Debonis 2008

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Auditory Processing Disorders: An Update for Speech-Language Pathologists
Article in American Journal of Speech-Language Pathology · March 2008

DOI: 10.1044/1058-0360(2008/002) · Source: PubMed
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Auditory Processing Disorders: An Update

for Speech-Language Pathologists
David A. DeBonis have expressed doubt about the relevance and very existence
of auditory processing disorders (APDs) in school-age chil-
College of Saint Rose and Sunnyview dren (Cacace & McFarland, 1998; Watson et al., 2003).
Rehabilitation Hospital, Albany, NY Speech-language pathologists (SLPs) are affected by this
current state of uncertainty because their professional re-
Deborah Moncrieff sponsibilities include screening for APD, making appropri-
University of Connecticut, Storrs ate referrals, and providing intervention services (ASHA,
2001). Also, nearly 60% of certified SLPs work in schools
(ASHA, 2002b), and it is during the school years that chil-
Purpose: Unanswered questions regarding the nature of dren move from listening to and learning language to using
auditory processing disorders (APDs), how best to identify language for learning. In fact, 67% of the ASHA-certified
at-risk students, how best to diagnose and differentiate APDs
from other disorders, and concerns about the lack of valid
SLPs who work with school-age children report regularly
treatments have resulted in ongoing confusion and skepticism serving students who have APD (ASHA, 2004c).
about the diagnostic validity of this label. This poses chal- The purpose of this article is to provide an update on
lenges for speech-language pathologists (SLPs) who are current APD literature for SLPs who work with school-age
working with school-age children and whose scope of practice children to guide them in their role with respect to APDs.
includes APD screening and intervention. The purpose of Will they accept this disorder as a reality and assume roles in
this article is to address some of the questions commonly referral and intervention of students or will they deem the
asked by SLPs regarding APDs in school-age children. This available evidence insufficient for that course of action? The
article is also intended to serve as a resource for SLPs to article uses a question-and-answer format, focusing on ques-
be used in deciding what role they will or will not play with tions commonly asked by SLPs. Answers are based on in-
respect to APDs in school-age children.
Method: The methodology used in this article included a com-
formation from position papers, technical reports, expert
puterized database review of the latest published information panels, controlled studies, and the most frequently published
on APD, with an emphasis on the work of established re- authorities. The questions and answers that follow are de-
searchers and expert panels, including articles from the signed to elucidate the major issues surrounding the disorder,
American Speech-Language-Hearing Association and the which include the following:
American Academy of Audiology.
Conclusions: The article concludes with the authors’ recom- 1. What is the definition of APD?
mendations for continued research and their views on the 2. What are its primary characteristics?
appropriate role of the SLP in performing careful screening,
making referrals, and supporting intervention. 3. What diagnostic tests are available to audiologists?
4. What associations exist between APD and specific
Key Words: auditory processing, classroom listening, language and learning disorders?
appropriate referrals, differential diagnosis 5. What are the ASHA-defined roles and responsibilities
of SLPs and audiologists as related to children with this
disorder?
6. How are school-age children screened for APD?
7. Who might make poor candidates for this testing?
I
n the introduction of the report of the Consensus Con-
ference on the Diagnosis of Auditory Processing Dis- 8. What management approaches are available and effective?
orders in School-Aged Children, Jerger and Musiek
(2000) stated: “The reality of auditory processing disorders An effort has also been made to provide the reader with
in children can no longer be doubted. There is mounting some appreciation of the complex nature of this disorder,
evidence that, in spite of normal hearing sensitivity, a fun- the numerous unresolved issues surrounding it, and some
damental deficit in the processing of auditory information suggestions for decision making in a climate of uncertainty.
may underlie problems in understanding speech in the pres-
ence of background noise, in understanding degraded speech, 1. What Is the Definition of APD?
in following spoken instructions, or in discriminating and According to an ASHA (2005) technical report, APDs
identifying speech sounds” (p. 467). Despite this claim, refer to difficulties in the perceptual processing of auditory
authorities in related fields and within our own profession information in the auditory nervous system as demonstrated
4 American Journal of Speech-Language Pathology • Vol. 17 • 4–18 • February 2008 • A American Speech-Language-Hearing Association
1058-0360/08/1701-0004
by poor performance in one or more of the following skill presence of noise. This is consistent with Jerger and Musiek
areas: auditory discrimination, auditory pattern recognition, (2000), who stated that processing deficits involved in APD
temporal aspects of audition, auditory performance in com- can be exacerbated in unfavorable acoustic settings.
peting acoustic signals, and auditory performance with de- This long list of behavioral signs associated with APD has
graded acoustic signals. Further, the Consensus Conference evoked considerable criticism because of its heterogeneous
on the Diagnosis of Auditory Processing Disorders in School- nature. This is certainly a far cry from what Friel-Patti (1999)
Aged Children (Jerger & Musiek, 2002) emphasized the called for when stating that APD must be “defined on the
importance of establishing that poor performance on tests of basis of a unique cluster of behaviors reflecting impairment
auditory processing is due to “an auditory-specific perceptual in some underlying mechanism” so that “clear descriptions
deficit in the processing of speech input” (p. 19) rather than of mutually exclusive and exhaustive diagnostic criteria
due to some other factor(s). ASHA (2005) agreed that in- can be specified” (p. 347). In fact, APD has been associated
dividuals who have APD “exhibit sensory processing deficits with a wide range of clinical populations, including young
that are more pronounced in the auditory modality” (p. 2), children with histories of otitis media, school-age children
but the report added that because sensory processing in the with learning difficulties, individuals who have neurological
central nervous system necessarily involves multiple modal- deficits, and older individuals (Bellis, 2003). While these
ities supported by cognitive and language systems, complete wide-ranging associations may fuel skepticism regarding the
modality specificity as a requirement for APD is not plau- validity of APD as a diagnostic category, they also may
sible. The fact that this continues to be a controversial issue provide information that APDs may interfere with normal
in APD assessment is evidenced by the devotion of an entire auditory functioning in a wide variety of individuals at all
recent issue of the American Journal of Audiology to the ages.
topic, with several contributing articles devoted to whether
APD should be diagnosed in a unimodal fashion. These issues 3. What Diagnostic Tests of Auditory Processing
are discussed in more detail in this article. Are Available to the Audiologist and What
Some confusion exists regarding the literature’s use of
the terms central auditory processing disorder and auditory Information Do They Provide?
processing disorder. The Consensus Conference on the Di- Assessment for APD is performed by a battery of auditory
agnosis of Auditory Processing Disorders in School-Aged measures that theoretically assess various aspects of the
Children (Jerger & Musiek, 2000) objected to the original construct. In order to make these measures more effective
term, central auditory processing disorder, for three reasons: in identifying disorders of the central auditory system, they
(a) it was not sufficiently operationalized, (b) it inappropri- have been “sensitized” in some way, typically by increas-
ately referred to anatomical loci, and (c) it did not reflect ing the complexity or reducing the redundancy of the test
potential peripheral and central interactions. The Consensus stimuli. Sensitization has been achieved by filtering out fre-
Conference suggested that it be replaced with auditory pro- quency information, adding background noise, or present-
cessing disorder. The ASHA (2005) technical report on ing competing auditory information simultaneously to both
central auditory processing disorders, noting the confusion ears. Cacace and McFarland (1998) have noted that this
created by the change in terminology, recommended contin- process of “sensitization” makes these tasks susceptible
ued use of the term central auditory processing disorder but to nonperceptual influences, such as attention. It is widely
added that the two terms could be considered synonymous. understood that speech-based auditory tests also engage
In this article, auditory processing disorder (APD) will be resources of attention and verbal working memory and, as
used. such, can provide important information about integration
of auditory neural pathways with these resources across de-
velopment (Hugdahl, 1995).
2. What Are the Primary Characteristics
As summarized in Table 1, four major types of behav-
of School-Age Children Who Have APD? ioral tests are typically used in current test batteries. Auditory
According to the ASHA (2005) technical report, individ- discrimination tests assess the students’ ability to detect
uals suspected of having APD frequently exhibit one or more subtle differences in similar sounds, including (a) acoustic
of the following characteristics: (a) difficulty with speech sounds that differ in frequency, intensity or temporal charac-
understanding in adverse listening environments, (b) mis- teristics or (b) similar sounding words or nonsense syllables
understanding messages, (c) responding inconsistently that differ, as in minimal pairs. Tests of auditory pattern
or inappropriately, (d) frequently asking that information be recognition may provide information about the perception
repeated, (e) difficulty attending and avoiding distraction, of suprasegmental cues in speech (Bellis, 2003). Dichotic
(f ) delay in responding to oral communication, (g) diffi- tests assess the student’s ability to either integrate or separate
culty following complex auditory directions, (h) difficulty out different auditory stimuli presented simultaneously to
with sound localization, (i) reduced musical and singing skills, both ears and provide information regarding neuromatura-
and (j) associated reading, spelling, and learning problems. tion of the central auditory system (Bellis, 2003). Monaural
Empirical support for some of these behaviors is noted in a low-redundancy speech tests assess students’ ability to under-
study by Smoski, Brunt, and Tannahill (1992), who found stand degraded speech, as might occur in background noise
that children diagnosed with APD were judged by their teachers or if speech is presented at a rapid rate.
to be poorer listeners than a group of control participants Jerger and Musiek (2000) recommended that behavioral
and that the greatest listening difficulty was noted in the measures be clinically supplemented with electrophysiological
DeBonis & Moncrieff: Auditory Processing Disorders 5

