What Does CAPD Look Like?

"How can he have a hearing problem when he overhears everything we say from three rooms away? He has the sharpest ears in the house."

That was the startled response of one typical couple when their son’s preschool teacher suggested he might be deaf. We know. We were the couple. And that was our first encounter with Central Auditory Processing Disorders, or CAPDs.

That experience was one of the crucial factors that led us to focus our medical careers on helping children – especially gifted children – with learning difficulties. In the years since, we have had many more encounters with CAPDs, and we are constantly surprised both by their prevalence and by the many difficulties they create in children’s lives. Published reports suggest CAPDs affect roughly 2 to 3 percent of children (Chermak, G., and Musiek, F., 1997), but the real numbers may be significantly higher. In our clinic, CAPDs are some of the most common disorders underlying school difficulties, and some of the most disabling.

Despite the significance of these disorders, children with CAPD often go undiagnosed and untreated. Indeed, many doctors, teachers, and therapists have never even heard of CAPD. What does a child with CAPD look like? Children with different CAPD subtypes will show different patterns of dysfunction, and most children with CAPD will show only a few of the symptoms we’ll discuss. No child will show all of the symptoms described in the following paragraphs.

In addition to the types of dysfunctions just described, children with certain CAPD subtypes may show difficulties with reading, phonology, and spelling. There is a close connection between the ability to process the sound structures of words and the ability to learn to read and spell. In fact, nearly 60 percent of dyslexics show significant deficits on CAPD testing.

The dysfunctions of CAPD can lead to significant social and emotional difficulties in children. Those with hypersensitivities may become agitated or anxious, and are often labeled as attention-seeking or immature. Others have difficulties engaging in social communication and are often unable to follow the thread of a rapidly changing conversation. These children are forever off-topic or one step behind.

Within their peer group, children with CAPD may have difficulty adopting the tone of social communication and may speak with distinctive diction, cadence, tone, or emphasis. They may have difficulty speaking interactively, or following up on another person’s interests. They may hinder discussions with repeated requests for clarification, or by returning to points others have already left. They may have difficulty catching the point of a joke or laugh only after a long delay. Furthermore, these children may show significantly prolonged “processing times” and an equally prolonged lag before answering. As a result, they may appear to others to be rude, unresponsive, stupid, slow, “uncool,” or just no fun to be around.

Consequently, children with CAPD frequently receive discouraging and disparaging feedback from others. Parents and teachers may berate them for their slowness; failure to listen or follow directions; and their apparent selfishness, self-absorption, or lack of interest in others. Often these children suffer from feelings of guilt and low self-esteem. They feel unloved, unlovable, a burden to others, and somehow deserving of the hostile treatment they receive for reasons they are helpless to understand. All too often they become anxious, depressed, and socially withdrawn; and when help is offered, most often it is in the form of counseling or medications to treat the emotional and behavioral consequences of their misdiagnosis and resulting mismanagement. Meanwhile, the underlying and ultimately responsible CAPD goes undiagnosed and untreated.

Many times children with CAPD are suspected of having attention deficit/hyperactivity disorder (AD/HD) because they can appear distractible or inattentive. Also, they often show signs of dysfunctional sensory and sensorimotor processing, which can result in motor hyperactivity, sensory seeking, and sensory distractibility. When CAPD children with auditory hypersensitivities become over-stimulated by noise, they are especially likely to be diagnosed with AD/HD. There are, however, behavioral characteristics that help differentiate children with AD/HD from those who have CAPD. (Chermak, G., Hall, J., and Musiek, F., 1999).

