07 Jan Auditory Processing Disorder (APD) in young children
Children who have difficulty in making sense of speech and other sounds may suffer from a hard to diagnose disorder, the symptoms of which are often overlooked in the early years, writes Donna Reis.
“Auditory processing disorder can mean that a child has trouble distinguishing sounds from each other, recalling and analysing what has been heard, and following established conventions of language, all signs which are often misdiagnosed or overlooked.”
When six-year-old Hugh* first made the connection between a word and the sound it began with, his mother, Louise Gleeson*, was over the moon. Still in his first year at school, Hugh had been struggling with reading, and most of his difficulty centred around understanding how the sounds he heard could be represented by letters of the alphabet. “I know a word that starts with an ‘F’ sound,” Hugh had said excitedly while Gleeson was helping him with his letters. Unfortunately, he’d chosen his ‘light bulb moment’ to associate the sound with altogether the wrong type of word for a six year old to be using, and his mother didn’t know whether to laugh or cry. “It was such a huge breakthrough, and I wanted to praise him to the hilt,” she says, “but instead I knew I had to say, ‘Well, yes, but you can’t use that word!’ I can laugh about it now, but there wouldn’t be too many other mothers who could say they were proud of hearing their child swear like a trooper!”
Recently diagnosed with auditory processing disorder, or APD, Hugh is one of a large number of children whose symptoms are vague and difficult to pinpoint until the early school years, when slowness in learning to read and a lack of concentration are often the first factors to be noticed by teachers. Auditory processing disorder has nothing to do with the child’s hearing, as many would assume, and nor does it affect intelligence. Instead, it relates to the brain’s ability to make sense of sounds and speech.
The basics of language confused him
“Auditory processing refers to what the brain does with what it hears,” says Devon Barnes, who is a speech and language pathologist, and the director of the Lindfield Speech Pathology and Learning Centre in Sydney. “Parents might notice that their child has difficulty following directions, or behaves as if he or she has hearing loss. I frequently hear parents complain, ‘He never listens to me,’ or ‘She is always saying “Huh? What did you say?”’ Auditory processing disorder can mean that a child has trouble distinguishing sounds from each other, recalling and analysing what has been heard, and following established conventions of language, all signs which are often misdiagnosed or overlooked.”
Gleeson was one of those parents who knew that something was not quite right. “Hugh was quite late to start talking,” she says. “When he did speak, he would struggle to get his ideas out. You can still see the confusion on his face when he tries to express himself. He tends to be more physical in his communication, such as showing anger towards his brothers by wrestling with them, rather than telling them what he feels. The basics of language confuse him – even at six-and-a-half, he’s saying ‘Me want it’, rather than ‘I’, or ‘Him is very nice to me’.” Barnes says that difficulties with the subtleties of language often do not stop with grammar for many children with APD: “Children with APD may have difficulty following the changes in tone or phrasing that are important to the verbal message. For example, saying ‘Gee, that was smart!’ to a child who has just dropped a drink on the floor might be misinterpreted as a compliment, because the child has missed any sarcasm meant by the speaker.”
“Talking to teachers about your child’s diagnosis is the most important thing you can do,” Barnes says.
“While it can be unrealistic to place too many demands on a teacher who has many other children to consider at the same time, it is often possible to work together to find the most workable system for all children in the class.” Confusing like-sounding words is also common. Barnes tells of a young client who was promised a warm crumpet after church one Sunday morning, if he sat quietly and behaved well during the service. “On arriving home at the end of an hour at church, during which he had been perfectly behaved, the child was dismayed to be presented with his promised breakfast. He wailed, ‘I thought I was getting a crumpet that you blowed into!’”
“The child becomes overloaded with sounds…”
“Apart from recognising differences in sounds, there are other areas that can be affected by this condition,” says Barnes. “There may be difficulty with localising sounds, such as listening to a teacher speak in a noisy classroom. Background noise can interfere dramatically with the processing of verbal messages.” Classrooms, ironically, are not easy places in which to learn for children with this condition. “The child becomes overloaded with sounds, and confused by what is being said,” Barnes says. “When a child has spent the entire day actively trying to listen and concentrate, and is then expected to come home and complete homework, you may as well be asking them to walk 10km after they have just run a marathon. It can all be too much. Putting in so much more effort, for a fraction of the outcome, makes it easy for the child to simply stop concentrating and eventually to lose confidence in their ability.”
Gleeson feels that Hugh’s frustration and confusion quickly turn into tantrums, a connection that is understood by many professionals. “When a child struggles hard to achieve, but still can’t feel good about themselves,” says Barnes, “it is no surprise that there are often behavioural problems which can go hand in hand with APD. The child might switch off from adults’ demands rather than continue to struggle to understand [them].”
“I’m asked to perform a task at work and don’t know which part to do first.”
Scenes like this are very familiar to Helen Steele. Having been diagnosed with the disorder at the age of seven, the now 28 year old says that her road has been a challenging one. “At school, I became skilled at taking a biro apart and then putting the bits back together again, so that I could look busy and avoid the teacher’s attention. A lot of teachers assumed that I had attention deficit disorder, because I would constantly get lost on task. I’d go to the library and then forget what I was doing there,” Steele says. “That still happens frequently. I’m asked to perform a task at work and don’t know which part to do first.”
