Sylvie, a kindergartner, loves to build blocks and to play active games with the other children, but becomes distracted during story-time. She shows no interest in the story, becomes fidgety, and asks to go to the bathroom. Her teacher wonders if she may have attention-deficit/hyperactivity disorder .
Jake, a 2nd grader, doesn’t seem to get class directions accurately. He wants to conform and relies on imitating the actions of the other children rather than listening to the teacher. He often asks "what" or "huh?" His teachers wonder if he may have a hearing impairment.
Arnold, in 4th grade, has difficulty in sequencing the sounds necessary for reading and spelling; he refuses to participate in reading instruction and disrupts the entire class. His teachers wonder if he may have an oppositional defiant disorder .
Lisa, a teenager, avoids sitting with others during lunch because she becomes confused with the quick give-and-take of teen-age conversation, particularly in a noisy environment. Her teachers wonder if she may have a social anxiety disorder .
Each of the children described above had difficulty in taking in information – in noticing, discriminating and listening to auditory cues. Careful evaluation indicated that each had a central auditory processing problem. Central auditory processing problems can seem similar to other problems and careful differentiation is essential.
What is central auditory processing disorder (CAPD)?
CAPD refers to the process of how the ears and brain take in auditory information. Children with CAPD can hear well, but they don’t listen well. Their brains don’t pick up the electrical signals coming from their ears. Children with CAPD have trouble listening, understanding speech, and developing language. Therefore they have difficulty in using auditory information to communicate and to learn. CAPD is a set of problems that occur in different listening tasks — receiving, analyzing, organizing, storing, retrieving and using information based on auditory stimuli. These difficulties may become exacerbated in noisy or unfavorable acoustic environments.
Some warning signs that might lead a parent to think that CAPD may be a factor in a child’s development include:
* Family history of similar difficulties with auditory processing or history of hearing loss
* History of frequent middle ear infections in the preschool years
* Hypersensitivity to loud sounds
* Developmental speech and language delay
* Poor readiness skill development or poor early academic achievement
At the present time, causes of CAPD have not been defined. The suspicion among scientists is that problems may arise from neurochemical abnormalities too subtle to identify.
CAPD – the diagnostic dilemma
CAPD can resemble other disorders and should be differentiated from impairment in hearing, intellectual capacity and ability to sustain attention. Most cases of CAPD develop in the early elementary grades when the curriculum demands require a child to be an active listener and to take in more complex auditory information. Difficulties in this area are common to the children diagnosed with attention deficit disorders , learning disabilities , behavioral problems or emotional disorders.
How are characteristics of CAPD observed in the classroom?
Children with CAPD may have difficulty in:
* following auditory directions
* remembering auditory information
* learning information presented auditorially
* understanding speech, especially in the classroom environment
* remaining attentive and non-distracted
More fine-tuned difficulties appear in:
* auditory discrimination, such as localization and pitch
* decoding, such as blending, sequencing sounds
* phonological awareness, such as rhyming, manipulating sounds, deleting sounds, and segmenting sounds
Specific characteristics of CAPD (ASHA CAPD Task Force, 1996)
* Sound localization and lateralization – where is the sound in space. Ex: where is the dog if I hear a barking noise.
* Auditory discrimination – distinguishing one sound from another. Ex: pat/pad; rice/rise.
* Auditory pattern recognition – similarities and differences in the patterns of sounds. Ex: apple/appeal; apple/chapel.
* Temporal aspects of audition – the sequencing of sounds into words. Ex: change the /ch/ in peach to a /s/ (peach/peace); change the /ee/ in sheep to a /i/ sheep/ship)
* Auditory performance decrements – the ability to perceive words if other sounds are present. Ex: listening to the teacher assign homework if there is a lot of noise in the hallway
* Auditory performance with degraded acoustic signals – Ex: perceiving the word if part is missing.
The series of abilities listed above are the results of CAPD, not the cause.
Evaluation for CAPD
Assessment should be interdisciplinary and collaborative. Parents who suspect that their child may have CAPD should first consult their pediatrician to rule out other possible problems, such as faulty hearing. A team approach is essential: other professionals who may need to be consulted include an otolaryngolgost (ear specialist), speech-language pathologist to assess language skills , and educator, a mental health professional to rule out factors such as behavior problems, and an audiologist who administers the actual tests. Tests are designed to measure highly specific skills – discerning speech among background noises, auditory memory, auditory discrimination, integrating sounds coming from different locations, among other abilities. The tests are not valid for children under the age of 7 because they have not yet developed the necessary auditory and attention abilities.
Although the above-listed abilities are critical to sound auditory processing, isolation and treatment of each ability separately is not helpful. An integrative approach which takes into account the interrelationships among abilities is effective. Children with CAPD seem to do best in a one-to-one situation and in an acoustically quiet environment. This can best be accomplished when remediation plans consider the following:
Modifying the listening environment when appropriate
* Classroom acoustics should be modified – Reduce reverberation within the room by adding room dividers, bookshelves, acoustic tiles, carpet, wall hangings, bulletin boards, etc.
