Auditory Processing Disorders: What You Need to Know
We all have trouble occasionally understanding and paying attention to what is said to us, but if your child seems to frequently struggle to process what they hear, they may actually have an auditory processing disorder. Auditory processing disorder (APD), also known as central auditory processing disorder (CAPD), is often misdiagnosed as an attention deficit disorder. To learn more about how the auditory pathways work and how we can best support our kids, we reached out to Dr. Bea Braun, founding audiologist at the Auditory Processing Center, as well as speech language pathologist Angie Thudium (M.A., CCC-SLP) of Formation Speech Therapy.
What APD means
Auditory processing is disrupted when a deficit in the auditory pathway of the brain results in a child’s inability to listen to or comprehend auditory information accurately. This doesn’t mean a child cannot understand meaning, or that their hearing is affected. Dr. Braun describes APD as the brain “mishearing” the sound. (For example, “Please raise your hand” might arrive as “Please haze your plan.”)
According to speech language pathologist Angie Thudium, more often than not, children who have APD:
- are male
- receive normal pure-tone hearing results
- have difficulty following oral directions
- have poor short-term and long-term memory
- appear to be daydreaming
- have difficulty listening when background noise is present
- have difficulty localizing sound
- may be easily distracted, impulsive, or frustrated
- frequently ask for verbal repetition (“huh?”)
- have a history of ear infections.
Prevalence and comorbidities
The Hearing Health Foundation estimates that at least 5% of all school-aged children in the U.S. have APD. Dr. Braun explains that it’s difficult to quantify the percentage of children who have auditory processing issues because they are often misdiagnosed or missed entirely. In fact, teachers, psychologists, and other care providers sometimes miss the signs of APD because it can look so similar to attention issues. “All of these things that can look like inattention — like playing with things on his desk, bugging his neighbor — might just be him not being able to process instructions, or maybe she doesn’t understand what you’re saying,” Dr. Braun says. “If you were in a lecture hall and someone was speaking a different language, you wouldn’t be riveted.”
While APD is often confused with or misdiagnosed as ADD, ADHD, or autism, Dr. Braun tells us that sometimes APD turns out to be a comorbidity (or co-occurring diagnosis). “I see a lot of kids with comorbid issues such as autism, ADHD, or learning or speech disorders alongside an auditory issue,” she says. “For me, though, it’s just consistency in my findings. So if a child [also] has attention issues . . . that just tells me we have both issues.”
Comorbidities are fairly common among children who have already been diagnosed with other disorders such as a speech delay or learning disability. “Among populations of children who are already identified as having a learning disability or speech and language disorder, I want to say that number is close to fifty percent,” Dr. Braun says. “[APD] is a big part of the whole picture of a kid who is struggling with learning issues, and it often gets completely ignored.”
Typical age of diagnosis
While the American Academy of Audiology (AAA) and the American Speech-Language-Hearing Association (ASHA) recommend that children be assessed for auditory processing disorders at around age six or seven, more recent findings indicate no reason to wait to evaluate a child for APD. (According to this article, neither ASHA nor AAA place limits on when a child can be tested.) Dr. Braun tells us she tests children as young as five. “What I have found is that if you do auditory training with kids that are young, the improvement is unbelievable. It’s really a magic bullet, so I feel the younger you can test them, the better,” she says.
Audiologists and other professionals often use screening questionnaires to determine if a child is showing signs of APD. Dr. Braun has developed her own, but also occasionally uses the Fisher’s Auditory Problems Checklist, which was developed in 1976, and is still used alongside other screening tools. (Some researchers question the validity of these screening protocols and how they’re used to diagnose CAPD.) Screening questions, such as how often the child asks “huh” or “what,” and how often they ask for instructions to be repeated, are designed to gauge how well children are absorbing what they’re hearing. Dr. Braun feels the questionnaires are a good starting point, but children’s academic performance in the classroom is often a bigger clue.
Behavioral markers such as difficulty listening and following multistep directions as well as needing a lot of repetition tend to be more apparent in an academic setting. “You’ll see issues with learning phonics, learning how to read, and reading comprehension,” Dr. Braun says. “Those are all pieces of the higher-level academic issues that will appear.”
