Comprehensive management of vestibular disorders                           

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What Is Central Auditory Processing Disorder?
Auditory Processing Difficulties Checklist
Central Auditory Processing Disorders (CAPD's)
Working toward an "auditorily favorably" classroom
problems with surface behavior tipoff behavior
possible adjustments
How to help
Choosing an audiologist
LD and ADD/ADHD

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What Is Central Auditory Processing Disorder?

Central auditory processing disorder (CAPD) occurs when the ear and the brain do not coordinate fully. Assuming your child's hearing is good (and this should be verified by an audiologist), auditory information breaks down somewhere beyond the ear. The causes of CAPD are varied and can include head trauma, lead poisoning, possibly chronic ear infections - and unknown reasons. Because there are many different possibilities - even combinations of causes - each child has to be assessed on an individual basis.

Problem Areas

Here are the five main problem areas that can affectboth home and school activities in children with
CAPD.

Auditory Figure-Ground Problems: This is when thechild cannot pay attention when there is noise in the
background. Noisy, low-structured classrooms couldbe very frustrating to this child.

Auditory Memory Problems: This is when the childhas difficulty remembering information such as directions, lists or study materials. It can exist on an immediate basis ("I can't remember it now") and/or a deferred basis ("I can't remember it when I need it for later").

Auditory Discrimination Problems: This is when the child has difficulty hearing the difference between sounds or words that are similar (COAT/BOAT or CH/SH). This problem can affect following directions, reading, spelling, and writing skills, among others.

Auditory Attention Problems: This is when the child cannot maintain focus for listening long enough to complete a task or requirement (listening to a lecture in school). Although health, motivation and attitude may also affect attention, among other factors, a child with CAPD cannot (not will not) maintain attention.

Auditory Cohesion Problems: This is when higher level listening tasks are difficult. Auditory cohesion skills - drawing inferences from conversations, understanding riddles, or comprehending verbal math problems - require heightened auditory processing and language levels. They develop best when all the other skills (levels one through four above) are intact.

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Auditory Processing Difficulties Checklist


Developmental history

This knowledge is extremely important in early identification and prevention of
listening problems. It also sheds light on the possible causes.
__ a stressful pregnancy
__ difficult birth
__ adoption
__ early separation from the mother
__ delay in motor development
__ delay in language development
__ recurring ear infections

Receptive listening

This is the listening that is directed outward. It keeps us attuned to the world
around us, to what is going on at home, at work, or in the classroom.
__ short attention span
__ distractibility
__ over sensitivity to sounds
__ misinterpretation of questions
__ confusion of similar sounding words
__ frequent need for repetition
__ inability to follow sequential instructions

Expressive listening

This is the listening that is directed within. We use it to control our voice when we
speak and sing.
__ flat and monotonous voice
__ difficulties with speech
__ weak vocabulary
__ poor sentence structure
__ overuse of stereotyped expressions
__ inability to sing in tune and in general musical ability
__ confusion or reversal of letters
__ poor reading comprehension
__ poor reading aloud
__ poor spelling
__ difficulty learning foreign languages

Motor skills

The ear of the body (the vestibule), which controls balance, coordination, and
body image, also needs close attention.
__ poor posture
__ fidgety behavior
__ clumsy, uncoordinated movements
__ poor sense of rhythm
__ messy handwriting
__ hard time with organization, structure
__ confusion of left and right
__ mixed dominance
__ poor sports skills

The level of energy

The ear acts as a dynamo, providing us with the energy we need to survive and
lead fulfilling lives.
__ difficulty getting up in the morning
__ habit of procrastinating
__ hyperactivity or hypoactivity
__ tendency toward depression
__ feeling overburdened with everyday tasks

Behavior and social adjustment

A listening difficulty is often related to these:
__ low tolerance for frustration
__ poor self-confidence
__ shyness
__ anxiety
__ depression
__ difficulty making friends
__ tendency to withdraw, avoid others
__ irritability
__ immaturity
__ low motivation, no interest in school / work
__ negative attitude toward school / work


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Central Auditory Processing Disorders (CAPD's)            
 

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Judith W. Paton
M.A., Audiologist


Beneath the academic, emotional, and social facade of learning disabilities lies a
mild neurologic dysfunction, and it is not unusual for an LD person to have subtle
hearing problems. The hearing impairment is rarely a loss of acuity in the ear itself,
once the common ear infections of early childhood have been corrected medically
or outgrown, but instead is usually located in the neural pathways of the brain
which link the ear with the highest intellectual centers (the central auditory
nervous system).


