If It's Not Hearing Loss, Then What? Confronting Nonorganic Hearing Loss in Children

Introduction:

Arguably, audiologists' greatest task is to ensure that those seeking their services reach the highest auditory potential possible. To achieve this goal, determination of accurate hearing levels is a clear prerequisite. However, at times, achieving accurate hearing test results can be elusive, as when a patient's presentation of admitted "threshold" responses, at levels suspected to be suprathreshold, delay the delivery of needed remediation and add to the clinical frustrations of the audiologist.

Among adults, the exhibition of nonorganic hearing loss may arise from a variety of origins but probably is most frequently rooted in a motivation based upon anticipated financial gain. When nonorganic hearing loss appears in children, the underlying motivation is frequently much less apparent. In these cases it becomes the audiologist's responsibility to determine if a hearing loss is indeed present, and to also ensure that any precipitating factors that may have led to the exhibition of falsely elevated thresholds are addressed. In children, the reasons for displays of nonorganicity are typically an anticipated psychological gain.

Clinical Prevalence:

Personal experience suggests it is rare for preschool children to exhibit nonorganic hearing loss behaviors. Typically, young children who offer elevated thresholds in the presence of normal hearing have done so due to inadequate comprehension of their role in the testing process. However, by the time a child has reached the age of approximately 6 years, he or she may indeed be conscious of the benefits derived from failing the hearing test at school or in the pediatrician's office.

Most studies of nonorganic hearing loss completed with adult subjects have been carried out within military environments, leaving the impression that nonorganic hearing loss is more prevalent among males than females. This research artifact may indeed be plausible given Burgoon, Buller, and Woodall's (1989) assertion that, in general, men are more prone to deceit than are women. According to these authors, women are more likely to lie to protect others, while men more frequently resort to fabrication as a means toward personal gain. Regardless of any possible gender difference among adults who exhibit nonorganic hearing loss, it is unlikely that such a difference appears among children.

Audiologists find the prevalence of nonorganic hearing loss among adults varies within different clinical populations in relation to the proportion of medical-legal cases a given practice may cater to (Kinstler, 1971). While data on the prevalence of nonorganic hearing loss in children is poorly defined, data on gender differences in the same population is practically nonexistent. However, it has been determined that within the pediatric population, prevalence of nonorganic hearing loss will generally be less than 7% (Campanelli, 1963; Maran, 1966; Zwislocki, 1963). Despite this relatively low prevalence, audiologists must recognize nonorganicity in children when they see it, know how to establish hearing levels, be prepared to talk with parents about the identified behavior, and know when and how to refer for additional psychological consultation.

Clinical Manifestation:

We can only speculate why children do the things they do. As stated earlier, some children may exhibit nonorganic hearing loss to obtain a psychological advantage or reward. A child who may have had a previous legitimate hearing loss (secondary to middle ear effusion, for example) may long for reinstatement of the benefits the disorder provided in terms of teacher and parental excuses for, and tolerance of, reduced academic performance.

Other children may feel a need for greater personal attention. These children may discover the "positives" of gained attention when they inadvertently fail a school test for legitimate, although non-auditory reasons such as improper equipment calibration, poor test site acoustics, poorly comprehended instructions, etc. Additionally, they may have seen the attention given to other children who have legitimately failed a hearing test, and then simulate one of their own.

Often, when a desire for increased attention underlies a child's nonorganic tendencies, disruptive social behaviors can be identified as well. These may include inappropriate aggression toward peers at school or siblings at home, or may be displayed through a lack of compliance to rules and expectations set by authority figures in the child's life. This latter behavior may be exhibited in the audiology clinic by some children with nonorganic hearing loss. By the time some of these children appear for a full audiologic evaluation they may have established a pattern of hearing screening failures and may possibly have recognized the benefits of these failures (e.g.: excuses or attention) so that they have become more committed to the maintenance of exaggerated thresholds (Rintelmann and Schwan, 1999). Despite this commitment, most audiologists find they are tipped to the possibility of nonorganic responses by the very behaviors these children may exhibit in the clinic.

By virtue of fewer life experiences in general, children are not as sophisticated as adults regarding fabricating the appearance of hearing loss. They may present with conversational and listening behaviors suggesting adequate hearing for speech, yet show markedly elevated thresholds on behavioral measures. In addition to typical nonorganic response patterns, such as of poor SRT/PTA agreement, unexplained low sensation levels for acoustic reflexes, and present otoacoustic emissions in the presence of apparent cochlear hearing loss, these children may exhibit excellent speech recognition at levels only slightly above their admitted thresholds (Martin, 2002). Some may even follow directions to "Say 'yes' when you hear the tone and 'no' if you do not," providing a fairly accurate pure-tone audiogram in the process.

Clinical Recommendation:

With adults who fail to give an accurate diagnostic picture, confrontation rarely leads to admission of the behavior or resolution of the problem. Audiologists know that taking the onus upon themselves, such as "failing" to properly instruct, or not placing the earphones or inserts properly, or testing too rapidly, can provide a gracious out to those who are not strongly committed to their ruse, thereby permitting a retest to yield a more profitable outcome.

This same non-confrontational approach may be a good place to begin with children. However, adults do have more influence on a child's behavior than we have on other adults.

A good protocol to gain accurate test results from children exhibiting nonorganic tendencies is to sit with them briefly, stating something like, "We need to have a serious conversation. I know my equipment is working, but somehow your responses just don't match up. Tell me what's going on." The response we receive may vary among children, but inevitably more forthright test results most often follow.

