We are pleased to welcome Gail Whitelaw, Ph.D., CCC-AUD as our
guest speaker for the SLP student chat tonight, Monday, April 1, 2002 at
9:00pm EST. Dr. Whitelaw will lead us in a chat about Central Auditory
Processing Disorders. She is currently the Director of Clinical Instruction
and Research in the Department of Speech and Hearing Science at The Ohio
State University. Dr. Whitelaw is an audiologist with primary interest in
pediatrics, including educational issues in children with hearing and listening
impairments, classroom acoustics, and amplification issues. She consults
and provides educational audiology services to a number of school districts in
Central Ohio. In addition, she is a frequent presenter on the topic of Auditory
Processing Disorders at State and National meetings. Dr. Whitelaw is currently
the audiology faculty member on a 5 year Maternal-Child Health (MCH) Grant with
the focus of leadership training in neurodevelopmental disorders at the Nisonger
Center at Ohio State. Dr. Whitelaw serves on the Board of Directors of the
American Academy of Audiology.
<Robin> We are very pleased to welcome Gail Whitelaw, Ph.D., CCC-AUD who will chat with us
tonight about Central Auditory Processing Disorders.
<Robin> Gail, could you please give us an overview of what CAPD encompasses?
<Gail Whitelaw> Thanks Robin--CAPD is a misunderstood diagnosis...it's really on the continuum
of hearing problems encountered by both audiologists and SLPs.
<Gail Whitelaw> We talk about bottom up and top down processess...top down is often what SLPs
deal with and bottom up is what audiologists deal with. CAPD is considered a bottom up
process.
<Gail Whitelaw> Bottom up refers to how information gets from the ear to the brain.
<Gail Whitelaw> In 1996, ASHA developed a consensus statement which describes well those
"behaviors" incorporated in CAPD.
<Gail Whitelaw> Those include sound localization, auditory discrimination, temporal aspects of
audition, auditory performance decrements with competing acoustic signals and auditory
performance decrements with degraded acoustic signals.
<Gail Whitelaw> You can see that lots of academics were involved, since there are alot of 50
cent words ;)...however it's important to think about what these behaviors mean in
clinical practice.
<Gail Whitelaw> I was hoping that the students would share with me if they have had any exposure
to CAPD to date, which gives me an idea of a place to start.
<Robin> have any of you had any exposure to CAPD? I know that I didn't when I was in school.
<slpgrad> I've read an article about CAPD in my language class, but that was an overview, no
personal experiences.
<reneemdol> The only exposure I have had was in the classroom, I begin some clinical practice
this summer and grad in the fall so I am trying to get as much information about
disorders as possible and what to look for in clinical practice.
<Maureen> I have only done observations for clinical observation class, but have not worked
with any.
<Gail Whitelaw> As Robin mentioned, most programs don't have much in this area. It's important,
since it's used as a catch phrase...so let's talk about why it's important, behaviors
that might classify a child as having CAPD, etiologies, and diagnosis.
<Gail Whitelaw> CAPD has been around as a concept in S and H since the 1950's.
<Gail Whitelaw> The concept as we know it as audiologists came from observation of patients
with known temporal lobe lesions. It was found that if their auditory system was "taxed"
(they used a filtered word test), the breakdown was evident.
<Gail Whitelaw> This was important, since in those days, the tests to diagnose brain lesions
were often "deadly".
<Gail Whitelaw> In the 1950's and 1960's, observations were made that some children behaved as
those adults with known brain lesions.
<Gail Whitelaw> That is, they "looked" like they had a hearing loss, however their "peripheral
hearing test" was normal.
<Gail Whitelaw> It's important to recognize that for most audiologists that work with auditory
processing, we see the audiogram (the pure tone testing) as just one measure of hearing
and listening.
<Gail Whitelaw> Some of the children you end up working with as an SLP will present as if they
have a hearing loss.
<Gail Whitelaw> That is, they will often ask for informaton repeated, they may be distracted or
struggle in less than optimal situations (e.g. the classroom).
<Gail Whitelaw> They may present with some persistent phonologic errors that lots of therapy have
not been able to address.
<Gail Whitelaw> Often they have issues with "attention" and many of these children often have
significant histories of ear infections (e,.g. otitis media).
<Robin> It sounds like this could be easily misdiagnosed.
<Gail Whitelaw> Robin...if there is one take home message for anyone tonight, it's to be sure
that before a child is to be considered as having CAPD, they must be known to have normal
peripheral hearing acuity.
<Gail Whitelaw> I can tell you case after case that gets to our clinic where children have
undiagnosed hearing losses.
