1. Central Auditory Processing Disorders
Presented by
Susan Lieb, MA, CCC-SLP and
James Garrity, NCSP,
School Psychologist

3. Definition of CAPD- from an auditory behavioral perspective) (from American Speech Language Hearing Association Technical Report, 2005)
The perceptual processing of auditory information in the Central Nervous System
Includes auditory mechanisms that underlie sound localization, auditory discrimination, auditory pattern recognition, temporal aspects of audition, auditory performance in competing acoustic signals and degraded acoustic signals

4. Definition of CAPD- from a top-down, general perspective
What is done with what is heard

5. Nature of CAPD
A deficit in neural processing of auditory stimuli that is not due to higher order language, cognitive, or related factors but
May lead to or be associated with difficulties in higher order language, learning and communication functions
May coexist with other disorders (ADHD, language impairment and learning disability)
It is not the result of these other disorders
Occurs in the absence of peripheral hearing loss

6. Associated Difficulties in School-aged Children
Learning
Speech
Language (including written language involving reading and spelling)
Social and related functions

7. Prevalence of CAPD 2-5% of school age population
2:1 ratio of boys to girls
(Chermak & Musiek, 1997)

8. Some Caveats
Language comprehension problems can occur in the presence of normal CAP.
CAPD does not always present with language problems.
Different combinations of auditory deficits are likely to be associated with different functional symptoms.
The same auditory deficit may have an impact on different people in different ways, based on each person’s unique confluence of “bottom up” and “top-down” abilities and on the extent of their neurobiological disorder, as well as other factors that affect CNS function.
We should not automatically assume that CAPD is the underlying cause of a learner with cognitive or language disorders without appropriate auditory diagnostic measures.

10. Characteristics of CAPD-one or more of the following behavioral characteristics may be present
Difficulty understanding spoken language in competing messages, noisy backgrounds, or in reverberant environments
Misunderstanding messages
Inconsistent or inappropriate responding
Frequent requests for repetitions,
Saying “What” and “huh” frequently
Taking longer to respond in oral communication situations

11. Characteristics, continued
Difficulty paying attention
Is easily distracted by auditory and visual stimuli
Difficulty following complex auditory directions or commands
Difficulty localizing sound
Difficulty learning songs or nursery rhymes
Poor musical and singing skills
Associated reading, spelling and learning problems
History of Otitis Media
Has memory deficits, both short term and long term

12. Some Behavioral Differences Between CAPD and ADHD
CAPD-an input disorder in which perceptual details are not properly transmitted by the central auditory system to the central processors.
Some inattention and distractibility
Difficulty hearing in background noise
Difficulty following oral instructions
Selective or divided attention problem (child can sit and listen until competing noise is introduced)
ADHD-an output disorder involving an inability to control behavior
Inattention and distractibility more prominent in children with ADHD
Difficulty hearing in background noise and following oral instructions not as pronounced.
Sustained attention problem.

13. Diagnosis An audiologist is the professional who diagnoses CAPD.
A multidisciplinary assessment involving other professionals should be used to determine the functional impact of the diagnosis, and to guide treatment and management of the disorder and associated deficits.
Peripheral hearing loss must be ruled out.
ADHD must be ruled out or medically treated.

14. Diagnosis, continued
Task difficulty and performance variability make test results on children under the mental age of 7 questionable.
Maturational age of auditory cortex is between 10-12
Children must have a cognitive level high enough to follow the directions.
Receptive vocabulary should be within an age-appropriate range.
Diagnosis generally requires deficits of at least 2 standard deviations below the mean on 2 or more tests in the test battery.

15. Symptom Comparison Chart

16. Intervention Strategies Tripod approach
Direct skills remediation- 2 main models of evaluation, identification and remediation:
The Buffalo Model
Bellis/Ferre Model
Compensatory strategies
Environmental modifications

17. The Buffalo Model (Jack Katz, PhD)
Decoding- difficulty analyzing auditory information, may have difficulty with temporal processing
Tolerance-Fading Memory- may have impulsivity and forgetfulness in response to auditory information, sensitive to noise, difficulty completing multi-step directions
Integration- difficulty putting auditory and non-auditory information together
Organization- difficulty with auditory sequencing, may occur with decoding or tolerance fading memory

18. Bellis/Ferre Model
Auditory decoding deficit- difficulty with speech in noise, speech discrimination, sound blending, retention of phonemes, blending, speech to print may be poor.
Integration deficit- difficulty with multimodality tasks that require inter-hemispheric transfer of information
Prosodic deficit- difficulty with humor, multiple meanings and utilizing information in suprasegmentals of speech
Associative deficit- may demonstrate receptive language difficulties, cannot apply rules of language to incoming auditory information
Output-Organization- difficulty in sequencing, planning and organizing responses.

