Today’s post will make a number of people quite angry and is intended to be controversial! Why? Because controversy promotes critical thinking, broadens perspectives, allows to acquire better knowledge of the construct in question as well as ultimately guides better decision making on the part of the parties in question. So why the lengthy disclaimer? Because today via the use of the latest research publications, I would like discuss the fact that the diagnosis of Auditory Processing Disorder (APD) or what some may know as Central Auditory Processing Disorder (CAPD) is NOT valid!
Here are just a few reasons why:
- There is a strong desire for the (C)APD label on the part of those encountering processing difficulties, yet once the label is given no direct/specific auditory interventions are provided by the audiologist. Subsequent to the diagnosis, confusion ensues regarding the type, frequency, and duration of service provision (typically performed by the SLP) as well as what those services should actually constitute
- Recommendations for training deficits specific areas such as working memory, auditory discrimination, auditory sequencing, etc., do not functionally transfer into practice and fail to create generalization affect
- Recommendations for specific costly auditory training programs such Auditory Integration Training (AIT), The Listening Program (TLP), Fast ForWord® (FFW) at the exclusion of all others, without the provision of a detailed breakdown of the child’s deficit areas often cause an incursion of unnecessary expenses for parents and professionals and are found to be INEFFECTIVE or limitedly effective in the long run
- General audiological recommendations for accommodations (e.g., FM systems, etc.) are frequently unnecessary, and may actually exacerbate the isolation effect while in no way alleviating the student’s deficits, which require direct and targeted intervention
- Auditory deficits don’t cause speech, language, and academic learning difficulties
- Numerous non-linguistic based disorders can be misdiagnosed as (C)APD without differential diagnosis
- (C)APD testing is hugely influenced by non-auditory factors grounded in higher order cognitive and linguistic processes
- Presently there’s no no clear performance criteria to make the (C)APD diagnosis
- The diagnosis of (C)APD is appealing because it presents a more attractive explanation than the diagnoses of language and learning disabilities for children with processing deficits
- The diagnosis of (C)APD may often detract from identifying legitimate language based deficits in the areas of comprehension, expression, social communication and literacy development, as the result of which these areas will not get adequate therapeutic attention by relevant professionals
A few words on (C)APD popularity, well sort of:
(C)APD is currently rampantly diagnosed in the United States, Australia and New Zealand, and is even beginning to be diagnosed in the United Kingdom (Dawes & Bishop, 2009). However, presently, (C)APD is not a mainstream diagnostic classifications in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) nor is part of an actual educational classification in United States. Already many of you can see the beginnings of the controversy. If this diagnoses is so popular and so prevalent why is that major psychological and educational governing bodies such as American Psychiatric Association and the US Department of Education still do not officially recognize it?
(C)APD symptomology:
A. Student presents with difficulty processing information efficiently
- Requires increased processing time to respond to questions
- Presents like s/he are ignoring the speaker
- May request frequent repetition of presented information from speakers
- Difficulty following long sentences
- Difficulty keeping up with class discussions in group settings
- Poor listening abilities under noisy conditions may be interpreted as “distractibility”
B. Student has difficulty maintaining attention on presented tasks
- Frequent loss of focus
- Difficulty completing assignments on their own
C. Student has poor short term memory – difficulty remembering instructions and directions or verbally presented information
D.Student has difficulty with phonemic awareness, reading and spelling
- Poor ability to recognize and produce rhyming words
- Poor segmentation abilities (separation of sentences, syllables and sounds)
- Poor sound manipulation abilities (isolation, deletion, substitution, blending, etc)
- Poor sound letter identification abilities
- Poor vowel recognition abilities
- Poor decoding
- Poor comprehension
- Spelling errors
- Limited/disorganized writing
E. The combination of above factors may result in generalized deficits across the board, affecting the child’s social and academic performance:
- Poor reading comprehension
- Poor oral and written expression
- Disorganized thinking (e.g., disjointed narrative production)
- Sequencing errors (recalling/retelling information in order, following recipes, etc)
- Poor message interpretation
- Difficulty making inferences
- Misinterpreting the meaning of abstract information
That is exactly what Dawes & Bishop, stated in 2009, when they asserted that “a child who is regarded as having a specific learning disability by one group of experts may be given an APD diagnosis by another.” They concluded that: “APD, as currently diagnosed, is not a coherent category, but that rather than abandoning the construct, we need to develop improved methods for assessment and diagnosis, with a focus on interdisciplinary evaluation“.