<slpgrad> What can I as an SLP in the school do to educate classroom teachers as to what to
look for, because can't this be mistaken for ADHD?
<Gail Whitelaw> slpgrad--that's a great question. First, this is a diagnosis of exclusion and
one that is based on interdisciplinary team assessment.
<Gail Whitelaw> There are a number of really good articles by Gail Chermak and her colleagues
that indicate that CAPD kids and ADHD/ADD kids actually have different constellations of
behaviors.
<Gail Whitelaw> In addition, slpgrad, we ask teachers to do an "authentic assessment" and use a
questionnaire...in our clinic we use the Children's Auditory Processing Performance
Scale (available from Educational Audiology Association), however a number of auditory
specific checklists exist.
<reneemdol> Gail, - you stated that this presents as a hearing loss, at that point the SLP
should refer for a hearing test, at that point can CAPD be diagnosed from an audiogram?
<Gail Whitelaw> reneemdol--CAPD can't be diagnosed from an audiogram, since the idea is to "tax"
the auditory system.
<Gail Whitelaw> Pure tone audiometry, or even speech audiometry in quiet and ideal situations,
cannot identify CAPD.
<Gail Whitelaw> However, many children have been labeled CAPD based on a poorly administered
hearing screening in school or no hearing screening...my "worst" case was a 6 year old
child with a moderate sensorineural hearing loss who was id'ed as CAPD.
<Robin> Gail, didn't you say before that the audiogram (pure tone) would be normal for a child
with CAPD?
<Gail Whitelaw> Robin...that's right and part of the definition of CAPD is normal peripheral
hearing acuity and also normal cognitive ability.
<Laura> Gail, could you please give us some general characteristics that teachers should look for.
<Gail Whitelaw> Laura--the "checklists" are helpful in identifying these for teachers. Included
would be the child who frequently asks "huh" or "what";
<Gail Whitelaw> The child who has difficulty focusing on auditory information;
<Gail Whitelaw> The child who may have difficulty with learning to read, particularly the
phonics aspect.
<Gail Whitelaw> These are often kids who have difficulty hearing unstressed sounds (word endings,
unstressed syllables, etc.
<Gail Whitelaw> In addition, Laura, the old adage that "production" mirrors perception often
holds true...these are often children with phonological or other types of language issues.
<Gail Whitelaw> CAPD kids are generally very bright, may have a family history of LD or similar
types of listening issues, and often have verbal IQ's that are poorer than "performance"
IQ's...they have a split of information or scatter on standardized types of tests.
<Gail Whitelaw> As several of you mentioned, these kids often look like something else, like
ADD, and there is co-morbidity, however CAPD alone is considered a really low incidence
population.
<Gail Whitelaw> No "true" estimates exist, however CAPD alone is considered to be present in
about 3-4% of school aged children.
<Gail Whitelaw> Those kids with histories of OM (Otitis Media) tend to be at higher risk, since
there are considerable physiologic reasons for that.
<AngieFSU> Do you have any stats on the prevalence of CAPD in hearing impaired children?
More or less common?
<Gail Whitelaw> AngieFSU--this is controversial. Many of us don't accept CAPD as a definition if
there is hearing loss involved.
<Gail Whitelaw> Peripheral loss, since difficulty processing auditory information is inherent
in this population
<AngieFSU> certainly
<Gail Whitelaw> However, it's clear that some children with equal degrees of hearing loss do
better than others.
<Gail Whitelaw> This is really evident in the cochlear implant population.
<Robin> Gail, how do you ultimately make the correct diagnosis for CAPD?
<Gail Whitelaw> Robin....as I mentioned, it's a diagnosis of exclusion and done by a team.
<Gail Whitelaw> It's best when I get to be the "last one" as I have been able to do both in
hospital settings and on MFE teams that I consult to.
<Gail Whitelaw> An audiologist administers a battery of tests.
<Gail Whitelaw> Those tests are designed to "tax" the auditory system.
<Gail Whitelaw> All of the behaviors that ASHA listed should be addressed. So when I am doing a
CAPD workup (or as popular now, APD...for auditory processing disorder) I want to look
at how a child does with specific kinds of tasks.
<Adrienne> I can see how it gets misdiagnosed alot.
<Gail Whitelaw> Anyways...we want to try to tax the internal redundancy of the auditory system.
<Gail Whitelaw> We do that by reducing the auditory information available in the signal
<Gail Whitelaw> If I were to test each of you, you would have more difficulty filling in
information if we filtered the signal electronically for example.
