20Q: Auditory Processing - What You Always Wanted to Know

From the Desk of Ann Kummer

There is often a misconception that an auditory processing disorder (APD) is a language deficit because there isn’t a body of knowledge and research to clearly define it as an entity unto itself.  It does often coexist with other comorbid conditions. This article by Drs. Geffner and Swain, is an effort to help clarify its existence and dispel the myths. 

By way of introduction, Donna Geffner, Ph.D. is a dually licensed and certified speech-language pathologist and audiologist who maintains a private practice after serving for 40 years as a Program Director and Clinical Director for a university in New York. Her practice is in Long Island where she evaluates and treats a population of children and adults with auditory processing disorders. She is the author of 5 books, over 300 articles/ webinars and a former ASHA president.

Deborah Ross Swain, Ed.D. is a speech-language pathologist and Clinical Director and CEO of The Swain Center for Listening, Communicating and Learning in Santa Rosa, California. She specializes in assessment and intervention of processing disorders, learning disabilities and early intervention. She is the author of numerous standardized tests and books. She is a nationally and internationally recognized speaker and a former president of the California Speech-Language-Hearing Association.

This course will address the most common questions that arise about auditory processing disorder regarding how it is identified, evaluated, and treated. The authors will describe the behaviors associated with APD. They will  discuss how APD is identified, including a list of tests for assessment. Finally, they will  describe how APD is managed and treated.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Auditory Processing - What You Always Wanted to Know

Learning Outcomes

After this course, readers will be able to: 

• Describe the behaviors associated with APD
• Discuss how APD is identified and what assessments are used to identify it.
• Describe 2-3 ways to identify APD.

Donna Geffner

Deborah Ross Swain

1. How is auditory processing defined?  

According to the American Speech-Language-Hearing Association (ASHA) and the American Academy of Audiology (AAA), auditory processing is defined as “the efficiency and effectiveness by which the central nervous system utilizes auditory information. It encompasses the perceptible processing of auditory information in the central nervous system and the neurobiological activity that underlies that processing and gives rise to electrophysiological auditory potentials” (ASHA, 2005). In other words, it is the ability of a hearing person to recognize, integrate, and discriminate auditory information to make sense of what is heard, especially in difficult listening conditions.

2. What is an auditory processing disorder (APD)?   

Functionally defined, an auditory processing disorder (APD), sometimes called a central auditory processing disorder (CAPD), is the inability to take in auditory information, integrate it, and discriminate it in a timely manner. Individuals who have APD have particular difficulty processing auditory information in certain conditions, such as in noisy environments. This results in an interference in the awareness of speech sounds and the ability to discern them to ultimately make individual words meaningful (Geffner, 2019). The individual may struggle with listening tasks to understand what was said, which can affect learning and lead to disabilities in higher-order language function. Often one of the first clues seen in a person who is experiencing an auditory processing problem is the look of confusion on the individual’s face or loss of understanding of the message. The person may frequently say “what?” or check with another person to confirm what was said.

APD is known as a “silent disability,” but would cause the person to rear his/her head to request repetition and re-clarification. If any one of these processes is awry, it constitutes a deficit. The ability to take in the message and make it meaningful invokes lexical and linguistic skills and ultimately the language area of the brain to make it meaningful.

The behaviors often seen in children and adults with APD are:

• Poor listening skills
• Poor speech recognition in noise  
• Difficulty learning through the auditory channel
• Difficulty following auditory instructions
• Weakened short-term memory span
• Difficulty understanding speech in the presence of noise, reverberant environments, or competing stimuli 
• Frequently asking “what?” or needing repetition
• Misunderstanding what is said or “mishearing”
• Difficulty understanding speech when it is muffled or distorted or in an environment where it is hard to hear
• Poor auditory attention, difficulty staying focused and feeling fatigued (listening is an active skill)
• Easily distracted by outside noises, hearing the background as loud or louder than the foreground (a figure-ground skill)
• Weak auditory integration and problems with sound blending, identifying sounds in words, and phonic skills
• Delayed response in answering
• Reduced tolerance for loud sounds or hypersensitivity to noise
• Inability to detect small differences in acoustic stimuli (loudness, pitch)
• Trouble understanding rapid speech
• Problems with spelling, reading, and writing
• Inability to detect subtle differences in tone of voice that convey meaning (i.e., sarcasm, emotions, etc.)
• Weak singing skills and poor pitch identification
• Tinnitus
• Academic difficulties, trouble taking notes and listening at the same time
• Inability to understand lyrics in a song 
• Difficulty understanding people with foreign language/accents (Geffner, 2019).

There are variations of APD, such as amblyaudia, which is a neural integration disorder. Amblyaudia was described by Moncrieff and Wertz (2008) as an abnormal asymmetry between ears during a binaural integration task. This is diagnosed when there is a stable interaural asymmetry across two or more tests in dichotic listening. Another form of APD is an auditory spatial processing disorder. This is characterized by the use of spatial hearing to integrate signals that arrive at the two ears from sound sources that vary in location and in space. The auditory system needs to integrate the two signals in a mechanism that allows the difference between ears to adjust in time of arrival and intensity (Cameron, et al., 2014).

