Auditory processing disorders is a term that is used in so many different ways that no one really knows what it mans.
Basically, in order to process information, one has to be able to hear audiitory informnation - both linguistic(i.e language) and non-linguistic with one's ears and process it all in the brain. There are many levels of breakdown in this incredibly complex system. Because it is so complex, there are many theories about what it is, how it happens, what goes wrong and how to fix it.

"Auditory processing disorders" can be

 

1. Developmental.

This means that in the absence of any known cause, children have difficulties processing auditory information. These difficulties can persist for life.

 

or

 

2. Acquired.

This means that some people can start to have difficulties processing auditory information following an event like a stroke, tumour, head injury.

 

or

 

3. Secondary.

This means that difficulties processing auditory information are associated with hearing loss.

 

 

 Children who have on-and-off ear infections often land up with difficulties processing auditory information, maybe because when they have ear infections, their hearing is:

(1) inconsistent

(2) unequal between the ears

(3) associated with fever and pain sometimes

(4) in the low frequencies which we need for vowel discrimination

(5) difficult. It takes effort to listen and like all human activity, if it is too hard, we stop doing it.

 

Older adults who lose their hearing, also have difficulties processing auditory information. This is because

(1) it's too much effort to hear

(2) the nature of the hearing loss itself interferes with hearing e.g. most older people lose the high frequencies which makes it really hard to discriminate  (like mish/mitch/miss/midge)

(3) it is often difficult to hear in noise

(4) loud sounds sound extraordinarily loud

(5) some older people lose their powers of concentration

(6) some older people get tired more easily

(7) there are also changes in the brain itself that make it difficult to manage hearing the sounds - we call it "phonemic regression"

(8) We start to lose concentration because we are confused

(9) we feel socially isolated if we cannot hear. We have no idea what the topic of conversation is and we feel excluded.

(10)  And depressed. And when we are depressed and anxious and confused, we can't process information.

 

Anyone with a hearing loss is at risk of having difficulties processing auditory information. When its difficult to hear, when the sounds are distorted, when hearing is unreliable, then it is very difficult to process sounds.

So, the EARS HEAR but the BRAIN PROCESSES

 

Many years ago, audiologists defined difficulties processing auditory information as "CENTRAL auditory processing disorder" (CAPD).  They came up with this terminology so that there would be a clear understanding that information processing is a function of the brain.  There was a lot of debate on this, and official organisations like the American, British, Canadian, Australian and the South African, associations of audiologists thrashed out arguments. Nevertheless, a host of measures were developed for audiologists to test what happened to auditory information beyond the level of the ears.   A whole lot of official documents recommended test protocols for the assessment of CAPD. They were really interesting, really expensive, really impressive. They were based on the fundamental theory that APD is a DISTINCT condition that is not linked directly  to language and cognition. On the ASHA website, the point is made very clear that APD is a distinct condition (See http://www.asha.org/public/hearing/Understanding-Auditory-Processing-Disorders-in-Children/)

 

However, there is literature today that questions this theoretical stance.

 

  (See DeBonis, D (2015) "Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children".  American  Journal of Audiology,  24 ,  124–136).

 

We have seen that the special tests don't really differentiate CAPD from other problems.  So we are left, again, with depending mainly on what we used to do before. We use behavioural testing. We observe listening behaviours in the various contexts of people's lives. We see AP as woven together with hearing, language, listening - focus and concentration and impulse control, personality, emotional state, intelligence, cultural norms, environment. We have to look at every INDIVIDUAL and DESCRIBE WHAT HE OR SHE CAN AND CANNOT DO, and work from there.

