How hearing loss gets confused with other concerns

Speech Pathology Blog 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 went unnoticed and he was misdiagnosed or was delayed in receiving services.  

How do children with hearing loss still go undiagnosed? 
We organized this post into three sections in order to answer this question and better prepare us for the next time we come across a child with potential hearing issues.  Let’s 1) check out which referral concerns are shared with concerns about hearing loss, 2) do a quick review of the relationship between speech and hearing, and 3) use a case study of a child who was misdiagnosed to bring the point home.

1.   Which referral concerns are shared with hearing loss?

We assembled data pairing observations made when children have a hearing loss with three major areas of concerns.    Let’s take a look.  The results are startling.   If we lack hearing status upon starting an evaluation, we can say good-bye to that nice long testing window.  Typically, we run in the direction of language, behavior, or pragmatic issues but “something just doesn’t feel right.”  Again, in the best case scenario, we catch the hearing loss late and still end up with a proper diagnosis.  Commonly, we misdiagnose and set the child up with speech therapy and social intervention that doesn’t match their needs.  Say hello to slow or zero progress.

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


fights with peers

has sleeping problems

has excessive energy levels

is unable to sit still and focus

is a picky eater

has frequent tantrums

loses things needed for activities at school and at home

forgets things

Is easily distracted

Is fidgety

runs or climbs inappropriately

cannot play quietly

blurts out answers

interrupts people

cannot stay in seat

talks too much

has trouble waiting his or her turn

does not use words to communicatedoes not imitatewill not play gamesis easily distractible

has oral-motor problems such as excessive drooling, trouble with solid foods, intolerance to touch in and around the mouth

uses only nouns

does not tolerate sitting for listening activity/looking at books, etc.

is not speaking in full sentences (not necessarily correct grammar, but a variety of word types)

is not using “I” to refer to self

cannot relate experiences, even in simple telegraph sentences

resists cuddling and holdingappears unaware of others’ feelingsloses previously acquired ability to say wordsdoes not make eye contact when making requests

speaks with an abnormal tone or rhythm — may use a singsong voice or robot-like speech

performs repetitive movements, such as rocking or spinning

develops specific routines

becomes disturbed at the slightest change in routines

may be fascinated by parts of an object, such as the spinning wheels of a toy

 2.  Speech’s Relationship to Hearing (Cliff’s notes version)

A great deal of research has focused on the role of audition as it relates to the development of speech.  Children receive greater access to language due to discoveries concerning early diagnosis, treatment, and advances in hearing aid fitting techniques.  Identifying relationships between speech and audition has hastened and improved therapy. It is not enough to say that audition and speech are uniquely intertwined.  Some components of speech and audition develop symbiotically where one has to be present for the other to exist.  Other aspects of speech and audition develop independently and have been shown to be present when the other is absent.  Speech and hearing relate differently across time (Oller, 1980) depending on severity of the hearing loss and concomitant problems.   A loss of hearing affects each parameter of speech (e.g. prosody, perception) in a unique way.

Prelinguistic vocalizations

Vocalizations of children with hearing impairment (HI) have a strong motoric base (Wallace, 1999), and resemble the sounds made by hearing children in the first half-year of life (Oller et al., 1985).

Canonical Vocalizations (Babbling)

In infants with profound hearing loss, canonical vocalizations (the trills, squeaks, and growls) do not normally appear until the twelfth month and has been reported to appear as late as the 31st month (Steffens et al., 1994).

The Emergence of the Sounds of Typical  Speech in Infancy. (Oller 1980)


Age (in months)


The Phonation Stage


Vowels, consonants, throaty sounds, phonation with a closed mouth
The Goo Stage


Velar (/g/) consonants, controlled but irregular movements
The Expansion Stage


Strong vowels, bilabial trills, squeals, growling
The Canonical Stage


Patterned, consonant-vowel combinations, reduplicated babble (mama), and non-reduplicated (ada)
The Variegated Babble Stage


Diverse babble (bada), gibberish, intonation

Consonant Repertoire

The number of consonants that are present in the speech of children with HI is dramatically lower than the number of consonants present in the development of normal hearing.  The limited number of consonants produced by children with HI coincides with a smaller number of consonant classes (Oller and Eilers, 1988; Wallace, 1999).  The consonant repertoire is diminished without cues from audition.

Vowel Repertoire

Deviations in vowel productions in children with HI can be characterized by substitutions or distortions rather than the omissions and class changes of consonant errors (Yoshinaga-Itano, 1998).  Vowels tend to be neutralized and substitutions occur on vowels that are in close proximity to the target vowel (e.g. /I/ & /i/) (Yoshinaga-Itano et al., 1992).

Syllable Shape

The repertoire of consonantal and vocalic phoneme pairs produced by children with HI is limited to low frequency of multisyllabic utterances (Oller et al., 1985).  Deaf speech is primarily composed of singleton syllables, dominated by labial or nasal consonants paired with neutral vowels (Oller et al., 1985, Oller &  Eilers, 1988; Yoshinaga-Itano et al., 1992, Davis et al., 2002).

Utterance Length

During typical development, around eight months marks the beginning of the explosion of speech-like utterances (Oller, 1980).  With an infant with HI however, there is still an increase in syllable structures until approximately eight months (Yoshinaga-Itano et al., 1992).  Speech development is slow and smaller numbers of utterances are recorded at each age range (Davis et al., 2002).

Phonological Development

Processes specific to severe-to-profound hearing populations include voicing substitutions (/b/ to /p/), omission and distortion of final consonants, reduction of consonant blends, and nasalization of consonants.  Yoshinaga- Itano summarized Ross, Brackett, and Maxin (1991) in stating that affricates and fricatives are the greatest sources of error in manner.  Furthermore she highlights Gordon’s study (1987) where lingua-palatal and lingua-alveolar sounds were found to make up the greatest source of error with regards to place (Yoshinaga-Itano, 1998).


The rhythmic cadence of typical speech is not often present in the speech of children with impaired hearing (Oller et al., 1985).  The speech of an infant with hearing loss is replete with inappropriately timed vocal patterns and prolongation.  In most instances, the transition to the vowel within each syllable set is too long.  This arrhythmic nature is compounded by abrupt changes in amplitude rather than a contour of sound change.

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 status was 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.

What events or facts distracted the staff from initially identifying the role that a hearing loss might have played in Patricio’s development? 

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 hear 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.

Refer to our CEU course on hearing loss or contact us for full references.

Written by: Scott Prath

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