1. ARIZONA T3 HOW TO TRAIN HEARING SCREENERS RENEWAL CURRICULUM: PRESCREENING
T3 Prescreening

2. Prescreening Learning Objectives
Recognize normal auditory development.
Understand the importance of early identification of hearing loss.
Know when and how hearing screening is conducted.
Practice selecting an appropriate screening method.
Be able to set up a hearing screening program.
These are the objectives contained in your first training on Prescreening. Review this list and decide which of the objectives you feel most in need of review for your own personal renewal. Write this one item on a post-it note to remind you during that section of this training to ask questions on anything you want further clarified or discussed. Give participants a couple of minutes to reflect.
T3 Prescreening

3. Screening Programs
Goal: to quickly and efficiently distinguish those children who need further evaluation from those children that probably are not having hearing difficulties significant enough to interfere with learning.
Read this slide.
After a hearing screening you have a small group of children you suspect may be having problems and a large group you are pretty comfortable saying is okay. You don’t want to miss children who have a hearing loss, but also you hope to refer very few children who do not have a hearing loss or medical problem.
To identify the small group of children, screening programs consists of two stages: 1) a massive screening of all students, and 2) 30 to 45 days after the first screening all students who did not pass the initial screening, absentees, medical referrals, and children who did not pass the screening within previous years are re-screened.
Remember that screening identifies those children who may have a hearing loss, but it does not tell you what may be causing the loss or how severe the loss is.
The Arizona Department of Health Services - Office of Sensory Programs, Hearing Screening Program (ADHS – OSP) does NOT screen infants; however, an understanding of early screening is helpful to a hearing screener. Most hospitals in Arizona conduct routine hearing screening for newborns to identify a hearing loss as early as possible, because children who have begun intervention by six months of age are likely to have language skills similar to their hearing peers. Early intervention can lead to typical language development. The Arizona Early Intervention Program (AzEIP) is a resource for screening very young children.
T3 Prescreening

4. Early Screening in Infants
Otoacoustic Emissions (OAE)
Auditory Brainstem Response (ABR) or Brainstorm Auditory Evoked Response (BAER)
Review slide.
Both of these early screening tests do not require active responses from the babies.
In Otoacoustic Emission (OAE), a small rubber-tipped probe with a microphone is placed in the baby’s ear. A computer makes a sound that enters the ear through the probe. A normal, healthy ear sends back an echo, called an “emission,” that is measured by the probe. If the cochlea is not functioning normally, or the middle ear has fluid in it, the echoes cannot be measured; therefore, the OAE is considered absent. In BAER (also called ABR, BSER), small electrodes are placed on the baby’s skin in three or four places on the head. Headphones are put on the ears. The computer makes a clicking sound the baby hears through the headphones. The electrodes pick up an electrical signal that is generated in response to the clicking sounds. Hearing loss, fluid in the middle ear or neurological problems may all cause the baby not to pass this test.
If babies don’t pass, they are usually re-screened and then referred for further evaluation. An audiologist will do further testing to determine if a hearing loss exists, how much hearing loss is present, and if it is a conductive or a sensorineural hearing loss. The audiologist will also decide if the baby would be helped by hearing aids or other devices. Of every 1,000 babies who are screened, 3-6 will have significant hearing loss in both ears. Of babies cared for in the neonatal intensive care unit (NICU), that number increases to approximately 30 of every 1,000 babies or ten times the incidence in a well-baby population.
T3 Prescreening

5. Risk Factors for Hearing Loss Birth to 28 days (Neonates)
A family member with a permanent hearing loss since childhood
Serious infection present during pregnancy or at birth of infant
Birth weight less than 3 ½ pounds (1500 grams)
Difficult birth or delivery affecting baby’s breathing
Unusual appearance of head, face or ears
Severe jaundice requiring a blood transfusion
Infection of the brain
Prolonged mechanical ventilation
Characteristics related to certain syndromes
Receiving drugs toxic to the ears
Risk Factors for Hearing Loss are conditions associated with hearing loss in Neonates, Infants and Young Children.
Review slide.
T3 Prescreening

