Treatment of (Central) Auditory Processing Disorder: Bridging the Gap Between the Audiologist and the Speech-Language Pathologist There is a history of debate and controversy about the assessment and intervention of children diagnosed with auditory processing disorder (APD). Professionals in communication sciences and disorders view APD from different perspectives. Speech-language pathologists (SLPs) tend to view APD from the language and literacy perspective, or a top-down model, whereas ... Article
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Article  |   October 01, 2012
Treatment of (Central) Auditory Processing Disorder: Bridging the Gap Between the Audiologist and the Speech-Language Pathologist
Author Affiliations & Notes
  • Velvet Buehler
    University of Tennessee Health Science Center, Knoxville, TN
  • Disclosure: Velvet Buehler has no financial or nonfinancial relationships related to the content of this article.
    Disclosure: Velvet Buehler has no financial or nonfinancial relationships related to the content of this article.×
  • Velvet Buehler is a Clinical Professor in the Department of Audiology and Speech Pathology with the University of Tennessee Health Science Center (UTHSC). She holds dual certification in Audiology and Speech-Language Pathology. Ms. Buehler has provided aural-habilitation services to children who are deaf or hard of hearing and their families for 25 years in the UTHSC Child Hearing Services Program. She has supervised practicum for graduate students in Audiology and Speech-Language Pathology in the areas of aural-habilitation, literacy, parent counseling and education, pediatric audiology, and auditory processing. Ms. Buehler teaches the Aural Rehabilitation Course, Clinical Education Seminars, and lectures in classes on the above topics. She serves on two cochlear implant teams providing pre- and postcochlear implant evaluations and treatment. Ms. Buehler provides in-services and consultations to professionals. She has presented at numerous regional and national conferences. Ms. Buehler is a certified trainer for the National Educators of Children with Cochlear Implants. Ms. Buehler is an ASHA steering committee member for Special Interest Group 9: Hearing and Hearing Disorders in Childhood.
    Velvet Buehler is a Clinical Professor in the Department of Audiology and Speech Pathology with the University of Tennessee Health Science Center (UTHSC). She holds dual certification in Audiology and Speech-Language Pathology. Ms. Buehler has provided aural-habilitation services to children who are deaf or hard of hearing and their families for 25 years in the UTHSC Child Hearing Services Program. She has supervised practicum for graduate students in Audiology and Speech-Language Pathology in the areas of aural-habilitation, literacy, parent counseling and education, pediatric audiology, and auditory processing. Ms. Buehler teaches the Aural Rehabilitation Course, Clinical Education Seminars, and lectures in classes on the above topics. She serves on two cochlear implant teams providing pre- and postcochlear implant evaluations and treatment. Ms. Buehler provides in-services and consultations to professionals. She has presented at numerous regional and national conferences. Ms. Buehler is a certified trainer for the National Educators of Children with Cochlear Implants. Ms. Buehler is an ASHA steering committee member for Special Interest Group 9: Hearing and Hearing Disorders in Childhood.×
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Hearing Disorders / Language Disorders / Social Communication & Pragmatics Disorders / Attention, Memory & Executive Functions / Articles
Article   |   October 01, 2012
Treatment of (Central) Auditory Processing Disorder: Bridging the Gap Between the Audiologist and the Speech-Language Pathologist
SIG 9 Perspectives on Hearing and Hearing Disorders in Childhood, October 2012, Vol. 22, 46-56. doi:10.1044/hhdc22.2.46
SIG 9 Perspectives on Hearing and Hearing Disorders in Childhood, October 2012, Vol. 22, 46-56. doi:10.1044/hhdc22.2.46

There is a history of debate and controversy about the assessment and intervention of children diagnosed with auditory processing disorder (APD). Professionals in communication sciences and disorders view APD from different perspectives. Speech-language pathologists (SLPs) tend to view APD from the language and literacy perspective, or a top-down model, whereas audiologists tend to view APD from an auditory perception perspective, or a bottom-up model. Professionals who assess and treat children with APD need to bridge the gap and merge their different perspectives to plan effective intervention for children with APD. A panel of audiologists who demonstrated expertise in the area of Central Auditory Processing Disorders (CAPDs) developed The American Speech-Language-Hearing Association's (ASHA's) technical report on APDs (ASHA, 2005). This report was approved by ASHA's Executive board in 2005. In this report, central auditory processing refers to the efficiency and effectiveness by which the central nervous system uses auditory information. Central auditory processing includes the auditory mechanisms underlying the skills of sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals (ASHA, 1996; Bellis, 2003; Chermak & Musiek, 1997; Jerger, 2009). A CAPD is a deficit in processing auditory input that is not due to higher-order language, cognitive, or related factors (Musiek, Bellis, & Chermak, 2005; Musiek & Chermak, 2007). However, children diagnosed with CAPD may experience difficulties in academic learning, speech, language, social skills, and literacy (e.g., encoding, decoding, reading comprehension, reading fluency, and written language).

