International Journal of Pediatric Otorhinolaryngology 78 (2014) 16771685

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

A test protocol for assessing the hearing status of students

with special needs
Hsiao-Chuan Chen a, Nan-Mai Wang b, Wen-Chen Chiu c, Shu-Yu Liu b, Yi-Ping Chang c,
Pei-Yu Lin d, King Chung e,*
a

Graduate Institute of Audiology and Speech Therapy, National Kaohsiung Normal University, Kaohsiung, Taiwan, ROC
School of Speech Language Pathology and Audiology, Chung Shan Medical University, No. 110, Section 1, Jiangou North Road, Taichung City 40201, Taiwan, ROC
National Womens League Foundation for the Hearing Impaired, No. 45, Cheng Hsing St., Beitou District, Taipei City 112, Taiwan, ROC
d
Kaohsiung Municipal Cheng Gong Developmental Disabilities School, Kaohsiung, Taiwan, ROC
e
Department of Allied Health and Communicative Disorders, Northern Illinois University, 323 Wirtz Hall, DeKalb, IL 60532, United States
b
c

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 11 December 2013
Received in revised form 13 July 2014
Accepted 14 July 2014
Available online 21 July 2014

Objectives: Individuals with disabilities are often reported to have a high prevalence of undetected
hearing disorders/loss, but there is no standardized hearing test protocol for this population. The
purposes of this study were (1) to examine the hearing status of students with special needs in Taiwan,
and (2) to investigate the use of an on-site hearing test protocol that would adequately detect hearing
problems in this population and reduce unnecessary referrals for off-site follow-up services.
Methods: A total of 238 students enrolled in two schools for special education and one habilitation
center participated in the study. Most students had intellectual disabilities and some also had additional
syndromes or disorders. A hearing screening protocol including otoscopy, tympanometry, and distortion
product otoacoustic emissions was administered to examine students outer, middle, and inner ear
functions, respectively. Pure tone tests were then administered as an on-site follow-up for those who
failed or could not be tested using the screening protocol.
Results: Only 32.4% of students passed. When administered alone, the referral rate of otoscopy,
tympanometry, and otoacoustic emissions were 38.7%, 46.0%, and 48.5%, respectively. The integration of
these subtests revealed 52.1% of students needed follow-up services, 11.8% could not be tested, 2.5% had
documented hearing loss, and 1.3% needed to be monitored because of negative middle ear pressure. The
inclusion of pure tone audiometry increased the passing rate by 9.9% and provided information on
hearing sensitivity for an additional 8.6% of students.
Conclusion: Hearing assessments and regular hearing screening should be provided as an integral part of
health care services for individuals with special needs because of high occurrences of excessive cerumen,
middle ear dysfunction, and sensorineural hearing loss. The training of care-givers and teachers of
students with special needs is encouraged so that they can help identify hearing problems and reduce the
negative impact of hearing disorders and hearing loss. The screening protocol needs to include subtests
that examine the status of different parts of their auditory system. The addition of pure tone audiometry
as an on-site follow-up tool reduced the rate of off-site referrals and provided more information on
hearing sensitivity.
2014 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Special needs
Intellectual disability
Hearing screening
Test protocol
Taiwan

1. Introduction
The availability of hearing health status information on
individuals with special needs, such as persons with intellectual,

* Corresponding author. Tel.: +1 8157538033.

E-mail addresses: chenhc@nknucc.nknu.edu.tw (H.-C. Chen), frances@csmu.edu.tw
(N.-M. Wang), taipei@nwlhif.org.tw (W.-C. Chiu), audio@csmu.edu.tw (S.-Y. Liu),
taichung@nwlhif.org.tw (Y.-P. Chang), pyl.tn@msa.hinet.net (P.-Y. Lin),
kchung@niu.edu (K. Chung).
http://dx.doi.org/10.1016/j.ijporl.2014.07.018
0165-5876/ 2014 Elsevier Ireland Ltd. All rights reserved.

physical disabilities, or multiple disabilities, is limited. When

available, the data unequivocally indicate that they have higher
prevalence of hearing disorders (e.g., impacted cerumen, middle
ear effusion) and hearing loss (i.e., loss of hearing sensitivity)
compared to the general population [17]. In 1996 and 2004,
American Speech-Language-Hearing Association (ASHA) recommended several clinical practice guidelines to screen or assess the
hearing status of children at different ages [8,9]. As children with
disabilities represent a diverse population, ASHA cautions hearing
professionals to treat the recommended protocols as practice