 

There are signs in adults and children of difficulties processing auditory information

(note that I am not talking about a "diagnosis" of APD but rather of looking at what the person can and cannot do with regard to processing auditory information. I do not believe, given the new literature that is available to us, that there such a diagnosis of APD, but that these AP difficulties are associated with a range of problems and their basis is not a central auditory processing one)

 

Signs in adults include: (from https://www.nidcd.nih.gov/health/voice/auditory.html)

  • talk louder than necessary

  • have trouble remembering a list or sequence

  • often need words or sentences repeated

  • have poor ability to memorize information learned by listening

  • interpret words too literally

  • need assistance hearing clearly in noisy environments

  • rely on accommodation and modification strategies

  • find or request a quiet work space away from others

  • request written material when attending oral presentations

  • ask for directions to be given one step at a time

 

Signs in children include

  • being disorganised

  • don't remember nursery rhymes or songs

  • don't remember people's names

  • muddle up their sounds (e.g. "merote" for "remote")

  • have trouble paying attention to and remembering information presented orally, and may cope better with visually acquired information

  • have problems carrying out multi-step directions given orally; need to hear only one direction at a time

  • have poor listening skills

  • need more time to process information

  • have low academic performance but some don't

  • have behavior problems but many don't

  • have language difficulties (e.g., they confuse syllable sequences and have problems developing vocabulary and understanding language)

  • have difficulty with reading, comprehension, spelling, and vocabulary

  • can't tell background noise from foreground noise

  • can't cope in noisy environments

  • are easily distracted

  • get overwhelmed by noise

 

 

Getting to the bottom of things:

 

1. Have a hearing test.

An audiologist is essential! We have to know about the ears and about speech discrimination.

 

2. Have a speech-language assessment which will include an assessment of language competency, phonological skills, as well as a behavioural assessment of AP.

 

3. Have a multidisciplinary assessment if need be (psychologist, neurologist, occupational therapist, physiotherapist etc).

 

 

 What to do to help:

 

 

 

  • Reduce background noise at home. Turn off TV, radios.

  • When talking to a person with difficulties processing auditory information, be aware of background noise - it really interferes with their processing.

  • If the person needs to work, study, focus, concentrate, make a quiet place available. A child with difficulties processing auditory information needs a quiet place to study. Try not to use the kitchen table.

  • When speaking:    

    • use short sentences 

    •   use a slightly louder voice OR a slightly softer voice

  • Ask the person to look at you while you speak - but for some children, this is HARD TO DO! Don't force it. Some listen better if they are NOT looking at you - and be aware of cultural norms - many South African cultures find eye contact abhorrent!

  • In the case of children, use "re-auditorisation" - get the child to repeat what you have said. But with meaning. Some can repeat what you have said but have not PROCESSED it.

  • Some people benefit from notes - diaries, lists, Post its.

  • Visual aids really help. Convince the boss or the teacher that the person or child NEEDS to take a photo of the notice board/blackboard/smartboard.

  • Ask the teacher to make sure she e mails the homework to you - the child might not PROCESS what she instructs. Also, may teachers "throw out" a last minute instruction just as children are packing up to move out of the classroom!

  • Use cell phone reminders

  • Use cell phone or digital recorders - so you or a child can listen again

 

Teachers can be of great help

  • Put the child near to where you do most of your teaching

  • Don't teach a child with difficulties processing auditory information from behind

  • Remember that group work is really hard for a child with difficulties processing auditory information

  • Lower the noise levels of your classroom. If you can - get a carpet, make sure your lights don't hum, put the child far away from a fan or anything else that makes a noise like an open window.

  • Give lots of visual aids to supplement auditory instruction BUT some children will be overwhelmed if they have visual processing problems as well.

  • Speak clearly. You don't have to SHOUT at a child with difficulties processing auditory information ...sometimes talking softly helps more.

  • Children with difficulties processing auditory information get ANXIOUS...when you talk to them, be gentle, reassuring, and smile. It really helps! Be genuine ... trust is a big issue for some children.

  • Provide written instructions or a homework list. You want the homework to be done. So what if you have to write it down.

  • Please get over the attitude "But he has to learn some time". You are right BUT  he can't right now. And no amount of putting a child with difficulties processing auditory information through the punishment of not helping him will teach him the skills you want him to learn. Rather just help him.

  • Provide additional aids for study like a digital recorder, photocopies of another (good) student's notes, or assign the student a “homework buddy.”

  • Don't expect children to ask their '"friends" for reminders or help. This does not happen - often these children do not have friends; or their friends don't like helping; or and they don't like asking more than once. It is YOUR responsibility as a teacher to make it happen.

  • Let them take photos of the work on the blackboard or smartboard.

