Incremental Therapy Approach for Children Identified with Auditory Processing Disorder

By Angela Loucks Alexander, Claire Lariviere, and Fatima Abbas

This article is a part of the March/April, Volume 35, Number 2, Audiology Today issue.

Little by little, a person can travel far (adapted from a Spanish saying) (Aubron-Bülles, 2021). And when that person is little, sometimes a little help is all it takes. 

We do not expect a child to develop or learn anything the first time on their own (for example, helping them stand and then take their first steps). We guide them through experiences and repetitions until, at some point, they master a new milestone. When development does not occur as quickly, easily, or linearly, there can be frustration and confusion about the next step in the process.

Auditory processing disorder (APD) is a communication problem related to deficits in sound processing at the level of the brain (Katz, 2007). We may never know why auditory processing difficulties occur in a specific individual or how each different behavioral or neurodivergent factor might affect a person; however, we can get started with a treatment protocol and measure the effects and improvements from that intervention systematically.

The experience of treating each client from an intrasubject perspective allows us to gather more experiences and data to become better diagnosticians and therapists for future clients.  

The future of auditory processing work will focus on each individual’s difficulties and on obtaining strategies to improve them regardless of age, cognition, co-occurring conditions, or audiogram.

We have multiple lenses and schools of thought to view auditory processing. Some of these lenses are specific and finely tuned. Others have larger pieces of the puzzle in their lens. We believe the future of auditory processing is in zooming out and seeing how all the pieces fit together. When working with pediatric brains, it is essential to consider the small incremental changes that can add up to improved sensory processing. The future of auditory processing work will focus on each individual’s difficulties and on obtaining strategies to improve them regardless of age, cognition, co-occurring conditions, or audiogram. The best way to do this is to view the client from multiple angles and to use a series of targeted treatments to achieve the necessary outcomes.

The following is a case study demonstrating an incremental approach to auditory processing treatment using multiple auditory training techniques. Although this article focuses on a pediatric case, it is important to note that the same principles apply to adults.

Case Study

Case History

Nate is an 11-year-old boy who was referred for an APD assessment after hearing concerns were noted in a routine hearing assessment following a suspected injury to the eardrum. Nate reported significant listening difficulties both at home and at school, particularly in the classroom when background noise was present. TABLE 1 summarizes the parents’ concerns.

TABLE 1. Reported Communication Concerns by the Child’s Parents

REPORTED PARENT CONCERNS

Inconsistencies in his listening skills and academic abilities.

Teachers complain that he does not listen in class.

Difficulties following multiple or multipart instructions.

Cannot respond when there is noise in the background.

Difficulty concentrating on tasks when there is noise in the background.

Need to be alone and in quiet to be able to complete his homework.

Some reading and spelling difficulties.

Attention and concentration issues.

When learning to read, he had difficulties with phonics.

Difficulties with breaking words down into sounds or putting them together.

Difficulties with reading complex words.

Difficulties understanding complex language in texts.

Difficulties following the coaches’ instructions during various sports, games, or practices.

Nate’s early history was unremarkable; his motor milestones were within normal limits. His speech milestones were slightly late but still within the normal range. No known history of otitis media was noted. There was a family history of presbycusis. His family reports no other disorders, delays, or diagnoses.

In the audiometric assessment, the otoscopic examination revealed clear canals bilaterally, and no abnormalities were noted. Impedance audiometry indicated type A tympanograms bilaterally. Acoustic reflex thresholds were present in all conditions assessed. Pure-tone testing showed normal hearing thresholds bilaterally. Speech recognition in quiet using a 10-item Arthur Boothroyd (AB) word list (Boothroyd, 1968) in each ear was within normal limits. Despite Nate’s good speech recognition scores, the evaluator noted some unusual speech sound errors in his responses. Nate also struggled with the speech-in-noise test, and screening test results indicated moderate difficulty hearing in noise. As these results and the reported listening difficulties were red flags for APD, Nate was referred for a full auditory processing assessment.