The fluid started early.

By six months, something was off. I cried more than other babies—especially at night, especially after lying down.
Sometimes there were fevers. Sometimes just congestion. Sometimes I’d wake up screaming, always tugging at my ears, especially the left one.

The pediatrician said it was normal. Said it was teething, or a cold, or allergies.
“You’ve just put him in daycare,” they said. “This is what happens.”

So they treated it like childhood.
Round after round of antibiotics.
Each time, the crying eased.
Then it came back.

Then came the plane ride.

I screamed during descent. Clawed at my ears. Afterward, my left ear stayed jammed. It didn’t pop for a week.

My mom brought me back in. The pediatrician said, “Let’s try one more round. It’ll clear up on its own.”

It didn’t.

It took months to see a specialist.
The ENT checked the pressure: negative in one ear, fluid in the other.
“He needs tubes,” they said. “He needed them a while ago.”

I was two.

Introduction

Meet Liam, age 7. He passed his hearing screening at school but struggles to follow conversations in noisy classrooms. He bumps into desks, gets overwhelmed at recess, and says his ears feel "off" even though nothing hurts. For kids like Liam, the problem isn't what traditional tests pick up. It's what they miss.

If your child has ever had chronic ear infections, asymmetric hearing, or a diagnosis of auditory processing disorder (APD), even if their hearing appears "normal" on testing, you need to know this. They may still be navigating the world with broken or inconsistent input.

Fluctuating or uneven hearing during early development doesn't just affect speech perception. It disrupts how the brain builds its internal map of space, motion, and orientation. And even after the ears clear up, the downstream effects often remain.

Chronic Fluid and Hearing Instability

One of the most common contributors is chronic middle ear fluid. Not just a passing infection or a week of congestion, but fluid that lingers, returns often, or causes hearing to fluctuate. This muffles sound, distorts clarity, and confuses spatial cues. A child may appear to hear, but the input is blurred or incomplete.

Asymmetry and Brain Miswiring

When fluid affects one ear more than the other, the brain gets unequal input. That disrupts how it learns to time, localize, and balance sound. Even short bouts of asymmetry can rewire the system in lasting ways. The brain needs balanced input to build proper auditory maps.

If you're considering an auditory processing disorder (APD) evaluation for your child, it’s normal to feel unsure about what to expect—not just during testing, but also when it comes to funding and follow-up care. Many families worry they’ll be on their own financially. While coverage is not guaranteed, there are several real pathways that can make both the testing and recommended interventions more affordable and accessible.

Paying for APD Testing

Because I am a licensed audiologist, families are typically able to use Health Savings Account (HSA) or Flexible Spending Account (FSA) funds to pay for APD testing directly.

I will provide detailed receipts and documentation as needed.

Many private insurance plans also reimburse for diagnostic audiology services, including APD testing, especially if your plan includes out-of-network coverage.

I do not bill insurance directly, but I provide a superbill that includes:

• Procedure codes
• My license and NPI information
• All necessary documentation for submitting a claim

The criticism of APD diagnostics isn’t wrong. There is a real problem.

And it’s not that auditory processing disorder isn’t real. It’s that the way we test and diagnose it is deeply flawed.

Here’s what the research actually says:

“Using different diagnostic criteria, the percentage of children identified as having APD ranged from 7.3 percent to 96 percent.”
— Wilson and Arnott, 2013

That’s from a study where the same group of referred children showed diagnosis rates that varied dramatically, just based on which test battery was used. That’s not scientific precision. That’s chaos.

Other researchers have noted that some of the most commonly used tests may miss large numbers of struggling children. For example:

“The sensitivity of the SCAN and SCAN-3 in identifying children with APD was only 50 percent and 33 percent, respectively.”
— Elsisy, 2013

In other words, children who are clearly struggling to process language in real life may still pass the most commonly used auditory tests. These false negatives can delay support, deny access to services, and undermine confidence in the diagnosis itself.

Dr. David DeBonis directly addressed this concern when he wrote:

“It is possible that the use of these protocols underestimates the presence of the disorder in children who do not meet the diagnostic criteria but are, in fact, experiencing functional difficulties.”
— DeBonis, 2015

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.”

When people think of Ehlers-Danlos Syndrome (EDS), they usually picture joint hypermobility, stretchy skin, and chronic pain. But one of the lesser-known impacts of EDS is how it can affect the auditory system—and not just in ways that show up on a standard hearing test.

We tend to treat hearing like it’s binary. You either have hearing loss, or you don’t. But for many people with EDS, especially children, their audiogram looks fine—yet they’re clearly struggling. They might complain of sensitivity to sound, fatigue in noisy environments, difficulty keeping up with verbal instruction, or frequent misunderstandings. And when they do, those symptoms are often brushed off as behavioral, attention-related, or emotional. In reality, their auditory system just isn’t working the way it’s supposed to.

Hearing depends on a delicate system of pressure regulation, mechanical movement, and reflexive protection. That means the eardrum has to vibrate with just the right tension. The ossicles—the tiny bones in the middle ear—need to move efficiently, with stable joints and well-tuned ligaments. And the acoustic reflex, which helps dampen loud noises, needs to fire quickly and reliably to protect the cochlea and brain from overstimulation. But in EDS, connective tissue doesn’t behave normally. The ligaments can be too lax, the membranes too stretchy, and the reflexes too inconsistent.

It’s like trying to control a marionette puppet with strings made of soft, unpredictable elastic. One day, everything looks normal. The next, the whole puppet collapses. The movement is inconsistent, the signal is unstable, and when that happens in the ear, what reaches the brain is already degraded.

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.