Let us now deconstruct each of the above statements with the assistance of direct quotes from current research.
1. (C)APD – what is it good for? Child goes to an audiologist and receives an ambiguous battery of (C)APD testing with unclear qualification criteria (more on that below). There are some abnormal findings, so the audiologist states that the child has (C)APD, recommends accommodations and modifications, services in the form of speech language therapy with a focus on auditory training (more below) and/or some form of program similar to Fast ForWord®, and doesn’t see the child again for some time (maybe even years). Since the child is now being seen by an SLP, who by the way frequently has no idea what to do with that child based on the ambiguous audiological findings, what exactly did the diagnosis of (C) APD just accomplish?
2. Processing Skills Training – Say What? In 2011 Fey and colleagues (many notable audiologists and speech language pathologists) conducted a systematic review of 25 journal articles on the efficacy of interventions for school-age children with auditory processing disorder (C)APD. Their review found no compelling evidence that auditory interventions provided any unique benefit to auditory, language, or academic outcomes for children with diagnoses of (C)APD or language disorder.
Presently there is no valid evidence that targeting specific processing skills such as auditory discrimination, auditory sequencing, phonological memory, working memory, or rapid serial naming actually improves children’s ‘auditory processing’, language or reading abilities (Fey et al., 2011).
To illustrate further, Melby-Lervåg & Hulme, 2013 performed a meta analysis of 23 working memory training studies. They found no evidence that memory training was an effective intervention for children with ADHD or dyslexia as it did not lead to better performance outside of the tasks presented within the memory tests. They concluded: “In the light of such evidence, it seems very difficult to justify the use of working memory training programs in relation to the treatment of reading and language disorders.” Further adding: “Our findings also cast strong doubt on claims that working memory training is effective in improving cognitive ability and scholastic attainment.” (Melby-Lervåg, 2013, p. 282).
3. The trouble with prescriptive programs. (C)APD assessments often yield recommendations for a number of specific costly prescriptive programs such as AIT, FFW, etc.. As humans we are “attracted to interventions that promise relatively rapid improvements in language and academic skills. Interventions that target processing abilities are appealing because they promise significant improvements in language and reading without having to directly target the specific knowledge and skills required to be a proficient speaker, listener, reader, and writer.” (Kamhi and Wallach, 2012)
These programs claim to improve the child’s processing abilities through music, phonics, hearing distortions, etc. When such recommendations are made parents and professionals are urged to carefully review evidence-based research supported information regarding these prescribed programs in order to determine their effectiveness. Presently, there’s no research to support the use of any of these programs with children presenting with processing difficulties.
Let’s take a look at Fast ForWord®, which is a highly costly program frequently recommended for children with auditory processing deficits. It is designed to help children’s reading and spoken language by training their memory, attention, processing, and sequencing by training 3 to 5 days per week, for 8 to 12 weeks. However, systematic reviews found no sign of a reliable effect of Fast ForWord® on reading or on expressive or receptive spoken language.
Now some of you may legitimately tell me: “How dare you? I’ve tried it with my child and seen great gains”. And that is terrific! However, it is important to note that ANY intervention is better than NO intervention! And there is currently no scientific proof out there that this program works better than other programs aimed directly at improving the children’s reading abilities and listening skills. Furthermore, if the child needs assistance with reading rather than spending the money on Fast ForWord® it would be far more effective to select a systematic Orton-Gillingham (OG) (or similar) reading based program to teach her/him reading!
