LSHSS

Review

Auditory Processing Theories

of Language Disorders:
Past, Present, and Future
Carol A. Millera

Purpose: The purpose of this article is to provide information

that will assist readers in understanding and interpreting
research literature on the role of auditory processing in
communication disorders.
Method: A narrative review was used to summarize and synthesize the literature on auditory processing deficits in children
with auditory processing disorder (APD), specific language
impairment (SLI), and dyslexia. The history of auditory processing theories of these 3 disorders is described, points of
convergence and controversy within and among the different
branches of research literature are considered, and the influence of research on practice is discussed. The theoretical and
clinical contributions of neurophysiological methods are also
reviewed, and suggested approaches for critical reading of the
research literature are provided.

Conclusion: Research on the role of auditory processing in

communication disorders springs from a variety of theoretical
perspectives and assumptions, and this variety, combined with
controversies over the interpretation of research results, makes
it difficult to draw clinical implications from the literature.
Neurophysiological research methods are a promising route
to better understanding of auditory processing. Progress in
theory development and its clinical application is most likely
to be made when researchers from different disciplines and
theoretical perspectives communicate clearly and combine the
strengths of their approaches.

ost school-based speech-language pathologists

(SLPs) are probably familiar with the term auditory processing and may have found that other
professionals, such as audiologists, psychologists, and reading specialists, also use the term. At first glance, this situation looks good: Colleagues with different backgrounds
share a vocabulary and, presumably, a theory. Stated very
simply, that theory might be something like auditory processing deficits cause language-related academic problems.
Intuitively, this seems like a reasonable approach. We learn
our native language by listening to speech (unless we are
exposed to a signed language). If the sounds of speech are
not delivered to the language system accurately and quickly,
then surely language ability will be compromised. However,
despite decades of research, a complete theoretical account

of how auditory perceptual deficits lead to impaired language

has proven elusive. In the absence of such an account, auditory processing has become a buzzword that has almost as
many meanings as there are people who use it. Therefore, use
of the term may generate confusion rather than reduce it.
In this article, I briefly review the history of auditory
processing theories of language-related learning difficulties.
I believe one reason for the confusion surrounding the term
auditory processing is that it has been studied by different
groups of researchers with different goals, assumptions, and
methods. With this background in mind, we can better understand points of convergence and controversy within and
among the different branches of research literature and how
research has influenced practice. The article will conclude with
an examination of the theoretical and clinical contributions
of neurophysiological methods, a discussion of future directions, and suggestions for informed reading of the literature.

The Pennsylvania State University, University Park

Correspondence to Carol A. Miller: cam47@psu.edu
Editor: Marilyn Nippold
Associate Editor: Ilsa Schwarz
Received May 26, 2010
Accepted March 26, 2011
DOI: 10.1044/0161-1461(2011/10-0040)

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Key Words: language disorders, auditory processing,

dyslexia (written comprehension), specific language
impairment, electrophysiology

Auditory Processing Deficits Are Implicated

in Multiple Disorders
Auditory processing deficits have most often been invoked in theories about three disorders: auditory processing

SCHOOLS Vol. 42 309319 July 2011 * American Speech-Language-Hearing Association

309

disorder (APD),1 specific language impairment (SLI), and

dyslexia. The presence of auditory processing deficits is the
motivation for the diagnosis of APD. Children with APD
demonstrate difficulties in one or more areas of perceptual
processing of auditory information, such as
sound localization and lateralization; auditory discrimination;
auditory pattern recognition; temporal aspects of audition,
including temporal integration, temporal discrimination (e.g.,
temporal gap detection), temporal ordering, and temporal
masking; auditory performance in competing acoustic signals
(including dichotic listening); and auditory performance
with degraded acoustic signals. (American Speech-LanguageHearing Association [ASHA], 2005, p. 2)

