Audiology in the Classroom
Is There Still a Role for School Hearing Screening Programs In 2025?
In the early 1970s, I recall sitting in the nurse’s office, wearing a pair of headphones, and tapping a ruler on the desk every time I heard a beep. After that, there was a vision chart to read. I passed the hearing screening but failed the vision screening, a surprise to everyone since, as the smallest student in the class, I was always seated in the front row and didn’t appear to have any difficulty. Years later, I heard a similar story from a student with hearing loss who told me that their vision impairment was not identified until long after it emerged, for the same reason – that as a student with hearing aids but no FM system, they were always seated at the front of the class. Without school screening, I suspect that my vision impairment would have remained undetected for quite some time.
Hearing and vision screening was standard in Canadian schools for many years, usually coordinated by the school nurse. Over the years, with the gradual disappearance of school nurses and budget cuts, they have almost disappeared from the education landscape. In Ontario, aside from a few pay-for-service companies operating in schools (as outside agencies) and a few school board-initiated screening projects, there is very little hearing and vision screening occurring. With universal newborn hearing screening in place, there may be a perception that school hearing screening is no longer necessary, as any school-age child with hearing loss has already been identified. Screening every student for hearing at school (as has been standard practice in the past) is an expensive endeavor that primarily identifies temporary issues, such as cerumen, negative middle ear pressure, and/or fluid. Where school hearing screening programs did exist, they were often confined to the time of school entry (i.e., in kindergarten). Strangely, in my experience, school hearing screening programs rarely included the additional step of rescreening students who received a refer-result the first time but whose middle ear issues subsequently resolved, something that would address the often high referral rates from school screening programs. Permanent hearing loss has a low incidence in the school population, and prevalence data for childhood hearing loss suggest that, in fact, we would only find 1-3 students with permanent hearing loss for every 1000 students screened. Not surprisingly, many school administrators came to view school hearing screening as having limited returns. And in 2025, if we’re already screening every infant for hearing loss, is there still a role for hearing screening at school in 2025?
In fact, in recent months, I have had several conversations with school board administrators who have expressed concerns about access to hearing testing for students for whom school staff have identified potential learning difficulties. I would argue that there is an important role for targeted school screening for two populations of students in particular - students born in Canada who are experiencing difficulty at school, and students born outside of Canada in countries where newborn hearing screening programs do not exist. If a student of any age is demonstrating difficulty at school, the appropriate first step is to ensure that hearing or vision loss is not responsible. Hearing or vision difficulties may not be necessarily suspected by school staff. Still, they must be ruled out before other assessments are recommended such as a referral to a school psychologist. For students whose hearing was screened at birth, the likelihood of permanent hearing loss developing later is certainly low, but it is not zero. There are a number of causes of hearing loss that can be associated with typical hearing levels at birth but acquired hearing loss later in childhood. It would be disastrous for a student with permanent hearing loss to be misidentified as having a learning disability or ADHD, and for the hearing loss to be unaddressed.
The need for school hearing screening for students from other countries whose hearing was not screened at birth is more pressing. These students may be at high risk for hearing loss due to healthcare gaps or other risk factors in their home country. When students who do not speak English or French arrive at school, they need time to settle in and adjust, as well as time to begin learning the language. School boards provide comprehensive supports for newcomers to Canada, but acquiring a new language takes time. Months and even years can pass in situations where a student is clearly seen to be struggling to learn English compared to their peers (even when enrolled in an English Language Learning program of some kind), but no one has considered that an unidentified hearing loss may be the cause.
In most school boards, when hearing or vision loss needs to be ruled out, parents are required to find, and pay for, a full vision and hearing test, something that is difficult for many families (particularly for new families to Canada). There may not be an audiology clinic in their community, families may not be able to afford the cost, and families new to Canada may struggle with navigating the Canadian health care system. Parents may resist a request to pay for a hearing test as a standard first step in investigating academic difficulties, when hearing loss is really not suspected. A targeted school screening program overseen by an educational audiologist would provide a way to ensure that a hearing and vision screening is easily done at the student’s school, with results quickly conveyed to the school team. If a potential hearing or vision problem is identified by the screening, school staff can support families to access a full assessment, and to navigate intervention services such as obtaining hearing aids with the help of the educational audiologist and teachers of the deaf and hard of hearing.
I would like to argue that we do not need to choose between having no hearing screening programs at school, and screening every student at an arbitrarily identified point in their academic career, such as at kindergarten. A school hearing screening program overseen by an educational audiologist, which provides both education for teachers on what to watch out for and an easy way for teachers to refer students who are struggling, to a timely and easily accessible screening to rule out hearing loss, would be a valuable use of resources. Cost-effective and accurate technologies for hearing screening that do not require someone to carry portable audiometers up multiple flights of stairs are readily available. There may be ways to think creatively about partnerships with university or college programs, or with community audiologists, to help school boards without an educational audiologist create targeted hearing screening programs. Targeted school screening programs are an important addition to our current universal newborn hearing screening programs in our quest to ensure that every child with a hearing loss receives the services they need.