Fey and colleagues (2011) conduced an evidence-based systematic review of Central Auditory Processing Disorders (CAPDs) and auditory/language interventions. They evaluated the peer-reviewed literature on the efficacy of interventions for school-age children with CAPDs. The researchers' overall conclusions indicated some support that auditory and language interventions improve auditory functioning in children with CAPD, and the effects on spoken and written language functions were limited based on current research. One might assume that improving a child's ability to perceive and process speech may lead to improvements in language and literacy skills. More research is warranted to provide clear guidance to speech-language pathologists (SLPs) treating children with CAPDs. Clinicians may choose to use auditory interventions in combination with assessments of language and literacy skills in order to plan effective management for children with CAPDs.
Research shows that traditional listening treatments are favorable for improving a variety of auditory processing skills (Fey et al., 2011). One traditional listening treatment included the skills of auditory memory with immediate and delayed recall of words, sentences, and paragraphs; auditory discrimination of phonemes, words, and phrases; auditory closure to predict information using contextual cues; auditory synthesis with phonological segmentation and blending; multimodal integration combining auditory with other modalities; and auditory figure-ground with following directions in the presence of background noise (Miller, 2011; Miller et al., 2005). In another study, English, Martonik, and Moir (2003) found a positive improvement from dichotic listening treatment. Putter-Katz and colleagues (2002) reported a significant increase in speech recognition in degraded and dichotic listening conditions following comprehension in noise and dichotic listening training. Jirsa (1992) also reported that intensive listening and auditory memory with competing noise intervention demonstrated improvements. Based on these reported outcomes, traditional listening therapy to address deficient auditory skills identified by the audiologist can be effective. The articles I have reported did not look at outcomes for language, only the bottom-up processes. The goals of intervention for these bottom-up processes identified by the audiologist can be combined with goals for the language and literacy deficits identified by the SLP to plan an effective intervention for children with CAPDs. If SLPs can measure a change in behaviors as a result of intervention and audiologists can measure change on the auditory test battery, they also should consider this level of evidence regarding the effectiveness of treatment for children with CAPD.
Because of the complexity and heterogeneity of CAPD, the American Speech-Language-Hearing Association (ASHA) recommends a team approach to assessment and intervention (ASHA, 2005). SLPs, audiologists, psychologists, educators, and other professionals should collaborate in the assessment and management of CAPD. In a team approach, the SLP assesses and provides treatment related to language and literacy in addition to treating the deficient auditory components identified by the audiologists. Additionally, the SLP can target objectives to treat the deficient auditory components that are identified by the audiologist. Merging the bottom-up and top-down models through team assessment and treatment may be the most effective way to address the needs of children diagnosed with CAPD.
As audiologists continue to assess and diagnose CAPD, it is typically the role of the SLP to provide additional assessments and to implement treatment. The SLP who is engaged in this team approach must have expertise in the disorder and its related consequences. ASHA's Code of Ethics specifies that “individuals may practice only in areas in which they are competent based on their education, training, and experience” (ASHA, 2010, p. 2). Clinicians may need to pursue additional education to engage in CAPD intervention and management. SLPs may be required to interpret the audiologists' APD assessment report if the report does not include pertinent case history information, specific scores on assessments, and the sub-profile of APD along with deficient auditory processes. Some CAPD reports contain pertinent case history information, specific scores on assessments, the auditory processes that are deficient, and the type or sub-profile of APD that is exhibited. However, many audiological reports do not include this valuable information to plan effective intervention.
