Hearing screening is mandated in public schools in Montana in grades K, 1, and either 9th or 10th grades. The Hearing Conservation Program, through the Montana Office of Public Instruction oversees the hearing screenings in schools, but it is up to the individual public school districts to take on the primary responsibility for conducting the screenings.
Screening of school-age children is the responsibility of the public school. The hearing screening is intended to identify those individuals in need of referral for evaluation and identification. The initial hearing screening is often the responsibility of the school nurse.
- The Montana office of public instruction has laid out guidelines for the educational hearing conservation program. They state that the purpose of the hearing conservation program are as follows:
- To identify children with educationally significant hearing losses through hearing screening, on-site audiology procedures, and comprehensive hearing evaluations;
- To assist schools and parents in determining appropriate educational placement and intervention;
- To serve as a consultant to school personnel, parents, and students regarding potential educational effects of an identified student's hearing impairment and the function of hearing aids and assistive listening devices;
- To provide consultative services regarding hearing aids, cochlear implants, assistive listening devices, and, where appropriate, classroom acoustics; • To provide education, as needed, regarding the prevention of hearing loss; and
- To provide follow-up support to children, families and schools.
Results of hearing screening program have shown that five to ten percent of the school age population do not pass audiometric tests. The majority of these children are in need of medical treatment. Such treatment may result in restoration of hearing and prevention of permanent hearing impairment. Approximately two percent will show permanent hearing impairment and will require special educational services. Communication is an integral part of human behavior. Seldom does one consider the implications of not being able to hear. The most serious effect of a hearing loss is the interference with and breakdown of communication between persons. In a child, some of the consequences may be: (a) Interference with normal speech and language development. (b) Development of abnormal social growth and behavior. (c) Interference with education and human potential. (d) Development of adjustment problems in the child and his/her family. (e) Isolationism in a hearing world.
A child’s behavior in the classroom may indicate the possibility of a hearing loss. The child may be inattentive, may ask for frequent repetitions, or his/her achievement may be low. The observation of such behavior will assist in identifying children in need of help and indicate the need to assess hearing levels.
ANATOMY AND PHYSIOLOGY OF THE EAR
The ear receives sound waves which are processed and transmitted to the hearing center in the brain for interpretation. The ear is divided into three parts: outer, middle, and inner. The outer ear consists of the auricle or pinna and external auditory canal. The auricle, or visible part of the ear, directs and concentrates the sound waves along the external ear canal to the tympanic membrane. The ear canal contains hairs and wax producing glands which serve to protect the eardrum from dirt, insects, or foreign matter. The tympanic membrane is a thin diaphragm which completely closes the end of the ear canal and separates the outer ear from the middle ear. The middle ear is a tiny, air-filled cavity between the eardrum and the bony wall of the inner ear and contains the three smallest bones, called ossicles. The first bone in the ossicular chain is the hammer (maleous) which is attached to the ear drum. The anvil (incus) fits between the hammer and the third bone, known as the stirrup (stapes). The footplate of the stapes is set in the window of the inner ear. A passage between the middle ear and the back of the nose (eustachian tube) serves as a means for equalizing air pressure and ventilating the middle ear cavity. The inner ear contains the sensory organ for balance (including the semicircular canals) as well as the organ for hearing known as the cochlea. The cochlea resembles a snail shell in appearance and is filled with fluid. Sound vibrations from the eardrum are transmitted through the ossicular chain to the oval window to the fluid in the cochlea. The sound sets in motion thousands of hair-like sensory cells in the cochlea called the Organ of Corti. These sensory cells transform fluid movements into electrical impulses and, by a series of complicated processes, transmit them to the auditory nerve to the brain, where they are perceived as sound.