Central auditory processing disorders (CAPD's)

Not all the hearing is done in the ear. In fact, simply stated, the ear merely brings in
all the environmental sounds human beings can hear and delivers them
unseparated to the bottom of the brain in the brain stem (just above the spinal
cord). As the hearing nerves criss-cross up these several inches the "sorting out"
or processing begins. Perhaps it begins because of a conscious decision of the
intellect ("I hear my sister- I wonder what she's going to say') but the job itself
should be done by the lower level structures without our thinking about it, like
breathing. This processing includes such operations as: focusing attention away
from or dividing it between other tasks (watching TV, taking a test, thinking about
what happened this morning): separating out "non-speech-like" sounds and
inhibiting them (sending down neural messages to reduce the activity of the
nerves bringing up the traffic noise or the dishwasher, for example); and locating
in space the voice you want to hear (perhaps focusing on the teacher in front of
you and ignoring two children talking to your left).

The auditory system must convey the speech sounds (they are not yet identified
as words) without distortion up to the cortex of the brain. Here the temporal lobe
organizes them into words and the information is routed to other centers of
thought, action, sight, and so on.

For all these jobs to be done we need several conditions. There must be enough
nerve fibers to share the work and no cell loss from such conditions as lack of
oxygen at birth or failure of development embryologically. Also, the nerves must
all transmit at normal speed, not slower in spots as when the brain is swollen (this
can happen with head injuries or strokes and, some people believe, with certain
allergies). The brain must be able to produce proper amounts of chemical
neurotransmitters for the nerves to carry their messages (we see such failures in
Parkinson's disease, and they are suspected in Gilles de la Tourette syndrome
and some forms of autism).

Testing

By dividing the listening job into small components or tasks with special
manipulations of tones or speech, we can "map out" in a crude way a hearing
disorder in the central auditory pathways of the brain. Such tests have been used
for decades to help locate damage in a medical caseload, and in the last ten years
some tests have been adapted for children school age and younger.

Establishing a locale for an auditory problem has two main uses for the learning
disabled. First, it points towards other helpful lines of inquiry. If there are brain
stem auditory problems, then looking for and treating brain stem visual or
vestibular problems could be considered. With cortical level findings on auditory
testing, therapists might decide to test for and remediate phonemic synthesis or
word-finding problems. Second, if the test pattern fits that of a CAPD, then a
learning problem is less likely to be misinterpreted as "laziness," poor parenting,
or uncaring teachers.

Controversy

The brain seems to operate lawfully and reasonably predictably across disorders,
so that hearing acts the same whether the reduced cell count was caused by a
stroke or lack of oxygen (allowing for age and recency of the problem in the
testing). We are just beginning to confirm by brain wave studies, PET scans,
autopsies and other research, that learning disabilities and central auditory
processing problems play by the same set of rules as the better researched
disorders. This is why you will hear the term "controversial" used for many
assessments of learning disabilities, including the audiologic ones.

Until we know the answers, professionals and parents must deal with the learning
problems as best suits their own philosophy. One common point of view is that
even if a child has CAPD-like hearing problems and fails central auditory tests, it is
not 100% proven that he actually has an organic problem of this type, and it
causes needless worry and can even interfere with parent-child bonding to
propose that a child's brain might be imperfect in any way. The other view holds
that it is better to offer help on the theory that there may be a true CAPD, since the
help is not intrinsically harmful and can be stopped it if proves ineffective, and that
much harm is done by allowing parents to think that they, the school or the child
might be the cause of the problem.

Deciding whether to test

One can get an idea of an auditory problem even in a preschool child simply by
watching for certain types of behavior:

1. greater tendency to ignore a speaker when engrossed in something;

2. unusual sensitivity to or complaints about noise;

3. difficulty telling the direction from which the parent is calling;

4. tendency to confuse similar-sounding words;

5. confuses or forgets directions if several given in one sentence.

