Audiological evaluation of children with autism spectrum disorders (ASD) is an important component of initial assessment (Filipek et al., 2000) and should be completed prior to any other professional evaluation. Research suggests that auditory characteristics and complaints such as sensorineural hearing loss, otitis media, hypersensitivity to sound, difficulty hearing in noise, and problems with competing signals are equally prevalent in children with ASD as in typical peers (Gravel, Dunn, Lee, & Ellis, 2006; Roper, Arnold, & Monteiro, 2003; Tharpe, Bess, Sladen, Schissel, Couch, &Schery, 2006). Some aspects of ASD, however, may present significant challenges to obtaining valid, reliable behavioral hearing assessment.

Obstacles in Hearing Assessments

Describing a "typical" child with ASD is nearly impossible, as these disorders are a complex neurological condition that manifest a range of behavioral, communicative, and cognitive attributes. However, a few common characteristics in children with autism can create unique obstacles during behavioral hearing assessment (Davis &Stiegler, 2005):

1. Comfort with sameness and an aversion to disruption. The entire audiological testing environment will almost certainly be novel: The clinical facility, the small test suite, equipment, furniture, smell of alcohol wipes or disinfectant, and the audiologist (who may be wearing medical attire) can cause stress, as these are either unfamiliar or negatively associated with previous visits to health care settings.

2. Unfamiliar, unexpected, or feared sensory input can elicit strong, negative behavioral responses. Audiology assessment delivers a barrage of tactile, auditory, and visual stimuli, such as the use of headphones and probes, use of visual reinforcement or play audiometry toys, and/or use of touch as a method for reassuring a client. The reactions of children with ASD vary, but any behavior that could affect the integrity of the auditory signal presented (e.g., humming, covering the ears, crying, or yelling) or cooperation with the test (e.g., removing headphones, withdrawing, or attempting to flee) creates a test situation in which reliability of results is questionable.

3. Communication differences that present obstacles to precise auditory assessment. Receptive language deficits may cause difficulty in comprehending instructions and stimulus words during speech testing. The child may not have developed speech, and even if speech is present, there may be issues with intelligibility and echolalia. Further, some children may not have acquired a reliable distal pointing gesture, decreasing the effectiveness of picture-pointing as a response mode.

Suggestions for Audiologic Assessments

Northern and Downs outlined general suggestions for behavioral assessment of pediatric clients and difficult-to-test clients (2002). Audiologists should apply these principles when testing children with ASD:

• Persistence—Multiple sessions may be needed to obtain complete, reliable results.
• Adaptability—Changes in the needs of a client within a session should be accommodated.
• Cross-check principle—The results of a single test should be cross-checked by another independent test measure, particularly when reliability is a concern (Jerger & Hayes, 1976).

In addition, other specific modifications to traditional methods are often necessary to achieve success. As a first step, unnecessary items should be removed from the test suite in order to minimize distractions. The audiologist also can partner with the managing speech-language pathologist and parents, who typically will know about the interests, fears, and reactions of the child to be tested. Professionals and parents should be educated about test procedures and the results/information the audiologist is hoping to obtain, so that this message can be conveyed to the child in the most appropriate and effective way.

Prior to the hearing test appointment, an attempt should be made to increase the child's familiarity with the test situation by having him/her visit the clinic with a trusted caregiver. This visit allows the child to explore the test environment on his or her own terms and to practice putting on the headphones and sound conditioning. Knowing and using the child's interests also can benefit the audiologist. For instance, the child's favorite character, toy, or video might be incorporated as a comfort source, motivational item, or reward during testing.

Techniques traditionally used by SLPs can increase cooperation, including use of a child-specific video (Charlop-Christy, Le, & Freeman, 2000) or social story (Gray, 1995) to illustrate what will take place during hearing testing and to provide reassurance. Videos or social stories can be presented to the child repeatedly at home and during speech-language intervention so that the child knows what to expect.

Parents and the managing SLP also may assist by providing information about the child's reactions to stressful circumstances. Knowing in advance when the child is showing signs of distress may help the audiologist to terminate testing or a procedure before the situation escalates to the point that the child cannot be soothed or refuses to participate in a future session.

Behavioral results yield invaluable information for any individual whose hearing may affect communication, learning, and quality of life, and children with ASD are no exception. Consideration and preparation for their unique qualities and needs are essential for obtaining reliable and valid results in behavioral assessment. In doing so, we provide a critical piece of the assessment puzzle that ultimately directs the management of these children within our respective fields and in working with other disciplines. Continued research is warranted as current evidence in this realm is sparse, and diagnoses of ASD are increasing.