In this article, I will attempt to bridge the gap between the audiologist's expertise and the SLP's ability to interpret the audiological CAPD report in order to plan effective and efficient intervention.
First, the SLP must understand the types of CAPD tests that the audiologist uses. The selection of tests should be individualized and based on the referring complaints; therefore, not all types may be included in every central auditory evaluation (Bellis, 2011). The audiologist can assess a variety of auditory processes within the Central Auditory Nervous System (CANS) using a number of measures (ASHA, 2005).
Auditory discrimination tests assess how acoustic stimuli differ in frequency, intensity, and duration as well as phoneme discrimination. Tests may include the Phonemic Synthesis test; phoneme discrimination; difference limens for frequency, intensity, and duration; and psychophysical tuning curves.
Auditory temporal processing and patterning tests analyze acoustic events over time. Tests include pitch pattern, duration pattern, and gap detection. The ability to label sequences of pitches as high or low, or to label sequences of durations as long or short requires the process of interhemispheric transfer.
Dichotic speech tests assess the ability to understand two different competing signals presented simultaneously (binaural integration), and to assess the ability to separate and selectively attend to one message while ignoring another message presented simultaneously (binaural separation). These tests include the staggered spondaic word test, dichotic digits, dichotic CVs, and competing sentences.
Monaural low-redundancy speech tests measure recognition of signals that are degraded at each ear. Tests include low- or high-pass filtered speech, time-compressed speech, and speech-in-noise tests. These tests assess the auditory processes of auditory closure (filling in the missing auditory information) and auditory-figure ground (listening with competing signals or noise).
Binaural interaction tests evaluate binaural processes that depend on acoustic intensity or time differences. Tests include masking level difference, localization, lateralization, and binaural fusion. These tests assess the auditory process of binaural fusion (how the two ears work together to transmit the acoustic signal higher through the CANS).
Electroacoustic measures assess acoustic signals from within the ear that are generated spontaneously or in response to acoustic stimuli. Tests include otoacoustic emissions (OAE), acoustic reflex thresholds, and acoustic reflex decay (Jerger & Musiek, 2000).
Elecytrophysiologic measures analyze electrical potentials generated by the central nervous system in response to acoustic events. Tests include auditory brainstem response (ABR), middle latency response, cortical event-related potentials (e.g., P300), and the mismatch negativity response (Jerger & Musiek, 2000).
The next step for the SLP is to identify which auditory processes are deficient according to the audiologist and provide process-based intervention. The processes that may be impaired are auditory closure, auditory-figure-ground, binaural separation, binaural integration, auditory synthesis, inter-hemispheric transfer/temporal patterning, and binaural fusion (Bellis, 2011). Some audiologists also may identify deficits in auditory synthesis, segmentation, auditory memory, sequencing, phonetic discrimination, decoding, and manipulation of sounds. This deficit-specific approach to CAPD remediation is based on treating the cause of the problem through auditory training and addressing the symptoms of the disorder through identified language, reading, and written language intervention; along with environmental modifications and compensatory strategies.
