298
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JULY, 1975
Prevalence of Speech, Language, and Hearing Disorders Among Harlem Children* R. M. HALLER, Ph.D., and
E. A. THOMPSON, M.D., Columbia University-Harlem Hospital Center, New York, New York
prevalence studies have typically estimated that from 7 to 12% of the elementary school age population have speech defects'1- and about 2 to 4% of the same population have handicapping hearing losses.3'6"1218 Most speech surveys include language impairments under the speech label. Our review of the literature failed to locate any survey of these disorders exclusively among black children. We would anticipate that the prevalence of communication disorders among black children is comparable to that of white children, controlling for socioeconomic class. However, a far greater percentage of blacks are at or below the poverty line where the prevalence of communication disorders has been estimated to be triple the national figures. 19 This is particularly true at Harlem Hospital where about 60% of clinic patients are covered by Medicaid. A dramatic example of this estimate was reported in a survey of hearing impairments at a children's shelter in New York City.20 To this shelter come children who have run away or have been legally removed from their homes or been apparently abandoned by their parents. A great majority of these children are black and poor. The survey found that 28.9% of the children tested failed audiometric screening. In another study,21 27.2% of American Indian children tested failed hearing screening, as opposed to only 19.2% of non-Indian children in the same *Read at the 78th Annual Convention of the National Medical Association, York City, August 1973.
News
state. This paper reports some preliminary prevalence data on communication disorders among black children in Harlem, one of the largest black communities in the nation. The screening program, from which these estimates were derived, and the follow up procedures are also described. The Speech and Hearing Center is a unit of the Otolaryngology Service at Harlem Hospital Center. Speech and hearing screening is provided routinely as part of the Health Department's multiphasic screening program for public and private school children. Day Care and Head Start children are also screened in our unit by group appointments. In addition, all pediatric in-patients are screened for hearing. PROCEDURES
Children are screened individually for speech and language by our speech therapists and for hearing by our audiologic specialists. The time required for each of the two screening procedures ranges from three to 10 minutes, depending on the age of the child and the severity of his communication problem. Our screening cards list all identifying information which facilitates our contacting both the parents and the referring agencies for followup purposes. Speech dimensions included on this card are articulation, phonation, resonation, flow. Both receptive and expressive language are screened. Hearing screening is accomplished in a sound treated
Vol. 67, No. 4
CCiildren's Communication Disorders
I. A. C. booth through pure tone audiometry, encompassing the octave frequencies from 500-4000 Hz in each ear by phones at a level of 15dB (ISO, 1964). Inadequate responses to one or more frequencies in either ear constitutes failure on this test. Examiners are all staff members who are supervised by the senior staff holding the certificates of clinical competence in speech pathology or audiology, issued by the American Speech and Hearing Association. Determinations of the child's adequacy in receptive and expressive language, phonation, resonance, and fluency are subjective and are based on the child's conversational sample, including his response to several oral instructions. We consider that the speech therapists' training and experience in black dialect are satisfactory for a determination of unacceptable language that is not based on normal dialectal variations in vocabulary, inflectional endings, syntax, or semantics. Articulation adequacy is based on the child's score on the Templin-Darley Screening Test of Articulation,22 a 50 item picture naming task. Since the age norms of this test are based on a predominantly white midwest sample, normal black dialectal variations have been incorporated into the acceptable responses at clinic. For example, in the standardized instructions of the test, only the responses "teeth "' and "string" may be scored as correct, for one point of credit each. Our procedure also scores as correct the widespread black dialectal versions "teef"' and "skring". Followup of all children failing speech, language, or hearing screening is first initiated in the Speech and Hearing Center by its diagnostic team. Those failing speech or language screening are normally examined during the same morning within three weeks of the initial contact by the otolaryngologist, pediatrician, speech therapist, psychologist, and social worker. The team then discusses each child, and the coordinator lists the recommendations on a special form, with copies in the child's medical and unit charts. The team examination routine concludes with one of the examiner's meeting with the parents to
