Auditory Processing Disorder (APD) in Children: Guide

Campbell, N., Grant, P., Moore, D,R. and Rosen, S. | View as single page | Feedback/Impact

APD testing - recommendations

As discussed under ‘APD tests and criteria’ referrals for APD evaluation from professionals are increasing, and parents are demanding appropriate services when they learn of the existence of APD on the Internet and other media sources.  Many audiologists have understandably been cautious about including APD assessment in their clinical practices, given the controversy and lack of evidence surrounding APD assessment (Kraus and Anderson, 2016)

Based on current evidence the British Society of Audiology (BSA, 2018) offers the following advice.

  1. Engage with, educate and inform stakeholders (professionals, individuals with suspected APD, parents) and funders about APD.
  2. Determine and address the difficulties that a child is experiencing in real life (a detailed case history, validated questionnaires and professionals’ reports can be used to obtain a 360° view of a child) .
  3. Understand the reported hearing difficulty against the background of a multi- or interdisciplinary assessment that considers aspects such as language, dyslexia, attention and memory.
  4. Recognise that audiological assessment for APD should not be done in isolation given that aspects such as language, attention and memory can affect test results.  There are different multi- or interdisciplinary models that can be considered.  For example, it is possible for the audiologist to request that other assessments such as a speech and language assessment and educational psychology assessment be done prior to referral for an APD assessment. Another approach is to have an interdisciplinary team all working together under one roof.
  5. Do an audiological work up to rule out peripheral hearing loss, middle ear dysfunction and APD look-alikes and also evaluate speech perception in quiet and noise.  Separate ear pure tone audiometry (250-8000Hz), with extended high frequencies if possible (up to 12000Hz) and immittance testing (including ipsi- and contralateral reflexes) are necessary to identify hearing impairment and medical ear pathology, requiring medical and/or audiological intervention.  As discussed earlier in this document (under Audiogram and baseline test’) there is some evidence of hearing loss in frequencies above 8000Hz for children with a history of glue ear.  There is also some evidence that contralateral acoustic reflexes can be absent for some children with APD and that oto-acoustic emissions in the presence of contralateral broadband noise may have diagnostic value.  Speech perception tests in quiet or using noise or speech maskers should follow next.  For example, the Listening in Spatialized Noise -Sentences (LiSN-S) test can be used to diagnose Spatial Processing disorder (a reduced ability to use spatial cues to hear in background noise, with a higher reported prevalence in children with a history of glue ear). Other speech-in-noise tests such as the Digits-in-Noise Test (DIN), Words-in-NoiseTest (WIN) and the Bamford– Kowal–Bench Speech in Noise Test (BKB-SIN) can be done to look at general speech perception in noise.  These tests are suitable for children and present digits, monosyllabic words and sentences, respectively, in a background of multi-talker babble.  They have some functional specificity, age-appropriateness, reliability and validity, and are well standardised (BSA, 2018).  It is helpful to compare speech perception in both quiet and noise on these different measures to determine the influence of language.  It is also helpful to compare the results on a simple speech-in-noise test (e.g. DIN) with a more complex one (e.g. BKB Speech-in-Noise).  Finally, if there is suspicion of Auditory Neuropathy Spectrum Disorder (ANSD) ABR together with oto-acoustic emissions and/or cochlear microphonic potentials is indicated to either identify or rule out ANSD.
  6. Make evidence-based decisions around APD testing.  Where a label of APD is necessary to secure support/funding only use tests that fulfil the criteria of functional specificity, reliability, validity, age-appropriateness and standardisation, with a clear statement of any diagnostic criteria used.
  7. Recognise the complexity and current controversy surrounding APD.  The British Society of Audiology, along with an increasing number of audiologists worldwide, are proposing that one way forward could be that only those audiologists with further training and accreditation by a professional academy or society be allowed to diagnose APD.