Peripheral hearing impairment is usually an exclusionary

criterion for APD. The ASHA definition does not specify
exclusionary criteria, but it does state that it is inappropriate
to apply the APD label to children with, for example,
language impairment or learning disabilities unless a
comorbid deficit in the CANS [central auditory nervous
system] can be demonstrated (ASHA, 2005, p. 2).
It has been suggested for decades (see Rees, 1973; Rosen,
2003 for reviews) that auditory processing deficits underlie
SLI. Children with SLI fail to learn language as quickly
and accurately as their age-mates, but in the absence of
hearing impairment, cognitive impairment, frank neurological disorder, or developmental disorders such as autism, and
in the presence of language input that should be sufficient
for normal learning (Bishop, 2006). There is also a long
history of associations between dyslexia and auditory processing problems. Children with dyslexia fail to acquire
fluent, accurate word-reading skills despite adequate instruction, and in the absence of cognitive impairment. The wordreading impairments are thought to result from impaired
phonology (Lyon, Shaywitz, & Shaywitz, 2003).
For each of these three disorders, there is an associated
body of research suggesting that observed problems with
spoken and/or written language result from auditory processing deficits. However, despite some points of contact,
these three branches of research literature have generally used
different measures, and perhaps different conceptions, of
what auditory processing is (Cacace & McFarland, 1998).
Therefore, a comprehensive account of the role of auditory
processing in these disorders is missing. The search for a
single, comprehensive theory of auditory processing is closely
tied to the following question: Are APD, SLI, and dyslexia
distinct disorders (Dawes & Bishop, 2009; Kamhi, 2011)?
If SLI and dyslexia can be explained by the same auditory
processing deficits that are found in APD, this would be
evidence in favor of considering them a single disorder. If
1
Some writers prefer the term central auditory processing disorder, and
others prefer auditory processing disorder (see American Speech-LanguageHearing Association [ASHA], 2005, for an explanation of the differing
terminology). In this article, I will use the term auditory processing disorder,
intending it to be synonymous with central auditory processing disorder.

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they can all be considered as one disorder, then the research

literature associated with each could be synthesized, and
such a synthesis might lead to advances in understanding the
role of auditory processing deficits in that single disorder.
However, it is by no means certain that APD, SLI, and
dyslexia are underlyingly the same disorder. Some researchers have argued that SLI and dyslexia are different labels
for the same disorder (Kamhi & Catts, 1986; Tallal, 1988,
2004); however, recent research (Bishop & Snowling, 2004;
Catts, Adlof, Hogan, & Ellis Weismer, 2005) suggests
that they are distinguishable. There have been a few systematic comparisons of APD with SLI and /or dyslexia
(Dawes, Bishop, Sirimanna, & Bamiou, 2008; Ferguson,
Hall, Riley, & Moore, 2011; Miller & Wagstaff, in press;
Sharma, Purdy, & Kelly, 2009). These studies have consistently shown that children with APD have very similar
profiles to children with language or reading impairments.
ASHAs technical report (2005) asserts that APD is distinct from language impairment, but research demonstrating
how to differentially diagnose them is lacking (Dawes &
Bishop, 2009; Kamhi, 2011).
With regard to SLI and dyslexia, a consensus has not
yet been reached regarding the causal role of auditory processing deficits. I will describe some points of contention
later in this article, but for now, it is enough to note that the
debate continues (Dawes & Bishop, 2009; Kamhi, 2011).
Importantly, the literature concerning these two disorders
begins with observation of certain behavioral symptoms
and searches for a mechanism to explain the symptoms. A
problem with auditory processing is a candidate mechanism.
For APD, however, the starting assumption is that some
individuals have problems with auditory processing, and
the question is how to assess those problems and determine
their association with behavioral symptoms. This description
of the difference in assumptions is necessarily somewhat
oversimplified, but the overview in the following section
will help to show how the difference has arisen.

History of Auditory Processing Research

There are several published reviews that trace the history
of auditory processing as a construct and a topic of research
(Jerger, 2009; Kamhi, 2011; Lahey, 1988; Leonard, 1998;
McFarland & Cacace, 2009; Rees, 1973; Rosen, 2003). As
one reads these reviews, along with the position statements
of professional organizations (ASHA, 1996, 2005; Jerger
& Musiek, 2000), it becomes clear that there are distinct
strands of research that have developed largely independently of one another. Jerger (2009) identified three such
strands: the audiological approach, the psychoeducational
approach, and the language processing approach. The audiological approach, according to Jerger, originated with
studies of adults with brain lesions. Tests that had been
developed to assess central auditory processing abilities
of these patients began to be used in the 1970s to assess

