Diagnosis and Treatment of CAPD

Because CAPD testing is as much an art as a science, the quality of a CAPD test battery is largely dependent on the operator. The choice of tests employed varies greatly among examiners, and it’s important to verify that the test battery chosen is comprehensive enough to identify or exclude the full range of deficits that could account for a particular child’s symptoms.

Many centers that offer “CAPD testing” actually only perform the SCAN-C, a limited battery of tests. The SCAN-C can detect only about 45 percent of children with CAPD. Therefore, if used alone, the SCAN-C is far from adequate as an evaluation for CAPD. (Bellis, T.J. 2003)

We haven’t space here to discuss all of the tests available to evaluate central auditory processing. Those interested in learning more about such tests should read the article “CAPD Tests” in the Spring 2004 edition of our on-line newsletter at: www.neurolearning.com/newspring04.htm. In general, though, we would agree with audiologist Teri Bellis’ recommendations that a truly comprehensive CAPD battery should include at least one test aimed at evaluating function in each of these categories:

Plus the testing should include physiologic measures of auditory function, such as

Despite its usefulness, CAPD testing is not for everyone. First, the testing is very rigorous. It places considerable demands on a child for focused attention, physical and mental endurance, and the ability to process complex linguistic information. Second, the auditory system undergoes considerable development in the first decade of life. As a result, developing assessment norms for the various tests has proven difficult. For these reasons, many audiologists feel it is not possible to administer a truly comprehensive CAPD battery to a child younger than 8 years old or, in special cases, 7. Some audiologists, however, do test children as young as 5. In our practice, we have generally found that testing children younger than age 8 is unrewarding, and we typically base our treatment of children under this age on history, clinical exam, and neuropsychological testing, deferring rigorous auditory testing until children reach the age of 8 or 9.

Finally, it’s important to realize that while CAPD testing is relatively sensitive and specific, it’s not perfect. A “normal” result does not mean that a child definitely does not have CAPD. Despite negative test findings, it may still be reasonable to take some of the measures described in the rest of this article if a child’s symptoms create a high level of suspicion.

The last decade has seen an explosion in research into the “hearing brain.” Some of this research has clearly demonstrated that the brain has an extraordinary capacity for reorganization in response to auditory training. However, clinical practice still lags behind theory.

In the United States there are wide variations among practitioners in the kinds of therapies recommended for patients with the various CAPD subtypes. We will discuss here our own approach to the treatment of children with CAPD. Please remember that these are general principles only, and that diagnosis and treatment of any child with hearing problems must be undertaken with a team of appropriate medical professionals.

Useful interventions for children with CAPD can be divided into two broad categories. Following are descriptions of these categories along with the major strategies within each.

Interventions in the first category minimize the functional problems that result from the auditory impairments. Four strategies in this category are as follows.

1.	Sound Amplification Strategies
	Consist of: Assistive listening devices that increase the volume of the teacher’s voice and bring the sound closer to the child’s ear Work by: Filtering out competing sounds and amplifying the desired signals Are effective with: Children whose CAPDs cause severe problems hearing speech in background noise Can benefit children such as: A boy referred to us for attentional difficulties. We sent him for an auditory evaluation due to problems with mishearing and delayed processing. His sustained auditory attention scores were 100% without background noise, and only 45% with background noise. He began using an assistive listening device and experienced marked improvement in attending to teacher lectures and in social conversations in noisy settings like group discussions.
2.	Sound Filtering Strategies
	Consist of: Either custom-fitted ear filters obtained where hearing aids are made or musicians’ earplugs, which are the best filters Work by: Helping to minimize irrelevant frequencies Are effective with: Children whose hyperacusis, or high sensitivity to sound, is causing social or academic impairment A note of caution: Sound filters must be used sparingly. Because evidence shows that chronic sound deprivation can actually worsen hyperacusis, filters should be saved for circumstances where they are clearly essential.
3.	Classroom Accommodations
	Consist of: Means for helping children with CAPD compensate for their hearing difficulties. Accommodations are essential for any child with CAPD; they vary depending on the nature of the child’s auditory problems, and on the child’s level in school. Classroom examples:
	·	Seat placement. Students with CAPD need a clear vision of the teacher’s face, and should be seated near the front of the room and away from windows to minimize distractions. They should not be placed near sound sources like buzzing lights or heaters; blowing air ducts; or noise-permeable partitions, walls, or doors.
	·	Floors and walls. Carpeting floors and covering walls will minimize echoes and cut down on background noise. A helpful discussion of acoustic environments is available in the book Speechreading.
	·	Note taking. For a variety of reasons, children with CAPD often have significant difficulty taking notes. Accommodations for note taking include:
		-	Let the student tape record lectures.
		-	Have the teacher or another student provide the notes.
		-	Provide important instructions, assignments, and due dates in written form.
		-	Make lectures easier to follow through pre-learning appropriate terms and topics from textbooks or teacher’s notes.
		-	Use close-captioned media whenever possible.
		-	Provide visual or tactile cues to reinforce important auditory information such as visual examples, hands-on learning projects, or lists of key words.
		-	Provide waivers for exclusively oral tests. (However, timed oral testing is inappropriate for children with significant processing delays.)
	Something to note: Homeschooling may offer a better learning environment than a traditional classroom for many children with CAPD. Online classes provide controllable acoustics, eliminate background noise, and sometimes emphasize visual learning, which may work better for certain children.
4.	Speech Therapy
	Consists of: Activities designed to improve vocabulary, sound decoding abilities, and understanding of the rules of language Works by: Boosting skills that can result in academic and social gains Is effective with: Children who lack the skills to fill in missing fragments of imperfectly heard messages, referred to as auditory closure skills Should include: Nonverbal aspects of communication, including facial expressions, mouth movements, body postures, and hand gestures

These interventions are aimed at relieving or even curing the impairments themselves. They include the following commercial and non-commercial options that employ auditory training/brain reorganization strategies.

