Central Auditory Processing Disorders Presented by Susan Lieb, MA, CCC-SLP and James Garrity, NCSP, School Psychologist

Definition of CAPD- from an auditory behavioral perspective) (from American Speech Language Hearing Association Technical Report, 2005) The perceptual processing of auditory information in the Central Nervous System Includes auditory mechanisms that underlie sound localization, auditory discrimination, auditory pattern recognition, temporal aspects of audition, auditory performance in competing acoustic signals and degraded acoustic signals

Definition of CAPD- from a top-down, general perspective What is done with what is heard

Nature of CAPD A deficit in neural processing of auditory stimuli that is not due to higher order language, cognitive, or related factors but May lead to or be associated with difficulties in higher order language, learning and communication functions May coexist with other disorders (ADHD, language impairment and learning disability) It is not the result of these other disorders Occurs in the absence of peripheral hearing loss

Associated Difficulties in School-aged Children Learning Speech Language (including written language involving reading and spelling) Social and related functions

Prevalence of CAPD 2-5% of school age population 2:1 ratio of boys to girls (Chermak & Musiek, 1997)

Some Caveats Language comprehension problems can occur in the presence of normal CAP. CAPD does not always present with language problems. Different combinations of auditory deficits are likely to be associated with different functional symptoms. The same auditory deficit may have an impact on different people in different ways, based on each person’s unique confluence of “bottom up” and “top-down” abilities and on the extent of their neurobiological disorder, as well as other factors that affect CNS function. We should not automatically assume that CAPD is the underlying cause of a learner with cognitive or language disorders without appropriate auditory diagnostic measures.

Characteristics of CAPD-one or more of the following behavioral characteristics may be present Difficulty understanding spoken language in competing messages, noisy backgrounds, or in reverberant environments Misunderstanding messages Inconsistent or inappropriate responding Frequent requests for repetitions, Saying “What” and “huh” frequently Taking longer to respond in oral communication situations

Characteristics, continued Difficulty paying attention Is easily distracted by auditory and visual stimuli Difficulty following complex auditory directions or commands Difficulty localizing sound Difficulty learning songs or nursery rhymes Poor musical and singing skills Associated reading, spelling and learning problems History of Otitis Media Has memory deficits, both short term and long term

Some Behavioral Differences Between CAPD and ADHD CAPD-an input disorder in which perceptual details are not properly transmitted by the central auditory system to the central processors. Some inattention and distractibility Difficulty hearing in background noise Difficulty following oral instructions Selective or divided attention problem (child can sit and listen until competing noise is introduced) ADHD-an output disorder involving an inability to control behavior Inattention and distractibility more prominent in children with ADHD Difficulty hearing in background noise and following oral instructions not as pronounced. Sustained attention problem.

Diagnosis An audiologist is the professional who diagnoses CAPD. A multidisciplinary assessment involving other professionals should be used to determine the functional impact of the diagnosis, and to guide treatment and management of the disorder and associated deficits. Peripheral hearing loss must be ruled out. ADHD must be ruled out or medically treated.

Diagnosis, continued Task difficulty and performance variability make test results on children under the mental age of 7 questionable. Maturational age of auditory cortex is between 10-12 Children must have a cognitive level high enough to follow the directions. Receptive vocabulary should be within an age-appropriate range. Diagnosis generally requires deficits of at least 2 standard deviations below the mean on 2 or more tests in the test battery.

Symptom Comparison Chart

Intervention Strategies Tripod approach Direct skills remediation- 2 main models of evaluation, identification and remediation: The Buffalo Model Bellis/Ferre Model Compensatory strategies Environmental modifications

The Buffalo Model (Jack Katz, PhD) Decoding- difficulty analyzing auditory information, may have difficulty with temporal processing Tolerance-Fading Memory- may have impulsivity and forgetfulness in response to auditory information, sensitive to noise, difficulty completing multi-step directions Integration- difficulty putting auditory and non-auditory information together Organization- difficulty with auditory sequencing, may occur with decoding or tolerance fading memory

Bellis/Ferre Model Auditory decoding deficit- difficulty with speech in noise, speech discrimination, sound blending, retention of phonemes, blending, speech to print may be poor. Integration deficit- difficulty with multimodality tasks that require inter-hemispheric transfer of information Prosodic deficit- difficulty with humor, multiple meanings and utilizing information in suprasegmentals of speech Associative deficit- may demonstrate receptive language difficulties, cannot apply rules of language to incoming auditory information Output-Organization- difficulty in sequencing, planning and organizing responses.

