From the Desk of Gus Mueller
For many of us, what first sparked our interest in the profession of audiology was the concept of differential diagnoses. This probably started with discovering that several pathologies have a signature audiogram configuration. And of course, the basic comparison of air conduction and bone conduction thresholds provided another level of preciseness. And then, when you add tympanometry, acoustic reflexes and OAEs, you have a test battery that will identify the primary pathology of most of your patients—at least to the extent that appropriate treatment can be determined.
But it’s not always that simple. Our task becomes more difficult when the hearing problem goes beyond what you see with basic testing, and when it co-exists with a more general disability. Such is the case with children with autism spectrum disorder (ASD), which has become more prevalent in recent years. In these cases, modified test procedures may be necessary, or we may need to include other tests, such as ABR, or those of auditory processing. This often moves us out of our “diagnostic comfort zone,” and it’s helpful to get a little advice from an expert. That’s what we’re doing this month here at 20Q.
Erin C. Schafer, PhD, is Professor and the Director of Graduate Studies in Audiology at the University of North Texas, where she has been a faculty member since 2005. You are probably familiar with her work, as she has been awarded numerous grants, is a frequent speaker at national conferences, and has over 100 publications, including four textbooks.
Dr. Schafer is the Editor of Audiology Today for the American Academy of Audiology and past President and Journal Editor for the Educational Audiology Association. She has been honored with the UNT Office of Research and Innovation Teacher Scholar Award, and the Cheryl Deconde Johnson Award for Outstanding Achievement in Educational and Pediatric Audiology.
Notice that “Audiologists Wanted” is part of Erin’s title. She tells me that this topic is of particular interest to her because early in her career, she worked as an educational audiologist and saw, first hand, the difficulties that children with ASD face when trying to learn and filter out unwanted auditory information in noisy school environments. After reading her excellent 20Q article, you just might want to respond to her help-wanted request.
Gus Mueller, PhD
Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q
20Q: Auditory Issues in Children with Autism Spectrum Disorder: Audiologists Wanted
After reading this article, professionals will be able to:
- Describe strategies to obtain a valid hearing test from children with ASD.
- Explain how to assess and manage common auditory difficulties faced by children with ASD and normal hearing sensitivity.
- List strategies to mitigate listening difficulties.
1. How common is autism spectrum disorder in children?
According to the Autism and Developmental Disabilities Monitoring Network, an estimated 1 in 54, eight-year-old children is diagnosed with autism spectrum disorder (ASD), which amounts to a prevalence of approximately 18.5 per 1,000 children (Maenner et al., 2020). These data indicate an increase in the prevalence of ASD since 2014. ASD is 4.3 times more prevalent in boys when compared to girls, with a similar distribution of cases across the ethnic, racial, and socioeconomic groups represented in the Maenner et al. study. Bottom line, the prevalence of ASD in children is high, and many of these children have co-existing intellectual or other disabilities.
2. Do these children tend to have a higher prevalence of hearing loss?
There is mixed evidence in the literature regarding the prevalence of hearing loss in children diagnosed with ASD. According to one systematic review, the prevalence rate of ASD within groups of children with hearing loss was 9% (Do et al., 2017), and the estimated risk of ASD was 14.1 times higher in in children with hearing loss relative to the general population. However, in another systematic review, there was no conclusive evidence of increased hearing loss in children with ASD (Beers et al., 2014). Future research is necessary in this area to determine a definitive answer to your question.
3. How should I manage children with ASD who might have hearing loss?
The first step is to conduct a hearing screening or a full audiologic examination, when warranted. Many moons ago, in my work as an educational audiologist, I experienced the acronym CNT (could not test) way too many times on hearing screening forms of children with ASD. In instances when hearing screening cannot be conducted behaviorally, consider other test methods to confirm normal pure-tone hearing sensitivity. If peripheral hearing loss is identified, children with ASD require the same audiologic management as any other child identified with hearing loss: family-centered counseling, appropriately fit and verified hearing technology, and validation measures to ensure optimal audibility and real-world benefit.
