Do You Hear What They Hear?
While auditory processing disorder (APD) isn't as well known as ADHD, it is becoming increasingly common. Roughly 7 percent of children have some type of auditory processing difficulty.
But what is it exactly? At its most general, APD is a glitch in the brain's ability to filter and process sounds and words. An APD child doesn't have difficulty hearing — in fact, in most cases, her hearing is good. Rather, her brain perceives the sounds incorrectly, affecting the child's ability to distinguish between similar sounds (da and ga, for example).
Some children with APD also have trouble screening out background noise, so they pick up bits of surrounding sounds. The echo in a gymnasium or the hum of the air conditioner in the classroom interferes with the conversation at hand. It's like listening to the radio with interference from other stations garbling the reception.
A child with the disorder typically tries so hard to understand what's being said that she forgets parts of the conversation or doesn't pick up on the nuances or subtleties of the words. Combine APD with ADHD, and a child's abilities to listen and remember are severely compromised.
Sorting Out Symptoms
Just as APD can affect a child's ability to focus, so an attention deficit can affect auditory processing. Symptoms of the two disorders often overlap. Studies suggest that 50 percent of those diagnosed with ADHD may also have APD. Experts continue to disagree whether APD is a manifestation of ADHD, or if they are separate disorders.
How can a parent tell if his or her ADHD child has APD? In general, children with ADHD exhibit inattention, distractibility, and hyperactivity in any environment. Children with APD, on the other hand, usually don't have difficulty focusing and paying attention in a quiet space. But many children with APD are exquisitely sensitive to sound. In fact, some sounds can "hurt" — a blender, a train engine, police sirens. My daughter, who has APD, plugs her ears before the movie previews, in case the sound gets loud.
"Children with ADHD may be poor listeners and have difficulty understanding or remembering verbal information," explains Teri James Bellis, author of When the Brain Can't Hear, but "it is the attention deficit that is impeding their ability to access or to use the auditory information that is coming in," not the processing of it in the brain.
A study conducted at the State University of New York in Fredonia looked at the effects of Ritalin on auditory processing in children with both ADHD and APD. The drug didn't improve auditory processing, despite improving children's performances on a standard test that measured attention and impulsivity.
Do you think your child's poor performance in school and his social awkwardness may be caused or exacerbated by APD? Here are the facts to help you determine whether this is the case and which treatments may help.
The underlying cause of APD isn't known. Experts debate whether heredity or environment — or both — are responsible for the condition. While the human auditory system is fully developed at birth, auditory pathways don't mature until the age of 10 to 12. Because of this, early influences — such as poor prenatal nutrition, a mother's exposure to cigarettes or alcohol, childhood malnutrition, and chronic ear infections — may negatively affect auditory processing. Premature birth, low birth weight, Lyme disease or other brain infections, closed head injury, and exposure to low levels of heavy metals (lead or mercury) may also play a role. The good news is that, because the auditory pathways continue to develop up until adolescence, APD is responsive to early intervention.
Three Disorders in One
Jack Katz, M.D., a pioneer in the field of auditory processing disorder, says that APD comprises three distinct conditions that often overlap but may occur in isolation.
Sound discrimination problems. When children learn to talk, they mimic the sounds they hear to produce speech. A child with APD may not speak clearly, using similar ("dat" instead of "that"; "free" instead of "three") rather than exact sounds long after peers have corrected themselves. Typically, children with faulty sound discrimination will run words together and drop word endings and unemphasized syllables when speaking. Reading and spelling may also be affected.
Auditory memory problems. This part of the disorder makes it difficult for a child to memorize numbers and facts, and also affects his reading and language skills. Children with auditory memory problems typically take longer to learn their telephone numbers and addresses, and have difficulty remembering basic math facts. Verbal instructions and lists are similarly tough to retain.
