1) The document discusses auditory processing disorder (APD) and debates whether difficulties on auditory tests are caused by auditory problems or other issues like language impairment. 2) Two options are presented: APD involves higher-level brain abnormalities or problems are not auditory and instead caused by limitations in attention, memory or language. 3) Many interventions for APD lack strong evidence and more research with controls is needed to identify most effective treatments.

1. Auditory processing disorder
(APD) and language
impairment
Dorothy V M Bishop

2. A diagnostic puzzle
• Child reports listening problems but passes hearing
test
• A common complaint: difficulties hearing speech in
noisy situations
• Two possibilities:
1. Auditory problems caused by higher level brain
abnormalities
2. Problem is not auditory at all
Moore, D. R., Rosen, S., Bamiou, D.-E., Campbell, N. G., & Sirimanna, T. (2012).
Evolving concepts of developmental auditory processing disorder (APD): A British
Society of Audiology APD Special Interest Group ‘white paper’. International Journal of
Audiology, (e print). doi: 10.3109/14992027.2012.723143

3. Option #1
• Auditory problems are caused by higher level
brain abnormalities
• This corresponds to idea of Auditory
Processing Disorder, or APD

4. Higher-level auditory processing
• Hearing test assesses ability to detect sounds
– Picks up problems in pathways from ear to auditory nerve
(peripheral hearing)
• Beyond auditory nerve, auditory information
processed in complex set of pathways
• Information about sound features such as pitch,
loudness, duration, spatial location, is extracted
• In adults, damage to higher auditory pathways can
produce problems recognising sounds

5. Auditory processing disorder in
children
• Audiologist assesses skills such as ability to:
– combine information from both ears
– identify speech in noisy background
– understand speech if some auditory cues removed
• If these skills are impaired, this could indicate a
problem with central auditory pathways

6. Three problems
• Accurate assessment requires good information on
how children of different ages perform on auditory
tests – not always available
– E.g. Widely-used SCAN tests not suitable in UK
– British children score low because don’t understand US
accent
• Most tests unsuitable for children below 7 yr old
• Poor performance on auditory tests can arise for
reasons other than auditory problem, e.g. limited
language ability, poor attentional skills
Dawes, P., & Bishop, D. V. M. (2007). The SCAN-C in testing for auditory processing disorder in a
sample of British children. International Journal of Audiology., 46, 780 - 786.

7. Option #2
• Auditory problems are not primary.
• Difficulties with auditory tests arise because of
limitations of attention, memory or language.
Loo, J. H. Y., Bamiou, D.-E., & Rosen, S. (2012). The impacts of language background
and language-related disorders in auditory processing assessment. Journal of Speech,
Language and Hearing Research, 1092-4388_2012_1011-0068. doi: 10.1044/1092-
4388(2012/11-0068)

8. Many children with poor language or
literacy do poorly on APD tests
• Could mean their language/literacy problems are caused by
auditory difficulties
• But could mean that the tests are misleading, and children fail
because they have problems recognising or remembering
words in difficult listening conditions
• Concern among experts that audiologists are diagnosing APD
in children that others would diagnose with dyslexia or SLI
Dawes, P., & Bishop, D. (2010). Psychometric profile of children with auditory processing disorder
(APD) and children with dyslexia. Archives of Disease in Childhood, 95, 432-436.
Ferguson, M. A., Hall, R. L., Riley, A., & Moore, D. R. (2011). Communication, listening, cognitive
and speech perception skills in children with auditory processing disorder (APD) or specific
language impairment (SLI). Journal of Speech Language and Hearing Research, 54(1), 211-227.
doi: 10.1044/1092-4388(2010/09-0167)

9. Does it matter?
Auditory Poor
processing language
#1 disorder skills
Poor Impaired
language performance
#2
skills on APD tests
Yes! Important implications for treatment

10. Key question
• Where a child with language problems does poorly on APD
tests, should we focus on training language skills or auditory
skills?
Bottom line: what is the most effective intervention?
• In general, we don’t know because adequate studies have not
been done
• Experimental studies of training of auditory skills typically find
you can improve performance but the training effect doesn’t
generalise to other skills
Halliday, L. F., Taylor, J. L., Millward, K. E., & Moore, D. R. (2012). Lack of
generalization of auditory learning in typically developing children. Journal of Speech,
Language and Hearing Research, 55(1), 168-181. doi: 10.1044/1092-4388(2011/09-

