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Title: Audiology services in the schools
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Title: Audiology services in the schools
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Full Text

Audiology Services in the Schools
Prepared for the Center on Personnel Studies in Special Education

Susan J. Brannen
Nancy P. Huffman
Joan Marttila
Evelyn J. Williams
American Speech-Language-Hearing Association

July 2003
(COPSSE Document No. IB-6)

Center on Personnel Studies in










COPSSE research is focused on the preparation of special education professionals and its
impact on beginning teacher quality and student outcomes. Our research is intended to inform
scholars and policymakers about advantages and disadvantages of preparation alternatives and
the effective use of public funds in addressing personnel shortages.

In addition to our authors and reviewers, many individuals and organizations have contributed
substantially to our efforts, including Drs. Erling Boe of the University of Pennsylvania and
Elaine Carlson of WESTAT. We also have benefited greatly from collaboration with the National
Clearinghouse for the Professions in Special Education, the Policymakers Partnership, and their
parent organizations, the Council for Exceptional Children and the National Association of State
Directors of Special Education.

The Center on Personnel Studies in Special Education, H325Q000002, is a cooperative
agreement between the University of Florida and the Office of Special Education Programs of
the U. S. Department of Education. The contents of this document do not necessarily reflect the
views or policies of the Department of Education, nor does mention of other organizations imply
endorsement by them.
Recommended citation:
Brannen, S.J., Huffman, N.P., Marttila, J., & Williams, E.J. (2003). Audiology services in the
schools. (COPSSE Document No. IB-6). Gainesville, FL: University of
Florida, Center on Personnel Studies in Special Education.

thatW ork
U. S. Office of Special
Education Programs

Additional Copies may be obtained from:
COPSSE Project
P.O. Box 117050
University of Florida
Gainesville, FL 32611
352-392-2655 (Fax)

There are no copyright restrictions on this document; however
please credit the source and support of the federal funds when
copying all or part of this document.


In tro d u c tio n............... ............................................................................

Professional Preparation for Audiologists in the Schools ........................................... 5

Professional Preparation Needs of Audiology Practitioners in the Schools ..................9

Certification and Licensing for Audiologists Practicing in Schools ................................11

A udiologist Supply and Dem and ............................................ 14

C o n c lu s io n s ........................................................................................................................................... 2 1

R E F E R E N C E S ........................................................................................................................ . . . 2 2


The American Speech-Language-Hearing Association (ASHA) is the professional, scientific, and
credentialing association for more than 109,000 audiologists, speech-language pathologists, and
speech, language, and hearing scientists. ASHA's mission is to ensure that all people with
speech, language, and hearing disorders have access to quality services to help them
communicate more effectively.

ASHA and its members advocate for and serve the needs of approximately 28 million Americans
who have hearing loss. Many of these are children who receive audiology services in the schools.
Educational audiologists providing services in and for schools typically have extensive
experience with pediatric populations and comprehensive knowledge of the effects that hearing
loss and (central) auditory processing disorders [(C)APDs] can have on communication,
academic performance, and psychosocial development. Educational audiologists also have a
unique understanding of legislation related to audiology service provision to children (birth to 21
years) and the processes of state education agencies (SEAs) and local education agencies
(LEAs). This paper will address issues related to professional preparation, certification/licensure,
and supply/demand that are of critical importance to audiologists and the children, SEAs, and
LEAs they serve.


Changes in Professional Preparation in Audiology

Audiology services in the schools are affected by changes in the field of audiology since the late
1990s. Audiologists recognized that in the 21st century there would be a greater need for
academic and clinical training: (a) to keep up with advancements in knowledge, techniques, and
technology in audiology and (b) to ensure provision of the highest quality service to consumers.
To broaden the knowledge base of audiologists and facilitate high-quality service provision
changes to audiology, preservice training and certification requirements are being instituted.

Transition to the Doctorate

Recognizing the need for audiologists to acquire advanced post-baccalaureate study that
emphasizes clinical practice, the audiology profession worked to develop and implement a
specialized doctoral program of study. Before January 1, 2001, it was the responsibility of
ASHA's Council on Professional Standards in Speech-Language Pathology and Audiology
(Standards Council) to develop and monitor standards for clinical certification in the context of
changes in the scope of practice of the professions. The Standards Council developed an action
plan to identify the "...academic, clinical practicum and other requirements for the acquisition of
critical knowledge and skills necessary for entry-level, independent practice of audiology"
(ASHA, n.d. b). As a part of that plan, the Educational Testing Service was commissioned by
ASHA to conduct a skills validation study for the profession of audiology. Following a review
of the data provided by the skills validation study, practice-specific literature, feasibility studies,
and other pertinent information, in October 1996, the Standards Council published proposed
standards for widespread peer review. The document with significant modifications was then
released for a second round of peer review in July, 1997. Additionally, ASHA commissioned an
independent research firm to conduct a telephone poll of academic programs to gather
information from 124 academic program chairpersons. Responses were obtained from 91
programs with this technique. Modifications to the proposed standards were based on the second
round of peer review, adopted by the Standards Council at its meeting in September, 1997, and
are to be implemented in 2007.

