In 2021, the CDC reported that 1 in 44 children in the U.S. is diagnosed with an autism spectrum disorder. Even as the awareness of autism grows, the national average of an autism diagnosis is after the age of 4, even though it can be reliably diagnosed much earlier.
Children with autism often appear like they might have hearing loss. Many parents report that their child doesn’t respond when their name is called and is tuned out to the world around them, while having minimal language development. An appropriate first step for a child with these behaviors is a hearing evaluation.
At Vanderbilt University Medical Center, a trio of pediatric audiologists—Margaret McRedmond, AuD; Alyssa Fosnight, AuD, CCC-A; and Lindsey Wheeler, AuD, CCC-A—evaluate patients generally referred from pediatricians and counsel their families to begin working toward better long-term outcomes.
OPPORTUNITY TO MAKE A DIFFERENCE
McRedmond has been at Vanderbilt for 14 years, and as the lead audiologist for the pediatric team, is proud to be a part of what is an increasingly proactive approach.
“When kids aren’t talking, pediatricians will send them to us for a hearing evaluation,” said McRedmond. “We are the first professionals that are seeing these kids. They are coming to us before they see anyone else.”
It is a golden opportunity that should not be wasted.
“We are also at a real advantage, we feel, in picking up the signs of autism,” said McRedmond. “We may be at a greater advantage than the pediatrician who is spending 10-15 minutes listening to what a family is reporting. We spend about 45 minutes with these kids. We complete similar tasks with children like Visual Reinforcement Audiometry. Pediatric audiologists quickly learn typical and atypical behaviors.”
McRedmond became aware that the Vanderbilt speech department had trained speech-language pathologists (SLPs) therapists to diagnose autism.
McRedmond said: “There were kids coming in with characteristics of autism, and it seemed like they had autism, but we weren’t doing anything about it. We would talk to the parents about our concerns, but we were not doing much more and often we wouldn’t say enough. We might hint at some things, but we really wouldn’t give them a whole lot of information. Then things just started coming together.”
Around that same time, an audiologist came to McRedmond to express interest in working on a protocol to better manage children with undiagnosed signs of autism.
From there, the audiology department began training their audiologists to look for the signs of autism while also working more closely with the speech department trained SLPs to get children with signs of autism scheduled for the dual speech/autism evaluation.
“That’s really how this project/research has grown, and it’s become a passion for several of us here,” she said.
Wheeler, who came through Vanderbilt as a student, is now in her 8th year on the staff.
“I have always been interested in the research,” she said. “We see these kids come through our clinic and it just seemed like there really could be more than we were doing for these kids—specifically how to navigate these difficult and complicated conversations with families. That’s how my interest in autism (and hearing loss) grew, and there was an opportunity to jump on the project and we just, basically, kind of ran with it.”
“I came into this fairly early on,” said Fosnight, who has been at Vanderbilt for over four years. “Our concerns, with children with autism, was to get them evaluated [for autism] as soon as possible. I thought it was very interesting. We see a lot of patients who exhibit challenging behaviors that can make it more difficult to test during the appointments.”
Directly from their study, they identified the following hurdles:
- Most children are not identified with autism spectrum disorder (ASD) until after 4 years of age (Baio et al, 2018).
- Children in the United States generally wait 14 months for a developmental evaluation once they are referred (Austin et al, 2016).
During a one-year span—August of 2018 to August of 2019—the Vanderbilt team broke national barriers, including the 14-month wait for a developmental evaluation and national average of age of diagnosis.
It came from knowing they could do better with a more concerted effort, just under their own roof.
Although the statistics were based on the one-year span, what the three audiologists made clear is that the project is ongoing.
While research is a large part of what the Vanderbilt team does, it is far from all of it. Parents are often frightened and apprehensive; delivering the information in a professional but sensitive manner is an important aspect of the job.
“One of the reasons that we don’t encounter a lot of challenges with the parents is that we talk with them about what we are trying to do with the process and with the testing,” said Wheeler. “We ask them for feedback about what might work best with their child. We really work on making sure they are active collaborators and contributors to their child’s appointment.”
When the Vanderbilt team refers patients for a speech/autism evaluation, they track the patients to gain insight on their new approach. If audiologists take a more aggressive approach, can they have a significant impact on patient care?
The results were revealing:
- 81% (75 of 93 in the one-year span) were diagnosed with ASD. Of these 75 children diagnosed with autism, autism had never been discussed before with 40 of the parents prior to their audiology evaluation.
- The average wait time for the speech/autism evaluation was 4.5 months.
- The average age of diagnosis was 35 months. Vanderbilt Audiology found that they could obtain enough audiological information on 83% of children to move forward with a speech/language evaluation in only one audiological visit.
- In only 4% of cases was an auditory brainstem response evaluation even discussed. They have also shown that pediatric audiologists with less than 5 years of clinical experience were effective in appropriately referring these patients.
These young professionals had a hit rate of 86%. Those with more experience were only slightly more effective.
Therefore, with a little training and the right tools, Vanderbilt feels that many other professionals could also provide similar care.
The greatest achievement in the ongoing battle against what is affecting 1 in 44 children, according to the CDC, is the timetable.
“We have this great opportunity to get children identified faster,” said McRedmond. “It’s not just about hearing loss for us. It’s about getting children to the services they need as quickly as we can.”