10 Tips For Testing Hearing in Children With Autism Not a lot of detail was known about Connor’s past hearing abilities, other than that he passed his newborn hearing screening. Other behavioral hearing screenings were unsuccessful because of the behavioral difficulties during the testing displayed by this 6-year-old with autism. On previous testing attempts, the audiologist noted that Connor ... Features
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Features  |   January 01, 2012
10 Tips For Testing Hearing in Children With Autism
Author Notes
  • Paul M. Brueggeman, Aud, CCC-A, leads the audiology services team at Children’s Care Hospital and School in Sioux Falls, S.D., where he works with children with disabilities. His previous university teaching and research interests include pediatric audiologic evaluation and treatment, audiologic counseling and rehabilitation, and noise issues in neonatology. He served several terms on the board of the South Dakota Speech-Language-Hearing Association and received an ASHA grant to research middle-ear functioning in the pediatric Native American population in South Dakota. Contact him at paul.brueggeman@cchs.org.
    Paul M. Brueggeman, Aud, CCC-A, leads the audiology services team at Children’s Care Hospital and School in Sioux Falls, S.D., where he works with children with disabilities. His previous university teaching and research interests include pediatric audiologic evaluation and treatment, audiologic counseling and rehabilitation, and noise issues in neonatology. He served several terms on the board of the South Dakota Speech-Language-Hearing Association and received an ASHA grant to research middle-ear functioning in the pediatric Native American population in South Dakota. Contact him at paul.brueggeman@cchs.org.×
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Hearing & Speech Perception / Hearing Disorders / Special Populations / Autism Spectrum / Early Identification & Intervention / Features
Features   |   January 01, 2012
10 Tips For Testing Hearing in Children With Autism
The ASHA Leader, January 2012, Vol. 17, 5-7. doi:10.1044/leader.FTR3.17012012.5
The ASHA Leader, January 2012, Vol. 17, 5-7. doi:10.1044/leader.FTR3.17012012.5
Not a lot of detail was known about Connor’s past hearing abilities, other than that he passed his newborn hearing screening. Other behavioral hearing screenings were unsuccessful because of the behavioral difficulties during the testing displayed by this 6-year-old with autism. On previous testing attempts, the audiologist noted that Connor would not sit or allow headphones to be placed on his ears. When Connor was referred to me for testing, the first things I wanted to know from his parent were: What was reinforcing to him? Did he use a visual schedule? What were his language and cognitive levels? With a few simple modifications to the test methodology, we were able to obtain accurate, ear-specific behavioral hearing results.
Autism spectrum disorders (ASDs) are reported to affect one in 110 children in the United States. This equates to approximately 730,000 children and adolescents age 0–21 years with ASDs, many of them served by education systems in the United States (Rice, 2006). Many of these students are placed in regular education classrooms and participate in routine school procedures—including hearing screenings.
As described by ASHA (1997), the purpose of these screenings is to “identify school-age children most likely to have peripheral hearing impairment that may interfere with education, health, development, or communication.”
But what if a student’s refusal or behavior makes completing a hearing screening difficult? As members of an interdisciplinary team that works with these students, speech-language pathologists and audiologists who work in educational settings should be included during routine school hearing screenings.
When conducting school hearing screenings, professionals often rely on behavioral methods outlined in the ASHA guidelines (1997) for typical school-age children. But when it comes to testing this special population, literature and textbooks misreport that children with ASDs cannot be tested using behavioral means. In fact, a survey of U.S. audiologists revealed that respondents preferred not to use behavioral methods of testing hearing, such as with standard pure-tone threshold testing, when testing children with ASDs (Dittman & Brueggeman, 2003).
On the contrary, traditional behavioral techniques for assessing children with ASDs have been found to be quite effective. Downs, Schmidt, & Stephens (2005) found that 87% of children with Asperger syndrome and 100% of children diagnosed with pervasive developmental disorder, not otherwise specified (PDD-NOS), were tested successfully via traditional behavioral methods using supra-aural earphones. Of the cohort of children in the study with an ASD diagnosis, 69% could be tested successfully via traditional behavioral methods using earphones. In recent years, others (e.g., Gravel, Dunn, Lee, & Ellis, 2006; Tharpe et al., 2006) have investigated behavioral hearing sensitivity and test measures used for assessment of children with ASDs. There is growing evidence of the behavioral audiometric screening and test results one can expect to obtain when working with children with ASDs.