4. Do you have any suggestions for conducting hearing tests with these children?
Brueggeman (2012) provides some excellent recommendations, many of which would be helpful with any child. These recommendations include using toys of interest to the child during testing; creating picture cards to indicate expectations, introduce the order of testing, and facilitate communication; sharing a social story with the child (e.g., thoroughly describe testing from the child’s point of view); letting the child explore the headphones or insert earphones before testing; and using preferred videos for reinforcement. During testing, the audiologist will need to be flexible, patient, and calm to ensure the child is comfortable with the procedures. Depending on each child’s abilities, more than one appointment may be needed to confirm hearing status.
5. Do children with ASD and normal pure-tone hearing sensitivity still have auditory challenges?
Absolutely. When compared to peers, many children with normal hearing and ASD have substantially poorer performance on multiple tests used to determine listening and auditory processing skills, even when intellectual ability is within normal limits. In comparison to their neurotypical peers, deficit areas in children with ASD who are high functioning include speech recognition in noise, spatial stream segregation, binaural integration on dichotic tasks, and temporal processing (DePape et al., 2012; Dunlop et al., 2016; Groen et al., 2009; Kozou et al., 2018; Rance et al., 2014, 2017; Schafer et al., 2013, 2016, 2020b). Overall, children with ASD show significant auditory challenges, which can impact listening abilities, particularly in noisy environments like classrooms.
6. What do parents typically report about their child’s hearing issues?
Parents often report that their children with ASD have poor attention to auditory signals, listening difficulties in noisy environments, abnormal sensory processing (under or overresponsive), and poor auditory filtering (Ashburner et al., 2008; Schafer et al., 2020b; Tomchek & Dunn, 2007). In particular, the inability to filter unwanted auditory signals makes it difficult for children with ASD to complete tasks and to recognize important signals like speech in background noise. In fact, Ashburner and colleagues (2008) report that poorer auditory filtering and sensory processing was associated with academic underachievement in children with ASD and normal intelligence.
7. How would you recommend that I evaluate these listening difficulties?
You can use existing auditory processing tests to identify listening weaknesses in children with ASD who are cooperative, have normal intelligence, and are able to understand and follow the instructions for the test. However, prior to testing, our clinic recommends an evaluation from a speech-language pathologist given that the majority of auditory processing tests used by audiologists require intact language processing to obtain valid results.
We use language- and age-appropriate speech-in-noise testing (e.g., BKB-SIN, 2005); dichotic processing (e.g., Audia Dichotic Software, n.d.) testing; and parent, teacher, and student questionnaires as the primary indicators of listening difficulty in children with ASD (Schafer et al., 2013, 2016, 2019a 2020b). As a general rule, our clinic does not diagnose children with ASD as having an auditory processing disorder given that their sensory issues are not auditory specific. Children with ASD often show global sensory processing issues in the visual, tactile, and auditory domains (Tomchek & Dunn, 2007). As a result, our clinic identifies specific listening weaknesses and recommends appropriate, evidence-based intervention strategies to address each deficit area.
8. What if a child with ASD cannot complete behavioral testing?
As expected, some children with ASD are not able to complete behavioral hearing tests or auditory processing testing due to limited verbal abilities, uncooperativeness, or inability to understand test instructions. When this occurs, objective measures, such as otoacoustic emissions and auditory brainstem response testing, will need to be used to confirm normal pure-tone hearing sensitivity.
To assess listening difficulties in the presence of normal pure-tone hearing, parent and teacher questionnaires may be used. In our research on children and young adults with ASD, we have used multiple questionnaires to document listening difficulties including the Listening Inventory for Education (Anderson et al., 2011), Child or Adolescent/Adult Sensory Profile (Brown & Dunn, 2002; Dunn, 2014), Children’s Home Inventory for Listening Difficulty (Anderson & Smaldino, 2011), the Screening Instrument for Targeting Educational Risk (Anderson & Matkin, 1996), and the Children’s Auditory Performance Scale (Smoski et al., 1998).
