Understanding Intervention for (C)APD

As Easy as A-'B-C
hy Jeanane M. Ferre Although (C)APD may be a complex problem, intervention need not be complicated.
ntervention refers to a balanced process in which rehabilitative procedures designed to improve deficient skills are iniplenienied in concert with management strategies designed to minimize a deficit's adverse effects. This process is maximized when remediation and management are implemented in a timely fashion, specific to the client's needs, and generalized acro.ss settings (ASHA, 2005). For many speech-language-hearing professionals, intervention for (central) auditory processing disorders [(C)APDs| remains a challenge due to tbe complex nature and impact of these disorders. Poor (central) auditory processing may manifest behaviorally in a variety of ways., including deficient academic performance, impaired communication, and altered sense of self. Tbis diversity in scope and severity implies not only that the assessment and intervention processes will involve a team of professionals, each contributing uniquely to the overall understanding of the (C)APD. but also that tbe elements of the intervention process itself will likely vary from simple to extensive. Although (C)APD may be a complex problem, intervenlion need not be complicated. Many professional resources are available that describe specific therapies and strategies for developing individualized intervention programs for listeners witb (C)APD. These resources have three basic elements in commonactivities, identification of barriers, and need for collaborationor tbe ABCs of intervention for (C)APD. listener hears two (or more) different targets presented simultaneously, one or more to each ear. and is asked to attend to one (separation) or both (integration) signals. Informal binaural separation/integration training can be accomplished by asking ihe student to repeat one or botb targets spoken by individuals standing on eitber side of tbe listener. While not a true dichotic experience, the activity approximates the skill. As with formal dichotic training programs, relative loudness levels between the two speakers can be varied, as can language of tbe target, for example, by asking the listener to repeat numbers given by two speakers versus repeating sentences or answering questions. Localization, or tbe ability to icKate an acoustic target in space, can be practiced through games sucb as "Blind Man's Bluff and "Marco Polo." For very young cbildren. "find the sound" involves having the child stand with eyes closed while a parent or sibling shakes a set of keys (or other noisemaker) at various locations near the child's bead (e.g.. above, below and to tbe left, etc.) and asking tbe cbild to try to take tbe keys or point to the sound source. Temporal processing, the ability to use timing aspects ofthe signal, includes temporal patterning, or tbe ability to recognize and use acoustic patterns such as tbose that occur in running speech. Games sucb as '"MadGab," "Bopit." "Bopit Extreme," "Simon," and "Simon2" facilitate pattern recognition practice at home or school. Enhancement of auditory-related skills may include games to enhance auditory vigilance (waiting for the target to cbange). interhemispheric communication, and/or the ability to use visual, linguistic, and cognitive cues. Vigilance-enbancing games include "Simon Says," "Twister," "duck-duck-goose," dichotic listening, and temporal processing (Ferre, 2002). Top-down therapy programs focus on improving metalinguistic and metacognitive skills, important for minimizing the impact of tbe (C)APD on functional communication (Ferre, 2006). These formal therapies are appropriate and important components of a (C)APD intervention plan and are discussed in detail in the literature (Chermak & Musiek, 2006). In addition to formal therapy, professionals should encourage parents, teachers, and students to "play" with sounds and language using games tbat require auditory discrimination, dicbotic listening, localization, temporal processing, and related top-down skills. These simple games, similar in scope to these (raining paradigms, can be implemented daily, at little or no cost, at home, in the car, or at scbool, and they meet the goal of extending rehabilitation beyond therapy to maximize mastery and generalization of skills for listeners with specific (C)APD. To practice auditory discriminationtbe ability to discriminate, identify, and recognize fine and/or rapidly changing acoustic cuesconsider simple rhyming games such as "give three rhymes for cat;" creating ending-sound word chains in wbich eacb player says a word tbat starts witb the last sound of the previous word (e.g., hiT - Top - PaTH - THeN - NaMe...); or the "telephone game," in which a message is whispered down a line of players or around a circle. Dichotic listening training can improve binaural integration and separation skills, wbicb require that tbe two cerebral hemispheres work together (Weibing & Musiek, 2007). In dichotic listening training, the

is for Activities
Remediation for (C)APD involves specific activities to improve specific auditory and related skills. Bottom-up training programs iire designed to improve auditory skills, including auditory discrimination, 20 AUGUST 14, 2007

