Pass the Screen, Fail the Kid? The Hidden Gaps in Early Hearing Tests

You want to understand what went wrong? You have to start at the very beginning.

Not when the speech delay showed up. Not when the reading fell apart. Not when the meltdowns became daily. Start at birth.

Because most babies get a hearing screen before they ever leave the hospital. Usually it’s either Otoacoustic Emissions (OAE) or Auditory Brainstem Response (ABR). And if they pass, the box is checked and they’re cleared as “normal.” But let me be very clear. Those tests don’t tell you what you think they do.

OAE only tells you that the outer hair cells in the cochlea bounce back sound. It doesn’t tell you whether the signal makes it to the brain. It doesn’t tell you if the auditory nerve works. It doesn’t tell you whether the child can hear speech or understand it.

ABR goes a little further. It measures the electrical signal traveling up the auditory nerve to the brainstem. It can tell us whether sound gets through to a basic relay station in the lower brain. But it doesn’t tell you whether the cortex, the thinking and processing part, ever receives or interprets that sound. You could pass an ABR and still be functionally deaf in terms of comprehension.

We call these “hearing tests,” but they’re not testing hearing the way people actually experience it. They test transmission. They don’t test perception. They don’t test clarity. They don’t test meaning.

Then the child grows up. Maybe they get ear infections. Maybe their language is slow. Maybe their articulation is off. Maybe they’re not following directions. But they passed the newborn screen, so nobody thinks to look at hearing again.

Eventually, if someone does test, we do booth testing. Maybe Visual Reinforcement Audiometry if they’re young. We look to see if they turn toward a puppet or a flashing light when a tone plays. That requires bilateral hearing, attention, spatial awareness, and trust in the test environment. A lot of things can break down in that chain.

When they’re older, we use conditioned play or standard audiometry. They raise their hand or drop a block when they hear the beep. But even then, how do we know what they actually heard? How do we know they didn’t just wait until they were sure? How do we know they weren’t guessing? What if they said “baseball” when the word was “hot dog” and we just misheard them, or they misheard us?

Most hearing tests are done in a silent booth with ideal conditions. That’s not real life. We don’t test speech in noise. We don’t check localization or spatial hearing. We don’t look at fatigue. We don’t test what happens when multiple people are talking. We don’t measure how they do when they’re overstimulated or burned out.

We declare them fine because they heard a tone.

But hearing a tone in silence is not the same as understanding speech in a chaotic classroom. Just because a child can detect sound doesn’t mean they can process language clearly. That has real consequences. A child who can’t separate sounds accurately won’t build strong phonological awareness, which is foundational to learning to read and spell. That’s different from struggling to hear speech in noise. Some kids have both problems. Some have only one. But we rarely check either.

And the interventions we do offer are far from perfect.

ASL is essential for language access and Deaf identity, and I support it fully. But it does not replace auditory stability. It doesn’t fix the impact of fluctuating access or the confusion caused by missed early auditory mapping. It’s not a cure for language delay caused by inconsistent sound.

Hearing aids, low-gain amplification, and FM systems can absolutely help. I fit them. I’ve seen the improvements firsthand. But they come with trade-offs too. FM systems, when not adjustable by the child, can strip away spatial cues. Kids can’t always control what they’re hearing or when, and that can increase anxiety and lead to sensory distress. Hearing aids that aren’t programmed carefully can amplify the wrong things or distort the signal further. These are tools. They’re not magic. They need to be handled carefully, with nuance, and ideally by someone who understands the full clinical picture.

If you have Ehlers-Danlos syndrome, it gets worse. Your Eustachian tubes may not open and close properly. Your eardrums might rupture easily or heal with scar tissue. The reflexes that are supposed to protect you from loud sounds may not fire in time. You may hear one way in the morning and a completely different way by the afternoon. The input fluctuates, but the expectation doesn’t.

If you have hyperacusis, normal sound can feel physically painful. If you have misophonia, certain sounds can cause full-body rage or shutdown. These conditions don’t show up on a standard hearing test. They don’t get flagged unless someone already knows to ask. And most don’t.

I see this in children, but I also see it in adults. Many were labeled with ADHD, autism, OCD, anxiety, or behavioral problems, and most were never tested for auditory function in a way that reflected real life. They adapted however they could. Some use headphones constantly. Others avoid restaurants, group conversations, or loud classrooms. A lot of them were told they had a learning disability when the real issue was unstable auditory access that no one caught.

I see it in myself.

I had repeated ear infections as a child. My ankles gave out easily. I spent years in a competitive art magnet program before I had to stop because my hands would swell and go numb. The same thing happened in my interpreting work. I also had severe stomach aches growing up. I would lie still for hours, crying from the pain, and no one had an explanation. Looking back, every one of those things fits the pattern of Ehlers-Danlos, even though I was never formally diagnosed.

I do have a formal diagnosis of autism and ADHD. The way I resist demands, push back, or shut down isn’t random. It came from years of sensory overload, unpredictable sound, and never knowing what input I could trust. I wasn’t trying to be difficult. I was trying to make it through the day with my nervous system intact.

That’s not a personality issue. That’s a survival response.

I see this same pattern in so many of the kids I work with. They pass their hearing test but still struggle to follow directions in noisy environments. They pass a reading screener but still can’t spell because they never built a stable map of how sounds connect to letters. They pass a speech articulation test but still mispronounce words when they’re tired or overwhelmed.

None of those test results prove that everything is okay. They only prove the child got through the test.

What we need is functional assessment. We need fatigue-sensitive measures. We need to test children in noise. We need to listen to the parent. We need to listen to the child. We need to look upstream.

Because what if the child being evaluated for autism, ADHD, or dyslexia is reacting to years of degraded auditory input? What if that behavior is not oppositional at all, but protective? What if the problem started with the signal itself?

What if the reason so many of us have kids just like us is because the same thing was missed in both generations?

These issues run in families. Auditory processing problems, misophonia, hyperacusis, EDS, sensory reactivity, and ear infections are all heritable. But we’re not looking at inherited auditory instability. We’re just documenting what it turns into after the damage is done.

You want evidence? Look in the jails.

Almost half of incarcerated youth have dyslexia. The same is true for adults in prison. Dyslexia is strongly linked to early hearing loss and inconsistent access to sound. Senator Bill Cassidy has been trying to pass legislation for years to push early intervention for ear infections and reading failure. He started in 2014. Still, almost no one is listening.

We keep testing beeps in silence and calling it enough.

We keep acting surprised when behavior and literacy fall apart.

We keep pushing kids to function in environments they were never set up to succeed in.

And honestly, I’m pissed.

I’m pissed at audiology. I’m pissed at speech. I’m pissed at ENT. I’m pissed at education. We had the information. We had the patterns. We had the tools to do better.

We failed the kids. We failed the parents. And some of us failed ourselves.

It is not too late to fix this, but we have to stop pretending it isn’t happening.

If we don’t start looking upstream, we are going to keep drowning in the consequences.