OCSLHA

Oakland County Speech-Language-Hearing Association

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Jeanane M. Ferre, PhD
Audiologist, CCC-A
1010 Lake Street, Suite 111
Oak Park, IL 60301
708. 848.4363 - km 708. 848.7233
e-rnailimfphd@aol.com

CAPD Assessment - General Principles

bulletthe 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 hemisphere

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 insula

ability to identify or recognize degraded or competing targets - requires all of the above
bulletcentral auditory deficits may result in or coexist with difficulties in other CNS-based skills, such as leaming disabilities, speech-language impairment, attention deficit, developmental disabilities;
bulletaudiologists 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

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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.

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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 CAPD.

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Tests of CENTRAL AUDITORY FUNCTION minimize influence of language, cognition and other sensory processing skills on performance and maximize function of CANS.

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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:

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hearing sensitivity - tests were designed for use patients having normal to near normal hearing. Test results are confounded by presence of peripheral hearing loss.

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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.

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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.

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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

Test Type Processes assessed Underlying site
standard audiometric tests
   puretone air/bone
   speech thresholds
   word recognition
hearing sensitivity/acuity
peripheral system
standard immittance tests
   tympanogram 
   acoustic reflexes
signal transmission peripheral/central systems
monaural low redundancy
   low-pass filtered speech
   time-compressed speech
auditory closure
auditory discrimination
auditory cortex (LH)
binaural interaction tasks
   binaural fusion
   masking level difference
cooperation between the ears brainstem
binaural integration tasks
   dichotic digits 
   dichotic rhyme 
   staggered spondaic words
   dichotic CVs
   competing words
closure
integration
ordering
corpus callosum,
LH, RH
binaural separation tasks
   competing sentences
neuromaturation corpus callosum,
LH, RH
temporal patterning tasks
   random gap detection
   pitch or duration patterns test
temporal resolution
temporal patterning
corpus callosum,
RH, LH
speech-in-noise tests varied varied

Issues in Management

bulletassessment results tell us about the neurological integrity of the system AND about the functional capabilities of the listener. Information about function can provide a better understanding of the listener's strengths and weaknesses with respect to academic achievement, communicative success, and life skills.
bulleteffective management of CAPDs includes modification of the communicative environment, use of compensatory strategies, and direct remediation to develop deficient skills.
bulletInclusion of remedial activities in any management program is based upon research in the area of neural plasticity. Plasticity refers to the brain's ability to organize and reorganize itself in response to internal and/or external changes. These changes are essential to memory development and learning.
bulletWhen choosing a therapy program, clinician should consider neuroscientific foundations - should it work AND reported efficacy for specific population including population for which TX was intended - does it work.
bulletBottom-Up Therapy Programs are stimulus-driven and intended to improve encoding of signal though adaptive stimulation. Top-Down Therapies focus on improving ability to use metalinguistic/metacognitive strategies and enhancing listener's experiences and expectations to allow strategies to be used.
bulletYou will use techniques that are both bottom-up and top-down for treatment for all types of CAPDs. How much of either type depends upon the type of CAPD.

Test Interpretation

The practical importance of making a correct diagnosis is that children having different types of
problems vary significantly in their needs and unless a ditferential diagnosis is made, their
potentialities are lost.
- H. Myklebust, 1954

The nature of the central auditory disorder may be discerned by examining performance across tests.

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Primary subtypes: based upon presumed anatomical site of dysfunction include Auditory Decoding Deficit, Integration Deficit, and Prosodic Deficit.

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Secondary subtypes: perhaps not appropriately termed "CAPD" but show unique test profiles include Auditory Association Deficit and Output-Organization Deficit.

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 target.

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, notetaking, direction following.

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:

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preferential classroom seating that maximizes BOTH auditory and visual channels

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reduction of extraneous

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increased use of visual/contextual cues

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improved signal-to-noise ratio usually via assistive listening technology

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target repetition to improve acoustic clarity

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target rephrasing to provide additional contextual/Iinguistic cues

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substitute verbal foreign language requirement with sign language

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adjust class schedule to minimize auditory overload

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closed set tests

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use of tape recorders

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combination of speech-languagelaural rehabilitation therapy to work "top-down" skills
and auditory training to work "bottom-up" skills

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Commercial programs: Earobics, FAST ForWord, Sloan, LiPS, M3.