299
discuss the recommendations and expedite such followup as referral to other clinics at the hospital. Followup of all children failing hearing screening consists first of an otolaryngological examination, followed by either hearing rescreening the same morning or later audiologic evaluation. If impacted cerumen or another material is removed from the ear canal, immediate hearing screening is indicated. However, if the apparent hearing loss is caused by other pathology requiring treatment in another unit of the hospital, an audiologic evaluation is ordered. This audiologic evaluation consists, at the minimum, of pure tone and speech reception thresholds, the former encompassing the octave frequencies from 250-8000 Hz. Utilization of a B and K Hearing Aid Test Chamber assembly helps to insure that all audiometers are in calibration. The full range of hospital facilities are utilized in the comprehensive evaluation and treatment of the child. All followup evaluation and treatment of communication disorders are done at the center. RESULTS AND DISCUSSION
Our prevalence data for this report are based on 979 children screened for speech and 990 children screened for hearing from February through June, 1973 and ranging in age from three through 17 years. Table 1 shows that 9. 1 % of the children failed speech TABLE 1. PERCENTAGE OF SPEECH AND HEARING SCREENING FAILURES AND AGE Age Range (Years & Months)
Number of Children Screened
15-0 to 17-11 12-0 to 14-11 10-Oto 11-11 8-Oto9-11 7-Oto7-11 6-0to6-11 5-0 to 5-1 1 4-6to4-11 4-0 to 4-5 3-6 to 3-11 3-0 to 3-5 Total
45 409
119 118 26 41 80 49 56 50 25 990: Hearing 979: Speech
Percentage of Children Failing: Hearing Speech 15.8 16.9 19.3 18.6 19.2 30.0 12.5 13.0 17.9 7.9 45.0 17.7
13.3 4.3 10.6 10.7 15.0 22.0 18.7 6.1 5.4 14.0 12.0 9.1
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
300
TABLE 2. PERCENTAGE OF SPEECH AND HEARING SCREENING FAILURE IN PRESCHOOL AND SCHOOL-AGE CHILDREN
School Status
Number of Children Screened
School Age* Preschool Age
838 180
Percentage of Children Failing: Hearing Speech 9.13 8.88
17.71 17.50
*Kindergarten through 12th grade
screening and 17.7% failed hearing screening. These figures fall within the typical ranges of prevalence data reported for predominantly white children in various parts of the country. Inspection of the percentages of speech and of hearing screen failures across age range categories shows no consistent trend, although the highest single percentage in each defect area occurred below the age of seven years, namely, 45% of the hearing screening failures in the age range three years to three years, five months, and 22.0% of the speech screening failures in the age range six years to six years, 11 months. However, Table 2 indicates that the incidence of both speech and of hearing screening failure was roughly comparable among children attending head start and day care centers vs. those attending public and parochial schools. The boys had a considerably higher incidence of test failure in each of the two categories than did the girls. More than 20% of the boys failed speech screening as opposed to only 3.6% of the girls. This finding is consistent with the speech pathology literature in estimating that from three to seven times as many boys than girls have speech impairments. Also 11.7% of the boys but only 6.0% of the girls failed hearing screening. These data support the impression that boys seem to be more susceptible to upper respiratory infections than are girls. Table 3 provides a breakdown of the percentages of speech screening failures which were attributable to various types of speech impairment. About two thirds of the children failing speech screening had articulation defects and about one fifth of the speech failures were dysphonic. The predominant dysphonia was hoarseness. Thus, the ratio of
JULY, 1975
articulation to voice defects was about three to one, as compared to about eight to one cited in the literature.3 This apparent discrepancy may be explained in two ways. First, there may be a higher prevalence of conditions causing laryngeal problems in children in Harlem than in most other communities. Second, our speech therapist may be more sensitive to vocal quality deviations than most of their peers due to their close working relationship with otolaryngology. A breakdown of hearing screening failure by the extent of frequencies failed that reveals 3.6% of children failed to respond adequately to all frequencies bilaterally and that only 5.9 failed all frequencies unilaterally with normal responses in the contralateral ear. On the other hand, 25.9% of the children failed only one frequency in one ear TABLE 3. DISTRIBUTION OF SPEECH SCREENING FAILURES IN DEFECT CATEGORIES
