Guidelines for Hearing Screening in the School Setting

Screening Schedule

Schools develop screening schedules based on a variety of situations; e.g. school board policy, special education plans, and tradition. Positive findings occur much more often in early elementary grades (Pre-K through grade three) and less often in older students. For this reason, it is not considered productive to screen large groups of students beyond third grade. Students screened at the secondary level may be screened as part of a hearing conservation program educating them about the causes of high-frequency hearing loss due to noise pollution.

It is estimated that up to 15 percent of students will have at least a transient loss of hearing at some time during their school years. The individuals or grades to be screened should be based on the availability of trained screeners, the environment available in which to screen, and the ability to complete a high percentage of the referrals. Emphasis is always placed on the youngest population. Consider screening the following groups:

• Students in Pre-K, K, 1st, 2nd, and 3rd grades; and all new students;
• Any student referred by the teacher, parent, or self;
• Special education evaluation requests; and
• Students in 7th grade–for educational purposes regarding noise exposure if time permits.

Use of Volunteers

Volunteers may be useful during screening events to assist with the flow of students through the screening procedure. The school nurse may also train some volunteers to conduct the initial screen. Holding a volunteer instruction session is helpful for all new volunteers, and should be scheduled close to the day of the screening. During the training session, familiarize volunteers with the equipment, screening forms, and procedures. Having volunteers who feel comfortable with the equipment increases the accuracy during the screening procedure. All volunteers should be counseled regarding confidentiality.

Care of Equipment

Equipment should be stored in an area that is climate controlled, and should be calibrated annually. Headphones should not be transferred from one audiometer to another without performing an additional calibration. They should also be cleaned between students. Avoid using alcohol to clean the headphones.

Prescreening Education

The nurse responsible for the screening should meet with kindergarten children as a group to orient them to the equipment and procedures used during the screening. The screener can take the audiometer to the classroom to explain the screening process.

1. Demonstrate how they will have headphones placed over their ears in order to hear the sounds.
2. Tell them they will hear a tone or sound like the one being demonstrated, only softer. Set the frequency at 2000 hertz (Hz) and the decibel level at 90-100 decibel (dB).
3. Hold the earphone with the opening facing the children.
4. Instruct them to raise their hand when they hear the sound. When the sound stops, instruct them to lower their hand. They can also say, “I hear it” when the sound is presented.

The extra time spent conducting these practice sessions will reap benefits during screening, as the children will have a better idea of what to expect. In the primary grades, it is helpful to visit the classroom prior to screening, to review the procedure. At this time, the nurse can provide age-appropriate information about noise in their daily lives.

Hearing screening preparation resource for children:

• http://ccox.sites.truman.edu/2018/01/24/hearing-screening-prep/
• http://ccox.sites.truman.edu/2018/08/28/hearing-screening-prep-spanish/ 

Preparing the Child for Screening

Preparing the child for his or her hearing screening is extremely important. The screener should give simple instructions to the child face-to-face prior to placing the earphones on him/her, even if the child has had pre-screening education. Stress the importance of responding quickly to the tone, even if it is very faint

Standard instructions can be as follows:

“You are going to hear some sounds (beeps, whistles, bells, etc.). Every time you hear one, raise your hand or say, yes. Raise your hand as soon as you hear the sound, even if it is very soft. Do you understand?”

Screeners should modify instructions for younger children and individuals with any developmental delay. Pantomime, where the examiner illustrates listening, then hearing the sound, and finally responding as directed, may help train the individual to the task. The words screeners choose to describe what is going to happen, as well as the tone of their voice, play a big part in eliciting cooperation and having a successful screen. For younger children, standard instruction can be as follows:

• “Let’s play a listening game. I’m going to put this on your ear so you can hear the birdie.” This directive approach can be more reassuring to a child than a question.
• If you feel the child needs to see and touch the earphone prior to placement, you may let the child feel while commenting “These are like an airplane pilot’s hat” or ‘it’s very soft like a pillow.”
• For very young children; however, it is sometimes better not to draw attention to the equipment by not saying anything about it at all. Instead, help maintain focus on something they enjoy. The last thing you want to do is direct attention to the sensation of the equipment being placed on them.
• Hand raising or verbal response cannot always be elicited from the younger population. When this happens, a “play” technique is implemented. If a play technique is necessary, it is important that he/she can do the “listen and drop” task without frustration. Examples of play techniques include:
  • Blocks and buckets
  • Peg boards – choose ones with large pegs for easy manipulation

The screener can demonstrate the procedure to a group of children who have been brought to the screening area. Using the audiometer, set the frequency selector to 2000 Hz, the attenuator to 90 dB, and the output selector to the right earphone. Having gained the group’s attention, turn the right earphone toward the children and present the tone.

