Mini-Grant Proposal Template
Updating Early Childhood Hearing Screening Practices

The following is a request for funding to the <INSERT FOUNDATION NAME FOUNDATION>  prepared by <INSERT PROGRAM NAME> with assistance from <INSERT NAME OF COLLABORATING ENTITY THAT WILL BE PROVIDING AUDIOLOGICAL SUPERVISION AND SUPPORT TO YOUR PROGRAM, SUCH AS YOUR STATE EHDI PROGRAM, ECHO TEAM, OR NCHAM>.  The purpose of this request is to fund the purchase of otocoustic emissions (OAE) hearing screening equipment that will enable all children, birth to three <or FIVE>  years of age served by the <INSERT PROGRAM NAME > to receive high quality, up-to-date hearing screenings to ensure that each child’s hearing health and related developmental needs are met. This funding will significantly increase the capacity of the (PROGRAM NAME) to conduct reliable hearing screenings that will benefit <#> children in year ahead and more than <#> children over the next five years. <INSERT ANY ADDITIONAL OUTCOMES SUCH AS INTERAGENCY COLLABORATIONS THAT WILL BENEFIT>
The < INSERT NAME OF PROGRAM>
The <INSERT PROGRAM NAME > is a program that serves <number> of children birth to three <or FIVE> years of age in <center or home based> settings.  As a licensed 501c3, non-profit organization, in operation since <DATE>, the  <INSERT PROGRAM NAME >  has provided services  to more than <NUMBER> children and families: <INSERT SERVICES/PROGRAMS>.    The <INSERT PROGRAM NAME> is an essential organization addressing the needs of economically challenged families and their children in the <INSERT GEOGRAPHIC> area and regularly collaborates with a variety of agencies and programs serving children and families in the community including: <LIST PROGRAMS LIKE EARLY INTERVENTION PROGRAMS,  WIC, etc.>    
All children attending <INSERT PROGRAM NAME > receive a comprehensive array of health and educational services designed to produce outcomes in children's development (including health, resiliency, social competence, and language). Recognizing the strong relationship between hearing, language acquisition, cognitive development, social competence, and literacy, Head Start performance standards require that all children be screened for hearing loss and referred for diagnosis and intervention when needed.    For the past <INSERT NUMBER> years, the  <INSERT PROGRAM NAME>  has had to rely on <INSERT SCREENING METHODOLOGY SUCH AS STARTLE TESTS AND PARENT QUESTIONNAIRES> as the primary hearing screening method for children birth to three.  However, advances in technology now make it feasible to conduct reliable, physiologic screening of infants and young children using Otoacoustic Emissions (OAE) technology.  OAE screening does not rely on any type of behavioral response and is considered to be the most objective, physiologic screening tool available to identify children with a wide range of children’s hearing health needs, including those with unidentified ear infections and permanent sensorineural losses.  
	The American Academy of Pediatrics, the American Speech-Language-Hearing Association and the American Academy of Audiology all consider OAE screening to be the most reliable tool available to screen the hearing of young children birth to three years of age.  To assess the feasibility of employing OAE hearing screening technology in Head Start programs, the National Center for Hearing Assessment and Management (NCHAM) has been engaged in a large research project including more than 70 programs across three states.  Data collected from these programs indicated that with proper training and audiological supervision, Head Start programs were able to use OAE technology very effectively to screen the hearing of young children enrolled in their programs.  The marked advantages of OAE screening over subjective methods, along with the proven feasibility of implementation, make it critical that <INSERT PROGRAM NAME> replace  previous screening methods with up-to-date OAE technology.     The purpose of this funding request is to update the <INSERT PROGRAM NAME> hearing screening practices  by implementing and maintaining OAE hearing screening as the standard screening practice with all children birth to three <or FIVE> years of age.   This initiative will be undertaken with appropriate assistance and guidance from < INSERT NAME OF COLLABORATING ENTITY THAT WILL BE PROVIDING AUDIOLOGICAL SUPERVISION AND SUPPORT TO YOUR PROGRAM, SUCH AS YOUR STATE EHDI PROGRAM, ECHO TEAM, OR NCHAM>.  (INSERT AS MUCH ADDITIONAL BACKGROUND INFORMATION, PROVIDED IN LATER SECTION OF THIS DOCUMENT, AS NEEDED TO JUSTIFY YOUR REQUEST/).
Proposed Outcomes
	As a part of meeting Head Start requirements, <INSERT PROGRAM NAME >  has been screening children for hearing loss within the first 45 days of enrollment in the program.   However, the hearing screening has been done using subjective methods which can no longer be considered adequately reliable.  With the proposed funding, <INSERT PROGRAM NAME > will be able to update hearing screening practices, using OAE technology, and following the screening and follow-up protocol recommended by the National Center for Hearing Assessment and Management.  All children will receive the benefit of reliable hearing screening at least  <insert INTERVAL>, while children who are at risk for chronic hearing health conditions will be screened more frequently.   This proposed update in screening methods represents a significant change for the <INSERT PROGRAM NAME> and will enable children with hearing health needs to be identified who would not have been recognized using previous screening methods. 
During the year <INSERT DATE> to <INSERT DATE> it is anticipated <# > of children will receive OAE screenings.  This funding will not only contribute to services in the year ahead, but will enable the <INSERT PROGRAM NAME > to screen more than <#> of children over the next five years to ensure than those needing medical and audiologic services are identified and referred in a timely way to meet their hearing health needs.
Equipment Specifications
	OAE equipment is available from several manufacturers.  The price of one OAE unit is approximately <INSERT CURRENT PRICE>.  Additionally, the equipment requires the use of disposable probe tips of different sizes that must be matched with the size of a given child’s ear in order to perform the screening successfully.  The small plastic probe covers inserted into the ear canal during screening must be discarded after use and cost approximately <INSERT PRICE>.  <ADD ANY OTHER ITEMS FOR WHICH FUNDING IS REQUESTED SUCH AS ANNUAL CALIBRATION COSTS, TRAINING, SERVICE/EXTENDED WARANTEES , ETC.> 
Funding Request:  

