The Great Debate: Is APD “Real”?

The Debate

A great debate exists questioning whether Auditory Processing Disorder (APD) is even “real”?
Could APD exist when test items are speech based or should a diagnosis be based only on tests using non-speech items?  (For more about speech vs. non-speech based APD testing see here.)
This thinking was based on the belief that when real speech items were used in testing, and deficits were manifest, it had to be due to a language processing disorder.

This argument is further supported by the research of audiologists, who in an effort to find a “pure” auditory pathway, were compelled to acknowledge that there are other neurological processes involved in demonstrating auditory processing skills behaviorally.  This includes attention controls, memory functions and other executive function and cognitive controls.

Considerations

A one way street that is taking us in circles

The irony of this argument is that these supporting processes are equally involved in language processing, and yet a diagnosis of language processing disorder (LPD) goes unquestioned.  Shouldn’t the LPD diagnosis be under greater scrutiny  than an APD diagnosis?
Both these processes depend in part on the same supporting neurological processes mentioned above.  When taking a bottom-up approach, a LPD diagnosis should require evidence that basic hearing acuity and auditory processing has not impacted the results of the language test(s).  We do so once a child is identified as hearing impaired.

Why would results of standardized academic tests be considered invalid if an identified hearing loss is not accommodated for as mandated in the IEP?
This is because we understand that if the test taker cannot hear properly your test results are not truly measuring your competence with the content being examined.  Once you accommodate for the hearing loss and remove that barrier the test result are more valid.  ( “More valid” because there could be other barriers as well, such as a visual deficit)

When we know there is an unidentified barrier to learning, wouldn’t we want to ensure that an auditory deficit is not negatively impacting the test scores of the Child Find or identification process?

The person being tested does need to understand the directions to correctly participate in the testing process.  Leaving us with the argument that all APD tests require good language skills.  This argument is circular, as conversely poor auditory skills would negatively impact performance on any orally administered test, including language tests and intelligence/psycho-educational tests.  A colleague recently shared the following example, a child was asked to point to the picture of a rocket, stumped the child finally turned to the examiner and exclaimed, “but there is no picture of a (tennis) racket!” 

Imagine the outcome for the child who in his eagerness to please simply guesses rather than questions.

Imagine the outcome for the child when the examiner interprets the above exchange as a basis for an ADD diagnosis rather than potentially a sign of ADD or possibly a sign of an auditory deficit, requiring a differential diagnosis.

 

All or nothing

An APD diagnosis requires a greater disparity from the norm than the other diagnoses discussed here.  Furthermore, failure in multiple tasks is recommended.  On the other hand, language has 5 distinct areas (phonology, morphology, semantics,  syntax and pragmatics).  Having a deficit in any one of these areas is sufficient for diagnosis, the assessor simply specifies what the Specific Language Impairment is in. (SLI was the terminology used precisely to indicate the need to specify what area(s) were impacted i.e. what type of SLI.)   This makes sense, for why should a child need to have deficits in multiple areas?  Just help them where they do have a deficit.  Similarly there are different types of APD and yet there is a cumbersome demand that APD be proven by manifesting in more than one area.  This results in denial of targeted remediation for those who suffer from such an auditory deficit.

Confidence in the Diagnosis

Clinical skill

Clinical practice requires the professional to employ both the science and the art of their profession.  A skilled practitioner can tweak apart many of the confounding concerns mentioned above.  This includes looking at the types of errors, the pattern of error, or the situation in which the error is manifest.

Will’s mom’s chief complaint was that Will could not read, even though he had received support services in school for a year.  Mom requested a level IV assessment, as she did not want to simply know if Will’s hearing and auditory processing were intact, she wanted to be informed of any contributing factors that were inhibiting Will’s success as well as how best to teach him to read.  When asked to read out loud, he couldn’t.  However, when asked to read to himself and answer comprehension questions on age appropriate material, Will scored 100%.  Will did not suffer from a reading problem, he suffered from poor practitioners, as neither the assessors nor his provider identified that he was in fact reading just fine, just not out loud.

Chuck passed the school hearing screening, a day after he demonstrated a moderate hearing loss at the audiology clinic due to middle ear fluid.  When asked how he had passed the screening he informed us that the person giving the screening would look down, press the button and then look up expectantly for a response.  Chuck passed a test of non-verbal communication, i.e. attending to the examiner, recognizing an expectant look, remembering what was expected and cooperating in his response.  This was not a hearing test. 

Assessment Rigour

Since the APD assessment process undergoes a far greater degree of scrutiny than the other assessments mentioned here, audiologists are typically more vigilant for confounding issues.  While there are some school districts that are an exception to this, in far too many locales no such rigour is demanded of language or psycho-educational testing, and ADD is usually not tested at all.  Too often we see people come for an APD assessment only after they have “tried everything else” .  An SLP does not have to defend that their findings of LPD may be due to an auditory issue while the audiologist is often dismissed as part of the child find process with the reasoning that APD findings may be explained by ADD or LPD.  Some school aged children have even been denied APD testing based on being deemed of “too low intelligence” by the school psychologist.  Never is the school psychologist required to defend that his/her results are perhaps impacted by an APD.

Samantha’s mom shared the results of the school-based CELF assessment.  Samantha performed within normal limits on all the language subtests and only failed on the auditory subtests.  The examiner dismissed this finding with a comment that “the participant had fatigued”.  Given that the auditory subtests are administered in the middle of  this battery, and testing was completed in one session with no break, it struck both mom and dad as odd for a child to fatigue and then spontaneously recover.  This was an obvious red  flag for APD that was dismissed.

Conclusion

It is important to be an educated consumer so that you know what you need and how to go about getting it.  At Hearing Kids we believe that potential bottom-up contributors should be assessed first.  In this way the necessary accommodations can be provided to facilitate obtaining valid results on higher order testing such as language skills or IQ.  We want your true intelligence to be celebrated rather than hidden under an unidentified physical disability of audition, praxis or vision.

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