Advancing Periodic Hearing Screening in Early Childhood Education Settings

November 2011

Jeff Hoffman, MS, CCC-A; Lenore Shisler, MS; William Eiserman, PhD

Audiologists have played an important role over the past 2 decades in ensuring that newborns in the United States receive a hearing screening. This is significant because approximately one to three children per thousand are identified with congenital hearing loss shortly after birth. Of the 1.6% of children who do not pass the newborn screen, however, nearly half may not be receiving the recommended follow-up diagnostic or intervention services (Centers for Disease Control and Prevention, 2011). Furthermore, illness, injury, or genetic factors can cause hearing loss at any time, and by school age, approximately six to seven children per thousand are likely to have a permanent hearing loss (Bamford et al., 2007; National Institute on Deafness and Other Communication Disorders, 2005). Periodic hearing screening during the early childhood years increases the likelihood that children lost to follow-up from newborn screening, along with children presenting with postneonatal hearing loss, will receive the timely diagnostic and intervention services needed during the critical language learning years. Audiologists and other knowledgeable professionals can help implement hearing screening practices and protocols that can be carried out effectively by lay screeners in a variety of early childhood settings.

Opportunities for Periodic Screening in Early Childhood Education Settings

There is great potential for audiologists to support the development of periodic hearing screening programs in early childhood education settings. In particular, Early Head Start (EHS) programs that serve economically disadvantaged children from birth to 3 years of age already have a long-standing commitment to conduct sensory screenings (O'Brien, 2001; U.S. Department of Health and Human Services, 2006). All children in EHS programs must receive a hearing screening within 45 days of enrollment. Since 2002, the Office of Head Start has funded initiatives carried out by the National Center for Hearing Assessment and Management to help EHS, Migrant and Seasonal, and American Indian-Alaska Native Head Start programs update their hearing screening practices for children birth-to-3 years of age using otoacoustic emissions (OAE) technology. As a result, more than 35 states have established Early Childhood Hearing Outreach (ECHO) training teams led or supported by pediatric audiologists and state Early Hearing Detection and Intervention (EHDI) coordinators. Data collected on screening and follow-up diagnoses indicate that approximately two of every thousand children screened in early childhood education settings are being identified with a previously undetected permanent hearing loss, and an additional 18 children per thousand are being identified and treated for transient conductive hearing loss (Eiserman et al., 2008).

In 2011, Parents as Teachers (PAT), one of the seven federally approved home visitation models, adopted new requirements which specify that OAE hearing screenings must be conducted on all enrolled children within 90 days of enrollment. New PAT affiliates must include OAE screening as part of their start-up plans, while existing programs have until 2014 to incorporate OAE screening.

The fact that EHS programs and PAT affiliates are already committed to hearing screening presents a meaningful opportunity for knowledgeable professionals to provide information, training, and ongoing support. Critical "lessons learned" and resources developed as a part of the ECHO Initiative are outlined below. Audiologists are encouraged to use these resources to:

Introduce early childhood professionals to objective hearing screening practices and methods;
Assist in the selection of appropriate equipment for screening this population;
Train lay screeners and implement a comprehensive and timely screening protocol;
Establish a tracking and follow-up data system and monitor program quality.

Introduce Early Childhood Professionals to Objective Hearing Screening Practices and Methods

One of the first steps an audiologist can take is to inform early childhood professionals about the importance of high-quality objective screening and follow-up practices to accurately identify hearing loss. One common misunderstanding that may need to be addressed is the belief that hearing for most children is already being checked periodically as part of routine well child visits. In reality, health care providers have the expertise and equipment to check for common middle ear conditions but are typically not equipped to screen for hearing loss with this population. Thus, the majority of children do not receive any additional hearing screening beyond newborn screening until closer to the age of school entry.

Early childhood programs will often need guidance in adopting appropriate screening practices. In selecting screening methods, EHS programs rely on the guidance from local Health Services Advisory Committees (HSACs). Too frequently, however, HSACs do not include audiologists or other professionals who are knowledgeable about current hearing screening practices. Consequently, many EHS programs employ outdated, subjective methods, such as hand clapping or noisemakers, rely only on parent questionnaires, or depend on newborn hearing screening results for several years (Munoz, 2003). When working with EHS, it can be valuable to contact the Head Start State Collaboration Office to introduce the staff there to the importance of objective screening and to coordinate screening improvement activities within the state. Contacting the state EHDI program can ensure that EHS, PAT, and other early childhood educational program screenings can be incorporated into the EHDI hearing screening and follow-up system.