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children who, as described by Myklebust (1954) as early as

the 1950s, had adequate peripheral auditory sensitivity but
could not fully make use of the speech they heard (Jerger,
2009). The term central auditory processing disorder
(CAPD), or APD, was used to describe children who
performed poorly on such instruments.
Jergers (2009) description of the second strand of
research, the psychoeducational approach, corresponds
closely to the specific-disabilities orientation toward explanation of language disorders as described by Lahey (1988).
Researchers in this orientation, often SLPs and psychologists, focus on rather narrowly circumscribed component
abilities that are believed to be necessary for the production
and comprehension of spoken language and/or literacy.
The specific-disabilities approach is often found in the literature on dyslexia as well as the literature on SLI. Auditory
perceptual skills, as Lahey noted, have been perennial
favorites in the search for specific disabilities. The reasoning behind the orientation is that if specific disabilities
contributing to language-related academic problems can be
identified, they can also be remediated. Lahey provided a
cogent critique of this approach. That critique exemplifies in
many ways the language processing approach, Jergers third
strand in the history of auditory processing research. The
language processing approach emphasizes the interactive
nature of speech and language processing, where knowledge
of language and sensitivity to the context of its use have
significant topdown effects on how the central nervous
system (CNS) deals with an auditory signal.
This brief overview helps to explain why the research
literature on APD, SLI, and dyslexia tend to remain distinct.
APD has usually been studied using the audiological approach. Equipped with knowledge of CNS lesions and tests
that are believed to assess their effects, researchers using
this approach ask: What is the outcome for an individual with
an APD? SLI and dyslexia have usually been studied using
the specific-disabilities approach. Researchers who adopt
this approach, equipped with knowledge of outcomes and
tests to assess those outcomes, ask: Could an auditory
processing deficit be the cause of this outcome? Here the
focus tends to be on identifying a deficit through psychophysical tasks, such as discrimination of tones or syllables,
and linking that deficit to a distinctive and well-described
outcome (e.g., a dyslexic profile). Research coming from
the specific-disabilities perspective has often been critiqued
by proponents of the language processing approach, who,
equipped with an appreciation for the topdown influence
of language knowledge, tend to emphasize the unique properties of speech and how speech may be processed differently from other auditory stimuli.

Controversies
There is no shortage of controversies in the research
literature on auditory processing, and it is beyond the scope

of this article to fully address these issues. I will, however,

briefly discuss a cluster of issues that may help to illustrate why, despite all the research on auditory processing, a
comprehensive theory remains hard to come by.
There is a central debate in the APD literature over the
modality specificity of APD. Cacace and McFarland (1998,
2005) argued that APD should be defined as a deficit in
the processing of auditory stimuli only. Therefore, assessment of processing in other modalities is required in order
to rule out supramodal deficits such as memory, attention,
or linguistic problems. Other researchers contend that the
interactive nature of the CNS precludes such modality specificity (ASHA, 2005; Musiek, Bellis, & Chermak, 2005).
Related to the modality specificity issue is a controversy
regarding the use of linguistic material to assess APD, and
auditory processing more generally in SLI and dyslexia.
Moore (2006) argued that APD should be defined on the
basis of processing of nonspeech sounds (see also Dawes
& Bishop, 2009). With regard to dyslexia, Farmer and
Klein (1995) argued from their review of the literature that
individuals with dyslexia likely have a general temporal
processing deficiency that encompasses not only nonlinguistic and linguistic auditory stimuli, but visual stimuli
as well. In contrast, Mody (2003) summarized arguments
that the evidence for nonlinguistic temporal processing
problems is weak. According to Mody, some of the data
presented as evidence of generalized deficits in rapid
temporal processing can be interpreted as demonstrating
phonological deficits. Furthermore, not all individuals with
dyslexia have difficulty processing brief, rapid stimuli
(e.g., Bishop, Adams, Nation, & Rosen, 2005).
Research on speech versus nonspeech deficits in children with SLI parallels that in children with dyslexia. For
example, there is evidence that children with SLI have
difficulty with frequency discrimination at the behavioral
level (McArthur & Bishop, 2004). Furthermore, even some
individuals with normal behavioral performance show abnormal cortical responses to tones (Bishop & McArthur,
2005). Children with SLI also have difficulty discriminating differences in amplitude envelope rise time (Corriveau,
Pasquini, & Goswami, 2007). However, not all of the children in any particular sample performed below the level of
their typically developing peers. In a study that examined
both SLI and dyslexia, Fraser, Goswami, and Conti-Ramsden
(2010) found rise time discrimination problems in children
with dyslexia, with or without comorbid SLI, whereas children with only SLI did not perform significantly worse than
typically developing age peers. Thus, it remains unclear
whether deficient processing of nonspeech auditory stimuli
is a consistent characteristic of either SLI or dyslexia.
Rosen (2003) emphasized that, even if some individuals
with SLI and dyslexia have deficits in processing nonspeech
stimuli, there is no viable theoretical account relating nonspeech to speech deficits. Leonard (1998) made a similar
point, arguing that although children with SLI are repeatedly
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found to have problems with brief or rapid stimuli, the