There are several tests that evaluate these types of deficits to arrive at a diagnosis. Since an auditory processing disorder contains several different components, it is best to determine the type and severity of the deficiency to provide a comprehensive profile and treatment plan.

3. What is the difference between APD and CAPD?

The terms APD and CAPD are often used interchangeably. However, the two terms reflect the controversy of whether the auditory processing disorder lies within the central auditory system or is the result of a breakdown in the entire auditory mechanism. Once the auditory stimulus enters the ear, it transforms from an acoustic signal to a lexical and then a linguistic signal to be interpreted by the brain. This process is a bottom-up process; thus, there is a need for a multimodality function and the involvement of the entire auditory system. Other audiologists restrict the term to the central auditory system only- that is the system beyond the peripheral one, since an auditory processing disorder does not involve the outer, middle, or inner ear or the lower brain stem. The position used by ASHA (2005a) is that APD is not a hearing loss, but instead it is a loss of hearing perception. For this disorder to be totally limited to the central auditory channel is not tenable, neurophysiologically (ASHA, 2005a). Further, a disorder could be due to damage to the auditory nerves from head trauma, complications or middle ear infections, lead poisoning, long-standing OME, and other causes. How auditory processing takes place in the central nervous system is an integrative process and involves several modalities and systems. 

The normal auditory system has the capability to perceive auditory stimuli varying from simple (tones), to complex  (i.e., music, degraded speech, etc.) both in quiet and noise. Humans can process various stimuli in the environment at the same time. The key dimensions of auditory stimuli are temporal, spatial, spectral and intensity (Rawool, 2016). In support of including the entire auditory mechanism in the processing of auditory information is the fact that auditory processing impacts listening which impacts learning and social functioning, the ultimate result of the entire central nervous system interacting with other neural networks in our integrative brain.

4. Who determines the diagnosis?

A diagnosis of APD should be made by an audiologist trained in this area, using behavioral and electrophysiological measures, observation, and case history. Seeking other areas of learning and perception and evaluating them may be useful in achieving a more complete profile of the individual because APD rarely occurs in isolation. According to the Scope of Practice of ASHA (2013, 2018, ASHA,2005a. 2005b), it is within the role and responsibility of audiologists to diagnose auditory processing disorders. However, there are other professionals who play a role in the overall assessment; namely, speech-language pathologists (SLPs) and psychologists.  "Audiologists provide patient-centered care in the prevention, identification, diagnosis, and evidence-based intervention and treatment of hearing, balance, and other related disorders for people of all ages. Hearing, balance, and other related disorders are complex, with medical, psychological, physical, social, educational, and employment implications. Treatment services require audiologists to know existing and emerging technologies, intervention strategies, and interpersonal skills to counsel and guide individuals and their family members through the (re)habilitative process. Audiologists provide professional and personalized services to minimize the negative impact of these disorders, leading to improved outcomes and quality of life (ASHA, 2018)."

Audiologists provide comprehensive audiologic (re)habilitation services for individuals and their families across the lifespan who are experiencing hearing, balance, or other related disorders (e.g., tinnitus and auditory processing disorder). Audiology is a dynamic profession, and the fact that the audiology scope of practice overlaps with those of other professionals is a reality in rapidly changing health care, education, industrial, and other environments. Hence, audiologists in various settings work collaboratively with other academic and/or health care professionals to make appropriate decisions for the benefit of individuals with hearing, balance, and other related disorders. This is known as interprofessional collaborative practice (IPP) and is defined as “members or students of two or more professions associated with health or social care, engaged in learning with, from and about each other” (Craddock, et al., 2006, p. 237).

It has become customary for SLPs to participate in evaluating auditory processing disorders in individuals since they are often the first person of contact and the one to provide the management and intervention. There are speech-language and listening tools available to them to contribute information to the diagnosis.

Another professional who contributes information regarding auditory processing by virtue of their testing measurements is the psychologist. Such tests as the Wechsler WISC-V (2014), WRAMl-3 (2021), WIPPSI( 2002), and Wechsler Oral Language (WISC-V) provide evidence for auditory processing problems, namely because these tests tap into listening skills and phonological processing.  

5. What is the hierarchy of auditory skills?

Auditory processing actually involves not only the auditory system but also language and cognitive processes. As a speech signal is presented to the brain, the primary task of the auditory cortex is to analyze or decode the complicated acoustic patterns to permit recognition of the words that will encode a linguistic message (Broadbeck, Prosecco & Simon, 2018). The auditory signal is brief before it engages phonetic, phonemic, and lexical information. Erber (1985) introduced a hierarchical model that is still relevant for our contemporary understanding of how we process input information through the auditory system. The process involves four steps that include: 1) detection; 2) discrimination; 3) identification and 4) comprehension.