The 1997 Standards for the Certificate of Clinical Competence in Audiology are intended to
make the scope and level of professional education in audiology consistent with the scope of
practice of the profession. They address the significant discrepancies between the level of
preparation and requirements for practice that were identified in the skills validation study.

The new standards include these salient features:

*Applicants for the certificate of clinical competence must complete a minimum of 75
semester credit hours of post-baccalaureate study that culminates in a doctoral or
other recognized academic degree. The increased credit hour requirement is
consistent with the increase in knowledge and skills required to support the change of
the scope of practice of audiologists that has occurred since the 30-unit requirement
was adopted in 1988. The requirement of 75 credit hours may be met by credits

awarded by the academic institution for formal courses, laboratories, and practicum

The requirement for 75 post-baccalaureate semester credit hours becomes effective
for persons who apply for certification after December 31, 2006. The requirement for
a doctoral degree is mandated for persons who apply for certification after December
31, 2011.

Graduate education in audiology must be initiated and completed in a program
accredited by AHSA's Council on Academic Accreditation in Audiology and Speech-
Language Pathology (CAA).

The program of study must include a practicum experience that is equivalent to a
minimum of 12 months of full-time, supervised experience.

The standards do not stipulate the specific courses or practicum experiences required.
The applicant must demonstrate that the acquisition of knowledge and skills was
assessed by the educational program that grants the post-baccalaureate degree.

The standards include maintenance of certification requirements (Standard VI) that
went into effect on January 1, 2003. Requirements for maintenance of certification
can be met through a variety of professional development activities or academic
course work (ASHA, 2001b).

The profession is in a time of transition. Not only is ASHA requiring a doctorate, the American
Academy of Audiology (AAA) also has doctoral-level requirements for certification (AAA,
n.d.). Audiologists in all practice settings are evaluating whether or not they will obtain a
doctoral degree, and individuals entering or currently enrolled in training programs are
evaluating their doctoral degree options in order to meet certification requirements. When the
new standards go into effect, audiologists holding ASHA certification will not be required to
obtain a doctoral degree as long as their certification remains current. To facilitate the acquisition
of doctoral degrees, especially the clinical Doctor of Audiology (AuD) degree, distance-learning
programs have been established to meet the academic and clinical needs for practicing
audiologists. Once a significant number of universities have audiology doctoral programs in
place, distance-learning programs may be phased out.

In addition to establishing the new audiology doctoral programs, academic programs are phasing
out their masters programs in audiology. Some universities are ready to bring new students into
doctoral programs, whereas others have not been able to meet doctoral degree standards or are
unable to obtain university funding to move to the doctorate.

Necessity of Continuing Education

Standard VI requires audiologists wishing to maintain their ASHA Certificate of Clinical
Competence in Audiology (CCC-A) to obtain and document continuing professional
development. This mandate began on January 1, 2003, and will be phased in according to initial
certification dates. The renewal period will be three years. This standard will apply to all
certificate holders, regardless of the date of initial certification (ASHA, 2001b). For audiologists
with masters degrees who already possess their ASHA CCC-A, continuing education is essential

to continue practicing audiology and to have a certificate that is portable across work sites and
state boundaries. For audiologists who have obtained their doctorate through distance-learning
programs or the newly established on-campus doctoral programs, continuing education is
essential as they continually improve their knowledge and practical skills.

According to Standard VI, professional development is defined as "any activity that relates to the
science of and contemporary practice in audiology, speech-language pathology, or speech,
language, and hearing sciences, and results in the acquisition of new knowledge and skills or the
enhancement of current knowledge and skills. Professional development activities should be
planned in advance and based on an assessment of knowledge, skills, and competencies of the
individual and/or an assessment of knowledge, skills, and competencies required for the
independent practice of any area of the professions" (ASHA, 2001b). Audiologists may
demonstrate continued professional development through one or more of the following options:

"Accumulation of 3 continuing education units (CEUs) [30 contact hours] from
continuing education (CE) providers approved by ASHA. ASHA CEUs may be
earned through group activities (e.g., workshops, conferences), independent study
(e.g., course development, research projects, internships, attendance at educational
programs offered by non-ASHA CE providers), and self-study (e.g., videotapes,
audiotapes, journals); or

Accumulation of 3 CEUs (30 contact hours) from a provider authorized by the
International Association for Continuing Education and Training (IACET); or

Accumulation of 2 semester hours (3 quarter hours) from a college or university that
holds regional accreditation or accreditation from an equivalent nationally recognized
or governmental accreditation authority; or

Accumulation of 30 contact hours from employer-sponsored in-service or other
continuing education activities that contribute to professional development" (ASHA,

Impact of Changes in Audiology Standards

The long-term impact of the changing standards on the profession of audiology and audiology in
the schools is unknown. Ultimately, audiologists will continue to broaden their knowledge base
and have more extensive preservice training. Specifically, the two major areas that will have an
impact on audiology services in and for the schools are: (a) financing and (b) knowledge.

Financial impact. One of the basic tenets of advocates for the AuD and other doctoral-level
degrees is that audiologists who possess a doctorate can expect to see salary improvements. For
audiologists practicing in school settings, this may actually be realized, because many salary
schedules in educational settings are based on academic degree. Individuals with various
advanced degrees (e.g., masters, education specialist, doctorate) frequently start out on
progressively higher salary schedules. In addition, most educators are able to better themselves
financially by obtaining advanced degrees after being hired by an LEA. It is anticipated that
audiologists with masters degrees who are currently practicing in the schools will move into
higher salary schedules if they obtain doctorates.


