Jeanane M. Ferre, PhD
1010 Lake Street, Suite 111
Oak Park, IL 60301
708. 848.4363 - km 708. 848.7233
CAPD Assessment - General Principles
|the term "Auditory Processing" refers to "what we do with what we hear" and an Auditory
Processing Disorder can result from ANY breakdown in the very broad set of skills that are
needed to deal with auditory information including, but not limited to, attention, memory,
cognition, and hearing. A CENTRAL auditory processing disorder (CAPD) is an auditory
processing deficit caused by deficiency in those skills that are subserved by the CENTRAL
auditory mechanism in the brainstem and brain and include (to date) (ASHA, 1996):|
sound localization - ability to hear sound in space, subserved by the brainstem
auditory discrimination - ability to tell the difference between two acoustic events, subserved
by cortex, primarily left hemisphere
auditory pattem recognition - ability to recognize an acoustic pattern, subserved by cortex,
primarily right hemisphere
temporal resolution - ability to perceive changes in speech spectra over time, subserved by
cortex, probably left hemisphere
temporal masking - blocking of one sound by ones that comes before or after it, probably left
temporal integration - ability to synthesize multiple cues over time, cortical and
interhemispheric sites support this
temporal ordering - perception of order of acoustic events, subserved by cortex, probably the
ability to identify or recognize degraded or competing targets - requires all of the above
|central auditory deficits may result in or coexist with difficulties in other CNS-based skills, such
as leaming disabilities, speech-language impairment, attention deficit, developmental
|audiologists are uniquely suited to diagnose central auditory deficits. Speech-language
pathologists, psychologists, neuropsychologists, and others variety of assessment tools that
can provide insights into the listener's auditory performance in a variety of contexts. This
information as well as lists of behavioral manifestations ARE NOT diagnostic for specific
central auditory deficit. An accurate diagnosis can help explain the manifestations. Keep in
mind - just because you have all the behaviors doesn't mean you have a CAPD. Conversely,
diagnosis of a specific central auditory deficit doesn't mean you'II have all of the behaviors.
Central Auditory Evaluation - Issues in Diagnosis
Audiological evaluation for CAPD involves a battery of tests designed to examine how
efficiently the CANS operates by "overloading" or "overworking" it. Central auditory tests go
beyond standard tests of hearing to examine how well the auditory system uses or interprets
the information that the ear sends it.
Appropriate for children as young as SIX, results are compared to an age-matched peer group
and performance profiles emerge that provide insights into the nature of the
Tests of CENTRAL AUDITORY FUNCTION minimize influence of language, cognition and
other sensory processing skills on performance and maximize function of CANS.
Results are examined with respect to the central auditory process (or processes) that are
being taxed as well as the underlying anatomical site that subserves those skills.
Issues related to testing:
hearing sensitivity - tests were designed for use patients having normal to near normal
hearing. Test results are confounded by presence of peripheral hearing loss.
receptive and expressive speech and language skills - tests use a verbal response.
There are picture-pointing versions, but that adds a confounding factor to testing (visual
cues). Language age for most of the tests' vocabulary is around 5-6 years.
intellectual function - tests were "normed" on persons with IQs of 85-115. Testing is
possible with individuals with sub-average to sub-normal intelligence but interpretation
is more cautious.
age - there are versions of some tests for use with kids as young as six. For some
tests, the norms are only good down to 8 years. Between ages of 3-6, use screening
measures to get a general idea of extent to which skills are developing BUT NOT to
diagnose a specific deficit. To date, THERE ARE NO BEHAVIORAL CAP tests for use
with children under three years.
Typical Components of Central Auditory Evaluation
|standard audiometric tests
|standard immittance tests
|monaural low redundancy
low-pass filtered speech
|auditory cortex (LH)
|binaural interaction tasks
masking level difference
|cooperation between the ears
|binaural integration tasks
staggered spondaic words
|binaural separation tasks
|temporal patterning tasks
random gap detection
pitch or duration patterns test
Issues in Management
|Decoding Deficit: poor discrimination of fine acoustic differences in speech. Likely site of
dysfunction - primary auditory cortex. Signal distortion at point of neural representation.
Keyword: They do not "hear". The "what" kids.
