Clinical Scenario:
A 3-year-old boy is referred for delayed speech and social communication. He uses only a few single words and frequently fails to respond when his name is called. His mother is confident that he can hear because he turns toward a vacuum cleaner, responds to the doorbell, and reacts to loud sounds at home. There is no history of recurrent otitis media.
On examination, the child has no obvious neurological abnormality.
What is the most appropriate next step in his assessment?
A. Arrange formal age-appropriate audiological assessment
B. Diagnose autism spectrum disorder and begin intervention
C. Reassure the mother that clinically significant hearing loss is unlikely
D. Request electroencephalography
E. Refer directly for speech therapy without hearing assessment
Correct answer & Explanation:
Answer: A. Arrange formal age-appropriate audiological assessment
Explanation
Hearing loss must be formally excluded in every child presenting with significant speech or language delay, even when parents report that the child responds to loud sounds.
A child may detect loud environmental sounds but still have clinically important hearing impairment that affects the perception and discrimination of speech sounds, particularly softer or high-frequency sounds. Behavioral observations at home therefore cannot reliably establish normal hearing.
Autism spectrum disorder may be considered because of the social-communication concerns and poor response to name, but hearing impairment should be excluded before attributing these features to autism.
EEG is not indicated in the absence of features suggesting seizures, and speech therapy should not replace an appropriate hearing assessment.
Exam pearl:
Language delay → formally assess hearing before attributing the delay to autism, developmental disorder, or environmental factors.
