Download Pediatric Nonorganic Hearing Loss

Pediatric Nonorganic Hearing Loss:
Psychosocial Issues and Management
Zarin Mehta
Rachel Martindale
Wichita State University, Wichita, KS
A
nonorganic hearing loss (NOHL) appears
greater in magnitude than what might be
expected on the basis of known auditory
pathology (Martin, 2002). Depressed auditory thresholds in
the absence of an organic pathology are commonly referred
to as NOHL, malingering, pseudohypacusis, or psychogenic
or functional hearing loss. In most instances, the presence
of NOHL is related to some kind of personal gain, which
may include monetary compensation, attention from others,
or, especially in children, an excuse for poor academic
performance (Barr, 1963; Rintelmann & Schwan, 1999).
Although the diagnosis of NOHL is generally easier in
children than adults, frequent instances of misdiagnosis of
pediatric NOHL (PNOHL) have been reported (e.g., Bailey
& Martin, 1961; Dixon & Newby; 1959). In a case study
ABSTRACT: Children as well as adults can present with
nonorganic hearing loss (NOHL), which may be the
result of conscious malingering or may be psychogenic
in nature. Some cases of pediatric NOHL (PNOHL) can
be symptomatic of underlying psychosocial stressors.
These issues, left unresolved, may become harmful to a
child’s well-being, especially if the hearing loss is
replaced with functional symptoms that are emotionally
and psychosocially damaging to the child. In most
clinical settings, attention is rarely focused on determining the underlying problems leading to the PNOHL or to
the management of the condition. Literature discussing
psychosocial stressors that lead to PNOHL and the
personality profile of children who present with PNOHL
are reviewed in this article. Techniques for managing this
condition also are presented.
KEY WORDS: functional, malingering, nonorganic hearing
loss, pseudohypacusis, psychosocial
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reported by Hallewell, Goetzinger, Allen, and Proud (1966),
what appeared as a severe hearing loss in a 13-year-old
boy was revealed as normal hearing sensitivity under
hypnosis. More recent studies also have reported initial
misdiagnosis of PNOHL (e.g., McCanna & DeLapa, 1981;
Pracy, Walsh, Mepham, & Bowdler, 1996; Radkowski,
Cleveland, & Friedman, 1998). In many instances, these
children had been referred for medical evaluations when no
medical condition was present. As a result of the initial
misdiagnosis, costly diagnostic procedures including
laboratory and serologic testing, autoimmune studies, and
computed tomography (CT) scan imaging were performed
(Radkowski et al., 1998).
Because financial gain and compensation issues, frequently cited predisposing factors for adult NOHL, are not
generally associated with PNOHL (Chaiklin & Ventry,
1963; Dixon & Newby, 1959), audiologists consider it a
minor clinical nuisance. The typical goal when dealing with
PNOHL is essentially twofold: diagnosing the condition and
determining true behavioral thresholds. According to
Northern and Downs (2002), however, children presenting
with PNOHL may have a basic underlying need that is
unfulfilled and may choose from a variety of symptoms,
ranging from the conscious to the psychosomatic, to
express that need. When symptoms enter the psychosomatic
realm, disorders such as eczema, chronic stomach problems,
and even psychosis may occur. These issues, if not identified quickly and resolved, may be harmful for the child’s
well-being. They also may result in the child engaging in
harmful, self-destructive behaviors as an adult (Brooks &
Geoghegan, 1992), and becoming a threat to family and
society (Northern & Downs, 2002).
In this article, precipitating stressors that may lead to
PNOHL in some children will be presented. The
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psychosocial and personality profile of children who have
been diagnosed with NOHL will be discussed. Techniques
useful for diagnosis and management of this condition also
will be presented.
PRECIPITATING STRESSORS
Different stressors can lead to the presentation of PNOHL,
which usually has a sudden onset following a stressful
event (Radkowski et al., 1998). The most common stressor
is trouble at school. Common examples include problems
with a teacher, using the hearing loss as an excuse for not
doing school work (Brooks & Geoghegan, 1992), or
difficulty adapting to the school environment (Hosoi, Tsuta,
Murata, & Levitt, 1999). Problems at home, such as
emotional and physical abuse (Lehrer, Hirschenfang, Miller,
& Radpour, 1964; Qiu, Stucker, Yin, & Welsh, 1998), are
other stressful events known to lead to PNOHL.
Radkowski et al. (1998) documented a history of
physical trauma immediately preceding the onset of
PNOHL. Examples of traumatic experiences varied from a
teacher pulling a child’s ear to a football tackle.
Berger (1964) reported that a 12-year-old female presented with PNOHL following conflict with a teacher.
Further investigation revealed that she was an orphan
moving between foster homes who recently had experienced
the death of a stepfather and grandfather.
Bailey and Martin (1961) reported a case study in which
a boy presenting with NOHL later admitted to having
normal hearing. He wanted to create the impression that he
could not hear because he wanted to attend the state
residential school for the deaf where his parents were
teachers and his girlfriend was a student. Further investigation revealed that he was not doing well academically in
high school.
Lumino, Jauhiainen, and Gelhar (1969) reported on three
sisters who had a hearing loss develop rather rapidly over a
period of a few months. Two of the three sisters also
complained of visual problems and were fitted with
eyeglasses. Hearing and visual problems apparently returned
to normal one day during a visit with an aunt. The visual
and hearing problems appeared related to family conflict
and resolved upon resolution of that conflict.
