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Central
Auditory Processing Disorder:
How CAPD is Helped by Auditory Integration
Training: A Technical
Explanation
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Complete
On-line AIT Checklist
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:
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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