THE JOURNAL OF SCHOOL HEALTH

A GROUP SCREENING TEST OF AUDITORY ACUITY

HARRY HOLLIEN, Ph.D. Communicat ion Sciences Laboratory, University of Florida

JOSEPH M. WEPMAN, Ph.D. Speech and Language Research Laboratory, University of Chicago

CARL L. THOMPSON, Ph.D. Communicat ion Sciences Laboratory, Louis iana State Uniuersity

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A white-uniformed school nurse stands before an easel facing a roomful of children seated at desks. Each student wears a set of earphones con- nected to an audiometer placed on a table a t the front of the room. The nurse points to the first line of the poster on the easel, a large replica of the aiiswer sheet lying on each child’s desk.

“Ready?” she says to the children, “Then listen to the sounds you will hear through your earphones. Now . . . mark your paper.”

The nurse in the classroom is a public school nurse.* The class is any grade in any school. The occasion is one of screening a group of school children for possible hearing loss-to identify those pupils who need additional individual hearing tests and medical referrals.

Specifically, this procedure for the auditory screening of hearing acuity parallels visual screening approaches using such tools as the Snellen Charts. Both of these screening tests are essential to ensure identification of those children with a relatively gross loss of auditory or visual ability.

Moreover, screening tests constitute the first step in the discovery of specific learning problems that an individual child may be having. Log- ically, tests of hearing acuity should precede the usual tests of auditory discrimination and memory now widely used to appraise students’ learn- ing readiness (1). I n fact, such specialized tests of hearing discrimination and auditory memory (used to measure the child’s assimilation of the speech signals he receives) always should be preceded by an auditory screening test, just as tests of the visual perceptual abilities (recognition of form, size, etc.-and the ability to recall them) always should be pre- ceded by visual screening tests. Fortunately, tests are now available to screen for both abilities.

The present paper describes a newly-available auditory screening test which has been evaluated experimentally with nearly 5000 school children. In its present form, i t is proving to be an adequate test in a wide variety of school situations.

Criteria for a n Effective Group Screening Test of Audi tory A c u i t y It has been suggested (2) that, to be satisfactory, a group test of hear-

1. Utilize .a pure-tone testing technique; 2 . Be brief, simple to administer and easy to grade; 3 . Use standard audiometric equipment; 4. Provide a practice sample prior to the administration of the test;

*It is not mandatory that the test administrator be a nurse. For example, she could be a special education teacher or a speech correctionist.

The test in its present standardized form, like its companion test of auditory discrimination, can be obtained from the Language Research Associates, 300 N. State St., Chicago, Illinois 60610.

ing acuity must:

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5 . Provide the students with visual as well as auditory cues; 6. Present selected test frequencies in a descending order of loudness; 7. Be of high validity, reliability and efficiency. The new Hollien-Thompson Group Screening Test of Hearing meets

The means by which it complies with each of the

1. This test utilizes pure-tone frequencies, the audiometric standard for testing hearing acuity. Hence, i t is based on the most effective ap- proach known in the identification of hearing losses of potential medical significance. 2. With respect to simplicity of administration, the Hollien-Thompson Test reflects the results of five years of laboratory and field tests and evaluation; these efforts led to appropriate revisions and refinements. I n its present form, the test can be given easily by nurses or teachers; for that matter, i t could even be administered successfully by PTA volunteers or other competent adults interested in the childrens' welfare.

The grading of the test can be accomplished, without prior train- ing, by a class aide or a student assistant. The grader uses a guide supplied with the test; specifically an overlay card or template with cutouts revealing the correct answer for each line (when it is placed on an answer sheet). Thus, each test can be graded quickly and easily by a non-professional.

Moreover, the test is economical in its consumption of class time, requiring only 15 minutes for classes of third graders and up; 20 minutes for first and second graders. Scoring the test requires only about 10 seconds for each answer sheet, or six to seven minutes in all for a class of forty pupils. 3. The Hollien-Thompson Test uses standard audiometric equipment, readily available to most schools; it requires only a standard manual audiometer and up to 40 headsets. 4. In order to introduce students to the test and prepare them for what they will be asked to do, they are given a prelimmary series of three trials which resemble the six sections of the test. This precau- tion eliminates false starts, panic or misunderstanding-and provides the class with a demonstration of the testing procedure they are going to follow. 5. The test administrator's gestures in relation to the poster on the easel and her vocal guidance provides students with both aural and visual guidance in taking the test. This double approach further in- sures that unnecessary errors will be kept to a minimum-as does the arrangement of the response elements on the answer sheets. 6. The method used presents test sounds in a descending order of loudness, a design preferable since i t allows pupils to become acquainted with the task they must perform before the sounds presented to them approach their auditory threshold. 7. The validity, reliability and efficiency of this test have been established by means of a series of experimental studies. Each stage of the redesign and refinement of the test was followed by repeated field tests and validation studies. These evaluations were performed by comparison of the group data to data from individual hearing acuity tests, and by a study of replications of the group procedure.

these requirements. criteria are discussed in the following section.