Environmental Modifications Enhance the listening environment through preferential seating and/or improving access to the acoustic signal Use of visual aids Assistive listening devices/systems Reduction of competing signals and reverberation time Advising speakers to speak more slowly, pause more often, and emphasize key words.

Bellis and Ferre CAP Deficit Profiles (based upon analysis of CAP test results) PRIMARY SUBPROFILES: Auditory Decoding Deficit Prosodic Deficit Integration Deficit SECONDARY SUBPROFILES: Associative Deficit Output-Organization Deficit

Auditory Decoding Deficit- associated with primary auditory cortex dysfunction Associated Behaviors Spelling Difficulties Reading/writing difficulties Speech in noise difficulties Sound blending difficulties Management Strategies Improve acoustic clarity-consider FM Auditory closure activities Speech sound/phoneme training Speech-to-print skill training Preteach new information

Classroom Activities for Auditory Decoding Deficits Auditory closure activities, first with familiar subject matter, moving on to unfamiliar messages. Vocabulary building exercises in which the listener uses context to derive word meaning Phoneme training starting with minimal contrast pairs in isolation, syllables, then words.

Prosodic Deficit- associated with right-hemispheric dysfunction Associated behavior Difficulty judging communicative intent Difficulty with humor, multiple meaning words Difficulty with perception and use of prosody Monotonic speech Mathematics calculation difficulties Management strategies Placement with animated teacher Prosody training Key word extraction Encourage music/dance lessons Reading aloud

Classroom Activities for Prosodic Deficits Teach different forms of poetry, noting rhythm, emphasis and stress in sentences and words Change the stress patterns in multi-syllabic words to show how acoustic factors change the meaning of a word or sentence (Eats, Shoots and Leaves, for example) Teach sound discrimination, using environmental sounds differing in intensity, frequency, duration or quality.

Integration Deficit-corpus callousum is not transferring information from one hemispher to the other Associated Behaviors Reading, spelling and writing problems Poor speech in noise skills Memory problems Poor coordination Poor music skills Management Strategies Provision of a notetaker Limit use of multimodality cues Interhemispheric exercises Encourage music/dance training Key word extraction

Classroom Activities Interhemispheric activities (reading a poster where color names are in a different color than the written word, barrier games, singing and musical instrument lessons) Lots of repetition. Rephrasing may be confusing. Key word detection. Reading aloud with emphasis on word/phrase. Word sequence discriminating (pen-pin-pen) Memory games

Associative Deficit-secondary subtype Associated Behaviors Receptive language problems including semantics, syntax and vocabulary Difficulty comprehending information of increased linguistic complexity Poor reading comprehension May surface around 3rd grade with increased linguistic demands within the classroom Management Strategies Rephrase speech using smaller linguistic units Speech-language therapy focusing on receptive language Systematic learning approach Rule-based approach

Classroom Activities for Associative Deficit- left (associative) cortex Train child on chunking methods, verbal rehearsal, outlining and other organizational strategies Use sequencing words: 1st, next, last Paraphrasing Webbing, mapping, study skills to aid in comprehension and recall Inferencing tasks Alternative endings to stories May perform better on multiple choice or other closed set tests rather than open-ended questions External organization in the classroom will help the child with independent work Speech-language therapy

Output/Organization Deficit- temporal-to-frontal and/or efferent system Associative Behaviors: Poor hearing in noise Poor organizational skills Motor planning difficulties Difficulties with expressive language and word retrieval Poor sequencing and follow-through Management Strategies: Highly structured environment Training in use of organizational aids Speech-language therapy focusing on expressive language Enhanced listening environment

Suggested Classroom Activities for Output/Organizational Deficit Language intervention is often a key component in remediation.Activities can include: 1. Ordering and sequencing 2. Verbal rehearsal and mnemonic devices 3. Retelling stories 4. Describing pictures (ex.: making captions for comic strips, box by box) 5. Using visualization techniques and visual imagery. 6. Outlines, checklists and specific notebooks for class assignments are beneficial.