Speech Defect Category Articulation Phonation Speech Rhythm Expressive Language Resonation Receptive Language More than one category
Percent of Children Failing in That Category 62.9 21.9 4.4 2.4 1 .5 0.5 6.3
while responding normally in the other ear, and another 15.0% failed only one frequency in each ear. However, the most frequently occurring failure (29.5%) w4s in children who failed at least three frequencies in both ears while responding normally to at least one frequency in each ear. The prevalence figures presented today are subject to two obvious sources of error. The speech data are heavily weighted by voice defects, many of which probably represent symptoms of acute laryngological conditions. In addition, many of the hearing screening failures may be "false positives" or may also have resulted from transient medical problems. In one study, 19 more than 35% of an "Inner City" sample who had originally failed hearing screening passed their rescreening tests. Fortunately, our followup
Vol. 67, No. 4
301
Children's Communication Disorders
procedures allows us to examine these possible artifacts, and these questions will be dealt with in our future research. SUMMARY
We have described the initial phase of a speech and hearing screening program at Harlem Hospital. Follow-up procedures stress the team approach and the role of the otolaryngologist. Results of screening of approximately 1,000 children suggest that the incidence of communication disorders among Harlem children is within the range of estimates in other parts of the country. In the present study, 9. 1 % of children failed speech screening, and 17.7% failed hearing screening. There was little evidence that communication disorders were less common with increasing age. Boys were about seven times as likely to fail speech screening as girls and had about twice the incidence of hearing screening failure as girls. About half of the children failed hearing screening in one ear only while the remainder appeared to have bilateral involvement. Articulation defects accounted for about 63% of the speech screening failures with voice problems constituting an additional 22% of the failures. LITERATURE CITED
1. ASHA COMMITTEE ON THE MIDCENTURY WHITE HOUSE CONFERENCE, Speech Disorders and Speech Correction. J. Speech Hear. Dis., 17: 129-137, 1952. 2. BLANTON, S., A. Survey of Speech Defects. J. Educ. Psychol., 7: 581-592, 1916. 3. CANTER, G. J. (Ed), Human Communication and its Disorders-An Overview. Bethesda, Md.: National Institutes of Neurological Disease and Stroke, U.S. Public Health Service, 1969. 4. HULL, F. M. and R. J. TIMMONS. A National Speech and Hearing Survey. J. Speech Hear. Dis., 31: 359-361, 1966. 5. HULL, F. M. and P. W. MIELKE, R. J. TIMMONS and J. A. WILLEFORD. The National Speech and Hearing Survey: Preliminary Results. ASHA, 13: 501-509, 1971. 6. IRWIN, R. B. Ohio Looks Ahead in Speech and Hearing Therapy. J. Speech Hear. Dis., 13: 55-60, 1948. 7. LOUTIT, C. M. and E. C. HALLS. Survey of Speech Defects Among Public School Children in
Indiana. J. Speech Dis., 1: 73-80, 1936. 8. MILLS, A. and H. STREIT. Report of a Speech Survey, Holyoke, Massachusetts. J. Speech Dis., 7: 161-167, 1942. 9. PRONOVOST, W. A. Survey of Services for the Speech and Hearing Handicapped in New England. J. Speech Hear. Dis., 2 16: 148-156, 1951. 10. PUBLIC HEALTH SERVICE, NINDB Research profile No. 4: Hearing and Speech Disorders. (PHS Publication No. 1156) Washington, D.C.: U.S. Government Printing Office, 1967. 11. WHITE HOUSE CONFERENCE OF CHILD HEALTH AND PROTECTION, Special education. N.Y. Century, 1931. 12. ALPINER, J. Public School Hearing Conservation. In D. E. Rose (Ed.), Audiological assessment. Englewood Cliffs, N.J. Prentice-Hall, 1971. 13. EAGLES, E. The survey, In Proceedings of the Conference on the Collection of Statistics of Severe Hearing Impairments and Deafness in the United States. Bethesda, Md.: USPHS Publication No. 277, 1964. 14. EAGLES, E. and S. M. WISHIK, L. G. DOERFLER, W. MELNICK, and H. S. LEVINE. Hearing Sensitivity and Related Factors in Children. Laryngoscope, 1963. 15. KINNEY, C., The Cleveland hearing conservation program. Trans. Amer. Acad. Ophthal. Otolaryng., Nov.-Dec., 1945. 16. MELNICK, W. and E. L. EAGLES and H. S. LEVINE. Evaluation of a Recommended Program of Identification of Audiometry with Schoolage Children. J. Speech Hear. Dis., 29: 3-13, 1964. 17. ROBINSON, G. C. and D. 0. ANDERSON, H, K. MOGHADAM, et al. A Survey of Hearing Loss in Vancouver School Children: I. Methodology and Prevalence. Canadian Med. Assn. J., 97: 1199-1207, 1967. 18. WEBER, H. J. and F. J. MCGOVERN, D. ZINK. An EvaluatiQn of 1000 Children with Hearing Loss. J. Speech Hear. Dis., 32: 343-354, 1967. 19. BRANDFORD, L. J. and D. NEWMAN. Hearing Problems of Inner-City Children. Maico Audiological Library Series, 11: unpaged, 1973. 20. FAY, T. H. and I. HOCHBERG, C. R. SMITH, N. S. REES and H. HALPERN. Audiologic and Otologic Screening of Disadvantaged Children. Arch. Otolaryngol., 91: 366-370, 1971. 21. CLIFFORD, S. and R. H. HULL, and J. B. GREGG. Survey of Disorders of Speech and Hearing and Ear, Nose, and Throat Pathology among Children of the South Dakota Indian Population. Paper presented at the 42nd Annual Con-
