To the Editor:
The editorial in Ear and Hearing on auditory processing disorder (APD; Moore 2018) announced a ban on the publication of certain scientific articles if the use of nomenclature does not accord with the nomenclature preferences of the Editorial Board. Board members take issue with the currently endorsed umbrella term “auditory processing disorder” (APD) for hearing disorders in the central auditory system and will only permit usage of the term under specified conditions. The editorial proposes use of a new term such as “listening difficulties” but states that it too should be used as an umbrella term. Presumably the proposed term will also be banned if it is not made clear that it is being used as an umbrella term. Both terms have their limitations but banning publication of scientific articles is a negative and extreme method with which to try and influence the evolution of terminology. A more commonplace and positive approach to change is through academic dialogue as exemplified in a recent article by Wilson (2018) who considers the evolving concept of auditory processing disorder, discusses different approaches, and suggests a new terminology for discussion by research, clinical, and general communities. The editorial claims publications in Ear and Hearing have in fact been guiding clinical management of APD in a new and better direction perhaps even leading to game-changing prevention and intervention. If the natural evolution of the science of central hearing disorders is progressing well why intervene so drastically to inhibit scientific reporting? Censorship will turn researchers away from Ear and Hearing, perhaps even from this area of research, with the danger that useful scientific contributions will be stifled.
It is informative to look at the area of autism. There too it is well recognized that there is no single “autism” entity and that perhaps in time that term will be replaced by dozens or even hundreds of different yet-to-be-identified entities to describe the conditions currently grouped together. A step towards this was to adopt the term autism spectrum disorder. Further evolution of terminology will ensue, but we are not aware of calls to censor the umbrella term autism spectrum disorder from scientific publications in the meantime.
The editorial argues that true cases of APD are rare. First, the author points out that comorbidities can be found in most of the cases he has examined. We agree that APD is often accompanied by other disorders. But this does not mean that central hearing deficits do not exist as an entity.
Second, it is argued that the majority of cases presenting for APD assessment can be explained by language, attention, or cognitive factors. A possible causative link between central hearing deficits and language impairment is still moot (Burns 2012). Hearing is a prerequisite for oral language development. When it comes to attention, most pediatric audiologists are skilled at detecting straying attention, mitigating its effects, and taking into account available information on any attention deficits. Some diagnostic markers used by audiologists employ within-subject comparisons, for example, between conditions or ears, to minimize confounding influences. More importantly, most published studies on cognitive influences on hearing tests used by clinicians in this field do not report that they allowed children with possible auditory disorders to wear amplification or use other assistive technology during orally presented memory and other cognitive testing. It would be unthinkable to deny use of their hearing aids or cochlear implants to children with sensory hearing disorders during cognitive assessment. That would lead to overestimation of cognitive influences on hearing test results. Scores on auditory memory tests, often employed in research on cognitive factors in APD, are adversely affected by impaired audition (Boxtel et al. 2000). Scores on auditory memory tests improve for some children with comorbid central auditory processing deficits when they are allowed to wear amplification during auditory memory testing (Schafer et al. 2016). Similarly, older adults with hearing deficits score more poorly on cognitive tests when tested without hearing aids (Dupuis et al. 2015; Jorgensen et al. 2016) and better when they are allowed to wear their hearing aids (Jedlicka Reference Note 1). Even nonverbal cognitive tests, commonly used in APD assessment and typically presented in the visual modality, may not tap true cognitive ability in persons with central hearing deficits given the potential for high comorbidity between central auditory and visual disorders (Tu’i’onetoa, Reference Note 3). Flawed estimation of cognitive influences on tests of central auditory function could lead to an unfounded assumption that poor performance on central hearing tests is correlated to impairment of cognitive skills. This in turn could lead to erroneous underdiagnosis of true central hearing disorders.
We have seen underdiagnosis of deafness before. As the editorial points out, we should learn from our history. Some of us have worked in this field long enough to have personally witnessed the tragedy of people misdiagnosed and incarcerated for life in old-style “mental institutions” because their deafness was not diagnosed in childhood, and they were assumed to be cognitively deficient. The potential consequences of overenthusiastic efforts to explain away most central hearing disorders as other developmental conditions may not be as drastic in the 21st century, but they are nonetheless concerning.
The editorial does not consider the point of view of patients. Banning a current term without prior agreement on a replacement would confuse patients and their families and create difficulties for the clinicians working with them. Moreover, it would adversely affect service provision, insurance, and other funding sources for patients. Some public agencies and insurance companies already use lack of standardization in APD protocols as an excuse to not provide for the needs of people with central hearing disorders. People living with APD are concerned that more attention should be given to their needs. Their call has been taken up by the International Federation for Hard of Hearing People, which invokes the United Nations Convention on the Rights of Persons with Disabilities in its advocacy (Carroll & Warick 2013). APD is included in International Federation for Hard of Hearing People’s United Nations Convention on the Rights of Persons with Disabilities Toolkit Workshops (National Foundation for the Deaf Inc: Human Rights Workshops; National Foundation for the Deaf Inc, Reference Note 2). Consumers want their voice to be heard in service provision for central hearing disorders. Any change to different nomenclature needs to occur in a measured and consultative manner. Not only should there be dialogue about, rather than imposition of, any changes in nomenclature, but the dialogue should also involve people with APD.
Clinical practices and terminology evolve, as long as such evolution is nurtured. We submit that any rejection of manuscripts by Ear and Hearing should be based on unsound scientific process or invalid interpretation of results, not aversion to current practice or terminology. The decision of Ear and Hearing Editorial Board members to censor scientific articles that do not agree with the Editorial Board’s beliefs brings to mind the banning of teaching evolution science in some schools because of beliefs which those in power hold to be correct beliefs. We cannot help but see parallels. Is this how science should advance?
Boxtel M. V., Beijsterveldt V. C., Houx V. P., et al. Mild hearing impairment can reduce verbal memory performance in a healthy adult population. J Clin Exp Neuropsychol, 2000). 22, 147–154.
Burns M. S. Geffner D, Ross-Swain D. Auditory processing disorders and literacy. Chapter 13. In Auditory Processing Disorders: Assessment, Management and Treatment (2012). 2nd ed., page San Diego, CA: Plural Publishing.301–317).
Dupuis K., Pichora-Fuller M. K., Chasteen A. L., et al. Effects of hearing and vision impairments on the Montreal Cognitive Assessment. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn, 2015). 22, 413–437.
Jorgensen L. E., Palmer C. V., Pratt S., et al. The effect of decreased audibility on MMSE performance: A measure commonly used for diagnosing dementia. J Am Acad Audiol, 2016). 27, 311–323.
Moore D. R. Editorial: auditory processing disorder, Ear Hear, 2018). 39, 617–620.
Schafer E. C., Wright S., Anderson C., et al. Assistive technology evaluations: Remote-microphone technology for children with autism spectrum disorder. J Commun Disord, 2016). 64, 1–17.
Wilson W. J. Evolving the concept of APD. Int J Audiol, 2018). 57, 240–248.
Jedlicka D. The Effects of Amplification on Performance on the Montreal Cognitive Assessment, VA Healthcare System Pittsburgh, University of Pittsburgh. Presented at AAA Convention, 2018) Nashville, TN.
Tu’i’onetoa L. The validity of questionnaires in teacher observation of auditory processing problems in children. Unpublished Psychology Honours Dissertation, The University of Auckland.2015).