Key CAF findings: poor auditory discrimination, closure, temporal resolution. Poor scores for
degraded speech tasks, right ear often poorer than left. Errors are phonemically similar to
Key behaviors: difficulty in situations with reduced extemal redundancy - unfamiliar with
vocabulary, few or no contextual or visual cues, excessive noise and/or reverberation, auditory
chaos; in groups. Report "can't hear", "didn't hear". Mishears, needs repetition, SLOW &
INACCURATE. May have communicative problems in vocabulary, syntax, semantics, second
language acquisition and/or academic problems in reading decoding, spelling,
Other considerations: Wepman ADT - reliable screener for poor discrimination,
memory tests - poor decoders rend to do more poorly on word memory tests than on sentence
memory test, spelling - if you can spell it the "way it sounds" you probably have adequate
auditory decoding skills
Key managernent strategies:
preferential classroom seating that maximizes BOTH auditory and visual channels
reduction of extraneous
increased use of visual/contextual cues
improved signal-to-noise ratio usually via assistive listening technology
target repetition to improve acoustic clarity
target rephrasing to provide additional contextual/Iinguistic cues
substitute verbal foreign language requirement with sign language
adjust class schedule to minimize auditory overload
closed set tests
use of tape recorders
combination of speech-languagelaural rehabilitation therapy to work "top-down" skills
and auditory training to work "bottom-up" skills
Commercial programs: Earobics, FAST ForWord, Sloan, LiPS, M3.
Games: diadokokinetic exercises, telephone game, direction following games, rhyming
games, Word- A- Day, Start-stop games (also work on vigilance), ANY awareness,
same-different, identification, or recognition sound game
|Integration Deficit: Deficiency in the ability to perform tasks that require intersensory or
interhemispheric communication. Reflects delayed or abnormal interhemispheric communication.
Deficiency in ability to coordinate multimodal inputs.
||Keyword: They do not "synthesize". "It's too much".
Key CAF findings: excessive left ear suppression on dichotic listening tasks, can't label
auditory patterns but can mimic them.
Key behaviors: trouble knowing "how to" do some task, tends to "watch and wait", poor starter,
poor transitions, needs more time; lots of "I don't know", "I don't get it" or "I have no idea".
Variable trouble in noise. Variable impact on communication. Academic effects in reading
recognition, spelling, writing skills, other integrative tasks.
Other considerations: spelling- tend to spell phonetically not by the rules,
the alphabet - can "sing" the alphabet but struggles to "say" it,
digit span tests- tend to have more trouble with digits reversed,
memory tests- difficulty with sentences - better on word memory
||Key management strategies:
|child may perform MORE poorly when visual information is added, they may need to
look OR listen or look THEN listen|
|DO make sure that visual cues MATCH the auditory target and DON'T compete with it|
|DON'T EVER rephrase to a child with Integration Deficit, it will just confuse them|
|DO repeat the information with an associated visual cues, demonstration, or model|
|bothered by "noise" as a function of the TASK DEMANDS, not necessarily the level of
noise, so change demands or remove child to quieter environment, especially for tests|
|require an experiential, structured, "hands-on" environment, lots of examples,
multimodal inputs given one at a time|
|must know task demands up front|
|consider Latin or Hebrew for foreign language requirement|
|use tape recorder, notetakers, books on tape, study guides, CliTs Notes|
|intervention focuses on academic and speech-language impact as needed and
appropriate remedial programs include Orton, Lindamood-Bell, Wilson, and similar|
|"Bottom-up'-type activities that enhance development of interhemispheric skills include
those that stimulate transfer of function, ability to extract key information, do "parts-to-
whole" (synthesize). Examples: dance, music, juggling, karate, gymnastics,
Scrabble, Boggle, UpWords, Rummy and other card games, Rummy-Q, Top it, Brain
Warp, Simon and Simon Says, Chess, Video games with pattern puzzles, "feely bag"|
|Pair OT-type activities with verbal tasks|
|Prosodic Deficit: Deficiency in ability to use prosodic features of target. Believed to reflect inefficient
right hemisphere function.
||Keyword: Subtle problems. It's all "too fast". "blah, blah, blah, something".
Key CAF lindings: poor labelling AND mimicking of temporal patterns. Poor temporal
integration. Reflects poor gestalt pattern recognition skills - unisensory in this case.
Key behaviors: pragmatic language problems including trouble with non-verbal cues, e.g.,
facial expressions, body language, gestures, sarcasm; heteronyms, expressive speech may
be monotone, poor rhythm perception. Possible deficits in music. Variable academic impact.
Part of the cohort of behaviors of nonverbal learning disability.
