J Community Health (2013) 38:569–574 DOI 10.1007/s10900-013-9652-6
ORIGINAL PAPER
Variability of State School-Based Hearing Screening Protocols in The United States Deepa L. Sekhar • Thomas R. Zalewski Ian M. Paul
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Published online: 26 January 2013 Ó Springer Science+Business Media New York 2013
Abstract The prevalence of hearing loss has increased among United States children. As schools commonly perform hearing screens, we sought to contrast current United States school-based hearing screening protocols. State department of health and education websites were reviewed to assess school hearing screening protocols for the fifty states and the District of Columbia. Individuals listed on these websites were contacted as necessary to confirm and/or acquire relevant data. School-based hearing screening is currently required in 34/51 (67 %) states. Of these 34 states, 28 (82 %) mandate grades for screening, but only 20 (59 %) require screening beyond 6th grade. Pure tone audiometry is the most common screening method (33/34 [97 %]). A majority of states screen at 1, 2 and 4 kHz usually at 20 or 25 dB hearing level. Six states recommend or require testing at 6 or 8 kHz, which is necessary to detect high-frequency hearing loss. The results indicate that United States school-based hearing screens vary significantly. They focus on low frequencies with few testing adolescents for whom high-frequency hearing loss has increased. Disparities in hearing loss detection are likely, particularly considering the evolution of hazardous noise exposures and rising prevalence of hearing loss. D. L. Sekhar (&) I. M. Paul Department of Pediatrics, Penn State College of Medicine, 500 University Drive, HS83, Hershey, PA 17033, USA e-mail:
[email protected] T. R. Zalewski Department of Audiology, Bloomsburg University, 400 E 2nd Street, Bloomsburg, PA 17815, USA I. M. Paul Department of Public Health Sciences, Penn State College of Medicine, 500 University Drive, HS83, Hershey, PA 17033, USA
Keywords Child and adolescent health School-based services Hearing Hearing loss Screening
Introduction School-based hearing screening was implemented in the late 1920s to identify hearing losses that can negatively impact educational achievement [1, 2]. Until the universal implementation of newborn hearing screening in the United States (US), school-based screening systems may provide the first opportunity for population-based hearing evaluations [1, 3]. However, there is no national standard for school-based assessments, with each state implementing testing protocols at their discretion [1, 2]. Historically, school hearing screens have focused testing on the lower hearing frequencies involved in speech perception (typically \3 kHz), with ear infections, wax impaction and foreign bodies being common sources of low-frequency hearing loss (LFHL) among young children [1, 2, 4, 5]. While school-based testing has focused on the lower frequencies, recent data has revealed that roughly 1 in 5 adolescents has hearing loss, with increases in high-frequency hearing loss (HFHL) of particular concern [6]. Shargorodsky et al. [6] utilized data from the National Health and Nutrition Examination Survey (NHANES) to demonstrate an increased prevalence of HFHL from 12.8 % in 1988–1994 to 16.4 % in 2005–2006 among 12–19 year-olds. HFHL is often associated with noise-induced hearing loss (NIHL), which is preventable if detected early [1, 5, 6]. Adolescent LFHL also increased from 6.1 to 9.0 % during the same time period [6]. Although HFHL and LFHL increased by approximately the same rate, HFHL is almost twice as common in adolescents as LFHL [6].
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With the increasing prevalence of hearing loss, all US children should have access to quality hearing screening. As each state determines the content and frequency of school-based hearing screening for its children, the objective of this research was to compare the current schoolbased hearing screening protocols across the US and determine whether disparities in testing exist. Our hypothesis was that despite the increasing prevalence of hearing loss, specifically HFHL, as well as the evolution of its sources (e.g. hazardous noise exposures), school-based hearing screening has remained unchanged and is likely inadequate to detect HFHL experienced by today’s adolescents.
Method State department of health and state department of education websites were reviewed during 2010–2011 to access school hearing screening protocols for the fifty states and the District of Columbia (DC; hereafter all referred to as ‘‘states’’ for simplicity). Individuals listed on these websites were contacted electronically and by telephone as necessary to confirm and/or acquire relevant data. As this study did not involve human subjects it was determined exempt by the Penn State College of Medicine Institutional Review Board. In evaluating the hearing screening protocol of each state five questions were asked: 1. 2. 3.