When screening most children age 3 or younger for hearing loss, OAE screening is the optimal tool because it does not require a behavioral response from the child and is quick, painless, portable, and reliable. In addition, nonaudiologists who are skilled at working with children can be taught to use the technology effectively. It is always important for screening staff to be reminded that screening is only the first step in identifying a possible hearing loss and is not equivalent to a comprehensive audiologic evaluation. Children who manifest speech and language delays, as well as those who do not pass the OAE screening, should be referred to a pediatric audiologist for a comprehensive assessment.

Assist in the Selection of Appropriate OAE Equipment for Screening This Population

Audiologists who have used OAE equipment exclusively in nursery or diagnostic settings may be surprised to learn that the equipment can also function effectively in classroom and home environments. One caveat to keep in mind when assisting programs is that not all screening equipment used with newborns is equally well designed to screen infants and toddlers. In addition to the overall cost of the equipment and associated disposables, key elements in equipment selection include the following:

The equipment should have the capacity to screen quickly in settings where there is a modest amount of ambient noise. Well-designed OAE screening equipment should allow the screening to be conducted successfully in the child's natural educational or home environment. Loud sounds, such as a child crying or manipulating a noisy toy nearby, should be avoided, but in general, the sounds of children talking, singing, or laughing within the classroom should not interfere significantly with test completion. Helping very young children to feel comfortable with the overall screening procedure in a natural environment, surrounded by peers and familiar caregivers, is one of the most important factors in screening success.
Probe tips must stay firmly seated in the ear canal whether the child is in an upright or prone position. Disposable foam tips that compress and conform to the ear canal are typically easier for lay screeners to use than silicone covers that have to be matched more precisely to individual ear canal size.
Easy-to-understand displays that convey screening progress and results, and that prompt the screeners on what to do next if the screening is not proceeding, are helpful for the lay screener.

Train Lay Screeners and Implement a Comprehensive and Timely Screening Protocol

Health specialists, nurses, home visitors, and teachers can all successfully conduct OAE screenings. The most important quality is an individual's ability to interact effectively with young children. More than one screener should be trained in a program to ensure continuity if personnel turnover occurs. At the same time, limiting how many individuals are trained increases competence because screeners have the opportunity to refine their skills by working with a significant number of children. There is no specific formula for determining how many screeners or how many pieces of equipment are needed based on child enrollment or program design. The managers overseeing program planning need to carefully consider the protocol and the availability of staff members to implement it. In general, it is best to train a small corps of screeners and then increase the number as needed.

Training materials used in the ECHO Initiative, including a training video and audiologist training manual, have been effective in conveying essential information to screeners in a standardized manner. Basic training information includes the following:

Purpose of OAE screening
Overview of the screener roles
Introduction to OAE equipment
Use of a screening and follow-up protocol
Equipment care and maintenance

A valuable training element is the opportunity for learners to develop practical screening skills. The inclusion of hands-on practice increases the lay screener's proficiency in preparing the screening environment, obtaining a good probe fit, becoming familiar with managing the equipment, and observing the effects of various factors that can influence the screening results, such as environmental noise.

An effective OAE screening protocol balances the risk of overreferring children for assessment against the need for timely referrals. In other words, programs will not want to refer children for further follow-up based on screener error or temporary middle ear conditions that would naturally resolve within a short period of time. The multistep screening protocol shown in Figure 1 is similar to the two-step protocol often used in hospital-based newborn screening programs, with the exception that a health care provider is often involved in resolving middle ear conditions prior to referral to a pediatric audiologist. The steps are as follows:

All children receive an initial OAE screening ("OAE 1" in Figure 1). Approximately 70%–75% of children in the birth-to-3 age group can be expected to pass the screening in both ears, with 25%–30% requiring a second OAE screening.
Children not passing the OAE 1 are screened again (OAE 2) within 2 weeks. Approximately 8%–10% of the total number of children screened initially will not pass either the first or second screening and will therefore need to be referred to a health care provider for a middle ear evaluation.
Children referred from the OAE screening should be evaluated as soon as possible by a health care provider for conditions affecting the outer or middle ear such as impacted cerumen or otitis media, which are common causes of an OAE refer. Screening staff will need to communicate with the health care provider about the diagnosis and treatment process so that when medical clearance is given (i.e., observable conditions interfering with OAE screening are no longer present), the child can receive an OAE rescreen. If screening is being conducted where a health care provider is present, the protocol may be streamlined, with a middle ear evaluation being performed immediately upon referral from OAE screening.
Children not passing the OAE rescreen, when the outer and middle ear are clear, are referred to a pediatric audiologist for a full diagnostic evaluation. Less than 1% of the total number of children screened typically require referral to a pediatric audiologist.

