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Frye-Osier, JackThe Wisconsin Guide to Childhood Hearing Screening.Bulletin No. 94143.Wisconsin State Dept. of Public Instruction, Madison.Bureau for Exceptional Children.9363p.

Bureau for Exceptional Children, Wisconsin Departmentof Public Instruction, 125 South Webster Street, P.O.Box 7841, Madison, WI 53707-7841.Guides Non-Classroom Use (055)

MF01/PC03 Plus Postage.Auditory Tests; *Disability Identification; EarlyChildhood Education; *Early Intervention; FederalRegulation; Government Role; *Hearing Impairments;Hearing Therapy; Parent Role; *Screening Tests; StatePrograms; Teacher Role; *Young Children*Wisconsin

This guidebook was developed to assist Wisconsinparents, educators, and other professionals who deal with youngchildren in the early identification of hearing problems. Section 1provides an overview of the topic and discusses the importance ofearly identification and treatment of hearing problems. Section 2examines state and federal laws, regulations, and programs thatrequire, facilitate, or encourage the identification of hearing lossin infants, toddlers, and children. Section 3 addresses significanthearing screening issues and the elements of an effective screeningprogram. Section 4 provides descriptions of specific screening tests,test protocols, and referral guidelines. Section 5 discusses theproblem of unresponsive children and children who are difficult toscreen, outlining strategies to include these children in screeningprograms. It also summarizes the main themes of the guide. Section 6consists of five appendixes, providing copies of an AmericanSpeech-Language-Hearing Association statement on infant hearing, alist of resources for parents and caregivers, a sample homeconditioning program, a glossary, and a list of relevant materials.(MDM)

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BEST COPY AVAILABLE

The Wisconsin Guide toChildhood Hearing Screening

Jack Frye-OsierConsultant

Educational Audiology

4.000NNqvDPI

Wisconsin Department of Public InstructionMadison, Wisconsin

9

This publication is available from:

Bureau for Exceptional ChildrenWisconsin Department of Public Instruction

125 South Webster St.P.O. Box 7841

Madison, WI 53707-7841(608) 266-6981 (Voice)(608) 267-2427 (TDD)

Bulletin No. 94143

© 1993 by Wisconsin Department of Public Instruction

The Wisconsin Department of Public Instruction does not discriminateon the basis of race, color, religion, sex, national origin, age or handicap.

Printed on Recycled Paper

ContentsForewordAcknowledgments vii

1 OverviewThe Issue 1

The Challenge 2Who Can Benefit from This Guide 2The Plan of the Guide 2References 3

2 State, Federal, and National Support 5National Initiatives 5Federal Laws, Regulations, and Programs 6Wisconsin Rules, Regulations, Programs, and Initiatives 7References 9

3 Screening Principles and Progra n ComponentsScreening Principles 13Selecting the Population to be Screened 14Hearing Screening Personnel and Training Elements 14The Referral Process 16The Medi,;al Component of the Screening Program 17The Audio logic Component of the Screening Program 17Monitoring and Follow-Up Responsibilities and Procedures 20Screening Equipment 22The Hearing Screening Environment 24References 25

4 Test Protocols and Pass/F'ail Referral CriteriaRecommended ProceduresNewborn Hearing Screening 27Recommended ProceduresHearing Screening of Infants

and rvoddlers, Ages 29 Days to Three Years 28Recomi. mded ProceduresHearing Screening of Children

Ages Three and Older 31References 38

5 Barriers to Successful Childhood Hearing ScreeningMisunderstanding the Need to Screen All Targeted Children 39Belief That Rehabilitation is Impossible for Some 40Difficulty in Locating Resources 40Summary 41Reference 41

6 AppendixesA. Joint Committee on Infsnt Hearing 1990 Position Statement 44B. Resources and Educational Materials for Parents a .id Caregiver, 52C. Sample Home Conditioning Program 53D. Glossary 55E. Relevant Materials 58

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Foreword

The normal development of children's language and communication skills is a wondrousprocess that occurs during the early years of life and provides the foundation for learning,socialization, and full participation in our communities. All of us entrusted with the well-being and education of our children must be vigilant to identify, early in their lives, threatsto normal development of language and communication skills and to minimize them.Unidentified hearing loss in infancy and early childhood poses such a threat to thousands ofWisconsin children. Minimizing this threat will require many in the community to shareresponsibility and to collaborate. Hospitals, public and private health care providers, Birthto Three Programs, nursery schools, Head Start programs, day care centers, and schools allhave a role to play.

The Wisconsin Department of Public Instruction developed this guide in collaborationwith the Wisconsin Department of Health and Social Services. Its purpose is to help agenciesand individuals in our communities entrusted with the health, education, and welfare of ourchildren to close the gap between what we know about identifying hearing disabilities earlyin life and what we currently do. The state developed this guide with formal input fromrepresentatives of the public schools, public and private health care providers, Head Startand Birth to Three programs, provider professional organizations, and the deaf and hard ofhearing community. The information in this guide reflects a wide consensus and describescurrent best practices for identifying hearing disabilities as early in life as possible.

This country's national education goal of ensuring that all children start school ready tolearn by the year 2000 cannot be fully met until hearing screening programs implementpractices that guarantee the early identification of hearing disabilities. Communities mustrecognize the importance of this issue and collaborate to get the job done. Communicationamong responsible agencies, programs, providers and families, which is grounded in acommon information base, is essential to success. Thi% guide provides that common informa-tion base.

John T. BensonState Superintendent

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Acknowledgments

The Department of Public Instruction wishes to recognize and thank the many people whoassisted with the development of this publication.

Statewide Task ForceJanice CollinsFormer SupervisorSchool Health ServicesAppleton Senool District

Robert BalasProfessor of AudiologySchool of Communicative DisordersUW-Stevens Point

Jim KiesowAudiologistCESA 10Chippewa Falls

Donna MacDonaldDirector of Pupil ServicesClintonville School District

Peggy CampSupervisor, Early Age ProjectDevelopmental Disability Service CenterKenosha

Karen DishnoOffice of the Hearing ImpairedDivision of Vocational RehabilitationMadison

Cindy RieckSpeech and Language PathologistNeenah Joint School District

Kathy DahlPublic Health NursePepin County Nursing ServiceDurand

Thomas GerberOtologistRice Lake

Nola LarsonSupport SpecialistGreat Lakes Resource Access ProgramCESA 5Portage

Raymond WahltonAudiologistFormerly of the Maternal

and Child Health SectionDivision of HealthMadison

Mindy SchaffnerFormer Birth to Three CoordinatorDivision of HealthMadison

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Staff ContributorsDivision for Handicapped Children and Pupil ServicesJuanita S. PawlischAssistant Superintendent

Paul T. HalversonDirectorBureau for Exceptional Children

Brent C. OdellChiefEarly Childhood, Sensory and Language Impaired Section

Division for Management and BudgetBureau for School and Community RelationsMargaret T. Dwyer, EditorVictoria Horn, Graphic ArtistGreg M. Doyle, Proofreader

Bureau for Information ManagementKathy Addie, Management Information TechnicianLinda Zach, Management Information Technician

B

The IssueFor most children, hearing is the primary sen-

sory channel in the complex multisensory, cogni-tive, and motor process through which speech andlanguage skills are normally learned, and humancommunication normally develops. This processseems to proceed effortlessly during the earlyyears of life providing the child with the basicskills necessary for successful communication andacademic and psycho-social developmen c. Manychildren, however, experience temporary or per-manent loss of hearing that, if undetected or inap-propriately managed, may interfere with the nor-mal development oflanguage and communication,academic success, and social-emotional well be-ing.

The developmental consequences of hearingloss are greatest during the critical early mor 'hsand years of life when language and cpmmunica-tion skills are learned (Downs, 1986). It has longbeen understood that the first three to four yearsof life are a very important period for the develop-ment of language skills. During this period, theinfant is highly receptive to the sensory, motor,and cognitive experiences on which language learn-ing is based. Infants with normal hearing learnlanguage as an auditory code: they repeatedlyexperience pairings of speech sounds with objects,events, and emotions. When disruptions in audi-tory reception occur in early infancy, prompt andsustained interventions are necessary to restorethe stability and full utility of the auditory experi-ence. For infants whose auditory system impair-ment is so severe that auditory language learning

Overview

is not possible, early identification is essential toprovide timely language interventions, based onvisual and/or tactile encoding strategies.

The numbers ofinfants and children with hear-ing loss are surprisingly high. While prevalenceestimates vary (Adams and Hardy, 1989; Berg,1986; Lundeen, 1991; and Ross and Giolas, 1978),it is likely that at least three percent of children inthe kindergarten through grade 12 populationhave significant hearing impairments. Includedin this number are children with unilateral andbilateral hearing loss, those with permanent im-pairments, and those with fluctuating hearinglosses due to chronic or recurrent middle eardisease. When one examines the statistics forspecific groups of children, the numbers are con-siderably higher. For example, 12 percent of thegeneral pediatric population have chronic or re-current otitis media and the resultant hearingimpairment. Most of these cases occur during thefirst three years of life when one in three childrenhave three or more episodes of this disease. (Blue-stone, et al., 1986)

Up to 50 percent of children with cognitive dis-abilities have been found with significant hearingloss (Kropka and Williams, 1986), and within thatpopulation, at least seven in ten children withDown Syndrome are known to have significanthearing loss. (Dahle and McCollister 19._.5; Davies,1988; and Kile, et al., 1990) In addition, school-agechildren with other disabilities suffer with per-sistent h earing loss more than eight times as oftenas children in the broader population ofschool-agechildren. (MacDonald, 1988; Mielke and Huntoon,1988; and Haasch, 1989)

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The vast majority of childhood hearing loss andthe conditions which lead to persistent fluctuatingchildhood hearing loss are present oi developduring early infancy. (Marchant, et al, 1984;Downs, 1986; and Riko, et al., 1985) Valid, reli-able, and cost-effective screening tools and meth-ods exist to identify them during that period. Yetin the U.S., children with severe to profound hear-ing losses are typically not identified until age two,and children with lesser degrees of permanenthearing impairment are frequently not identifieduntil at least age four. In addition, this country'shealth care system does not typically identifyinfants and preschoolers at risk for chronic orrecurrent otitis media, nor does it track them forhearing loss and communicative impairments.This situation can result in the loss of auditoryinformation that is critical for language develop-ment during the preschool years.

In Wisconsin, most hearing screening for chil-dren occurs in the school-age population and usu-ally in the school setting. In addition to screeningchildren for hearing loss relatively late in life,many school programs suffer from other short-comings. Among them are inadequately trainedand supervised screening personnel, lack offollow-up of' children who fail the screening pro-cess, nonstandard screening tools and procedures,inadequate communication and recordkeeping sys-tems, and inattention to the populations of school-age children most at risk for hearing loss and itsconsequences. (Frye-Osier and Wahlton, 1988)

The ChallengeComprehensive community hearing screening

programs for appropriate populations of children,implemented as early in life as possible, wouldresult in the identification of most hearing impair-ments well before children enter school. The lossof sen sory input and costly delays in rehabilitativeinterventions during the critical pre-school yearscould be prevented. Clearly there is a need toimprove childhood hearing screening programs inWisconsin.

To be successful, comprehensive hearing screen-ing programs for infants and children must be acommunity effort. Physicians, public health pro-viders, hospitals, medical clinics, nursery schools,day care centers, Head Start programs, Birth-to-Three programs, public and private schools,social service agencies, and families all must playa role and collaborate to get the job done. Success-ful screening programs must ensure the applica-

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tion of valid and reliable screening tools bywell-trained and well-supervised staff. Commu-nication systems mustbe developed among screen-ing programs, families, educational systems, andhealth providers to build understanding and acommon sense of purpose and to ensure a promptand dependable exchange of information.

Identifying children who fail hearing screeningtests and the middle ear function screening tests,however, is only the beginning. Both medical andaudiologic evaluations must occur, and resultsmust be communicated clearly to families, screen-ers, and educators. Families and educators mustunderstand the developn.ntal, communicative,and academic implications of documented hearingloss. Lastly, quality hearing screening shouldmake certain that children's hearing is monitoredduring and after the medical treatment process toensure resolution of the hearing loss or documen-tation of permanent or persistent temporary loss-es of hearing.

Who Can Benefit fromThis Guide

This guide is written to assist hearing screen-ing leadership personnel throughout the commu-nity to understand and provide the elements nec-essary for quality, comprehensive screeningservices. Leadership personnel must make a com-mitment to state-of-the-art screening methods;well-trained and well-supervise1 screening per-sonnel; effective communications with families,medical providers, and educators; accurate record-keeping; and persistent monitoring and follow-upif screening efforts are to have value. This guidewill assist program leaders in all of these areas,and should be the basis for hearing screeningprogram planning and development.

The Plan of the GuideThis guide exists as a resource to assist commu-

nities in the identification of children with hearingimpairments from birth through their public schoolyears and to facilitate prompt and effective evalu-ations, treatment, and rehabilitative interven-tions. Section 2 of the guide acquaints the readerwith state and federal laws, regulations, and pro-grams that require, facilitate, or encourage theidentification of hearing loss in infants, toddlersand children. Section 3 provides the reader witha discussion ofimportanthearingscreening issuesand the elements of a screening program; profes-

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sionals must carefully consider these as they es-tablish or update their hearing screening pro-grams. Description s of th e specific screening tests,test protocols, and referral guidelines are includedin section 4. Section 5 discusses the problem ofunresponsive children and children who are diffi-cult to screen and strategies for managing andincluding these children in the hearing screeningprogram. Finally, section 5 summarizes the im-portant themes in this guide and challenges com-munities to work toward the provision of qualityhearing screening programs.

Most readers will find Appendix D, the glossa-ry, an important reference tool when reading thisguide. Many terms in this book are technical anddescribe audiological procedures or techniques.Readers should rely on the glossary when anyconfusion over a term's mz-ianing or significancearises.

The guide will also assist the reader with refer-ences to relevant professional literature, sampleprogram forms, helpful resources, and referencesto professional organizations which may provideuseful educational and informational materialsfor hearing screening programs.

ReferencesAdams, Patricia P., and Ann M. Hardy. "Current

Estimates from the National Health Survey,1988." Vital and Health Statistics. Series 10.(Oct. 1989), pp. iv+.

Berg, F.S. "Characteristics of the Target Popula-tion." In Educational Audiology for the Hard ofHearing Child. Ed. F.S. Berg et al. New York:Grune and Stratton, 1986, pp. 1-24.

Bluestone, C.D., et al. "Controversies in Screeningfor Middle Ear Disease and Hearing Loss inChildren." Pediatrics 77.1 (1986), pp. 57-70.

Dahle, A.J., and F.P. McCollister. "Hearing andOtologic Disorders in Children with Down Syn-drome." American Journal of Mental Deficien-cy 90.6 (1986), pp. 636-42.

Davies, B. "Auditory Disorders in Down Syndrome."Scandinavian Audiology Supplements 30(1988), pp. 53-61.

Downs, M.P. "The Rationale for Neonatal HearingScreening." In Neonatal Hearing Screening.Ed. E.T. Swigart. San Diego, CA: College HillPress, 1986, pp. 3-19.

Frye-Osier, J. and R. Wahlton. 1985-86 WisconsinSchool District Hearing Screening Survey. Wis-consin Department of Public Instruction, 1988.

Haasch, K. Report on PL 99-457 DiscretionaryGrant in Educational Audiology. AppletonSchool District, 1989.

Kile, J., et al. "Children with Down Syndrome:Hearing, Language, and Speech Issues." Paperpresented to the annual meeting of the Ameri-can Speech-Language-HearingAssociation. Se-attle, Washington, November 16-19, 1990.

Kropka, B., and C. Williams. "The Epidemiologyof Hearing Impairment in People with MentalHandicap." In Sensory Impairment in MentallyHandicapped People. Ed. David Ellis. SanDiego, CA: College Hill Press, 1986.

Lundeen, C. "Prevalence of Hearing ImpairmentAmong School Children." Language, Speech,and Hearing Services in the Schools 22.1(1991),pp. 269-71.

MacDonald, D. Report on PL 94-142 Discretion-ary Grant in Educational Audiology. RacineCounty Handicapped Children's EducationBoard. Union Grove, WI, 1988.

Marchant, C.D., et al. "Course and Outcome ofOtitis ' in Early Infancy: A Prospecti s'eStudy. Journal of Pediatrics. 6.5 (November1984), pp. 151-57.

Mielke, D., and J. Hunt; on. Summary of 1987-88Special Project in Edinational Audiology. Co-operative Educationfil Service Agency 6. Osh-kosh, WI, 1988.

Riko, K., et al. "Issues in Early Identification ofHeari. Loss." Laryngoscope 95(1985),pp. 373-81.

Ross, M., and T. G. Giolas, eds. Auditory Manage-ment of Hearing Impaired Children. Balti-more, MD: University Park Press, 1978.

Ii 3

State, Federal, and National Support

Professionals have learned much abt ut theimpact of unidentified hearing loss in infants andchildren in recent years, and there is now a strongnational consensus among those in the health,communicative disorders, educationd, and 6hilddevelopment fields thathearing loss mustbe iden-tified as early in life as possible. Legislation acrossthe nation reflects the strength of this consensus:18 states now have legislative mandates for screen-ing for hearing loss in newborns (Welsh and Slat-er, 1993); and 34 states have la\ is or regulationsthat require hearing screening in specific popula-tions of children. (Wisconsin Department of Pub-lic Instruction, 1990) Additional evidence docu-menting this consensus is found in the followingmaterial, which consists of a summary of n ationalinitiatives; federal and Wisconsin laws and regu-lations; and policies and programs that mandate,facilitate, or encourage hearing screening effortsin various populations of infants and children.

National InitiativesThe Joint Committee on Infant ',tearing

For over 20 years, professional groups con-cerned with hearing loss in infants have collabo-rated nationally, which has resulted in positionpapers on neonatal screening. Since 1973, theJoint Committee on Infant Hearing, which con-sists of representatives from national medical andcommunicative disorders organizations, has pro-duced three position statements detailing specificmethods for identifying hearing loss in the new-born period. Each of the advocated methods fromthe Joint Committee includes the application ofrisk criteria to all infants. The most recent docu-

ment, published in 1990, outlines methods thatthe Joint Committee recommends as the bestpractice in neonatal and infant he ring screening.(see Appendix A) It contains the most comprehen-sive list to date of the factors that place an infantat increased risk for hearing loss. These methodsidentify at least half of moderate and greaterhearing impairments in the newborn. They areused in 15 of the 18 states that have mandatednewborn hearing screening and in the five statesthathave non mandatory statewide newborn hear-ing screening program s. (Welsch and Slater, 1993)

Healthy People 2000 Report

Another example of an organized national ef-fort to address the need for early identification ofhearing impairment is Healthy People 2000: Na-tional figalth Promotion and Disease PreventionObjectives (U.S. Department of Health and Hu-man Services, 1991). This report is the priduct ofan effort, facilitated by the national government,to promote health and disease prevention. Allstate health departments and 300 national orga-nizations produced a comprehensive documen.containing strategies and specific objectives forthe year 2000 to improve national health anddisease prevention. Included in the report are twoobjectives related to the identification of hearingloss in children. The first objective is to reduce theaverage age at which children with significanthearing loss are identified to no more than 12months. The second objective is to increase to atleast 80 percent, the proportion of primary careproviders who routinely refer or screen infantsand children for hearing impairment.