On the other hand, the increased salary demands of doctoral-level audiologists may decrease the
number of audiologists directly employed by LEAs and increase the use of audiology support
personnel, e.g., technicians, in order to balance the budget of LEAs that employ audiologists. For
LEAs that contract with audiologists in private practice, hospital, clinical, or university settings,
the cost of obtaining equivalent contracted services will increase. In addition, the CCC-A will
have increased importance to LEAs as they seek to bill Medicaid and other third-party insurers
for audiology services, as third-party payers often require the use of ASHA-certified providers.

Knowledge impact. The audiology doctorate will broaden the knowledge base and the clinical
skills of audiologists. Traditional masters degree programs in audiology are sometimes able to
provide the knowledge base and practicum experience necessary for success in audiology
practice in schools. The audiology doctorate can meet the needs of audiologists providing
services in the schools if one or more of the components of the doctoral program focuses on
audiology practice issues specific to educational settings. It is critical that advocates for and
experts in audiology service provision in the schools participate in the development of audiology
doctoral programs. This can assure that course work and clinical experience are relevant to
pediatric populations and educational settings. The next few years will be a golden opportunity
to shape audiology doctoral programs to meet the needs of LEA-based practitioners as well as
those providing services for LEAs.

The need for continuing education will also affect audiologists in the schools. Educators have
traditionally used academic course work at the graduate level as a way to enhance their
knowledge base and improve their salaries. Although graduate credit classes can meet the
continuing education requirements of ASHA if they result "in the acquisition of new knowledge
and skills or the enhancement of current knowledge and skills" in audiology or related
communication sciences (ASHA, 2001b), other activities can also be used to meet the continuing
education requirement. LEAs will need to provide: (a) graduate courses or continuing
professional development programs that are relevant to the practice of audiology or (b) adequate
release time and financial support for their audiologists to obtain necessary continuing education
through other mechanisms outside of the school setting. Some LEAs may already have these two
options in place; others will need to establish them.

The importance of ASHA's CCC-A will increase as LEAs strive to meet the Individuals with
Disabilities Education Act (IDEA) qualified provider provisions (IDEA, 1997). The preservice
and continuing professional development requirements attached to acquiring and maintaining the
CCC-A will ensure that audiologists have current knowledge about and skill in the practice of


New Standards

Various professional organizations have helped define the role of the audiologist in the schools.
Most recently, Guidelines for Audiology Service Provision in and for Schools (ASHA, 2002b)
have provided information about the legal mandates and the critical components of audiology
service delivery in the schools. The document highlights the need for audiologists to provide
audiologic assessment, audiologic rehabilitationo, education management, education training,
counseling, classroom acoustics measurements and recommendations, and integration with early
hearing detection programs. The Educational Audiology Association (EAA) developed
Minimum Competenciesfor EducationalAudiologists (EAA, 1994) that describes the knowledge
necessary for practitioners to work in the school setting. Preservice competencies (e.g., service
delivery models, overviews of educational theory of curriculum and instruction, speech and
language acquisition, and the psychological aspects of hearing loss in children and its impact on
the family) are included in the EAA document. The Recommended Professional Practices for
Educational Audiology (EAA, 1997) also describes skills that the competent school practitioner
needs in the areas of identification and assessment, amplification, hearing loss management,
conservation and consultation, program management, and professional leadership and

ASHA's new Audiology Standards address knowledge, skills, and attitudes pertinent to
educational audiology practice. Clearly, the intent of the new Audiology Standards is to prepare
audiologists to provide competent, comprehensive services in all settings, including school-based
audiology programs. For example, Standard III requires that "students shall participate in
practicum only after it has been determined that they have had sufficient preparation to qualify
for such experience. A variety of clinical practicum experiences must be obtained so that the
applicant can demonstrate skills across the scope of practice in audiology" (ASHA, 1997, p. 7).
Standard III also describes the program of graduate study that must be completed for ASHA
certification. The program requires at least 75 semester hours of "academic course work and a
minimum of 12 months' full-time equivalent (FTE) of supervised clinical practicum sufficient in
depth and breadth to achieve the knowledge and skills outcomes stipulated in Standard IV" ( p.

Standard IV describes the knowledge and skills outcomes necessary for certification in
audiology. Standard IV provides advocates for audiology services in the schools an
unprecedented opportunity to shape the doctoral course of study to meet the needs of school
practitioners and meet the requirements of IDEA. It describes the areas of knowledge that the
doctoral audiology student must master: skills and foundations of practice, prevention and
identification, evaluation, and treatment. Standard IV also provides many opportunities for issues
related to audiology services in the schools to be infused into the curriculum. For instance, it
mandates the necessity for the student to have knowledge about "educational, vocational, and
social and psychological effects of hearing impairment and their impact on the development of a
treatment program" (p. 8). It also requires that the student be able to "interact effectively with
patients, families, other appropriate individuals, and professionals" (p. 8). Finally, Standard IV

mandates the need to "develop culturally sensitive and age-appropriate management strategies"
(p. 8).

