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Disorders in Language
and Auditory Processing:
is there a relationship?
Stuart Rosen,
PhD, Professor of
Speech and here is currently much interest in the notion of auditory processing disorder
Hearing Science

Correspondence
Stuart Rosen,
Professor of Speech
and Hearing
T (APD), both in adults and children. Most attention has been focused on chil-
dren, primarily because of suspicions that an APD may lead to learning diffi-
culties, especially affecting language and literacy, and hence to poor school performance.
Science, On the face of it, the connection seems obvious. Insofar as a child has difficulties in pro-
UCL Speech
Hearing and cessing auditory information, and particularly speech, how can this not have an impact
Phonetic Sciences,
Division of
on the development of language and literacy? Perhaps surprisingly, it appears that APD
Psychology plays little or no causative role in any cognitive deficits, including language and literacy.
& Language
Sciences,
2 Wakefield Street,
London, Let us first specify the kinds of develop- and a language disorder would be of little
WC1N 1PF, UK. mental language disorders of concern here. utility. For example, it might be considered
Email: stuart@
phon.ucl.ac.uk Everyone has heard of dyslexia, a deficit in reasonable to test speech perception
Homepage: reading and spelling despite adequate intel- through asking children to repeat back sen-
www.phon.ucl.ac.uk ligence and access to conventional instruc- tences in a background of noise. Yet perfor-
/home/stuart
tion. Much less well known, even in the sci- mance in a sentence repetition task, even in
Declaration of entific community, is Specific Language quiet, has been shown to be a very useful
Competing Interests
Impairment. SLI is typically diagnosed by marker of SLI.6
None declared.
late-developing and impaired language In an attempt to create a working defin-
Acknowledgements abilities alongside more-or-less normal ition of APD in the light of such difficulties
Much appreciation cognitive abilities. In both cases, there are (and broader considerations), the APD
to Katherine Mair,
Lorna Halliday,
no frank neurological signs or peripheral Steering Group of the British Society of
Sam Evans and hearing impairment, and the deficit is con- Audiology has proposed the following
Doris-Eva Bamiou sidered to be a relatively specific one, so (British Society of Audiology APD Special
for comments on
an earlier version of not due to more general deficits in intelli- Interest Group Steering Committee, 2008)7:
the manuscript. gence. Dyslexia, in fact, is often known as ‘APD results from impaired neural func-
specific reading disorder (SRD), in order to tion and is characterised by poor recogni-
emphasise this. Interestingly, there is a great tion, discrimination, separation, grouping,
deal of co-morbidity between these two localisation, or ordering of non-speech
disorders, although they can also occur in sounds. It does not solely result from a
isolation.1 deficit in general attention, language or
The notion of APD is much more con- other cognitive processes.’
tentious, even in its definition.2-4 One cen- This is not to say that an APD cannot
tral issue concerns the problem of disentan- result in a language disorder, simply that
gling an auditory processing disorder from a evidence of impaired linguistic processing
language disorder, as a language disorder on alone is not sufficient to diagnose it.
its own can result in what are claimed to be Fortuitously, the BSA definition is highly
APD-like symptoms of poor speech per- consistent with the approach taken by the
ception. Insofar as language-related abilities most staunch proponents of the view that
are used to define APD (and one of the not only is there a relationship between
most commonly used tests for APD, the developmental language disorders and
SCAN-C, uses only speech material — APD (strictly defined as a deficit involving
Keith, 2000)5, the co-occurrence of an APD nonspeech sounds), it is the APD that
directly causes the language disorder.
