Submission to the Senate Select Committee on Autism
Introduction
Audiology Australia (AudA) welcomes the opportunity to make a submission in response to the inquiry by the Senate Select Committee on Autism (the Committee) into the services, support and life outcomes for autistic people in Australia and the associated need for a National Autism Strategy.
AudA is the peak professional body for audiologists with over 2,900 members practising across Australia. Audiologists provide diagnostic audiological assessments to a wide range of clients, including children who have, or may be suspected of having, autism spectrum disorder (ASD). As auditory and speech processing impairments are core features of ASD, audiologists are frequently one of the earliest professional contacts a family may have when a child is suspected of having ASD (Rabidoux, 2005).
AudA strongly supports the development of a National Autism Strategy and would like to highlight the role audiologists play in the ASD diagnostic process; and the importance of determining auditory function as a fundamental, necessary step in diagnosing and providing interventions for individuals with ASD (Kealey, 2014).
Our submission focuses on sections (a) (d) and (h) of the Committee’s Terms of Reference as outlined in bold below.
a. current approaches and barriers to consistent, timely and best practice autism diagnosis
AudA members are concerned that audiologists are generally not considered to be part of the multidisciplinary team of health professionals that contribute to the diagnosis and management of children with ASD; and are called upon during the ASD diagnostic process merely to rule out a peripheral, permanent hearing loss. We note that this is primarily due to a lack of awareness of the services audiologists can provide in general; and more specifically, the value audiologists can add to the identification and management of functional listening challenges often present in children with ASD.
AudA highlights that hearing impairment is more prevalent in individuals with ASD than the general population (Demopoulos et al, 2016). Furthermore, the symptoms of ASD can be exacerbated by hearing difficulties. For example, undiagnosed comorbid hearing impairment, if left untreated, can reduce the benefit that a child with ASD gains from the relevant early intervention therapies. In addition, auditory processing skills for children with ASD can range from completely normal to substantively defective, although overall are lower than those of age-related typically developing children. We note that auditory processing abnormalities are diverse and can include atypical processing of perceptual features such as pitch, loudness and timing cues, as well as more complex auditory information such as subtle prosodic cues in language, which is reflected in the pitch, loudness and duration of language and the use of greater articulatory force to emphasise a word or phrase.
We note that auditory processing disorder (APD), a condition which impacts how sounds are processed and understood, may co-exist with ASD. However, APD is not the result of a global condition such as ASD; rather, APD and ASD are two separate conditions. That being said, some of the behaviours of children with ASD and APD may appear very similar, such as difficulty understanding speech in noisy environments, following directions and behaving as if a hearing loss is present. We highlight that careful assessment by an audiologist can assist in ensuring an accurate diagnosis is provided.
AudA notes that hearing loss and associated disorders are important elements to take into account when considering the prospect of ASD diagnosis for different age groups (0-5 years, 6-16 years, 17 years or older). Of particular relevance is the elevated incidence of temporary middle ear related hearing loss in children of preschool age and its potential impact on a variety of other behaviours and assessments; and APD that may impact classroom learning and behaviour. In addition, we note that atypical behavioural responses, specifically, hyper or hypo-responsiveness to auditory information; and symptoms of Attention Deficit Disorder (ADD) and/or Attention Deficit Hyperactivity Disorder (ADHD) are factors which can also significantly influence a child’s functional listening and attention skills, impacting on classroom learning and behaviour.
We emphasise that a multidisciplinary team approach is crucial to fully assessing and understanding the problems exhibited by children who may have ASD; and note that audiologists play an important role in this process by determining the type of auditory condition a child may exhibit and recommending appropriate audiological management and treatment activities. AudA therefore recommends that a comprehensive, audiological assessment be included as part of the best practice model for diagnosing ASD; and that a referral for audiology assessment be made concurrently with referral to an interdisciplinary ASD assessment team, unless an audiologist is part of the team (Nachshen et al, 2008).
Recommendation 1: AudA strongly recommends that a comprehensive, audiological assessment be included as part of the best practice model for ASD diagnosis; and that a referral to an audiologist be made concurrently with a referral to an interdisciplinary ASD assessment team, unless an audiologist is already part of the team.
d. international best practice with regards to diagnosis, support services and education, effectiveness, cost and required intensity Best practice recommendations in regard to behavioural hearing assessments for children who have, or may be suspected of having, an ASD diagnosis AudA highlights that paediatric audiologists are equipped in identifying functional listening challenges, including auditory deficits; diagnosing APD; and recommending evidence-based, therapeutic management options to children who present with functional listening, attention and/or sensory processing deficits in relation to auditory stimuli.
In consultation with AudA members who provide paediatric audiology hearing services, we would like the Committee to take into consideration the following best practice recommendations in regard to behavioural hearing assessments for children who have, or may be suspected of having, an ASD diagnosis.
We particularly wish to emphasise the importance of testing the hearing of children suspected of ASD aged under 5 years and - in terms of best practice - if possible, referring these children for behavioural hearing assessments before the age of 2½ years. This gives the paediatric audiologist the best chance of successfully assessing hearing using conventional behavioural techniques.