T H E

A S H A

LEADER

"musical chairs," and "cake walks." Communication across tbe corpus callosum should be enhanced by any activity that requires interhemispheric communication, sucb as gymnastics, karate, playing an instrument, dancing, tossing a ball from one band to anotber, "Simon," "name tbat tune," or "feely bag" (players reach into a bag and identify an object without looking at it). In addition, the latest generation of interactive video games (e.g., "Donkey Kong Jungle Beat,"

"Mario Mix Dance Revolution," "Eye-Toy" for PlayStation2) require whole-body integration for success. Tbe ability to use visual, linguistic, and/or cognitive cues is promoted tbrough no-cost or low-cost games sucb as "Charades," "Read My Lips." and "Pictlonary" tbat promote attention to and use of visual cues, or "HangMan." "Twenty Questions," crossword puzzles, "Password." "Taboo," "CatchPhrase." and "Tribond," wbicb stress metalinguistic and metacognitive skills.
A S M A

is for Barriers
In addition to improving skills, a goal of any intervention program is to minimize tbe adverse effect of the disorder on the individual. Communication is enhanced for individuals with (C)APDand all listenersby idenlifying and minimizing barriers to auditory processing. These barriers may exist in the listening environment or in the message itself. See Intervention page 22

LEADER

AUGUST 14.2007

21

Intervention from page 21

(Central) Auditory Processing Defined

(Central) Auditory Processing has been defined broadly as the efficiency and effectiveness with wbich the central nervous system (CNS) utilizes auditory information. The skills used include sound localization and lateralization, auditory discrimination, dichotic listening, and temporal processing. In addition, effective auditory processing is associated with other higher-order cognitive-communicative skills including phonological processing, comprehension and interpretation of auditory information, and attention to and memory for auditory information (ASHA. 2005).

It has been estimated tbat nearly two-thirds of a student's day consists of listening to and participating in spoken communication (ANSI, 2(X)2). Thus, it is essential that listening environments be free of acoustic (e.g., noise, reverberation, distance) and nonaeoustic {e.g., lighting, visual cues, or distractions) barriers. Background noise is any auditory disturbance that interferes with listening. The combination of noise and reverberation, or echo, adversely affects the ability to process wbat we hear by masking the acoustic and linguistic cues in tbe message and/or by distracting the listener from tbe communication event (Crandall & Smaldino, 2002). Improving classroom acoustics can involve extensive and often expensive infrastructure changes such as eliminating open classrooms, relocating teaching spaces, or altering beating or air conditioning systems. Simpler and less expensive solutions in school and at home include closing doors and windows; carpeting rooms; using curtains, drapes, and/or acoustic ceiling tiles; placing baffles within the listening space; damping acoustically reflective surfaces; reducing radio, stereo, and television volume; changing lighting; and minimizing the number of speakers talking at once. Distance between the speaker and listener

can affect speecb recognition. For most listeners, a distance of three to six feet from tbe sound source is considered optimal (Bootbroyd, 2004). By locating the listener with (C)APD nearer the primary sound source at home or in school, listening and processing are enhanced. Nonaeoustic factors such as lighting, availability of visual cues, and presence of visual and physical distractions also should be considered. Room ligbting can affect ability to use visual cues and maintain attention on task. Speakers should avoid being backlit, or standing with tbe light coming from behind rather tban on tbe speaker's face. Using incandescent lighting rather than fluorescent lighting eliminates the hum often produced by these lights and reduces harshness and glare, thus minimizing a source of noise and improving access to visual cues. Preferential seating, use of study carrels at home and school, and/or changes to desk or chair design can minimize visual

TccU ^or Involving ParenU in Carly Language Intervention!

