When It’s More Than Hearing Loss be attuned to sign of autism spectrum disorder


Camden, age 18 months, has been using binaural hearing aids for a year. His parents know that he may not understand language or develop speech as early as children his age with normal hearing and are not concerned about his lack of communication.
However, his audiologist notices that Camden does not look to his parents or point to share his interest in the cars he lines up by color in the exam room, and he rarely pushes the cars in play. Also, his auditory-verbal therapist reports that Camden is making minimal progress in treatment. These observations raise concerns that Camden may have something else going on, possibly autism spectrum disorder.
Not all those who work with this population are aware that children like Camden, who have hearing loss, are at higher risk for ASD and a number of other developmental disabilities. In its 2009–2010 Annual Survey of Deaf and Hard of Hearing Children and Youth, the Gallaudet Research Institute estimates about 40 percent of children with hearing loss exhibit another disability and notes the prevalence of ASD to be 1 in 59 (see sources). To address such co-existing conditions, my colleagues and I established an interdisciplinary Hearing and Development Clinic at the Carolina Institute for Developmental Disabilities.
Often, we see families and professionals so focused on a child’s hearing loss or other medical issues that they miss signs of ASD, leading to delayed initiation of ASD-specific interventions. That’s why we recommend that audiologists and speech-language pathologists who work with children with hearing loss be on the look-out for signs of ASD and, when noticed, refer the child for a skilled assessment as early as possible. Here is what to look for.

Learn the signs
 Children with ASD display challenges in social communication and interaction and restricted or repetitive interests or behaviors. Children with ASD and those with hearing loss often experience delays in receptive and expressive language, which, in turn, may affect social interactions. However, with early identification, access to appropriate hearing technology and intervention services, typically developing children with hearing loss demonstrate progress in language development at a rate similar to hearing children.

Given that some symptoms overlap, how can clinicians tell if a child with hearing loss also has ASD? Let’s examine the ASD diagnostic criteria from the “Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition” to determine which symptoms are not typically seen in children with hearing loss.

The first ASD diagnostic domain notes: “Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following:”

1. Deficits in social-emotional reciprocity: Children with hearing loss may have difficulty with social interactions, such as approaching or participating in conversation, particularly with hearing peers, and may inconsistently respond to others. However, the following would be atypical for children with hearing loss:

  • Not responding when tapped on the shoulder to get attention.

  • Not sharing interests, emotions and/or affect.

  • Not initiating interactions with familiar people by directing vocalizations or using eye contact and gestures.

  • Not initiating joint attention with familiar people, or sharing interests by giving, showing or pointing out something.

2. Deficits in nonverbal social communicative behaviors: Children with hearing loss may not integrate verbal production with nonverbal communication, and those with limited expressive language may use another’s hand as a tool for communication. In general, children with hearing loss should use, and may rely on, nonverbal communication, particularly eye contact and gestures (for example, pointing, nodding, signing, pantomiming) to communicate for a variety of pragmatic purposes. It’s concerning, however, if a child:

  • Exhibits absent, limited or inconsistent use of nonverbal communication: eye contact, body language, gestures and facial expression.

  • Has a flat affect.

3. Deficits in developing, maintaining and understanding relationships:Children with hearing loss are usually socially motivated, although they may experience challenges with social relationships and making friends due to communication and pragmatic language difficulties. However, concerns for ASD include:

  • Lack of interest in peers.

  • Limited functional or imaginative play at an appropriate developmental level.

The second ASD diagnostic domain notes: “Restricted, repetitive patterns of behavior, interests or activities, as manifested by at least two of the following:”

1. Stereotyped or repetitive motor movements, use of objects, or speech:Children with hearing loss may sometimes exhibit repetitive language, echolalia and/or idiosyncratic phrases (in speech or sign) when developing speech and language; however, these behaviors should have communicative intent and disappear as language improves. Signs of ASD may include:

  • Persistent echolalia, use of unusual phrases, insistence on verbal rituals or scripting shows/movies.

  • Repetitive use of objects (lining up toys or nonfunctional play with objects) or playing only with a limited variety of toys.

  • Odd motor mannerisms (for example, flapping, toe-walking, rocking, spinning).

2. Insistence on sameness, inflexible adherence to routines or ritualized patterns of verbal or nonverbal behavior: Children with hearing loss may prefer things to be predictable but are less likely to be rigid or inflexible. They may have difficulty with transitions or changes in routine if they don’t understand what is happening, but changes should not cause distress beyond their developmental level. A child with ASD, however, may exhibit:

  • Significant difficulty with transitions or changes in routine or environment.

  • Insistence on sameness or control over others’ behaviors (for example, controlling play).

3. Highly restricted, fixated interests that are abnormal in intensity or focus:Children with hearing loss may have specific interests, but they tend not to persist for long periods of time. However, concerns arise if a child:

  • Has a seemingly developmentally appropriate interest (for example, trains or cars) that is excessive or all-consuming for a long time.

  • Has odd interests that are not developmentally appropriate and/or unusual in their intensity (for example, dates, bus routes, toilets).

  • Carries a preferred object with no intended purpose (such as a rock, piece of string or hockey puck).

4. Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment: Although children with hearing loss may have unusual sensory responses to auditory or vestibular input or initial sensitivity to the use of hearing aids or cochlear implants, a child with ASD might show:

  • Sensory-seeking behaviors, such as visual inspection, tactile exploration, or smelling objects or people.

  • Limited response to appropriate amplification.

  • Avoidance or aversive responses to stimuli related sight, feel, taste or smell.


The complex nature of determining a dual diagnosis of hearing loss and ASD requires an interdisciplinary team. Our team obtains a comprehensive picture of the child that includes nonverbal intelligence, adaptive behavior and language abilities, and we carefully consider expected developmentally appropriate skills and hearing age when examining symptoms of ASD.

Although not validated with children who are deaf or hard of hearing, we administer the Autism Diagnostic Observation Schedule, Second Edition, with modifications and a cautious, qualitative interpretation. We also conduct a diagnostic caregiver interview to gain a thorough developmental history and review past and present symptoms of ASD across settings.

As an interdisciplinary team, we use our collective judgment to determine whether a child’s social and behavioral challenges are due to intellectual disability, language delays related to hearing loss, language impairment, and/or learning disabilities. Although challenging, it is possible to conduct the comprehensive assessment needed to establish or rule out an ASD diagnosis for a child with hearing loss.

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