nature of these problems remains unclear and lacks a
well-explicated link to the observed speech and language
impairments.
In debating whether there is a unique processing deficit
for speech, or for auditory input, researchers are trying to
address the thorny issue of causality. Auditory processing
deficits are associated with SLI and dyslexia, but do the
deficits cause those disorders or are the auditory processing
problems caused by the language and reading impairments
in the disorders? Similarly, does APD result in deficits of
language (or memory or attention), or can APD be explained
as a consequence of such deficits?
There are reasons to think, as suggested in the language
processing approach, that higher level constructs such as
linguistic knowledge affect the processing of auditory input at an early stage. Banai and Kraus (2009) summarized
evidence showing that auditory brainstem responses (ABRs)
for speech can be changed by a lifetime of musical experience or by a few weeks of experience with a computer
training program. They also described how ABRs are
affected by what stimulus a participant chooses to attend
to (Galbraith, Bhuta, Choate, Kitahara, & Mullen, 1998;
Galbraith, Olfman, & Huffman, 2003). In a study of children with speech sound disorders, Johnson, Pennington, Lee,
and Boada (2009) found phonological awareness at age 5
to better predict backward masking performance (thought
to index rapid temporal processing) at age 8 than age 5 backward masking performance predicted age 8 phonological
awareness. Findings such as these suggest the presence of
topdown influences on perception and call into question
any model in which auditory processing causes language
and reading problems.
There are further reasons to doubt that there is a direct
link from rapid auditory temporal processing to language
or reading. A study by Watson et al. (2003) with a community sample found that temporal speech processing
measures were relatively poor predictors of reading achievement and overall academic performance in first and second
grade. Moore, Ferguson, Edmondson-Jones, Ratib, and Riley
(2010), also using a community sample of schoolchildren,
found that auditory processing was a less effective predictor
of communication and listening outcomes than measures of
attention and cognition. Interventions designed to improve
auditory processing through the use of modified speech have
been found to be no more effective than other interventions
(e.g., Gillam et al., 2008; see the Intervention section).
There is evidence, however, that favors a causal role for
auditory processing in language and reading impairment.
Much of this evidence comes from longitudinal studies of
infants and young children. Infants with a family history
of language impairment performed more poorly than peers
without such a history on behavioral measures of rapid
auditory processing at age 69 months, and their performance
predicted language scores at 12 and 16 months (Choudhury,

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Leppnen, Leevers, & Benasich, 2007). Compared to typically developing peers, children with low word production
at 12 and 24 months had, at age 5 months, shown reduced
electrophysiological evidence of discriminating stress patterns based mainly on temporal cues (Weber, Hahne, Friedrich,
& Friederici, 2005). These and other findings indicating
that differences in auditory processing can be observed
in young infants (e.g., Guttorm, Leppnen, Tolvanen, &
Lyytinen, 2003) and are associated with later language development (e.g., Guttorm et al., 2005) suggest that auditory processing deficits exist before language begins to be
used. Yet infants are in the process of learning language even
before they are born; therefore, given the evidence for top
down effects on auditory responses (Banai & Kraus, 2009),
it is possible that differences in infants auditory processing
are the result, not the cause, of abnormal language processing.
Furthermore, the speech versus nonspeech debate raises its
head again even here. Molfese, Molfese, and Molfese (2007),
in a review of studies from their own and other labs, suggested
that infants event-related potential (ERP) responses to
speech may be particularly predictive of language and reading outcomes.
Even these few examples pertaining to speech versus
nonspeech processing, modality specificity, and direction
of causal influence illustrate that the literature on auditory
processing is rife with conflicting results and conflicting
interpretations of results. Given this state of affairs, it is
perhaps not surprising that a comprehensive theoretical
account uniting research on APD, SLI, and dyslexia has
proven elusive. Nonetheless, there are some points of
convergence.