Strategies that can be used specifically to improve the likelihood of successfully obtaining behavioral responses from children with ASDs are less well-defined. The following are the top 10 tips for professionals when screening or evaluating the hearing of children who have ASDs.
Find out what is reinforcing to the child.
Knowing what the child likes allows the screener to reward the child appropriately for behavioral responses to pure-tone stimuli. Ask the child’s parents, teachers, or consistent staff what works best for the child. Some children with ASDs are best reinforced with edible treats, while others prefer social reinforcers (a high-five, saying “way to go,” etc.). Other forms of reinforcement may include tactile rewards (a fan with switch, vibrating toys/fidgets, deep pressure, etc.), or access to a favorite fidget or toy.
Practice with the child the appropriate motor movements to make in response to sound.
When we teach a child to respond to a tone, we rely not only on the child’s ability to process our verbal instructions, but also on the child’s ability to imitate our hand-raising instruction. To help the child understand the expectation, I have used a diagonally split first/then card divided with a sound wave on the top and a stick-figure person raising its hand on the bottom. This visual cue has improved understanding for many children who otherwise could not successfully imitate. The screener also may want to try using several trials with real pure tones—played with the headphone in your hand near the child’s ear at a clearly audible level—while you and the child raise your hands together in response to the stimulus. After several successful trials, say to the child, “Now (child’s name) raises (his/her) hand!” and play another pure-tone stimulus. Begin the hearing screening when the child can show two independent responses to pure tones.
Incorporate preferred interests and videos into testing.
A laptop, hand-held computer, or tablet that can play videos is a hearing screener’s best friend. Children with ASDs may have perseverative interests that manifest in many ways and often change with age. I always have my laptop with me during any hearing screening to show videos as reinforcers during all types of audiologic testing. Hands down, the most reinforcing item for the vast majority of the children with ASDs I work with every day is access to a favorite video. Playing the video clip for each response can be triggered by a child pushing a “Big Mac” switch, pointing, or using a touch screen. Also attempt the first/then concept during video reinforcement (see “first/then” tip below).
Be fun, goofy, and inviting to help reduce fear.
If a child is clearly anxious about the testing, spend a moment talking at the child’s level about his or her play interests. Pediatric clinicians think outside the box and go with the flow of testing and treatment daily. A comfortable, relaxed, and inviting hearing screener provides a calm environment for testing.
Use first/then concepts and language to establish routines and expectations.
Using “First ears, then break” language or picture cards for children with ASDs helps them understand what is expected behaviorally and what will occur after the hearing screening. Children with ASDs may use Picture Exchange Communication System (PECS) or other picture cards to communicate that they want a break. Allow children to request a break to avoid maladaptive behaviors or non-compliance. You may want to consult with the child’s SLP, behavioral therapist, or psychologist before the hearing screening to review the child’s functional level. SLPs are the service providers who often know the most about a child’s communicative level and preferences and can be instrumental in understanding a child’s communication level. They can assist in prescreening orientation with the child using PECS and/or charts to prepare the child for the screening process. Children with ASDs often operate better in an environment in which the end of a non-preferred activity is clearly marked by a visual timing device or chart. A chart indicating the progress of the session may help children visually understand how close they are to the end of the hearing screening.
So...do you want this or that?
There is no realistic reason to follow a particular order of testing. Flexibility regarding testing order, stimuli order, and earphone type gives a child who seemingly has no choice in the matter a number of options. Give the child the choice of supra-aural or insert earphones, or high pitches before mid-pitches.
Help a child with tactile oversensitivity and related anxiety become at ease.
Let the child touch and explore insert earphones and supra-aural earphones. Allow a child to fit them on a stuffed animal or the examiner. Cloppert and Williams (2005) suggest asking parents to practice having the child wear earphones at home or have the child listen to a preferred video while wearing headphones, to make the child more comfortable with the device.
Develop a social story for your specific hearing screening routine.
Read the story to the child or have the child read the story to you. Review the story with the child and talk about the testing. If the child is still anxious and the hearing screening can be done on another day, the delay may give a child time to process and prepare for testing. On the testing day, review the social story with the child. Other forms of social stories include video and involving familiar family members (Davis & Stiegler, 2005). See page 14 for a closer look at using social stories with children with ASDs.
Use a picture schedule when appropriate so children can anticipate the test routine.
The use of visual picture schedules has become common among those who work educationally and clinically with children with ASDs. A visual schedule that illustrates the testing routine for the child can be developed using computer software or with “found” images online. Simply laminate your images and apply Velcro. A picture of an ear for otoscopy works quite well, as does a picture of headphones for pure-tone testing. When explaining the test schedule, show the child the actual headphones or otoscope.