9. Do most audiologists conduct testing for these patients?
Pediatric audiologists who have experience testing children with ASD will be in the best position to help families identify their child’s specific listening issues. However, even audiologists who do not conduct auditory processing assessments can identify listening difficulties in most children with ASD through speech-in-noise testing and questionnaires. Also, as mentioned before, it is helpful to consider how language levels could influence test results. In our clinic, we conduct a joint assessment with the audiologist conducting speech-in-noise, dichotic, and auditory attention testing and the speech-language pathologist collecting a thorough case history and a hierarchical test of auditory processing with skills ranging from phonological segmentation to auditory reasoning (Schafer et al., 2020b). While all audiologists might not be able to perform joint assessments, reviewing outside speech-language and other reports can inform results and management.
10. Are there any hearing technologies that can help children with ASD and normal pure-tone hearing sensitivity?
Yes. Over the past 10 years, our work and the work of others has documented the benefits of personal remote microphone (RM) systems for children with ASD. Because these systems substantially improve the signal-to-noise ratio at the listener’s ears, benefits of RM systems for children and young adults with ASD include significantly improved speech recognition and acceptance of noise, auditory comprehension, physiologic stress levels, and self-perceived and observed listening difficulty (Rance, 2014, 2017; Schafer 2013, 2014, 2016, 2019a, 2020a). These RM systems are designed specifically for listeners with normal hearing and consist of a transmitter for the primary talker and small, open-fit, ear-level receivers for the child’s ears. Unlike traditional RM systems coupled to hearing aids, these stand-alone receivers do not contain microphones. They are designed only to transmit the signal from the transmitter microphone directly to the child’s ears.
11. Do the children use this technology at home or only during school?
RM systems are beneficial in most noisy situations at school, but also at home or in social situations. In addition to the benefits I already mentioned, according to parent and teacher observations, RM systems improved on-task behaviors and many auditory listening behaviors (Schafer et al., 2013, 2014, 2016, 2019a). For example, one parent recalled how use of the RM system with her two children who had ASD enabled her to more easily communicate during a shopping trip. Unlike most trips to the store, her kids were better able to listen, help with the shopping, and put items in the cart.
12. Do you have some recommendations on how to fit this RM technology?
We published some step-by-step guidelines in an open-access journal for fitting and verifying open-ear RM systems on children and young adults with ASD and normal-hearing sensitivity (Schafer et al., 2019b; see link to article in the reference list). Essentially, we recommend that audiologists use probe-microphone equipment to (1) conduct the real ear to coupler difference (RECD) for each ear to convert the child’s HL thresholds (or screening results) to ear canal SPL, (2) generate targets using the child’s age and the DSLv5.0 fitting algorithm, (3) place the probe tube and RM receiver in the child’s ear with the RM transmitter placed in the test box near the reference microphone, (4) measure the SPL in the child’s ear in response to a 84 dB SPL speech signal, which is appropriate for RM systems, and (5) adjust the volume of the RM receiver to meet the DSLv5.0 target as closely as possible (+ 2 dB 1000-4000 Hz).
13. Interesting, not a procedure I’ve ever conducted before, but I’ll give it try. How do you then determine the effectiveness of the device?
After verifying the fitting, we validate its effectiveness by conducting parent, teacher, and sometimes student questionnaires using one or more of the questionnaires I mentioned before. In children who have higher functioning, speech-in-noise testing with recorded materials also may be conducted with and without the RM system. The output of the speech signal should be approximately 60 dBA. In the RM test condition, the transmitter will need to be placed on a stand near the primary single-coned loudspeaker (~ 6 inches) in front of the child, and noise, at a 0 dB signal-to-noise ratio or a level challenging to the child, presented through spatially-separated loudspeakers (90 or 180 degrees relative to the listener). In addition, school-based audiologists may consider classroom observations before and after the RM fitting to evaluate any changes in on-task and off-task classroom behaviors (Schafer et al., 2013).
