Auditory processing disorder

‘School can be a very boring place if the child suffers from Auditory Processing Disorders’

I was recently invited to have an interactive facebook chat session on AUDITORY PROCESSING DISORDER by a dynamic Indian telecare therapy portal, 1SpecialPlace. Posting the edited chat here for Audiology Planet audience. The names are anonymised for obvious reasons.

1SpecialPlace Hello everyone. I welcome Dr. Jay Jindal who is our esteemed guest today. Dr Jindal, we are thankful that you could take out time to join us today. We are eager to learn more on Auditory Processing Difficulties in children.

Jay Jindal May I extend my warm welcome to all of you who have joined this fantastically arranged 1SpecialPlace session on auditory processing disorders. My thanks to the organising team for inviting me to have a chat with you wonderful people.

My name is Dr Jay Jindal. I am an audiologist- hearing and balance care specialist for children and adults. The youngest person I have seen in my hearing was 7 days old and the oldest one-well, just over 105. So, I get to meet many interesting young and old persons in my job.

So, without further ado, please fire away all your burning questions.

1SpecialPlace Thanks again for taking out time for us. To start with, could you tell us what Auditory Processing Disorder really is?

Jay Jindal Auditory processing is basically ‘what we do with what we hear’. Ears serve the mere function of carrying sound to its master- the brain. Brain deciphers the meaning of the sounds or speech. Low and behold, our hearing is, more or less similar. However, our auditory processing or ‘listening abilities’ are different because no two brains are the same. Sometime these abilities are below average causing issues with understanding, and therefore, learning or remembering etc. This is termed as APD.

It makes sense because we can only learn or remember what is being said, if we understand it. Think of watching a foreign language film and trying to decipher the meaning. Most you can understand is by watching rather than by listening to what’s being said. And, what you can understand is limited to how visual the movie is. This is how a child with APD may feel at school in their class

So, simply speaking Auditory Processing Disorder (APD) is difficulty in understanding and/or remembering information coming from hearing organs, that is-our ears. It is characterised by poor perception of speech and non-speech sounds in the brain due to impaired neural function (how the hearing structures represents sounds for the brain to interpret meaning); whereas their ears and hearing may be working perfectly well.

1SpecialPlace That’s an elaborate and well explained take on APD

SK I thank 1SpecialPLace and Dr Jindal for this great support. My daughter 3.5 yrs has difficulty in listening. How do I improve that?

Jay Jindal Many thanks for your question. I think the first thing to do is to see a children’s hearing specialist (audiologist) to have a thorough check up of her hearing. Once they help you identify your daughter’s specific hearing issues, they should be able to offer the management.

Jay Jindal Also remember, ‘glue ear’ (mucous stuck behind the ear drum and not draining properly) is one of the most common childhood condition that 90% children below age of 4 will suffer at some point. It can cause hearing and listening problem

I will post some general things that can enhance listening in a moment

Jay Jindal To answer your question, the simplest way to enhance listening skills in children is to play lots of listening games with them-

● ‘Musical chairs or statues’ (vigilance)
● ‘Simon says’ (vigilance, auditory discrimination, following directions)
● ‘Marco Polo/ Blind Man’s Bluff’ (localization and tracking)
● ‘Same and different’ (auditory discrimination)
● Exposure to rhymes and songs (phonological awareness, auditory discrimination)
● Following directions (auditory memory and sequencing)

1SpecialPlace Great tips about listening games

1SpecialPlace Jay Jindal could you elaborate a bit on the subtle signs to identify APD in children?

Jay Jindal Ah! where do I start… So, my working assumption in my paediatric clinics is that- mum knows the best! If the mum says to me that the child has a hearing/listening problem- I start by believing in them. Basically these are children who are otherwise very bright but don’t show the same level of academic or learning in general life. You give them two sets of instructions- go to the room and get your socks. They will go to their room and forget what to do next. You will find them staring at the cupboard.