What Needs to Be Done

The impetus for the audiology doctorate sprang from the needs of audiologists working in private
practice and hospital settings to have increased autonomy and an expanded knowledge base.
Indeed, the vast majority of audiologists are employed in hospitals or private practice settings
(ASHA, 2001c). Audiology services in the schools have always been provided by a relatively
small number of audiologists. As audiology doctorate programs are developed, it is critical that
the needs of the school practitioner be incorporated into the doctoral program. This will take
dedication and perseverance because the majority of audiology doctoral graduates will be
employed in other practice settings.

Although many courses within the audiology doctorate framework will benefit from the
information about audiology service provision in educational settings, the inclusion of specific
course work focusing on pediatric audiology, educational/legal issues, and client/family/student
issues will realize the greatest benefit. Pediatric audiology courses will need to include areas
relating to identification, assessment, amplification, and audiologic intervention. Educational/
legal course work should examine federal legislation such as IDEA, the Americans with
Disabilities Act (ADA), and Section 504 of the Rehabilitation Act of 1973 (Section 504).
Discussion of IDEA is a perfect opportunity to stress the importance of qualified providers and
the importance of a well-run "Child Find" program that will identify children who are at risk for
hearing loss. Discussion of educational/legal issues might also encompass issues that occur in the
education setting and might cover information about health provider systems and case manager
responsibilities. Client/family/student course work should stress the importance of: (a)
counseling, (b) including parents as part of the educational team, and (c) increasing the
audiology student's understanding of and sensitivity to cultural diversity and socioeconomic

The mandate for the doctoral degree as the entry-level credential for audiologists and for
continuing education gives proponents for school audiology services the opportunity to advocate
for better preparation of individuals who practice in this setting. By doing so, the general
knowledge level of those who practice will be broadened and the pediatric population will be
better served. Now is the time for changes to occur.


National Credentials

Audiology, like many other education and health-related professions, has national certification
that is often required for employment, reimbursement, and career advancement. ASHA's
Certificate of Clinical Competence in Audiology (CCC-A) is the national credential held by most
audiologists seeking national-level recognition. Approximately 13,000 audiologists currently
hold this credential (ASHA, n.d. a). The American Board of Audiology (ABA) has a national
credential that is held by approximately 700 audiologists (Phil Darrin, personal communication,
April 9, 2003).

State Credentials

Licensure is required for the practice of audiology in most states. Forty-seven (47) states regulate
audiologists, 44 through licensure and 3 through registration or certification (ASHA, 2002c). To
date, licensure credentials have been modeled on ASHA's CCC requirements. Licensure boards
are discussing how to modify their licensure laws to accommodate the impending change in
educational preparation. Consistent with national trends, many licensure boards require
continuing education/competence for renewal. However, not all employment in the public school
sector requires state audiology licensure. Only 21 of the states that require licensure for the
practice of audiology use this as the credential required in the public schools. Another 20 states
have a special audiology credential for the practice of audiology in the schools. A review of
these credentials suggests that they are also based on equivalent requirements found with the
CCC-A and additional pedagogy courses or tests. Within the regulations for most of the states,
the title audiologist is protected and reserved for individuals who hold state licensure or
registration regardless of practice setting. In addition, many states also require registration or
licensing that allows otherwise licensed or registered audiologists to dispense hearing aids. This
often includes fitting and dispensing hearing-assistive technology as it relates to classroom
educational amplification (e.g., FM systems). Typically, continuing education requirements are
tied to this credential, allowing audiologists to fit and dispense hearing aids and other hearing
assistive technology. Some LEAs prefer that the audiologist also hold a teaching credential-
part of an antiquated system where teachers went on to become audiologists. It also reflects the
management systems of SEAs where an audiologist category did not exist. The need for
audiology to become recognized as a distinct profession in the public schools becomes more
important as greater implementation of IDEA and Section 504 is realized. Professional
development and staff improvement plans are most often a part of the requirements for continued
employment within LEAs.

Anecdotally, many of the audiologists employed or contracted by LEAs seem to hold a variety of
credentials that allow them to work across practice sites and maintain all aspects of their
professional practice. For example, in New York State, an audiologist working in the public
schools typically holds three different credentials from three different state-level credentialing
bodies (State Department of Labor; State Education Department, Office of the Professions; and
State Education Department, Office of Teaching).

1 1

Issues Facing the Credentialing Agencies

Credentials required for audiologists employed in the public school sector vary from state to
state. Although most of the entry-level credentials appear to be based on the national
certification, ASHA's CCC-A, there are differences. As mentioned, the continuing
education/competence requirement for audiologists has been instituted in many states.
Continuing education is also now a requirement for maintaining national certification.
Credentialing agencies in states as well as national certifying agencies have unique requirements.
Although some of these may overlap, they do not all require the same type, format, or amount of
professional development for audiologists practicing in the schools. The new requirements for
continuing professional development and a doctorate as the entry degree for practice as an
audiologist will affect these credentialing bodies. As college and university programs that offer
masters degrees in audiology close (a trend already in evidence), audiologists seeking positions
in all settings will hold a doctoral-level degree. Credentialing bodies will need to determine if
their credential will reflect the new standard and, if not, how to resolve the difference.

