Recently, I responded to a professional conversation about auditory processing disorder, sparked by a research summary questioning whether APD can be reliably diagnosed or meaningfully separated from ADHD, language disorder, and other conditions. I acknowledged the limitations of our current tests. I’ve said many times that we don’t have a gold standard. But I also shared why I still believe the diagnosis matters, and why waiting for perfect tools while kids continue to struggle is not a neutral choice.

The response I got wasn’t just disagreement. I was accused of misrepresenting the field, of relying on “anecdata,” of promoting my own agenda. Someone even suggested I wasn’t a real person.

You might wonder why I keep engaging in these conversations when they so often become heated. The answer is simple. If I don’t advocate, who will? There’s that old warning: First they came for one group, then another, and no one spoke up until it was too late. I’m not comparing our situation directly, but the lesson still holds. Silence, even well-intentioned silence, allows harm to grow. I’m not willing to step aside while kids with auditory processing challenges get left behind just because the science hasn’t caught up yet.

Auditory Processing Disorder (APD) is under fire right now. A widely circulated article published just days ago by The Informed SLP questions the validity of APD as a diagnosis and casts doubt on how it’s tested and treated—particularly from the perspective of speech-language pathology.

This article is my direct response. I’ve been in the field of audiology for over 25 years, and for the past seven, I’ve focused almost exclusively on auditory processing, working with hundreds of families across the country and internationally. I am also a pioneer of the programming and applications of the low-gain hearing aid (LGHA) model for APD—a non-invasive, science-based intervention that has changed the lives of many children with subtle but significant listening challenges.

As someone who works with these children every day, I want parents, educators, and fellow professionals to understand that APD is real, it’s physiological, and it cannot be dismissed as attention, language delay, or behavior.

This isn’t just a clinical debate—it’s about whether children get the help they need, or whether we keep blaming them for missing a signal they never heard clearly in the first place.

If you work with or care for kids who “hear fine” but still struggle to understand, this is for you.

We all know that The Very Hungry Caterpillar is a favorite because of the food. Kids love pointing out their favorite snacks like pickles, cake, cheese, and ice cream, and imagining the feast. It’s colorful, it’s silly, and it feels good.

That’s the idea behind this kind of listening work. We start with what feels good. We start with dessert first.

A few weeks ago, my nine-year-old daughter and I created a song called Caterpillar Lies. It began with her fear. What if the stories she had grown up hearing about change, transformation, and growing into something beautiful weren’t true? She came up with the concept, the emotional message, and many of the lyrics. I helped shape the structure and phrasing. Together, we worked line by line to match syllables, rhyme, and meaning. She reviewed every section and made sure it said what she wanted it to say. Now she listens to it regularly, plays it on the piano, and takes full ownership of the message.

As the first verse puts it:

“The book said feast, then nap, then fly.

But real life’s gross, and bugs still die.”

“Where’s my pickle? Where’s my ham?

All I got was mulch and jam.

Not jelly jam, I mean dirt-nap glue

And a leaf that smelled like beetle poo.”

Parents often ask me, “If my child has trouble listening and they’re diagnosed with ADHD, wouldn’t stimulant medication fix that?” The answer is nuanced but important.

Auditory Processing Disorder, or APD, is not an attention issue. It is a brain-based difference in how sound is processed, especially speech. Kids with APD might pass a hearing test, but still struggle to follow directions in noise, understand fast talkers, or tell similar sounds apart. This is a problem with access to clear sound, not effort or motivation.

That said, attention can absolutely affect how well a child performs on listening tasks. If a child is distracted or mentally fatigued, they may miss more information. But that does not mean attention is the root of the problem.

In fact, the relationship goes both ways. APD can look like ADHD. When a child is constantly straining to listen, especially in noisy classrooms, they may fidget, zone out, or seem defiant. Not because they are not trying, but because they are overwhelmed. This is called listening fatigue.

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.

My son runs across the beach, his laughter echoing through the salty air. I watch, a flicker of concern crossing my mind. One foot, ever so slightly, turns inwards with each stride. It’s subtle but noticeable, especially when fatigue sets in. My husband captures the moment in a flurry of clicks—snapshots of pure joy. Gleeful chases through the sand, toes dipped in tide pools, surrendering to the rhythm of the waves. Every image is a picture of perfection.

But perfection is an illusion, especially when it comes to nuanced realities. In still photographs, I could choose to believe everything is fine. There’s no hard evidence of a problem. Just a whisper of doubt. Maybe it’s my imagination. Maybe I’m just being a hypervigilant mother.

Then November arrives. My son’s Montessori teacher, a seasoned educator, reaches out. She has noticed it too. Not a doctor. Not a physical therapist. Just someone with a trained eye and years of experience who catches what static images miss. At school, we get daily photos—frozen moments in time. None of them show anything wrong.

But the truth is not in stills. It’s in motion. A longer video reveals what those photos cannot. Suddenly, it is clear. This is not something to watch and wait. It is something to act on—now—before a tendency becomes a pattern, before that pattern becomes permanence. But I am an audiologist, not a gait specialist. Can I make that call? Should I?

I found myself in a thoughtful disagreement this week with an Orientation and Mobility (O&M) specialist who questioned the relevance of auditory processing disorder (APD) and phonological awareness in blind children learning to read Braille.

She pointed out that the EY braille curriculum includes phonics instruction, which is true, and I respect the structure and purpose of these programs. But here is where our views diverge.

Phonics instruction only works when the brain can clearly access and process the sounds. That becomes difficult for children with APD, even if they are blind. If a child’s auditory input has been distorted because of repeated ear infections, neurological processing issues, or brain-based auditory differences, their ability to form accurate internal sound maps can be impaired. And that affects decoding and spelling, whether the child reads print or Braille.

Verse 1

I remember the hallway

the light buzzing low

The boy with the stare

and no place to go

He flinched at the voices

curled into the wall

And I couldn’t reach him

though I heard it all

Verse 2

I remember the girl

with her arms open wide

She flew into safety

and stayed by my side

But her mother grew shadows

and lies took their toll

So I carried her memory

like a mark on my soul

Misophonia isn’t just “not liking sounds.” It is disgust. It is rage. It is panic.

That gut-deep reaction when someone chews too close, breathes your air, or invades your sensory space without realizing how violated your body feels. It is not a preference issue. It is a boundary issue, especially for autistic individuals or those with PDA, also known as Pathological Demand Avoidance. The reaction is not fear. It is a survival reflex.

It is also not psychological at first. It becomes psychological when the world refuses to accommodate it. When it is treated like bad behavior, defiance, or oversensitivity. That is when trauma takes root. That is when coping turns into meltdowns, shutdowns, or dissociation.

Autism, PDA, and misophonia often appear together as a kind of sensory and emotional Trinity. Each amplifies the other. Autism heightens sensory sensitivity, PDA intensifies the need for control and autonomy, and misophonia focuses the distress on specific auditory intrusions. Together, they create a perfect storm—one that is often misunderstood and mislabeled as defiance or emotional instability.

Why aren’t more audiologists fitting low-gain programmed hearing aids to children with APD?

Because it’s between fields.

Because there’s no prescriptive formula.

Because it requires listening differently, to data, to people, and to what doesn’t yet exist on paper.

And because it doesn’t fit the typical profile of who enters this profession.

But I never fit either.

So I made something that does.