Additional ideas

  • FM systems are electronic devices that the teacher and the child wears. The child hears the teacher's voice  directly. they therefore lower the background noise. There is quite a lot of data that shows these systems are effective. The speech therapist and/or audiologist will advise you.

 

 

 

 

 

 

There is no one definition of auditory processing disorders, and there is a lot of controversy regarding how to assess and manage these problems. I am going to present an overview of this area to give some idea of the complexity, but also to warn people about being sucked into signing up for therapy that is questionnable. There are a lot of programmes out there that promise the earth, cost the earth, and deliver next to nothing.
 
Auditory processing disorders go by many names:
Central auditory processing disorder
Listening disorder
Auditory processing disorder
Auditory information processing disorder.
 
It includes, but is not the same as "PHONOLOGICAL PROCESSING DISORDER - see the page on this topic specifically by clicking here).
 
Many people refer to phonological processing problems as auditory processing problems, but the two things are not the same.

 

 

 

 

 

 

 

 

In a brief,  AUDITORY PROCESSING means "what we do with what we hear":

 

  • Discriminating between speech and non speech sounds

  • Holding the sounds in one's memory

  • Putting the sounds together

  • Comparing what was heard with what one has heard before

  • Determining if the sounds make a new or familiar word

  • Linking the sound to one's language

  • All the time remembering what was heard

  • Acting on what was heard

  • And doing it simultaneously with trillions of sounds being heard at the same time.

 

 

 

'Auditory Processing Disorders' are usually not isolated. The entire speech-language-hearing system is an integrated system.  Difficulties with processing what we hear are more often than not associated with speech, language and hearing problems. This means that difficulties processing speech and/or language may be the reason for the speech and language problems OR the speech and/or language problems may be the cause of the difficulties processing speech and/or language.

So children with receptive language problems can also have difficulties processing sounds; people with hearing losses can also have difficulty processing sounds; people with apraxia of speech which is really a MOTOR function can also have difficulties processing sounds. etc - the point is that we must not lose focus on the WHOLE system.

"Auditory processing disorders" can be

 

1. Developmental.

This means that in the absence of any known cause, children have difficulties processing auditory information. These difficulties can persist for life.

 

or

 

2. Acquired.

This means that some people can start to have difficulties processing auditory information following an event like a stroke, tumour, head injury.

 

or

 

3. Secondary.

This means that difficulties processing auditory information are associated with hearing loss.

 

 

 Children who have on-and-off ear infections often land up with difficulties processing auditory information, maybe because when they have ear infections, their hearing is:

(1) inconsistent

(2) unequal between the ears

(3) associated with fever and pain sometimes

(4) in the low frequencies which we need for vowel discrimination

(5) difficult. It takes effort to listen and like all human activity, if it is too hard, we stop doing it.

 

Older adults who lose their hearing, also have difficulties processing auditory information. This is because

(1) it's too much effort to hear

(2) the nature of the hearing loss itself interferes with hearing e.g. most older people lose the high frequencies which makes it really hard to discriminate  (like mish/mitch/miss/midge)

(3) it is often difficult to hear in noise

(4) loud sounds sound extraordinarily loud

(5) some older people lose their powers of concentration

(6) some older people get tired more easily

(7) there are also changes in the brain itself that make it difficult to manage hearing the sounds - we call it "phonemic regression"

(8) We start to lose concentration because we are confused

(9) we feel socially isolated if we cannot hear. We have no idea what the topic of conversation is and we feel excluded.

(10)  And depressed. And when we are depressed and anxious and confused, we can't process information.

 

Anyone with a hearing loss is at risk of having difficulties processing auditory information. When its difficult to hear, when the sounds are distorted, when hearing is unreliable, then it is very difficult to process sounds.