Issues Facing the State and Local Education Agencies

SEAs, LEAs, and administrators must examine carefully job descriptions, supervision
requirements, and budgetary issues as they relate to audiologists. Although some LEAs may
have doctoral-level staff, it is not the common degree. Attracting and retaining these
professionals in the public school arena to provide service to children with a variety of
significant needs will be a challenge. Salaries, equipment and material resources, autonomy, and
respect are hurdles LEAs and SEAs will face. Additionally, collective bargaining units will need
to examine their contracts carefully to represent best the needs of this small, but important,
category of professionals. A question often posed is which credential is best suited for the types
of responsibilities an audiologist has in the public schools. To date, it does not appear that one
single credential suffices, but the prevailing credentials would suggest that the CCC-A does
provide the basic clinical, rehabilitation, and counseling requirements needed. It becomes
incumbent, however, on the State to define clearly the credentials necessary for practice in the
schools. In doing so, consideration must be given to IDEA, ADA, and Section 504 provisions
and Medicaid requirements as they pertain to reimbursement and school practices. LEAs also
need guidance from the State to assure proper credentialing of independently contracted
audiology providers. As mentioned earlier, credentials currently include for some: (a) teaching
certificate, (b) license, and/or (c) registration for dispensing. This discussion alone can cause
administrators to look at current staff to fulfill the functions of an audiologist. The myriad of
credentialing requirements may cause confusion for administrators and result in inappropriate
assignment of audiologist functions to another staff member.

Issues Facing Families and Children

Parents of young children first identified with hearing loss are often without the supports
necessary to manage their child's intervention services and education appropriately. At the time
of diagnosis and initiation of services, they must meet and work with so many different
professions and people that they often feel alone and unprepared. Knowing the services
available for infants, toddlers, and school-age children and then learning how to access these
services can be overwhelming. Audiologists in the schools can assist parents in managing the
educational experiences of their child with a hearing loss.

Children with hearing loss and/or auditory disorders may consider themselves academic failures,
isolated, and/or singled out. School personnel often become the primary witnesses of the
student's frustration, fatigue, and anger; but staff do not always recognize that the behaviors they
see are a result of the child's hearing loss and/or auditory disorder. The educational audiologist
is also able to assist school personnel in learning how to work with children with hearing loss
and/or auditory disorders.

Issues Facing the Audiologist

Surveys, membership information, and other data suggest that there are fewer than 1,300
audiologists working in the schools in some capacity nationwide-a much smaller number of
audiologists than is needed. School audiologists are a small percentage of the professional staff
employed in this sector. This can lead to professional isolation, an overextension of
responsibilities, and a tendency to be under-appreciated or supported by the administration.

Finding out the credentials needed, which is also the responsibility of the audiologist who
chooses to work in the schools, can be formidable, because often required credentials are
managed by different governmental bodies or divisions. Fees to obtain/maintain multiple
credentials and the common need to affiliate with a collective bargaining unit are extra expenses
for the audiologist working in the schools. Additionally, representation in a collective
bargaining unit is often difficult, because audiologists often have a nontraditional role in the
school setting. Gaining representation may also present another challenge to the audiologist who
chooses to practice in schools and affiliate with collective bargaining units.

Continuing professional development will become an overwhelming activity for the busy
audiologist employed in the LEA. Release time and financial support are concerns. Meeting and
reconciling various requirements to maintain multiple credentials is indeed a challenge.

Audiologists are faced with rapidly changing technology, new research, and advanced and
expensive instrumentation. Children in schools have increased listening and hearing needs.
Schools have shrinking budgets. Ensuring quality services in or for schools will demand that
audiologists work with LEAs to manage the provision of audiology services, program
development, and contractual arrangements carefully.

Audiology services, which are clearly delineated in IDEA, are often delivered in a non-
traditional manner in schools. Many parents and teachers do not know about these services.
Advocacy at all levels is required to allow audiologists to provide services to our children in the
schools. Organization of this effort and quality information continues to be a challenge for the
audiologist working in the schools.

With all of its challenges, the critical role the audiologist plays in the schools is mandated by
public law. The issues, hurdles, and challenges will be met with success if SEAs, LEAs,
audiologists, administrators and other professionals, and bargaining units understand the
importance of including the credentialed audiologist as a permanent and integral part of the
educational team.


Needs Estimates

Estimates of the number of students in schools requiring audiology services.
Estimating the number of students in schools requiring educational audiology services is a
difficult task. Some LEAs may elect to provide services only to students who qualify under
IDEA, Section 504, and ADA. Others may choose to make certain audiologic services available
to all students, depending on the size and depth of the program. LEAs may currently choose to
provide educational audiology services to children from birth to age 21, 3 to 21, or 5 to 21.
LEAs, often by state law, are typically required to conduct audiologic screenings and hearing
conservation programs for all children. Universal newborn screening programs have been helpful
in early identification of hearing loss and better delineation of hearing needs by school age. It is
anticipated that the increased number of children receiving cochlear implants will attend their
neighborhood schools rather than being placed in special or self-contained classrooms or
schools. LEA-based audiologists are involved in many of the programs and services directed
toward children with hearing loss and/or auditory disorders. Depending on the depth and breadth
of the services required and offered, estimating the numbers of students requiring audiology
services can be complicated.