19. Environmental Modifications
Enhance the listening environment through preferential seating and/or improving access to the acoustic signal
Use of visual aids
Assistive listening devices/systems
Reduction of competing signals and reverberation time
Advising speakers to speak more slowly, pause more often, and emphasize key words.

20. Bellis and Ferre CAP Deficit Profiles (based upon analysis of CAP test results)
PRIMARY SUBPROFILES:
Auditory Decoding Deficit
Prosodic Deficit
Integration Deficit
SECONDARY SUBPROFILES:
Associative Deficit
Output-Organization Deficit

21. Auditory Decoding Deficit- associated with primary auditory cortex dysfunction
Associated Behaviors
Spelling Difficulties
Reading/writing difficulties
Speech in noise difficulties
Sound blending difficulties
Management Strategies
Improve acoustic clarity-consider FM
Auditory closure activities
Speech sound/phoneme training
Speech-to-print skill training
Preteach new information

22. Classroom Activities for Auditory Decoding Deficits
Auditory closure activities, first with familiar subject matter, moving on to unfamiliar messages.
Vocabulary building exercises in which the listener uses context to derive word meaning
Phoneme training starting with minimal contrast pairs in isolation, syllables, then words.

23. Prosodic Deficit- associated with right-hemispheric dysfunction
Associated behavior
Difficulty judging communicative intent
Difficulty with humor, multiple meaning words
Difficulty with perception and use of prosody
Monotonic speech
Mathematics calculation difficulties
Management strategies
Placement with animated teacher
Prosody training
Key word extraction
Encourage music/dance lessons
Reading aloud

24. Classroom Activities for Prosodic Deficits
Teach different forms of poetry, noting rhythm, emphasis and stress in sentences and words
Change the stress patterns in multi-syllabic words to show how acoustic factors change the meaning of a word or sentence (Eats, Shoots and Leaves, for example)
Teach sound discrimination, using environmental sounds differing in intensity, frequency, duration or quality.

25. Integration Deficit-corpus callousum is not transferring information from one hemispher to the other
Associated Behaviors
Reading, spelling and writing problems
Poor speech in noise skills
Memory problems
Poor coordination
Poor music skills
Management Strategies
Provision of a notetaker
Limit use of multimodality cues
Interhemispheric exercises
Encourage music/dance training
Key word extraction

26. Classroom Activities
Interhemispheric activities (reading a poster where color names are in a different color than the written word, barrier games, singing and musical instrument lessons)
Lots of repetition. Rephrasing may be confusing.
Key word detection. Reading aloud with emphasis on word/phrase.
Word sequence discriminating (pen-pin-pen)
Memory games

27. Associative Deficit-secondary subtype
Associated Behaviors
Receptive language problems including semantics, syntax and vocabulary
Difficulty comprehending information of increased linguistic complexity
Poor reading comprehension
May surface around 3rd grade with increased linguistic demands within the classroom
Management Strategies
Rephrase speech using smaller linguistic units
Speech-language therapy focusing on receptive language
Systematic learning approach
Rule-based approach

28. Classroom Activities for Associative Deficit- left (associative) cortex
Train child on chunking methods, verbal rehearsal, outlining and other organizational strategies
Use sequencing words: 1st, next, last
Paraphrasing
Webbing, mapping, study skills to aid in comprehension and recall
Inferencing tasks
Alternative endings to stories
May perform better on multiple choice or other closed set tests rather than open-ended questions
External organization in the classroom will help the child with independent work
Speech-language therapy

29. Output/Organization Deficit- temporal-to-frontal and/or efferent system
Associative Behaviors:
Poor hearing in noise
Poor organizational skills
Motor planning difficulties
Difficulties with expressive language and word retrieval
Poor sequencing and follow-through
Management Strategies:
Highly structured environment
Training in use of organizational aids
Speech-language therapy focusing on expressive language
Enhanced listening environment

30. Suggested Classroom Activities for Output/Organizational Deficit
Language intervention is often a key component in remediation.Activities can include:
1. Ordering and sequencing
2. Verbal rehearsal and mnemonic devices
3. Retelling stories
4. Describing pictures (ex.: making captions for comic strips, box by box)
5. Using visualization techniques and visual imagery.
6. Outlines, checklists and specific notebooks for class assignments are beneficial.

