diagnose and treat those with the disease or if those in need of diagnostic testing do not comply with that component of the program. Diagnostic and treatment resources must be able to accommodate the influx of clients who are referred after the screening test(s).

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G. Appropriateness of the Test

In general, a screening test should be simple. A screening test that is easy to administer, comfortable for the patient, short in duration, and inexpensive will be better received by those being screened and by those responsible for administering it. The test must also meet performance criteria. It must be sensitive, specific, precise, and accurate. There must be an acceptably low over-referral rate to avoid overburdening those who make the diagnoses and to minimize the number of referrals of those without the disease. Those who do not have the condition but are positive on the test (i.e., false-positive outcomes) must bear the costs (time, money, discomfort, anxiety, etc.) associated with “failing” the screening and going through the follow-up procedures. There must also be an acceptably low under-referral rate so that the number of those with disease who are not referred (false-negative outcomes) is minimized. The costs of failing to detect disease during screening can be quite serious and include delayed identification, diagnosis, and treatment. There must be a standard widely accepted as the best (i.e., a “gold” standard) against which to measure screening test performance. The measurement of the screening test versus the standard (i.e., validation) must be done in a blind study and must be done using a patient population that is representative of the population on whom the screening test will be used.

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H. Screening Program Evaluation

Screening programs can and must be evaluated. Protocols should be based on data that demonstrate that individuals identified through screening have better outcomes than those not screened. This should be done using randomized, controlled clinical trials. Program costs can be estimated. Direct monetary costs of screening can be computed. There are also costs associated with the level of risk involved in the screening test itself, costs to the client and family associated with assigning a label of a disease to an individual, and costs associated with the false positives and the false negatives of a screening program. Such costs can be modified through administrative decisions, such as changing the population to be tested (e.g., identification of a high-risk group), changing screening-test cutoffs (thus affecting false-positive and false-negative rates), changing the definition of the disease, multiple testing, and others.

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ASHA Guidelines for Screening

This section is a review of existing Association guidelines and reports related to screening for hearing impairments, disability, and middle ear disorders. Ultimately, screening guidelines should be organized according to the relevant categories (i.e., age and condition [disorder, impairment, disability]). However, in current guidelines there is some overlap with respect to age, and in some documents the condition to be screened is not clearly defined. This section is organized according to the specific existing guidelines, rather than by age group or by condition to be screened. Each document is briefly reviewed and generally critiqued. Terminology and issues related to age and test methods are included when appropriate. Such a review should facilitate the transition from the present status of our guidelines to the guidelines of the future. Implementation of specific recommendations or suggestions should be the task of future committees formed for those purposes.

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Guidelines for Audiologic Screening of Newborn Infants Who Are at Risk for Hearing Impairment (1989a, March). Asha, pp. 89–92.

Guidelines summary. This set of guidelines describes audiometric screening for hearing impairment in newborn infants who meet high-risk criteria, as provided by the Joint Committee on Infant Hearing (JCIH) Position Statement (JCIH, 1982). (Since publication of the 1982 guidelines, the JCIH put forth an updated [1990] position statement [JCIH, 1991], primarily updating their high-risk register [HRR]. A new draft position statement is currently undergoing the approval process by participating organizations [JCIH, 1993]). The auditory brainstem response (ABR) test is recommended, with referral criteria consisting of failure to detect the ABR at 40 dB nHL in one or both ears. Screening is done as part of a program including follow-up and management components.

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a. General comments

The screening protocols in this set of guidelines apply only to infants in the neonatal period (age 0–28 days). The guidelines recommend that, first, a subgroup of infants be identified who are considered “at risk” for hearing impairment. Risk factors for hearing loss (i.e., the HRR) are those specified by the Joint Committee on Infant Hearing (JCIH) in their 1982 Position Statement.

The second phase of the 1989 screening protocol involves measurement of an auditory evoked electrophysiologic response, the auditory brainstem response (ABR), only for those infants identified as “at risk” by the HRR. This policy deliberately specifies the use of an audiometric test procedure or evoked electrophysiologic response for screening only those neonates who meet the HRR criteria. In that regard, one major component of our proposed comprehensive screening framework (i.e., infants who are not at risk based on the HRR) is not addressed in Association guidelines.

Following adoption and publication of these guidelines, controversy arose over whether the current guidelines constituted a two-tiered (or double-screen) process (see Turner, 1990; ASHA, 1990c) or if it should be interpreted as simply an audiometric screening of a subpopulation of newborns. The general definition of screening is the selection of a subpopulation for which the prevalence of the disorder is greater than in the general population, so the argument is largely semantic. That is, according to our definition of screening and the screening principles previously outlined, the HRR is a screening device, so the current guidelines include two separate screening procedures: Application of the HRR to all infants (stage 1) and then an ABR screen (stage 2) that is administered to only the first-stage failures. The guidelines were designed to address the best technique for testing auditory function in the high-risk group, identification of which was based on the JCIH position statement (ASHA, 1982). For screening protocols that require failure on each of two tests in order to have a positive outcome, sensitivity is sacrificed to gain specificity (e.g., Griner, Mayewski, Mushlin, & Greenland, 1981; Thorner & Remein, 1982). In these guidelines the infants must fail both stage 1 (HRR) and stage 2 (ABR) to be referred for further audiologic evaluation, making it more difficult to fail the screening protocol.

The sensitivity of the 1989 recommended protocol is poor. Approximately 50% of newborns with hearing impairments are missed because the first stage (HRR) identifies only about 50% of those with hearing impairments. Because of the poor sensitivity of the 1989 recommended protocol and the projected costs of universal screening, controversy exists regarding the use of a physiological test of auditory function (e.g., ABR, acoustic reflexes, or otoacoustic emissions [OAE]) with a subgroup of the neonatal population versus use of such a test with all newborns.

The guidelines (ASHA, 1989a) were based on research findings available at the time they were written and on the JCIH position statement (JCIH, 1982), and were supported subsequently by the JCIH 1990 Position Statement on Infant Hearing (JCIH, 1991). That is, the data did not support universal screening of newborns using an audiometric test such as ABR or OAE. Until recently, data on cost and performance of the various tests have not been sufficient to justify such a change in protocol. However, the JCIH (1993, November) recently drafted a position statement that includes a recommendation for universal screening of all newborns. Moreover, the recent 1993 National Institutes of Health (NIH) Consensus Conference (NIH, 1993) on the early identification of hearing loss in infants and young children recommended universal screening of newborns.

Turner (1990) has criticized the lack of comprehensive cost-benefit analyses of the 1989 newborn hearing screening guidelines (ASHA, 1989a). Cost-benefit analyses should be included in future updates and new guidelines.

Any neonatal screening guidelines will be affected by the policies of groups made up of representatives from other associations, those with which ASHA participates (e.g., the JCIH), and those with which ASHA has no official representation (e.g., the National Institutes of Health); by state and federal legislative mandates; and by new research data and changing technology.

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b. Conditions screened

  1. Hearing impairment. This screening protocol is designed to identify infants with hearing impairments that will interfere with speech recognition. That is, those with hearing impairment sufficient to cause a disability with regard to understanding speech are targeted by the identification program. As such, the guidelines define hearing impairment as a “bilateral conductive or sensorineural deficit.” However, the document also states that “infants who do not demonstrate an ABR at intensity levels 40 dBnHL or less in both ears should enter the audiologic evaluation, follow-up, and management system.” Thus, the guidelines are designed to identify both unilateral and bilateral impairments. The document specifies a follow-up strategy for those who have responses at 40 dBnHL or less in only one ear (i.e., suspected unilateral impairment). If the intent of the guidelines is to suggest that a unilateral failure on the ABR puts the newborn at sufficient risk for bilateral hearing impairment to warrant the referral for follow-up, then it should be stated directly. Otherwise, the identification and recommendations for follow-up of those with possible unilateral hearing loss seem inconsistent with the definition in the guidelines of the condition for which screening is being done (i.e., bilateral hearing impairment) and, one could argue, is inconsistent with the notion of a deficit that “interferes with speech recognition.” According to current screening principles, the definition of the disease or disorder being screened for is not clearly spelled out in the 1989 guidelines.

