Home Academia & Research Does Auditory Processing Disorder Meet the Criteria for a Legitimate Clinical Entity?

Does Auditory Processing Disorder Meet the Criteria for a Legitimate Clinical Entity?

by Andrew Vermiglio
Teacher explaining something to young student

Editor’s note: In response to our recent School Matters column, “Don’t Wait to Diagnose Auditory Processing Disorder,” we are presenting a series of blog posts sharing various views on the validity of APD as a specific diagnosis.

A legitimate communications disorder is called a “clinical entity.” The concept of the clinical entity is important when addressing controversial conditions such as auditory processing disorder (APD)—sometimes also called central auditory processing disorder. Although the ASHA Working Group on APD concluded in 2005 that sufficient evidence exists to support APD as a diagnostic entity, others—me included—remain skeptical.

In his 2011 article published in Language, Speech, and Hearing Services in Schools (LSHSS), Alan G. Kamhi wrote that there are, “compelling theoretical and clinical reasons to question whether APD is in fact a distinct clinical entity.” Other communication sciences and disorders professionals agree with Kamhi’s take on APD, including Geraldine Wallach in an article from the same issue of LSHSS. She notes: “Professionals are hard pressed, even if they accept the APD diagnosis, to find agreement about how to proceed to help the children and adolescents in their care.”

“The evidence base is too small and weak to provide clear guidance to speech-language pathologists faced with treating children with diagnosed APD,” concludes a review from the ASHA Committee on the Role of the Speech-Language Pathologist in Identifying and Treating Children with APD.

These viewpoints lead me to pose a question: “How do we determine if a condition is a legitimate disorder deserving of specific diagnoses and treatment?”

In 1677, Thomas Sydenham—known as a founder of clinical medicine—wrote in the preface to his Observationes Medicae, “Nature, in the production of disease, is uniform and consistent; so much so, that for the same disease in different persons the symptoms are for the most part the same.”

Homogeneity is a hallmark of Sydenham’s description of disease. Using Sydenham’s description of disease, along with the 1949 writings of physician Otto Ernst Guttentag, I construed four criteria on how to identify a clinical entity: It 1) possesses an unambiguous definition, 2) represents a homogeneous patient group, 3) represents a limitation for the patient, and 4) facilitates diagnosis and intervention.

When applying these criteria to APD, the disorder doesn’t hold-up as a legitimate clinical entity. First, APD does not possess an unambiguous definition. James Jerger—founding president of the American Academy of Audiology—said: “There are more definitions of APD than there are children who have the disorder.” Second, APD does not represent a homogeneous patient group. Audiologists and SLPs use a battery of tests—chosen from a number of available behavioral assessments—for diagnoses. The wide variety of test content results in a clearly heterogeneous patient group. Varied definitions of APD, plus the lack of test standardization, makes it unclear if an APD diagnosis meets the third criteria—a limitation for the patient. As for the fourth criteria, the construct of APD does not facilitate (or make easy) the process of diagnosis or intervention.

Based on the Sydenham-Guttentag criteria for the clinical entity, APD is not a legitimate disorder. However, a number of listening deficits currently associated with APD may meet these criteria. For example, a speech recognition in noise disorder qualifies as clinical entity. Other potential clinical entities include amblyaudia, a spatialized listening in noise disorder and a temporal resolution disorder. These diagnoses are consistent with a proposed alternative procedure to the APD construct that moves away from testing “auditory processing” and toward identifying and supporting clients with listening challenges. By focusing our efforts on clearly defined clinical entities, we can better serve our patients.