Detection is the ability to hear a signal. This refers to hearing acuity and is the work of the ear and its ability to detect sound. Hearing acuity should be assessed when auditory processing is thought to be problematic.

Discrimination is the brain’s ability to automatically recognize differences between similar sounding sounds or words. Discrimination is fundamental to the understanding of input information. If one does not efficiently and effectively understand the spoken message, there will be huge implications for listening, learning, and communicating.

Identification is synonymous with association. For example, if the speaker says the word “pen” and the listener hears “pan,” the incorrect association will result and can then manifest in mishearing and misunderstanding what has been said. Impairment with discrimination is a common complaint among individuals experiencing auditory processing problems. Discrimination problems are most likely exacerbated by competing noise or acoustically incompetent environments such as restaurants or gymnasiums.

Comprehension is the brain's ability to understand the meaning of the words being said in order to understand the spoken message. Comprehension deficits can interfere with one’s ability to understand and follow directions, understand conversations, and understand verbal input.

Auditory processing is complex because of the pansensory nature of its functions. Medwetsky (Ross-Swain & Medwetsky, 2021) describes the integration of the auditory signal, spoken language, and information processing for effective processing to take place. This would involve the decoding of words, understanding the language that is used, and engaging attentional and focusing properties for maintaining engagement in the processing of input information.

6. What is the assessment conducted by the SLP?

Speech-language pathologists play an integral role in the assessment of children who are suspected of having an auditory processing disorder or auditory skill weaknesses. The processing of input information through the auditory modality involves several skills that the SLP can assess and measure. These same skills affect communication, learning, social interactions, executive function, attention, and focusing. According to Ross-Swain (2019) the following skills should be assessed:

• Sound and word perception and discrimination
• Auditory association and receptive vocabulary
• Immediate auditory memory
• Auditory working memory
• Phonological processing
• Auditory closure
• Auditory comprehension
• Auditory conceptual function
• Understanding and following directions
• Auditory perception under degraded listening conditions
• Social-pragmatic abilities
• Metalinguistic abilities

The SLP is charged with selecting the most appropriate battery of standardized tests that can provide the best information for determining appropriate interventions and accommodations to maximize learning, communication, and social success as well as provide information that can explain a child’s current struggles with learning, communication, and social interactions. Given the significant number of standardized tests available for assessing processing skills the following battery of tests may be considered:

1. The Listening Inventory (Geffner & Ross-Swain, 2006)
2. SCAN-3:C: A Test for APDs in Children-Revised (Keith, 2000; Keith, 2009a; 2009b)
3. Auditory Skills Assessment (Geffner & Goldman, 2010)
4. The Auditory Phoneme Sequencing Test (Ross-Swain & Aten, 2015)
5. The Lindamood Auditory Conceptualization Test-Third Edition (Lindamood & Lindamood, 2004)
6. The Token Test for Children-Second Edition (McGhee et al., 2007)
7. The Comprehensive Test of Phonological Processing (Wagner et al., 2013)
8. The Auditory Processing Abilities Test (Ross-Swain & Long, 2004)
9. The Test of Auditory Processing Skills-Fourth Edition (Martin, Brownell & Hamaguchi, 2018)
10. The Receptive-Expressive Social Communication Assessment-Elementary (Hamaguchi & Ross-Swain, 2015)

7. How early can we test for CAPD/APD?   

It is commonplace to think of testing younger children for language, articulation, and reading.  As such, we currently test children around the age of 3 ½.  Previously, the age acceptable to test for auditory processing disorders was 7, because tests below that age were not available.  For fear that the testing would not be reliable, many school administrators denied access to testing for younger children, even when the child presented with red flags. As a result, many decision-makers of special education waited for the child to turn 7 or in some cases age 8 before they would allow APD testing. Other personnel attending IEP meetings, would abstain from requesting such tests because a) they didn’t believe in the tests, b) they couldn’t treat it, c) they didn’t understand it, or d) they didn’t have the personnel to manage it.

Tests with norms for younger children include the following: SCAN-3C (Keith, 2009) starts at age 5; Staggered Spondaic Word Test (Katz 1986) starts at age 5; Phonemic Synthesis Picture Test (Katz, 2000) starts at age 4; Phonological and Print Awareness Scale starts at age 3 (Williams, 2020); and Auditory Skills Assessment (Geffner, Goldman, 2000) normed down to age 3 ½. The latter test was designed to identify younger children who are at risk for APD, by virtue of their response to speech in noise and speech mimicry. It was determined that for children at risk, their ability to discriminate words in noise was an identifying factor. It was later found that those children who couldn’t tolerate the “din” of the classroom were at risk for reading disorders (Kraus, 2015). Further, the intervention that becomes available to these young children can not only resolve, or at least, improve the deficiencies, but it can also promote better hearing, learning, reading, listening, and processing at a time when neuroplasticity is at its greatest.