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The U.S. Surgeon General's InitiativeIn 1989, the Surgeon General of the United

States established the goal that by the year 2000,90 percent of all children with significant hearingimpairment we ild be identified by 12 months ofage and encouraged states to initiate neonatalscreening programs based on risk registers forhearing loss.

Federal Laws, Regulations,and Programs

The Individuals with DisabilitiesEducation ActPart B

The federal government has addressed theimportance of identifying hearing loss 'n the earlymonths of life on several fronts. For xample, thefederal regulations that implemen, the law gov-erning the provision of special education in theUnited States, the Individuals with DisabilitiesEducation Act (IDEA), require local school dis-tricts to have procedures that identify childrenwith disabilities who are in need of special educa-tion and related services. These disabilities in-clude mental retardation, visual impairments,and hearing impairments including deafness,among others. This regulation covers infants,children, and youth from birth through age 21. Inaddition, the IDEA regulations require that allchildren being evaluated for the need for specialeducation and related services 13,- assessed in allareas related to the suspected disability including,if appropriate, hearing. (34 Cede of Federal Reg-ulations [CFR] 300.532)

IDEA--Part HPart FI of IDEA, also known as the Early

Intervention Program for Infants and Toddlerswith Disabilities, provides federal funds and pro-gram guidelines to help states plan and imple-ment a comprehensive, coordinated, and inter-disciplinary program of early intervention servicesfor children ages birth to three who are develop-mentally disabled or delayed, or who have a phys-ical or mental condition that is likely to lead to adevelopmental delay. The program requires thatstates design an identification system that may becoordinated with existing public and private ef-forts to find these children.

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Section 504 of the RehabilitationAct of 1973

Section 504 of the Rehabilitation Act of 1973protects the rights of individuals with handicapsin programs and activities that receive federalfinancial assistance. Similar to IDEA, Subpart D,subsection 104.32 of Section 504 requires schooldistricts to ". . . identify and locate every qualifiedhandicapped person residing in the recipient's(school's) jurisdiction . . . ." The regulation de-fines a handicapped person as". . . any person who(i) has a physical or mental impairment whichsubstantially limits one or more major life activi-ties; (ii) has a record of such an impairment, or (iii)is regarded as having such an impairment . . . ."(34 CFR 104.3) With respect to elementary andsecondary education services, a qualified handi-capped person is a child with a handicap who is inthe same age group as other children who aremandated by the state to receive a free and appro-priate public education.

Head Start ProgramPerformance Standards

The Federal Head Start Program PerformanceStandards, 45 CFR 1304, define the standardsnecessary for local Head Start programs to achievethe federal Head Start goals and objectives. Com-pliance with the performance standards is ..e-quired as a condition of federal funding. Healthperformance standard number three requires pro-grams to screen children for hearing loss every twoyears beginning at age three. This standard in-cludes pure-tone screening with an audiometerand encourages tympanometry screening for mid-dle ear problems. Scheduling requirements forHead Start program screening services are de-fined in 45 CFR 1308.6, as are the program'sresponsibilities for evaluating children with a pos-sible disability identified through screening. Atthe beginning of the 1993-94 program year, HeadStart must provide hearing screening services toall its children no later than 45 calendar days afterthe start of program services in the fall or 45 daysafter the child enters the program. Head Startmust refer all children over the age of three witha possible disability to their local school district forevaluation as soon as the need is evident. If theschool district does not evaluate the child, theHead Start program is responsible for ensuring an

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evaluation to determine if the child meets theHead Start specific disability eligibility criteria.45 CFR 1308.11 includes recurrent temporary orfluctuating hearing loss caused by otitis mediaand lasting for a period of three is wnths or more inthe Head Start program eligibility criteria forhearing disability.

The Commission onEducation of the Deaf

The Commission on Education of the Deaf(COED) was established by the Education of theDeaf Act of 1986 to study the quality of educationof deaf persons. In its 1988 report to Congress andthe President, the COED recommended that

"The Department of Education, in collab-oration with the Department of Healthand Human Services, should issue federalguidelines to assist states in implement-ingimproved screening procedures for eachlive birth. The guidelines should includethe use of high risk criteria and shoulddelineate subsequent follow-up proceduresfor infants arid young children consideredto be at risk for hearing impairments."(COED, 1988)

Proposed Federal ManditeDuring the first session of the 103rd Congress,

a bill was introduced in the U.S. House of Repre-sentatives which would require hearing loss test-ing for al newborn children in the United States.The Hearing Loss 'resting Act of 1993, H.R. 419,establishes uniform standards for hearing losstesting programs and reo.uires coverage for hear-ing loss testing in all insarance policies and healthmaintenance organization (HMO) contracts thatprovide an.; benefits for newborn children. New-borns not covered by HMOs, private insuranceplans, or Medicaid would be covered for hearingloss testing by programs or grants provided by theU.S. Department of Health and Human Services.

The National Institute on Deafness andOther Communication Disorders

The National Deafness and Other Communica-tion Disorders Act of 1988, PL 100-553, estab-lished the National Institute on Deafness andOther Communication Disorders (NIDCD) as the13th Institute of the National Institutes of Health(NIH). The act requires that the director of NID-CD establish a multifaceted program to ". . . ex-

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pand, intensify and coordinate activities of theInstitute respecting disorders ofhearing. . . ." (sec.464). The act requires that the program includeresearch activities in the area of prevention andearly detection and diagnosis of hearing loss. Inorder to meet these requirements, the NIDCD hasoutlined a national strategic research plan (Na-tional Institute on Deafness and Other Communi-cative Disorders, 1989) that identifies ". . . im-proved methods for early screening and diagnosisof hearing loss in infants end young children. . ."as one of its primary goals.

In order to addi ess this goal, in lAarli ofthe NIDCD, together with the Office of MedicalApplications and Research of the NiH, convened aeonsensus development conference, entitled "TheEarly Identification of Fearing Impairment inInfants and Young Children." The conferencebrought together specialists in communicatived:sm.ders, medicine, hearing science, neurologicalscience, epideniology, and health care adminis-tration with re ffesentatives of the public to studythe issues in ve hied in neonatal hearing screeningand to mak e re:..ommendation s for best practice inthat endeavor. The consensus statement thatemerged from the conference included the recom-mendation that all newborns be screened for hear,.ing impairment before they leave the hospitalnursery. When that is not possible, universalhearing screeni ng should occur before three monthsof age. This goal is made possible, according to theconsensus statement, by r ecent technological de-velopments that permit the measurement of tran-sient evoked otoacoustic emissions from newbornband infants. Otoacoustic emissions are discussedin section 3 of this guide.

Wisconsin Rules, Regulations,Programs, and Initiatives

Wisconsin Special Education Lau)Wisconsin Special Education Law, Subchapter

V of Chapter 115 of the Wisconsin statutes, andPI 1:1_, the rules which implement it, define a localschool district's role in the identification of chil-dren who have a hearing handicap and because ofit may need special education services. Eachschool board is required to screen ". . . each child inthe school district who has not graduated fromhigh school to determine if there is reasonablecause to believe that the child is a child withexceptional educational needs," (s. 115.80(2), Wis.Stats.) PI 11.03(1) of the Wisconsin Administra-

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tive Code also states that the school board shallscreen any child upon request including childrenbelow school age. While these rules do not dictatespecific screening procedures for individualhandicapping conditions, the intent to identifythem in children of all ages is clear. Further, PI 11requires school districts to evaluate all childrenreferred for suspicion of exceptional educationalneed (EEN) as well as children identified in thedistrict's own screening program as potentiallyeligible for EEN services. More information aboutlocal school district screening and evaluation ser-vices can be obtained by contacting the specialeducation department in each school district.

The Wisconsin Birth-to-Three EarlyIntervention. Program

Further evidence of Wii>consin's commitmentto the early identification of infants and toddlerswith disahilitif..s, including those with hearingloss, is found in the state's participation in Part Hof IDEA. The regulatory rules that implement theBirth to Three Program in Wisconsin require thatlocal agencies administering the program provideservices to ensure the identification of all childrenwho may be eligible for the program, and referchildren for screening or evaluation. Childrenwith .tocumented hearing impairment that willresult in a developmental delay are eligible for theprogram. The regulations do not require the massapplication of specific hearing screening tests toall infants and toddlers. However, local programsare required to participate in public awarenessactivities about disabling conditions in thebirth-to-three period as well as to establish formalsystems of communication between agencies andothers in the community that will facilitate thereferral process. Help in locating local birth-to-three programs can be obtained by callingWiscon-sin First Step at 1-800-642-STEP (voice) and1-800-282-1663 (TDD) or local county and citypublic health agencies.

Wis.onsin Health Check ProgramAdditional Wisconsin supportforthe early iden-

tification of hearing impairment can be found inthe Wisconsin Health Check Program. The Wis-consin Health Check program is Wisconsin's Ear-ly Periodic Screening Diagnosis and Treatment(EPSDT) Program. All states that accept federalreimbursement under the national Medical Assis-tance Prcgram, (MAP) must have an EPSDT pro-

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gram. The Health Check Program provides pre-ventative health check-ups, evaluations, and treat-ment services for eligible children from low-incomefamilies. Program participants must providecomprehensivehealth screening services, includinghearing screenings, as recommended by profes-sionals in the field. In Wisconsin, provider guide-lines require hearing screening services at birthand continuing at regular intervals throughoutinfancy, early childhood, childhood, and adoles-cence. These hearing screening requirements areoutlined in the Wisconsin MAP Provider Hand-book and include the following elements:

For children ages birth to five years, otoscopicexams or tympanometric measurements for thedetection of chronic or recurrent otitis media.

For children ages birth to three years, the useof the risk register process described in Appendix Aand of the Speech and Hearing DevelopmentalChecklist illustrated in Figure 1.

For children ages three to nine years, annualpure-tone audiometric screening, and at four-yearintervals thereafter until the age 16 years.

For children older than age eight years withexcessive exposure to noise, delayed speech andlanguage development, or first-time access toHealth Check screening services, pure-tone audi-ometric screening.

Local Health Check services can be located bycontacting local city or county public health agen-cies or by calling Wisconsin First Step at1-800-642-STEP (voice) and 1-800-282-1663 (TDD).

Wisconsin Inter-Agency NewbornHearing Screening Promotion

Since 1989, the Wisconsin Department of Pub-lic Instruction (DPI) and the Department of Healthand Social Services (DHSS) have collaborated topromote neonatal hearing screening in Wisconsinhospitals. This statewide effort offers to hospitalnursery administrators and personnel backgroundinformation on the nature of the problem, a ratio-nale for the screening effort, and program materi-als with which to implement a hospital screeningprogram. This promotion encourages use of the1990 Joint Committee on Infant Hearing's recom-mended methods for neonatal hearing screening.Recent surveys indicate that the number of Wis-consin hospitals following the Joint Committee'srecommendations are growing. (Wahlton andFrye-Osier, 1992) In February 1992, the statesurveyed 127 Wisconsin newborn nurseries re-garding their hearing screening practices. Of the

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79 hospitals responding to the survey, 34 reportedscreeningforhearingloss using the methods recom-mended by the Joint Committee. In a 1991 survey,only 21 hospitals reported having a hearing screen-ing program for newborns.

ReferencesCommission on the Education ofthe Deaf. Toward

Equality: Education of the Deaf. Washington,DC: U.S. Government Printing Office, 1988.

The National Institute on Deafness and OtherCommunicative Disorders. A Report of theTask Force on the National Strategic ResearchPlan. Bethesda, MD: National Institutes ofHealth, 1989.

Wahlton, R., and J. Frye-Osier. Data from theWisconsin Department of Health and Social

Services and the Wisc3nsin Department of Pub-lic Instruction, 1991.

Welsch, Robin, and Sarah Slater. "The State ofInfant Hearing Impairment Identification Pro-grams." Asha 35 (April 1993), pp. 49-52.

U.S. Department of Health and Human Services,Public Health Service. Healthy People 2000:National Health Promotion and Disease Pre-vention Objectives. Washington, DC: GPO,1991.

Wisconsin Department of Public Instruction. Au-diology Services in the Schools Study Commit-tee: Final Report and Recommendations. Mad-ison: Wisconsin DPI, 1990.

Wisconsin Department of Health and Social Ser-vices. The Wisconsin Medical Assistance Pro-vider Handbook. Madison: Wisconsin DHSS.

1 6

II Figure 1Your Child's Speech and Hearing Development Checklist*Instructions: Read each question through the child's age group and check Yes or No. Add thetotal number of Nos. If you obtain two or more Nos within any age level, or three or more Nosin all age groups through the child's age group, refer for audiological and communicativescreening/assessment.

CheckOne

Yes NoHearing and Understanding Child's Age Talking

CheckOne

Yes No

Does your child listen to $,peech?Does your child startle or cry at

noises?Does your child awaken at loud

sounds?

Birth

Does your child make pleasuresounds?

When you play with your child,does he/she look at you, lookaway, and then look again?

Does your child turn to youwhen you speak?

Does your c3 Ad smile whenspoken to?

Does your ch;ld seem to recog-nize your voice and quietdown if crying?

0-3Months

Does your child repeat the samesounds a lot (cooing, gooing)?

Does your child cry differentlyfor different needs?

Does your child smile whenhe/she sees you?

Does your child respond to "no"or to changes in your tone ofvoice?

Does your child look around forthe source of new sounds, forexample, the doorbell,vacuum, dog barking?

Does your child notice toys thatmake sound?

-4-6

Months

Does your child's babbling soundmore speechlike with lots ofdifferent sounds, including p,b, and ni?

Does your child tell you (bysound or gesture) when he/she wants you to do some-thing again?

Does your child make gurglingsounds when left alone?when playing with you?

Does your child recognize wordr.for common items like "cup,""shoe," "juice"?

Does your child listen whenspoken to? 7 Months -

1 Year

Does your child's babbling haveboth long and short groups ofsounds such as "tata upupbibibibr?

Does your child imitate differentspeech sounds?

Does your child use speech ornoncrying sounds to get andkeep your attention?

Can your child point to picturesin a book when they arenamed?

Does your child point to a fewbody parts when asked?

Can your child follow simplecommands and understandsimple questions ("Roll theball," "Kiss the baby,""Where's your shoe")?

Does your child listen to simplestories, songs, and rhymes?

1-2 Years

Is your child saying more andmore words every month?

Does your child use some 1-2word questions ("wherekitty?" "go bye-bye?" "what'sthat?")?

Does your child put 2 wordstogether ("more cookie," "nojuice," "mommy back")?

Does your child use many dif-ferent consonant sounds atthe beginning of words?

10 17

CheekOne

Yes NoHearing and Understanding Child's Age Talking

CheckOne

Yes No

Does your child understanddifferences in meaning ("go-stop"; "in-on" "big-little;" "up-down")?

2-3 Years

Does your child have a word foralmost everything?

Does your child use 2-3 word"sentences" to talk about andask for things?

Do you understand your child'sspeech most of the time?

Does your child often ask for ordirect your attention to objectsby naming them?

Does your child hear you whenyou call from another room?

Does your child hear televisionor radio at the same loudnesslevel as other members of thefamily?

Does your child answer simple"who," "what," "where,""why" questions?

3-4 Years

Does your child talk about whathe/she does at school or afriend's house?

Does your child say most soundscorrectly except a few, like r,I, th, and s?

Does your child usually talkeasily without repeatingsyllables or words?

Do people outside your familyusually understand yourchild's speech?

Does your child use a lot ofsentences that have four ormore words?

4-4 1/2Years

Does your child's voice soundclear like other children's?

Does your child use sentencesthat give lots of details (forexample, "I have two red ballsat home")?

Can your child tell yon a storyand stick pretty much to thetopic?

Does your child hear and under-stand most of what is said athome and in school?

Does everyone who knows yourchild think he/she hears well(teacher, baby sitter, grand-parents, and others)?

Does your child pay attention toa story and answer simplequestions about it?

4 1/2-5 Years

Does your child communicateeasily with other children andadults?

Does your child say ail soundscorrectly except maybe one ortwo?

Does your child use the samegrammar as the rest of thefamily?

TOTAL TOTAL

* From the brochure, "Baby Dear, Can You Hear?" published by the Wisconsin Department ofHealth and Social Services.

18

BEST COPY AVAILABLE

11

<

Screening Princinles andProgram Components

The development of a new hearing screeningprogram or the evaluation of an existing programshould be based on fundamental scieening princi .ples, an understanding of the essential p-ogramelements necessary for achieving a meaningfulresult, and a commitment to provide them. To dootherwise may waste valuable resources, or worse,create a false sense of security among families,educators, and caregivers. The purpose of thissection is to present the reader with a discussionof the basic issues and elements necessary toensure a quality hearing screening program.

Screening PrinciplesScreening is the process of applying tests and

measurements to large populations of individualsin order to separate those who are likely to have aspecific disorder from those who are not. Screen-ing is not a diagnostic process. It is a process thatproduces false positive and false negative resultsthat are directly related to how the criteria forpassing and failing are selected.

Successful screening programs require adher-ence to several basic principles. For example, themeasures used to screen must be valid and reli-able. That is, the tests must be able to identifymost of those who have the disorder without false-ly identifying many of those who do not. Also, nomatter who administers the tests, the resultsmust be reproducible. Specific tests are discussedin section four of this guide.

Screening personnel should base the decisionto screen for a specific disorder on consideration ofthe following additional principles:

The occurrence of the disorder should befrequent enough or the consequences seri-ous eaough to justify the screening efforts.The reader should refer to the overview of thisguide for the prevalence figures ofhearing impair-ment when considering this principle. Most loss ofhearing and conditiens which lead to hearing lossare present in early infancy. Permanent child-hood hearing loss that begin s after early childhoodis infrequent. Also, the prevalence of ear diseaseand related loss of hearing sensitivity peaks inearly childhood, then gradually declines in theearly elementary school years. (Bluestone, et al.,1983)

Treatment or intervention will reduce thenegative consequences of the disorder. Uni-dentified hearing loss and/or inadequate interven-tion leads to predictable negative outcomes forchildren. (Davis, et al., 1986) Timely, appropriateinterventions can reduce and sometimes elimi-nate most of the negative consequences of child-hood hearing loss. (Northern and Downs, 1984)

All affected individuals should have accessto diagnosis and treatment services. Bothgeography and financial ability will determineaccess to treatment services. In Wisconsin, allcommunities should have access to necessary fed-eral, state, and local community resources whichmeet the diagnostic, treatment, and educationalneeds of children with hearing loss.