Convergence
The three strands of research identified by Jerger
(2009)the audiological, psychoeducational (or specific
disabilities), and language processing approachesare
not without their similarities. For example, the traditional
emphasis of the audiological approach on describing a
profile of strengths and weaknesses in a number of component auditory processing abilities such as temporal processing, sound localization, auditory discrimination, and so
on (ASHA, 2005) shares some of the philosophy of the
specific-disabilities orientation (Kamhi, 2011). The audiological approach most clearly converges with the specificdisabilities approach when different auditory processing
profiles are hypothesized to lead to distinct patterns of
behavioral symptoms (Bellis, 2003; Katz, 1992). Also, in
recent years, the audiological approach has incorporated
knowledge about topdown influences of language knowledge and cognitive ability (Musiek & Chermak, 2007),
showing some convergence with the language processing
approach. In addition to these philosophical similarities,
researchers from all three approaches have increasingly
begun to turn to neurophysiological techniques such as

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ERP and functional magnetic resonance imaging (fMRI) for

better understanding of auditory processing.

Neurophysiological Methods
One reason for the controversies regarding the role of
auditory processing in APD, SLI, and dyslexia is a reliance
on behavioral measures. The behaviors that characterize
these disorders are the result of multiple factors, from signal perception to interpretation of the signal (giving it
meaning) to integrating the interpretation with existing
knowledge and current context. When a behavior is observed
for example, poor discrimination of syllablesit is very
difficult to determine where in the process failure occurred.
Is there a general problem with signal perception or only with
the perception of auditory input? Do problems arise before
the signal is interpreted as linguistic, or afterward? How can
we distinguish between perception and retention of a signal?
Given the current state of knowledge about the CNS,
these questions are extremely difficult to answer; however,
neurophysiological techniques may help provide answers
(Dawes & Bishop, 2009). These techniques have some advantages over the behavioral methods that have been used
in the audiological, specific-disabilities, and language processing approaches. Behavioral tests must often be sensitized, or made more difficult, so they will reveal weaknesses
(Cacace & McFarland, 2005). For example, an auditory processing test might require the repetition of sentences presented
in background noise. The overt response is influenced by
the participants understanding of the instructions, perception and processing of the stimulus, attention, motivation,
memory, and speech ability. In an ERP or fMRI study, no
overt response is required (although an overt response may be
used), and in some cases, the participant does not even need to
be attending to the stimulus. Brain activity associated with
simply perceiving the stimulus can be assessed. Brain activity
associated with the other factors in the behavioral response
may also be assessed if the researcher chooses.
Event-related potentials are obtained through electroencephalography (EEG), by measuring the electrical activity
(or potential) of the brain that is time-locked to a stimulus
eventhence, ERPs. ERPs are also called evoked potentials, and auditory evoked potentials have been used by
hearing scientists for many years as a window into how the
brain processes auditory input. The ABR can be measured
within the first 1015 ms following stimulus onset. The
middle latency response, from approximately 12 ms to
50 ms poststimulus onset, is probably generated by the
upper brainstem and primary auditory cortex and is followed by later cortical responses 50250 ms after stimulus onset (Hall, 1992). Both ABRs and cortical responses
have been used in investigations of auditory processing in
children with APD, SLI, and dyslexia (e.g., Basu, Krishnan,
& Weber-Fox, 2010; Bishop & McArthur, 2005; Jerger,
Martin, & McColl, 2004; Jirsa, 1992; Jirsa & Clontz, 1990;

Marler & Champlin, 2005; Martin, Jerger, & Mehta, 2007;