One source of information on the number of children who might potentially require or benefit
from the services of an audiologist is the 23rdAnnual Report to Congress on the Implementation
of the Individuals in i/h Disabilities Education Act (2001). The total resident population of
children 3 to 21 years old in 1999-2000 was 74,453,695 (Table AF1). The birth to age 2 resident
population was 11,334,677 (Table AF2). Adding these two figures yields approximately 86
million children in the U. S. in need of audiology services of some nature.

Students identified with Hearing Impairments, (Table AA2) in the 1999-2000 school year were
71,539 students from 6 to 21 years old. If students with Deaf-Blindness (Table AA2) are added,
an additional 1,840 students 6 to 21 years old were served. It is reasonable to assume that these
children required audiology services. Knowing that hearing loss and/or auditory processing
problems can coexist with all of the disabling conditions identified under IDEA, Table AA1
shows that during the 1999-2000 school year 6,253,853 students with disabilities from 3 to 21
years old were served under IDEA. Extrapolating from these figures suggests that the number of
children from 3 to 21 years old in need of educational audiology services is over 6 million.

In addition to data from the report to Congress, which focuses only on services to students served
under IDEA, data dealing with the prevalence and incidence of hearing loss in children are
available. For example, in the document Healthy People 2000, the U. S. Public Health Service
makes several statements about hearing loss in children:

Over one million children in the U. S. have a hearing loss.

5% of children 18 years old and under have a hearing loss.

Approximately 83 of every 1,000 children in the U. S. have what is termed an
educationally significant hearing loss (U. S. Public Health Service, 1990).

1 A

Additionally, in Healthy People 2010, 2 or 3 out of every 1000 live births result in a baby with a
congenital hearing loss and approximately 15% of all children have a hearing loss (U. S. Public
Health Service, 2000).

Berg (1985) and Lundeen (1991) reported that approximately 19 out of every 1000 school-aged
children have unilateral hearing loss that may interfere with their education. More recent
research has found the number to be between 11.3% and 14.9%-an average of 131 of every
1,000 school-age children have some degree of hearing loss that affects learning and
development (Bess, Dodd-Murphy, & Parker, 1998; Niskar, Kieszak, Holmes, Esteban, Rubin, &
Brody, 1998).

While audiologists are very involved in the assessment, intervention, and management of
children with (C)APD, it is difficult to estimate the number of children who may have auditory
processing problems. Factors that complicate obtaining demographic data include the varying
definitions of (C)APD and the fact that (C)APD is not a category of disability under IDEA.
These children are often classified under IDEA as having a learning disability and/or a speech-
language impairment. Chermack and Musiek (1997) estimated that 2% to 3% of all children have
a (C)APD. Based on this estimate, given the resident population of children 3-21 years old as
74,453,685 (U. S. Department of Education, 2001), there are approximately 1,489,073 to
2,233,611 children in the U. S. with an auditory processing disorder.

Estimates of the number of audiologists currently employed in schools. Again, the
23rd Annual Report to Congress on the Implementation of the Individuals i /ih Disabilities
Education Act (2001) cites data on FTE audiologists employed during the 1998-1999 school
year (the only year reported) to provide special education and related services for children and
youth with disabilities. In 1998-1999 (Table AC3), 1,051 fully certified audiologists were
employed. In addition, there were 175 audiologists employed who were not fully certified as
audiologists. This represents an increase in employment of 122 not fully certified as audiologists
in comparison to the 22nd Annual Report (U. S. Department of Education, 2000). Data on
vacant positions are not available in this 23rd Annual Report. However, the previous 22nd Annual
Report noted 36 FTE positions vacant. The presence of funded but vacant positions and the
dramatic increase in the employment of individuals not fully certified suggests a shortage of
educational audiologists. Using the total resident population figure for 1999-2000 of children 3
to 21 years as 74,453,685, there is approximately 1 educational audiologist for every 70,840
students in the U. S.

ASHA reports that 12,650 audiologists hold the Certificate of Clinical Competence in Audiology
in the document Highlights and Trends: Annual Counts of the ASHA Membership and Affiliation,
2002. Table 6 of that report, Demographic Profile of the ASHA Member and Nonmember
Certificate Holders Certified in Audiology Only for January 1 through December 31, 2002,
indicates that of those who identified a primary employment facility (n = 10,095), 9.5%, or 959
certificate holders, indicated they were employed in a school (ASHA, n.d. a).

Current and suggested ratios of educational audiologists to children. To serve
adequately the needs of children in educational settings, 1 FTE audiologist for every 10,000
children aged birth through 21 years old served by an LEA is recommended (Colorado
Department of Education Special Education Unit, 1998). ASHA's Guidelines for Audiology
Service Provision in and for Schools (2002b) recommends 1 FTE audiologist for every 10,000
children as well. However, the guidelines state "when audiologists provide time-intensive
services (e.g., direct management/intervention, service to infants and toddlers) and one or more

of the factors listed below is present a caseload ratio of 1:10,000 will be unreasonable and must
be reduced. These factors will affect and influence the audiologist's case load:

itinerancy/excessive travel time

number of schools and LEAs served

student placements with an LEA

number of children with hearing loss and/or (C)APD

number and ages of children with other disabilities requiring audiologic assessment
and intervention services

number of hearing aids, cochlear implants, and HATs (hearing-assistive technology
systems) in use

number of tests provided, including auditory test batteries

number and ages of students receiving direct, ongoing audiologic intervention

number of infants and preschoolers receiving assessment and intervention services

EHDI (early hearing detection and intervention) program responsibilities

hearing loss identification/prevention/conservation program responsibilities

scope of audiologic services provided (e.g., assessment, intervention, hearing aid

extent of supervisory and administrative responsibilities

number of multidisciplinary team meetings and reporting requirements

in-service training and counseling responsibilities

other duties assigned that are outside the audiologist's scope of service delivery."

