Early intervention is a key tenet in audiology, except when it comes to Auditory Processing Disorder. This case study report argues that early intervention, with appropriate cautions, is also possible for children with APD.
Dr Bill Keith is Director of SoundSkills APD Clinic. Dr Suzanne Purdy is Professor and Head, Discipline of Speech Science, School of Psychology at the University of Auckland. The other co-authors are members of the SoundSkills APD Clinic multi-disciplinary team.
Balancing diagnostic considerations and the benefits of early intervention in the management of Auditory Processing Disorder: A case study report
Published in the New Zealand Audiological Society Bulletin, July 2014, 24:2, 11-22
William Keith, Suzanne C. Purdy, Anne Toth, Emma Russell, Chloe Young, Isabella Wojciechowski, Jenny Coutts, Jill Tyler
The SoundSkills project to develop a scalable model multi-disciplinary specialist auditory processing disorder (APD) clinic is in its fifth year. One of the many issues faced is the lower age limit at which APD can be diagnosed and intervention initiated. At our free monthly APD seminars for parents and professionals we often ask the question At what age have you heard APD can be diagnosed? The answer is usually seven years. This is a common belief and practice though some clinics in New Zealand and overseas only see APD cases from age eight. The belief that management of APD should be deferred until age seven is attributed to three factors. Firstly, some early APD tests were only normed on children down to age seven. Secondly, parts of the central auditory nervous system do not fully mature until adolescence or young adulthood, especially in the case of myelination of the corpus callosum which can continue into the early 20s (Yap et al, 2013). Thirdly, and in part because of these maturational factors, behavioural measures on young children show greater variability than behavioural measures on older children; hence behavioural test results on young children have to be interpreted with caution. However, these factors do not impede early intervention for other types of deafness.
In fact several APD tests and auditory skill assessment tools have norms for children younger than seven. These tools enable assessment of some auditory skills from age three or three years six months upwards with the proviso that it is important to keep in mind the variables mentioned above and cautions about making a definitive diagnosis in young children. Suspected diagnosis of APD in children below the usual age range for testing is qualified by SoundSkills as being at risk for, provisional, or criteria for diagnosis not met but auditory skill deficits are confirmed. Follow-up is scheduled to enable more comprehensive and definitive testing when the child is older.
Fortunately APD treatments are not harmful and generally are of benefit to most children. Hence early intervention when auditory deficits are suspected is very feasible. This paper presents two case studies on intervention in cases of suspected APD in young children.
It is well established that early intervention for hearing and learning disorders is critical if the effectiveness of treatment is to be maximised. This applies to auditory processing disorder (APD) just as much as to any other type of deafness. Yet it is also often stated that children cannot be assessed for APD until age 7 or even age 8. This viewpoint came about because some early APD tests only had norms for children from about age 7, and also because there is considerable variability in auditory performance on tests in young children.
At SoundSkills we believe that early intervention is critical. Not only does it enable early treatment of the hearing disorder, it helps the child to start learning more effectively as soon as possible. If children are not diagnosed and treated until after they have been at school for a number of years their impaired ability to hear and learn has led to them falling further and further behind.
Most APD tests can be administered from age 6. A number of assessments can be carried out at age 5. And more limited assessment can be carried out on even younger children. The youngest age at which we assess for APD is 4 years. Different tests and different norms are used according to age.
We make it clear that below age 6 we can only make a provisional diagnosis or a diagnosis of at risk for APD, with the necessity to follow up when the child is older. If the child does not perform well on tests it is important to observe whether there might be another explanation for the poor performance. It is also important to consider the test results in the broader context of observations by parents, teachers and other professionals. Usually children referred to us with suspicion of APD at ages 4 to 5 have quite clear and obvious hearing problems.
Fortunately treatments for APD are not harmful and in fact are usually generally beneficial to any child. Therefore a provisional diagnosis does not prevent a trial of intervention. We have seen good responses to intervention on the very youngest of our clients.
This is a helpful checklist if you’re a teacher working with APD in the classroom.