6. Risk Factors for Hearing Loss 29 days to 2 years
Factor(s) from the previous slide
Factors associated with progressive hearing loss (infection, mechanical ventilation, heredity)
Parent or caregiver is concerned about hearing, speech, language or developmental delays
History of head trauma
History of an infectious disease associated with sensorineural hearing loss (measles, mumps)
Many babies with a hearing loss will have no prior risk factors that can be identified. Ninety percent will be born to hearing parents who have no expectation that their child will have a hearing impairment.
Review slide.
T3 Prescreening

7. Arizona Hearing Screening Rules
Hearing Screening Population
Screening Requirements
Criteria for Passing a Hearing Screening
Requirements for Performing a Second Hearing Screening
Referral, Notification and Follow-Up
Screener & Trainer Qualifications
Equipment Standards
Record Keeping Reporting Requirements
Once the child is no longer an infant and enters preschool, their screening may* come under The Arizona Department of Health Services - Office of Sensory Programs.
ADHS - OSP handles the hearing screening of school children. This means that all public, private and charter school students are required by law to be screened. Therefore, all of these schools must have trained screeners to conduct their programs. To accomplish this goal, ADHS – OSP utilizes the Arizona T3 Training Collaborative.
Refer to Arizona Hearing Screening Rules handout.
During T3 training you learn information relating to the rules. Review slide.
*Only if the child attends a preschool that receives federal funding.
T3 Prescreening

8. Required each year for students:
Enrolled in preschool, kindergarten, or in grade 1, 2, 6, or 9
Enrolled in grade 3, 4, or 5, unless there is written documentation that student had a hearing screening in or after grade 2
Enrolled in grade 7 or 8, unless written documentation shows student had hearing screening in or after grade 6
Enrolled in grade 10, 11, or 12 unless there is written documentation that student had a hearing screening in or after grade 9
Receiving special education
Who failed second hearing screening in prior school year
Who needs to be screened for the purposes of this program?
This slide is Section A. R Hearing Screening Population of the Arizona Hearing Screening Rules. Read the slide and/or allow participants to find the guideline in their copy of the Arizona Hearing Screening Rules.
Section B. of R states that a school administration shall ensure that a student has a hearing screening at the request of the student, the student’s parent, a schoolteacher, a school nurse, a school psychologist, an audiologist, a physician, a primary care practitioner, a speech language pathologist, or Department staff.
Section C. R is on the next slide.
T3 Prescreening

9. Screening NOT Required If:
Child is 16 years or over
Child’s parent objects in writing to the screening as allowed in state rules
Written diagnosis or evaluation from an audiologist states that a child is deaf or hard of hearing
Child has a hearing aid, an assistive listening device, or a cochlear implant
Arizona state rules do not require screening in these circumstances. Review slide.
T3 Prescreening

10. Four Reasons NOT to Screen
Fluid or drainage from the ear
Blood
Open sore
Foreign object in the ear canal
There are times when you will not be able to screen a child.
T3 Prescreening

11. ADHS Approved Screening Methods
Pure Tone
Tympanometry
Otoacoustic Emission (OAE)
Read the slide.
These tools are objective.
Let’s look at each of these appropriate screening methods and when to use each one.
T3 Prescreening

12. Pure Tone Screening Can the child: Attend to sound? Follow directions?
Give a behavioral response?
Pure Tone Screening is a method of conventional audiometry. Easily accomplished, Pure Tone is simple sound waves with a single frequency and intensity. A pure tone audiometer generates pure tones. For screening to be successful a child must be able to attend to sound, follow directions, and give a behavioral response.
IMPORTANT: Remember that while screening identifies those children who may have a hearing loss, it does not tell you what may be causing the loss or how severe the loss is.
T3 Prescreening

13. Pure Tone with Conditioned Play Audiometry (CPA)
Requires child be able to wear headphones and learn a play activity in response to sounds
Is useful with 3-5 year olds
Is useful with children developmentally able to tolerate headphones and learn a repetitive task, but unable to follow complicated directions or stick with a task
Is useful with older children who are developmentally delayed
Conditioned Play Audiometry (CPA) requires that a child be able to wear headphones and learn a play activity or play a game in response to sounds.
Review slide.
Usually children in the 3-5 year old age-group do well when CPA is utilized with Pure Tone Screening. It is also good to use with older children who are developmentally delayed. Activities and suggestions will be added to this topic during the Pure Tone Screening unit.
T3 Prescreening