TABLE 1. Overview of four types of behavioral auditory processing disorder tests, associated deficits, and suggestions for management.
Possible deficits associated

Test type Purpose of test with reduced performance Management suggestions
Auditory discrimination Assess ability to discriminate Difficulty perceiving subtle Improve acoustic access to auditory
tests nonspeech stimuli that differ differences in similar sounds, information through flexible seating,
in frequency, intensity, and/or similar sounding words, or use of FM, reduction in classroom
temporal characteristics; assess tone of voice noise; preteach new concepts and
ability to discriminate speech vocabulary; implement auditory
stimuli that differ as in minimal phoneme discrimination training;
pairs teach compensatory strategies to
strengthen top-down mechanisms,
including vocabulary building, use
of context to increase understanding,
and teaching principles of active
listening
Auditory pattern Assess ability to discriminate Reduced speech perception, Higher level language therapy to
recognition tests among and sequence including content of the improve understanding, combined
auditory information over time message and intent of the with prosody training
speaker
Dichotic speech tests Assess the ability to separate Difficulty attending to one piece Improve acoustic access to information
(binaural separation) or integrate of information while ignoring in the environment as noted above;
(binaural integration) differing another; difficulty attending teach compensatory strategies
auditory stimuli (e.g., words, in group or noisy settings regarding directing attention;
sentences) presented to each interhemispheric exercises, dichotic
ear simultaneously training
Monaural low- Assess recognition of degraded Problems “filling in” the missing Improve acoustic access to auditory
redundancy speech stimuli presented to one piece of information when it is information; preteach new concepts
speech tests ear at a time (e.g., filtered speech, presented in poor acoustic and vocabulary; implement auditory
time-altered speech) or speech conditions or degraded in phoneme discrimination training;
presented in background of some way teach compensatory strategies to
noise or speech competition strengthen top-down mechanisms,
including vocabulary building, use of
context to increase understanding,
and teach principles of active listening
Note. Information in table is from ASHA (2005) and Bellis (2003, 2006).
and electroacoustic measures, specifically otoacoustic emis- children whose deficits are not perceptual in nature, such test
sions and the auditory brainstem and middle latency re- protocols should be “abandoned in favor of a more valid ap-
sponses. Katz and colleagues (2002) disagreed, stating that proach” (p. 120). They proposed the use of an APD test
research has not supported the premise that such measures are battery that compares performance on auditory and analo-
valuable in APD assessment or remediation. Jerger and col- gous visual tasks. According to the researchers, the child who
leagues (2002) reported behavioral and electrophysiological truly has a “pure” APD will perform poorly only on the au-
data from a study of fraternal twin girls, only one of whom ditory tasks; a child whose deficits are more global in nature
appeared to exhibit some type of auditory perceptual disorder. (i.e., supramodal, nonperceptual) will demonstrate difficul-
The researchers found that although “there was little to dif- ties on all tasks. Importantly, this latter group will perform
ferentiate the two twins” on behavioral measures, they dif- poorly on auditory measures as part of a broader problem and
fered significantly on event-related potential measures, with not because they have an isolated APD; this distinction is not
the twin who demonstrated reduced performance in noise possible using a unimodal battery, according to the research-
also demonstrating abnormal brain activation patterns in re- ers. Cacace and McFarland also believe that establishing
sponse to auditory but not visual stimuli (p. 459). Finally, modality specificity as a diagnostic criterion for APD would
Moncrieff, Jerger, Wambacq, Greenwald, and Black (2004) address the potential influence of uncontrolled factors, such
found that some children with reading deficits also exhibited as attention and motivation. For example, the child whose
left ear evoked response deficits on dichotic testing. performance on visual measures is normal but whose per-
A survey of audiologists’ APD diagnostic practices by formance on analogous auditory measures is abnormal most
Emanuel (2002) reported that none were using a protocol that likely has some type of auditory deficit that is not due to lack
met the minimum guidelines as recommended in the Con- of attention or motivation to the tasks.
sensus Conference report (Jerger & Musiek, 2000). Despite In response to Cacace and McFarland’s suggestions, Katz
efforts to characterize a battery of tests that can minimally and Tillery (2005) cited two cases of children who demon-
diagnose an auditory processing deficit in school-age chil- strated reduced performance only on one competing condi-
dren, a true consensus has yet to be well established. Regard- tion of the Staggered Spondaic Word Test (Katz, 1986). The
ing the use of auditory measures alone to diagnose APD, researchers contrasted this profile with a third individual
Cacace and McFarland (2005a) stated that because the cur- whose performance was depressed in all four conditions.
rent “unimodal” testing approach leads to misclassification of They suggested that nonauditory factors can have a negative
6 American Journal of Speech-Language Pathology • Vol. 17 • 4–18 • February 2008

