Intervention Considerations for Deaf and Hard-of-Hearing Children with Co-Occurring Autism Spectrum Disorder

The issue

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Estimates of the presence of an autism spectrum disorder (ASD) among children who are deaf and hard of hearing (DHH) suggest that identified cases of ASD are on the rise and occur at least as frequently, if not more frequently,  than among hearing peers. Unfortunately, DHH children are often diagnosed with ASD much later, which may lead to delayed or ineffective intervention. We are just starting to understand how to appropriately distinguish ASD symptoms from behaviors which may be indicators of typical developmental variation secondary to a child’s hearing loss. Much less is known about evidenced based intervention (EBI) for treating symptoms of ASD among DHH children.

What we know and what we don’t know

The presence of ASD in addition to hearing loss can significantly complicate language acquisition and other developmental outcomes. When ASD co-occurs with hearing loss, children may not respond as expected to typical speech/language interventions. Symptoms of autism, such as reduced eye contact, inconsistent responses to sound/language, and imitation difficulties can interfere with the acquisition of spoken or signed language. Difficulty with perspective-taking can be seen in difficulty with pronoun confusion in spoken languages and with pronoun avoidance or difficulty establishing spatial referents in signed languages. Children with ASD may have reduced social interest. In these situations, targeting the ASD symptom is critical. For example, it may be necessary to first build the child’s social interest before attempting to teach speech sounds or signs. More time may need to be spent on building early social communication skills, such as establishing eye contact and building imitation skills, before working on auditory skill training or other interventions. Many behavioral interventions for ASD target these skills, but we do not yet know how well they work or how they are best adapted for DHH children.

Although sign language has often been used as an intervention for hearing children with ASD who are slow to acquire language, we know that the symptoms of ASD can affect children’s language acquisition, regardless of communication modality. When they also have ASD, even deaf children with deaf parents who sign have more difficulty than their DHH peers acquiring language. This suggests that providing sign language alone is unlikely to resolve the communication delays associated with ASD, instead requiring specific behavioral intervention targeting ASD symptoms.  Furthermore, a multimodal communication approach may be necessary. Because ASD symptoms can interfere with acquiring and producing language, the communication mode in which DHH children with ASD understand language may differ from the mode in which they best express themselves, and this may change over time. Therefore, intervention should target enhancing the child’s communication through the mode(s) that work best for the individual. In some cases, this may include the use of Augmentative and Alternative Communication (AAC).

ASD symptoms can also interfere with audiological management and the child’s adjustment to use of assistive technology. For reasons we don’t fully understand, children with ASD with cochlear implants (CIs) often are slower to acquire language and may be less likely to use their CI. It may be difficult to appropriately program hearing aids and CIs for children with ASD who do not respond typically to sound. They also may be more likely to resist using technology due to sensory sensitivities.  Autism specific strategies such as the use of social stories or picture schedules to visually show children what to expect during an audiological evaluation may be helpful. Behavioral strategies, sometimes in combination with occupational therapy, may help children gradually adjust to any discomfort they experience with using/wearing their technology.

Intervention for ASD must also target frequently co-occurring medical conditions that are known to affect behavior (e.g., sleep disturbance, toileting/gastrointestinal symptoms).

Implications

Limited research exists regarding evidenced-based or promising ASD interventions with DHH children. Without understanding of how DHH children may be expected to respond to ASD interventions, it can be difficult to gauge an expected rate of progress to know whether an ASD intervention should be adjusted or abandoned. Until  research sheds light on which ASD  interventions work best for them, use of evidence-based ASD interventions should be applied but may need to be modified based on each DHH child’s unique communication needs and learning style. (For a review of autism interventions and guidelines for intervention, see https://www.autismspeaks.org/what-autism/treatment). Appropriate intervention for symptoms of autism among DHH children requires collaboration between providers from fields of autism and deafness when dually-trained providers are not available. Our collective goal should be to strive for early identification of ASD and early, targeted, intensive intervention.

Posted on July 7, 2016 by
Deborah Mood
Children’s Hospital Colorado
Deborah.Mood {at} childrenscolorado.org

Further reading