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guidelines but not standards, and encourages the adaptation of

different protocols to suit the needs of different sub-populations.
This study examined the hearing health status of students with
special needs in Taiwan and compared the passing rates of several
commonly used audiological tests. The goals were to examine
hearing health care needs among these individuals and to
determine a practical on-site hearing testing protocol to be used
in the eld.
The World Health Organization estimated that more than one
billion people have some kind of disabilities worldwide [10].
People with disabilities generally experience more barriers to
receiving health services than the general public and they tend to
have worse health conditions [11,12]. Various organizations and
countries advocate for (1) increasing the awareness of the needs,
(2) adopting national plans to provide better services, (3)
improving the availability, accessibility, and the quality of data
regarding disabilities, (4) strengthening research on disabilities
around the world, and (5) closing the gap in health disparities
between the general public and people with disabilities [10,13
17].
Hearing is one of the most important senses for connecting
people with the world and for children to develop speech and
language. The loss of hearing can be the result of disorders in the
outer, middle, and/or inner ear. Cerumen occlusion/impaction of
the ear canal is one of the most common outer ear disorders among
individuals with disabilities [6,1824]. Impacted cerumen can
result in mild to moderate degrees of hearing loss [23,2527].
Individuals with intellectual disabilities also are more likely to
have reoccurring cerumen impaction [23]. Additionally, children
with a history of cerumen impaction are found to have higher
likelihood of developing otitis media with effusion and permanent
hearing loss [27].
Otitis media is the most common cause of middle ear disorder
[2830]. Studies in the United States reported 7183% of children
had at least one episode of otitis media by age four [2931]. In
Taiwan, 2031% of normally developing children are reported to
have at least one episode before they are 5 years old [32] and 50% of
children have at least one episode before age 10 [33]. Conductive
hearing loss caused by otitis media is often temporary/episodic.
The degree of hearing loss is generally in the mild to moderate
range [34].
Disorders in the inner ear and/or the auditory pathway usually
cause sensorineural hearing loss which is usually irreversible.
Individuals with intellectual disabilities and congenital syndrome
(e.g., Down syndrome, Usher syndrome, or CHARGE syndrome) are
reported to have higher prevalence of sensorineural hearing loss
and the degree of hearing loss typically increases with age [3,34
36].
In general, children with hearing loss are more likely to have
delays in speech and language development, central auditory
processing disorders, negative cognitive and educational consequences, problems in communication, and lower quality of life
[31,3448]. They are also more likely to experience fatigue,
helplessness, and have social, emotional, or behavior issues [42
49]. The negative effects of hearing loss generally increase with the
degree of hearing loss and the duration of hearing loss [43,49].
Additionally, hearing loss interacts negatively with coexisting
cognitive disorders [36,49], likely because children with intellectual disabilities have limited cognitive resources to compensate for
the loss of sensory information. Fortunately, the negative effects of
conductive hearing loss usually can be reversed if the affected
individuals are identied and timely follow-up services are
provided. The negative effects of sensorineural hearing loss can
also be partially alleviated by using various amplication options,
such as personal hearing devices, or sound eld amplication
systems.

