Guest Editorial: Auditory Processing Disorder

A recent submission to Ear and Hearing on early diagnosis is controversial that people with hearing loss or identified brain
of auditory processing disorder (APD)* ended up on my desk lesions may have (additional) hearing deficits originating in the
after three expert reviewers, and another member of our Edito- central auditory system. However, the notion that children with
rial Board provided a highly detailed critique of the paper. What listening difficulties† have a disorder of central auditory func-
most caught my attention was that two of three reviewers ques- tion that may be diagnosed with some arbitrary combination
tioned the premise of whether an earlier diagnosis of APD will of the commonly used clinical tests for APD (Emanuel et al.
ultimately prove useful because the status of APD is so contro- 2011) is unjustified in the view of many scientists and clini-
versial (reviewer 1) or difficult to verify (reviewer 2). I know of cians, including the Editorial Board of this journal. Such a diag-
no other area of audiology or neuroscience where such a long- nosis could even be harmful if it prevents children receiving
standing intellectual, theoretical, and practical impasse exists. evidence-based and soundly reasoned diagnosis and treatment.
In contrast to the “consensus on CAPD” cited by the authors
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(American Speech, Language and Hearing Association, ASHA THEORY

2005; American Academy of Audiology, AAA 2010), it has been
increasingly argued recently that most if not all cases of child- Several scholarly papers have questioned the construct of APD.
hood “APD” are either better characterized by more commonly For example, Cacace and McFarland (2009) have long argued that,
recognized learning disorders, especially language disorder to be a useful construct, APD should produce poor performance
(de Wit et al. 2018), or by specific difficulties, for example hear- that is relatively specific to tasks involving auditory stimuli. They
ing speech in noise (DeBonis 2015) or spatial hearing (Cameron have demonstrated that aspects of acquired APD may satisfy this
et al. 2014), that are firmly grounded in psychoacoustics. So criterion but that is not the case for developmental APD. Based
the bigger question I began to ask is whether and how Ear and on criteria firmly established in medical science, Vermiglio (2014)
Hearing and other academic journals should be handling work contrasted the case for “APD” with that of “hearing speech in
submitted on “APD.” After consultation with and encourage- noise” as “clinical entities” (disease categories), concluding that
ment from our Editorial Board, I thus prepared this article that is whereas hearing speech in noise does meet the criteria, APD does
endorsed by the whole Board and that will become journal edito- not, despite the recent inclusion of APD in the International Clas-
rial policy, effective immediately for new submissions. Briefly, sification of Diseases 10. DeBonis (2017) has recently presented
the new policy is that “articles that either implicitly or explicitly an evaluation of the American Academy of Audiology recommen-
assume APD is a single diagnostic characteristic of the auditory dations on APD (AAA 2010) in terms of their effectiveness as
system likely will not be considered for publication.” credible and useful clinical practice guidelines. He found that they
did not meet many of those key requirements and therefore failed
to provide meaningful guidance for clinicians.
HISTORY, ANCIENT, AND MODERN One key theoretical issue advocated by proponents of APD
It is not clear when the term APD was first used. Robert is that the major current tests derive legitimacy from their sen-
Keith, recently retired from the University of Cincinnati, has sitivity and specificity. However, there is no recognized “gold
been in the field longer than most and he first heard it in 1973, standard” for APD (Dillon et al. 2012; Vermiglio 2016). Com-
used by Jack Willeford at an ASHA meeting. Long before that, parison with such a gold standard would be the normal route
Myklebust (1954) had observed that some children with appar- for determining clinical sensitivity and specificity. Instead, the
ently normal-hearing sensitivity “cannot listen…they cannot argument for sensitivity and specificity (AAA 2010, pp. 15–16)
direct their attention selectively to an unexpected sound.” James appears to be based on the following logic. Adults with brain
Jerger has a very readable chapter on the history of APD in a lesions known to involve the central auditory system often per-
book that was influential on my thinking, “Controversies in form poorly on the most commonly used behavioral tests for
Central Auditory Processing Disorder” (Cacace & McFarland APD. Some children without suspected or confirmed brain
2009). Numerous international audiology societies have pub- lesions also perform poorly on those same tests. Because the
lished their own guidelines on APD but I would like to cite one tests provide good sensitivity and specificity for central auditory
part of the British Society of Audiology guidelines (BSA 2011, lesions in adults, so the argument goes, a similar pattern of test
2018; Moore et al. 2013) that may help define and limit what it results in children confirms a biological entity, APD, in those
is I object to. The BSA proposed three types of APD: secondary children with assumed similar test sensitivity and specificity.
APD, acquired APD, and developmental APD. Secondary APD The primary flaw in this argument is a simple logical one, that if
was so called because of its association with a known genetic A(lesions) is associated with B(poor test results) and B is asso-
cause or peripheral hearing impairment. Acquired APD is asso- ciated with C(some children), then A must be associated with C.
ciated with a known neurological event, such as trauma, stroke, Although we might accept that impaired “auditory processing”
or infection. But it is developmental APD, normal audiometry is associated with brain lesions in adults, there are many factors
with no other known etiology and presumably present from other than brain lesions that produce impaired auditory percep-
birth, to which this article is primarily directed. I do not think it tion in both children and adults, for example, inattention.
†  “Listening difficulties” is used here and in the literature to summarize any
*  The terms APD and central (C)APD are used interchangeably in the literature. self-, caregiver-, or professional-reported problems of hearing or listening,
despite normal audiometry. It does not imply any mechanism.

