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Prevention of communication disorders – screening
pre-school and school-age children for problems with
hearing, vision and speech: European Consensus
Statement
Henryk SkarżyńskiAEG, Anna PiotrowskaAEF
Institute of Physiology and Pathology of Hearing, Warsaw, Poland
Source of support: Self financing
Summary
	 Background:	 Communication is an integral part of human behaviour. Communication disorders are associated
mainly with impairment in hearing, vision, and/or speech, which influences the ability to receive,
comprehend, produce, and express verbal, nonverbal, and graphic information. When unrecognized
and unmanaged, these very often “invisible” conditions can have a significant detrimental
effect on a child’s development, affecting educational, social, and psychological progress.
	Material/Methods:	 A panel of experts discussed the screening of pre-school and school-age children for problems with
hearing, vision, and speech during the 10th
Congress of the European Federation of Audiology
Societies (EFAS), held in Warsaw, Poland, on 22 June, 2011.
	 Results:	 The European Consensus Statement on Hearing, Vision, and Speech Screening in Pre-School and
School-Age Children was the result of the scientific discussions. It was endorsed by experts in audiology,
otolaryngology, phoniatry, ophthalmology, and speech language pathology from throughout
Europe*. Key elements of the consensus, as described herein, are: 1) defining the role of screening
programmes in the identification and treatment of communication disorders; 2) identifying
the target population; 3) promoting general awareness about the consequences of communication
disorders; 4) recognizing the need for a quality control system in screening programmes; 5)
encouraging cooperation among European countries to provide a high level of public health services
for the prevention, identification, and treatment of communication disorders.
	 Conclusions:	 The European Consensus Statement on Hearing, Vision, and Speech Screening in Pre-School and
School-Age Children will encourage the appropriate authorities of the various countries involved
to initiate screening for communication disorders in pre-school and school-age children.
		* Henryk Skarżyński – Director of the Institute of Physiology and Pathology of Hearing, State Consultant for
Audiology and Phoniatrics, Poland; Jerzy Szaflik – State Consultant in Ophthalmology, Poland; Linda Luxon
– President of the European Federation of Audiology Societies; Antoinette am Zehnhoff-Dinnesen – President
of the Union of European Phoniatricians; Michèle Kaufmann-Meyer – Vice President of the Standing Liaison
Committee of Speech and Language Therapists/Logopedists in the European Union.
	 key words:	 screening • hearing loss • communication disorders • school-age children • consensus
statement
	 Full-text PDF:	http://www.medscimonit.com/fulltxt.php?ICID=882603
	 Word count:	2236
	 Tables:	—
	 Figures:	—
	 References:	51
	Author’s address:	 Anna Piotrowska, Institute of Physiology and Pathology of Hearing, Zgrupowania AK “Kampinos” 1, 01-943 Warsaw,
Poland, e-mail: a.piotrowska@ifps.org.pl
Authors’ Contribution:
	A	 Study Design
	B	 Data Collection
	C	 Statistical Analysis
	D	 Data Interpretation
	E	 Manuscript Preparation
	F	 Literature Search
	G	 Funds Collection
Received:	 2011.10.20
Accepted:	 2012.02.04
Published:	 2012.04.01
SR17
Special Report
WWW.MEDSCIMONIT.COM© Med Sci Monit, 2012; 18(4): SR17-21
PMID: 22460107
SR
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Background
Communication is a complex human skill that combines
physical and mental elements. Language and communication
are crucial to all children and young people [1].
Modern society requires a high level of communication
skills; speech, language, vision, and literacy are the foundation
skills that are needed to meet these demands [2].
Dysfunction in one or more of these areas, for example,
caused by various medical conditions, may lead to communication
disorders. Communication disorders can involve
impairment in hearing, vision and/or speech, which influences
the ability to receive, comprehend, produce, and express
verbal, nonverbal, and graphic information.
When untreated, communication disorders in childhood
can result in further negative consequences, such as developmental
delay in communication abilities and the normal
acquisition of language. In turn, this can lead to limited educational
achievement, reduced employment opportunities,
and problems with social adaptation. Hence, early identification
and intervention are essential [1] so that effective
treatments can be undertaken before significant limitations
develop. Effective and directed early detection, diagnosis,
and treatment, as well as promotion, prevention, and education,
can create better opportunities for children with
communication disorders. Children who face difficulties
in acquiring the ability to communicate require appropriate
support to allow them to interact socially, to participate
fully in education, and to lead safe, healthy lives [1]. High
levels of communicative competence are essential for progress
at school and work.
Hearing Disorders
The prevalence of hearing loss increases with age and may
involve conductive hearing loss, acquired and delayed onset
sensorineural hearing loss and/or auditory processing
disorders that cannot be identified by neonatal hearing
screening (NHS) [3,4]. Children with conductive hearing
impairment can have either congenital or acquired middle
ear pathology. Some forms of middle ear pathology, such as
subtle middle ear abnormality with no apparent hearing loss
and otitis media with effusion, are usually insidious and difficult
for parents or care givers to detect. Sensorineural loss
can result from inner ear defects or auditory nerve damage.