  2. Hearing disability and middle ear disorders. The guidelines for screening newborns for hearing impairment do not explicitly address screening for hearing disability or middle ear disorders. However, the definition used in the guidelines suggests they are designed to identify a level of hearing impairment that can cause disability (i.e., interference with speech recognition). Neither direct measures of hearing disability for newborns nor otoscopic and tympanometric criteria for the identification of outer and middle ear disorders in newborns are currently available.

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c. Test methods

The ABR was recommended because it is objective, correlates well with hearing, and has very good performance statistics (i.e., sensitivity and specificity). At the time the guidelines were written, insufficient data were available on the use of alternative test procedures, such as OAEs, to recommend them for screening neonates. Although data are available now (White, Vorh, & Behrens, 1993), and in spite of the recommendation of the NIH Consensus Conference (NIH, 1993), it is still premature to recommend new procedures (e.g., OAEs or others). In fact, NIH has recently funded a multicenter project to investigate the performance of various methods of screening hearing in newborns and young infants. Because new data are becoming available at a rapid pace, any revisions of the guidelines for newborns should consider new developments and procedures for screening for auditory impairment (see JCIH, 1993, for details).

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d. Recommendations for newborn screening

  1. The position on screening only high-risk infants versus universal screening of newborns should be reconsidered, especially in light of cost-effectiveness. However, it is cautioned that different geographic regions of the country, populations, or socioeconomic environments may necessitate different screening practices. More data are needed on the efficacy of universal versus high-risk screening as well as on practical and financial issues related to the two approaches.

  2. The efficacy of new and currently available screening procedures (e.g., OAEs, acoustic reflexes) should be studied.

  3. Although the new JCIH position statements (JCIH, 1991; 1993, November Draft) include high-risk criteria for infants from 1 month to 24 months of age, and although ASHA has guidelines for assessment of hearing in that age group (ASHA, 1991a), guidelines for screening should be extended to the infant population beyond newborn (i.e., 29 days to 36 months of age).

  4. Data on the relationship between hearing impairment and disability and data on middle ear disorders in newborns should be considered in future guidelines.

  5. Revisions of the current guidelines should continue to reflect the need for follow-up programs for those infants who fail newborn hearing screening. Future guidelines should address specifically the availability of resources for the screening program as well as for the treatment, follow-up, and habilitation of infants identified by the screening process.

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Guidelines for Screening for Hearing Impairment and Middle Ear Disorders. (1990a, April). Asha (Suppl. 2), pp. 17–24.

Guidelines summary: Protocols include screening for hearing impairment using the pure-tone hearing screening protocol in the 1985 Guidelines for Identification Audiometry (see below), and screening for “medically significant ear disorders that have been undetected or untreated.” Identification of outer and middle ear disorders is done using visual (otoscopic) examination of the external ear canal, history of otologic abnormality, and aural acoustic immittance measures. Screening is positive when equivalent ear canal volume is outside the normal range (too large) in the presence of a “flat” tympanogram (possible opening in tympanic membrane), and visual inspection and/or history reveals discharge from the middle ear or ear pain. If peak admittance is outside the normal range (too low) or tympanometric width is outside the normal range (too wide) in either ear, the individual is to be screened a second time in 4 – 6 weeks. A second positive finding results in referral. Information on equipment and personnel is also provided. A failure on pure-tone screening in association with abnormal tympanometric results is “evidence of a significant medical and communicative disorder” and requires immediate follow-up. Appendices provide interim norms for a selected age group and suggestion for scoring tympanometric width. Guidelines are designed for use with individuals from 3 to 40 years of age.

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Guidelines for Identification Audiometry. (1985, May). Asha, pp. 49–52.

Guidelines summary: Guidelines are geared primarily toward mass screening programs for children and provide information on who should be screened and how screening can be done. A recommendation is made for a hearing screening using monaural presentation of pure tones 500, 1000, 2000, and 4000 Hz at a screening level of 20 dB HL for individuals between approximately 3 years through third grade and any high-risk children in other grade levels. However, the guidelines may be applied up to age 40 years. A screening positive is failure to respond to test signals at any frequency in either ear. All screening positives are to be rescreened, preferably within the same session, but certainly within 2 weeks. If acoustic immittance measures are done or if ambient noise levels are too high, hearing screening at 500 Hz may be omitted. Procedural considerations, such as those related to personnel, instructions, time, acoustic environment, equipment, and reporting are also addressed.

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a. General comments

Used in conjunction, these two guidelines are designed to screen for (a) hearing impairment that interferes with or has the potential for interfering with communication and (b) outer ear and middle ear conditions that, with or without hearing loss, require medical examination. Because of the dependence of the two documents on each other, they are discussed together.

The Guidelines for Screening for Hearing Impairment and Middle Ear Disorders (ASHA, 1990a) address primarily screening for outer and middle ear disorders using (a) case history information; (b) visual inspection of the outer ear, external auditory meatus, and tympanic membrane; and (c) acoustic immittance measures. The 1990 guidelines refer to the Guidelines for Identification Audiometry (ASHA, 1985) for recommendations on monaural pure-tone screening for hearing impairment. Note: the Guidelines for Identification Audiometry (ASHA, 1985) refer to earlier ASHA guidelines for screening for middle ear disorders (ASHA, 1979), which have been superseded by the current Guidelines for Screening for Hearing Impairment and Middle Ear Disorder (ASHA, 1990a).

Several issues apply, in general, to the two guidelines (ASHA, 1985, 1990a). Those issues will be discussed first, followed by issues that are specific to the condition or the age group targeted. Neither of the two guidelines, Guidelines for Identification Audiometry (ASHA, 1985) or Guidelines for Screening for Hearing Impairment and Middle Ear Disorders (ASHA, 1990a), provides an extensive rationale for the importance of screening for hearing impairment. Only minimal attention is given to using audiometry either to identify those children and/or adults with hearing losses that may impact negatively on communication or, to serve as an adjunct to acoustic immittance, case history, and visual inspection in identifying persons with medically significant pathology of the ear. A stronger rationale for screening for hearing impairment is appropriate to highlight the link between hearing impairment and its potential consequences (e.g., abnormal or delayed speech/language development, delayed educational progress, hearing disability, etc.).

Personnel. The guidelines state that the persons who do the screening should be sufficiently trained to obtain accurate and reliable results and that the screening program should be supervised by an audiologist. ASHA's guidelines (ASHA, 1981a) on use of support personnel provide information on the qualifications, training, and supervision of aides in providing services. The issue of speech-language pathologists doing screenings for hearing impairment, disability, and outer and middle ear disorders is not specifically addressed in the guidelines. According to the current interpretation on “crossover practice,” Clinical practice by certificate holders in the profession in which they are not certified (ASHA, 1992c), speech-language pathologists can perform and/or supervise pass/fail pure-tone air-conduction hearing screening for cooperative clients who are able to respond in a conventional way or be conditioned to respond in play tasks. The 1992 “crossover” practice statement also states that if speech-language pathologists perform audiologic procedures other than pure tone audiometric screening (e.g., acoustic immittance), they should be considered functioning in the capacity of support personnel and under the supervision of an audiologist as specified by the current guidelines for support personnel (ASHA, 1981a). This issue was examined by the ad hoc committee at the request of the Executive Board. A summary of the findings and recommendations was forwarded to the Executive Board as a separate report.

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b. Conditions screened

1. Hearing impairment. The guidelines, although covering a wide age range, are most often applied to screening for hearing impairments in children. Children may acquire hearing losses because of illness, medication side effects, genetic conditions, head trauma, or other physiological reasons. Many children are also at risk for chronic middle ear disorders. Prevalence of these disorders and their potential associated sequelae, such as hearing impairment, tympanic membrane abnormality, cholesteatoma, and others, are well documented. Examples of children at risk for hearing impairment are included in a footnote to the Guidelines for Identification Audiometry (ASHA, 1985).