While some high income countries mandate hearing assessment as an integral part of services provided for individuals with
disabilities (such as the Individuals with Disabilities Educational
Act in the United States), hearing health care services are often
limited or not available to individuals in other developed or
developing countries [5,10,31,5052]. Sometimes, when other
disabilities are so severe and draw so much attention, effort, and
time that hearing may be the last item on their health care
checklist [50]. Also, the lack of hearing care awareness or
knowledge among caregivers and the inability of the individuals
to verbalize or describe their hearing conditions (e.g., I cant hear
you) may render their hearing loss undetected [49]. If individuals
with disabilities do not respond, others may assume they did not
understand or they ignored the instructions instead of assuming
they could not hear. Consequently, their hearing loss often goes
undetected, unidentied, and untreated [5,38,39]. Yet, identifying
hearing loss and ensuring instructions are heard may be one of the
most effective ways to deliver educational and rehabilitation
activities and/or to correct potential emotionalbehavioral problems for some individuals [50].
There is a general lack of procedures, guidelines, and research
studies on which audiological tests should be used for testing
children with special needs, who have syndromes/disorder/
conditions that restrict or impose a lack of ability to perform an
activity [9]. The American Speech-Language-Hearing Association
recommends that protocols assessing childrens hearing status
should include a battery of tests to examine the outer, middle, and
inner ear [8,9]. This recommendation suggests that Guidelines for
Standardized Screening Procedures [12] for athletes of Special
Olympics are not appropriate for testing children with special
needs. Specically, the Special Olympics protocol calls for otoscopy
and evoked otoacoustic emissions in the rst round, tympanometry and pure tone screening in the second round, and pure tone
threshold testing in the third around [12]. Athletes can be
discharged from the hearing screening at the end of each round.
As children are much more prone to having middle ear disorders
than adults but tympanometry is not included in the rst round of
the protocol, children with robust otoacoustic emissions and
middle ear problems may be discharged after the rst round,
leaving their middle ear disorders undetected.
Widely accepted hearing screening protocols for newborns or
normally developing children also may not be appropriate for
testing children with special needs. Newborn hearing screening
programs typically do not conduct tympanometry to check the
middle ear status [7,53] and, again, middle ear disorders in schoolaged children can be missed. Additionally, hearing screenings for
normally developing children often require behavioral hearing
tests, which can be impossible or very time consuming for
children with special needs because they may not be able to
understand the testing procedures or be conditioned for
behavioral testing. A desirable protocol, therefore, need to include
the examination of middle ear status and to reduce the need for
behavioral tests.
Another concern for establishing test protocols for students
with special needs is the lost to follow-up rate. In the United
States, about half of babies who fail newborn hearing screenings,
do not complete follow-up appointments [5456]. Factors identied by a National Institute of Health study group include
transportation barriers, funding barriers, stafng barriers, lost
message and ineffectiveness communication, and language and
literacy barriers [55]. Parents and/or guardians of children with
special needs are often under higher levels of stress and experience
more struggle in time and nancial allocation [50]. Thus, hearing
test protocols for individuals with special needs should consider
the challenges of follow-up services and include additional on-site
testing, if feasible.

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1679

In Taiwan, most students enrolled in special education schools

or (re)habilitation centers have never received a hearing test or any
hearing health care [5,51]. There is a general lack of research
studies examining the prevalence of hearing loss among students
with special needs [5] and there was no well-established hearing
screening protocol for testing this population. The purposes of the
present study were (1) to investigate the hearing health status of
school-aged students with special needs in Taiwan, and (2) to
examine a desirable hearing test protocol that can reduce
unnecessary referrals without sacricing accuracy for students
with special needs. The long-term goals were to increase the public
and government awareness of the hearing health needs of students
with special needs, and to facilitate the provision of quality hearing
services in Taiwan and around the world.
2. Methods
2.1. Participant characteristics
A total of 238 students from two schools for special education
and a habilitation center for individuals with special needs
participated in the study. The two schools were located in northern
(Taipei) and southern (Kaohsiung) Taiwan and the habilitation
center in central Taiwan (Taichung). There were a total of 24
schools for special education in Taiwan with a total enrollment of
approximately 6700 students. The 238 participants represented
3.6% of the student population enrolled in special education
programs. Their age and gender distributions are shown in Fig. 1.
Teachers and nursing staff of the schools and the rehabilitation
center reported the types of disabilities each student had (Fig. 2).
All students with multiple disabilities had intellectual disabilities.
Students belonging to the other category were reported to have
speech-language delay, developmental delay, chromosome abnormally, or cerebral palsy. The study obtained Institutional Review
Board approval from Northern Illinois University and a written
consent was obtained from each students parents/guardians.
2.2. Testing procedures
2.2.1. Hearing screening
The hearing screening protocol include: (1) otoscopy to
examine the outer and middle ear status (Welch Allyn Macroview
Otoscopes); (2) tympanometry to assess middle ear functions
[(Fig._1)TD$IG](Maico EroScan Pro); and (3) distortion product otoacoustic

Fig. 1. Gender and age distributions of students with special needs.

