Dr Wiley, please tell HearingFamilies readers a bit about yourself and your background.
I am a developmental pediatrician in Cincinnati Ohio, USA. I have been in practice in developmental pediatrics since 2001. I became interested in children who are deaf/hard of hearing as my hearing aunt and uncle taught at a residential school for the deaf. They would bring students to family Thanksgiving gatherings.
As a developmental pediatrician, I see children with a variety of developmental problems such as autism, intellectual disability, learning disabilities, and ADHD. I have a special interest in children who are deaf/hard of hearing and have other developmental issues.
I have been able to work together with speech pathologists, audiologists, and ENTs in an interdisciplinary clinic for children who are deaf/hoh. In this capacity, I have had the opportunity to see many children with the dual diagnosis of hearing loss and another developmental problem.
1. Children with hearing loss, who often take longer to process what they hear and may have delays in language may seem like children with ADHD – how can parents tell if their child with hearing loss has ADHD as well?
My favorite line of questioning when we try to figure out why a child with a hearing loss isn’t doing an activity are:
Did they hear the instruction?
Did they understand the instruction?
Can they do the task asked?
The first question helps us look at the hearing environment. The second question tries to sort through the language aspects related to a hearing loss. And the third looks at the level of difficulty of the task at hand which may speak more to learning.
Only after we are certain each of these areas are within a child’s capabilities, can we consider focus and attention as aspects of the problem.
O’Connell and Casale published an article in the Volta Review in 2005 which included a nice chart comparing features of ADHD and typical characteristics of children with hearing loss. This is a nice reference to guide us in evaluating children with hearing loss who may also have ADHD. We have included this chart as a word document. CLICK HERE TO READ.
They have developed a checklist for children who are deaf/hoh with suspected ADHD. Their contact information is: CLARKE School for the Deaf/Center for Oral Education 47 Round Hill Road, Northampton, MA 01060 USA or email at email@example.com.
2. How should ADHD be diagnosed in a child with hearing loss? Is this process different from diagnosis of children with normal hearing?
It is helpful to have a team approach in identifying ADHD in a child with hearing loss. This may be different than for a child without hearing loss. The American Academy of Pediatrics has a diagnosis and treatment guideline describing how to identify and manage children with ADHD (American Academy of Pediatrics Clinical Practice Guidelines: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity Disorder 2000 Pediatrics 105:1158-1170.
American Academy of Pediatrics Clinical Practice Guidelines: Treatment of the School-Aged Child with Attention-Deficit/Hyperactivity Disorder 2001 Pediatrics 108:1033-1044.).
The recommendation is to use a behavior rating scale test form that is specific to ADHD (such as a Vanderbilt ADHD Rating Scale or Connors Report Form) and are obtained from at least two settings. These settings usually include home and school. This allows a look at attention and activity level across settings, as ADHD should have impact in all settings. Additionally, it is important to show a functional impact such as difficulties with school work, peer interaction, or family interactions.
One of the challenges of any behavior rating scale is its reliance on a person’s report which by the very nature implies expectations. One person may be quite tolerant of a behavior and another may have much less tolerance. These two people might rate a child very differently. It is also sometimes helpful to have different teachers rate a child as there may be more concerns in learning than attention. If a child is fine in a math class but the reading class teacher rates them high in features of ADHD, a learning problem should be suspected.
For children who are deaf/hoh, I tend to use traditional ADHD forms, but then interpret them in context with hearing and language (see above for obtaining ADHD forms developed specifically for children with hearing loss). If a child’s understanding of concepts is below their chronological age, this must be considered when answering behavior rating forms.
I prefer to do broader testing on children who are deaf/hoh such as language capabilities and psychology testing of learning/IQ/development to provide a broader context on which to rate behavior. The other evaluation I use is an aural rehabilitation evaluation. This is not an evaluation that is available in every setting, but typically an aural rehabilitation therapist will look at auditory skills including things like auditory memory and processing of oral directions. This can help find any areas of weakness that may mimic attentional problems. These evaluations also give you another setting to have professionals look at attention span and focus. However, in these settings, the distractions are less and one-on-one supports can help children with attentional problems.
