Audiologists, by virtue of academic degree, clinical training, and license to practice, are qualified to provide guidance, development, implementation, and oversight of hearing screening programs. See ASHA's
Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles and responsibilities for audiologists include
- selecting screening protocols appropriate for the setting, population, and personnel;
- selecting, upgrading, and calibrating screening equipment;
- completing hearing screenings;
- training screening personnel and monitoring the competencies of screening personnel;
- selecting and/or developing educational materials for families;
- monitoring key indicators (pass/fail rates, miss rates, adherence to follow-up protocol, etc.);
- developing and implementing written policies and procedures—
- infection control procedures,
- screening techniques and process,
- documentation of screening results (per state/district/program policies);
- communicating screening results to families, appropriate program and/or school representatives, state public health agencies (e.g., Early Hearing Detection and Intervention [EHDI]), primary care physicians, and diagnostic audiology centers as indicated;
- providing counseling and education;
- completing rescreenings and diagnostic evaluations as indicated;
- referring for medical and/or other professional services as indicated;
- collaborating with health and education professionals to ensure appropriate follow-up and outcomes;
- remaining informed of research in the area of childhood hearing screenings and childhood hearing loss.
As indicated in the
Code of Ethics (ASHA, 2016a), audiologists who work in this capacity should be specifically educated and appropriately trained to do so.
Speech-language pathologists (SLPs) play a role in the screening, speech/language/communication assessment, and rehabilitation of individuals with hearing loss and the referral of individuals suspected of having hearing loss to an audiologist as appropriate. See
ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for speech-language pathologists include
- collaborating with audiologists in the development of screening protocols, equipment selection, and quality improvement;
- performing hearing screenings;
- referring children who do not pass screenings for audiologic, medical, and/or other professional services as indicated;
- referring children who are difficult to test to an audiologist;
- communicating screening results to families, including recommendations for timely follow-up;
- sharing screening results with appropriate program and/or school representatives, state public health agencies, state EHDI programs for children under 3 years, primary care physicians, and diagnostic audiology centers as indicated;
- providing counseling and education for families, educators, and other service providers;
- collaborating with audiologists, school nurses, teachers, physicians, and/or other professionals to ensure appropriate follow-up and outcomes.
As indicated in the
Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.
Periodic screening of all children will help to identify those who were either lost to follow-up or not identified during the newborn period or those who developed hearing loss after the newborn period. Such screening includes the following:
- Ongoing surveillance and hearing screening beyond the newborn period, per the American Academy of Pediatrics (AAP; Harlor & Bower, 2009).
- Children ages 6 months to 3 years typically require screening with automated technology (i.e., otoacoustic emissions [OAEs]).
- Although OAEs are considered an acceptable screening tool, pure-tone screening remains the gold standard and is ideally accomplished by the time the child is 5 years old.
- Children who cannot complete a pure-tone screening prior to kindergarten may be considered for an audiologic referral.
- Mandated hearing, vision, and comprehensive developmental screening within 45 days of entry into Early Head Start and Head Start programs (U.S. Department of Health and Human Services [HHS], 2015a, 2015b).
- Targeted, careful monitoring of children who are at high risk for delayed-onset hearing loss based on Joint Committee on Infant Hearing (JCIH) risk indicators (JCIH, 2007).
- Screening of child’s hearing in response to a concern raised by the parent/guardian/caregiver or by a teacher/service provider.
- Inclusion of hearing screening as part of any comprehensive speech-language evaluation.
Screening for school-age children may include:
- screening of child's hearing upon initial entry or transfer into school and every year in Grades K–3 and 7 and 11 (ASHA, 2006);
- hearing screening as part of educational monitoring for home-schooled or privately educated children;
- annual risk assessment (and follow-up as needed) each year that the child's hearing is not screened or assessed, per the AAP (Hagan, Shaw, & Duncan, 2008);
- screening of adolescents with an adapted protocol (e.g., one that includes 6000/8000 Hz, threshold testing, the use of otoacoustic emissions [OAEs]) for increased likelihood of identifying early high-frequency hearing loss/noise-induced hearing loss (Meinke & Dice, 2007; Sekhar et al., 2014);
- required/mandated hearing screenings, per state (See
- screening of child's hearing upon notice of any parent/guardian/caregiver or teacher/school staff concern;
- hearing screening as part of any comprehensive speech-language evaluation.