Known causes of acquired sensorineural hearing loss include
viral and bacterial infections, ototoxicity, and head trauma.
Noise-related hearing impairment can also pose a serious
health problem to children [5]. Auditory processing disorders
seen in children can result from neuromorphological
disorders, maturational delay of the central auditory nervous
system, and neurological disorders [6].
It is estimated that 9–10 per 1000 children will have identifiable
permanent hearing loss in one or both ears by school
age [7]. Moreover, there is evidence that children with unrecognized
and unmanaged unilateral hearing loss or minimal
bilateral hearing loss have significant speech-language
delays, negative educational consequences, and behavioural
problems [8–12]. Thus far, screening programmes for hearing
at schools have been offered mostly as local initiatives
in the USA [13,14], Australia [15], China [16], and some
European countries [17–19].
Vision Disorders
According to the World Health Organization, approximately
153 million people worldwide are visually impaired as a result
of uncorrected refractive errors. This population includes
children [20,21]. There is no doubt that problems with visual
ability have considerable impact on a child’s learning potential,
and that severe uncorrected refractive errors affect general
development, resulting in lower educational achievement
and impairing learning ability [22]. Normal visual acuity is of
particular importance, especially at the beginning of school
education. Given the number of visual activities that are performed
at close range at school and at home, the assessment
of near and distance vision is critical. Refractive errors – hyperopia
and myopia – are age-dependent. Hyperopia is typical
of infants, and decreases gradually towards emmetropia
[23]. Early development of emmetropia is a risk factor for the
occurrence of myopia. Significant uncorrected refractive errors
in childhood can result in amblyopia, developmental delays,
and problems with spatial orientation [24]. Significant
hyperopia in toddlers and schoolchildren may lead to educational
difficulties and problems with mobility [22,25,26].
In cases of severe hyperopia, the constant accommodation
effort that is required to overcome uncorrected hyperopia in
near vision activities can result in strabismus at any age [27],
together with headache and eye discomfort [28].
Information is not available in the literature on the screening
programmes for vision that are offered in schools in Europe.
Data from the USA indicate the need for interventions to correct
decreased visual acuity in students in the first grade [29].
Speech/Language Disorders
Speech and language development should be consistent with a
child’s overall development and is related to success at school
[30,31]. Speech and language difficulties and abnormalities
cover a wide range of childhood conditions. Speech disorders
refer to difficulties in the expression of speech sounds or problems
with voice quality. Language disorders are impaired ability
to understand and/or to use words in context, both verbally
and nonverbally. Speech and language problems can result
from global developmental conditions, or they can occur in a
normal developmental course and have no obvious cause [32].
Although speech and language disorders are differentiated,
they are highly comorbid [33], and children with speech disorders
often have complex health and developmental needs
[34]. The prevalence of childhood speech disorders varies, depending
on the methodology used to measure it [35]. Shriberg
et al. [36] reported that approximately 15% of children with
persistent speech disorders also have a language disorder, and
approximately 5% of children with specific language impairment
experience difficulties with speech. Early identification
and intervention in children with speech/language disorders
assist with educational planning and are often associated with
better long-term outcomes [37,38]. However, it is not clear how
consistently clinicians screen for speech and language disorders
in primary care practice [39], and there is no uniformly
accepted screening technique [40].
Paediatric Health Programmes
Paediatric health programmes are intended to provide equal
opportunities for children to develop [41]. The major purpose
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of a paediatric health programme is to provide primary care
for sick children, as well as preventive care, by maintaining,
improving, and promoting the health of the child [42,43].
One of the fundamental health services in paediatric care is
the appraisal of health by routine evaluation at specified intervals,
at specific stages of growth and development, such as
before beginning school [44]. Screening for problems with
hearing, vision and speech/language functions, and associated
conditions, throughout infancy, childhood, and adolescence,
should be recommended as a part of preventive
paediatric health care [45]. The objective of screening programmes
for hearing, vision, and speech impairment is to
identify communication disorders, which in many cases are
not obvious or apparent, but may hinder a child’s ability to
communicate and which can be treated more effectively when
detected at an early stage. This is particularly crucial for children,
whose good health is fundamental for their proper development
and influences their quality of life and social and
economic situation in the future. In a child, a breakdown in
communication may cause the development of abnormal social
growth and behaviour, interfere with education and human
potential, and lead to the development of adjustment
problems in children and their families. Hence, the impaired
child’s requirements for adequate health care, whether physical,
developmental, emotional or social, should be identified
as promptly as possible. Such needs should be brought
to the attention of the parents and other care givers [46].
Key point 1: Screening programmes have great potential to enable
effective identification and treatment of hearing, vision, and speech/
language disorders in at-risk children and to remediate detrimental
effects for both the individual and society.