Neuroplasticity refers to the ability of the nervous system to change with physiological and behavioral consequences. Such changes can occur at the molecular, cellular, and cognitive levels. Neural connections, chemical changes, and synapses can change. Cognitive levels can change as a result of intense training. We know more about the neurodevelopment of the brain, the advantages of stimulation, exposure, and intervention to grow dendritic connection and arborization of neurons.  We know there are critical periods when functions can be reversed by introducing normal or enriched sensory experiences. For instance, the critical period for language development appears to last until 7 years of age. Deaf children introduced to sound and language after that period will show abnormal processing of sound. There is also a critical period for non-speech stimuli, such as music. Early music training before the age of 8 years is more likely to show absolute pitch compared to those with later training after the age of 8 (Deutsch, Henthorn, Marv, 2016).  We know that if you don’t use it, you lose it. Also, the younger the brain the more plastic it is.

Thus, if we know what young children are supposed to do and if there is a cadre of children not doing it, then they need to be identified and brought for early intervention for the purpose of remediation at a time when the brain is most malleable.

8. Who treats APD?

Treatment interventions for auditory processing disorders can be provided by either an SLP or an audiologist. Regardless of who provides the treatment, the initial evaluation will be used to determine therapy goals and objectives and the type of intervention that will be most beneficial. Geffner and Ross-Swain (2013, 2019) offer sections on evidence-based interventions for treating auditory processing disorders. Utilizing current cognitive science research (Burns, 2019) and evidence-based interventions, audiologists and SLPs can provide effective and beneficial therapeutic programs and management strategies that can result in improved listening, communicating, and learning. The therapy should be consistent, intensive, and ecologically valid to result in the necessary neuroplasticity for effective changes.

9. What behaviors are seen at home and at school?

Effective and efficient processing of input information through the auditory modality provides the foundation for listening, communicating, and learning. Weaknesses with processing skills typically present as problems with learning achievement and success as reflected by learning struggles, poor grades, and the inability to meet grade and age level expectations. Remember that we don’t “see” processing, but rather behaviors that can be interpreted as “red flags” for processing disorders. Red flags include (Geffner & Ross-Swain, 2019):

• Frequently saying “huh” or “what
• Misunderstands or misinterprets what is being said
• Needs input information repeated or rephrased
• Is easily distracted by noise
• Has difficulty understanding and following age-appropriate directions
• Has difficulty following conversations
• Has difficulty listening with background noise
• Mishears words
• Has difficulty with immediate memory
• Has difficulty retaining auditory information
• Has difficulty with sound-symbol correspondence and blending sounds into words

10. What are the risk factors for an auditory processing disorder?

Causes and risk factors for APD may include the following (Bamiou, Musiek, & Luxon, 2001; Chermak & Musiek, 2011):

• Age-related changes in central nervous system function
• Genetic determinants
• Neurological disorder, disease, or damage
  • Brain injury (e.g., head trauma, meningitis)
  • Cerebrovascular disorder (e.g., stroke)
  • Degenerative diseases (e.g., multiple sclerosis)
  • Exposure to neurotoxins (e.g., heavy metals, organic solvents)
  • Lesions of the central nervous system (CNS)
  • Seizure disorders
• Neuro-maturational delay secondary to deafness and auditory deprivation
• Otologic disorder, disease, or injury (e.g., auditory deprivation secondary to recurrent otitis media)
• Prenatal/neonatal factors, such as anoxia/hypoxia, cytomegalovirus (CMV), or hyperbilirubinemia
  • Low birth weight
  • Prematurity
  • Prenatal drug exposure

11. How important is sound enhancement?           

A child with poor vision, who cannot see the blackboard, is fitted with eyeglasses.  In the same way, the child with hearing loss should be fitted with hearing aids and/or an FM (frequency modulated) system.  Although children with APD have a loss of hearing perception (rather than hearing loss), amplification of the auditory signal helps them to perceive more clearly. Sound amplification helps them to hear the signal louder than the background noise. In other words, it enhances the signal-to-noise ratio.  For children in a special education classroom, it is best to have the signal-to-noise ratio (SNR) at +35dBHL (S/N+35), that is the signal should be 35dBHL louder than the background noise.

An FM system is a wireless communication technology with two-way radios and wireless headsets. This system amplifies and optimizes speech intelligibility in situations where distance, noise, and reverberation interfere with communication, by improving the SNR. It consists of a microphone and a transmitter which picks up the voice at the speaker’s mouth and transmits it through the radio waves to the FM receiver worn as a headset, earbuds, hearing aid, or speaker.

There are many types of FM systems, including a personal FM system worn at the ear level, a wireless system coupled with hearing aids, sound field speakers in the classroom, an infrared induction loop, and a hard-wired system. All systems should improve speech recognition in noise for individuals with normal hearing and with hearing loss. Tharpe and Wilkerson (2005) found that school-aged children with minimal to mild hearing loss benefitted from using FM systems in speech perception. It was further revealed that on average, an 8.3 dB SNR advantage was obtained in the FM condition.

