Considerations for Testing Children with Autism Spectrum Disorder

One in 59 children have Autism Spectrum Disorder (ASD). Think back on your clinical journey thus far. How many children have you seen with ASD? A few? A lot? Not sure?  Before beginning my second year in school, I had no idea what the relationship was between audiologists and children with ASD.

Did you know that children with suspected ASD or those being considered for an ASD evaluation typically receive a hearing test prior to additional ASD-related testing? I certainly did not. This is because children with ASD have similar characteristics with children that have hearing loss. For example, a child with ASD may not turn their head when their name is called, may not search for a sound source, and may have challenges socializing or communicating with peers. Children with undiagnosed hearing loss will also show a lot of these characteristics simply because they have difficulty hearing others! My professor told me about a child that was suspected of having ASD. The child completed the entire evaluation and was then diagnosed with ASD. Some time later, it was determined that the child actually had hearing loss and once aided, they no longer appeared to have ASD. In reality, that child was missed in hearing screenings at school and was incorrectly diagnosed with ASD! We all know what late identified hearing loss means for a young child.

Therefore, we as audiologists play a critical role in differential diagnosis of a child with suspected ASD. A child may come into our office because we need to either rule in, or rule out hearing loss, as a contributing factor as to why they are demonstrating delays. Being a student that is interested in pediatric audiology, I acknowledge that kids are generally a lot more difficult to test. However, children with ASD present additional challenging behaviors. Following significant review of the literature, I want to discuss why it can be challenging to test these children, as well as things we can do as audiologists to improve our outcomes, and obtaining accurate and reliable results is absolutely essential.

The literature suggests that children with known or suspected ASD can be difficult to test because they may be less reliable than their neurotypical peers when completing a hearing test. Tharpe and colleagues (2006) tested normal hearing, neurotypical children and normal hearing children with known ASD and found that the children with ASD had poorer test-retest reliability compared to their peers. This means that some of these children, although shown to have normal hearing through objective measures, appeared to have mild hearing loss when tested behaviorally—merely because they were less reliable and did not respond to threshold pure tones within the normal hearing range. The author suggests that this may demonstrate how children with ASD may process auditory information differently than their neurotypical peers. Furthermore, children with ASD can actually have different physiological results than neurotypical peers. Some studies have found that wave V in the ABR can be delayed in children with ASD (but still within normal limits) (Roth et al., 2012). One study has even suggested that children with ASD can have reduced OAEs at 1000 Hz (Bennetto et al., 2017)! While reasons behind these differences are still largely unknown, Kwon and colleagues (2007) have determined that it is likely due to structural brain differences between children with ASD and children without ASD, which may be why children with ASD process auditory information differently (alas, children with ASD are more likely to have auditory processing disorders—check out Autism Speaks for more information).

Additionally, children with suspected or known ASD may be challenging because this population may have non-auditory related characteristics that make testing difficult. For example, some may have tactile sensitivities which may cause them to reject wearing headphones or inserts. Children with ASD may also exhibit difficulty transitioning from one task to the next, especially if the tasks and the audiologist they are working with are unknown. This tends to cause a lot of anxiety for these children, making testing difficult (as it would be challenging to test any child that is anxious about the task). A child with ASD may also be easily distracted by all of the cords and extra toys within the booth, as they can tend to fixate on specific objects of interest.

So, what are ways that we, as audiologists, can improve audiometric testing for children with ASD?

1. Set up clear expectations: use visual schedules in the office which demonstrate which steps in the procedure are coming next. Children with ASD use these all of the time in many different situations, so why not use them while testing? (Here is what they typically look like and how to use them. If you are interested in obtaining visual schedules to use in an audiological appointment, feel free to email me at haley.mctee@colorado.edu. I have made many versions of these).
2. Use concrete language: children with ASD benefit from clear, concise, and concrete language. It is better to be direct and use less language. For example: you may usually say something like “this magic crayon will draw a picture of your ear” (for tympanometry). Instead try this: “this rubber part will go in your ear. Then it will all be done”.
3. Allow children with ASD to explore your tools: let them touch everything that will be going in/on their ears to reduce anxiety and tactile sensitivities.
4. Allow a longer response window: because children with ASD may process auditory information differently, it is important that you wait a couple of seconds longer to make sure they are finished processing what was said.
5. Minimize distractions: get rid of unnecessary toys/cords in the booth. Even using blankets to cover things up may be helpful.

While we can always tell a parent that they can come back for a second, third, or even fourth appointment to get the rest of the necessary information from their child—what if making some of these adjustments allows you to get more information in the first or second appointment?

I would love to finish this post with a discussion for those that are interested, so I leave you with these questions and/or thoughts:

• Have you ever seen delayed wave V on ABRs for children with known ASD? (I have only seen it once).
• Have you seen unusual OAE responses for a child with ASD?
• Have you ever tried using visual schedules for children with ASD before or during testing?
• What other modifications to testing or techniques have you used when working with a child with ASD? Was it effective?

If you have any questions or want to discuss more about this topic, feel free to email me at haley.mctee@colorado.edu. I would love to chat more about this topic! Thanks for reading.

References

Bennetto, L., Keith, J. M., Allen, P. D., & Luebke, A. E. (2017). Children with autism spectrum disorder have reduced otoacoustic emissions at the 1 kHz mid‐frequency region. Autism Research, 10(2), 337-345.

Kwon, S., Kim, J., Choe, B. H., Ko, C., & Park, S. (2007). Electrophysiologic assessment of central auditory processing by auditory brainstem responses in children with autism spectrum disorders. Journal of Korean medical science, 22(4), 656-659.

Roth, D. A. E., Muchnik, C., Shabtai, E., Hildesheimer, M., & Henkin, Y. (2012). Evidence for atypical auditory brainstem responses in young children with suspected autism spectrum disorders. Developmental Medicine & Child Neurology, 54(1), 23-29.

Tharpe, A. M., Bess, F. H., Sladen, D. P., Schissel, H., Couch, S., & Schery, T. (2006). Auditory characteristics of children with autism. Ear Hear, 27(4), 430–441. https://doi.org/10.1097/01.aud.0000224981.60575.d8

Haley McTee is a third-year doctoral student in the Doctor of Audiology program at the University of Colorado Boulder. She completed her undergraduate studies at the University of Colorado Boulder with a double major in Speech, Language, Hearing Sciences and Psychology. She is a LEND fellow, as well as the representative of Colorado for the National Student Academy of Audiology. In the future, she is interested in working with the pediatric population, and hopes to specialize in Cochlear Implants. She is also interested in early language acquisition, sign language, and Deaf culture.