Jay Jindal They will be much more comfortable speaking to you in quiet one to one conversation. In school or in noisy get together- they will become a different person

Jay Jindal Some general things that have been said about APD:

1. Difficulty understanding speech in the presence of competing background noise or in reverberant acoustic environments
2. Difficulty hearing on the phone
3. Inconsistent or inappropriate responses to requests for information
4. Difficulty following rapid speech
5. Frequent requests for repetition and/or rephrasing of information
6. Difficulty following directions
7. Difficulty learning a foreign language or novel speech materials, especially technical language
8. Problems with the ability to localize the source of a signal
9. Difficulty or inability to detect the subtle changes in prosody that underlie humor and sarcasm
10. Difficulty maintaining attention
11. A tendency to be easily distracted
12. Poor singing, musical ability, and/or appreciation of music academic difficulties, including reading, spelling and/or learning problems

TT Wow! That’s a vast list of signs.

TT But could a child with APD also have other sensory processing difficulties?

Jay Jindal Indeed. There are various brain interactions (cognitive or higher order interactions as we call them in technical language) that may result in multitude of symptoms. In fact, most children I and my colleagues see, have APD with another condition that coexists with it (or the other way round) e.g. sensory difficulties, dyslexia, autistic spectrum disorder etc etc

Jay Jindal Just to give you an idea of the interactions that I mentionedAuditory Processing Disorder

Here’s a clever infograph on executive functions:

Executive functions. Source: https://www.understood.org

Source: https://www.understood.org

SS Hello Jay. Could you elaborate on the treatment aspects in children having APD with autism?

Jay Jindal Now there is a tough question. However, just as no two children in a class at school are same, no two children with autism (I call it autistic spectrum disorder or ASD) have the same ability. So, it makes sense that the management strategies are tailor made by a specialist therapist to cater for the individual child (rather than a disorder). I will post some management options in a minute.

1SpecialPlace Agree

SK True

Jay Jindal In general, two greatest assets that somebody could have are two greatest therapies for the APD management as well- music and foreign language. So, learning to a musical instrument or learning a foreign language is very good for listening abilities (and learning), whether you have an APD or not. This is one thing that all parents and professionals can follow at will.

Jay Jindal More in a bit

1SpecialPlace Jay Jindal great input!

SK Can you also provide information on the importance of Assistive listening devices for children with CAPD

1SpecialPlace In the perspective of an Audiologist, what are the diagnostic tests that you carry out for assessing children with APD?

Jay Jindal Another great question- as I said in one of the posts above- APD has interactions with many other conditions of childhood (think I forgot to mention SLI- specific language impairment there, which is  an under-diagnosed condition in school age children). The starting point is to capture how children are performing in the real world (rather than just relying on the tests that I perform in an artificially created clinical environment; and interpret them using data averages). There are several history forms and questionnaire available for this. My choice of questionnaire is Evaluation of Children’s Listening and Processing Skills [ECLiPS]), which is validated for supporting the clinical assessment of children referred for auditory processing disorder (APD). The ECLiPS is particularly sensitive to cognitive difficulties, an important aspect of many children referred for APD, as well as correlating with some auditory processing measures.

Auditory Processing Disorder

Jay Jindal Furthermore, my job as an audiologist is to find the issues in hearing and/or listening system of the body that cause symptoms by poor representation of sounds/speech in the brain. For this, we use a series of specialist speech and non speech tests, which assess ability to understand speech in quiet and noisy environment; and understanding speech coming from different localisation angles (speech understanding in space is an important factor in listening).

Jay Jindal There are also, what we call, dichotic listening tasks where we present speech or sounds in both ears together and ask the child to tell us what is being presented; and temporal processing tasks such as pattern recognition- presenting different pitches together and asking child or adult to tell which itches were low or high; gap in noise test to check how well the brain can pick up the gaps in between sounds.

See the thing is, if you think about it- our brain is nothing but a pattern recogniser. So, when you say a word like ‘DOG’, the ears’ job is to convert the mechanical vibrations into electricity, via special hair like cells in the snail shaped inner ear (cochlea). This electric pattern of three sounds ‘D’, ‘O’, ‘G’ reaches the brain via hearing nerve. The brain correlates this pattern with previous memory and recognises the pattern as the animal ‘dog’ as we know it. If however, brain fails to recognise the pattern because e.g. by the time it heard the sound ‘G’, it already forgot the sound ‘D’ then although ear passed ‘DOG’ to the brain but it heard ‘OG’, which doesn’t make any sense. This, in itself, is not a big issue as the brain is a clever thing. It can take the contextual cues to put two and two together to still interpret the word as ‘DOG’ even with missing sound. If you don’t believe me try reading this sentence where I have intentionally spoiled the pattern of written sounds- ‘Suond of msiuc is sewet’. You probably guessed it already but I jumbled up the alphabets of ‘sound of music is sweet’ However, it might have taken you a second more to read when the pattern was jumbled up. Brain takes longer to understand the pattern of audible sounds in the same way. (that’s also why slowing down and breaking down the information helps children with APD).

