Barrie Morganstein, Ph'D'

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Auditory Processing Disorders

• Barrie Morganstein, Ph.D.

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Auditory Processing Disorder

• Auditory Processing Related Concepts
• Symptoms Implications of Auditory Processing
  Disorders
• Types of Auditory Processing Disorders
• Testing for Auditory Processing Disorders
• Differential Diagnoses
• Remediation Accommodations
• How Related Professionals Help
• Recommended Readings

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What is Auditory Processing?

• What happens when your brain recognizes and
  interprets the sounds around you.
• Humans hear sound through the ear and is then
  interpreted by the brain.
• The "disorder" part of auditory processing
  disorder means that something is adversely
  affecting the processing or interpretation of the
  information.

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What You Should Know About Auditory Processing
Disorders

• CAPD can occur with or without hearing loss
• CAPD may run in families
• CAPD can affect a person's ability to interact
  socially
• Children with CAPD typically have normal
  intelligence
• Many of the difficulties that are experienced by
  people with CAPD are also common to people with
  ADD and hearing impairments

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Common Symptoms of CAPD

• Poor expressive or receptive language
• Difficulty with reading comprehension, spelling,
  and vocabulary
• Difficulty following long conversations
• Problems understanding or remembering
  orally-presented information
• Difficulty following verbal directions especially
  when involving multi-step directions

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Common Symptoms of CAPD cont.

• Inappropriate responses to "wh" questions
• Problems with rhyming or identifying words that
  start with the same letter, etc.)
• Needs extra time processing information
• Frequently needs repetition of directions or
  information
• Difficulty taking notes
• Difficulty with tasks requiring attention

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Common symptoms of CAPD - cont.

• Difficulty learning a foreign language or
  challenging vocabulary words
• Decreased comprehension in noisy environments
• Difficulty repeating words or numbers in sequence
• Difficulty with phonics or speech sounds

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Behavioral Indications of CAPD

• Appearance of hypersensitivity to sound
• Talks less than peers
• Difficulty focusing during story time
• Prefers puzzles or watching videos to listening
  to books
• Uses "memorized" phrases and sentences
• Repeats back a question before responding to it

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Behavioral Indications of CAPD cont.

• Tunes out or seems to be in a world of her
  own
• Difficulty carrying on telephone conversations
• Less social because of comprehension problems
• Likes music but difficulty learning the words

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Behavioral, Social and Emotional Implications of
CAPD

• Feeling lost or overwhelmed can lead to losing
  interest and poor attention (which can look like
  ADHD).
• Frustration can also lead to lowered self esteem,
  feelings of helplessness, and fear of failure,
  coupled with feeling dumb.

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Behavioral, Social and Emotional Implications of
CAPD

• Feeling tired, stressed, or excited will lessen
  the ability to process spoken language
• The intense focus needed to accurately take in
  auditory information can lead to fatigue which
  further adds to processing problems and
  frustration.

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What causes CAPD?

• Middle ear infections (Otitis Media)
• Auditory pathways and centers in the brain
  develop as they are stimulated with sound.
• A hearing loss (even temporary) limits the
  auditory stimulation that is necessary to promote
  optimal development of the auditory nervous
  system.
• Genetic factors
• Birth trauma
• Maturational delays and idiosyncrasies in the
  central nervous system (CNS)

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CAPD and Language Processing

• Sound Localization and Lateralization refers to
  the ability to know where a sound has occurred in
  space.
• Auditory Discrimination refers to the ability to
  distinguish one sound from another. The term is
  most often used for distinguishing speech sounds,
  such as phoneme /p/ from phoneme /t/ as in hop
  and hot.
• Sound/Symbol Association is the ability to
  associate a symbol (i.e., a letter) with a sound
  such as s with the sound ssss.

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CAPD and Language Processing cont.

• Temporal Auditory Processing is the ability to
  integrate a sequence of sounds into words or
  other meaningful combinations or perceive sounds
  as separate when they quickly follow one another.
  
• Auditory Figure Ground refers to the ability to
  perceive the main message when other sounds are
  present (e.g., understanding a conversation while
  the TV is on).
• Tolerance-Fading Memory refers to weak short
  term memory for auditorily presented
  information this difficulty frequently occurs in
  the presence of distracting sounds.

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CAPD and Language Processing cont.

• Sound Blending is the ability to blend individual
  speech sounds together into a meaningful word
  (e.g., b-a-t ? bat).
• Auditory Closure refers to the ability to
  perceive information in which some of the
  information is missing (e.g., there was a lot of
  traffic so I was ___ to work).
• Decoding problems are related to difficulties
  with phonics. Individuals with decoding problems
  may spell words phonetically, spell
  inconsistently, have reading problems, confuse
  similar sounding words, and may have problems
  with speech clarity and articulation.