<Gail Whitelaw> However, you would still be able to do it...partially because you have "top
down" skills (language" and particalally because of the way that your auditory system is
organized...
<Gail Whitelaw> You are "wired" to process multiple signals at the same time...the "dendritic
branching" of the auditory system.
<Gail Whitelaw> When a person has a CAPD, they are not able to make use of that infomration,
due to the manner in which information gets from the ear to the brain.
<Gail Whitelaw> Dr. Katz from the University of Buffalo talks about auditory processing as
"what we do with what we hear".
<Gail Whitelaw> In order to know what that is, an audiologist will administered a number of
tests (usually this testing takes 1-2 hours).
<Robin> Gail, is CAPD found more in males than females by any chance?
<Gail Whitelaw> Robin--that's often thought--however many of us with large data bases believe
that it's a different type of CAPD in boys.
<Gail Whitelaw> This is a heterogeneous disorder.
<Robin> Thank you, I was curious.
<Gail Whitelaw> Boys are often more obvious, since they have the type that is bothersome in
noise.
<Gail Whitelaw> So they are like the "tazmanian devil" in the classrooms.
<Gail Whitelaw> Girls are often more in the temporal processing area and shut down with rapid
presentation of information or struggle with reading.
<Gail Whitelaw> However, these kids often don't draw much attention to themselves.
<Adrienne> That is very interesting!
<Gail Whitelaw> We have a large data base of kids we see where we see this pattern over and
over...most audioloigsts don't administer tests until about age 7, however girls are
often Id'ed much later.
<Robin> What types of tests does the audiologist administer during the evaluation?
<Gail Whitelaw> Robin--in our clinic, we have no "cookbook" however I would choose among these
types of tests if a child were referred.
<Gail Whitelaw> We often use the SCAN-C battery, which is a good screening tool for a school
based SLP. It has 4 subtests and is easy to administer.
<Gail Whitelaw> We like to look at processing of timing information and pattern perception,
so we use Pitch or duration pattern testing.
<Gail Whitelaw> We also like to look at the ability to do "dichotic" information (how you
combine infomration between two ears).
<Gail Whitelaw> So, a big part of dichotic listening is using lots of materials that have
varying levels of linguistic information (CV's, workds, sentences, etc.)
<Gail Whitelaw> We have recently started working with some more basic "psychoacoustic" skills,
like gap detection.
<Gail Whitelaw> One of the criticisms of CAPD was that audiologists used too much linguistically
based test materials.
<Gail Whitelaw> So, we try to address this with the behavioral tests we choose.
<Gail Whitelaw> There is a test called the ACPT which helps to differentiate between attention
and CAPD
<Gail Whitelaw> It looks at attention, impulsivity errors vs. the ability to process
<ariela> What is the ACPT?
<Gail Whitelaw> ariela, the ACPT is the Auditory Continuous Performance Test. It's a list of a
bizillion (more like 592 words) where the child needs to listen for a target word.
<Gail Whitelaw> There are probably about 6-8 more tests that we might choose on the behavioral
front.
<ariela> Wouldn't attention interfere with the ability to process? How do you rule that out?
<Gail Whitelaw> ariela...you are right, however many of these kids have the ability to attend
to the task well, they just can't do the task. It's the same as you would have to deal
with in administering a language battery.
<Gail Whitelaw> In addition, there are a number of catch trials to address attention.
<ariela> How do you know if a child has an inability to process as a result of an attention
problem?
<Gail Whitelaw> In nearly 20 years of seeing kids with CAPD, that question becomes easier to
see over time. Most attentional kids just won't do the task...the CAPD kids "can't" do
the task. The ADD kids get the task, catch on quickly , and can perform,,,,they just
need alot of redirection. The CAPD kids are slow to get the task, however often have no
difficulty attending...they may pace as they do this (remember we're in an auditory
booth)
<Gail Whitelaw> But cannot do what's required. They'd "attend" all day long...as most do in
school. Also, these are kids who have great attention to information in other modalities.
<Adrienne> What would you address in treatment for CAPD?
<Gail Whitelaw> A differential diagnosis starts the process.
<Gail Whitelaw> Once the child's areas of weakness are identified, the treatment usually
consists of a 3 pronged approach....direct intervention, compensatory skills, and
environmental modifications.
<Gail Whitelaw> Secord talks about person centered and context centered treatment.
<Gail Whitelaw> One of the main things that helps kids with deficits processing in auditory
environments that are less than optimal is addressing classroom acoustics.
<Gail Whitelaw> I do research in classroom acoustics and it's a hot topic at the moment.
Since school is auditory oral, if this issue were addressed, it would certainly help all
kids, however it does benefit children identified as high risk listeners.
