Auditory Processing Disorder Is a Legitimate Clinical Entity I have concerns regarding the ASHA Leader Blog post “Does Auditory Processing Disorder Meet the Criteria for a Legitimate Clinical Entity?” Auditory processing disorders (APDs) are accepted in the medical community. If auditory processing disorders are not valid clinical entities, then why do the ICD-9-CM and ICD-10 diagnostic codes include ... Inbox
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Auditory Processing Disorder Is a Legitimate Clinical Entity
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Hearing Disorders / Attention, Memory & Executive Functions / Inbox
Inbox   |   July 01, 2017
Auditory Processing Disorder Is a Legitimate Clinical Entity
The ASHA Leader, July 2017, Vol. 22, 4. doi:10.1044/leader.IN1.22072017.4
The ASHA Leader, July 2017, Vol. 22, 4. doi:10.1044/leader.IN1.22072017.4
I have concerns regarding the ASHA Leader Blog post “Does Auditory Processing Disorder Meet the Criteria for a Legitimate Clinical Entity?” Auditory processing disorders (APDs) are accepted in the medical community. If auditory processing disorders are not valid clinical entities, then why do the ICD-9-CM and ICD-10 diagnostic codes include central auditory processing disorders as legitimate diagnostic categories?
Under the old ICD are three codes specific to APDs: 389.14 (Central Hearing Loss), 388.40 (Disorder of Auditory Perception), and 388.45 (Acquired Auditory Processing Disorder). The term Central Hearing Loss means a disorder in processing auditory stimuli. Auditory perception is another term for auditory processing, and the third code uses the words “Auditory Processing Disorder.”
The new ICD-10 codes include H93.25 (Central Auditory Disorder) and H93.299 (Abnormal Auditory Perception). As such, the medical community—which identifies “clinical disorders”— has accepted auditory processing disorder. Thus, ICD codes for well over a decade have included the codes listed above, indicating that the medical community identifies that auditory processing disorders are valid and legitimate clinical entities.
Further support comes from neurophysiological research based on electrophysiological measures of auditory processing. For example, research from Nina Kraus and colleagues has identified significant differences in electrophysiological functioning in the brains of people identified with auditory processing disorders. Thus, auditory processing disorders affect the brain, which makes them neurophysiological, clinical disorders. There is more than sufficient evidence to support that auditory processing disorders are legitimate clinical entities.
Jay Lucker, Colesville, Maryland

Thank you for your point of view. We present a variety of perspectives on auditory processing disorders in The ASHA Leader and on the Leader Blog, and welcome further discussion.

1 Comment
July 22, 2017
Andrew Vermiglio
Response to Dr. Lucker Regarding the Legitimacy of APD
Dear Dr. Lucker,

I appreciate your letter regarding my ASHA Leader Blog post “Does Auditory Processing Disorder meet the Criteria for a Legitimate Clinical Entity.” In this post I have argued that auditory processing disorder (APD) is not a legitimate clinical entity based on the Sydenham-Guttentag criteria (Vermiglio, 2014).

You have argued that APD is a legitimate clinical entity based on two points. 1) APD is part of the ICD-9-CM and ICD-10 diagnostic codes and therefore the medical community (which identifies clinical disorders) has accepted APD and 2) research from Dr. Kraus’ lab has shown “significant differences in electrophysiological functioning in the brains of people identified with auditory processing disorders.”

However, we are left with a dilemma. There is currently no way to determine the diagnostic accuracy of any of the test protocols for APD because there is no reference standard test (gold or otherwise) for the determination of the presence or absence of APD. Therefore, all diagnoses of APD are based on unverified test results. Without a reference standard, we do not know if an APD diagnosis is true or false. Thus, there are no true positive, false positive, true negative or false negative APD test results. There are only positive and negative test results of unknown validity (Vermiglio, 2016). This is consistent with Aetna (2016) who wrote, “APD testing is considered not medically necessary as there is insufficient evidence to support the validity of the diagnostic tests…”

So even if we say, “according to a consensus of the medical community, APD is a legitimate disorder,” there is still no way to verify the validity of the test protocols. I have argued that the reason we cannot determine the validity of an APD test protocol is that there is no reference standard for APD. Moreover, there is no reference standard for APD because APD is not a legitimate clinical entity based on the Sydenham-Guttentag criteria, listed as follows.

1) The clinical entity must possess an unambiguous definition.
2) It must represent a homogeneous patient group.
3) It must represent a perceived limitation.
4) It must facilitate diagnosis and intervention.

I question the arguments used by the authorities who report that APD is a legitimate clinical entity. These arguments include the argument from authority, “consensus,” or the untested presumption that tests, sensitive to a lesion of the central auditory nervous system, are relevant for the diagnosis of an APD.

Though you state that there is evidence to support APD as a legitimate clinical entity, there is no evidence regarding the validity of the test protocols.

Best regards,

Andrew Vermiglio
East Carolina University

Aetna. (2016). Auditory Processing Disorder (APD) Clinical policy bulletin. No. 0668. Retrieved from Retrieved from: http://www.aetna.com/cpb/medical/data/600_699/0668.html 4/1/2017.
Vermiglio, A. J. (2014). On the Clinical Entity in Audiology: (Central) Auditory Processing and Speech Recognition in Noise Disorders. J Am Acad Audiol, 25(9), 904-917. doi:10.3766/jaaa.25.9.11
Vermiglio, A. J. (2016). On Diagnostic Accuracy in Audiology: Central Site of Lesion and Central Auditory Processing Disorder Studies. J Am Acad Audiol, 27(2), 1-16.
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July 2017
Volume 22, Issue 7