 

Andrew Vermiglio, AuD, CCC-A, is the director of the Speech Perception Lab at East Carolina University. He also helped with the development of the Source Azimuth Identification in Noise Test (SAINT) and a number of commercial versions of the Hearing in Noise Test (HINT).vermiglioa@ecu.edu

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12 comments

Leonie Wilson April 29, 2017 - 5:32 pm

I like the World Health organisation definitions better.
Also having all three of my children diagnosed with apd I know the effects of late diagnosis and early diagnosis in their lives and futures.
I am also a researcher and have set up an apd group in New Zealand to provide support, education and advocacy for those living with apd in New Zealand and their Families so have worked with many people with apd and in particular children. The debate over apd while useful and informative at a theoretical and educational level is also at times damaging for those living with apd as clinician continues to deny the diagnostic services and appropriate treatment/management.
The area of apd has progressed some much in recent years thanks to a small number of amazing clinicians and researchers but still has a long was to go in order to treat have people with apd appropriately and professionally. While some “don’t believe in fairies” as one clinician once said about the condition APD, I live in a family deeply and consistently effected by said fairies physically, emotionally, socially and educationally. It is often debated if apd is or isn’t a hearing loss but looking at the functional impacts on people with apd and those with other forms of hearing loss they are very similar. The world were we are most accepted is by other who have more conventionally accepted forms of hearing loss and deafness.
It is great to debate and discuss all of these issues, it a great way of learning and develop knowledge, but please don’t forget those who at the end of the day are living with APD and all the challenges it brings. Think of us when you are doing your research and having you debates, the benefits and the damage.

“Nothing about us without us”

Kind regards and forever grateful to those who take up the cause. Apd can be brutal on us and your work is saving lives, futures and helping to ignite dreams.

Leonie Wilson
New Zealand

Andrew Vermiglio May 1, 2017 - 7:54 pm

Leonie,
Thank you for your comments. Do you have a link to the World Health Organization’s definitions? Are you referring to definitions of APD or a clinical entity?

You mentioned that the “debate over APD while useful and informative at a theoretical and educational level is also at times damaging for those living with APD as clinician continues to deny the diagnostic services and appropriate treatment/management.” You have also noted the challenges and negative effects of this condition. You admonish researchers in the field to “think of us.”

I humbly suggest that this is precisely the point of the debate over the legitimacy of APD. As I note in my paper (Vermiglio, 2014), to say that APD is not a legitimate disorder is not the same as saying children and adults diagnosed with APD do not have problems. However, the ambiguity of the APD construct does not promote clarity nor guidance for the diagnosis and treatment of this “condition.” We would better serve our patients with a systematic approach to the identification of legitimate disorders currently associated with the construct of APD. This will promote clarity in regards to diagnosis and treatment.

In your involvement with this condition, you may have read that there is “no gold standard” for APD. A gold standard is also known as a reference standard. A reference standard is used to verify the accuracy or validity of tests used for the diagnosis of various conditions. Without a reference standard, it is not possible to determine if the test results are correct. In other words, without a reference standard there are only positive and negative test results. There are no true positive, true negative, false positive, or false negative results. Without a reference standard, there is no verification of the presence of the disorder. If you were a clinician in a medical or allied health field, would you be willing to conduct surgery or begin intervention for an unverified disorder?

While I have argued that APD is not a legitimate disorder according to the Sydenham-Guttentag criteria for the clinical entity, I also suggest that speech and hearing professionals should endeavor to identify legitimate disorders associated with the construct of APD. It would be far more beneficial for those in our care if we diagnose disorders that 1) are unambiguous, 2) represent a homogeneous patient group, 3) represent a limitation for the patient, and 4) facilitate diagnosis and intervention.
I encourage you to read my 2014 paper – just follow the link within the blog post.

Best regards,
Andrew Vermiglio

Shannon Palmer May 3, 2017 - 10:26 am

I think this is an ongoing debate that keeps coming back. As a researcher and clinician in the field of auditory processing disorder I agree that there is heterogeneity in the patient population. However, you argue that instead of using APD as an umbrella term, we carve out 4-5 separate disorders such as amblyaudia, spatial listening in noise disorder, temporal resolution disorder, etc. I would argue that clinicians are already evaluating for these different difficulties during an APD test battery. An APD report should include a description of what processes a patient struggles with and recommend strategies to address those difficulties. Therefore, the APD evaluation should facilitate diagnosis and intervention. I don’t really see what the benefit would be of having 4-5 different diagnoses.