The cosi s of the screening process are justi-fied by the benefits to affected individuals.The early identification, evaluation, treatment,and rehabilitation of hearing loss in infants and

1 913

children reduces the need for costly and prolongedspecial educational aud medical services later inchildhood and adolescence. (Downs, 1986) Valid,cost-effective methods of screening in newborns,infants, and children are well established and willreceive more attention later in this guide.

Selecting the Population to beScreened

The onset of most significant hearing loss andthe disease processes that lead to rome commonchildhood hearing losses occur well before the agethat children enter kindergarten. Therefore, ifannual hearing screening was routinely conduct-ed for all, children ages birth to five years, screen-ing in grades K-12 could be restricted to6 children known to have recurrent or chronicear disease;

children with other medical conditions knownto be associated with hearing loss (see risk factorsin Appendix A);

children referred by teachers, parents, or oth-ers because of 13 concern for a hearing loss; and

children knowil to be at risk for noise-inducedhearing loss. (Children at risk for noise-inducedhearing loss include those who habitually engagein very noisy leisure time and recreational activi-ties and children enrolled in vocational trainingprograms or engaged in employment activitiesinvolving loud equipment.)

Comprehensive hearing screening in all hospi-tal nurseries, well-baby clinics, child care institu-tions, Head Start programs, and early interven-tion programs currently does not occur in mostWisconsin communities. Therefore, the need toscreen in the elementary and secondary schoolpopulation will continue to exist in many commu-nities until screening programs for children frombirth to age five are improved.

The populations to be screened are as follows:all newborns;all infants and children from birth to age five,

annually;all children ages five and older in the four

restricted categories listed above, when a satisfac-tory pre-kindergarten hearing screening historycan be documented; and

all children ages five and older for whom asatisfactory pre-kindergarten hearing screeninghistory cannot be established.

14

Many children in the target populations aredifficult to screen. Successful screening may re-quire special skills, procedures, and environments.A full discussion of screening difficult-to-screenchildren can be found in section 5 of this guide.

Hearing Screening Personneland Training Elements

PersonnelScreening for hearing loss in infants, toddlers,

and children in high priority designated popula-tions is often difficult. Without a solid commit-m nt to well-trained, supervised, and experiencedscreening personnel, hearing screening programscannot be successful. This is particularly truewhen sereening requires a behavioral responsefrom preschoolers and other children who aredifficult to test. Successful screening of thesechildren will often require that the screening bedone by the most skilled and experienced screen-ers in the program.

The Program Director. The program director isresponsibile for all aspects of the screening pro-gram and should coordinate with a local licensedaudiologist to ensure that all program criteria aremet in order to guarantee a quality screeningprogram.

The Audiologist. The licensed audiologist is anessential resource and should play a part in allhearing screening programs for infants, toddlers,and children. The extent of the audiologist's in-volvement will vary with the population beingscreened, the skills and experience of others in theprogram, and the degree of community collabora-tion and consensus in the screening process. Theaudiologist's roles may include, but are notlimitedto the following:

Consultation in the development and evalua-tion of the screening program.

The development and provision of training pro-grams for screen '. ng personnel. Training programsshould include on-the-job training and supervi-sion and the use of performance evaluation crite-ria for the determination of minimal competence.

The provision of screening services for childrenfound to be unscreenable by others.

The provision of pure-tone threshold tests priorto medical referral for children who have failed thepure-tone screening process.

0

The development of informational materialsfor parents, medical providers, and school person-nel.

The development of communication and record-keeping systems that ensure an uninterruptedflow of useful information among the screen gprogram, families, medical providers, and schools.

The calibration of audiometric equipment.

The Pure-Tone Threshold Tester. Some mod-els for pure-tone hearing screening recommendthe completion of pure-tone threshold testing pri-or to Cie medical referral. The pros and cons of thisprocedure will be discussed in section 4 of thisguide. Pure-tone threshold testing is considerablymore difficult than pure-tone screening, becausethreshold testing requires greater levels of skilland experience. Mostpersonnel in hearing screen-ing programs do not have the training, skills, andexperience or the necessary test environment andequipment to complete this task successfully, es-pecially for children who are the highest priorityfor screening. Therefore, if threshold testing is tobe done before the medical referral is made, itshould only be conducted in appropriate environ-ments, using appropriate equipment, by a licen sedaudiologist, or by an experienced person trainedand supervised by a licensed audiologist.

The Screener. The screen er is the most impor-tant component in the hearing screening program.Without competent screening personnel, all otherhearing screening program resources are wasted.Unless a commitment to well-trained, experienced,and supervised screening personnel can be made,hearing screening should notbe attempted. Screen-ing services provided by unskilled personnel areworse than no services at all, because the mereexistence of a screening program implies validityin the minds of many parents and educators. Suchimpressions can lull parents and educators into afalse sense of security and forestall actions thatmight otherwise identify a problem early. Con-versely, the reporting of potential hearing prob-lems where none exist can create unnecessarystress and expense for the family and can damagethe credibility of the screening program.

The screener's primary responsibility is to effi-ciently and accurately apply appropriate screen-ing measures to children in assigned populations.This requires a basic understanding of th e screen-ing tools, the methods for applying the tools, nor-mal and abnormal auditory mechanisms, and theimplications of hearing loss for communicationand learning. Screeners involved in behavioral

screening of children must also be familiar withthe children's response characteristics during hear-ing screening. Screeners must also know how totrain children for behavioral screening. Theseresponsibilities require skills that can only bedeveloped over time, with appropriate trainingand supervision. When screening programs haveto recruit and retrain new screening personnelevery year, the program will not work well.

TrainingHigh quality training for hearing screening

personnel is critical. Training should only beprovidect ay someone who is knowledgeable aboutthe minimal training elements listed below andwho has extensive hearing screening ex perienceand well-developed skills.

The licensed audiologist may be the only indi-vidual who meets these criteria for some pro-grams. However, many programs include nurses,speech and language pathologists, and others whohave the necessLey skills and experiences to offerquality training and supervision for screeningpersonnel. All hearing screening programs shouldengage a licensed audiologist to make a periodicconsultation, observation, and program evalua-tion. The program director then, in collaborationwith the licensed audiologist, will make the deci-sions about who is the most appropriate person totrain and supervise hearing screening personnel.

Minimal Training Elements. The minimaltraining for screening will vary with the popula-tion screened. However, minimal training for allscreeners should include:

anatomy and physiology of the auditory sys-tem,

hearing disorders and their causes,screening tooic, methods, and procedures, andthe consequences of hearing loss for communi-

cation and learning.

Training for Neonatal Hearing Screening.The recommended hearing screening for the new-born population is initially accomplished throughvisual examination of the infant and review offamily and pre-, peri-, and postnatal history. In-fants who are positive for one or more of the riskcriteria listed in Appendix A should be referred assoon as possible for Auditory Brainstem Response(ABR) screeningby or under the direct supervisionof an audiologist. ABR screening procedures arediscussed later in this section. In addition to theminimal training described above, training forscreeners of newborns should include:

2 115

the examination and interprr of medicalrecords,

the visual examination of the infant for cranio-facial anomalies associated with hearing loss (seerisk criteria in Appendix A),

interview techniques for acquiring relevantfamily history from family members,

supervised experience in the above resulting insatisfactory independent performance, and

whnn appropriate, completion of a supervisedexperiL admit, istering and scoringABR screen-ing tests, supervised by an audiologist and result-ing in satisfactory independent performance.

Training for Screening in InfancyFirstThree Years of Life. The recommended hearingscreening during this period compares a child'sspeech and hearing behavior to children's normaldevelopment of communication skills. Tympa-nometry is also included in the recommendedscreening protocol for children in this populationbeginning at age seven months (corrected forprematurity). Tympanometry measures and doc-uments certain physical characteristics of themiddle ear system. In addition, given the appropri-ate equipment, environment, and training, VisualReinforcement Audiometry (VRA) screening canalso be accomplished. More detailed informationabout the procedures of tympanometry and VRAappears in section 4. Training for screeners ofchildren in this population should include theminimal elements defined above and:

knowledge of developmental milestones inspeech and hearing,

techniques for interviewing parents and care-givers,

when appropriate, completion of a supervisedexperi ence administering and interpreting tympa-nometric tests in this population, resulting insatisfactory independent performance, and

when appropriate, completion of a supervisedexperience administering and interpreting VRAbehavioral hearing screening tests in this popula-tion, resulting in satisfactory independent perfor-mance.

Training for Screening ChildrenAges Threeto Five. Beginning at about age three, mostdevelopmentally normal children can be suffi-ciently trained to respond to auditory stimuli topermit audiometric pure-tone hearing screening.Pure tones are used as signals in hearing tests andare generated by an audiometer. However, suc-cessful pure-tone screening in this age group re-quires very skilled and experienced screeners.

16

Therefore, the training of those who screen thesechildren must meet high standards, because therisk of unreliable pure-tone screening results ishigh for this population. When attempting toscreen children in this population who cannotaccomplish the pure-tone screening task, screen-ers may use the methods employed for infants.Tympanometric screening is also recommendedfor children during thi s peri od. Training for screen-ers of these children should include the minimalelements described above plus:

the elements described for screeners of chil-dren in the first three years of life, and

satisfactory completion of a supervised experi-ence conducting pure-tone screening tests (includ-ing play-conditioning techniques) for this popula-tion, res,:.,:-ing in satisfactory independentperformance. iescribed in more detail in sec-tion 4)

Training for Screening in the School AgePopulationAge 5 to 21. Most children in thispopulation can be screened using audiometrIcpure-tone screening techniques. Those who can-not accomplish the pure-tone screening task maybe screened using the methods employed for chil-dren during the first three years oflife. Tympano-metric screening is not recommended during thisperiod except for some children with disabilities,including cognitive disabilities, hearing loss, se-vere developmental delays, severe physical hand-icaps, recent (within one year) histories of chronicor recurrent ear disease, and others. Therefore,training for screeners of this population should becomprehensive and include the elements describedabovo for all children from birth to age five.

The Referral ProcessWhen an infant or child fails th e hearing screen-

ing, the process of facilitating a prompt medicalevaluation should beg.a. When working withparents, program personnel should do the follow-ing:

immediately notify them of the tests results;explain the screening process;emphasize that the screening results are not

diagnostic, but advisory, and suggest the presenceof a hearing loss;

explain the need for prompt medical and hear-ing evaluations which will provide a diagnosis anddocument any hearing loss;

explain that there are potential negative devel-opmental consequences for the child when a hear-ing loss is ignored; and

22

provide consultation for locating evaluationand treatment services and financial assistance, ifnecessary.

When working with medical providers, pro-gram personnel should do the following:

provide complete screening information thatincludes the dates of the failures and the screeningtests used, and

request feedback about the evaluation results.Parental education about the screening pro-

cess and the causes and consequences of childhoodhearing impairment is very important. Programpersonnel may find that this task is easier if theyuse c.ommercially available brochures, pamphlets,and other publications. Appendix B lists organiza-tions that publish brochures, pamphlets, and oth-er inexpensive puillications designed to educateparents and caregivers about childhood hearingloss and its causes, consequences, and treatment.

An example of a parental notification lettersuitable for use in a school hearing screeningprogram is shown in Figure 2. The letter includesthe dates of the failure, encouragement to seekmedical and bearing evaluations, guidance forseeking financial assistance for the evaluations,and specific requests for evaluation information.

Prompt and understandable reporting to thefamily and the screening program director regard-ing the outcome of the evaluation is critical, be-cause a documented hearing loss requires imme-diate intervention. A parental notification lettercan facilitate this prompt feedback, if it includes ablank reporting form for the parent or guardian togive to the physician at the time of the evaluation.Figure 3 is an example of such a form. Screeningpersonnel should urge parents to require the physi-cian and audiologist to complete the form andreturn it to them. The family then returns theform to the hearing screening coordinator. Thisform may be designed as a carbon copy form, sothat the family, medical provider, and screeningagency all have a record ofthe screening dates, thereferral, and the evaluation findings.

No official medical release form is needed whenthe physician provides the results of the evalua-tion to the family and the family shares thisinformation with the screening program. Howev-er, if this feedback mechanism fails, the physiciancould send medical evaluation information direct-ly to the screening program if the family files asigned release-of-information form with the phy-sician.

The Medical Component of theScreening Program

Hearing loss is a symptom of physiologicaldysfunction in the auditory system and thus is amedical issue. Therefore, even before the programproduces the first medical referral, the programdirector should communicate the program's objec-tives, procedures, methods, and expectations tophysicians in the community who will receive thehearing screening failure referrals. Such effortsprovide opportunities for mutual education andconsensus building, reduce the potential formisunderstandings and conflicting messages toparents, and create the common sense of purposethat is so important for quality community hear-ing screening programs for children.

The hearing screeningprogram sh ould promptlyrefer all children who fail the hearing screeningprocess to a physician with experience in tile eval-uation and management of childhood ear diseaseand disorders. The medical component of hearingscreening should be appropriately integrated withother aspects of the program.

As described earlier, the medical referral pro-cess should give the physician the dates of thescreening tests, a description of the specific testsused, and the test results. When pure-tone screen-ing is used, screening personnel need not reporteach frequency failed in each ear. Simply specify-ing which ear(s) failed the pure-tone screening isadequate. When using pure-tone threshold test-ing, screeners should include the specific resultsin the medical referral information. Similarly,when screeners use tympanometric measurements,the results should be included in the referralinformation. The sample form shown in Figure 4is an efficient tool for recording and reportingscreeningtest procedures and results when screen-ers conduct simultaneous pure-tone and tympano-metric procedures. If a hearing loss is found, themedical report should include a description of themedical cause of the loss, the prescribed medicaltreatments, the predicted future stability of thehearingloss, and the need for periodic medical andaudiologic monitoring.

The Audiologic Component ofthe Screening Program

The ultimate goal of any hearing screeningprogram is to reduce the communication problemswhich are secondary to a hearing loss. Therefore,evaluations that follow screening failure should

23 17

IIII Figure 2

Sample Parental Notification Letter

Date:

Dear Parent/Guardian:

Your child recently participated in the school hearing screening program and failed thescreening on (date) and (date) . These results indicate that yourchild MAY have a hearing loss that is medically and educationally significant.

We recommend that you have your child's ears examined by a physician and his/her hearingevaluated by an audiologist as soon as possible. Early identification and treatment of ahearing problem could prevent it from interfering with your child's learning.

If you need assistance in locating providers to complete evaluations, please contact us at theaddress and phone number below. We may also be able to refer you to agencies or programswhich can provide financial assistance for these evaluations.

At the time ofyour child's evaluations, please make sure that sections A and B on the enclosedform are completed. It is very important that we receive this information. Please return thecompleted form to the address below so that we can update your child's school health recordsand inform his or her teachers about a hearing loss if it exists. If your child is already undermedical care for an ear problem, please ask your physician and audiologist to complete theform.

Thank you for your cooperation. Please call if you have any questions.

Name:

Address:

Phone Number:

1824

Figure 3 111

Hearing Screening Referral/Medical Evaluation

Date

Referring Program Street Address

Referring Program Address City, State, ZIP Phone No. Area Code

Child's Name Child's Birthdate Mo. IDay IYr.

Dear Physician:

The child named above failed the school hearing screening process on (date) . and(date) . When two successive hearing screenings are failed four to six weeks apart,

we recommend tbat children be referred for medical and hearing evaluations.

It is very important that we learn of the results of the medical and hearing evaluations. There-fore, please return this form with sections A and B completed to the child's parent or guardianor to the above address as soon as possible. As always, your feedback is greatly appreciated.

A. Physician's Findin s and Recommendations(Describe Findings)Right Left

Recommendations:

Otitis Media

Otitis ExternaEardrum AbnormalityEar WaxOther Pathology

No Pathology

Physician's Name Please Print or TypeD ENT 0 PED 0 FP

Physician's Signature Date Signed

B. Hearing Evaluation Findings (attach audiogram and tympanograms and include auditorymanagement recommendations)

Tester's Name Please Print or Type Audiologist

0 Yes

Tester's Signature Date Signed

19

25

include an assessment of the child's hearing by alicensed audiologist. If the audiologist finds ahearing loss, any report should clearly interpretthe potential communication and learning conse-quences of the hearing loss and recommend proce-dures and strategies for auditory management.

In many Wisconsin communities, evaluationsby audiologists are deferred until sometime aftermedical treatment has begun. The decision todefer hearing evaluations is often based on falseassumptions, including:

The 1. ss of hearing sensitivity is probably mi-nor and/or transient and does not significantlydisable the child.

The hearing loss is related to some visible andtreatable pathology, and treatment will resolve it.

The loss of auditory information during thetime period required for treatment of the diseaseprocess bas no developmental or learning conse-quences for the child.

The bearing problem is only in one ear and,therefore, does not significantly disable the child.

Follow-up appointments will be kept, and thehearing evaluation can be done at the next visit.

Somebody else (the hearing screening programor the school, among others), will follow up toensure that hearing concerns are addressed.

These assumptions are often wrong, and thedecision to defer audiological evaluations for chil-dren referred for hearing screening failure cancause significant auditory deprivation forthe child.Important months can lapse, during which thechild's family and school are unaware of the extentof the hearing problem and important interven-tions may be delayed. The bearing evaluation bya licensed audiologist is an essential eomponent inthe initial evaluation of the child following ascreening failure and in subsequent follow-upevaluations until a temporary hearing loss isresolved or a stable loss is documented.

Monitoring and Follow-UpResponsibilities and Procedures

Follow-up activities are a vital part of everyhearing screening program. A screening programshould provide follow-up hearing screening testsof children after a medical evaluation at six- toeight-week intervals until the program eitherclears the childrs n medically and audiometricallyor until it documents a persistent auditory prob-lem. Individuals throughout the community sharethe responsibility to monitor a child's progressthrough screening, evaluation, intervention, andtreatment.

20

The Responsibility to Facilitate the Process.Clearly, parents or guardians have the primaryresponsibility to secure the evaluation, treatment,intervention, and follow-up services for their chil-dren. For a variety of reasons, however, parentsacting alone often cannot get the job done. Thereasons are many:

Family stresses and limited resources may pre-vent following through on screening program rec-ommendations.

Families may have no knowledge of availableresources.

Families may not receive accurate informationfrom tbe screening program about the potentialsignificance of the problem for their children or theappropriate steps to take to guarantee a satis-factory outcome.

Medical providers may offer little or no guid-ance about appropriate nonmedical interventions.