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Auditory Discrimination Problems

• People who cannot readily or easily distinguish
  or discriminate the differences between sounds of
  speech, especially similar sounds like the /p/,
  /t/, and /k/ can become easily confused,
  frustrated, and overworked.
• This often leads to "shutting down" and appearing
  inattentive or "spaced out."
• People with these problems are often processing
  word-by-word. This can easily lead to an overload
  and falling behind.
• Imagine how difficult it would be to keep such a
  high level of concentration working to decode
  every word.

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Auditory Discrimination Problems

• Twhnkke, tvinjle kitsle rtaq.
• Hov I wnnddr wgat wou zre.
• tp aaovd thd woqd sn hifh,
• lhke z dizmomd im thd skx.
• Thnkke, tvinjle kitsle rtaq.
• Hov I wnnddr wgat wou zre.

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Auditory Discrimination Problems

• Twinkle, twinkle little star.
• How I wonder what you are.
• Up above the world so high,
• like a diamond in the sky.
• Twinkle, twinkle little star.
• How I wonder what you are.

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Auditory Figure Ground

• Hicqkorwy, edicrkorty, ydocuk,
• Tihe omoupse arans upd thfe cglochk.
• Thhe jclokck lstrzuckx oxnkce,
• Tvhe bmounse mran doqwnr
• hqickworye, dricktoryy, duock.

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Auditory Figure Ground

• Hickory, dickory, dock,
• the mouse ran up the clock.
• The clock struck one,
• the mouse ran down,
• hickory, dickory, dock.

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Auditory Figure Ground

• Little Jack and Jill Horner sat went up in the
  corner hill eating to fetch his a pail of
  Christmas pie water.
• He Jack fell in his thumb down and pulled out a
  broke his plum crown and said "What Jill came a
  tumbling good boy am after I."

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Auditory Figure Ground

• Little Jack and Jill Horner sat went up in the
  corner hill eating to fetch his a pail of
  Christmas pie water.
• He Jack fell in his thumb down and pulled out a
  broke his plum crown and said "What Jill came a
  tumbling good boy am after I."

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Auditory Closure

• O ing ol was a ry o ol
• And a ry o ol was e.
• He al or is pi an e
• Al or is owl and he
• Al or is ler ee.

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Auditory Closure

• Old King Cole was a merry old soul
• and a merry old soul was he.
• He called for his pipe and he
• called for his bowl and he
• called for his fiddler three.

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Dichotic Listening

• The ability to process and understand different
  information entering each ear.
• It is very normal for young children to have a
  slight right-ear advantage, which suggests that
  language is appropriately established in the left
  hemisphere of the brain.
• However, as children age, the advantage should
  disappear and all information should enter the
  language center of the brain regardless of which
  ear it is presented to.
• A left-ear advantage most likely suggests a delay
  in maturation or damage to the central auditory
  processing pathways.

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Dichotic Listening

• Some children with CAPD may be very poor with
  dichotic listening tasks because of an abnormal
  ear advantage
• A left-ear advantage can suggest a right
  hemisphere dominance for language, but it most
  likely suggests a delay in maturation or damage
  to the central auditory processing pathways.
• The greater the left-ear advantage, the greater
  the likelihood of a neurologically-based learning
  disability.

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Tests In a FullPsychological CAPD Battery

• IQ tests WPPSI (preschool), WISC (6-16), WAIS
  (16)
• Academic tests Woodcock Johnson
• Auditory Processing tests SCAN-C SCAN-A
• Parent teacher questionnaires Devereux Scale
  (DSMD) and Conners
• Attention test -- IVA

Can test for CAPD earlier with some
psychological tests than with audiological
tests
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How a Child with CAPD May Look on an IQ Test
(e.g., WISC-IV)

• Low scores on verbal subtests with higher scores
  on non-verbal subtests
• Low scores on subtests requiring extensive verbal
  responses
• May do better on verbal subtests that tap
  information in long-term memory such as
  Vocabulary and Information, than on verbal
  subtests that test information in short-term
  memory such as Arithmetic or Digit Span.

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How a Child with CAPD May Look on an Academic
Test (e.g., WJ-R)

• Low scores on subtests posing extensive verbal
  questioning and/or requiring extensive verbal
  responses
• Poor spelling and/or pronunciation of words while
  reading.
• Poor performance on subtests requiring extensive
  auditory memory and/or multi-step processes.