Some of these items also appear with ordinary peripheral (in the ear) hearing
losses, so your doctor or school should do a regular hearing test first. A pediatric
audiologist can test infants and preschoolers.

If the behavior you notice cannot be explained by a hearing loss, then there is
reason to suspect a CAPD. This testing is done by an audiologist and is covered
by the same insurance that pays for the peripheral hearing test. Complete cost
ranges from $150-$300. Still testing may not be necessary if changes in the
environment or education solve the practical problems.

Here are some guidelines to help with the decision. If some of the above hearing
problems are noticed, you should consider formal audiologic testing if any of the
following is also true:

1. explanations given you for the hearing or learning problem contradict you own
common sense or knowledge of the problem;

2. You need more information to help distinguish an organic learning problem
from an emotional one, for school or job placement or counseling purposes;

3. progress in the present program is disappointing despite everyone's best
efforts.

What is it like to have an auditory processing disorder? We have all experienced
the problems that beset someone with this type of hearing impairment. It just takes
much more to push us into "auditory overload," so that such problems are
unlikely to occur on a daily basis. Try recalling some of these situations and how
they made you feel, and then imagine how it would be if they went on and on and
you couldn't get away from them. The following are examples of some of the
common features of CAPDs.

1.) Some speech sounds are distorted. When you talk to someone with a foreign
accent you must make a series of mental adjustments to understand. These are
usually based on context (the nearest English word that would logically fit, given
the topic you are discussing) or on experience (such as how someone of that
nationality usually pronounces an "r" ). It gets easier to decode after a few
minutes' practice, but isn't it tiring? And what if you were too young to have much
vocabulary or general information to help with the guesswork? We suspect that
some children with persistent speech articulation problems are saying the words
as they hear them. Imagine how school would be if you couldn't trust your
hearing-if you had to deal with different distortions with different speakers but
were still expected to follow a classroom discussion.

2.) Background noise is too loud. When we strain to follow a conversation at a
large party we are experiencing the effects of having too much extraneous sound
delivered to our conscious awareness. One way we survive is by pinpointing the
location of the voice we want to pay attention to and neurologically suppressing
some of the sounds coming in from other locations. Now imagine having poor
inhibitory mechanisms, as in ADD (Attention Deficit Disorder). If that example
seems extreme, picture yourself trying to balance your checkbook with merely the
TV going and two other people making occasional remarks. We generally avoid
such situations because we can't stay on task, but make "silly" mistakes as the
noise intrudes on the visual-intellectual-motor parts of the operation. But how
often may a student say, "Stop that noise - I can't concentrate!" or what freedom
do most children have to go to a quiet office to take a test?

3.) Sound combinations (words) are not easily connected with their meanings or
uses. This category covers many types of auditory dysfunctions affecting the
most "human" operations of communications, learning, and empathy. In this
population we find people who get complex directions wrong, who miss spoken
cues in social situations, and who don't "speak up" for themselves, who don't
infer or "read between the lines." Think back to a time when someone was telling
you something elaborate, such as giving you directions to his house, or
explaining the computer or some other function at work. You may have heard
every word yet not been able to visualize the driving route, or you may realize that
by tomorrow you won't remember all the parts of the work operation. You could
say, "Draw me a map," or "Let me go through this myself while you watch," using
the visual and haptic/motor systems of the brain to help you learn. But what if the
teacher in a class of 30 hasn't time for that? Or what if you have poor language
pragmatics so that it never occurs to you that you could ask? Imagining yourself
in a foreign culture will give you some idea of what it means to lack easy social
scripts (did you learn the polite way of asking for the bathroom in your French
classes?), not get the joke (because you haven't picked up alternate word
meanings and slang in your travels), or to misunderstand the mood of the person
speaking because you didn't know the meaning of their tone of voice. These are
some of the ingredients to the social problems we see in children who mean well
but have trouble making and keeping friends.

Finally, to fully realize the load CAPD people carry, you need to remember that
these problems rarely occur in isolation. A child who cannot suppress unwanted
background sound also may not be able to focus his eyes or track smoothly
across the page for easy reading. A sound distortion may be compounded by
temporary hearing losses from middle ear infections or allergic congestion. The
combinations are endless.