The 1985 guidelines are aimed at “identifying persons who have hearing impairments that interfere with or have the potential for interfering with communication.” The actual screening procedure for hearing impairment (Guidelines for Identification Audiometry [ASHA, 1985]) calls for the presentation of 500, 1000, 2000, and 4000 Hz pure tones via earphones to each ear at 20 dB HL. The 500 Hz test tone may be omitted if testing is done in conjunction with acoustic immittance screening or if ambient noise levels are too high. Failure to respond to any one signal in either ear constitutes a failure for this portion of the screening protocol. Latitude is provided in the guidelines to adjust the protocol to respond to any special circumstances, but there is no specific information regarding when modifications can and should be made and what types of modifications might be useful. To minimize the problem of overreferral, the guidelines call for those persons failing the initial pure-tone screen to be rescreened in a timely way, preferably in the same session. A failure on both screens results in a referral for a complete audiologic evaluation.

By defining the degree of hearing impairment as one that interferes with or has the potential to interfere with communication, this document alludes to the link between hearing impairment and hearing disability and is selecting a level of impairment for which to screen based on the concept of disability. That is, screening is intended to identify those with an impairment that is sufficient to cause disability (loss of ability of the individual to perform a function in the manner considered normal for a human being). Of course, practical considerations must play a role in selecting any screening protocol, and in this case the need to identify impairment was balanced against the ability to measure impairment in typical screening environments. Therefore, a screening level was selected that would both detect impairment sufficient to cause disability and provide reliable and valid measures in most environments typically used for hearing screenings. However practical this level may be, it is important to note that the degree of impairment that puts an individual at risk for disability is not universally agreed on and may vary for different age groups.

2. Disability. These guidelines do not directly address screening for hearing disability. Although we know that hearing loss can cause significant hearing disability (e.g., communication/educational difficulties), screening guidelines have not been developed to identify those with communication/educational difficulties among the group with hearing impairments.

3. Outer and middle ear disorders. The title of the 1990 guidelines, The Guidelines for Screening for Hearing Impairment and Middle Ear Disorders (ASHA, 1990a), suggests that only middle ear disorders are targeted (i.e., to the exclusion of outer ear disorders). However, all four methods of screening (history, visual inspection, identification audiometry, and acoustic immittance) can contribute toward identifying individuals with outer ear as well as middle ear pathology. Although use of the term middle ear may be accurate for a significant majority of the persons who fail the screen, the fact remains that not all of those who fail the history, visual inspection, hearing, and/or acoustic immittance components of the protocol have middle ear, inner ear, or retrocochlear pathology. Rather, many have structural defects of the outer ear and/or obstructions such as excessive cerumen or various other abnormalities of the external ear canal that may not be associated with middle ear pathology at all. In short, the guidelines do more than screen for middle ear disorders and hearing impairment, so the outer ear should be included in references to screening as well.

In spite of the broad range of disorders and impairments that can be identified using the procedures recommended in the guidelines, the efficacy of all of the protocols has yet to be established. For example, the recommended tympanometric protocol is based exclusively on use of normative data. That is, according to the guidelines, the criteria that should be used to identify middle ear disorders should be based on cutoffs for peak compensated acoustic admittance and tympanometric width for which 5% of normal ears fail. This essentially predicts specificity. Although the guidelines recommend that clinical data be gathered, the currently recommended protocol calls for identifying those who are outside the normal range. Of course, without sensitivity data (i.e., data on abnormal ears), there is no way to know how well a given protocol will perform. (Since publication of the guidelines, several research studies have been published that discuss the sensitivity and specificity of one or both of the acoustic immittance components of the recommended protocol (Karzon, 1991; Nozza, Bluestone, Kardatzke, & Bachman, 1992; Roush, Drake, & Sexton, 1992; Silman, Silverman, & Arick, 1992) and others are currently under way. On the other hand, the new guidelines make a significant contribution by moving classification of acoustic immittance data away from a pattern detection scheme that at times seems arbitrary and leaves us with inconclusive data, toward an objective system based on actual physical values of acoustic immittance. Although the specific choice of cutoffs may be arguable, the fact that the new guidelines are in step with the recent ANSI standard for aural acoustic immittance (ANSI, 1987) and recommend a quantitative approach for classification of immittance data makes the guidelines an extremely important document within our profession. The significance of this step taken by the Committee on Audiological Evaluation and the Working Group on Acoustic Immittance Measurements in the development of the guidelines for screening for middle ear disorders (ASHA, 1990a) is great and should not be underestimated.

It is appropriate to point out here, also, that the performance of the acoustic immittance variables is affected by instrumentation settings (such as ear canal pressure at which equivalent ear canal volume is estimated) and/or the method for calculating peak admittance, probe tone frequency, pump speed, direction of pressure sweep, and possibly others. The guidelines make it clear that they are based on data using one group of instrumentation settings and may not be generalizable to other settings. Tympanometric norms that are offered in the Appendix to the guidelines are based on a limited sample of children in a narrow age range (approximately 3–6 years old). Therefore, professionals responsible for programs designed to screen for middle ear disorders must remain aware of current research and how it relates to the specific circumstances within which they must work.

The 1990 guidelines do not provide suggestions regarding high-risk groups, such as who they are, how to determine who they are, or what effect using a high-risk or other select group for screening has on performance of the acoustic immittance test. Not defining high-risk groups has been seen as a major limitation of Association guidelines for screening for outer and middle ear disorders (e.g., Bluestone et al., 1986). There is also controversy over the efficacy of visual inspection (otoscopy) for screening for outer and middle ear disorders in all age groups. The reliability of historical information provided by the person being screened or by a significant other (e.g., parent, caregiver, spouse) has yet to be demonstrated.

In spite of the limitations of the 1990 guidelines with respect to the proposed comprehensive framework, they provide a good base from which to launch a more comprehensive set of guidelines. In addition, future guidelines will benefit from the research that has been motivated to a great extent by the development of the 1990 guidelines.

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c. Application of guidelines by age group

Because the breadth of this set of guidelines is so great, and because, ultimately, considerations for screening will be organized by age group, the following section on age-specific information is included. The comments in this section are restricted to issues specific to the age groups and do not, in general, apply to many of the issues discussed above.

1. Infants and Toddlers (29 days to 3 years). One of the missing components in the proposed comprehensive framework of guidelines is guidelines for audiologic screening for infants and toddlers between 1 month and 3 years of age. Even though there are no ASHA guidelines for screening for hearing impairment, disability, and middle ear disorders for infants and toddlers, documents do exist that contain relevant information regarding screening the hearing of those under 3 years of age. For example, the Joint Committee on Infant Hearing 1990 Position Statement (JCIH, 1991) suggests that recurrent otitis media is a risk factor in infants and children between 29 days and 3 years of age. The same position statement also recommends ABR screening of infants under the age of 6 months who meet any of the specified risk factors on the HRR for the age group 29 days to 3 years. The reasons for the Joint Committee recommendation of a two-tiered screening protocol deal primarily with the cost-effectiveness and manageability of applying the ABR test to the high-risk group, which has a prevalence rate of sensorineural hearing loss many times greater than the general newborn population. For infants older than 6 months, the 1990 JCIH position statement recommends ABR testing or behavioral testing using a conditioned response. However, no specific protocol for behavioral screening is recommended for either infants or toddlers. (The Guidelines for the Audiologic Assessment of Children from Birth through 36 Months of Age [ASHA, 1991a] provide assessment protocols for infants, toddlers, and preschoolers that can be used as a starting point for developing behavioral screening protocols for these age groups.)

An important point, made clear by the Joint Committee on Infant Hearing 1990 Position Statement (JCIH, 1991), is the need for early identification of hearing impairment in order to initiate intervention services needed for developing optimal communication and social skills. A discussion in the statement of the effect of childhood hearing impairment on communication and social skills and on educational achievement reminds us that hearing impairment can lead to hearing disability.

2. Preschool (age 3 years to 5 years). The Guidelines for Screening for Hearing Impairment and Middle-Ear Disorders (ASHA, 1990a), in conjunction with the Guidelines for Identification Audiometry (ASHA, 1985), address screening for hearing impairments and outer and middle ear disorders in the preschool population. According to the 1985 guidelines, all children functioning at a developmental level of 3 years of age through third grade, and any high-risk children, should be screened annually using the recommended protocol. Both guidelines are intended for use with children in the toddler and preschool age groups. Groups considered to be at risk for hearing impairment are identified in the 1985 guidelines on identification audiometry, although much of the information relates to school-age children. Also, there is little information in the guidelines on how to improve access to infants and young children or regarding the application of the screening tests in the preschool and school settings or through the primary care provider. From the time children are born until they enter school, access to them for early identification of communication disorders is limited.

