Bridging the Great Divide: A Clinical and Research-Based Response to The Informed SLP’s Article on Auditory Processing

Background and Context: Navigating the APD Controversy

Earlier this month, The Informed SLP published "Do You Hear What I Hear? Navigating Controversies in Auditory Processing." The piece raised several critiques of auditory processing disorder (APD), including variability in testing, diagnostic overlap with ADHD and language disorders, and questions about the long-term effectiveness of interventions, particularly auditory training.

As an audiologist with more than 25 years of experience, including seven years focused almost entirely on auditory processing, I felt it was important to respond. I work virtually and moderate a support group of nearly 13,000 members—including parents, professionals, and adults living with APD, hyperacusis, misophonia, tinnitus, and other related auditory challenges. Many members are international and neurodivergent, as am I. I am autistic, and I intentionally chose this population because I understand how often their needs are dismissed or misinterpreted by systems not built for them.

This article is intended for clinicians, educators, and researchers who are actively navigating the complexity of listening challenges and diagnostic uncertainty. It contributes to an ongoing professional conversation about how to move forward—ethically, effectively, and collaboratively.

The Ongoing Dialogue: Why Nuance Matters

I originally shared my response to The Informed SLP article, titled "Why the APD Label Still Matters, Even if the Tests Aren’t Perfect," within my support groups and on my blog. The ensuing discussion quickly became intense. I was accused of promoting propaganda, creating strawman arguments, and even being an AI bot. As someone who is autistic and communicates through long-form writing, I found the response both disappointing and familiar. One of the most common critiques I hear is that I write too much, but I think in context. I see patterns. I do not believe in giving partial answers to complex questions, because if the conversation leaves out nuance, then it also leaves out people—especially the children and adults who are struggling with access and clarity every day.

The author of The Informed SLP article, which raised concerns about the validity and utility of APD testing and interventions, invited me directly to share any studies or clinical perspectives I believed were missing from that discussion. I appreciated that invitation, and what follows is my contribution to that ongoing dialogue. It includes peer-reviewed research, clinical context, and insights drawn from working with a population often invisible in conventional protocols. This conversation continues a longstanding debate in the literature about the APD label, including critiques from Dr. David R. Moore and Dr. Andrew J. Vermiglio. Both have questioned the consistency, construct validity, and clinical relevance of current APD diagnostic frameworks, especially when applied to individuals with normal audiograms who struggle in real-world environments. My goal is not to win a debate, but to help expand a conversation that is overdue for more nuance, more collaboration, and more attention to functional outcomes, not just theoretical models.

I am also aware of the weaknesses in our current diagnostic protocols; testing varies widely between clinics, and identification of APD can be inconsistent depending on the tools used. This is part of why I have developed a more functionally grounded approach—one that focuses on the lived reality of listening, not just test performance.

Differentiating APD from Overlapping Conditions

Moore et al. (2020) used fMRI to examine brain activation during speech-in-noise tasks. They found that children with APD had reduced auditory cortex activation, while children with ADHD showed reduced prefrontal activation. This suggests distinct neural systems are at play. Koohi et al. (2017) used auditory brainstem response (ABR) to study children with APD, ADHD, and language disorders. Delayed ABR latencies were found only in the APD group. These findings demonstrate that APD can be physiologically differentiated from attentional or linguistic challenges.

Revisiting Auditory Training and the Role of Signal Access

There are certainly proponents of auditory training who believe it can be used in isolation to make permanent changes to the brain. However, I believe in addressing these issues more efficiently and accessibly. A treatment trial of LGHAs, with or without a remote microphone or FM system, allows families to observe real-world benefit without committing to months of time and resources that may or may not lead to generalization. Devices can be trialed, adjusted, or discontinued; time cannot be returned.