Today, with Bluetooth technology, the use of low gain hearing aids is gaining attention and success. Why not place a low gain hearing aid on a youngster to enhance speech, limit noise in the background, and provide ease of use with the microphone and receiver within the same unit? Thus, no need to hand over a microphone to the teacher, often an embarrassing moment for a youngster. Further, many hearing aids come with remote microphones, mimicking the FM system, but sleeker and less obvious. Such Bluetooth-accessible hearing aids can be in sync with one’s iPhone and stream phone calls using iPhone apps and music from the iPhone to the ears of the listener. The student can even download the app for the hearing aid and have independent use of the aids for adjustments, volume control, and settings.

If children with normal hearing and auditory perception can benefit from  +10dBHL SNR and children with high risk for hearing loss or APD require a +12-20 dBHL SNR, then enhancement improves the listening environments for all.

Frederichs & Frederichs (2005) found that use of a personal system after a full year of wear, students improved in their discrimination scores, as shown on electrophysical measures. Thus, there were physiological changes that occur in the auditory cortex after such use, accelerating the neuro-maturation process when using the FM system. In addition, Frederichs  & Frederichs (2005) reported that after consistent use, parents reported improvement in overall school performance and conduct. Finally, Hornickel and colleagues (2012) reported that assistive listening devices drive neuroplasticity in children with dyslexia.

12. What are recommended treatments that are deficit specific?

An evaluation of auditory processing should determine what aspect of processing is deficient because one child may exhibit poor figure-ground listening skills, another may exhibit an integration problem, and another may have difficulty with temporal processing. After a determination is made as to the specific nature of the deficit, then goals and strategies for remediation can ensue.

Auditory training can take a variety of approaches. For example, if one has difficulty with discrimination, especially in noise, then a speech-in-noise training program will be helpful. That is often handled with background noise and a speaker or figure in the forefront-giving directions or reading aloud. The child is trained to listen as the noise increases in volume and interest.

For the child who is struggling with reading and phonological awareness, then a phonological awareness program such as the Phonemic Synthesis Program (Katz, 2019) is appropriate because it helps the child identify individual phonemes and make acoustic judgments between vowels and consonants.  Other programs that address phonological awareness with phoneme identification are seen in Table 1. HearBuilders from SuperDuperinc.com has one program: Phonological Awareness which is helpful. It also provides noise in the background to address the aspects of figure-ground training as well. 

If there is a problem in integration, as noted on dichotic word or dichotic sentence tests, then dichotic listening training would be useful. Dichotic Interaural Intensity Difference (DIID) program (Weihing & Musiek, 2019) addresses dichotic listening so that the stimuli are enhanced to the weaker ear, with the intention to establish equal potentiality between both ears.  The ARIA (Moncreif & Wertz, 2008) is also utilized for binaural hearing whereby one ear is stronger than the other in an attempt to administer stimuli dichotically, while favoring the weaker ear.  Zoo Caper from Acoustic Pioneer is another game for dichotic listening, administered as an app on an iPhone.

Interhemispheric transfer – an integration skill deficit can be addressed with movement games such as “Bop-It” or “Loopz.”  Pattern recognition can be addressed with an App called “Drums Challenge,” or “Simon” whereby the youngster must follow the auditory pattern at the same frequency and time.  Prosodic training can be accomplished by the app “Blob Chorus,” which asks the youngster to discern different pitches with the model (King) Blob.  Prosody training can be accommodated with the Hamaguchi App "Between the Lines" whereby the actor takes on an expression that conveys an emotion, and the subject must guess at the emotion based on the suprasegmentals of the utterance.

Fast Forward is a web-based program that is designed to help children with language-based learning disabilities and enhance cognitive skills  Since its inception in 1997, there have been four language cognitive programs designed by neuroscientists to enhance the underlying cognitive skills of attention, memory, and oral language (Burn, 2019).

Another program that is intensive and shows evidence-based positive results is Cap Dots (Lau, 2019), an online therapy program for intensive binaural integration and binaural separation deficits. According to its developer, it significantly improves dichotic listening and figure-ground discrimination. It requires attention to the program 5 days a week for 30 minutes. In each session, the listener is presented with dichotic materials which he/she must report to an administrator who sits alongside the student. 

Table 1. Phonological processing programs for reading.

13. Is phonological awareness training helpful in APD?

Children with APD often have difficulty with the acquisition and mastery of written language and may even have a diagnosis of dyslexia. Phonological awareness involves the detection, recognition, and manipulation of sounds in syllables and words. Phonological awareness is also a component of a larger phonological processing system used for speaking and listening. Researchers agree that phonological awareness is a metalinguistic skill that requires conscious awareness on the structure of language (Gillon, 2004), whereas other phonological awareness skills of attending to speech, discriminating sounds, and holding sounds in immediate memory do not require conscious attention. Therefore, general listening skills are typically a part of phonological awareness interventions.

