Preschool Hearing Screening: Pass/Refer Rates for Children Enrolled in a Head Start Program in Eastern North Carolina
Allen, Rose L
This 4-year project investigated the pass/refer rates of preschool children in a hearing screening program. Three- and 4-year-old children who attended Head Start centers in rural, traditionally medically underserved, eastern North Carolina participated (n = 1,462). Screening procedures and pass/refer criteria were based on the Guidelines for Audiologic Screening (American Speech-Language-Hearing Association [ASHA], Panel on Audiologic Assessment, 1997). Only 54% (n = 787) of children passed the initial screening (i.e., passed all three of the screening components, which included pure-tone audiometry, tympanometry, and otoscopy), and an additional 22% (n = 323) passed the rescreening, for an overall pass rate of 76%. The initial pass rate was 90%, 71%, and 71% for otoscopy, tympanometry, and pure-tone audiometry, respectively. After the initial screening, 675 children were referred (i.e., 83%, 2%, and 15% for audiologic rescreening, medical evaluation, or both, respectively). About 71% (n = 478) received the recommended evaluation. Follow-up assessment compliance after the rescreening was poor. Slightly more than 10% of children were evaluated. The hearing status of 267 (i.e., 18.3%) children was never determined. Six (i.e., 0.5%) of the 1,195 children who completed the audiologic screening and/or received diagnostic audiologic assessment were confirmed to have hearing loss. Methodological factors that may have contributed to this high refer rate include the use of all screening techniques (pure tones, tympanometry, and otoscopy), procedural considerations in testing protocol and pass/refer criteria, and the demographic characteristics of the children screened.
Keywords: preschool, hearing screening, ASHA guidelines, tympanometry, pure-tone audiometry
The importance of early identification of hearing loss has been well established (Joint Committee on Infant Hearing [JCIH], 2000). Furthermore, it has long been accepted that the presence of even a mild bilateral or unilateral sensorineural hearing loss may result in delays in speech and language development, cognitive development, social emotional development, academic performance, or later vocational activities (American Speech-Language-Hearing Association (ASHA], 1997; Bess, Dodd-Murphy, & Parker, 1998; JCIH, 2000; Karchmer & Allen, 1999). In recent years, much attention has been given to the development and implementation of screening protocols for universal newborn hearing screening programs. According to the JCIH, protocols that screen only those infants at risk for hearing loss will fail to identify 50% of the infants with hearing loss. Additionally, newborn hearing screening programs will not identify infants with delayed onset or acquired hearing loss. Therefore, it remains imperative that hearing screening programs be conducted for children of all ages.
In 1997, ASHA published revised guidelines for audiologic screening of individuals from birth through adulthood. Of particular importance to the present project are the guidelines for preschool children 3 to 5 years of age, which address the identification of outer and middle ear disorders and hearing impairment. These guidelines describe specific pass/refer criteria for otoscopic, tympanometric, and audiometric screening procedures.
Previous research has demonstrated varying pass/refer results among different screening protocols and samples of children. Roberts (1976), for example, compared pure-tone, impedance, and otoscopic hearing screening methods in a population of 1,109 Native Canadian children in British Columbia. Children ranged in age from less than 2 years to 14 plus years. On the basis of the guideline of 25 dB HL for pure-tone stimuli at 500, 1000, 2000, and 4000 Hz, 62% of the children passed the pure-tone screening, 19% failed, and 19% of the children could not be tested by pure-tone audiometry. When considering only the 2- to 4-year-olds, 110 of 161 (i.e., 68%) children could not be tested by pure-tone audiometry. With respect to impedance audiometry, Roberts reported that 54% of the total 1,109 children passed, 38% failed, and 8% of the children could not be tested. Note that only Jerger Type A (Jerger, Jerger, & Mauldin, 1972) tympanograms with present stapedial reflexes were considered to be normal results. An otolaryngologist performed ear, nose, and throat (ENT) examinations. Of the 1,109 children, 88% had normal otoscopic findings, 12% were abnormal, and less than 1% (n = 6) could not be tested.
In a study of 619 prekindergarten and kindergarten students, Hamill (1988) compared a pure-tone (i.e., 500, 1000, 2000, and 4000 Hz) screening protocol to the Verbal Auditory Screening for Children (VASC) speech audiometry method. An intensity level of 20 dB HL was used for the pure-tone pass/refer criterion. Tympanometry was not included in the screening protocol. Hamill reported a total pure-tone refer rate of 7.8% and that 1.7% of the regular program students could not be tested reliably with pure-tone audiometry.
