Lois K. Heymann (MA, CCC-SLP), is a Speech and Language Pathologist with over 30 years experience working with children with hearing, listening, and learning challenges and their parents. Heymann's book, THE SOUND OF HOPE: Recognizing, Coping with, and Treating Your Child's Auditory Processing Disorder [http://www.listenlovelearn.com/].
We talked to Lois about her book, the diagnosis and treatment of Auditory Processing Disorder (APD/CAPD), and how parents need to learn to listen just as much as their children do.
1: What is APD and how is it different from ADD, ADHD, etc?
LOIS: APD (sometimes identified as CAPD) stands for Auditory Processing Disorder. To understand what an APD is, it's important to remember that sorting out and using the sounds we hear with our ears and engaging with the world by listening is accomplished primarily in the brain. An APD affects the transfer of sound information within the brain not the ability to hear with our ears. A person with an APD may be physically able to hear, but as sound moves from the outer and inner ear into the brain to be identified, understood, and transformed into useful information, along the way the message gets confused, garbled or distorted. When the language and speech centers within the brain repeatedly receive unclear or distorted messages because of an APD, the act of listening, the use of language, learning, and social interactions can all become extremely difficult.
The major difference between APD and ADD, ADHD, PDD and some of the more commonly diagnosed disorders that your readers are likely familiar with is that APD solely effects the transfer of sound information within the brain and diagnosis and treatment focus specifically on how the brain listens. It gets confusing, though, because an APD can stand-alone or co-exist with other disorders and difficulties like ADD, etc. The behavioral symptoms of these varied conditions can also appear quite similar to one another. As I said, APD primarily affects the language-oriented parts of learning and communication. But since so much of healthy development, effective education, and positive social interaction depends on communicating and listening, a child with APD can become extremely isolated and frustrated as they try to successfully interact in an ever-expanding world of words and sounds.
Children with APD struggle in classroom situations and at home and can appear to act out or tune out when dealing with parents, teachers, and other children. Impulsive, inattentive, or aggravated behavior in a child with APD is usually not the direct result of hyperactivity or attention deficit, it's an expression of feelings of confusion, frustration and failure coming from a perfectly intelligent growing person who is repeatedly not understanding and not being understood. Also, ADD and ADHD may respond to medication while APD does not.
2: What kind of testing would a child need to undergo to determine they have APD?/ How early can it be recognized?
LOIS: Testing for APD involves evaluating auditory processing – the ability to transfer and translate sound into information within their brain – and determining if and to what extent an APD handicaps or restrict an individual child's ability to communicate, learn, and deal with emotions. That's a lot to consider. A full APD assessment involves testing, interviews, and a process of elimination that looks at several different areas of an individual child's life.
First, an Audiologist tests the child for hearing loss – problems with the physical act of hearing, rather than the processing of sound within the brain. Once hearing loss is ruled out, a Speech-Language Pathologist like myself works with the Audiologist and explores whether a child may have an APD by looking at the way the child uses speech, language and listening skills through audiological (APD) and speech and language testing. Getting a complete picture also involves parents and teachers filling out a checklist questionnaire detailing aspects of the child's behavior in school and at home. Additional information from psychological and educational tests helps distinguish APD from other diagnoses such as AD/HD and PDD.
It's a lot of information requiring a collaboration between the Audiologist and the Speech-Language Pathologist and input from several specialists including the most important and unfortunately sometimes overlooked child specialist – the parent. But, once that detailed diagnosis is complete, appropriate interventions and therapies best suited to an individual child can begin immediately.
Because so much happens physically and developmentally in the first half decade of a child's life and children grow and mature at different rates through those years, a conclusive diagnosis of Auditory Processing Disorder cannot be made until a child is around seven years old. APD screening by the Audiologist and the Speech-Language Pathologist looks at listening behavior and communication skills. Testing these abilities in children under six just doesn't yield definitive and reliable enough results to form a complete APD diagnosis. Nevertheless, if a parent suspects their 6 and under child is struggling with listening and comprehension, testing by a Speech-Language Pathologist can help suggest intervention strategies to build listening and language skills before a precise APD diagnosis gets made. If you feel that your child is challenged by listening at any age, have him or her evaluated by a Speech-Language Pathologist. The developmental path from hearing to listening to effectively understanding and using language begins at birth and early intervention is very important if any listening or hearing roadblocks develop as a child grows from infant to toddler to pre-teen and beyond.
3: Is this a disorder that can be "cured" or will a child outgrow it or is it lifelong?