The best practice recommendations are (in no particular order):
- Otoscopy
- Tympanometry
- Otoacoustic Emissions
- Auditory Processing Disorder Assessments
- Behavioural Hearing Assessments (i.e. Visual Reinforcement Orientation Audiometry (VROA), play audiometry etc.)
We note that VROA is an internationally recognised technique of behavioural hearing assessment and is likely to be the most effective, particularly if conducted before the child is 2 to 2½ years old. This technique uses a natural head turn response to indicate that the child has heard a sound and an enjoyable visual reward to motivate the child to continue responding. Although the particulars of the exact set up will vary between clinics, the essential features are consistent. We recommend that this test be conducted by experienced paediatric audiologists in an appropriately sound treated environment. Ideally, the procedure should involve two paediatric audiologists due to the built-in checks for bias which are missing when one audiologist performs VROA.
The question being asked as part of this process is essentially: “Is there a hearing loss sufficient to account for the child’s communication delays?” Audiologists endeavour to answer that question first for VROA before doing any objective tests since these may frighten children with ASD, making further assessment difficult. We note that VROA was developed with, and is very effective for, obtaining behavioural hearing test results for typically developing children. It can be relied on to diagnose most significant hearing losses in children who are following a normal developmental pathway. However, assessment with VROA can be challenging for some children developing in atypical ways.
We note that children being considered for an ASD diagnosis are often challenging to assess using conventional techniques. Many children with ASD find it difficult to sit in one place for any length of time, engage with a stranger and tolerate novel situations such as an audiology booth. This may lead some medical practitioners to wait until the child is older before referring them for a hearing assessment in the belief that they will be able to cope better at an older age.
However, AudA recommends that - if possible - the initial hearing test should not be delayed. Situations may occur where there are 6-year-old children with severe ASD who are too old
for VROA but are not yet ready to wear headphones or do play audiometry. We note that there are objective assessment techniques available to measure a child’s ear health and the responsiveness of the receptors within the inner ear. Passing these tests (as well as newborn hearing screening) can indicate that the child is unlikely to have more than a mild hearing loss and suggests that language delays and behaviours driving parental concerns are unlikely to be hearing related. However, these tests are not infallible and do not reflect the child’s experience of the auditory world, only the health of their peripheral hearing system. In certain circumstances, sedating the child for an objective assessment by a hospital audiologist undertaking an Auditory Brainstorm Response test may be the only available option.
As hearing assessments are often viewed as a necessary first step in further ASD diagnosis, the challenge for paediatric audiologists is to obtain a test result in a timely fashion so as not to disadvantage the child and delay their further diagnosis and access to therapy and the enabling National Disability Insurance Scheme (NDIS) funding or any other relevant funding scheme. However, if the completion of a hearing assessment presents a barrier, a recommendation may be that the doctor directs the child into 6 months of speech therapy or occupational therapy and – following this time – that the child undertakes another hearing assessment. During therapy, the therapist, parent and child will work on developing strategies to facilitate activities, including practising sitting in one place for an extended time, engaging with another person, participating in tasks which may not be of the child’s choosing and maintaining focus on the task, in order to help the child subsequently complete a successful hearing assessment.
Lastly, AudA notes that headphones should only be introduced if a parent is completely confident that their child will accept the headphones and will tolerate sound coming through them. In a recent example, AudA members had a parent of a child indicate that their child ‘wears headphones all the time at home’ but the child became very distressed on the first presentation of a sound through the headphones. Only subsequently did the parent advise that their child ‘uses the headphones at home to block out all the sounds.’ We note that parents should be encouraged to inform the audiology clinic when booking the appointment that their child is suspected of or undergoing assessment for ASD to ensure that the child is booked into an appointment with appropriately skilled staff and to ensure that any special needs their child has can be met.
Recommendation 2: AudA recommends that the following audiological assessments be performed as a minimum test battery to assess behavioural hearing in children who have, or may be suspected of having, an ASD diagnosis:
- Otoscopy
- Tympanometry
- Otoacoustic Emissions
- Auditory Processing Disorder Assessments
- Behavioural Hearing Assessment - Visual Reinforcement Orientation
Audiometry
Recommendation 3: AudA recommends that the initial hearing assessment for a child who has, or is suspected of having, an ASD diagnosis should not be delayed.
Available audiological supports for children with ASD and functional listening challenges
AudA highlights that there are two categories of evidence-based remediation options audiologists recommend to children with auditory processing deficits, which is dependent on the child’s pattern of test results and the family’s preference as to what would work better for their lifestyle.
The first category is computer-based auditory training programs which are designed to target and improve specific auditory processing skills, for example, speech perception-in-noise. The second category is remote microphone assistive listening devices which can improve specific auditory processing skills such as speech discrimination-in-noise and also help address a broader range of listening-related challenges, including listening fatigue, distractibility/attention, and sensory overload in noisy, visually distracting settings.