More recently, Mundy (2001) reported pure-tone audiometry and tympanometry screening outcomes for children in preschool and Head Start, kindergarten, first grade, and second grade. Her data indicated an increase in the percentage of children passing the first screening from 81% for children enrolled in preschool/Head Start to 98% for second graders. Mundy also used procedures and criteria that were modified from ASHA’s (1997) guidelines. For instance, a minimal response level was obtained for children who did not detect one or more pure tones at the initial screening level of 20 dB HL. More important, Mundy’s criterion for peak compensated static admittance referral was less strict than the ASHA (1997) guidelines (cf.
Taylor and Brooks (2000) investigated the sensitivity and specificity of transient evoked otoacoustic emissions (TEOAEs) screening procedures as compared with pure-tone screening and tympanometry from a group of 297 ears from 152 preschool and school-age children 3 to 8 years of age (M = 5 years 5 months). Pass/refer criteria were based on the ASHA (1997) guidelines. A TEOAE pass was defined as a robust response 3 dB above the noise floor present for at least three center frequencies of 1000, 2000, 3000, 4000, and/or 5000 Hz. The data were analyzed according to individual ears. The pass rates for pure-tone, tympanometric, and TEOAE screening procedures were 89%, 91%, and 87%, respectively.
In summary, investigators who have reported pass/refer values for otoscopic, tympanometric, and pure-tone screening procedures have used varying protocols, none of which were specific to the 1997 ASHA guidelines. The purpose of the present study was to determine, through the use of the Guidelines for Audiologic Screening (ASHA, 1997), the pass/refer rates for middle ear disorders and hearing impairment for a cohort of preschool children age 3 to 5 years. Specifically, the present investigation involved children enrolled in a Head Start program. The project was implemented through East Carolina University (ECU) Department of Communication Sciences and Disorders to assist the Martin County Community Action (MCCA), Inc., Head Start program in meeting its goals for completion of the health screenings required for all children. The MCCA, Inc., Head Start program encompasses a three-county area in eastern North Carolina that has been established as a medically underserved geographic area. The hearing screening was part of a multidisciplinary health screening effort (i.e., speech-language, vision, dental, fine and gross motor, blood pressure, height/weight, hemoglobin, and other procedures).
Method
Participants
Three- and 4-year-old children who attended one of seven Head Start centers in three counties (i.e., Beaufort, Martin, and Pitt) in eastern North Carolina during the 4 academic years from 1998 to 2002 participated. The mandate of the Head Start program is to test all children who enter the program irrespective of whether they are receiving medical management. Approximately 65% of the total student body was tested (n = 1,462). Table 1 contains the frequency distribution of the participants as a function of age and academic year. The 4-year-old children who participated in the study did not include any of the same children who were included in the 3-year-old group. Table 2 contains the frequency distribution of the participants as a function of gender and academic year. As evident in Tables 1 and 2, the overwhelming majority of children tested were 4 years of old (i.e., 80%), and there were slightly more boys than girls (cf. approximately 52% vs. 48%). Eastern North Carolina is a rural, traditionally medically underserved, geographic area. In a typical academic year, more than 75% of children receive Medicaid benefits or have no health insurance at all. Approximately three-fourths of the children came from single-parent families with gross annual incomes of less than $15,000. The children who attended these centers were primarily African American (cf. approximately 92%, 4%, and 4%, for African American, Caucasian, and other, respectively). From available data for the children enrolled during the 2001-2002 academic year, 25% had speech and/or language delays, 4% had visual deficits, 7% had low hemoglobin counts, 55% needed dental treatment, 8% were overweight, 18% had asthma, and approximately 10% had at least one disability that is defined as an impairment that affects learning potential. The most common disability among this group of children was delayed speech and/or language development. There were no children with physical or mental disabilities.
Apparatus
Testing was conducted in quiet rooms at each of the seven Head Start centers. Ambient noise levels were assessed at each site before testing. A precision sound level meter (Bruel & Kjær model 2231) using a half-inch polarized free-field microphone (Bruel & Kjær model 4145) and a third-octave filter set (Bruel & Kjær model 1625) was used to assess ambient noise levels. The sound level meter was calibrated according to manufacturer’s specifications with a piston phone (Bruel & Kjær model 4228) before all measures. In all cases, test rooms met specifications for permissible ambient noise (American National Standards Institute, 1999) for the screening test levels. That is, ambient noise levels did not exceed maximum third-octave band levels allowed when testing for 20 dB HL in the 500 to 8000 Hz range for ears covered with supra-aural earphones.