(ASHA, 2002b, p. II-122)

Trends that illustrate the impact of the factors listed above are identified in an ASHA report 2001
Omnibus Survey Practice Trends in Audiology (ASHA, 2001c). ASHA questioned a sample of
its constituents regarding their case loads. Those respondents working in schools reported an
increased number of students with digital amplification and cochlear implants on their case
loads. In ASHA's Audiology Survey 2000 Edition: Final Report (2000), 71.8% of audiologists
working in schools report that they participate Frequently to Very Frequently on Individual
Educational Program (IEP) development teams. More than 27% report that they participate on
Individualized Family Service Plan (IFSP) development teams.

Based on the number of students with hearing loss identified and served under IDEA and the
number of children with hearing loss and/or auditory disorders receiving or in need of audiology
services under mandates (e.g., Section 504, ADA and/or other federal, state, local initiatives), it
is clear that the need for LEA-based or contracted audiology services will not diminish in the
near future. Additionally, with the advent of universal newborn and infant hearing screening,
hearing loss in children will be identified early, and intervention programs will be instituted
early. In increasing numbers, audiologists in educational settings should and will be involved in
assessment, intervention, and management of these children. It is clear that educational
audiologists provide comprehensive services in and for LEAs. Roles have expanded and
continue to expand, which suggests that the recommended ratio of 1 FTE audiologist for every
10,000 students may be inadequate and should be improved.

Factors Influencing the Demand for Educational Audiologists

Legislative mandates. Mandates such as IDEA, Section 504, and the ADA all have
requirements for determining eligibility, assessment and evaluation, re-evaluation, and program
implementation and monitoring that require the services of an audiologist. IDEA's requirements
for assistive technology and the assurance of proper functioning of hearing aids also require the
expertise of an audiologist.

Health care regulations. Recently enacted legislation for universal newborn hearing
screening will place identified children into early intervention programs sooner. In those states
where the lead agency for "Child Find" and early identification and intervention programs is the
SEA or LEA, educational audiologists have and will continue to have a major role in program
development, management, and implementation.

Unique hearing and listening disabilities of children in schools that require
specialized and frequent audiology services and technology. Some examples of
situations requiring specialized and frequent audiology services are:

an increasing number of children with cochlear implants in schools requiring
extensive coordination, communication, and intervention between the LEA-based
audiologist and the audiologist/other professionals at the cochlear implantation center

proliferating use of hearing assistive technology (such as FM systems and classroom
amplification) to complement student's personal hearing aids and the detailed on-site
management required

monitoring of fluctuating hearing loss (occurring with otitis media) and the
accommodation required to assure a student's accessibility to the acoustic
instructional environment

providing direct intervention services to students with hearing loss or (C)APDs.

New federal initiatives in education. Legislation such as the No Child Left Behind Act
(NCLB), Reading First, and other initiatives in the general education arena have involved
audiologists in programs in listening skills development and phonemic awareness skills
development for children who have not been classified as having disabilities.

1 -7

Expanded roles of audiologists in schools beyond those associated with hearing
loss. Examples of expanded roles of educational audiologists are:

consulting with teachers as they employ strategies for meeting state standards dealing
with listening skills

consulting with teachers and administrators on reducing the effects of damaging noise
on hearing that occurs in instructional environments, particularly in career and
vocational education

assisting schools in implementing standards for classroom acoustics including
analysis of classroom noise and acoustics, making recommendations for improving
the listening environment, facilitating acoustic accessibility to instruction (Acoustical
Society of America [ASA], 2000; American National Standards Institute [ANSI],
2002; ASHA, 1995, 2002a, 2002b)

working with teachers and administrators to assure appropriate classroom acoustics
for instruction (creating an environment with appropriate signal-to-noise ratios and
reverberation times) (ASA, 2000; ANSI, 2002; ASHA, 2002a, 2002b)

providing assessments for children who fail audiologic screening as well as children
with disorders other than peripheral hearing loss (e.g., (C)APDs, attention deficit
disorders, learning disabilities, autism) and children served under Section 504 plans

providing for and monitoring hearing assistive technology (e.g., personal and sound
field amplification systems) to improve listening capability for students with hearing
loss, (C)APDs and other disorders (e.g., attention deficit disorders).

Value placed on audiology services by a school district in the absence of
mandates. Although all school districts must comply with state and federal mandates, some
districts have come to value and involve the expertise of the educational audiologist throughout
their programs and services. Educational audiologists have an understanding of curricula, the
variety of settings and contexts of instruction (natural environments, hospitals, distance
learning), and instructional dynamics (co-teaching, using teacher aides, one-on-one aides for
individual students, instruction involving related service providers) (Huffman, 1997).