If a patient's auditory closure skills are deficient, as evidenced by poor monaural low redundancy speech tests such as low-pass filtered speech, then the SLP should target auditory closure by providing activities that require filling in a missing word, syllable, or phoneme. The SLP should write goals in a hierarchy starting with the simplest (final word of rhyming statement omitted) and progressing to harder tasks. The hierarchy would continue with omitting the final word of a sentence or phrase, omitting the final word of a spondee or compound word, omitting the medial word of a sentence or phrase, and omitting the initial word of a sentence or phrase, the most difficult task. SLPs should begin the intervention using missing word exercises and progress to words with missing syllables, and, finally, to words with missing phonemes (Bellis, 2003). The intent of auditory closure exercises is to improve the child's ability to fill in the missing auditory parts in order to understand the meaning as a whole. Context clues are important for this skill; therefore, it may be important for SLPs to include activities that facilitate understanding and prediction based on context. SLPs can write goals to improve the child's ability to learn the meaning of new vocabulary through contextual derivation and to use the context clues to predict the meaning of the unfamiliar vocabulary word (Chermak & Musiek, 2007). SLPs can include this goal to teach deduction, and patients can complete definitions in their own words using word maps and writing sentences with the new word. It may also be beneficial to teach formal and content schema induction. Formal schema induction involves training to recognize and interpret discourse cohesion devices to make predictions. This may involve teaching tag words such as first, last, before, and after; adversative terms such as but, although, and however; referents such as pronouns; additives such as also; and causal terms such as because and therefore. Content schema induction involves teaching how scripts based on context and experience assist in interpreting the message. For example, if you enter a restaurant, you may anticipate the hostess to ask, How many?, or Do you have a reservation? as opposed to Where do you live? (Chermak & Musiek, 2007). Another activity involving reducing the redundancy of the auditory signal would include repeating the auditory closure exercises, following directions, and answering questions about auditory passages presented in the presence of noise or competition (Ferre, 2006).
An additional auditory process that may be deficient is binaural integration, or the ability to integrate and perceive two different auditory signals presented simultaneously. This process involves dichotic listening. The auditory process of binaural separation also may be identified during dichotic listening. Binaural separation is the ability to separate or selectively attend to one auditory message while ignoring a competing message presented at the other ear. This is related to selective listening and listening in noise. A real world example would be attending to the teacher while ignoring other auditory messages in the environment. The Differential Processing Training Program by Kerry Winget (LinguaSystems, 2007) includes acoustic tasks on a CD to target dichotic listening. Dichotic listening training involves the use of an interesting passage presented to one ear while a competing signal is presented to the other ear. The task is to set and manipulate the target-to-competition ratio as the child describes what happened in the target story. Localization training and games such a Blind Man's Bluff and Marco Polo may also be beneficial (Bellis, 2011).
Deficits in auditory discrimination and temporal processing also may be evident. These children have difficulty processing rapidly changing acoustic stimuli, to discriminate between nonspeech sounds that differ in duration, frequency, or intensity, and to discriminate between phonemes in isolation and at the word level. These skills are important for temporal patterning and auditory closure. Activities to improve this deficit area include nonspeech discrimination activities such as asking the child to report whether two tones are the same or different when they vary in duration, frequency or intensity. As skills improve, the differences in duration, frequency and intensity can be decreased. Also, children can be asked to discriminate between tone glides that rise or fall in frequency or intensity. Research is still needed to demonstrate the validity of these tasks; however, it appears logical that the ability to perceive time-based intensity, duration, and frequency contrasts may be related to contrasts between phonemes and may lead to improved phonological awareness abilities (Chermak & Musiek, 1997). Because these tasks are difficult to implement under controlled acoustic conditions, clinicians may emphasize phoneme discrimination tasks and speech-to-print skills. Sloan (1995) developed a program for phoneme training that stressed the importance of consonant discrimination of minimal contrast phoneme pairs. Clinicians present phonemes in isolation, followed by consonant-vowel (CV) and vowel consonant (VC) contrast pairs, and then words of increasing complexity. Clinicians also may need to implement vowel training. The Processing Power program (Ferre, 1997) targets phoneme discrimination training in addition to other auditory skills such as rhyming, word associations, speech-in-noise, and speech reading. Phonological awareness activities such as rhyming, blending sounds into words or syllables, segmenting words and syllables into individual sounds, identifying individual phonemes,, manipulating syllables and phonemes, and deleting phonemes and syllables to form new words also may be beneficial. Speech-to-print skills involve making the connection between phoneme segments and their corresponding printed letter symbols. This is addressed in Sloan's program (Sloan, 1995) and any program that highlights sound-symbol association.
