The scope of this page is hearing screening for toddlers, preschoolers, and school-age children. For information on screening children ages 0–6 months, see the ASHA Practice Portal page on Newborn Hearing Screening.
See the Screening section of the Hearing Loss (Early Childhood) Evidence Map and the Hearing Loss (School-Age) Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner perspective.
Hearing-related terminology may vary depending upon context and a range of factors. See the ASHA resource on hearing-related topics: terminology guidance for more information.
A hearing screening is used to identify individuals who may require a more comprehensive hearing assessment and/or medical management. Hearing screenings for children may take place in early childhood settings, school settings, community settings, audiology clinics, medical settings, and/or home settings.
As of 2020, 98.2% of babies born in the United States were screened for hearing loss shortly after birth (Centers for Disease Control and Prevention, 2023). Minimal, frequency-specific, late-onset, or progressive hearing loss may not be identified during newborn hearing screenings (see Newborn Hearing Screening). By school age, close to 15% of children in the United States exhibit some type of hearing loss of at least 16 dB HL (Niskar et al., 1998). In 2020, 1% of students who received an individualized education plan qualified under the disability category of “hearing impairment” (Office of Special Education Programs, 2023).
Hearing screenings during childhood are vital for early identification and management of hearing loss. “Failure to detect congenital or acquired hearing loss in children may result in lifelong deficits in speech and language acquisition, poor academic performance, personal-social maladjustments, and emotional difficulties” (Harlor et al., 2009, p. 1253). Any level of hearing loss may impact a student’s access to auditory-based classroom instruction. Educationally significant hearing loss can be unilateral, bilateral, minimal in degree, high frequency, or long-standing conductive. See the ASHA Practice Portal page on Hearing Loss in Children for more information.
Other relevant ASHA Practice Portal pages include Central Auditory Processing Disorder, Counseling For Professional Service Delivery, Cultural Responsiveness, and Documentation in Schools.
Audiologists, by virtue of academic degree, clinical training, and license to practice, are qualified to provide guidance, development, implementation, and oversight of hearing screening programs. Professional roles and activities in audiology include clinical and educational services (e.g., screening); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).
The following roles and responsibilities are appropriate for audiologists:
As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists who work in this capacity should be specifically educated and appropriately trained to do so.
Speech-language pathologists (SLPs) play a role in the hearing screening process and in the referral of individuals suspected of having hearing loss to an audiologist. Professional roles and activities in speech-language pathology include clinical and educational services (e.g., screening); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).
The following roles and responsibilities are appropriate for SLPs:
As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who work in this capacity should be specifically educated and appropriately trained to do so.
Periodic screening of all children will help to identify those who were either lost to follow-up or not identified during the newborn period or those who developed hearing loss after the newborn period. Such screening includes the following activities:
The Educational Audiology Association provides guidance in the document Hearing Screening Considerations for Children With Significant Disabilities [PDF].
Hearing screening for school-age children may include the following activities:
The selection and implementation of hearing screening protocols and equipment is guided by the specific goals of the individual hearing screening program. The target population, available personnel, and the screening environment—as well as program-specific needs and/or limitations—are important considerations. Ideally, an audiologist will be involved in selecting screening equipment, developing and implementing an appropriate screening and follow-up protocol, and providing training and technical assistance to screeners and other professionals.
Pure-tone audiometry, OAE technology, and tympanometry may all be appropriate options for inclusion in hearing screening programs. Automated versions of hearing screening tools are available and can be utilized by trained support personnel (e.g., audiologist, SLP, audiology assistant, speech-language pathology assistant, nurse, another trained screener). Evidence has been compiled regarding commonly used screening tools (Prieve et al., 2015).
The Educational Audiology Association provides guidance in the document Hearing Screening Considerations for Children With Significant Disabilities [PDF].
Otoscopy completed by a trained examiner allows for visualization of the tympanic membrane and inspection of the external ear canal for drainage, foreign bodies, impacted cerumen, infection, or structural abnormalities. A screener who is not trained in otoscopy can perform a general visual inspection of the outer portion of the ear and make note of any abnormalities. The information obtained during visual inspection and otoscopy may have an important impact on screening results and/or call for the discontinuation of screening and referral to medical personnel.