Pure-tone audiometry was conducted with portable audiometers (Beltone Model Scout). Stimuli were presented to each participant through supra-aural earphones (Telephonies Model TDH 50P). All audiometers were calibrated to specifications before the screening activities (American National Standards Institute, 1996). Otoscopy was performed with Welch-Allyn otoscopes (Model 25070). Middle ear status was assessed with portable middle ear analyzers (Grason Stadler Models GSI 28 and GSI 38 and Interacoustics Model 235H). Tympanometry was performed with a 226-Hz probe tone with a positive to negative air pressure sweep. The pump speed was 600/200 daPa/s (i.e., pump speed was 600 daPa/s except near the tympanometric peak, where the sweep rate slowed to 200 daPa/s). All otoscopes and middle ear analyzers worked according to the manufacturer’s specifications.
Procedure
Children were screened within 45 days of the beginning of the academic year at each of their respective school sites. ASHA-certified and North Carolina-licensed audiologists and/or supervised graduate students in speech-language pathology and audiology conducted the tympanometry and pure-tone screening. Otoscopy was performed by audiologists and/or supervised graduate students in audiology. Screening tests were administered bilaterally to all children. In addition, demographic data, as part of the Head Start protocol, were recorded.
The Guidelines for Audiologic Screening (ASHA, 1997) were used as a basis for all initial screening procedures and pass/refer protocols. Guidelines pertinent for this study included “Guidelines for Screening Infants and Children for Outer and Middle Ear Disorders, Birth Through 18 Years” and “Guidelines for Screening for Hearing Impairment-Preschool Children, 3 to 5 Years.” For pure-tone screening, children participated in conditioned play audiometry using 1000-, 2000-, and 4000-Hz tones presented at 20 dB HL. A child was considered to pass the audiometry if two of three reliable responses were obtained at 20 dB HL for all three frequencies in both ears. If this criterion was not met, the child was categorized as “an audiology refer” (or simply “refer”) for rescreening. Children who were referred for audiometric rescreening were categorized as to whether the refer was unilateral or bilateral and whether one or multiple frequencies were not passed. In terms of assessment for outer and middle ear disorders, children first underwent otoscopy and then tympanometry, unless contraindicated. On examination of the outer ear, external ear canal, and tympanic membrane, a child passed if she/he was negative for ear drainage, a previously undetected structural deficit, or ear canal abnormalities (i.e., obstruction, impacted cerumen, foreign object, blood or secretion, stenosis or atresia, otitis externa, perforated tympanic membrane, or other abnormality of the tympanic membrane). Any positive findings in either ear during otoscopy resulted in a medical referral. Children who were referred for positive otoscopy findings were categorized as unilateral or bilateral refers, and the reason for referral was recorded (i.e., ear drainage, structural deficit, ear canal abnormality). A positive result during tympanometry was considered if the peak compensated static acoustic admittance (Y^sub tm^) was less than 0.3 mmho and/or tympanometric width (TW) exceeded 200 daPa. Positive findings resulted in an audiology refer for rescreening. Children with positive tympanometry findings (i.e., decreased Y^sub tm^ or increased TW) accompanied with an equivalent ear canal volume (V^sub ec^) greater than 1.0 cm^sup 3^ in the absence of a tympanostomy tube in place were referred for medical evaluation.
Children who did not pass the initial screening were rescreened within 2 to 4 weeks, in compliance with the Head Start hearing screening guidelines (U.S. Department of Health and Human Services, 1997). This procedure was in contrast with the ASHA (1997) recommendation of rescreening those who fail at 6 to 8 weeks following the initial screening. The pass criterion was defined as passing each of the pure-tone, tympanometry, and otoscopy screenings. A refer could have resulted from not passing one, two, or all of the pure-tone, tympanometry, and otoscopy screenings. The same criterion for pass/refer described above was applied during rescreenings. Children who did not pass the audiologic rescreen were subsequently referred for a diagnostic audiologic assessment.