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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:
bulletchild may perform MORE poorly when visual information is added, they may need to look OR listen or look THEN listen
bulletDO make sure that visual cues MATCH the auditory target and DON'T compete with it
bulletDON'T EVER rephrase to a child with Integration Deficit, it will just confuse them
bulletDO repeat the information with an associated visual cues, demonstration, or model
bulletbothered 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
bulletrequire an experiential, structured, "hands-on" environment, lots of examples, multimodal inputs given one at a time
bulletmust know task demands up front
bulletuntimed tests
bulletNO ALDs
bulletconsider Latin or Hebrew for foreign language requirement
bulletuse tape recorder, notetakers, books on tape, study guides, CliTs Notes
bulletintervention focuses on academic and speech-language impact as needed and appropriate remedial programs include Orton, Lindamood-Bell, Wilson, and similar
bullet"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, Bopit, 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"
bulletPair 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:
bulletrequires animated teacher with a melodic voice, lots of demonstration/examples, multisensory inputs and additional visual cues
bulletchange rate, pacing of speech, emphasis on key words
bulletuntimed tests
bulletmay require speech-language TX for pragmatic and nonverbal language, rhythm perception, prosody training
bulletfor academic intervention, consider Lindamood-Bell or Wilson
bulletconsider music TX and/or social work services (for social language)
bulletuse 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.
bulletKeep in mind: It's not just the perception of the timing cues for these children, it's what those cues MEAN.
bulletCheck for similar problems in other modalities - difficulty reading facial expressions or problems with tactile patterns
bulletCheck for NVLD
Associative Deficit: not applying RULES of LANGUAGE to acoustic signal. Inefficient communication between primary and associative cortical regions (i.e. inefficient intrahemispheric cooperation).
Keyword: They do not "translate". The "huh" kids.

Key CAF results: bilaterally depressed scores on dichotic listening tasks. OK pitch pattern labelling.

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:

bullet focus on "use of the rules"
bulletneeds an educational environment that is systematic, logical, multisensory, & rule- based
bulletrephrase instead of repeating, emphasize linquistic clarity, avoid ambiguity
bulletuse multiple choice or closed set tests
bulletwaive foreign language
bulletincrease linguistic familiarity, books on tape, study guides, Clifs Notes
bullettell the rules up front
bulletspeech-language TX to build linguistic/metalinguistic and metacognitive skills
bulletacademic intervention may include Orton-based programs, Lindamood-Bell, Wilson
bulletuse 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 assignments.

Other considerations: free vs. directed recall tasks - tend to perform much better with free recall than with directed recall tasks

Key management strategies:

bulletneeds training and practice in the rules for organization
bulletbreak info into smaller units, use tag words
bulletuse outlines, checklists, assignment notebooks, computers
bulletuse activities with specific order
bulletteach verbal rehearsal, information chunking, use of mnemonics, metacognitive strategies, visual imagery and visualization.
bulletmay need speech-language intervention for expressive speech-language skills
bulletmay need academic TX for study, note-taking and test-taking strategies
bulletconsider ALD for attentiveness
bulletuse 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

Information sites:

http://pages.cthome.net/cbristol/capd-idx.html
Homepage of a web portal of other CAPD resources site

http://www.ncapd.orq/
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).

http://www.1isten-up.orq/capd-htm
Links to information on auditory processing.

http://www.angelfire.com/bc/capd
Site was developed by a parent of a child with APD. Has good links and has information packets.

www.maelstrom.stjohns.edu/archives/capd.html
Discussion forum for parents about APD. Some professionals on this list as well.

www.tsbvi.edu/Outreach/seehear/spring00/centralauditory.htm
Provides definitions, behavioral manifestations, explanation of the assessment process, educational implications, gives some management strategies and provides a list of references for further reading.

Product sites:

www.cogcon.com
Cognitive Concepts' Earobics remediation software.

http://www.scilearn.com/
Fast ForWord therapy products for auditory training.

http://www.Iindamoodbell.com/learningcenters/
Lindamood Bell therapy products for reading, spelling, phonemic Awareness (e.g., LIPS Program).

http://www.UseVisualStrategies.com/
Books and information on using visual strategies for learning.

http://rmlearning.com/dyslexia.htm
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.

http://www.thinkingpublications.com
Ordering information for "Map it Out' book - graphic organizers and semantic maps for visual leaming.

http://www.donjohnston.com/
Site for Don Johnston catalog including software for monitoring writing through auditory feedback, writing, spelling, composition, grammar.

http://www.learninginfo.com/index.htm
PACE therapy for attention, working memory, visual and auditory processing, and comprehension.

http://www.Iearningbydesigninc.com
Website for Learning by Design, Inc. offering educational software, especially spelling (SPELL).

http://www.linguisystems.com
Website for LinguiSystems, Inc., offering educational and speech-language materials.

http://www.PsychCorp.com
Website for The Psychological Corporation, offering psychoeducational, speech-language, auditory processing, and related assessment and therapy tools and materials.

http://www.Iexialearning.com
Website for Lexia Leaming Company with educational strategies for older students

Readings:

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: LinguiSystems, Inc.

Sloan, C. (1995). Treating auditory processing difficulties in children. San Diego, CA: Singular Publishing Group.

Foreest-Pressley (ed). Metacognition, Cognition, & Human Performance, vols 1 & 2, Academic Press.

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 Research Press.

Mooney, J. & Cole, D. Learning Outside the Lines. Fireside Press.

Resources:

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.

 

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