14. Tympanometry Looks for fluid in middle ear Does not measure hearing
Is useful with young population that has high incidence of middle ear fluid
Tympanometry is a test that looks for fluid in the middle ear. It bounces sound off of the eardrum and measures the presence of fluid which might be related to an ear infection and a possible conductive hearing loss. It does not measure hearing, but is used along with a screening of hearing ability such as pure tone. Children who are deaf or have minimal hearing usually have normal results for tympanometry.
This tool is very useful with a young population that has a high incidence of middle ear fluid. Ear infections or otitis media are very common in young children, especially those in group child care settings. Although often temporary, fluid in the middle ear usually causes a hearing loss while fluid is present. Children often outgrow a tendency to have ear infections by the time they are seven years old.
Tympanometry alone will only pick up middle ear problems—not hearing loss.
T3 Prescreening

15. Otoacoustic Emission (OAE)
Is mostly used with very young or difficult to screen children
For school age children, must complete pure tone screening first
Looks for middle ear problems and hearing loss caused by damage to cochlea or sensorineural hearing loss
Is quick
Otoacoustic Emission (OAE) screens for middle ear problems and hearing loss caused by damage to the cochlea, or sensorineural hearing loss. However, it is not possible to tell by the results what is causing the hearing loss. This screening tool is very quick and requires almost no cooperation from the child, making it an excellent tool to use with very young or difficult to screen children.
T3 Prescreening

16. Selecting the appropriate screening method depends on:
Age of the child
Abilities of the child (developmental age)
Availability of trained personnel
Availability of equipment and other resources
Ability of the child to follow instructions
Selecting which method to use for an individual child depends on several factors.
Read the slide.
Developmental age is the estimated age of a child according to his/her levels of development.
T3 Prescreening

17. Selecting a Hearing Screening Site
Is it quiet?
Are there enough outlets?
Are noisy conditions limited?
Is area adaptable to traffic flow?
Adjust your environment; never adjust your equipment!
Now that we know who we are required to screen, who we are not required to screen, and have a basic idea of the various methods used to screen, what are the logistics involved in getting ready to screen? First, let’s consider WHERE we are going to do it.
Select the site:
in a quiet room
noisy conditions within the room limited
plenty of electrical outlets
daily schedule modified
ADJUST YOUR ENVIRONMENT; NEVER ADJUST YOUR EQUIPMENT!
T3 Prescreening

18. Preparing the Hearing Screening Site
Decide on the number of stations
Obtain a table, 2 chairs & screening equipment for each station
Design traffic flow
Designate areas for screening and waiting
Obtain extension cords, 3 prong adapters, power strips & duct tape
Set out necessary paperwork and pens
Set out headphone cleaning supplies
Have “Quick Kit” on hand
Next, we need to prepare the site we’ve selected:
Designate area for children waiting, with an adult monitor
Coordinate with facility staff to establish a tentative schedule for each group
Develop communications system, older students or volunteers as “gofers” or runners to deliver “ready!” message to the next class
Have a table and two chairs (at least one chair adult-size) and screening equipment at each station
Have extension cords, 3-prong adapters and power strips (duct tape to secure cords against tripping)
Have all necessary forms and extra pens at each station (classroom rosters, lists of children with known hearing loss, recording forms, etc.)
Have supplies to clean headphones (alcohol wipes, or isopropyl alcohol and cotton balls)
Assemble “Quick kit” to help manage unexpected situations
Refer to handout: Screening Supply Checklist to use during the rest of this unit.
T3 Prescreening

19. Quick Kit Several pairs of latex gloves Paper towels
Self-closing plastic bags (e.g., Zip-loc ®)
Moistened towelettes, or waterless handwashing gel
Small bottle of freshly-made bleach and water solution mixed in a ratio of 1 part bleach to 10 parts of water - Keep this solution out of the reach of children!
A “quick kit” is needed because children may have bowel or bladder accidents, may bleed (from injuries, bloody noses, tooth loss). They may also vomit or have drainage from the eyes, nose, ears, or wounds. Although you will try to avoid coming into contact with these body fluids, Quick Kit supplies will help you handle these kinds of events.
Read the list of Quick Kit items on slide. (Know that not all schools allow bleach.)
Moistened towelettes and waterless handwashing products are not good substitutes for handwashing! However, in the absence of running water and soap they provide a quick clean up.
Remember: precautions should be taken to minimize the spread of infectious diseases. Distribute handout: Infection Control Measures. Keep a copy of this handout in your Quick Kit to remind you about steps which must be taken when body fluid spills occur.
T3 Prescreening