Gleeson also has to be careful with instructions to her son: “I couldn’t ask Hugh to go outside to the chook pen, collect the eggs, remember to shut the gate, and then wipe his feet before coming inside, for example. He would simply get lost on the first part,” she says. Barnes confirms that being unable to remember a set of instructions can be a common sign of an auditory processing disorder. “Our working memory requires that we perform several steps when asked to follow instructions. We need to listen, remember what was said, analyse what is required, and then perform an action.
In a classroom setting, particularly, as instructions become longer and more complex, a child can have huge trouble recalling and making sense of it all. They appear to ignore requests, or to only remember one part of what was asked, and the teacher might complain that the child appears distracted or uninterested.” Barnes stresses the importance of obtaining a thorough and professional diagnosis.
“Diagnosing this disorder correctly will have an enormous effect on the outcomes. Firstly, the condition can affect children in many different ways, and it is important to be certain about the specific challenges faced by your child. Then there is the common tendency for auditory processing disorder to coexist with many other learning disabilities, making diagnosis more complex. Children may often present with other conditions such as dyslexia, attention deficit disorders and even autism, and there can often be a crossover of symptoms, although auditory processing disorder can exist on its own, too.”
Barnes highly recommends finding professionals who know the area well, since assessment methods and treatments “When a child struggles hard to achieve, but still can’t feel good about themselves… it is no surprise that there are often behavioural problems which can go hand in hand with APD. The child might switch off from adults’ demands rather than continue to struggle to understand [them].” are highly specialised and frequently under review.
“A specialist audiologist will undertake what is sometimes called a ‘bottom up’ assessment,” explains Barnes. “They will begin with ensuring that the child can hear. A series of tests will then establish other abilities, such as sound localisation, and the ability to distinguish changes in pitch and tone. Once a firm understanding of the child’s hearing processes has been performed, a speech therapist who has been trained in the area can begin a ‘top down’ assessment, meaning that the functional abilities are considered. This might include the child’s awareness of the distinction between different sounds, and how well they can reproduce those sounds when speaking. Ideally, we need both points of view, both neurological and functional, before we can meet in the middle to work on increasing the child’s abilities.”
Steele credits her mother with gaining her early diagnosis of a condition that was not well recognised 20 years ago. “My mother worked really hard to get me professional help that was specific to my needs. She also put in a lot of work to help me to read. It would have been much more difficult for me to get by without her persistence; but even so, it took a long time to even get a diagnosis. I was lucky – many children can easily fall through the cracks.”
Speech-language pathologists can help children with APD in many ways, including helping them to break down and recognise the internal structure of words, and to develop their auditory memory and listening skills. There are a number of computer programs available that can also help with APD. However, Devon Barnes warns, “It is important to distinguish between those programs that are based on scientific research, the results of which are scientifically validated, such as the FastForWord program, and others that are more in the nature of ‘computer games’, and which have no scientific research validation”.
Modifying the classroom environment to improve the child’s understanding is also beneficial. “Talking to teachers about your child’s diagnosis is the most important thing you can do,” Barnes says. “While it can be unrealistic to place too many demands on a teacher who has many other children to consider at the same time, it is often possible to work together to find the most workable system for all children in the class.
Newer or more progressive schools are able to modify the environment to absorb noise rather than reflect it, such as using carpets and curtains. Even stoppers on chairs can help reduce noise levels, as can preferential seating, so that children with auditory processing problems are seated closest to the teacher.”
Barnes points to the current trend of seating children around tables, rather than directly facing the teacher, and recommends in these settings that the teacher is able to subtly monitor children with the disorder, with regular checks to ensure they are receiving and understanding instructions. She says, “Some children will benefit from classroom amplification equipment or individual FM systems”. Visual aids can help, too. “Charts and diagrams, or any form of multi-sensory instruction can help many children, not just those with APD,” says Barnes. “Providing homework instructions in clear, step-by-step written form is helpful for older children.”
Although she still experiences the effects of APD in adulthood, Helen Steele has been helped greatly by these types of strategy, and has completed several qualifications by learning to draw on her own strengths. “I still have to reread things over several times before they make sense. I have to make sure important information is written down. But I’ve always been a fantastic cook,” she says. “I can easily follow a recipe, because it’s given to me in distinct steps. I don’t need to analyse the information, or decide what to do first; it’s all there for me.” Music is another area in which she has done well. “Reading the music on a page becomes like riding a bike, and for me, is far less complex than the language of words.”
Louise Gleeson has also worked hard to help her son keep up at school. Trained as a primary teacher, she has made clay models of the letters of the alphabet to make learning a more physical experience for him, which seems to better suit Hugh’s style of learning. In accordance with instructions from the speech therapist, Gleeson helps him to learn words using cued articulation, which is “like a type of sign language”, to help him to visually differentiate between sounds. With Hugh’s extra teaching taking up a lot of Gleeson’s time, she still finds dealing with the emotional side of the disorder most exhausting.
“Even though he might eventually grow out of the condition, or learn to adjust to it, the constant blows to his self-confidence will last a lot longer.”
Gleeson would love to see Hugh receive remedial help in the classroom, but this type of funding is not available for children with APD. “There are children with Asperger’s and dyslexia in Hugh’s class who can get extra help at school, and it is frustrating that APD still isn’t recognised by the education department, because those children can read better than he can. Hugh struggles even to learn his alphabet.”
Meanwhile, Gleeson is still waiting for Hugh’s next big breakthrough in putting words and sounds together, and is hoping that it will be with a word that she can proudly report back to his teachers!
* Names have been changed.