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WORKING TOWARD AN "AUDITORILY FAVORABLE" CLASSROOM
PROBLEMS WITH SURFACE BEHAVIOR TIPOFF BEHAVIOR POSSIBLE
ADJUSTMENTS
 

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How to help

The good news is that reducing even some of these problems can lighten the load
the child carries and free up energy to deal with the remaining ones. These are the
main types of help we can offer:

1.) Taking over some of the hearing functions for the person. If a student or worker
makes errors on exacting tasks because he/she is distracted by background
noise we might move the desk away from obvious noise sources (very talkative
children or a computer printer), or we could allow him/her to do the job later in
another location. Handouts, memos, manipulatives, Hands-on- learning, and
"listening buddies" are all examples of how deficient auditory information can be
supplemented. A corollary of this is to discover and use the person's learning
style rather than insist that he/she adapt to your learning style. The chart
accompanying this article describes one system for discovering and reducing
auditory processing problems.

2.) Empowering the person to help with the problem. This can only be done
through careful evaluation and diagnosis to find out what the problem is, so that
we don't give naive advice like "Pay attention," or "Don't interrupt with
questions." The problem can be broken down into manageable units and
explained to the CAPD person in language he can understand, and the same is
done with his strengths and learning style. Improvable functions can be worked
on by the appropriate specialist (e.g., a taped Phonemic Synthesis program may
be offered, memory devices taught, or language pragmatics and social scripts
practiced in speech therapy groups), and the person then generalizes the
strategies into daily life.

When an accommodation is needed, students and workers must be respected in
their right to request and negotiate. A student should be able to say, "Neat
handwriting is hard for me physically," or "Even tutoring hasn't helped a lot with
my spelling. Would you be willing to give me two separate grades on my written
work for content and mechanics?" Working people should know that Federal law
requires employers to make reasonable accommodations for physical handicaps
(e.g., a telephone amplifier or desk relocation), so long as the written job
description does not already require the abilities the employee does not have (e.g.,
"Needs to communicate accurately by two-way radio in machine area.")

3.) Putting the person in the best physical condition for learning. This avenue of
help seems, in my experience, the least often explored. Remember that Learning
Disabilities is basically a physical disorder with more than one component. A
significant number of the learning disabled have allergies, disturbances of
balance, or sense of touch, and problems with visual functions such as focusing,
binocularity (using the eyes together as a team). Perhaps allergy treatment can
reduce the swelling and congestion that further reduce hearing or interfere with
sleep and can bring the body under better voluntary control to improve
handwriting, coordination for sports, or ability to sit still without constant
movements to maintain balance. It may be possible to share some costs between
school and health insurance so that, for example, reading therapy is speeded up
by fitting the child with reading glasses to lessen the effects of poor focusing
ability.

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Choosing an Audiologist

As with other professions where there is licensure, professional certification, and
a code of ethics, competence is not likely to be a concern. The main issues in
selection will be thoroughness, experience, and philosophy as discussed earlier.

Four main questions should sort us out:

1.) Do you (or does someone on your staff) see many people with learning or
central auditory problems? One such case every week or two over a year or two is
enough to insure an interest and expertise, I think.

2.) How long is the appointment? It takes an hour or more to test peripheral
hearing and to check and double-check the central auditory pathways; then there
has to be time to take a history, to explain the results clearly, and to answer
questions. Thus if the total time (some audiologists might schedule more than one
visit) is not 1 1/2- 2 hours, you are probably not getting all that you need. Certainly
a half-hour test in a doctor's office will not cover the central auditory system, but
your doctor can refer you for more testing if you ask.

3.) Do you have a sliding fee scale ? (This is for people without private or public
health coverage.)

4.) How might your report be useful? Part of what you are paying for is a report
that can advance your efforts to solve the problem. You may need a statement that
helps qualify your child for school services or health insurance coverage, or
yourself for the right kind of help from the Department of Rehabilitation. You may
need puzzling or mislabeled behavior explained to a teacher or psychologist. You
might want suggestions for other types of follow-up. The audiologist needs to
know what your concerns are, and can tell you which he can and cannot address.