The selection and implementation of hearing screening protocols and equipment will be guided by the specific goals of the individual hearing screening program. The target population, available personnel, and type of hearing loss to be included—as well as program-specific needs and/or limitations—are important considerations. Pure tone audiometry, OAE technology, and tympanometry may all be appropriate options for inclusion in hearing screening programs. Automated versions of hearing screening tools are available and can be utilized by trained support personnel. Evidence has been compiled regarding commonly used screening tools (Prieve, Schooling, Venediktov, & Franceschini, 2015).
Otoscopy completed by a trained examiner allows for visualization of the tympanic membrane and inspection of the external ear canal for drainage, foreign bodies, impacted cerumen, infection, or structural abnormalities. A screener who is not trained in otoscopy can perform a general visual inspection of the outer portion of the ear and make note of any abnormalities. The information obtained during visual inspection or otoscopy may have an important impact on screening results and/or call for the discontinuation of screening and referral to medical personnel.
Pure Tone Screening
Pure tone screening is typically accomplished with the use of a pure tone audiometer. Pure tone stimuli at octave-band frequencies are routed through TDH supra-aural earphones or insert earphones. With younger children, pulsed or warble tone stimuli may be presented instead of pure tones. Some screening audiometers limit the screening frequencies and presentation levels. These audiometers will not provide the flexibility of a single channel audiometer in regard to adapting protocols for different populations (Johnson & Seaton, 2012).
Factors to Consider
- Personnel may include an audiologist, SLP, nurse, or other trained lay or volunteer screener.
- Noise contamination in the screening environment may prohibit screening in any or all frequency ranges.
- It may not be possible to complete pure tone screenings in the low frequency range, even in a quiet environment, due to physiologic noise from the child or poor acoustics.
- In order for pure tone screening to be accurate, the child must be able to reliably respond to stimuli (i.e., by raising his or her hand when the stimuli are presented). For younger students or students with developmental, cognitive, or motoric challenges and/or delays, conditioned play techniques can also be effective (Harlor & Bower, 2009; Johnson & Seaton, 2012). The cognitive requirements to respond accurately and appropriately to the pure tone tasks may preclude participation by certain groups, such as the very young pediatric population and those with developmental delays.
Pure Tone Screening Procedure
- Condition the child to respond appropriately using suprathreshold (e.g., 40 dB HL) stimuli prior to initiation of screening. Administer a minimum of two conditioning trials to ensure that the child understands the task.
- Play audiometry may be more appropriate for children ages 2–4 years (Harlor & Bower, 2009). This type of pure tone screening requires screeners who are specially trained in conditioned play audiometry techniques.
- Present pure tones (typically presented at 1000, 2000, 4000 Hz in each ear at 20 dB HL).
- Note: Some screening programs may choose to add 500 Hz at 25 dB HL.
- Note: Some screening programs for older students may choose to add 6000 Hz at 20 dB HL in order to identify possible high-frequency hearing loss consistent with damage from noise exposure.
- Limit testing to no more than four presentations per frequency to reduce false positive responses (American Academy of Audiology [AAA], 2011).
- If the child does not respond at one or more frequencies, reinstruct, reposition earphones, and rescreen within the same screening period
- Follow-up may include referral to a health care provider for evaluation of ear canal obstruction and/or middle ear dysfunction.
Pure Tone Screening Results
Pass—appropriate response to all presentation stimuli at screening levels in both ears
Fail—lack of response to any test frequency at screening levels in either ear
Could Not Screen—lack of cooperation, inability to be conditioned to the response task, etc.
