Question:

Dear Shari;

I am an elementary school resource specialist. I work with a ten year-old student who has extreme difficulty following oral directions in the general class. His effort, learning and attention are extremely inconsistent and he is behind academically, though he has average ability. He was diagnosed with AD/HD three years ago and once took medication but it did not seem to work well. Since he resisted taking medication, his mother stopped giving it to him. In general, his behavior and social interaction are not a problem, but in class, he is “spaced out” and does not seem to understand what is going on. He does fine in 1:1 situations or in a quiet room. Could he have central auditory processing disorder in addition to or instead of AD/HD?

Thanks
Paula

Answer:

Dear Paula;

Thank you for the interesting but complex question. I say “complex” because AD/HD and central auditory processing disorder (CAPD), also known as auditory processing disorder (APD) have symptoms that overlap significantly. In fact, psychologists and audiologists have questioned whether the disorders have distinct identities. Most authorities agree that the two can occur together or separately. Eighty four percent of children who have been diagnosed with (C)APD also have AD/HD(Geffner). (C)APD is estimated to occur in 45 to 75% of children with AD/HD (Brown).

The reason for this is that both disorders involve problems with attention. In paper in 2005, the American Speech and Hearing Association defined (C)APD as “difficulties in the processing of auditory information in the central nervous system (CNS) as demonstrated by poor performance in one or more of the following skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination (e.g., temporal gap detection), temporal ordering and temporal masking; auditory performance in competing acoustic signals (including dichotic listening); and auditory performance with degraded acoustic signals.” In short, the child can hear information but has difficulty attending to, storing, locating retrieving and/or clarifying that information to make it useful for academic and social purposes. For additional information on the technical definition of (C)APD refer to:

American Speech and Hearing Association(Central)Auditory Processing Disorders – The Role of the Audiologist: Working Group on Auditory Processng Disorders.available at: http://www.asha.org/default.htm

In layperson’s terms, (C)APD is the impaired ability to attend to, discriminate, remember, recognize, or comprehend information presented auditorily in persons with normal intelligence and normal hearing. (C)APD influences a child’s behavior, social interaction and often impedes phonics and other literacy skills.

A diagnosis of (C)APD requires demonstrating that a child’s auditory problems involve a deficit in the neural processing of auditory stimuli. When the ears hear sound, the auditory stimulus travels through the structures of the ear to the central auditory nervous system that extends from the brain stem to the temporal lobes of the cerebral cortex. The auditory stimulus travels along the neural pathways where it is “processed.” This processing allows the listener to determine the direction from which the sound comes, identify the type of sound, separate the sound from background noise, and interpret the sound. (ERIC Digest) (C)APD should be diagnosed by an audiologist. Before referral to an audiologist, a multidisciplinary team including a speech and language specialist, a psychologist and educator should complete a full assessment to gather information about auditory and other possible factors that contribute to the child’s difficulties. These professionals also need to be involved because they will be responsible for implementing treatment.

Most authorities acknowledge that discriminating between (C)APD and AD/HD, particularly inattentive type, is difficult if not impossible. The reason for this is that children with AD/HD usually have auditory processing difficulties. Donna Geffner, a speech and language specialist has compiled a list of auditory processing difficulties common to children with AD/HD and (C)APD:

• Hyperacusis . Hearing levels are often better than normal. For example, parents sometimes report that the child hears an airplane before it approaches.

• Hypersensitivity. Children with AD/HD are often hypersensitive to loud noise and have reduced tolerance for noise.

• Poor speech discrimination in noise. Individuals with AD/HD have difficulty listening in noisy situations.

• Easily distracted when background noise is present.

• Reduced auditory memory for directions and sequences. Children with AD/HD and (C)APD both have difficulty following directions, especially in a noisy classroom.

• Short-term auditory memory deficits. Individuals with AD/HD often remember only part of a command. A common characteristic is recall of only the first or last part of a sequence.

• Auditory closure. Individuals with AD/HD often have difficulty filling in the missing sounds of a word when parts of the word are missing.

Dr. Geffner has published a checklist to assist in diagnosing auditory deficits in children with AD/HD in her book:

Attention-Deficit/Hyperactivity Disorder: What Professionals Need to Know. Eau Claire, WI: Thinking Publications. (available at Amazon.com or from the publisher)

About the only characteristic distinguishing children with AD/HD from children with (C)APD is visual distractibility. Children with AD/HD will be distracted by a person walking by, even if no sound is apparent and may be overwhelmed by visual clutter.

If you are concerned about the possibility that your student might have (C)APD in addition to AD/HD consider sharing his symptoms with his educational team, including his parents. Should they be interested in pursuing this further, remember that diagnosis requires a full multi-disciplinary assessment, including assessment by an audiologist.

Some online resources to share are:

Auditory Processing Disorder in Children . National Institute on Deafness and Other Communicaiton Disorders. Available at:

http://www.nidcd.nih.gov/health/voice/auditory.asp

Cleveland, Sandra. Central Auditory Processing Disorder: When is Evaluation Referral Indicated? The ADHD Report. Vol 5, No.5, October, 1997. Available at:

http://www.ldonline.org

Paton, Judith. Central Auditory Processing Disorders (CAPD’s).

http://www.ldonline.org/ld_indepth/process_deficit/capd_paton.html