(Concluded on page 325)
TABLE 2. CLASSIFICATION OF STUDENTS BY GROUP AND RELATION TO CLASS MEDIAN ON PRACTICAL EXAMINATIONS Year 1972 1973
325
Briefs
Vol. 67, No. 4
Group Minority
Median
6(75%) 76(49%) 82(50.3%) 13(62%) 75(48%) 88(49.7%)
N 8 155 163 21 156 177
Two interpretations are advanced from these data. 1. It would seem that the format of standardized objective examinations favors white students. While the disparity in educational backgrounds of white and black medical students could account for this occurrence, the higher proficiency of white students in taking objective examinations may correlate directly with the frequency of objective test-taking, the formats of tests taken, and the instructional content given over many years. Given that such experiences contribute to the mastery of test achievement skills among white students, it follows that the absence of such experiences would operate against the black student. Additionally, one must question whether or not reading proficiency (speed, retention and comprehension) of technical matter and grounding in "nonstandard" English2 are not also products of dissimilar educational backgrounds. It is possible that where there is a divergence of student populations, as at Temple, some individuals and/or groups are placed outside of the confidence band. Specifically, as it may pertain to black and mainland Puerto Rican students, most are not exposed as early to many of the aids more readily available to other students - aids which not only complement the general study structure, but possibly proficiency in taking objective examinations. Such aids would be the range of leads, cues, unofficial directives, and other communications that reinforce the learning environment. 2. The better than average performance of black and other ethnic minority students on the practical examinations suggests that their proficiency for achievement in an applied situation is greater than that of their white counterparts. While the earlier discussion concerning disparity in educational backgrounds may pertain here, it is suggested that the transfer of other antecedent experiences may well operate in favor of these black students' proficiency in the practical test-taking situation. Their achievement on practical examinations may be the function of other experiences which are needed for success as a cultural group in our society. The acquisition of functional manipulative and negotiative skills may well serve them in more successfully dealing with the format characterized by the practical examination. These findings have implications for more closely examin-
TABLE 3. CLASSIFICATION OF STUDENTS BY GROUP AND RELATION TO CLASS MEDIAN ON OBJECTIVE EXAMINATIONS Year
Group
Median 3(37.5%) 78(50.7%) 81(50%) 2(10%) 87(55.4%) 89(50%)
N 8 154 162 21 157 178
ing existing admissions criteria and for identifying a range of experiential factors that can have predictive value relative to a student's later performance. Performance in the basic sciences and in clinical areas may require distinct competencies which are not reflected in applicants' academic credentials from college. What is described is preliminary and may only apply at Temple for the two classes in pathology. However, the examination of these outcomes is sufficiently interesting as to inform other educators, and to request information from whose who may have had similar or divergent experiences. SUMMARY This paper presents a retrospective study of the examination performance of minority students in two consecutive Patholgy courses at Temple University School of Medicine. Two different evaluation instruments are used: an objective multiple choice examination addressing theory; and a practical examination directed toward tissue recognition and diagnosis of disease. The objective examination was machine-graded. The practical examination was manually graded against a fixed performance standard. Minority student performance was below class medians on objective examinations and above on practicals. The lower objective scores reflect a well documented if unexplained phenomenon. The higher practical scores suggest that if faced with a pragmatic requirement minority students perform well. The possible influence of background experiences and implications for the selection and evaluation of medical students are discussed. ACKNOWLEDGEMENT The authors wish to acknowledge the extensive consultations provided by Ms. Shirley D. Braverman, associate professor of biometrics, and the preponderant role in the preparation and grading of the practical examinations by Dr. Paul Putong, associate professor of pathology.
LITERATURE CITED 1. HUBBARD, J. P. Measuring Medical Education. Phila., Pa., Lea and Febiger, 1971, pp. 21-28. 2. HALL, W. S. Cited in Carnegie Quarterly. Vol. 21, No. 4, Fall 1973.