Qiu et al. (1998) documented the case of a 9-year-old
female who had a history of child abuse and learning
disability. She demonstrated no response to pure-tone
audiometry. She was later diagnosed with bilateral
“psychogenic deafness” and referred for psychological
rehabilitation.
Brooks and Geoghegan (1992) reported the case of a 28year-old female with recurrent NOHL. At age 13 years, she
had been diagnosed with a hearing loss and fit with
amplification, but a year later decided that her hearing was
normal and the aids were no longer necessary. Pure-tone
audiometry confirmed normal bilateral hearing sensitivity. It
was determined that the girl had been going through a
stressful situation at school at the time that involved
bullying. After that situation was brought to her parents’
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attention and resolved, the hearing loss resolved as well.
Fourteen years later, that same person, now a young
woman, presented with recurrence of the hearing loss on
the eve of her wedding, another possibly stressful event.
Children with emotional problems also can present with
NOHL. There are numerous accounts of children in the
literature who have been diagnosed with NOHL who
displayed emotional disturbances (e.g., Broad, 1980; Brooks
& Geoghegan, 1992; Cobb & Butler, 1949). Lehrer et al.,
(1964) reported on 10 adolescents, ages 11 to 16 years,
who had been diagnosed with PNOHL who had significant
emotional problems such as free-floating anxiety and
tension, feelings of inadequacy, aggression, hostility toward
parents, and a need for attention and approval that were
considered to be associated with PNOHL.
PSYCHOSOCIAL AND PERSONALITY
PROFILE ASSOCIATED WITH PNOHL
There is little information regarding the psychosocial and
personality profile of children presenting with PNOHL.
Children who present with PNOHL often have a history of
prior auditory disorders such as otitis media (Aplin &
Rowson, 1986, 1990; Pracy & Bowdler, 1996). Many
researchers believe that attention gained from a past
medical problem may seem to be a logical way to gain
attention/sympathy for a current underlying emotional/
psychosocial problem (e.g., Aplin & Rowson, 1986; Berger,
1964). Several authors have stressed that NOHL in children
should be detected as early as possible before children
realize that there are secondary gains to be enjoyed from
the hearing disorder (Barr, 1963; Martin, 2002; Miller, Fox,
& Chan, 1968; Ross, 1964). Others believe that the choice
of the ears as an expression of a troubled psyche may be
related to the role audition plays in the psychological
development of a child. Isakower (1939), for example,
considered audition pivotal to the development of the
superego. Shopper (1978) stressed the role of audition in
“separation–individuation.” According to Shopper, developmentally, there is a natural progression of the child’s need
for tactile and visual awareness of the mother to the
reliance on auditory reassurance of her existence until the
child attains emotional and cognitive object stability. It is,
therefore, not surprising that audition becomes embodied in
intrapsychic conflicts.
Earlier researchers (Cobb & Butler, 1949; Semenov,
1947; Ventry, 1971) had suggested that NOHL was a
child’s way of avoiding unpleasant and/or dangerous
situations or unpleasant memories that were usually related
to a painful early childhood. The PNOHL was, therefore,
the child’s denial mechanism. In a study, regarded as a
classic in the psychiatric literature, Fromm (1946, as cited
in Broad, 1980) documented the case of a 10-year-old male
with congenital osteogenesis imperfecta that prevented him
from walking. This child also exhibited a severe hearing
loss. It was later determined that the child could hear but
chose only to respond to “pleasant” auditory stimulation.
Fromm reasoned that because the child could not walk, he
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could not avoid situations he perceived as dangerous. The
child’s reaction to perceived dangers was the hearing loss;
in his mind, if he could not hear in those situations, they
did not exist, sparing him the frightening and impotent
realization of his own helplessness.
According to Broad (1980), the core psychopathology
associated with PNOHL involves “poorly consolidated self
representations” (p. 56) with the functional hearing loss
serving to protect an enfeebled sense of self. He noted that
these children exhibited poor self-concepts, low self-esteem,
an extreme sensitivity to criticism, and an inability to deal
with peers. In another study, Aplin and Rowson (1986)
administered a personality inventory scale to 30 children
who had been diagnosed with PNOHL. The children in
their study had high scores for neuroticism and introversion, suggesting the possibility of a personality trait
associated with PNOHL. Twenty-three of the children
(77%) also had a history of middle ear pathology. The
researchers suggested that PNOHL may be an adaptive
mechanism for such children, allowing them to continue
introverted behaviors yet also offering an excuse for them.
Psychological tests, such as the Rorschach test (Rorschach, 1921) for analysis of personality and psychopathology, were often used to determine the psychodynamics of
PNOHL (Broad, 1980; Kodman & Waters, 1961). Kodman
and Waters performed the Rorschach test on 8 children who
had been diagnosed with NOHL and reported that these
children demonstrated repressed and restricted affect that
was characteristic of “hysterics.” The researchers, however,
concluded that these children could not be considered
“clinical neurotics.” Results from the Rorschach test should
be interpreted cautiously. The Rorschach test also had been
used in several studies of NOHL for adults, but the results
were often inconclusive. There were difficulties identifying
Rorschach differences between individuals with a nonorganic component and those without (Wolfe, 1960, as cited
in Chaiklin & Ventry, 1963).