<Gail Whitelaw> However, this is not a panacea for kids with CAPD and does not benefit them all.
<Robin> What can realistically be done to the classroom acoustics?
<Adrienne> and who pays for it?
<Gail Whitelaw> Robin and Adrienne---there is a new standard that has just been adopted for
classroom acoustics and that means that the tax payers will pay in the development of
schools etc.
<Gail Whitelaw> However, there are lots of low cost things to address this. Merely closing the
classroom door can reduce signal-to-noise ration by as much as 10 dB
<Robin> That is significant.
<Adrienne> wow
<Gail Whitelaw> In addition, soundfield FM systems benefit all kids in the classroom, as more
and more research points out (great article by Rosenberg 2 years ago)
<Gail Whitelaw> and many schools are now providing these as part of the "equipment" for the
classroom...just like lights, etc.
<Maureen> That is interesting!
<Gail Whitelaw> Other issues should be addressed, including auditory training.
<Robin> Please tell us more about auditory training.
<Gail Whitelaw> Many kids with CAPD are poor at being "incidental learners" so must be trained
like kids with hearing loss. There are a number of computer programs available and well
publicized, like Earobics and Fast ForWord programs.
<Gail Whitelaw> However, again, not a panacea and not for every child.
<Adrienne> Please tell us about compensatory skills.
<Gail Whitelaw> Compensatory skills are numerous and depend on the child.
<Gail Whitelaw> For example, a child might have a notetaker, be given guided notes, etc.
<ariela> I am still curious about how you differentiate between ADHD inattentive type and
auditory processing disorder.
<Gail Whitelaw> ariela...Many children with ADHD are diagnosed by someone at school. This isn't
supposed to happen but it does. Many kids with CAPD have different profiles
<Gail Whitelaw> They do poorly on medication.
<Gail Whitelaw> They do well on the ACPT (again, those inattentive kids don't do well on
this test).
<ariela> Meds are a trial and error issue, I hope that it is not decided based on one trial
of meds...
<Laura> As a grad student from MI, I don't believe that under MI's IDEA, CAPD is seen as
a disorder requiring intervention provided by the school system. What steps can be taken?
<Gail Whitelaw> Laura--the only state that recognizes CAPD in state guidelines at the moment is
Colorado.
<Robin> really?!!!!!
<Gail Whitelaw> yes, however I consult to a pile of school districts in OH and I can tell you
that they are all over the board on this issue.
<Robin> What is being done to change this?
<Gail Whitelaw> Nothing is being done to change it in many states, which is unfortunate.
<Maureen> That is interesting since so much research has been done in Buffalo, NY.
<Gail Whitelaw> Most of us recognize CAPD on the continuum of hearing loss, however that's also
poorly advocated for in many schools and states.
<Robin> What is an SLP in the schools to do then?
<Gail Whitelaw> An SLP in the school can educate themselves on the topic and resist the
temptation to over identity and over-refer.
<Gail Whitelaw> I think schools are "nervous" that this will be a catch all term and that too
many kids will get services.
<Gail Whitelaw> If nothing else, using a good questionnaire, such as the CHAPs or Fishers helps
the school based SLP appropriately address which children should be screened.
<Robin> Gail, it is getting late....your fingers must be getting tired! There is a lot of
information to cover on this subject!
<Gail Whitelaw> I know it's getting late, so if there are other pressing questions, fire away!
<Laura> If a child is diagnosed with CAPD by an audiologist, then how can he/she be brought on
the caseload?
<Gail Whitelaw> The SLP is usually the "corrector" since the audiologist is the "detector"
<Gail Whitelaw> One of my colleagues has coined this.
<Robin> catchy!
<Adrienne> There is a lot of info about this topic I did not realize. Thanks Gail!
<Robin> Thank you so much for the wonderful information Gail.
<Gail Whitelaw> My pleasure...!
<ariela> thank you!
<Maureen> thank you!
<Laura> thank you Gail.
<Robin> I can see that we will have to revisit this topic in the future since there is so
much to discuss!
<Gail Whitelaw> The more it's revisited, the more questions arise!
<Maureen> Another topic I would like to chat about is cochlear implants, very interesting topic.
<Maureen> another evening of course!
<Robin> Yes Maureen, we will most certainly have to address that topic!
<Robin> Gail, thank you so much for sharing your wisdom about CAPD...its a facinating topic!
<ariela> Good night!
<Robin> thank you all for coming! Goodnight!
<Gail Whitelaw> Robin...you're welcome--thanks to all of you--goodnight!