Otoacoustic Emissions (OAE)
Otoacoustic emissions (OAEs)—either transient-evoked OAEs (TEOAEs) or distortion product OAEs (DPOAEs)—are measured using a sensitive probe microphone inserted into the ear canal. OAEs are a direct measure of outer hair cell and cochlear function in response to acoustic stimulation and yield an indirect estimate of peripheral hearing sensitivity. OAEs do not technically test an individual's hearing, but rather OAE results reflect the performance of the inner ear mechanics. OAEs are not sensitive to disorders central to the outer hair cells, such as auditory neuropathy spectrum disorder (ANSD), which is a neural hearing loss that leaves cochlear (outer hair cell) function intact.
Factors to Consider
- Personnel may include an audiologist, SLP, nurse, or other trained volunteer screener. Equipment can be automatic with no decision making required regarding equipment parameters or pass/fail criteria.
- "The involvement of a pediatric audiologist is essential in selecting OAE screening equipment, developing and implementing an appropriate screening and follow-up protocol, and providing training and technical assistance to screeners and other professionals" (Eiserman et al., 2008, p. 190).
- The use of OAE technology may be appropriate for screening children who are difficult to test using pure-tone audiometry (those who cannot respond to traditional pure tone or conditioned play techniques; Stephenson, 2007).
- Screening in quiet environments typically reduces the amount of time needed to complete an OAE hearing screening. A reasonable amount of noise may be present without interrupting the OAE screening process. OAE equipment may indicate when the screening environment is too noisy.
- It may not be possible to complete OAE screenings in the low frequency range, even in a quiet environment, due to physiologic noise from the child or poor acoustics.
- With OAE protocols taking less time than pure tone protocols, more children may be screened on a given day (Kreisman, Bevilacqua, Day, Kreisman, & Hall, 2013).
- OAEs will usually be absent when there is outer or middle ear dysfunction.
- OAEs may miss some cases of educationally significant mild and mild-moderate hearing loss or ANSD (AAA, 2011).
- OAE protocols may result in refer rates that are higher than those of pure tone and OAE/tympanometry protocols. Multiple OAE screenings may be needed/used to limit false positive findings and medical referrals for children who fail the initial OAE screen, but who do not actually need treatment (Eiserman et al., 2008).
OAE Screening Procedure
- Complete otoscopic or visual inspection to determine presence or absence of impacted cerumen, drainage, foreign bodies, infection, or structural abnormalities of the pinna, canal, or tympanic membrane. Make note of abnormalities to inform decisions related to follow-up recommendations (Johnson & Seaton, 2012). Follow-up may include referral to a health care provider for evaluation of ear canal obstruction and/or middle ear dysfunction.
- Place small probe in the ear canal to deliver the sound stimuli.
- Read results. Automated OAE screening units will analyze the emission and provide a result of either "pass" or "fail/refer." Diagnostic units will require interpretation of the findings by audiologists. Screeners other than audiologists should not independently change the parameters of the test equipment or provide interpretation of findings.
TEOAEs: Clicks or tone bursts are used as the stimuli at one level—for example, 80 dB SPL. Normal distributions for this condition for normal hearing are documented in the literature (Hussain, Gorga, Neely, Keefe, & Peters, 1998).
DPOAEs: Pure tones are used as the stimuli. Normal distributions for this condition for normal hearing are documented in the literature (Gorga et al., 1997).
OAE Screening Results
Screening programs that use OAE equipment often use the manufacturer's pre-set stimulus and pass/fail parameters, which will vary. This allows for participation by screeners who do not have the background or knowledge to adjust or interpret result parameters. When automated equipment is used, findings will be recorded as either "pass" or "fail/refer." For children who could not complete screening due to lack of cooperation, internal or external noise, or other reasons, the findings are recorded as "could not screen."