The other factors I think about in evaluating children for ADHD is that the symptoms must be present before 7 years of age. Most children with ADHD will have a long history of short attention span and high activity level that occurs even in the early childhood years.
Some risk factors for hearing loss also put a child at risk for attention problems. Children with prematurity can have difficulties with what is called executive functioning skills (organization, attention, flexible problem solving). Children who have had meningitis may also have more difficulties in these areas as well.
Family history is also helpful in determining a genetic risk for ADHD. A family history of siblings, parents, cousins, aunts/uncles with ADHD can provide some push for further evaluation.
Although some people think that one way to diagnose ADHD is to try a medication for ADHD and if there is a response, it must be ADHD. This in fact is not necessarily true. Most people will perform better on a stimulant as it does enhance performance in people even without ADHD.
3. What do you recommend in a case where the teacher thinks the child has ADHD and the parents don’t see it?
Sometimes the demands of school are higher than at home. This may be one reason teachers see more difficulties than parents. It is always reasonable to have parents observe in the classroom setting to see what the teacher is describing. It is helpful to watch not only your child, but another child in the classroom as a comparison.
Sometimes schools also bring in a psychologist to observe in the classroom and actually document how much time a child is working or off-task (looking around, doing things that is not work, etc). Usually in these observations, the psychologist will pick another child who is in the mid-range for performance as a comparison. A good observer will also be able to sort through when a child is looking around to clarify what to do on their work as compared to looking around because they are distracted.
One of the struggles is knowing what is “typical” deaf/hoh and what is “more than” hearing. Having a team who understands deafness and other issues can sort through this distinction.
4. What is unique about children with hearing loss and ADHD? How can the combination sometimes fool professionals?
I have seen professionals be fooled in both directions. There are children who are diagnosed with ADHD who never get a good hearing test and later are diagnosed with mild hearing loss. The opposite situation can occur in which a child truly has ADHD but their symptoms are attributed to the hearing loss, especially if a professional has little experience with the breadth of capabilities of children with hearing loss.
Again, as ADHD is a behavior checklist diagnosis, we have to sort through the underlying reason a child is not finishing work (didn’t understand it vs. started and couldn’t finish it). We have to use critical thinking skills and make sure we are addressing all of a child’s needs to sort out the complexities. I have also seen children who have not had appropriate amplification or FM system to help with background noise have very big changes in behavior and attention once they received appropriate hearing services.
5. What treatment and intervention do you recommend to children with hearing loss and ADHD?
The treatment and interventions for children with hearing loss and ADHD need to address all of a child’s needs.
I always want to make sure a child’s hearing loss is appropriately accommodated in school programming (i.e. amplification, FM system, language supports, educational audiologist, teacher of the deaf/hoh).
But there also needs to be energy placed on the functional impact of attention/focus/hyperactivity that can occur from ADHD. It is helpful to consider specific target behaviors we wish to see improve.
Behavioral strategies to help with attention, focus, and organizational skills are critical to the long-term success of all children with ADHD. Despite often excellent response of many children to medication management of ADHD, if we do not help children develop skills to self-monitor, help with organizational skills, and so forth, as they get older, these issues will persist. The combination of behavioral strategies and medication management has the most long-lasting assistance.
Although it can be concerning to put a child on medication, if we treat appropriately and effectively (not too high of a dose, not too low of a dose, and treating the right diagnosis) the long-term outcomes are much better in regards to academic achievement, social skills, and long-term life skills.
If a child is doing well and then seems to hit a bump in the road in school or with behaviors, it is important to re-evaluate hearing and consider the possibility of fluctuating hearing loss from middle ear fluid. This would be a good first step before simply increasing a medication dose.
Thank you very much for your sharing your time and expertise with HearingFamilies, Dr Wiley!