4. The dreaded FM system! FM systems have become an almost automatic recommendation for children diagnosed with (C)APD but are they actually effective?
Here is what one notable audiologist had to say in the subject. “An FM system brings the speaker’s voice via the mic to the listener via loudspeakers or earphones through an amplifier. Only personal systems appropriate for children with TRUE APD-based auditory distractibility problems (understanding speech in the presence of background noise)”. However, when he did his testing he found that only ~25% of children with (C)APD had issues with hearing speech in noise, the other ~75% didn’t.
Guess what… a recent meta-analysis showed? Lemos et, al, 2009 did a systematic literature review of articles recommending the use of FM systems for APD. They concluded that: “Strong scientific evidence supporting the use of personal FM systems for APD intervention was not found. Since such device is frequently recommended for the treatment of APD, it becomes essential to carry out studies with high scientific evidence that could safely guide clinical decision making on this subject.“
5. (C)APD diagnosis does NOT Language Disorder Make. “There little evidence that auditory perceptual impairments (not referring to hearing deficits) are a significant risk factor for language and academic performance (e.g., Hazan, Messaoud-Galusi, Rosan, Nouwens, & Shakespeare, 2009; Watson & Kidd, 2009)” (Kamhi, 2011, p. 265).
- Watson et al., 2003 found that measures of auditory processing (NOT hearing) had no impact on children’s reading or language abilities in Grades 1 through 4.
- Sharma, Purdy, and Kelly (2009) found that having auditory processing difficulties did not increase the likelihood that a child would have a language or reading disorder.
- Hazan et al., 2009; Ramus et al., 2006) found that despite poor phonological processing abilities, individuals with dyslexia perform within normal limits on measures of speech perception.
(From Kamhi, 2011, p. 268)
6. Are you sure it’s (C)APD?
Without a careful differential diagnosis, numerous non-linguistic based medical, psychiatric neurological, psychological, and cognitive conditions can be misdiagnosed as (C)APD including (but not limited):
- Respiratory Disorders
- Adenoid hypertrophy, asthma, allergic rhinitis
- Metabolic/Endocrine Disorders
- Diabetes hypo/hyperthyroidism
- Hematological Disorders
- Anemia
- Immunological Disorders
- Acquired and congenital immune problems
- Cardiac Disorders
- Congenital and acquired heart disease, syncopy
- Digestive Disorders
- Irritable bowel syndrome, GERD
- Neurological Disorders
- Traumatic Brain Injuries, Tumors, Encephalopathy
- Genetic Disorders
- Fragile X Syndrome
- Toxin Exposure
- Lead, Mercury, Drug Exposure
- Infections and Infestations
- Yeast overgrowth , intestinal worms/parasites
- Sleep Disorders
- Sleep Apnea
- Mental Health Disorders
- Trauma, Anxiety, mood disorders, adjustment disorders
- Sensory Processing Disorders
- Vision, hearing, auditory, tactile
- Acquired Disorders
- FASD
7. (C)APD testing is NOT so PURE
(C)APD testing does not simply consists of pure tone audiometry and is heavily comprised of higher order linguistic and cognitive tasks. Testing requires that the listeners attend to given directions, remember and label the presented auditory sequences, etc, in other words participate in tasks aimed to task their linguistic system and executive functions (DeBonis, 2015)
So what does the research show?
- Wallach (2011) has indicated that (C) APD ‘symptomology’ “reflects broader underlying problems in language comprehension and metalinguistic awareness.
- Dawes and Bishop (2009) compared children with a CAPD to children diagnosed with dyslexia and found similar attention, reading, and language deficits in both groups.
- Kelly et al. (2009) found that 76% of a sample of 68 children with suspected auditory processing disorder also had language impairment with 53% demonstrating decreased auditory attention and 59% demonstrated decreased auditory memory.
- Ferguson et al. (2011) concluded that “the current labels of CAPD and SLI [specific language impairment] may, for all practical purposes, be indistinguishable” (p. 225).