There is an ongoing debate regarding the intellectual
ability and academic achievement of children who have
been diagnosed with NOHL. It is generally believed that
these children have normal intelligence, although as a
group, their intelligence may be considered below average.
They do not, however, demonstrate a particularly great
ability for studying (Barr, 1960, 1963; Chaiklin & Ventry,
1963; Dixon & Newby, 1959; Trier & Levy, 1965).
Children who have been diagnosed with PNOHL were
assessed for an overall estimate of intelligence by Aplin
and Rowson (1990) using the Wechsler Intelligence Scale
for Children—Revised (WISC–R; Wechsler, 1974). These
children demonstrated IQ scores that were significantly
below the mean of 100. Measures of educational attainment
also were obtained. Reading ability was assessed using the
Burt Word Reading Test (Scottish Council for Research in
Education, 1976). Approximately 30% of the children in the
sample were reading at a level of 2 or more years below
their chronological age, and all of those children had low
verbal IQ scores on the WISC–R. The authors noted that
almost all of these children had otitis media at a younger
age; therefore, in addition to the PNOHL, continuing
effects of the earlier occurrence(s) of otitis media may have
some impact on the children’s current reading and verbal
IQ scores.
Psychosocial and personality characteristics similar to
those reported for PNOHL have been documented for adults
with NOHL, which may suggest a “personality type”
associated with NOHL. According to Trier and Levy
(1965), adults who have been diagnosed with NOHL tend
to score lower on all socioeconomic measures. They also
score lower on tests of verbal intelligence and demonstrate
a greater degree of clinically significant emotional disturbances. Gleason (1958) reported that these individuals
typically tend to display emotional immaturity, instability,
hypochondriasis, and an inadequate response to social
demands. They also tend to manifest a reliance on denial
mechanisms and appear to have a diminished sense of
confidence in their abilities to meet the needs of daily
living (Martin, 2002).
INCIDENCE AND PREVALENCE OF PNOHL
According to some reports, the incidence of PNOHL ranges
from 1% to 12% (e.g., Barr, 1960; Doerfler, 1951). The
validity of these percentages may be questionable because
of lack of consensus regarding the criteria used in arriving
at a diagnosis (Broad, 1980). Prevalence rates of PNOHL
are reported at approximately 5% to 7% (Hopkins, 1973;
Rintelmann & Harford, 1963). Children typically present
with PNOHL between 6 and 19 years of age (Dixon &
Newby, 1959; Rintelmann & Harford, 1963), with peak
occurrence at approximately 11 years of age. It was
believed that for girls, the high prevalence of PNOHL at 11
years of age might be associated with stress related to
menarche. Coles (1982), however, presented data showing
similar peaks of maximum prevalence for both boys and
girls, which he suggested may be related to “examination
stress” at school. A review of the literature indicated a
significantly higher incidence of girls presenting with
PNOHL (Aplin & Rowson, 1986; Dixon & Newby, 1959;
Pracy & Bowdler, 1996; Radkowski et al., 1998). The
reasons for this gender difference are not fully explained.
In addition, girls with adjustment problems may tend to
adopt introverted, withdrawn, and anxious forms of
behaviors such as PNOHL; boys may tend to display
overtly aggressive behaviors (Aplin & Rowson, 1986).
Interestingly, the literature also indicated a higher
incidence of conversion disorder in females (Wolf, Shoshan,
Birger, & Kronenberg, 1993), with reported ratios varying
from 2:1 to 10:1 (American Psychiatric Association, 1994).
According to the Diagnostic and Statistical Manual of
Mental Disorders (American Psychiatric Association, 1994),
a conversion disorder is a somatoform disorder with the
symptoms or deficits affecting voluntary, motor, or sensory
systems that suggest a neurological or other general
medical condition. Hearing loss is one of several symptoms
that may be associated with conversion disorder. The
symptoms do not conform to known anatomical pathways
or physiological mechanisms, but instead follow the
individual’s conceptualization of a condition. The DSM-IV
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(1994) definition indicates a temporal relationship between
a psychologically stressful situation and the appearance or
exacerbation of the symptom. A conversion disorder may
present as NOHL, but it is not a conscious manifestation of
deceit, deception, or exaggeration. Instead, the underlying
problem is psychologic in nature. True reported cases of
conversion hearing loss are, however, sparse in the literature (e.g., Coles, 1982; Mehta, 2003; Qiu et al., 1998;
Ventry, 1968).
If underlying psychosocial issues of childhood are not
resolved, they may have ramifications that last into adulthood. If children do not receive the help and/or attention
they need for these psychosocial issues, they may replace the
symptoms of a hearing loss with other functional symptoms
that could be more damaging both emotionally and psychosocially. Brooks and Geoghegan (1992) identified individuals
who had been diagnosed with PNOHL between 6 and 27
years before their study to determine whether there was
evidence of long-term effects related to the PNOHL. The
researchers found that among the 29 individuals identified,
only 1 was a self-confessed malingerer. Approximately half
of the individuals had psychosocial problems as adults. One
individual was still complaining of subjective residual
hearing problems that were not confirmed by audiometry.
Another person reported that her hearing was now satisfactory but she was having visual problems of some obscure
pattern. She appeared to be enjoying the attention gained
by her physical problems. Six people had speech disorders
(including disfluency and one case of possible dyslexia).
