Let’s face it.  Obtaining a correct hearing screening before completing an evaluation is often a hassle.  Not to mention that 99% of the time a child’s hearing is within normal limits.  However, each year we hear about evaluations that were disasters at worse and sad at best because a child’s hearing loss symptoms went unnoticed and he was misdiagnosed or was delayed in receiving services.  

We organized this post into three sections in order to better prepare us for the next time we come across a child exhibiting hearing issues symptoms.  Let’s:

1. Check out which referral concerns are shared with concerns about hearing loss
2. Do a quick review of the two main types of hearing loss
3. Use a case study of a child who was misdiagnosed to bring the point home.

May is Better Hearing and Speech Month, but this is information we can bookmark to use throughout the year.

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1.   Which referral concerns for other communication disorders are shared with hearing loss symptoms?

Hearing loss and speech difficulties are obviously related. However, there are some hearing loss symptoms that can mimic other difficulties such as behavior, language disorders, and Autism. The real danger lies not in misdiagnosis, but not checking hearing status if some of these behaviors are present. Let’s take a look. 

Signs of Common Disorders and those that may be shared by Children with Hearing Loss 

Signs of Behavior Difficulties	Signs of Language Disorder	Signs of Autism
hits, pushes, yells fights with peers	does not use words to communicate	resists cuddling and holding
has sleeping problems	does not imitate	appears unaware of others’ feelings
has excessive energy levels	is easily distractible	loses previously acquired ability to say words
is unable to sit still and focus	uses only nouns	does not make eye contact when making requests
has frequent tantrums	does not tolerate sitting for listening activity/looking at books, etc.	speaks with an abnormal tone or rhythm
loses things needed for activities at school and at home	is not speaking in full sentences (not necessarily correct grammar, but a variety of word types)	develops specific routines
forgets things	is not using “I” to refer to self	becomes disturbed at the slightest change in routines or loud environmental changes

The results are startling. If we run in the direction of the “more obvious” diagnosis we can set the child up with speech therapy and social intervention that doesn’t match their needs. All of which can be avoided by establishing hearing status at the beginning of the testing window and being on the look out for signs and symptoms of hearing loss with the children already on our caseload.

How Your Student or Client Might Report Hearing Loss Symptoms

Most people don’t actually think they are having trouble hearing unless there was a specific event like an accident or illness that caused the hearing loss. Here are great questions for the child, parent, or teacher to get to the root of the problem:

• Do you avoid social situations?
• Do you have trouble hearing people on the phone?
• Do you have trouble understanding people when it is noisy?
• Has anyone told you that your music or the TV is turned up too loud?
• Do you have to ask people to repeat themselves?
• Do you think other people are mumbling when they are talking?

Conductive and Sensorineural Hearing Loss Symptoms

Since it’s been a while since most SLPs first learned about hearing loss, let’s brush up on the two primary types and what symptoms they have or share.

Conductive Hearing Loss Symptoms

Conductive hearing loss is what we most often encounter. This is a hearing loss that can be caused by:

• Ear infections
• Fluid in the middle ear (e.g. allergies)
• Perforated eardrum
• Blocked ear canal from earwax or another object
• Structural issues like the narrowing of the ear canal

Conductive hearing loss symptoms may include:

• Pain in the ear
• Gradual hearing loss over time
• Difficulty with quieter sounds (e.g. unvoiced)
• Unclear hearing – muffled speech
• Fluid drainage

Sensorineural Hearing Loss Symptoms

We want to talk about sensorineural hearing loss here for one quick minute. We see conductive hearing loss so much more frequently that it is easy to forget about sensorineural hearing loss symptoms and might miss the fact that something more serious might be at hand. Sensorineural hearing loss symptoms can include:

• Ringing in the ears
• Both muffled voices and sounds
• Difficulty hearing certain pitches, specifically high pitched sounds
• Trouble understanding children and female voices
• Possible balance problems
• Dizziness
• Problems hearing when there is a lot of background noise

3.  A Case Study

Patricio was a Spanish-speaking first grader who repeated Kindergarten before being admitted to first grade.  He was well known to all campus members for screaming in the halls, throwing himself on the floor, and running out of the classroom. He was regularly seen “fighting in a battle royal” after school with his siblings.  Patricio was one of eleven children, nine of whom were boys.  His mother was a single parent who had been attending parenting classes since her older children began at the school.