Tap into and use the child’s primary/preferred language form.
Using non-verbal behavior, an augmentative and alternative communication device (AAC), PECS book, sign, or spoken language, many children with ASDs can and will communicate. It is imperative that the child bring the assistive technology (e.g., AAC device) to the hearing screening. Ask the child’s SLP about the child’s preferred communication method to ensure that the child’s voice is heard during the evaluation. In an educational setting, the person doing the screenings is likely to know the children well enough to know the details of their communication systems. If not, the burden is on us to ensure we know children’s preferred language forms.
Behaviorally testing the hearing of children with disabilities, such as ASDs, can be challenging even for the most experienced clinician. By using these suggestions, clinicians should less frequently need to note “could not test” across the top of the hearing screening form. More successful hearing screening methodology for children with ASDs would lead to fewer outside referrals for further audiometric evaluation, as well as less time and money spent on these additional evaluations. Every clinician appreciates ways to improve productivity by finding tools and resources that allow for more efficient and complete evaluation processes.
Sources
American Speech-Language-Hearing Association. (1997). Guidelines for Audiologic Screening [Guidelines]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association. (1997). Guidelines for Audiologic Screening [Guidelines]. Available from www.asha.org/policy.×
Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006 Principal Investigators, Centers for Disease Control and Prevention (CDC) (2009). Prevalence of autism spectrum disorders: Autism and developmental disabilities monitoring network, United States, 2006. Morbidity and Mortality Weekly Report, 58(10), 1–20. [PubMed]
Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006 Principal Investigators, Centers for Disease Control and Prevention (CDC) (2009). Prevalence of autism spectrum disorders: Autism and developmental disabilities monitoring network, United States, 2006. Morbidity and Mortality Weekly Report, 58(10), 1–20. [PubMed]×
Cloppert, P., & Williams, S. (2005). Evaluating an enigma: What people with autism spectrum disorders and their parents would like audiologists to know. Seminars in Hearing, 26(4), 253–258. [Article]
Cloppert, P., & Williams, S. (2005). Evaluating an enigma: What people with autism spectrum disorders and their parents would like audiologists to know. Seminars in Hearing, 26(4), 253–258. [Article] ×
Davis, R., & Stiegler, L. (2005). Toward more effective audiological assessment of children with autism spectrum disorders. Seminars in Hearing, 26(4), 241–252. [Article]
Davis, R., & Stiegler, L. (2005). Toward more effective audiological assessment of children with autism spectrum disorders. Seminars in Hearing, 26(4), 241–252. [Article] ×
Dittman, C., & Brueggeman, P. (2003). Audiologists’ aptitude in the upper midwest to test and treat audiologic problems in children with autism. Poster presented at annual meeting of South Dakota Speech-Language-Hearing Association, April 2003. Sioux Falls, SD.
Dittman, C., & Brueggeman, P. (2003). Audiologists’ aptitude in the upper midwest to test and treat audiologic problems in children with autism. Poster presented at annual meeting of South Dakota Speech-Language-Hearing Association, April 2003. Sioux Falls, SD.×
Downs, D., Schmidt, B., & Stephens, T. (2005). Auditory behaviors of children and adolescents with pervasive developmental disorders. Seminars in Hearing, 26(4), 226–240. [Article]
Downs, D., Schmidt, B., & Stephens, T. (2005). Auditory behaviors of children and adolescents with pervasive developmental disorders. Seminars in Hearing, 26(4), 226–240. [Article] ×
Gravel, J., Dunn, M., Lee, W., & Ellis, M. (2006). Peripheral audition of children on the autistic spectrum. Ear and Hearing, 27(3), 299–312 [Article] [PubMed]
Gravel, J., Dunn, M., Lee, W., & Ellis, M. (2006). Peripheral audition of children on the autistic spectrum. Ear and Hearing, 27(3), 299–312 [Article] [PubMed]×
Tharpe, A., Bess, F., Sladen, D., Schissel, H., Couch, S., & Schery, T. (2006). Auditory Characteristics of Children with Autism. Ear & Hearing. 27(4), 430–441. [Article]
Tharpe, A., Bess, F., Sladen, D., Schissel, H., Couch, S., & Schery, T. (2006). Auditory Characteristics of Children with Autism. Ear & Hearing. 27(4), 430–441. [Article] ×
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January 2012
Volume 17, Issue 1