How do we learn to speak?
It was my fascination with that question that brought me to my specific studies in higher education and to my occupation.
First of all, we’re not born speaking. The newborn, however, is acutely aware of its surroundings with all five senses: hearing, seeing, touching or feeling, smelling, and tasting. And, I happen to think that hearing might be the most important in that line up for us homo sapiens. It is likely one of the reasons I became an audiologist.
What is critical for normal speech and language development?
Hearing is essential, so much so that Marion Downs, who I like to call the mother of audiology, was largely responsible for the fact that today, in the United States, ALL babies have their hearing screened before they leave the hospital.
Audiology is a young profession, only realizing a clinical role largely after World War II. Before that, we were largely hearing scientists and psycho-acousticians confined to the laboratory, busy accumulating normative data, developing tests of auditory function, and doing research to better understand the auditory system. and, we’ve made a lot of headway.
However, in the present, we are now struggling with hearing issues that bear a multitude of labels—central auditory processing disorders, auditory neuropathy, and hyperacusis, just to name a few that are floating in our sphere. At the same time, labels potentially identifying hearing and listening issues and “sensory” processing problems have burgeoned in other related professions and other fields of study—attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), autism “on the spectrum” (including Aspergers), sensory processing disorders (SPD), pervasive developmental disorders (PDD), learning disabilities, language disorders, apraxia, reading disorders, and the list keeps growing.
One of the newest on the scene is social communication disorder (SCD). What is going on? What if all of these issues, or the vast majority of them, have something to do with compromised hearing?
My own experience in these matters started with my grandson, Luke. A strapping, healthy nine-pound, six-ounce boy (at birth) who wasn’t talking much at one year. Trying not to be alarmed because of my background, I took a wait-and-see approach for a while, but then it seemed reasonable for him to have a repeat hearing test, even though he passed his newborn screening. Mistakes happen, equipment sometimes malfunctions—especially with all the pass/fail automation.
Luke passed his hearing test. And another one. And then, at about age two and a half, he was diagnosed as autistic.
I went to graduate school at the University of Connecticut in the early 1980s, at a time when ADD was just being bandied about with a bit of frequency, and the autism rate was approximately one in 2,000. Today, the rate is now estimated at one out of 34, of which 28 are male. Some would say we are just better at diagnosing, but the reality is that cannot possibly explain that amount of increase over time. Neither can genetics. Yes, the waters are muddied with differences in terminology. After all, there isn’t a definitive “test” for a lot of these conditions.
We are generally talking about a constellation of unusual or abnormal symptoms, not the least of which very often include a child not speaking. In addition, many of these children spin, but do NOT get dizzy (like my grandson used to do). So, it didn’t seem a ridiculous idea for me to question whether there was something wrong with his vestibular/cochlear function. In addition, Luke began to exhibit symptoms of hyperacusis—just confirming my suspicion that something or many things—were not working as they should in his auditory system, and that would explain why he wasn’t talking. Some people are calling this “invisible” hearing loss.
So, I started re-reading the classic Marion Downs book, Hearing in Children. And, I learned a lot. I started doing a ton of research and I learned even more. I started to read James Hall’s Handbook of Auditory-Evoked Responses. I even re-read some of Ira Hirsh’s The Measurement of Hearing.
Children with autism may have reduced OAEs at 1 KHz (Bennetto et al, 2017). In addition, children with APD have been found to have different P3 responses (Jirsa, 1992). Fluctuating, negative middle-ear pressure greater than normal characterizes both autistic and learning-disabled children with negative middle-ear pressure greater in autistic children than learning-disabled children with the condition typically being bilateral for autistic children (Smith et al, 2008).
In other words, a lot of the children with the alphabet soup of diagnostic labels—autism, ADD, ADHD, central auditory processing disorder (CAPD)—have hearing problems. Because I am an audiologist, and probably more so because I have been affected personally by this, I believe that audiologists should become aware of this and take their rightful place in the “developmental delay” world we find ourselves in.