Communication between medical providers andscreening progTams may be poor, and each mayfurnish conflicting information to the family.

Communication among screening prograrearly intervention programs, and schools may oepoor.

Educators and early interventionists may notunderstand the developmental and educationalimplications of the disorder.

Parents may assume that the existence of thescreening program means that "someone" is fol-lowing through appropriately for their child when,in fact, no one is.

The Responsibility to Provide Assistance toFamilies with Children from Birth to AgeThree. In Wisconsin, the responsibility to assisteligible infants and toddlers from birth to agethree with significant hearing impairments, andtheir families, lies with county birth-to-three earlyintervention programs. Screening programs thatsuspect children have hearing impairments mayrefer them to the County Birth-to-Three Programfor evaluation. The county agency must assign aservice coordinator to facilitate the child's evalua-tion. If the evaluation finds a "significant orprogressive" hearing loss that will likely result indevelopmental delay, the child and the child'sfamily are eligible for birth-to-three program ser-vices, including comprehensive services from theservice coordinator. The coordinator assists thefamily in the development and full implementa-tion of the individualized family service plan.

26

Figure 4Data Reporting Form

Child's Name Last, First

Address Street

City State Zip

Birthdate ma/day/yr Age Sex (Check one)

D Male 0 Female 1

School Name

Name of Parent or Guardian Last, First

Date of Screening mo/dapyr )-

0 Pass Pure Tones 0 Pass Tympanometry0 Fail Pure Tones 0 Fail Tympanometry0 CNT Pure Tones0 CNT Pure Tones and Failed 0 Follow-up Tympanometry

Speech and Hearing Developmental 0 CNT Tympanometry

Checklist (Refer)

Date of Screening mo/dapyr .11-

Pure Tone Rescreening

1000HZ 2000HZ 3000HZ 4000HZ Tested by

20c8 20c113 ME 25dB

Reliability: 0 Poor 0 Fair 0 Good

Recommendations

0 PassNo Further Action Required0 Refer for Otologic/Audiologic

0 Tympanometric Follow-up--8 weeksO Retest Next Year

2 7

21

The Responsibility to Provide Assistance toFamilies with Children Ages Three and Old-er. The person with leadership responsibility forthe hearing screening progam must he preparedto provide the support necessary to empower fam-ilies to act successfully on behalf of their children.Those services include6 promptly notifying families about the screen-ing test results, including all of the informationalelements identified in the "The Referral Process"discussed earlier in this section;

checking for parental follow-threugh on themedical referral recommendation and assessingthe family's ability to successfully complete themedical visit;

informing the medical and audiological provid-ers about. the needed evaluation results and moni-toring and facilitating their completion;

communicating evaluation results to educationand intervention programs, including formal refer-ral of the child to the school board of residencewhen there is reason to believe a child may needevaluation for special education services;

assisting families to interact successfully witheducational and intervention programs;

monitoring to ensure resolution of the hearingloss, documenting stable hearing loss, or continu-ing medical care, if needed; and

recordkeeping, and encouraging schools to keeprecords that will facilitate efficient hearing screen-ing in K-12 populations (see "Selecting the Popu-lation to be Screened" in this section), and provid-ing current sensory information about children intransition between programs.

nO

Screening EquipmentIt is not within the scope of this document to

compare and contrast the characteristics of equip-ment from various manufacturers, to list prices, orto identify equipment suppliers and repairers.Such information can be obtained readily from theaudiologist who consults with the screening pro-gram or from other audiologists in the community.If screening personnel need assistance locating anaudiologist in their area, they should contact theirlocal public health office or audiologists in eitherthe Department of Public Instruction (voice 608-267-3720, and TDD 608-267-2427) or the Depart-ment of Health and Social Services (voice 608-267-3720, and TDD 608-267-3720).

22

Auditory Brainsterr ResponseMeasurement Equipment

The recommended hearing screening proce-dure for newborn infants is the application ofspecific risk criteria (described in more detail insection 4 of this guide) and measurement of theauditory brainstem response (ABR) of those in-fants who meet one or more of the risk criteria.The ABR test measures the electrical response inthe child's brain to the presentation of auditorytest signals. When the purpose of the ABR test isto evaluate hearing or screen for hearing loss inthe newborn population, a licensed audiologistexperienced in these measurements or otherappropriately trained and experienced personnelshould conduct the test. ABE equipment and testprocedures are so technically comp:ex as to bebeyond the scope of this guide.. Interested readersare referred to the text Handbook of AuditoryEvoked Responses by James Hall (listed in Appen-dix E) for a complete discussion of ABR test proce-dures.

Otoacoustie Emission MeasurementEquipment

Another physielogical phenomenon that can bemeasured in infants and children and which holdsgreat promise for hearing screening and evalua-tion is the otoacoustic emission (OAE). OAEs aresounds measured in the ear canal that are pro-duced by an active biomechanical process origi-nating within the inner ear. This process enhanc-es and amplifies the normal motions in the innerear structures produced by external sound stimu-lation.

Audiologists use brief sound stimulations ofthe ear to evoke OAEs. They appear to be presentin all normally functioning ears and are not foundin ears with mild or greater hearing loss. Theapplicability of OAEs for hearing screening ofinfants and children is currently being studied.For a review of the subject of OAEs, including theirpotential as a hearing screening tool and theequipment necessary to record them, the reader isreferred to articles by Glattke and Kujawa (1991);Lounsberry-Martin, Whitehead, and Martin,(1991); and White and Behrens (1993). Informa-tion about these materials is found in Appendix E.

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V isual Reinforcement AudiometryEquipment

Licensed audiologists may behaviorally screenthe hearing of devek,pmentally normal infantswho are five months or older and have adequatevisual and motor skills using a conditioning tech-nique that employs a visual reinforcement para-digm. The technique, called Visual ReinforcementAudiometry (VRA), is diseussed in further detailin section 4 of this guide. If a licensed audiologistis not available, someone thoroughly trained andsupervised by a licensed audiologist may conductthis behavioral screening. Auditory stimulusequipment employing standard audiometric stimu-li for VRA screening should meet the require-ments of the American National Standards Insti-tute (ANSI) for wide range audiometers (ANSI,1989). Calibration to the ANSI standards shouldoccur at least once every year. When VRA equip-ment employs nonstandard acoustic stimuli, thehearing screening program should have completeacoustic descriptions of the stimulus and outlinesof the annual calibration strategies.

The audiologist may conduct VRA screeningusing audiometric earphones, but most frequentlythe procedure requires testing in the sound fieldusing calibrated loudspeakers located some dis-tance from the child. Sound field VRA screeningrequires compliance with strict acoustical require-ments for the test environment. Requirements forscreening test environments will be discussed lat-er in this section.

Finally, the VRA test protocol requires the useof a strategically placed visual reinforcement de-vice that is remotely controlled by the tester. Thedevice must be novel and highly interesting toinfants and children. Visual reinforcers that areanimated and out of sight until activared are mosteffective. (For a discussion of VRA procedures andequipment, see the listings for the following mate-rials in Appendix E: Moore, Wilson, and Thomp-son, 1977; Primus, 1988; and Primus and Thomp-son, 1985.)

Pure-Tone AudiometerPure-tone audiometers are devices that gener-

ate and present single frequency tones of varymghearing levels (HL) for the purposes of testinghearing acuity and screening for hearing loss.Pure-tone audiometric individual discrete frequen-cy screening can be successfully condutted withchildren who are functioning at a developmentalage of at least three years. Audiometers used for

pure-tone screening must meet ANSI S3.6-1989specifications and should be calibrated annuallyto those specifications. Audiometers purchasedfor pure-tone screening purposes need not includebone conduction testing or masking capabilities.Neither are normally included in pure-tone screen-ing, and both add significant cost to the price of anaudiometer.

If pure-tone air conduction threshold testing isincluded in the screening protocol, the audiometerused should include narrow-band masking capa-bilities which meet the ANSI 1989 specifications.Annual calibration to the ANSI standards mustoccur. When pure-tone threshold testing occurs,the program director has the responsibility toensure that

testers meet the appropriate personnel stan-dards,

the test environment meets the necessary stan-dards, and

the test is conducted according to the AmericanSpeech-Language-Hearing Association's (ASHA)"Guidelines for Manual Pure-Tone Threshold Au-diometry," (ASHA, April 1978)

Noise-Exclusion DevicesStandard screening pure-ton e audiometers can

be modified in ways that permit some. attenuationof the background noise in the screening environ-ment. For example, noise-exclusion devices thatcontain and fit over audiometric earphones andaround the listener's external ear are available.These devices provide significant attenuation ofbackground noise a'. some test frequencies, andpermit valid hearing screening to occur in someenvironments that otherwise would be too noisy.Potential users should be cautioned, however,that some noise-exclusion devices of this typechange the volume of air that is normally trappedin the ear canal under the earphone during screen-ing. Such air volume changes may change theloudness of the test signal at the ear drum andcould render the hearing screening test resultinvalid. In addition, these devices are too largeand heav-y for use with small children and can addg,5 percent to the cost of the screening audiometer.

Another way to modify audiometers to permitpure-tone screening in environments that other-wise would be too noisy is to replace the standardaudiometric earphones with insert earphones.These devices deliver signals to the ear canal viaa small plastic tube that is held in place in the earcanal by a compressible foam :ear plug similar tothose used for hearing protection in noisy environ-

292 3

ments. This ear plug, when properly inserted,attenuates background noise. Correct use of theinsert earphone requires practice and can be diffi-cult with small ear canals. In addition, insertearphones can add as much as 50 percent to thecost of the screening audiometer.

TympanometersTympanometry, an effective method for identi-

fying abnormalities ofthe middle ear, is employedfrequently in hearing screening programs for spe-cific populations of infants and children. Tympa-nometers measure compliance changes in the mid-dle ear as air peessure is varied in the ear canal,and their specifications must he in accordancewith the ANSI standard on aural acoustic immi-tance instruments. 'ANSI, 1983) Tympanome-te.rs can be designed as either clinical or screeningdevices. Clinical devices are generally larger, lessportable, and more complex. While they allow formore user control of the measurements, they aremore expensive than screening devices. Screeningtympanometers are generally suitable for use inhearing screening programs as long as they meetthe ANSI standard and reliably and clearly pro-vide the following infonnation:g a plot of changes in the compliance of themiddle ear system as pressure in the ear canal iscontinually varied from positive to negative val-ues (tympanograrn),

quantification of the compliance value mea-sured at the most compliant point on the tympan-ogram,

quantifieation of the equivalent ear canal vol-ume, andg quantification of the ear canal pressure valuecorresponding to the most compliant, point on thetympanogram.

Currently, no national standard for the calibra-tion of tympanometers exists. Tympanometersmay, however, be calibrated to the equipmentmanufacturer's specifications. Minimum dailyequipment checks should include the use of themanufacturer's calibration cavities and comparisonof current tympanograms with sample tym-panograms obtained over time from an individualwith no known active or past middle ear disease.Large deviations from the expected cavity mea-sures or gross changes in key values on the sampletympanograms (in ths absence of changes in mid-dle ear health) shoule prompt a complete calibra-tion of the tympanometer to manufacturer's spec-ifications.

24

Programs may purchase screening tympanom-eters that are combined with screening audiome-ters in the same instrument. Equipment thatintegrates a tympanometer and a pure-tone audi-ometer can result in certain economies in screen-ing and transportation but can also result ininconveniences. For example, if one of the devicesneeds to be repaired or recalibrated, both deviceswill be unavailable for use.

OtoscopeThe use of an otoscope in hearing screening

programs prior to administration of the hearingscreening tests can produce prompt referrals foractive ear disease and/or medically significant earcanal and ear drum abnormalities. Otoscopicexamination prior to hearing screening can alsoreveal the presence of excessive amounts of ceru-men. This is a common cause ofhearing screeningfailure and tympanornetric screening failure inchildren. Visualizing, examining, and detectingabnormalities of the ear canal and ear drum re-quire training and experience and can be espe-cially difficult with young children. Therefore, thedecision to include otoscopy in the screening pro-cess should be made in conjunction with either theadvice and assistance of a physician, a nursepractitioner or a physician's assistant experiencedin otoscopic evaluations of the target population.

The Hearing ScreeningEnvironmentBackground Noise

Excessive levels of noise in the screening envi-ronment, can alter the ABR response index andwill affect the sensitivity of OAE recordings. Back-groimd noise can also mask perception of the testsignals used in pure-tone and VRA screening pro-cedures with infants and children. Unless thescreener carefully controls background noise lev-els, false positive screening results will occur.False positives must be minimized, because un-neceesary medical referrals result in wasted timeand money for families and loss of credibility forscreening programs.

Screeningpersonnel can verify acceptable back-ground noise levels for pure-tone screening andVRA screening either electronically, with soundlevel measurement insta-uments, or behaviorallywhen sound level measuring equipment is notavailable. If a calibrated sound level meter withoctave-band filters s available, screeners can eas-

30

ily determine the acoustic adequacy of a screeningenvironment. With the octave-band filters cen-tered on the test frequencies, the maximumpermissible octave-band sound pressure level (SPL)for each test frequency is listed below for severaltesting procedures.

Permissible Ambient Noise Lel cqs During_Pure-Tone Threshold Testing h Audiomet-

ric Earphones500 Hz 19.5 dB SPL

1000 Hz 26.5 dB SPL2000 Hz 28.0 dB SPL4000 Hz 34.5 dB SPL

_Pure-Tone Screening (20 dB HL at 500, 1000,and 2000 HZ, and 25 dB HL at 4000 HZ) withAudiometric Earphones

500 Hz 39.5 dB SPL1000 Hz 46.5 dB SPL2000 Hz 48.0 dB SPL4000 Hz 54.5 dB SPL

VRA Screening Without Audiometric Ear-phones (35 dB HL narrow band stimuli)500 Hz 49.5 dB SPL

1000 Hz 49.0 dB SPL2000 Hz 43.5 dB SPL4000 Hz 44.0 dB SPL

VRA Screening With Audiometric Earphones(35 dB HL narrow band stimuli)

500 Hz 54.5 dB SPL1000 Hz 61.5 dB SPL2000 Hz 63.0 dB SPL4000 Hz 69.5 dB SPL

VRA screening often employs speech st;--nulibecause speech is a particularly interesting stim-ulus for infants and toddlers. Screening withspeech stimuli can be accomplished either with orwithout earphones, and each test condition re-quires acceptable background noise levels.

Permissible Ambient Noise Levels During_VRA Screening without Audiometric Ear-

phones (25 dB HL speech stimulus)500 Hz 39.5 dB SPL

1000 Hz 39.0 dB SPL2000 Hz 33.5 dB SPL4000 Hz 34.0 dB SPL

VRA Screening with Audiometric Earphones(25 dB HL speech stimulus)

500 Hz 44.5 dB SPL1000 Hz 51.5 dB SPL2000 Hz 53.0 dB SPL4000 Hz 59.5 dB SPL

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Ifsound-level measuring equipment is not avail-able, behavioral standards may be applied to esti-mate the acoustic adequacy of the room. Anyenvironment in which the screening test signalscan be easily heard every time they are presentedis acoustically adequate. The program directormust exercise caution to ensure that the personlistening to the test signals has normal or nearnormal hearing. Otherwise, acoustically adequatescreening environments may be incorrectly elim-inated. Screening must not be conducted if any ofthe criteria above are not met. The criterionTiLs for pure-tone or VRA screening shouldnever be increased because of excessive back-ground noise.

(For a discussion of the background noise re-quirements for ABR screening, the reader is re-ferred to the chapter by Michael Gorga in Jacob-son's The Auditory Brainstem Response. Concernsabout background noise in OAE testing are dis-cussed in a 1991 article by Glattke and Kujawa.Both are listed in Appendix E.)

Visual DistractionsSuccessful completion of a behaviora/, screen-

ing task requires that the child being tested focuson the task. Many children, especially youngchildren, will have difficulty paying attention tothe task if interesting visual distractions arepresent in the screening environment. To improvethe chances for success, face the child away from orcover windows that look out on any possible dis-tractions. Avoid screening in the presence of otherchildren; if this is unavoidable, face the child awayfrom any peers. If using play-conditioned audiom-etry, allow the child to handle only the toys neces-sary for screening. Behavioral pure-tone hearingscreening of young children can be successful andfun for both the screener and the child, especiallywhen the best conditions exist for focusing thechild's attention on the task.

ReferencesAmerican National Standards Institute. Maxi-

mum Permissible Ambient Noise Levels for Au-diometric Test Rooms. New York: ANSI, 1991.

. American National Standards Specifica-tions for Audiometers. New York: ANSI, 1989.

Specifications for Instruments to MeasureAural Acoustic Impedance and Admittance. NewYork: ANSI, 1988.

25

AI/

American Speech-Language-Hearing Association."Guidelines for Manual Pure-Tone ThresholdAudiometry." Asha (1978), pp. 297-3011.

Bluestone, C.D., et l. "Workshop on Effects ofOtitis Media on the Child." Pediatrics 71.4(1983), pp. 639-52.

Davis, J.M., et al. "Effects of Mild and ModerateHearing Impairments on Language, Educa-

26

tion, and Psychosocial Behavior of Children."Journal of Speech and Hearing Disorders 51(1986), pp. 53-61.

Downs, M.P. In E.T. Swigart. Neonatal HearingScreening. San Diego, CA: College Hill Press,1986.

Northern, J.L., and M.P. Downs. Hearing inChildren. 3rd ed. Baltimore, MD:Williams andWilkins, 1984.

Test Protocols and Pass/Fail Referral Criteria

Recommended ProceduresNewborn Hearing Screening

Studies show that when hearing screening pro-grams apply the risk criteria for hearing im-pairment recommended by the Joint Committeeon Infant Hearing in 1982 to all newborns, sevento 12 percent will be found to be at greatly in-creased risk for hearing loss. (ASHA, 1989) IfWisconsin had applied these risk criteria to the71,872 children born in Wisconsin in 1991, 5,000to 9,000 children would have been identified withprenatal, perinaeal, or family histories that placethem at much greater risk for serious heariregimpairment than other children. If an aggressivestatewide program had facs.en in place, most of theaffected children in this high risk population wonldhave been identhied before their first birthday.Children without the benefit of such a programprobably will not be identified until after tbeirsecond birthday.

How many of the 5,000 to 9,000 infants at riskborn in Wisconsin in 1991 could be expected tohave significant sensory neural hearing loss?Moderate to severe sensorineural hearing loss hasbeen confirmed in two to four percent of newbornsmanifesting any of the risk criteria in the 1982 list.;ASHA, 1989) Therefore, between 100 and 360infants in this "high risk" population have moder-ate or greater sensorineural hearing loss. Thisdata reveals that, of all the infants born in Wir,con-sin in 1991, one in every 200 to one in every 719 hasserious sensorineural bearing loss.