I also agree that there is no “gold standard” for the diagnosis of APD. However, there are other widely accepted disorders that do not have a “gold standard,” like autism and language disorder. These diagnoses require a test battery and symptoms vary greatly between patients, yet there is no argument that autism or language disorder are not legitimate.

Overall, we do need more research in this area, but I think arguing over whether APD is legitimate or not undermines the help that our patients are seeking.

Leonie Wilson May 3, 2017 - 5:57 pm

Thanks for this response Shannon, I support and agree with your comments.

Also Andrew, I don’t “admonish” researchers to think of us, but simply ask that you think of us and the impact of these debates and research on those living with APD as these things have significant impacts in our live and futures. Note in my comment I also sincerely thank researchers and clinicians working with apd.

In terms of the treatment/management of apd Andrew the current best practice guides provide evidence based research on the diagnosis and treatment of apd.

Also note that the treatment of apd doesn’t involve and surgery or high risk treatment options that I’m aware of so I’m unsure why you use this as an example of why you want apd divided up into multiple individual subcategories. If you are aware of significant harms caused by the current best practice guidelines please send me that information. This stance also implies that all people currently working in apd are working with an unverified disorder and are therefore acting unprofessionally, this is definitely not the case. A good test battery will identify the range of auditory processing issues the individual has.

Most people I know and those have worked with over the years with apd have a combination of auditory processing deficits, few have just one area effected. So they would as Shannon pointed out have multiple diagnoses of issues, so then and umbrella term is useful. Also as a community of people living with we see ourselves and our issues as unified, the functional impacts of apd are something most of us can relate to.

Also one of the points I was trying to get across to you is that the debate you undertaking is causing harm to those living with apd.

There are many disorders that have collections of symptoms as outlined above by Shannon. Others like Ehler Danlos too.

Happy to keep discussing.

Andrew Vermiglio May 4, 2017 - 9:02 am

Dr. Palmer,

Thank you for your comments. The debate over the legitimacy of ambiguous disorders has been with us for many decades. This debate spans outside of the field of speech and hearing. For example, Petersen and Morris (2005) have argued that mild cognitive impairment (MCI) while heterogeneous is “an evolving construct” and that “while appropriate questions have been raised concerning its definition, outcome and potential treatments, considerable progress has been made.” They note that the heterogeneity of MCI reflects a refinement of the entity rather than a weakness.” (Sound familiar?)

Gauthier and Touchon (2005), on the other hand, have argued that MCI is not a clinical entity and therefore should not be treated with a specific drug therapy. This is consistent with the Food and Drug Administration (FDA) who remarked that labeling of a drug for treatment of a clinical entity that is poorly defined is potentially misleading, since it would not be possible to adequately inform clinicians through labeling as to the appropriate use of the proposed drug treatment (FDA, 2000). Gauthier and Touchon and the FDA make a connection between the clinical entity and intervention. This connection is missing in the current construct of APD (see Fey et al, 2011). This is evident in the ASHA committees’ comment that the “…evidence base is too small and weak to provide clear guidance to speech-language pathologists faced with treating children with diagnosed APD…”

The ambiguity of APD does not facilitate diagnosis or intervention. You may be familiar with the paper by our colleagues Wilson and Arnott (2013). They conducted APD assessments for 150 children with normal pure tone thresholds using six different criteria for APD. These included the criteria from the American Academy of Audiology (2010), the American Speech-Language-Hearing Association (2005), the British Society of Audiology (2011), Dawes and Bishop (2009), McArthur (2009), and Bellis (2003). There was a remarkable range of positive diagnoses for APD. When using the ASHA criteria for APD, 96.5% of the children were diagnosed with APD. When using the Bellis criteria, only 7.3% of the same children received the APD diagnosis. The ambiguity of APD does not promote clarity in diagnosis.

If I understand you correctly, you are arguing that there is no need to identify a number of disorders as clinical entities since these are already addressed by the test battery for the diagnosis of APD. However, since there is no standardization for the APD test battery this may or may not be the case.

