By Yolande Loftus, BA, LLB of AutismParentingMagazine.com (article republished with permission)
When kids on the spectrum struggle with listening, especially the processing and comprehension of sound, parents may wonder if it’s a characteristic of autism or an issue with auditory processing. Auditory processing disorder is a complicated condition courting controversy like most other sensory processing disorders.
We tend to think of hearing in a simplistic way focusing mostly on the ears. The involvement of the brain and nervous system in the process of hearing, and interpretation of sounds, receives a lot less attention. That is until your child, who can hear perfectly, seems unable to listen. Or in the words of a mother whose child struggles with auditory processing: “She doesn’t have a hearing problem, but she seems unsure of what she’s supposed to do with what she hears.”
Parents with autistic children are often experts when it comes to sensory processing disorders. They need to be, as research tells us almost all kids (more than 90%) on the spectrum display atypical sensory behaviors (Chang et al., 2014). With a brain wired differently, it probably makes sense that auditory processing may be atypical.
Even when parents are familiar with auditory processing disorders, the condition is difficult to distinguish from other hearing and speech-language disorders. Understanding the condition, the way it’s defined and the way it manifests may be helpful—particularly when a child also has a neurodevelopmental condition with symptoms overlapping with those associated with auditory processing disorder (APD).
What are auditory processing disorders and how do they present?
For years the condition was referred to as central auditory processing disorder; in fact many in the medical community still prefer this term. Officially, however, the condition is called auditory processing disorder. International prevalence statistics indicate between 2-5% of kids may have some sort of auditory processing disorder (Chermak et al., 2007).
The complexity of hearing and processing sound in the brain means many things can go wrong at multiple stages. Auditory processing disorder is not a precisely defined disorder but rather a group of varying functional deficits. Individuals with such deficits often struggle in complex listening circumstances, such as following conversations in noisy environments.
Parents aiming to explain why their child has such difficulty following verbal instructions, often explain that while their child hears auditory information, they just don’t process it appropriately. Unfortunately, parents may struggle to obtain an accurate early diagnosis as auditory processing disorder is tough to assess and difficult to distinguish from conditions like attention deficit hyperactivity disorder (ADHD), autism, and other language processing disorders.
While audiologists diagnose auditory processing disorders, a multidisciplinary team is usually required for assessment. This team may include physicians, speech-language pathologists, occupational therapists, educators, psychologists and other professionals. Since austistic children may already have an intervention team consisting of some of the above mentioned professionals, parents should disclose observance of any of the following symptoms:
- A child who requests multiple repetitions, or frequently asks: “Huh?” or “What?” This may of course indicate other hearing problems which is why it is important to seek a diagnosis from an experienced medical professional
- The child may have difficulty remembering names, nursery rhymes and the words to familiar songs
- The child may find following conversations tough, compensating by looking for visual or facial cues for better comprehension
- They may seem distracted, with teachers making remarks about their poor listening skills
- They may muddle up sounds and pronounce words incorrectly
- They may struggle to pay attention when information is presented orally, while well-developed concentration is displayed when instructed visually or while reading
- They seem to need much more time to process information than peers of similar intellect
- The child may struggle to block out background noise (loud noises and sound barely perceptible to parents); the child may say they could not concentrate or finish homework because their alarm clock was ticking
- Children with auditory processing deficits may find verbal instructions, especially instructions with multiple steps, difficult to follow
These symptoms are frequently observed in conditions presenting similarly to sensory processing disorders; a child with ADHD (for example) may struggle to follow directions or verbal instructions and a child with autism may prefer being taught with visual aids rather than auditory instruction. Whether this is due to auditory processing difficulties or a characteristic of ADHD will have to be determined by knowledgeable experts. Parents do remark that their first clue leading to diagnosis (of auditory processing disorders) is often the improvement of their child’s behavior in quiet environments.
How would my child experience auditory processing disorder?
We are learning a lot about conditions associated with autism from adults on the spectrum. Autistic children with communication deficits may find it tough to verbalize how they experience auditory and other sensory processing disorders. Adults, however, describe auditory processing disorder vividly. They speak of a disconnect between hearing spoken language sounds and interpreting such sounds.
Even more descriptive is their comparison to the way adults sound in old Charlie Brown cartoons—many autistic adults experience this garbled sound when someone is talking, especially while loud noises are playing in the background. Still others say their hearing is perfect but sometimes speech sounds blurry, muffled, garbled, or like gibberish. A wish for spoken conversations to be accompanied by subtitles is common.
In a quiet environment, without the distraction of competing sounds, most say a one-on-one conversation becomes possible to follow. Add ticking clocks, barking dogs, giggling kids and many competing conversations and it’s back to hearing Charlie Brown’s “wha, wha, wha”.
The pandemic probably made everything worse. After months of quiet lockdown isolation many felt lost in conversations muffled by mandatory mask wearing. Adults on the spectrum, already feeling at a disadvantage in certain social situations, speak of the fatigue and frustrations of trying to participate in a conversation where speech is heard well but processed poorly. Those with the condition would love more understanding and for people to realize their deficits in processing sounds and speech have nothing to do with intelligence or motivation.
Your child may not be able to verbalize how they experience sensory processing disorders and the related symptoms, but by watching their behavior around sound and spoken conversation, valuable clues related to auditory processing may be revealed.
Should I have my autistic child evaluated for APD?
While observing such clues, parents may be unsure whether their child’s symptoms are due to autism or an APD. Autism is characterized by communication deficits; difficulty in social situations may therefore be due to core autism symptoms, but it could also be because the child is struggling to process spoken language and other auditory input.