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SCAN-C and SCAN-A

• Same general tests, but developed for children or
  adolescents adults
• Measures Auditory Figure Ground, Auditory
  Closure, and Dichotic Listening (measures ear
  advantage and attention problems)

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Questionnaires

• Developed to measure a variety of problems that
  can contribute to academic, social, and emotional
  problems including
• ADHD symptoms like attention problems,
  impulsivity, and hyperactivity
• Behavioral problems like oppositional behavior
• Symptoms of emotional problems like depression,
  anxiety, etc.
• Social problems

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IVA-CPT

• Developed to measure ADHD symptoms like attention
  problems, impulsivity, and fine-motor
  hyperactivity
• Rules out ADHD in testing in order to better
  measure CAPD
• Also helps identify CAPD by offering a
  Comprehension measure

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Differential Diagnoses

• Attention Deficit Disorder poor attention and
  distractibility can prevent information from
  accurately and completely entering the brain.
• Anxiety stress and worry can also cause poor
  attention and distractibility prevent information
  from accurately and completely entering the
  brain.
• Anxiety and low self-esteem can also cause
  children to hesitate in responding which can look
  like comprehension difficulties or verbal apraxia.

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Remediation/Accommodations for CAPD in the
Classroom

• Education of teachers and other school personnel
  about teaching strategies, modification of
  environment, and recognizing at-risk children
• Development of Individualized Education Plan
  (IEP) or 504 Plan
• Preferential seating so the child can see the
  teacher and the blackboard
• Access to word processors and other technology
  like Franklin Speller to help improve their
  written output and check their accuracy

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Remediation/Accommodations for CAPD in the
Classroom -- cont.

• Provide specific opportunities to practice newly
  learned skills
• Hand-outs and written directions like outlines
  of lectures, study-guides for tests, directions
  for projects, directions for tests, etc.
• Visual aids such as drawings, overheads, and/or
  written material to accompany lectures and
  teachings
• Try to avoid creating projects and class
  assignments where children have to multi-task
  like listening and drawing, listening and acting
  (e.g., science experiments), etc.

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Remediation/Accommodations for CAPD in the
Classroom -- cont.

• Notes provided by the teacher or by a notetaker
• Limit background noises such as loud air
  conditioners
• Provide additional time for tests and/or projects
• Use of assistive listening devices such as an FM
  system or Feedback Loop to improve clarity of
  sound and eliminate distracting noises.

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Remediation/Accommodations for CAPD in General

• Reduce external visual and auditory distractions
• Encourage eye contact
• Get attention before speaking
• Speak slowly and clearly (but not
  over-exaggerated)
• Use simple, brief instructions

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Remediation/Accommodations for CAPD in General
cont.

• Give directions in a logical, time-ordered
  sequence
• Review previously learned material
• Use words such as first, next, and finally
• Use visual aids such as notes, pictures, charts,
  and sign language
• Emphasize key words
• Write things down

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Remediation/Accommodations for CAPD in General
cont.

• Check comprehension by asking child to give brief
  summary
• If child does not understand, re-phrase
  directions or question (i.e., use shorter simpler
  sentences)
• Use gestures that will clarify information (adds
  a visual component) but are not distracting

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Remediation/Accommodations for CAPD in General
cont.

• Avoid asking the child to multi-task (i.e.,
  listen and write at the same time) use triggers
  to help with this like Stop, Look, and Listen
• Recognize fatigue and give breaks as necessary
• Avoid showing frustration when the child
  misunderstands

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Remediation/Accommodations for CAPD in General
cont.

• Participate in a variety of training to aid in
  auditory processing and language expression
  (e.g., work with speech pathologist,
  psychologist, etc.)
• Do supplemental work at home to help children
  catch up to their peers and learn new skills

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How an Audiologist Can Help

• Confirming the presence of auditory processing
  problems
• Determining the specific type of problems

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How a Speech Pathologist Can Help

• Conduct assessments to find out how well a person
  understands and uses language
• Help the child to build vocabulary, rhyming, etc.
  
• Offer suggestions to improve language-building
  skills
• Develop a specialized treatment program that is
  specific to each child.
• Educate family and professionals on how to best
  help the child deal with CAPD and making specific
  recommendations for them to follow.
• Offer unique training that is specialized in
  improving auditory processing skills such as Fast
  ForWord.

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Neural Plasticity

• The idea that the brain can learn new processes
  through repeated intensive practice.

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Computerized Learning Programs

• Computerized language learning programs like Fast
  ForWord, Earobics, and Diphonics help children
  rapidly build oral language comprehension and
  other critical skills necessary for improved
  communication and reading.
• They are based on the concept of neural
  plasticity.

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Examples of Fast ForWord Exercises

• Flying Saucer Deep in outer space, students
  differentiate between the sounds of a flying
  saucer to develop listening and sequencing
  skills.
• Drag Racer In this drag race the student
  improves their sustained auditory attention and
  auditory discrimination skills.