(From DeBonis, 2015 pgs. 126-127)
8. What to Test and How to do it – That IS the Question?
“Despite lofty claims to the contrary, there is no clear consensus concerning the battery of tests that lead to a diagnosis of CAPD.” (Burkard, 2009, p. vii) Presently, neither the American Academy of Audiology nor the American Speech Language Hearing Association have a clear criteria on what testing to administer, how many standard deviations the client has to be in order to qualify, as well as even who is a good candidate for (C)APD testing. (DeBonis, 2015 pg. 125)
As such, presently children diagnosed with (C)APD are diagnosed purely in an arbitrary fashion rather than based on a specific widely accepted standard. To illustrate W. J. Wilson and Arnott (2013) found that “in a sample of records of 150 school-aged children who had completed at least four CAPD tests, rates of diagnosis ranged from 7.3% to 96% depending on the criteria used” (DeBonis, 2015 pg. 125). Are you “processing” what I am saying?
9. Looking for the “Right” Label
As an SLP, I frequently hear the following statement from parents: “We were searching for what was wrong with our child for such a long time; we are so happy that we were finally able to identify that it’s (C)APD.
The above comment is certainly understandable. After all (C)APD sounds manageable! The appeal to it is that presumably if the child undergoes specific auditory interventions to improve deficit areas, s/he will get better and all the problems will go away. In contrast, finding out that the child’s processing difficulties are the result of linguistic deficits in the areas of listening, speaking, reading, and writing can be incredibly overwhelming especially because what we know about the nature of language impairments and that is that more often than not they turn into lifelong learning disabilities.
Some parents and professionals may disagree. They might point out that many children with (C)APD test just fine on generalized language testing and only present with isolated deficits in the areas of attention, memory, as well as phonological processing. Yet here is the problem! General language testing in the form of administration of tests such as the CELF-5 or the CASL does not complete language assessment make!
The same children who test ‘just fine’ on these assessments often test quite poorly on the measures of social communication, executive function, as well as reading. In other words if the professionals dig deep enough they often find out that something which outwardly presents as (C)APD is part of much broader language related issues, which require relevant intervention services. This leads me to my final point below.
10. Missing the Big Picture
“The primacy given to auditory processing abilities has resulted at times in neglect of other cognitive factors” (Cowan et al. 2009, p. 192). Focusing on the diagnosis of (C)APD obscures REAL, language-based deficits in children in question. It forces SLPs to address erroneous therapeutic targets based on AuD recommendations. It makes us ignore the BIG Picture and “Consider non-auditory reasons for listening and comprehension difficulties, such as limitations in working memory, language knowledge, conceptual abilities, attention, and motivation and consequently targeting language, literacy, and knowledge-based goals in therapy.” (Kamhi &Wallach, 2012)
Conclusion:
So what will happen next? Well, I can tell you with certainty that the controversy will certainly not end here! Presently, not only is that there is a fierce academic debate between speech language pathologist and audiologists but there is also a raging debate among audiologists themselves! This controversy will continue for many years among some highly educated people. And SLPs? Well, we will continue seeing numerous children diagnosed with (C)APD. Except, I do hope something will change and that is our collective outlook on how we view ambiguously defined and assessed disorders such as (C)APD.
I sincerely hope that we do not blindly defer to other professions and reject current valid research regarding this controversial diagnosis without first spending some time reflecting and critically reviewing these findings in order to better assist us with making informed and educated decisions regarding our clients’ plan of care.
Click HERE to read the second part of this post, which describes how SLPs SHOULD assess and treat children diagnosed by audiologists with (C)APD.
References:
- Burkard, R. (2009). Foreword. In A. Cacace & D. McFarland (Eds.), Controversies in central auditory processing disorder (pp. vii-viii). San Diego, CA: Plural.
