What is an Auditory Processing Disorder?

Dr. Rebecca Blaha, lead audiologist at the Pennsylvania Ear Institute (PEI), along with Dr. Aaron Roman and Dr. Amanda Ayers, both clinical audiologists at PEI, discuss auditory processing disorders in a new podcast.

Blaha: Auditory processing has been in the news recently here in Pennsylvania from the midterm elections, where Senator John Fetterman requested during his debate with Dr. Oz a teleprompter to assist with his auditory processing. So, what is an auditory processing disorder?

Roman: I think before we talk about what is an auditory processing disorder (APD), I think it's important to actually define what is auditory processing. A lot of times when we talk about hearing loss, which is something as audiologists we talk about quite often, we're talking about how are the ears functioning? When we talk about auditory processing, it's a little bit of a different story. Auditory processing usually refers to the aspect of listening. When I talk to patients, I usually say that hearing is very different than listening. Listening is a very active activity. It requires a lot of focus, it requires attention, it requires memory, it requires intelligence. Auditory processing is this really complex, very cognitive process. 

Ayars: The best way I kind of break it down is our hearing is our perception of sound and our ears kind of bring the sound to our brain. But auditory processing is how well your brain puts all those puzzle pieces back together to understand what's being said.

Roman: If you think about the word cat, hearing is the aspect of hearing the word cat, and we get all of the sounds from it. So the “ca” sound, the “ah” sound, and the “ta” sound. That is what hearing is. It's not until it comes up to the brain that we're able to fuse those sounds together to form a word. And then to go beyond that, we say not only is this a word, but it's an animal with four legs that meows. Auditory processing is the ability to take all of the information that we hear and really put meaning behind it. 

Ayars: So auditory processing disorder is where all the different functions that our brain uses to put the sound together to be able to understand it, some of those processes have broken down. In some cases it might be that someone doesn't understand sarcasm and the timing of this speech isn't there for them. Or it could just be an inability for their brain to separate the difference between one sound and another sound. It basically all boils down to where the brain and all of its processes are having a hard time understanding that C-A-T is cat with four legs and meows.

Roman: When we talk about auditory processing disorder in a classical definition, we generally talk about how it presents in children. And what we tend to see in this population is something like the child will present with what looks like a hearing loss. Either they or their parents will say, "I can't hear a noise. I struggle to hear when people are talking to me. Speech isn't very clear." But when we test them for hearing, their hearing is generally normal. That's usually an indicator that we might be dealing with an auditory processing disorder. Now, to bring this back to Senator Elect Fetterman, what we saw here is an instance where Senator Elect Fetterman had a stroke, and after that he exhibited difficulty to auditory processing challenges.

I think our immediate reaction is to throw around the term auditory processing disorder as though that is a standalone disorder. I'm not sure if that's what I would personally call it. A stroke affects the entire brain. Because of that, it can present with challenges to auditory processing and even clinically something that we would consider an auditory processing disorder. But his primary problem was that he had a stroke and that stroke deprived his brain of some of the resources that he uses to pull these sounds together to make sense and meaning of the word. Whether or not we would clinically define that as an auditory processing disorder is one thing or another. The way we would view it and the challenges that would appear to it would be the same.

Ayars: One thing that's important is, clinically speaking, we cannot give someone an actual diagnosis of auditory processing disorder if they have any amount of hearing loss at all. Two people who have the exact same hearing loss could have different levels of auditory processing. Again, it's not at the ear level, we’re going higher up into neural and brain.

Blaha: In this instance with children, is this a developmental type of disorder or an acquired disorder? It sounds like for adults, it could potentially be an acquired disorder, but then with children, how would that kind of come about?

Roman: If you read studies about the prevalence of auditory processing disorder, you'll see those numbers range wildly. Most studies I've seen estimate the prevalence of auditory processing disorder in children to be about 1 to 2 percent of the population. I've seen studies that go so high as say 98 percent of the population has an auditory processing disorder, which I would challenge because if the vast majority of people have it, it's probably not a disorder. It's more likely a characteristic. The question is really, is it developmental to a point?

Personally, I do not test children under seven for auditory processing disorder. The reason is, when we think about brain development and all the aspects that go into auditory processing, all the aspects that go into listening, our brains don't even fully start to develop to be able to do those really complex abilities until at least seven in most cases, not even until eight or nine years of age. Depending on the task that we're asking, there's some evidence that shows the brain doesn't fully develop until around age 20 to be able to do that at an optimal level. There is a level of development that needs to be considered.