		·	Fast ForWord, Phonomena, and Earobics, the only programs with credible scientific support for their efficacy. In fact, MRI studies of persons with phonological impairments who have completed the full Fast ForWord course have actually shown visible evidence of improved function in the areas of the brain responsible for phonological processing. (Temple, E., G.K. Deutsch, R.A. Poldrack, S.L. Miller, P. Tallal, M.M. Merzenich, and J.D. Gabrieli, 2003.)
		·	AIT, or Auditory Integration Therapy, a program for which there are anecdotal claims but no peer-reviewed scientific studies to support its efficacy with CAPD children
		Program drawbacks:
		·	Very labor demanding, requiring a commitment of approximately one hour per day, five days per week, over a span of six weeks
		·	Often difficult for younger children or for children with attentional difficulties
		·	Work for many but not all children with phonological or temporal deficits
		·	Costs ranging to over $1,000

In closing, we would like to stress three crucial points for adults involved in the care and education of children with CAPD. First, remember that variability in symptoms of children with CAPD is the rule, not the exception. Most children with CAPD hear easily at some times and appear functionally deaf at others.

Children with CAPD do not have a fixed level of hearing deficit that causes equal symptoms on all occasions or in all environments. These children can experience marked variations in processing efficiency due to fatigue, ill health, emotional disturbance, variations in background noise, changes in a teacher’s voice due to illness or strain, changes in the relative positions of the speaker and the listener, and countless other factors. This variability often leads to accusations of poor attention, lack of effort, or willfulness in ignoring a speaker’s requests or instructions.

Unjust accusations of this sort can lead to confusion, resentment, hurt feelings, or despair in the child. Teachers, particularly, must not to fall into the trap of thinking that accommodations like those listed here are unnecessary for a particular child just because that child has done well without them on certain days or because they have conversed easily with that child one-on-one after class.

Second, adults must realize how important a well-functioning auditory system is to essentially every aspect of a child’s life. Social communication, interactive play, personal relationships, speech comprehension, and academic success are all threatened by CAPD.

Third, adults should remember the importance of using a child’s strengths to compensate for his or her auditory weaknesses. Children with CAPD often have outstanding skills in higher-order language, inference, and visual learning domains that may enable them to function well in many environments. With appropriate care and interventions, they should be able to flourish, both academically and in later life. Understanding the particular nature of their auditory difficulties, including the environments and situations that will be particularly troublesome for them as well as the strategies they can use to optimize their abilities to hear and understand, can go a long way toward helping children with CAPD function well in whatever aspects of life they choose to pursue.

	Some Reading Recommendations from the Drs. Eide
	Tony Attwood's Asperger’s Syndrome: A Guide for Parents and Professionals contains excellent sections dealing with auditory and prosodic speech difficulties in persons diagnosed with Asperger Syndrome. Many of these difficulties are common in persons with CAPD, as well. Whether these similarities arise from similar causes requires further investigation. For those interested in a more detailed discussion of CAPD aimed at the general reader, we recommend Teri James Bellis' When the Brain Can’t Hear. For a professional level discussion, read the same author’s Assessment and Management of Central Auditory Processing Disorders in the Educational Setting. For a moving narrative from a parent's perspective, we recommend Like Sound Through Water by Karen J. Foli. For some helpful resources for parents and teachers, visit our website: www.mislabeledchild.com/html/Library/AuditoryProblems/index.html

Bellis, T.J. (2003). Assessment and Management of Central Auditory Processing Disorders in the Educational Setting from Science to Practice. Clifton Park, NY: Thomson.

Eide, B.L. and Eide, F.F. (2004). "Hearing Beyond the Ears, Part I." Gifted, NSW Association of Gifted and Talented Children, July, pp. 27-29.

Eide, B.L. and Eide, F.F. (2004) "Hearing Beyond the Ears, Part II.: Gifted, NSW Association of Gifted and Talented Children, October, pp. 22-25.

Temple, E., G.K. Deutsch, R.A. Poldrack, S.L. Miller, P. Tallal, M.M. Merzenich, and J.D. Gabrieli. (2003). "Neural deficits in children with dyslexia ameliorated by behavioral remediation: evidence from functional MRI," Proceedings of the National Academy of Sciences USA.100(5): 2860-5.

Brock and Fernette Eide are physicians from Edmonds, WA. In addition, they serve on the Professional Advisory Committee for SENG (Supporting Emotional Needs of the Gifted) and are the authors of the book, The Mislabeled Child. Visit their website and blog at: http://mislabeledchild.com/.

Diagnosis and Treatment of CAPD

November, 2006