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State-by-State Trends in School-Age Hearing Screening

Worthington, Megan AuD; Partain, Mark AuD; Thomas, Madeleine AuD

doi: 10.1097/01.HJ.0000579576.37550.17
Pediatric Audiology

Dr. Worthington is an audiologist and the manager of clinical education for the audiology academic program at Rush University in Chicago, IL. She was a clinical audiologist specializing in pediatric audiology and cochlear implants. She also served as a clinical preceptor for audiology students. Dr. Partain is an audiologist at Kirsch Audiology in Santa Monica, CA. He received his AuD degree from Rush University, and completed his externship at Weill Cornell Medicine. Dr. Thomas is a recent graduate from Rush University. She is an educational audiologist at Chicago Public Schools who combines personal experience with hearing loss and clinical knowledge to provide personalized care for deaf and hard-of-hearing students.

School-age hearing screenings (SAHS) are a secondary access point to audiologic care following universal newborn hearing screenings (UNHS). However, many U.S. states either do not require or regulate SAHS. While many countries have implemented UNHS, Watkins and Baldwin1 showed that in the United Kingdom, 3.65 of every 1,000 children have a permanent hearing impairment of any degree. The U.K. UNHS identified only 0.9/1,000 of these hearing impairments; about 51 percent of hearing impairment in these children was identified after the time frame of the UNHS. In a separate study, Weichbold, et al.,2 found that about 25 percent of the children in their study cohort developed hearing loss after the UNHS time frame. While these results give concern for the sensitivity and effectiveness of some UNHS methodologies, U.S. states have no standardized process for follow-up provided by SAHS. Similarly, though professional organizations governing audiology provide guidelines, they sometimes do not provide all of the information needed. For example, the American Academy of Audiology recommends a “pure tone sweep at 1,000, 2,000, and 4,000 Hz at 20 dB HL” for children in “grades 1, 3, 5, and either 7 or 9 at a minimum.”3 While the Speech-Language-Hearing Association (ASHA) Guidelines for Audiology Service Provision in and for Schools4 do not provide specific guidelines, their Guidelines for Audiologic Screening5 provide the same pure tone screening of 1,000, 2,000, and 4,000 Hz at 20 dB HL. In this study, we evaluated the state-by-state trends and requirements for SAHS.



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Our study used state statutes, regulation, codes, and other publicly available documents obtained from legal databases such as LexisNexis, Justia, and individual state databases to create a database for all 50 U.S. states and Washington, DC. While creating this database, it became clear that the largest organized level of screening requirements was at the state level, complete with county- and city-specific requirements. However, noting our focus on creating a comprehensible database, state-level requirements were found to have the lowest level of distinguished requirements.

We found that 34 U.S. states legally require SAHS (about 67%); of these, only 18 have a mandated protocol (51%). Therefore, 18 out of 51 states require SAHS and legally mandate the process (35%). This indicates that about two-thirds of school-age children in the country are not receiving adequate hearing screenings.

Colorado is an example of a state with comprehensive requirements for SAHS of children from kindergarten to high school, as well as various other entry points. Colorado has specific requirements for frequencies and intensities tested, referral criteria, and follow-up guidelines. The state also explores other methods that should be utilized for hearing screenings, such as tympanometry and otoscopy, the recommendations for which are provided in Guidelines For Childhood & Youth Hearing Screening Programs.6 On the other hand, some states like Alabama, which previously required SAHS but repealed the requirement in 2015, have removed requirements and recommendations for SAHS, UNHS, and other general health screenings.

Following data collection, we developed an accessible online database ( of the SAHS requirements by state. Each state, plus Washington, DC, has an individual page with a summary of our findings.

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A major limitation of this study is that the search of legislations was only performed at the state level, which does not include county-, city-, or department-specific legislations or rules. It is highly likely that some individual areas within each state have different requirements or require testing despite the absence of statewide requirements. We find that this variability is something that could be improved upon.

One welcomed finding was that SAHS are still being conducted in some states that don't require this screening. While this is a good initiative, the lack of legal requirements to perform these screenings means there's no accountability. If more stringent, statewide legal requirements were implemented, hearing screening services would be more regulated and thus potentially more beneficial. Furthermore, there is the problem of “too many cooks in the kitchen” due to the wide variability of regulations across each state.

Finally, the issue remains that SAHS have not been addressed on the scale that UNHS have been; advocacy for the importance of UNHS led to the development of statewide and nationwide requirements, trainings, and guidelines for these screenings. As many as 51 percent of children are identified with hearing loss after their UNHS. Without adequate SAHS, affected children may not be identified and treated in a timely manner. The solution to this problem may lie where it did for UNHS—audiologists advocating for improved screenings. Health care professionals in other fields were able to accomplish important feats through advocacy, such as that for school-age vision screenings, which have been implemented and updated more often than SAHS. It is up to audiologists at the state level to advocate for improved laws and hearing care services to better identify and treat children with late-onset hearing loss.

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1. Watkin PM, Baldwin M. Arch Dis Child. 2011 Jan;96(1):62-6. doi: 10.1136/adc.2010.185819. Epub 2010 Nov 2.
2. Weichbold V. Universal Newborn Hearing Screening and Postnatal Hearing Loss. Pediatrics. 2006;117(4). doi:10.1542/peds.2005-1455.
3. American Academy of Audiology Task Force. American Academy of Audiology Childhood Hearing Screening Guidelines. Reston, VA
4. American Speech-Language-Hearing Association. Guidelines for Audiology Service Provision in and for Schools. American Speech-Language-Hearing Association. Published 2002. Accessed May 29, 2019.
5. American Speech-Language-Hearing Association. Guidelines for Audiologic Screening. American Speech-Language-Hearing Association. Published 1997. Accessed May 29, 2019.
6. Patrick K et al. Guidelines For Childhood & Youth Hearing Screening Programs; 2017.
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