Five others had been referred to a psychiatrist and one to a
psychologist. Issues that they had dealt with or were
dealing with included alcoholism, drug abuse, compulsive
behaviors, stealing, and suicide.
ROLE OF THE AUDIOLOGIST
Audiologists are not professional counselors. Moreover, the
scope of practice for audiology does not include diagnosis
and treatment of emotional and psychosocial issues. If a
feigned hearing loss is a child’s chosen way of expressing
an underlying psychosocial or emotional problem, the
audiologist may be the first professional dealing with the
issue. If audiologists simply serve as a means for accurate
diagnosis of audiometric thresholds regardless of underlying
problems a child may be facing, they act as technicians.
They disregard their responsibility as professionals to make
informed decisions for appropriate management of the
condition necessary for the well-being of that child.
What, then, is the role of the audiologist in such
situations? Given the possible long-term ramifications of
PNOHL and the cry for help and attention inherent in the
presentation of PNOHL (Northern & Downs, 1974), it is a
situation that should not be taken lightly. According to
Northern and Downs (2002), any child who presents with
an NOHL has a problem, whether it is a minor transient
difficulty or a deep-seated permanent disorder. The NOHL
is usually a symptom of some other problem and should
never be disregarded or passed off as a temporary foible.
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The literature suggests that investigation of any underlying
problem is warranted. This investigation might be accomplished by close attention to the case history and by
looking for signs of a problem (Northern & Downs, 1974).
Audiologists need to recognize that exaggerated behaviors
such as verbosity, brashness, overwithdrawal, lack of
personal affect, and exaggerated straining to hear test tones
may be indicators of PNOHL (Northern & Downs, 2002).
If a child demonstrates poorer hearing thresholds than
expected, it is important to determine whether the hearing
loss is organic or nonorganic. Misunderstanding or unfamiliarity with the test procedure must be ruled out before
making the diagnosis of PNOHL (Northern & Downs,
2002). In addition, environmental factors such as noise,
insufficient motivation of the child, improper testing
technique, and poorly calibrated equipment should all be
discounted before making a diagnosis of PNOHL (Martin,
2002). Further, organic causes of sudden hearing loss such
as viral infection, trauma, or toxins, which are more
common than NOHL, also should be excluded (Bowdler &
Rogers, 1989). If PNOHL is suspected, two factors must be
determined: the true hearing sensitivity and the cause of the
NOHL (Hosio et al., 1999).
Determination of True Hearing Sensitivity
Children with PNOHL typically show no evidence of
hearing loss during normal conversational speech or outside
of a testing situation (Dixon & Newby, 1959; Gelfand,
2001), which is why, for these children, failure on school
hearing screening tests is the primary reason for audiologic
referral (Bowdler & Rogers, 1989; Northern & Downs,
2002). PNOHL is typically easier to diagnose than adult
NOHL because of the child’s naivete in understanding the
relationship between test procedures and hearing loss and
an inability to consistently provide erroneous test results.
The child’s voice quality and performance during speech
audiometry testing also may be better than suggested by the
volunteered behavioral pure-tone thresholds. In addition, the
needs that drive the child to present with PNOHL are
typically more honest and engender more sympathy than
those that drive an adult (Northern & Downs, 2002).
The classic literature suggests that there are no characteristic audiometric patterns that typify NOHL (Chaiklin,
Ventry, Barrett, & Skalbeck, 1959; Ventry & Chaiklin,
1965). One aspect of NOHL, however, that is widely
accepted in the adult literature is the high prevalence of the
nonorganic component superimposed on an existing organic
hearing loss (Chaiklin & Ventry, 1963; Gelfand & Silman,
1985, 1993). This finding also is reported for children
(Aplin & Rowson, 1986, 1990; Pracy & Bowdler, 1996).
The configuration of the nonorganic overlay in adults is
related to the configuration of the underlying organic
hearing thresholds (Coles & Mason, 1984; Gelfand &
Silman, 1985, 1993) and is most evident in individuals with
precipitously sloping hearing loss. In general, the
nonorganic components are larger at the lower frequency
levels where the organic thresholds are better and smaller
at the higher frequency levels where the organic thresholds
are worse because high-frequency hearing loss is so
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common in adults (Gelfand 2001). In addition, loudness
recruitment, which is related to the degree of hearing loss,
also may result in smaller nonorganic components at the
higher frequency levels where the actual hearing loss is
worse. These findings also may be related to the internalized reference levels for loudness or “anchor” used by most
individuals feigning a hearing loss; they will not respond to
an auditory stimulus until its loudness reaches that of the
internal anchor (Gelfand, 2001; Gelfand & Silman, 1985,
1993; Martin, Champlin, & McCreery, 2001). Contrary to
what is observed for adults with NOHL, the nonorganic
overlay for children may not always present with larger
nonorganic components at lower frequency levels because
of hearing loss related to middle ear pathology (e.g., otitis
media), which is common in school children.
Several signs of a nonorganic component can be obtained
during routine audiologic evaluation. One of them is the
lack of false-positive responses (Gelfand, 2001). Falsepositive responses are exhibited by listeners when no test
stimuli are present. These responses are common when
evaluating individuals with normal hearing or those with an
organic hearing loss because they want to cooperate with
the audiologist and establish accurate hearing thresholds.
