Why can't you just hear?

The most important facts in brief

• Auditory processing and perception disorder (AVSD or just AWS) is a disorder in the perception and processing of auditory stimuli in the brain, whereby the auditory organ itself functions perfectly.
• It is estimated that 2 to 3 per cent of all people worldwide are affected by AVWS.

• The exact causes are still unclear, but heredity seems to play a certain role.
• The most important symptoms include Sound localisation problems; difficulties in distinguishing similar sounding letters and syllables and reproducing them accordingly; problems in filtering useful sound from background noise; a severely shortened auditory memory.
• The diagnosis is a diagnosis of exclusion. It is only possible from the age of at least eight years and is very complex.
• AVWS cannot be cured, but therapies from the field of speech therapy can help to improve speech comprehension and sound discrimination. Practical tips and tricks help to bridge the deficits in auditory memory. Other important and very helpful measures include certain behaviours during speech and communication as well as structural acoustic changes aimed at keeping background noise as low as possible.
• The diagnosis of AVWS is still relatively new and is sometimes the subject of controversial debate among experts. The most important points of criticism include a lack of differentiation from existing developmental disorders and no purely AVWS-specific therapy.

For Loris, 20 mistakes and more in dictations are not uncommon. This is frustrating, as the third-grader is clearly trying hard to improve his performance. However, Loris is unable to distinguish between words and syllables that sound similar. He also quickly forgets what he has said. It took a complex diagnostic test to determine the reason for the problems - Loris has an auditory processing and perception disorder (AVWS).

Experts estimate that around two to three per cent of all people are affected by this disorder. The terms auditory processing disorder, central hearing disorder or auditory partial performance disorder are often used synonymously and basically all refer to the same thing.

The disorder leads to a range of problems at school and in everyday life for affected children.

«It is a disorder of central hearing processes,» explains Jochen Rosenfeld, Head Physician of the Department of Phoniatrics and Paediatric Audiology at the Cantonal Hospital of St. Gallen. "Peripheral hearing, i.e. the organic hearing function, is intact.

However, the perception and processing of auditory stimuli in the brain are impaired." This leads to a range of problems at school and in everyday life, which can vary from child to child.

For example, it is typical of possible AVWS that affected children cannot locate the direction from which a sound is coming. These children also find it difficult to distinguish between similar-sounding sounds and syllables, such as «book» and «cloth» or «cup» and «till».

«Those affected also have great difficulty filtering and following an ongoing conversation in the presence of background or background noise such as chattering classmates, a running dishwasher or passing cars,» says Rosenfeld. «Auditory memory can also be severely shortened, making it difficult to memorise verbal tasks and generally extremely difficult to learn by heart.»

Problems start at school age

However, real problems usually only arise at school age when the children have to concentrate on following the teacher's voice and spoken words are requested in writing in dictations. «Because affected children sometimes don't even notice what the teacher is saying during lessons, they become inattentive, start to get bored and tend to exhibit behavioural problems,» emphasises the paediatric audiologist. «In addition, they usually perform very poorly in dictation, reading and spelling.»

However, there are also other possible causes for these abnormalities. «It must first be clarified that there is no hearing loss, i.e. whether the hearing organ is functioning properly,» says Rosenfeld. «It is also important to clarify a possible intellectual disability and other developmental disorders such as ADHD, a language acquisition disorder or an autism spectrum disorder in advance.»

Diagnosis only from the age of eight

Only then does the actual AVWS diagnosis begin, usually in a specialist centre. Here, four professional groups usually work together as a team: Audiometrists, speech therapists, psychologists and paediatric audiologists. They each carry out various validated tests.

Rosenfeld: «An AVWS diagnosis is therefore very complex and can only be carried out from the middle of second grade at the earliest, as the child's development is only at a stage where the tests are optimally effective from the age of eight.»

Once an AVWS has been diagnosed, there are a number of ways to provide the affected children with the best possible support and promote their development. AVWS cannot be cured in the traditional sense, as it is not a disease but a developmental disorder.

Once an AVWS has been diagnosed, there are a number of ways to provide the affected children with the best possible support and promote their development.

The causes are not yet fully understood. «A polygenetic cause is assumed,» says the paediatric audiologist from St. Gallen. This means that certain genetic information, which is located on several genes, favours the development of the disorder.

Speech therapy and the parrot trick

In order to compensate for the auditory impairments, the affected children usually receive comprehensive speech therapy. «The children practise distinguishing and allocating syllables and sounds better,» explains the paediatric audiologist.

However, as auditory memory can unfortunately only be improved to a limited extent through practice alone, additional compensatory strategies and practical tips are taught to improve the memorisation of spoken words. «One example is the parrot trick, in which the sentence to be memorised is drawn, written down or repeated like a mantra until the action has been performed,» says Rosenfeld.

It is also very important and useful to have a discussion with the school and the class teacher, in which the parents or specialists provide information about the existing AVWS and ask for measures that will help the child to follow the lessons better.

These are well summarised in the «practical aids» of the S1 guideline of the German Society for Phoniatrics and Paediatric Audiology. "These include sitting close to the teacher, speaking directly to them and frequent eye contact when communicating.

The teacher also tries to reduce reverberation and background noise in the classroom," says the paediatric ear specialist. «Even simple measures such as closing windows and doors can make a big difference.»

Rooms with carpets, curtains and wall panelling that dampen the reverberation are also considered favourable for AVWS. If possible, the classroom should be retrofitted accordingly or the class should be able to move to a suitable room.

It is important to have a discussion with the school and the teacher in which parents are informed about the diagnosis and ask for measures to help the child.

Another way to make the useful sound - such as the teacher's voice - more perceptible for the affected child is to use so-called frequency modulation systems, or FM systems for short. These are hearing aids that are wirelessly connected to a microphone worn by the teacher, for example.

They then transmit the teacher's voice directly to the child's ear. «However, these devices are very expensive and are currently only covered by insurance in a few cases,» explains ENT specialist Rosenfeld. "I'm therefore somewhat cautious about this recommendation.

Also because the consistent implementation of conventional measures - together with speech therapy - already brings a great deal of improvement in many cases."