Does the state have a protocol for school-based hearing screening? Is the screening required or recommended? What grades are to be screened?
Fig. 1 State policies on schoolbased hearing screening
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4. 5.
What frequencies (Hz) are screened? What is the intensity of the screening?
Questions 4 and 5 were based on the assumption that the majority of school-based screenings are completed using pure tone audiometry [1]. In this procedure, a student responds to the presence of a pure-tone signal presented via earphones [1]. Descriptive statistics were calculated in order to provide a summary of the current school-based hearing screening protocols.
Results Information was obtained concerning hearing screening programs from all 51 states. School-based hearing screening is currently required by 34/51 (67 %) states. The remaining states either recommend (7/51 [14 %]) a schoolbased hearing screen or did not have any requirement (10/ 51 [20 %]) for school hearing screening (Fig. 1). Therefore, a total of 41 states have either a required (34) or recommended (7) school-based hearing screening program that is available at the time this data was collected. Of those states which require a school-based hearing screen, 28/34 (82 %) mandate specific grades for screening. However, only 20/34 (59 %) require a hearing screen to be done beyond 6th grade to capture students in junior or senior high school (Fig. 2). Pure tone audiometry is the most commonly employed method to screen school-age children (33/34 [97 %]) [1]. Only Rhode Island utilizes the method of distortion product otoacoustic emissions as the initial screening method. This test utilizes a microphone placed in the ear canal to stimulate a predictable series of acoustic signals from the
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Fig. 2 Grade levels for required school-based hearing screening
cochlea and does not require a response from the subject [7]. Recommended or required pure tone audiometry protocols were publicly available for 38/41 (93 %) states. The majority of the states, 28 of 38 (74 %), screen at 1, 2 and 4 kHz at either 20 or 25 dB HL (DC uses 35 dB HL). Some states, 6/38 (16 %), include 0.5 kHz which results in the following frequencies screened, 0.5, 1, 2 and 4 kHz. The 4 remaining protocols add test points such as 0.25 or 6 kHz (Fig. 3). Although all the states (38/38 [100 %]) include 4 kHz as part of the screening, only 6/38 (16 %) include 6 or 8 kHz. Specifically, protocols from Tennessee, Missouri, Mississippi and Maryland recommend the inclusion of 6 and/or 8 kHz, but these frequencies are not required frequencies to be screened. Only two states
require high-frequency testing; Kansas requires 6 kHz be included to the screening for 4th grade and above while Colorado requires 6 kHz testing for 6th grade and above.
Discussion This is the first contemporary study to examine state school-based hearing screening protocols for US adolescents. There are a variety of protocols in use with only 2 states requiring high-frequency testing, leaving the majority of US adolescents without appropriate screening given the common sources of acquired, adolescent HFHL in the twenty-first century.
Fig. 3 Frequencies tested per school hearing screen protocols
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It is difficult to project if HFHL in adolescents will continue to rise. Currently, roughly 1 in 5 adolescents has hearing loss with 16.4 % demonstrating HFHL [6]. The prevalence of adolescent hearing loss (19.5 %) is even higher than the 18.4 % prevalence of obesity among 12–19 year-olds, and obesity is considered a national epidemic [8]. Even if the prevalence of adolescent hearing loss does not increase, the current prevalence rate indicates the inclusion of high frequencies is warranted in the school screening protocol. Failure to identify students with even mild HFHL may have long-term consequences. HFHL is usually related to NIHL [1, 4]. As individuals continue to expose themselves to sound hazardous environments hearing loss will progress, which will have negative consequences on speech, communication and educational success [1, 9]. Research has demonstrated that individuals with HFHL as a result of occupational NIHL experience a significant negative impact on quality of life [10]. Adolescents are specifically at increased risk of exposure to music listening levels that may damage the auditory system [11, 12]. Audiologic damage caused by excessive sound exposure is irreversible, although it is the most preventable type of hearing loss by avoiding sound hazardous environments [1, 5]. Avoidance of sound hazardous environments is more important if an individual is identified with early indications of HFHL. This simple strategy can allow adolescents to achieve their full academic potential as well as a better quality of life. Some have previously advocated for including highfrequency (C3 kHz) testing in the school hearing screen in order to detect HFHL as a result of NIHL [1, 2, 4], yet to date these suggestions have not been implemented. A 1999 study by Penn and Wilkerson, also found few states recommending hearing screening in junior and senior high school [2]. The lack of response may be due to the types of adolescent exposures which were deemed high risk for hearing loss. Prior to the widespread and visible use of personal listening devices, studies indicated youth exposed to farm equipment and firearms were at risk for HFHL as a result of NIHL [4, 9]. As these types of exposures declined for children in large metropolitan areas, the impetus to pursue a high-frequency hearing screen for adolescents may have been lost, leaving school hearing screening programs unchanged. This analysis is unique in providing an updated evaluation of school based hearing with a focus on adolescents. This analysis lays the foundation for a comparison of screening outcomes between those states utilizing high frequency test points and those which do not. These data can be used to develop a sensitive and specific evidenced based high-frequency school hearing screen for adolescents. The questions of which high-frequency test points need to be added to the current screenings and for which age