Individuals presenting with NOHL have no such desire and,
therefore, false-positive responses are rare. Chaiklin and
Ventry (1965) reported in their study that 86% of listeners
with a true organic hearing loss gave one or more falsepositive response. By contrast, only 22% of listeners
presenting with NOHL gave one or more false-positive
response.
Typically, individuals with NOHL have exaggerated
responses or no responses on behavioral tests. It is important to perform a complete diagnostic test battery whenever
possible because then the responses obtained can be
compared, and inconsistent inter- and intratest results
become apparent. Common inter- and intratest inconsistencies include (a) lack of reliability across test sessions, (b)
wide threshold ranges, (c) speech recognition threshold
(SRT)–pure-tone average (PTA) disagreement, (d) halfspondee responses, (e) pure-tone bone-conduction thresholds
poorer than pure-tone air-conduction thresholds, (f) lack of
cross hearing (Gelfand & Silman, 1993; Martin et al., 2001),
and (g) audiometric threshold variations of as much as 15 to
25 dB HL at the same frequency (Northern & Downs, 2002).
Speech audiometry alone often is sufficient for detecting
PNOHL. In most cases, the SRT is significantly better than
the PTA (500, 1000, and 200 Hz) by as much as 20 to 40
dB HL (Hosoi et al., 1999; Lehrer et al., 1964). An SRT–
PTA discrepancy of 12 dB HL or more is considered an
indication of NOHL (Chaiklin & Ventry, 1965). According
to Chaiklin and Ventry, SRT–PTA discrepancy and falsepositive responses, when used together, compare favorably
with other screening tests for detecting NOHL and result in
a high percentage of correct identifications.
Because the child presenting with NOHL typically is less
sophisticated than an adult, and the deception is generally
easier to detect, the use of other diagnostic behavioral tests,
such as the Doerfler-Stewart test (Doerfler & Stewart,
1946) and the Lombard reflex test (Lombard, 1911), is
rarely required. The Stenger test (Stenger, 1907; Taylor,
1949) may have to be performed if the suspected PNOHL
is monaural. Other behavioral tests designed specifically for
diagnosis of NOHL and particularly useful with the
pediatric population include the Yes-No test (Frank, 1976),
the Swinging Story test (Newby, 1979), and its later
variation, the Varying Intensity Story test (Martin,
Champlin, & Marchbanks, 1998). Currently, however, some
behavioral tests such as the Doerfler-Stewart test and the
Lombard reflex test have limited usefulness because even
though these tests are useful in identifying a nonorganic
component, they fail to quantify its degree. If discrepancies
are still present between behavioral test results, despite
repeating instructions and behavioral test procedures, the
best approach is to schedule another appointment (Chaiklin
& Ventry, 1963; Gelfand, 2001).
Behavioral tests alone may not be reliable in diagnosing
PNOHL or determining actual hearing sensitivity. Physiologic measures should be used to rule out organic pathology and to confirm the diagnosis of NOHL (Durrant,
Kesterson, & Kamerer, 1997; Gelfand, 1994; Mehta, 2003;
Qiu et al., 1998). Possible physiologic procedures include
middle ear muscle reflexes (MEMRs), otoacoustic emissions (OAEs), and auditory evoked potential measurements.
Certain conditions such as neurological disorders (e.g.,
Katz, 1980) and auditory neuropathy may present as NOHL
and may not be diagnosed on a pure-tone audiogram. The
true diagnosis may be missed if physiologic tests, such as
the MEMR, OAEs, and evoked potentials measures (e.g.,
the auditory brainstem response [ABR] measurement), are
not performed (Berlin, 1999). One limitation of OAEs is
the prevention of recording of responses due to attenuative
influences of the external and middle ear on reverse energy
transmission and their insensitivity to disorders affecting
inner hair cells or higher levels of the auditory pathway
(Norton et al., 2000). Similarly, a possible limitation of the
MEMR when used as a diagnostic tool for PNOHL may be
the extreme sensitivity to the presence of conductive
pathology (Jerger, Anthony, Jerger, & Mauldin, 1974). With
conductive pathology, more intensity is needed to reach the
reflex threshold, which may exceed the maximum available
stimulus level (Gelfand, 2002). In which case, changes in
acoustic immittance occurring at the probe tip will not be
recorded even if the stapedius muscle were contracting.
Both OAEs and MEMRs can, therefore, be absent in
children presenting with PNOHL who have an underlying
middle ear pathology, limiting their diagnostic value.
Further, Gelfand (1994) reported that although the MEMR
is an effective nonbehavioral tool for detection of NOHL, it
cannot identify a functional component if the volunteered
thresholds are less than or equal to 60 dB HL because the
MEMR would normally be present with a cochlear hearing
loss of that magnitude. Even with these limitations,
immittance measures should be performed initially for all
routine audiologic assessments because they can discourage
pseudohypacusis (Martin, 2002) and alert the clinician to
the possible presence of NOHL. The presence of normal
OAEs, normal tympanogram, and bilateral MEMRs rule out
the possibility of a conductive hearing problem. The ABR
threshold exploration procedure can be used to validate
hearing thresholds (Northern & Downs, 2002).