One in six children in the United States are now diagnosed with some kind of developmental disability, with ADD being the most frequent diagnosis (Boyle et al, 2011). People in our field are calling this a special education epidemic (Focus for Health, 2017). I believe it is an obligation of our profession and a tribute to our heritage that audiologists commit themselves to helping these children and their families.
The first chapter in Marion Downs’ Hearing in Children makes a compelling case for the normative range of hearing to be -10 to 15 dB. She speaks very effectively regarding the problem of recurrent ear infections in young children, as well as the concomitant decreases and fluctuations in hearing with chronic middle-ear effusion, and the long term adverse ramifications of these conditions on education and literacy of the affected individuals. Autistic kids have 10 times more ear infection in the first three years of life than neurotypical children (Epedmic Answers, 2017).
We have a lot of work to do—which is a good thing. Although all of these labels appear that they may have a multitude of contributing factors, we are the profession that understands the critical importance of normal hearing in early childhood development. Who, other than our profession, will advocate for 15 dB being the limit of “normal hearing” for our youth? How many times in my work have I had misgivings about the child that had 15–25 dB hearing thresholds, as opposed to the one that sat up there at 0 and 5 dB HL across all frequencies?
As we struggle with our most recent growing pains as a profession, I would like to present a great hope. These are our children. They are our future. They need us and maybe we need them.
I recently sat in on a C&P exam with a colleague at a Veteran Affairs (VA) hospital where I do some fee basis/contract work. She is a recent graduate who came out of her clinical doctorate program being well versed in CAPD testing, electrocochleography (EcoG) testing, and lots of vestibular testing. Back in the day, I was doing lots of auditory brainstem response (ABRs) and electronystagmography (ENGs), and I certainly was exposed to CAPD testing in my program with Toni Maxon, a great pediatric audiologist. However, at the VA, equipment funding is always challenging, and our diagnostic testing is rather limited. At one point, my colleague stated, with a bit of frustration because of our equipment issues “Peggy, I didn’t go to school to be a hearing aid dealer.” I had to really smile to myself. When I was just becoming interested in audiology, which was also due to a magnificent mentor and teacher, Bob Jirsa, the controversy of the day was whether audiologists should dispense hearing aids, with precisely her statement as the argument against.
Although I don’t think I hold that position, I do want to encourage my profession, not only for the health and well-being of our children, but also because of the great work of the people that came before us, to spread our wings, do our research, and help these children and their families. They need us just as much (if not more) than the children with “visible” hearing loss. The words that we use matter.
We, more than a lot of people, are aware of that fact, and, just because we can’t pinpoint exactly what the problem is, it doesn’t mean there isn’t a problem. These children, including my grandson, have hearing problems, and, who better than us to pay attention and research and help? We are in the profession that is most able to speak the language of hearing.
This is an excerpt from the forward of the book The Language of Hearing by Margaret Glenney.
Bennetto L, Keith JM, Allen PD, Luebke AE. (2017) Children with autism spectrum disorder have reduced otoacoustic emissions at the 1 kHz mid frequency region. Autism Res 10: 337–345.
Boyle CA, Boulet S, Schieve LA, Cohen RA, Blumberg SJ, Yeargin-Allsopp M, Kogan MD. (2011) Trends in the prevalence of developmental disabilities in US children, 1997–2008. Peds 127(6):1034–1042.
Jirsa RE. (1992) The Clinical Utility of the P3 AERP in Children With Auditory Processing Disorders. J Sp Lang Hear 35(4):903.
Smith DE, Miller SD, Stewart M, Walter TL, Mcconnell JV. (1988). Conductive hearing loss in autistic, learning-disabled, and normal children. J Autism Devel Dis 18(1):53–65.
The Special Ed Epidemic: What is Happening to our Children? www.focusforhealth.org/special-ed (accessed May 2, 2018).
Ear Infections and Autism. https://epidemicanswers.org/ear-infections-and-autism (accessed July 21, 2017).