While the 1982 risk criteria procedures will notidentify all newborns (often referred to as "neo-nates") with serious sensorineural bearing loss,longitudinal studies have shown that from 50 to75 percent of all infants born with moderate orgreater hearing loss could be identified using the1982 Joint Committee protocol. (Elssman, Mat-kin, and Sabo, 1987; Feinmesser and Tell, 1976;and Stein, Clark, and Kraus, 1983) In 1990, theJoint Committee on Infant Hearing expanded the1982 risk criteria list for newborns, and added aset of risk factors for infants ages 29 days to twoyears (see Appendix A). This expanded list ofcriteria will increas3 the number of newborns andinfants referred for formal hearing screening, andtherefore, the sensitivity of this screening methodshould improve.

The joint Committee recommends that all new-borns and infants found to have met one or more ofthe risk criteria be referred as soon as possible forformal ABR screening and, when appropriate,behavioral (\MA) screen ing by or under the super-vision of an audiologist. The risk criteria are listedin Appendix A for both newborns and infants.

When the screening process identifies a childwith a hearing impairment, early interventionservices should be offered to the child's family inaccordance with Part H of IDEA and ChapterHSS 90 of the Wisconsin Administrative Code. Allinfants failing the screening process should beevaluated by an audiologist and a physician whospecializes in diseases of the ear.

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Recommended ProceduresHearing Screening of Infants andToddlers, Ages 29 Days to ThreeYears

Joint Committee on InfantHearing Criteria

All children in this age group should be screenedusing both sets of risk criteria described in theJoint Committee on Infant Hearing 1990 PositionStatement. (See Appendix A.) Screeners shouldnot rule out hearing loss even if a child passes bothrisk screening procedures, because data haveshown that the risk register identifies only from 50to 75 percent ofinfants with serious sensnrineuralhearing loss. (Elssman, Matkin, and Sabo, 1987;Feinmesser and Tell, 1976; and Stein, Clark, andKraus, 1983) In addition, screeners should notconclude that an infant found to be at risk forhearing loss who passes a formal hearing screen-ing test need not be screened again. Some of thelisted risk factors are associated with delayedonset hearing loss, including family history ofdelayed onset childhood sensorineural loss, cer-tain congenital infections, bacterial meningitis,and prolonged mechanical ventilation in the new-born period. Finally, the Joint Committee's meth-ods were not designed to address the problem ofchronic or recurrent ear disease and concurrentconductive hearing loss in infants, toddlers, andchildren.

Therefore, in addition to the application of themethods described in the 1990 Joint CommitteePosition Statement, all infants and toddlers needscreening that uses the developmental milestonemethod, and tympanometry. Both of these meth-ods are described in detail below. VRA screeningtechniques are also appropriate for this popula-tion but require specialized equipment, testenvironments, and well-trained and experiencedscreening personnel. So, although a description ofthe VRA screening protocol appears below, pro-grams should only consider it as a part of thescreening battery for this population by programsthat are prepared to meet the equipment, testenvironment, and personnel requirements for thisprocedure (see section 3 of this guide).

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Speech and HearingDevelopmental Milestones

An important additional screening tool for in-fants and toddlers is the Speech and HearingDevelopmental Checklist, adapted from materialpublished by ASHA and published by the Wiscon-sin Department of Health and Social Services(DHSS) in a brochure entitled "Baby Dear, CanYou Hear?" This checklist is reproduced in Fig-ure 1 (see section 2) and allows parents and care-givers to compare an infant's speech and h3aringdevelopment to standards of normal development.The brochure also assists parents with helpfulrecommendations in the event that the child failsthe criteria defined in the scoring system of thistool. The DPI and the DHSS encourage parentsand caregivers to refer to this checklist oftenthroughout the child's early years. Children whomeet the brochure's criteria for failure require areferral to an audiologist for formal hearing screen-ing and, if necessary, comprehensive evaluation.Copies of this brochure may be obtained by con-tacting the Wisconsin Department of Health andSocial Services, Forms and Publication Office,1 West Wilson Street, P.O. Box 7850, Madison,Wisconsin 53707; (608) 266-8001.

Ty mpanometry

Another important screening tool for childrenin this age group is the measurement of auralacoustic immitance, commonly known as tympa-nometry. Reliable tympanometric measurementscan be made in children as young as seven monthsof age (corrected for prematurity). Tympanomet-ric screening is a reliable method for identifyingabnormalities of the middle ear, including themost common otologic disease in infants and chil-dren; otitis media with effusion (OME). Thisdisease is accompanied by temporary and fluctu-ating hearing loss. This loss is thought to be themain factor in the speech, language, communica-tion, and academic deficits so often found in chil-dren for whom the disease is recurrent or chronicin infancy and early childhood.

Since over half of all initial episodes of OME areasymptomatic, and 20 percent of all episodes areasymptomatic (Bluestone, et al, 1986), tympa-nometry is an important tool for identifying chil-

34

dren who suffer from chronic or recurrent OME.Tympanometry is especially useful in populationsof children ages seven months to three years forwhom pure-tone screening is not possible. OME ismost prevalent during this period. The AmericanAcademy of Pediatrics (AAP) endorses the identifi-cation of infants and children with chronic andrecurrent OME and encourages referring thesechildren for assessment of hearing and communi-cative function. Figure 5 is the AAP Policy State-ment, "Middle Ear and Language Development."The average hearing loss associated with middleear effusion is 28 dB ILL (Fria, et al. 1984), and isa significant barrier to the reception of the audito-ry cues to speech and language.

Estimates of the prevalence of sensorineuralhearing loss in the infant population vary from .1to .6 percent. (Downs, 1986; Matkin, 1984) Theincidence of chronic and recurrent otitis mediaand concurrent hearing loss, however, is muchhigher. One-third of all children have three ormore episodes in the first three years of life.(Bluestone et al., 1986) The prevalence of thedisease peaks in early childhood, then declineswith age and becomes progressively less commonafter age seven. (Bluestone et al., 1983) Craniofa-cial anomalies in children are often accompaniedby a higher prevalence of otitis media and accom-panyinghearing loss. This is well-documented forchildren with a cleft palate or children with DownSyndrome. (Dahle and McCollister, 1986)

In order to forestall the developmental conse-quences of this common childhood malady, chil-dren with chronic and recurrent otitis media mustbe identified early in life when their spee:.h, lan-guage, and communication skills develop rapidly.Routine medical evaluations for middle ear dis-ease, supplemented by annual tympanometricscreening in child care and early interventionprograms could easily recognize most infants andtoddlers with significant histories of persistentmiddle ear disease well before these children reachschool age. Since the majority of hearing loss inschool-age children is a result of active middle eardisease or its consequences, such preschool-agescreening practices would identify the majority ofschool-age children with hearing loss before theyenter school.

Most episodes of otitis media are self-limitingand resolve spontaneously without treatment inabout four weeks. Therefore, children who fail theinitial tympanometric screening must be re-screened in four to six weeks before the referraldecision is made. This strategy will reduce the

number of false positive referrals for medical eval-uation and more reliably identify only those chil-dren with persistent middle ear problems.

Screenings that produce tympanograms whichexhibit significantly reduced eardrum mobilitymeet the criteria for failure. These children shouldbe rescreened using tympanometry in four to sixweeks. In addition, rescreening in four to sixweeks should also occur for children whose initialscreening findings in either ear include a tympa-nogram showing normal mobility but with a mid-dle ear negative pressure value of -250 deca Pas-cals (daPA) or more.

When the rescreening of children who wereinitially found to have significantly reduced mo-bility produces the same result for either ear,screeners should refer these children for medicaland audiologic evaluation. Children who continueto yield normal tympanograms but with peaks atnegative pressure values of -250 daPA or morewhen rescreened do not meet the criteria for fail-ure. Screeners should monitor these children ateight-week intervals until the results meet thecriteria for failing or passing the tympanometricscreening. Medical and audiological referralsshould never be based on a single tympanometryscreening failure. Screening failures must occurin the same ear during separate screenings four tosix weeks apart before a referral based on tympa-nometry screening can be justified.

Valid applications of the above criteria requireadequate training and experience. Those whoscreen and make pass/fail and referral decisionsshould be thoroughly trained in interpretingtympanometric results (see section 3 for a discus-sion of the training elements for screeners ofchildren in the first three years of life).

Visual Reinforcement AudiometryUp until this point in the guide, none of the

described screening tests for infants and toddlersfrom birth to age three are direct tests of auditoryacuity. Developmentally normal children cannotlearn the skills necessary for traditional behavior-al pure-tone screening until at least age two and ahalf. Even then, a screener requires considerableskill to focus the child's attention for a long enoughperiod of time and motivate the child sufficientlyto complete the screening task.

The auditory sensitivity ofinfants and toddlerscan be screened using frequency-specific stimuliby employing a technique called Visual Reinforce-ment Audiometry (VRA). Screeners can use thistechnique successfully to rule out all but mild

35

29

30

III Figure 5

Middle Ear Disease and Language Development*

There is growing evidence demonstrating a correlation between middle ear disease withhearing impairment and delays in the development of speech, language and cognitive skills.A parent or other caretaker may be the first person to detect such early symptoms asirritability, decreased responsiveness, and disturbed sleep. Middle ear disease may be sosubtle that a full evaluation for this condition should combine pneumatic otoscopy, andpossibly tympanometry, with a direct view of th e tympanic membrane. This statement is notmeant to be a recommendation for specific treatment methods. When a child has frequentlyrecurring acute otitis media and/or middle ear effusion persisting for longer than threemonths, hearing should be assessed and the development of communicative skills must bemonitored.

The Committee feels it is important that the physician inform the parent that a child withmiddle ear disease may not hear normally. Although the child may withdraw socially anddiminish experimentation with verbal communication, the parent should be encouraged tocontinue communicating by touching and seeking eye contact with the child when loudly andclearly speaking. Such measures, along with prompt restoration of hearing wheneverpossible, may help to diminish the likelihood that a child with middle ear disease will developa communicative disorder. Middle ear disease can occur in the presence of sensory neuralhearingloss. Any child whose parent expresses concern about whether the child hears shouldbe considered for referral for behavioral audiometry without delay.

Committee on Early Childhood, Adoption, and Dependent CareSelma Deitch, M.D., ChairDavid L. Chadwick, M.D.Thomas Coleman, M.D.Donna O'Hare, M.D.Burton Sokoloff, M.D.George G. Sterne, M.D.Virginia Wagner, M.D.

Liaison representativesElaine Schwartz, Children's Bureau, OHD, DHHSJeanne Hunzeker, DSW, Child Welfare League of AmericaKenneth Grundfast, M.D., Section of OtolaryngologyCarol Gerson, M.D., Section of Otolaryngology

References

Hanson, D.G., and R.F. Ulvestad, eds. "Otitis Media and Child Development: Speech,Language and Education." Ann Otol Rinol Laryngol no. 5, part 2 (suppl 60) (1979), p. 88.

Bluestone, C.D., et al. "Workshop on Effects of Otitis Media on the Child." Pediatrics 71.4(1983), pp. 639-52.

Date of approval by Executive Board: July 1984Date of publication: September 1984

*Used with permission of the American Academy of Pediatric,I, Elk Grove Village, IL.

36

hearing loss in developmentally normal infantsand toddlers as young as age six months correctedfor prematurity. (Moore et al., 1977) VRA is aneffective screening technique for children withnormal development well into their second year oflife. The technique has also been successful fordevelopmentally delayed children for whom tradi-tional audiometric screening methods are oftenunsuccessful. (Thompson, Wilson, and Moore,1979)

The VRA procedure depends on the child learn-ing the contingent relationship of a very reward-ing and motivating visual display to the presenceof carefully chosen, frequency-specific auditorystimuli. When the tester pairs the auditory stim-ulus with the visual reinforcer, the child is taughtthat the appearance of the visual reinforcer de-pends on the presence of the auditory signal. Thevisual reinforcer is located in close physical prox-imity to the source of the test sound during soundfield testing and on the side of the room corre-sponding to the test ear in earphone testing. Oncethe child consistently turns to search for the visualreinforcer when an auditory signal appears, screen-ing can begin. Most infants and toddlers from agesix months to two years will respond reliably tosoft sounds, enabling the screener to rule out allbut mild hearing loss.

The screener should choose auditory stimulithat include low, mid, and high frequency sounds.Standard audiometric stimuli (ANSI 1989) thatare appropriate for VRA screening involvenarrow-band noise signals or warble-tone signals,with center frequencies at 4000 Hz and 1000 Hz,and single syllable speech sounds, such as "buh"that contain mostly low frequency energy. Thesestimuli are not produced by simple ANSI Type IVor Type V screening audiometers. (ANSI 1989)ANSI Type I or Type II audiometers are necessaryto accomplish this testing. The 1000 Hz and 4000Hz screening signals should be presented at 35 dBHL, and the low frequency speech sound should bepresented at 25 dB HL. Children must respondconsistently to all three screening stimuli to passthe screening test.

VRA screening of each ear can be carried outusing earphones, but young children often do nottolerate earphones. VRA screening is more likelyto be successful when done in the sound field usingloudspeakers at some distance from the child(Primus, 1992). Sound field VRA screening canrule out all but mild hearing loss in the better earonly. For a full discussion of test protocols usingVRA see the listings for Moore, Wilson, and

Thompson, 1977; Primus, 1988; and Primus andThompson, 1985 in Appendix E.

When a screening program identifies a hearingproblem with any ofthese methods, the leadershippersonnel should refer the family to the localcounty Birth-to-Three program for evaluation andearly intervention services in accordance withPart H of IDEA and Chapter HSS 90, WisconsinAdministrative Code. The services should includeevaluation by a licensed audiologist and a physi-cian experienced in evaluating and treating chil-dren with ear disease.

Recommended ProceduresHearing Screening of ChildrenAges Three and Older

Beginning at about age three, developmentallynormal children are able to successfully completebehavioral audiometric pure-tone hearing screen-ing tests. Pure-tone audiometr'c screening is themost popular hearing screening method, becauseit directly assesses the child's auditory sensitivityfor sounds that are important for understandingspeech. While generally an easy test to administerto most school-age children, it can be very difficultto administer to children who are young, physi-cally disabled, developmentally delayed, or unre-sponsive. Techniques and strategies for screeningdifficult to test children appear in section 5. Thefollowing information describes the proceduresand the pass/fail and referTal criteria for pure-toneaudiometric screening.

Screening tests other than pure-tone are ap-propriate for some children in this population. Forexample, annual tympanometric screening is ap-propriate for children in the following categories:ages three to five years; those older than five whocannot be screened using pure-tone methods; andthose who receive services for exceptional educa-tional needs such as cognitive disability, hearingloss, severe developmental delay, and severe phys-ical disability. Tympanometry should not be usedas a screening tool for school-age children in reg-ular education. However, it can be used for thechildren who have failed both parts ofthe pure-toneaudiometric screening process. When used in thiscontext, the tympanograms simply add additionalinformation for the physician who will evaluatethe child; they should not contribute to the deci-sion to refer for evaluation. In addition, wheneverthree- to five-year-olds cannotbe screened success-fully usingpure-tone methods, the screener shouldapply the Speech and Hearing Developmental

3731

Checklist shown in this guide as Figure 1, found insection 2.

Otoscopic screening is also an option for allinfants, toddlers, and children. Given the difficul-ties of this procedure with young children, howev-er, screeners use it more often with populations ofschool-age children. Screeners should seek inputfrom a physician experienced in otoscopic evalua-tions of children before making the decision toinclude otoscopy.

Pure-Tone ScreeningAs described in section 3 of this guide, pure-tone

screening requires the following: appropriatelytrained and supervised personnel, ade vote acous-tic environments, and equipment that meets spe-cific performance and calibration requirements.Even though prcgrams calibrate test equipmentannually, testers should perform daily listeningchecks to verify the integrity of the equipment.Instructions for performing the daily listeningcheck are included in the "Instructions for Perform-ing the Initial Audiometric Pure-Tone HearingScreening Test" (Figure 6). The program directormay wish to incorporate this instruction summaryinto the screening training program.

As in the protocol for tympanometric screening,pure-tone screening should be a two-step process,with screeningsessions occurringfour weeks apart.This test-retest interval reduces the number offalse positive referrals because it allows time forspontaneous resolution of middle ear disease, themost frequent cause of hearing screening failurein school-age children. In addition, children whofail the initial screening test should be rescreenedduring the same test session. Careful reinstruc-tion as well as repositioning of the earphones cansignificantly reduce failure rates. Only manualand individual pure-ton e screening is recommend-ed. Group screening and automated pure-tonescreening methods are not recommended, becausethey are not effective with young children.

Instructing the ChildScreeners should expect that many develop-

mentally normal four-year-olds and all devel-opmentally normal five-year-olds will be able tosuccessfully complete a traditional pure-tone hear-ing screening task. The task, explained in Fig-ure 6, requires a motor activity from the child inresponse to the test tone. Successful screening isdependent on the child understanding exactlywhat is expected. The instructions in Figure 6

32

should be delivered simply and clearly, and re-peated as necessary to complete the screeningprocess. For some reluctant four- and five-year-olds, the screener may have to provide demonstra-tions. That process is also explained in Figure 6.Additional procedural information is provided inFigure 6, and in Figure 7, "Instructions for Per-forming the Audiometric Pure Tone Hearing Re-screening Test."

Most developmentally normal three-year-oldsand many developmentally normal four-year-oldswill not be screenable using the techniques re-ferred to in Figures 6 and 7. For these children,the task must be more interesting and rewardingin order to elicit motor actions in response to testtones. For these children, "play audiometry" tech-niques are necessary, because they substitute astimulating and motivating action fo- the simplemotor responses that older children use. Forexample, screeners may train younger children tothrow a colorful pop-bead into a noisy containereach time a test signal is present. Testers canmake this motivating activity even more meaning-ful if they offer strong positive feedback when thechild successfully accomplishes the task.

Screeners should learn this technique in astructured, supervised training experience thatresults in satisfactory independent performance.The program's consulting audiologist or other ex-pert screener should provide the training andsupervision. Because screening using play audi-ometry may require several sessions, it is veryhelpful if parents or other caregivers can contrib-ute to the child's training. Appendix C containsinstructions to parents for training their childrenin this task. This "Sample Home ConditioningProgram" can also serve as a guide for trainingscreening personnel.

Prior to conducting the hearing screening test,the tester must ensure that the audiometer isworking properly and that the test room is quietenough to permit valid testing.

