Online conference attendees recently chatted with Teri Bellis, an expert on central auditory processing disorders, about how to discern between CAPD and attention deficit/hyperactivity disorder. The Leader was there, too.
Lynn Staubach Williams: Teri, you mentioned in your presentation that you prefer to test children [while] on their ADHD medications. For auditory training sessions, given the time of day that much of the treatment can occur—afterschool hours, a.k.a. "the bewitching hour"—have you found a significant issue as the medications are wearing off, or have run their course, on the effectiveness of therapy?
Teri James Bellis: Most of the kids I work with are on "maintenance doses" later in the day. That being said, I do see an effect. I have one kiddo who does it first thing in the morning. I make sure it's highly individualized.
Sandra Johnston: Are there any children you would defer testing based on other diagnoses? As part of their work-up, do you request cognitive or language testing prior to your APD testing?
Bellis: Yes, I ask for all of that. I firmly believe that CAPD is not a starting point in the diagnostic journey. All of the kids I see provide their testing, IEPs, etc., prior to being "accepted" for testing. And I screen them very carefully.
Renee Shellum: What protocol do you use clinically for children's CAPD testing? I do not have access to electrophysiological testing (functional magnetic resonance imaging or auditory brainstem response).
Bellis: That is a tall order to answer in a short chat. I follow the American Speech-Language-Hearing Association's (2005) and American Academy of Audiology's (2010) recommendations for test battery selection and go from there. Not all of my kiddos—or adults—get electrophysiology ... nor is it needed in most cases.
Cheri Wolff: What's the most reliable testing a speech-language pathologist can do to determine if a child should be referred to an audiologist for CAPD testing? There is always the school district's concern about who's paying for the CAPD testing—parents or the school district. Therefore, it's important for us to have a strong feeling that we need to rule out or rule in CAPD.
Teri James Bellis: I am always careful not to tell the SLP how to do his or her job! I have a very detailed screening program that I undergo with the team that is outlined in my books. There really isn't a "gold standard" for CAPD screening.
Jacqueline Callanan: Should children in preschool who test low in auditory comprehension and have difficulty with answering questions and following directions be referred to an audiologist for a diagnosis?
Bellis: Hmm ... it is important to note that CAPD—with behavioral tests—cannot be diagnosed below the age of 7–8. In these preschoolers, I defer to the SLP, but we can make "best-guess" hypotheses regarding strengths and weaknesses based on overall presenting symptoms.
Pat Maletto: Would you briefly discuss the auditory training that your 12-year old case study received during the eight-week intervention?
Bellis: I talk about it in both of my books. I use two iPods and, usually, I have the same book playing—at different points in time—to the ears so that the speaker is the same ... I have found that I do not need to "redo" therapy after a period of time. The post-therapy results are holding for up to three years later, for those for whom I've been able to collect those data. This is useful, because the vast majority of the folks with whom I work live some distance away and, therefore, cannot come into the clinic on a daily basis.
Rebekah June Strombom: Could you please give examples of speech and language weaknesses one might see in preschool-age children to help better advise parents in pursuing a CAPD versus ADHD diagnosis?
Bellis: That's a book in itself. But if I start to see solely distraction in visual and auditory modalities, along with difficulties organizing tasks, materials, etc., I start to think ADHD. On the other hand, if they have more difficulty in the auditory modality than would be expected, I start to suspect CAPD or comorbid disorder.
Heidi Allan: I have become increasingly aware of children who perform poorly on the verbal labeling portion of the Frequency Patterning Test and very well on the humming portion, yet do not perform poorly on any of the dichotic listening tasks. Is this still and indicator of a weakness in interhemispheric integration or could this be a confrontation naming/language based issue?
Bellis: If there isn't a pattern across tests—including dichotics—it can certainly be an "organizational" or output issue ... yes! I wouldn't say that those kiddos have CAPD without other evidence!
Helaine Rosenfield: Because a preschool ADHD child is too young for a true CAPD diagnosis, do you recommend auditory training if CAPD is suspect? Are there any programs appropriate for a preschooler?
Bellis: I really do, but the therapy should fit the pattern of strengths and weaknesses. I talk in depth about these little kiddos in my books. We need to analyze the pattern to determine what types of program/AT might be appropriate.
Dianna Nathan: Have you found that many kids with attention difficulties show a right ear advantage due to the testing methods of the right ear always being tested first? How would we account for that?
Bellis: Hmm ... nice point, Dianna, but I really don't notice that. If I am concerned about an order effect, I counterbalance—that is, right ear first on one, left ear first on the next.
Lisa Hilbert: What are your thoughts on testing kids with known ADHD whose parents choose not to medicate?
Bellis: That is fantastic question we all deal with! If the child can attend sufficiently for me to test, I can figure out if it's comorbid or not. If not, and the child really needs meds, there's not much I can do beyond additional education of the parents.
Crystal Dvorak: The case study showed an improvement in right ear middle latency response. Aside from natural maturation of the response, could there have been any positive effect of the patient being on appropriate medications?
Bellis: It could not have been maturation in six weeks, and she was already on everything prior ... remember, she had been pre-tested without auditory training, then retested after auditory training. We were able to rule out both maturation and medication.
Nathan: I am testing in the schools and don't have access to electrophysiological testing, should I refrain from diagnosing APD, and mainly focus on the areas of difficulty and strategies/training to help in those areas?