impact on performance in general but are less likely to in- individuals whose lesions are well-defined, and ASHA (2005)
fluence performance in only one condition of the test. The noted that this approach to validity is common in cognitive
researchers concluded that such intraindividual comparisons and neuropsychological fields. Cacace and McFarland
are effective for separating out auditory from nonauditory (2005b) expressed concern with this approach because brain
effects and that testing using multiple modalities is not nec- lesions are often not limited to auditory areas, and Bellis
essary. Similarly, Moncrieff (2006) suggested that a unilateral (2003) noted the potential problems in using data collected
deficit on a dichotic listening test is not linked to a global from adults with brain lesions to draw conclusions about test
language, attention, or cognitive disorder because the child is validity for children who do not have brain lesions.
able to attend to and process information normally when it There is general agreement that more information is
is presented to the dominant (usually right) ear. The researcher needed about APD test reliability. Test–retest reliability has
believed that the presence of a large interaural asymmetry been shown to improve when clients are asked to identify the
during dichotic listening tests that is not present for monaural correct choice from a series of options, rather than repeat-
listening tests is strongly suggestive of an auditory-specific ing back what was heard (Voyer, 2003) and when computer-
deficit in processing speech during binaural listening. controlled adaptive test procedures are used to control floor
Musiek, Bellis, and Chermak (2005) also expressed con- and ceiling effects (Levitt, 1971). These methodologies
cern about the use of multimodal testing and questioned would be appropriate to include in APD testing. Information
whether true visual analogs could be created for auditory obtained from future studies on the reliability of tests of
measures, particularly in view of differences in central inte- auditory processing will help clinicians determine the extent
gration in the visual and auditory systems. Instead, the re- to which such tests correlate with other important measures of
searchers advocated the use of a multidisciplinary approach to ability in school-age children (Cacace & McFarland, 1995).
testing using professionals from related fields (e.g., academic, Finally, the criterion for determining the presence of APD
speech-language, neuropsychological) who could provide based on test performance is a concern. ASHA (2005) stated
supplemental information about nonauditory areas. that the diagnosis of the disorder generally requires perfor-
A second issue regarding assessment of APDs in children mance deficits of 2 SDs below the mean on two or more tests
has to do with test validity and the lack of a “gold standard.” in the battery. However, the diagnosis may also be made
A gold standard may be defined as an “outcome or condi- if performance on any one test is 3 SDs below the mean or
tion that is designated as the criterion against which the test the client is exhibiting significant functional difficulty in
characteristics of all other measures are compared” (Stach, behaviors that are related to the auditory process in question.
2003, p. 119). An example of a gold standard in audiology The fact that the diagnosis could be made on the basis of one
would be the use of magnetic resonance imaging (MRI) in test for which reliability and validity information is likely
studying whether auditory brainstem response (ABR) test- limited is of great concern. Rates of misdiagnosis are likely
ing is a valid tool for the identification of medium to large to increase in cases where test reliabilities are low, multiple
acoustic tumors. The gold standard against which the ABR tests assessing different auditory processes are used, and
findings would be compared would be the MRI because this reduced performance on a small number of tests is consid-
would represent the definitive measure of the “truth” that ered evidence of the disorder (McFarland & Cacace, 2006).
is being measured. One study has linked differences in the
fMRI hemodynamic response recorded from reading dis- 4. Does APD Cause Specific Language
abled children with a unilateral dichotic listening deficit,
especially when the children were initially primed to attend to and Learning Disorders?
their right ears during a challenging listening task (Moncrieff, Jerger and Musiek (2000) claimed that deficits in auditory
McColl, & Black, in press). Future studies of this kind could processing likely underlie problems with understanding
potentially provide important standards for brain activation speech in a background of noise, understanding speech that is
patterns during a variety of auditory processing skills. degraded, following orally presented instructions, and speech
In the absence of a current gold standard for the identifi- sound discrimination. They noted that APD may coexist
cation of APD in children, several researchers have measured with other disorders, but they did not suggest that it was caus-
test validity within groups of children who are suspected ative in nature. Also, they suggested that APD should be
of having APD. This approach is problematic because it viewed as a “discrete entity apart from other childhood prob-
leaves open the possibility that the participants have uniden- lems” (Jerger & Musiek, 2002, p. 19). As a corollary, ASHA
tified language, attention, or general learning disabilities. The (2005) stated that APD “is best viewed as a deficit in the
possibility of comorbid factors interferes with the true assess- neural processing of auditory stimuli that may coexist with,
ment of the sensitivity and specificity of individual APD but is not the result of, dysfunction in other modalities” (p. 3).
tests, as well as the efficiency of any proposed test battery In contrast, Katz and colleagues (2002) claimed that APDs
(Cacace & McFarland, 2005a). may cause speech and language impairment, dyslexia, and
Another approach to establishing test validity is to use attention deficit disorder.
individuals who have been identified with lesions of the cen- Cacace and McFarland (1998) reviewed the available em-
tral nervous system. This is based on the premise that a test pirical evidence regarding the proposition that deficits in
which has been shown to be valid in identifying gross ab- auditory processing underlie language and learning problems
normality of the central nervous system (e.g., a tumor) can be and concluded that validation of this theory is nearly impos-
presumed to be valid for use with children who have APD. sible because almost all of the research employed only acous-
Musiek et al. (2005) advocated the use of this approach with tic stimuli. ASHA (2005) concluded from their review that