3. School-Age Children. For many children, the school hearing conservation and/or screening program may be their first encounter in the process of diagnosing a previously unidentified sensorineural or conductive hearing loss. In addition to the risk factors for hearing impairment listed earlier, many school-age children are also at risk for noise-induced hearing loss by taking part in recreational or work activities in which exposure to high levels of noise occurs.

The student depends on hearing to acquire or maintain communication skills in generally unfavorable listening settings (i.e., classrooms), and to acquire academic skills. The disability caused by bilateral sensorineural hearing loss is well documented. Students with unilateral hearing losses can also experience educational/communication disability. In addition to the health disorders that chronic middle ear disease can cause, some studies indicate a correlation between chronic or fluctuating conductive hearing loss and educational/communication disability. The negative effects on a student with even a mild sensorineural or chronic conductive hearing loss are much more global than the effects of a mild hearing loss that is acquired in adulthood.

Failure of a hearing impairment screening simply sets the audiological assessment protocol into motion. Intervention is not always based on this evaluation alone. It is often based on the failure model. Students often must fail academically or in development of communication skills before they are eligible to receive any special education services. Unfortunately, limited screening tools are available to measure potential educational or communication disability. The importance of developing both screening tools and guidelines for hearing disability in the school-age child cannot be overstressed.

The Guidelines for Screening for Hearing Impairment and Middle-Ear Disorders (ASHA, 1990a) apply to school-age children and are limited by the same factors that limit them in the preschool population. If anything, the problems in using these guidelines are greater for the school-age population because the normative data for tympanometry in the guidelines were developed on children only between 3 and 6 years of age. As mentioned earlier, no specifics regarding high-risk groups for outer and middle ear disorders among the school-age population are offered, although it is probably most reasonable to select subgroups from that population for screening. Because middle ear disorders are more prevalent in the infant and preschool populations than in the school-age population, universal middle ear screening of the school age population will yield only a small number of true positives and may, therefore, be limited in cost-effectiveness. The 1990 guidelines do suggest that pass/fail criteria may need to be modified, depending on specific circumstances, to optimize the screening program as a whole. Modifications presumably would be based, at minimum, on the type and settings (e.g., pump speed, pressure at which ear canal volume is estimated, etc.) of the instrument that is used, age, whether individuals are from a high-risk group or from the general school population, the reason for screening, and availability of follow-up resources. As already mentioned, the efficacy of using visual inspection (otoscopy) and history as part of a screening for school-age children, as well as other age groups, has not been proven.

4. Adults (to 40 years of age). The key aspects of the audiometric screening protocol appear appropriate in light of the intended purpose (i.e., to identify hearing impairment that may interfere with communication). However, some rationale for the selection of the frequency and intensity parameters of the test stimuli is lacking. Adding information detailing these in future guidelines would be welcomed.

An issue that should be considered in future guidelines is whether routine screening for outer and middle ear disorders is warranted with adults, based on the relatively low prevalence of this problem in the adult age group. No direct reference to this is found in the present guidelines. This calls into question the wisdom of recommending one screening protocol for both children and adults, when the circumstances associated with each age group are different in some important respects. The need is evident for the development of a screening protocol that specifically addresses the relevant issues of adults, particularly in view of changing national health care delivery services (“wellness issues”).

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d. Recommendations for screening for hearing impairment and middle ear disorders

  1. More rationale regarding the recommended screening protocols should be provided in documents.

  2. There is a need to develop new methods for access to infants and young children. People other than audiologists and speech-language pathologists (e.g., parents, primary-care physicians, and day-care workers) are more likely to have regular and periodic interactions with the very young. Better ways to incorporate those outside the professions related to communication disorders into the identification of children with hearing impairment, disability, and outer and middle ear disorders should be developed.

  3. There is a need to consider new or different screening instruments in future revised guidelines. The present set of screening guidelines describes the use of some specific screening tools, i.e., visual inspection (otoscopy), history, pure-tone audiometry, and tympanometry. New guidelines should address the possible inclusion of other screening procedures, such as OAEs, acoustic reflectometry, the use of the Audioscope (Welch-Allyn), and others. The inclusion of any procedure should be dictated by its proven reliability and validity, along with measures of its sensitivity, specificity, and predictive values for the populations on which it would be used.

  4. There is a need for the identification of populations or subpopulations (e.g., high-risk groups) to be screened, especially in terms of screening for outer and middle ear disorders.

  5. There is a need for development of behavioral screening tests for children from 6 months to 3 years of age.

  6. There is a need for more data on tympanometric norms for infants and toddlers, more data for preschoolers and school-age children, and data on the relationship between acoustic immittance and middle ear disorders.

  7. The efficacy of visual inspection and history-taking in all age groups must be determined through controlled clinical research.

  8. There is a need for research into the relationship between auditory thresholds and other measures of auditory function and auditory/communication competence at all age levels so we can develop valid definitions of impairment and disability. Included should be any delay or disability in auditory processing of complex signals and processing of auditory signals in unfavorable (noisy) environments. Following that, guidelines for screening for hearing disability in infants, toddlers, preschoolers, and school-age children should be developed.

  9. ASHA documents related to ethical practice and use of support personnel should be revised to reflect a different category for supervision of speech-language pathologists performing screening tests for outer and middle ear disorders.

  10. Education of professionals and the public concerning speech, language, and hearing problems is needed if early identification programs are to function optimally.

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Report: Considerations in Screening Adults/Older Persons for Handicapping Hearing Impairments. (1992d, August), Asha, pp. 81–87.

Report summary: This report reviews issues that have been debated regarding screening in the adult/elderly population. A review of the relevant data illustrates the complexity of the problem and provides a starting place for those wishing to develop a screening program for noninstitutionalized adults and elderly individuals.

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a. General comments

This report is the work of an ASHA Ad Hoc Committee on Hearing Screening in Adults, formed in 1991 to summarize information on hearing screening issues and suggested protocols for adults. In 1987, a subcommittee of the ASHA Committee on Aging and the Committee on Audiologic Evaluation was formed to write hearing screening protocols for noninstitutionalized adults and older people. Although proposed guidelines for adult screening were published in draft form for peer review (ASHA, 1989b), they were not approved by ASHA's Legislative Council and consequently were not adopted as Association policy.

As noted in the preface of the report Considerations in Screening Adults/Older Persons for Handicapping Hearing Impairments (“adults/older persons” report; ASHA, 1992d), the purpose of the document was to “outline the issues surrounding selection of a screening protocol for identifying adults/older persons with handicapping hearing impairments requiring some form of intervention.” The report does not provide a specific screening protocol because of the “dearth of data on the ‘ideal’ hearing screening protocol.” Without data to clearly support one method over another, debate over the different protocols has persisted. The report does, however, include a comprehensive review of the goals of audiologic screening in adults, test instrument options and pass/fail criteria, epidemiological criteria that should be considered in selecting a screening protocol, and examples of protocol options appropriate to the needs of specific populations. As emphasized in the 1992 report, the issues surrounding screening in this population are complex and have been hotly debated. This report addresses the issues raised in the “adults/older persons” report even though it is not a set of guidelines to emphasize the importance of the issues, to help to keep the issues before the Association, and to stimulate thinking, research, and debate on the issues.

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b. Conditions to be screened

In differentiating between the domains of impairment and handicap, the “adults/older persons” report refers to definitions established by the World Health Organization (WHO, 1980). Authors of that report acknowledge a discrepancy in nomenclature between the WHO and the ADA, especially with respect to the use of the term handicap. In fact, the “adult/older persons” report does not use the term disability. In this section, the term handicap will be used as presented in the “adults/older persons” report with the understanding that the use of the term handicap in that report cannot be distinguished from disability as we have defined it in the present report or as it is defined in the ADA and in the Prevention of Communication Disorders Tutorial (ASHA, 1991b). This is done to avoid adding to the confusion for those who refer to the “adults/older persons” report while studying our report. Future guidelines should use terminology consistent with that used in the Prevention of Communication Disorders Tutorial (ASHA, 1991b), in current national policy statements (e.g., ADA), and as provided in the terminology section of the present report.