Other considerations: The Alphabet Song - song off-key or off-tempo
music & musical cues - doesn't like music or can't "carry a tune"
multisyllabic production - "trips" over multisyllabic words or leaves syllables out
||Key management strategies:
|requires animated teacher with a melodic voice, lots of
multisensory inputs and additional visual cues|
|change rate, pacing of speech, emphasis on key words|
|may require speech-language TX for pragmatic and nonverbal language, rhythm
perception, prosody training|
|for academic intervention, consider Lindamood-Bell or Wilson|
|consider music TX and/or social work services (for social language)|
|use games/activities similar to those for poor integrator including singing, Math Rap,
Schoolhouse Rock, Bopit, sing-along tapes/videos, books on tape, activities that work
on pattern recognition (auditory, visual, or tactile) and symbolic language, listening to
color, "soap" operas, dramatic arts.|
|Keep in mind: It's not just the perception of the timing cues for these children, it's what
those cues MEAN.|
|Check for similar problems in other modalities - difficulty reading facial expressions or
problems with tactile patterns|
|Check for NVLD|
|Associative Deficit: not applying RULES of LANGUAGE to acoustic signal. Inefficient
communication between primary and associative cortical regions (i.e. inefficient intrahemispheric
||Keyword: They do not "translate". The "huh" kids.
Key CAF results: bilaterally depressed scores on dichotic listening tasks. OK pitch pattern
Key behaviors: request clarification, saying "I don't know what you MEAN" or "I don't
understand". Communicative problems in syntax, vocabulary, semantics, verbal and/or written
expression, pragmatics, social communication, foreign language acquisition. Reading
decoding OK but weak comprehension. Trouble with math word problems. Early academics
may be OK but declines with increasing linguistic demands.
Other considerations: language-biased IQ tests - tend to underestimate true potential. Will get
more reliable estimate with non language-biased instrument such as Leiter or TONI.
Key management strategies:
| focus on "use of the rules"|
|needs an educational environment that is systematic, logical, multisensory, & rule-
|rephrase instead of repeating, emphasize linquistic clarity, avoid ambiguity|
|use multiple choice or closed set tests|
|waive foreign language|
|increase linguistic familiarity, books on tape, study guides, Clifs Notes|
|tell the rules up front|
|speech-language TX to build linguistic/metalinguistic and metacognitive skills|
|academic intervention may include Orton-based programs, Lindamood-Bell, Wilson|
|use games/activities that get you to OR let you think "outside the box" andlor build
facility with vocabulary, (meta)Iinguistic rules or concepts (including problem solving):
Catch Phrase, Scattergories, UpWords, Tabu, Clever Endeavor, Alphabet games,|
Plexers, Rebus games, Password, Boggle, Scrabble, Wheel of Fortune, Word-A-Day
calendars, Word Jumble, Word Search Puzzles, words-from-a-word games, "It pays to
increase your word power" - Readers' Digest, Change-a letter games, dramatic arts
|Output-Organization Deficit: Deficiency in the ability to organize, sequence, plan, or recall
appropriate responses. Difficulty on tasks requiring efficient motor path transmission/motor planning.
May be behavioral manifestation of impaired efferent function or planninglexecutive function deficit.
||Keyword: They can't "get it back out".
Key CAF results: poor performance in noise, target reversals, ordering problems, omission of
target/substitution with previously heard word.
Key behaviors: disorganized, impulsive, poor planner. Deficits in expressive language,
articulation, syntax. Educational problems: direction following, note-taking, remembering
Other considerations: free vs. directed recall tasks - tend to perform much better with free
recall than with directed recall tasks
Key management strategies:
|needs training and practice in the rules for organization|
|break info into smaller units, use tag words|
|use outlines, checklists, assignment notebooks, computers|
|use activities with specific order|
|teach verbal rehearsal, information chunking, use of mnemonics, metacognitive
strategies, visual imagery and visualization.|
|may need speech-language intervention for expressive speech-language skills|
|may need academic TX for study, note-taking and test-taking strategies|
|consider ALD for attentiveness|
|use games that emphasize sequence, order, rules, planning: Alphabet games, drama,
follow the leader, Bopit, Topit, Brain Warp, Freddie Fish, memory games, Scrabble,
chess, Battleship, model building, cooking
Websites -Readings - Activity Resources of Interest to parents and service providers
Homepage of a web portal of other CAPD resources site
Homepage of the National Coalition on Auditory Processing Disorders, Inc. Has a link to a parent
group. Can join a CAPD listsery from this site (one for professionals, one for parents).
Links to information on auditory processing.
Site was developed by a parent of a child with APD. Has good links and has information packets.
Discussion forum for parents about APD. Some professionals on this list as well.