(Haller and Thompson, from page 301.) vention of the American Speech and Hearing Association Washington, D.C., Nov. 20, 1966. 22. TEMPLIN, M. E. and F. L. DARLEY. The Templin-Darley Tests of Articulation. Iowa City,
Ia.: Bur. of Educational Research and Service, Div. of Extension and University Services, U. of Iowa, 1960.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
JULY, 1975
Prevalence of Speech, Language, and Hearing Disorders Among Harlem Children* R. M. HALLER, Ph.D., and
E. A. THOMPSON, M.D., Columbia University-Harlem Hospital Center, New York, New York
prevalence studies have typically estimated that from 7 to 12% of the elementary school age population have speech defects'1- and about 2 to 4% of the same population have handicapping hearing losses.3'6"1218 Most speech surveys include language impairments under the speech label. Our review of the literature failed to locate any survey of these disorders exclusively among black children. We would anticipate that the prevalence of communication disorders among black children is comparable to that of white children, controlling for socioeconomic class. However, a far greater percentage of blacks are at or below the poverty line where the prevalence of communication disorders has been estimated to be triple the national figures. 19 This is particularly true at Harlem Hospital where about 60% of clinic patients are covered by Medicaid. A dramatic example of this estimate was reported in a survey of hearing impairments at a children's shelter in New York City.20 To this shelter come children who have run away or have been legally removed from their homes or been apparently abandoned by their parents. A great majority of these children are black and poor. The survey found that 28.9% of the children tested failed audiometric screening. In another study,21 27.2% of American Indian children tested failed hearing screening, as opposed to only 19.2% of non-Indian children in the same *Read at the 78th Annual Convention of the National Medical Association, York City, August 1973.
News
state. This paper reports some preliminary prevalence data on communication disorders among black children in Harlem, one of the largest black communities in the nation. The screening program, from which these estimates were derived, and the follow up procedures are also described. The Speech and Hearing Center is a unit of the Otolaryngology Service at Harlem Hospital Center. Speech and hearing screening is provided routinely as part of the Health Department's multiphasic screening program for public and private school children. Day Care and Head Start children are also screened in our unit by group appointments. In addition, all pediatric in-patients are screened for hearing. PROCEDURES
Children are screened individually for speech and language by our speech therapists and for hearing by our audiologic specialists. The time required for each of the two screening procedures ranges from three to 10 minutes, depending on the age of the child and the severity of his communication problem. Our screening cards list all identifying information which facilitates our contacting both the parents and the referring agencies for followup purposes. Speech dimensions included on this card are articulation, phonation, resonation, flow. Both receptive and expressive language are screened. Hearing screening is accomplished in a sound treated
Vol. 67, No. 4
CCiildren's Communication Disorders
I. A. C. booth through pure tone audiometry, encompassing the octave frequencies from 500-4000 Hz in each ear by phones at a level of 15dB (ISO, 1964). Inadequate responses to one or more frequencies in either ear constitutes failure on this test. Examiners are all staff members who are supervised by the senior staff holding the certificates of clinical competence in speech pathology or audiology, issued by the American Speech and Hearing Association. Determinations of the child's adequacy in receptive and expressive language, phonation, resonance, and fluency are subjective and are based on the child's conversational sample, including his response to several oral instructions. We consider that the speech therapists' training and experience in black dialect are satisfactory for a determination of unacceptable language that is not based on normal dialectal variations in vocabulary, inflectional endings, syntax, or semantics. Articulation adequacy is based on the child's score on the Templin-Darley Screening Test of Articulation,22 a 50 item picture naming task. Since the age norms of this test are based on a predominantly white midwest sample, normal black dialectal variations have been incorporated into the acceptable responses at clinic. For example, in the standardized instructions of the test, only the responses "teeth "' and "string" may be scored as correct, for one point of credit each. Our procedure also scores as correct the widespread black dialectal versions "teef"' and "skring". Followup of all children failing speech, language, or hearing screening is first initiated in the Speech and Hearing Center by its diagnostic team. Those failing speech or language screening are normally examined during the same morning within three weeks of the initial contact by the otolaryngologist, pediatrician, speech therapist, psychologist, and social worker. The team then discusses each child, and the coordinator lists the recommendations on a special form, with copies in the child's medical and unit charts. The team examination routine concludes with one of the examiner's meeting with the parents to
