By Jay R. Lucker, Ed.D., CCC-A/SLP, FAAA
In the Spring 2020 issue of Hearing Health magazine, Monica Chiarappi wrote an article about her daughter’s experience with auditory processing disorder. This led her to publish a children’s book titled “The Silent Mockingbird.”
In the article Ms. Chiarappi identifies herself as not being a professional or specialist involved with auditory processing and its disorders, but writes about symptoms and coping strategies that may better be labeled as modifications and accommodations.
While I am sympathetic to her family’s experience, as a professional in this area, what struck me was that parents and others reading this article may walk away with some incorrect ideas and assumptions about auditory processing and its disorders that may lead them to think some children have it.
Below I expand on the information presented, clarify issues, and ensure that readers obtain an appropriate understanding of what auditory processing disorders are really all about, how they are appropriately evaluated, and how specific treatments are identified for the different types of auditory processing disorders (APD) that may be found in a child.
The Role of the Brain
Ms. Chiarappi says her daughter has typical hearing in both ears and that APD is a challenge to diagnose because the various parts of the ear (outer, middle, inner) do not provide information regarding why the child is having problems.
This focuses auditory processing and its disorders on a problem with the ear or the auditory system. This was the belief about auditory processing for many years and was even identified as the factor accounting for APD by professional associations such as the American Speech-Language-Hearing Association, the American Academy of Audiology, and the Educational Audiology Association.
However, years of research on auditory processing, since it was first discussed back in the 1970s and 1980s when the problem was initially seen as an auditory system disorder, have identified that the primary factors contributing to a person having problems processing and, thus, making sense out of what the person hears involves many different parts of the brain, not just the auditory system.
As a certified/licensed audiologist and speech-language pathologist specializing in auditory processing disorders and language processing disorders, since 1981 I have identified and presented at professional conferences how auditory processing involves multiple systems in the brain. Auditory processing involves not only the auditory, cognitive, and language systems, but also the executive functioning/self-regulation/attention system, the emotional regulation and reaction system, and the sensory processing system.
Auditory processing is not specifically related to language processing. However, poor auditory processing can lead to language disorders, but poor language processing can contribute to poor auditory processing. Thus, auditory processing and language processing affect each other.
Cognitive factors include cognitive understanding, memory, and cognitive decision making as well as self-regulation decision making (which involves executive functioning). As such, auditory processing disorders should be pluralized since there are various types of disorders that can lead to processing problems and difficulties making sense out of what we hear.
Making sense out of what the person hears involves many different parts of the brain, not just the auditory system. Credit: @averey/Unsplash
Multiple Neural Systems
Considering this multisystem concept, what is important is to identify how each system is working and how each system may contribute to problems the child may have processing what is heard. For example, one thing often stated about children with APD is that they have difficulties listening in the presence of noise and other auditory distractions. However, think about this. We all have more difficulties listening to someone speaking to us in noisy environments compared with quiet environments. The difference is we have learned how to deal with this problem.
Now consider a child who may have problems filtering out background noise. Is the filtering problem due to poor auditory filtering (an auditory system disorder)? Or to poor attention (an attention/executive functioning problem)? Or to poor decision making (the child has problems deciding what should be the focus of their listening so the primary speaker gets confused with the background noise)? Or to negative emotional reactions (because they cannot understand, the reaction can be negative and strong and the child’s processing system shuts down)?
Merely saying that the child failed tests of understanding speech in noise that are used to evaluate auditory processing is not enough. We must understand which factors are causing the problem of not hearing well in noise so that appropriate accommodations can be made, such as reducing or removing the background noise, along with teaching the child how to listen and choose the appropriate auditory message when more than one message is heard (because speech and noise are two messages). We may also need to provide treatment to reduce the negative emotional reactions.