because APD and learning are both complex and heterogeneous, deficits and specific language impairment and dyslexia, con-
“it is to be expected that a simple, one-to-one correspondence cluded that “auditory deficits do not appear to be causally
between deficits in fundamental, discrete auditory processes related to language disorders, but only occur in association
and language, learning, and related sequelae may be diffi- with them” (p. 521). He added that the position held by Tallal
cult, if not impossible, to demonstrate” (pp. 3–4). and Piercy (1973, 1974) that the auditory deficit noted in
Other research has attempted to link one particular audi- individuals diagnosed with specific language and reading
tory process with weaknesses in language, learning, and impairment is related to rapid auditory processing “is no
reading. For example, Tallal and colleagues have asserted that longer viable” (p. 518).
the underlying impairment in children who have reduced Watson and colleagues (2003) examined the degree to
phonological processing (and subsequent reading deficits) which various sensory, cognitive, and linguistic factors were
is one of temporal processing, which refers to perception of associated with success or failure in the first years of school
rapid changes in acoustic information (Tallal & Piercy, 1973, and found low correlations between reading achievement
1974). But Troia (2003) noted that the same children who and measures of auditory processing. In fact, low scores on
demonstrated these auditory difficulties also exhibited greater measures of APD were associated with “virtually any level of
difficulty with rapidly presented visual patterns and perceiv- reading achievement” (p. 181) and cast doubt on the thesis
ing and producing rapid sequential motor movements. This that “children with auditory processing deficits have lan-
suggests that the auditory deficits are part of a broader pan- guage and reading problems as a consequence of the diffi-
sensory disorder. Troia added that at this point a functional culty they have in understanding spoken language, especially
relationship has not yet been established between auditory under difficult listening conditions” (p. 188). Musiek et al.
perceptual deficits and phonological processing deficits. (2005), in response to Watson’s findings, stated that they do
Also in contrast to claims by Tallal and colleagues, Studdert- not view APD as the direct cause of academic, learning, or
Kennedy and Mody (1995) asserted that the difficulties noted reading problems but rather one small but important compo-
in temporal processing tasks among children who have read- nent of listening and learning.
ing deficits reflect linguistic deficits that interfere with the What all of these studies suggest is that a one-to-one cor-
ability to identify phonemic categories for the stimuli at hand. respondence between APD in general, or even a particular
Mody, Studdert-Kennedy, and Brady (1997), in a study us- deficit in one type of auditory processing skill, may be diffi-
ing two complex nonverbal tones, required listeners to dis- cult to link to any specific learning, language, or reading
criminate the tones based on perception of brief transitions in disability. One study noted that some dyslexic children dem-
format frequencies; because the tones were nonverbal, lis- onstrated evidence of a unilateral deficit during dichotic lis-
teners were not required to create phonological representations tening tasks and that the prevalence of this deficit was much
of the stimuli. Also, these researchers assessed participants’ greater among the children with dyslexia than among normal
ability to discriminate additional pairs of consonant-vowel controls (Moncrieff & Black, in press). This study suggested
syllables that differed on specific articulatory features. The that APD may be present in children with school-based learning
fact that less skilled readers did not perform significantly disabilities to a greater extent than among children without
differently in their ability to discriminate based on acoustic them, but additional research in this area is clearly needed.
transitions but did perform more poorly in discriminating
phonetically similar phonemes lends support to an underlying 5. What Are the ASHA-Defined Roles and
linguistic deficit in children with reading deficits, rather than Responsibilities of SLPs and Audiologists
an underlying auditory one. Consistent with this, Agnew,
Dorn, and Eden (2004) found that intensive daily intervention as Related to School-Age Children With APD?
using a computerized program designed to improve temporal Children at risk for listening, learning, and language
processing skills resulted in improvements on auditory duration disorders in the school are usually referred to the SLP for
tasks but not on phonological awareness or nonword reading. evaluation to determine eligibility for services. Among the
McAnally, Castles, and Bannister (2004) compared good tools utilized to make these determinations are a variety of
and delayed readers on auditory temporal pattern discrimina- language assessments that include measures related to au-
tion tasks and found that both groups were equally able to ditory processing skills. Table 2 provides information about
perform these tasks. Similarly, Breier, Fletcher, Foorman, tests of auditory perceptual skills. When an auditory pro-
Klaas, and Gray (2003), in a study examining perception of cessing weakness is suggested by the results from any of
auditory temporal cues among children with reading disabili- these tests, the SLP may then choose to either directly refer
ties, did not find support for fundamental deficits in audi- to an audiologist for a diagnostic assessment or perform
tory temporal ability. Earlier studies reported variable results additional screening measures designed more specifically to
when assessing temporal integration and resolution perfor- address APD.
mances in children with reading disorders, suggesting that Although both audiologists and SLPs may screen for
(a) many temporal resolution skills mature very early (gap de- and treat individuals who have or are suspected of having
tection and masking level difference), (b) some but not all APDs (ASHA, 2004b, 2005), only audiologists diagnose this
children with reading disorders may demonstrate a temporal disorder. ASHA (2005) also noted the important role of SLPs
processing deficit, and (c) more evidence is needed to deter- in “the differential diagnosis of language processing dis-
mine which children are most likely to have this particular orders from APD” (p. 6).
difficulty (see Moncrieff, 2004b, for a review). Rosen (2003), Richard (2006) noted that these definitions may not
in a review of the relationship between auditory processing sufficiently clarify the division of responsibilities between

TABLE 2. Summary of information regarding tests of auditory perceptual skills.
Name of test Publisher/year Standardization Target population Auditory skills measured Reliability/validity Comments
Lindamood Auditory Pro-Ed (1979) n = 1,003; diverse School-age children Phonemic awareness and Content sampling (.94)
Conceptualization population, from kindergarten auditory conceptualization Time sampling (.96)
Test multiple regions to 12th grade
Test of Auditory- Psychological and n = 1,038; representative Ages 4 to 12 years Perception and processing of Internal consistency Subtests measure different
Perceptual Skills— Educational population within auditory stimuli with digit (.85–.90) aspects of auditory
Revised Publications San Francisco span, sentence memory, Total score (.49–.81) perceptual skill.
(1996) Bay area interpretation of directions, Total group (.69–.93)
dictation, word discrimination,
and reasoning
Comprehensive AGS (1999) n = 1,700; diverse Ages 3 to 21 years Auditory comprehension, oral Internal consistency This subtest measures
Assessment of population, expression, and word (.64–.94) different skills from those
Spoken Language multiple regions retrieval in one of four Test–retest reliability measured by other three
subtests (.65–.95) with higher subtests.
values for core
(.92–.93)
Language Processing LinguiSystems n = 1,673; diverse Ages 5 to 11 years Assesses ability to demonstrate Test–retest reliability 95% of the individual items
Test (1995) population, strategies needed to perform (.67–.79) were significantly
multiple regions focused tasks appropriate for Internal consistency correlated with subtest
classroom behaviors (.43–.78) scores.
Comprehensive Test Pro-Ed (1999) n = 1,656; diverse Version 1: ages 5 Assesses phonological Reliability coefficients Test is useful for differentiating
of Phonological population, to 6 awareness, phonological ranged from .70 to individuals with reading
Processing multiple regions Version 2: ages 7 memory, and rapid naming .99 disabilities from controls.
to 24
The Listening Test LinguiSystems n = 1,509; diverse Ages 5 to 11 Assesses strengths and Test–retest reliability
(1992) population, weaknesses in classroom (.85–.97)
multiple regions listening skills Internal consistency
(.53–.65)
Concurrent validity
(.64–.81)
Auditory Processing Academic Therapy n > 1,000; diverse Ages 5 to 12 Assesses specific areas of Internal consistency
Abilities Test Publications population, auditory weakness in (.69–.89)
(2004) multiple regions children at risk for APD Test–retest reliability
(.99)
Criterion-related validity
(.50)
DeBonis & Moncrieff: Auditory Processing Disorders