Fig. 2. Students disabilities reported by classroom teachers.

emissions (DPOAEs) at 1500, 2000, 3000, 4000, 5000, and

6000 Hz to examine the health of outer hair cells in the inner
ear (Maico EroScan Pro). The EroScan Pro units were calibrated by
their manufacturers before conducting the tests.
The presentation levels of the two tones used to elicit DPOAEs
were 65 dB SPL for the lower tone and 55 dB for the higher tone.
The frequency ratio of the two tones was 1.2. The presence of
DPOAEs was dened by a signal-to-noise ratio of 6 dB. The
stimulus levels and the signal-to-noise ratio criterion have been
shown to be effective in separating individuals with hearing
thresholds better than 25 dB HL and worse than 35 dB HL [5760].
DPOAEs instead of transient otoacoustic emissions were used in
the screening protocol because (1) DPOAEs allow the testing of
frequencies greater than 4000 Hz [58,59], and (2) tonal language
listeners usually do not experience much difculty in understanding speech until their pure tone averages in the better ear is greater
than 40 dB HL due to low frequency tonal speech cues [61].
If the hearing screening revealed any one of the following
conditions in either or both ears, the student was sent for a pure
tone audiometry in the failed ear(s):
(1) abnormal otoscopic ndings (e.g., impacted or excessive
cerumen, tympanic membrane perforation),
(2) middle ear dysfunctions (i.e., non-Type A tympanograms), or
(3) absent otoacosutic emissions in three or more test frequencies.

2.2.2. Pure tone testing

All pure tone tests were conducted using portable audiometers
(EarScan 3), which were calibrated before testing in each location.
The test frequencies were 500, 1000, 2000, and 4000 Hz. All test
stimuli were presented via insert earphones. Depending on the
functional and intellectual levels of the students, their hearing
sensitivity was examined using various pure tone audiometric
testing procedures. Typically, high-functioning students were
asked to raise their hands when hearing beeping sounds (i.e.,
pure tones). They were also encouraged to respond even if they
were not sure.
Conditioned play audiometry was used for most students. This
testing technique is typically used to test children aged 25 years
with normal intellectual development. During testing, students
were conditioned to throw a wooden block or a small toy into a
bucket when they heard a pure tone signal. If the examiners

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detected boredom, a different game (e.g., putting a peg on a peg

tower after hearing a sound) was used to maintain students
interests and attention in testing.
For students with very low cognitive functions, behavioral
observation audiometry was used to examine students minimal
response levels to pure tones. This technique is typically used for
babies younger than 6 months. Each testing station was manned by
at least two examiners. At least one of the examiners was a licensed
audiologist. All stimuli were presented via insert earphones. When
a sound was presented, the examiners watched the student closely
for any change in body movements and/or facial expressions (e.g., a
smile, a vocalization, or a stop in movement). A minimal response
level was recorded if the student responded to a pure tone
presentation level for more than 2 times.
Note that the result of BOA was not used to estimate frequencyspecic thresholds. Instead, it was a tool to infer whether further
services were needed, and to support caregivers observation of
childrens response to auditory stimuli [9]. Specically, if an
individual responded to the stimuli at levels lower than 40 dB HL,
he/she likely had hearing sensitivity within normal limits. If an
individual responded to levels higher than 40 dB HL, he/she was
referred for follow-up testing.
2.3. Data analysis
2.3.1. Pass
Students who met all of the following criteria were classied as
pass.
(a) Normal outer ear (outer hair cell) functions: Clear ear canal or
minimal cerumen accumulation in the ear canals of both ears.
(b) Normal middle ear functions: Type A tympanograms in both
ears.
(c) Normal inner ear sensitivity: Present otoacoustic emissions at
three of the six test frequencies; OR pure tone thresholds
40 dB HL at all the test frequencies.
2.3.2. Refer
The Refer category was divided into three subcategories:
(a) Clear canal: students had a clear ear canal or minimum
cerumen in the ear canal, and they had one or more of the
following conditions in either one or both ears:
(i) Type B Tympanograms; or
(ii) Absent otoacoustic emissions at three or more test
frequencies and pure tone thresholds >40 dB HL at any
of the test frequencies.
(b) Cerumen only: the student had excessive or impacted
cerumen that would require cerumen removal from a hearing
care professional but they had either
(i) Type A Tympanograms, passed otoacoustic emissions or
pure tone thresholds, or
(ii) Type B Tympanograms with small ear canal volume and
passed otoacoustic emissions.
(c) Cerumen plus: the student had excessive/impacted cerumen
and more than one of the following conditions:
(i) Type B Tympanogram with normal, or large ear canal
volume.
(ii) Absent otoacoustic emissions at three or more test
frequencies and pure tone thresholds >40 dB HL at any
of the test frequencies.
Note that the fence level of 40 dB HL was used because students
with special needs are most likely to respond at minimal response
levels. Previous studies showed that minimum response levels
given by younger children using visual reinforcement audiometry