If a clinician identifies temporal patterning deficits such as frequency and/or duration patterns in the labeling and/or the humming conditions of the pitch or duration pattern tests, remediation may be necessary. The clinician may begin treatment by targeting identification of same-versus-different patterns of knocks without visual cues. Treatment can proceed to verbal tasks like the imitation of various rhythms, durations, and pitches with an increasing number of elements and then labeling of various durations and pitches as long/short or high/low in increasing number of elements. The Central Auditory Processing Kit (LinguaSystems, 1999) contains many suggestions for targeting temporal patterning.
Clinicians also can provide prosody training (Bellis, 2011). This includes the recognition of words that change in syllabic stress to alter their meaning (i.e., homographs) and the recognition of sentences in which a change in stress can alter the meaning with exaggerated prosodic features progressing to normal intonation. An example would be targeting discriminating that PRO-gress and pro-GRESS are different, as well as matching the correct stress with the appropriate definition. Audiologists can use sentences such as “YOU can't go with us”, and you can't go with US” to target discriminating they are different and have different meanings dependent upon the stress. Asking the child to read aloud or practice repeated reading with exaggerated prosodic features may be beneficial. Activities targeting key word extraction and recognizing sarcasm and the emotional content of the message also may be warranted. These activities are included in the Central Auditory Processing Kit (LinguaSystems, 1999).
If a child exhibits a pattern of a significant left ear deficit on dichotic speech tasks in addition to difficulty labeling pitches and durations on the pitch pattern or duration pattern tests, audiologists may indicate intervention providing interhemispheric exercises (Bellis, 2011). A left ear deficit is expected on dichotic tests for children who are 8 or 9. This is because longer and more complex central auditory pathways carry the message from the left ear to the right hemisphere and then cross the corpus callosum to the left hemisphere where language is processed. Children diagnosed with APD may evidence a left ear deficit that is more than expected when compared to same aged peers. If there is evidence of corpus callosum dysfunction, there are many tasks that can be completed outside of therapy as well as within therapy settings. The clinician can use verbal-to-motor or motor-to-verbal tasks. For example, the child will touch items out-of-sight in a bag or box and thoroughly describe them. The items should be felt with the left hand (motor-verbal transfer). In addition, based on a given description, the child will find objects with the left hand (verbal-motor transfers). Another example would be to draw an object verbally described to the child (verbal-motor transfer), or ask the child to describe as he/she draws the picture (motor-verbal transfers). These activities use skills predominant in both the left and right hemisphere; therefore, communication via the corpus callosum is necessary to complete each task (Bellis, 2011). Dance lessons may also be recommended; especially a dance such as tap, which requires listening to the step and then completing it (verbal-motor transfers) such as “shuffle, shuffle, ball change.” Dance lessons also require bipedal coordination. Extracurricular sports and karate also are beneficial, they require bipedal and bimanual coordination. Music lessons also facilitate interhemispheric transfer. Piano lessons require bimanual coordination and reading treble and bass clefs simultaneously. Singing requires both linguistic output and melodic expression that facilitates coordination of information between the right and the left hemisphere via the corpus callosum. Listening to lyrics and answering questions about the lyrics also requires coordination of both the left and the right hemisphere. Video games, which require visual and auditory vigilance and bimanual coordination, may be recommended.
Audiologists may provide information related to auditory memory and literacy skills (including phonemic and phonological awareness); however, these assessments typically are completed by the SLP either before or after the CAPD evaluation (Miller, 2011). The treatment provided to address literacy deficits is not within the scope of this paper. Children diagnosed with CAPD often struggle with various aspects of literacy; therefore, clinicians should develop goals following a comprehensive literacy assessment (Wallach, 2008).
Audiologists may introduce activities in treatment to improve auditory memory by following directions that increase in length and complexity or repeating sentences, lists of numbers, or related and unrelated words in quiet. To improve working memory, clinicians can ask the child to repeat words or numbers in a reverse order or to identify the first sound in each word of a sentence, and then blend those sounds together to make a word. An example would be “Rabbits act shy” = rash. If auditory figure ground or listening in noise is deficient, audiologists can complete the above auditory memory activities in the presence of varying intensities of background noise. The competing message may be environmental sounds, white noise, speech babble, music, or a competing story read aloud on tape. This is called speech-in-noise training (Bellis, 2011).