Tell them:

“This is what you will listen for. Each time you hear the whistle, raise your hand. Put your hand down when it stops. Later when you wear the earphones, the whistles will be tiny little ones. Let’s practice.”

Present the tone several more times until the group responds as requested. The tone’s intensity may be reduced, or the frequency changed, if more demonstration appears to be needed.

School Screening Environment and Ambient Noise Level Check

The choice of the hearing screening environment is very important.

• The area must be reasonably quiet. Select the screening site during school hours, so noise problems can be identified. The site should be away from stairs, windows, street noise, hall traffic, cafeterias, gyms, heating/cooling vents and equipment, bathrooms, play areas, etc.
• Sound treated areas may be available in school libraries or band/music rooms. Use these areas when available.
• Each screening room should accommodate a three-foot by four-foot table and two chairs, and have an electrical outlet (if audiometer requires electrical plug in).
• The screening environment should have limited visual distractions (i.e. windows, bulletins boards, etc.).
• Ideally, there will only be one screener per room.

Noise levels in the test environment must be checked prior to any hearing screening procedure. The person performing the check should have normal hearing sensitivity. A sound meter can also be used to determine the room noise. Ambient noise levels for hearing screening environments should not exceed those listed below when measured with a sound level meter with octave band filters centered on the screening frequencies. It is a good idea for schools or districts to invest in a basic, inexpensive sound level meter to accurately assess noise levels. It is important to note that these levels were derived from the American National Standards Institute (ANSI) current standards for pure tone threshold testing, and have been adjusted for the 20 dB hearing level screening level.

The noise level can also be checked easily with the audiometer. Wearing the audiometer earphones, the screening frequency pure tones (1000 Hz, 2000 Hz, and 4000 Hz) should be heard at a level of 10 dB (screening level for a child is 20 dB and for adults is 25 dB). If the screener cannot hear the tones at 10 dB at each screening frequency, do not screen in that environment.

If ambient noise exceeds the recommended values, the noise level will effectively mask the reference threshold level. This will cause pure tone threshold levels to be inaccurate. Possible solutions to this problem include:

• Select an alternate screening site;
• Modify the existing screening environment. For example:
  • Cover floor with carpet;
  • Apply absorptive acoustical treatment to walls and ceiling;
  • Place baffles in ventilation system; or
  • Position the ballast for fluorescent lamps outside the test room.
• Use a completely enclosed screening room. For example:
  • Small single wall booth–thin walls, 1,000 lbs.;
  • Single wall sound room–one 4” thick wall; or
  • Double wall sound room–two isolated 4” thick walls.

The range of normal hearing is -10 to 20 decibels. Screening for hearing problems during “health fairs” is not productive unless the facility provides a quiet environment in which to screen, e.g., sound treated booth or van.

Alternatives to consider include sound enclosures that are similar to music practice rooms or a mobile hearing screening van, which schools often obtain through a variety of sources including:

• Speech-language or audiology budget;
• Discretionary funds;
• Regular education monies;
• Monies slotted for building improvements;
• Grants;
• Monies received from third party billing (Mo HealthNet);
• Parent teacher organizations; or
• Increased monies via Individuals with Disabilities Education Act (IDEA).

Note: If the school cannot find an appropriately quiet screening environment, do not implement the screening. If noise levels become too high during the screening, discontinue the test. Do not increase tone levels to compensate for background noise.

Infection Control Considerations for Hearing Screenings (2021)

This section outlines considerations for modifying existing school-based hearing screening practices to improve infection control. Each school setting is unique and not all strategies will always be applicable. Hearing screeners and school nurses are responsible for complying with applicable federal, state, and local laws, regulations, ordinances, executive orders, school board policies, and any other applicable sources of authority, including any applicable standards of practice.

Information for School Nurses and Other Healthcare Personnel Working in Schools and Child Care Settings [BROKEN LINK] (CDC)