“The school nurse must know and understand the anatomy and physiology of the ear if she/he is to understand the results of hearing tests. Interpretation of the findings of the hearing tests are often based on the structure and functioning of the ear and its many parts. It is easier for the teacher to understand the problem of a child with a hearing loss if the nurse will first explain the functioning of the ear, and then explain how the child’s problem relates to the functioning of the ear.” -National Association for School Nurses, Hearing Screening Guidelines
“The two most common types of hearing loss found in school age children are sensorineural (permanent) losses, and conductive (not permanent) hearing loss. Sensorineural loss can result from inner ear defects; auditory nerve damage, or damage to the auditory center in the temporal lobe of the brain. Known causes of sensorineural losses include viral (especially measles and mumps) and bacterial infections; prolonged exposure to loud noises such as rock bands, gunfire, motorcycles, and power motors; ototoxicity; congenital abnormality; and head trauma. Treatment for these losses includes auditory training with amplification devices (hearing aids); and special habilitation, including speech reading (lipreading) and speech therapy.
Conductive hearing loss, which is the most common loss in children, results from a problem in the external ear canal, tympanic membrane, or middle ear cavity, interfering with the transmission of sound. Causes include: impacted earwax, foreign objects (beans, erasers, cotton, etc.) in the ear canal, otitis media, congenital abnormalities, and ruptured or scarred eardrums secondary to trauma or infection. Conductive losses can be mild or more severe, and are considered significant when they interfere with a child’s ability to communicate effectively. Many cases of conductive loss respond to medical or surgical treatment. However, these losses may fluctuate over time so that a pupil who is referred to a physician for follow-up may not be experiencing the loss at the time of medical evaluation. This is another strong argument for the necessity of rescreening before referring a pupil.”
Though the conduction of hearing screening and rescreening is the responsibility of the school, the hearing conservation program provides significant help to the school nurse in the following ways:
The Hearing Conservation Program provides training and technical assistance, comprehensive hearing evaluations, and follow-up technical assistance and support to schools and families in the event the child has a confirmed hearing loss. The audiologist under contract with the Hearing Conservation Program is available to the schools in the area for assistance in training screening personnel, interpreting screening results for referral, providing hearing evaluation following screening, participating in child find screenings, providing inservice training for teachers, counseling parents regarding hearing loss, participating in evaluation and individualized education program (IEP) team meetings, when appropriate, and the various other functions as time will allow.
Hearing Conservation Program
Initial Screening Screening personnel should perform a listening check of equipment prior to screening to assure that equipment is working and that the ambient noise will not preclude valid results. The room in each building that is the most quiet should be used for hearing screening with constant attention to changing noise levels throughout the day. The mandatory grades to be screened annually may be limited to grades Kindergarten (K), 1, and 9 or 10.
Pure tone air conduction screening for the school-age child must be conducted in each ear at the frequencies of:
1000 Hz, at 20 dB
2000 Hz at 20 dB
4000 Hz, at 25 dB
Students who have a history of fluctuating hearing should be screened at the initial screening or by the area audiologist at a follow-up screening. Students with a known sensorineural hearing loss should not be screened at the initial screening, but should be monitored by the area audiologist during a school visit. The frequency of the monitoring will be determined by the area audiologist.
If a child fails the initial screening, he/she should be screened again in a quieter area on the same day if possible. Implementation of this procedure will help to reduce the number of over-referrals due to ambient noise levels.
Follow-up screening should not be done for one to three weeks after the initial screening except where distance is a factor and then it may be done on the same day as the initial screening. Follow-up screening should be accomplished by personnel with a thorough knowledge of screening procedures and the screening process (audiologist, audiology aide, nurse, speech-language pathologist or someone approved by the HCP audiologists, etc.). Additional screening procedures may be used when determined necessary by the audiologists or specifically trained audiology aide to determine the need for referral. These procedures may include otoscopy, tympanometry, acoustic reflex screening, otoacoustic emissions screening, and/or air conduction thresholds. Preventing over-referral or under-referral is the priority of a good screening program.
Tympanometry screening, utilizing noninvasive probe tips, is encouraged but not mandatory and may be performed by trained personnel for grades kindergarten and first, following careful visual inspection of the ear canal.