Test SignalsFor the initial hearing screening, pure-tone

stimuli with frequencies of 1000, 2000, and 4000Hz should be used. "Guidelines for IdentificationAudiometry" (ASHA, 1985) recommend including500 Hz in the screening process if tympanometryis not part of the screening process and if ambientnoise levels in the screening environment permit.Experience in public school screening programshas shown that ambient noise levels are almostalways too high for screening at 500 Hz, and if

38

Figure 6 1111

Instructions for Performing the Initial AudiometricPure-Tone Hearing Screening Thst

Audiometer Performance CheckWith the audiometer set to a loudness of 60 dB and a frequency of 2000 Hz and set to

"normally on," determine that. the tones reaching both earphones are steady (no static orinterruptions). This should be done while the tester wiggles the earphone wires of bothearphones at each end. If static or tone interruptions are heard, the audiometer must berepaired before it can be used.

Test Room Noise Level CheckThe test room must be quiet enough so that the tester or a young adult with normal

hearing can clearly hear all of the test tones at the screening intensity levels specified in"PASS/FAIL CRITERIA" below. If all of the test tones cannot be heard clearly, a quieter testroom must be found for screening.

Pass I Fail Criteria1. The frequencies of 1,000 Hz, 2,000 Hz, and 4,000 Hz should be used.2. The intensity dial (H.T.L. Dial) should be set at 20 dB.3. The child must respond correctly two out of three times at each frequency in both ears

in order to pass the test.4. If there is no response at 4,000 Hz at 20 dB, the intensity may be raised to 25 dB. If the

child still does not respond, he/she has failed the test.

Instructions to the ChildThe instructions to the child should be simple and clear so that he/she knows exactly what

is expected of him/her.1. Explain that the tones will be soft and may be hard to hear.2. Seat the child facing 45° away from the tester so that the tester can observe the child's

reactions and so that the child cannot see the tester operating the audiometer.3. Have the child place his or her hand on his or her knee while waiting for the tone.4. Instruct the child to raise his or her hand every time he/she hears the tone even if it is

very soft and difficult to hear.5. Instruct the child to raise his or her hand right away as soon as he/she hears the tone.6. Instruct the child to return his or her hand to his or her knee when the tone stops.7. Be sure the child knows to which ear the tones will be presented.

When the Child is Ready for Screening1. Expand the headband and place the red earphone on the right ear and the blue earphone

on the left ear.2. The tester should make certain that the opening in the center of the earphone is in direct

line with the ear canal. Place the earphones on the child while facing him.3. Adjust the earphones to the approximate size of the child's head before placing them in

position. The headband should rest squarely in the center of the child's head.4. Start with a one second tone presentation in the right ear at 1,000 Hz. If the child raises

his or her arm, allow the child to return his or her hand to his or her knee. Present thetone a second time, and if he or she does not respond, present the tone a third time. The

39 33

child must respond orrectly two out of three times in order to pass the screening in theright ear at 1,000 Hz.

5. Repeat the procedure in number four for 2,000 Hz and 4,000 Hz in the right ear. Thenrepeat the entire three-tone sequence for the left ear. The child must pass the screeningat all tones in both ears in order to pass the screening test. Remember: The intensitymay be raised to 25 dB at 4,000 Hz if the child does not hear the 4,000 Hz tone at 20 dBin either ear.

6. If the child fails the screening, he or she should be rescreened by another testerimmediately, if possible, or by the same tester after a short rest period. Carefullyreinstruct the child before rescreening.

Cautions1. Do not develop a rhythmic presentation. Vary the timing of the tone presentations so

that the child cannot anticipate when the next tone is coming.2. The child should be seated facing 450 away from the tester. The child is positioned

correctly when he or she cannot see the tester's hand operating the audiometer and thetester can see the side of the child's face.

3. Keep the length of the tones roughly equal. A one-second tone duration is desirable.4. It is not necessary to tell the child the results of the screening test. Never tell a child he

or she has failed the test. If a child asks about the results, simply say, "You did a goodjob on your hearing test today."

5. You may not be able to test some children. Some children will give false or no responseseven after you have taken the time to carefully rein struct and demonstrate the task forthem (see "Demonstration Techniques" below). Be sure to report which children wereuntestable to the person in charge of your hearing screening program.

Demonstration Techniques1. Place the earphones on the table near the child, with the centers of the earphones facing

the child.2. Position the child to face you.3. Adjust the intensity/H.T.L. dial to 110 dB and the frequency dial to 2,000 Hz.4. Present the tone and demonstrate the desired response by raising your hand.5. Repeat number four and encourage the child to join you in responding. You may

demonstrate softer tones by presenting tones at 70 to 80 dB.6. Once the child is responding correctly all by him or herself, resume the normal screening

process as explained above.

All children who fail the audiometric pure-tone hearing screening test should be referredfor rescreening a minimum of four weeks later.

4 ()34

Figure 7

Instructions for Performing the AudiometricPure-Tone Hearing Rescreening Thst

Selecting the Test EnvironmentA quiet test environment is absolutely essential. A room is quiet enough if the test tones

can be heard easily by a person with normal hearing. If the tester's hearing is not normal,locate a young adult with no history of hearing problems to listen to the test tones. Do notproceed with the rescreening if all the test tones cannot be heard easily. The room noisesources must be located and reduced or a quieter room must be found if the test tones cannotbe heard easily.

Audiometer Performance CheckWith the audiometer set to a loudness of 60 HL and a frequency of 2,000 Hz and set to

"normally on," determine that the tones reaching both earphones are steady (no static orinterruptions). This should be done while you wiggle the earphone wires of ,.,:tch earphoneat both ends. If any interruption of the tone is heard, do not proceed with the rescreeninguntil the audiometer is repaired. Next, without changing the settings of the audiometer,move the ear selector switch back and forth between "left and right." The tone should beequally loud in both ears if the listener's hearing is normal and if the audiometer is workingproperly.

Instructions to the ChildThe tester's instructions to the child should be simple and clear so that he or she knows

exactly what is expected of him or her.1. Explain that the tones will be soft and may be difficult to hear.2. Seat the child facing 450 away from the tester so that the tester can observe the child's

reactions and so that the child cannot see the tester operating the audiometer.2 Have the child place his or her hand on his or her knee while waiting for the tone,4. Instruct the child to raise his or her hand every time he or she hears the tone, even if it

is very soft and difficCt to hear.5. Instruct the child to raise his or her hand right away as soon as he or she hears the tone.6. Instruct the child to return his or her hand to his or her knee when the tone stops.7. Be sure the child knows to which ear the tone will be presented.

When the Child Is Ready for Screening1. Expand the headband and place the red earphone on the right ear, the blue earphone on

the left ear.2. The tester should make certain that the openingin center of the earphone is in direct line

with the ear canal. Place the earphones on the child while facing him.3. Adjust the earphones to the approximate size of the child's head before placing them in

position. The headband should rest squarely in the center of the head.4. Let the child know how he or she is doing. Praise him or her if he or she is doing well

and reinstruct him or her if he or she is having difficulty with the task.

4 1

BEST COPY AVAILABLE

35

1

Demonstration TechniquesIt may be necessary to demonstrate the test for some children who do not respond to the

tones. Demonstration techniques are explained in the "Instructions for Performing theInitial Audiometric Pure-Tone Hearing Screening Test." (Figure 6)

Pass I Fail and Referral Criteria1. The frequencies of 1,000 Hz, 2,000 Hz, and 4,000 Hz should be used.2. The audiometer loudness will be set to 20 dB HL for 1,000 and 2,000 Hz and 25 dB HL

for 4,000 Hz.3. The child must respond two out of three times to pass each frequency in each ear.4. If the child passes at 1,000 and 2,000 Hz but fails at 4,000 Hz in either ear, then test 3,000

Hz at 20 dB HL in that ear.5. Failure at 1,000 or 2,000 Hz in either ear is a rescreening failure. Failure at 4,000 Hz

only in either or both ears is not a failure but will require a retest next year.6. Failure at 3,000 AND 4,000 Hz in either or both ears is a rescreening failure.

Verifying the FailureThere are causes other than hearing loss for failure on the rescreening test. It is the

tester's job to rule out these causes before accepting the failure. If a child fails any frequencyin either ear,1. Reposition the earphones and rescreen. The center of the earphone mustbe directly over

the opening of the ear canal.2. Increase the loudness of the tone failed to 60 dB HL to be sure the child underst^ nds the

task and is paying attention. When it is clear that the child is paying atten6ion andunderstands the task, reduce the loudness to the screening level and retest. If the childdoes not understand or is not paying attention, proceed to number three below.

3. Reinstruct the child, and remind him or her that the tones are soft. If necessary, removethe earphones and repeat the demonstration activity. Be generous with your praise forcorrect responding.

4. If a child cannot learn the screening task and does not respond to any 60 dB sounds,report him or her to the person in charge at your hearing screening program.

ReferralsParents of children who fail the rescreening test should be informed of the failure and

should be encouraged to obtain medical and audiological evaluations for their children. Itis important that hearing screening personnel seek the results of the medical and audiolog-ical evaluations. If the hearing loss does not resolve with medical treatment, the child'sschool should be made aware of the problem. Periodic rescreening of children referred formedical evaluations and treatment is important to document the resolution of temporaryhearing losses and the persistence of other hearing losses.

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screeners include that frequency in the steeeningprotocol, it increases the false positive referralrates substantially. Finally, because few sig-nificant hearing problems in children affect audi-tory sensitivity at 500 Hz and not. any of the otherthree test frequencies, screeners may eliminatethe 500 Hz stimuli from the screening protocol.Screening should occur at levels of 20 dB HL forthe 1000 and 2000 Hz signals and at 25 dB HL forthe 4000 Hz signal. (ANSI, 1989) An additionaltest signal should be added to the rescreeningsession. During the rescreening session, screen-ing at 3000 Hz at 20 dB HL (ANSI, 1989) shouldalso occur in the ear(s) in which the child passesthe screening at all frequencies except 4000 Hz.

Pass I Fail and Referral CriteriaThe child must respond reliably to 75 pcncent of

the presentations of all test signals in both ears topass the initial pure-tone screening test(s). Dur-ing the initial screening session, a child who failsshould receive a second opportunity to pass thescreening after careful reinstruction and reposi-tioning of the earphones. When a child fails theinitial pure-tone screening, the program shouldschedule a rescreening session for four weekslater. If signs of acute ear disease are present, orif the screener notes significant ear drum or earcanal abnormalities, the program director shouldmake a prompt medical referral.

During the rescreening session, failure at 1000or 2000 Hz in either ear shoutd be followed by amedical and audiological evaluation. In the eventoffailure at only 4000 Hz in either or both ears, thetester must rescreen at 3000 Hz at 20 dB HL.Failure at both 3000 and 4000 Hz in either earshould result in medical and audiological evalua-tion. Failure at only 4000 Hz in either ear may notjustify a medical referral. Periodic audiometricrescreening twice annually, however, should oc-cur to rule out further decreases in auditory sen-sitivity at other test frequencies. In addition, thechild's family should be notified, and the child'srisks of dangerous noise exposure should be as-sessed. If such exposures exist, precautions shouldbe taken to avoid them. Parents may wish to seekan audiological evaluation to establish a formalaudiometric baseline of hearing sensitivity.

Alternative Pure-Tone Screening ModelThe ASHA model for pure-tone hearing screening,as described in the "Guidelines for IdentificationAudiometry" (ASHA, 1985), differs in some re-

spects from the pure-tone protocol recommendedabove. A primary difference is that the ASHAmodel recommends that programs refer all chil-dren who fail the screening process for evaluationby an audiologist prior to the medical referral. Therationale for this step is: "Some persons, particu-larly young children, will fail both the screeningand rescreening procedures and then yield normalthresholds on an audiologic evaluation." Thisstatement implies that something in the screeningprocess (possibly the environment or errors byscreeners) generates false positive results; andthat skilled threshold testing by an audiologist isnecessary to keep false positive test results to anacceptable level.

Hearing screening coordin ators sh ould be awareofthe followingimplications ofehoosing this model:

Threshold testing requires very quiet test envi-ronments usually found only in sound-treated testrooms.

Equipment. must be capable of masked thresh-old testing and meet strict ANSI standards.

Hearing loss is a medical symptom which re-quires a prompt referral for medical evaluationwhen the screening program deteees a possibleproblem. Referral for threshold testing or evalu-ation by an audiologist or other skilled testershould not result in delays that prevent promptmedical evdivation.

Unless the services of an audiologist are part ofor supported by the screening program, audiologictesting before the medical evaluation may resultin added costs to the family. Many third-partypayers will not reimburse for audiologic testingunless it is part of a medical evaluation.

Audiometric evaluations and threshold testresults obtained during the screeningprocess maynot represent the status of the child's hearing atthe time of the medical evaluation. Since medicalevaluations are often significantly delayed afterthe family is notified of the failure, repeat testingwill likely be required.

Threshold tests alene should not be referred toas "hearing evaluations," even when done by alicensed audiologist. Threshold testing is only onepart of a hearing evaluation. Persons who includethreshold test results with medical referrals shouldensure that physicians understand that the re-sults do not constitute a hearing evaluation. Chap-ter 459 of the Wisconsin statutes restricts thosewho may do hearing evaluations to licensed audi-ologists. However, licensed hearing instrumentspecialists may measure hearing for the purposesof selecting, adapting, or selling hearing aids.

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If the primary rationale for conducting audio-logical testing prior to medical referral is thereduction of false positive referrals, the directormay wish to consider other means to accomplishthe same result. Well-trained and supervisedscreeners are the most important element in re-ducing false positive screening results. This doc-ument provides guidance in minimal training ele-ments for the screeners listed in section 3.

ReferencesAmerican National Standards Institute. Ameri-

can National Standards Specifications for Au-diometers. New York: ANSI, 1989.

American Speech-Language-HearingAssociation."Audio logic Screening of Newborn Infants WhoAre at Risk for Hearing Impairment." Asha(March 1989), pp. 89-92.

. "Guidelines for Identification Audiome-try." Asha (May 1985), pp. 49-52.

Bluestone, C.D., et al. "Workshop on Effects ofOtitis Media on the Child." Pediatrics 71.4(1983), pp. 639-52.

Bluestone, C.D., et al . "Controversies in Screeningfor Middle Ear Disease and Hearing Loss inChildren." Pediatrics 77.1 (1986), pp. 57-70.

Dahle, A.J., and F.P. McCollister. "Hearing andOtologic Disorders in Children with Down Syn-drome."American Journal of Mental Deficiency90.6 (1986), pp. 36-42.

Downs, M.P. "The Rationale for Neonatal HearingScreening." In Neonatal Hearing Screening.Ed. E.T. Swigart. San Diego, CA: College HillPress, 1986, pp. 3-19.

38

Elsmann, S.F., N.D. Matkin, and M.P. Sabo. "Ear-ly Identification of Congenital SensorineuraiHearing Impairment." The Hearing Journal(September 1987), pp. 13-18.

Feinmesser, M., and L. Tell. "Neonatal Screeningfor Detection of Deafness." Archives of Oto-laryngology 102.5 (1976), PP. 297-99.

Fria, T.J., et al. "The Effects of Otitis Media withEffusion on Hearing Sensitivity in Children."In Recent Advances in, Otitis Media with Effu-sion. Eds. D.J. Lim et al. Ontario, Canada: B.C.Decker, Inc., 1984, pp. 320-24.

Matkin, N.D. "Early Recognition and Referral ofHearing Impaired Children." Pediatrics inReview 6.5 (November 1984), pp. 151-57.

Moore, J.M., W.R. Wilson, and G. Thompson. "Vi-sual Reinforcement of Head-Turn Responses inInfants Under 12 Months of Age." Journal ofSpeech and Hearing Disorders 42 (1977),pp. 328-34.

Primus, M.A. "The Role of Localization in VisualReinforcement Audiometry." Journal of Speechand Hearing Research 35 (1992), pp. 1137-41.

Stein, L., S. Clark, and N. Kraus. "The HearingImpaired Infant: Patterns of Identification andHabilitation." Ear and Hearing 3.5 (1983),pp. 232-36.

Thompson, G., W.R. Wilson, and J.M. Moore. "Ap-plications of Visual Reinforcement Audiometryto Low Functioning Children." Journal ofSpeech and Hearing Disorders 44 (1979)pp. 80-90.

4 4

Barriers to SuccessfulChildhood Hearing Screenhig

When adequately trained and supervised per-sonnel screen for hearing loss using traditionalprocedures in appropriate environments, mostchildren will be screened successfully. However,those who perform the initial screening test arefrequently unable to screen some school childrensuccessfully. It is important to understand thatthis is a normal occurrence, and they should feelno pressure to produce only "pass" or "fail" resultsfor all children. It is vital that initial screeners beencouraged to report all screening tests that are oflow reliability or are unsuccessful. When theseresults occur, a more experienced individual shouldattempt a screening. That person may be theaudiologist who consults with the screening pro-gram, the hearing screening director, or otherqualified person designated by the director andconsulting audiologist to assume this role. Re-peated screening attempts spanning several daysor weeks may be necessary, and sometimes refer-ral to a licensed audiologist in a clinical settingmay Pe required.

In addition to school-age children who cannotbe screened successfully, large numbers of chil-dren in high-risk and difficult-to-test populationsare not included in hearing screening efforts:(Frye-Osier and Wahlton, 1988) This section ex-amines the barriers that prevent the successfulhearing screening of some children and the exclu-sion of others from screening programs and ex-plores possible resolutions.

Misunderstanding the Need toScreen All Targeted Children

Many people outside the field of communica-tive disorders assume that young children withsocially adequate speech and language and nor-mal auditory responsiveness in favorablecommunication situations have normal hearing.The reality is that young children can exhibitthese "normal" behaviors while experiencing de-velopmentally significant mild and high frequen-cy, unilateral, or fluctuating hearing loss. Unlessthis fact is understood, such children who ,:annotbe screened successfully may be dismissed fromfurther efforts to screen for hearing loss.

One way to rule out, significant hearing loss inchildren is to employ the formal hearing screeningprocedures described in this publication. Subjec-tive screening methods, informal "testing" withnoisemakers, and subjective impressions of audi-tory acuity do not work and will miss children withsignificanthearing impairments. In order to facil-itate valid screening for young or uncooperativechildren, screeners must provide careful parentalcounseling so families will understand the impor-tance of formal hearing screening and the use ofvalid screening tools and procedures. This empow-erment of parents is essential if they are to advo-cate for appropriate screening services from theirmedical providers.

39

Belief That Rehabilitation IsImpossible for Some

Children with severe physical, cognitive, emo-tional, or multiple disabilities are often very diffi-cult to screen for hearing loss, even by skilledaudiologists. Many of these children in Wisconsinhave notbeen screened for hearing loss before theyenter school, and the majority of them are notscreened in their school hearing screening pro-grams. (Frye-Osier and Wahlton, 1988)

Certain beliefs and attitudes prevent vigorousefforts to screen for hearing loss in this population.Some people believe that hearing assessment andeffective auditory rehabilitation is impossible inthis population. Actually, audiologists can suc-cessfully assess the hearing of ma-4 of thesechildren and provide important aud tory rehabil-itative interventions.