Results
Initial Screening
The frequency distribution of initial-screening results is presented in Table 3. As is evident in Table 3, approximately 54% of children passed the initial screening (i.e., passed all three of the screening components, which included pure-tone audiometry, tympanometry, and otoscopy). The majority of children who did not pass the initial screening were referred for audiologic rescreening (i.e., 38.4%). The small percentages that were referred for medical examination or for both audiologic rescreening and medical examination reflect the small numbers that were referred from otoscopy screening (i.e., approximately 7%).
Tables 4, 5, and 6 contain the frequency distributions of initial-screening results of pure-tone audiometry, otoscopy, and tympanometry, respectively. Approximately 71% passed the pure-tone audiometry screening. For those children who could be tested, “unilateral one-frequency refers” was the most common category of refers (i.e., 9.3%; see Table 4). Approximately 90% of children passed the otoscopy screening (see Table 5). The majority of those who failed presented with structural deficits (i.e., 4.3% and 3.3% for unilateral and bilateral deficits, respectively). Approximately 71% passed the tympanometry screening (see Table 6). For tympanometry, “multiple indices” (in most cases decreased Y^sub tm^ and increased TW) was the most common category of referrals observed (i.e., 14.8%). Of the three screening tools, more children could not be tested during audiometry than any other test protocol (cf. 10.0%, 1.2%, and 2.9%, for audiometry, otoscopy, and tympanometry, respectively).
Rescreening
After the initial screening, 675 children were referred for rescreening, medical evaluation, or both. Table 7 contains a breakdown of those referred and those receiving follow-up examinations. Clearly, the majority were referred for audiologic rescreening only (cf. roughly 83%, 2%, and 15% for audiologic rescreening, medical evaluation, or both, respectively). About 71% (n = 478) of the 675 referrals received the recommended further evaluation. More than 80% of those referred for audiologic rescreening only were evaluated. Of those referred for medical examination only, none were seen for follow-up. Only 8% recommended for both audiologic and medical examinations actually received them. Of the 100 referred for both audiologic rescreening and medical examination, 72 received audiologic rescreening alone. An additional 2 children received a medical examination only. Of the 470 receiving recommended audiologic rescreening, 290 passed; of the 8 receiving both audiologic rescreening and medical examination, none passed either. The 2 children who received a medical examination only passed that examination reflecting resolved ear drainage or ear canal abnormalities. Of the total cohort of 1,462, 787 (53.8%) passed initial screening and 323 (22.1%) passed the rescreening (i.e., 75.9% of the total). Recall that the pass criterion was a pass for all three of the screening components, including pure-tone audiometry, otoscopy, and tympanometry.
Table 8 contains the frequency distribution of the follow-up audiologic rescreening results of those evaluated (n = 550). These results include those children referred for audiologic rescreening only (n = 470), those who were referred for both audiologic rescreening and medical examination who were evaluated (n = 8), and those referred for both audiologic rescreening and medical examination who received only audiologic rescreening (n = 72). Approximately 59% passed the audiologic rescreening (n = 323). The remaining 41% consisted of approximately 21% (n = 116) referred for diagnostic testing, 8.5% (n = 47) referred for medical evaluation, and 11.6% (n = 64) referred for both audiologic rescreening and medical examination. Of the original 1,462, 80.0% (n = 1,170) passed the audiologic screening at the initial- or second-screening evaluation. This total represents those who passed the initial and follow-up screening (i.e., 787 and 323 from Tables 3 and 8, respectively) and those who were referred for medical examination only but passed the initial or follow-up audiologic screening (i.e., 13 and 47 from Tables 3 and 8, respectively).
Follow-Up Assessment
The frequency distribution of participants receiving referral recommendation and follow-up assessment after rescreening, as a function of academic year, is illustrated in Table 9. Overall, follow-up assessment compliance was poor. Slightly more than 10% of children were seen. Approximately one-third of the children referred for medical examinations were evaluated (i.e., 31.9%). Roughly 9%, referred for diagnostic audiology testing and both diagnostic audiology testing and medical examination, were seen. Of the 9 19 children seen for diagnostic testing, 4 presented with conductive losses, 1 with a sensorineural loss, and 1 could not be tested using standard behavioral test techniques. Of the 15 children seen for medical examinations, 11 presented with abnormal findings (e.g., either otitis media or impacted cerumen). Of the 6 children seen for both diagnostic audiology testing and medical examination, 4 presented with otitis media and 1 with impacted cerumen. With respect to hearing status, 3 presented with normal hearing sensitivity, 2 with conductive losses, and 1 with a unilateral sensorineural loss.