Interestingly, the inspiration for this early
APD appears to work was clearly drawn from a study of an
acquired language disorder as described in
play little or no a remarkable paper entitled ‘Temporal per-
ception, aphasia and déjà vu’. In it, Efron
causative role in any (1963)8 mixed references to Tennyson,
Dickens, Heller and French films of ‘La
cognitive deficits Nouvelle Vague’ with psychoacoustic
experiments involving temporal order

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judgement on people with aphasia. He indisputable auditory deficit. The group to some unspecified combination of pro-
concluded that ‘we should not look upon with hearing loss had the poorest acuity for gram intensity, practice, and even the bias
the aphasias as unique disorders of lan- detecting frequency modulations (a task of the testers to obtain improved test per-
guage but rather as an inevitable conse- that has often been used to demonstrate formance for all children. Cohen et al.
quence of a primary defect in temporal auditory deficits in dyslexics), but no evi- (2005)20 compared three groups of children
analysis’. This idea was then applied by dence of impairments in literacy. with SLI, all receiving therapy as usual, and
Paula Tallal and colleagues to children with Some of my own work has attempted to found those who underwent FFW did no
SLI and dyslexia, leading them to claim that clarify, from a more clinical point of view, better than a control group receiving no
both these disorders arose from a more pri- the distinguishing features of children who extra intervention, as did Given et al.
mary auditory deficit, particularly one are suspected of suffering from APD (2008)21 in a similar study of children iden-
involving rapid temporal information.9,10 (susAPD) on the basis of a medical referral tified on the basis of difficulties in reading.
Stein’s (2001)11 magnocellular deficit theory due to concerns about difficulties in ‘listen- Perhaps the strongest evidence that
runs along similar lines, although his focus ing’. First, we applied a battery of auditory improving an auditory deficit will have no
is on dyslexia, and his explanation more tests to these susAPD children and a con- impact on a language disorder comes from
detailed as regards the underlying physio- trol group, in the hope of finding objective the recent study of McArthur et al. (2008).22
logical deficit. evidence of APD. As it turned out, the two They explicitly trained a group of children
The primary support for these theories groups performed significantly differently, with both poor auditory skills, and dyslexia
comes from studies of nonspeech auditory on average, for two of the auditory tasks.15 and / or SLI on a variety of auditory tasks,
processing in people with dyslexia and SLI It therefore appeared that at least some of and concluded that although auditory pro-
who, in fact, typically do show impaired the susAPD children had some genuine cessing deficits can be successfully amelio-
performance compared to age-matched auditory problems. Perhaps most interest- rated, ‘… this does not help them acquire
control groups on some auditory tasks, at ingly, although the susAPD group as a new reading, spelling, or spoken language
least at a group level. In an extensive review whole performed worse than controls on a skills’. In short, there appears to be no
of this body of literature however, I argue number of tests of verbal and nonverbal advantage of auditory training on the
that such a result on its own does not pro- cognition, there were no differences in the development of language and literacy, even
vide proof that an APD can cause a lan- cognitive abilities of two susAPD sub- when improved auditory functioning can
guage disorder, for the following reasons groups (children with or without the be demonstrated. Note though, that the
(Rosen, 2003)12: demonstrable auditory deficit — see Figure dyslexic / SLI group did improve their lan-
● Only a minority of people with language 1). In other words, the children referred for guage test scores, but so did an untrained
disorders actually evidence an auditory ‘listening’ problems who actually had an control group of typically-developing chil-
deficit of any sort, so an auditory deficit auditory deficit seemed to be no different dren (although it would have been better
is not a necessary part of a language dis- in other ways than those who had none. A to have a control group with dyslexia / SLI).
order similar independence of language / literacy McArthur et al. argue that such improve-
● Correlations between measures of audi- and speech perceptual skills has been con- ments in test scores with re-testing are
tory processing and language skills are vincingly demonstrated in a large study of quite common, so that ‘… training effects
typically weak or non-existent within children entering school.16 reported by studies of clinical training pro-
the language-impaired population, Evidence against auditory deficit theo- grammes that do not include an untrained
implying that the auditory deficit is asso- ries of language impairments also comes test–retest control group are virtually unin-
ciated with the language deficit rather from recent attempts to remediate the dis- terpretable’.