The next step for the SLP is to consider the case history information. If the case history information in the CAPD report does not address some of these characteristics, the SLP may need to obtain additional case history information related to birth history; speech/language and social communication development; attention issues; academic history (especially in the areas of decoding, encoding, reading comprehension, written language, and math); family history of learning problems; current academic performance; vocabulary development; hobbies; and any other special services or evaluations the child has received. Information provided by the classroom teachers is also beneficial.
The SLP also must think about the specific type or subprofile of CAPD that the audiologist has diagnosed and provide a type-specific intervention. If the audiologist has not identified a specific type, there are some characteristics and audiological test findings to consider. The specific subprofiles are outlined by Ferre (1997) and Bellis (2011).
The most purely auditory profile of CAPD is an auditory decoding deficit originating in the left auditory cortex. Audiologists can use a number of CAPD test results to indicate this profile such as bilateral or right ear deficit on dichotic tests, deficits on phonemic synthesis, bilateral deficits on monaural low redundancy speech task, poor auditory discrimination, and poor temporal resolution. Children with this profile do not spell words the way they sound. Cognitive testing may reveal poorer verbal than visual-spatial skills and deficits on memory subtests for unrelated items with an improvement on memory for sentences as a result of the availability of context cues. Characteristics may include academic difficulties with spelling, phonics, phonological and phonemic awareness, reading decoding (especially with nonsense words), note-taking, and following directions. These children may have weak vocabulary and syntax. When there is reduced extrinsic redundancy such as unfamiliar vocabulary, insufficient context and visual cues, and excessive noise and reverberation, these children tend to understand less. These children experience auditory fatigue and their listening deteriorates over an extended period of time. They appear to mishear similar-sounding words and have poor auditory discrimination. They frequently say, “I did not hear you” or “Huh?” The auditory decoding deficit can be managed by using an assistive listening device, assigning preferential seating, using visual augmentation, offering note-taking assistance, minimizing auditory overload, and teaching the student self-advocacy and listening strategies such as “look and listen” and asking for repetition and rephrasing with a more acoustically salient response. Treatment should address auditory closure, formal and content schema, and contextual derivation of vocabulary meaning. Treatment also should focus on phonological/phonemic training and auditory discrimination tasks. Visualizing and Verbalizing® Curriculum along with Lindamood Phoneme Sequencing (LIPS®) from Lindamood-Bell may be beneficial to use in treatment, along with various phonological awareness curriculums. The Sloan program (Sloan, 1995) and the Processing Power program (Ferre, 1977) also may be helpful for auditory discrimination, listening-in-noise, and speech-to-print skills. SLPs should provide speech-in-noise training to include improved auditory memory for words and sentences as well as following directions of increasing length and complexity. They should also teach auditory memory compensatory strategies. The HELP for auditory memory and the CAPD Kit by LinguiSystems are good resources.
Another primary CAPD Profile described by Bellis (2011) and Ferre (1997) is a prosodic deficit, which originates in the right hemisphere and leads to a deficiency in the ability to use the prosodic features of speech. Audiological findings include a significant left ear deficit on dichotic speech tasks along with difficulties on labeling and humming conditions on temporal patterning. Cognitive testing results indicate performance abilities lower than verbal abilities and difficulty with visual-spatial abilities, math calculation, and part-to-whole processing. These children appear to hear adequately, but they have difficulty with understanding what they hear. They may exhibit pragmatic language problems such as difficulty interpreting nonverbal cues, gestures, and expressions; difficultly with sarcasm and humor; and weak social language skills. Their speech may be monotone, especially in oral reading. Typically, they have poor musical abilities. These children may have good decoding skills, but difficulty with sight words. They may have characteristics of attention deficit. Often, these children are described as bright, but not meeting their true potential. They may be highly verbal, especially with adults. They have a history of sensory integration deficits and tactile defensiveness. Clinicians can manage prosodic deficit through prosody training, key word extraction activities, temporal patterning training, fluency and automaticity training during reading aloud, and language intervention focusing on pragmatics and social language skills. Because gestalt patterning abilities are compromised, it may be beneficial to teach the imagery of letters and spelling rules to increase sight word reading and spelling. At school, these children will benefit from placement with an animated teacher who uses a lot of visual support and demonstrations during class activities. Dance and music lessons also may be beneficial.