Tympanometry can be added to the protocols of either pure tone or OAE testing to measure the mobility of the tympanic membrane and the status of the middle-ear transmission system. During tympanometry, a probe is fit snuggly into the ear canal. Pressure between the probe and eardrum is varied between +200 dB PA and -400 dB PA. Reflected sound from the probe tone is recorded across the pressure range, and a tympanogram is created. Tympanogram results convey the status of the middle ear system and suggest conditions that may need medical attention, such as eustachian tube dysfunction, middle ear fluid, or perforated eardrum.
Factors to Consider
- Personnel may include an audiologist, SLP, nurse, or other trained volunteer screener. Automated equipment may be used.
- Because younger children are at increased risk of failing the pure tone screen due to middle ear fluid (i.e., otitis media with effusion [OME]), consideration may be made to incorporate tympanometry in screening of children ages preschool through first grade (AAA, 2011). "Children with chronic OME may develop structural changes of the tympanic membrane, hearing loss, and speech and language delay" (American Academy of Otolaryngology–Head and Neck Surgery, 2013, p. S15).
- Tympanometry can better target the need for a rescreening or an immediate referral for medical or audiologic evaluation.
- "Combining office-based otoacoustic emission screening with tympanometry allows the physician to monitor transient conductive hearing loss (CHL) associated with middle ear effusion in the office setting and refer to audiology only those patients with concerns for more persistent CHL or sensorineural hearing loss (SNHL)" (Bhatia, Mintz, Hecht, Deavenport, & Kuo, 2013).
- It is appropriate to immediately refer a child for audiologic assessment if he/she passes tympanometry, but fails pure tone screening.
Tympanometry Screening Procedure
- Complete otoscopic or visual inspection to determine presence or absence of impacted cerumen, drainage, foreign bodies, infection, or structural abnormalities of the pinna, canal, or tympanic membrane. Make note of abnormalities to inform decisions related to follow-up recommendations (Johnson & Seaton, 2012). Make note of the presence or absence of PE tubes. Follow-up may include referral to a health care provider for evaluation of ear canal obstruction and/or middle ear dysfunction.
- Place probe in ear canal to deliver tones and vary the air pressure between positive and negative.
- Tympanogram is created.
- Note: A 220 Hz probe tone is appropriate for the 6 month–18-year-old population (Margolis, Bass-Ringdahl, Hanks, Holte, & Zapala, 2003).
Tympanometry Screening Results
- Automated equipment will report results as "pass" or "fail/refer."
- When nonautomated equipment is used, the recommended referral criteria is >250 da Pa tympanometric width for children 3–12 years of age and >275 da Pa tympanometric width for children below age 3. If the use of tympanometric width is not possible,
<0.2 mmhos static compliance is recommended (AAA, 2011).
- Note: Ear canal volume of >1.0 cm3 and flat tympanogram can indicate either patent PE tubes or tympanic membrane perforation.
- Lack of cooperation and/or other factors may result in inability to screen.
Note: The presence of PE tubes may lead to a "refer" result; however, this result must be confirmed with otoscopy by a trained examiner. The presence of patent PE tubes is not differentiated from a perforated tympanic membrane with the use of tympanometry alone.
The choice of protocol for a hearing screening program is based on factors such as the type(s) of hearing loss to be included, available technology, population to be screened, and staffing/audiology resources. State regulations must also be considered, as they vary. Obtaining informed parent/legal guardian permission is a recommended part of the protocol; however, extant state statutes/regulations or institutional policies supersede this recommendation.
Decision trees [PDF] for four screening protocols are provided. These decision trees represent examples of the decision-making process that is undertaken during childhood hearing screenings. While processes may vary between screening programs, they should be documented and consistent within a given program.
- Pure Tone Screening Only
- Pure Tone and Tympanometry
- OAE Screening Only
- OAE and Tympanometry
Considerations for Screen/Rescreen Timelines
- Timelines for referral and rescreening must be determined on a case-by-case basis, with consideration given to the child's overall health, otoscopic examination findings, and individualized educational concerns.