than being causal (see Ramus, 2003 for a order explicitly through auditory training. So where does this leave the clinician
similar view)13 The most important development in this concerned with hearing? There is reason-
● There has been no convincing demon- area concerns Fast ForWord (FFW), a com- ably good evidence, both from my own
stration of how the nonspeech deficit puter-run rehabilitation program for which study and that of Dawes et al. (2008)23, that
relates to a deficit in speech perception, were claimed remarkable results in amelio- children referred with concerns about ‘lis-
even though all the variants of the audi- rating SLI primarily through improving tening’ evidence a much higher incidence
tory deficit theories posit that the dele- auditory processing.17,18 Unfortunately, of deficits in language than is found in the
terious effects on language and literacy these results have not been replicated in general population, whether or not they
development flow from a deficit in the independent studies of FFW, nor in related appear to have any auditory processing
representation and / or processing of work. problems. Therefore, children referred for
speech sounds arising from the non- Gillam et al. (2008)19 compared four suspected APD need to have, in addition to
speech deficit. The evidence is also very treatments (but unfortunately no untreat- their audiometric assessment, a reasonably
clear that whatever auditory deficits ed control group) in an intensive summer thorough psychometric work-up, including
there are cannot be attributed to failures program for children. These included FFW assessments of nonverbal ability, language
in rapid auditory processing. and a set of educational computer games and literacy, because problems in these
Since that review, other studies using dif- targeting academic enrichment (AE) that areas may contribute to problems experi-
ferent approaches have cast doubt on were not specifically designed to improve enced by the child. Furthermore, difficulties
auditory deficit theories of language disor- language or reading skills. It appeared that in these central cognitive skills are sure to
ders. Halliday & Bishop (2006)14 compared all groups improved in language scores, and impact on academic achievement, and
the auditory abilities of children who were even in an auditory task of backward mask- there appear to be well-proven rehabilita-
typically-developing to those who had ing, even though auditory and language tion strategies (not within the remit of spe-
dyslexia (but with normal peripheral func- skills were not explicitly remediated in the cialists in hearing like audiologists) that can
tion) and to children with mild to moder- AE treatment. It therefore seems most like- improve children’s performance in these
ate sensorineural hearing loss, so with an ly that the improvements noted were due areas (for example Bowyer-Crane et al.)24

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Figure 1: Boxplots comparing the cognitive abilities


of children who performed poorly on tests of audi-
tory processing compared to those who performed
well. All children were medically referred for prob-
lems associated with ‘listening’. Each box indicates
the inter-quartile range of values obtained, with the
median indicated by the solid horizontal line. The
range of measurements is shown by the whiskers
except for points more than 1.5 box lengths from
the upper or lower edge of the box (indicated by
‘o’). BPVS is the British Picture Vocabulary Scale and
TROG is the Test for Reception of Grammar, testing
different aspects of language development. None of
the three pairs of clustered boxplots are significantly
different from one another.

If deficits in auditory processing (at least 5. Keith RW. SCAN-C: Test for Auditory Processing 17. Merzenich MM, Jenkins WM, Johnston P, Schreiner
Disorders in Children - Revised. The Psychological C, Miller SL, Tallal P. Temporal processing deficits of
of the type discussed here) do indeed turn Corporation; San Antonio, TX, USA; 2000. language-learning impaired children ameliorated by
out to have little or no causal role in the 6. Conti-Ramsden G, Botting N, Faragher B. training. Science 1996;271:77-81.
development of language and literacy, this is Psycholinguistic markers for specific language 18. Tallal P, Miller SL, Bedi G, Byma G, Wang XQ,
not to say that there is no point in identify- impairment (SLI). Journal of Child Psychology and Nagarajan SS, Schreiner C, Jenkins WM, Merzenich
Psychiatry and Allied Disciplines 2001;42:741-8. MM. Language Comprehension In Language-
ing children with APD. For example, and as is 7. British Society of Audiology APD Special Interest Learning Impaired Children Improved With
commonly believed, such children may Group Steering Committee (2008). Working defini- Acoustically Modified Speech. Science
tion of APD. 1996;271:81-4.
experience unusual difficulty in perceiving
[http://www.thebsa.org.uk/apd/Home.htm#workin 19. Gillam RB, Loeb DF, Hoffman LM, Bohman T,
speech in noise, which could have an impact g%20def] Champlin CA, Thibodeau L, Widen J, Brandel J,
on the ability to comprehend a teacher in a 8. Efron, R. Temporal perception, aphasia and déjà vu. Friel-Patti S. The efficacy of Fast ForWord
bustling classroom. If this proved to be the Brain 1963;86:403-24. Language Intervention in school-age children with
language impairment: A Randomized controlled
case, then the remediation of an auditory 9. Tallal P. Auditory temporal perception, phonics and
trial. Journal of Speech Language and Hearing
reading disabilities in children. Brain and Language
deficit might be desirable in itself (although 1980;9:182-98.