Other people believe that the developmentalpotential and the quality of life are so limited forthese children that little will be gained for theeffort necessary to deal with their loss of hearing.Hearing loss is far more likely for the child with asevere disability than for other children, and theconsequences are more serious. These childrenoften face huge obstacles to learning and commu-nication in addition to possible sensory impair-ments. In reality, bearing loss may be among theeasiest of the child's problems to identify andrehabilitate. To allow hearing loss to go undetect-ed in these children is to impose unnecessaryadditional barriers to communication and learn-ing and to reduce their quality of life by deprivingthem of the auditory experiences that people withnormal hearing enjoy.

Difficulty in Locating ResourcesSuccessful hearing screening of children who

are young, unresponsive, or severely disabled canbe expensive and time-consuming. Screening pro-grams often cannot accomplish screening thesechildren in traditional screening environmentsand must refer them to a licensed audiologistexperienced in assessing difficult-to-test children.Not all communities in Wisconsin have the neces-sary audiologic expertise, and this lack of person-nel may require the child's family to travel. Inaddition, the screening process may take multiplevisits to complete, may entail parental participa-tion in training the child, and may necessitate theinvolvement of a physician and the use of seda-tives or anesthetics.

40

The following resources are available to fami-lies to assist in securing needed services:

County and/or city public h ealth programs serveeveiy Wisconsin community. Health professionalsin these agencies are knowledgeable about theresources, both public and private, that are avail-able to assist families in securing needed services.

The Wisconsin Health Check Program is re-sponsible for providing screening services for eligi-ble children. This program also includes transpor-tation services for eligible children.

County birth to three programs screen andevaluate children who are identified as being poten-tially eligible for services. These programs includeservice coordination, family education, audiologyservices, and transportation.

The Wisconsin Program for Children with Spe-cial Health Care Needs (PCSHCN), located in theWisconsin Department of Health and Social Ser-vices, can be contacted by calling 800-441-4576(voice), or 608-266-5485 (TDD). The PCSHCNprovides financial assistar:te for medical evalua-tion and treatment services for children whosefamilies meet the eligibility requirements of theprogram. In addition, program staff offer consul-tative services to families and can assist in locat-ing medical and audiologic services in their com-munities.

Head Start programs can assist eligible chil-dren from low-income families with obtaininghear-ing screenings. Transportation sprvic _ may alsobe provided.

Public schools must provide ongoing specialeducation screening programs for all children inthe school district who have not graduated fromhigh school. The local education agency (LEA)must evaluate all children that it suspects havehandicapping conditions and who may be eligiblefor special education services. While LEAs are notspecifically required to screen for hearing impair-ment in children in all EEN categories, they mustevaluate children in all areas related to the sus-pected handicapping conditions. If the LEA sus-pects a hearing impairment in a child who is beingevaluated for special education services, the LEAmust ensure that ahearing evaluation takes place.

Successful hearing screening of all infants andchildren can be a reality, especially when there arecoordinated community screening efforts begin-ning at birth and continuing into the early schoolyears. Hearing screening leadership people inevery community must break down the barriers ofmisinformation and inaccurate beliefs and advo-cate for the resources necessary to accomplish thetask.

46

SummaryQuality hearing screening programs for infants

and children, delivered as early in life as possible,are essential to limiting or eliminating the nega-tive developmental and social consequences ofhearing loss. Therefore, this guide is offered toprovide the reader with the information necessaryfor justifying and designing valid and reliablehearing screening programs for appropriate popu-lations of children. The guide emphasizes theneed for the involvement of a licensed audiologistin every hearing screening program, the impor-tance ofhighly trained and well-supervised screen-ing personnel, the importance of comprehensivehearing screening services in the preschool years,and the involvement of many service deliverysystems in the community. In addition, the guideattempts to provide a comprehensive treatment ofthe critical components of quality hearing screen-ing programs, screening test protocols, and equip-ment issues and options.

Improvement of infant and childhood hearingscreeniqg programs in Wisconsin will require anew commitment of effort and resources and en-hanced ciAaboration among individuals, agen-cies, and families in every community. Only whenthere ir a community consensus about the impor-tance of quality hearing screening programs for allchildren will progress occur. This consensus willrequire communication, collaboration, and theresolution of difficult issues related to prioritizingthe needs of children in the context of limitedresources. Until a consensus is reached, Wiscon-sin will not loP able to accomplish the importanttask of identifying every child with impaired hear-ing as early in life as possible. Hopefully, thisguide will stimulate and promote the necessaryconsensus building.

ReferenceFrye-0 sier, J., and R. Wahlton. 7985-86 Wisconsin

School District Hearing Screening Survey. Wis-consin Department of Public Instruction, 1988.

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Appenclixes

A. Joint Committee on Infant Hearing 1990 PositionStatement

B. Resources and Educational Materials for Parentsand Caregivers

C. Sample Home Conditioning Program

D. Glossary

E. Relevant Materials

4843

II Appendix A

Joint Committee on Infant Hearing 1990 Position Statement*

44

The following expanded position statement was developed by the Joint Committee on InfantHearing. Representatives of the member organizations who prepared this statement include thefollowing: American Speech-Language-Hearing AssociationFred H. Bess, chair, Noel D. Matkin andEvelyn Cherow, ex officio; American Academy of Otolaryngology-Head and Neck SurgeryKennethM. Grundfast, co-chair; American Academy of PediatricsAllen Erenberg and William P. Potsic;Council for Education of the DEAFLita Aldridge and Barbara Bodner-Johnson; Directors of Speechand Hearing Programs in State Health and Welfare AgenciesThomas Mahoney. Consultants: AlanSalamy and Gregory J. Matz. ASHA monitoring vice president: Ann L. Carey.

I. BackgroundThe early detection of hearing impairment in children is essential in order to

initiate the medical and educational intervention critical for developing optimalcommunication and social P,kills. In 1982, the Joint Committee on Infant Hearingrecommended identifying infants at risk for hearing impairment by means of sevencriteria and suggested follow-up audiological evaluation of these infants untilaccurate assessments of hearing could be made (ASHA, 1982). In recent years,advances in science and technology have increased the chances for survival ofmarkedly premature and low birth weight neonates and other severely compromisednewborns. Because moderate to severe sensorineural hearing loss can be confirmedin 2.5 percent to 5.0 percent of neonates manifesting any of the previously publishedrisk criteria, auditory screening of at-risk newborns is warranted (Hosford-Dunn, etal., 1987; Jacobson and Morehouse, 1984; Mahoney ar d Eichwald, 1987; Stein, et al.,1983). Those infants who have one or more of the risk factors are considered to beat increased risk for sensorineural hearing loss.

Recent research and new legislation (PL 99-457) suggest the need for expansionand clarification of the 1982 criteria. This 1991 statement expands the risk criteriaand makes recommendations for the identification and management of hearing-impaired neonates and infants. The Joint Committee recognizes that the perfor-mance characteristics of these new risk factors are not presently known; furtherstudy and critical evaluation of the risk criteria are therefore encouraged. Theprotocols recommended by the Committee are considered optimal and are based onboth clinical experience and current research findings. The Committee recognizes,however, that the recommended protocols may not be appropriate for all institutionsand that modifications in screening approaches will be necessary to accommodatethe specific needs of a given facility. Such factors as cost and availability ofequipment, personnel and follow-up services are important considerations in thedevelopment of a screening program (Turner, 1990).

II. IdentificationA. Risk Criteria: Neonates (birth-28 days)

The risk factors that identify those neonates who are at-risk for sensorineuralhearing impairment include the following:

1. Family history of congenital or delayed onset childhood sensorineuralimpairment.

*Reprinted by permission of the American Speech-Language-Hearing Association.

4 9

2. Congenital infection known or suspected to be associated with senso-rineural hearing impairment such as toxoplasmosis, syphilis, rubella,cytomegalovirus and herpes.

3. Craniofacial anomalies including morphologic abnormalities of fin pinnaand ear canal, absent philtrum, low hairline, et-cetera.

4. Birth weight less than 1500 grams (-3.3 lbs.).

5. Hyperbilirubinemia at a level exceeding indication for exchange transfu-sion.

6. Ototoxic medications including but not limited to the aminoglycosidesused for more than five days (e.g., gentamicin, tobramycin, kanamycin,streptomycin) and loop diuretics used in combination with aminoglyco-sides.

7. Bacterial meningitis.

8. Severe depression at birth, which may include infants with Apgar scoresof 0-3 at 5 minutes or those who fail to initiate spontaneous respiration by10 minutes or those with hypotonia persisting to two hours of age.

9. Prolonged mechanical ventilation for a duration equal to or greater than10 days (persistent pulmonary hypertension).

10. Stigmata or other findings associated with a syndrome known to includesensorineural hearing loss (Waardenburg or Usher's Syndrome).

B. Risk Criteria Infants (29 daystwo years)The factors that identify those infants who are at-risk for sensorineural

hearing impairment include the following:1. Parent/caregiver concern regarding hearing, speech, language and/or

developmental delay.

2. Bacterial meningitis.

3. Neonatal risk factors that may be associated with progressive sen sorineu-ral hearing loss (cytomegalovirus, prolonged mechanical ventilation andinherited disorders).

4. Head trauma especially with either longitudinal or transverse fracture ofthe temporal bone.

5. Stigmata or other findings associated with syndromes known to includesenscrineural hearing loss (Waardenburg or Usher's Syndrome).

6. Ototoxic medications including but not limited to the aminoglycosidesused for more than five days (gentamicin, tobramycin, kanamycin, strep-tomycin) and loop diuretics used in combination with aminoglycosides).

7. Children with neurodegenerative disorders such as neurofibromatosis,myoclonic epilepsy, Werdnig-Hoffman disease, Tay-Sach's disease, infan-tile Gaucher's disease, Nieman-Pick disease, any metachromatic leukod-ystrophy, or any infantile demyelinating neuropathy.

8. Childhood infectious diseases known to be associated with sensorineuralhearing loss (e.g., mumps, measles).

50

46

III. Audio logic Screening Recommendations for Neonates and I,ifantsA. Neonates

Neonates who manifest one or more items on the risk criteria should bescreened, preferably under the supervision of an audiologist. Optimally,screening should be completed prior to discharge from the newborn nursery butno later than three months of age. The initial screening should includemeasurement of th e auditory brainstem response (ABR) (ASHA, 1989). Behav-ioral testing of newborn infants' hearing has high false-positive and false-negative rates and is not universally recommended. Because some false-positive results can occur with ABR screening, ongoing assessment andobservation of the infant' s auditory behavior is recommended during the earlystages of intervention. If the infant is discharged prior to screening, or if ABRscreening under audiologic supervision is not available, the child ideally shouldbe referred for ABR testing by three months of age but never later than sixmonths of age.

The acoustic stimulus for ABR screening should contain energy in thefrequency region important for speech recognition. Clicks an, the most com-monly used signal for eliciting the ABR and contain energy in the speechfrequency region (ASHA, 1989). Pass criterion for ABR screening is a responsefrom each ear at intensity levels 40 dB nHL or less. Transducers designed toreduce the probability of ear-canal collapse are recommended.

If consistent electrophysiological responses are detected at appropriatesound levels, then the screening process will be considered cohiplete except inthose cases where there is a probability of progressive hearing loss (familyhistory of delayed onset, degenerative disease, meningitis, intrauterine infec-tions or infants who had chronic lung disease, pulmonary hypertension or whoreceived medications in doses likely to be ototoxic). If the results of an initialscreening of an infant manifesting any risk criteria are equivocal, then theinfant should be referred for general medical, otological, and audiologicalfollow-up.

B. I nfant s

Infants who exhibit one or more items on the risk criteria should be screenedas soon as possible but no later than three months after the child has beenidentified as at-risk. For infants less than six months of age, ABR screening (seeII A.) is recommended. For infants older than six months, behavioral testingusing a conditioned response or ABR testing are appropriate approaches.Infants who fail the screen should be referred for a comprehensive audiologicevaluation. This evaluation may include R, behavioral testing (6 months)and acoustic immittance measures (see ASHA, 1989 Guidelines, for recom-mended protocols by developmental age).

IV. Early Intervention for Hearing-Impaired Infants and Their FamiliesWhen hearing loss is identified, early intervention services should be provided, in

accordance with Public Law 99-457. Early intervention services under PL 99-457may commence before the completion of the evaluation and assessment if thefollowing conditions are met: (a) parental consent is obtained, (b) an interimindividualized family service plan (IFSP) is developed, and (c) the full initialevaluation process is completed within 45 days of referral.

51

The interim IFSP should include the following:

A. The name of the case manager who will be responsible for bothimplementation of the interim IFSP and coordination with otheragencies and persons;

B. The early intervention services that have been determined to beneeded immediately by the child and the child's family.These immediate early intervention services should, include the following:

1. Evaluation by a physician with expertise in the management of earlychildhood otologic disorders.

2. Evaluation by an audiologist with expertise in the assessment of youngchildren, to determine the type, degree, and configuration of the hearingloss, and to recommend assistive communication devices appropriate tothe child's needs (hearing aids, personal FM systems, vibrotactile aids).

3. Evaluation by a speech-language pathologist, teacher of the hearing-impaired, audiologist, or other professional with expertise in the assess-ment of communication skills in hearing-impaired children, to develop aprogram of early intervention consistent with the needs of the child andpreferences of the family. Such intervention would be cognizant of andsensitive to cultural values inherent in familial deafness.

4. Family education, counseling and guidance, including home visits andparent support groups to provide families with information, child man-agement skills and emotional support consistent with the needs of thechild and family and their culture.

5. Special instruction that includes:

a. the design and implementation of learning environments and activ-ities that promote the child's development and communication skills;

b. curriculum planning that integrates and coordinates multidisci-plinary personnel and resources so that intended outcomes of theIFSP are achieved; and,

c. ongoing monitoring of the child's hearing status and amplificationneeds and development of auditory skills.

V. Future Considerations for Risk CriteriaBecause of the dynamic changes occurring in neonatal-prenatal medicine, the

committee recognizes that forthcoming research may result in the need for revisionof the 1991 risk register. For example, the committee has concerns about the possibleototoxic effects on the fetus from maternal drug abuse; however, present data areinsufficient to determine whether the fetus or neonate are at risk for hearing loss.In addition, yet-to-be-developed medications may have ototoxic effects on neonatesand infants. Therefore, the committee advises clinicians to keep apprised ofpublished reports demonstrating correlations between maternal drug abuse andototoxicity and between future antimicrobial agents and ototoxicity. Cliniciansshould also take into account the possible interactive effects of multiple medicationsadministered simultaneously. Finally, the committee recommends that the positionstatement be examined every three years for possible revision.

52 47

48

ReferencesAmerican Speech-Language-Hearing Association. "Guidelines for Audio logic Screening of

Newborn Infants Who Are At-risk for Hearing Impairment." Asha 31.3 (1989), pp. 89-92.

Early Intervention Program for Infants and Toddlers With Handicaps: Final Regulations.Federal Register 54.119, June 22, 1989, pp. 26,306-26,348.

Hosford-Dunn, et al. (1987). "Infant Hearing Screening: Program Implementation andValidation." Ear and Hearing 8 (1987), pp. 12-20.

Jacobson, J., and R. Morehouse. "A Comparison of Auditory Brainstem Response andBehavioral Screening in High Risk and Normal Newborn Infants." Ear and Hearing 5.4(1984), pp. 245-253.

"Joint Committee on Infant Hearing." Position statement. Asha 24.12, pp. 1,017-1,018.

Mahoney, T. M., and J.G. Eichwald. "The Ups and 'Downs' of High Risk Hearing Screening:The Utah Statewide Program." Seminars in Hearing 8.2 (1987), pp. 155-163.

Stein, L., et al. "Follow-up of Infants Screened by Auditory Brainstem Response in theNeonatal Intensive Care Unit." Journal of Pediatrics 63 (1983), pp. 447-453.

Turner, R. G. "Analysis of Recommended Guidelines for Infant Hearing Screening." Asha32.9 (1990), pp. 57-61.

Suggested Reading

Early Intervention"Early Intervention Program for Infants and Toddlers with Handicaps: Final Regulations."

Federal Register 54.119, June 22, 1989, pp. 26,306-26,348.

Levitt, H., N. McGarr, and D. Geffner. Development of Language and Communication Skillsin Hearing Impaired Children. (Monograph No. 26). Rockville, MD: American Speech-Language-Hearing Association, 1987.

Ling, D. "Early Speech Development." In Early Management of Hearing Loss. Eds G.Mencher and S.E. Gerber. New York: Grune & Stratton, 1981, pp. 310-335.

McFarland, W. H., and F.B. Simmons. "The Importance of Early Intervention with SevereChildhood Deafness." Pediatric Annals 9, pp. 13-19.

U.S. Department of Health, Education, and Welfare. The Commission on Education of theDeaf. Toward Equality: Education of the Deaf. A Report to the Congress of the U.S.,Washington, DC, 1988.

Early Identification of Hearing Impairment in Neonates and InfantsAlberti, P., et al. "Issues in Early Identification of Hearing Loss. Laryngoscope 95.4 (1985),

pp. 373-381.

American Academy of Pediatrics. Committee on Fetus and Newborn. "Use and Abuse of theApgar Score." Pediatrics 78 (1986), pp. 114-18.

American Speech-Language-Hearing Association. "Guidelines for Audiologic Screening ofNewborn Infants Who Are At-risk for Hearing Impairment." Asha 31.3 (1989), pp. 89-92.

American Speech-Language-Hearing Association. "Guidelines for Infant Hearing Screen-ing: Response to Robert G. Turner's Analysis." Asha 32.9 (1990), pp. 63-66.

53

Bergman, I., et al. "Cause of Hearing Loss in the High-Risk Premature Infant." Journal ofPediatrics 106 (1985), pp. 95-101.

Bess, F.H., ed. Hearing Impairment in Children. Parkton, MD: York Press, 1988.

Brummett, RE. "Ototoxicity Resulting from the Combined Administration of PotentDiuretics and Other Agents." Scandinavian Audiology Supplement 14 (1981), pp. 215-224.

Brummett, R.E., et, al. "Interaction Between Aminoglycoside Antibiotics and Loop-Inhibit-ing Diuretics in the Guinea Pig." In Aninoglycoside Ototoxicity. Eds S. Lerner, G. Matz,and J. Hawkins. Boston: Little, Brown, 1981, pp. 67-77.

Brummett, R.E., et al. "Cochlear Damage Resulting from Kanamycin and Furosemide." ActaOtolaryngologica 80 (1975), pp. 86-92.

Church, M.W., and K P. Gerkin. "Hearing Disorders in Children with Fetal AlcoholSyndrome: Findings from Case Reports." Pediatrics 82 (1988), pp. 147-154.