- Preferential seating
- Within 2m of teacher (unless wearing remote microphone hearing aids)
- Seated away from auditory distractions such as doorways or air conditioners
- Gain students attention before speaking
- Face student when speaking
- Limit distracting noises where possible
- Use clear speech with student
- Use a slightly reduced rate
- Use slightly increased volume
- Emphasise key words
- Pause often
- Repeat or rephrase as needed to ensure message has been understood
- When giving instructions:
- Give written as well as verbal instructions for home and class work
- Give clear and specific instructions without using too many words
- Link verbal instructions to visual cues to help the student remember
- Avoid multi-tasking (e.g writing while listening)
- Use a buddy who can then confirm what has been said
- Be aware that students who struggle to process information tend to fatigue more easily
- Consider having breaks in listening
- Consider the time of day when presenting auditory tasks
- Give adequate response time
- Allow the student time to work out the answer. For example, let the student know that you are coming back to them for an answer and ask someone else a question before coming back to them.
- Allow extended time to complete tasks More time is needed to comprehend
- Encourage the student to self-monitor the listening environment and identify any problems
The Ministry of Education was criticised for its discrimination against children with Auditory Processing Disorder (APD) by the CEO of the National Foundation for the Deaf, Louise Carroll, on TV1 News. The news item focused on ten year old Lachlan who needs remote microphone hearing aids to hear well in class.
Children with hearing loss due to any other cause receive free hearing aids from the Ministry of Health. However under current government policy, children with APD are singled out and may only apply to the Ministry of Education for hearing aid funding. The problem is that the Ministry of Education disallows applications in the majority (90% or more) of cases. This is a major inequity compared to other children who need hearing aids, and to adults. Even the wealthiest of adults with hearing impairment are entitled to a subsidy of $1022.22 towards hearing aids.
Critics believe that hearing aid fitting is a health matter, that the Ministry of Education is not an appropriate organisation to be fitting or funding hearing aids, and that hearing aids for children with APD should be managed and funded by the Ministry of Health on the same basis as hearing aids for children with other types of deafness.
At least one child in every New Zealand classroom is believed to have a hearing problem that can seriously affect their ability to learn.
Auditory processing disorder (APD) is believed to affect from three to 15 per cent of children and can be difficult to detect as it is not picked up by a normal hearing test.
As a result, many children continue to struggle with reading, writing, spelling and often lose interest in school altogether.
Dr Bill Keith is an audiologist with 40 years’ experience who now deals solely with APD.
He said the problem is worse in boys than girls and can be caused by birth trauma or early history of glue ear.
In the past year Dr Keith has seen nearly 100 children, mostly from Auckland, who struggled in school before being diagnosed with APD.
He said he is now getting about half a dozen new referrals each week, many from friends and relatives of diagnosed children.
Children with the disorder are not deaf – which is why it’s not picked up in normal hearing tests.
Their ears process sounds normally but the brain struggles to understand what is being said, especially when there are competing noises, such as in a classroom.
As a result children have trouble following instructions that are lengthy or require more than one task and that is often reflected in problems with reading, spelling and language.
“APD can present as a learning or behavioural problem and can cause underachievement because these children are missing out on vital information,” said Dr Keith.
“The problem lies in the hearing pathways and centres in the brain. Children are unable to extract the message they need from all the sounds and noise around them.”
Professor Suzanne Purdy, head of speech science and senior researcher in the Centre for Brain Research at Auckland University, said APD was often overlooked or mistaken for another condition that affects learning and behaviour.
“It is important that children who appear to have poor classroom listening skills, and who are struggling with literacy in particular, be assessed by an audiologist to determine whether APD is an underlying factor.”
Help was available from a FM device which blocked out background noise, enabling children to focus on what they were being told by a parent or teacher.
Over time FM use could also lead to an improvement in auditory skills.
Vauxhall Primary principal Aaron Kemp, who has a child diagnosed with APD in his school, said the FM devices made a huge difference in helping children to follow instructions.
He said children had hearing and vision tests when they start school.
If teachers felt there was still something wrong they usually asked parents to get more comprehensive tests which would hopefully identify something like APD.
Making Sense of Messages to the Brain
Thomas Crook’s reading wasn’t bad, but he wasn’t as good as his twin brother Alex and he was “hopeless” at following instructions, especially ones that involved doing more than one thing.
While many might put that down to different personalities, his mother Helen was worried there was more to it and starting making inquiries that would eventually make a huge difference in Alex’s school life.