20. Legal Considerations Liability Confidentiality
Obtaining Parental Consent
Liability
Unexpected events can occur during the course of a screening session. Screeners, volunteers or even children can be injured. Accusations of misconduct or incompetence can be made. It is in everyone’s best interest to explore liability issues with their agency, program, service organization, or sponsor. Explore this with your school.
Confidentiality
Screeners and volunteers must respect the confidentiality of the children who are screened. This means not discussing with anyone the names or other information about the children or their screening results. If you are a health care provider, communicating the results of a child’s hearing screening for referral or reporting purposes may be regulated by medical privacy standards. See the information at
Obtaining Parental Consent
This is one of the first prerequisites to getting the program off to a start, so ALWAYS find out what the facility policy is regarding sending notices or permission forms to parents/guardians to notify them about upcoming hearing screening. Find out the facility policies; don’t assume you know!
Most systems require a parent/guardian to notify in writing if they do not want their child to be screened. A method needs to be devised to keep track of those not to be screened because of parental request, so that exclusion of the child/ren is handled properly on the day of screening.
T3 Prescreening

21. Volunteers Role Recruiting Training T3 Prescreening Role of Volunteers
Other people such as volunteers who have not been approved by the ADHS Office of Sensory Programs may perform or assist with the initial pure tone screening. Volunteers may help coordinate getting students to and from the screening, complete paperwork or do other tasks. They may not perform tympanometry, OAEs, or the second pure tone screen.
Recruiting Volunteers
Parents may enjoy participating in the hearing screening process. It may be helpful to contact service organizations, local universities, as well as parents to recruit volunteers. Senior citizens’ groups often enjoy an opportunity to work with children. Check facility policies regarding use of volunteers. Specific requirements for volunteers may include a verifiable history of immunizations, background or fingerprint checks, special orientation.
Training Volunteers
Have a location and date chosen for the training of volunteers. Make sure you have trained volunteers before the actual screening time; do not train on the day of screening. Allow one and one-half hours to complete the training. Arrange for the exact kind of screening equipment and any forms volunteers will be using on screening day to be available for volunteer training; nothing replaces hands-on experience. Allow adequate time for practice. This should be a friendly and fun time; provide coffee or cold drinks and simple snacks (a bowl of pretzels) to make volunteers feel appreciated. Call volunteers the day before the screening to confirm they will be there!
T3 Prescreening

22. Equipment
Must meet requirements specified in Arizona rules
Maintenance and calibration are required
Every audiometer must receive a comprehensive calibration once a year by a certified technician!
Equipment for screening must meet requirements specified in Arizona rules:
1) For pure tone screening, a portable audiometer allowing at least pure tone air conduction testing is needed. Screening frequencies of 500, 1000, 2000, and 4000 Hz are needed as a minimum.
2) For tympanometry, a tympanometer which produces a print-out of tracings is preferable.
Names and telephone numbers of companies who sell audiometry of equipment may be obtained through a local audiologist or through ADHS - Office of Sensory Programs. Equipment may also be borrowed from state or county health departments or local school districts. The Sensory Program also has equipment available to loan to schools or group child care settings. Tympanometers and audiometers can be borrowed for up to one week.
Refer to handout: Hearing Equipment Loan Procedures.
Every audiometer must receive a comprehensive calibration once a year by a certified technician. Do not use an audiometer that has not been calibrated within the last year. The standard (ANSI or ISO) by which the audiometer is calibrated should appear in a statement somewhere on the audiometer as well as the year of the calibration. Note: Audiometers are calibrated with the headphones. This means that headphones can not be exchanged between machines without calibration.
T3 Prescreening

23. Think, Pair & Share Activity
Be familiar with state rules
Know your equipment is calibrated
Be sure you use the right screening method for each child
Screen in a quiet area
Have everyone trained before the screening day
Gather all necessary supplies before setting up!
To summarize, hearing screeners must be prepared.
Review the slide.
Written Assignment Actvity: Analyze Your Program.
Discuss issues surrounding their screening program; for example, the screening room, the population, the equipment, the set up, working with teachers, etc.. Discuss their own strengths and weaknesses, and brainstorm possible solutions. If you are involved in a new program, you may discuss the potential issues.
T3 Prescreening