Treating the Whole Child: When Hearing Loss and ASD Co-Occur How can hearing, speech and medical professionals ensure dually diagnosed children access the support they need? All Ears on Audiology
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All Ears on Audiology  |   October 01, 2018
Treating the Whole Child: When Hearing Loss and ASD Co-Occur
Author Notes
  • Susan Wiley, MD, is co-director of the Division of Developmental and Behavioral Pediatrics, director of the Thomas Center for Down Syndrome, and co-director of the CHARGE Program at Cincinnati Children’s Hospital. susan.wiley@cchmc.org
    Susan Wiley, MD, is co-director of the Division of Developmental and Behavioral Pediatrics, director of the Thomas Center for Down Syndrome, and co-director of the CHARGE Program at Cincinnati Children’s Hospital. susan.wiley@cchmc.org×
Article Information
Hearing & Speech Perception / Hearing Disorders / Special Populations / Autism Spectrum / All Ears on Audiology
All Ears on Audiology   |   October 01, 2018
Treating the Whole Child: When Hearing Loss and ASD Co-Occur
The ASHA Leader, October 2018, Vol. 23, 18-19. doi:10.1044/leader.AEA.23102018.18
The ASHA Leader, October 2018, Vol. 23, 18-19. doi:10.1044/leader.AEA.23102018.18
When children who are deaf/hard of hearing (D/HH) are diagnosed with autism spectrum disorder (ASD), they struggle that much more to access needed communication and behavioral support. Compounding matters, they’re often diagnosed with ASD later than peers who are non-D/HH, since general autism-screening tools are not well-adapted for those with hearing loss.
It is helpful to start with what we can learn from the broader autism field and consider how these tenets could apply to children with a dual diagnosis. Evidence—from studies examining eye-tracking patterns, differences in processing visual and auditory information, as well as differences in neural networks (see sources below)—supports the existence of distinct neurological differences in children with ASD as compared to neurotypically developing children.
Just like for children who are D/HH, for children with ASD, early recognition and identification is critical to accessing evidence-based interventions targeting core difficulties in communication, social interactions and behavior.
ASD rates are higher in children who are D/HH as compared to the general population (see sources), possibly associated with ASD risk factors such as CHARGE syndrome, prematurity and congenital CMV (see sources). To recognize ASD earlier in children who are D/HH, we need to closely monitor their progress in the areas of language, play and social interactions.
What we know (and what we don’t)
Advancements in our knowledge of ASD are limited by the lack of biomarkers or objective tests to identify an autism spectrum disorder. The ASD diagnosis comprises a constellation of behaviors catalogued by the Diagnostic and Statistical Manual of Mental Disorders. Optimally, a multidisciplinary team diagnoses ASD, ensuring the identification of other conditions that could mimic features of ASD.
Multidisciplinary team members may include—in addition to an audiologist—a physician, speech-language pathologist and psychologist. Some teams include an occupational therapist, classroom educator and social worker. Through a multidisciplinary approach, a child receives the needed range of medical and genetic evaluations to determine developmental needs.
The National Autism Center’s National Standards Project publishes a quality review of evidence-based interventions for children with ASD. This information highlights interventions that can improve outcomes for children with ASD.
How does all of this knowledge apply to children who are D/HH with a diagnosis of ASD? For them, we must prioritize the general tenets of early and accurate identification, implementation of evidence-based treatment, and a broader medical work-up that considers more than the ear/hearing. We also must ensure family-to-family support—an approach to link families to other families through regional support groups and family information networks—for this population.

To recognize autism earlier in children who are D/HH, we need to closely monitor their progress in the areas of language, play and social interactions.

Screening and evaluation
It can be difficult to diagnose ASD in children who are D/HH because of the dual reasons affecting language processing. When screening children who are D/HH for ASD, we typically use a combination of clinical observations, consideration of developmental patterns, and objective measurement of the quality of speech and language turn-taking (see sources).
Unfortunately, autism-screening tools commonly used in the general population have not been well-studied in children who are D/HH. Diagnostic evaluations pose complex challenges as well, but can be accurately implemented (see sources). Using autism-specific tools helps guide a systematic approach to evaluating children for ASD. When we evaluate children who are D/HH, we need to understand the responses to these evaluation tools in the context of a child’s hearing and communication skills. A qualitative interpretation is important.
In one study, researchers accurately identified ASD among children who were deaf-blind, suggesting that even among a group of highly complex children, atypical social-communication patterns were evident and distinguishable from aspects of a child’s hearing and vision (see sources).
Children who are D/HH with ASD need treatment beyond what is typical for hearing loss. This does not negate the need for treatment that addresses a child’s hearing loss, but limiting our focus to hearing loss is insufficient to address the underlying needs related to ASD.
For example, children with ASD experience difficulty understanding subtle nonverbal cues and facial expressions. Some children with ASD avoid direct eye contact, which can affect speech-reading, visual highlighting of speech sounds, and attention to signing space and nonmanual markers (see sources). Nonmanual markers are facial expressions and movements that confer meaning to a sign. If these behaviors are not considered within the treatment setting, dually diagnosed children may make limited progress.
The available evidence for implementing ASD-specific interventions for children who are D/HH with ASD is limited to small case reports. Interventions evaluated include applied behavioral analysis, functional behavioral analysis for problem behaviors, and picture exchange communication system (see sources below). These evidence-based interventions show promise but may require adaptations for children who are D/HH.

We must prioritize the general tenets of early and accurate identification, implementation of evidence-based treatment and a broader medical work-up that considers more than the ear/hearing.

Change it up
What can we do differently as professionals focusing on children who are D/HH? For one, we can use an interprofessional approach to guide language learning and progress. Audiologists can strongly encourage families to seek a speech-language pathologist’s help monitoring their child’s language. This monitoring may help even if a child seems to be making “good” progress: Some children with ASD have “normal” vocabulary and use their language to get what they need, but struggle in conversation and with more subtle aspects of communication.
Educating families on the progress they can expect to see based on a child’s hearing loss and available supports (amplification, language intervention, access to sign language models) can prepare them for a discussion if the child fails to meet timelines and benchmarks. Those working with a child daily can discuss with families observations that may relate to a child’s hearing loss versus other developmental or behavioral needs. When considering a child’s communication progress, recognize that families do their best to communicate with their child.
Families of children who are D/HH with ASD have challenges in many areas, and family-to-family support is important—but families often struggle to find others with similar needs. One possible strategy is using online forums to link families (see sources).
Children who are D/HH with ASD benefit most when interventions are ASD-specific and provided early. By guiding families in their understanding of their child’s unique needs, providing networking from families of children with ASD, and building a network and team of support, children who are D/HH with ASD can make life-changing progress.
Here’s what success can look like: I diagnosed a young boy with autism at age 5. He had received a cochlear implant by age 1, but struggled with communication and behavior. I learned from a mutual contact that the client, now an adult, recently volunteered at a soup kitchen. He noticed some children having a difficult time waiting and making a bit of noise. He started reading books to them, which settled them down. His journey was long—but after receiving the right supports for his dual diagnosis early in childhood, he was able to reach out as an adult to strangers in a moment of kindness and compassion.
Looking for More?

ASHA will present “Early Identification of Autism in Children Who Are Deaf/Hard of Hearing,” a live webinar on Dec. 12. Co-presented by an audiologist and speech-language pathologist, the webinar will explore the differential diagnosis of autism spectrum disorder (ASD) in children who are deaf/hard of hearing and highlight the importance of interdisciplinary collaboration when working with children who have ASD and hearing loss.

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October 2018
Volume 23, Issue 10