31. Summary of Bellis Ferre Subtypes
DECODING (primary auditory cortex)
LOOKS LIKE
Speech in noise
Sound discrimination
Sound blending
Poor phoneme retention
STRATEGIES
Phoneme discrimination
Pattern recognition
Listening in noise
Writing to dictation
ACTIVITIES
Auditory closure
Vocabulary building
Phonemic training
PROSODIC (right hemisphere dysfunction)
Difficulty with communicative intent
Difficulty with humor and multiple meaning words
Monotonic speech
Difficulty with perception and use of prosody
Animated teacher
Prosody training
Key word extraction
Dance/music lessons
Read aloud
Teach poetry
Change stress patterns
INTEGRATION (corpus callosum)
Reading, spelling and writing problems
Poor speech in noise
Memory
Coordination
Poor music skills
Provide note taker
Limit multimodal cues
Music/dance lessons
Interhemispheric exercises
Interhemispheric activities
Lots of repetition
Memory games
Word sequence discriminating

32. Bellis Ferre Subtypes, continued
ASSOCIATIVE
(left cortex)
Receptive language including semantics, syntax and vocabulary
Difficulty comprehending information of increased linguistic complexity
Poor reading comprehension
Often does not surface until around 3rd grade
Rephrase (not repeat)
Give information in smaller units
Rule based, systematic approach to learning
Child needs frequent breaks due to fatigue on system from processing
Speech-language therapy for receptive language
Explicit teaching of rules of grammar
Chunking methods
Inferencing tasks
Tag words (1st, next, last)
Webbing, mapping
Paraphrasing
OUTPUT/ORGANIZATION
(temporal to frontal or efferent system)
Poor hearing in noise
Poor organizational skills
Motor planning difficulties
Difficulties with expressive language and word retrieval
Good comprehension, poor spelling and writing
Poor sequencing and follow-through
Use of organizational aids
Visualization techniques
Verbal rehearsal and mnemonic devices
Highly structured environment
Repeat and rephrase information
Use smaller linguistic units
Metacognitive techniques to improve listening and organizational skills
Expressive language speech-language therapy

33. Summary CAPD is complex, and heterogeneous.
A multidisciplinary approach is required for evaluation, classification and treatment.,
The “tripod” management approach of direct therapeutic remediation, environmental modifications and compensatory strategies work in concert to strengthen higher- order, top-down skills so that greater effort can be spent on the more difficult bottom-up remediation activities.
Strengthening active listening techniques, linguistic, metacognitive and metalinguistic skills enable students to recognize conditions that interfere with learning and enable the child to improve listening outcomes for him or herself.

34. References
American Speech Language Hearing Association (ASHA) “Central Auditory Processing Disorders Technical Report”
American Speech Language Hearing Association (ASHA) 1996, “Central Auditory Processing: Current Status of Research and Implications for Clinical Practice”, American Journal of Audiology, Vol. 5
Bellis, Teri James, “Subprofiles of Central Auditory Processing Disorders”
Iskowitz, Marc, “Assessing and Managing CAPD”, ADVANCE for Speech-Language Pathologists and Audiologists, July 26, 1999.
Katz, Jack “APD Evaluation to Therapy: The Buffalo Model”
Matson, “Central Auditory Processing: A Current Literature Review and Summary of Interviews with Researchers”
McGlynn, Michele and Barbara Adams “Assessment and Management of Auditory Processing Disorders: Case Studies”, 2002
Mosheim, Jason, “Auditory Processing Disorders”, ADVANCE for Speech-Language Pathologists and Audiologists
Phonak, “Building the Link Between Hearing, Understanding and Learning”, Edulink,
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