I’ll have a Sausage and People Pizza: The Controversy over Auditory Processing Disorder


This post is hopefully the start of an open dialog among colleagues about Auditory Processing Disorders.  I have had this post in draft mode for some time and it’s almost the start of a larger post but due to the recent discussion on twitter about Auditory Processing Disorders I thought I would post this. ( I am by no means an expert in the matter and this  post is merely to get people thinking.)

I recently became aware of the controversy over Auditory Processing Disorder. Are you aware of this controversy? It’s apparently very similar to the argument against non-speech oral motor exercises. There are basically two camps on this topic- audiologists/slps that believe that this is a true disorder and SLP’s that insist that APDs simply do not exist and it really all involves a weakness in the individual’s language skills.

This past November at the ASHA convention I sat through two very different talks about Auditory Processing Disorders. The first talk was titled A Speech Pathologist’s Guide for Interpreting the Auditory Processing Evaluation and was given by Velvet Buehler who is a  dual certified Audiologist and Speech-Language Pathologist. She who discussed  how to properly interpret an auditory processing evaluation as well as what the course of treatment looked like. After this talk I felt good that what I was currently doing as far  as assessment and treatment was on par with what this speaker was presenting.  However I then walked into a talk titled What Speech-Language Pathologists Need to Know About Auditory Processing Disorders. The presenters for this session were Alan Kamhi and Geraldine Wallach.  Their stance on APD is essentially that it doesn’t exist and cite their research with the following quote:

“Because there is no evidence that auditory interventions provide any unique therapeutic benefit (Fey et al., 2011), clinicians should treat children who have been diagnosed with APD the same way they treat children who have been diagnosed with language and learning disabilities. The theoretical and clinical problems associated with APD should encourage clinicians to consider viewing auditory deficits as a processing deficit that may occur with common developmental language and reading disabilities rather than as a distinct clinical entity.”

They started their talk off with some real life examples that really made sense at the time. One of the examples was about a woman who who was in a German bar. She was learning the German language and could partake in general conversation however in the bar it was very loud and she was having a very difficult time understanding the other people speaking in German to her. She asked if they spoke English which they did and as they spoke to each other in English she found that she was able to now understand everything that she heard. So what was the difference here? Well the difference was that she had a weak foundation in German and had trouble filling in the parts that she had missed due to the loud environment  This makes lots of sense right? If she was weak in the language she was learning then she couldn’t keep up with the conversation as quickly as she would with her native language of English.  This whole example really started to make me question the earlier session that I had sat through. Was APD really based on some shotty research and questionable auditory intervention techniques?

A few weeks later I was at a  pizza place with a group of friends. This was a Friday night so it was busy and very noisy inside. A friend of mine was in line ordering the pizza for us. We ordered Sausage and Meatball pizza however the cashier taking the order was standing in the kitchen and was having difficulty hearing the order. She asked him to repeat himself a few times and finally questioned his order with “You want a sausage and people pizza?”  Yes you read that right, she asked if he had ordered a pizza with both sausage as well as people on it. Last time I checked  Soylent Green was against the law (Insert funny Charleston Heston joke here —>) So what happened here ? You would think a grown women would have at least the language skills to complete the auditory closure task of I’ll have a  sausage and ________ pizza, right? or does she really have some auditory processing deficits and instead heard people.

I’ll end with this blurb from a study that McArthur and Bishop conducted hinting at the fact that there are components of both language and auditory processing deficits in play.

“McArthur and Bishop (2004b) also found that a subgroup of children with specific language disorder showed difficulty on auditory discrimination (consistent with the view of APD as an impaired skill) and poor reading. Another subset of children inMcArthur and Bishop ’ s study had poor sustained auditory attention and/or auditory memory as well as APD.”

What are your thoughts?


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16 thoughts on “I’ll have a Sausage and People Pizza: The Controversy over Auditory Processing Disorder

  1. Very interesting perspectives. I wasn’t aware of the controversy around this. I am a believer of the language based side but I am now wondering if “sensory processing disorder” with information overload is perhaps another ‘topping ‘ on this pizza.

  2. Good post – I’m not certain about the current research and would like to dig into it again. I was at a session about 6 years ago jointly put on by an SLP and AUD talking about CAPD (they were of the Buffalo model http://bit.ly/15cVX7z – did you know there are two models of testing/interpreting APD??). They had a lot of research at the time, but it’d be older now.