In summary, 1,170 children passed the audiologic screening and an additional 25 children received diagnostic audiologic assessment. Of those 1,195 children, 6 (i.e., 0.5%) were confirmed with hearing loss (i.e., 4 conductive and 2 sensorineural losses). The hearing status of 267 (i.e., 18.3%) children was undetermined.
Discussion
The most disconcerting finding of this study was that only 53.8% of all children passed the initial screening per the ASHA (1997) guidelines (“Guidelines for Screening Infants and Children for Outer and Middle Ear Disorders, Birth Through 18 Years” and “Guidelines for Screening for Hearing Impairment-Preschool Children, 3 to 5 Years”). Recall, however, that a pass consisted of passing all three components of the screening protocol (i.e., otoscopy, tympanometry, and pure-tone audiometry). For individual tests, pass rates were approximately 90%, 71%, and 71% for otoscopy, pure-tone audiometry, and tympanometry screening, respectively. The data from the present study also indicated a 58.7% pass rate for the children who participated in the rescreen, yielding an overall pass rate of 75.9%.
Differences in reported pass/refer rates among studies may be attributed to numerous methodological differences between this and previous studies. First, the low pass rate for the initial screening in this study may be attributed to adherence to the ASHA (1997) guidelines for screening of outer and middle ear disorders and hearing impairment, with 3- to 5-year-old children. That is, the pass criterion was defined by both “Guidelines for Screening Infants and Children for Outer and Middle Ear Disorders, Birth Through 18 Years” and “Guidelines for Screening for Hearing Impairment-Preschool Children, 3 to 5 Years” (ASHA, 1997). The pass criterion was defined as passing each of the pure-tone, tympanometry, and otoscopy screenings. In contrast, Taylor and Brooks (2000), using the same ASHA (1997) tympanometry and pure-tone criteria, reported pass rates for pure-tone and tympanometry alone of 89% and 91%, respectively. Further, their data reflected ear-specific findings and not individual children. Tables 4, 5, and 6 show ear-specific pass rates for our cohort of children of 93%, 77%, and 75% for otoscopy, pure-tone audiometry, and tympanometry screening, respectively. The pass rates for otoscopy and pure-tone audiometry are higher than the overall pass rate of 75.9%.
Second, differences in pass rates between studies reflect differences in procedural considerations in both testing protocol and pass/refer criteria. For example, our pass/refer criterion for Y^sub tm^ was
Additional differences among pass/refer rates may result from using the Head Start Program Performance Standards (U.S. Department of Health and Human Services, 1997) for hearing screenings in conjunction with the ASHA (1997) guidelines. The Head Start Program Performance Standards advocate the use of an audiometric screening as the first part of a hearing screening program and immittance audiometry as the second part. Screening procedures for pure-tone audiometry are consistent with the ASHA guidelines for screening for hearing impairment. Pass/refer criteria are not specified in the Head Start Program Performance Standards. However, the standards state that the audiometric rescreen should be conducted within 2 weeks of the initial screening. Pass/refer criteria for immittance screening are not defined in the Head Start standards. For this project, audiometric and immittance pass/refer criteria for the initial screenings were based on the ASHA guidelines. Rescreens were conducted 2 to 4 weeks after the initial screening, which was a compromise between the Head Start standard of 2 weeks and the ASHA recommended guideline of 6 to 8 weeks for immittance referrals. The Head Start standards state that all screenings and rescreenings should be conducted within 45 calendar days of the beginning of the academic year. When large numbers of children are being screened, these time limitations may not allow for spontaneous resolution of otitis media before the rescreens are conducted. As such, the 41% failure rate at the follow-up audiologic rescreening may be elevated with respect to testing at 6 to 8 weeks rather than 2 to 4 weeks after initial screening.