14. For children with ASD who are non-verbal, how do you know the device is working properly?
Good question. In some cases, we are unable to complete real-ear measures, but the child will tolerate the RM system after a trial period. As a result, we have to set the RM receivers to provide conservative output, check the signal with a listening scope, and observe and document listening behaviors using parent and teacher questionnaires. After the fitting, a signal check should be conducted every day before the child begins using the RM system.
15. Are these devices just for kids with ASD?
Absolutely not! These systems can help anyone who has normal, pure-tone hearing sensitivity and has difficulty listening in noise (and of course, people with hearing loss too!). Some other populations who may benefit include children diagnosed with unilateral hearing loss, auditory processing disorder, attention-deficit hyperactivity disorder (ADHD), and language disorders (Schafer et al., 2013, 2014, 2020a). Although our laboratory has not explored adult populations with normal hearing that may benefit from RM systems, based on my experience, I would recommend a RM system trial period for adults who report difficulty in noise, which may include individuals with hidden hearing loss, traumatic brain injury, auditory processing issues, and ADHD.
16. Are there other issues to consider when fitting personal hearing technology?
Some children have tactile sensitivities, but the majority of children in our studies have tolerated using an ear-level RM system, while others demonstrated tolerance of the system over a period of weeks (Schafer et al., 2013). In children who struggle to accept the device, patience and perseverance may result in acceptance over time. Many children with ASD strongly dislike change, so if it is possible to integrate the RM system in the daily routine, acceptance can occur. However, after a slow trial period, some children with ASD still will not tolerate an on-ear RM receiver. When this occurs, we recommend a classroom audio distribution system (CADS) to improve the signal-to-noise ratio in school classrooms.
17. Do some of these children have hypersensitivity to sound?
Yes; some children do. First and foremost, I do not encourage or recommend full-time use of noise-cancellation headphones. In rare situations, headphones are appropriate, such as the cafeteria, gymnasium, or during an assembly at school. However, in my experience, full-time use of earphones will only increase auditory hypersensitivity in children with ASD and attenuate important sounds in the environment including teacher and peer speech, safety alarms, etc. Instead, use of the RM system can improve hypersensitivities by allowing the child better attend to and hear the signal of interest. In our previous studies, several children with ASD showed increased acceptance of noise when comparing a RM and no-RM listening condition (Schafer et al., 2016, 2019a).
18. Are there any other strategies to help with auditory issues?
I’m glad you asked this question. In some of our more recent work, we found that a combination of auditory training and use of a RM system significantly improved auditory performance (Schafer et al., 2019a). Participants in our study completed a 12-week training period including adaptive speech-in-noise training with a speech-language pathologist, computerized dichotic training, and use of the RM system. After the training period, participants showed significantly improved binaural integration (dichotic processing) and subjective listening abilities in the classroom, and use of the RM system resulted in significantly improved speech recognition and acceptance of background noise.
19. What other school-based recommendations do you have?
Several classroom accommodations can be provided to children with ASD to improve their listening abilities including strategic seating away from hallways, doors, and windows; use of a notetaker or access class recording to review material; reduced visual and auditory distractions in the classroom; student training on communication strategies to improve conversation breakdowns; written assignments and instructions, and frequent checks for understanding.
20. What is the most important things audiologists should know about children with ASD?
First, based on my experience, patience and empathy are the most important aspects to working with families and children with ASD. These families struggle with many issues and stressors on a daily basis, so we need to be mindful of their need for support. Second, given that ASD is a spectrum disorder, audiologists will need to recognize that every child with ASD has different auditory and intervention needs. Finally, I encourage audiologists to begin to consider serving this very large population. Based on the literature we’ve just talked about, they truly need us! Through RM technology, we have the potential to improve their auditory filtering ability, which is directly related to academic success.
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Schafer, E. (2021). 20Q: Auditory issues in children with autism spectrum disorder - audiologists wanted. AudiologyOnline, Article 27860. Available at www.audiologyonline.com