9
audiologists and SLPs within this population. Both profes- indicates severe difficulty. The listening conditions are
sionals are directed to provide both screening and interven- (a) noise, (b) quiet, (c) ideal, (d) multiple inputs, (e) auditory
tion, but only the audiologist is directed to provide diagnostic memory/sequencing, and (f ) auditory attention span. Al-
services for APD. Because the SLP is directed to screen for though the original respondents used in developing the tool
APD, it is necessary that screening tools for this purpose were classroom teachers, the tool can be used by others,
be clearly identified and provided to the SLP to use in the including parents. The test is not standardized, but the test
schools. Intervention is even more complicated because un- developers state that children whose total score meets or
der current reimbursement standards, only the SLP is entitled exceeds a specified criterion are more likely to require special
to reimbursement for the intervention services that are typi- resource support services in school.
cally involved in remediating APDs in children. Regarding screening by test, the Consensus Conference
(Jerger & Musiek, 2000) suggested that for children older
than 6 years, the screening that is developed should include
6. How Are School-Age Children Screened for APD? dichotic digit and gap detection measures. Neither of these
The ASHA (2005) technical report on APD defines screen- tests is generally administered by the SLP, however. Further-
ing as “systematic observation of listening behavior and/or more, ceiling effects may interfere with the utility of a dichotic
performance on tests of auditory function to identify those digits test utilizing double-digit pairs among children past
individuals who are at risk for APD” (p. 5). Unfortunately, age 9 (Moncrieff & Musiek, 2002).
no national professional organization has yet issued a The SCAN-C test (Keith, 1986, 2000a, 2000b) is an avail-
policy statement on the screening of APD in school children able screening tool that contains subtests which assess under-
(Jerger & Musiek, 2000) and “there is no universally ac- standing of low-pass filtered words, auditory figure-ground
cepted method of screening for APD” (ASHA, 2005, p. 5). abilities, and dichotic listening performance with competing
In fact, the latest ASHA technical report on APD dedicates words and competing sentences. It can be administered by
only one paragraph to the topic of screening and states that nonaudiologists in a quiet room using a CD player, although
“an in-depth discussion of the role of the SLP and other anyone administering it should be careful to monitor presen-
professionals is beyond the scope” of the report (p. 1). tation level throughout the test. The test has demonstrated
Despite the lack of information on the topic of screening, poor predictive value when used outside a sound-treated
the ASHA technical report (2005) does refer the reader to four booth (Emerson, Crandall, Seikel, & Chermak, 1997, 1998),
sources of information about screening for APD, each of suggesting that a failure to maintain an appropriate presen-
which is reviewed in this section of the article. The SCAN-C: tation level may result in poor test results. Also, Amos and
Test for Auditory Processing Disorders in Children (Keith, Humes (1998) investigated the reliability of the SCAN-C for
1986, 2000a, 2000b) and Children’s Auditory Performance first- and third-grade children using a 6–7-week retest inter-
Scale (CHAPS; Smoski et al., 1992) are widely used screen- val. They found that for both grade levels, raw and stan-
ing tools. The other two sources, the Consensus Confer- dard scores improved significantly from the first to second
ence on the Diagnosis of Auditory Processing Disorders test administration for the Filtered Words and Competing
in School-Aged Children (Jerger & Musiek, 2000) and Words subtests, as well as for the composite score. The com-
Bellis (2003) text, both provide discussions of screening posite percentile rank and age-equivalent data also demon-
approaches. strated significant test–retest improvement for both grades.
The report of the Consensus Conference (Jerger & Musiek, Poor and nonsignificant test–retest correlation values were
2000) stated that development and validation of a screening noted for the Filtered Words and Auditory Figure-Ground
procedure specifically for school-age children is necessary subtests (r < .35), and significant moderately strong positive
and should (a) assess the perceptual processing of complex correlations (r = .7–.78) were noted for both grades on the
auditory stimuli, (b) meet acceptable psychometric standards, Competing Words subtest and composite score. These re-
(c) rely minimally on cognition, attention, and language, searchers concluded that the composite score (rather than
and (d) be able to be administered in a brief period of time. individual subtest scores) should be used for making de-
The participants at the Consensus Conference concluded that cisions about the need for further testing.
the screening procedure could take the form of either a ques- The Competing Words subtest of the SCAN-C, which
tionnaire, a test, or a combination of the two. provides information on dichotic listening performance, could
According to the Consensus Conference (Jerger & Musiek, be scored separately from the composite score as a screening
2000), screening by questionnaire should assess evidence instrument in place of or in addition to the dichotic digits test.
of difficulty (a) hearing/understanding in background noise According to Moncrieff (2006), the prevalence of disordered
or reverberant settings, (b) understanding speech that is performance was shown to increase dramatically when the
degraded, (c) following oral directions, and (d) identifying scores for the individual ears were compared in order to
and discriminating speech sounds. Evidence of inconsistent derive a measure of interaural asymmetry. The research sug-
auditory awareness or inconsistent responses is also included. gested that this alternative scoring method may prove useful
The CHAPS, developed by Smoski et al. (1992), is a in screening for dichotic listening deficits in the school-age
behavioral questionnaire that is used to assess auditory func- population (Moncrieff, 2006).
tion. Using a rating scale of +1 to –5, respondents are asked to The SCAN-A: Test for Auditory Processing Disorders
rate the child on six listening conditions by comparing the in Adolescents and Adults (Keith, 1994) is a modification of
child to other children of similar age and background; a rating the SCAN-C for use with older students as well as adults.
of +1 indicates less difficulty than their age peers, and –5 The SCAN-A is a 20-min test that includes four subtests:

Filtered Words, Auditory Figure-Ground, Competing Words, According to the ASHA (2005) technical report, “task
and Competing Sentences. Test–retest reliability for the total difficulty and performance variability render questionable re-
test is reported by Keith to be .69. The SCAN-A can be sults on behavioral tests of central auditory function” in chil-
administered by audiologists or SLPs. dren whose mental age is below 7 years (p. 6). Despite this,
One problem with the SCAN-A is that it presumes that by Jerger and Musiek (2000) suggested that children as young
age 12 years, a child’s performance is similar to that of an as 6 years could be tested with whatever screening tool is
adult’s. In a recent retrospective study of results obtained eventually developed. Electrophysiological measures are
from adolescents, it was found that the prevalence of dis- sometimes recommended for younger children, but research
ordered performance increases dramatically once children is lacking to suggest that students with APD would have
are above 12 years and must be assessed with normative in- auditory nerve or brainstem pathology (Katz et al., 2002). In
formation obtained from adults (Eichert, Heithaus, & Brown, addition, middle latency responses are variable in children
2007). It is important that normative information be sepa- (Kraus, Smith, Reed, Stein, & Cartee, 1985) and are influ-
rately obtained from children between 12 and 18 years of enced by nonauditory factors, including client age and the test
age in order to adequately screen and diagnose them for protocol used (Jerger & Jerger, 1985). Finally, abnormality on
an APD. electrophysiological measures yields no specific informa-
To determine whether the SCAN-A’s total score test–retest tion about how the child processes incoming auditory infor-
reliability of .69 (Merz, 1998) was adequate, McFarland and mation (Bellis, 2003).
Cacace (2006) simulated test performance using a simple Some disagreement exists in the literature regarding the
statistical model. The researchers generated percentages of appropriateness of performing tests of auditory processing
false alarms (i.e., test value is below 1 SD, but trait value is on individuals with peripheral hearing loss. Although some
not), misses (i.e., trait value is below 1 SD, but test value is authorities view APD as a disorder that, by definition, oc-
not), and hits (both values are below 1 SD). Using this model, curs in the presence of normal peripheral hearing (Jerger &
it was determined that reliabilities approaching .80 were Musiek, 2000), the literature does address the issue of per-
required in order for the rate of correct decisions to exceed forming these tests on individuals who have peripheral hear-
the rate of errors. Keith (2000a, 2000b) reported subtest test– ing loss. Although some researchers have found that hearing
retest reliability correlations for the SCAN-C for 5- to loss minimally affects scores on dichotic digits and pattern
7-year-olds ranging from .65 to .82. recognition tasks (Musiek, Baran, & Pinheiro, 1990; Speaks,
Bellis (2003) advocated a screening process that requires Niccum, & Van Tasell, 1985), Neijenhuis, Tschur, and Snik
a collaborative, multidisciplinary team (e.g., audiologist, (2004) found that performance of participants who had mild,
SLP, teacher, psychologist) in order to gain an understanding flat, symmetrical sensorineural hearing loss was significantly
of the child’s strengths and weaknesses and to develop an poorer than that of the normal hearing participants, even
initial auditory profile. According to Bellis, this profile is nec- for the dichotic digits and pattern recognition tasks. The re-
essary because of the degree of interdependency that exists searchers also noted that increasing the stimulus intensity for
between auditory processing, language, and learning. Integral other auditory processing measures (e.g., words in noise, fil-
to this screening process is the assessment of overall cog- tered speech) was not sufficient to compensate for the mild
nitive, language, and achievement abilities (prior to any loss.
decision to administer an APD test battery) in order to
identify the presence of more global issues that might ex- 8. What Management Approaches Are Available
plain the students’ presenting difficulties. Once data from for Children With APD and What Evidence Exists
the multidisciplinary team have been collected, they are
examined for patterns that might support a referral for APD Regarding the Effectiveness of These Interventions?
testing. Data specifically addressing the efficacy of interventions
for students with APD are seriously lacking, and many of the
recommendations commonly made are based on theory. In
7. Are Some Children Poor Candidates
fact, Cacace and McFarland (2006) suggested that the peer-
for Diagnostic Testing for APD? reviewed literature does not contain any evidence of a vali-
The ASHA (2005) technical report describes APD as “a dated model of APD intervention. Empirical studies have,
deficit in neural processing of auditory stimuli that is not due however, documented the efficacy of interventions commonly
to higher order language, cognitive, or related factors” (p. 2). used with students who have APD as they have been applied
In view of this, children whose listening/auditory difficul- to other populations or other disorder areas (e.g., use of
ties clearly stem from broader deficits in cognition, attention, metacognitive strategies, acoustic modifications). Table 1
memory, or language comprehension would not be good test summarizes some common management recommendations
candidates. The ASHA document specifically mentions sig- generated from test data, as conceptualized by Bellis (2003,
nificant intellectual impairment as an example of a comor- 2006). It is important to emphasize that the management
bid diagnosis that would preclude APD testing, and Bellis strategies noted are largely based on theory and are not sup-
(2003) noted that although normal cognitive abilities are not ported by outcome studies performed specifically on students
required for testing, the child must have the capacity to fol- diagnosed with APD.
low the test directions and respond appropriately. Bellis also A number of broad, guiding themes appear in the cur-
included uncontrolled behavior disorder as a diagnosis that rent APD intervention literature (ASHA, 2005; Bellis, 2003,
could prevent reliable testing. 2006; Ferre, 2006). One such theme is to provide, whenever