McArthur, Atkinson, & Ellis, 2009; Sharma et al., 2006).
One major advantage of ERPs is their excellent temporal resolution, allowing researchers to track the brains
response to stimuli almost millisecond by millisecond. It
is very difficult to determine, however, where in the brain
the responses are occurring. Although we categorize some
auditory evoked potentials according to the location of their
generators, such as the brainstem, this categorization is
based on our knowledge of the anatomy and physiology
of the CNS, not on any locational specificity of the EEG
signal itself. In contrast, fMRI has excellent spatial resolution but relatively poor temporal resolution. It measures
blood flow to areas of the brain; areas that get more blood are
presumably more active. It takes several seconds for blood
flow to change, however. Therefore, ERP and fMRI offer
complementary data about brain activity.
It is important to understand that neither ERP nor fMRI
techniques offer a perfectly transparent window into the
workings of the brain. There are many steps of data processing and interpretation between the actual brain activity
and the results of a neurophysiological study. Furthermore,
the data are only as good as the design of the experiment
that elicits them. Still, ERPs and fMRI do offer data about
what the auditory nervous system is doing that cannot be
obtained through behavioral methods. The following paragraphs summarize some illustrative findings using electrophysiological and MRI methods to investigate auditory
processing.
Several studies have demonstrated that a substantial
proportion of children with language and /or reading impairments have abnormal ABRs. These results have been obtained with different types of stimuli such as backward
masked tones (Marler & Champlin, 2005), tonal sweeps
and rapid clicks (Basu et al., 2010), and synthesized speech
syllables (Banai, Nicol, Zecker, & Kraus, 2005; Johnson,
Nicol, Zecker, & Kraus, 2007). A larger body of literature
has found abnormal cortical responses in many children with
language and/or reading impairments (see Banai & Kraus,
2007, for a review that includes findings for both subcortical
and cortical responses). Bishop and McArthur (2005) investigated behavioral and ERP responses in a frequency
discrimination task. Among their participants with SLI,
ranging in age from 12 to 20 years, not all demonstrated
difficulty with frequency discrimination. However, many
of the participants had abnormal cortical responses, even
in the presence of adequate behavioral frequency discrimination. Children with APD or suspected APD have been
found to have abnormal cortical responses to speech or
nonspeech stimuli (Jerger et al., 2002, 2004; Jirsa, 1992;
Jirsa & Clontz, 1990; Martin et al., 2007).
Structural MRI studies, which examine brain morphology
rather than brain activity, suggest that the brains of children with SLI differ from those of typically developing controls, with some areas being smaller and/or more symmetrical
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across hemispheres in children with SLI (Gauger, Lombardino,

& Leonard, 1997; Leonard, Eckert, Given, Virginia, &
Eden, 2006; Leonard et al., 2002; Plante, Swisher, Vance,
& Rapcsak, 1991). There are few fMRI studies of brain activity in individuals with SLI, and they do not directly address
auditory processing; however, there is some evidence that
on certain tasks, individuals with SLI show less activation
and/or different patterns of activation than typical language
peers (Dibbets, Bakker, & Jolles, 2006; Ellis Weismer, Plante,
Jones, & Tomblin, 2005; Hugdahl et al., 2004). A case
study of a 20-year-old male with APD suggested reduced
activity in areas of the auditory cortex (Kim et al., 2009).
Auditory processing in children with dyslexia has been
investigated using fMRI. Temple et al. (2003) investigated
phonological processing in children with and without dyslexia
before and after remediation with Fast ForWord (Scientific
Learning Corporation, 1998), a computerized intervention
program that is described in more detail in the section on
intervention. Following the intervention, Temple et al. found
increased brain activation during the phonological tasks in
children with dyslexia. Some of the increased activation was
in areas that were also activated in controls, and some activity
was found in other brain areas. In another fMRI study, Gaab,
Gabrieli, Deutsch, Tallal, and Temple (2007) investigated
brain activity in response to nonlinguistic stimuli that were
structured like speech syllables. The duration of the frequency
transitions within these stimuli was manipulated. Before
intervention, several brain regions in typically developing
children showed greater activation for rapid compared to
slower transitions, but children with dyslexia showed differential activation in only one area. After intervention with Fast
ForWord, children with dyslexia showed greater activation
in several brain regions that were active in their typically
developing peers in response to rapid frequency transitions.
Given the growing body of neurophysiological research,
illustrated by the studies described above, increased understanding of the complexity and plasticity of the auditory
system is recognized to be necessary for resolving questions
about the role of auditory processing in language development (Musiek & Chermak, 2007). Indeed, the ASHA (2005)
technical report on APD emphasized that the massively
interactive nature of the CNS makes it difficult if not impossible to disentangle auditory processing from language
processing and other higher cognitive functions. Acknowledging this interactiveness highlights a question raised most
recently by Wallach (2011), influenced by Lahey (1988,
1990), who in turn echoed a call from Rees (1973): If it is
impossible to single out specific disabilities causing language impairment, how effective can targeted intervention
be?

Intervention
Some hypotheses about auditory temporal processing
have led directly to interventions. Data regarding the success