Tests for impairment, disability, and handicap produce results that are not perfectly correlated and therefore measure different aspects of function. The “adult/older persons” report emphasizes that in screening adults a test for hearing handicap may be of equal or greater importance than a measure of impairment. The report does not make specific recommendations for screening protocols; rather the report briefly summarizes several different suggested protocols. Some screen exclusively for impairment, some for handicap, and some include a two-tiered approach that includes screening for both hearing impairment and hearing handicap. The importance of screening for outer and middle ear disorders using history and visual inspection is also emphasized.

1. Hearing impairment. The most controversial issues in adult screening relate to which audiometric test frequencies and intensity levels should be used to screen for impairment. Evidence is reviewed in the report for selection of one of several combinations of audiometric frequencies between 1000 and 4000 Hz, at levels of 25 to 40 dB HL, with a variety of failure criteria. Pure-tone options reviewed in the report can be reduced basically to consideration of two screening levels, 40 and 25 dB HL, and whether to include 4000 Hz with 1000 and 2000 Hz. In the 1992 report, selection of the appropriate screening stimuli and intensity level, based presumably on specific population needs, is left to the clinician. In this regard the report outlines eight criteria (from epidemiological literature), similar to those presented in this report, which can be taken into account in evaluating the potential effectiveness of a particular screening protocol. The eight items in the “adults/older persons” report include: proven effectiveness of a given protocol from randomized trials, availability of treatments when the disorder is identified, whether the amount of suffering from the disorder is identified, whether the amount of suffering from the disorder warrants screening, availability of good screening tests, access to a screening program by those who can benefit, whether the health care system can handle the increased load resulting from screen failures, and finally, whether compliance rates justify screening efforts.

It is on the issue of compliance that much of the controversy regarding stimulus frequencies and intensity levels seems to hinge. In the 1992 report, compliance is discussed in terms of whether persons who fail the screening follow through with recommendations to see a physician or to pursue hearing aid use. The report includes evidence that low screening fences (e.g., 25 dB HL) are associated with low compliance rates. On the other hand, high screening fences (e.g., 40 dB HL) may give the wrong impression to persons who pass the screening but are truly impaired or experience disability (e.g., those persons with failing scores on a self-report handicap measure). This misimpression may cause delay in seeking needed help, failure to seek help at all, or wasted efforts to find the cause of their problem elsewhere.

2. Disability/handicap screening. Two self-report scales standardized to a reasonable degree on adult populations are mentioned in the report Self Assessment of Communication (SAC; Schow & Nerbonne, 1982) and Hearing Handicap Inventory for the ElderlyScreening (HHIE-S; Ventry & Weinstein, 1983). The report acknowledges that other scales, with good reliability and validity, can be used. Copies of the two above-mentioned scales are included in the report for those not familiar with self-report procedures or who may not use such measures.

3. Outer and middle ear disorders. The screening protocol options outlined in the report include some combination of a pure-tone screening for hearing impairment, a handicap/disability screen, and a brief case history and visual inspection. Acoustic immittance screening is not mentioned in the report, although acoustic immittance testing might be considered for some elderly populations. There is little debate over the contribution of case history and visual inspection; however, further research is needed to determine the value of these procedures, especially in the case of visual inspection.

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c. Application of guidelines by age

No age limit is specified in the report, and thus the reader may assume that information in the report applies to legally defined adults age 18 and older. This creates some confusion with the Guidelines for Identification Audiometry (ASHA, 1985) and Guidelines for Screening for Hearing Impairments and Middle Ear Disorders (ASHA, 1990a), which are specified for children and adults through age 40. This overlap should be clarified with the restructuring of the ASHA screening documents. As indicated in the “adult/elderly” report, there are no good data to support a limit of 40, or any other age, for adult screening in the guidelines.

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d. Recommendations

  1. Guidelines for screening for hearing impairment, disability, and middle ear disorders for adults/older persons should be developed. The report on screening for adults/older persons makes a valuable contribution in bringing together in a concise statement the issues involved in adult/elderly screening. However, screening guidelines (rationale, definitions, protocols, pass/fail criteria, etc.) for adults/older persons are still needed. The report is a useful interim publication, but it is not a substitute for guidelines.

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Report: Telephone Hearing Screening. (1988b, November), Asha, p. 53.

Report summary: This report is a discussion of issues related to screening for hearing impairment using the telephone.

For reasons similar to those used to justify review of the “adults/older persons” report, the report on telephone hearing screening is reviewed here as well. As stated in that report, the rationale for telephone hearing screening is to provide a convenient and private means for the public to access hearing screening. At the same time, its existence may also increase general public awareness about hearing loss and the availability of services for people with hearing loss.

However, the report states that there are no published data that establish that telephone screening is effective in differentiating those with hearing loss from those with normal hearing. Moreover, a number of variables are identified in the reportinconsistent signal levels, variability in the electroacoustic properties among both telephones and transmission lines, unacceptable ambient noise levels, and variability in the coupling force and/or position of the telephone receiver relative to the listener's earthat individually and collectively cast doubt on the validity of hearing screening via telephone.

Consequently, although telephone hearing screening holds promise as a cost-effective and highly accessible method of screening adults for hearing impairment, its widespread use appears ill-advised. Issues basic to the validity and reliability of telephone screening should be resolved through further research before consideration is given to development of guidelines for hearing screening by telephone.

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General Recommendations

The following recommendations highlight areas of ASHA policy and practice with respect to the development of guidelines for screening for hearing impairment, disability, and outer and middle ear disorders.

1. There should be a mechanism (e.g., standing committee) within the Association administrative structure to monitor screening guidelines and protocols for hearing impairment, disability, and middle ear disorders. Such a body would review guidelines regularly. New information related to screening is dynamic. New information related to auditory disfunction is constantly coming to light; new technological developments appear periodically on the scene; new data are reported in the literature; and activities of other committees (ASHA and otherwise) and other professional associations often bear directly on the issue of screening in audiology. For example, the Joint Committee on Infant Hearing is currently drafting a new position on screening that will recommend universal screening of all newborns, and the report of the NIH Consensus Conference on Newborn Screening recommends universal screening as well. Further, although it is important that ASHA monitor ongoing activities on a number of fronts and respond to changes in those areas, ASHA cannot be satisfied simply with reacting to new developments. ASHA must be directly involved (indeed, take a leadership role) in the process of early identification and management of auditory disfunction at all ages. Sole dependence on ad hoc committees to address issues of identification and screening, so critical to audiology as a professional discipline, will perpetuate the fragmented development of guidelines that may be outdated by the time they are published.

The critical state of affairs with respect to certain aspects of screening (e.g., the rapidly changing position on newborn screening, the lack of guidelines for infants and toddlers, the lack of guidelines for adults/older persons, the inconsistencies within documents such as the cumbersome use of two documents to cover screening for hearing impairment and outer and middle ear disorders and others) suggests that time is of the essence and ad hoc committees should be formed immediately, if the Association will not move to have a standing committee for screening in audiology.

2. ASHA should develop a comprehensive and systematic method for development of screening guidelines. Given that ASHA recommends early identification of hearing loss throughout the life span (ASHA, 1988a), guidelines should be developed for screening for all ages and all conditions (disorder, impairment, and disability). The plan should be driven by current trends and current research and should be constantly monitored and revised as necessary. Guidelines should not be consolidated into a single “super-guideline” but rather should remain in modules. The guidelines should be independent and lend themselves to easy revision. Having guidelines assembled in a single location with the common rationale, terminology, and guiding principles presented in an introductory section seems reasonable.

Guideline modules should be organized according to condition (disorder, impairment, disability) or age (newborns, infants, children, etc.) or some other relevant classification scheme. In that regard, although the consolidation of some of the information in the Guidelines for Identification Audiometry (ASHA, 1985) and the Guidelines for Hearing Impairment and Middle Ear Disorders (ASHA, 1990a) is necessary, the wisdom of having guidelines that cover such a broad age range is questioned.

3. A standard format for all guidelines should be developed. Consideration should be given to all aspects of screening as outlined in this report.