Phonological awareness is typically associated with literacy training and performed by the SLP. Evidence-based programs include: Lindamood-Bell Learning Processes (https://ganderpublishing.com/pages/lips-overview, Slingerland (https:www.Slingerland Literacy Institute, WA), Orton-Gillingham(info@ortonacademy.org, 1995) and Barton (www.BartonReading.com). The research supporting the efficacy of these programs is based on specific delivery models. That is, therapy is typically individually delivered and in-person, sessions are consistent, multisensory, and the duration of the sessions is 45-50 minutes.

Phonological awareness interventions can be very effective in improving speech, listening comprehension, and literacy weaknesses (Kurtz, 2010). Phonological awareness skills can be improved through a variety of activities that expose children to the basics of sound structure of language and help their brains automatically recognize, identify and manipulate various sounds and structures. One such program is the Katz Phonemic Awareness Program (Katz, 2019). The outcome of successful phonological awareness training is improved listening, communicating, learning, and literacy skills (Virginia Department of Education, 1998).

14. What do audiologists do in auditory training?

Auditory training has traditionally been aligned with speech-language pathologists. However, it behooves the audiologist to engage in rehabilitation for children and adults to improve their auditory processing skills. We know that there is efficacy in auditory training. First, audiologists should be responsible for developing and fitting sound enhancement devices on individuals in need.  They should advise educators, teachers, and administrators on using FM systems, hearing aids, or sound enhancement systems in the classroom. They can advise on the use of telecoil loops which can be installed in auditoriums for better hearing through instruments. They should teach self-advocacy skills and compensatory strategies to limit the restrictions imposed by having a weak processing system, such as where to sit in a restaurant to avoid noise, how to attenuate noise in the environment, how to adjust to wearing and troubleshooting hearing aids, how to ask for clarification, how to position oneself in a classroom and select the best seat, and when to ask for clarification and repetition.  There is a process in processing the sound system through the auditory channel; namely, to provide adequate discrimination, binaural integration - to listen with integrity and precision with both ears - and temporal processing - to listen in a timely manner. There are higher-order cognitive-communicative skills in that process such as phonological processing, comprehension, and interpretation of the information. When the latter part of the processing chain involves the cognitive, linguistic, and interpretation of the auditory signal, then the SLP participates in enhancing those skills and bringing them into focus for remediation. Further, attention and memory interact in the continuum of the process. Some clinicians work on the bottom-up theory such as training the skills directly, while others work on the bottom-down theory based on metacognitive-metalinguistic skills.

The audiologist has a responsibility to ensure that clear speech is heard and that the environment ensures that. Adding visual cues, reducing extraneous noise in the environment, improving speaker-listener distance, and reducing reverberation in the room, all contribute to improving the quality of the communication. One should encourage “clear speech,” as Ferre discusses (2019). It often means that the speaker needs to reduce rate, enunciate speech, use visuals or other cues, rephrase, use easier vocabulary, “look then listen,” and check for understanding.  It is known that children with speech-language impairment or APD, or with academic challenges, need to hear speech at least at an SNR level of +2-15dBHL louder than the noise. This level is higher than what would be necessary for normal children.  For most listeners, 3-6 ft from the source of sound is optimal with speech recognition decreasing beyond that critical distance (Boothroyd, 2004). One of the goals the audiologist can do is to ensure such a distance and be sure that rooms are conducive to hearing clearly. The audiologist can also help establish a better listening environment and help the student recognize speech under various listening conditions (noise, reverberation, etc.).

Audiologists can also work on interhemispheric transfer and integration, namely dichotic listening utilizing the soundproof booth. Such programs as the Dichotic Interaural Intensity Difference (DIID) (Weihing and Musiek, 2013) and Auditory Rehabilitation for Interaural Asymmetry (ARIA) (Moncrief and Wertz, 2008),  which require alteration of the signal in one ear, can most efficiently be carried out in a soundproof booth with an audiologist. An audiologist can carry out games and activities for auditory, phonological, and linguistic processing.  There are simple rhyming,  discrimination, and phonic games available for home use. Localization games can be played (Marco Polo, Telephone game, Blind Man’s Bluff). Board games such as Password, Taboo, and Scattergories are beneficial in building vocabulary and labeling word associations. The audiologist can also encourage and teach lip reading, as such cues help the person clarify what was heard by looking at the lips and face. 

Speech-language pathologists can and should work collaboratively to enhance the training of those individuals whose auditory processing skills are impaired. Interprofessional collaboration is encouraged.

15. How can we work with children who we identify early (3-6 yrs)?

We should treat young children with auditory processing disorders as if they are hearing impaired. That would involve exposing them to clear sounds, clear speech, limiting the aversive environmental noise, stimulating them with songs and nursery rhymes, and exposing them to language.