299
discuss the recommendations and expedite such followup as referral to other clinics at the hospital. Followup of all children failing hearing screening consists first of an otolaryngological examination, followed by either hearing rescreening the same morning or later audiologic evaluation. If impacted cerumen or another material is removed from the ear canal, immediate hearing screening is indicated. However, if the apparent hearing loss is caused by other pathology requiring treatment in another unit of the hospital, an audiologic evaluation is ordered. This audiologic evaluation consists, at the minimum, of pure tone and speech reception thresholds, the former encompassing the octave frequencies from 250-8000 Hz. Utilization of a B and K Hearing Aid Test Chamber assembly helps to insure that all audiometers are in calibration. The full range of hospital facilities are utilized in the comprehensive evaluation and treatment of the child. All followup evaluation and treatment of communication disorders are done at the center. RESULTS AND DISCUSSION
Our prevalence data for this report are based on 979 children screened for speech and 990 children screened for hearing from February through June, 1973 and ranging in age from three through 17 years. Table 1 shows that 9. 1 % of the children failed speech TABLE 1. PERCENTAGE OF SPEECH AND HEARING SCREENING FAILURES AND AGE Age Range (Years & Months)
Number of Children Screened
15-0 to 17-11 12-0 to 14-11 10-Oto 11-11 8-Oto9-11 7-Oto7-11 6-0to6-11 5-0 to 5-1 1 4-6to4-11 4-0 to 4-5 3-6 to 3-11 3-0 to 3-5 Total
45 409
119 118 26 41 80 49 56 50 25 990: Hearing 979: Speech
Percentage of Children Failing: Hearing Speech 15.8 16.9 19.3 18.6 19.2 30.0 12.5 13.0 17.9 7.9 45.0 17.7
13.3 4.3 10.6 10.7 15.0 22.0 18.7 6.1 5.4 14.0 12.0 9.1
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
300
TABLE 2. PERCENTAGE OF SPEECH AND HEARING SCREENING FAILURE IN PRESCHOOL AND SCHOOL-AGE CHILDREN
School Status
Number of Children Screened
School Age* Preschool Age
838 180
Percentage of Children Failing: Hearing Speech 9.13 8.88
17.71 17.50
*Kindergarten through 12th grade
screening and 17.7% failed hearing screening. These figures fall within the typical ranges of prevalence data reported for predominantly white children in various parts of the country. Inspection of the percentages of speech and of hearing screen failures across age range categories shows no consistent trend, although the highest single percentage in each defect area occurred below the age of seven years, namely, 45% of the hearing screening failures in the age range three years to three years, five months, and 22.0% of the speech screening failures in the age range six years to six years, 11 months. However, Table 2 indicates that the incidence of both speech and of hearing screening failure was roughly comparable among children attending head start and day care centers vs. those attending public and parochial schools. The boys had a considerably higher incidence of test failure in each of the two categories than did the girls. More than 20% of the boys failed speech screening as opposed to only 3.6% of the girls. This finding is consistent with the speech pathology literature in estimating that from three to seven times as many boys than girls have speech impairments. Also 11.7% of the boys but only 6.0% of the girls failed hearing screening. These data support the impression that boys seem to be more susceptible to upper respiratory infections than are girls. Table 3 provides a breakdown of the percentages of speech screening failures which were attributable to various types of speech impairment. About two thirds of the children failing speech screening had articulation defects and about one fifth of the speech failures were dysphonic. The predominant dysphonia was hoarseness. Thus, the ratio of
JULY, 1975
articulation to voice defects was about three to one, as compared to about eight to one cited in the literature.3 This apparent discrepancy may be explained in two ways. First, there may be a higher prevalence of conditions causing laryngeal problems in children in Harlem than in most other communities. Second, our speech therapist may be more sensitive to vocal quality deviations than most of their peers due to their close working relationship with otolaryngology. A breakdown of hearing screening failure by the extent of frequencies failed that reveals 3.6% of children failed to respond adequately to all frequencies bilaterally and that only 5.9 failed all frequencies unilaterally with normal responses in the contralateral ear. On the other hand, 25.9% of the children failed only one frequency in one ear TABLE 3. DISTRIBUTION OF SPEECH SCREENING FAILURES IN DEFECT CATEGORIES
