The mission of Independent Audiologists Australia is to promote and support clinical practices owned by audiologists.

Submission on the proposed Thriving Kids program and the diversion of children with autism and developmental delay from the NDIS

1 October 2025

Executive summary

The Commonwealth’s proposed Thriving Kids program would shift many children with mild to moderate developmental delay and autism off the NDIS into new “foundational” supports delivered outside the scheme. While the goals—earlier identification and community-based supports—are laudable, the proposal as described risks systematically overlooking hearing and middle ear health, a foundational determinant of communication, learning, behaviour and participation.

Audiologists must be embedded from first contact and throughout care; otherwise Australia risks over-diagnosing neurodevelopmental conditions in children whose primary driver is remediable hearing loss, while also underservicing children with Autism, who have higher rates of ear disease, ENT procedures and hospital contacts. Middle ear pathology and associated hearing loss can lead to sequelae such as speech and language delays, behaviour concerns, and lack of eye contact to speech.

In addition, many autistic children experience sound sensitivities (decreased sound tolerance), which are common in autism and, in children under six—when middle ear pathology is at its peak—can often reflect periods of fluctuating conductive hearing status after episodes of glue ear.

Finally, from school-age onward, a structured assessment of auditory processing abilities is required to profile how a child listens and learns in real-world environments. Sensory processing profiles obtained by Occupational Therapists often explore sound sensitivities and auditory questions, without necessarily the input of a suitably qualified Audiologist which could again lead to the potential for misdiagnoses. ALL other therapies (speech pathology, occupational therapy and psychology) hinge on a child’s hearing profile remaining normal, or on therapies being adapted to the child’s true auditory access.

Context: what government is proposing

Public statements indicate that children with mild–moderate autism and developmental delays will transition off the NDIS into Thriving Kids, a nationally coordinated portfolio of ‘foundational supports’ funded jointly with States and Territories. The government frames this as implementing the 2023 NDIS Review vision for

earlier, community-based supports. Details of delivery and the health–disability interface are still being designed, but timelines indicate phased transition once the program is fully operational.

The audiology problem the proposal currently misses

1) Many very young children displaying “autism-like” behaviours actually have undiagnosed middle ear pathology and hearing loss.

Reduced eye contact, limited play, clumsiness, reduced social engagement and delayed speech/language are classic warning signs for autism — and all can be driven or exacerbated by conductive hearing loss from otitis media with effusion (OME). OME is the most common cause of childhood hearing impairment and is highly prevalent in the first years of life (peaking in the preschool years). When present, OME and recurrent otitis media degrade the acoustic cues children require for language learning and social communication. Without mandated early audiology, children may be misrouted into therapy pathways on the basis of behaviour alone, inflating autism and developmental-delay caseloads and delaying simple, high-value interventions for ear disease and hearing.

2) Sound sensitivities (decreased sound tolerance) are common and clinically important.

Many autistic children show heightened sensitivity to everyday sounds (hyperacusis/auditory over-responsivity). In children under six—the same period when OME is most prevalent—episodes of sound intolerance can often reflect fluctuating hearing status, for example, when hearing rapidly improves after an effusion resolves or following middle-ear procedures, making normal sounds seem uncomfortably loud. This profile requires systematic audiological assessment (including repeat tympanometry and, where appropriate, loudness discomfort measures), counselling and clear management plans for families and early childhood settings. Treating sound sensitivity purely as a ‘behavioural’ issue risks mismanagement.

3) Even when autism is correctly diagnosed, ear disease is more common and more severe.

Clinical and population studies show children with autism spectrum disorder (ASD) have higher rates of middle ear pathology, more abnormal tympanograms, more ventilation tube procedures, and higher risk of otitis-related complications, all of which increase hospital contacts and compound participation barriers. These data support routine middle-ear examinations and vigilant hearing management in ASD care.

4) Hearing status is the substrate upon which all other therapies depend.

Speech pathology, occupational therapy and psychology all assume adequate auditory access for learning new skills. Childhood hearing loss (permanent or transient conductive) is associated with poorer language outcomes, literacy precursors and classroom functioning; risks rise with earlier onset, longer duration of effusion and greater severity. If hearing fluctuates or is reduced, therapy efficiency and value plummet.

5) From school age, assess auditory processing abilities to guide practical classroom supports.

From approximately 6–7 years (when most behavioural central auditory processing tests become reliable and well-normed or standardised), an auditory processing assessment should be considered for children with ongoing listening concerns. This assessment profiles auditory skills across domains—spatial hearing, speech-in-noise, temporal processing, binaural integration/separation and auditory closure—yielding a functional listening profile comparable in concept to the sensory processing profiles used by occupational therapists. The output directly informs accommodations (e.g., remote microphone technology, classroom

acoustics, repetition/rephrasing, visual supports) and targeted auditory training where indicated. Diagnostic APD decisions must be made by audiologists, using best-practice guidelines and age-appropriate norms, and always anchored to a recent peripheral hearing assessment.