- When a pure tone or pure tone and tympanometry protocol is used, the rationale for the 6- to 8-week timeline between initial failed screen and rescreening is based on the timeline for spontaneous recovery of middle ear effusions and the prevalence of middle ear effusions in children. The AAP (2004) indicates that a child with otitis media with effusion (OME) and no other significant risk can be managed with watchful waiting for up to 3 months from the date of onset or diagnosis. OME after untreated acute otitis media (AOM) had 59% resolution by 1 month and 74% resolution by 3 months (Rosenfeld & Kay, 2003).
- The 6- to 8-week timeline also allows the clinician to provide information about the persistence of possible middle ear effusion to the primary care provider or other medical professional. "When children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration … and provide additional relevant information such as history of AOM and developmental status of the child" (Rosenfeld et al., 2004, p. S96).
- Some school districts choose to use a shorter 2- to 4-week timeline, which has the benefit of earlier assessment and management of those children with undiagnosed permanent hearing loss. A drawback of a shorter timeline is possible over-referral of children who may have a middle ear effusion in the process of resolution. Otitis media is among the most common health care concerns prompting childhood visits to a doctor.
There are many factors that must be considered by administration and/or appropriate staff prior to initiation of a childhood hearing screening program. When a childhood hearing screening program is developed, it is important to include procedures related to appropriate and timely follow-up. Consideration of the resources necessary to provide appropriate services and to maintain ongoing communications with children and their families is vital.
Audiometric equipment must meet applicable specifications of ANSI/ASA S3.6-2010 (ANSI, 2010) and/or manufacturer recommendations to ensure accurate results. Exhaustive electroacoustic calibrations should be performed annually using instrumentation traceable to the National Institute of Standards and Technology. Functional inspection, performance checks, and bioacoustic checks should be conducted to verify equipment performance prior to each use (American National Standards Institute [ANSI], 2010). Visual inspection may be completed to check for any obvious equipment damage. All calibration activities should be conducted by a trained audiologist or an external company/individual who is properly trained in performing such tasks.
Currently, there are no ANSI standards for the calibration of OAE equipment. For this reason, there may be differences in signal calibration, calculation of the noise floor, and response determination algorithms between manufacturers. These differences could impact the level of hearing loss that can be detected during screening.
Screening programs with supervision provided by an educational audiologist use more uniform protocols that "should result in more accurate screening results, a better system for referrals, and proper diagnoses" (Richburg & Imhoff, 2008, p. 41). All screeners receive thorough initial training and refresher training as needed to maintain screening skills and knowledge. It may be beneficial for the results of new screeners to be validated by experienced screeners until novices become more comfortable with the equipment and screening process. While it is beneficial for screening programs to be flexible and adaptive to meet their specific personnel needs, adherence to stated or written policies/procedures that were chosen or developed for their specific program is essential.
Audiology Assistants for information on the training, educational standards, and roles/responsibilities of these paraprofessionals.
Test environments for pure tone screening should meet the specifications detailed in Maximum Permissible Ambient Noise Levels for Audiometric Test Rooms (ANSI, 2003).
- Based on a 20 dB HL screening level, the allowable ambient noise, if an individual has 0 dB HL hearing threshold, is 50, 58, and 76 dB SPL respectively for 1000, 2000, and 4000 Hz (ANSI, 2003).
- An alternative approach is to use a biologic noise level check prior to the commencement of hearing screening. This has been defined as the ability to establish hearing thresholds at least 10 dB below the screening level (e.g., 10 dB HL for screening conducted at 20 dB HL) at all frequencies for a person with known normal hearing. If these thresholds cannot be established, the area must not be used for screening (Minnesota Department of Health, 2006). Results of this approach may not necessarily reach ANSI standards.
- The screening environment is free from visual distractions and interruptions.
- There are currently no ANSI standards regarding the OAE screening environment.