possible, early and intensive intervention in order to capital- although Bellis advocated use of such activities, she also
ize on the known plasticity of the central nervous system noted that a lack of evidence currently exists to support the
(Chermak & Musiek, 1992). Animal studies suggest that assumptions that (a) basic auditory processes do, in fact, un-
the effect of external auditory input (or lack thereof in the derlie more complex listening, learning, and communication
case of auditory deprivation) on plasticity is time-limited abilities (p. 287), (b) such processes can be identified with
to some critical period (Arnold, Bottjer, Nordeen, Nordeen, current tests, and (c) remediation of the deficient processes
& Sengelaub, 1987), the exact length of which is still un- will result in functional improvements in listening and
known. Before early auditory training for children with APD communication.
can become commonplace, empirical data will have to be In addition to attempts at direct remediation of APD, the
collected regarding the types, frequency, and duration of ac- ASHA (2005) technical report on APD addressed two other
tivities that would be effective with specific types of APDs, broad components of intervention: compensatory strategies
as well as the optimum age period for delivering therapy. and environmental modifications. Compensatory strategies
Another theme that emerges from the current APD lit- training, classified as a top-down approach, attempts to de-
erature is that intervention should be broad and comprehen- velop cognitive, metacognitive, linguistic, and metalinguistic
sive in order to address the potential impact the disorder may skills to support overall listening and communication and
have on listening, communication, and academic function- to reduce the functional deficits imposed by the APD (Bellis,
ing. “Bottom-up” approaches to intervention address the 2003; Chermak & Musiek, 1997). Such metacognitive in-
listener’s ability to receive and analyze the acoustic signal, struction approaches have a long and rich history in develop-
whereas “top-down” approaches address the listener’s ability mental and cognitive psychology and have been shown to be
to understand the message and attach meaning to it (ASHA, effective for a variety of children with various learning dif-
2005; Richard, 2006). ficulties, including attention deficits (Meichenbaum, 1977)
An example of a bottom-up remediation approach is and reading comprehension difficulties (Palincsar & Brown,
dichotic listening training, described by Bellis (2003). This 1984). One specific metalinguistic/metacognitive strategy
intervention involves systematic variation of the relative for students with APD provided by Chermak and Musiek
intensity levels of signals presented to each ear as clients are (1997) is to teach students to identify linguistic structures that
asked to either integrate or separate incoming information. connect related ideas into complex messages. For example,
Although controlled study of this type of intervention is very in the sentence “Joe saw the bird,” opportunities for under-
limited, Moncrieff (2004a) recently found considerably im- standing are increased if the student understands the role of
proved performance for the weaker ear in children with a pronouns and that this message may become “He saw it.”
unilateral deficit in dichotic listening. Broader improvements Instruction in the use of content schema is another strategy
in listening and language skills following the dichotic train- recommended by Chermak and Musiek to support under-
ing exercises were also reported. standing among students with APD. By considering what
Research involving auditory training activities designed they already know about a particular experience (e.g., attend-
to produce physiological and behavioral changes in children ing a birthday party), students are able to use this already
represent another type of bottom-up intervention and may established structure to facilitate spoken language compre-
have promise for determining both the existence of APDs and hension. A third example of a compensatory strategy noted by
treatment effectiveness. This type of research typically in- Chermak and Musiek is building students’ skills in using
volves a between-groups research design with (a) pretreatment context cues to increase understanding. This involves teach-
measures of auditory behaviors and electrophysiological ing the student to analyze incoming spoken language and
data, (b) intervention targeting discrete auditory skill areas, deduce a missed word from the parts of the message that have
and (c) posttesting of auditory behaviors and electrophysio- been successfully received. A final example of a compen-
logical measures. For example, a study by Hayes, Warrier, satory strategy comes from Bellis (2003), who suggests
Nicol, Zecker, and Kraus (2003) compared two groups of teaching whole body listening. This child is instructed not
students who had learning disabilities, one of which received only to position himself so that his attention is toward the
computer-based auditory training and a control group that teacher, but also to instruct himself to maintain his attention
did not receive any remediation. Researchers assessed and avoid distraction.
(a) speech- and click-evoked ABRs in quiet, (b) speech- Environmental modifications may be either bottom-up
evoked cortical responses in both quiet and noise, and or top-down in nature and are made to improve the listener’s
(c) standardized measures of academic achievement and cog- access to incoming auditory information. According to ASHA
nitive skills. Postintervention measures revealed cortical (2005), these may include (a) preferential seating, (b) use
responses that were more resistant to degradation in noise of visual aids, (c) control of background noise, and (d) use of
and positive behavioral changes in the auditory processing communication repair strategies. Bottom-up environmental
abilities of the experimental group; no such changes were modifications are typically preceded by an analysis of the
noted in the control group. listener’s acoustic environment, followed by specific modifi-
Other bottom-up auditory training activities are described cations designed to bring noise and reverberation levels to
by Bellis (2002) and Chermak and Musiek (2002) and use acceptable standards (American National Standards Institute,
tones and simple speech in activities designed to remediate 2002; ASHA, 2002a). These may include decreasing rever-
“basic auditory skills or processes” that are presumed to serve beration by covering hard surfaces, strategically placing
as the foundation for “more complex listening, learning, and acoustic dividers, and using absorption materials in open
communication abilities” (Bellis, 2002, p. 287). Importantly, spaces. Also, ASHA (2005) notes that FM technology is