* A self-contained, structured environment is sometimes helpful. An open, unstructured teaching environment should be avoided.
* Preferential seating, such as being closer to the teacher, can be helpful.
* Face-to-face communication should be facilitated. However seating should take into account the student’s ability to follow when the teacher moves around. Children who take cues from other children may do better when seated toward the rear of the classroom. Child should be seated away from the hall and street noise.
* A quiet study area should be provided
* Provide pauses for extra processing time.
* Consult with an audiologist to ensure that the acoustic environment is appropriate. For some children, the use of an auditory trainer which beams a teacher’s voice directly into earphones that a child wears, is helpful. Some classrooms can be "wired" for better auditory processing.
Using strategies for improved communication
* Consider input vs. intake. Input refers to all the language to which a child is exposed. Intake refers to whether the child notices, hears and listens to the input and how the child interprets the information. The goal of improving communication is to adjust the input for maximum intake.
* Gain the child’s attention by using alerting cues and signs, such as calling the child’s name or by a gentle touch.
* Monitor the child’s comprehension. Periodically ask the child questions related to the subject under discussion.
* Restate material by rephrasing what has been misunderstood rather than repeat the information.
* Use brief instructions. Reduce complexity of the message.
* Pre-tutor. Familiarize the child with new vocabulary and concepts to be covered in class. Parents can be particularly helpful in this activity.
* List key vocabulary before dealing with new material.
* Present information in several formats. The children need to interact with information in a variety of ways, such as in small groups, individually, collaboratively with others, and to have different opportunities and ways in which to express themselves.
* Multisensory approaches are helpful.
* Write instructions on the board.
* Provide visual aids. Jotting key words on the board or providing simple written/picture outlines may be useful.
* Auditory attention can be enhanced by having child listen to tapes, transcribing from tapes, and playing games such as Simon Says.
* Provide breaks since children with auditory processing expend more effort in paying attention and in discriminating information than other children.
Teaching a child strategies to help interpret, organize and synthesize auditory information
* Using categories to organize information.
* Grouping information to be learned into meaningful chunks.
* Reading and summarizing by thinking of a title for the story.
* Learning to solve math word problems by extracting important information and determining what process to use to solve a problem.
* Solving riddles.
* Practicing with contingency problems such as: "if you like ice cream more than spinach, count to ten."
Teaching the child to be a self advocate
* Promote self assertiveness by teaching a child to ask the teacher to slow down, or to give directions or information in another way.
* Help a child to bypass her difficulties by giving her a list (in words or pictures) of the tasks you’d like her to accomplish or of the directions you’d like her to follow. Pair those directions with brief verbal prompts.
* Strengthen areas of where the child excels so he doesn’t feel hopeless.
* Help children learn how to reflect on what they are learning, monitor their learning, and to be aware of when they are inattentive and develop strategies to stay focused.
Special Intervention Software
The following materials may be helpful as an adjunct to other interventions to help the child with CAPD.
Step l – for children 4 – 7. Six interactive games that focus on auditory skills.
Step 2 – for children 7 – 10
I for adolescents and adults (ages 10+)
Computer-based training program from Scientific Learning (ages 4 – 12)
The Listening Program
Based on the Tomatis Program
Lindamood-Bell Learning Processes Program
Lindamood Phoneme Sequencing™ (LiPS®) Program
The Nancibell® Visualizing and Verbalizing® for Language Comprehension and Thinking (V/V™) Program
About the Authors
Susan Schwartz, M.A. is the Coordinator of the Institute for Learning and Academic Achievement at the New York University Child Study Center.
Anita Gurian, Ph.D., Clinical Assistant Professor of Psychiatry, NYU School of Medicine, Editor of the NYU Child Study Center Letter and Executive Editor of www.AboutOurKids.org.
References and related books
Central auditory processing disorder in school-aged children: A critical review
Cacace, Anthony T; Dennis J., McFarland
. Journal of Speech Language & Hearing Research . Vol 41(2) Apr 1998, 355-373.
American Speech-Language-Hearing Assn, US
Identification of language-impaired children on the basis of rapid perception and production skills
Tallal, Paula; Stark, Rachel E; Mellits, E. David
Brain & Language . Vol 25(2) Jul 1985, 314-322
Child Neuropsychology: Assessment and Interventions for Neurodevelopmental Disorders
Teeter, Phyllis Anne and Margaret Semrud-Clikeman. (1997) Chapter 8, Needham Heights, MA:
Allyn and Bacon
Are prelinguistic abilities predictive of learning disability?: A follow-up study
Preschool Prevention of Reading Failure
Stark, Rachel E; Ansel, Beth M; Bond, Jennifer
Masland, Richard L. (Ed); Masland, Mary W. (Ed). (1988)
Language Learning Disabilities in School-Age Children and Adolescents
Chapter 14, Needham Heights, MA: Allyn and Bacon
Wallach, Geraldine P. and Katharine G. Butler (Eds.). (1994)
NYU Study Center is dedicated to the understanding, prevention, and treatment of child and adolescent mental health problems. For more information visit AboutOurKids.org.