Screening of Preschool-Age Children
Preschool child find screenings are those organized by the public schools for the purpose of identifying preschool children, birth through five, who are not enrolled or provided services by the public school that may have a disability. The area 3 audiologist is expected to participate in this child find activity by conducting the hearing screening. Preschool hearing screening must be done by the area audiologist. This is generally accomplished with the assistance of another person. Children suspected of having a hearing impairment are referred for a hearing evaluation to determine the presence of a hearing impairment. Otoacoustic emissions and/or air conduction audiometry are an essential part of this screening and should be done whenever possible. The audiologist may include other screening methods as well, such as: otoscopy, tympanometry, and/or pure tone conduction audiometry (utilizing the same pass/fail criterion as for school-age testing). The methods used are typically dependent on the child's developmental age and other relevant factors as determined by the audiologist. Preschool-age children who did not participate in the preschool child find screening, but are referred later for hearing screening, may be referred to the audiologists for screening at the audiology clinic or the audiologist may elect to screen the child at the school, if feasible.
Management/Referral Following Screening/Rescreening
After the area audiologist has conducted and/or interpreted the results of a school follow-up screening or preschool screening, management decisions may include, but are not limited to the following as determined by the audiologist:
- Recheck in one year (such as for borderline middle ear problems);
- Periodic or annual monitoring (such as for chronic fluctuating hearing loss, child with ventilating tubes, or mild loss which is not educationally significant);
- Follow-up screening after an upper respiratory infection or middle ear condition has had time to resolve; and
- Referrals may include, but are not limited to: comprehensive audiological evaluation in the Hearing Conservation Program area audiology center, medical referral, or medical referral with follow-up screening or audiological evaluation.
Medical evaluations are performed by physicians and are essential for proper diagnosis and treatment of children suspected of having ear or vestibular disease. Medical services are not provided by the Hearing Conservation Program. If a child is referred by the audiologist for a medical evaluation or the audiologist recommends that a medical evaluation be conducted, it is the parent's decision whether the medical evaluation will be done. The parent is responsible for the cost of the medical evaluation. The role of the audiologist is one of referral and monitoring.
For any medical referral or referral for audiological evaluation, the family of the child will be notified by mail. The audiologist may also contact the family by phone or in person.
The purpose of a comprehensive hearing evaluation is to determine the degree and nature of hearing difficulty and to provide educationally relevant recommendations. The audiologic evaluation shall be performed by a fully or provisionally licensed audiologist. Written parent permission is required prior to conducting the evaluation. The HCP audiologist is expected to provide a timely and relevant report of the evaluation to the school, parent and/or referral source.
Effects of Hearing Loss Threshold Degree of Loss Effects
- 15 to 30 db Mild (hard of hearing) Difficulty hearing faint or distant speech; may require hearing aid; needs preferential seating in classroom.
- 30 to 50 db Moderate (hard of hearing) Difficulty hearing distant speech; requires amplification; preferential seating, auditory training, and probably speech therapy.
- 50 to 70 db Moderate to severe Difficulty with conservation, unless loud; great difficulty in group/classroom discussion; requires hearing aid; may require special class for hard of hearing.
- 70 to 90 db Severe (deaf) May hear loud voice close to ear; may hear some vowels, recognize some sounds in environment; needs special education for the deaf, with specific training in speech language.
- Over 90 db Profound (deaf) May hear some loud sounds; does not rely on hearing for communication; requires special education for the deaf.
DIFFICULT TO TEST OR UNTESTABLE PUPILS
Pupils found to be difficult to test or untestable by pure tone audiometry because of inability to respond or understand instructions should have:
(a) An ear examination, using an otoscope, by the school physician, school nurse practitioner, or school audiologist.
(b) Teacher input regarding child’s performance in classroom.
(c) Gross testing procedures such as alerting (eye movement, head turn, facial expression) to noise maker, finger-snap, hand-clap, crinkling paper, voice, etc., when presented at varying loudness and distance from the ear and outside the child’s visual field and awareness.
(d) Parent input regarding child’s auditory awareness and responsiveness to voice, music, and sound in the home environment.