It is important to ensure that adherence to universal precautions and appropriate infection control procedures are in place during screenings. Instrumentation that comes into physical contact with the patient must be cleaned and disinfected after each use (and per manufacturer's instructions), and clinician hand washing between patients should be routine (Siegel, Rhinehard, Jackson, Chiarello, & the Healthcare Infection Control Practices Advisory Committee, 2007). Disposable equipment, such as probe tips, should be discarded after each use. See Occupational Safety and Health Administration (OSHA) standards relating to
occupational exposure to bloodborne pathogens and the Centers for Disease Control and Prevention's
universal precautions for preventing transmission of bloodborne infections.
Follow-Up and Referral Procedures
Appropriate follow-up for screening programs includes the rescreening of those children who did not pass the initial screen and the screening of children who were absent during the initial screen, as well as proper referrals for medical, audiologic, or educational evaluations as appropriate (Johnson & Seaton, 2012).
Documentation and Recommendations
Screening documentation generally includes identifying information, comprehensive results, and recommendations, including the need for rescreening and appropriate referrals (ASHA, 2006).
Local, state, and federal regulations may vary with regard to parent/guardian notification and permission for a child to participate in hearing screening. Parents/guardians may be informed in writing prior to the screening date to give them the opportunity to express any preference for their child not to be screened, to request that they provide any important background information regarding the child's hearing, and to inform them of the type of follow-up communication they can expect. Parent/guardian notification materials may include basic information about the process and purpose of hearing screening, as well as information about the educational impact of hearing impairment. See
Screening and Rescreening Forms
Recordkeeping methodology will be determined, in part, by the setting and/or material availability. Options include student-specific paper forms, classroom-specific paper forms, or computer database entry, among others. Screening form use and type may be determined by the policies of each program/school/district with respect to the compilation and maintenance of child/student health records.
Proper documentation of screening results may include reporting to the program/school, reporting to the parents/guardians, and receiving information back regarding follow-up recommendations (Johnson & Seaton, 2012). When providing results to parents/guardians whose child is referred for medical or audiologic follow-up, the screener may give the parents/guardians a feedback form to give to the provider and then return to the program/school. Providing screening results to program/school personnel (e.g. health specialists, nurses, teachers, administrators, SLPs) will facilitate the proper follow-up and/or accommodations appropriate for the student. It may be beneficial to notify the parents/guardians after any failed screening, even if a rescreening is planned, so that they can be involved in any decision making regarding next steps. See
In determining the effectiveness of the screening program, various quality indicators can be used. It is important to collect data, such as the number of children screened, the number of children who did not pass the initial screen and/or rescreening, the number of children referred for medical or audiologic follow-up, the number of children seen for professional follow-up, and the number of children diagnosed with and/or treated for hearing disorders. Other quality indicators may include how quickly children move through the recommended protocol and the number of provider reports returned following referral, as well as parent/guardian satisfaction. Such data "can help document need for the hearing screening program, identify over or under referrals that can target equipment or training needs, help track loss to follow-up, and clarify other issues that impact the efficiency and effectiveness of a hearing screening program in the schools" (AAA, 2011, p. 46).
- Most states have
hearing screening requirements pertaining to newborns and school-age children. It is important to check with your state for the most current information on its policies and regulations.
- Local Head Start/Early Head Start programs must comply with the Head Start Performance Standards (45 CFR Parts 1300–1311) and are monitored by the Administration for Children and Families under HHS. See
Head Start Regulations Relating to Hearing Screening.
- The Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program is the child health component of Medicaid. EPSDT provides access to screening, diagnostic, and treatment services for low-income children. See
EPSDT and Title V Collaboration to Improve Child Health.
Individuals with Disabilities Education Act (IDEA)
Part B (34 CFR 300) includes hearing screening in the audiology services provided. IDEA
Part C requires that audiologists and SLPs who identify hearing loss or language delays in children younger than age 3 initiate a referral to the Part C program "as soon as possible," but not more than 7 calendar days after identification.