or play audiometry were generally 1015 dB higher than the

hearing thresholds given by older children using conventional
audiometry, in which children raised hands or pressed a button
when tones were heard [63,64]. In addition, Sabo and colleagues
[63] showed that no child with normal hearing responded at
presentation levels higher than 40 dB HL regardless of the method
of testing. Although students in the present study were older in
chronological age, the fact that they could not be tested using
conventional audiometry suggested that their cognitive functions
might be similar to children at or younger than 5 years old.
Additional considerations regarding the use of 40 dB as the
fence level include (1) all students live in environments with tonal
language speakers who tend not to notice hearing problems until
the better ear had hearing loss of >40 dB HL [61]; (2) most students
in the present study had severe intellectual disabilities and/or
multiple disabilities and their natural tendency was to pull the
EroScan probes from their ears during testing. It would be unlikely
for these students who only had mild hearing loss to wear personal
amplication devices because they may not tolerate amplication
devices in the ear. The fence level was, therefore, set at 40 dB HL to
avoid over-referral.
2.3.3. Monitor
A student receives the Monitor designation if all criteria of
Pass were met with the exception of a Type C tympanograms in
either one or both ears. As Type C tympanograms (i.e., negative
middle ear pressure with normal ear drum compliance) might be
precursors to or resolutions of middle ear effusion or infection,
monitoring the middle ear pressure was recommended.
2.3.4. Cannot test (CNT)
The CNT category included students who could not be tested or
who participated in part of the test but did not nish all the tests.
The most common reasons for CNT were: (1) the student refused
to allow the probe tip of the EroScan Pro unit or the foam tip of the
insert earphone to be inserted into ear canals, or (2) they pulled the
probe/foam tips out before the completion of the tests. In some
incidences, a proper seal could not be obtained during tympanometry either due to normal testing variations or excessive
movement of the student.
2.3.5. Hearing loss (HL)
The category of HL was assigned if the student had a
documented hearing loss prior to the administration of the hearing
tests.
3. Results
3.1. Overall performance
The test results of all students as well as those of three major
subgroups, namely, students with multiple disabilities (N = 83),
with intellectual disabilities (N = 74), and with autism (N = 41) are
shown in Fig. 3. In general, the three groups showed similar trends:
only 32.4% of all students passed the hearing tests in the hearing
screening and/or the pure tone audiometry (Fig. 3). Also, only
28.9% of students with multiple disabilities, 36.5% of students with
intellectual disabilities, and 41.5% of students with autism passed
the tests.
All the students whose hearing conditions warranted audiological
or medical attention (i.e., refer) were referred to see appropriate
professionals. Among these students, 52.5% of all students and
between 41.5% and 58.1% of students with autism, multiple
disabilities, or intellectual disabilities needed follow-up hearing
services for one or more conditions (Fig. 3). Three students (N = 1.3%)
required monitoring of their middle ear status (i.e., monitor).

[(Fig._3)TD$IG]

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1681

Fig. 3. Hearing status of students with special needs.

Approximately 11.7% (N = 28) of all students could not be tested or

their test results did not allow a clinical decision.
Among the 238 students, ve students had documented hearing
losses (i.e., HL, Fig. 3). One student was wearing bilateral hearing
aids and one student had a cochlear implant in the right ear. An
otoscopic examination and tympanometry were performed to
check their outer and middle ear functions. All ve students had
clear ear canals and normal middle ear functions.

rates among different groups are compensatory with the

differences in the CNT rates whereas the referral rates were
similar. As age increased, the CNT rates decreased and the Pass
rates increased. All three groups, however, had similar referral
rates: 50% for ages 26 years, 52.2% for ages 712 years, and 52.4%
for ages 1321 years. This trend is somewhat contradictory to the
trend for children enrolled in mainstream schools in Taiwan that
younger children have higher referral rates (5.6%) than older
children (1.9%,) [52].