The ambiguity of the APD construct starts with the definition, and then works its way into the make-up of the patient group, diagnosis, and intervention. As Dillon et al (2012) have noted, “the level of deficit in the ability that is needed to create problems in real life may be much larger than the pass-fail criterion determined solely on the basis of a certain number of standard deviations of people who have not reported marked difficulties…” Additionally they state, “A fail does not necessarily indicate that the patient actually has a problem!” According to the Sydenham-Guttentag criteria for the clinical entity, if a condition does not represent a limitation for the patient then that condition is not a disorder that we should diagnose and treat. It is not a clinical entity. How does it help our patients if we diagnose a disorder that does not represent a problem for the patient? What is the point?

A reference standard (aka “gold-standard”) is required for any type of diagnostic accuracy study. I have argued that the Standards for the Reporting of Diagnostic Accuracy (STARD; Bossuyt, 2013) should be part of the guidelines for authors in speech and hearing. The STARD statement is part of the authors’ guidelines in over 200 journals including the British Medical Association, Radiology and the Lancet. These guidelines require a reference standard in order to determine if the results of an index test are true or false. As I mentioned previously, since there is no reference standard (gold or otherwise) for APD there is no way to determine the diagnostic accuracy of APD diagnostic tests or test batteries. It should be noted that as of January 1, 2017, the STARD statement is now part of the guidelines to authors of diagnostic accuracy studies in the ASHA journals.

I would expect my physician to know the diagnostic accuracy of the tests that he selects for the assessment of my health. Shouldn’t speech-language pathologists and audiologists be expected to do likewise?

Kind regards,

Andrew Vermiglio

Andrew Vermiglio May 4, 2017 - 3:48 pm

Leonie,

Thanks again for your comments. They are appreciated.

Here is the situation as I see it. The construct of APD as you know is controversial. Not everyone accepts this as a legitimate disorder. You have stated, “the current best practice guides provide evidence based research on the diagnosis and treatment of apd.” Since there is no reference standard for APD this statement is false. This is the point made by the insurance companies who hold that testing for APD is not medically necessary.

According to Excellus Blue Cross/Blue Shield, “Based upon our criteria and review of the peer-reviewed literature, auditory processing disorder (APD) testing is considered not medically necessary, as there is insufficient evidence to support the validity of the diagnostic tests utilized in diagnosing an auditory processing disorder.”

The “validity” of a diagnostic test is determined through a diagnostic accuracy study that requires a reference standard. The APD construct is ambiguous and vague, therefore a reference standard has not been found. However, if we identify conditions associated with the APD construct that meet the Sydenham-Guttentag criteria for the clinical entity then reasonable reference standards could be found. Next, diagnostic accuracy studies would need to be conducted for the index tests used to determine the presence of these clinical entities. This means that we could then argue for diagnosis and treatment of legitimate disorders based in part on the evidence provided from the diagnostic accuracy studies.

I argue that this alternative plan would be better for our patients than the current construct of APD.

Respectfully,

Andrew Vermiglio

Jennifer McCullagh May 5, 2017 - 7:06 am

Dr. Vermiglio,

As a clinician and researcher, I have to agree with Dr. Palmer’s argument. If speech-language pathologists and audiologists strictly followed the primary argument regarding the Sydenham and Guttentag criteria and the existence of an established “gold standard”, many diagnoses would not be made, including childhood apraxia of speech, language impairment, and reading disorder/dyslexia. A lack of diagnosis would preclude all of these children from receiving the services they so desperately need to succeed. If applying these strict criteria outside our profession, we would lack diagnoses of AD/HD, executive functioning disorder, and Autism Spectrum Disorder, for example. While I can certainly appreciate the need to continue doing the valuable research to improve diagnostic capabilities and achieve a gold standard for all of these disorders, I do not think this argument helps the children and adults (and their families) that we serve day-in and day-out through our clinics and our on-going research efforts.