Provides definitions, behavioral manifestations, explanation of the assessment process, educational
implications, gives some management strategies and provides a list of references for further reading.
Cognitive Concepts' Earobics remediation software.
Fast ForWord therapy products for auditory training.
Lindamood Bell therapy products for reading, spelling, phonemic Awareness (e.g., LIPS Program).
Books and information on using visual strategies for learning.
Rocky Mountain Leaming System's reading & phonics program (Orton-Gillingham based).
http://www.inspiration.com and http://www.kidspiration.com
Information, demonstration and ordering of semantic mapping software.
Ordering information for "Map it Out' book - graphic organizers and semantic maps for visual leaming.
Site for Don Johnston catalog including software for monitoring writing through auditory feedback,
writing, spelling, composition, grammar.
PACE therapy for attention, working memory, visual and auditory processing, and comprehension.
Website for Learning by Design, Inc. offering educational software, especially spelling (SPELL).
Website for LinguiSystems, Inc., offering educational and speech-language materials.
Website for The Psychological Corporation, offering psychoeducational, speech-language, auditory
processing, and related assessment and therapy tools and materials.
Website for Lexia Leaming Company with educational strategies for older students
American Speech-Language-Hearing Association Task Force on Central Auditory Processing
Disorder Consensus Development. (1996). Central auditory processing: Current status of research
and implications for clinical practice. American Joumal of Audiology, 5(2), 41-54.
Bellis, T. (1996) Assessment and Management of central auditory processing disorder in the
educational setting. San Diego, CA: Singular Publishing Group.
Bellis, T. (2002) When the Brain Can't Hear. Pocket Books. A book for PARENTS.
Bellis, T. J. & Ferre, J.M. (1996) Assessment and management of CAPD in children. Educational
Audiology Monograph, 4, 23-27.
Chermak, G & Musiek, F (1997). Central Auditory Disorders: New Perspectives. San Diego, CA:
Singular Publishing Group.
Ferre, J. M. (1997). Processing Power: A Guide to CAPD Assessment and Management. San
Antonio, TX: The Psychological Corporation.
Ferre, J.M. (2002) Behavioral therapies for auditory processing disorders. In Katz, J. (ed.) Handbook
of Clinical Audiology, EP edition. Lippincott Williams & Wilkins.
Lasky, E. & Katz, J. (1983). Central auditory processing disorders: Problems in speech, language,
and leaming. Baltimore: University Park Press.
Kelly, D. (1995). Central Auditory Processing Disorder: Strategies for use with children and
adolescents. San Antonio, TX: The Psychological Corporation.
Masters, M, Stecker, N, & Katz, J. (1998). Central auditory processing disorders: Mostly
Management. Boston, MA: Allyn & Bacon.
McAleer Hamaguchi, P. (2002). It's time to listen: Metacognitive activities for improving auditory
processing in the classroom. Austin, TX: Pro-Ed.
McAleer Hamguchi, P. (2003). A metacognitive approach for treating auditory processing disorders.
Austin, TX: Pro-Ed.
Richard, G. (2000). The Source for auditory-language processing disorders. Rock Island, IL:
Sloan, C. (1995). Treating auditory processing difficulties in children. San Diego, CA: Singular
Foreest-Pressley (ed). Metacognition, Cognition, & Human Performance, vols 1 & 2, Academic
Higbee, K. Your Memory- How it Works and How to improve it. (1996). Prentice-Hall.
125 Ways to be a Better Student. LinguiSystems, Inc.
Gordon & Asher. Meeting the ADD Challenge: A Practical Guide for Teachers. (1994), Illinois
Mooney, J. & Cole, D. Learning Outside the Lines. Fireside Press.
Connections - activities for deductive thinking, Dandy Lion Publications, San Luis Obispo, CA.
Quizzles - logic problem puzzles, Dale Seymour Publications, PO Box 10888, Palo Alto, CA.
Great ideas for Teaching! - auditory-language workbooks, PO Box 444, Wrightsville Beach, NC.
Plexers - a collection of word puzzles, Dale Seymour Publications, PO Box 10888, Palo Alto, CA.
Puzzlemania, Which Way USA, Top Secret Adventures - all from Highlights for Children, great
puzzles of all kinds for enhancing language arts. 888.876.3809
Rags to Riches - idioms game - Super Duper Publications, 800.277.8737, LinguiSystems also has
an idioms game.
Mavis Beacon Typing Series, CD-ROM for learning keyboarding - also strengthens spelling.