Speech Defect Category Articulation Phonation Speech Rhythm Expressive Language Resonation Receptive Language More than one category
Percent of Children Failing in That Category 62.9 21.9 4.4 2.4 1 .5 0.5 6.3
while responding normally in the other ear, and another 15.0% failed only one frequency in each ear. However, the most frequently occurring failure (29.5%) w4s in children who failed at least three frequencies in both ears while responding normally to at least one frequency in each ear. The prevalence figures presented today are subject to two obvious sources of error. The speech data are heavily weighted by voice defects, many of which probably represent symptoms of acute laryngological conditions. In addition, many of the hearing screening failures may be "false positives" or may also have resulted from transient medical problems. In one study, 19 more than 35% of an "Inner City" sample who had originally failed hearing screening passed their rescreening tests. Fortunately, our followup
Vol. 67, No. 4
301
Children's Communication Disorders
procedures allows us to examine these possible artifacts, and these questions will be dealt with in our future research. SUMMARY
We have described the initial phase of a speech and hearing screening program at Harlem Hospital. Follow-up procedures stress the team approach and the role of the otolaryngologist. Results of screening of approximately 1,000 children suggest that the incidence of communication disorders among Harlem children is within the range of estimates in other parts of the country. In the present study, 9. 1 % of children failed speech screening, and 17.7% failed hearing screening. There was little evidence that communication disorders were less common with increasing age. Boys were about seven times as likely to fail speech screening as girls and had about twice the incidence of hearing screening failure as girls. About half of the children failed hearing screening in one ear only while the remainder appeared to have bilateral involvement. Articulation defects accounted for about 63% of the speech screening failures with voice problems constituting an additional 22% of the failures. LITERATURE CITED
1. ASHA COMMITTEE ON THE MIDCENTURY WHITE HOUSE CONFERENCE, Speech Disorders and Speech Correction. J. Speech Hear. Dis., 17: 129-137, 1952. 2. BLANTON, S., A. Survey of Speech Defects. J. Educ. Psychol., 7: 581-592, 1916. 3. CANTER, G. J. (Ed), Human Communication and its Disorders-An Overview. Bethesda, Md.: National Institutes of Neurological Disease and Stroke, U.S. Public Health Service, 1969. 4. HULL, F. M. and R. J. TIMMONS. A National Speech and Hearing Survey. J. Speech Hear. Dis., 31: 359-361, 1966. 5. HULL, F. M. and P. W. MIELKE, R. J. TIMMONS and J. A. WILLEFORD. The National Speech and Hearing Survey: Preliminary Results. ASHA, 13: 501-509, 1971. 6. IRWIN, R. B. Ohio Looks Ahead in Speech and Hearing Therapy. J. Speech Hear. Dis., 13: 55-60, 1948. 7. LOUTIT, C. M. and E. C. HALLS. Survey of Speech Defects Among Public School Children in
Indiana. J. Speech Dis., 1: 73-80, 1936. 8. MILLS, A. and H. STREIT. Report of a Speech Survey, Holyoke, Massachusetts. J. Speech Dis., 7: 161-167, 1942. 9. PRONOVOST, W. A. Survey of Services for the Speech and Hearing Handicapped in New England. J. Speech Hear. Dis., 2 16: 148-156, 1951. 10. PUBLIC HEALTH SERVICE, NINDB Research profile No. 4: Hearing and Speech Disorders. (PHS Publication No. 1156) Washington, D.C.: U.S. Government Printing Office, 1967. 11. WHITE HOUSE CONFERENCE OF CHILD HEALTH AND PROTECTION, Special education. N.Y. Century, 1931. 12. ALPINER, J. Public School Hearing Conservation. In D. E. Rose (Ed.), Audiological assessment. Englewood Cliffs, N.J. Prentice-Hall, 1971. 13. EAGLES, E. The survey, In Proceedings of the Conference on the Collection of Statistics of Severe Hearing Impairments and Deafness in the United States. Bethesda, Md.: USPHS Publication No. 277, 1964. 14. EAGLES, E. and S. M. WISHIK, L. G. DOERFLER, W. MELNICK, and H. S. LEVINE. Hearing Sensitivity and Related Factors in Children. Laryngoscope, 1963. 15. KINNEY, C., The Cleveland hearing conservation program. Trans. Amer. Acad. Ophthal. Otolaryng., Nov.-Dec., 1945. 16. MELNICK, W. and E. L. EAGLES and H. S. LEVINE. Evaluation of a Recommended Program of Identification of Audiometry with Schoolage Children. J. Speech Hear. Dis., 29: 3-13, 1964. 17. ROBINSON, G. C. and D. 0. ANDERSON, H, K. MOGHADAM, et al. A Survey of Hearing Loss in Vancouver School Children: I. Methodology and Prevalence. Canadian Med. Assn. J., 97: 1199-1207, 1967. 18. WEBER, H. J. and F. J. MCGOVERN, D. ZINK. An EvaluatiQn of 1000 Children with Hearing Loss. J. Speech Hear. Dis., 32: 343-354, 1967. 19. BRANDFORD, L. J. and D. NEWMAN. Hearing Problems of Inner-City Children. Maico Audiological Library Series, 11: unpaged, 1973. 20. FAY, T. H. and I. HOCHBERG, C. R. SMITH, N. S. REES and H. HALPERN. Audiologic and Otologic Screening of Disadvantaged Children. Arch. Otolaryngol., 91: 366-370, 1971. 21. CLIFFORD, S. and R. H. HULL, and J. B. GREGG. Survey of Disorders of Speech and Hearing and Ear, Nose, and Throat Pathology among Children of the South Dakota Indian Population. Paper presented at the 42nd Annual Con-
