Deconstructing Auditory Processing Disorder (APD) for Parents and Professionals: Informational Handout

The diagnosis of auditory processing disorder (APD) has long been steeped in significant controversy. I have been writing about the serious issues surrounding it for a number of years. Today I am expanding upon the posts I wrote in the past on this subject by adding a link to a handout for parents and professionals succinctly summarizing the current controversies relevant to APD in a 2-page handout. You can download it from my online store for FREE, HERE

What are some key takeaway points from that handout?

Auditory Processing Disorder (APD) is a condition that is often characterized by difficulty processing orally presented information. Reported symptoms include but are not limited to, the increased processing time to respond to questions, requests for frequent repetition of information, difficulty following directions and attending to speech, difficulty keeping up with class discussions, difficulty listening in noisy environments, difficulty maintaining attention on presented tasks,  difficulty remembering instructions and directions or verbally presented information, as well as poor/weak phonemic awareness, reading, spelling, and writing abilities affecting the student’s social and academic performance. Frequent recommendations for the above difficulties include referral to an audiologist once the student is typically 6-7 years of age in order to undergo auditory processing testing.

Prior to referring the students or having them tested for APD, it is important to understand certain facts pertaining to this diagnosis.

Presently the diagnosis of APD is considered to be very controversial due to the following reasons:

1. There’s currently no gold standard for reliably diagnosing APD as a standalone and valid diagnosis.
2. The diagnostic accuracy of the APD test protocols is unknown.
3. There are currently no reliable tests to accurately diagnose APD
   • There’s no clear performance criteria to make the ’APD’ diagnosis because there is no clear consensus concerning the battery of tests that lead to a diagnosis of APD”  (Burkard, 2009, p. vii). Furthermore,  neither the American Academy of Audiology nor the American Speech Language Hearing Association have a clear criteria on what testing to administer, how many standard deviations the client has to be in order to qualify, as well as even who is a good candidate for ‘APD’ testing.” (DeBonis, 2015 pg. 125). Children diagnosed with ‘APD’ are diagnosed purely arbitrary rather than based on a specific widely accepted standard. For example, W. J. Wilson and Arnott (2013)found that “in a sample of records of 150 school-aged children who had completed at least four ‘APD’ tests, rates of diagnosis ranged from 7.3% to 96% depending on the criteria used” (DeBonis, 2015 pg. 125)
   • APD testing involves processing of sounds, words and sentences of language so as a results deficits are linguistic and not auditory in nature. For example, auditory deficits such as Tolerance-Fading Memory (TFM) deficitsare actuallytwo skills that are often found together: “tolerance” – understanding speech in noise (processing of language) and “fading memory “or auditory short-term or working memory.  However, memory is a higher-level cognitive skill rather than a pure auditory entity. Deficits processing language in noisy environments are related to difficulty processing language and not unique auditory entities
4. Testing is typically quite costly and is not covered by numerous insurance companies because there is “insufficient scientific evidence to support the validity of any diagnostic tests and the effectiveness of any treatment for APD.” (AETNA)
5. The meaning of an APD diagnosis is unclear as it does not functionally contribute to a targeted treatment of the student’s deficits.
6. Deficits attributed to APD have consistently been proven to be the result of the student’s language and literacy weaknesses/deficits as reliably identified by high-quality, comprehensive language and literacy speech pathology testing  
7. Because the meaning of an APD diagnosis is unclear, the benefit of intervention cannot be determined.
8. Best type of intervention for APD is unknown.
9. Students diagnosed with APD are typically provided with one of the following 3 options: 
   • Sent back to speech pathologists for non-specific (asked to treat unspecified language deficits) or overly specific treatment (asked to perform auditory interventions)
   • Treated with auditory interventions via use of specific auditory programs or applications (e.g., CAPDOTS [dichotic listening], Fast ForWord®,  Auditory Integration Training (AIT), The Listening Program (LP), Earobics, etc.)
     • The problem with the above is that in 2011 Fey and colleagues conducted a systematic review of 25 journal articles on the efficacy of interventions for school-age children with APD and found no compelling evidence that auditory interventions provided any unique benefit to auditory, language, or academic outcomes for children with diagnoses of APD or language disorder. Concluded that presently, there is no valid evidence that targeting specific processing skills such as auditory discrimination, auditory sequencing, phonological memory, working memory, or rapid serial naming actually improves children’s ‘auditory processing’, language or reading abilities (Fey et al., 2011).  Systematic reviews also found no sign of a reliable effect of Fast ForWord® on reading or on expressive or receptive spoken language
     • In 2012 Bellis and colleagues in a response to Fey and colleagues wrote “…auditory interventions are intended to improve auditory deficits that have been identified by valid tests of auditory function in a targeted, deficit-specific manner.”  “The goal of auditory training is not to improve spoken or written language abilities (AAA, 2010; ASHA 2005a, 2005b).”
     • What is the functionality of improving something that has no bearing on academic abilities?
   • Given accommodations and modifications (e.g., preferential seating, extended testing time, FM system, etc.) in school setting without targeted therapy services.
     1. Lemos et, al, 2009 did a systematic literature review of articles recommending the use of FM systems for APD. They concluded that: “Strong scientific evidence supporting the use of personal FM systems for APD intervention was not found.