    With their info on what deficits exist and how those play out in language and/or reading they highlighted the various tests we give and how to take note of the kinds of deficits or behaviours (e.g. make a lot of last minute answer changes and whether or not those answer improve or don’t improve score). They even lined it up with the most typical areas of difficulty on specific subtests. I brought that info home and used it to ID kids to be tested for CAPD by our local audiologists and I am about 99% accurate in my predictions that a) CAPD will be identified and b) often what subtype – based on how they behave in testing and classroom/home environment.

    So, it’s clearly demonstrating *something* consistent – the Q is what exactly that is. Either way, I get a LOT of kids the FM system in the class that they need to be more successful (it helps the other kids and the teacher too) – so I’m pretty satisfied that something exists for which FM often helps and for now I’ve had to content myself with that. We then work on the verbal memory/direction following (Tolerence Fading Memory) and phono awareness (Decoding) issues on our end that usually go with CAPD to help support the students.

    But I’ve had kids who don’t really have any language issues on testing that I’ve been able to identify but their behaviours (answer changes, a LOT of extra processing time, etc) suggest CAPD and it turns out they test to have it. Or I’ve had kids with no language issues, just reading issues as a result of very weak phono awareness at the phoneme level (blending, segmenting, deleting, substituting) and who also come out with Decoding CAPD. Again – something is being consistently tested/Identified – is it CAPD or something else? And why do they some test out OK for language but not for CAPD?

    I would like to read more research on this now – thanks for getting me thinking about it!

  3. Great article! This has been a big controversy for years. Or maybe I should say, it was very BIG about 8 or 10 years ago then died down a bit but is still very much a debatable issue. I like your analogy with NSOME. That works. I am no expert on this issue but I would have to agree with you, Nikki & Mary. You can call this anything you want but the treatment will be found in the same methods used for language disorders. There is a huge processing piece here as well but we can’t separate that from how it presents. I currently have a student that is going through an eval that is the poster child for this sort of profile. Thanks for posting this article. Very timely for me!

    1. Hello! I’ve been reading your site for a while now and fnlliay got the courage to go ahead and give you a shout out from Houston Tx! Just wanted to tell you keep up the good job!

  4. I was part of the pilot for the clinical trials research on Fast Forward that was spearheaded by Ron Gillam. Using behavioral and event-related potentials as a way of testing for auditory processing difference, I found that there was a small group of children who had a difficult time effectively processing certain types of sounds (poorer behavioral responses and really different brain activity at the brainstem and cortical level). There have been many well-designed studies showing the same thing.

    That said, I agree with Fey and Bishop and Gillam and Nittrouer who report that the best way to work with children who have these types of sensory processing issues is to MAXIMIZE the language content of therapy goals. That will help them to learn the system and minimize the negative impact of sensory issues. I think we also must work with the child’s interests, and in the current culture, use techie tools (Story book maker, Comic Strip, etc), find a back door and woo our language impaired children through graphic narratives.

  5. I test both children and adults for APD. Many adults that I test have great difficulty comprehending speech in auditory competition. (This is also true of children, but I am focusing on the adults right now.) They have good, or even excellent, language skills. They spend their whole lives relying on their linguistic base to disambiguate “crazy” things they hear. They assume that when they hear “sausage and people pizza” that they must have mis-understood, and their brains work overtime to figure out what was actually said. That kind of hearing is a daily occurrence for them. These are articulate adults who finished college and hold down jobs demanding good verbal skills. Yes, they tend to be people who had delayed speech and language as children (i.e. they often had speech therapy as children), but their language skills are fine now. And they still have difficulty comprehending auditory information in background noise.

    If APD is nothing but a form of language disorder, why do these people have excellent linguistic abilities? Why do the auditory problems persist even when language issues have vanished?

    I definitely do not see APD as simply a form of language disorder. I test children and adults who have APD and no language disorder. I also see many children and adults who have co-present APD and language difficulties. And I see children and adults who have a language problem, but no APD. Do the two interact? Of course. But are we audiologists just taking a simple language problem and blowing it up into something it really isn’t? No. People who think that have not seen a range of persons with APD.

    And is the treatment just to do the same thing as you do with language disorders? Sometimes. Especially if APD and language problems co-occur. But working with the auditory part is important too. Improving the acoustic environment is crucial. APD people typically have normal hearing acuity, but many benefit from using mild gain digital hearing aids with directional microphones. APD is definitely more than and different from a simple language disorder.

    1. @Laura Polich wrote,

      Yes, they tend to be people who had delayed speech and language as children (i.e. they often had speech therapy as children.