useful for some students diagnosed with APD. Although 5 dB or more. According to Berard, in order to reduce these
empirical documentation exists regarding the benefits of FM distortions, the audiogram must be flattened by having the
technology for improving literacy and academic achievement client listen to specifically modulated and filtered music twice
(Loven, Fisk, & Johnson, 2003; McCarty & Gertel, 2003), daily for 30 min over a 10-day period.
speech recognition (Prendergast, 2001; Updike & Connor, ASHA (2004a), in its most recent technical report, ad-
2003), and attending/listening (Loven et al., 2003; Rosenberg dressed the value of AIT in treating various “communication,
et al., 1999), a comprehensive review of the literature on sound behavioral, emotional, and learning disorders” (p. 7) and
field amplification by Rosenberg (2005) did not reveal any concluded that “despite approximately one decade of practice
studies done specifically with students diagnosed with APD. in this country, this method has not met scientific standards
Although computer-delivered interventions have become for efficacy and safety that would justify its inclusion as a
popular in recent years, the literature support for such ap- mainstream treatment for these disorders” (p. 7). ASHA also
proaches is being questioned. We noted previously that work pointed out that this is the same conclusion reached by the
by Tallal and Piercy (1973, 1974) suggested a causal link American Academy of Audiology (1993), American Acad-
between academic differences and impairment in the tem- emy of Pediatrics (1998), and Educational Audiology As-
poral aspect of sound recognition. Based on this finding, sociation (1997).
Scientific Learning Corporation (Tallal & Merzenich, 1997)
developed Fast ForWord, a popular computerized training
program in which the listener is exposed to sounds and words Summary and Recommendations
that have been electronically lengthened. The theory involved At this point in our discussion, it should be clear that APD
here is that the manner of speech modification and massed- is a topic of great controversy and one that is perplexing
practice learning trials incorporated into the program will result to SLPs seeking to find their role in working with students
in changes in neural pathways so as to improve language who are suspected of having or are diagnosed with the dis-
learning. order. Not only have different researchers collected contra-
Although initial research data by the program developers dictory data regarding APD, different authorities in the field
(Merzenich et al., 1996; Tallal et al., 1996) were impres- have drawn different conclusions from the same data. This
sive (i.e., 1.5- to 3-year gains in language over a 6-week is likely related to the fact that individuals interpret data
period), subsequent analysis of these studies revealed a num- based on their own mindset, experiences, and roles. For ex-
ber of methodological concerns, summarized by Gillam ample, researchers are more likely to require overwhelming
(1999). These included (a) outcome measures that were very empirical evidence before endorsing new ideas or para-
similar to training activities, (b) lack of control for regression digms; clinicians, however, are more likely to consider other
to the mean, (c) use of examiners to deliver the interven- factors in making such decisions (Kamhi, 1999). For these
tion, and (d) failure to measure language in authentic contexts. reasons, “the translation of evidence into recommendations
Hook, Macaruso, and Jones (2001) used a between-groups is not straightforward” (Burgers & van Everdingen, 2004,
design with three groups: one received FastForWord, one p. 392).
received the Orton-Gillingham reading program, and one In view of the above, we conclude this article with our
received no treatment. The researchers found that both treat- own personal views of the need for future research and
ment groups made equivalent gains in phonological aware- conclusions about the role of the SLP with respect to APD.
ness, but neither group made statistically significant gains Recommendations for Future Research
in word recognition. The Orton-Gillingham group scored 1. Modality specificity is an important concept and should
higher on the decoding tasks compared with the group re- be further explored, in conjunction with adaptive test
ceiving Fast ForWord. Also, although children in the Fast procedures, to reduce misdiagnosis and improve reli-
ForWord group made gains in producing oral language, gains ability. This will also help to determine if there truly are
in comprehending the language and production were not students whose reduced performance on auditory tasks
noted upon a 2-year follow up. Other studies using Fast represents a fundamental auditory deficit rather than a
ForWord reported some language improvements on stan- broader, nonperceptual problem.
dardized measures, but clinically significant changes in
spontaneous language were not found (Friel-Patti, DesBarres, 2. The use of auditory training to produce physiological
& Thibodeau, 2001; Loeb, Stokes, & Fey, 2001). and/or auditory behavioral change could one day pro-
Brief mention should be made of auditory integration vide important information about the existence of APD
training (AIT; Berard, 1993) because anecdotal reports have and treatment efficacy. Measuring both behavioral and
suggested that it improves attending and auditory compre- physiological changes (rather than just physiological) is
hension, two common signs of APD. Also, the majority of the important and should be continued. Additional research
AIT practitioners in the United States and Canada are SLPs of this type should include functional measures of
or audiologists (ASHA, 2004a). As described by Berard listening and long-term follow-up testing.
(1993), AIT is based on the idea that the underlying cause 3. Development of a valid screening tool for APD in school-
of autism spectrum disorders, learning disabilities, and ag- age children should be a priority. Also, we agree with
gressive behaviors, for example, is the presence of auditory the conclusion of the report of the Consensus Conference
distortions. These auditory distortions are revealed as “peaks on the Diagnosis of Auditory Processing Disorders in
and valleys” on the client’s audiogram and are created when School-Aged Children (Jerger & Musiek, 2000) that some
the threshold of adjacent audiometric frequencies differ by type of screening tool for children younger than 6 years