Finally, discrepancies in demographic characteristics of children screened in reported studies may affect pass/refer rates. First, as mentioned above, the children screened in this study came from an impoverished, rural, traditionally medically underserved, geographic area. Families from which the children came had low socioeconomic status, which is a requirement for Head Start eligibility. It has been well documented that children from low socioeconomic status families are more likely to have middle ear disorders (Castagno & Lavinsky, 2002; Noh & Kim, 1985; Paradise et al., 1997). Second, the children in this study were generally younger than those examined in previous studies (i.e., approximately 80% were 4 years old, and the remaining were 3 years old). In general, pass rates increase with increasing age. The low pass rate may reflect in part the fact that the cohort here was relatively younger than those in other studies. Mundy (2001), for example, reported an initial-pass rate increasing from 81% for children enrolled in preschool to 98% for second graders. Higher pass-rate results from Taylor and Brooks (2000) cited above included children from 2 to 8 years of age, with a mean age of approximately 5 ½ years.
The goal of any screening program is to efficiently identify those children who have a medical condition or hearing loss that would interfere with the development of speech and language skills or school readiness. With that in mind, two points are worth noting. First, there was a low incidence of hearing loss relative to the reported incidence values for hearing impairment among children (for a review, see Mencher, 2000). Of 1,170 children who passed the audiologic screening and the 25 who received diagnostic audiologic assessment, only 6 children (i.e., 0.5%) were confirmed to have hearing loss. Admittedly, 35% of the total student body was not tested. Further, the hearing status of approximately 18% of those children initially screened was never determined. In all likelihood, more children with hearing impairment would have been discovered if they had all been evaluated. Second, regardless of discrepancies among reports, what remains is a high referral rate among 3- to 5-year-olds as a result of implementing the Guidelines for Audiologic Screening (ASHA, 1997). That is, nearly half of all children in this population will not pass an initial screening. This was a consistent finding over a 4-year period. It remains to be determined whether transient middle ear effusion or an inappropriate screening protocol resulted in a high initial-refer rate. If the latter is the reason, changes in screening procedures need to be found that would improve the sensitivity and specificity of the guidelines. Presently, it appears that the goal of efficiently identifying children who have a medical condition or hearing loss is not met due to a high over-referral rate and a low identification of hearing impairment.
There are more current data that suggest the recommended initial tympanometric screening test pass/refer criteria should be reevaluated. Currently, the pass/refer criteria are the same for children age 1 year to school age. The values for Y^sub tm^ (i.e., 200 daPa) come from work by Nozza, Bluestone, Kardatzke, and Bachman (1992, 1994), who investigated children 1 to 12 years of age who were undergoing myringotomy and tympanostomy tube surgery. Normative data generated recently by De Chicchis, Todd, and Nozza (2000) suggest more strict age-specific values. They examined ear canal volume, peak compensated acoustic admittance, tympanometric width, and tympanometric peak pressure in children age 6 months to 4 years 11 months. De Chicchis et al. reported significant age-related differences between the youngest and oldest children for all three tympanometric indices. The mean Y^sub tm^ values for their 3- and 4-year-old participants were 0.34 (SD = 0.14) and 0.52 (SD = 0.32) mmho, respectively. These values suggest that the ASHA recommended value of
As with any mass-screening program, there are challenges that affect the success of the program. These challenges may be related to the physical characteristics of the facility (space availability, lighting, electrical outlets, room acoustics), the agency requesting the services (staff cooperation and federal, state, or local regulations), attributes of the child (absenteeism, health status, behavior), audiological factors (equipment malfunction), and administrative constraints (personnel availability, budgetary factors). Certainly, the competence of the personnel performing the screening procedures is a critical issue. Students must be well trained and closely supervised while conducting audiological screenings with children in this 35-year age range. The funding of such screening programs is also a major issue. In this project, the university provided all equipment, supplies, and materials for the screenings because the project provided an excellent opportunity for graduate students to accrue clinical practice. Even though the majority of children were on Medicaid assistance, third-party reimbursement is not granted for screening procedures. From an administrative standpoint, it is important to have screening criteria that do not result in large numbers of rescreens due to the costs involved in conducting large-scale screening projects.
Perhaps the greatest challenge of all, however, is the tracking of children. It is understood that some children will drop out of any screening program. Prieve et al. (2000) reported a 72% follow-up rate for infants identified in the New York State Universal Hearing Screening Demonstration Project. Based on those data, the JCIH (2000) cited the following factors that contributed to noncompliance for follow-up care: lack of adequate tracking procedures, changes in the names of mother and/or child, absence of a medical home (e.g., primary care physicians and other health care professionals working in partnership with parents), and lack of health insurance that covers follow-up. Folsom et al. (2000) reported that 64% of their high-risk infants were successfully recruited into follow-up testing 8-12 months after initial identification in the neonatal intensive care units or well-baby nurseries. Among the maternal factors cited by Folsoin el at. for noncompliance for follow-up were nonwhite race, no insurance, substance abuse, young maternal age, and more than two children in the home.
