Diagnosis and Treatment of Amblyaudia, a type of Auditory Processing Disorder

[A preview of a the presentation at Pathways for AAA by Deborah Moncrief]

Amblyaudia is a deficit in binaural integration, a process that begins with excitatory and inhibitory activation in the medial and lateral superior olivary complexes of the auditory brainstem (Tollin, 2003).  Interaural timing and intensity differences are used to detect coincident signals and to prioritize neural codes for transmission.  Binaural integration is assessed by simultaneous presentations of temporally aligned competing signals to the two ears during dichotic listening tests.  Most listeners produce an ear advantage in the ear that is contralateral to the listener’s language-dominant cortical hemisphere.  Amblyaudia is characterized by larger than normal ear advantage during dichotic testing.

Several neural mechanisms for amblyaudia have been proposed including abnormal suppression of neural activity in the non-dominant ear by input to the dominant ear (Popescu & Polley, 2010), reduced inhibition in sub-lenticular auditory pathways (Schmithorst, Holland & Plante, 2011), abnormal cellular development in the medial geniculate body of the auditory thalamus (Galaburda, Menard, & Rosen, 1994), and poor interhemispheric transfer of information through the corpus callosum (Westerhausen, Grüner, Specht, & Hugdahl, 2010).

Amblyaudia is diagnosed following a consistent pattern of abnormal responses on at least two dichotic tests.  When clinically assessed, 47% of 141 children were diagnosed with amblyaudia (Moncrieff, Keith, Abramson, & Swann, 2016).  With objective testing, children with amblyaudia demonstrated no left-right ear correlation in cortical event-related potentials (Moncrieff, et al., 2004) and shorter latencies in the right ear and smaller amplitudes in the left ear for the Pa response of the MLR (Moncrieff, et al., in preparation).

Amblyaudia responds to a treatment similar to occlusion or penalization used for amblyopia.  In early studies, Auditory Rehabilitation for Interaural Asymmetry (ARIA) resulted in significant improvement in non-dominant ear dichotic scores following 4 weeks of treatment (Moncrieff & Wertz, 2008).  Children with amblyaudia also improved in listening comprehension, word recognition and oral reading whereas normal controls did not.  A change in protocol from 3 sessions per week to 1 session per week produced similar improvements in binaural integration and allowed for higher rates of enrollment during the school year (Russo, Snyder & Moncrieff, 2014).

At several clinical sites, 133 children were enrolled in four one-hour ARIA training sessions (Moncrieff, et al., 2017).  Children diagnosed with amblyaudia showed significant improvements in dichotic listening non-dominant ear performance and reductions in interaural asymmetry at the fourth training session and again at least 3 months after completion with no significant differences in performance between the two times, demonstrating that improvements from ARIA do not regress.

Levels of brain activity were measured with fMRI in 9 children diagnosed with amblyaudia before and after enrollment in ARIA.  Greater left than right hemisphere bilateral activation was noted during silence (noise only from the scanner), diotic listening (same word in both ears) and dichotic (competing words in the two ears).  Subtraction methods demonstrated that dichotic listening resulted in dramatically increased activity in the left hemisphere that significantly decreased in temporal and parietal regions following ARIA treatment (Moncrieff & Schmithorst, in preparation).

Many children with amblyaudia also have difficulties when listening to words spoken together with background babble.  To assess whether ARIA training generalizes to other auditory processing skills, pre- and post-ARIA measures of words-in-noise performance were compared and significant improvements were noted in 15 children diagnosed with amblyaudia (Moncrieff, AAA 2018).

Current standards of diagnosis for APD have been seriously criticized for lack of homogeneity among multiple symptoms associated with the disorder (AAA, 2010; ASHA, 2005) and the use of sensitized speech tests (Cacace & McFarland, 1998) with poor validity (Moore, et al., 2013) that lead to wildly different results across clinical settings (Wilson & Arnott, 2013). A failure to represent a uniform pattern of results makes APD a poor clinical entity whereas amblyaudia does represent a uniform pattern of behavioral results. Several researchers have reported variable results from using the CHAPS as a reference standard for the diagnosis of APD (Allen & Allan, 2014; Dawes, et al., 2007; Ferguson, et al., 2010; Iliadou & Bamiou, 2012). A recent study in 77 children seen for an APD assessment noted that CHAPS scores were significantly different between children diagnosed with amblyaudia and normal controls for the quiet, ideal, and memory conditions on the questionnaire (Moncrieff & Vermiglio, 2017).