3.2. Age-related performance

3.3. Auditory test results

[(Fig._4)TD$IG]

Young children (ages between 0 and 6 years) typically are more

prone to having middle ear dysfunctions than older children (ages
above 7 years) because their Eustachian tubes are more horizontal
compared to older children or adults [62]. The results of this study,
therefore, were analyzed in three different groups: (1) ages
between 2 and 6 years (i.e., preschool students), (2) ages between 7
and 12 years (i.e., primary school students), (3) ages between 13
and 21 years (i.e., secondary school students).
Fig. 4 shows the hearing status of these three groups of
students. The ages of 7 students were not reported and their data
were not included in the analysis. The differences in the Pass

Fig. 5 shows the test results of individual ears of the 238 students
to shed light on the status of students outer, middle, and inner ears
at different age ranges.
3.3.1. Otoscopy
Among the 476 ears tested, approximately 61.3% passed with
unremarkable ndings, and 27.5% had excessive cerumen that
needed professional attention and removal. A total of 19 ears (4%)
were labeled Abnormal due to retracted ear drum (N = 4),
perforated ear drum (N = 2), suspected mass behind the ear drum

Fig. 4. Hearing status of students with special needs divided into three age groups (1) ages between 2 and 6 years old, (2) ages between 7 and 12 years old, and (3) ages
between 13 and 21 years old.

[(Fig._5)TD$IG]

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Fig. 5. The test results of otoscopy, tympanometry, and otoacoustic emissions (OAEs).

(N = 1), whitish or reddish ear drum (N = 8), or red ear canal (N = 4).
Thirty-four of the ears (7.1%) could not be viewed or tested (i.e.,
CNT).
3.3.2. Tympanometry
Testing attempts were made on 476 ears for tympanometry. A
total of 85 ears (17.9%) could not be tested (CNT) and 18 ears (3.8%)
were not tested (i.e., DNT). Two hundred and fty-seven ears
(54.0%) yielded Type A tympanograms (i.e., normal middle ear
functions). Thirty-seven ears (7.8%) and 8 ears (1.7%) had Type As
and Type Ad tympanograms, which suggested stiff and accid ear
drums, respectively. Eighteen ears produced Type C tympanograms. They were marked as Monitor in Fig. 4 but they were
grouped into the Pass column in Fig. 5.
Fifty-three ears (11.1%) yielded Type B tympanograms. These
ears were further divided into Type B with small ear canal volume
(11 ears, 2.3%) and Type B with normal ear canal volume (42 ears,
8.8%). A Type B tympanogram with small ear canal volume
combined with the visualization of cerumen accumulation during
otoscopy indicated that the cerumen accumulation was so severe
that it had impacted the ear canal. The middle ear function of this
ear cannot be determined. On the other hand, a Type B
tympanogram with normal ear canal volume indicated middle
ear dysfunction. Nine ears (2%) were found to have cerumen
accumulation accompanied by Type B tympanograms with normal
ear canal volumes, indicating non-occluding cerumen accumulation in addition to middle ear dysfunctions. No student obtained
Type B tympanogram with large ear canal volume. This indicated,
among the students with relatively clear ear canals, no one had a
perforated ear drum.
3.3.3. Distortion product otoacoustic emissions
Among the 476 ears tested, 245 ears (51.5%) passed and 147
ears were classied into the refer to pure tone audiometry
category because they had absent otoacoustic emissions at 3 or
more test frequencies (Fig. 6). When the results were examined
closely, 16.6% of ears passed the DPOAE test had one or more
disorders detected by otoscopy and/or tympanometry (e.g., the ear
passed DPOAEs but had excessive cerumen, Type B or C
tympanograms). Additionally, 21 students (4.4%) who could not
be tested using otoscopy or tympanometry did not pass the DPOAE
test. These results indicated that all three tests should be included
in the screening protocol in order to detect possible disorders in
the outer, middle, and inner ear. The inclusion of all the tests in the

protocol also allowed multiple attempts using different test

procedures to examine students hearing status.
A total of 84 ears (17.6%) were grouped into the CNT/DNT
category with 76 ears (16.0%) could not be tested and 8 ears (1.7%)
were not tested. Two of the eight ears in the DNT category were not
tested because the student had a cochlear implant in one ear.
3.3.4. Pure tone audiometry
A total of 231 ears needed pure tone audiometry testing. Fifty ears
were not tested (i.e., DNT) due to various reasons, e.g., out of time,
student left the testing rooms before all tests were completed.
Among the 181 ears tested using pure tone audiometry, 47 (26.0%)
responded at or below 40 dB HL at all test frequencies and 41 ears
(22.7%) responded at levels higher than 40 dB HL at one or more
frequencies (Fig. 6). These results suggested that the inclusion of
pure tone audiometry reduced the number of referred students by
9.9% (i.e., 47 passes/476 total ears tested  100) and provided
additional hearing sensitivity information for 8.6% (41 refers/476
total ears tested  100) of students. Ninety-three ears (51.4% or 48
students) could not be tested even though multiple pure tone
audiometry testing paradigms were tried (e.g., regular pure tone
audiometry, play audiometry, and behavior observations).

