CAPD, ADD, EF or
Alphabet Soup:
Symptoms, Strategies
and Solutions
26th Annual Colorado Metro Speech/Language Symposium
Saturday, February 4, 2012
Donna Massine Au.D. CCC-A/SP, FAAA
Plan
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Auditory Processing Theories-Past & Present
CDE-CAPD Guidelines 2008
Defining A P and EF
Symptoms ADHD and CAPD
CSI(Child Scene Investigation)
Putting it all together: CAPD, ADD and EF
Sharpening observation tools to inform
instruction- Ecological Assessment
• Applying Brain Based Research to CSI
• Intervention- CSI Returns (Child Scene
Intervention)- Interventions at the level of the Scene
(environment) and at the level of the child
• More on CDE- CAPD Guidelines
• Suggestions for clinicians
Auditory Processing Theories: Past and
Present
Auditory Processing Deficits are Implicated in
Multiple Disorders
- Most often invoked in theories about three
disorders: Auditory Processing Disorders (APD),
Specific Language Impairment (SLI) and dyslexia
(Miller, LSHSS July 2011)
- ASHA definition 2005 inappropriate to apply APD
to children with language impairment or learning
disability unless a comorbid deficit can be
demonstrated
History of Auditory Processing
Research
• Audiological Approach
originated from the study of brain lesions (1970’s)
• Psychoeducational Approach
auditory perceptual skills
• Language processing Approach
interactive nature between speech and language
processing (top down influences bottom up)
Controversies about APD:
• Modality specificity – Auditory! Need to assess
processing of other modalities
• Linguistic vs. non-linguistic components
• APD role in Language processingcause or consequence?
• Other factors influence processing response in
behavioral testing such as attention, motivation,
memory, and speech ability
Controversies about
APD
• Concerns about the reliability and validity of
APD tests (Kahmi, LHSS July 2011)- test
standardization and specificity- false negatives
• Need additional tests (spatial listening)
• High co-morbidity likely reflects the influence
of attention, memory and language abilities on
APD (Kahmi, LSHSS July 2011)
Controversies about APD
• APD subtypes – Purdy n=90 7-13 subtyping
not possible (cluster analysis)
• source of the deficit (APD) needs to be
identified and acknowledged as there is
not enough good research to determine
which position has more validity Wallach
(2011) and Medwetsky (2011)
(Richard, LSHSS July 2011)
CDE-CAPD Guidelines 2008
CDE-CAPD Guidelines
2008
Neuroscience
• Researchers from all three strands have begun to turn to
neurophysiological techniques
• Need to develop a comprehensive theory of auditory
processing
• Neurophysiological Techniques
• Event-related potentials or evoked potentials (ERP)
obtained through Electro-encephalography by measuring the
electrical activity of the brain
• Functional MRI (fMRI) examines brain morphology
Neuroscience: Brain
Development R-L, B-F
Normal
Impaired
Trained (formerly impaired)
Temple, Poldrack, Gabrieli, et al., PNAS
Defining AP and EF
• What is “auditory
processing”?
• What the brain
does with what the
ear hears?
• What are
“executive
functions?”
• Control of self,
others and planning
Processing and Executive
Function
• Processing
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Perception
Attention
Language processes
Visual spatial processes
Sensory Inputs
Motor outputs
Memory
Knowledge/skills
• Executive
Functions
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Inhibit
Cognitive flexibility
Initiate
Working memory (hold and
manipulate)
• Plan
• Organize
• Self monitor/evaluate
Memory
• (Short Term Memory (sensory and
immediate memory)
• Working Memory
• Long Term Memory (declarative and
non-declarative memory)
Learning and retention are different
( can learn for a few minutes but not retain
it)
ADHD, CAPD or………???
• Rank order ADHD
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inattentive
distracted
hyperactive
fidgety/restless
hasty/impulsive
interrupts/intrudes
– Differential Diagnosis
– (Chermak, et. al. 1998)
• Rank order CAPD
– difficulty hearing in
background noise
– difficulty following oral
directions
– poor listening skills
– academic difficulties
– poor auditory assoc.