Preparation of the Pupil
The procedure for testing should be described and demonstrated briefly to the entire class or entire group. A suggested method of carrying this out is to present exaggerated tones from the audiometer and ask the children to respond by raising their hands when they hear the tone. Practice with a group will simplify the testing on individual children. Should a child be confused, it would be wise to demonstrate with one or two tones before starting to test. Another helpful suggestion is to have one or two children in the testing room while another is being tested. This will enable them to follow the example of the child being tested. The following instructions should be provided to each class to be tested: “You are going to have your hearing tested. You will hear sounds from the earphones. Some will be high-sounding and some will be low-sounding. Some will sound like whistles and some will sound like hums. When you hear the sound, no matter how soft or little it is, you are to raise your hand. Keep your hand up as long as you hear the sound, and put it down as soon as the sound goes away. When you hear a sound again, raise your hand again. Remember, no matter how soft the sound is, if you think you hear it, raise your hand.
Primary School Screening Form: Vision-Hearing-BMI
Secondary School Screening Form: Vision-Hearing-BMI
Montana has no mandate concerning scoliosis screening. In fact, routine screening for scoliosis is a bit controversial and many states do not require this screening. Scoliosis is an appreciable lateral deviation of the normally straight vertical line of the spine or one or more lateral rotary curvatures of the spine. (see diagram below)
One can find studies that both support and discourage school screenings. Some studies show that screenings can catch students with idiopathic scoliosis and, if referred in a timely manner for further treatment, might prevent them from worsening Other studies seem to indicate that routine screening in schools is not effective as the number of students screened is far too large to justify the few who might benefit from it, and there could be a danger of over-referral.
It is estimated that approximately 4% of school-age children will have a curvature of varying degrees. The effect of scoliosis depends upon its severity, how early it is detected, and how promptly it is treated. Rate of treatment is 2 per 1,000 children in the target age group. Early identification and management of scoliosis is the purpose of a screening program.
Your school district may have a policy about screening students for scoliosis and if so, at what age they will be screened. If your school district does have a policy requiring scoliosis screening, the following will be helpful in implementing the screening.
Preparation of Students for Screening
- Explanation of the screening procedure.
- Boys and girls should be screened separately.
- Boys should strip to the waist.
- Girls should wear a bra, bathing suit top, or halter under a blouse or sweater.
- Boys and girls should remove shoes.
- A marked line should be placed on the floor. With toes on the line, each student will be viewed in both the erect standing and forward bend positions. The screener may wish to stand, or be seated, several feet from the line.
- With the student standing erect, feet together and arms hanging relaxed at sides, the screener scans the back for obvious abnormalities:
a. Are the shoulders level?
b. Are the hips level?
c. Is one shoulder blade higher, or more prominent than the other?
d. Are there unequal distances between the arms and the body?
e. Does the spine appear curved?
(This data is not recorded, but is used as a guide).
3. The student now assumes the forward bend position, bending at the waist to 90°, with fingertips of the hands together.
The screener observes for signs of a possible scoliosis:
a. Rib hump on either side of the upper back – rib hump
b. Rotational hump on either side of the lower back – lumbar rotation
4. The student should be viewed from both the front and the back standing and forward bend positions (see diagram ).
5. The screener observes for:
a. Excessive prominence of thoracic spine; possible Kyphosis.
b. Excessive sway back; possible Lordosis.
c. Other orthopedic conditions.
d. Prominence of sacrum or buttocks.
Second Screening (Rescreening)
All students who have positive findings shall be further screened by a more experienced screener prior to referral. It is important that an excess referral rate does not occur. In order to avoid the possibility of unnecessary referral, all students with positive findings in any part of the screening should be rescreened at a separate session.
Referral and Case Management
Following the re-screening program, those students with positive findings should be referred for a physician evaluation. A positive rib hump in the forward bend position is the major criteria for scoliosis referral (see Diagram ). The other observations made by the screener are merely supportive of the rib hump finding. In most cases, it will be helpful to speak with those students to allay their fears and encourage their cooperation. It will also be helpful to call each parent to describe the screening procedure and encourage physician evaluation.
Sample Parent Information Letters
Sample Scoliosis Screening Program: Parent Information Letter #1
Sample Scoliosis Screening Program: Parent Information Letter #2
Scolionmeter for use with smart phone
Video to show kids before doing a scoliosis screening