More in this series
Part 1: Memphis brainpower takes on ‘epidemic’ of chronic poverty, trauma
Part 2: Memphis wired to explore impact of trauma on young brains
A third-grader put on a set of headphones and listened to pairs of short, single-syllable words.
The recorded words were recited simultaneously, one into his right ear, the other into his left.
An audiologist asked the child to repeat both words after each pairing.
when/dog
boat/dip
read/chair
Most third-graders can correctly repeat both words nearly every time, even though one ear will perform a little better than the other. But in some children, the deficit in the nondominant ear (usually the left) is pronounced and significant.
This child’s right ear scored 20 points higher. Her left ear couldn’t keep up. He doesn’t have a hearing problem. She has a brain problem.
“There’s a world of sound coming into both ears at the same time,” said Dr. Deborah Moncrieff, assistant professor at the University of Memphis School of Communication Sciences and Disorders.
“In some cases, one ear’s auditory pathway into the brain is processing that sound poorly and interfering with the other ear. These children struggle to hear and pay attention and learn. They have trouble following instructions and remembering. They get into trouble. It’s not their fault.”
Moncrieff calls the auditory processing problem amblyaudia, or “lazy ear.” It’s a term she coined in 2010 to resemble the more familiar amblyopia, or “lazy eye.”
Most states, including Tennessee, require schools to screen students for “lazy eye,” which is found in 2-5% of all preschool children.
No states require schools to screen students for “lazy ear”, which Moncrieff believes is more prevalent — and more consequential — especially among low-income and low-achieving students.
Moncrieff’s work is an example of the cutting-edge brain research being done here in Memphis.
The research could have a profound impact on children and adolescents who struggle to learn, communicate, behave and cope.
auditory system wreaks far more havoc on learning when it’s not working properly, so it’s past time to get folks to recognize it.”
Dr. Deborah Moncrieff, brain researcher
Moncrieff believes it could have a significant impact on a community like Memphis, where a disproportionate number of children are exposed to poverty, trauma, neglect and other social determinants of health that make them more susceptible to brain-based auditory deficits.
But brain researchers like Moncrieff still face medical, political and financial obstacles that could prevent their work from being widely accepted and applied.
“The importance of the visual system has been established for much longer, but the auditory system wreaks far more havoc on learning when it’s not working properly, so it’s past time to get folks to recognize it,” said Moncrieff.
“Lazy eye can be diagnosed and treated relatively easily. So can lazy ear, but the fact that it’s so easy has actually worked against me.”
WHEN THE BRAIN CAN’T HEAR
Debbie Moncrieff wanted to go to medical school after she graduated from college in the 1970s. She was fascinated by the brain.
Instead, she got a job on Wall Street, met her husband, started a family and moved to Texas. By the time she went to graduate school, she was in her 40s.
Fortunately for her, it was the 1990s that turned out to be the “Decade of the Brain” — as proclaimed by former President George H.W. Bush.
“The need for continued study of the brain is compelling,” Bush said in 1990. “Millions of Americans are affected each year by disorders of the brain ranging from neurogenetic diseases to degenerative disorders such as Alzheimer’s, as well as stroke, schizophrenia, autism, and impairments of speech, language, and hearing,”
Suddenly, neuroscience was hot. Backed by the National Institutes of Health, neuroscientists used breakthrough imaging technologies to explore and understand specific brain regions and the countless connections among them.
Moncrieff went in through the ear.
We hear with our ears but we make sense of what we hear with our brains.
The ears capture sound waves and convert them into vibrations, then into electrical impulses. Those neural impulses are sent instantly to several relay stations in the brain.
The brain organizes, analyzes and processes the impulses and translates them into sounds we can learn, recognize and recall.
The ears collect sound. The brain processes sound. One can’t do its job without the other. Hearing loss and deafness are ear-based auditory problems. An auditory processing problem is a brain-based problem. Something is interfering with how the brain recognizes and interprets sounds, especially speech.
The ears collect sound. The brain processes sound. One can’t do its job without the other.