Pure-tone screening is typically accomplished with the use of a pure-tone audiometer. Pure-tone stimuli at octave-band frequencies are routed through supra-aural earphones or insert earphones. With younger children, pulsed- or warble-tone stimuli may be presented instead of pure tones. Some screening audiometers limit the screening frequencies and presentation levels. These audiometers will not provide the flexibility of a single-channel audiometer regarding adapting protocols for different populations (Johnson & Seaton, 2012). Factors to consider when using a pure-tone screening protocol include the following:
An appropriate response to all presentation stimuli at screening levels in both ears results in a “pass.” A lack of response to any test frequency at screening levels in either ear results in a “fail/refer.”
OAEs—either transient-evoked OAEs (TEOAEs) or distortion product OAEs (DPOAEs)—are measured using a sensitive probe microphone inserted into the ear canal. OAEs are a direct measure of outer hair cell and cochlear function in response to acoustic stimulation and yield an indirect estimate of peripheral hearing sensitivity. OAEs do not technically test an individual’s hearing. Results reflect the performance of the inner ear mechanics. OAEs are not sensitive to disorders central to the outer hair cells, such as auditory neuropathy spectrum disorder, which is a neural hearing loss that leaves cochlear (outer hair cell) function intact.
When using TEOAEs, clicks or tone bursts are used as the stimuli at one level—for example, 80 dB SPL. Normal distributions for this condition for normal hearing and summary data are documented in the literature (Carter et al., 2015; Hussain et al., 1998; Liu & Wang, 2012). When using DPOAEs, pure tones are used as the stimuli. Normal distributions for this condition for normal hearing and summary data are documented in the literature (Carter et al., 2015; Gorga et al., 1997).
Factors to consider when using an OAE screening protocol include the following:
Screening programs that use OAE equipment often use the manufacturer’s preset stimulus and pass/fail parameters, which vary. This allows for participation by screeners who do not have the background or knowledge to adjust or interpret result parameters. When automated equipment is used, findings will be recorded as either “pass” or “fail/refer.”
Tympanometry can be added to the protocols of either pure-tone or OAE screening to measure the mobility of the tympanic membrane and the status of the middle ear transmission system. During tympanometry, a probe is fit snuggly into the ear canal. Pressure between the probe and the tympanic membrane is varied between +200 dB PA and −400 dB PA. Reflected sound from the probe tone is recorded across the pressure range, and a tympanogram is created. Tympanogram results convey the status of the middle ear system and suggest conditions that may need medical attention, such as eustachian tube dysfunction, middle ear fluid, or a perforated tympanic membrane. Factors to consider when adding tympanometry to a screening protocol include the following:
Automated equipment will report results as “pass” or “fail/refer.” When nonautomated equipment is used, the recommended referral criteria are > 250-daPa tympanometric width for children 3–12 years of age and > 275-daPa tympanometric width for children below the age of 3 years. If the use of tympanometric width is not possible, < 0.2-mmhos static compliance is recommended (AAA, 2011). Ear canal volume of > 1.0 cm3 and a flat tympanogram can indicate either patent PE tubes or tympanic membrane perforation.
Note: The presence of PE tubes may lead to a “fail/refer” result; however, this result must be confirmed with otoscopy by a trained examiner. The presence of PE tubes is not differentiated from a perforated tympanic membrane with the use of tympanometry alone.
Childhood hearing screening protocols may include the following approaches:
Each screening approach has distinct advantages and disadvantages. Processes vary between screening programs and school districts as do state regulations regarding hearing screening. Obtaining informed parent/guardian permission is a recommended part of any hearing screening protocol; however, extant state statutes/regulations or institutional policies supersede this recommendation.
Recommendations based on hearing screening results may include the following:
Timelines for referral and rescreening are determined on a case-by-case basis, with consideration given to the child’s overall health, otoscopic examination findings, and individualized educational concerns. Examples of considerations regarding rescreen timelines include the following:
There are many factors that must be considered prior to the initiation of a childhood hearing screening program. It is important to include procedures related to equipment calibration, personnel training, screening environment, universal precautions, and appropriate and timely follow-up. Consideration of the resources necessary to provide appropriate services and to maintain ongoing communications with children and their families is vital.