– distracted
– inattentive
Ecological Assessment:
Informal Probes/Observation
• Behavioral observation during formal
testing
• Classroom Performance Impact
Questionnaire (CPIQ)
• Classroom observations: parent/teacher
reports of concerns
• Identify specific behaviors that are a
problem…the symptoms are the symptoms
CPIQ
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Classroom Concerns (overall perspective)
Oral language/listening
Sustained attention (aud/visual)
Working memory (order, aud/visual)
Thinking/reasoning
Reading, Writing and Math
Task Initiation
Organization
Time management
Metacognition
Emotional Regulation
CSI
Investigating the Child
and the Learning Scene
• Compare referred student with
typical student
• Observe the student in an array of
scenes: large group,small group and
independent work
Look for what’s working and what’s
not
Observation
Checklists and other
Informal Assessment
Applying Brain Based
Research to CSI
• Retrieval = recognition (match outside
info) or recall (with hints goes into LTM
retrieve/decode in WM (retrieval depends
on adequate cues, context of retrieval and
mood of retrieval
• Rate of learning impacted by motivation,
emotional mood, degree of focus and
context that learning occurs in
Brain Based Research and
CSI (intervention)
• Limit number of items (WM Capacity)
• Make information meaningful (model, use
prime time, avoid controversial issues, create
artificial meaning/mnemonics
• Use motivation to increase process time
Brain Based Research and
CSI
• Length of Instruction: Shorter is Better
(20 minutes)
• Prime Time-1 (9 min), Down Time (2 min), Prime
Time-2 (9 min)
• Amount of Down time increases with longer
chunks (e.g. 10 min. in a 30 min block)
• Teachers who call on fast processors
signal slow processors to stop the retrieval
process- lowers self concept and missed
opportunity to relearn
Brain Based Research and CSI
• Use chunking to aid processing and retention
(pattern, categorical and cumulative)
• Using Rehearsal Strategies
• Using primacy-recency effect
• Using wait time to increase student
participation/promote processing
Windows of Opportunity
as a child’s brain matures
MUSIC
MATH/LOG
VOCAB
EMOTION
MOTOR
0
5
10
15
Changes in Capacity of Working
Memory with Age
Keep the number of items in a lesson objective
within the capacity limits of students and they re
likely to remember more of what they learned.
Approximate age
range in years
Younger
than five
Between 5
&14
14 & older
Capacity of working
memory in number
of chunks
Minimum
Maximum
Average
1
3
2
3
7
5
5
9
7
The relationship of sense to
meaning
IS
M
E
A
N
I
N
G
Yes
No
Moderate to
high
Very low
No
Very high
Moderate to high
Yes
Is Sense Present?
P
R
E
S
E
N
T
?
AVERAGE RETENTION RATE AFTER 24 HOURS
VERBAL PROCESSING
LECTURE
5%
READING
AUDIOVISUAL
VERBAL &VISUAL PROCESSING
DEMONSTRATION
DISCUSSION GROUP
10%
20%
30%
50%
PRACTICE BY DOING
75%
DOING
TEACH OTHERS / IMMEDIATE LEARNING USE
90%
CSI Returns:
Child-Scene-Intervention
• At the level of the Environment
Presentation
Accommodations
• At the level of the Student
• Metacognition and Compensatory
Strategies
CSI: Enhancing Auditory Access
for School Age Learners
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Questioning and Clarifying
announce topic changes and purpose of lessons
encourage students to use repair strategies
ask open ended questions
build from the known
give enough “wait time” for-wait for 8-9 hands to go up
for short answers-allow for multiple repetitions
determine which approach is most successful (repeating or rephrasing)
pause between phrases
use sabotage technique to assist with clarification
minimize “learned helplessness”- promote auditory rehearsal
CSI:Enhancing Auditory Access
for School Age Learners
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Communication/Presentation to the Class
minimize walking and talking
use visuals (graphic organizers, outlines)
cue the students by addressing all class members when they are
speaking
sequence directions chronologically/present them one at a time
avoid speaking while facing away
minimize noise and time in transitions (use timer, flashing light to cue)
wait for class to be quiet before beginning-develop a silent signal to