Hearing loss and deafness are ear-based auditory problems.
Something blocks or muffles sound. It could be anything from earwax, fluid or foreign objects to infections, tumors or genetic or environmental damage.
An auditory processing problem is a brain-based problem. Something is interfering with how the brain recognizes and interprets sounds, especially speech.
Impaired auditory processing becomes a “telephone game” as each message is relayed imprecisely from one station to the next.
“Children with an auditory processing disorder (APD) may act like they have a hearing loss,” wrote Dr. Teri James Bellis, a leading authority on APD and author of “When the Brain Can’t Hear.”
“They may not follow directions, or they may give the wrong answers to questions. It can be hard to know if your child has APD. It is often confused with attention, language or learning problems. Children with APD can have trouble in school and at home.”
‘HE WAS PAYING ATTENTION’
A succession of experts told Marie that her 8-year-old son, Zack, was fine. Her “mom gut” told her otherwise.
Zack couldn’t follow a teacher’s instructions, especially if they involved more than one step.
He couldn’t talk to others at lunch, not even a friend sitting next to him, because he couldn’t filter out the other noises in the cafeteria.
He couldn’t hear his name called on a bullhorn when his mom came to get him after school, no matter how hard he concentrated on listening for it.
“They’d have to go find him, and every now and then someone would sort of scold him and say, ‘You should have been paying attention,'” Marie recalled.
“That’s all he was doing. He was trying to listen for his name as hard as he could. His hearing was fine, but his brain wouldn’t cooperate.”
Specialists tested Zack’s hearing. His ears were working fine.
They ruled out higher-level cognitive issues such as intellectual disability, autism, and attention deficit/hyperactivity disorder.
They also ruled out auditory processing disorders (APD), even though he’d had tubes in his ears since he was an infant, the result of chronic ear infections.
Turns out, the specialists were using APD tests from the 1970s, two decades before breakthrough technologies revolutionized neuroscience.
“Children with an auditory processing disorder (APD) may act like they have a hearing loss. They may not follow directions, or they may give the wrong answers to questions. It can be hard to know if your child has APD. It is often confused with attention, language or learning problems. Children with APD can have trouble in school and at home.”
Dr. Teri James Bellis, author of “When the Brain Can’t Hear”
“Zack’s IQ is 99th percentile, so what’s considered to be normal for a typical child indicates a gap for him,” his mom said.
The experts suggested that Zack sit closer to the teacher, or that the teacher speak directly into his ears with a small wireless microphone. Or that he just had to work harder to pay attention.
Marie knew that wasn’t the issue. “My ‘mama gut’ told me there was something wrong. I knew something could be done and I wasn’t going to stop till we found it,” she said.
Through a Google search, she found Moncrieff and brought Zack to the U of M’s Memphis Speech and Hearing Center.
‘TOO MANY CHILDREN ARE STRUGGLING’
Moncrieff has spent more than two decades studying the brain’s auditory nervous system.
She believes amblyaudia is the most common type of auditory processing disorder. She believes its diagnosis and treatment could have a profound impact on children who struggle to learn, communicate and behave.
She also knows it’s not that simple.
Auditory processing disorder, or APD, is a controversial topic, even among audiologists.
“APD is a poorly defined and controversial label that has not become an agreed international standard, despite more than 40 years of attempts,” seven audiology scientists wrote in the journal Frontiers in Neurology earlier this year.
The article was another volley in a debate that has been raging since the 1950s. That’s when Helmer Myklebust, an audiology professor at Northwestern University, published his landmark study, “Auditory Disorders in Children,”
Myklebust, who taught at the Tennessee School for the Deaf in the 1930s, observed that some children with normal hearing and intelligence “cannot listen … they cannot direct their attention selectively to an unexpected sound.”
His study was the first to suggest that auditory processing difficulties were separate from hearing and language learning difficulties. Audiologists and speech pathologists still aren’t sure about that.
They generally agree that APD can interfere with a child’s ability to learn, concentrate and interact with others.