Audiology is a medically-based field and the report will almost certainly go back to
your doctors for their input. You are also legally entitled to a copy for your own
uses if you sign a release. If words or ideas presented to be clear to a doctor or
educator are not clear to you, call the audiologist for an explanation.
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LD and ADD/ADHD

Question and Answer by Jerome J. Schultz, Ph.D.


Question: My 12-year-old daughter has Central Auditory Processing Disorder
(CAPD). She is going into seventh grade this fall and hasn't completely learned
her multiplication tables yet, so her division skills are also behind grade level. She
has trouble getting the "main idea" from reading also. I was wondering if these
problems are characteristic of CAPD kids and if so, why?

When I spoke with the head of the school district speech and language
department, he gave me the impression that there wasn't very much the school
could really do to help her with this disability. I figured it all out this year when I
realized that the school had just been passing her along every year without
substantial academic progress.

I've decided to try her in a better school district and have a meeting this summer
with the school psychologist about implementing her existing IEP. Do you have
any suggestions about particular speech therapies that I could try to get her into?
Educational strategies?

Answer: Let me take this opportunity to help our readers understand CAPD a bit
better, since this condition often goes unrecognized or is misdiagnosed as ADHD.
The American Speech-Language-Hearing Association (ASHA) established a task
force in 1996 to gain a better understanding of central auditory processing
disorders (CAPD) in children. They defined CAPD as "a deficiency in one or more
of the following phenomena (my explanations in parentheses): Sound
localization (telling where a sound comes from; who's talking and where),
Auditory discrimination (telling two or more sounds apart), auditory pattern
recognition (hearing the "beat" of a sound pattern and knowing whether two
rhythmic patterns match or not), recognition of temporal aspects of audition
(knowing which sound in a word or word in a sentence came first, second, etc.),
Auditory performance decrease with competing acoustic signals (the ability to
hear and process information when there are lots of voices or similar sounds, like
the principal talking over the teacher on the public address system in a school),
and Auditory performance decrease with degraded signals (the ability to hear and
understand something when something breaks up the quality of the sound: like
an air conditioner or traffic noise).

These kinds of problems, which are a form of learning disability, quite often
coexist with attention deficit disorder (ADHD). When this condition (CAPD) exists
early in a child's life, which may be the case when auditory processing is affected
by repeated ear infections (otitis media), then the way a child's brain processes
auditory information is affected. This includes what your daughter hears "in her
head" when she reads silently or orally. This helps to explain why she's having
trouble getting the main idea. The words (even when she's reading well) get all
jumbled up and this affects the meaning.

Learning multiplication tables involves auditory pattern recognition, and temporal
factors (the order of the language). Differentiating 8 x 7 = 56 from 6 x 7 = 42 is very
difficult, since these are abstract symbols for a particular quantity. If she just says
them over and over again, she may remember one...until she hears the next one.
Your daughter has to be instructed in a concrete visual, hands-on way to
understand ("see" in her mind's eye) that a number represents a quantity.
Otherwise, the times tables are just another jumble of numbers.

There are generally two ways of dealing with CAPD. One has to do with training
your daughter to process information more effectively. The other has to do with
creating a classroom that is set up in a way that gets the messages sent by the
teacher and others into the ears (and brains) of children with this condition.
Drapes, carpets, acoustic tiles, and study carrels (personal "offices") help to keep
down the level of background noise and echoing in a classroom. Teachers have
to be aware that talking into surfaces that reflect sound can add to the confusion.
This means that they should refrain from lecturing while writing on the chalkboard
(and there's that chalk noise, too; felt markers are better). They should always let
your daughter sit in the place in the room where the sound is the best (not next to
the door to the hallway or an air conditioning vent). Teachers can use a wireless
FM sound projecting device (like a little microphone that they wear) so that their
voices go right in a headphone your daughter is using. An audiologist can help
you determine whether this would be helpful and can help the school set it up.

A speech and language pathologist should be working with your daughter to help
her improve her auditory processing skills and to teach her compensatory
strategies (ways to deal with or work around the problem of poor auditory
processing). This might involve teaching her how to get clarification from the
speaker or to do a better job at "guessing" what sound element is missing or
distorted by being more aware of the visual cues that she's getting. If your school
says they can't do much to help your daughter, they need to be better educated
about this condition, which can make learning an absolutely miserable experience
for many kids.                                 Return to Top