THE JOURNAL OF SCHOOL HEALTH 585

Therefore, i t can be seen that extensive research and large-scale field testing have substantiated the usefulness of the Hollien-Thompson Test as a screening vehicle for the hearing acuity of school-age popula- tions. Incidentally, i t is equally valid for screening adult groups such as office and factory workers.

It should be stressed again that the test is designed for simultaneous screening of substantial numbers of individuals for the express purpose of achieving reasonably quick and easy identification of medically signifi- cant hearing problems. The test identifies those test-takers who probably have hearing losses, and individuals thus identified always should receive individual hearing tests and be provided with medical referrals.

Test Description As stated, this test was developed to fulfill the need for an efficient and

expeditious means of surveying the hearing acuity of large numbers of school children. Research was conducted by the authors and their staffs in eight separate experiments in cooperating schools in Wac0 and Mexia, Texas, in Wichita, Canton and Wellington, Kansas, and in Gaines- ville, Florida; the test population numbered nearly 5,000 elementary school boys and girls.

The test consists of a series of prescribed, controlled signals that reach the pupil through individual headsets, or earphones, connected to the audiometer. The student marks on his answer sheet the number of pulsed signals he hears through his earphone.

After the students finish taking the test, the answer sheets from the entire class are graded and students who fail to receive a “passing” score are recalled with a subsequent class to take another group test. A second failure indicates tho need for an individual hearing test.

In the test, sounds are administered in six four-part groups: 1,hat is, in 24 short segments, or lines. Each of the 24 segments consists of from zero to three pulses of the specified frequency. On each of the 24 lines on his answer sheet, the student marks an “X” over the number of pulses he hears for that presentation.

The administrator’s guide is, except in two respects, an exact replica of the answer sheet placed O K ~ the desk before each student and of the identical larger reproduction of the answer sheet resting on the easel a t the front of the room. The administrator’s form shows the frequency and the level at which she is to set the audiometer for each of the test units; i t also identifies the number of pulses to be presented (by an “X” printed over that number).

The administrator first tests the acuity of the left ear, transmitting via the earphones three groups of pulsesets, four to a group. This pro- cedure is then repeated for the right ear. The frequencies employed :we 500, 1000 and 4000 HZ (cps); the hearing levels used in the test are 35, 25, 20 arid 20 d13. ASA standards currently are used throughout but the test can be converted easily to the new IS0 standards.

Preparing to Give the Test Since most classes contain forty (or fewer) students, the test is designed

with that number as a maximum. Moreover, forty phones are convenient since often there is fewer than that number in a class; hence, all members of the class can be evaluated as well as some pupils returning for retesting.

The following suggestions may be helpful in preparation for the test.

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1. In advance of testing time, the nurse or teacher should distribute a blank answer sheet for each student to all home room teachcrs. Further she requests that students come to the testing room a t the appointed time with the identification section already filled out, and that they seat themselves in the testing room quickly and quietly. Home room teachers should also be told that some students may be recalled (with subsequent groups) for a re-testing. 2. The test room is arranged with four rows of desks, ten desks wide. 3. The easel and poster should be positioned a t the front of the room in clear view of the class arid within easy reach of the administrator’s pointer. 4. The audiometer should be placed on a table or stand beside the poster, oriented toward the class so as to conceal the administrator’s hands from view while the pulses are being presented. 5. The headsets are then connected to the audiometer and one head- set placed on each desk.

The administrator is now ready for the first group of pupils. Giving the Test

After the students are seated, the test administrator explains in general terms that they are going to discover what sounds they can hear; and that, although this is called a test, i t will not be graded in the usual manner; that is, pupils’ answers simply will be checked to see that they are hearing.

Then she asks the pupils to place their earphones over the left ear and administers the test as follows:

1. Pointing to the poster, the administrator directs pupils’ attention to the appropriate line on the answer sheet. 2 . Beginning with the practice group, top center, she calls out the position, saying, “Practice Group, Line 1 .,’ Requesting attention she then says ‘LListen.J’ This warns the children that the test is about to begin. She then presents the pulses for the first item of the Practice Group and says to the class, “Mark.” The students mark an “X” on Line 1 in the box having the digit corresponding to the number of pulses or “beeps” they heard. The administrator provides the class with the correct answer and marks an “X” in the correct box on the poster. It should be noted that,, in one case, no pulses are presented. This procedure is to alert the pupils to the fact that they may not hear any pulses during parts of the test. 3. Having finished the Practice Group, the administrator then pro- ceeds to the three frequency groups for the left ear; then she instructs the class to change earphones to the right ear and repeats the pro- cedure for the right ear.