“When auditory input and processing is compromised, speech perception is impaired, inhibiting the development of vocabulary, syntax, semantics, and ultimately academic performance,” states the Educational Audiology Association.
But they disagree on how (and whether) to define, diagnose and treat APD.
Brain imaging technologies often fail to identify any structural of functional damage that might cause APD.
No one knows for sure what causes auditory processing deficits. It may result from ear infections, head injuries, lead poisoning, neglect, abuse or other forms of developmental trauma. It might be genetic or epigenetic — the result of the environment’s impact on your genes.
No one knows for sure what causes auditory processing deficits. It may result from ear infections, head injuries, lead poisoning, neglect, abuse or other forms of developmental trauma. It might be genetic or epigenetic — the result of the environment’s impact on your genes.
And APD symptoms often co-exist with those of attention deficit/hyperactivity disorder, autism, and other learning or language disorders.
Various studies have reported widely varying estimates of the prevalence of APD in children with known learning issues who are evaluated by an audiologist anywhere from 7 percent to 93 percent.
“The evidence base is too small and weak to provide clear guidance to speech-language pathologists faced with treating children with diagnosed APD,” the American Speech-Language-Hearing Association concluded in 2011.
As a result, APD is not universally recognized as a specific disorder.
Even Moncrieff has her doubts.
“I would never diagnose a child with APD,” she said. “It’s so broad and vague, it doesn’t mean anything. We’ve got to find ways to be more precise. Too many children are struggling with this.”
MISDIAGNOSING BAD BEHAVIOR
Before she came to the University of Memphis last summer, Moncrieff was a professor at the School of Health and Rehabilitation Sciences at the University of Pittsburgh.
In 2015, she got permission to test hundreds of adolescents at a nearby juvenile detention center for amblyaudia.
She tested 782 adolescents ages 13-18 whose hearing was normal. Seven of 10 failed at least one of two tests (words and digits). Three out of 10 failed both.
The results mirrored other studies that show a large majority of adolescents (and adults) in the criminal justice system have some sort of learning disability.
“The high prevalence of failing scores in this study suggests that many adolescents detained in juvenile facilities may have significant difficulties processing language-based auditory information,” Moncrieff wrote.
For Moncrieff, the implications are clear.
“School-age children referred for disciplinary action may have undiagnosed deficits in auditory processing and/or language,” she wrote.
“Poor performance, especially among minority students, is attributed to behavioral and emotional disorders rather than to cognitive issues related to learning,”
Earlier this year, Moncrieff tested 70 fourth- and fifth-grade students at Believe Memphis Academy charter school in North Memphis. Results indicated amblyaudia in 23.
“In some cases, one ear’s auditory pathway into the brain is processing that sound poorly and interfering with the other ear. These children struggle to hear and pay attention and learn. They have trouble following instructions and remembering. They get into trouble. It’s not their fault.”
Dr. Deborah Moncrieff, brain researcher
“That’s a high number, but it wasn’t surprising, given that a third of those students came to school reading below kindergarten level,” said Danny Song, founding head of school at Believe Memphis.
“I’d not heard of auditory processing disorders or amblyaudia before Dr. Moncrieff screened our students, but it makes sense. Reading skills begins with listening skills.”
This school year, Moncrieff plans to treat the kids who were diagnosed with amblyaudia at Believe Memphis. She received a $6,000 grant from the Urban Child Institute to cover the cost.
She hopes to show that testing for and treating amblyaudia is easy, relatively inexpensive and effective.
She believes it could change the way parents and teachers, police officers and judges and others understand and address children and youths who can’t seem to pay attention, or follow instructions, or keep up in class, or behave.
But major obstacles remain.
Hearing begins in utero, but the central auditory system continues to develop for at least the first decade of a person’s life. Moncrieff doesn’t test children under age 6 for amblyaudia because there are no reliable tests to use on younger children. But she believes such testing can be developed.
“For too long mainstream auditory science has simply turned a blind eye to APD. In the meantime, thousands of children are being inappropriately or inadequately advised about the nature and management of their listening difficulties.”