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617
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618 Moore / EAR & HEARING, VOL. 39, NO. 4, 617–620

Another erroneous belief that appears to underpin much of CLINICAL PREVALENCE, PRESENTATION, AND
the foundation of APD is that impaired auditory performance in EVALUATION
someone with a “normal” pure-tone audiogram must be due to
There is no doubt that many children have listening difficul-
disordered processing in the central auditory system. Although
ties and that many of those who present at audiology or other
this may be the case in some instances, there are at least two
pediatric clinics have “normal” audiograms. In a retrospective
other well-recognized sources of such disordered processing.
record review covering a 5-year period at Cincinnati Children’s
One is the cochlea, where we know that impaired hair cell func-
tion and resulting changes in cochlear compression influence Hospital, we identified 1113 children who had normal audio-
spectral and temporal tuning somewhat independently of pure- grams and had undergone a “central auditory processing evalu-
tone sensitivity (Oxenham & Bacon 2003). The second is so- ation” (Moore et al. 2018). These children almost all had other
called top-down influences on hearing, for example, attention, complications, most typically speech/language or attention
memory, emotion, and learning as elaborated below. impairments and a variety of other well-recognized learning
A final issue concerns the words auditory, processing, and disorders (e.g., behavioral/emotional, cognitive delay, dyslexia).
disorder. As argued above, APD does not satisfy the criteria of Evaluation of all children included the SCAN battery but just
a “disorder” and, below, the problems it attempts to describe are 14 children would be classified “disordered” according to the
not confined to the central “auditory” system. Neuroscientists SCAN manual (Keith 2009). Eleven of those 14 had a diagnosis
and psychoacousticians have also expressed strong reserva- of either or both speech/language or attention disorders, 2 had
tions about the word “processing” (e.g., Brian Moore, Novartis academic problems, and just 1 child lacked an associated diffi-
Foundation, London, 2009). It has been used to imply central culty or an alternative explanation of their listening difficulties.
neural function, but major “processing,” including transduc- After a 2-year search in an ongoing, prospective study, we
tion of sound, also occurs in the ear. It is thus my contention have found 2 of nearly 100 extensively examined children who
that “processing” is everything—and therefore nothing—as a may have a specific, auditory-based problem. All these children
description of auditory function and pathology. had normal pure-tone audiograms but caregiver reported lis-
tening difficulties, assessed using the “ECLiPS” questionnaire
(Barry et al. 2015). Several of those who have come closest to
EVIDENCE the elusive “pure APD” had subclinical or minimal hearing loss
Based on my own experience of reading and reviewing hun- (e.g., high-frequency pure-tone thresholds of 15 to 25 dB HL).
dreds of submissions and publications on APD over a 15-year No physiological, central auditory system processing abnormal-
period of research in this area, I offer the following observa- ities have yet been observed. Testing has included click-evoked
tions. Some papers are based on original experimental data brainstem responses, frequency following responses, and 3-T
and have been peer reviewed, but publications on APD often magnetic resonance imaging of auditory cortex in an attempt
state a series of opinions or clinical anecdotes that lack rig- to differentiate these children with listening difficulties from
orous review and have no solid foundation in theory or evi- their typically developing, age-matched peers. Faced with this
dence. Many of these publications are lavishly referenced but evidence, or lack of evidence, it cannot be said that APD does
the references are often inappropriate, obscure, or unreviewed not exist. However, using the most specific and sensitive tests
sources. Among those that have been reviewed, the premise of central function in children selected by concerns about their
for the study usually assumes, and review sometimes insists ability to listen, we do not see any clear APD. By contrast, there
on adherence to the ASHA and AAA position paper guidelines is no shortage among the children with listening difficulties in
that identify a child with APD based on performance 2 or 3 SDs this sample who have poor speech in noise hearing, correlated
below the norm for one or more commonly used clinical tests with slight to moderate impairment of cognitive skills (using the
(Emanuel et al. 2011; DeBonis 2017). For the most part, these NIH Cognition Toolbox; Weintraub et al. 2013).
norms do not actually exist and, where they do, they may only
be gleaned from sources unavailable for verification. There are
ACTION
some exceptions (e.g., SCAN-3 battery; Keith 2009) but per-
formance on the tests used is, without exception, dependent on Let’s be bold! For too long, mainstream auditory science
a complex set of skills of which “processing” within the classic has simply turned a blind eye to APD. In the meantime, thou-
central auditory system (auditory nerve to auditory cortex) is sands of children are being inappropriately or inadequately
just one. Rather than carefully describing the data and point- advised about the nature and management of their listening
ing to the myriad interpretational issues and limitations of the difficulties. On the clinical side, only about half the larger
study, publications in this area typically advocate their results audiology services in US children’s hospitals offer an APD
as supporting a clinical diagnosis for children whose symp- evaluation or at least they did 3 years ago when a small survey
toms lack any clear connection with the tests they have been of 18 services was performed (L. L. Hunter, Cincinnati Chil-
given or any well-evidenced form of intervention other than dren’s Hospital, personal communication, 2017). At Cincin-
simple advice on listening strategies or other acoustic enhance- nati Children’s Hospital, the number of children being tested
ments. An article by Wilson and Arnott (2013) examined per- for and diagnosed with APD has been on a steep downward
formance on commonly used APD tests of 150 children with spiral over the past decade (Moore et al. 2018). Why do so
normal peripheral hearing using nine sets of diagnostic criteria many services with some of the best records for audiological
drawn from published sources. Based on published guidelines, research and training not have an active APD clinic? I can-
they found rates of potential APD ranging from 7% to 93% of not provide evidence on this but personal enquiry about APD
the study children. The authors supported “calls to abandon the in those services usually results in rolling eyes and a polite
use of (C)APD as a global label.” suggestion we move the conversation along to things that are