Factors Influencing the Supply of Educational Audiologists

Desire to work in a public school. Audiologists work in a number of employment settings,
including health care (hospitals, nursing homes, home health, private physician's offices); clinics
and agencies (speech and hearing centers); colleges and universities; private practice; industry;
and schools (special schools, preschools, elementary and secondary schools, and intermediate
units) (ASHA, 2001a). Given the roles/responsibilities and the knowledge/skills required for
educational audiology services, some audiologists may choose not to work in schools. On the
other hand, the working conditions, roles and responsibilities, and prestige in the school setting
may be highly appealing for others.

Availability of employment. Regarding demand, small school districts may not necessarily
hire audiologists. They may use intermediate education agencies or cooperatives to provide

audiology services or contract with a local agency, clinic, university, or private practice for
specified audiology services. Regarding supply, there may be geographical "pockets" where
universities in close proximity produce audiology candidates for certification, resulting in an
oversupply of available audiologists. In other geographical regions (e.g., rural areas), there may
be an undersupply.

Before recent changes to the audiology standards, the number of audiology students seeking
doctoral-level degrees was declining. Therefore, audiology programs transitioning to the doctoral
degree are faced with a shortage of doctoral-level faculty, thus limiting the number of students
who can be admitted to programs. This may ultimately lead to an initial reduction in the number
of audiologists entering the profession and a need for LEAs to increase recruitment and retention

Salary. ASHA's 2001 Omnibus Survey Salary Report (2001d) reports median academic-year
salaries in school settings as $42,600 per year for audiologists. Median calendar year salaries for
audiologists in private practice are $50,000. Audiologists working in LEAs are often covered by
collectively bargained salary and benefits packages that may have immediate and long-term
appeal. On the other hand, as audiologists begin to command higher salaries based on their
doctoral degrees, salaries offered by LEAs may not be appealing or will have to be negotiated
differently or outside of collective bargaining units.

Credentialing requirements. Credentialing requirements are in transition. Many
audiologists, including those currently employed in schools, are in the process of obtaining an
AuD or other doctoral degree. Individual states have requirements for licensing and teacher
certification, which may or may not include a doctorate requirement for school employment. For
example, with a transition to a doctoral degree, fewer audiologists may graduate, those who do
graduate may be attracted to private practice where more attractive salaries are perceived, and
schools with collective bargaining agreements may not offer salaries that persons holding
doctoral degrees find attractive. Nonetheless, the impact on the supply of educational
audiologists remains to be seen.

Critical Questions

Issues of supply and demand for audiologists in the schools require answers for several critical

Given the unique needs of children with hearing and listening disabilities in today's
schools, how do professional preparation requirements for audiologists influence the
supply and demand of audiologists who wish to work in school settings (i.e.,
educational audiologists)?

How can certification requirements and licensure requirements promote easily
accessible and high-quality services for students in schools?

Given changing credentialing requirements, how can the supply of qualified
audiologists be increased to meet recommend service levels, e.g., 1 FTE audiologist
per 10,000 students?

* Given the date of the 23rd Annual Report to Congress, what accounts for the
significant increase in the number of personnel employed who are not fully certified
as audiologists?

* Given legislative mandates and the limited funding resources of LEAs, how can
educational audiology services be made available to students in need?

* What will the audiologist's role be in federal initiatives targeting children who are not
identified as disabled but who must be provided services (e.g., those required in the
No Child Left Behind Act, Reading First, and other initiatives undertaken as a result
of presidential commissioned panels)?

* How can educational audiologists demonstrate efficacy? Given the current climate
and interest on outcomes, how can audiologists better define and educate others about
the value of their services?

* How can audiologists increase the visibility of their services and promote the
provision of services when they are not mandated? If states and LEAs are not
mandated to provide services, they are not likely to do so. Parents who are not aware
of their rights to services will not request them. If name recognition is increased, will
demand for services increase?


Research continues to document the high incidence of hearing loss in children of all ages and the
potentially negative consequences hearing loss and/or (C)APD can have on communication,
academic performance, and psychosocial development. The variable effects of hearing loss
and/or (C)APD depend on several factors (e.g., nature and degree of loss or disorder). Thus, it is
essential that children with hearing loss and/or (C)APD receive comprehensive audiologic
services to reduce the possible negative effects of the loss or disorder and maximize their
auditory learning and communication skills. Furthermore, all children in educational settings can
benefit from audiologic services in developing listening skills, instruction in prevention of
hearing loss, and the provision of accessible acoustic environments. It is clear that the
preparation of audiologists who provide services in educational settings will be impacted by: (a)
changes in audiology standards facilitating a need for SEAs and LEAs to evaluate and to modify
the way in which they access and provide audiology services in the schools and (b) continuing
professional development for LEA-based audiologists. As national credentialing standards
change, it is imperative that states, SEAs, and LEAs examine and perhaps modify their licensure,
registration, and/or certification requirements to accommodate provisions of the new audiology
standards. In addition, as audiologists obtain and/or enter the profession with doctoral degrees,
SEAs and LEAs will need to make fiscal modifications to accommodate the increased salary
demands of LEA-based audiologists as well as increased fees for contracted services. LEAs will
also need to implement or modify recruitment and retention efforts to attract audiologists with
doctoral degrees to school settings.


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