Guidelines for Hearing Screening in the School Setting

Purpose

The purpose of any screening program is to detect individuals with a suspected deviation that requires further examination at the earliest age possible in order to refer for diagnosis and treatment, if required.

In the United States, one to three children per 1,000 are born with hearing loss each year (CDC, 2020). Hearing deficits in children can interfere with normal speech and language development, communication, and the ability to learn. It is important to detect even a mild hearing loss in order to treat the problem or compensate for the loss when possible. The earlier a child who is deaf or hard of hearing starts getting services, the more likely the child’s speech, language, and social skills will reach their full potential. Children with mild to moderate hearing deficits may be at a disadvantage educationally, emotionally, and socially. Thus, ongoing review of hearing and speech age-appropriate milestones and risk factors, and routine hearing screening is critical.

Schools are an ideal setting for hearing screenings because:

• Large numbers of children of many ages are readily accessible;
• Screenings can be accomplished in a short period of time with relative ease;
• Less expensive than a comparable service performed in another sector of the healthcare system;
• Allows an ongoing opportunity to observe, assess, and investigate potential areas of concern; and
• Provides the opportunity to screen children not previously identified.

Characteristics of Screening Programs

Screening is a brief or limited evaluation of a group of individuals presumed to be normal, but at risk of developing a problem. The extent of a screening program should be based on documented health needs of the population served. This may have been determined by an outside agency, e.g. state health department, or identified on a local basis. The value of early detection of a problem must be weighed against the time and human resources required to conduct the screening. The value of the screening process depends on how well the program is carried out and how the findings are used. Results must be communicated, and follow-up on referrals for those “at risk” continued, until the problem is resolved in some manner.

Evaluation of Hearing Screening Programs

To determine the effectiveness of a hearing screening program, careful evaluation of the planning, implementation, referral process, and referral outcomes must be completed with each hearing screening. The purpose of program evaluation is to quantify the pass/refer rates; estimate the sensitivity and specificity of the screening; and assure effectiveness of follow-up protocols for children failing the screening. Much of this information is essential for reports to the board of education and the school health advisory committee.

Information gathered in the evaluation process includes the number of students screened, the number of referrals, the types of hearing problems identified, and the utilization of insurance and/or payment method.

Additional considerations for program evaluation include:

• Validity–ability to identify those who have the condition;
• Reliability–consistency of results of screening process;
• Yield–number of persons screened and referrals made;
• Cost–personnel and equipment;
• Acceptance–informed parents agree to value of screening; and
• Follow-up–communicating results to parents who respond with appropriate actions to get necessary diagnosis and treatment, if indicated.

Setting Up a School-Based Screening Program

The school or community health nurse should work with school administration to coordinate a school-based hearing screening program. Hearing screening programs should be a part of an overall hearing conservation program. This program should:

• Establish procedures and standards (best practices) for training nurses and others who will conduct the screenings;
• Establish procedures and standards (best practices) to determine whether or not the student may have a significant need for hearing health care;
• Provide personnel and facilities to reach the target population;
• Enter the student into a healthcare system which can provide follow-up care including rescreening, monitoring, and further diagnosis and/or treatment;
• Provide counseling and education about hearing health to prevent the development or recurrence of hearing impairments, and to prevent or reduce the handicap resulting from that impairment; and
• Reach all children at the earliest age possible.

The school nurse is the appropriate person to assume management of the hearing screening program. It is very important that school nurses receive necessary orientation and training to perform the hearing tests as indicated in this manual. Additionally, school nurses can ensure that volunteers who assist with, or perform hearing screenings, are also appropriately trained.

Almost as important as conducting the training is documenting the fact that it occurred. The Resources section includes a sample form schools can use in creating their own training record. It is strongly recommended that initial and routine training be conducted for all personnel involved in a school hearing screening program.

A variety of personnel from speech language professionals to trained volunteer conduct screening programs in schools. In schools where the speech-language specialist does the screening, the nurse may refer students for screening, and assist with follow-up. It is important to see that results of the screening are recorded in the student’s health record. If the nurse is doing the screening, he/she will need to determine which groups and individuals will be screened, schedule and conduct the screenings, and then evaluate the overall effort.

School nurses may develop or adapt forms for their use in screening programs. This guide includes a number of sample forms, which may be duplicated; however, referral forms should include district information (e.g., on letterhead). Screening Program forms may include:

• Screening worksheet;
• Pertinent history/observation for use in re-screening/referral;
• Parent notification of normal/abnormal results;
• Tracking logs by type of screening;
• Reminder forms to re-contact parent/guardian; and
• Statistical reports by screening for use in program evaluation.

Screening programs must continually be reviewed for quality assurance purposes if they are to produce valid results and appropriate referrals. To assure quality, the school nurse should:

• Have equipment calibrated at least yearly, and maintain it properly;
• Document adequate training of volunteers and paraprofessionals;
• Ensure the best environmental conditions for screening, e.g., minimal ambient noise;
• Adhere to established screening protocol;
• Complete follow-up of referrals to extent possible; and
• Periodically evaluate the screening program for validity and reliability.