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Other evoked potential measures such as middle and long
latency auditory evoked responses can be beneficial in
ruling out neurological conditions beyond the level of the
brainstem before establishing a diagnosis of NOHL. Middle
latency auditory evoked potentials (MLAEPs) consist of a
series of auditory-evoked responses that occur between 10
and 80 ms following the onset of an acoustic stimulus. By
definition, MLAEPs follow the ABR and precede the long
latency auditory evoked potentials (LAEPs) (Kraus, McGee,
& Stein, 1994). Clinical uses of MLAEPs include the
estimation of frequency-specific hearing thresholds,
especially in the lower frequencies (Musiek & Geurnink,
1981; Scherg & Volk, 1983); assessment of auditory
pathway function, including ruling out a central auditory
pathology when NOHL is suspected; and localization of
auditory pathway lesions (Buchwald, Erwin, Read, Van
Lancker, & Cummings, 1989; Jacobson & Grayson, 1988;
Kileny, Paccioretti, & Wilson, 1987; Kraus & McGee,
1988). The LAEPs are recorded in a time period from
approximately 50 to 250 ms after acoustic stimulation by a
transient sound such as a click, toneburst, or speech
element at a relatively slow rate (approximately 1 to 2
stimuli per second) and include both exogenous and
endogenous potentials (Scherg, Vajsar, & Picton, 1989;
Velasco, Eelasco, & Velasco, 1989). Exogenous auditory
responses are those responses that are generated primarily
by the physical characteristics of the stimulus. Endogenous
auditory responses are those that are produced after internal
processing of the stimulus has occurred. The LAEP can be
a useful clinical tool in the estimation of hearing sensitivity
of individuals when a nonbehavioral, frequency-specific,
and sensitive measure is needed, such as for medicolegal
and compensation assessments and the evaluation of a
suspected NOHL (Hyde, 1994). Currently, only a small
percentage of clinicians routinely use MLAEPs and LAEPs
(Martin, Champlin, & Chambers, 1998), probably due to
the limitations of availability of equipment, experience of
clinicians, and third-party reimbursement issues.
Determination of the Cause of PNOHL
A good case history can be quite helpful in determining the
cause and nature of PNOHL; it can help the audiologist
determine whether it is a transient, isolated event or the
manifestation of a more severe underlying problem. Some
events in a child’s life that indicate that the hearing loss
may be nonorganic include (a) recent history of ear-related
problems (e.g., otitis externa or media), (b) recent relocation, (c) transfer to a new school, (d) recently falling
grades, (e) poor peer relationships, (f) poor relationships
with parents and/or other family members, (g) parental
inadequacies, (h) a new baby in the family, (i) a recent
death in the family, (j) a sick child in the family who
requires a great deal of caregivers’ time and attention, (k)
recently divorced parents, and (l) recent adoption or
transfer to foster care. Establishing a relationship of trust
with the pediatric client is as important as it is with adult
clients. Children may sometimes be more open to talking
and discussing a stressful situation, such as problems in
school, with a trusted professional than with caregivers.
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Most cases of PNOHL are isolated events that are
resolved fairly quickly and present no additional concerns. In
those instances, reinstructing and repeating the behavioral
test procedures, talking to the child in a respectful, nonconfrontational manner and, therefore, allowing the child a
way out often is all that is needed. Nonthreatening statements are recommended, such as, “All these tests tell me
that you should be hearing well, except this one test. Let’s
try again. This time I will do a better job of explaining
exactly what you need to do and you can try and listen
carefully for me one more time.” Such statements that do
not assign any blame toward the child, coupled with
encouragement during the behavioral threshold search, can
be helpful in establishing actual hearing threshold levels. A
follow-up evaluation, typically within the next 3 months,
often is helpful. The follow-up evaluation can serve two
purposes: (a) establish reliability of the obtained behavioral
hearing thresholds and (b) dictate direction of management.
Reassuring caregivers that the child’s hearing appears normal
but explaining that a follow-up appointment will help ensure
that there are no lingering problems can alleviate caregivers’
anxieties without any confrontations or assigned blame. If,
on the other hand, the child is showing signs of a psychosomatic problem (e.g., chronic stomach ache and eczema) or
other psychosocial issues, or if the NOHL is not resolved
despite the best efforts of the audiologist, the PNOHL may
be deeply entrenched. Psychological referral may then be
warranted.
MANAGEMENT OF PNOHL
Chaiklin and Ventry (1963) stated that the negative
emotional reactions of professionals toward clients with
NOHL are reflected dominantly as a preoccupation with the
“unmasking” of malingers. They also stated that these
negative reactions may have impeded or contaminated
research in this area and, even worse, may have occasionally resulted in clinical mismanagement of such clients.
Although great strides have been made in the management
of newly diagnosed hearing loss in children, little progress
has been made on how to manage newly diagnosed
PNOHL. It is unrealistic to think that early intervention in
every case of PNOHL would necessarily produce a better
outcome. If early intervention can, however, minimize
ensuing problems in only a few cases, timely and appropriate action is justified (Brooks & Geoghegan, 1992).
In many respects, detecting PNOHL and determining true
hearing sensitivity is often the easy part of the process. The
difficult decision is what to do with that information.
Should the caregivers be informed? Is a talk with the child
warranted? Are there underlying psychosocial issues that
need to be addressed? Should counseling be recommended?
Should all children who are diagnosed with PNOHL be
referred for counseling and/or a psychological evaluation?
It is at this time that the judgement and experience of the
audiologist becomes important before making a decision.