“I was chatting to my sister who is a primary teacher in the UK and Thomas’ reading level was certainly not up to the level Alex was reading,” said Mrs Crook.
Her sister quizzed her further on a few subjects, such as whether he was very good at following multiple tasks.
“I said he’s absolutely hopeless at that. You ask him to brush his teeth and put his shoes on and he’ll come back with a sweater. I kind of thought that was just a boy thing and first thing in the morning but evidently there could be more to it than that.”On her sister’s recommendation she took Thomas to have his ears and eyes tested.
These tests found no problems, but staff at the ear-test clinic suggested Mrs Crook take Alex to the Sounds Skills unit at Auckland University if she was still concerned.
Several tests later, Thomas was diagnosed with auditory processing disorder – a problem in which the ear processes the sound but the brain struggles to interpret the message.
To help him, he now wears a discreet FM device at school – two tiny pieces behind his ears which enable him to hear his teacher’s voice more clearly while blocking out other classroom noises.
Thomas’ teacher Zane Cooper said he noticed a big improvement once he started wearing the device last year.
“You suddenly start seeing his hand going up and putting his ideas forward.
“The biggest improvement that I saw in him was his enjoyment at school.
“Once a child can get a full enjoyment out of being in the classroom, the learning follows.”
Mr Cooper encouraged parents to get their children tested if they were worried about possible hearing difficulties.
“You don’t want kids missing three or four years of learning because they can’t process instructions.”
by Elizabeth Binning, New Zealand Herald (Mar 2011)
(Published with permission)
There is at least one child per classroom in New Zealand struggling with auditory processing difficulties and many teachers and parents are not aware of the serious impact this could have on a childs learning.
Auditory Processing Disorder (APD) is a hearing disorder in which the ears process sound normally but the brain cannot always understand or hear. Children with APD may exhibit signs of hearing loss, especially when there are competing sounds at even moderate levels, yet they pass standard hearing tests conducted in quiet. Despite having normal intelligence they may need instructions repeated and may have difficulty following directions in the classroom. In particular they may not respond appropriately to instructions that are lengthy or that include more than one task. Audiologist and CEO of APD specialist clinic, SoundSkills, Dr Bill Keith, says a child who has difficulty understanding verbal instructions and who struggles with reading and spelling could have an auditory processing disorder.
APD affects an estimated 3-15% of children more boys than girls and most go undiagnosed. In the past year weve identifi d close to 100 cases, primarily in Auckland, says Dr Keith. APD can present as a learning or behaviour problem and can cause under-achievement because these children are missing out on vital information says Dr Keith. The problem lies in the hearing pathways and centres in the brain. Children are unable to extract the message that they need to from all the sound and noise around them. Or they have trouble retaining auditory information unless it is brief.
Causes of APD include birth trauma, early history of otitis media (glue ear) and hereditary factors. The condition often occurs in conjunction with other areas of difficulty such as Attention Deficit Disorder (ADD), language and speech sound problems, and reading disorders. It can be the underlying cause of language, spelling, reading and learning disorders. The underlying auditory problem should be addressed before trying to remedy the language, spelling, reading or learning difficulty.
The condition requires specialised testing and assessment, and individualised treatment. A multi-disciplinary team approach is necessary. But, says Dr Keith, the good news is that there is now robust evidence for the effectiveness of a number of interventions including hearing training to improve listening skills, language therapy to improve understanding and wearing a personal FM listening device in the classroom to transmit the voice of the teacher clearly, and lessen the impact of background noise.
Professor Suzanne Purdy, Head of Speech Science and senior researcher in the Centre for Brain Research at the University of Auckland has recently concluded research showing that FM usage delivers a double benefit for children with APD. Firstly it provides immediate assistance with hearing, but over time FM usage also can lead to an improvement in auditory skills so that use of the FM system may not be permanently necessary. Professor Purdy notes that APD is often overlooked or mistaken for another condition that affects learning and behaviour. Her research with colleagues at the University of Auckland and Macquarie University in Sydney has shown that APD often is associated with literacy and language difficulties. It is important that children who appear to have poor classroom listening skills and who are struggling with literacy in particular be assessed by an audiologist to determine whether APD is an underlying factor, says Professor Purdy.