<CONTACT MANUFACTURERS FOR CURRENT PRICES>

1 OAE Unit		<>
300 probe tips		<>
Total			<>

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Supplementary Background Information 
Note:  Some proposals may require only the above information.  If more background and justification is needed, include supplementary information provided below.  This background information may be integrated as part of the proposal text or included as an appendix or attachment to your grant proposal to support your request for funding.
1.  Incidence and implications of hearing loss.  Hearing loss is the most common birth defect.  Approximately one of out every 300 children, or 33 babies each day, are born with a hearing loss in the United States (White, 1996).   In addition, late-onset hearing loss caused by illness or injury can affect a child at any time.  One of the most common early childhood health problems, chronic middle ear infection, can cause fluctuating hearing loss that may also disrupt a child’s language acquisition if left undiagnosed and untreated.  It is estimated that approximately 50% of preschool children will have at least one episode of middle ear infections by one year of age. Between one and three years of age 35% will have had repeated episodes (American Speech Hearing Association, 2003).  It is further estimated that 83 out of every 1000 children in the US have what is termed an educationally significant hearing loss (US Public Health Service, 1990).
 The repercussions of unidentified hearing loss are significant.  As noted by the United States Department of Health and Human Services (1990):
If hearing impaired children are not identified early, it is difficult, if not impossible,
for many of them to acquire the fundamental language, social, and cognitive skills that provide the foundation for later schooling and success in society.  When early identification and intervention occurs, hearing impaired children make dramatic progress, are more successful in school, and become more productive members
of society.  The earlier intervention and habilitation begin, the more dramatic the benefits. 
The link between infant hearing loss and language/literacy deficits has been
well documented for decades (Mauk & Behrens, 1993). A number of independent studies have documented the negative effects that hearing loss can have on children’s academic achievement.  The American Speech Language Association (2003) summarizes these effects as follows:
•	Children with hearing loss have difficulty with all areas of academic achievement, especially reading and mathematical concepts.
•	Children with mild to moderate hearing losses, on the average, achieve 1-4 grade levels lower than their peers with normal hearing, unless appropriate management occurs.
•	Children with severe to profound hearing loss usually achieve skills no higher than the third or fourth grade level, unless appropriate educational intervention occurs early.
•	The gap in academic achievement between children with normal hearing and those with hearing loss usually widens as they progress through school (Allen, 1986). 
2.  Advances in early hearing detection and intervention.   Over the past decade, dramatic improvements in hearing screening technology have significantly lowered the age at which children with hearing loss can be identified.  Although auditory brainstem response (ABR) hearing testing equipment had been used in the late 1980s to screen some babies in neonatal intensive care units considered to be at greater risk for hearing loss, this equipment was costly to purchase and use and also required that infants be asleep or sedated during testing.  Universal, physiologic screening of all infants and young children was therefore impractical.  By the early 1990s however, a new technology called otoacoustic emissions (OAE) screening had been introduced in the U.S. and was starting to gain acceptance among audiologists as a potentially effective hearing screening tool (White, 1996).
          Figure 1.  Photo of child being screened using OAE technology 