See how our hearing works here in this video:

1SpecialPlace Right, Thanks for explaining that

Jay Jindal Diagnostic APD assessment is again individualised to the child and their ability. Finding the norms (how average children will perform on a task) is the biggest challenge, particulalry when you are in India with close to 30 official languages and more than 600 dialects

1SpecialPlace True

TT What approach or theory you use for the management of APD?

Jay Jindal Great- this is what it all boils down to, sn’t it? Firstly, although I have a regime of tests that I can do in my clinic- I am very outcome focused and I tend to spend more energy on making a management strategy (which includes referral to other professionals). In fact, diagnosing APD is a part of my management strategy and not a mean to label a child with APD. Sometimes, the ‘label’ may be necessary for extra support at school for example. That’s that.

1SpecialPlace Agree with you on the labelling part.. and yes since children keep learning and outgrow their problems with guided intervention, their assessment has to be an ongoing process.

Jay Jindal Ok. I am going to post a series of things that generally sums up the contemporary thinking around the management. This should answer many of other questions here as well. Lot of it is a very common sense based approach, keeping the child (and their family) at the heart of the solution. Researchers have given us professionals material to recommend things to you with some confidence although, you can’t design a universal therapy for all children in one go (music, I believe is an exception- which helps everyone with all abilities).

Jay Jindal We know that one of the main symptoms that APD can cause is affecting the understanding speech in noisy environment such as school and play grounds. We have a technological solution to that. One of the things that your audiologist can do to enhance your child’s listening ability at school and home is to prescribe them with a smart personalised hearable (think of a bluetooth headset!). There are two types, one is an FM based system that is generally used at school where the teacher will speak in a lapel mic (like studio presenters) which is remotely connected to a special device in child’s ear. Therefore, the child doesn’t hear any noise in the background and hears the speech. Many schools will have this system in place already.

Jay Jindal There are other special hearing devices which come with a remote microphone that a parent, teacher, therapist can tuck in their collar. This essentially does the same thing as FM- makes a wireless connection between the speaker and child’s ear, reducing the noise in the background but is logistically easier to carry around and use (and slightly cheaper) than an FM system. (Ask us for more details www.audiologyplanet.com)

Jay Jindal I have mentioned the so called informal approaches, learning a musical equipment, playing some listening games; and learning foreign language/s. These are great armaments for you if you are a parent or educator dealing with and I can’t stress their importance enough. I will argue that they are life skills, which help your mental health as well and are as important as learning to swim, for example. There is a lot of research coming out, particularly on music and how it positively affects the cognition, learning and listening in children as well as adults.

The other simple and DIY way to enhance listening skills in children is to play lots of listening games with them-

● ‘Musical chairs or statues’ (vigilance)
● ‘Simon says’ (vigilance, auditory discrimination, following directions)
● ‘Marco Polo/ Blind Man’s Bluff’ (localization and tracking)
● ‘Same and different’ (auditory discrimination)
● Exposure to rhymes and songs (phonological awareness, auditory discrimination)
● Following directions (auditory memory and sequencing)

TT Good to know these approaches!

Jay Jindal Then, there are computer and smartphone based therapy approaches

Jay Jindal There are a thousand of smartphone applications based products on listening, some of which are really good. Basically, think about the games in the post above and see if you can use some of the apps in your smartphone to create the same sort of virtual listening environment.

www.acousticpioneer.com has worked in this area and have validated some of their results via studies. Couple of their auditory training games are “Zoo Caper Skyscraper” Insane Earplane”. Word of caution though- you should seek professional advice before trying something which costs money. Also, nothing, in my experience, works in a splendid isolation. So, you can’t undermine the value of professional help here.