It is my belief that referral for electrophysiologic measures to confirm hearing thresholds is not the appropriate next step when accurate thresholds are not forthcoming in the presence of results clearly indicative of nonorganicity, and which strongly suggest normal or near-normal hearing levels. Certainly an accurate depiction of hearing status is the goal of every audiologist and further assessment will be needed for any child whose hearing status is yet to be determined. However, accurate results may be more readily attained through conventional means after the underlying reasons for the nonorganic behavior have been addressed.

Children who elevate their thresholds do so for a reason. Some children will readily give up the ruse when they show up at the audiology clinic and are given a ready and gracious out from their behavior with the audiologist's reinstruction and self-placed blame for poor results. Others may give it up when gently confronted with the realization that we know something is afoot. Those who continue to give inaccurate test results have a greater need, one that arguably goes beyond the audiologist's scope of responsibilities.

Children who maintain that a physical disorder exists, when it does not, likely have a psychological need for the favorable attention they perceive as associated with the disorder. Something may be disturbing these children at home (e.g.: a pending divorce) or at school (e.g.: a bullying peer or perceived pressure for greater academic achievement) or in the neighborhood. This issue must be defined and addressed prior to determination of hearing status.

Talking with Parents:

It is normal for parents to become upset with their children when the children create an additional and unnecessary burden. Life moves at a fast pace and is more hectic at times than any of us would like. Parents who have been required to shuffle and manage their own schedules, to accommodate a child for what is later perceived to be an unnecessary appointment, may not be pleased with their child. It does little good for the child, or for the parent/child dynamic, when the discovery of nonorganic hearing loss becomes a bone of contention after they have left the clinic.

It can be highly beneficial to the child, and to the family, for the audiologist to speak separately with the parents advising them of some reasons why a child may present nonorganic thresholds; including a perceived need for attention or an excuse for school performance. It is helpful for parents to see their children, in these circumstances, as resourceful, not deceitful. It is a clever child who can create circumstances that can provide the psychological reinforcements to deal with significant life stressors. The audiologist should present to the parents some "food for thought," regarding the possible confrontations a child may be facing, which may have led to the nonorganic findings and associated behaviors.

Referring for Psychological Intervention:

A child who fails a hearing screening at school or in the pediatrician's office, due to nonorganic issues, may present with normal hearing test results at the audiology clinic. A discussion with the parents, as described above, is typically all that is needed to help set the child and parents down the right path.

Of greater concern is the child who maintains the existence of hearing loss in the presence of contrary test findings. It is this child who needs additional, non-audiology professional services.

After discussing the test findings and what they indicate with the parents, and after discussing potential reasons a child may manifest these behaviors, a counseling consultation with the school counselor should be recommended. Importantly, considerable societal stigma toward mental health services still exists, and the term "counselor" is frequently preferable over "psychologist" when making referrals (Clark & English, in press).

It should be explained to the parent that consultation with the school counselor will help identify the issues that led to the hearing test failure, so the child and the family can address these concerns together. The supportive therapy provided through psychological referral is frequently the most efficacious treatment for the child with nonorganic hearing loss (Andaz, Heyworth & Rowe, 1995).

The audiologist's referral report to the school counselor should request a "return referral" for additional testing when the counselor deems appropriate, to document accurate hearing test results. The audiologist's report to the original referral source (school or pediatrician) should give the results of test findings, and importantly, should support the audiologist's statement of, and justification for, referral to a counselor.

Conclusion:

Unlike adult nonorganic hearing loss which is most frequently rooted within financial gain, the underlying motivation in children is less apparent but typically found in anticipated psychological gain. When confronted with pediatric nonorganic hearing loss, it is the audiologist's responsibility to not only determine if hearing loss is indeed present but to also ensure that any precipitating psychological factors are adequately addressed. When behavioral hearing thresholds cannot be accurately attained, it is frequently best to refer for supportive counseling with the child's school counselor before further testing is attempted.

References:

Andaz, C., Heyworth, T., & Rowe, S. (1995). Nonorganic hearing loss in children - A two year study. Journal of Oto-Rhino-Laryngology and Its Related Specialties, 57: 33-55.

Burgoon, J.D., Buller, D.B., & Woodall, W.G. (1989). Nonverbal communication: The unspoken dialogue. New York: Harper & Row.

Campanelli, P. (1963). Simulated hearing losses in school children following identification audiometry. Journal of Auditory Research 3: 91-108.

Clark, J.G. & English, K.M. (in press). Counseling in Audiologic Practice: Helping Patients and Families Adjust to Hearing Loss. Boston: Allyn & Bacon.

Kinstler D.B. (1971). Functional hearing loss. In L.E. Travis (ed.), Handbook of Speech Pathology (pp. 375-398). New York: Appleton-Century Crofts.

Maran, A. (1966). The causes of deafness in children. Journal of Lanryngology and Otology, 80: 495-505.
Martin, F.N. (2002) Pseudohypacusis. In J. Katz (Ed.) Handbook of Clinical Audiology (pp. 584-596). Baltimore: Lippincott, Williams & Wilkins

Rintlemann, W.F. & Schwan, S.A. (1999). Pseudohypacusis. In F. E. Musiek & W.F. Rintelmann (Eds.) Contemporary Perspectives in Hearing Assessment (pp.415-435). Boston: Allyn & Bacon.

Zwislocki, J. (Ed.) (1963). Critical evaluation of methods of testing and measurement of nonorganic hearing impairment. Report of Working Group 36, NAS-NRC Committee on Hearing, Bioacoustics and Biomechanics.