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In 1993, the Ad Hoc Committee on Screening for Hearing Impairment, Handicap, and Middle Ear Disorders recommended the establishment of a mechanism within ASHA to “monitor screening guidelines and protocols for hearing impairment, disability, and middle ear disorders” (ASHA, 1995). Appropriateness of the Test - Ideally a screening test should be easy to administer, comfortable for the patient, short in duration, and inexpensive. The appropriate selection of a screening test depends, in part, on the test's performance in separating those with the target condition from those without the target condition.
To understand the screening process, it is necessary to understand how the performance of a screening test is estimated and how relevant variables interact. Sensitivity and specificity of a test relate to the ability of the test to identify correctly both those with the disease (sensitivity) and those without the disease (specificity). The test performance (sensitivity and specificity) together with the percentage of the population with the disease (disease prevalence) determine predictive values and the rates of over- and under-referral for diagnosis.
Consistent with terminology previously defined in the Report on Audiologic Screening (ASHA, 1995), the Panel developed separate guidelines for screening of hearing disorder, impairment, and disability. The Panel also considered the term handicap as defined by the ASHA Committee on Screening for Hearing Impairment, Handicap, and Middle Ear Disorders (ASHA, 1995). The Panel concluded that due to federal initiatives (Americans With Disabilities Act, Individuals With Disabilities Education Act) and consumer preferences (ASHA, 1994), the term handicap had undergone a process of definitional evolution. Screening for hearing disability in children should be included in a general developmental screening of any child. Screening infants and children for hearing disorder and hearing impairment requires considerable professional expertise and technological sophistication.
The Rhode Island Hearing Assessment Project: Implications for universal newborn hearing screening. Outer and middle ear conditions that may result in hearing loss or that may have significant health or developmental consequences. Children diagnosed with sensorineural hearing loss (Pappas, 1985), learning disabilities, behavior disorders, or developmental delays and disorders. Conduct the first regularly scheduled screening program in the fall in conjunction with screening for hearing impairment (see age-appropriate guideline).
Note that infants and children under the care of a physician for middle ear disorder need not participate in a screening program. All hearing screening programs should include an educational component designed to provide parents with information, in lay language, on the process of ear disorder screening, the likelihood of their child having an ear disorder, and follow-up procedures. Be aware that the recommended test criteria may need to be adjusted based on important factors specific to each individual program (See Discussion). In the absence of data, an alternative method based on the limits of the normal range may be used to determine screening test criteria. This guideline recommends that a child with unilateral or bilateral tympanogram meeting referral criteria other than those that are consistent with a TM perforation should be rescreened 6 to 8 weeks after the initial test.
Pure-tone hearing screening to identify those at risk for outer or middle ear disease is not recommended. Audiologic screening serves a secondary prevention function; that is, if a hearing disorder, impairment, or disability is detected and treated early, potential hearing-related problems can be prevented or ameliorated.

The test must also meet certain performance criteria; that is, it must be sensitive and specific. Whatever screening test is selected, a single cutoff value (the test criterion) must be chosen. Also, the concepts of overlapping distributions and their relationship to sensitivity, specificity, prevalence, and predictive values need to be understood to evaluate test performance. Sensitivity is the ratio of the number with the disease who are positive on the screening test to the number of all those with the disease.
The over-referral rate is the proportion of those referred who do not have the disease (1-PPV), and the under-referral rate is the proportion of those not referred who do have the disease (1-NPV). Risk factors in hearing screening programs may include potential for infection, inaccurate screening results based on equipment malfunction or errors in calibration, and errors in patient referral and follow-up. The Panel concluded that it is inappropriate, therefore, to identify a person as having a hearing handicap.
Each set of guideline materials contains a general introductory section, an outline of recommended guidelines, and a discussion of important issues related to the assumptions and rationale underlying the Panel's recommendations. The prevalence rises in older infants and toddlers if mild conductive hearing losses associated with otitis media with effusion are included in the estimates. Because the performance of acoustic immittance testing in identifying middle ear effusion (MEE) in young infants remains controversial, and access to that age group is limited to primary care physicians, the Panel refrained from developing guidelines that address screening for disorder in younger infants. The Panel provides a discussion of issues related to the rationale and assumptions underlying the recommendations. Do not refer if tympanostomy tube is in place or a perforation of the TM is under management of a physician. Note that some instruments are restricted for certain test parameters, so the influence of different instrumentation settings on tympanometric measures must be considered. Unless a child has a tympanotomy tube in place or is known to have a TM perforation that is under management of a physician, an immediate referral for medical examination is indicated.
Factors related to the population, the test parameters, the disease as defined by the screening program administrators, and the availability of diagnostic referral resources also affect the choice of a referral criterion (Nozza, 1995). On second thought, maybe you can use the 19kHz frequency to tell if someone is lying about what she can and can't hear (we all know that person who would cheat on a hearing test). Test criteria recommendations herein reflect a desire to find a test value that maximizes the performance of the test in identifying those with the disease while maintaining an acceptable rate of correctly identifying those without the disease.
In other words, sensitivity represents the percentage labeled positive on the screening test of all those who truly have the target condition. Positive predictive value (PPV) is the ratio of the number of those scoring positive on the test who truly have the disease to the number of all those who scored positive on the test.
The most important period for language and speech development occurs during the first 3 years of life, but despite methods for identifying hearing impairment in newborns, the average age of identification in the United States continues to exceed 12 months (Harrison & Roush, 1996). Children with unilateral sensorineural hearing loss: Cognitive, academic, and social development. Age of suspicion, identification, and intervention for infants and young children with hearing loss: A national survey.

A comparison of unilaterally hearing-impaired children and normal-hearing children on a battery of standardized language tests. Congenital hearing disability—Epidemiology and identification: A comparison between two health authority districts. A review of the documents, however, revealed that some guidelines overlapped, others needed updating and revision, and as a whole, the guidelines did not address audiologic screening across the life span (ASHA, 1985, 1989, 1990, 1991b; Joint Committee on Infant Hearing, 1994). Specificity is the ratio of the number of those without the disease who are negative on the screening test to the number of all those without the disease. Negative predictive value (NPV) is the ratio of the number of those scoring negative who truly do not have the disease to the number of all those scoring negative on the test.
A high under-referral rate, which means that those with a disease are not identified, is also problematic and often results in delayed diagnosis and related consequences. Early identification of infants with significant hearing loss and the Minnesota Child Development Inventory.
The clinical process includes an optional case history, visual examination, and acoustic immittance testing. Some underserved populations, however, may not get medical attention promptly even for URI, so screening during seasons of high incidence and prevalence is indicated. As stated above, by monitoring screening program outcomes, program administrators can adjust test criteria to reach satisfactory pass and refer rates. In other words, specificity is the percentage labeled negative on the screening test of all those who truly are free of the target condition. Identification, assessment, and management of children with unilateral sensorineural hearing loss.
In addition, children with sensorineural hearing impairment, learning disabilities, and other conditions that might affect learning should continue to be screened for middle ear disorders throughout the school years. However, when using data from normal ears to select a screening criterion, information on the distribution of test scores for abnormal ears is lacking, so no estimate of sensitivity can be made. Whereas sensitivity and specificity of the test remain constant as long as the condition screened and the test criterion remain constant, predictive values vary with disease prevalence.
A screening program that relies on criteria determined using only normative data must monitor program performance carefully and use information on program outcomes to modify screening test criteria, if necessary.
Screening results are compared to diagnostic test findings for verification of the patient's true status. In that regard, an estimate of prevalence of the condition must be known in addition to the sensitivity and specificity of the chosen test.

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