However, because research has shown that none of the above options are effective treatments of APD, students with “APD” will continue to significantly struggle in school setting in functional academic areas of listening, speaking, reading and writing.

It is very important to understand that the diagnosis of APD does not inform the evidence-based treatment of the student’s deficits. At best it will result in non-specific vs. targeted in school or private language therapy services. Most students will be given accommodations and modifications because school professionals have no idea of what to do with these students.

What is the evidence-based solution?

A comprehensive language and literacy assessment of deficit areas is mandatory to appropriately determine the student’s linguistically based deficits! Without such assessment, it is impossible to determine which language and literacy goals need to be prioritized and targeted in therapy by the treating professionals.  Assessors have to use psychometrically sound assessments and supplement them with strong clinical tasks in order to appropriately uncover deficit areas. Alone administration of common comprehensive tests such as CASL-2, OWLS-II, RESCA-E, CELF-5, etc. IS NOT ADEQUATE due to the fact that these tests poorly identify language and literacy deficits of students secondary to having weak or unidentified discriminant accuracy (cannot distinguish between language/literacy impaired students and typically developing students). Professionals assessing students with suspected APD need to have strong knowledge of language and literacy in order to create strong assessments which directly target student deficit areas (vs. using a test available to them that may not appropriately identify deficits). Professionals must create functional treatment goals (with a focus on improving academic outcomes) based on language and literacy assessment findings to meaningfully address language and literacy abilities of children with suspected/confirmed “APD”.  

Select References:

1. Beck, D. L., Clarke, J. L., & Moore, D. R. (2016). Contemporary issues in auditory processing disorders: 2016. The Hearing Review, 23(4), 36–40.
2. DeBonis, D. A. (2015) It Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children. American Journal of Audiology. v. 24, 124-136.
3. DeBonis, D. A. (2016) Response to the Letter to the Editor From Iliadou, Sirimanna, and Bamiou Regarding DeBonis (2015). American Journal of Audiology, December, V. 25, 371-374.
4. de Wit, E., Visser-Bochane, M.I., Steenbergen, B., van Dijk, P., van der Schans, C.P., & Luinge, M.R. (2016). Characteristics of Auditory Processing Disorders: A Systematic Review. Journal of Speech, Language, and Hearing Research, 59, 384–413.
5. de Wit E, Steenbergen B, Visser-Bochane MI, et al. Response to the Letter to the Editor From Moncrieff (2017) Regarding de Wit et al. (2016), “Characteristics of Auditory Processing Disorders: A Systematic Review”. Journal of Speech, Language, and Hearing Research : Jslhr. 2018 Jun;61(6):1517-1519.
6. Fey, M. E., Richard, G. J., Geffner, D., Kamhi, A. G., Medwetsky, L., Paul, D., Schooling, T. (2011). Auditory processing disorder and auditory/language interventions: An evidence-based systematic review. Language, Speech and Hearing Services in Schools, 42, 246–264.
7. Hazan, V., Messaoud-Galusi, S., Rosen, S., Nouwens, S., Shakespeare, B. (2009). Speech perception abilities of adults with dyslexia: Is there any evidence for a true deficit?. Journal of Speech, Language, and Hearing Research. 52 1510–1529
8. Iliadou, V., Sirimanna, T., & Bamiou, D.-E. (2016). CAPD is classified in ICD-10 as H93.25 and hearing evaluation—not screening—should be implemented in children with verified communication and/or listening deficits. American Journal of Audiology. v. 25, 368-370
9. Kamhi, A, Vermiglio, A, & Wallach, G (2016) Never-Ending Controversies With CAPD: What Thinking SLPs and Audiologists Know. Presented at ASHA Annual Convention, Philadelphia, PA.
10. Norrix, L. W., & Faux, C. (2019). Comment on Yathiraj & Vanaja (2018), “Criteria to Classify Children as Having Auditory Processing Disorders”. American journal of audiology, 28(1), 144-146.
11. Stoody, T & Cottrell, C (2018) “The Effect of Presentation Level on the SCAN-3 in Children and Adults”. American Journal of Audiology. 27 (2): 238–245.
12. Vermiglio, A (2014) Application of a Medical Definition of the Clinical Entity to (C)APD. North Carolina Speech Language and Hearing Association
13. Vermiglio, A. J. (2014). On the clinical entity in audiology: (Central) auditory processing and speech recognition in noise disorders. Journal of American Academy of Audiology, 25, 904–917.
14. Vermiglio, A. J.  (2018).The gold standard and auditory processing disorder. SIG 6 Perspectives of the ASHA Special Interest Groups, 3(6), 6–17.
15. Wallach, Geraldine (2014) Improving Clinical Practice: A School-Age and School-Based Perspective. Language, Speech, and Hearing Services in Schools. Vol. 45, 127-136
16. Watson, C., Kidd, G. (2009). Associations between auditory abilities, reading, and other language skills in children and adults. Cacace, A., McFarland, D. Controversies in central auditory processing disorder.  218–242 San Diego, CA Plural.
17. Wilson, W.  (2018). Evolving the concept of APD. International Journal of Audiology, 57(4), 240–248.

Useful Resources:

Differential Assessment and Treatment of Processing Disorders in Speech-Language Pathology

Central Auditory Processing Disorder Controversy by Dr. Vermiglio

Auditory Processing Disorder Diagnosis: Science or Pseudoscience? by Tatyana Elleseff