To work with a young population, the following areas should be addressed: sound identification, sound matching, sound discrimination, sound-letter association, sound blending, and phonological awareness. Here are some recommendations:

• Provide sound stimulation in their home.
• Limit background noise and ensure a quiet environment where the child can process language.
• Provide stimulation of sounds in the environment, and play sound games.
• Utilize apps that provide different noises or activities to enhance overall attention to auditory information.
• Establish auditory vigilance by having the child listen for target words.
• Play games like ”Musical Chairs,” Marco Polo, Simon Says, and Bop it to enhance auditory attention and establish listening and movement coordination.
• Use a musical instrument to help the child use visual cues with the sound.

To prepare the child for early literacy skills, the Phonemic Synthesis Program (Katz, 2013 ) can be used to help the child to differentiate between phonemes and learn to discriminate between two consonants. Learning "same/different" in phonemes is an important concept and can be accomplished with different recordings, apps, and games. Children with early phonemic awareness problems often have trouble learning to read, and early phoneme awareness training is needed to prevent problems of later reading deficits. When the child learns to match sounds - both initial and final, to blend sounds into words, and to recognize whole words and break them into their component parts, he/she is acquiring early reading skills. Other reading component skills involve having the child segment a word into its component parts (sound segmentation).  Children should be taught and be exposed to rhyming, a skill obtainable by the age of 4, and learn to associate letters with their corresponding sounds. All these skills enhance reading proficiency. A child who can associate sounds with letters and blend letters together to form a word and recognize that word on paper can begin to learn to read. Games, whereby the child identifies two words as being same or different, are therapeutic. There are apps and CD’s available to train early listening skills, such as HearBuilder-Phonological Awareness (SuperDuperinc.com), Acoustic Pioneer (Zoo Capers), Earobics (out of print, but available on Ebay), Pocket Phonics, Pocket Phonics Sentences, Smarty Ears, Sounds Abound (LinguiSystems), Hear Coach (Starkey), and Developing Auditory Figure-Ground Skills (by Foundations Developmental House LLC). Other programs for stimulation are: What’s that Sound? (By Different Roads to Learning), The Rehabilitation Game (Oticon), Oz Phonics 1 (DSP Learning, PTY Ltd), Sound matching, Discrimination and Sound Awareness (Schuler, 2019).

16. What are the comorbid conditions associated with APD?

Comorbid conditions can confound assessment and treatment of APD. The most common comorbid condition is attention deficit hyperactive disorder (ADHD). One study found that 84% of children in a cohort diagnosed with auditory processing disorder demonstrated behaviors consistent with ADHD, 83% had a speech and language disorder, and 47% had a reading disorder (DiMaggio & Geffner, 2003).

Another study found that 72% of children with APD in their cohort experienced difficulty with speech, language, and reading. Only 4% of the population of individuals studied had an isolated auditory processing disorder (Sharma, Purdy, and Kelly, 2009).

Common other comorbidities include:

• Social-pragmatic disorder
• Specific language impairment (SLI)
• Dyslexia
• Learning disabilities
• Non-verbal learning disabilities
• Sensory processing disorder
• Autism spectrum disorder
• Neurobiological disorders (e.g., anxiety, obsessive-compulsive disorder, depression, etc.)

Because of the pansensory nature of APD, a comprehensive multidisciplinary approach to assessment and treatment should be used whenever possible (Ross-Swain & Geffner, 2019; Bellis, 2003a; Bellis, 2007).

17. What are the multisensory interventions for APD?

There are multimodality/multisensory programs to enhance the entire body movement and rhythmicity such as Interactive Metronome. Interactive Metronome is a program designed to build body rhythmicity and integration skills. It is an evidence-based program whereby the client synchronizes his/her actions to the beat of a metronome (Swain et al., 2013). There are several types of triggering devices from buttons the client will press to foot tap mats and even gloves. The client synchronizes his/her actions to the beat of a metronome called for in the game of their provider. It is reported to improve cognition, attention, focus, memory, speech/language, executive function, comprehension as well as motor and sensory skills (Interactive Metronome).    

Fast Forward is a group of web-based programs that are designed to work for children with language-based learning disabilities (www.scilearn.com/products). It has been shown to enhance cognitive skills  Since its inception in 1997, there have been four language cognitive programs designed by neuroscientists to enhance the underlying cognitive skills of attention, and memory and to build oral language. These are intense interventions that adapt to each keystroke a participant makes. In addition to language programs, there are reading programs that continue to build cognitive skills. The programs are based on theories of neuroplasticity and have proven results as cited by many published independent sources in reputable journals.

There is Cogmed for memory training and non-medication intervention (www.cogmed.com).  It is an intensive computerized intervention to correct defects in working memory. Brain scan studies back the efficacy of the program. There is a training aide and a Cogmed coach to help motivate and direct users. They aim to improve academics, attention, and daily living resulting in plastic changes to the brain after training.  It is also recommended for patients suffering from brain insults.