	To understand the basic concept behind OAE screening, remember that the ear is comprised of the outer ear, the middle ear chamber containing three small bones or “ossicles” and the inner ear, or “cochlea.”  During OAE screening, the screener places a small probe, fitted with an extremely sensitive microphone, in the child’s ear canal (see Figure 1). The probe delivers a quiet tone or clicking sound into the ear canal.  In a healthy ear, sound is transmitted through the middle ear to the inner ear where the cochlea responds by producing an emission similar to an “echo”. This emission is then picked up by the microphone, analyzed by the screening unit, and a “pass” or “refer” result is displayed on the unit’s computer screen.
	Every normal, healthy inner ear produces an emission that can be recorded in this way with the total screening process taking approximately five minutes per child.   If a child has a structural problem in the middle ear that interferes with hearing, if excess fluid is present in the middle ear (often due to ear infection), or if the cochlea itself is not responding to sound, the ear will not pass the screening.   Thus, OAE screening can help identify children who have fluctuating losses associated with ear infection as well as children who have permanent hearing loss associated with physical abnormalities of the middle or inner ear.   It is important to emphasize that OAE screening is not synonymous with audiological assessment.   OAE screening can be conducted by non-audiologists and is simply the first step in identifying children who may be at risk for hearing loss.  As with any type of hearing screening, children who do not pass the OAE screening should be referred for appropriate medical and audiological diagnosis and treatment.  The value of OAE screening is that it can be conducted on children as young as a few hours old, as well as on toddlers and young children, since it does not rely on a behavioral response. The result is that children with hearing health needs can be identified years earlier than in the past.

3.  Implications for continuous screening in Head Start programs.   The documented effectiveness of OAE hearing screening in hospital-based newborn screening programs (Maxon, et al., 1997), coupled with the development of an array of state resources to serve infants and young children identified with hearing loss, now makes it both feasible and imperative that early childhood programs update their continuous hearing screening practices.  In doing so, Head Start grantees can ensure that any child enrolled receives timely assessment of a hearing loss and that every child identified with a loss has access to intervention critical for developing language and literacy skills. 
Providing high-quality, continuous, hearing screening throughout early childhood is vital because:
•	Permanent hearing loss may occur at any time in a child’s life and many young children suffer from otitis media (ear infection), which, unidentified and untreated, can result in temporary hearing loss during critical language-learning years.  This, in turn, affects a child’s language, cognitive, and social development.

•	Not all children are initially screened for hearing loss at birth. Approximately 15% of children in the U.S. born at home or in hospitals where hearing screening is not occurring, along with majority of children born outside the U.S. who are served in Migrant Head Start programs, were not screened at birth for hearing loss.  