(Concluded on page 325)
TABLE 2. CLASSIFICATION OF STUDENTS BY GROUP AND RELATION TO CLASS MEDIAN ON PRACTICAL EXAMINATIONS Year 1972 1973
325
Briefs
Vol. 67, No. 4
Group Minority
Median
6(75%) 76(49%) 82(50.3%) 13(62%) 75(48%) 88(49.7%)
N 8 155 163 21 156 177
Two interpretations are advanced from these data. 1. It would seem that the format of standardized objective examinations favors white students. While the disparity in educational backgrounds of white and black medical students could account for this occurrence, the higher proficiency of white students in taking objective examinations may correlate directly with the frequency of objective test-taking, the formats of tests taken, and the instructional content given over many years. Given that such experiences contribute to the mastery of test achievement skills among white students, it follows that the absence of such experiences would operate against the black student. Additionally, one must question whether or not reading proficiency (speed, retention and comprehension) of technical matter and grounding in "nonstandard" English2 are not also products of dissimilar educational backgrounds. It is possible that where there is a divergence of student populations, as at Temple, some individuals and/or groups are placed outside of the confidence band. Specifically, as it may pertain to black and mainland Puerto Rican students, most are not exposed as early to many of the aids more readily available to other students - aids which not only complement the general study structure, but possibly proficiency in taking objective examinations. Such aids would be the range of leads, cues, unofficial directives, and other communications that reinforce the learning environment. 2. The better than average performance of black and other ethnic minority students on the practical examinations suggests that their proficiency for achievement in an applied situation is greater than that of their white counterparts. While the earlier discussion concerning disparity in educational backgrounds may pertain here, it is suggested that the transfer of other antecedent experiences may well operate in favor of these black students' proficiency in the practical test-taking situation. Their achievement on practical examinations may be the function of other experiences which are needed for success as a cultural group in our society. The acquisition of functional manipulative and negotiative skills may well serve them in more successfully dealing with the format characterized by the practical examination. These findings have implications for more closely examin-
TABLE 3. CLASSIFICATION OF STUDENTS BY GROUP AND RELATION TO CLASS MEDIAN ON OBJECTIVE EXAMINATIONS Year
Group
Median 3(37.5%) 78(50.7%) 81(50%) 2(10%) 87(55.4%) 89(50%)
N 8 154 162 21 157 178
ing existing admissions criteria and for identifying a range of experiential factors that can have predictive value relative to a student's later performance. Performance in the basic sciences and in clinical areas may require distinct competencies which are not reflected in applicants' academic credentials from college. What is described is preliminary and may only apply at Temple for the two classes in pathology. However, the examination of these outcomes is sufficiently interesting as to inform other educators, and to request information from whose who may have had similar or divergent experiences. SUMMARY This paper presents a retrospective study of the examination performance of minority students in two consecutive Patholgy courses at Temple University School of Medicine. Two different evaluation instruments are used: an objective multiple choice examination addressing theory; and a practical examination directed toward tissue recognition and diagnosis of disease. The objective examination was machine-graded. The practical examination was manually graded against a fixed performance standard. Minority student performance was below class medians on objective examinations and above on practicals. The lower objective scores reflect a well documented if unexplained phenomenon. The higher practical scores suggest that if faced with a pragmatic requirement minority students perform well. The possible influence of background experiences and implications for the selection and evaluation of medical students are discussed. ACKNOWLEDGEMENT The authors wish to acknowledge the extensive consultations provided by Ms. Shirley D. Braverman, associate professor of biometrics, and the preponderant role in the preparation and grading of the practical examinations by Dr. Paul Putong, associate professor of pathology.
LITERATURE CITED 1. HUBBARD, J. P. Measuring Medical Education. Phila., Pa., Lea and Febiger, 1971, pp. 21-28. 2. HALL, W. S. Cited in Carnegie Quarterly. Vol. 21, No. 4, Fall 1973.
(Haller and Thompson, from page 301.) vention of the American Speech and Hearing Association Washington, D.C., Nov. 20, 1966. 22. TEMPLIN, M. E. and F. L. DARLEY. The Templin-Darley Tests of Articulation. Iowa City,
Ia.: Bur. of Educational Research and Service, Div. of Extension and University Services, U. of Iowa, 1960.