- Cowan, J., Rosen, S., & Moore, D. (2009). Putting the auditory back into auditory processing disorder in children. In Cacace, A., & McFarland, D. (Eds.),Controversies in central auditory processing disorder(pp. 187–197). San Diego, CA: Plural Publishing.
- Dawes, P., & Bishop, D. (2009). Auditiory processing disorder in relation to developmental disorders of language, communication and attention: A review and critique. International Journal of Language and Communication Disorders, 44, 440–465.
- DeBonis, D. A. (2015) It Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children. American Journal of Audiology. v. 24, 124-136.
- Ferguson, M. A., Hall, R. L., Moore, D. R., & Riley, A. (2011). Communication, listening, cognitive and speech perception skills in children with auditory processing disorder (APD) or specific language impairment (SLI). Journal of Speech, Language, and Hearing Research, 54, 211–227.
- Fey, M. E., Richard, G. J., Geffner, D., Kamhi, A. G., Medwetsky, L., Paul, D., Schooling, T. (2011). Auditory processing disorder and auditory/language interventions: An evidence-based systematic review. Language, Speech and Hearing Services in Schools, 42, 246–264.
- Hazan, V., Messaoud-Galusi, S., Rosen, S., Nouwens, S., Shakespeare, B. (2009). Speech perception abilities of adults with dyslexia: Is there any evidence for a true deficit?. Journal of Speech, Language, and Hearing Research. 52 1510–1529
- Kamhi, A. G. (2011). What speech-language pathologists need to know about auditory processing disorder. Language, Speech, and Hearing Services in Schools, 42, 265–272.
- Kamhi, A & Wallach, G (2012) What Speech-Language Pathologists Need to Know about Auditory Processing Disorders. ASHA Convention Presentation. Atlanta, GA.
- Kelly, A. S., Purdy, S. C., & Sharma, M. (2009). Comorbidity of auditory processing, language, and reading disorders. Journal of Speech, Language, and Hearing Research, 53, 706–722.
- Lemos IC, Jacob RT, Gejao MG, et al. (2009) Frequency modulation (FM) system in auditory processing disorder: An evidence-based practice? Pró-Fono Produtos Especializados para Fonoaudiologia Ltda. 21(3):243-248.
- Melby-Lervåg, M., & Hulme, C. (2013). Is working memory training effective? A meta-analytic review. Developmental Psychology, 49, 270–291.
- Ramus, F., White, S., Frith, U. (2006). Weighing the evidence between competing theories of dyslexia.Developmental Science. 9 265–269
- Sharma, M., Purdy, S. C., Kelly, A. S. (2009). Comorbidity of auditory processing, language, and reading disorders. Journal of Speech, Language, and Hearing Research. 52 706–722
- Wallach, G. P. (2011). Peeling the onion of auditory processing disorder: A language/curricular-based perspective. Language, Speech, and Hearing Services in Schools, 42, 273–285.
- Watson, C., Kidd, G. (2009). Associations between auditory abilities, reading, and other language skills in children and adults. Cacace, A., McFarland, D.Controversies in central auditory processing disorder. 218–242 San Diego, CA Plural.
- Wilson, W. J., & Arnott, W. (2013). Using different criteria to diagnose (central) auditory processing disorder: How big a difference does it make? Journal of Speech, Language, and Hearing Research, 56, 63–70.
Hi,
Thank you for writing this article and validating my thoughts on this subject. I recall a well respected professor teaching us a little about CAPD in 1993 and he seriously questioned its validity. So I had long ago written this off as pseudoscience. But I recently came across a couple of continuing education courses on the topic and thought I’d take a gander. Well, I was struck by the presenter’s tone of voice. She was quite hostile in her defense of this disorder. She said she was tired of people questioning if this was a real “thang.” She said it is a real “thang” over and over again in a very aggressive tone of voice. She was yelling at the microphone! All I kept thinking was, “The lady doth protest too much, me thinks.” So before I wasted anymore time listening to her drivel and go on and on claiming this to be an audiologist’s prime real estate, I thought I’d go see what ASHA said. I quickly learned that despite her protestations, there is in fact, “…currently no reference standard for diagnosing CAPD (American Academy of Audiology [AAA], 2010; ASHA, 2005; Vermiglio, 2016).” Aren’t we supposed to be using evidence based practices? Anyway, I would suggest people be careful in the CEU’s they pursue and question, question, question like the good scientists we are supposed to be!