Several Scenarios
For example, if a child has a significant high frequency hearing loss, the child may not be able to hear the sounds for the consonant “s” which is also representative of plurals in English grammar. Thus, the child may see a group of cats and the speaker may say, “Look at the cat,” pointing to all the cats. But the child does not hear the high frequencies for the phoneme sound of “s” and only processes “Look at the cat” (singular) and becomes confused trying to figure out which cat is being talked about. It could be that frustration emerges as a negative emotion and the child cries or just “shuts down” instead of responding. In this case, a hearing loss is present, and the difficulty processing high frequency information contributes to this child having negative emotional reactions.
Now consider a similar but different child. This second child also has a high frequency hearing loss but doesn’t experience confusion when hearing but instead assumes what they hear is correct, getting into a verbal argument with the speaker. The second child may have self-regulation problems, in that they are not able to reflect on what they are saying compared with what the speaker is trying to explain. So, reducing background noise will not help this second child. Instead what may help is a means for the child to hear the high frequency sounds (such as with a hearing aid), or teaching the child how to interpret the words the child hears to distinguish if there may or may not be a plural or the sound of “s” in what is said. The child also could be taught the regulatory mechanism of asking for clarification rather than becoming argumentative.
Auditory processing disorders can present differently among children. Some may have trouble with phonemic discrimination. Such children have challenges learning to read, spell, and distinguish words, especially new and unfamiliar ones, because of poor abilities to process all the appropriate sounds (phonemes) in words. Credit: @shs521/Unsplash
Consider a third child who has a problem with auditory phonemic discrimination, also called phonemic decoding. One of the many types of auditory processing disorders, this can be present in a child with typical hearing. This child will tend to have challenges learning to read, spell, and distinguish words, especially new and unfamiliar ones, because of poor abilities to process all the appropriate sounds (phonemes) in words. This child may then have issues associating the sounds of the language with the specific symbols we use in reading and spelling. In English and many other languages, these symbols are letters and letter combinations such as “th” for one sound as in the word the or thumb.
There are also auditory processing disorders related to sensory processing difficulties in the form of an intolerance of sounds, especially noise. Some children cannot filter out noise appropriately which results in negative emotional reactions. But removing the noise for these children is not sufficient. We must deal with their negative emotional reactions and, if found, their inability to process sensory information appropriately.
Identification and Evaluation
In the examples above, we have seen problems that may be related to auditory filtering (distractibility), auditory phonemic processing (discriminating), identifying the sounds (extraction or decoding), and associating sounds with the symbols in reading and spelling (auditory phonological integration). What is important is to find professionals who can evaluate and identify the specific types of auditory processing disorders a child may have.
Note again that the word “types” is plural since the professional needs to look at all the types of auditory processing issues that can exist and which systems may be contributing to each of the types.
Auditory processing disorders are not merely a hearing problem. It may have nothing to do with hearing ability. The child may have only one type or many different or related types of APD. Many audiologists do not evaluate auditory processing specifically, so parents need to find one who specializes in APD evaluations and can interpret auditory processing test results in light of evaluations from other professionals, such as psychological assessments of cognitive functions, executive functioning, memory, emotional factors, and behavioral issues. They should also be able to interpret and integrate information from speech-language pathologists, who evaluate language abilities and language processing, and from occupational therapists, who look at sensory processing and sensory integration.
It is the goal of the team of professionals to identify the specific factors that contribute to the child’s inability to process what is heard and to provide interventions and accommodations that can be used in school, at home, and in life, so that a child with APD can learn to successfully overcome any problems they may have in processing what they hear.
Jay R. Lucker, Ed.D., CCC-A/SLP, FAAA, a professor and director of the Five-Year Accelerated Master’s Degree Program in Speech-Language Pathology in the department of communication sciences and disorders, Cathy Hughes School of Communication, Howard University, in Washington, D.C. He also has a practice evaluating and providing consultations for children and adolescents with auditory processing and language processing disorders. He has published numerous professional articles about auditory and language processing and is an internationally recognized expert in these areas and has been invited to present internationally on these topics.