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of these interventions, therefore, can provide evidence for

or against the theories that motivated the interventions. An
excellent example is the computer-based training system
Fast ForWord. Based on the work of Tallal and colleagues
(Merzenich et al., 1996; Tallal et al., 1996), Fast ForWord
uses modified speech in a series of computer games that
react adaptively to the users performance, increasing or
decreasing the difficulty level on the basis of prior responses.
The modified speech is slowed, with selective amplification of rapid formant transitions (Nagarajan et al., 1998).
If deficits in rapid auditory processing underlie language
and reading problems, then the Fast ForWord intervention,
targeting speed of processing, should ameliorate those
problems.
A recent meta-analysis (Strong, Torgerson, Torgerson, &
Hulme, 2011) identified six high-quality studies regarding
the effectiveness of Fast ForWord. The authors concluded
that there was no convincing evidence that Fast ForWord
improved participants reading or language skills, whether
compared to no-treatment controls or to controls receiving
an active treatment. The participants in the reviewed studies
were selected on the basis of language or reading impairment, and for one study, impairments in both. An illustrative
example of the studies reviewed is a randomized, controlled
clinical trial conducted by Gillam et al. (2008). The study
compared Fast ForWord to another computer-based language intervention, to academic computer games without a language focus, and to intervention by an SLP. The
results suggested that all interventions were effective in
improving the childrens language performance and auditory
processing (measured by a backward masking task), but
that Fast ForWord was no more effective than the other
treatments. The two language-focused computer interventions resulted in more improvement in phonological awareness than the other two treatments. There was no evidence,
however, that intervention specifically targeted to auditory
processing was more effective than other intensive interventions (Gillam et al., 2008).
Two recent systematic reviews examined studies regarding the effectiveness of auditory interventions, including
but not limited to Fast ForWord. Fey et al. (2011) examined studies of auditory interventions for children with APD,
language disorder, or both. Loo, Bamiou, Campbell, and
Luxon (2010) reviewed studies of computer-based auditory
interventions in which the children had language- or readingrelated difficulties. The two reviews included many of the
same studies, but each also included some unique studies,
as the inclusion criteria were not the same. In both reviews,
the studies reviewed varied in their quality, and quality
was rated by the authors.
Fey et al. (2011) concluded that weak evidence exists
to suggest that auditory interventions can improve auditory functioning in children with APD, but there is little
or no evidence that such interventions improve language
outcomes. Similarly, there is some evidence that auditory

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interventions improve auditory processing in children with

language disorders, but the effects are not greater than control
interventions, and the auditory interventions were not found
to improve language outcomes in children with language
disorders.
Loo et al. (2010) concluded that there is some evidence
that computer-delivered auditory interventions improve
auditory processing and phonological awareness in children
with language- and/or reading-related learning problems.
However, they found little evidence that such interventions
were effective in improving language and reading outcomes.
They also noted that two studies using paired audiovisual
stimuli found promising results for improving reading skills.
An illustrative example of auditory intervention studies
not involving Fast ForWord is Russo, Nicol, Zecker, Hayes,
and Kraus (2005). These authors assessed the effect of using
an auditory training computer program, Earobics (Cognitive
Concepts, 1997), on brainstem and cortical responses and on
behavioral responses in a rather broadly defined sample
of children with language difficulties. Following intervention, the brainstem responses of the children more faithfully
encoded timing characteristics of a synthetic speech syllable
presented in background noise. These changes were associated with more mature cortical responding. Similar changes
were not seen in a control group. Children in the intervention group showed improved behavioral performance on
some tests of auditory language processing, but these changes
were not associated with the changes in ABR. A listening
comprehension test, which did not show a pretestposttest
difference, was associated with decreased variability of the
brainstem response in noise. Thus, there is some evidence
of improved auditory processing, but its relation to language
performance is unclear.
An auditory perceptual training study was conducted
by Moore, Rosenberg, and Coleman (2005) with typically
developing children ages 8 to 10 years. The study investigated whether a phoneme discrimination computer game
would result in increased phonological awareness and word
discrimination. Both phonological awareness and word
discrimination scores improved in the treatment group versus
the no-treatment control group, although the evidence that
phoneme discrimination itself improved was equivocal.
Moore et al. suggested that the improvements in outcome
measures were due to both perceptual learning and increased
attention. As the authors noted, perhaps perceptual
learning is a type of improved attention (Moore et al., p. 83).
The hypothesis that gains in attention led to improved
outcomes is consistent with a recent study from the same
laboratory (Moore et al., 2010) in which a communitybased sample completed auditory processing, speech recognition, language, cognitive, and attention measures. As
described earlier, the results of the study suggested that
attention and cognition were the best predictors of speech
recognition, communication, and listening skills as rated
by caregivers.