Bellis: No! I get my most important info for treatment from the behavioral, not the EP, testing.
Maxine Young: Teri, I find that many youngsters who have significant REA on dichotic tests, also have had difficulty learning to tie their shoes. What percentage of REA cases in children would you also expect to see motor cross-midline problems as well? Is there research to suggest that dichotic studies are just the tip of the corpus callosum delayed development iceberg?
Bellis: Yes, this can be a sign of interhemispheric (corpus callosum) dysfunction. It all depends on what else we find (e.g., right hemi, etc.). There is a lot of research regarding dichotics and corpus callosum.
Ellen King-Facchiano: I get many referrals for autistic children to be assessed for CAPD as well as ADHD. What is your opinion on CAPD assessment for autistic children?
Bellis: The ASHA documents (2005) are pretty clear on this, I think. Yes, children with autism have difficulties processing in multiple modalities, but I'm not comfortable ascribing their difficulties to CAPD. That being said, take a look at Nina Kraus's (and colleagues) work on auditory training with children with autism ... and stay tuned.
Joanne Roberts: Are you aware of any tests being developed to assess the auditory processing skills of non-native English speaking children?
Bellis: I believe Eliane Schochat and her colleagues in Brazil have been working there on this. And I've been working with the Republic of Ireland to see if even dialects affect this testing. In addition, Benoit Jutras has been working regarding French in Canada. Otherwise, I'm not sure. Non-verbal tests—for example, pitch patterns, etc.—may be best in these situations.
Tiffany Colon: Aside from complete case history and thorough audiological evaluation, we utilize the low-pass filtered speech test, competing sentences, the digits test, and the frequency pattern test. I understand that the "test battery approach" needs to be tailored to the specific needs of the child but are there any tests you could recommend to round out our auditory processing battery? I am also looking into your iPod method for dichotic listening training since all of our kiddos are highly attached to their electronics!
Bellis: Actually, your test battery is a lot like mine! While there are many tests on the market, there are precious few that have efficiency data behind them ... keep doing what you're doing. Maybe add time-compressed speech, 45 percent with and without reverb for those over 11, and duration patterns.
Kelly Rinehart: I am an SLP working with students who also have complex communication needs and use speech generating devices to aid communication. Some of them are just beginning their journeys with SGDs. How might I go about finding a good resource for quality CAPD assessment such as you have outlined? Is there an online resource for finding such folks? Also, have you worked with nonverbal kids before and could you share any thoughts regarding testing them for CAPD? It would be hard for the kids I have in mind to give feedback for the behavioral tests you mentioned. There is a whole other layer of cognitive demand involved in navigating through their devices to provide you with a response.
Bellis: I'm very careful about this ... I simply don't know everyone who does CAPD in the United States. And I'm really concerned about the application of CAPD labels to these complex kiddos. [Regarding nonverbal children] I'm not at all sure about this. Remember, if these kiddos are really nonverbal I think they have larger issues than CAPD.
Jennifer Henderson: I am an SLP in early intervention with an almost 6-year-old son with suspected CAPD (and currently has a diagnosis of language processing disorder). I live in a rural town with the closest audiological support two hours away. We will test him at age 7, but [can you suggest] resources to guide my current therapy with him? We do Earobics, phonological awareness activities, auditory memory, etc. I need help incorporating auditory training while waiting for him to reach a testable age. I need a greater understanding of auditory training.
Bellis: Yes, I feel your pain. I live in South Dakota. A lot of the therapy I do is home-based or distance-based. There are a lot of resources, books—including my own—to assist with ideas. But the most important thing is to get an accurate diagnosis—which, I realize, can't happen at age 6. Still, auditory training activities can be based on observed strengths and weakness patterns.
Allan: When considering ADHD versus CAPD, is it valuable to conduct both the dichotic digits test and a competing sentence test (forced attention), and how would you report those findings confirming either one or the other, or both?
Bellis: I personally do both, as they assess integration and separation. I would expect a true CAPD to show a similar deficit in both. If only in one—for example, competing sentences—I'm more likely to report a likely attention confound.
Jane Woods: I just did a CAPD evaluation on a child for whom we don't have information on what his primary language was, especially receptively, from birth to 4 years old. It has been English since. Parents are Asian but different languages. Could early exposure to other languages cause problems later in auditory pathways?
Bellis: Absolutely. We know that if phonemes do not appear in a natively learned language, they are difficult to discriminate later on. The classic Japanese r/l confusion is an example.
Kaitlin Condo: How can a school-based SLP help advocate for a student suspected as having CAPD during the evaluation process? Under what area would that student qualify for special education services?
Bellis: It would depend on the state. Often these kiddos qualify under speech-language, learning disorder or hearing. It depends on the effect on education and that state's definitions of the disorders.
Synthia Jones: I know that children can be diagnosed with CAPD without the comorbidity of ADHD. But, can one clearly omit the presence of CAPD in a child with ADHD?
Bellis: Yes, I have seen many kids who perform poorly but do not show a pattern of central auditory pathway involvement. Qualitatively, these kids clearly have attention confounds. I find it very clear, when one looks at the patterns, to omit CAPD in a child with ADHD ... if one approaches it from a central auditory pathway perspective.