Evidence base

• Autism & ear disease: Children with autism have significantly increased rates of otitis media/OME, otorrhoea and ventilation tube placement; some studies also report higher risk of serious complications such as mastoiditis.
• Sound sensitivity in ASD: Meta-analytic and cohort data show high current (~40–60%) and lifetime (~60–70%) prevalence of decreased sound tolerance/hyperacusis in autistic individuals.
• Glue ear & sound sensitivity in young children: NHS guidance notes children with glue ear may experience sound sensitivity when hearing improves, making everyday sounds seem much louder.
• OME burden and age distribution: OME is the most common cause of childhood hearing impairment, with highest incidence in the preschool years and substantial prevalence still detectable at ages 5–6.
• Hearing loss — language/learning: Childhood hearing loss (including from OME) is associated with poorer language, reading and classroom outcomes; therapy yield depends on reliable access to sound.
• Auditory processing after ~6–7 years: Major professional guidelines (AAA, BSA/UK) describe school-age assessment batteries, typically normed from approximately 7 years, to characterise listening difficulties and guide management.

What Thriving Kids must include (minimum safeguards)

• Audiology-first gatekeeping for all children entering Thriving Kids (and for any child whose NDIS eligibility is being reconsidered): mandatory baseline diagnostic audiology before therapy allocation; fast-track ENT/audiology pathways for red flags.
• Embed ongoing audiological monitoring: scheduled 3–6-monthly reviews in preschool years or sooner after OME episodes/tube surgery; adapt allied-health plans when speech and hearing are not normal, including surveillance for middle ear pathology.
• Explicit inclusion and funding of audiology in commissioning: named items for diagnostic assessment, middle-ear surveillance, loudness discomfort/sound tolerance assessment, auditory processing assessment, and counselling, auditory habilitation, access to remote microphone technology as per the University of Melbourne’s evidence-based standard of care, parent coaching and case-conferencing.
• Sound sensitivity care pathway: standardised triage questions for decreased sound tolerance; ready access to audiology for assessment (including up-to-date tympanometry), education on gradual sound exposure and environmental strategies in early years settings.
• School-age auditory processing pathway (≥6–7 years): structured listening profile across key domains, with clear translation to classroom accommodations (e.g., remote microphones, teacher-facing seating, acoustic treatment, repetition/rephrasing) and targeted training.

• Clinical governance: “no therapy blind to hearing.” Commissioned providers (speech pathology, OT, psychology, ECEC inclusion) must sight a current hearing profile (within 6-12months) and adapt therapy when hearing is not normal, and including monitoring for hearing loss with recognition of symptoms for OME (frequent colds and flu, loud voice, mouth breathing, snoring, limited eye contact).
• Data & outcomes: collect hearing-related indicators (time to baseline audiology; OME detection; tube surgery; hospital presentations for otitis complications; change in language/learning by hearing status and by presence of sound sensitivity/APD).

Addressing common counterarguments

1) “We can screen hearing later; early therapy shouldn’t wait.”

Therapy without accurate hearing status is low-yield and risks misclassification. OME and fluctuating hearing degrade auditory input quality, hampering the very behaviours therapists seek to teach. Early audiology is a patient-safety and value-for-money requirement.

2) “OME evidence on long-term language harm is mixed, so why prioritise audiology?”

Short- to medium-term impacts on auditory access and learning are well documented, especially with early onset and prolonged effusion—precisely when Thriving Kids will intervene. Therapy effectiveness hinges on normal hearing or on therapy being adapted to the child’s actual auditory access.

3) “APD is controversial; why include it?”

Professional bodies provide guidance for school-age auditory processing assessment that focuses on functional listening outcomes. Framing results as an audiology-led listening profile—analogous to sensory processing profiles—ensures supports are concrete, measurable and coordinated with educators and OTs.

Recommendations to Government

• Legislate/contract an “Audiology Standard” within Thriving Kids requiring baseline diagnostic audiology, periodic reviews, sound tolerance assessment where indicated, and rapid ENT access. Ensure that community based audiologists, and the organisation that represents them (Independent Audiologists Australia) are included.
• Fund audiologists as core providers with claimable items for assessment, monitoring, sound tolerance management, auditory processing assessment, profiling (school age), therapies and supports including assistive technology (remote microphone technology), parent coaching and multidisciplinary case conferences.
• Publish implementation guidance co-developed with Independent Audiologists Australia and paediatric ENT societies, aligned to best-practice paediatric hearing care pathways.
• Stage any NDIS off-ramping only once these audiology safeguards are operational, with public reporting of hearing-related indicators during transition.