The Hanen Centre helps you involve parents in Their child's early language intervention. The It Takes Two to Talk^" guidebook provides parents with practical, user-friendly information on language facilitation strategies. The companion DVD brings the guidebook to life with delightful examples of parents applying the strategies in everyday situations. Together, these versatile tools can be used to supplement consultations with parents, direct therapy or home programming and are applicable to young children of varying ages and developmental stages. IiTu---toTalk Save over 20% off when you buy both the DVD fi Guidebook
Special price until August 31, 2007 DVD only $49

\ Guidebook Combo!
DVD 6

Guidebook only DVD & Guidebook

$46

-$7

The Hanen Centre.

For more injormofion on the&e items, viiit www.hanen.ors or call 4i6-g2i-ioj3.

and physical barriers that may interfere with li.stening or studying. For the listener with (C)APD, what we say and bow we say it can be critically important. Modifying the message by using elear speech and clear language, increasing message familiarity, and adding visual cues enhances prtwessing for alt listeners, not jusl those with (C)APD. Clear speech and clear lan^uaiie focus on enhancing speech recognition by mtnlifying the speech or language ofthe talker. Too often, speakers talk too fast or too softly, drop word endings, and blur acoustic boundaries between targets (Schum. 1997). By speaking at a sligbtly reduced rate and sligbtly increased volume, spectral bouiiilarics and characteristics are enhanced and signal timing and prosody improve, improving speech intelligibility. Wbile clear .speech improves signal percepti<m, clear language improves comprehension. Speakers can enhance message salience by rephrasing, minimizing tbe use of ambiguous and generic language, adding "tag" words (such us first, lust, before, after), providing verbal cues and prompts, and verbally stressing key words. Limiting the overall amount of information presented at once, breaking long messages ASHA has established an Ad Hoc Comdown into shorter sequences, mittee on the Role of the Speech-Language and allowing "thinking" Pathologist in Identifying and Treating Children with Auditory/Linguistic Processor "waiting" time before ing Disorders. The committee is charged a respon.se is required can with reviewing and analyzing the evidence improve message ct>mprehenrelated to auditory/iinguistic processing sion as well as the listener's disorders in children and developing docuability to demonstrate underments related to the role of the speechstanding. language pathologist. The committee will In general, the more work to clarify the role of the SLP, reach familiar one is with the target, consensus on what to call such disorders, and determine the interface between audiolthe easier the processing ogy and speech-language pathology In becomes. In ihe classroom, the identification, assessment, diagnosis, pre-teaching or previewing and intervention of disorders involving the material enhances familiarity auditory processing of linguistic information. with the target and tbe task. Members of the committee, chaired Audio b<ioks, copies of teachby Gail J. Richard, are Marc E. Fey, Alan ers' notes/texts, study guides, G. Kamhi. Janet M. Krebs, Jay R. Lucker, movies, and reading aloud Deborah Ross-Swain. Sally E. Shaywitz, to children ean enhance their Diane R. Paul (ex officio), and Brian familiarity with Ihc subject, B. Shulman (monitoring vice president). For more information, contact Diane Paul at task demands, main idca.s.

New Committee on Auditory/ Linguistic Processing Disorders

[email protected].

See Interventiitn pa^e 34

22 AUGUST 14, 2007

LEADER

Intervention from page 22 key elements, and vocabulary. At home and school, prior knowledge of the rules, structure, and task demands can minimize overload. Listeners will become more familiar with and better able to use tbe rules of language through a combination of repeated exposure and, as needed, explicit instruction, across a variety of contexts and settings throughout tbe day (Ferre, 2006). Adding visual cues to a message intensifies processing tbrough increased neural interaction. Thus, looking and listening should be modeled by parents and teachers if the same bebavior is expected from cbildren. However, some listeners are deficient in tbeir ability to integrate auditory and visual information and tbe addition of visual cues may create furtber confusion. In tbese cases, "look

Effective assessment and intervention of (C)APD requires collaboration.