Audiometric equipment must meet applicable specifications of ANSI/ASA S3.6-2018 (American National Standards Institute/Acoustical Society of America, 2018) and/or manufacturer recommendations to ensure accurate results. Exhaustive electroacoustic calibrations should be performed annually using instrumentation traceable to the National Institute of Standards and Technology. Functional inspection, performance checks, and bioacoustic checks should be conducted to verify equipment performance prior to each use. Visual inspection may be completed to identify any obvious equipment damage. All calibration activities should be conducted by a trained audiologist or an external company/individual who is properly trained in performing such tasks.
Currently, there are no ANSI standards for the calibration of OAE equipment. For this reason, there may be differences in signal calibration, calculation of the noise floor, and response determination algorithms between manufacturers. These differences could impact the level of hearing loss that can be detected during screening.
Screening programs with the supervision of an educational audiologist and more uniform protocols may “result in more accurate screening results, a better system for referrals, and proper diagnoses” (Richburg & Imhoff, 2008, p. 41). It is important that all screeners receive thorough initial training and refresher training as needed to maintain screening skills and knowledge. It may be beneficial for the results of new screeners to be validated by experienced screeners until they become more comfortable with the equipment and screening process. While screening programs often necessitate flexibility and adaptability, adherence to the policies and procedures that were chosen or developed for a specific program is essential.
See the ASHA Assistants Program for information on the training, educational standards, and roles/responsibilities of these professionals.
Test environments for pure-tone screening should be free from visual distractions and interruptions and should meet the specifications detailed by the American National Standards Institute/Acoustical Society of America (2023) regarding allowable ambient noise. Calibrated phone applications offer one mechanism to assess ambient noise. An alternative approach is to use a biologic noise level check prior to the commencement of hearing screening. This has been defined as the ability to establish hearing thresholds at least 10 dB below the screening level (e.g., 10 dB HL for screening conducted at 20 dB HL) at all frequencies for a person with known normal hearing. Results of this approach may not necessarily reach ANSI standards.
Adherence to universal precautions and appropriate infection control procedures during screenings is essential. Instrumentation that comes into physical contact with the child must be cleaned and disinfected after each use (and per manufacturer’s instructions), and clinician handwashing between patients should be routine. Disposable equipment, such as probe tips, should be discarded after each use. For more information, see the ASHA page on infection control resources for audiologists and speech-language pathologists.
Appropriate follow-up for screening programs includes the rescreening of those children who did not pass the initial screen and the screening of children who were absent during the initial screen, as well as proper referrals for medical, audiologic, or educational evaluations (Johnson & Seaton, 2012).
Screening documentation generally includes identifying information, comprehensive results, and recommendations, including the need for rescreening and appropriate referrals (ASHA, 2006).
Local, state, and federal regulations may vary regarding parent/guardian notification and permission for a child to participate in hearing screening. Parents/guardians may be informed in writing prior to the screening date to give them the opportunity to express any preference for their child not to be screened, to request that they provide any important background information regarding the child’s hearing, and to inform them of the type of follow-up communication they can expect. Parent/guardian notification materials may include basic information about the process and purpose of hearing screening, as well as information about the educational impact of hearing loss. See the ASHA resource on health literacy.
Recordkeeping methodology will be determined, in part, by the setting and/or material availability. Options include student-specific paper forms, classroom-specific paper forms, or computer database entry, among others. Screening form use and type may be determined by the policies of each program/school/district with respect to the compilation and maintenance of child/student health records.
Proper documentation of screening results may include reporting to the program/school, reporting to the parents/guardians, and receiving information back regarding follow-up recommendations (Johnson & Seaton, 2012). When providing results to parents/guardians whose child is referred for medical or audiologic follow-up, the screener may give the parents/guardians a feedback form to give to the provider and then return to the program/school. Providing screening results to program/school personnel (e.g., health specialists, nurses, teachers, administrators, SLPs) will facilitate the proper follow-up and/or accommodations appropriate for the student. It may be beneficial to notify the parents/guardians after any result of fail/refer on a screening, even if a rescreening is planned, so that they can be involved in any decision making regarding next steps. See the ASHA resource on health literacy.
Various quality indicators can be measured to determine the effectiveness of a screening program. It is important to collect data, such as the number of children screened, the number of children who did not pass the initial screen and/or rescreening, the number of children referred for medical or audiologic follow-up, the number of children seen for professional follow-up, and the number of children diagnosed with and/or treated for hearing disorders. Other quality indicators may include how quickly children move through the recommended protocol and the number of provider reports returned following a referral, as well as parent/guardian satisfaction. Such data can be used to “document need for the hearing screening program, identify over or under referrals that can target equipment or training needs, help track loss to follow-up, and clarify other issues that impact the efficiency and effectiveness of a hearing screening program” (AAA, 2011, p. 46).