So, the EARS HEAR but the BRAIN PROCESSES

 

Many years ago, audiologists defined difficulties processing auditory information as "CENTRAL auditory processing disorder" (CAPD).  They came up with this terminology so that there would be a clear understanding that information processing is a function of the brain.  There was a lot of debate on this, and official organisations like the American, British, Canadian, Australian and the South African, associations of audiologists thrashed out arguments. Nevertheless, a host of measures were developed for audiologists to test what happened to auditory information beyond the level of the ears.   A whole lot of official documents recommended test protocols for the assessment of CAPD. They were really interesting, really expensive, really impressive. They were based on the fundamental theory that APD is a DISTINCT condition that is not linked directly  to language and cognition. On the ASHA website, the point is made very clear that APD is a distinct condition (See http://www.asha.org/public/hearing/Understanding-Auditory-Processing-Disorders-in-Children/)

 

However, there is literature today that questions this theoretical stance.

 

  (See DeBonis, D (2015) "Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children".  American  Journal of Audiology,  24 ,  124–136).

 

We have seen that the special tests don't really differentiate CAPD from other problems.  So we are left, again, with depending mainly on what we used to do before. We use behavioural testing. We observe listening behaviours in the various contexts of people's lives. We see AP as woven together with hearing, language, listening - focus and concentration and impulse control, personality, emotional state, intelligence, cultural norms, environment. We have to look at every INDIVIDUAL and DESCRIBE WHAT HE OR SHE CAN AND CANNOT DO, and work from there.

 

There are signs in adults and children of difficulties processing auditory information

(note that I am not talking about a "diagnosis" of APD but rather of looking at what the person can and cannot do with regard to processing auditory information. I do not believe, given the new literature that is available to us, that there such a diagnosis of APD, but that these AP difficulties are associated with a range of problems and their basis is not a central auditory processing one)

 

Signs in adults include: (from https://www.nidcd.nih.gov/health/voice/auditory.html)

  • talk louder than necessary

  • have trouble remembering a list or sequence

  • often need words or sentences repeated

  • have poor ability to memorize information learned by listening

  • interpret words too literally

  • need assistance hearing clearly in noisy environments

  • rely on accommodation and modification strategies

  • find or request a quiet work space away from others

  • request written material when attending oral presentations

  • ask for directions to be given one step at a time

 

Signs in children include

  • being disorganised

  • don't remember nursery rhymes or songs

  • don't remember people's names

  • muddle up their sounds (e.g. "merote" for "remote")

  • have trouble paying attention to and remembering information presented orally, and may cope better with visually acquired information

  • have problems carrying out multi-step directions given orally; need to hear only one direction at a time

  • have poor listening skills

  • need more time to process information

  • have low academic performance but some don't

  • have behavior problems but many don't

  • have language difficulties (e.g., they confuse syllable sequences and have problems developing vocabulary and understanding language)

  • have difficulty with reading, comprehension, spelling, and vocabulary

  • can't tell background noise from foreground noise

  • can't cope in noisy environments

  • are easily distracted

  • get overwhelmed by noise

 

 

Getting to the bottom of things:

 

1. Have a hearing test.

An audiologist is essential! We have to know about the ears and about speech discrimination.

 

2. Have a speech-language assessment which will include an assessment of language competency, phonological skills, as well as a behavioural assessment of AP.

 

3. Have a multidisciplinary assessment if need be (psychologist, neurologist, occupational therapist, physiotherapist etc).

 

 

 What to do to help:

 

 

 

  • Reduce background noise at home. Turn off TV, radios.

  • When talking to a person with difficulties processing auditory information, be aware of background noise - it really interferes with their processing.

  • If the person needs to work, study, focus, concentrate, make a quiet place available. A child with difficulties processing auditory information needs a quiet place to study. Try not to use the kitchen table.

  • When speaking:    

    • use short sentences 

    •   use a slightly louder voice OR a slightly softer voice

  • Ask the person to look at you while you speak - but for some children, this is HARD TO DO! Don't force it. Some listen better if they are NOT looking at you - and be aware of cultural norms - many South African cultures find eye contact abhorrent!

  • In the case of children, use "re-auditorisation" - get the child to repeat what you have said. But with meaning. Some can repeat what you have said but have not PROCESSED it.

  • Some people benefit from notes - diaries, lists, Post its.

  • Visual aids really help. Convince the boss or the teacher that the person or child NEEDS to take a photo of the notice board/blackboard/smartboard.