Summary of Bellis Ferre Subtypes DECODING (primary auditory cortex) LOOKS LIKE Speech in noise Sound discrimination Sound blending Poor phoneme retention STRATEGIES Phoneme discrimination Pattern recognition Listening in noise Writing to dictation ACTIVITIES Auditory closure Vocabulary building Phonemic training PROSODIC (right hemisphere dysfunction) Difficulty with communicative intent Difficulty with humor and multiple meaning words Monotonic speech Difficulty with perception and use of prosody Animated teacher Prosody training Key word extraction Dance/music lessons Read aloud Teach poetry Change stress patterns INTEGRATION (corpus callosum) Reading, spelling and writing problems Poor speech in noise Memory Coordination Poor music skills Provide note taker Limit multimodal cues Music/dance lessons Interhemispheric exercises Interhemispheric activities Lots of repetition Memory games Word sequence discriminating

Bellis Ferre Subtypes, continued ASSOCIATIVE (left cortex) Receptive language including semantics, syntax and vocabulary Difficulty comprehending information of increased linguistic complexity Poor reading comprehension Often does not surface until around 3rd grade Rephrase (not repeat) Give information in smaller units Rule based, systematic approach to learning Child needs frequent breaks due to fatigue on system from processing Speech-language therapy for receptive language Explicit teaching of rules of grammar Chunking methods Inferencing tasks Tag words (1st, next, last) Webbing, mapping Paraphrasing OUTPUT/ORGANIZATION (temporal to frontal or efferent system) Poor hearing in noise Poor organizational skills Motor planning difficulties Difficulties with expressive language and word retrieval Good comprehension, poor spelling and writing Poor sequencing and follow-through Use of organizational aids Visualization techniques Verbal rehearsal and mnemonic devices Highly structured environment Repeat and rephrase information Use smaller linguistic units Metacognitive techniques to improve listening and organizational skills Expressive language speech-language therapy

Summary CAPD is complex, and heterogeneous. A multidisciplinary approach is required for evaluation, classification and treatment., The “tripod” management approach of direct therapeutic remediation, environmental modifications and compensatory strategies work in concert to strengthen higher- order, top-down skills so that greater effort can be spent on the more difficult bottom-up remediation activities. Strengthening active listening techniques, linguistic, metacognitive and metalinguistic skills enable students to recognize conditions that interfere with learning and enable the child to improve listening outcomes for him or herself.

References American Speech Language Hearing Association (ASHA) 2005. “Central Auditory Processing Disorders Technical Report” American Speech Language Hearing Association (ASHA) 1996, “Central Auditory Processing: Current Status of Research and Implications for Clinical Practice”, American Journal of Audiology, Vol. 5 Bellis, Teri James, “Subprofiles of Central Auditory Processing Disorders” Iskowitz, Marc, “Assessing and Managing CAPD”, ADVANCE for Speech-Language Pathologists and Audiologists, July 26, 1999. Katz, Jack “APD Evaluation to Therapy: The Buffalo Model” Matson, “Central Auditory Processing: A Current Literature Review and Summary of Interviews with Researchers” McGlynn, Michele and Barbara Adams “Assessment and Management of Auditory Processing Disorders: Case Studies”, 2002 Mosheim, Jason, “Auditory Processing Disorders”, ADVANCE for Speech-Language Pathologists and Audiologists Phonak, “Building the Link Between Hearing, Understanding and Learning”, Edulink, www.phonak.com pee