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Central Auditory Processing Disorder: How CAPD is Helped by Auditory Integration Training: A Technical Explanation

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by Rosalie Seymour, SLP/A, Berard AIT Practitioner

The subject of auditory processing is still a controversial one, with most professional service providers and diagnosticians being uninformed on the matter. Speech therapists and audiologists have gained the use of more sophisticated assessment tools, but are for the most part uneasy about involvement with this problem for a variety of reasons. Some feel we are "Saying more than we know". Others dispute the value of "giving the ill we cannot cure a name".

However, the demand for services is on the increase, and Berard Auditory Integration Training practitioners are becoming more aware that their intervention could have a significant impact in this area, as the focus of our attention turns to embrace more than solely hyperacusis and peaks in the listening test.

Berard Auditory Integration Training is essentially a listening-skills boosting system, that tones up or exercises the ear’s response to the sound signal, seeming to act upon the whole listening pathway.

Definition of Central Auditory Processing Disorder CAPD

Jack Katz defines Auditory Processing as “What we do with what we hear”. Once the ear has heard a sound (audition), before it can be understood (conceptualization), the input must be:

  • located (localization)

  • attended to (auditory awareness and vigilance)

  • differentiated (including background/ foreground separation)

  • integrated

  • coordinated with other sensory input
    and then

  • stored in such a way that it can be...

  • retrieved

“An Auditory Processing problem (APD) is present when a person is not able to make full use of the heard signal” (AJ Katz). This in-ability can lead to scholastic underachievement, and is likely to have personal and social impacts as well.

APD may be present in a mild form, or in a severe form. In its milder form, one may notice only occasional difficulty with listening skills. In its more severe form, one may see profound handicap, learning problems, even receptive language disorders.

APD may be present together with a hearing loss, and also without the presence of a hearing loss. Any other condition may co-exist with APD, e.g. mental retardation, cerebral palsy, Downs syndrome, and so on. APD has been associated with learning disabilities since 1932 (Monroe). Orton (1964) and Sawyer (1981), Bannantyne (1969) Tomatis (1954), Tallal (1976), and Kraus are among the many who investigated this link.

When children show signs of CAPD, they may also demonstrate other characteristics:

  • visual processing deficits

  • motor problems

  • balance

  • and other deficits of sensory modulation or attention.

CAPD children and adults have problems with:

  • listening

  • attending

  • following directions

  • processing speed

  • localizing a sound source

  • listening against a noisy background
    (refer to the Auditory Problems Checklist )

  • In addition, these children have often come to the notice of school staff in a negative way - being at the centre of disturbances, for inappropriate and rude behavior, for disobedience.

  • All these behaviors can be the direct result of APD, and proper identification and information can remove the stigma as staff, parents and the child better understand the problem.

The incidence of conductive hearing loss is high in pre-school and primary-school-age children, due to the prevalence of otitis media in this population. This condition (O-M) is now known not to be the benign condition it was once believed to be. Whether the condition is inflammatory, infectious, or whether there is simply an a-symptomatic effusion, the conductive hearing loss associated with this condition has, in many cases, a lasting effect on the CNS (Central Nervous System) organization of AP. The term Central APD (CAPD) is often used to emphasize that the disorder is in the brain’s ability to “work with” sound , and not in the ear’s ability to receive sound.

Children with a fluctuating hearing loss (as a result of recurrent ear-infections ) are considered to be at-risk for language, speech and learning problems. A threshold shift of 15 dB is significant as a handicapping loss for a young child, even if it is a unilateral loss. (A. J. Katz). Drs Northern and Downs (1991) state that this effect is especially severe if the fluctuating hearing loss occurred in the first year and a half of life!

Identifying Central Auditory Processing Disorder (CAPD)

The aim of attempting to identify APD is to find out to what extent it handicaps or restricts the person (AJ Katz). Many specialists will have to collaborate to determine the presence of a CAPD, since it is a medical diagnosis. However, while investigations are being conducted, parents and educators are advised to treat the person as if a CAPD was indeed present, until testing proves otherwise. The audiologist may be one of the first professionals called in to assess the difficulty. The pure-tone threshold assessment is the standard beginning, and in audiological procedures, other assessments may follow , e.g.:

  • The bone conduction evaluation.
    This is especially important when a hearing loss is evident word discrimination and speech reception threshold, immittance audiometry, acoustic impedance, & reflex thresholds.