      News Flash: When children have a speech problem, often hearing problems are lurking as well. What’s more, according to Chuck Berlin, Linda Hood, Thierry Morlet et al, 15% of children who have hearing problems have Auditory Neuropathy Spectrum Disorder (ANSD).

      Dan Schwartz,
      Editor, The Hearing Blog
      Follow The Hearing Blog on Facebook
      Send me a Friend request on Facebook for Hearing & Deafness discussions

    2. Well said, Laura. My practice with both adults and children shows the same thing. It is very tiresome that the turf wars of our professions creates a spirit of “disinclusion” when the fact is that none of really has the entire gnosis on what is constituted by APD, and where the lines between audition, language, cognition, sensory integration are–I suspect the margins are fuzzier than some would have us think. And for Dan Schwartz who thinks it necessary to send “news flashes” to you about ANSD (in case you hadn’t heard of it), many of us in APD specialized practice have and use AEP’s–for many reasons, but also to help with that one.

  6. Somehow my reply to Laura got away from me before I added my information. I became, therefore, Anonymous, which was not my intent. Dan is obviously passionate about ANSD. I am passionate about APD. I’m very thankful that, while I don’t always get where the margins of co-morbidity lie, I’m thankful to work with a community of various professionals who see the need for each other and the common need of the patient. Evidence-based is broader than academia can ever get at…not that we shouldn’t try.

    1. Michael, the margins between ANSD and (C)APD are brightly illuminated when impedance audiometry and electrodiagnostics are used:

      1) When acoustic (stapedial) reflexes are elevated, specifically above 90dB, or are missing, then ANSD can be in play, as there will be a weakened or absent afferent signal arriving via the VIII vestibular-cochlear nerve, which means the cochlear nuclei does not have the input to trigger the stapedial reflex’ efferent signal via the VII facial nerves;

      2) Conducting the special ABR using alternating high level (90dB nHL) compression & rarefaction clicks, which is required to cancel out the cochlear microphonic artifact: When this is done, ABR wave V will be absent;

      3) There are four possible lesion sites for ANSD:

      Missing inner hair cells in the cochlea;
      Misfiring of the inner har cell ◄▬▬► spiral ganglion synapse;
      Neuropathy or damage to the spiral ganglion;
      Neuropathy of the VIII vestibular-cochlear nerve

      Anything from the VIII vestibular-cochlear nerve ◄▬▬► cochlear nucleus junction on in is outside the scope of ANSD.

      Pretty simple, ehh?

      Read Auditory neuropathy spectrum disorder: Evaluation and management, by Patricia Roush PhD; and Multi-site diagnosis and management of 260 patients with Auditory Neuropathy-Dys-synchrony (Auditory Neuropathy Spectrum Disorder), by Berlin, Hood, Morlet et al.

      Dan Schwartz,
      Editor, The Hearing Blog
      Follow The Hearing Blog on Facebook
      Send me a Friend request on Facebook for Hearing & Deafness discussions

  7. I have strong language skills.

    I would have used CONTEXT CLUES (toppings offered on the menu and facial expression – was the customer joking?) and PREDICTION (closure i.e., I would not have predicted ‘people’ but ‘peperoni’), and if these failed me, I would quietly relax because sometimes the auditory signal slowly creeps up my vestibulocochlear nerve and I “hear” following this delay (I also have really poor balance – connected?). When all above fails, then I ask for a repeat.

    I find that published research papers are, on the whole, very naïve. Instead of the researcher asking question, then taking precautions to establish that the results actually answer the question (validity), I see research that simply attempts to prove the researcher correct in his/her beliefs. This may explain these polar camps of beliefs.

    I appreciate Discpad’s comments regarding ANSD and Dan’s on appropriate diagnosis. Years ago as an SLP grad student enjoying my required semester of audiology, I diagnosed this twice during ADP testing. However, I rarely get this testing done due to the cost. I have been instructed to treat the symptoms.

    I have been working in early intervention and am interested in the connection Nikki mentioned between sensory processing and listening skills. Has anyone seen info?

  8. I am a Speech-Langauage Therapist running a private clinic in Wellington, New Zealand. Based on my experience, I solidly support the “APD is real” camp.

    I have had half a dozen children who had been diagnosed with APD and although building their language skills was part of my long-term treatment plan, I saw auditory intervention in the form of personal FM systems working time and time again, providing immediate relief for the APD child in the classroom.

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