•	A significant percentage of those who are being screened are still not receiving the diagnostic and intervention services they need.  For example, hospital-based hearing screening programs report that significant numbers of children not passing the newborn hearing screening are not returning to receive the needed diagnostic assessment. State EHDI programs report that as many as half of the infants who did not pass the newborn hearing screening may become lost to follow-up before diagnosis and intervention can occur.  

•	Most health care providers and clinics cannot adequately screen for hearing loss as part of a well-child checkup.  Traditional tools only allow a health care provider to view the child’s tympanic membrane (eardrum) using an otoscope or check for the presence of middle ear fluid using a tympanometer.  Thus, when attempting to screen a child for hearing loss, most primary care providers are also forced to fall back on less effective observational techniques (bell-ringing, hand-clapping, etc.)

Although introduced initially as a hearing screening device for newborns, OAE technology lends itself to screening children of any age because it is:
•	Painless for the child and does not require a behavioral response; 
•	Reliable,  efficient (taking about five minutes per child) and inexpensive;
•	Hand-held and portable, thus can be used  in either center or home-based settings;
•	Simple to administer when a child initially enters a Head Start program, at annual intervals, and at any other time that a parent voices concerns about their child’s hearing or educators have cause to question the child’s hearing health;
•	Straightforward to use and does not require technical skill or in-depth understanding of the auditory system.  With the proper training, protocol, and audiological oversight, screening can be performed by anyone who is skilled in working with children. 
The dramatic improvements in hearing screening technology hold important implications for updating Head Start hearing screening practices.   First, the technology has improved to the point where grantees no longer need to rely exclusively on less reliable behavioral observations (hand clapping, belling ringing or parent questionnaires) to screen 0 – 3 year-old children.  Second, OAE screening can be performed on children at any age.  The fact that it does not require a behavioral response makes it especially valuable for screening older children who have language or cognitive delays or are not fluent in the language spoken by program staff and therefore may not respond reliably to typical audiometry screening.  Third, Head Start Health Coordinators, and other staff who are skilled in working with children can easily be trained to use OAE screening equipment.  Finally, training in the appropriate use of OAE screening and follow-up for children birth to three years of age is now available to Head Start programs.

References

Allen, T. E. (1986).  Patterns of academic achievement among hearing-impaired students: 1974 and 1983.  In A. N. Schildroth & M. A. Karchmer,   Deaf children in America (pp.161–206).  San Diego: College Hill Press.

American Academy of Pediatrics Task Force on Newborn and Infant Hearing (1999).  Newborn and infant hearing loss:  Detection and intervention.  Pediatrics, 103(2), 527-530.

American Speech-Language-Hearing Association (2003). Status of state universal newborn and infant hearing screening legislation and laws. http://professional.asha.org/resources/legislative/overview.cfm

ASHA (2004) Causes of hearing loss in children.  Retrieved from www.asha.org/public/hearing/disorders/causes.htm  May 24, 2004.

Mauk, G. W., & Behrens, T. R. (1993).  Historical, political, and technological context associated with early identification of hearing loss.  Seminars in Hearing, 14(1), 1-17.

Maxon, A.B., White, K.R., Culpepper, B., & Vohr, B.R. (1997). Maintaining acceptably low referral rates in TEOAE-based newborn hearing screening programs. Journal of Communication Disorders, 457-475.

O’Brien, J. (2001).  How screening and assessment practices support quality disabilities services in Head Start, Head Start Bulletin: Enhancing Head Start Communication, U.S. Department of Health and Human Services, Administration for Children and Families, Administration for Children, Youth and Families, Head Start Bureau, April, No 70.

U.S. Department of Health and Human Services (HHS). (1990). Healthy People 2000: National Health Promotion and Disease Prevention Objectives.  Washington, DC: Public Health Service.

U.S. Public Health Service (1990).  Healthy People 2000. Washington, DC: Public Health Service.

White, K. R. (1996).  Universal newborn hearing screening using transient evoked otoacoustic emissions:  Past, present, and future.  Seminars in Hearing, 17(2), 171-183.