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Examples of Earobics Exercises

• Wizards and Pigs Move the wizard to find a
  needed potion while practicing rhyming, rhythm,
  and alliteration. Children improve auditory
  attention and sound discrimination.
• Buggy Trails Children practice following
  three-step directions.
• Monkey Business Children practice understanding
  word usage and sentence structure.

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Lindamood-Bell Programs

• Intensive teaching programs to improve academic
  skills
• Phoneme Sequencing for Phoneme Awareness,
  Reading, and Spelling
• Seeing Stars Symbol Imagery for Phoneme Awareness
• Visualizing and Verbalizing for Language
  Comprehension and Thinking
• On Cloud Nine (Math)

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The Listening Program The Therapeutic
Listening Program

• Psychoacoustically modified music is designed
  to stimulate, or exercise the different
  functions of the auditory.
• They claim to improve processes like memory,
  attention, language, balance, coordination,
  sensory integration, energy, and creativity.

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How a Psychologist Can Help

• Diagnose CAPD by administering tests to measure
  auditory processing skills.
• Help distinguish CAPD from other disorders that
  produce similar-looking behaviors by conducting
  cognitive, academic, and personality testing.

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How a Psychologist Can Help cont.

• Identify each childs specific strengths and
  weaknesses and make specific recommendations.
• Help parents with supplemental work at home to
  help catch up on skills
• Make recommendations to help the child within the
  school and home settings.
• Help the parents and child with tactics and
  skills to improve upon daily life.

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Ways I Work with CAPD Kids

• Psychological assessment
• Teaching the child how to express wants, needs,
  and feelings verbally
• Developing alternate methods to learning new
  skills (e.g., Round Robin, Charades, Guess Who,
  etc.)
• Teaching social skills that are not able to be
  developed normally because of processing
  difficulties (e.g., assertiveness)
• Teaching communication skills (e.g., eye contact,
  appropriate voice volume levels, how to ask for
  clarification, etc.)

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Ways I work with CAPD kids cont.

• Teaching and encouraging stress management to
  deal with the daily stressors of CAPD
• Teaching and encouraging positive self-esteem and
  confidence that are hard to develop because of
  frustration from CAPD
• Teach concepts to children that parents deem
  essential (e.g., safety, how to express pain and
  illness, how to adjust to new situations, etc.)

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Ways I work with CAPD kids cont.

• Teach tactics to parents that they can use to
  help their child practice skills outside of
  therapy (e.g., how to best communicate, how to
  give directions, how improve memory skills, etc.)
• Read and write with children to develop feedback
  to make improvements (e.g., discussing pictures
  with text or emphasizing voice tone to improve
  comprehension)
• Give teachers feedback and techniques to use with
  children in the classroom
• Re-testing to measure childrens progress (e.g.,
  increase in Verbal IQ, verbal expression,
  auditory memory, etc.)

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Ways I work with CAPD kids coaching

• Help kids identify their specific strengths and
  weaknesses
• Help kids develop techniques to compensate for
  their specific weaknesses (e.g., improve
  organization, listening skills, note-taking
  skills, test-taking skills, etc.)
• Help kids identify their needs and advocate for
  themselves
• Help kids and parents work with their schools and
  teachers to develop good academic plans.

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How Children Can Help Themselves

• Keep your eyes on the speaker, and try to get eye
  contact.
• Use good listening behavior -- quiet body and
  closed mouth.
• Stop-Look-and-Listen when someone begins
  speaking, stop what you are doing, look at them,
  and listen to them completely.
• Speak up let your teacher know exactly what
  your learning needs are and how you would like
  your teacher to help.

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How Children Can Help Themselves cont.

• Ask to have directions repeated or clarified when
  you feel confused or unsure of what to do.
• Ask someone to explain what words mean, or use a
  dictionary or thesaurus, when you arent sure.
• Repeat information quietly to yourself after
  verbally-presented directions or information.

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How Children Can Help Themselves cont.

• Visualize make a picture in your mind, to help
  you remember important points.
• Wait until your parent or teacher finishes giving
  directions and answers questions before starting
  a task.
• Write down your assignments at school to help you
  remember what youre supposed to do when you get
  home.
• Borrow a friends notes to compare to yours to
  make sure you did not miss any information.

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Recommended Readings

• When the Brain Cant Hear Unraveling the Mystery
  of Auditory Processing Disorder Teri J. Bellis,
  Ph.D.
• Like Sound Through Water A Mothers Journey
  Through Auditory Processing Disorder Karen J.
  Foli Edward M. Hallowell
• Learning Disabilities Sourcebook Basic
  Information About Disorders Such As Dyslexia,
  Visual and Auditory Processing Deficits,
  Attention Deficit/Hyperactivity Linda M. Shin
  Linda M. Ross