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
American Academy of Audiology Subcommittee on Childhood Hearing Screening. (2011). American Academy of Audiology: Childhood hearing screening guidelines [White paper].
American Academy of Family Physicians, American Academy of Otolaryngology-Head and Neck Surgery, & American Academy of Pediatrics Subcommittee on Otitis Media With Effusion. (2004). Otitis media with effusion. Pediatrics, 113(5), 1412–1429. https://doi.org/10.1542/peds.113.5.1412
American National Standards Institute/Acoustical Society of America. (2018). Specification for audiometers (ANSI S3.6-2018).
American National Standards Institute/Acoustical Society of America. (2023). Maximum permissible ambient noise levels for audiometric test rooms (Rev. ed.) (ANSI S3.1-1999).
American Speech-Language-Hearing Association. (2006). Preferred practice patterns for the profession of audiology [Preferred practice patterns]. https://www.asha.org/policy/
American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of practice]. https://www.asha.org/policy/
American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. https://www.asha.org/policy/
American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://www.asha.org/policy/
Bower, C., Reilly, B. K., Richerson, J., Hecht, J. L., & Committee on Practice & Ambulatory Medicine. (2023). Hearing assessment in infants, children, and adolescents: Recommendations beyond neonatal screening. Pediatrics, 152(3), e2023063288. https://doi.org/10.1542/peds.2023-063288
Carter, L., Williams, W., & Seeto, M. (2015). TE and DP otoacoustic emission data from an Australian cross-sectional hearing study. International Journal of Audiology, 54(11), 806–817. https://doi.org/10.3109/14992027.2015.1046505
Centers for Disease Control and Prevention. (2023, January). 2020 summary of national CDC EHDI data. https://www.cdc.gov/ncbddd/hearingloss/2020-data/01-data-summary.html
Eiserman, W. D., Shisler, L., Foust, T., Buhrmann, J., Winston, R., & White, K. (2008). Updating hearing screening practices in early childhood settings. Infants & Young Children, 21(3), 186–193. https://doi.org/10.1097/01.IYC.0000324548.54693.fc
Gorga, M. P., Neely, S. T., Ohlrich, B., Hoover, B., Redner, J., & Peters, J. (1997). From laboratory to clinic: A large scale study of distortion product otoacoustic emissions in ears with normal hearing and ears with hearing loss. Ear and Hearing, 18(6), 440–455.
Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). American Academy of Pediatrics.
Harlor, A. D. B., Jr., Bower, C., Committee on Practice and Ambulatory Medicine, & the Section on Otolaryngology-Head and Neck Surgery. (2009). Hearing assessment in infants and children: Recommendations beyond neonatal screening. Pediatrics, 124(4), 1252–1263. https://doi.org/10.1542/peds.2009-1997
Hussain, D. M., Gorga, M. P., Neely, S. T., Keefe, D. H., & Peters, J. (1998). Transient evoked otoacoustic emissions in patients with normal hearing and in patients with hearing loss. Ear and Hearing, 19(6), 434–449.
Johnson, C. D., & Seaton, J. B. (2012). Educational audiology handbook (2nd ed.). Plural.
Joint Committee on Infant Hearing. (2019). Year 2019 position statement: Principles and guidelines for early hearing detection and intervention programs. Journal of Early Hearing Detection and Intervention, 4(2), 1–44.
Kreisman, B. M., Bevilacqua, E., Day, K., Kreisman, N. V., & Hall, J. W., III. (2013). Preschool hearing screenings: A comparison of distortion product otoacoustic emission and pure-tone protocols. Journal of Educational Audiology, 19, 48–57. www.edaud.org/journal/2013/5-article-13.pdf [PDF]
Liu, J., & Wang, N. (2012). Effect of age on click-evoked otoacoustic emission: A systematic review. Neural Regeneration Research, 7(11), 853–861.