Kind Regards,

Jennifer McCullagh

Andrew J. Vermiglio May 5, 2017 - 11:06 am

Dr. McCullagh,

Thank you very much for your comments.

In regards to APD, the state of California licensing board for speech-language pathologists and audiologists stated, “It is incumbent upon the licensed audiologist and licensed speech-language pathologist to use only diagnostic assessments and therapies that are supported by rigorous empirical evidence.”

Does this sound reasonable?

Here is a statement from Aetna’s policy on APD. “Aetna’s policy on APD is based upon the limited evidence for APD as a distinct pathophysiologic entity, upon a lack of evidence of established criteria and well validated instruments to diagnose APD and reliably distinguish it from other conditions affecting listening and/or spoken language comprehension, and upon the lack of evidence from well designed clinical studies proving the effectiveness of interventions for treating APD. The reported frequent co-occurrence of APD with other disorders affecting listening and/or spoken language comprehension suggests that APD is not, in fact, a distinct clinical entity.”

If we as professionals endeavor to clarify the disorders that we diagnose and treat, procure reasonable reference standards and conduct diagnostic accuracy studies in order to provide empirical evidence for the validity of our assessment tools, do you think that this will improve or reduce our patients’ access to the services they need?

Thank you for taking the time to respond to this issue.

Best regards,

Andrew Vermiglio

Jennifer McCullagh May 5, 2017 - 3:27 pm

Dear Dr. Vermiglio,

Thank you for your thoughtful response. Like I said in my initial post, I certainly believe we need to continue to do the research to better validate existing measures and also to create new measures of central auditory processing. Using an insurance company as a metric for validation is dangerous for a number of reasons. Until recently insurance companies wouldn’t consider coverage for hearing aids, but by no uncertain terms did that preclude people from purchasing hearing aids and improving their quality of life by maximizing residual hearing. I believe strongly that I cannot deny the children and adults (and their families) on my caseload diagnostic and rehabilitative tools available to us while we continue to research this complex disorder.

Respectfully yours,

Jennifer McCullagh

Andrew J. Vermiglio May 8, 2017 - 12:56 pm

Dear Dr. McCullagh,

Thanks again for your thoughts. They are valued.

I appreciate your statement that “we need to improve our validation of existing measures and also to create new measures of central auditory processing.” However, the only way to validate an index test is to compare the index test results to the results of a reference standard. The heterogeneity of APD precludes the procurement of a reference standard. My argument is that it is easier to find a reference standard when the disorder possess an unambiguous definition, represents a homogeneous patient group, and represents a limitation for the patient. This in turn will facilitate diagnostics and intervention.

You mentioned the dangers of using an insurance company as a metric for validation. Ironically, it appears that the insurance companies are using our literature as the metric (or rather evidence) to determine the validity of our diagnostic measures and the legitimacy of the APD construct.

You may have already reviewed Aetna’s policy statement on APD. Their conclusions are based on a review of over 70 articles. Most of these papers are found in our journals. The authorship includes both proponents and skeptics of APD. http://www.aetna.com/cpb/medical/data/600_699/0668.html

If you had the opportunity to provide direction for the advancement speech and hearing, would you advocate for ambiguity or would you endeavor to provide clarity? According to King (1982), “Hippocrates described the clinical entity puerperal fever in terms so precise, so vivid, that even twenty-five hundred years later we have no difficulty in reaching a diagnosis from the data he presented.” Shouldn’t we desire the same in regards to clinical entities in our field?

Sincerely,

Andrew Vermiglio

Cecilia von Mentzer May 30, 2017 - 5:22 pm

To Dr. Vermiglio,

I want to thank you for bringing up the problems associated with keeping the diagnostic entity “auditory processing disorder.” I am a Swedish Speech Language Pathologist (SLP) currently doing my postdoc in the United States. I have worked clinically for 18 years with children who have had various neurodevelopmental problems of varying severity. Many of them struggled with learning and needed individual approaches to reach their potential.

