The scope of this page is hearing screening for toddlers, preschoolers, and school-age children. For information on screening children ages 0–6 months of age, see Newborn Hearing Screening.
A hearing screening is used to identify individuals who may require a more comprehensive hearing assessment and/or medical management. Hearing screenings for children may take place in early childhood settings, school settings, community settings, audiology clinics, medical settings, and/or home settings.
As of 2011, 97.9% of babies born in the United States were screened for hearing loss shortly after birth (Centers for Disease Control and Prevention [CDC], 2013). Minimal, frequency-specific, late-onset, or progressive hearing losses may not be identified during newborn hearing screenings (See Newborn Hearing Screening). By school age, close to 15% of children in the U.S. exhibit some level/type of hearing loss of at least 16 dB HL (Niskar et al., 1998).
Hearing screenings during childhood are vital for early identification and management of hearing loss. "Failure to detect congenital or acquired hearing loss in children may result in lifelong deficits in speech and language acquisition, poor academic performance, personal-social maladjustments, and emotional difficulties" (Harlor & Bower, 2009, p. 1253). Hearing loss does not have to be severe in order to impact a student's access to auditory-based classroom instruction. Educationally significant hearing loss can be unilateral, bilateral, minimal in degree, high frequency, or long-standing conductive. See Permanent Childhood Hearing Loss for more information.
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
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
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:
Screening for school-age children may include:
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 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
Pure Tone Screening Procedure
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 (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
OAE Screening Procedure
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
Tympanometry Screening Procedure
Tympanometry Screening Results
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.
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.
See 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).
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.
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 Health Literacy.
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 Health Literacy.
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).
American Academy of Audiology Task Force. (2011). Childhood hearing screening guidelines. Retrieved from www.audiology.org/publications-resources/document-library/pediatric-diagnostics.
American Academy of Otolaryngology–Head and Neck Surgery. (2013). Clinical practice guideline: Tympanostomy tubes in children. Otolaryngology – Head and Neck Surgery, 149(S1), S1-S35.
American Academy of Pediatrics. (2004). Otitis media with effusion. Pediatrics, 113(5), 1412-1429.
American National Standards Institute. (2003). Maximum permissible ambient noise levels for audiometric test rooms(Rev. ed.) (ANSI S3.1-1999). New York, NY: Author.
American National Standards Institute. (2010). Specification for audiometers (ANSI S3.6-2010). New York, NY: Author.
American Speech-Language-Hearing Association. (2006). Preferred Practice Patterns for the Profession of Audiology [Preferred practice patterns]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of practice]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. Available from www.asha.org/policy/.
Bhatia, P., Mintz, S., Hecht, B. F., Deavenport, A., & Kuo, A. A. (2013). Early identification of young children with hearing loss in federally qualified health centers. Journal of Developmental and Behavioral Pediatrics, 34(1), 15-21.
Centers for Disease Control and Prevention. (2013). Summary of 2011 national EHDI data. Retrieved from www.cdc.gov/ncbddd/hearingloss/2011-data/2011_ehdi_hsfs_summary_a.pdf.
Eiserman, W. D., Shisler, L., Foust, T., Buhrmann, J., Winston, R., & White, K. (2008). Updating hearing screening practices in early childhood settings. Infants & Young Children, 21(3), 186-193.
Gorga, M. P., Neely, S. T., Ohlrich, B., Hoover, B., Redner, J., & Peters, J. (1997). From laboratory to clinic: A large scale study of distortion product otoacoustic emissions in ears with normal hearing and ears with hearing loss. Ear and Hearing, 18(6), 440-455.
Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). (2008). Bright Futures: Guidelines for health supervision of infants, children, and adolescents(3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics.
Harlor, A. D., Jr., & Bower, C. (2009). Hearing assessment in infants and children: Recommendations beyond neonatal screening. Pediatrics, 124(4), 1252-1263.
Hussain, D. M., Gorga, M. P., Neely, S. T., Keefe, D. H., & Peters, J. (1998). Transient evoked otoacoustic emissions in patients with normal hearing and in patients with hearing loss. Ear and Hearing, 19(6), 434-449.
Johnson, C. D., & Seaton, J. B. (2012). Educational Audiology Handbook(2nd ed.). Clifton Park, NY: Delmar.
Joint Committee on Infant Hearing. (2007). Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics, 120(4), 898-921.
Kreisman, B. M., Bevilacqua, E., Day, K., Kreisman, N. V., & Hall, J. W. (2013). Preschool hearing screenings: A comparison of distortion product otoacoustic emission and pure-tone protocols. Journal of Educational Audiology, 19,48-57.
Margolis, R. H., Bass-Ringdahl, S., Hanks, W. D., Holte, L., & Zapala, D. A. (2003). Tympanometry in newborn infants-1kHz norms. Journal of the American Academy of Audiology, 14(7), 383-392.
Meinke, D. K., & Dice, N. (2007). Comparison of audiometric screening criteria for the identification of noise-induced hearing loss in adolescents. American Journal of Audiology, 16,S190-S202.
Niskar, A. S., Kieszak, S. M., Holmes, A., Esteban, E., Rubin, C., & Brody, D. J. (1998). Prevalence of hearing loss among children 6 to 19 years of age. Journal of the American Medical Association, 279(14), 1071-1075.
Prieve, B. A., Schooling, T., Venediktov, R., & Franceschini, N. (2015). An evidence-based systematic review on the diagnostic accuracy of hearing screening instruments for preschool- and school-age children. American Journal of Audiology, 24,250-267.
Richburg, C. M., & Imhoff, L. (2008). Survey of hearing screeners: Training and protocols used in two distinct school systems. Journal of Educational Audiology, 14,31-46.
Rosenfeld, R. M., Culpepper, L., Doyle, K. J., Grundfast, K. M., Hoberman, A., Kenna, M. A., … Yawn, B. (2004). Clinical practice guideline: Otitis media with effusion. Otolaryngology–Head and Neck Surgery, 130(5), S95-S118.
Rosenfeld, R. M., & Kay, D. (2003). Natural history of untreated otitis media. The Laryngoscope, 113(10), 1645-1657.
Sekhar, D. L., Zalewski, T. R., Ghossaini, S. N., King, T. S., Rhoades, J. A., Czarnecki, B., … Paul, I. M. (2014). Pilot study of a high-frequency school-based hearing screen to detect adolescent hearing loss. Journal of Medical Screening, 21(1), 18-23.
Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee. (2007). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings.Retrieved from www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf.
Stephenson, M. (2007). The effect of classroom sound field amplification and the effectiveness of otoacoustic emission hearing screening in school-age children. New Zealand Health Technology Assessment Technical Brief, 6(3), 1-60.
U.S. Department of Health and Human Services. (2015a). Head Start Program Performance Standards; 45 CFR,§1304.20 (b)(1).Retrieved from http://eclkc.ohs.acf.hhs.gov/hslc/standards/hspps/1304/1304.20%20Child%20health%20and%20developmental%20services.htm.
U.S. Department of Health and Human Services. (2015b). Head Start Program Performance Standards; 45 CFR,§1308.6 (b).Retrieved from http://eclkc.ohs.acf.hhs.gov/hslc/standards/hspps/1308/1308.6%20%20Assessment%20of%20children.htm.