Bellis (2011) and Ferre (1997) identified another primary CAPD Profile as integration deficit, which is a deficit in interhemispheric integration across the corpus callosum. Characteristics of this may appear similar to prosodic deficit because difficulties may result from either a right hemisphere or a corpus callosum origin. Audiological test results reveal an excessive left ear deficit on dichotic speech tasks such as the staggered spondaic word, the dichotic digits, or the competing sentences tests. In addition, results will indicate weaknesses on labeling pitches or durations (temporal patterning). Results reveal normal humming abilities but poor labeling abilities on temporal patterning tests. Results may reveal normal low-redundancy speech tests such as low-pass filtered speech, time compressed speech, and listening-in-noise tests. These children, as the word “integration” implies, have difficulty with coordinating multimodal inputs and synthesizing information from different modalities. Clinicians may observe communication deficits such as poor phonological skills related to encoding and decoding; difficulty following directions and processing ongoing conversations; difficulty with auditory memory and sequencing; and syntactic, pragmatic, and semantic receptive language deficits. Academically, these children may have difficulty with both sight word and word attack skills and with reading comprehension and written language skills. These children tend to be poor self-starters and want to “watch and wait” before beginning tasks. They need more time to process information and to complete work because they have difficulty combining visual and auditory input. Teachers may report that these children say “I don't know” or “I don't get it” frequently. To manage these deficits, SLPs can focus on language and literacy deficits identified in comprehensive assessment. Additionally, treatment to improve interhemispheric transfer of information such as extracting key information, verbal-to-motor or motor-to-verbal transfers, and temporal patterning or prosody training may be warranted. Children with integration deficit may benefit from a structured but hands-on environment where multimodal inputs are presented singularly. For example, teaching the child to look OR listen or look THEN listen is more advantageous than teaching them to look AND listen. Providing a peer-note-taker or lecture outlines prior to discussion in class may be beneficial. Preferential seating is warranted to minimize visual and tactile distractions. If sensory issues have not been evaluated, then a referral for a sensory integration evaluation may be warranted. Teaching a child with an integration deficit to request “repetition” versus rephrasing of information is important. Music, dance, gymnastics, and karate lessons may be beneficial.
Bellis (2011) and Ferre (1997) reported two secondary CAPD profiles, associative deficit and output/organization deficit. For patients with associative deficit, audiological assessment would reveal bilateral deficits on dichotic speech tasks with good auditory closure (low-pass filtered speech) and phonemic synthesis skills. Associative deficit characteristics include hearing well, but not understanding the meaning of the auditory message. Communication weaknesses are the hallmark of this type of CAPD, therefore a comprehensive speech-language and literacy evaluation is warranted. These children may have good decoding skills but overall poor reading comprehension. They have difficulty with written language with errors in syntax, punctuation, and composition of paragraphs. Word math problems may be more difficult than calculation math skills. These children may perform well academically in the early years and evidence delays later as the linguistic demands in the classroom increase. To manage associative deficit, clinicians should treat the identified language and literacy deficits with a rule-based and multisensory approach. Activities and programs to enhance auditory memory and comprehension also may be beneficial. These children should be taught to ask for a rephrasing or paraphrasing of the message with smaller linguistic units. Repetition will not be as effective for understanding the auditory message for children with associative deficit.