But when we see really severe cases of auditory processing in children, it is most likely linked to what we would consider a developmental delay. It could be a neurological delay in that the brain is just not developing physically in the manner that you would expect it to, or it could be a delay in intelligence. It could be a delay in attention abilities, it could be a delay in learning abilities, and that can kind of present as difficulty with auditory information. One of the most common things that we see kind of coexist during childhood is how would you define this versus something like ADHD, which has very similar symptoms. 

Ayars: A big part of understanding speech and listening is your ability to stay on task and the ability of your brain to stay focused on what it's doing and using it short-term memory as well. With auditory processing, in some ways it's almost like a diagnosis of exclusion because we have to disregard any hearing loss. We've got to deal with any sort of ADHD, certain anxiety disorders with similar symptoms, autism is definitely a big thing that we have to rule out. We also have to eliminate any sort of learning disability like Dr. Roman was saying earlier. 

Roman: That's also not to say that those with ADHD, those with autism, those with learning disorders, anything like that, don't have difficulties with auditory processing. The only way we could formally diagnose those is to rule out all these other disorders and diagnoses. So that's what we see in kids. 

What we want to talk about a little bit more is what we see with Senator Elect Fetterman. He relied on the use of a teleprompter during a conversation because verbal questioning was very difficult for him. That's something not uncommon in both auditory processing disorder and in situations of strokes and aphasia, which he has admitted to experiencing. So what do we see in adults with auditory processing? I would say the majority of situations that we see adult APD are in those that have sort of traumatic brain injury, those that have strokes, and we see it a lot in the veteran population, those with blast exposure, those with PTSD. It doesn't have to be necessarily a physical impact, in situations like PTSD where we have a high stress, high anxiety neurological deficit, that can also present itself. 

The presentation is very similar to that of children, though. You generally see individuals struggle to hear a noise, to hear when many people are speaking, if the speaker is far away. If you're talking over the phone our voice gets distorted to a bit [and] that might present with challenges. It might present with challenges when they're speaking to individuals that have accents or dialects. There's a whole range and sort of array of symptoms that could happen. What we tend to see and what we saw with Senator Fetterman is by no means unusual. And what he used, the use of a teleprompter, is almost exactly what we would recommend in cases of APD, be it adult or children.

When we talk about auditory processing, I should note that just like autism, just like ADHD, it's a bit of a spectrum. As Dr. Ayars alluded to, it can present where you have just issues with timing. What we recommend for those who have issues with auditory timing is very different than what we recommend with those who have difficulty hearing and noise, or what I would call auditory closure. The use of verbal cues, in this case a written teleprompter, is something I recommend to nearly every patient that I diagnose with auditory processing disorder because sometimes our brain can't process all of those sounds at once. It's not that I can't process it at all, there's a lot of noise to break through. By using visual cues, be it lipreading, be it words, it allows our brain to narrow in on what the message is and it allows us to focus and work a little less hard.

I don't think the argument should be that Senator Elect Fetterman, for example, could not understand the spoken sentences. I think he certainly could. I think his brain was working very hard to do so. By use of these visual cues, he's able to tune in a lot faster and a lot more efficiently. And I think that's something that we would see in any patient. We also see that in many patients who have hearing losses in older age because as your brain matures, its ability to process these signals in complex environments kind of degrades over time.

Ayars: I know sometimes I have trouble understanding people. When masks became so popular, I was like, "Oh my gosh, what is this person saying? I need to be able to see your face." Because it's not necessarily just lip reading, it's face reading, it's body reading. And so that's important for almost anyone, but especially for someone who has some issues with auditory processing. I think one of the great things that I loved about these debates that was brought up is the advocacy. He was like, "Hey, I have this, so therefore I need help in this area, or I need this additional support in order for me to do my job normally."

Because the biggest issue is that a lot of people will suffer for so much longer with some sort of hearing problem or auditory processing problem and struggle so much longer than they need to in order to get help in a certain area because they're not willing to admit it. I really appreciate him talking about it and opening up about it because then it allows us the opportunity to have this podcast and kind of talk about these issues and maybe some strategies and some different places that you can go to get some help with all of these.