How APD is typically diagnosed
The first step to evaluating a child for an auditory processing disorder is checking their hearing. Dr. Braun begins with a full hearing assessment to make sure both ears are healthy and hearing is balanced in both ears. Once she has ruled out an issue with the child’s hearing, she assesses for processing using a wide variety of listening activities. The child will hear tonal patterns, pitches, and sentences that are spoken very quickly or warped. Dr. Braun’s goal is to determine exactly where the processing issue is occurring, so she can recommend the best accommodations for the child. “Auditory processing is actually an umbrella, and there are several different subtypes under that umbrella. That’s why it’s important to get a full assessment [in order] to pinpoint where along the auditory pathway the breakdown is occurring,” she says.
While professionals like speech language pathologists, therapists, and psychologists can note the symptoms of APD and conduct initial screenings, only a trained audiologist can diagnose it due to the technical nature of the testing. If a school assesses a child for APD, and an audiologist determines that your child needs more assessment, you can request a private evaluation, which Dr. Braun says many school districts will reimburse.
Supporting our kids from home
Auditory training programs can help children develop stronger auditory processing pathways and understand more of what is said to them by teachers, parents, caregivers, and peers. Dr. Braun often recommends dichotic listening programs such as CAPDOTS and HearBuilder for at-home training.
With strong auditory training, Dr. Braun says she’s found many children may not need long-term accommodations: “Auditory training is like weight lifting for the brain,” she says. “Repetition is super important.”
SLP Angie Thudium suggests the following classroom accommodations be written into the IEP to best support a child with APD:
- Preferential seating: The student should sit close to the area of instruction where they can see the teacher’s face. The goal is less to sit at the front of the classroom than it is to limit distraction, so avoid seating a child by an open door or window, especially when shifting light affects a student’s ability to see the teacher clearly.
- Reduce background noise: Before beginning instruction, teachers should scan the classroom for sources of background noise such as open doors or windows or group learning. Even mild noises such as the hum of a fan may be enough to create a poor listening and learning environment for the child.
- Consider the acoustics: If the room has a tiled floor and unfinished walls, there is a high probability of echos. Placing a rug or carpet on the floor can reduce this effect. Decorating the walls with student art or other items that absorb sound will also help.
- Provide additional written or visual material: Consider using technology like projected screens to outline key points on the board. Write down important words, concepts, and assignments for the class to see. Whenever possible, supplement verbal instruction with written material. Provide study guides at the beginning of the lesson. Distribute vocabulary lists or written outlines to accompany instruction.
- Consider an FM system to amplify the teacher: An FM system is a broadcast-type device that increases the volume of the teacher’s voice while minimizing background noise. Headphones can help ensure a student hears the teacher’s voice clearly with fewer surrounding noises.
- Consider your distance: When a child is spoken to from a great distance (more than 5 feet), they will be challenged to comprehend what is said. Sound intensity drops quickly over a short distance. Moving closer is a great, easy help.
- Ensure the child’s attention: Use attention-getting methods such as making eye contact before beginning instruction, calling the student’s name, telling the class to “Listen” or “Pay attention,” or touching the child on the shoulder.
- Modify speech and gestures to enhance verbal presentations: Use body language, facial expression, and verbal emphasis and gestures to clarify content. Altering inflection, pitch, volume, and speaking rate can emphasize key words and emotional content.
- Ask questions to check comprehension: Formulate questions for the student to think about and answer as the information is presented. Check the who, what, when, where and how facts. Encourage questions, discussion, and class comments to encourage active participation in learning.
- Simplify directions and verbal instruction: Present short, focused directions when giving assignments or summarizing information. Divide complex instruction or materials into numbered parts or steps. Shorten sentences and use less complex vocabulary to describe tasks. Children with APD need time to take in and process what is said.
- Use a peer-pairing or buddy system to check notes and/or assignments: Children are more open to help from peers than the teacher, and can access their peer whenever they have a question or want to check the accuracy of materials.
- Restate, paraphrase, and emphasize the important words: Have the student repeat information after it is presented by the teacher. Use verbal markers and stress to emphasize content. Use phrases like “This is important” to cue children with APD that important information is coming.
Has your child received an APD diagnosis? Can you share any support strategies you’ve learned? We’d love to know!