Communication disorders in children should be identified
by screening as early as possible. Entry into school is the
last opportunity to detect the problem in order to avoid or
reduce its negative impact on language and the cognitive
development of children. This is endorsed by the fact that
hearing, vision, and speech disorders are significant reasons
for delay in learning and for difficulties in the acquisition of
language skills, which are crucial for children if they are to
communicate effectively. Given that a child develops particular
skills and abilities gradually through their entire childhood
in physiological steps and in a defined order, this process
should be controlled and checked periodically. Hence,
hearing, vision, and speech/language should be screened at
critical stages of development [47]. Furthermore, a healthpromoting
elementary school environment was recognized
as one of four targets for preventive environment, as an outcome
of the European Community Health Indicators (ECHI)
Project supported by the European Commission [48].
Key point 2: The primary target population for pre-school and schoolage
screening of hearing, vision, and speech is all children aged 4–7
years. In addition, students in higher grades can also be screened.
Screening Programmes for Communication
Disorders
As with any mass-screening programme, there are many challenges
that can affect the success of a programme of screening
for communication disorders. These challenges may be
related to the physical characteristics of the screening facility,
the methodological factors used (procedures, tools,
methods), the agency that requests the services (staff cooperation,
state regulations), and administrative constraints
(availability of personnel, budgetary factors). Success will be
strongly influenced by the logistics and quality of the testing
system, as well as the competence of the personnel who
perform the screening procedures. Another critical issue is
the follow-up system for those who are positive on screening.
It is very important to organize the programme in a way
that does not result in large numbers of repeat screens and
referrals, owing to the costs involved in conducting largescale
screening projects. An appropriate tracking system
must be implemented to secure an adequate follow-up rate.
Key point 3: There is a need to increase awareness among policy
makers, health care professionals, and the general public of the
consequences of communication disorders, as well as the crucial
role of early detection and intervention in cases of impairment of
hearing, vision, and speech in children.
Key point 4: A system of quality control is an essential component of
a pre-school and school screening programme. It is necessary that all
personnel who are involved in screening have adequate training and
instruction in order to acquire and maintain the appropriate skills.
Public Health Services in Europe
Health is central to people’s lives and needs to be supported
by effective policies and actions at the European Community
and global levels [49]. Public health services have a vital role
to play in meeting the health challenges that Europe faces.
The governance of public health in Europe is complex
and multifaceted. The organization and delivery of public
health services involves many distinct institutions and
professions within the health sector. There are also differences
in general health within and between EU Member
States, which are related to various factors, including differences
in education, socioeconomic situation, living and
working conditions, health-related behaviour, and health
care. Furthermore, there have been significant changes in
health care systems during recent years, in part as a result
of the rapid development of new technologies such as information
and communication technologies (ITC) and the
E-health strategy [49]. This dynamic situation requires the
continued interest and commitment of EU Member States,
as well as the maintenance of an expert facility linked to
the Commission that can coordinate and guide the process.
For these reasons, the European Commission’s Health
Monitoring Programme [50] was established to:
1.	Measure health status, its determinants, and the trends
therein throughout the Community;
2.	Facilitate the planning, monitoring, and evaluation of
Community Programmes and actions;
3.	Provide Member States with appropriate health information
to make comparisons and support their national
health policies.
According to a set of specific guidelines formulated by the
Child Health Indicators of Life and Development (CHILD)
project and the (ECHI) project [48,51], which were developed
under the Health Monitoring Programme, cooperation
among European countries is essential in order to apply
new methods of assessment of child health in screening
programmes for pre-school and school-age children and to
ensure the appropriate adjustment of public health services.
Med Sci Monit, 2012; 18(4): SR17-21 Skarżyński H et al – European Consensus Statement
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Key point 5: To provide a high level of public health services, there
should be cooperation among European countries by means of the
exchange of knowledge and good practice, continuous improvement
of methods and procedures, introduction of e-Health tools, and
creation of national and European databases.
Conclusions
In the context of the above statements, the representatives
of the European societies of audiologists and phoniatricians,
ENT (ear-nose-throat) physicians, ophthalmologists, psychologists,
and speech therapists endorsed the European
Consensus Statement and presented the following opinions.
The European Consensus Statement on Hearing, Vision and
Speech Screening in Pre-School and School-Age Children
determined that:
1.	Screening programmes have great potential to enable effective
identification and treatment of hearing, vision and
speech/language disorders in at-risk children and to remediate
detrimental effects for both the individual and
society.
2.	The primary target population for pre-school and schoolage
screening of hearing, vision, and speech is all children
of age 4–7 years. In addition, students in higher grades
can also be screened.
3.	There is a need to increase awareness among policy makers,
health care professionals, and the general public of
the consequences of communication disorders, as well
as the crucial role of early detection and intervention in
cases of impairment of hearing, vision and speech in chil-
dren.
4.	A system of quality control is an essential component of
a pre-school and school screening programme. It is necessary
that all personnel who are involved in screening
have adequate training and instruction in order to acquire
and maintain the appropriate skills.
5.	To provide a high level of public health services, there
should be cooperation among European countries by
means of the exchange of knowledge and good practice,
continuous improvement of methods and procedures,
introduction of e-Health tools, and creation of national
and European databases.
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