In 2005, I shifted from working mainly with children with language and/or reading disorders, to seeing children who were deaf and hard of hearing. This change first brought me closer to the field of audiology. I eventually began to study phonological processing skills and reading in children using cochlear implants or hearing aids as part of my PhD studies (2014). In the last year, I have studied hearing, speech discrimination, and cognition in children with normal hearing thresholds for tones, who have been diagnosed with speech sound disorder (phonological language impairment, LI) and/or grammatical LI. My aim is to test the hypothesis that high frequency hearing and/or speech perception in noise may be compromised in some of these children. In the United States, I am collaborating closely with a hearing scientist. Our efforts to bridge audiology and speech language pathology has made me highly aware of how different professional perspectives have an impact on how we label children’s problems. To improve our service to children who struggle with language and learning, I strongly believe that we need to discuss and explain our perspectives better, which is why I am writing to you today.

Some weeks ago, I brought up the “Simple view of reading” at our lab meeting (Gough & Tunmer, 1986) which states: “Reading = decoding x (listening) comprehension. The Simple view of reading is one theoretical model that has guided SLPs, psychologists, and educators (researchers and clinicians) to better understand the relationship between decoding (the technical aspects of reading) and comprehension in reading. With the model, we identify four types of learning profiles: 1) typically developing children (good decoding, good listening comprehension), 2) dyslexia (poor decoding, good listening comprehension), 3) hyperlexia (good decoding, poor listening comprehension), and 4) garden variety poor readers (poor decoding, poor listening comprehension). The fourth category may be seen as a catch-all for a variety of learning issues children may have. In the fourth category, we can find children with severe language disorders, children with sensory issues, or children who have not received proper instruction, to name a few examples. In the metaphorical garden, there are many flowers and all sorts of plants, and it is not always possible to organize them in any particular order or category, hence garden variety. At the lab meeting, I proposed that the fourth category might in fact resemble “auditory processing disorder,” as it presently appears in many discussions among audiologists and SLPs.

Recently, Dr. Shapiro, presented one example of this particularly unclear and mixed view of what “auditory processing disorder” is, in her ASHA-leader article “Don’t wait to diagnose auditory processing disorder” (December 2016). Her bullet point list was especially staggering because she included so many symptoms. The high number of symptoms prevents us from having a deeper understanding of what “auditory processing disorder” is and why using this label will help children.
Below I present my own thoughts after reading Dr. Shapiro’s bullet points. My argument is that I strongly agree with you Dr Vermiglio: we do need to disentangle the different parts of the questionable term, “auditory processing disorder.” We, as professionals cannot continue labeling children as having “auditory processing disorder” without knowing which symptoms we are referring to when we say it. If we continue to label children with such a variety of different combinations of symptoms as having “auditory processing disorder”, we are limited in our ability to choose an appropriate intervention and provide help to the child that seeks our support.

Below, I provide Dr. Shapiro’s list along with my comments and some suggestions for actions:

• History of otitis media (ear fluid, infections, tubes)
My notes: Otitis media is associated with a conductive hearing loss. Having a conductive hearing loss means that the child encounters periods when he/she hears less intelligible speech signals, which may lead to less detailed phonological representations in long term memory. This in turn has the potential to hinder the development of vocabulary knowledge and global knowledge in the particular child. Vocabulary skills are important in all kinds of learning. Action: seek medical care at the ENT-clinic. Work with language enrichment activities. Be certain to sit closer than usual to the child when speaking.

• Easily distracted or bothered by noise
My notes: Reduced selective attention or inhibitory control is classified as an executive functioning (EF) problem, which is a part of cognition. EF matures at different speeds in different children.
Being bothered by noise is mostly observed in children who have social communicative difficulties but may also be present when a child is tired or distressed.

• May be noisy when in noisy conditions
My notes: Children may speak loudly in a noisy environment because they suffer from a hearing loss or because they have trouble coping with many different stimuli at the same time. Action: Because there are multiple possible causes, it is important to evaluate the child’s hearing or reduce the stimuli to identify the true problem.