[(Fig._6)TD$IG]

Fig. 6. The test results of otoscopy, tympanometry, otoacoustic emissions (OAEs),

and pure tone audiometry.

H.-C. Chen et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 16771685

Note that although >50% of students who failed screening could

not be tested using pure tone audiometry (Fig. 6), only the results
of 11.8% of all students did not allow a clinical decision (i.e., CNT
in Fig. 3) after all the test results are considered. This is because
some students who could not be tested using pure tone
audiometry, were found to have excessive cerumen or middle
ear disorders. They were subsequently referred for cerumen
management or medical interventions as well as full audiological
evaluations.
4. Discussions
4.1. Hearing status and the need for service
In this study, 238 students enrolled in two schools for special
education and a habilitation day care center were tested using a
screening protocol including otoscopy, tympanometry, and
DPOAEs. An on-site follow-up pure tone audiometry was also
conducted if they failed the OAE tests or if they could not be tested
using the screening protocol. Students with autism seemed to have
a slightly higher passing rate and lower referral rate than students
with intellectual and multiple disabilities (Fig. 3). Overall, only
32.4% of students had clear ear canals, normal middle ear
functions, and hearing sensitivity 40 dB HL (Fig. 3). More than
half of the students (52.5%) were referred for follow-up audiological and/or medical services (Fig. 3). No clinical decision could be
made for 11.7% of students and they were referred for further
audiological testing.
In general, students with special needs had a remarkably higher
prevalence of hearing disorders/loss than children with normal
developments. Pure tone audiometry results showed that about
25% of students responded at levels higher than 40 dB HL in at least
one test frequency. The prevalence of hearing loss for students
enrolled in mainstream schools in Taiwan was 5.6%, 2.9%, 2.0%, and
1.6% for 1, 4, 7, and 10 graders, respectively [47], when hearing loss
is dened as having pure tone averages at 500, 1000, and 2000 Hz
greater than 25 dB HL. The much higher failure rates obtained in
this study are consistent with previous studies that individuals
with special needs are more prone to have hearing disorders/loss
than their normally developing peers [14,6,6568]. The results
also highlight the great demand of hearing loss/disorder identication and follow-up services for students with special needs.
4.2. Hearing test protocols
In general, hearing test protocols chosen for individuals with
special needs should have some built-in redundancy so that if
students fail one test, another test may be used to provide similar
information. For example, if a student cannot hold still during an
otoscopy, tympanometry may be able to give some information
about whether cerumen has occluded the ear canal or whether
there is uid/negative pressure in the middle ear.
In this study, otoscopy, tympanometry, and a DPOAE test were
included in the screening protocol. More than 80% of students
could be tested using the screening protocol, and only 4.2% (20
students) could not be tested using any of the tests. The results of
individual tests also support the need for a combination of tests to
examine possible outer, middle, and inner ear pathologies.
Specically, the referral rates for all the students were 31.5% for
otoscopy, 24.4% for tympanometry, and 30.9% for DPOAEs. These
rates were considerably lower than the referral rate after taking the
results of all three tests into account (52.1%, Fig. 3).
This need for a combination of tests is further illustrated in
Fig. 5 which showed that students passed the DPOAE test even
though they had various disorders/abnormal clinical ndings that
may require follow-up services. This is because outer or middle ear

