Hyperacusis in Children With ADHD

Hyperacusis, or hypersensitivity to sound, can negatively influence the behavior of children in a considerable way. Children with hyperacusis perceive sounds as painful, which may lead to avoidance behaviors and, as a consequence, may hinder social interactions, daily activities, learning, and communication.¹

Although researchers have recognized the correlation between hyperacusis and neurodevelopmental disorders, such as autism spectrum disorders,² the occurrence of hyperacusis in patients with attention deficit hyperactivity disorder (ADHD), in particular, hasn’t been investigated until recently.¹

In a newly published preliminary study, Massimo Ralli, MD, PhD, from the Department of Sense Organs, Sapienza University of Rome, Rome, Italy, and the Center for Hearing and Deafness, University at Buffalo, Buffalo, New York, and fellow researchers found an increased prevalence of hyperacusis among children with ADHD compared with a control group of healthy children. Their finding were published in April 2020 in the International Journal of Environmental Research and Public Health.¹

A preliminary look

The study group consisted of 30 children with a neuropsychiatric diagnosis of ADHD (83.3% male; mean age: 7.7 years). Dr. Ralli and his fellow researchers included only those children with a diagnosis of ADHD, combined presentation, “to make the sample more homogeneous.” The researchers excluded children with predominantly inattentive or predominantly hyperactive/impulsive ADHD presentations. The control group comprised thirty healthy children matched for sex and age.¹

All children underwent multidisciplinary neuropsychiatric assessments. Pure tone audiometry, acoustic immittance tests, and full otolaryngology examinations were used to evaluate hearing. All study participants were found to have clinically normal hearing.¹

Questionnaires were administered to parents to determine their children’s hypersensitivity to everyday sounds and their corresponding reactions. Interviews were conducted with children to investigate hearing loss, the presence of tinnitus, and hypersensitivity to sounds. Hyperacusis was considered present if children scored hypersensitive to sounds according to responses in both the parent questionnaires and children’s interviews.¹

ADHD-hyperacusis link?

The percentage of children with hyperacusis was significantly higher in the ADHD group (36.7%) than in the control group (13.3%; P=0.03). On the parent questionnaire regarding children’s reaction to loud sounds, responses were positive most often for question 5 (cover ears). In particular, as reported by parents, 50% of children with ADHD versus 13.3% of children in the control group covered their ears as their most common reaction to loud sounds (P=0.001). None of the other differences in reactions to loud sounds (eg, crying or escaping from sound) between the 2 study groups reached statistical significance. On the basis of children’s interviews, 83.3% in the study group versus 23.3% in the control group reported being bothered by any type of sound or noise (P<0.0001). Similarly, on average, children in the study group and control group were annoyed by 5.4 and 3 sounds, respectively (P=0.006).¹

“The higher prevalence of hyperacusis found in the study group suggests a potential association between ADHD and hyperacusis, as already hypothesized by other authors, and is in line with the evidence that hyperacusis can be more frequent in children affected by neurodevelopmental disorders, in particular ASD [autism spectrum disorder],” Dr. Ralli and his colleagues commented in their report.^2-4

“The study highlights an underreported aspect of ADHD,” comments Joseph F. McGuire, PhD, who is Assistant Professor of Psychiatry and Behavioral Sciences at Johns Hopkins Medicine in Baltimore, MD. “Children with ADHD may struggle with inattention, impulsivity, and hyperactivity to a greater degree because of sound sensitivities,” says Dr. McGuire, who wasn’t affiliated with the study.

Differentiating entities

As Dr. Ralli and his fellow researchers pointed out, they weren’t able to definitively differentiate between hyperacusis, misophonia, and phonophobia due to limitations of their study design, which could have led to possible confusion between these conditions.¹

Dr. Ralli and his colleagues targeted the hyperacusis piece, but didn’t measure misophonia, Dr. McGuire noted. One possibility is that the children in this study had both hyperacusis and misophonia. “These two conditions are not mutual exclusive. They both could be present and causing challenges for these children,” he speculates. “Future research will hopeful examine both hyperacusis and misophonia in children and adolescents to better understand these conditions.”

There has been pretty minimal research on sound sensitivity in children; consequently, we don’t know as much as we would like about these conditions, he says.

Complementary collaboration

Dr. Ralli and his colleagues suggested in their report that, although larger studies are needed to corroborate their preliminary findings, it might be useful for children with ADHD to undergo an audiological evaluation and, similarly, children diagnosed with hyperacusis to undergo a neuropsychiatric assessment.¹

“In fact,” they wrote, “hyperacusis may worsen the typical symptoms of ADHD, resulting in a deterioration of the quality of life for children and their families and may contribute to the failure of cognitive-behavioral therapy.”¹

Dr. McGuire agrees with the authors’ stance. Children presenting to an otolaryngology or audiology clinic for concerns of hyperacusis might also benefit from meeting with a psychologist or psychiatrist to determine if misophonia and/or other psychiatric symptoms are present. Similarly, for children undergoing psychological and neuropsychiatric evaluations in clinical settings, it could be equally important to determine if audiological concerns, such as hyperacusis, are contributing factors.

Multiple perspectives through a collaborative approach enable clinicians to conduct more comprehensive assessments, Dr. McGuire says. The take-home message from the study is that multidisciplinary evaluations may be more beneficial, he adds, although changes to standard of care for children with ADHD or hyperacusis shouldn’t be made at this point.

Published: June 02, 2020