4. Screening guidelines and reports should use consistent terminology. As recommended by the Committee on Prevention of Speech Language and Hearing Disorders (ASHA, 1988a; 1991b), speech-language pathologists and audiologists should “utilize consistent terminology related to prevention.” Specifically, the use of terminology related to secondary prevention (early identification/screening) as put forth in this report and in the Tutorial on Prevention of Communication Disorders (ASHA, 1991b) is recommended.

5. It is essential that the guidelines be clear in defining the entity to be screened. Are the guidelines for a screening program designed to screen for disorder, impairment, or disability? Once determined, the definition of the terms as they apply to the population must be clearly expressed. Is the screening designed to make decisions about employment (i.e., rule out) or educational placement (i.e., identify)? Is there a high-risk population for whom the guidelines apply exclusively?

6. ASHA should have as a priority keeping issues and research related to screening before the Association. It is important that ASHA encourage research into the epidemiology of disorders of the auditory system, hearing impairment, and hearing disability and research into the performance of various tests in discriminating those with disorder, impairment, or disability from those without disorder, impairment, or disability. ASHA should actively support clinical trials of different test methods and different populations. In addition, it is essential that ASHA continue to promote the study of ways to estimate screening program costs.

7. Issues regarding personnel and their education and training for screening in audiology should be addressed.

  1. Personnel: Audiological screening can take many forms. All screening for disorders of the auditory system, hearing impairment, and hearing disability should be overseen by a certified audiologist. That is, any program or program component that calls for screening for hearing impairment, disability, or outer and middle ear disorders should be under the direction of a certified audiologist. Any use of support personnel (e.g., communication aide or technician) for various aspects of screening must adhere to ASHA policy regarding support personnel (ASHA, 1981b, 1992a). The current policy can be interpreted as applying particularly to those in training as professionals or those with bachelor's degrees in communication disorders. In fact, the minimum requirement for the audiology assistant is a high school diploma or equivalent. It seems that this approach to support personnel was not developed with the certified speech-language pathologist in mind.

    There is currently some ambiguity with regard to the participation of speech-language pathologists in screening programs designed to identify hearing impairment, disability and middle ear disorders. ASHA documents, such as Preferred Practice Patterns for the Professions of Speech-Language Pathology and Audiology (1993b), Scope of Practice, Speech-Language Pathology and Audiology (ASHA, 1990b), Code of Ethics (ASHA, 1992b) and Clinical Practice by Certificate Holders in the Profession in Which They Are Not Certified (ASHA, 1992c), which is also referred to as the “crossover practice statement,” have information that is relevant to participation of speech-language pathologists in audiologic screening. For pure-tone air-conduction hearing screening, speech-language pathologists can perform a pass/fail hearing screening “for persons who can reliably participate in such procedures through conditioned play or conventional behavioral responses” (“crossover practice document”; ASHA, 1992c). With respect to screening for outer and middle ear disorders, the interpretation has been less clear. ASHA documents suggest that speech-language pathologists doing acoustic immittance screening must do so in the role of support personnel. That stipulation is derived from the above-mentioned documents most notably the “crossover practice statement,” which states that “certificate holders in one profession may…provide support services in the other profession under appropriate supervision. Such services shall comply with the Association guidelines regarding the use of support personnel.” A major question is whether speech-language pathologists, when screening for outer and middle ear disease, should be treated as support personnel, as currently defined by ASHA, or should be treated differently. For example, there are very strict rules regarding the level of direct supervision required for support personnel; the question is whether such intense supervision is required in the case of speech-language pathologists doing acoustic immittance screening in the context of a program designed to screen for (not diagnose) middle ear disorders.

    By request of the Executive Board, the ad hoc committee considered the question of speech-language pathologists doing acoustic immittance tests and prepared a report. The report to the Executive Board recommends that a change in Association policy be made that separates certified speech-language pathologists from “support personnel” with respect to use of acoustic immittance for screening for middle ear disorders. In short, the recommendation reaffirms the importance of having all screening testing done as part of a comprehensive screening program and confirms that supervision of all screening programs for hearing loss and middle ear disorders be done by a certified audiologist. The audiologist who has responsibility for the screening program would develop the appropriate screening criteria, train and supervise the speech-language pathologist(s) based on the specific circumstances (including level of skill and experience of the speech-language pathologist(s), the population served, the instrumentation used, etc.) and monitor the screening data.

  2. Education and training: All audiologists and speech-language pathologists should further their education with respect to epidemiology of disease and screening principles. Understanding sensitivity, specificity, predictive ability, and other terms related to screening is essential to the proper management of screening programs. Those who perform screening tests for disorders of the auditory system, hearing impairment, and hearing disability should undergo a minimum amount of training under the supervision of a certified audiologist. This includes those using active audiometric tests (e.g., pure-tone air-conduction screening) or other instruments. Continuing professional education activities should include state-of-the-art information on screening procedures and protocols.

    As part of their training, those responsible for doing screenings must be made aware of the various instrument settings that could be used and how they may differ with those on which relevant guidelines are based. Normative data and test performance (i.e., sensitivity, specificity, and predictive values) depend, in part, on the specific test parameters used in gathering those data.

    Caution should be exercised by those who would use a “black box” screening device or an instrument in “default” mode without knowing the instrument parameters being used and without a clear understanding of how the test pass/fail criteria were developed.

8. Efforts of future committees should be directed at defining high-risk groups and determining the efficacy of screening such groups.

9. ASHA should continue efforts to educate the general public and professionals about the importance of communication and the importance of early identification of communication disorders.

10. Guidelines for infants (29 days to 3 years) and adults/older persons must be developed.

11. Future guidelines should consider discussing unacceptable screening methods as well as those that are recommended. For example, many methods are used to screen hearing that do not include the use of calibrated signals (e.g., noisemakers, hand-held signal generators, etc.). Such devices provide a noise stimulus for which it is difficult, if not impossible, to specify spectrum and intensity in the settings where they would be used. Furthermore, such devices, when used with young children or infants, require observation and interpretation of behavioral responses. The high likelihood of false-negative findings using such techniques makes them unacceptable, especially when performed by inexperienced persons (i.e., those not certified in audiology).

12. Current guidelines should incorporate ASHA policy on ethical professional practice (see 7a: Personnel, above) and any existing national (e.g., ANSI) standards on test procedures and test environments. Issues surrounding the prevention of hearing loss as discussed in the 1991 ASHA tutorial The Prevention of Communication Disorders should also be acknowledged.

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References

American Medical Association. (1979). Guide for the evaluation of hearing handicap. Journal of the American Medical Association, 241, 2055–2059.

American National Standards Institute. (1987). American national standard specifications to measure aural acoustic impedance and admittance (aural acoustic immittance). In New York: Author.

American Speech-Language-Hearing Association. (1979). Guidelines for acoustic immittance screening of middle-ear function. Asha, 283–288.

American Speech-Language-Hearing Association. (1981a, March). Guidelines for the employment and utilization of supportive personnel. Asha, 165–169.

American Speech-Language-Hearing Association. (1981b). On the definition of hearing handicap. Asha, 293–297.

American Speech-Language-Hearing Association. (1985, May). Guidelines for identification audiometry. Asha, 27(5), 49–52.

American Speech-Language-Hearing Association. (1988a, March). Position statement: Prevention of communication disorders. Asha, 90.

American Speech-Language-Hearing Association. (1988b, November). Report: Telephone hearing screening. Asha, 53.

American Speech-Language-Hearing Association. (1989a, March). Guidelines for the audiologic screening of newborn infants who are at risk for hearing impairment. Asha, 89–92.

American Speech-Language-Hearing Association. (1989b, August). Guidelines for the identification of hearing impairment and handicap in adult/elderly persons (Draft). Asha, 59–63.

American Speech-Language-Hearing Association. (1990a, April). Guidelines for screening for hearing impairments and middle ear disorders. Asha, 32(Suppl. 2), 17–24.

American Speech-Language-Hearing Association. (1990b, April). Scope of practice, speech-language pathology and audiology. Asha, 34(Suppl. 2), 1–2.