The role of musical training in auditory perceptual skill

development is ripe for investigation. In a recent review,
Chandrasekaran and Kraus (2010) argued, based on evidence
that musicians exhibit superior speech processing compared to nonmusicians, that musical training is a promising
method for improving speech perception in individuals
who have difficulty excluding background noise, which, the
authors suggested, is a common symptom in children with
APD, SLI, and dyslexia. Listening to music (as opposed to
being trained as a musician) has been used as a treatment
approach for children with language, reading, and /or auditory processing disorders. The Listening Program (Advanced
Brain Technologies, 2010), for example, uses a schedule
of exposure to acoustically modified classical music. No
published reports of effectiveness are available as yet.
The results of the intervention studies reviewed here
suggest that auditory processing can be changed, even at
the level of the brainstem. However, some important points
can be drawn from these studies. One is that interventions
not designed to affect auditory processing are equally as
effective as an intervention that is intended to change auditory processing. Thus, we are left knowing no more than
we did about a causal relationship between auditory processing and language. It is possible that other aspects of
the interventions used, such as their intensive nature and
requirements for focused attention, led to improved outcomes, when such improvements were found. Another lesson
is that electrophysiological changes do not necessarily result in behavioral changes, at least not on the time scale of
a few months. A corollary to this result is the finding by
Bishop and McArthur (2005) that many youths with SLI
had abnormal cortical responses to pure tones despite adequate behavioral frequency discrimination. The imperfect
correlation between electrophysiology and behavior highlights the difficulty of establishing the direction of causality
between auditory processing and language.

Future Directions
As noted at the outset of this article, there is an intuitive sense that accurate auditory perception is essential for
normal language development. However, it is crucial to
remember that speech perception does not proceed in an
exclusively bottomup manner. We might imagine a strictly
bottomup model in which sounds are converted to neural
signals that are relayed from the periphery, through the
auditory nerve and brainstem, to subcortical structures and
finally the auditory cortex, with smaller units being combined into larger units somewhere along the way. But as Rees
(1973) pointed out, speech perception requires phonological,
semantic, syntactic, and contextual knowledge throughout
the process, and acoustic units do not correspond in straightforward ways to linguistic units. The research available at
that time was unable to single out any auditory skill or set of
skills that was essential for language or reading development.
Miller: Auditory Processing Theories

315

As Rosen (2003) noted 3 decades later, that situation has

changed little.
Have those 30 years been wasted? Certainly not. We have
learned a great deal about the brain in general and the central
auditory nervous system in particular, and our knowledge
grows daily. The technology available to study the auditory
system in action is rapidly improving. Still, the task of understanding auditory processing is extremely challenging.
The central auditory nervous system is a magnificently
intricate set of structures that subserves, among other functions, the amazingly complex speech perception and language
comprehension systems. Audition, speech perception, and
language processing occur in the context of a lifetime of
experience and knowledge about language. Even if that lifetime is the mere 3 or 4 years of a preschooler, an immense
amount of experience is put into play in every encounter with
speech. Thus, there is not going to be a simple story about
how auditory perception and language interact. In order for
the story to be told in all its complexity, researchers coming
from audiological, psychoeducational, and specific-disabilities
perspectives, as well as researchers taking a neuroscientific
approach, must find a way to communicate so that shared
constructs, methods, and goals can be identifiedas well
as constructs, methods, and goals that are distinct to each
perspective. To the extent that researchers and clinicians
can communicate clearly about their theories, hypotheses,
and findings, the full story of auditory perception and language can be discovered through a rich combination of
approaches from the fields of audiology, speech-language
pathology, education, psychology, and neuroscience.
There is a still a long way to go in developing a
comprehensive theory of auditory processing that will guide
the practice of SLPs and audiologists, as well as teachers,
psychologists, and other professionals. I am confident that
such a theory can and will be constructed, but in the meantime, here are a few questions that readers can ask when
evaluating information about auditory processing.
& What is the authors perspective: audiological,
psychoeducational, specific disabilities, neuroscience,
or a combination? How does this perspective shape
the research questions, methods, and interpretation?
& If the author is making recommendations for practice,
what are they based on: the research literature, the
authors own data, the authors clinical experience,
or the opinion of experts in the field?
& What population is the author talking about: children
with APD, SLI, dyslexia, or a broader category such
as language-learning problems or learning disability?
How confident are you that your client(s) is similar
to the authors population?
These questions do not provide a checklist for identifying
good or bad research, but they should help clinicians
in organizing and evaluating the sometimes confusing
literature on auditory processing.

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Auditory Processing Theories of Language Disorders: Past, Present, and Future

Carol A. Miller
Lang Speech Hear Serv Sch 2011;42;309-319
DOI: 10.1044/0161-1461(2011/10-0040)
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