Completing the screening and follow-up protocol within an appropriate time frame is critical to program success in identifying and treating children with hearing health needs. It is helpful to keep this protocol and the anticipated initial pass rate in mind when evaluating OAE equipment options for use by lay screeners in natural settings. Equipment that, for any reason, does not appear to provide for a comparable pass rate may not be appropriate.

Establish a Tracking and Follow-Up Data System and Monitor Program Quality

Early childhood education programs often need assistance in establishing a mechanism for documenting screening outcomes and tracking children who need further screening or evaluation. Just like newborn screening, the success of an early childhood OAE screening program in identifying and serving children with hearing health needs is dependent on the program's capacity to accurately track children who do not pass the initial screening through subsequent follow-up steps in the protocol. Therefore, as an initial part of program planning, program staff must be assisted in thinking through how screening results will be documented and referrals made to ensure timely and appropriate follow-up. Any child identified with a permanent hearing loss should be reported to the state EHDI program, and a referral to Early Intervention/Part C should be ensured.

Similar to hospital-based screening efforts, there are a number of ways that audiologists and other professionals can help Head Start program staff monitor the quality of a hearing screening program:

Periodically review pass rates for the initial screening (OAE 1), which should be approximately 70%–75%. This rate may be slightly lower when screeners are first learning to screen, but the rate should improve over time. Referral rates may be expected to increase during cold and flu season, as a larger percentage of children are likely to have middle ear issues.
Periodically observe screeners to ensure that they are using the techniques they were taught during the training and guide them to adopt appropriate recommended practices.
Remind programs to calibrate their OAE equipment annually and provide consultation on any equipment concerns that arise in the interim.
Monitor adherence to the screening and follow-up protocol in terms of the sequence of screening and follow-up activities (i.e., whether the steps for rescreening and referral are occurring in the recommended order) and the timing of follow-up activities (i.e., whether the steps for rescreening and referral are occurring within the recommended time frame). The more closely programs comply with the sequence and the timing of the steps recommended in the screening and follow-up protocol, the more effective they will be in identifying children with hearing health needs.

Conclusion

EHS programs that are incorporating OAE screening often serve as examples to other early childhood programs and service providers. Sharing the success of OAE screening in EHS settings can lead to the adoption of OAE screening in other venues such as Early Intervention/Part C programs and health care settings, resulting in more children having the benefit of periodic hearing screenings during the early childhood period. In the decade ahead, there will be an ongoing need, and more opportunities than ever before, for audiologists to become involved in periodic early childhood hearing screening initiatives in a variety of education and health care settings. Efforts in this area will yield positive benefits in reducing loss to follow-up from newborn screening and in identifying postneonatal hearing loss at the earliest possible time.

About the Authors

Jeff Hoffman (jeffhoffman.echo@gmail.com) is an outreach coordinator with the ECHO Initiative with the NCHAM at Utah State University. He served as the program manager for the Nebraska EHDI for 6 years. In addition to audiology and public health work, Jeff has also provided training and technical assistance service to Head Start programs in the areas of management, administration, and child outcomes. He served as president of the Directors of Speech and Hearing Programs in State Health and Welfare Agencies in 2008. In 2007, Jeff received the American Speech-Language-Hearing Foundation's Louis M. DiCarlo Award for Outstanding Recent Clinical Achievement.

Lenore Shisler is a Senior Research Scientist with the NCHAM at Utah State University. Her work scope has included providing technical assistance to states implementing EHDI programs, data management software development, and instructional material development for early childhood educators, physicians, and parents. Her current projects are focused on promoting and improving periodic hearing screening and follow-up in early childhood settings, including EHS, and in developing the capacity of primary care providers to incorporate objective hearing screening into the health care services offered to young children.

William Eiserman is the Director of the ECHO Initiative at the NCHAM at Utah State University. As Director of the ECHO Initiative, Dr. Eiserman has led a national effort in assisting Early, Migrant and Seasonal, and American Indian-Alaska Native Head Start programs in updating their hearing screening and follow-up practices. Working in close collaboration with a team of pediatric audiologists and other EHDI experts, Dr. Eiserman has been responsible for the design of training systems and mechanisms for tracking and follow-up, as well as evaluation strategies associated with early and continuous hearing screening activities. The ECHO Initiative has also contributed to improvements in hearing screening practices in early intervention programs and health care settings using the resources and support provided by Dr. Eiserman and his project team.

References

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U.S. Department of Health and Human Services. (2006). Head Start Program Performance Standards; 45 CFR Chapter XIII, §1304.20 (b) (1). Retrieved from http://eclkc.ohs.acf.hhs.gov.