Karen Levin, Ph.D Speech Therapist, Johannesburg

Auditory processing disorders is a term that is used in so many different ways that no one really knows what it mans.

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Basically, in order to process information, one has to be able to hear audiitory informnation - both linguistic(i.e language) and non-linguistic with one's ears and process it all in the brain. There are many levels of breakdown in this incredibly complex system. Because it is so complex, there are many theories about what it is, how it happens, what goes wrong and how to fix it.

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"Auditory processing disorders" can be

 

1. Developmental.

This means that in the absence of any known cause, children have difficulties processing auditory information. These difficulties can persist for life.

 

or

 

2. Acquired.

This means that some people can start to have difficulties processing auditory information following an event like a stroke, tumour, head injury.

 

or

 

3. Secondary.

This means that difficulties processing auditory information are associated with hearing loss.

 

 

 Children who have on-and-off ear infections often land up with difficulties processing auditory information, maybe because when they have ear infections, their hearing is:

(1) inconsistent

(2) unequal between the ears

(3) associated with fever and pain sometimes

(4) in the low frequencies which we need for vowel discrimination

(5) difficult. It takes effort to listen and like all human activity, if it is too hard, we stop doing it.

 

Older adults who lose their hearing, also have difficulties processing auditory information. This is because

(1) it's too much effort to hear

(2) the nature of the hearing loss itself interferes with hearing e.g. most older people lose the high frequencies which makes it really hard to discriminate  (like mish/mitch/miss/midge)

(3) it is often difficult to hear in noise

(4) loud sounds sound extraordinarily loud

(5) some older people lose their powers of concentration

(6) some older people get tired more easily

(7) there are also changes in the brain itself that make it difficult to manage hearing the sounds - we call it "phonemic regression"

(8) We start to lose concentration because we are confused

(9) we feel socially isolated if we cannot hear. We have no idea what the topic of conversation is and we feel excluded.

(10)  And depressed. And when we are depressed and anxious and confused, we can't process information.

 

Anyone with a hearing loss is at risk of having difficulties processing auditory information. When its difficult to hear, when the sounds are distorted, when hearing is unreliable, then it is very difficult to process sounds.

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So, the EARS HEAR but the BRAIN PROCESSES

 

Many years ago, audiologists defined difficulties processing auditory information as "CENTRAL auditory processing disorder" (CAPD).  They came up with this terminology so that there would be a clear understanding that information processing is a function of the brain.  There was a lot of debate on this, and official organisations like the American, British, Canadian, Australian and the South African, associations of audiologists thrashed out arguments. Nevertheless, a host of measures were developed for audiologists to test what happened to auditory information beyond the level of the ears.   A whole lot of official documents recommended test protocols for the assessment of CAPD. They were really interesting, really expensive, really impressive. They were based on the fundamental theory that APD is a DISTINCT condition that is not linked directly  to language and cognition. On the ASHA website, the point is made very clear that APD is a distinct condition (See http://www.asha.org/public/hearing/Understanding-Auditory-Processing-Disorders-in-Children/)

 

However, there is literature today that questions this theoretical stance.

 

  (See DeBonis, D (2015) "Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children".  American  Journal of Audiology,  24 ,  124–136).

 

We have seen that the special tests don't really differentiate CAPD from other problems.  So we are left, again, with depending mainly on what we used to do before. We use behavioural testing. We observe listening behaviours in the various contexts of people's lives. We see AP as woven together with hearing, language, listening - focus and concentration and impulse control, personality, emotional state, intelligence, cultural norms, environment. We have to look at every INDIVIDUAL and DESCRIBE WHAT HE OR SHE CAN AND CANNOT DO, and work from there.