We highlight that a review of studies investigating the effects of remote microphone listening devices for children with auditory processing difficulties consistently show assistive and therapeutic benefits (Keith & Purdy, 2014). The immediate assistive benefits include improvements in cortical auditory evoked potential amplitudes to tone stimuli, auditory brainstem responses to speech stimuli, frequency discrimination, binaural temporal resolution, frequency pattern recognition, auditory working memory, core language, phonological awareness, and speech perception in spatially separated noise. Remote microphone listening devices appear to treat a wide range of auditory skills simultaneously, facilitating neuroplastic change while also providing access to the auditory world. From a funding perspective, children who wear remote microphone listening devices typically do so for two years. Therefore, it is unlikely the device would need to be purchased more than once.
We note that there is currently little or no reliable scientific evidence of the effectiveness of auditory integration therapy (AIT) or other sound therapies based on the Tomatis method for the treatment of auditory challenges in individuals with ASD.
h. the adequacy and efficacy of the National Disability Insurance Scheme (NDIS) for autistic people AudA members consider that access to therapy can help some children improve their ability to successfully complete a hearing assessment as part of an ASD diagnosis. However, many children may not be able to attend therapy prior to accessing the NDIS or other funding scheme for reasons including that their parents cannot afford the therapy sessions, do not know who to consult and/or do not recognise the need for therapy. We note that the inflexible insistence of obtaining a hearing assessment first may prevent the child and their parents from accessing therapy which can aid the child’s successful completion of the desired hearing assessment.
AudA highlights that if access to ASD diagnosis and NDIS funding were more readily available to children without first ruling out hearing loss, the access to the benefits of therapy may occur more quickly and can make hearing assessments simpler in the long term. If clinicians referred a child suspected of having ASD to an audiologist and paediatrician simultaneously, we note that less time would be wasted. We consider that funding for intervention for children for ASD should proceed as a priority, but it may need to be reviewed once the outcome of the hearing assessment is known if it has not been possible to obtain the information prior to the intervention commencing.
Furthermore, AudA members have raised concerns in regard to audiological supports provided under the NDIS. Our members believe that a better awareness of the effectiveness, necessity and value of supports recommended by audiologists by the NDIS is required. Supports such as remote microphone systems and noise-cancelling technology are inconsistently funded by the NDIS. In addition, pathways to assistive technology funding are difficult to navigate by both health professionals and NDIS participants and/or their family members. We note that a greater general awareness of the audiological challenges and management options audiologists can identify and recommend to individuals with ASD is needed for medical and allied health professionals, educators and caregivers working with and supporting individuals with ASD. Within the NDIS specifically, we recommend that further education on the importance of audiological interventions and supports is needed across all levels of the NDIS, including for Local Area Coordinators and NDIS planners. We also highlight that the management of functional listening challenges is a necessity for many children with ASD. Assistance with functional listening is likely to influence development in other areas such as speech, language and cognitive skills; therefore, potentially reducing therapeutic requirements in these areas in the long-term. Children who are assisted with the development of their functional listening skills from an early age will likely require less supports in their educational settings; and early intervention will allow these children the best chance of reaching their potential academically. For adults with ASD, the effective management of functional listening skills, including sensory concerns around noise, can support and empower them to contribute to the economy through being comfortable and effective in their work environment, and participate in their community.
Recommendation 4: AudA recommends that the Committee take into consideration the following to improve the adequacy and efficacy of the NDIS:
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Further education on the importance of audiological interventions and supports across all levels of the NDIS, including for Local Area Coordinators and NDIS planners; and
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Improvements to the assistive technology funding pathway so that it is easier to navigate for both health professionals and NDIS participants and/or their families.
References
Demopoulos C, Lewine JD. Audiometric Profiles in Autism Spectrum Disorders: Does Subclinical
Hearing Loss Impact Communication?. Autism Res. 2016;9(1):107-120. Doi:10.1002/aur.1495
Kealey C. Autism spectrum disorder: importance of audiology. CMAJ. 2014;186(5):372.
Doi:10.1503/cmaj.114-0020
Keith WJ, & Purdy SC. (2014, February). Assistive and therapeutic effects of amplification for auditory processing disorder. In Seminars in Hearing (Vol. 35, No. 01, pp. 027-038). Thieme Medical Publishers.
Nachshen J, Garcin N, Moxness K, Tremblay Y, Hutchinson P, Lachance A, Beaurivage M, Breitenbach M, Bryson S, Burack J, Caron C, Condillac R. A, Cornick A, Ouellette-Kuntz H, Joseph S, Rishikof E, Sladeczek I. E, Steiman M, Tidmarsh L, Zwaigenbaum L, Fombonne E, Szatmari P, Martin-Storey A, & Ruttle P.L. (2008). Screening, Assessment, and Diagnosis of Autism Spectrum
Disorders in Young Children: Canadian Best Practice Guidelines. Miriam Foundation, Montreal,
Quebec.
Rabidoux P. Early Identification of Autism: Roles of the Speech-Language Pathologist and Audiologist on a Transdisciplinary Team. Semin Hear. 2005; 26(4): 210-216. Doi: 10.1055/s-2005-922443