LOIS: The bad news about APD is that there is no cure. The good news is that once an APD is appropriately and accurately diagnosed it will usually respond well, even dramatically, to treatment. Targeted intervention using strategies for helping the APD child learn to listen and understand language to the best of their ability can work wonders. After an APD diagnosis is made a Speech-Language Pathologist formulates specific intervention goals and strategies tailored to specific listening and language weaknesses and difficulties identified during testing and evaluation. Once we know a child's individual problem areas and deficiencies in processing auditory information, we can map out a plan to address and minimize the impact those deficiencies have at school, at home and at play.
A child with an APD needs to "build their listening muscles." Since listening and using language is something children do in every part of their lives, parents, teachers and the therapist share the responsibility for helping a child to strengthen those listening skills. Specific accommodations and changes to the child's school and home environment are also part of most APD intervention plans as is yearly follow-up testing by an audiologist.
4: How does one explain APD to the child diagnosed? (Say for a child in the 7-11 age range)
LOIS: Like any serious conversation you have with a child, explaining an APD diagnosis requires that you be honest and give a clear and simple description that's appropriate to your child's age and experience. A parent might begin with "Tommy, you know how when the classroom gets noisy and the teacher gives a homework assignment, sometimes you don't hear it correctly even though you were listening? This is something called Auditory Processing. It has nothing to do with being smart or hearing well. You are smart and you hear just fine. Sometimes it just becomes harder to listen. We're going to learn ways to help you learn to listen even better so that it won't be so hard."
Letting your child know that you are going to face this challenge together is as important as keeping your explanation honest, simple and rooted in actual experiences. Your child will feel more secure knowing that his or her parent or parents are partners and will be learning new skills and exploring new territory together. Helping a child with APD understand that everyone struggles with something can also make things easier. I often counsel parents to remind their child of things that are fun and come easily to them and to share a struggle that the parent has had and still sometimes works to overcome.
5: What are simple things a parent can do at home to make the sound quality better for an APD child?
LOIS: Children with APD have a very difficult time listening in environments with a lot of extraneous noise. We're all bombarded by sound 24/7 and for a child with an APD even a seemingly innocuous sound that few of us consciously register like a scraping chair or a sneeze can cause or increase confusion. I'm not suggesting that parents keep their children out of all noisy environments and maintain complete silence at all times. Parents do however need to be aware that dealing effectively with noise and the problems it causes for children with APD begins at home and that they have the power to make enormously helpful common sense choices that will address their child's listening needs. Any home can be made less noisy and more comfortable for a child who struggles with listening. Think about the individual rooms in your home.
Is one room noisier than another because of outside traffic? Do the sounds of appliances like a dishwasher or running the sink make your kitchen a particularly loud place? Do you eat dinner with the television or radio on or is there a TV on in several rooms in your house or apartment? Once you realize that background noise interferes with your child getting all the auditory information they need, you can begin to gauge where the noisiest places are in your home and in your life together and begin to make adjustments. Turn the TV off. Make an effort to conduct important learning activities and conversations and give directions in quieter rooms. Perhaps your kitchen isn't the best place to deliver detailed instructions. Think about how you speak to your child.
Do you talk to them from another room or from a great distance away? Do you shoehorn your child into alternating conversations with several people in the family or while talking on the phone? A child with APD needs the advantage of focused, face-to-face, one on one conversation. Cutting down on unnecessary background noise and cross talk will help them understand and participate in the conversation and benefit from the words you share.
6: How is communication different for an APD child? What do they process (or not process in a sentence) vs. what the average child would?
LOIS: Listening is such a varied and pervasive skill that an APD may adversely affect a child in several ways. If a child has difficulty with what's called "Auditory Attention" they may miss the beginning of a sentence and have to guess at a word or meaning to fill in the piece that they didn't catch. If the child's difficulty is a matter of "Auditory Discrimination" they may confuse similar sounding words. For instance, when their teacher says what sounds like, "she went to the dog," when in fact what was actually said was, "she went to the door," though the child knows the sentence didn't make any sense the way they heard it, a girl or boy with an APD still has to stop and think about it. While they're doing that repair work on their own, their teacher continues and the child then misses whatever information comes next.
If a child has what's identified as "Figure-Ground" difficulty, words and sounds will cut in and out or get canceled out by background noise such as another child's cough, a door closing, or a lawn mower running outside the school building. For these children extraneous noises most of their peers ignore are just as prominent as the words the child is expected to hear and understand. Any one of these situations can wreak havoc on verbal comprehension, understanding instructions and participating in conversations. Constantly having to think over what they thought or believe they heard and mentally repair mistakes, sorting out jumbled sentences, and asking for words to be repeated is incredibly demanding for a child. Children with APD simply become exhausted, frustrated by most verbal communication and quickly lose interest.
