Few people would argue that busy professionals have a hard time communicating effectively not only with each other, but also with patients and their caregivers. That may be the root of the problem in the post-diagnosis world of auditory processing disorders (APD). What do speech-language pathologists need to know? What do parents need to know?
On too many occasions, neither parents nor clinicians are told what the diagnosis means in a child's everyday life or how it affects behavior or success, said Cynthia Richburg, PhD, CCC-A, FAAA, associate professor in the Department of Special Education and Clinical Services at Indiana University of Pennsylvania.
She and colleague Lisa Price, PhD, CCC-SLP, are proponents of an interdisciplinary approach to diagnosis and treatment for APD. They believe that the problem begins with the fact that only one or two professionals make those calls. "This label is placed on the child with the belief that the diagnosis of APD is enough for parents and speech-language pathologists to hit the ground running with therapy and finding solutions to the problem," Dr. Richburg told ADVANCE.
Speech-language pathologists know a lot, but sometimes they don't realize the strategies they were trained to use for treating children with language disorders also are effective for students who have an auditory processing component to their language issues, Dr. Price said. "If a child is having difficulty with phonemic awareness, they need to work on phonemic awareness. If a child is having difficulty with metalinguistic skills, that could be an area to target."
Speech-language pathologists still can use the therapy techniques they use for other problems. "There's nothing new just because the diagnosis is auditory processing disorder," added Dr. Richburg.
"There's no auditory processing magic," said Dr. Price. "It's a matter of looking at the different symptoms a child has and trying to figure out which label is the most accurate given their difficulties. We have seen kids who had a million labels, and they do much better when somebody takes a multidisciplinary look at what is going on."
There are two primary models of categorizations for APD. The Buffalo Model, designed by Jack Katz, PhD, is used most often. Its categories are decoding, tolerance-fading memory, integration and organization.
The Bellis/Ferre Model, developed by Teri Bellis, PhD, CCC-A, FAAA, and Jeanine Ferre, PhD, CCC-A, reshaped and divided these four categories into primary (decoding, integration and prosodic deficits) and secondary (associative and output organization deficits) types of APD, which also has some usefulness.
"But the four categories within the Buffalo Model can help us understand the child's deficits," Dr. Richburg said. Decoding deficits refer to the difficulty children have in processing what they hear accurately and quickly. They have problems keeping up with the flow of communication and running discourse.
"These children have problems processing at a phonemic level," she explained. "They can't put 'sh,' 'u' and 't' together to make the word 'shut.' They have poor phonic abilities and trouble reading and spelling."
These children also may have receptive language problems and impairments in discrimination, closure abilities and temporal resolution. "That's my problem with these categories," she said. "A lot falls under this one decoding deficit classification."
Children with tolerance-fading memory deficits have difficulty blocking out background noise. Their performance suffers in a noisy classroom environment, leading teachers to label them as distractible. They have poor reading comprehension, oral and written expression, and short-term memory, which prevents them from filling in the information they might have missed.
Integration deficits make it difficult for children to bring in information from different modalities, such as receiving auditory and visual information at the same time. These children often are labeled as learning disabled or even dyslexic. They may be poor readers, have trouble with spelling, and exhibit difficulty with multimodal tasks. "If they see and hear something, it's as if one is cancelling out the other," Dr. Richburg said. "It creates confusion." They may have word-finding problems and trouble with oral and written language expression as well.
Children with organization deficits often have a disheveled appearance, disorganized thoughts and messy handwriting. They turn in sloppy work and fatigue easily because of the constant energy they must exert in trying to organize their thoughts.
"The literature says they frustrate easily and try to take shortcuts because that seems easier for them," said Dr. Richburg. "They are trying to reduce all the strain and fatigue they have when trying to listen to their environment."
A third model has been proposed by Frank Musiek, PhD, CCC-A, director of Auditory Research at the University of Connecticut, and others. It eschews the idea of categories altogether and instead considers a child's specific neurophysiological symptoms when planning treatment. Drs. Richburg and Price rely on this model in their multidisciplinary assessments. After identifying a child's deficits, they design treatment to address each one.
Modifying the environment is one way to manage APD at school and in the home. A TV that is too loud, a dog barking in the backyard, or siblings playing nearby can prevent children with APD from completing their homework.
Parents must be more intentional about stopping what they are doing and getting the attention of their child with APD, Dr. Richburg said. "They can't try to give direction to the child while wiping the face of a younger sibling. They have to look directly at the child when giving directions." Asking children with APD to repeat directions back to them helps to make sure they understand.
"A lot of the things that you would instruct the parent of a hearing-impaired child to do, you could instruct the parent of a child with APD to do because the symptoms are very much like a peripheral-type hearing loss," she stated. "In fact, parents often say, 'I just don't think he's hearing me.'"
While this approach can be difficult to implement in a family's daily routine, parents will find that the extra effort is worthwhile when they see that their child can be much more successful. Many parents simply don't realize how much they are expecting the child to do. Once parents understand the need to slow down their speech, speak more clearly and directly to the child, and eliminate other distractions, they can work on developing the skills their child needs.
Some children benefit from visual stimuli. For example, Dr. Price helps children convert auditory information into a picture so they can retain and understand it better. The Visualizing and Verbalizing for Language Comprehension and Thinking® program from Lindamood-Bell, in Bryn Mawr, PA, can be helpful in such situations.
"We can also eliminate some of the auditory directions that we give by providing visual supports, such as a visual schedule," she said. "You replace the auditory with a visual. All you have to do is go over to the visual and ask, 'What do you need to be doing?' They convert the pictures into 'I'm supposed to be getting dressed, brushing my teeth, or getting breakfast.'"
The environment can be modified so children with APD will be more successful, Dr. Price said. "Then when we are working on the auditory modality, we can stress those skills and not fatigue them."
Auditory fatigue is a big obstacle, she said. "Many of the kids I've worked with are spent when they get home. They are not able to follow auditory direction at that point, and they shouldn't be expected to without support. Yet, parents have to get through the rest of the day. They need some strategies to use at home."
Some parents may worry that they do not give their children enough time to master auditory skills when they rely on visual stimuli. Clinicians should reassure them that it is not about whether the child "gets away" with not having to learn auditory skills, it's about making the child more successful in life.
"Bypassing auditory can be very helpful at times and very important for these kids for success," Dr. Price said. "In the meantime we help the child develop better auditory skills through therapy."
Speech-language pathologists should not jump to the conclusion that a child who misbehaves or doesn't listen has APD. "Does the child really have a problem, or is he just being himself at 8 years old?" cautioned Dr. Richburg. "Prove that it's an auditory processing problem. Get several professionals to agree on a diagnosis, and address the problem by focusing on the deficit, not the label."
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Jason Mosheim is a Senior Associate Editor for ADVANCE. He can be contacted at firstname.lastname@example.org.