For this project, the Head Start staff members were responsible for conveying notices of the screening events, obtaining parental consents, and providing screening results and referral information to parents for follow-up care. Of the 662 children recommended for audiologic rescreening (see Table 7), nearly 100 (17%) were “lost.” That is, children moved, dropped out of the program, or were absent on the rescreen day. Additionally, only 11.6% of those children who were subsequently referred for audiologic diagnostic testing, medical examinations, or both had results reported back to the Head Start health care coordinator. As seen in Table 9, the percentage of children who were followed for these procedures increased over the 4-year period from 0% during 1998-1999 to 36.2% in 2001-2002. Prieve et al. (2000) saw this same type of effect with regard to the percentage of infants that returned to the hospitals for retesling, after failing an initial hearing screening at birth. That is, the longer the program was in operation, the higher the percentage of infants who returned for follow-up testing. Prieve et al. noted that most of the increases occurred in the 2nd or 3rd year of the program and concluded that these improved percentages may have been due to better tracking of infants by program personnel and greater acceptance of the program by medical personnel and the community.
One disturbing finding, during this multidisciplinary health screening effort (i.e., speech-language, vision, dental, fine and gross motor, blood pressure, height/weight, hemoglobin, and other procedures), was the discrepancy regarding compliance with follow-up referral recommendations. For example, the percentage of children who received diagnostic vision examinations and treatment (i.e., corrected vision) was 97% during the 2001-2002 academic year, nearly three times the percentage for follow-up for hearing problems. Why are parents more likely to comply with follow-up care following vision versus hearing screening? It can be assumed that the transient nature of otitis media and the subclinical sequelae (abnormal admittance measures in the presence of normal hearing as evidenced by a pass for pure tones) contribute to the view that hearing problems are not as important as visual problems. It is true that otitis media may resolve without attention or treatment. Parents may have experienced earlier episodes of watchful waiting, in which visits to a physician did not result in actual treatment. Some parents may also fear the possibility of their child needing or wearing amplification and the long-standing stigma of hearing aid use. Or, it may be that parents do not view hearing impairment as a detriment that would interfere with the development of speech and language skills or school readiness. If the latter two points carry some truth, hearing health care professionals need to do a better job in public education concerning the importance of identification and habilitation of hearing loss.
In summary, the data from this study indicate that when the age-appropriate ASHA (1997) guidelines (“Guidelines for Screening Infants and Children for Outer and Middle Ear Disorders, Birth Through 18 Years” and “Guidelines for Screening for Hearing Impairment-Preschool Children, 3 to 5 Years”) are followed, nearly half of all 3- and 4-year-old children in an impoverished, rural, traditionally medically underserved, geographic area will not pass an initial screening. This was a consistent finding over the 4-year period. Methodological factors that may have contributed to this high refer rate include the use of all screening techniques (pure tones, tympanometry, and otoscopy), procedural considerations in testing protocol and pass/refer criteria, and the demographic characteristics of the children screened.
Acknowledgments
A portion of this paper was presented at the North Carolina Speech, Hearing and Language Association 47th Annual Convention, Wilmington, NC, April 22, 2001. Funding from the Kate B. Reynolds Charitable Trust of Winston-Salem, NC, supported audiological equipment used in this project. This project could not have been completed without the assistance of numerous graduate students in the Department of Communication Sciences and Disorders, East Carolina University, and the administrators, teachers, and health care assistants employed by the Martin County Community Action, Inc., Head Start in Williamston, NC. Special thanks are extended to Verna Spivey-Carter, Glenda Page, Tim Saltuklaroglu, and Karen Nix.
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Rose L. Allen
Andrew Stuart
East Carolina University, Greenville, NC
Deborah Everett
Martin County Community Action, Inc.-Head Start, Williamston, NC
Saravanan Elangovan
East Carolina University
Received April 15, 2003
Accepted November 20, 2003
DOI: 10.1044/1059-0889(2004/006)
Contact author: Rose L. Allen, PhD, East Carolina University, School of Allied Health Sciences, CSDI-Belk Annex 1, Greenville, NC 27858. E-mail: allenro@mail.ecu.edu
Copyright American Speech-Language-Hearing Association Jun 2004
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