Auditory training was a central focus in The Informed SLP article. While I agree that outcomes are often inconsistent, the reality is more nuanced. In my clinical model, auditory training is not used in isolation. It is most effective when combined with improved signal access through devices like LGHAs or FM systems. Rance et al. (2017) showed that FM systems not only improved speech-in-noise perception but also enhanced cortical encoding as measured by EEG. Standalone training may have benefits in narrow cases like amblyaudia, but real-world generalization is limited unless the incoming signal is first clarified. Generalization is also difficult if the child is not motivated or interested, or if the training does not directly apply to the child’s or adult’s life. Stabilize the system first, then build the skills.

Amplification and the Importance of Personalized Control

Smart et al. (2023) used pupillometry to show that low-gain hearing aids reduced listening effort in adults with normal audiograms but functional APD. These devices improved comfort, focus, and cognitive endurance during speech-in-noise tasks. Shiels et al. (2023) found that remote microphone systems improved academic performance in children with normal hearing but significant listening difficulty.

Amplification strategies were largely missing from The Informed SLP’s review, but they are essential. I have also argued that hearing aids should not be reserved only for permanent, bilateral losses. Children with fluctuating or temporary hearing loss deserve prompt support, as waiting for thresholds to drop ignores the developmental cost of degraded input (Stout, 2024b). Amplification alone is not enough. What matters is whether the child can control the signal in a way that supports comfort, regulation, and real-life function. Personalized gain and microphone access, especially for neurodivergent children, are tools for agency, not just hearing (Stout, 2024a).

Diagnostic Refinement and Fatigue-Based Variability

Dillon et al. (2021) proposed a battery combining the LiSN-S and Dichotic Digits Test to separate APD from ADHD and language disorders. They showed that spatial processing deficits on the LiSN-S were highly specific to APD. Rouillon et al. (2021) found that using interdisciplinary teams reduced misdiagnosis by more than 40 percent. This highlights the importance of collaboration and integrated assessment.

But we must go further. In my practice, I assess not only accuracy but endurance. Many children perform well at the start of testing but show significant breakdown by the end of the session. This collapse in clarity and attention reflects listening fatigue, a functional concern that often goes unmeasured (Stout, 2024e). Likewise, excluding children from evaluation based on normal hearing thresholds ignores those whose most disabling challenges are not reflected in a pure-tone audiogram. Hearing and listening are not the same thing (Stout, 2024d).

Exploring Physiological Measures of Listening Effort

I have spoken with several researchers who are actively involved in studying pupillometry and other physiological tools for assessing listening effort. They have shared thoughtful perspectives on both the promise and the limitations of these methods in clinical settings. All three expressed optimism about the science but also cautioned against using these tools for individual diagnostic decisions at this stage. Environmental control, luminance, task timing, and individual variability make real-world pupillometry complex and currently unsuited for standalone clinical use.

Still, I am actively exploring dual-task paradigms, behavioral fatigue testing, and passive data collection as a way to capture what patients and families already know: that listening is not binary, and that effort matters. One researcher confirmed that there are no published studies yet on pupillary response in people with APD and encouraged comparative research. I would gladly support that work and involve willing patients in future studies.

Conclusion: Toward Rigorous and Compassionate Care

Honestly, I believe we should be working to return to a physiological model of auditory processing whenever possible. The behavioral model introduces too much variability across clinicians and settings. In the meantime, treatment trials offer a practical middle ground. They allow us to observe whether symptoms improve when the auditory system is supported, giving us a clearer sense of whether the difficulty is physiological or behavioral in origin.

That said, over-diagnosis is a valid concern, particularly when clinicians rely on too few measures or do not consider overlapping developmental, linguistic, or attentional differences. Mislabeling a child can carry real consequences. But so can failing to identify those who are struggling. That’s why nuanced, team-based interpretation matters. It is not about expanding labels—it’s about clarifying the source of difficulty so we can provide the right support.

I am not here to divide professionals by specialty or to suggest that any one approach has all the answers. What I am asking is that we stop letting old debates block real solutions. Children and adults who struggle with listening deserve access, not infighting. They deserve to be believed, not bounced between disciplines. And they deserve care that reflects their reality, not just their test scores.