American Speech-Language-Hearing Association. (1990c, September). Guidelines for infant hearing screening: Response to Robert G. Turner's analysis. Asha, 63–66.

American Speech-Language-Hearing Association. (1991a, March). Guidelines for the audiologic assessment of children from birth through 36 months of age. Asha, 33(Suppl. 5), 37–43.

American Speech-Language-Hearing Association. (1991b, September). The prevention of communication disorders tutorial. Asha, 33(Suppl. 6), 15–41.

American Speech-Language-Hearing Association. (1992a, March). ASHA policy regarding support personnel. Asha, 34(Suppl. 9), 18.

American Speech-Language-Hearing Association. (1992b, March). Code of ethics. Asha, 34(Suppl. 9), 3–5.

American Speech-Language-Hearing Association. (1992c, March). Code of ethics: Clinical practice by certificate holders in the profession in which they are not certified. Asha, 34(Suppl. 9), 6–7.

American Speech-Language-Hearing Association. (1992d, August). Report: Considerations in screening adults/older persons for handicapping hearing impairments. Asha, 81–87.

American Speech-Language-Hearing Association. (1993a, March). Guidelines for audiology services in the schools. Asha, 35(Suppl. 10), 24–32.

American Speech-Language-Hearing Association. (1993b, March). Preferred practice patterns for the professions of speech-language pathology and audiology. Asha, 35(Suppl. 11), i–102.

Bluestone, C. D., Fria, T. J., Arjona, S. K., Casselbrant, M. L., Schwartz, D. M., Ruben, R. J., Gates, G. A., Downs, M. P., Northern, J. L., Jerger, J. F., Paradise, J. L., Bess, F. H., Kenworthy, O. T., & Rogers, K. D. (1986). Controversies in screening for middle ear disease and hearing loss in children. Pediatrics, 77, 57–70.

Cadman, D., Chambers, L., Feldman, W., & Sackett, D. (1984). Assessing the effectiveness of community screening programs. Journal of the American Medical Association, 252, 1580–1585.

Davis, A. C. (1987). Epidemiology of hearing disorders. In D. Stephens (Ed.), Adult audiology (pp. 90–126). Boston: Butterworths.

Frankenburg, W. K. (1974). Section of diseases and tests in pediatric screening. Pediatrics, 54, 612–616.

Griner, P. F., Mayewski, R. J., Mushlin, A. I., & Greenland, P. (1981). Selection and interpretation of diagnostic tests and procedures. Annals of Internal Medicine, 92, 557–570.

Hyde, M. L., Davidson, M. J., & Alberti, P. W. (1991). Auditory test strategy. In J. T. Jacobson & J. L. Northern (Eds.), Diagnostic audiology. Pro-Ed: Austin, TX.

Joint Committee on Infant Hearing. (1982, December). Position statement. Asha, 1017–1018.

Joint Committee on Infant Hearing. (1991, March). 1990 position statement. Asha, 33(Suppl. 5), 3–6.

Joint Committee on Infant Hearing. (1993, November). 1993 position statement (Draft) Draft.

Karzon, R. G. (1991). Validity and reliability of tympanometric measures for pediatric patients. Journal of Speech and Hearing Research, 34, 386–390.

National Institutes of Health. (1993). Early identification of hearing impairment in infants and young children. NIH Consensus Statement, 11(1).

Nozza, R. J., Bluestone, C. D., Kardatzke, D., & Bachman, R. N. (1992). Toward the validation of aural acoustic immittance measures for diagnosis of middle ear effusion in children. Ear and Hearing, 13, 442–453.

Roush, J., Drake, A., & Sexton, J. E. (1992). Identification of middle ear dysfunction in young children: A comparison of tympanometric screening procedures. Ear and Hearing, 13, 63–69.

Schow, R., & Nerbonne, M. (1982). Communication screening profile used with elderly clients. Ear and Hearing, 3, 133–147.

Silman, S., Silverman, C. A., & Arick, D. S. (1992). Acousticimmittance screening for detection of middle-ear effusion in children. Journal of American Academy of Audiology, 3, 262–268.

Stephens, D., & Hétu, R. (1991). Impairment, disability and handicap in audiology: Toward a consensus. Audiology, 30, 185–200.

Swets, J. (1988). Measuring the accuracy of diagnostic systems. Science, 240, 1285–1293.

Thorner, R. M., & Remein, Q. R. (1982). Principles and procedures in the evaluation of screening for disease. In J. B. Chaiklin, I. M. Ventry, & R. F. Dixon (Eds.), Hearing measurement: A book of readings (2nd ed., pp. 408–421). Reading, MA: Addison-Wesley.

Turner, R. G. (1990, September). Recommended guidelines for infant hearing screening: Analysis. Asha, 32, 57-61, 66.

Turner, R. G. (1991). Making clinical decisions. In W. F. Rintelmann (Ed.), Hearing assessment (2nd ed.). Pro-Ed: Austin, TX.

U.S. Department of Health and Human Services, Public Health Service. (1990). Healthy people 2000: National health promotion and disease prevention objectives. Washington, DC: U.S. Government Printing Office.

Ventry, I., & Weinstein, B. (1983, July). Identification of elderly people with hearing problems. Asha, 25, 37–42.

Weinstein, M., & Fineberg, H. (1980). Clinical decision making. Philadelphia: Saunders.

White, K. R., Vorh, B. R., & Behrens, T. R. (1993). Universal newborn hearing screening using transient evoked otoacoustic emissions: Results of the Rhode Island Hearing Assessment Project. Seminars in Hearing, 14, 18–29.

World Health Organization (WHO). (1980). International classification of impairments, disabilities, and handicaps: A manual of classification relating to the consequences of disease. World Health Organization, 25–43.

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Appendix A: Cross-Reference Outlines—Information by Document

Guidelines for Audiometric Screening of Newborn Infants Who Are at Risk for Hearing Impairment

American Speech-Language-Hearing Association. (1989a, March). Guidelines for infant screening of newborn infants who are at risk for hearing impairment. Asha, 31(3), 89–92.

  • Conditions screened for: “Hearing impairment and communication disability.”

  • Age group: Neonates

  • Methods: High-Risk Register (HRR). Auditory Brainstem Response (ABR) test of HRR failures.

  • Cross References

    1. Joint Committee on Infant Hearing. (1993, November Draft). 1993 position statement. (Draft).

    2. Joint Committee on Infant Hearing. (1991, March). 1990 position statement. Asha, 33(Suppl. 5), 3–6.

    3. Joint Committee on Infant Hearing. (1982, December). Position statement. Asha, pp. 1017–1018.

    4. American Speech-Language-Hearing Association. (1988a, March). Position statement: Prevention of communication disorders. Asha, 30, 90.

    5. American Speech-Language-Hearing Association. (1991b, September). The prevention of communication disorders tutorial. Asha, 33(Suppl. 6), 15–41.

    6. American Speech-Language-Hearing Association. (1992c, March). Code of ethics: Clinical practice by certificate holders in the profession in which they are not certified. Asha, 34(Suppl. 9), 6–7.

    7. Turner, R. G. (1990, September). Recommended guidelines for infant hearing screening: Analysis. Asha, 32, 57–61, 66.

    8. American Speech-Language-Hearing Association. (1990c, September). Guidelines of infant hearing screening: Response to Robert G. Turner's analysis. Asha, 32, 63–66.

  • Committee Recommendations

    1. Guidelines should be monitored and updated regularly to reflect current practice, procedures, and policy.

    2. The definition of what is being screened for, in this case hearing impairment, should be clarified.

    3. Data on the cost-effectiveness, efficiency, and compliance of any screening protocols recommended should be incorporated into the guidelines.

    4. The position on screening only high-risk infants versus universal screening of newborns should be reconsidered.

    5. Guidelines should be extended to the infant population beyond newborn (1 month through 24 months of age).

    6. The efficacy of new and currently available screening procedures (e.g., otoacoustic emissions) should be addressed.

    7. Statements on screening for “disability” and “middle ear disorders,” which are not addressed in the neonatal screening document, should be included in future revisions.

    8. Revisions of the current guidelines should continue to reflect the need for follow-up programs for those infants who fail newborn hearing screening.