Amblyaudia is a clinical entity that represents asymmetric performance on tests of binaural integration that improves under treatment through targeted training exercises with ARIA.  Future studies will help elaborate the neurophysiologic underpinnings of amblyaudia and help to disambiguate it from other auditory processing weaknesses.





  1. AAA. (2010). American Academy of Audiology Clinical Practice Guidelines: Diagnosis, Treatment and Management of Children and Adults with Central Auditory Processing Disorder. Retrieved from http://www.audiology.org/resources/documentlibrary/documents/capd%20guidelines %208-2010.pdf
  2. ASHA. (2005). (Central) Auditory Processing Disorders. Retrieved from www.asha.org/policy
  3. Cacace, A.T. & McFarland, D.J. (1998) Central auditory processing disorder in school-age children: A critical review. Journal of Speech Language and Hearing Research 41:355-373.
  4. Dawes, P., Bishop, D.V.M., Sirimanna, T., & Bamiou, D. (2007). Profile and aetiology of children diagnosed with auditory processing disorder (APD). International Journal of Pediatric Otorhinolaryngology 72:483-489.
  5. Ferguson, M.A., Hall, R.L., Riley, A., & Moore, D.R. (2010). Communication, listening and cognitive and speech perception skills in children with auditory processing disorder (APD) or specific language impairment (SLI). Journal of Speech Language and Hearing Research 54:211-227.
  6. Galaburda, A.M., Menard, M.T., & Rosen, G.D. (1994). Evidence for aberrant auditory anatomy in developmental dyslexia. PNAS 91:8010-8013.
  7. Iliadou, V. & Bamiou, D-E. (2012). Psychometric evaluation of children with auditory processing disorder (APD): Comparison with normal hearing and clinical non-APD groups. Journal of Speech Language and Hearing Research 55:791-799.
  8. Litovsky R.Y. 2011. Review of recent work on spatial hearing skills in children with bilateral cochlear implants. Cochlear Implants Int, 12 Suppl 1, S30-34.
  9. Moncrieff, D., Jerger, J., Wambacq, I., Greenwald, R., & Black, J. (2004). ERP evidence of a dichotic left-ear deficit in some dyslexic children. Journal of the American Academy of Audiology 15(7):518-34.
  10. Moncrieff D., Keith W., Abramson M., Swann A. (2016). Diagnosis of amblyaudia in children referred for auditory processing assessment. International Journal of Audiology, 55, 333-345.
  11. Moncrieff, D., Keith, W., Abramson, M., Swann, A. (2017) Evidence of Binaural Integration Benefits Following ARIA Training in Children and Adolescents Diagnosed with Amblyaudia, International Journal of Audiology
  12. Moncrieff, D., & Vermiglio, A. (2017). Keep the baby, not the bathwater. Oral presentation at the American Speech Language and Hearing annual convention, Los Angeles, CA.
  13. Moncrieff, D.W. & Wertz, D. (2008). Auditory rehabilitation for interaural asymmetry: preliminary evidence of improved dichotic listening performance following intensive training. International Journal of Audiology 47(2):84-97.
  14. Moore, D.R., Rosen, S., Bamiou, D., Campbell, N.G. & Sirimanna, T. (2013) Evolving concepts of developmental auditory processing disorder (APD): A British Society of Audiology APD Special Interest Group ‘white paper,’ International Journal of Audiology 52:3-13.
  15. Popescu, M.V. & Polley, D. P. (2010). Monaural deprivation disrupts development of binaural selectivity in auditory midbrain and cortex. Neuron 65:718-731.
  16. Russo, A., Snyder, M., & Moncrieff, D. (2014). ARIA: Auditory rehabilitation for interaural asymmetry. Poster presented at the American Academy of Audiology annual conference, Orlando, FL.
  17. Schmithorst, V.J., Holland, S.K., & Plante, E. (2011). Diffusion tensor imaging reveals white mater microstructure correlations with auditory processing ability. Ear and Hearing 32(2):156-167.
  18. Tollin, D.J. 2003. The lateral superior olive: A functional role in sound source localization. The Neuroscientist, 9, 27-143.
  19. Westerhausen, R., Grüner, R., Specht, K., & Hugdahl, K. (2009). Functional relevance of interindividual differences in temporal lobe callosal pathways: A DTI tractography study. Cerebral Cortex 19:1322-1329.
  20. Wilson, W.J. & Arnott, W. (2013). Using different criteria to diagnose (central) auditory processing disorder: How big a difference does it make? Journal of Speech Language and Hearing Research 56:6370.

About Pathways

Pathways is both a column that covers topics related to CAPD and Neuroaudiology and a society for people interested in central auditory disorders that regularly meets to discuss these issues.

Leave a Reply

Your email address will not be published.