Research 2008;51:97-119.
it is not yet clear how or if this is possible) 20. Cohen W, Hodson A, O’Hara A, Boyle J, Durram T,
10. Tallal P, Piercy M. Defects of non-verbal auditory
McCartney E, Mattey M, Naftalin L, Watson J.
because classroom behaviour or acquisition perception in children with developmental aphasia.
Effects of computer-based intervention through
of general academic knowledge might then Nature 1973;241:468-9.
acoustically modified speech (Fast ForWord) in
11. Stein, J. The magnocellular theory of developmen- severe mixed receptive-expressive language impair-
improve. This would certainly be worthwhile tal dyslexia. Dyslexia 2001;7:12-36. ment: outcomes from a randomized controlled
even if the improved auditory performance 12. Rosen, S. Auditory processing in dyslexia and spe- trial. Journal of Speech Language and Hearing
had little impact on the development of lan- cific language impairment: is there a deficit? What Research 2005;48:715-29.
guage and literacy.  is its nature? Does it explain anything? Journal of 21. Given BK, Wasserman JD, Chari SA, Beattie K, Eden
Phonetics 2003;31:509-27. GF. A randomized, controlled study of computer-
13. Ramus F. Developmental dyslexia: specific phono- based intervention in middle school struggling
References logical deficit or general sensorimotor dysfunction? readers. Brain and Language 2008;106:83-97.
1. McArthur GM, Hogben JH, Edwards VT, Heath SM, Current Opinion in Neurobiology 2003;13:212-8. 22. McArthur GM, Ellis D, Atkinson CM, Coltheart M.
Mengler ED. On the ‘specifics’ of specific reading 14. Halliday LF, Bishop DVM. Is poor frequency modu- Auditory processing deficits in children with read-
disability and specific language impairment. Journal lation detection linked to literacy problems? A ing and language impairments: can they (and
of Child Psychology and Psychiatry and Allied comparison of specific reading disability and mild should they) be treated? Cognition
Disciplines 2000;41:869-74. to moderate sensorineural hearing loss. Brain and 2008;107:946-77.
2. American Speech-Language-Hearing Association Language 2006;97:200-13. 23. Dawes P, Bishop DVM, Sirimanna T, Bamiou DE.
(2005). (Central) Auditory Processing Disorders -The 15. Vanniasegaram I, Cohen M, Rosen S. Evaluation of Profile and aetiology of children diagnosed with
Role of the Audiologist [Position statement]. selected auditory tests in school-aged children sus- auditory processing disorder (APD). International
3. Cacace AT, McFarland DJ. The importance of pected of auditory processing disorder (APD). Ear Journal of Pediatric Otorhinolaryngology
modality specificity in diagnosing central auditory & Hearing 2004;25:586-597. 2008;72:483-9.
processing disorder. Am J Audiol 2005;14:112-23. 16. Watson CS, Kidd GR, Horner DG, Connell PJ, 24. Bowyer-Crane C, Snowling MJ, Duff FJ, Fieldsend E,
4. Jerger J, Musiek F. Report of the Consensus Lowther A, Eddins DA, Krueger G, Goss DA, Rainey Carroll JM, Miles J, Gotz K, & Hulme C. Improving
Conference on the Diagnosis of Auditory BB, Gospel MD, Watson BU. Sensory, cognitive, and early language and literacy skills: differential effects
Processing Disorders in School-Aged Children. linguistic factors in the early academic performance of an oral language versus a phonology with read-
Journal of the American Academy of Audiology of elementary school children: The Benton- IU pro- ing intervention. Journal of Child Psychology and
2000;11:467-74. ject. Journal of Learning Disabilities 2003;36:165-97. Psychiatry 2008;49:422-32.

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