Dr. David Moore, Cincinnati Children’s Hospital
No national professional organization has yet issued a policy statement on screening for auditory processing problems in school children. And there’s no universally accepted method of screening for APD.
Meanwhile, federal funding for research into brain-based auditory disorders still lags way behind funding for other sensory processing and learning disabilities.
The National Institutes for Health spent nearly $1 billion on eye diseases and vision disorders in 2018, and less than half that amount on “deafness and other communication disorders.”
Dr. David Moore of the Cincinnati Children’s Hospital notes that only half of the largest audiology services in U.S. hospitals offer an APD evaluation.
“For too long mainstream auditory science has simply turned a blind eye to APD,” Moore wrote in a recent edition of Ear and Hearing, the journal of the American Auditory Society.
“In the meantime, thousands of children are being inappropriately or inadequately advised about the nature and management of their listening difficulties.”
‘MOM, I HEARD MY NAME’
Eight-year-old Zack sat in a chair in the middle of a sound booth, staring at a stuffed animal propped up in one corner.
As he looked at the toy, he listened to pairs of short, single-syllable words and repeated them out loud.
The recorded words were being recited simultaneously, one into Zack’s right ear, the other into a speaker by his left ear.
The words coming from the right speaker were much softer than those coming from the left speaker. That made Zack’s left ear work harder.
The child had a significant left-ear deficit. The audiologist was trying to strengthen his “lazy” left ear’s auditory pathway. As his left ear got stronger, the sound from the right speaker was gradually increased.
The therapy is called ARIA — Auditory Rehabilitation for Interaural Asymmetry.
Last month, New Zealand became the first country to include amblyaudia and ARIA in its national guidelines for auditory processing disorders. Moncrieff hopes others will soon follow.
“The therapy allows the weaker ear to get stronger and grow new neuralpathways, ” Moncrieff said. “A lazy ear can be retrained and typically corrected in just four one-hour therapy sessions.”
During the past year, the U of M clinic has treated two dozen children ages 6-18 for amblyaudia. All received ARIA therapy. All improved so much that their left- or right-ear deficits were all but eliminated.
“I was skeptical of the treatment at first, it seemed too simple,” said Dr. Jennifer Taylor, director of clinical services at the U of M’s Speech and Hearing Center.
“But I thought let’s try it. Why would we identify a problem and not do anything about it? The results have been amazing. It works. The kids are listening and learning better. They’re not struggling as much.
“I was skeptical of the treatment at first, it seemed too simple. But I thought let’s try it. Why would we identify a problem and not do anything about it? The results have been amazing. It works. The kids are listening and learning better. They’re not struggling as much.”
Dr. Jennifer Taylor, U of M Speech and Hearing Center
“Auditory problems are a hidden problem. People can’t see what’s wrong. So they attribute a child’s learning or attention problems to being stupid or lazy or being defiant. So this is also helping their emotional well-being. They feel normal.”
A year ago, Zack’s left ear tested 22% weaker than his right. By June, his left-ear deficit was down to 8, which is within normal limits.
“Tonight was the 4th-grade sock hop,” Zack’s mom wrote a few months ago in an email to Moncrieff and Taylor. “There were probably 150-200 kids there. At the end, the kids all went to the gym to wait to be picked up. When I got there, his teacher went and got him. He came out and, after this big night with so much activity and fun, the first thing he said was, ‘Mom, I heard my name easily.’
“I was a complete skeptic, but love seeing the changes in Zack — more confidence, willing to try things because he’s not worrying about ‘hearing’, being more engaged in what’s going on around him, his face lighting up when he can hear his name in a crowded room… But I think my favorite thing is that he can now talk to his buddy sitting next to him at lunch because he can ‘hear’ him. Life changing.”
David Waters’ reporting on issues affecting Memphis children is funded, in part, by a grant from the Urban Child Institute. UCI has no prior knowledge of topics Waters chooses nor is it involved in any aspect of the editorial process.
This story first appeared at www.dailymemphian.com under exclusive use agreement with The Institute. Photos reprinted with permission of The Daily Memphian.