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groups has yet to be determined in large population-based studies. Adding high frequencies to the school screening protocols without evidence based research is unlikely to be effective. Hearing screening in the school setting is difficult due to the impact background noise can have on the testing, which can result in a large number of false positive screens. Additionally, adequate follow-up has to be ensured for adolescents whose screening results indicate the need for a thorough diagnostic evaluation to rule out or verify a permanent hearing disorder. Hearing loss due to excessive sound exposure is characterized by an audiometric configuration known as a noise notch. Although all of the school-based hearing screening protocols include 4 kHz which will provide some high frequency information; 6 and 8 kHz are required to further investigate NIHL. Research found 6 kHz is the most commonly involved frequency among US adolescents demonstrating notched hearing loss [13]. Meinke and Dice [1] examined current school-based hearing screening protocols to determine their ability to identify notched HFHL audiometric configurations. They found that the most common US school-based hearing screening protocol, utilizing 1, 2 and 4 kHz at 20 or 25 dB HL would identify only 22 % of students with a high-frequency notched audiometric configuration [1]. Thus, failure to include high-frequency screening potentially misses a large number of adolescents with hearing loss. Primary care physicians often perform hearing screening in the office setting. The current screening recommendations are very similar to the school-based protocol. For pure tone audiometry testing the American Academy of Pediatrics recommends screening at 0.5, 1, 2 and 4 kHz with children failing if they cannot hear the tones at 20 dB HL [7]. Objective hearing screening is recommended as a newborn and at ages 4, 5, 6, 8 and 10 years [7]. Once again, the focus is not on adolescents or HFHL. An evidenced based protocol for school-based use could easily be applied in the office setting. It may be that certain age groups are better screened in the physician’s office versus the school setting. Another option might be a two-tiered approach with initial screenings in the school, followed by a confirmatory screen in the pediatric office and ultimate audiology referral for those adolescents who do not pass both screening protocols. Thus, the responsibility for adolescent hearing screening does not have to rest solely with the school system. There are multiple different school-based hearing screening protocols in use. These protocols vary in the frequencies that are screened, the intensity levels and the grade levels screened As a majority of states have a system for school-based hearing screening in place, it would seem prudent to work towards standardizing screening to identify those at risk for the types of hearing loss most prevalent
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among adolescents today. Standardization of the school hearing screening protocol would allow data from across the country to be compared over time. It would allow those involved in the screening process to address problems from a common ground. If trends are followed on a national level, changes to the school screening process to keep pace with the evolution of hazardous noise exposures for adolescents will be much more feasible to implement. This will help to ensure school hearing screening is cost and time effective. Limitations This is a cross-sectional analysis and thus is only representative of one moment in time. Several of the personal communications with state representatives mentioned changes proposed to legislation for school-based hearing screening. Therefore, the data presented in this article may not represent the most current protocols. In fact, in certain cases, the printed laws did not exactly match what was done in practice. Due to the lack of standardization of school hearing screening, individual districts, schools and those responsible for conducting the screenings may vary the testing protocol based on their discretion. This is another factor the authors did not explore and requires additional research.
Conclusions School-based hearing screens vary significantly across the US with a focus on the elementary grades and detection of LFHL. Screening adolescents is not mandated in a majority of states with very few testing above 4 kHz. Because the prevalence of HFHL is increasing and may result from preventable hazardous sound exposures, more consistent screenings including testing for HFHL should be considered, particularly for those in secondary schools.
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