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 Moore / EAR & HEARING, VOL. 39, NO. 4, 617–620 619

defined and measurable. It may be impossible to separate fully assume APD is a single diagnostic characteristic of the auditory
the sensory and cognitive components of hearing. The separa- system likely will not be considered for publication.
tion becomes more difficult as stimulus and task complexity More broadly, is it the role of a scholarly journal to place
become increasingly realistic. To make a verbal or other report even a partial ban on a controversial subject? I think the answer
of what an individual hears it is necessary for a sound or its is in the word “scholarly.” Definitions include “learning” and
neural representation to pass through the various elements of a “fund of knowledge…drawing on the ancients.” In science,
the middle ear, cochlea, brainstem, midbrain, thalamus, audi- unless we learn from reason and respect our legacy of experi-
tory cortex, the many multimodal parts of the cortex with their ments, painstakingly documented, reviewed, and curated, we are
heavy, bidirectional interconnectivity, and finally, the motor nothing.
(action) centers and their effector systems that all play a criti-
cal role in even the most simple auditory-verbal tasks. How
then, as recommended in APD guidelines, does an audiolo- ACKNOWLEDGMENTS
gist working in a busy clinic use their “professional skills” to I wish to thank Bob Burkard, Harvey Dillon, Lisa Hunter, and Robert Keith
ensure that a child with listening and other behavior issues is for helpful and spirited comments on earlier drafts of this article. However,
attentive, motivated, and intellectually gifted enough for those opinions expressed here remain mine, with the endorsement of conclusions
multitudinous, multimodal systems not to influence the child’s and policy from the Ear and Hearing Editorial Board.
perception of a threshold-level, complex auditory task? My own pediatric research is supported by the National Institutes of Health
Audiologists will continue to see children with listening (Grant R01DC014078), the Oticon Foundation, and the National Institute
difficulties but with normal audiograms. There is active dis- of Health Research (NIHR Manchester Biomedical Research Center, UK).
cussion and some implementation of alternate clinical models Address for correspondence: David R. Moore, PhD, Communication
(Cameron et al. 2015; BSA 2018). These typically begin with a Sciences Research Center, Cincinnati Children’s Hospital, Cincinnati, OH,
well-validated questionnaire, to establish or confirm the nature USA. E-mail: [email protected]
of the reported difficulties, and a thorough audiological exam.
They also incorporate speech in noise testing following rigor-
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