needs to be developed. This is particularly important and a need for spoken information to be repeated. These
because parents and teachers often note listening diffi- difficulties are believed to be related to reduced academic
culties in younger children, and early testing may provide performance and have led to concerns about Michael’s con-
important initial information that can be used to establish fidence in the classroom and anxiety about school. Speech-
baseline measures for later diagnostic testing. This will language testing reveals age-appropriate language skills,
also be very difficult to achieve because the issues that and psychoeducational testing reveals normal cognitive abil-
make reliable and valid testing of APD so challenging ities, including good memory and attending skills. No sig-
(e.g., the influence of maturation, motivation, language nificant social-emotional difficulties are observed.
ability, attending) will be even greater in younger The SLP involved in this case adds to the data that have
children. already been collected on Michael and, using the CHAPS,
4. Research that establishes correlations between auditory finds Michael to have significantly more difficulty (compared
processing skills and other measures of learning, lan- with his classmates) understanding speech when background
guage, and listening (Watson et al., 2003) is important noise is present. Also, on the Competing Words subtest of
and should be encouraged. However, a lack of associa- the SCAN-C, Michael demonstrates an age-appropriate num-
tion does not mean that the construct is unimportant ber of errors on the right ear and a significant number of errors
because the relevance of APD as a diagnostic entity does on the left ear. Finally, on the Listening Test, Michael dem-
not hinge solely on school performance in the younger onstrates reduced performance. Based on the resulting pro-
grades or on any one particular learning, language, or file, Michael is referred to an audiologist for tests of auditory
listening skill. For some children, it is not until the later processing and is found to have reduced speech understand-
grades (even as late as middle school or high school) that ing in noise and reduced dichotic listening skills. Based on
difficulties in auditory processing become apparent. these findings, a series of recommendations are made that
What is needed is evidence of the prevalence of auditory include (a) an analysis of the sources of noise within the
processing difficulties within the population of school- classroom and recommendations to reduce that noise, (b) use
age children, from which measures of the associated of a sound-field FM system to improve the signal-to-noise
sequelae can ultimately be derived. ratio, and (c) language therapy, designed in collaboration with
the classroom teacher, to increase Michael’s familiarity with
5. Randomized clinical trials represent a powerful method new vocabulary used in class and to promote his ability to
of controlled study, and clearly more such research needs use contextual cues to support comprehension.
to be pursued if a validated model of treating APD is Consider now the sequence of events had the SLP decided
to be established. not to engage in a process of screening with Michael. On what
6. Other forms of research should also be encouraged, in- basis would Michael have received the additional support
cluding those that can be performed by SLPs in schools. that he needed to succeed in the classroom? More broadly,
One important example is single-subject designs. Al- if no initial screening process is in place, on what basis
though frequently viewed as a lesser form of evidence of are students with APD brought to the attention of school
treatment efficacy, these designs can be very useful in personnel so that they can receive necessary instructional
justifying clinical decisions for individual clients when accommodations and modifications? Doesn’t an assessment
they are based on well-documented trial therapy (Kamhi, of the potential costs of intervening versus the potential
2006; Ylvisaker et al., 2002). risk of not intervening strongly support intervention?
7. Both ASHA and the American Academy of Audiology Our conclusions regarding APD and the role of SLPs are
should explore the use of specific criteria for all prac- as follows:
tice guidelines that are published. According to Grilli, First, we agree with ASHA (2005) that current evidence
Magrini, Penna, Mura, and Liberati (2000), these criteria is sufficient to support the existence of APD as a diagnostic
should include a description of the types of professionals entity. We also agree with Bellis (2002) that until data are
involved in creating the guidelines, the specific strat- obtained to validate the nature of the disorder, the best testing
egy used in searching for primary evidence, and a grad- protocols, and the most effective intervention, “the clinical
ing of all recommendations to inform the reader of the utility of the APD diagnosis will remain limited” (p. 294).
quality of the evidence used and to clarify the degree to Second, despite the limitations inherent in working with
which expert panel recommendations are consistent with an evolving construct, the process of identifying school-age
the literature and free of conflicts of interest. children with APD and providing management recommen-
dations can, if done cautiously, be valuable. This is not
Recommendations Regarding the Role of the SLP unlike the situation that currently exists in diagnosing a num-
Given the current state of the literature on APD, SLPs ber of complex, incompletely understood disorders that
appear to have two choices: to reject the use of APD screen- affect children (e.g., autism).
ing and diagnostic measures or to engage cautiously in a Third, although no universally accepted screening ap-
process of screening, which in some cases will lead to diag- proach for school-age children exists, the literature does
nosis (by an audiologist) and then intervention. In consid- provide some guidance to SLPs interested in determining
ering these two options, think about the following case whether a given student who is exhibiting specific classroom
example. Michael is an 8-year-old student exhibiting diffi- difficulties (e.g., reduced speech understanding in noise,
culties in the classroom that include poor direction follow- frequent need for spoken information to be repeated) might
ing, reduced speech understanding (particularly in noise), benefit from diagnostic tests of APD. Consistent with the

approach described by ASHA (2005) and Bellis (2003), evidence, found that no greater than 60% of the group ratings
screenings should be multidisciplinary and should begin with agreed with the data provided. Qualitative follow-up inter-
assessment of cognitive, psychoeducational, and language views revealed that factors such as client preference, clinical
skills. By starting the process with these more global mea- judgment, and an unwillingness to do nothing influenced the
sures, school personnel can determine whether one of these physicians’ judgments. Malterud (2001) not only acknowl-
broad areas is contributing to the student’s classroom diffi- edged the importance of physicians’ clinical insights in mak-
culties. If deficits are noted, appropriate intervention can be ing decisions, but recommended that these insights be studied
planned and tests of APD would likely not be necessary. If, on using qualitative research in order to systematize such
the other hand, these broad measures do not reveal deficits, knowledge for “description and analysis” (p. 398).
the SLP could explore the student’s auditory abilities further We agree with Gillam (1999), who noted that “the best
by analyzing, for example, results from the SCAN-C com- any parent, clinician, or educator can do is make treatment
bined with ratings on the CHAPS and/or performance on decisions that are based on careful consideration of the data
selected tests of auditory perceptual skills (see Table 2). The that are presently available” (p. 364). It should be noted that
SLP with evidence of auditory deficits based on these mea- the fathers of the evidence-based practice movement in
sures would be making a significant case that further testing medicine make this same point about decision making in the
for APD was warranted. presence of inadequate research evidence (Sackett, Rosenberg,
Fourth, current test protocols for auditory processing diag- Gray, Haynes, & Richardson, 1996).
nosis, although flawed, should not be abandoned. Careful Seventh, although theoretically, a team approach involv-
audiologic testing that uses all available methods to control ing the audiologist and the SLP in remediating APDs seems
for the influence of language, attention, and motivation, to logically provide a combination of bottom-up and top-
combined with data from other professionals, can yield a down methodologies, SLPs should be aware of the lack of
meaningful diagnosis. We understand that use of an inter- data supporting the use of popular bottom-up tools, such as
disciplinary testing process is not a substitute for developing FastForWord and AIT. Also, less well-known bottom-up
better testing protocols, but there is a steady and growing approaches described in the literature by Bellis (2002) and
demand for clinicians to assist parents and teachers with Chermak and Musiek (2002) are largely theoretical and in
identification of APD, and this demand cannot be put on hold our view would be difficult to justify to a school district
until more exact clinical protocols are in place. pressed to find the time and money to provide services to
Fifth, despite pressure to do so, SLPs should avoid refer- students. Recommending therapy that uses noncontextual-
ring students who are not good candidates for APD testing. ized, nonspeech tasks in the hopes of targeting an isolated
This includes students with significant intellectual impair- auditory process that may or may not positively affect func-
ment, uncontrolled behavior disorders, and significant sen- tional understanding of language is difficult to justify when
sorineural hearing loss. Attention, language ability, and more global and empirically validated approaches exist.
motivation must also be considered. Adherence to selection Based on this, management should focus on the types of top-
criteria that are consistent with the literature reviewed in this down approaches discussed previously that are designed to
article will reduce the likelihood of misdiagnosis as well as support overall comprehension and functional communica-
the misuse of an APD diagnosis as a substitute for a more tion. These approaches, along with improvements in the
accurate but less acceptable label (e.g., reduced cognitive acoustic environment, can be very useful.
ability, attention deficit). Our eighth and final conclusion is that, as Kamhi (1999)
Sixth, although we encourage the badly needed research noted, clinicians are trained professionals “educated to make
in the area of treatment for APD, we also acknowledge that informed decisions concerning clinical practice” (p. 97).
validation of a treatment is typically a time-consuming They are, as Hedge (1994) noted, systematic problem solvers
process (Dawes, 1994), and clinicians are unlikely to have who cautiously implement solutions to clients’ challenges.
students in need of services and support wait until a critical While important research is ongoing, and always mindful
mass of research is available. Also, based on the current of the limitations inherent in a construct that is still under
disagreements in the literature, it is uncertain that consensus investigation, we hope that clinicians will carefully use
would develop regarding whether adequate evidence had their considerable skills for the benefit of their students and
been collected on which to base treatment decisions. families.
In the absence of treatments that have been validated
specifically for students with APD, clinicians should make
every attempt to use approaches that have been validated with
References
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Auditory Processing Disorders: An Update for Speech-Language Pathologists

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