  • Ask the teacher to make sure she e mails the homework to you - the child might not PROCESS what she instructs. Also, may teachers "throw out" a last minute instruction just as children are packing up to move out of the classroom!

  • Use cell phone reminders

  • Use cell phone or digital recorders - so you or a child can listen again

 

Teachers can be of great help

  • Put the child near to where you do most of your teaching

  • Don't teach a child with difficulties processing auditory information from behind

  • Remember that group work is really hard for a child with difficulties processing auditory information

  • Lower the noise levels of your classroom. If you can - get a carpet, make sure your lights don't hum, put the child far away from a fan or anything else that makes a noise like an open window.

  • Give lots of visual aids to supplement auditory instruction BUT some children will be overwhelmed if they have visual processing problems as well.

  • Speak clearly. You don't have to SHOUT at a child with difficulties processing auditory information ...sometimes talking softly helps more.

  • Children with difficulties processing auditory information get ANXIOUS...when you talk to them, be gentle, reassuring, and smile. It really helps! Be genuine ... trust is a big issue for some children.

  • Provide written instructions or a homework list. You want the homework to be done. So what if you have to write it down.

  • Please get over the attitude "But he has to learn some time". You are right BUT  he can't right now. And no amount of putting a child with difficulties processing auditory information through the punishment of not helping him will teach him the skills you want him to learn. Rather just help him.

  • Provide additional aids for study like a digital recorder, photocopies of another (good) student's notes, or assign the student a “homework buddy.”

  • Don't expect children to ask their '"friends" for reminders or help. This does not happen - often these children do not have friends; or their friends don't like helping; or and they don't like asking more than once. It is YOUR responsibility as a teacher to make it happen.

  • Let them take photos of the work on the blackboard or smartboard.

Additional ideas

  • FM systems are electronic devices that the teacher and the child wears. The child hears the teacher's voice  directly. they therefore lower the background noise. There is quite a lot of data that shows these systems are effective. The speech therapist and/or audiologist will advise you.

 

 

 

 

 

 

There are a number of "auditory integration" therapies or programmes available that are being promoted in South Africa and around the world. These should be considered controversial. I am a little unwilling to  say that there is absolutely no evidence that they work, but there is too little to justify using them. Also, my opinion is that anything that is extraordinarily expensive must be justified seriously.

 

Examples are:

SoListen

Tomatis

Berard

Johansen

 

The American Academy of Audiology stated, "There are no published results of peer reviewed studies using controlled populations and using scientific methods that demonstrated whether this auditory training program provides significant improvement in any dimension for any population." http://www.audiology.org/publications-resources/document-library/auditory-integration-training

 

 

An important review of studies regarding ASD and AI that I recommend is Sinha Y, Silove N, Hayen A, Williams K. Auditory integration training and other sound therapies for autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2011;12:CD003681.

 

 

Plain language summary of the 2011 review regarding AIT and autism:

Auditory integration therapy for autism spectrum disorders

People with autism spectrum disorders have difficulties with communication, behaviour and social interaction, and many also experience abnormal responses to sounds. The purpose of this review was to assess the evidence for the effectiveness of auditory integration therapy and therapies like it that have been developed to improve abnormal sound sensitivity and autistic behaviours in such individuals. Seven relatively small studies met the inclusion criteria for the review. These often measured different outcomes and reported mixed results. Benefits for participants receiving auditory integration therapy were only reported in two studies, involving 35 participants, for two outcomes. A study of Tomatis therapy did not measure behavioural outcomes and did not find any difference in language development between intervention and control groups. As such, there is no evidence to support the use of auditory integration therapy or other sound therapies at this time.

 

 

See the following links

 

www.musec.mq.edu.au/public/download.jsp?id=48941

 

http://www.asha.org/policy/TR2004-00260.htm

 

And see this for an excellent overview of the issue in people with autism:

 

http://www.operationautismonline.org/news/how-science-and-evidence-won-out-against-auditory-integration-therapies/

 

 

 

This is a video uploaded in 2016 by the American Speech Language and Hearing Association to YouTube. Although some of us today - given what we have learned over the years and from what has been published recently - are reticent to use the "diagnosis", this talk describes the entire process of processing what we hear, and how this system is tested by audiologists.

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