Each individual case is different, and there is no “cook
book” approach that is appropriate for every client. The
DISORDERS • Volume 32 • 11–21 • Spring 2005
guiding principles for professionals should be to handle
situations within their scope of practice and professional
comfort level and to enlist the help of appropriate professionals for issues outside their scope of practice and
professional expertise.
Some authors suggest a “no interference” approach when
dealing with PNOHL (e.g., Pracy & Bowdler, 1996); once
it has been established that the child has thresholds within
normal limits, reassuring the caregivers and child that the
hearing “will improve” may be sufficient without trying to
determine the underlying cause of the problem. Pracy and
Bowdler also recommend that audiologists should not
attempt to identify the loss as nonorganic. Other authors
suggest talking privately and frankly with caregivers,
explaining the situation to them, encouraging them to try
and understand why the child has chosen to fake a hearing
loss, and suggesting professional counseling (e.g., Northern
& Downs, 2002). Confronting or accusing the caregivers,
however, is not recommended (Berger, 1964). When talking
with caregivers about PNOHL, it is important for professionals to choose their words carefully and think of how
those words will be perceived by the listeners. According
to Gelfand (2001), professionals should avoid using
judgmental or accusatory language and labels when
counseling caregivers of children presenting with a nonorganic overlay. In the listener’s mind, use of words such
as “malingering” and “feigning” may translate into “liar.”
Use of clinical terms such as “functional,” “psychogenic,”
and “nonorganic” hearing loss may be equated with “crazy
liar.” It also is important to point out that counseling by
student clinicians is not recommended when NOHL is an
issue because of their lack of expertise and experience.
New clinicians also should be advised to involve more
experienced professionals when these situations arise
(Gelfand, 2001).
Professionals need to understand the impact on families
of a sense of loss that may accompany the diagnosis of a
communication disorder (Stone, 1992). Not unlike caregivers of children with an organic hearing loss, these
caregivers also may suspect that there is a problem but
may not be ready to admit it to themselves. They also may
go through similar stages of guilt and grief (Friehe,
Bloedow, & Hesse, 2003; Kubler-Ross, 1969; Tanner,
1980). Strategies similar to those used for counseling
caregivers of children with a newly diagnosed hearing loss
can be used to counsel caregivers of children with a newly
diagnosed PNOHL. According to English (2002), it is
important to talk to caregivers in a private area without the
child present so that they can express their emotions and
ask questions. It also is important to be sensitive to the
time that caregivers may need to comprehend and resolve
the emotions they are experiencing before they can discuss
options for management of the condition (Tanner, 1980).
Professionals also need to use active listening strategies.
Active listening conveys empathy, which communicates
support, rather than sympathy, which communicates pity
(Jenkins, 1996). Presenting the results in a factual yet
empathetic manner allows caregivers the opportunity to ask
questions and talk among themselves, which may clarify
the underlying problem/concern that led to the PNOHL.
Such information would not only be useful in management
of the condition, but also may allow the adults to realize
what is bothering the child and resolve the situation. Again,
it is important to neither confront the caregivers nor assign
blame, but instead to report the test results factually and, if
needed, recommend professional counseling for the child. It
also is important to advise the child’s physician of the
outcome (Northern & Downs, 2002) after receiving consent
from the caregivers.
Although there are differing opinions on how to deal
with caregivers, the literature advocates avoiding confrontation with the child (Bowdler & Rogers, 1989; Rintelmann
& Schwan, 1999). Confrontation produces unfavorable
results because the child has no chance to back down and
is not provided with an opportunity to “save face,” which
is usually an important step toward resolution of the
problem (Gelfand, 2001; Northern & Downs, 1974, 2002).
In addition, if the child’s emotional or psychological state
is fragile, the audiologist does not possess the professional
knowledge and skills needed to deal with such a situation.
It is inappropriate, however, to operate on the assumption
that if the hearing loss is not genuine, the problem can be
ignored (Brooks & Geoghegan, 1992).
Although audiologists are not trained counselors, nonprofessional counseling is within the scope of practice of
audiology. When counseling caregivers of children with
PNOHL, informational and personal adjustment counseling
are both necessary. Informational counseling provides
clients with the relevant knowledge necessary to understand
the nature of the disorder and recommendations for its
management. Personal adjustment counseling helps clients
deal with the emotional aspect of the information provided.
One critical but often ignored variable associated with
informational counseling is client recall. Clients do not
remember all that is said by the health care provider. When
anxiety levels are high (Kessels, 2003), or if the client is in
denial (Scheitel, Boland, Wollan, & Silverstein, 1996), even
the most obvious findings including the diagnosis can be
forgotten. Anxiety and denial often are present when
dealing with caregivers of children with PNOHL. It also is
important that clinicians and caregivers agree on the
diagnosis and the need for follow-up because if they do
not, the likelihood of appropriate management can be
significantly lower (Starfield et al., 1979). The way in
which information is presented becomes important when
trying to maximize client recall. Margolis (2004) recommends that information be presented simply and in an easyto-understand format. The most important information
should be presented first as that tends to be remembered
better by the listener. It also is important to restate critical
pieces of information such as the diagnosis and recommendations. The listener should be given the opportunity to ask
questions before moving on to the next category because
that also can enhance recall.
Audiologists are generally comfortable providing informational counseling to their clients but not quite as
comfortable providing personal adjustment counseling.