Conclusion

Thriving Kids will not succeed if it treats hearing as an optional consideration. Autism diagnoses could be inflated due to this core oversight. The program’s ambition—getting children help earlier, closer to home—depends on building hearing and middle-ear care into the core architecture, not bolting it on later. Without this, Australia risks over-diagnosing neurodevelopmental conditions in children whose needs are primarily auditory, while also underservicing autistic children who face a higher burden of ear disease, surgeries and hospital admissions. Audiologists must be an ongoing, funded part of every child’s care so that speech pathology, OT and psychology—indeed, every developmental intervention—has a stable foundation: a child who can hear the world they are learning to join.

We thank you for the opportunity to contribute to this important reform.

Yours sincerely,

redacted

Julie Watts MAudSt, BSocSci(Psych), AAudA

Executive Officer

Independent Audiologists Australia

Email: exec@independentaudiologists.net.au

Submitted on behalf of the Executive Committee of Independent Audiologists Australia:

Ms Rachel Gibson BSocSci MClinAud AAudA MIAA (President)

Dr Heidi Modrovich BA, BSc, MClinAud (CCP), MBA, AuD (Vice President)

Dr Tegan Keogh PhD, MClinAud, BA (Psych), AAudA (Advocacy Chair)

Mr Mo Helou BMedSc, MClinAud, AAudA (Treasurer)

Dr Greg Butcher AuD, MAudSt, AAudA, BA(Music), FTCL, FCompASMC

Mr Grant Collins B.Psych(Dist), MAudSt.,AAudA, M.IAA., MAICD., M.NOTSA

Dr Signe Steers BSpch&HrgSc, MClinAud, Au.D, AAudA

References (selected public sources)

1. Kaur K, Doody JT, Morris N, et al. Otitis Media and Related Complications Among Children with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders. 2015;45:1636–1642. https://doi.org/10.1007/s10803-015-2689-x
2. Yan T, et al. Tympanostomy Tube Placement in Children with Autism Spectrum Disorder. Otolaryngology–Head and Neck Surgery. 2022. (Europe PMC summary: https://europepmc.org/article/MED/36426745)
3. Williams ZJ, Suzman E, Woynaroski TG. Prevalence of Decreased Sound Tolerance (Hyperacusis) in Individuals with Autism Spectrum Disorder: A Meta-analysis. Ear & Hearing. 2021;42(5):1137–1150. (Europe PMC: https://europepmc.org/article/PMC/PMC8349927)
4. Carson T, et al. Brief Report: Prevalence and Severity of Auditory Sensory Over-Responsivity in Autism. Journal of Autism and Developmental Disorders. 2021. https://link.springer.com/article/10.1007/s10803-021-04991-0

5. Hull University Teaching Hospitals NHS. Sound Sensitivity in Children (Hyperacusis). 2024. https://www.hey.nhs.uk/patient-leaflet/sound-sensitivity-in-children/
6. University Hospital Southampton NHS. Sound sensitivities (hyperacusis) in children – patient information. 2023. https://www.uhs.nhs.uk/Media/UHS-website-2019/Patientinformation/Audiology/Sound-sensitivities-hyperacusis-in-children-2741-PIL.pdf
7. AAO–HNSF. Clinical Practice Guideline: Otitis Media with Effusion (Update). Otolaryngology–Head and Neck Surgery. 2016. https://www.entnet.org/quality-practice/quality-products/clinical-practice-guidelines/ome/ (see also AAFP summary: https://www.aafp.org/pubs/afp/issues/2016/1101/p747.pdf)
8. NICE Guideline NG233. Otitis media with effusion in under 12s. 2023. Summary in BMJ 2023;383:p2314. https://www.bmj.com/content/383/bmj.p2314
9. Golding J, et al. Associations between autistic traits and early ear and upper respiratory signs: ALSPAC cohort. BMJ Open. 2023;13:e067682. https://bmjopen.bmj.com/content/13/3/e067682
10. AAFP. Otitis Media: Rapid Evidence Review. Am Fam Physician. 2019;100(6):350–356. https://www.aafp.org/pubs/afp/issues/2019/0915/p350.html
11. American Academy of Audiology. Clinical Practice Guidelines: Diagnosis, Treatment, and Management of Children and Adults with (C)APD. 2010. https://www.audiology.org/practice-guideline/clinical-practice-guidelines-diagnosis-treatment-and-management-of-children-and-adults-with-central-auditory-processing-disorder/
12. British Society of Audiology. Position Statement & Practice Guidance: Auditory Processing Disorder. 2018. https://www.thebsa.org.uk/wp-content/uploads/2023/10/Position-Statement-and-Practice-Guidance-APD-2018.pdf