	Children with AD/HD	Children with CAPD
	Have a higher incidence of hyperactivity, restlessness, impulsivity, and interruptions or intrusions Are inattentive across more situations	Are more likely to show difficulty hearing in background noise Have trouble following directions Display poor listening skills and poor auditory association skills Typically show distractibility and inattentiveness during tasks with significant auditory demands

Children with CAPD may also be mistakenly diagnosed with Asperger Syndrome or autism spectrum disorders. Often, because of unusual timing in their speech or prosody (the melodic sound of speech), or because of difficulties with social interactions due to their inability to process sound, these children are mistakenly assumed to be emotionally cold, distant, or unable to perceive human feelings. Paradoxically, the children are usually affectionate and loving with their families. This mistaken diagnosis is especially common among gifted children who often have vocabularies and interests that appear unusual for their age, and who pursue their interests with an intensity bordering on obsession.

Conclusion

It’s important to remember that auditory impairments, including CAPD, are seldom “all or none” phenomena. Any child who frequently mishears words, misses instructions, has difficulty rapidly and accurately processing verbal information, has trouble with the prosodic (melodic) aspects of speech, or has noticeable difficulty hearing in background noise, should be suspected of having an auditory processing deficit and should receive a thorough evaluation. This is especially true of children with risk factors for auditory impairments, which include:

History of frequent or prolonged ear infections
Head trauma
Birth distress or prematurity
Craniofacial or external ear abnormalities
Meningitis or other significant peri- or prenatal infections
Family history of CAPD or other auditory impairments.

If Your Child Has
Prosodic Speech Deficits...

Prosody refers to the melodic sound of speech, including rhythm, intonation, and stress. Children with prosodic auditory deficits often benefit from speech therapy that improves their perception of the rhythms, inflections, and intonations of speech. Too often children with these deficits are herded into social skills classes where noise and other distractions prevent necessary attention to the subtle sound qualities they are trying to develop. The focus of these classes also tends to center more on cooperative play and social interaction than on speech prosody per se. One-on-one training which focuses on these skills better serves these children.

Processes that Comprise the Central Auditory Processing System and Possible Processing Deficits
Processes*	Description	Symptoms of Deficits
Sound localization and lateralization (also called binaural interaction)	The ability to discern that sounds are coming from different sources or locations	· Difficulty hearing with background noise (the most common symptom) · Difficulty identifying or looking toward speakers · Easily distracted by competing noise
Auditory discrimination	The ability to distinguish between different sounds	· Difficulty in recognizing words or comprehending speech in quiet and noisy environments · Difficulty distinguishing the melodic (prosodic) aspects of speech
Auditory pattern recognition	The ability to recognize patterns in sounds (e.g., duration, pitch, and volume) and in the intervals between sounds; commonly grouped with the next category due to the inextricable links between such patterns and the characteristics of timing	· Difficulty determining sound order in words (e.g., past versus pats) · Difficulty perceiving the different emphasis in dime versus time or pat versus bat · Difficulty hearing the rhythmic and melodic (or prosodic) elements of speech and music · Difficulty in recognizing words or comprehending speech in quiet and noisy environments
Temporal aspects of audition: · Temporal resolution · Temporal masking · Temporal integration · Temporal ordering	The recognition of time-related cues in acoustics
Auditory performance decrements with competing acoustic signals	The ability to attend to some information while ignoring other information	Inability to listen to one person speaking when others are talking or background noise is present
Auditory performance decrements with degraded acoustic signals	The ability to process incomplete or corrupted signals	· Difficulty understanding someone speaking softly or with a strong accent · Difficulty filling in gaps in a message when information is missing or distorted such as in a conversation when a cell phone is cutting out

*As identified in the 1996 report published by the American Speech Language Hearing Association (ASHA) Task Force on Central Auditory Processing: “Central Auditory Processing: Current Status of Research and Implications for Clinical Practice” (American Journal of Audiology, 5, 41-54)

Chermak, G., and Musiek, F. (1997). Central Auditory Processing Disorders: New Perspectives. San Diego, CA: Singular Publishing Group.

Chermak, G., Hall, J., and Musiek, F. (1999). Differential diagnosis and management of central auditory processing disorder and attention deficit hyperactivity disorder. Journal of the American Academy of Audiology, 10, pp. 289-303.

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.

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/.

What Does CAPD Look Like?

November, 2006