11. Interventions for APD
• British Society for Audiology guidelines:
– Reviews of different interventions for APD, noting
whether there is any good evidence for them
British Society of Audiology. (2011). An overview of current management of auditory
processing disorder (APD).
http://www.thebsa.org.uk/images/stories/docs/BSA_APD_Management_1Aug11_FINAL_
amended17Oct11.pdf.

12. Assistive listening FM devices
• E.g. wireless devices that amplify distant auditory input (such
as teacher voice) and deliver to the ear of the listener.
BSA noted numerous studies but “Strong evidence supporting use of personal FM
systems for APD intervention was not found.”
Also, studies typically funded by manufacturers who have financial interest.
Need for well-designed, independent, randomised controlled trials.

13. Computerised training:
FastForword
• Intensive training programme designed for children
with specific language impairment.
• Aims to train ability to perceive brief and transient
aspects of sound signals.
• Initial reports encouraging, but later independent
randomised controlled trials on children with SLI failed
to show any difference from controls
Strong, G. K., Torgerson, C. J., Torgerson, D., & Hulme, C. (2010). A systematic meta-
analytic review of evidence for the effectiveness of the ‘Fast ForWord’ language
intervention program. Journal of Child Psychology and Psychiatry, 52(3), 224-235. doi:
10.1111/j.1469-7610.2010.02329.x

14. Computerised training: specific
applications to children with APD
• Review by Loo et al (2010), looking at computerised
interventions including FastForword and Earobics.
• Phonological awareness skills, which are specifically trained,
improved, but not much generalisation to other skills.
• Conclusion: insufficient evidence: randomised control studies
are necessary
Loo, J. H. Y., Bamiou, D.-E., Campbell, N., & Luxon, L. M. (2010). Computer-based
auditory training (CBAT): benefits for children with language- and reading-related
learning difficulties. Developmental Medicine and Child Neurology, 52(8), 708-717.

15. Computerised training:
LiSN and Learn Auditory Training Software
• Specifically designed to remediate spatial processing problems
in children with APD, i.e. problems with sound source location
cues
• Training for 15 mins per day for 12 weeks
• Randomised controlled trial. Results promising but small
sample size, 2/7 children dropped out, and limited data analysis
• No evidence of generalisation to improved language skills
• Need for larger, independent, randomised controlled trials
looking at wider range of outcomes
Cameron, S., & Dillon, H. (2011). Development and evaluation of the LiSN & Learn
auditory training software for deficit-specific remediation of binaural processing deficits in
children: Preliminary findings. Journal of the American Academy of Audiology, 22(10),
678-696. doi: 10.3766/jaaa.22.10.6

16. Auditory integration therapy (AIT)
• This and similar treatments not recommended by BSA
because little or no evidence of efficacy and conflicting
expert opinion.
• Also ethical and safety issues raised in the USA
– Position statement by American Speech-Language Hearing
Association:
– http://www.asha.org/docs/html/TR2004-00260.html

17. Conclusions:
Interventions for APD
• Most APD treatments either have only anecdotal
evidence in support, or uncontrolled studies.
• For explanation of why controls are essential, see:
http://deevybee.blogspot.co.uk/2010/08/three-ways-to-
improve-cognitive-test.html
• Also concern if only evidence comes from those with
financial interests in the intervention
• Urgent need for better research looking at impact on
language and literacy skills

18. Overall conclusion
• Most children presenting with auditory symptoms will
have broader problems with language, literacy,
attention, or social interaction
• Children who present with language problems may
have hidden auditory problems
• Important to have multidisciplinary assessment to
ensure children get full diagnosis and appropriate
recommendations for intervention
Witton, C. (2010). Childhood auditory processing disorder as a developmental disorder:
The case for a multi-professional approach to diagnosis and management. International
Journal of Audiology, 49(2), 83-87. doi: 10.3109/14992020903289808