There are other programs: PACE (Processing and Cognitive Enhancement), Integrated Listening Systems (ILS), Ear-Brain Program, Brain Balance, and Sound Scaper for Spatial Processing Disorders. For a complete description of these programs, please see Auditory Processing Disorders: Identification, Management and Treatment (2019).

18. What is the relationship of APD to reading and what is its impact on language?

Neurological research over the last ten years has revealed information regarding the relationship between APD and reading disorders.  The brains of adults and students with dyslexia exhibit noncellular collections in the language regions of the left hemisphere, the same ectopic collections that cause temporal auditory processing deficits. Children with reading impairment show deficits in speech-in-noise perception compared with their typically developing peers (Bradlow et al., 2003), along with temporal discrimination problems which are predictive of reading deficits and language delays. Functional MRI (fMRI) studies of children and adults with dyslexia revealed that the cortical neurological structures in the left hemisphere that support language learning and working memory also support reading (Temple, 2002). fMRI studies further indicate that as children learn to read, they rely on temporal/parietal /occipital regions of the left hemisphere that underlie phonological awareness and other aspects of oral language comprehension (Shaywitz & Shaywitz, 2004). It is thought that impaired slow auditory sampling underlies dyslexia.  Thus, disruptive timing of auditory processing particularly in the range relevant to phonemes is a core deficit in dyslexia. As Burns (2013) indicated, the genetic, longitudinal, and electrophysical studies are beginning to point to at least a partial causative relationship. It is further indicated that children with impaired perception and neurophysiological encoding of speech sounds with learning problems can be improved with training incorporating acoustic cue enhancements (Kraus, 2001). Several research studies using auditory processing intervention in language and reading impaired children have shown improvements in several cognitive domains, mostly in reading after treatment directed at increasing auditory processing speed and speech-sound discrimination (Burns, 2013).    

19. What are the educational implications for a child with APD?

Children with APD can be at a great disadvantage in classrooms, particularly if the processing skill weaknesses have not been identified or diagnosed. This “at-risk” population will typically struggle with listening, communicating, learning, socially interacting, and engaging with peers (Ross-Swain and Geffner, 2021). The day-to-day struggles for these children include:

• Difficulty understanding age-appropriate instructions
• Difficulty understanding discussions, conversations, and social interactions
• Difficulty acquiring and mastering written language
• Difficulty understanding and mastering new concepts, vocabulary, and instructional methods
• Difficulty retaining information and learning
• Difficulty advancing in levels of learning

With these ongoing struggles the associated implications include the following (Ross-Swain & Geffner, 2021):

• Anxiety
• Depression
• Embarrassment
• Shame
• Loss of confidence and joy for learning
• Erosion of self-esteem
• Social isolation and bullying
• Frustration, anger, and meltdowns

Many children with processing disorders do not fall at or below the 7th percentile to receive intervention services through the public school system. However, that does not preclude them from having the effects of processing impairments acknowledged and affirmed. APD is not something that can be “seen.” Instead, professionals, parents, and educators will notice certain behaviors that reflect underlying weaknesses in listening, communicating, and learning.

20. What are the social-emotional risks for a child with APD?

Children with APD typically struggle with learning and social skills which can affect their emotional well-being. They don’t just experience a brief struggle with reading, spelling, or math and then move on. These children struggle daily to learn and master what their peers seemingly master quickly. For some, the struggles persist grade after grade with numerous tutoring sessions, speech-language sessions, resource specialist provider (RSP) sessions, and prolonged homework sessions. These well-intentioned efforts often do not result in measurable improvement in struggles or academic achievement. The ongoing lack of success can result in emotional fallout and create havoc (Ross-Swain & Fogel-Schneider, 2019).

For school-aged children, there are two types of success: academic and social. Children with APD are at risk of falling short of these key success areas. They can experience daily embarrassment and shame when they cannot learn or master what their peers can. They anticipate failure rather than success when their learning experiences have been negative and have occurred over time (Ross-Swain & Fogel-Schneider, 2019).

Children with APD can have difficulty developing age-appropriate social skills. The breakdown in social skills may be due to difficulty in many areas, including understanding and remembering the “rules” of social interaction, understanding what peers are saying, and reading facial expressions. They may also be self-conscious due to previous experiences associated with APD. Emotional and social risk factors can include:

• Ongoing embarrassment and shame
• Negative self-talk
• Low self-esteem and eroding confidence
• Loss of joy of learning
• Social isolation, teasing, bullying
• Feeling defeated
• Educational trauma
• Educational defeat
• Acting out
• Defiance and oppositional behavior
• Anxiety, depression, physical ailments (e.g., headaches, stomach aches, etc.)

Social and emotional problems associated with APD can disrupt learning and home environments and erode a child’s desire to learn. Through careful assessment and intervention, the social-emotional challenges can be minimized to maximize a child's success. Clinicians should not forget to recognize these factors as they work with the individual and his/her family. 

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