Cop lan, J. "Deafness: Ever Heard of It? Delayed Recognition of Permanent Hearing Loss."Pediatrics 79 (1987), pp. 206-213.

Elssman, S., N. Matkin, and M. Sabo. "Early Identification of Congenital SensorineuralHearing Impairment." The Hearing Journal 40 (1987), pp. 13-17.

Gerkin, K.P. "The High Risk Register for Deafness." Asha 26.3 (1984), pp. 17-23.

Gerkin, K.P., and A. Amochev. "Hearing in Infants: Proceedings from a National Sym-posium." Seminars in Hearing. 8 (1987), pp. 77-187.

Gorga M. "Auditory Brainstem Responses from Graduates of an Intensive Care Nursery:Normal Patterns of Response." Journal of Speech and Hearing Research 30 (1987),pp. 311-318.

Gorga, M., J.R. Kaminski, and K.A. Beauchaine. "Auditory Brainstem Responses fromGraduates of an Intensive Care Nursery Using an Insert Earphone." Ear and Hearing 9(1988), pp. 144-147.

Halpern, J., H. Hosford-Dunn, and N. Malachowski. "Four Factors That Accurately PredictHearing Loss in 'High Risk' Neonates." Ear and Hearing 8 (1987), pp. 21-25.

Hendricks-Munoz, K.D., and J.P. Walton. "Hearing Loss in Infants with Persistent FetalCirculation." Pediatrics 81.5 (1988), pp. 650-656.

Hosford-Dunn, et al. "Infant Hearing Screening: Program Implementation and Validation."Ear and Hearing 8 (1987), pp. 12-20.

Hyde, M., et al. "A Neonatal Hearing Screening Research Program Using Brainstem ElectricResponse Audiometry." Journal of Otolaryngology 13 (1984), pp. 49-54.

Jacobson, J., anfi 7 Morehouse. "A Comparison of Auditory Response andBehavioral Se in High Risk and Normal Newborn Infants." Ear Lard Hearing 5.4(1984), pp. 2,*o. 253.

"Joint Committee on Infant Hearing." Position statement. Asha 24.12 (1982), pp. 1017-1018.

Kahlmeter, 0., and J. Dahlager. "Aminoglycoside Toxicity: A Review of Clinical StudiesPublished Between 1975 and 1982." Journal of Antimicrobial Chemotherapy 13 (suppl. A)(1984), pp. 9-22.

Kaka, J., C. Lyman, and D. Kllarskl. "Tobramycin-Furosemide Interaction." Drug Intelli-gence and Clinical Pharmacy 18 (1984), pp. 235-238.

54

50

Lary, S., et al. "Hearing Threshold in Preterm and Term Infants by Auditory BrainstemResponse." Journal of Pediatrics 107 (1985), pp. 593-599.

Mahoney, T.M., and J.G. Eichwald. "The Ups and "Downs" of High Risk Hearing Screening:The Utah Statewide Program." Seminars in Hearing 8.2 (1987), pp. 155-163.

Matkin, N.D. "Early Recognition and Referral of Hearing Impaired Children." Pediatricsin Review 6 (1984), pp. 151-158.

Matz, G. "Clinical Perspectives on Ototoxic Drugs." Annals of Otology, Rhinology andLaryngology 99 (1990), pp. 39-41.

Naulty, C.M., 1.P Weiss, and G.R. Herer. "Progressive Sensorineural Hearing Loss inSurvivors of Persistent Fetal Circulation." Ear and Hearing 7 (1986), pp. 74-77.

Nield, T.A., et al. "Unexpected Hearing Loss in High-Risk Infants." Pediatrics 73 (1986),pp. 417-422.

Northern, J.L., and M.D. Downs. Hearing in Children 3rd ed. Baltimore, MD: Williams &Wilkins, 1984.

Salamy, A., L. Eldridge, and W.H. Tooley. "Neonatal Status and Hearing Loss in High-RiskInfants." Journal of Pediatrics 114 (1989), pp. 847-852.

Schwartz, D.H., R.E. Pratt, and J.A. Schwartz. "Auditory Brain stem Responses in PretermInfants: Evidence of Peripheral Maturity." Ear and Hearing 10 (1989), pp. 14-22.

Stein, L., et al. "Follow-up of Infants Screened by Auditory Brainstem Response in theNeonatal Intensive Care Unit." Journal of Pediatrics 63 (1983), pp. 447-453.

Surgon ski, N., et al. "Hearing Screening of High-Risk Newborns." Ear and Hearing 8 (1987),pp. 26-30.

Turner, R.G. "Analysis of Recommended Guidelines for Infant Hearing Screening." Asha32.9 (1990), pp. 57-61.

Diagnosis and ManagementBess, F.H. Hearing Impairment in Children. Parkton, MD: York Press, 1988.

Clark, T.C., and S. Watkins. The SKI* Hi Model Programming for Hearing Impaired InfantsThrough Home Intervention. Logan, UT: SKI* Hi Institute, 1985.

Dodge, P.R., et al. "Prospective Evaluation of Hearing Impairment as a Sequela of AcuteBacterial Meningitis." The New England Journal of Medicine 311 (1984), pp. 869-874.

Fitzgerald, M.T., and F.H. Bess. "Parent/Infant Training for Hearing Impaired Children."Monographs in Contemporary Audiology 3 (1982), pp. 1-24.

Gravel, J.S. "Assessing Auditory System Integrity in High-Risk Infants and Young Chil-dren." Seminars in Hearing 10 (1989), pp. 213-290.

Hosford-Dunn, H., et al. "Delayed Onset He aring Loss in a Two-Year-Old." Ear and Hearing7 (1986),pp. 8-82.

Matkin, N.D. "Key Considerations in Counseling Parents of Hearing Impaired Children."Seminars in Speech and Language 9.3 (1988), pp. 209-222.

Mencher, G.T., and S.E. Gerber. Early Management of Hearing Loss. New York: Grime &Stratton, 1981.

Ross, M., and T.C. Giolas, eds. Auditor), Management of Hearing Impaired Children.Baltimore, MD: University Park Press, 1978.

55

Thompson, G., and R. Wilson. "Clinical Application of Visual Reinforcement Audiometry."Seminars in Hearing 5 (1984), pp. 85-89.

Thompson, M., J. Atcheson, and C. Pious. Birth to Three: A Curriculum for Parents, ParentTrainers, and Teachers. Seattle: University of Washington Press, 1985.

United States House of Representatives. Report Accompanying the Education of theHandicapped Act Amendments of 1986. 99th Cong. 2nd Sess. Washington, DC: U.S.Government Printing Office 1986

5 8 51

IIII Appendix B

Resources and Educational Materials for Parents and Caregivers

The American Speech-Language-Hearing Association *

10801 Rockville PikeRockville, MD 20852(800) 638-6868 (Voice/TDD)

The Charming L. Bete Co., Inc.200 State RoadSouth Deerfield, MA 01373(413) 665-7611

The Alexander Graham BellAssociation for the Deaf*

3417 Volta Place, N.W.Washington, DC 20007-2778(202) 337-5220 (Voice/TDD)

* some materials available in Spanish** some materials available in Hmong

52

The National Information Center on DeafnessGallaudet University800 Florida Ave. N.E.Washington, DC 20002-3695(202) 651-5051 (Voice)(202) 651-5052 (TDD)

Minnesota Foundation for BetterHearing and Speech **

166 4th Street East, Suite 320St. Paul, MN 55101(612) 223-5130 (Voice/TDD)

National Association for Hearing andSpeech Action

814 Thayer AvenueSilver Spring, MD 20901(800) 638-8255 (Voice/TDD)

57

Appendix C

Sample Home Conditioning Program

Dear Parents:

In order for us to evaluate your child's hearing; it is necessary that he or she be able to perform a taskwhen he or she hears a sound. If your child could perform such a task when he cr she arrives for thehearing test, it would be very helpful.

The following is -igram we have written for you and your child to teach him or her to perform therequired tasks for our sts. Begin the program slowly and do only a small amount each day. Do not forcehim or her to do the task, bw; make it part of a game and a pleasant exper'ence. We would appreciateit if you would br".:ag the toys (blocks, rings, etc.) you use in the program with you when you come for thetest. Your child will then be working with familia.: toys during the test. If you have headphones at home,have your child, listen to music or other programs with them. Explain to your child that he or she willbe playing a listening game with the headphones on at the testing center.

Purpose. We would like to get your child to respond to sound by performing a certain task.

Guidelines.

The training should be pleasant and fun for your Child.The training should be done for short. periods of time, five to ten minutes.When your child is doing good work, be sure and let him or her know by using praise or other rewards.

Materials. The following are suggested materials or toys that can be used to follow the program. Theyare only suggestions, and you may use other items that, you think may work better with your child.

Noisemakers: xylophonedrumsrattlebells

Toys: plastic rings and pole on which to place the ringsblocks and can to put blocks intopegs and a pegboardmacaroni into a shoeboxbuttons into a coffee can

Goals. The goal is that each time you hit the xylophone, hit. the drums, shake a rattle, or ring the bells,your child will respond to the sound by: (1) putting a plastic ring on the pole or (2) putting a block intoa can, or (3) putting a piece of macaroni into a shoebox, or (4) any other similar activity. It is importantthat your child respond to the sound and not to the movement ofyour hand while you hit the xylophone.This is not only important with the xylophone but with any noisemaker used.

Procedure. All the examples we prcsent will use the xylophone and putting blocks into a can. You maysubstitute any noisemakers or toys that your child enjoys. For instance, if she would rather put smallcars in a truck when she hears the sound, let her do it.

Step One. Sit down facing your child and explain in simple words that when you hit the xylophone, youwant him to put a block into the can. You should demonstrate this several times. Before you hit thexylophone, hold the block close to your ear. That way your child will get the idea of listening carefully.

5853

Step Two. Give your child the block and have her hold it close to her ear. You may hold her hand andhelp her put the block into the can when you make the sound. Be sure to praise your child (or give heranother type of reward she likes) each time he or she does well. Continue this step until she starts doingit without your assistance.

Step Three. When your child starts putting the block into the can with no assistance four out of fivetimes, continue facing him; but do not let him see you hit the xylophone (for example, put it under thetable). You can tell him it is a new game and that now he has to put the block into the can by only listeningfor the sound. You may have to help your child put the block into the can the first couple of times. Rewardhim (praise or other) each time he does well. You should continue this until he can do it seven out of tentimes.

Step Four. Sit down behind your child. You again hit the xylophone and help her put the block into thecan the first couple of times. You may explain this step to her by saying, "This is the hardest job, andif you hear this you are a good listener." This is to make sure that she is responding to the sound andnot to you when you make the sound. Again, reward her each time he or she does well.

Step Five. If your child is doing well, you might try a different noisemaker and a different toy. He willthen get used to different sounds and learn to respond in different ways. This may provide some varietyin the testing and hold his attention for a longer period of time. Be sure to reward him or her for doingthe new task.

Step Six. If your child is not doing well, you should also try a different noisemaker and/or a differenttoy and/or a different reward. All children do not enjoy the same things. Your child may not respond tothe xylophone by putting blocks into a can, but she might respond to a bell by stacking blocks. Again weremind you to use whatever works with your child.

Step Seven. Finish one step before proceeding to the next. If your child has forgotten a previous step,be sure to go over it again.

Remember: (1) Always make the sessions fun and pleasant.

54

(2) It is better to do the sessions a number of short periods, rather than one long time; itis hoped, however, that eventually these short periods of time can be stretched toperiods of 15-20 minutes in length.

(3) Always let your child know he or she is doing a good job.

59

Appendix D

,r Glossary

Air Conduction Testing. The hearing testing which stimulates the ear with sound energy which ispropagated through the air in the ear canal to the ear drum.

Ambient Noise. All the noise in a specific environment. As used in this guide, noise refers to allunwanted acoustic energy present in the hearing screening environment.

Attenuation. The reduction of energy (for example, sound energy or electrical energy). The attenuatorof an audiometer reduces the electrical energy that is delivered to the audiometer earphones and, therebycontrols the level of sound energy delivered to the external ear canal.

Audiologist. A professional trained to measure human auditory function and to provide and direct theauditory management services necessary for the successful use of residual hearing for learning,communication, and social/emotional well being. Audiologists must earn at least a master's degree inaudiology from an approved university program, meet national testing and experience requirements,and in most states, meet requirements for state licensure.

Audiology. The profession concerned with measurement of auditory system function and nonsurgical,non-medical management of persons with auditory and communication impairments. Areas of studyinclude the anatomy and physiology of the normal and pathological auditory system, acoustics andpsychoacoustics, electronics, measurement ofhearing and site oflesion testing , the effects of hearing losson speech and language development, and the (re)habilitation of children and adults with hearing loss.

Audiometer. An instrument for determining the threshold of hearing. Audiometers employ a varietyof acoustic test signals including pure tones and speech stimuli.

Bilateral Hearing Loss. A hearing loss in both ears.

Bone Conduction Testing. The hearing testing which stimulates the inner ear by conducting soundthrough the cranial bones.

Calibration. The process of checking and adjusting a quantitative measurement instrument to ensurethat it meets standardized specifications. Audiometers must be calibrated to the standards of theAmerican National Standards Institute.

Cerumen (ear wax). A yellowish waxy substance secreted by the external ear canal. Excess cerumenin the ear canal can result in conductive hearing loss.

Cognitive Disability. The significantly subaverage intellectual functioning during infancy andchildhood which exists simultaneously with deficiencies in the adaptive skills needed to meet thedemands and expectancies of the general society.

Conductive Hearing Loss. The hearing loss resulting from abnormalities of the external and/ormiddle ear.

Congenital. The conditions in infants that are present at or before birth.

daPa. The abbreviation for the term deca Pascal, which is the unit for air pressure used intympanometric measures. Th e term h on ors Blaise Pascal, a French scientist. The daPa is approximatelyequal to one millimeter of water pressure, and 0 daPa on the tympanometric pressure scale equals normalatmospheric pressure.

55

6 0

Decibel (dB). A dimensionless unit for expressing the ratio between two sound pressures or two soundpowers.

Down Syndrome. A collection of cognitive and physical disorders present at birth that are caused bya genetic disorder. Common characteristics include mental retardation, heart disease, slanting almondshaped eyes, broad nc se bridge, protruding tongue, open mouth, small slightly flattened skull, smallears, and reduction of muscle Vine.

Earphones. The devices worn over, on, or in the ear for presenting a sound stimulus to the ear.

Exceptional Educational Needs. The needs of children with mental, physical, emotional or learningdisabilities which require special educational services to supplement or replace regular educationalservices.

Fluctuating Hearing Loss. The temporary, frequent changes in auditory sensitivity which occur asthe result of ear disease. The most common cause of fluctuating hearing loss in children is middle eardysfunction and liquid in the middle ear space.

Frequency is the physical unit which corresponds to the pitch of an acoustic signal. The frequency ofa pure tone equals the number of sine waves cycles occurring within one second and can be expressedin cycles per second.

Hearing Impairment. All disorders of hearing regardless of their nature, cause, or severity, whetherpermanent or fluctuating, which impair one or more of the following: auditory language learning,auditory/verbal communication, academic perfor-mance, and social or emotional development.

Hearing Loss. A general term which refers to any diminution in normal auditory functioning includingreduced hearing sensitivity and ability to understand speech. Normal auditory functioning is definedbased on the measured auditory abilities of healthy young adults with negative histories for ear diseaseand damaging noise exposures. The presence of a hearing loss does not necessarily imply a hearingimpairment.

HL (hearing level). The number of decibels above or below the average normal threshold for a specificsound at which an individual can just detect the presence of the signal about one-half of the time.

Hz (hertz). The universal symbol for the unit offrequency of a sound, named after the German physicistHeinrich Rudolph Hertz. One Hz = 1 cycle per second.

Masking. The audiometric procedure used to prevent or alter the detectability or identification ofacoustic signals during hearing evaluations. Masking is often necessary to independently test each ear.

Middle Ear. The portion of the ear which includes the tympanic membrane (ear drum) and the air-filledcavity behind it which contains the three middle ear bones.

Neonatal. The newborn period.

Otoscope. A hand-held instrument for inspecting the external canal and tympanic membrane (TM).The otoscope illuminates the ear canal and permits an improved view of the canal and TM through amagnifying eyepiece.

Play Audiometry. A testing technique used for testing the hearing of young children who cannot betaught to respond to auditory stimulation directly with a motor response. In play audiometry, the child'sresponse to sound is part of a game that is highly motivating for the child.

Pure Tone. A sound wave that has the same shape as a sine wave and consists of a single unvaryingfrequency.

Reliable. Tests that produce results that are reproducible when conducted over time.

56 61

Sensorinueral Hearing Loss. A loss of hearing sensitivity due to an impairment of the inner ear(cochlea) or the nerve pathways to the brain.

SPL (sound pressure level). The ratio, expressed in decibels, of the sound pressure of a particularacoustic signal to a standard reference pressure.

Threshold. The minimum effective sound pressure of an acoustic signal which is capable of evokingan auditory sention about half the time.

Threshold Testing. The standardized procedure for determining a listeners threshold to pure tone orother acoustic stimuli.

Tympanometry. The measurement of changes in the compliance (flexibility) of the eardrum as airpressure is varied in the external ear canal.

Unilateral Hearing Loss. A hearing loss in only one ear.

Valid. The hearing screening tests that identify individuals as positive who have hearing sensitivityworse than the established criteria, and those as negative who have hearing sensitivity better than theestablished criteria.

6257

NI Appendix E

Relevant Materials

Glattke, T.J., and S.G. Kujawa. "OtoacousticEmissions." The American Journal of Audiolo-gy 1.1 (1991), pp. 29-40.

Hall, J.W. Handbook of Auditory Evoked Re-sponses. Needhum Heights, MA: Allyn andBacon, 1992.

Jacobson, J.T. The Auditory Brainstem Response.San Diego, CA: College Hill Press, 1985.

Lounsberry-Martin, B.L., M.L. Whitehead, andG.K. Martin. "Clinical Applications ofOtoacoustic Emissions." Journal of Speechand Hearing Research 34 (1991), pp. 964-81.

58

Primus, MA "Infant Thresholds with EnhancedAttention to the Signal in Visual Reinforce-ment Audiometry." Journal of Speech andHearing Research 31 (1988), pp. 480-84.

Primus, MA, and G. Thompson. "ResponseStrength of Young Children in Operant Audi-ometry." Journal of Speech and Hearing Re-search 28 (1985), pp. 539-47.

White, Karl R., and Thomas R. Behrens. "TheRhode Island Hearing Assessment Project:Implications for Universal Newborn HearingScreening." Seminars in Hearing 14.1 (Feb.1993), pp. 1-119.

6 °0