The last secondary profile Bellis (2011) and Ferre (1997) reported is output organization deficit. Audiological test findings reveal difficulties on any task that requires memory of multiple elements. Sequencing errors also may be evident, along with poor abilities while listening to speech presented in noise. Overall, these children may have difficulty sequencing, planning, and organizing responses. They hear well when the environment is quiet, but they have problems remembering what they hear. They do not understand auditory messages well in noise, therefore, an assistive listening device may be beneficial. Academically, they have difficulty following directions, sequencing, and following through with tasks. They may have good reading comprehension, but poor writing and spelling skills due to the nature of multi-elements in these tasks. Management would be similar to associative deficit with a focus on language and memory. Teaching compensatory strategies such as re-auditorization, chunking, mnemonics, and imagery may be beneficial. Curriculums designed to improve study skills, note-taking, and test-taking skills, along with improved organization may be helpful. These children also may benefit from an occupational therapy evaluation to identify motor planning and execution skills that may need intervention. Teaching this child to ask for repetition with reduced number of elements is important.
It should be noted that Katz (1992) also specified specific types of CAPD related to his recommended CAPD test battery. These may be considered in addition to the Ferre profiles. Katz specifies that the four main types of CAPD are Decoding, Tolerance-Fading Memory, Integration, and Organization. Children with the Decoding type may exhibit deficits in word-finding, prosody, articulation, receptive language (in the area of morphology), and oral and written discourse. They have difficulty with phonics, reading, spelling, following directions, written tests, and following oral directions. Children who exhibit the Tolerance-Fading Memory type may have difficulty with receptive and expressive language (related to elaborated syntax) and deficits in written and oral discourse. These children tend to be distractible, impulsive, and have attention issues along with short-term memory deficits and poor handwriting. The third type is a combination of Decoding and Tolerance Fading Memory called Integration Type. Children with the Organization type may have difficulties with sequencing, organization, and executive functioning (Katz, 1992).
Treatment of APD is individualized. There is no single treatment approach that is appropriate for all children diagnosed with CAPD (Bellis, 2011). Educators and clinicians have developed various curriculums and materials to identify goals and provide activities to improve auditory processing skills, language, and literacy. Some of these include the Central Auditory Processing Kit, Help for Auditory Memory, the Wisnia-Kapp Reading Program, the Lindamood Bell programs (LiPs®, Visualizing and Verbalizing®, and Seeing Stars®), the Phonological Awareness Kits, The Source for Reading Fluency, Processing Power, the SPELLs, and the Christine Sloan Program for Auditory Processing. Wallach (2011) outlined 10 suggestions for SLPs as they make decisions about CAPD assessment and intervention for school-aged children. First, consider that when auditory processing problems exist, SLPs must get to them through language (e.g., Kaderavek, 2011); however, the evidence suggests that auditory processing deficits alone may not be risk factors for speech, language, and academic achievement. SLPs need to understand the language that underlies academic success and the impact of contextual support in spoken and written language. It is also essential to identify metalinguistic aspects of language learning. Intervention should consider the curricular demands placed on students and should improve a student's ability to derive meaning from spoken and written text, as well as assist students with organizing incoming information. It is important to understand the relationship of auditory processing to spoken and written language. Print literacy and written language abilities may facilitate auditory processing through targeting metalinguistic awareness, language, written language, and phonological/phonemic awareness. Because students are asked to process language through the auditory channel, both the auditory and the language components may need to be addressed. Professionals in communication sciences and disorders should acknowledge that the processing of auditory signals encompasses a variety of different skills, both acoustic and linguistic in nature. Therefore, audiologists and SLPs need to collaborate and use each other's expertise for the best outcome for each child. Each discipline is important, a team approach is essential (Richard, 2011).
Audiologists diagnose children with CAPD every day. Intervention can be effective when professionals work as a team to address perspectives of both audiologists and SLPs in the assessment and management of CAPD. This article is an attempt to assist the SLP in navigating through the audiological assessment results to plan intervention for children with CAPD. In addition to the audiologist's assessment, the SLP can incorporate his or her expertise in language and literacy to the management plan following comprehensive assessment. Bridging the gap between the audiologist and the SLP may positively impact the lives of children diagnosed with CAPD.
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We've Changed Our Publication Model...
The 19 individual SIG Perspectives publications have been relaunched as the new, all-in-one Perspectives of the ASHA Special Interest Groups.