Patricio had been diagnosed with an articulation impairment and a receptive and expressive language impairment in his first Kindergarten year.  His hearing screening was not fully completed due to “an inability to follow directions” and his hearing was deemed satisfactory for testing purposes.  His communication could be described as being unintelligible at the two-word level.  He had difficulty following directions, was not at grade level despite being his second year, and was “constantly acting out.”

By half way through his second kindergarten year, counseling and special education interventions were initiated due to low academic performance, behavior problems, and social anxiety.  Patricio’s development appeared to be regressing.  Absences due to sickness were more frequent.  He would crawl under the piano when the class entered the cafeteria and would cover his ears.  He would become violent and angry when put in a time-out corner for not doing his work.  He could not walk down the hall with his class.  He appeared nervous during portions of the day and began going to the bathroom in his pants.  Counseling was suggested for the family and Patricio began seeing the counselor at school.  Behavioral interventionists, a Spanish-speaking SLP, an OT, a PT, and Childhood Protective Services visited the class.

When Patricio’s hearing loss symptoms were investigated and found to be below normal limits, he was sent to the hospital for a full hearing evaluation.  The bilingual SLP attended the visit to assist with behavior issues and translation.  Patricio’s mother was given childcare by the school and agreed to use sedation if the hearing evaluation could not be completed.  Patricio was diagnosed with a bilateral moderate to severe hearing loss due to previous infections.  It was observed that one or both ear drums had previously ruptured and that there was little to no movement of the middle ear due to recurring infections.  Patricio’s progress in academics, communication, socialization, and behavior improved as soon as his ear infections began to be followed medically.

Think about his demeanor, socio-economic issues, home language issues, and medical history.

1. Home language:  Staff questioned whether Patricio’s Spanish exposure was complicating his assimilation to the classroom and learning.
2. Socio-economic Status:  On one hand, the assumption was made that Patricio’s family would follow-up on medical concerns whereas the mother didn’t have child care or transportation.  On the other hand, limited knowledge and resources made it difficult for Patricio’s mother to concentrate on her son’s needs due to a heavy work schedule.
3. Parenting:  Known behavior of siblings made it seem that Patricio’s behavior was typical for his family. His siblings did have questionable behavior; however none of them were identified as needing additional services.  Additionally, due to Patricio’s family size, it was assumed vocally that his mother did not have control of her children.
4. Reputation:  Patricio was “known” on campus and his behavior was tied to his personality.
5. Academic Need:  Patricio’s need to repeat a grade made it appear as though he was cognitively challenged and these behaviors were a result of low mental abilities.
6. Additional Diagnosis:  Many of Patricio’s behaviors (hiding under the piano, unable to transition in and out of the classroom, anxiety) were prematurely linked to Autism/ADHD and other causes were not pursued until that testing was negative.

Take away points to keep us insisting on getting hearing results before we test:

• The degree of hearing loss is the greatest contributing factor to the impairment of speech development (Yoshinaga-Itano et al., 1992; Yoshinaga-Itano, 1998; Wallace 1999).
• There is a magnitude of difference in speech abilities in children who operate across the mild-moderate-severe hearing-impaired continuum (Stoel-Gammon & Otomo, 1986).
• Even a minimal amount of residual hearing greatly improves a child’s chances at producing accurate speech when compared to a child with no access to the sound system.
• The two most powerful signs of hearing loss are family history and child history of ear infections.
• Ear infections can permanently reduce the pliability of the tympanic membrane causing a mild permanent loss.
• For each infection, a child might not be hearing well for 2-6 weeks.  If a child has numerous ear infections, this can add up to a great percentage of their young life.