Jay Jindal There are several computer based auditory training programs available

They mainly focus more on language than fundamental auditory processing training. Interesting computer graphics also help engage the child. The tasks are typically reported to improve phonological awareness, phonics, auditory attention and language

  1. Earobics www.earobics.com
  2. Fast ForWord www.scilearn.com or www.innovative-therapies.com (UK)
  3. Phonomena www.mindweavers.co.uk
  4. LiSN and Learn https://capd.nal.gov.au/lisn-learn-about.shtml  (for spatial processing disorders)

Jay Jindal Some of the non computer based structured programs include

  1. Just for Me! Phonological Awareness
  2. The Lindamood Program (LIPS Clinical Version) – Phoneme Sequencing Program for Reading, Spelling, and Speech
  3. Winget (2007). Differential Processing Training – 3 workbooks: Acoustic Tasks, Acoustic-Linguistic Tasks, and Linguistic tasks

If you are interested, the above and other materials are available from companies such as Linguisystems www.linguisystems.com

Please refer to guidance from British Society of Audiology for more information here

1SpecialPlace Awesome inputs Jay Jindal

Jay Jindal Everything a therapist/educator/parents plans for a child, should be done with child at the heart of it and not outside. Working with child’s own abilities and pace; and thinking about their individual environment- will go a long way in management. In particular, child’s acoustic environment should get a special attention. You can’t help a child with all the therapies in the world if they are in a classroom where the teacher’s voice is mixed up with a loud echo from the walls and noise from next door for example.

1SpecialPlace Agree!

TT Totally agreeable

APK Dr.Jindal, do you recommend 1:1 support at school?

Jay Jindal Depends on the severity of the issue the child has and usually, it is the combination of issues (rather than just listening), which will result in warranting a 1:1 support. Listening issues alone may be managed well with technology and gadgets at school.

1SpecialPlace So is there like a mild APD problem and a severe one? Can we categorise APD based on degree of difficulty.

Jay Jindal In general, I refrain from the terms that we have historically used in audiology a lot- mild, moderate, severe hearing loss etc. This is due to a variety of reasons, main one of which, is misinterpretation. A so called ‘mild difficulty’ in hearing could be synergistically compounded by a ‘severe’ difficulty learning. This will mean that the overall difficulty a child will have will be more than a child with a so called ‘mild’ hearing loss and/or ‘severe’ learning diffciulty. So, ‘mild’ hearing loss will be a very misleading term in that case.

In the same way, different people with APD can have different symptoms and depending on additional issues they are having, can make their life ‘differently’ difficult e.g. listening issues with dyslexia will make the child to suffer more in their reading and writing than listening issues causing reading problem because the child hasn’t heard the teacher what they need to, in order to read. So, in that sense it can be more severe. Hope that makes sense. Tell me if it doesn’t so, I can try to explain it better.

1SpecialPlace Sure does make sense..

SD Will music therpay help children with apd

Jay Jindal Music definitely helps. I am a strong supporter of teaching children and adults music. It does wonders to your listening- APD or not. It is a definitely yes

APK Overall, what is the prognosis or expected learning outcomes for:
1. Children with mild APD
2.Children with moderate and severe APD

Do these children require long term technology assistance to support their learning in different areas ?

And what are some of the low tech or high tech options for them ?

Jay Jindal I have to reiterate that no two children will have same ability and therefore, the same outcome. So, I am trying to move away from a disorder centric approach to define management outcome. All I will say is that you can help all children with all problems mild or strong- you can make their lives better than they are. And so you should. Beyond this, is a lot of guess work and your guess is as good as mine.

1SpecialPlace These are all awesome inputs Dr Jay Jindal..

1SpecialPlace I think today the audience has been a mixed lot with SLPs, educators, OT s and parents too. I bet all the information provided by you has been of utmost help to all of us.

1SpecialPlace It’s been a pleasure to have you here with us today. Technology has surely moved mountains and I’m deeply thankful to you Jay Jindal for your time.

Jay Jindal Your most welcome. It was great talking to you and other audience here. Great session indeed. Many thanks everyone. Checking out now. All the best. Have fun and stay curious.

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Disclaimer: This text has been optimised for publication purpose with some additions and editing. 

Reference: An overview of current management of auditory processing disorder (APD). Available here. Accessed on 11/03/2017