and listen" sbould be changed to "look or li.sten" (Bellis, 2()O3). The addition of complementary visual cues or use of manipulatives, examples, and demonstration (e.g., show me) improves understanding, particularly for unfamiliar or abstract information. For some students, these additional cues can be provided with simultaneous auditory input. For others, mullisensory cues sbould be given sequentially, e.g., "look then listen," in order to minimize potential overload on integration and/or organization skills {Bellis, 2(M)3).

is for Collaboration
The professional scopes of practice of both speech-language patbologists and audiologists make it clear that effective assessment and intervention of (C)APD requires collaboration. Audiologists use well-controlled diagnostic tools to evaluate the integrity of tbe auditory system and offer deficitspecific recommendations for treatment and management. SLPs provide information concerning tbe cognitivecommunicative aspects that relate to (C)APD, implement treatment recommendations, and communicate with teachers and related professionals regarding educational accommodations and strategies. In addition, because (C)APD sbares behavioral characteristics witb other sensory processing, neurocognitive, and educational difficullies. related professionals such as occupational therapists, pbysical therapists, psychologists, and specialists in learning disabilities are among the team members working together to develop effective individualized intervention programs. Finally, clients and their families should be included in tbe pnKess to maximize carryover of new skills and minimize the adverse effects of the disorder on daily life. Collaboration may include co-written lesson plans, joint treatment sessions, classroom visitation, or specific activities to be completed at home. The behavioral similarity of (C)APD to other disorders suggests that treatment options and management strategies may be shared among
A S H A

individuals diagnosed with different deficits. For example, activities suggested by the tKcupational therapist lo enhance a student's sensory processing skills also may be useful for the student with impaired interhemispheric integration. The classroom management strategies recommended for the student with a nonverbal learning disability also may meet ihc needs of tbe student with temporal processing deficits. Audiologists and SLPs are uniquely positioned to sbare information, strategies, and resources with clients, related professionals, teacbers, and parents to find creative and effective ways to meet intervention goals across a variety of settings. By looking at the whole listener and thinking "outside the box," team members may find unique approaches to seemingly different and complex problems. It's as simple as A-B-C. W Jeanane M. Ferre, an tiiidiologi.st, is in private practice in Oak Park, Hi Her practice /,v limited to as.se.s.smeni and intervention of central auditory processing disorders in children and adults. Contact her at jmfphd @ comcast. net.

THE FI5CHLER SCHOOL

CH > THE LIV

Selected References
American Speech-Language Hearing Association. (2005). Technical report: (Central) auditory processing disorders. Rockville. MD: Author. Bellis, T. (2003). Assessment and management of central auditory processing disorders in the educational setting (2nd ed.y Clifton Park, NY: Thomson Delmar Learning. Chermak, G. D. & Musiek, F. E. (Eds). (2006). The Handbook of (central) auditory processing disorders. Volume I: neuroscience and diagnosis. Volume II: intervention. San Diego. CA: Plural Publishing. Ferre, J. M. (2002). Behavioral therapeutic approaches lor central auditory problems, (pp. 525-531). In J. Katz (Ed.), Handbook of clinical audiology, 5th ed. Baltimore, MD: Lippincott Williams & Wilkins.

Learning, causing a ripple effect that can still be felt today. We're Ihe Fischler School of Education and Human Services. Our ideas. our approach, and our programs in speech-Language pathbtrig^' will inspire you to inspire the people around you to move the world.

cause an effect > www.FischlerSchoolr)ov<

>^q4HBH&

FISCHLER SCHOOL
OF EDUCATION 8, HUMAN SERVICES

NOVA SOl'THLASTERN I'NIVERSITY

Nova Si-uihcislflrn liniveisin iWnuW sttHicnis ol .my \Kf. roloi. ."CKual uiieiiiation. and national ot ethnic prigiii Hc\a SotiTheasier lii'iii'JStlv s,icctliw(l hv Bw Cemmiss!! im Collfeps o' Ifw Souihetn Assucaiion tit Colleges arid SchuolsllPlS Souilv"! Una, Dccaiui &ecw..

Addilional references (or this article can be found af Jt)e Leader Online. Search on Ihe tille of fhe article.

34

AUGUST 14. 2007

LEADER