SoundSkills is dedicated to diagnosing and treating APD. SoundSkills audiologists, speech therapists and education adviser provide specialised testing and individually tailored remediation programmes.
Vibrations Autumn 2011
Magazine of the National Foundation for the Deaf
If your child appears to have trouble learning and seems to be “away with the fairies” they could have a hearing problem.
There’s often one in every class – the kid who seems to be off in a world of their own and has difficulty paying attention or following instructions. Some develop behavioural problems and act up, while others try to shrink into the background and not be noticed. Speech and language skills can be affected.
There are many reasons why some children are like this, but one explanation parents and teachers don’t always consider is that they may have a hearing problem called auditory processing disorder (APD).
Called the “hidden disorder” by experts, APD isn’t always picked up. But if it is, the child’s abilities can be greatly improved. It affects between three and 15% of children – more boys have it than girls – and many cases go undetected, but help is available.
What is auditory processing disorder?
It’s a condition in which the ears process sound normally, but the brain can’t always understand what has been said. It’s as if the ears and the brain don’t quite co-ordinate properly.
Audiologist Dr Bill Keith, of the Auckland-based APD specialist clinic Sound Skills, says the problem lies in the hearing pathways in the brain. “Children are unable to extract the message that they need from all the noise around them. Or they have trouble retaining auditory information, unless it’s brief.”
Parents or teachers may suspect a child has a hearing problem, but the child will pass standard hearing tests.
They may also have a normal level of intelligence, but need instructions repeated to them, and may struggle with complicated directions.
What causes APD?
The cause is unknown, but it’s thought there may be links to head trauma – during birth, for example – or an early history of glue ear. It’s also sometimes associated with other conditions, such as dyslexia, attention deficit disorder, autism or developmental delay.
How do you know your child has APD?
It can be hard to pick up – symptoms can range from mild to severe, and can also indicate other conditions. But some behavioural signals include:
- Being easily distracted or unusually bothered by loud or sudden noises
- Getting upset in noisy environments
- Noticeable improvement in behaviour and performance in quiet settings
- Difficulty following directions
- Struggling to read, spell or write
- Difficulty doing verbal maths problems
- Finding it hard to follow conversations
They may also be quiet and shy, have behavioural problems and struggle academically and socially.
How is APD diagnosed?
Specialist clinics can carry out specific tests to see if your child has APD, although they usually don’t check children until they’re seven years old, as some of the skills that need to be evaluated for APD diagnosis don’t develop until they’re around this age.
What treatment is available?
Each child needs individual treatment, and may need to see several specialists, including an audiologist and speech therapist. Treatment options include training sessions to improve listening skills and language therapy to improve understanding, says Dr Keith.
Children may also have great results wearing a personal FM hearing device in the classroom. The teacher wears a microphone which clearly transmits their voice to a small headset worn by the child. This cuts out background noise, making it easier for the child to focus on what the teacher is saying.
Research done by the University of Auckland recently has found that not only do FM aids provide immediate help so children can hear their teachers better, but long-term use may also significantly improve their auditory skills to the point where they can do without the device.
How can you help children with APD?
- Try to cut background noise
- Use simple sentences
- Ask your child to repeat directions
Laura used to lack confidence, find school work challenging and spend her time in a dream world.
“We used to call it ‘Laura Land’,” says her dad Grant. “She was away with the fairies.”
Today, Laura is a bright and chatty youngster who’s brimming with confidence and finding it much easier to pay attention. Since being diagnosed with APD and using an FM listening device, she’s made huge improvements, such as doing better in class.
“She wasn’t below average before, but had to work so much harder than everyone else to understand things,” says Grant. “Maths was particularly challenging – she needed to see things visually and didn’t always do very well. But she recently came top of her year in a maths test, which was fantastic.
“It’s incredible what a difference the listening aids have made.”
Laura has had problems with her ears since she was little, suffering from numerous ear infections, and when she started school, teachers worried she might have a hearing problem as she didn’t seem to be paying attention. Tests showed her hearing was fine, but an audiologist said she could have APD, which Grant and his wife had never heard of.
They had to wait until she was seven to get her ears tested by a specialist, and it was a relief to learn she did have the condition. “It was good to know what was wrong and that something could be done about it,” says Grant, who was also relieved the government paid for Laura’s FM device.