1683

conditions only reduced the amplitudes of the otoacoustic

emissions to some extent but might not have totally eliminated
the emissions [5356]. Those ears with robust emissions would
still pass the otoacoustic emissions tests. It is, therefore, important
to include tympanometry in screening children with special needs
in addition to otoacoustic emission tests.
Besides the hearing screening, pure tone audiometry was added
to the testing protocol as an on-site follow-up test. This addition
lowered the overall referral rate by 9.9% (Fig. 6) and provided
additional information on the minimum response levels of 8.6% of
all tested students. The additional information allowed more
accurate diagnoses of hearing disorders/hearing loss and helped
determine which students needed follow-up services. If a student
passed the otoacoustic emissions test or the pure tone audiometry
and he/she was sent for cerumen removal, there would be no need
to conduct an exhausting hearing evaluation. Carrying out the pure
tone testing on-site thus can help reduce the anxiety and nancial
burden of parents and help allocate limited resources to the
students who needed them most.
ASHA recommended using pure tone audiometry to test
childrens hearing and use otoacoustic emissions and auditory
brainstem responses if the reliability of the behavioral test is
doubtful [8]. For students with special needs, however, it is more
appropriate to include otoacoustic emission tests in screening
protocols and then use pure tone audiometry as a follow-up test.
The otoacoustic emission test is an objective test which does not
require an individual to understand the tasks and provide
responses. It is much more efcient and less labor intensive than
pure tone audiometry (a subjective test) for this population. In this
study, >50% of students who needed pure tone audiometry as a
follow up could not be tested, especially for those with more severe
disabilities and those who were very young (Fig. 6). Most students
except 17.7%, however, could be tested using DPOAE tests (Fig. 5).
The disadvantage of using otoacoustic emission tests is that
students with auditory neuropathy spectrum disorder would pass
the tests with their disorder undetected. It is, therefore, very
important to train care-givers and teachers to recognize signs of
hearing disorders/loss. When hearing disorder/loss is suspected,
they would take the students for audiological assessments.
4.3. Future directions
Ideally, full audiological assessments are integrated into the
disability or educational assessments of all children with special
needs because hearing is essential for their speech and language
acquisition/development and educational success. When behavioral results are questionable, the individual is followed up by
electrophysiological tests such as auditory brainstem response
tests or auditory steady-state responses to estimate their degree of
hearing loss and to identify neurological disorders. These
electrophysiological tests will likely need to be conducted in
hospitals with physician supervision because of the need for
sedation.
Additionally, regular hearing screenings should be established
to ensure their hearing health through their school years and
possibly across their lifespan. Students with intellectual disabilities are more likely to experience recurring hearing problems [22]
and the number of referrals needed does not decrease as their age
increases (Fig. 4). The resolution of hearing problems can improve
students hearing health and potentially enhance their learning
potential, social interactions with teachers and peers, and quality
of life.
Further, the training of care-givers and teachers to recognize
the signs of hearing disorders/loss and to practice effective
communication strategies can be an essential part of the
rehabilitation process of students with special needs. Fellinger

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H.-C. Chen et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 16771685

and colleagues [69] reported that caregivers often could not

accurately discern whether individuals with special needs had
hearing problems. Similar ndings are also reported among
coaches and care-givers of Special Olympics athletes [66]. If they
can recognize the problem and utilize effective communication
strategies to increase the chances of conversations and instructions
being heard, they can serve as an advocate for the students and
reduce the duration and the extent of negative consequences of
undetected hearing loss.
Taken together, regular and quality hearing services are greatly
needed for students with special needs because they are much
more likely to have hearing disorders and/or hearing loss than
students enrolled in mainstream schools [16,1827]. Due to the
high referral rate revealed in this study and the high prevalence of
hearing loss reported by other researchers, a more reasonable
hearing health care approach is to assume they have hearing loss
until proven otherwise [6]. Further, it is essential to increase the
awareness of hearing health care needs of students with special
needs among teachers and care-givers so that they can help
identify hearing problems and take care of students hearing health
in order to reduce the negative impact of undetected hearing
disorders and hearing loss. Regarding hearing screening protocol, a
combination of tests is needed to identify potential disorders in
different parts of the auditory system. The majority of students
with special needs can be tested using a screening protocol
including otoscopy, tympanometry, and otoacoustic emissions.
The addition of pure tone audiometry as an immediate follow-up
test reduced the referral rate and provided additional information
on the hearing sensitivity of students. The redundancy among the
subtests provides valuable cross-check opportunities and information to allow examiners to make appropriate clinical decisions.
Future studies are needed to estimate the time and human
resource costs per student for hearing services to help professional
organizations and/or the local government plan and budget
hearing services into health care plans for individuals with special
needs.
Conict of interest
King Chung: Oticon USA partly sponsored the travel costs of the
four audiology graduate students to go to Taiwan for data
collection. They did not have any inuence on the study design,
the collection, analysis and interpretation of data; the writing of
the manuscript; or the decision to submit the manuscript for
publication. There is no conict of interests with other companies
or entities that would potentially bias the current work.
Other authors: There is no conict of interests with any
company or entity that would potentially bias the current work.
Acknowledgment
The authors would like to thank students and Mr. Rex Lo at the
Audiology program of Chung Shan Medical University, students
and audiologists at National Kaohsiung Normal University in
Taiwan, and four audiology graduate students at Northern Illinois
University in the United States for data collection. We also would
like to thank Oticon USA for funding part of the travel expenses for
data collection in Taiwan.
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