Margolis, R. H., Bass-Ringdahl, S., Hanks, W. D., Holte, L., & Zapala, D. A. (2003). Tympanometry in newborn infants—1 kHz norms. Journal of the American Academy of Audiology, 14(07), 383–392. https://doi.org/10.1055/s-0040-1715757
Meinke, D. K., & Dice, N. (2007). Comparison of audiometric screening criteria for the identification of noise-induced hearing loss in adolescents. American Journal of Audiology, 16(2), S190–S202. https://doi.org/10.1044/1059-0889(2007/023)
Niskar, A. S., Kieszak, S. M., Holmes, A., Esteban, E., Rubin, C., & Brody, D. J. (1998). Prevalence of hearing loss among children 6 to 19 years of age: The Third National Health and Nutrition Examination Survey. JAMA, 279(14), 1071–1075. https://doi.org/10.1001/jama.279.14.1071
Office of Special Education Programs. (2023). 44th annual report to Congress on the implementation of the Individuals with Disabilities Education Act, 2022. U.S. Department of Education, Office of Special Education and Rehabilitative Services. https://sites.ed.gov/idea/files/44th-arc-for-idea.pdf [PDF]
Prieve, B. A., Schooling, T., Venediktov, R., & Franceschini, N. (2015). An evidence-based systematic review on the diagnostic accuracy of hearing screening instruments for preschool- and school-age children. American Journal of Audiology, 24(2), 250–267. https://doi.org/10.1044/2015_AJA-14-0065
Richburg, C. M., & Imhoff, L. (2008). Survey of hearing screeners: Training and protocols used in two distinct school systems. Journal of Educational Audiology, 14, 31–46. www.edaud.org/journal/2007-2008/4-article-07-08.pdf [PDF]
Rosenfeld, R. M., & Kay, D. (2003). Natural history of untreated otitis media. The Laryngoscope, 113(10), 1645–1657. https://doi.org/10.1097/00005537-200310000-00004
Sekhar, D. L., Zalewski, T. R., Ghossaini, S. N., King, T. S., Rhoades, J. A., Czarnecki, B., Grounds, S., Deese, B., Barr, A. L., & Paul, I. M. (2014). Pilot study of a high-frequency school-based hearing screen to detect adolescent hearing loss. Journal of Medical Screening, 21(1), 18–23. https://doi.org/10.1177/0969141314524565
Stephenson, M. (2007). The effect of classroom sound field amplification and the effectiveness of otoacoustic emission hearing screening in school-age children. New Zealand Health Technology Assessment Technical Brief, 6(3), 1–60.
U.S. Department of Health and Human Services. (n.d.). Head Start policy and regulations: 45 CFR §1302.42 (b)(2). https://eclkc.ohs.acf.hhs.gov/policy/45-cfr-chap-xiii/1302-42-child-health-status-care
Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Childhood Hearing Screening page:
Several ASHA documents were consulted during the development of the Childhood Hearing Screening Practice Portal page. ASHA thanks the members of the Ad Hoc Committee on Screening for Impairment, Handicap, and Middle Ear Disorders (Technical Report on Audiologic Screening); the members of the Working Group on Audiology Services in Schools (Guidelines for Audiology Service Provision in and for Schools); and the members of the Panel on Audiologic Assessment (Guidelines for Audiologic Screening) whose work was foundational to the development of this content.
Members of the Ad Hoc Committee on Screening for Impairment, Handicap, and Middle Ear Disorders were Robert Nozza (chair), Judith Gravel, Joan Martilla, Michael Nerbonne, Diane Scott, Thayne Smedley, and Jo Williams (ex officio). Guidance on the report was provided by Jean Lovrinic, vice president for governmental and social policies (1991–1993).
Members of the Working Group on Audiology in Schools were Merrill Alterman, Gail Rosenberg, Paula Schauer (working group facilitator), and Evelyn J. Williams (ex officio). Serving as monitoring vice president was Susan J. Brannen, vice president for professional practices in audiology (2001–2003).
The Panel on Audiologic Assessment was led by Chie Craig (chair). The pediatric working group included Deborah Hayes (coordinator), Kathryn Beauchaine, Stefanie Bronson, Robert Nozza, Anne Marie Tharpe, and Judith Wilson. The adult working group included Sabina Schwan (coordinator), Gary Jacobson, and Wayne Olsen. Evelyn Cherow served as ex officio. Larry Higdon served as the monitoring executive board officer.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Childhood hearing screening [Practice portal]. https://www.asha.org/Practice-Portal/Professional-Issues/Childhood-Hearing-Screening/
Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.