A child without APD who has typical auditory processing abilities doesn't shoulder these burdens. With no additional barriers to listening effectively, he or she is understands a message appropriately and in context without all that extra confusion and struggle and is free to communicate clearly and happily throughout the day.
7: How can parents become better listeners for an APD child?
LOIS: A few guidelines:
- Try to speak to your child on the same physical level. When talking to your child, face-to-face always works best. There are all sorts of visual cues we take for granted in conversation. For a child who is learning and struggling with listening, the more they can see of your mouth, face and body language, the more advantage they'll have in paying attention and getting your meaning.
- Give your child your full attention when she or he speaks. Your focus on what they are saying will work miracles.
- Make eye contact and demonstrate with your expression that you are interested in what your child is telling you.
- Listen patiently. Children with APD often take extra time to choose words and think about the meaning of what's been said.
- Try not to interrupt your child before he or she has finished speaking. What's common courtesy amongst adults is a vital stepping-stone for a child learning to communicate effectively.
- Remember that you are always teaching your child through your behavior. A child that is listened-to will become a good listener. Parents who work at being a better listener themselves help their children to do the same. Children return the respect they receive – not just to you but to anyone they engage with at home, school or play.
8: Are there simple things parents of an APD child can ask the child's teacher/school to do in order to help meet a child's needs?
LOIS: If your child has a diagnosed disorder, accommodations and recommendations will be outlined in their school system mandated Individualized Educational Plan (IEP). Even if your child does not have these accommodations detailed in an educational plan there are some simple and highly effective things that teachers can do to help your child do their best.
- Arrange preferential seating – moving your child to a place in the classroom where the teacher can be seen and best heard during instructional time can work wonders.
- Reduce classroom noise – especially while the teacher is giving lessons and directions. This can range from simply asking and waiting for quiet before saying anything important, to installing sound dampers on the tips of chair legs and other physical classroom modifications that minimize distracting noise.
- Use closed captioning when showing videos and DVDs
- Repeat and rephrase questions and comments from other children during class discussions
- Implement a one-voice rule during discussions to avoid more than one speaker at a time creating cross talk.
- Write homework assignments on the blackboard in addition to giving out the assignments verbally.
- Many teachers may not have had a child with APD or listening challenges in their classroom before. It's important that parent and teacher work together to learn the best ways to help and support your child in their classroom.
9: As reading plays an important role in communicating with APD children, can you recommend some books that you've found most helpful?
LOIS: Books are an indispensable tool for expanding any child's perspective of the world and allowing them to experience new concepts, new words and new uses of language they would not otherwise encounter. Hearing stories read aloud is one of the most powerful ways for a child to develop and strengthen their listening and communicating skills. I list a variety of age and developmentally appropriate books in THE SOUND OF HOPE, but really almost any book is a "good" book if it captures your child's interest and helps the two of you form a bond of mutual curiosity and share a dual flight of imagination together. The children's librarian at your local library is another good resource for books appropriate to your child's age and interest level.
Having read to my two children as they grew up at home and worked with hundreds of children with listening issues in my clinical and therapeutic work, the books I've grown to love the best are classic fairy tales. The stories may be simple but they run deep through generations of re-telling, contain characters that have remained compelling for hundreds of years, and describe situations and concepts that are relevant and capture a child's (and adult's) imagination. The only children's books I caution about are one's that are too firmly based in characters and stories from other media. Children may like the familiarity of a TV or movie tie-in book, but those stories have already been shaped and defined on screen and can limit a child's imagination, ideas and choices. But again, any book that keeps your child interested and the two of you turning the pages together is fine.
10: What is one thing you would like to tell parents who suspect their child might have APD? Conversely, what is one thing you tell kids newly diagnosed with APD?
LOIS: I would tell parents to trust their instincts and seek help right away. Parents usually sense when there is something not quite right with their child's development even if they can't put their finger on precisely what it is or decide on their own what to do about it. If you suspect there is an issue with your child's listening and learning skills, don't wait; an evaluation will help you confirm if your child's skills are developing appropriately and give you peace of mind. Help is always available for children and finding the right help will make all the difference. Parents who suspect their birth to three-year-old child might have APD or a listening challenge should call their local Health Department for an Early Intervention evaluation. For a suspected problem with a child 3-5 or school age, they should call their school district's Department for Special Services and request a speech and language evaluation.
For a child diagnosed with APD the one thing I work hard to make them understand is that they are not alone. With the help of their parents and teachers, together we can and will find ways to make listening, learning and talking a whole lot easier and a whole lot of fun just like they should be!