Thank you so much for this comment! When it comes to any diagnosis, a label, a treatment, or a program, it’s never about the personal feelings of people! The focus should always be what does the research have on the subject as well as what do our clinical cases show us is the reality of students diagnosed with controversial labels who are being treated in a non-evidenced based manner for made up disorders vs. true academic difficulties in the areas of listening, speaking, reading, and writing.
Thank you Tatyana.
I am a parent that happens to agree with you. When my oldest son, Nick, was around 3, my sister-in-law, a special education teacher, recommended that Nick go to kindergarten screening with her to just see the fun test they do. When they came back, she suggested Nick had CAPD. I knew she was trying to help; however, I knew Nick had something else wrong. Call it mom’s instinct. As time went on, he started taking medicine for ADHD and had an IEP to give him extra time on tests. It helped him achieve, but I still knew there was more. Finally, in about 5th grade, I asked the doctors for a speech evaluation done at App State that identified more specific processing disorders like autism. Lo and behold, Nick’s speech evaluation and some follow up tests identified him as on the autism spectrum. He started using tips and tricks like noise canceling headphones, a weighted blanket to sleep and decrease anxiety, etc. I’m glad I stuck with my gut, Nick is currently enrolled in Bible college and is doing very well.
Could it be that (C)APD is not fully understood, yet? The term Autism was originally used to diagnose people with schizophrenia, and then the children were thought to have mothers that were cold and not affectionate. Autism, at one point, was a very broad diagnosis, and also over diagnosed. Is it possible the same thing is happening with (C)APD?
There’s a significant difference between lack of initial understanding ASD from its inception in the early 1940’s and the state of APD in 2019. To date CAPD, has been amply researched and all the objective and independent studies being released with each year still cannot support APD as a valid standalone diagnostic entity due to lack of appropriate testing practices and significant overlap with other symptomology.
[…] Processing Disorder” (“APD”) is suspected? Here’s the problem! Even after the APD diagnosis is made, the audiologist will still refer the child for treatment to a speech-language pathologist. Of […]
I’ve. Found this as I’m googling APD and adHD for my 13-year-old daughter. Was diagnosed with APD at 7 and Still we see minor improvements. We’re still searching out diagnoses but I wonder why?? What can really help as she has had Speech, OT, vision, music therapies, tutors IEPs.
Hi. I appreciated your article and found it thought-provoking, but I just want to share some perspective from my personal experience. I am almost 50 years old, and I have an 11-1/2 year old son who received an autism diagnosis at age 2. As you can imagine, after his diagnosis I heard and learned about this particular diagnosis. However … what really became clear to me is that I obviously suffer from this problem. I have always suffered from hearing amidst background noise, to the point that when I was a child in the 70s, many people were convinced I had hearing loss. However, repeated testing always came back normal. yet, I talked too loud, sometimes seemed to ignore people, and had to sit on the very front row in class. What I want to stress is that far from having difficulty with school, though, I was in the gifted program, national honor society, and eventually went to law school. I had zero language issues, and to the contrary, graduated #1 in my class in law school, was an editor on the law review, and a tutor for the Legal Writing class (i.e., a “teaching assistant”). Fast forward to today, and I have a very difficult time talking on a cell phone and I carry special headphones that I have to use. Thus, when someone tells me my child has this problem, I more than believe it, I know it, from the inside out. Do I think it explains all of his other problems too? nope. Don’t get me wrong, the diagnoses today for children with learning and language problems is like the wild west, and it is such a huge industry that between the teachers and parents who are forced to try to figure out what’s going on, but don’t have the training, and the “professionals” who also don’t really have the qualifications they should have to perform this kind of testing and diagnosis — well, I just can’t be surprised if 3/4 of any particular diagnosis are invalid. The same thing is going on with “autism” and “ADHD” diagnoses. But it doesn’t mean those conditions aren’t real. Just sharing my perspective as a parent and a person with hearing problems.