promote class awareness of importance of quiet
use pre-teach/ teach/ re-teach approach when needed
CSI: Enhancing Auditory
Access for School Age
Learners
Background Noise
Kid’s don’t hear like short adults-use
ALD technology-windows/doors closed
Assess value of background music for
independent work times
•use “Yacker Tracker” or traffic light
poster to identify expectation for noise
level (quiet, whisper, regular voices)
CSI:Visual Teaching
Strategies
• Graphic Organizers
• Visual representations
• Link background knowledgeeasier to remember than
expanded text
• Hierarchical Patterns:
• Conceptual Patterns:
• Sequential Patterns:
• Cyclical Patterns:
• Color Coding: organization
• Icons: symbol, picture
associations:
• Story Grammar Marker:
Glove, Braidy or SGM tool
CSI:Visual Teaching
Strategies
• General Visual
Teaching Techniques
• Choose visuals that are
developmentally
appropriate/easy to
recognize
• Use a variety
(combination of words
and graphics best
choice)
• Job and Choice Menus
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Classroom Rules Chart
• Task organizers (list
steps/completion)
• Daily schedules
• Internet (library of
pictures, graphics,
photos and videos)
• Props for younger
students
• Transition Time
cards/charts
CSI: Teaching All Kids to be
Better Self-Advocates
• Identify obstacles for self-advocacy
(student,environment, teacher and other
factors)
• Evaluate baseline for self-advocacyteacher/student input
• Awareness of Learning Style (kinesthetic,
visual, auditory)
• Awareness of Level of Knowledge (know well,
know somewhat, barely know)
CSI: Self Advocacy
• Keys to self-advocacy (acknowledgement,
assertiveness, communication exchange)
• Awareness of communication style
(passive/timid, aggressive/bossy,
assertive/self-confident)
• Teach Communication Repair Strategies
(repetition, revision, simple addition,
clarifying addtion, nonverbal)
CSI: Communication
Repair Strategies
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Repetition (no new info)
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Revision (meaning unchanged)
Simple Addition (new info)- increases thru age 9
Clarifying Addition (specific new info)
• Inappropriate responses decrease until rare age 7, non
existent after age 9)
• Taken from SCRIPT. Building Skills for Success in the
Fast-Paced Classroom. Karen Anderson. 2011
Percentage of Use of Communication Repair
Strategy Types by Age
from K. Anderson
Age 9-11
Repetition
Revision
Age 9
Simple Add
Age 7
Clarify Add
Inapprop
Age 5
Age 3
0
50
100
From K. Anderson Building Skills for Success in the Fast-Paced Classroom
Commication Repair for Students
Repetition
Addition
Revision
Repetition
1. Slowly 2. Clearly 3. Louder 4. Key Wds
Revision
5. Two Sentences 6. Different Wds 7.
Different Form
Addition
8. Simple addition
9. Define terms
10. Backgroun context
Nonverbal
Sign/spell, Show/Express, Write/Draw
CSI:All Learners Need to be Self
Advocates
• Develop vocabulary to use when asking
questions (includes awareness knowledge)
• Apply prior knowledge to question
• Identify reason for confusion, breakdown
• Discussion of self-advocacy as a social skill -highlight
when and how clarification should be used
“Kids are not like tube socks…one size does not fit
all.”
Using Story Books to Promote Self
Advocacy and Listening Skills
• Self-Advocacy
• A Case of Bad Stripes
• Stand Tall Molly Lou
Melon
• Odd Velvet
• Today Was a Terrible
Day
• I Like Me
• What If the Teacher
Calls on Me
• I Like Myself
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Listening
Listen Buddy
Mr. Mumble
Bendomelena the cat
with a pot on her head
The Hungry Thing
Polar Bear Polar Bear
What Do You Hear?
The Listening Walk
Things I Can Do
CDE-APD Guidelines 2008
CDE-APD Guidelines 2008
CDE-APD Guidelines 2008
Preschoolers As Listeners (PAL)
Listening Continuum
(STAR)
Self Taught Advocacy and Responsibility
Turn taking ( my turn to talk your turn to listen)
Body basics (Help develop good listening posture body alertness)
Asking questions 1.(Where?Who?What?)2. Asking questions
(when? Why? How?)
Develop vocabulary for keywords for sequencing/organizing, (first
next last) and emotions.