In order to avoid giving any clues to the class, the administrator should appear to provide three pulses for each unit of each group, regardless of how many signals the administrator’s guide instructs her to give. In addition, and for the same reason, she should say “Listen” arid “RIark” using the same speech rhythm for each presentation.

Grading the Test As explained above, answer sheets for the Hollien-Thompson Test can

be graded rapidly by student assistants utilizing an appropriate template. Student assistants, seated in the rear of the testing room, can score the :mswer sheets for one class while the next class is being tested. In any case, to score the answer sheets, the grader places the template over

T H E JOURNAL OF SCHOOL HEALTH 587

each answer sheet in turn; only boxes with correct answers will show through cutouts in the template. The grader marks a red cross in any box she can see (which the student failed to mark) and counts the red crossmarks in order to compute the score for that answer sheet.

A student “passes” the test if he has marked correctly a t least one of the last two (20 bB) items in each of the six groups. (If he heard a 20 decibel signal, he is assumed to possess hearing keen enough to receive any sounds or signals louder than that.) A student “fails” the test if he did not mark correctly a t least one of the last two (20 dB) lines in each of the six groups.

Retaking the Test When a student “fails” the test as defined here, he is asked to return

the same day (with a later class) to retake the test. This replication can be arranged inconspciously by having the student assistant summon pupils for retesting while escorting a subsequent group to the testing room.

Technical Data Widespread concern over the lack of an adequate group screening test

for hearing acuity for use in the schools led the authors to investigate a number of available tests (References 3, 4, 5, 6, 7). However, none of these were found to meet adequately the several criteria listed above. Hence, the authors’ search for a practical and effective group hearing test led them along predictable paths of research, testing and retesting.

The search began with modification of what they considered to be the best then-existing group screening vehicle for children (8, 9). The initial modification (2) tried with little success to improve the ease of administration of the Reger-Newby instrument by utilizing a more widely accessible and more easily operated manual testing device in lieu of the previously required special automatic audiometer. However, the results obtained by this modification, on a school child populat8ion of 495, indicated the advisability of developing an entirely new vehicle for group screening in preference to continued revision and modification of the Reger-Newby test.

Following the realization that a new approach was called for, the authors designed and evaluated, in actual school classroom situations, an approach that attempted to meet the criteria for satisfactory tests of this nature. The research data can be found in references 10 and 11; these efforts led to the group screening test of auditory acuity described above.

REFERENCES 1. Wepman, J. M. The perceptual basis for learning. Chap. 4 in Meeting Individual

Differences in Reading, (Ed. A. Robinson), Supplementary Education Monograph, No. 94. Chicago: University of Chicago Press, 1964.

2. Hollien, H. and Thompson, C. L. An evaluation of the Reger-Newhy group hearing test administered manually, J. Auditory Res., 1961, 1,294-305.

3. Curry, E. T. and Nagel, R. F. An evaluation of group hearing tests methods. Except . Child., January, 1959, 25, 199-201.

4. U. S. Department of Health, Education and Welfare. Health aspects of hearing conversation. Supp., 1959, page 38.

5. Glorig, A. and House, H. P. A new concept in auditory screening. Arch. of Otlaryng., Chicago, 1957, 66, 228-232.

6. Johnston, P. W. The Massachusetts hearing test. J . Acoust . Soc. Am., 1948,

7. Nielsen, S. F. Tonandiometermethode zur gruppenuntersuchuny dm gehors der Acta . Oto-Laryngol., Stockh., 1944, 32, 263-283.

8. Reger, S. and Newby, H. A. A group pure-tone hearing test. J . Speech and

Trans. A m e r . A c . Opthal. and Otolaryng.

20, 697-703.

schulkinder.

Hear. Dis. , 1947, 12, 61-66.

588 THE JOURNAL OF SCHOOL HEALTH

9. Newby, H. A. Group pure-tone hearing testing in the public schools. J . Speech and Hear. Dis., 1947, 12, 359-362.

10. Hollien, I€. and Thompson, C. L. A group screening test of hearing. J . Auditory Res 1967, 7, 85-92.

11. Hoden. II. and Thomuson. C. L. Fornis C and D of the Hollien-Thomoson group screening test of hearing. J. Aid i tory Res., 8, 1968, 143-150.

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