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Guidelines for Screening for Hearing Impairment and Middle Ear Disorders

American Speech-Language-Hearing Association. (1990a, April). Guidelines for screening hearing impairments and middle ear disorders. Asha, 32(Suppl. 2), 17–24.

  • Conditions screened for: “Hearing impairment that potentially interferes with communication and/or medically significant ear disorders that have been undetected or untreated.”

  • Age group: Children and young adults aged 3 through 40 years old (must be able to be screened by behavioral audiometry and tympanometry).

  • Methods: History, visual inspection, acoustic immittance measurements, identification audiometry.

  • Cross References

    1. American Speech-Language-Hearing Association. (1985, May). Guidelines for identification audiometry. Asha, 27(5), 49–52.

  • Committee Recommendations

    1. The issues of hearing impairment and middle ear disorders are directly tied to each other and should be represented in the same sets of guidelines.

    2. More rationale regarding the suggested screening protocols should be given.

    3. There is a need for the identification of populations or subpopulations (e.g., high-risk groups) to be screened, especially in terms of screening for outer and middle ear disorders.

    4. There is a need for development of behavioral screening tests for children from 6 months to 3 years of age.

    5. There is a need for the development of tympanometric norms for infants and toddlers, more data for preschoolers, and data on the relationship between acoustic immittance and middle ear disorders.

    6. The efficacy of visual inspection and history taking at the time of screening in all age groups must be determined through controlled clinical research.

    7. There is a need to consider new or different screening instruments in future revised guidelines.

    8. There is a need for research into the relationship between auditory thresholds and auditory/communication competence at all age levels so we can develop valid definitions of impairment and disability.

    9. There is a need to develop new methods for access to infants and young children.

    10. Education of professionals and the public concerning speech, language, and hearing problems is needed if early identification is to function optimally.

    11. ASHA documents related to personnel doing screening should be revised to treat speech-language pathologists doing acoustic immittance screening as something other than “supportive personnel.”

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Guidelines for Identification Audiometry

American Speech-Language-Hearing Association. (1985, May). Guidelines for identification audiometry. Asha, 27, 49–52.

  • Conditions screened for: “Hearing impairment that interferes or has the potential to interfere with communication.”

  • Age group: 3 years through 40 years.

  • Method: Monaural hearing test using pure tones of 500, 1000, 2000, and 4000 Hz at 20 dB HL. Failure is no response at any frequency in one or both ears.

  • Cross References

    1. American Speech-Language-Hearing Association. (1979, April). Guidelines for acoustic immittance screening of middle-ear function. Asha, 21, 283–288. This has been superseded by the Guidelines for Screening for Hearing Impairment and Middle-Ear Disorders (ASHA, 1990a).

  • Committee Recommendations

    1. Consolidate with Guidelines for Screening for Hearing Impairment and Middle Ear Disorders

    2. Define at-risk population to include students who are older than third grade and who exhibit characteristics that indicate that their hearing should be screened.

    3. Develop screening guidelines for disability.

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Report: Considerations in Screening Adults/Older Persons for Handicapping Hearing Impairments

American Speech-Language-Hearing Association. (1992d, August). Report: Considerations in screening adults/older persons for handicapping hearing impairments. Asha, 34, 81–87.

  • Conditions screened for: Hearing impairment, Hearing disability

  • Age group: Adults of all ages

  • Method: Pure-tone audiometry and self-report (“handicap”) disability scales

  • Cross References

    1. American Speech-Language-Hearing Association. (1990a, April). Guidelines for screening for hearing impairment and middle ear disorders. Asha, 32(Suppl. 2), 17–24.

    2. American Speech-Language-Hearing Association. (1992d, August). Report: Considerations in screening adults/older persons for handicapping hearing impairments. Asha, 34, 81–87.

    3. American Speech-Language-Hearing Association. (1985, May). Guidelines for identification audiometry. Asha, 27, 49–52.

  • Committee Recommendations

    1. Guidelines for adults/older persons should be developed.

    2. Future guidelines should address screening adults for impairment, disability, and disorders (i.e., outer and middle ear disorders).

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Report: Telephone Hearing Screening

American Speech-Language-Hearing Association. (1988b, November). Report: Telephone hearing screening. Asha, 30, 53.

  • Conditions screened for: Hearing impairment

  • Age groups: Unspecified, but targeted mainly for adults

  • Method: No specific protocol outlined

  • Cross References

    1. American Speech-Language-Hearing Association. (1985, May). Guidelines for identification for audiometry. Asha, 27, 49–52.

  • Committee Recommendations

    1. Evaluate existing data pertaining to validity, reliability, and other basic issues, and identify areas in need of further investigation.

    2. ASHA should lead in establishing an acceptable protocol if the efficacy of telephone screening can be established.

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Appendix B: Screening Documents by Age Group

I. Infants (newborn to 28 days)

  1. American Speech-Language-Hearing Association. (1989a, March). Guidelines for the audiologic screening of newborn infants who are at risk for hearing impairment. Asha, 31, 89–92.

  2. Joint Committee on Infant Hearing. (1993, November Draft). 1993 position statement (Draft).

  3. Joint Committee on Infant Hearing. (1991, March). 1990 position statement. Asha, 33(Suppl. 5), 3–6.

  4. Joint Committee on Infant Hearing. (1982, December). Position statement. Asha, 24, 1017–1018.

  5. American Speech-Language-Hearing Association. (1988a, March). Position statement: Prevention of communica tion disorders. Asha, 30, 90.

  6. American Speech-Language-Hearing Association. (1991b, September). The prevention of communication disorders tutorial. Asha, 34 (Suppl. 6), 15–41.

  7. American Speech-Language-Hearing Association. (1992c, March). Code of ethics: Clinical practice by certificate holders in the profession in which they are not certified. Asha, 35(Suppl. 9), 6–7.

  8. American Speech-Language-Hearing Association. (1991a, March). Guidelines for the audiologic assessment of children from birth through 36 months of age. Asha, 34(Suppl. 5), 37–43.

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II. Infants and Toddlers (29 days to 3 years)

  1. American Speech-Language-Hearing Association. (1990a, April). Guidelines for screening for hearing impairments and middle-ear disorders. Asha, 33(Suppl. 2), 17–24.

  2. Joint Committee on Infant Hearing. (1993, November Draft). 1993 position statement (Draft).

  3. Joint Committee on Infant Hearing. (1991, March). 1990 position statement. Asha, 34(Suppl. 5), 3–6.

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III. Preschoolers (3 years 1 day to 5 years)

  1. American Speech-Language-Hearing Association. (1985, May). Guidelines for identification audiometry. Asha, 27, 49–52.

  2. American Speech-Language-Hearing Association. (1990a, April). Guidelines for screening for hearing impairments and middle-ear disorders. Asha, 33(Suppl. 2), 17–24.

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IV. School-age children (5 years to 18 years)

  1. American Speech-Language-Hearing Association. (1985, May). Guidelines for identification audiometry. Asha, 27, 49–52.

  2. American Speech-Language-Hearing Association. (1990a, April). Guidelines for screening for hearing impairments and middle-ear disorders. Asha, 33(Suppl. 2), 17–24.

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V. Adults I (19 years to 40 years)

  1. American Speech-Language-Hearing Association. (1985, May). Guidelines for identification audiometry. Asha, 27, 49–52.

  2. American Speech-Language-Hearing Association. (1990a, April). Guidelines for screening for hearing impairments and middle-ear disorders. Asha, 33(Suppl. 2), 17–24.

  3. American Speech-Language-Hearing Association. (1988b, November). Report: Telephone hearing screening. Asha, 30, 53.

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VI. Adults II (40 years and older)

  1. American Speech-Language-Hearing Association. (1992d, August). Report: Considerations in screening adults/older persons for handicapping hearing impairments. Asha, 35, 81–87.

  2. American Speech-Language-Hearing Association. (1988b, November). Report: Telephone hearing screening. Asha, 30, 53.

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Index terms: screening

Reference this material as: American Speech-Language-Hearing Association. (1994). Audiologic screening [Technical Report]. Available from www.asha.org/policy.

© Copyright 1994 American Speech-Language-Hearing Association. All rights reserved.

Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.

doi:10.1044/policy.TR1994-00238

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