Develop awareness of understanding “hunh”
PAL
Develop self awareness, self esteem( help parents and caregivers
recognize strengths and learning styles)
Develop awareness of environment/speaker impact ( too much, too
noisy, too fast, too far)
Develop self awareness of learning styles (vis/aud/kin)
Develop awareness of known/unknown
Develop awareness of communication breakdown
STAR
Develop compensatory strategies (organization, note taking, key
words, skimming)
Suggestions for
Clinicians
Wallach LSHSS July 2011
• Keep auditory weaknesses identified in alternative
settings in perspective
• Understand what language skills and strategies
underlie the academic tasks
• Keep contextualized (facial expression) and
decontextualized aspects of language clearly
defined –understand role of contextualized
language in spoken/written language development
• Read the research on the efficacy of auditory
intervention in improving auditory, language
andacademic outcomes (Fey, 2011) (Gillam, 2008)
Suggestions for
Clinicians
• Evaluate the curricular/instructional demands
over the grades
• Consider the metalinguistic aspects of language
learning
• Develop language initiatives that focuses on the
content-area subjects
• Focus on intervention strategies that help
students derive meaning from spoken/written
text or metacognitive awareness
Suggestions for Improving Auditory Processing
in the Classroom
Child
Develop skills and use strengths,
connections, interests * see
intervention
Scene
Signal enhancement
environmental modifications
Visual supports/schedules
Investigation/Intervention
Observe child in authentic
learning environment- identify
obstacles/symptoms – adjust!
Design a program that includes:
Developing attending/listening
skills- teacher and peers in
class (eye contact)
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• Developing rehearsal
strategies- words,
directions, stories using
inner voice, chunking,
visualization, note taking
• Developing Active Listening
skills- formulate appropriate
comments, avoid redundancy
• Developing Self Advocacy
skills -recognize confusing
information, seek
clarification, repair.
• Developing Coping with
listening obstacles (noise)identify and solve noise
problems, tuning out noise
References
• Anderson, K. Arnoldi, K. (2011) Building Skills for
Success in the Fast-Paced Classroom. OR: Butte
Publications.
• Burns, M. (2009) Neurologically Speaking.
Colorado Speech Language Hearing Conference.
• Dawson,P. Guare,R. (2004) Executive Skills in
Children and Adolescents: A Practical Guide to
Assessment& Intervention. NY: Guilford Press..
• Dise-Lewis, J. (2007) Executive Functions:
Developmental Conditions. Courage to Risk
Conference, CO.
References
Dise-Lewis, J. (2007) Impact of Executive
Function on Academic Performance. Speech
Language Metro Symposium, CO.
• Fey,M. et. al. (2011).Auditory Processing Disorder
and Auditory/Language Interventions: An
Evidence-Based Systematic Review. Language,
Speech and Hearing Services in Schools. 42. 246264.
• Gillam,R., et. al. (2008). The efficacy of Fast
Forward Language Intervention in school-age
children with language impairment: A randomized
controlled trial. Journal of Speech, Language and
Hearing Research, 51. 97-120
References
• Isquith, P. (2008) Executive Function
Concepts,Assessments and Intervention.
CO:Courage to Risk Conference.
• Janusz,J. Conjunction, Junction: What’s Executive
Function? CO:CSHA Fall Conference
• Kahmi, A. (2011) What Speech-Language
Pathologists Need to Know About Auditory
Processing Disorder. Language, Speech and
Hearing Services in Schools. 42. 265-272.
References
• Meltzer,L. (2007) Executive Function in
Education:From Theory to Practice. NY: Guilford
Press.
• Miller, C. (2011) Auditory Processing Theories of
Language Disorders: Past, Present and Future.
Language, Speech and Hearing Services in
Schools. 42. 309-319.
• Purdy, S. (2010) Diagnosis and treatment for APD:
Current status and unanswered questions.
Presentation. C.U. Boulder.
References
• Sousa, D. (2006). How the Brain Learns. CA: Corwin Press
• Richard, G. (2011) The Role of the Speech-Language
Pathologist in Identifying and Treating Children with
Auditory Processing Disorder. Language, Speech and
Hearing Services in Schools. 42. 297-302.
• Wallach, G. (2011) Peeling the Onion of Auditory Processing
Disorder: A Language/Curricular-Based Perspective.
Language, Speech and Hearing Services in Schools. 42. 273285.
References
• Colorado Department of EducationAuditory Processing Deficits: A Team
Approach to Screening, Assessment and
Intervention Practices 2008.
http://www.cde.state.co.us/cdesped/downl
oad/pdf/APDGuidelines2008.pdf
Notes
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