Language processing problems. This component of APD is the most troublesome. It affects a child's abilities to understand what's being asked of him and to socialize with peers. A child with this cognitive glitch has trouble taking oral tests and becomes confused when reading and telling stories with lots of characters and events. He will often pass up a chance to hold a conversation because of the time it takes to process words being spoken and to formulate responses.
Christina suffered from all three elements of APD. She never sang as a small child, even though she clearly enjoyed listening to music and to others' singing. "Christina could never put everything together — the words, the rhythms, the tunes," says her mother, Tricia. "Her hearing was fine — exceptional. But put her into a circle of kids singing nursery rhymes and playing spoons and tambourines, and all she wanted was to get away!" When Christina was finally diagnosed with APD, Tricia was relieved.
"Not all language problems are due to APD, and not all cases of APD lead to language and learning problems," cautions Bellis. APD isn't diagnosed by checking off a laundry list of symptoms.
The only way to diagnose the condition is with a battery of tests, performed by an audiologist who monitors the child's hearing. A child listens to words and sentences as background noise is slowly increased and to instructions spoken at faster speeds, to determine if the ability to listen decreases.
A child should be at least 6 or 7 years old before undergoing testing. "The symptoms you commonly see in a 3- or 4-year-old are sound sensitivities and difficulties discriminating between sounds, which you'll hear in their speech," explains Wendy Tepfer, a speech and language pathologist in New York City. "They need to work with an expert in APD."
When a child reaches school age, however, Tepfer advises that APD may begin to compromise academic success. "At that age, I would recommend evaluation for APD," she says, "because now, it's not only the language but also his performance in the classroom. To manage the disorder, the student may need remediations other than speech and language therapy. A full evaluation will help you know what those are."
APD can be treated from childhood through adolescence — when the auditory pathways stop developing — and even later, although experts agree that the earlier the diagnosis and treatment, the better. As with ADHD, a combination of professional, school, and home therapies is most effective.
Working with a Professional
Treatment includes a wide variety of exercises that target specific auditory deficits. Therapy can range from computer-assisted software programs like Fast ForWord and Earobics to one-on-one training with a speech and language therapist. Here are some common approaches:
- To overcome sound discrimination problem, a professional trains the child's brain to differentiate sounds — first in a quiet environment, then with increasingly louder background noise.
- To sharpen auditory memory, an audiologist uses sequencing routines — having the child repeat a series of numbers and directions — to exercise the listening "muscles."
- To manage language-processing problems, a therapist will train and encourage a child to ask a teacher, adult, or peer to repeat or rephrase an instruction or comment. The therapist and child might also work on developing a customized note-taking system that enables him to capture the information being taught in the classroom.
Classroom accommodations can often include:
- Improving the acoustics — closing a window, shutting a door, adding a rug — can help an APD child "hear" the teacher.
- Seating a child in the front of the classroom, away from students who might be disruptive, will also enhance a child's ability to listen.
- Asking a teacher to face a child, speak slowly, and use simple sentences when giving assignments can help an APD student retain the information. Writing instructions on a blackboard or a piece of paper can reinforce what was said.
The following tips will increase your child's ability to listen when he or she is at home:
- Don't try to have a significant conversation when your child is in another room, watching television, or listening to music - or when an appliance is running.
- Before you start a conversation, be sure your child is ready to listen (finished with what she was doing). Also, face her directly and make sure she's looking at you.
- Speak slowly and use simple, short sentences; pause between ideas.
- Encourage your child to ask you to repeat something that he doesn't understand.
Christina, now 11, has learned to use the latter strategy — asking questions until she grasps what's being said — with friends, parents, and teachers. "It's been successful for her," says Tricia. Eight years of speech and language therapy have helped her daughter accomplish many of her social and academic goals.
But Christina did something that her mother thought she'd never achieve — joining the chorus. "There she was, on stage, at the parents' day assembly, singing her heart out, and playing drums!" says her mother. "She was so proud of herself, and I was the only fourth-grade mom with tears streaming down her cheeks."