Hearing starts with a complex set of actions incorporating the outer, middle and inner ear. It enables us to identify sounds and their meaning; for example, it tells us when we hear barking that it is a dog we hear. This is listening, the medical term being auditory processing. When hearing is tested and proved to be in normal limits but understanding of the sounds is not present, this is called an auditory processing disorder (APD).
There is no firm evidence on how many children have APD but it is possible it could be between five and nine per cent. Correctly diagnosing APD is problematic as there is no universal consensus as to what constitutes APD. There is a need to clarify the roles that cognition, attention, memory, processing speech and the processing of speech sounds play in the diagnosis. There is little doubt that further research is needed to obtain widely established criteria in diagnosing APD, otherwise it can be confused with a range of other special needs.
One must ask whether APD is wrongly diagnosed on many occasions because it is a more acceptable term than “specific or generalized language impairment”. However, there is no argument that it does co-exist with other education needs. Pupils with attention deficit hyperactivity disorder (ADHD), autistic spectrum disorder (ASD) or sensory processing disorder (SPD) can be poor listeners and have difficulty in listening and comprehending language. However, this is usually due to their main presenting need (for example their ASD) and although APD can co-exist, careful diagnosis needs to be made to ensure correct therapies are introduced.
APD refers to how the central nervous system uses auditory information: “What we do with what we hear” (Stecker and Henderson, 1992). It is important to remember that APD is specifically an auditory deficit and “does not increase the likelihood that a child would have a language or reading disorder” (Sharma, Purdy and Kelly, 2009). Disagreements of the nature of APD persist, The British Society of Audiologists (BSA) have changed their stance and now believe ‘there is no evidence that it is produced by a primary, sensory disability’ (March 2011).
Bellis believes that APD can only be infallibly diagnosed by an audiologist but nevertheless acknowledges that a multi-disciplinary team approach is critical with input from the teacher, psychologist, and speech and language therapist. Tests have been administered by these professionals and have pointed to some children having an “auditory processing type of disorder”. While I am comfortable with this approach, it is not always easy to achieve because of the lack of suitably qualified personnel, time and funding. I agree with DeBonis (2015) who suggests that merely presenting a variety of sounds by an audiologist in a soundproof room is insufficient evidence to make a diagnosis. Pupils should participate in tasks aimed to test their linguistic system and executive functioning.
Classroom signs of APD
The following are generally believed to constitute classroom behaviours and symptoms exhibited by a pupil with suspected APD:
- difficulty understanding speech in noisy environments
- difficulty following directions
- difficulty discriminating between similar sounding speech sounds
- repeatedly asking for repetition or clarification
- difficulty with oral and written expression
- poor message interpretation
- difficulty making inferences
- poor reading comprehension
- sequencing problems
- paucity of vocabulary
- forgetting information despite over learning
- requiring increased processing time to respond to questions.
Children who come under the umbrella of “language impairment” can equally exhibit these types of difficulties. Dawes and Bishop stated this view in 2009: “A child who is regarded as having a specific learning disability by one group of experts may be given an APD diagnosis by another”.
Should a diagnosis of APD be made, however, it is important not just to confine intervention to a blanket type remediation strategy. It is essential to adopt an individualised approach, as APD manifests in a range of areas. Difficulties can be present in one or more of these areas:
- auditory discrimination – difficulty comparing and distinguishing separate sounds. For example, eight and eighteen may sound alike
- auditory figure ground – inability to disregard background noise, making focusing on a speaker a problem
- auditory memory – forgetting information despite over learning
- auditory sequencing – difficulty in recalling order of sounds and words.
The right support
There are number of key strands involved in assisting a pupil with APD, many of which are common to supporting any child with a specific learning difficulty.
- remember that extra processing time is needed
- maintain structure and routine so directions are predictable
- frequently summarize and emphasize key information, vocabulary and topics
- chunk information into manageable units
- present directions in short segments, using visual cues if possible
- provide written homework instruction
- make sure the pupil is seated in an advantageous position in the class, for example, away from a noisy corridor
- write key words on the whiteboard
- if possible, allow the student to become familiar with classroom material before it is taught
- provide a quiet area for independent learning.
A quiet environment is essential for all pupils, especially those with any degree of learning difficulty. Competent class control to ensure internal noise is kept to a minimum is essential. Use of various modifiers such as sound field systems, hush-ups placed on chairs and acoustic boards are all useful. There is a tendency to prescribe individual FM systems which enable the speaker’s voice to be heard, via an amplifier, close to the ear of the listener. However, research by Lemos (2009) concluded, “strong evidence supporting the use of personal FM for APD intervention was not found”. This also has the added disadvantage of reinforcing the child’s difficulty and risking isolation from peers
Direct intervention programs promise great improvements in listening and concentration. Despite the attraction of an “easy fix”, though, it is questionable whether they (a) have any positive effect on children’s overall language and learning abilities, (b) take into account the individual’s needs and (c) make learning transferable to the classroom.
I have found that interventions concentrating on individual need, although time consuming, provide a valuable alternative. These would include practice in:
- following instructions
- remembering information from text
- drawing from a description
- working memory
- the use of word maps
- identifying the main idea in a piece of text
- recall from listening exercises
- using prompt cards/story bubbles for story writing.
At present there is no gold standard for diagnosing APD. The condition can be confused with other difficulties such as dyslexia, ADHD and ASD. Not all pupils with APD will present with the problems discussed above in all areas and an individualised approach to helping pupils should always be adopted.