 

There are signs in adults and children of difficulties processing auditory information

(note that I am not talking about a "diagnosis" of APD but rather of looking at what the person can and cannot do with regard to processing auditory information. I do not believe, given the new literature that is available to us, that there such a diagnosis of APD, but that these AP difficulties are associated with a range of problems and their basis is not a central auditory processing one)

 

Signs in adults include: (from https://www.nidcd.nih.gov/health/voice/auditory.html)

• talk louder than necessary

• have trouble remembering a list or sequence

• often need words or sentences repeated

• have poor ability to memorize information learned by listening

• interpret words too literally

• need assistance hearing clearly in noisy environments

• rely on accommodation and modification strategies

• find or request a quiet work space away from others

• request written material when attending oral presentations

• ask for directions to be given one step at a time

 

Signs in children include

• being disorganised

• don't remember nursery rhymes or songs

• don't remember people's names

• muddle up their sounds (e.g. "merote" for "remote")

• have trouble paying attention to and remembering information presented orally, and may cope better with visually acquired information

• have problems carrying out multi-step directions given orally; need to hear only one direction at a time

• have poor listening skills

• need more time to process information

• have low academic performance but some don't

• have behavior problems but many don't

• have language difficulties (e.g., they confuse syllable sequences and have problems developing vocabulary and understanding language)

• have difficulty with reading, comprehension, spelling, and vocabulary

• can't tell background noise from foreground noise

• can't cope in noisy environments

• are easily distracted

• get overwhelmed by noise

 

 

Getting to the bottom of things:

 

1. Have a hearing test.

An audiologist is essential! We have to know about the ears and about speech discrimination.

 

2. Have a speech-language assessment which will include an assessment of language competency, phonological skills, as well as a behavioural assessment of AP.

 

3. Have a multidisciplinary assessment if need be (psychologist, neurologist, occupational therapist, physiotherapist etc).

 

 

 What to do to help:

 

 

 

• Reduce background noise at home. Turn off TV, radios.

• When talking to a person with difficulties processing auditory information, be aware of background noise - it really interferes with their processing.

• If the person needs to work, study, focus, concentrate, make a quiet place available. A child with difficulties processing auditory information needs a quiet place to study. Try not to use the kitchen table.

• When speaking:    

  • use short sentences 

  •   use a slightly louder voice OR a slightly softer voice

• Ask the person to look at you while you speak - but for some children, this is HARD TO DO! Don't force it. Some listen better if they are NOT looking at you - and be aware of cultural norms - many South African cultures find eye contact abhorrent!

• In the case of children, use "re-auditorisation" - get the child to repeat what you have said. But with meaning. Some can repeat what you have said but have not PROCESSED it.

• Some people benefit from notes - diaries, lists, Post its.

• Visual aids really help. Convince the boss or the teacher that the person or child NEEDS to take a photo of the notice board/blackboard/smartboard.

• Ask the teacher to make sure she e mails the homework to you - the child might not PROCESS what she instructs. Also, may teachers "throw out" a last minute instruction just as children are packing up to move out of the classroom!

• Use cell phone reminders

• Use cell phone or digital recorders - so you or a child can listen again

 

Teachers can be of great help

• Put the child near to where you do most of your teaching

• Don't teach a child with difficulties processing auditory information from behind

• Remember that group work is really hard for a child with difficulties processing auditory information

• Lower the noise levels of your classroom. If you can - get a carpet, make sure your lights don't hum, put the child far away from a fan or anything else that makes a noise like an open window.

• Give lots of visual aids to supplement auditory instruction BUT some children will be overwhelmed if they have visual processing problems as well.

• Speak clearly. You don't have to SHOUT at a child with difficulties processing auditory information ...sometimes talking softly helps more.

• Children with difficulties processing auditory information get ANXIOUS...when you talk to them, be gentle, reassuring, and smile. It really helps! Be genuine ... trust is a big issue for some children.

• Provide written instructions or a homework list. You want the homework to be done. So what if you have to write it down.

• Please get over the attitude "But he has to learn some time". You are right BUT  he can't right now. And no amount of putting a child with difficulties processing auditory information through the punishment of not helping him will teach him the skills you want him to learn. Rather just help him.

• Provide additional aids for study like a digital recorder, photocopies of another (good) student's notes, or assign the student a “homework buddy.”

• Don't expect children to ask their '"friends" for reminders or help. This does not happen - often these children do not have friends; or their friends don't like helping; or and they don't like asking more than once. It is YOUR responsibility as a teacher to make it happen.

• Let them take photos of the work on the blackboard or smartboard.

Additional ideas

• FM systems are electronic devices that the teacher and the child wears. The child hears the teacher's voice  directly. they therefore lower the background noise. There is quite a lot of data that shows these systems are effective. The speech therapist and/or audiologist will advise you.