Blaha: For hearing aid patients, we know that the longer you go without aiding your hearing loss, your auditory skills will naturally break down because you're not maintaining them through consistency in practice. With hearing aids, I often recommend the patients read out loud to begin the auditory training because you're reading, and your brain will start to recognize what new sound quality the hearing aid's going to provide. So you're reinforcing it to train the brain because maybe the sounds are not what you remember when your hearing was better. That training process is helpful to get better benefit from your devices. Are there similar types of trainings for people that maybe do not have hearing loss? What types of interventions are recommended? 

Roman: Auditory processing disorder is a spectrum, so it's not just like, you have auditory processing disorder, here is your recommendation. It really depends in what part of auditory processing do you have a disorder in? You can have a disorder in sort of the processing of understanding speech when it's clipped off. Like when we communicate in noise, for example, we're not getting the full message. So, you can just have problems understanding when you don't get the full message. You can have problems with timing, you can have problems understanding where speech is or where signals are, I should say, in a 360 degree world. So, it's really dependent on that.

It's not as clean cut to say I would recommend this product or this hearing aid or this training product. There are trainings out there that claim to help with processing. If you personally are listening and say, "Hey, this sounds like me," I would really recommend that you consult with an audiologist because it's a really, really specific and really, really unique problem that takes a very specialized approach into treatment. Rather than just saying do a little bit of auditory training or go to the specialist or anything like that, I think you really need to have a conversation to see where those deficits lie.

Ayars: There’s definitely different versions of auditory processing. If a patient has this form of auditory processing disorder, then these are the things that I want you to work on and I want you to practice on. But those recommendations would be absolutely, totally inappropriate for someone else who has a different form of auditory processing disorder. That's why it is so important to get properly examined and diagnosed with exactly what's going on.

Roman: Nine times out of 10, by no means is auditory processing disorder a debilitating disorder. It's something that takes a lot of work and a lot of effort, but it never should exclude someone from participation. I remember hearing after the debate, for example, about Senator Fetterman, how it's like, "Oh, he has auditory processing disorder, that should, I don't know, exclude him from whatever." That's absolutely not the case. I've seen students, I've seen adults, everyone I've seen who has auditory processing disorder, you might have to make some modifications, you might need to do some practices, some therapies, but that will not stop them from living a very complete, very successful lifestyle. I do want to kind of caveat that while we put the term disorder behind it, it's more of a moniker to say this is something that you need to get extra help on, or you need to make some considerations or make some adjustments in your life. But it's not to exclude anyone from any level of participation.

Ayars: In some ways it can even be a benefit. Someone who has this type of disorder is naturally going to pay a lot more attention when they're listening to things. And so when they get that help that they need, they're that much better at listening to people because they've already been practicing and working on those skills for so long.

Blaha: It sounds like there are multiple issues that could arise with auditory processing. When you're evaluating someone, do you see a particular processing deficit more often than another? Are there certain areas where you will see the breakdown more often, such as temporal processing?

Roman: There's some evidence out there that temporal processing or timing is linked directly to early stages of cognitive impairment, which we often think about as dementia. So I guess the question is what do we see most often? It really depends on the population. I would say in children, what we tend to see more is what we would call classical auditory processing disorder, more difficulty understanding speech and noise. There's a thing called dichotic listening, or when you hear with one ear something different than what you hear in the other ear, but you hear both at the same time. It's a really hard task. And something I would see a deficit more in children than in adults. But those are probably the two primary tests that we do that we see challenges in. But again, it really just depends on the person.

Ayars: My patients who have had a stroke or a TBI have also had the same thing with the dichotic listening, where it's just the communication between both sides of their brain just isn't working as well as it should. And so oftentimes for those patients, that's also a main issue.

Roman: To summarize, auditory processing disorder, it's not uncommon. We see it a lot in children, but it's also very common in adults, especially those who've had brain-related injuries, impairments or traumas. What we saw with Senator Elect Fetterman, it really brought light to auditory processing disorder and it allows us to have conversations like this and to educate those who may not know so much about it. I can't tell you how many students I've seen or how many parents I've talked to when I say, tell me what you know about an auditory processing disorder, they really struggle to define what it is. They're like, “Oh, I've heard of it, but I don't know." And so I think it's really important that we keep having these conversations because it's something that affects a lot of people and unless we have conversations like this, it can really be misconstrued.