  • the Staggered Spondaic Words test (SSW)

  • Competing Sentences Test (CST)
    These yield valuable insights into the significance of the APD in the individual’s functioning.

  • Of these tests, Dr Katz illustrates that the results of the SSW and CST are the most reliable.

Physiological measures can yield valuable information regarding CAPD, and is especially useful to convince sceptics.

  • Auditory Brainstem Response (ABR), Middle Latency Response (MLR), and Long Latency Response (LLR) testing tell us about the area between the VIII cranial nerve end and the temporal (auditory) cortex. MLR and LLR especially give information about the central processing areas of the brain. The ABR gives brainstem-information, chiefly.

  • In 1990, Jirsa and Clontz studied LLR, and found longer latencies in the experimental group for N1 and P2, and P3. There was also considerable LLR variability for this group.

These assessments may yield interesting results for research purposes. They are not commonly available to clients, however, and the cost involved, and the invasiveness of some of these procedures make them inappropriate for routine evaluations.

Since the aim of the evaluation is, as previously stated , to determine the implications of the CAPD on the child’s life experiences, and to point the way towards intervention,- a strong argument may be made for the use of less invasive and less expensive assessment tools.

The “battery” that fits this requirement, would seem to consist of:

  • An Auditory Problems Checklist

  • The Berard Listening Tests (all three)

  • A case history

  • In 1976 Fischer published the Auditory Problems Checklist that is useful to identify potential CAPD’s.

  • Willeford and Burleigh’s scale (the Willeford and Burleigh Behavior Rating Scale for Central Auditory Disorders), and Smoski et al published the CHAPPS.

  • These are useful to school personnel as well.

Similar to these, the IELP New Format Auditory Problems Checklist yields valuable behavioral indicators, especially if completed by the teacher and the parents.

Dr. Berard’s Hearing Assessments Included:

  • the listening test, using pure tones

  • the test for laterality

  • the test of selectivity.

  • The above tools, with the case history, yield a valuable profile of the impact of the child’s CAPD on his life and learning.

  • On occasion, there may be a need to ensure that more thorough testing is done, since the presence of a CAPD could be masked by factors e.g. emotional, intellectual, and inaccurate reporting by both parents and teachers, as well as the presence of a hearing loss.

  • In these cases, referral to an audiologist is advised; if possible, one who is familiar with Auditory Integration Training and comfortable with assisting the practitioner.

The speech therapist may also perform a collection of assessments, covering areas of:

  • speech sound discrimination

  • memory for digits

  • memory for words, or syllables

  • memory for sentences

  • memory for story

  • symbol-to-sound association

  • auditory analysis and synthesis

  • sound blending

  • auditory closure

  • vocabulary comprehension

  • linguistic competence (reception, and use)

  • word-finding ability

  • Where these tests are performed on a yearly basis, as they sometimes are, the results can provide useful material as a record of progress after Auditory Integration Training.

Classroom Management Before the advent of Auditory Integration Training as an intervention option, management was best done by:

  • Changing and managing environmental factors to provide the easiest listening environment during the school day by reducing background noise and enhancing the foreground speech.

  • Teaching the skills and strategies to deal with the listening task.

Unfortunately these measures do not address the difficulty, but do offer support.

Mechanical Aids for Central Auditory Processing Disorder (CAPD

Besides these traditional approaches to management of CAPD, there have been various mechanical devices to assisting these children in classroom situations. These are known as Assistive Listening Devices, usually minimal gain FM systems. The most well-known is the Phonic Ear ©.

This device acts as a sound-boosting system, making the teacher’s voice louder for the child, i.e. improving the signal-to-sound ratio. It is found to be quite helpful, but only in the classroom situation, since when in play, or at sports, or at home, this system cannot be used, and the child still suffers the effects of his APD.

Auditory Integration Training in Central Auditory Processing Disorder (CAPD)

Berard Auditory Integration Training is essentially a listening-skills boosting system, that tones up or exercises the ear’s response to the sound signal, seeming to act upon the whole listening pathway.

Reports from parents, clients, and research studies have demonstrated

  • the impact of Auditory Integration Training on the symptoms of CAPD, seeming to indicate that for many who undergo the Auditory Integration Training training,

  • the impact of the CAPD on their lives and learning is lessened.

  • Some report dramatic improvements, others report minimal improvements.

  • Interestingly, none report worsening of their CAPD.

  • This would seem to indicate that Auditory Integration Training may indeed be, as many have commented: “A risk worth taking".

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