A child with auditory processing deficits may find listening to speech exhausting. Keeping up when conversing may feel taxing and the child may withdraw, leading to reduced language opportunity. Autistic children may also appear withdrawn, often shunning opportunities to participate in conversation and other social interactions.
Adults on the spectrum speak about the difficulty of filtering out sensory stimuli, especially in a difficult listening environment like a busy restaurant. In addition, while having a conversation in this type of environment, the other person may smack their gum, their phone may ping loudly and they may speak fast and a little on the loud side. All this sensory input may be overwhelming for someone on the spectrum. They may withdraw to find safety in solitude, away from the overwhelming world of sound.
When it comes to sensory processing differences in kids on the spectrum, visual processing disorders, tactile sensitivities and auditory processing difficulties are amongst the most common. In fact, a study looking at the association between sensory abnormalities and quantitative autism traits found auditory and tactile hypersensitivity predicted an autism diagnosis (Jussila et al., 2020).
Parents may rightly wonder whether these auditory processing difficulties are related to the visual learning style of many autistic children. If listening to verbal instruction is difficult and exhausting, it makes sense that visual learning may be a welcome alternative.
Another interesting intersection between autism and auditory processing disorder could be ear infections. Evidence (Khavarghazalani et al., 2016) indicates kids with a history of otitis media with effusion suffer from auditory processing disorder to a certain extent. Autistic children are often reported as having an abnormal immune system; they are more likely than typically developing children to suffer from an infection (like ear infection) in the early years of life (Sabourin et al., 2018).
In fact, many parents with kids on the spectrum speak of chronic ear infections in their kids’ early years. It would be interesting to find out if such infections are the major contributing factor when it comes to APD or whether kids on the spectrum are just more likely to have auditory processing issues and other sensory processing disorders.
The overlap between autism and APD needs more research, but what we do know is a hearing specialist or audiologist would need awareness and experience working with kids on the spectrum to distinguish autism’s symptoms from those of APD for targeted intervention and accurate diagnoses.
Ask for recommendations from your occupational therapist and speech-language pathologist and speak to other parents in support groups to find specialists who are familiar with the autism spectrum, especially the way autism presents in terms of sensory processing.
Making sound less scary
If your child is diagnosed with APD, or if your autistic child struggles in noisy environments, you can do many things to help your kid cope better:
- Background noise is a major obstacle for many children who struggle with auditory processing. Reduce background noise and improve acoustics in rooms whenever possible
- This is especially important when your child is studying or doing homework. Music, TV, fans, and even clocks may cause additional challenges when you are trying to get your child to listen to instructions
- In situations where it is important for your child to listen to you, speak in short clear sentences in a quiet room. Your child should be facing you (avoid eye contact if this causes stress and overwhelm for your autistic child), and depending on the nature of their processing disorder, you may need to speak louder or softer
- If your child does not have a visual processing disorder, visual timers, aids, and reminders may be used to complement or replace auditory instruction and/or directions
- You should work with your child’s teachers and talk to them about your child’s processing difficulties so they can accommodate your child in a way that fosters better learning
- Talk to your child about their special interests (this is probably a topic they love talking about)/ They may be relaxed and this could create stress-free conversations allowing them to become better at processing spoken language
While APD can’t be cured yet, a therapist could work with your child to improve symptoms. Treatment may be especially useful in helping your child overcome sound discrimination problems. Early diagnosis and intervention is best as the auditory pathways keep developing up until adolescence.
Don’t simply assume your child is a poor listener; processing sound may be so trying that they’ve given up on trying! With patience, appropriate treatment, and opportunities to practice conversation in safe sound environments, your child’s conversational confidence may soon improve.
Chang, Y. S., Owen, J. P., Desai, S. S., Hill, S. S., Arnett, A. B., Harris, J., Marco, E. J., & Mukherjee, P. (2014). Autism and sensory processing disorders: shared white matter disruption in sensory pathways but divergent connectivity in social-emotional pathways. PloS one, 9(7), e103038. https://doi.org/10.1371/journal.pone.0103038
Chermak, G. D., Silva, M. E., Nye, J., Habrouck, J., & Musiek, F. E. (2007). An Update on Professional Education and Clinical Practices in Central Auditory Processing. Journal of American Academy of Audiology, 18, 428-452.
Jussila, K., Junttila, M., Kielinen, M., Ebeling, H., Joskitt, L., Moilanen, I., & Mattila, M. L. (2020). Sensory Abnormality and Quantitative Autism Traits in Children With and Without Autism Spectrum Disorder in an Epidemiological Population. Journal of autism and developmental disorders, 50(1), 180–188. https://doi.org/10.1007/s10803-019-04237-0.
Khavarghazalani, B., Farahani, F., Emadi, M., & Hosseni Dastgerdi, Z. (2016). Auditory processing abilities in children with chronic otitis media with effusion. Acta oto-laryngologica, 136(5), 456–459. https://doi.org/10.3109/00016489.2015.1129552.
Sabourin, Katherine & Reynolds, Ann & Schendel, Diana & Rosenberg, Steven & Croen, Lisa & Pinto-Martin, Jennifer & Schieve, Laura & Newschaffer, Craig & Lee, Li‐Ching & Diguiseppi, Carolyn. (2018). Infections in children with autism spectrum disorder: Study to Explore Early Development (SEED). Autism Research. 12. 10.1002/aur.2012.