According to Clark and English (2004), because audiologists are not trained as professional counselors, they may
feel insecure in their client interactions, especially when
Mehta • Martindale: Pediatric Nonorganic Hearing Loss
17
dealing with possible psychosocial issues. They may feel
that they cannot provide the right response each and every
time or minimize the problems in their clients’ lives. A
straightforward, empathetic, human response, however, can
allow the audiologist to concentrate on the crisis at hand
and become an effective nonprofessional counselor. Clark
and English also advocate recognizing the characteristics of
clients that indicate their style of social interaction so that
audiologists can adjust their behaviors to be more conducive to their clients’ needs and expectations. In the case of
PNOHL, the success of dealing with the nonorganic
component may depend significantly on the perception
caregivers have formed of the clinician as a professional.
If, for example, the caregivers are reserved individuals who
want just the facts, an over-friendly or over-empathetic
clinician may not come across as a competent professional,
and the gravity of the situation may not be appreciated nor
the recommendations taken seriously. On the other hand,
some caregivers, when presented with factual information
without the interlude of friendly conversation, may not be
able to absorb and retain all of the information, may feel
overwhelmed with the facts and, therefore, be unable to
make clear decisions about helping their child. It is beyond
the scope of this article to provide an in-depth discussion
of client–practitioner dynamics. For more on this topic, see
Clark and English, who also provide a comprehensive
discussion on styles of social interaction that would be
helpful when counseling all clients.
One area that requires thoughtful consideration when
dealing with PNOHL is report writing. To label a child as
“functional,” “malingerer,” or “psychogenic” implies
deliberate falsification or the presence of a psychiatric
disorder—charges that can be difficult to expunge and may
be unjust (Martin, 2002), particularly when it is uncertain
who will be reading the report over time. One way to
address this issue is to state that the test results were
inconsistent with a hearing disorder without assigning
labels. If a psychologic evaluation or counseling appears
necessary, a nonjudgmental statement can be made to that
effect. Although the recommendation may be written on the
report and caregivers made aware of the need for psychiatric counseling, they may not be ready to follow through at
that time because of an unwillingness to accept the
diagnosis and/or because of the social stigma attached to
such referrals (Martin, 2002). Caregivers can be reminded
during the follow-up visit that there are professionals
available if they need to talk to someone. Recommending a
pediatric clinical psychologist or psychiatrist that the
clinician is familiar and comfortable with also may make it
easier for caregivers to take that first step. It is common
for children to initially present with PNOHL on school
hearing screening tests. Reports of school hearing screening
tests, therefore, should not include recommendations for
preferential seating or other special classroom considerations based on those results. Recommendations should,
however, include a comprehensive hearing evaluation to
determine the nature of the hearing loss in order to rule out
PNOHL.
In some instances, PNOHL may have its roots in
physical and/or emotional abuse at home. If such a
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situation is suspected, it may be best not to discuss the
outcome of the evaluation with the caregivers, but to report
back to the referring authority, which in most cases would
be the managing physician or school authorities. These
entities typically have both the professional and legal
authority and expertise to deal with such situations. Many
states also have laws that require professionals to report
suspected cases of child abuse to appropriate authorities.
CONCLUSION
The possibility of PNOHL should be considered for
children with a new-onset hearing loss. PNOHL can occur
in a diverse population with unpredictable audiometric
patterns. Additionally, the clinical history or presentation
may support the diagnosis of an organic hearing loss,
which can confound the ability to discover the nonorganic
component. The PNOHL also can present as an overlay to
an existing organic hearing loss. Unfamiliarity with test
procedures and hearing loss due to a medical pathology
must be ruled out before making the diagnosis of PNOHL.
A combination of behavioral and physiologic tests is
generally needed to diagnose this condition.
Most children who are diagnosed with PNOHL have a
history of otitis media. The attention gained from a past
medical problem may seem to be a logical way for these
children to gain attention and sympathy for a current
psychosocial problem. The psychosocial and personality
profile of PNOHL that emerges from the literature is that
of children with poor coping skills, introverted behavior
patterns, emotional immaturity, difficulty with peer and/or
parental relationships, and often a history of a painful
childhood. Their intellectual abilities, as a group, are
generally normal, but they may not perform well at school.
The NOHL also may be used by these children as a denial
mechanism, in their minds, protecting them from painful or
dangerous situations in their lives. Research studies have
shown that if the underlying emotional or psychosocial
problems associated with PNOHL are left unattended, these
problems can worsen and may persist into adulthood,
sometimes manifesting as more detrimental behaviors.
Timely recognition of the problem and appropriate recommendations are, therefore, important. Appropriate counseling of caregivers is critical for recommendations to be
followed and for the child to receive the necessary help.
The follow-up visit may be the most important part of the
management of PNOHL. During a follow-up visit, reliability of behavioral thresholds can be assessed and the nature
of the PNOHL can be determined, whether it is an isolated
event or the result of an entrenched psychosocial problem.
Once the nature of the PNOHL has been determined,
further recommendations can be made accordingly.
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Contact author: Zarin Mehta, Wichita State University, Department of Communication Sciences and Disorders, 1845 N.
Fairmount, Wichita, KS 67260-0075. E-mail:
[email protected]
Mehta • Martindale: Pediatric Nonorganic Hearing Loss
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