• Difficulty locating source of sound
According to certain researchers, some children with learning disorders have stream segregation problems – i.e., trouble disentangling target speech from noise sources in the environment. Recently, high frequency hearing loss has been observed in a number of these children. Action: More evidence should be collected in a larger population to learn more about high frequency hearing loss.

• Does not remember simple directions
My notes: The child may have reduced phonological working memory and/or complex working memory or may have difficulties focusing on what the teacher says. Action: evaluate the child’s memory and attention skills in different settings to identify the core of the problem, i.e. whether the difficulties lie within the child or are related to the context or are related to both.

• Difficulty with finger-play, such as “Itsy-Bitsy Spider”
My notes: Finger play is classified as a fine-motor skill. Many children with language impairment, attention difficulties, or social communicative problems also have immature fine motor skills. Action: we need to consider comorbidity.

• Difficulty learning nursery rhymes
My notes: Many children who are at risk for dyslexia or who have language impairment show difficulties with phonological awareness (learning the form aspects of language) in their preschool years. Phonological difficulties may also surface in adults who have had a language based learning disorder as a child when we test them with non-word repetition and/or spelling tasks. Action: we need to implement phonological awareness games in preschool settings and educate families about the importance of talking and reading with their child.

• Poor language (receptive or expressive)
My notes: Learning spoken language rests on a foundation of perceptual knowledge. Thus, the infant stores the sound information from the native language and constructs his/her language early in life. Within the first year, the child’s speech perception skills are tuned to the phonology of the native language, at 6 months to the vowel system, and at 10 months to the consonants. Action: it is important to speak, sing, and read with children from the beginning.

Learning language is also a “guessing game.” That is, the child needs to use his/her social cognitive skills to connect the sounds heard to the events happening in daily life. Action: adults need to support these connections by being communicative models.

Poor language (receptive or expressive) is an even more heterogeneous label than “language impairment,” which is estimated to affect approximately 7% of the population.

• Poor articulation
My notes: Poor articulation in speech might be connected to reduced tonus of the articulatory muscles in the child. Reduced tonus may be observed in children who are experiencing a developmental immaturity and/or disorder. They may catch up or may appear to have less developed motor skills as adults. Fine motor skills (which articulation is dependent on) vary in the adult population and even more during childhood. Action: we should avoid training programs that focus on oro-motor functions if our goal is to enhance language and learning.

• Has/had sensory-integration or speech-language treatment
My notes: Children who have a large variety of neurodevelopmental issues may receive sensory integration treatment. For example, children with delayed fine or gross motor skills or children who have difficulties with social communication. Children receive speech language treatment for an even greater variety of reasons, and speech language treatments vary depending on the cognitive, physical, and social skills of the child.

I believe that children will not become better suited to face the reality of their educational settings by being diagnosed with an “auditory processing disorder,” as Dr. Shapiro proposes. Children need individual approaches that fit their neurodevelopmental profile. Understanding their profile is best achieved by working in teams where each professional brings his/her knowledge piece to the puzzle. Meanwhile, we need to collect scientific evidence to better understand how hearing relates to language and learning.

I thank Dr. Vermiglio for bringing up this issue and I hope that we are approaching greater professional precision in this field.

Best wishes,

Cecilia Nakeva von Mentzer

Andrew Vermiglio July 22, 2017 - 5:54 pm

Dear Dr. von Mentzer,

Thank you for your very thoughtful response.

I appreciate all of your comments and observations. In particular you noted, “The high number of symptoms prevents us from having a deeper understanding of what ‘auditory processing disorder’ is and why using this label will help children.” You also mentioned how limiting this heterogeneous disorder is on “our ability to choose an appropriate intervention.” We are in agreement.

You have delineated several communication functions and disorders. As you have indicated, each of these areas may be evaluated and treated. There is no need to invoke the abstract and ambiguous construct of CAPD.

When I listen to presentations on CAPD case studies, I will ask the presenter, “Without using the term CAPD, how would you describe the client’s disorder?” The answer is invariably much more instructive than the overly broad term of CAPD.

Best regards,

Andrew Vermiglio

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