Believing in Bottom-Up
Dear Speech Pathologist,
Thank you for the work you are doing with children who face complex language and learning challenges. I truly respect your commitment to structured, language-based intervention, and I agree that many children benefit significantly from approaches that target phonemic awareness, expressive language, and structured literacy. These tools are essential, especially for older students who have already developed gaps that need direct support.
That said, I want to offer a broader clinical perspective, based on what I see in my work with children who have auditory processing disorder and related auditory access challenges. In many cases, what is called a bottom-up approach in language therapy actually begins in the middle. It assumes that the auditory signal is already clear and consistent, and that the brain has stable access to well-formed phonemic representations. However, for many of these children, especially those with central auditory dysfunction or a history of otitis media, eustachian tube dysfunction, or fluctuating hearing loss, the signal has never been fully reliable.
When we begin with phonemic awareness or structured literacy without first addressing the quality of the input, we are asking children to manipulate sounds they have never fully perceived. It is like asking someone to build sentences in a language they have only ever heard through static. They may learn to get by through compensation, using memorized patterns, routines, or contextual guessing, but they are doing this with significant cognitive effort. Over time, that effort can lead to fatigue, avoidance, or inconsistent performance that is misunderstood as behavioral or attentional.
The work I do typically begins at the true sensory level. I focus first on cleaning up the auditory signal using tools such as low-gain hearing aids, spatial listening supports, and sometimes targeted auditory training to build skills like figure-ground discrimination, sequencing, and auditory closure. These strategies are designed to reduce distortion, improve clarity, and help the brain create more accurate speech maps. Once the input becomes more stable, many children begin to develop language and literacy skills naturally, with less need for intensive downstream intervention.
In younger children, especially those with a history of fluctuating hearing loss, persistent middle ear fluid, or loss of the acoustic reflex following PE tube placement, early intervention at the sensory level can make all the difference. These are not separate problems. All of them can cause auditory deprivation. If we address them early, many children are able to catch up through everyday exposure and natural development. The brain fills in the missing pieces when it receives consistent, high-quality input at the right time.
We see a similar pattern in Deaf education. Children who receive cochlear implants or hearing aids early in life tend to develop language more fluently than those who receive amplification later. This is because language develops in response to consistent and meaningful input during early brain development. The same principle applies to children with central auditory dysfunction. If a child spends their early years hearing distorted or inconsistent input, they are building language and literacy on a compromised signal. The effects often do not show up until later, when they appear as difficulties with reading, writing, attention, or expressive language.
For older children, the situation is more complex. These students often need immediate access to language and literacy instruction so they do not fall further behind in school. I fully support the use of structured intervention in these areas. I am not suggesting these therapies are short-term fixes. In many cases, they are absolutely necessary, especially when the child has aged out of the most plastic developmental windows. However, I still believe that improving the quality of auditory input remains essential. Even for older children, improving access to a clearer, more stable signal can make their speech and literacy work more efficient and sustainable. It may not be as transformative as early intervention, but it still matters.
Unfortunately, the school system usually does not identify these issues until they become visible as reading delays, articulation problems, or broader academic struggles. By the time a child is referred for testing, they may have spent years operating with a degraded auditory signal. At that point, we are often trying to catch up to the consequences of missed access rather than addressing the root cause.
This is why I believe access must come first. When we stabilize the auditory signal, children can begin learning from real-world input more naturally and with far less effort. The interventions that follow, including language, literacy, and expressive communication, become more efficient and effective.
This is not about choosing one method over another. It is about aligning the right intervention with the right entry point and recognizing that when access improves, many downstream interventions may no longer be needed, or may work much more quickly and with less frustration.
Thank you for your time and for your openness to this perspective. I truly believe that speech-language pathology and audiology are strongest when they work together.
With respect and shared purpose,
Rae
Dr. Rae Stout, CCC-A
Doctor of Audiology
P.S.: If you’re still wondering how speech and audiology can work together, maybe a duet will help: https://suno.com/song/ae569386-bca4-4074-a73e-cfdbe8f1ffff