“It means she can hear, she’s just unable to process the information the same way as other people do. It’s like a door has been opened to a whole new world for her.”
If you know a child who has difficulty understanding verbal instructions and who struggles with reading and spelling, they could have an auditory processing disorder.
Auditory Processing Disorder (APD) is a hearing disorder in which the ears process sound normally but the brain cannot always understand or hear.
Children with APD may exhibit signs of hearing loss, especially when there are competing sounds at even moderate levels, yet they pass standard hearing tests conducted in quiet.
Despite having normal intelligence they may need instructions repeated and may have difficulty following directions in the classroom. In particular they may not respond appropriately to instructions that are lengthy or that include more than one task.
Audiologist and CEO of SoundSkills, Dr Bill Keith, says APD affects an estimated five per cent of children (more boys than girls) and most go undiagnosed.
The team of experts at SoundSkills is dedicated to diagnosing and treating APD. SoundSkills audiologists, speech therapists and education adviser provide specialised testing and individually tailored remediation programmes.
APD can present as a learning or behaviour problem and can cause under-achievement because these children are missing out on vital information, says Dr Keith.
The problem lies in the hearing pathways and centres in the brain. Children are unable to extract the message that they need to from all the sound and noise around them. Or they have trouble retaining auditory information unless it is brief.
The condition often occurs in conjunction with other areas of difficulty such as Attention Deficit Hyperactivity Disorder (ADHD), Language and Phonological Awareness problems, and reading disorder. It can be the underlying cause of language, spelling, reading and learning disorders.
The underlying auditory problem should be addressed before trying to remedy the language, spelling, reading or learning difficulty.
The condition requires specialised testing and assessment, and individualised treatment. A multi-disciplinary team approach is necessary. But, says Dr Keith, the good news is that there is now robust evidence for the effectiveness of a number of interventions.
- Information for the child, family and teachers so they understand the problem and learn some simple techniques to reduce the effects.
- Hearing training therapy to improve listening skills.
- Fitting of a personal FM listening device (specialised for APD), particularly for classroom use, to transmit the voice of the teacher clearly, so that distance and background noise are no longer a problem.
- Language therapy to improve understanding.
- The exciting conclusion from recent research at the University of Auckland by Dr Suzanne Purdy and her colleagues is that FM usage delivers a double benefit for children with APD.
Firstly it provides immediate assistance with hearing, but over time FM usage also can lead to an improvement in auditory skills so that use of the FM system may not be permanently necessary.
Says Dr Keith,Assistive devices cant normally cure hearing pathology, but thanks to the neuroplasticity of the brain they can apparently assist the development of improved auditory skills in some children with APD.
Auditory Processing Disorder (APD) is the most neglected and under diagnosed area of hearing services in NZ according to Dr Bill Keith, audiologist of specialist APD clinic SoundSkills. Under diagnosis is compounded by false reassurance to conscientious parents who seek a hearing test for their child with hearing difficulties only to be told her hearing is fine.
Basic hearing assessment tests the peripheral auditory system but not the central pathways and hearing centres of the brain that may be involved in APD. Specialised audiological tests are required. There are APD screening tools and tests that can be used on children from about age four. Its a myth that APD tests can only be carried out from age seven.
Unrecognised APD is sometimes misdiagnosed as dyslexia. Sometimes the two conditions go together. In fact 39 per cent of children with dyslexia have an observed auditory deficit (Ramus, 2003).
Thanks to the neuroplasticity of the brain, APD is more treatable than sensory hearing losses. SoundSkills uses a combination of therapy and assistive listening devices for optimal results. Auditory skills training helps people to better discriminate sounds and to hear better in the presence of competing sounds. Phonological awareness training and language therapy address the deficits commonly seen from years of not having heard properly. And use of personal FM systems in class enable children to finally hear the teacher.
Says Bill Keith, “one of the most exciting recent research findings is that, over time, use of a personal FM system by a child with APD can actually improve the childs ability to hear. In many cases theres a double benefit, an immediate assistive effect and a longer term therapeutic effect”.
Article from Eduvac – The Education Weekly
By Shona Cox
Eduvac News – The Education Weekly