If we can move beyond defending our turf and instead focus on what works, we have a chance to build a model of care that is both rigorous and compassionate. I welcome continued dialogue, shared case reviews, and honest debate, as long as the goal stays the same: supporting people who are still being left behind. By understanding and treating the root physiological causes of listening difficulties, the fewer downstream symptoms we are likely to see in behavior, language, and learning. Addressing the upstream issue may reduce the need for years of compensatory therapies, allowing children to make progress more efficiently and with greater comfort.

References

Dillon, H., Cameron, S., Glyde, H., Wilson, W., & Tomlin, D. (2021). An opinion on the assessment of people who may have an auditory processing disorder. American Journal of Audiology, 30(1), 1–6.

Koohi, N., Vickers, D., Lakshmanan, R., Warren, J., Werring, D., & Bamiou, D. E. (2017). Use of auditory brainstem responses for the diagnosis of auditory processing disorder in children. Frontiers in Neurology, 8, 649.

Moore, D. R. (2018). Editorial: Auditory processing disorder. Ear and Hearing, 39(4), 617–620.

Moore, D. R., Hugdahl, K., Stewart, H. J., Vannest, J., Perdew, A., Sloat, N. T., & Hunter, L. L. (2020). Listening difficulties in children: Behavior and brain activation produced by dichotic listening of CV syllables. Ear and Hearing, 41(6), 1649–1660.

Rance, G., Chisari, D., Saunders, K., & Rault, J. L. (2017). Reducing listening-related stress in school-aged children with auditory processing disorder. Journal of Neurodevelopmental Disorders, 9(1), 1–10.

Rouillon, I., André, A., Millot, M., Béranger, B., & Thai-Van, H. (2021). The importance of interdisciplinary assessment in the diagnosis of auditory processing disorder in children. Journal of Clinical Medicine, 10(11), 2403.

Shiels, L., Tomlin, D., & Rance, G. (2023). The assistive benefits of remote microphone technology for normal hearing children with listening difficulties. Ear and Hearing.

Smart, J. L., Newall, P., & Hickson, L. (2023). Listening effort and benefit of low-gain hearing aids for adults with normal hearing and auditory processing disorder. Trends in Hearing, 27, 1–15.

Stout, R. (2024a, May 21). We will not wait and see: Why can’t we do temporary fittings for temporary losses. https://www.drraestout.com/blog/we-will-not-wait-and-see-why-cant-we-do-temporary-fittings-for-temporary-losses

Stout, R. (2024b, May 28). Locked-in listening: Why personalized hearing aids and microphone control matter for kids with peripheral hearing loss.

Stout, R. (2024c, June 1). Why “normal hearing” shouldn’t be a gatekeeper for auditory processing disorder (APD) testing. https://www.drraestout.com/blog/why-normal-hearing-shouldnt-be-a-gatekeeper-for-auditory-processing-disorder-apd-testing

Stout, R. (2024d, June 2). Why the APD label still matters, even if the tests aren’t perfect. https://www.drraestout.com/blog/why-the-apd-label-still-matters-even-if-the-tests-arent-perfect

Stout, R. (2024e, June 5). The collapse after the sprint: Why alert vs. fatigued state testing changes everything.

The Informed SLP. (2024, June). Do you hear what I hear? Navigating controversies in auditory processing.

Vermiglio, A. J. (2014). On the clinical entity in audiology: (Central) auditory processing and speech recognition in noise disorders. Journal of the American Academy of Audiology, 25(9), 904–917.

Vermiglio, A. J. (2024, April . 20Q: Auditory processing disorders – Is there a gold standard? AudiologyOnline. https://www.audiologyonline.com

Wilson, W. J., & Arnott, W. (2013). Using different criteria to diagnose (central) auditory processing disorder: How big a difference does it make? Journal of Speech, Language, and Hearing Research, 56(1), 63–70.