Dear Chris,
Thank you for your insight and perspective. Here are a few thoughts regarding the provided information. The diagnosis of APD is the diagnosis of exclusion. In other words, if an individual has a highly genetically heritable condition such as autism, then the diagnosis of APD cannot be made as one of inherent difficulties associated with autism are difficulties in the area of sensory perception including that in the auditory realm. Furthermore, a number of researchers have proposed that speech in noise is a distinct disorder separate form “APD” one that can be specifically tested and potentially addressed (although the treatment carryover into the linguistic realm remains questionable). Furthermore, a number of studies found a significant connection between speech in noise difficulties in individuals without known diagnosis of APD. These include individuals with psychiatric diagnoses such as anxiety and depression, neruodevelopmental disorders such as autism and even bilingual and multilingual speakers who present with difficulty hearing speech in noise in their second but not in their birth language. As such, none of the above provided information confirms that APD is a solid standalone diagnosis BUT does indicate that difficulties processing linguistic information exist with other known or previously undiagnosed conditions. At the end of the day it’s what we do with respect to remediation of these difficulties which is important and not the diagnosis itself. After all, what is the next evidence based step after the audiologist makes the APD diagnosis? The answer is always language therapy. After all it’s the only thing that actually makes the symptoms of “APD” better and nothing else comes even close.
[…] Why (C) APD Diagnosis is NOT Valid! […]
[…] Why (C) APD Diagnosis is NOT Valid! […]
[…] Why (C) APD Diagnosis is NOT Valid! […]
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When I was in graduate school (not too long ago), our audiology professor assigned a research paper on this subject. We were to prove/disprove that CAPD exists as a separate entity. My audiology professor did not believe it was a separate entity, and after doing an incredibly amount of research, neither do I. You have done a fantastic job of compiling the research into one article. Thank you!
Hi!! As I neuropsychologist I really appreciate this post!! In my 20 years of clinical practice I have not found that CAPD actually exits and agree with all the information you posted. All the research I have read has also indicated it does not exist and its creation did not follow the standard rules/research of nosology in creating diagnoses. That said what I have found is that children with CAPD diagnoses, actually have either ADHD, Dyslexia or language impairment -every time really. I have had this discussion with several local SLP’s who agree with me. I recently gave a talk to SLP’s about Executive Dysfunction in ADHD, but I really want to give a presentation to them about Dyslexia. Many of the symptoms/issues you mention overlap with the diagnoses I listed and with each other. I think SLP treatment for Dyslexia via the Lindamood-Bell programs ( i.e. LiPs) or Orton Gillingham for phonological/reading issues are key. Children with language impairment also need intervention from SLPs on higher language meanings, finally children with ADHD benefit from help with executive function, organizational strategies, planning help etc…. Thanks again for a great post!!
THANK YOU for this article! What really get me going is that an audiologist will often times evaluate a student for (C)APD without having a whole picture of the child. The parent just takes the child in for an eval, but doesn’t take in the educational psychological report. OR, they don’t know (because the parent didn’t inform them) that the child is ADD/ADHD.
I recently ran into a former student, and the mom was ecstatic that her child had been diagnosed with (C)APD. I never got a chance to ask mom if the audiologist received all of her previous evaluation reports from the SLP & the psychologist…I have a feeling she didn’t. The SLP she is seeing has her on “Fast Forward”. The SLP proceeded to bash the School SLP, although the student’s language skills are WNL according to the state, so she did not qualify for language services. The first thing I do when I receive a (C)APD report is to look to see if the audiologists received the reports, which has never happened. It’s a shame that so many parents waste so much time (and money) on an answer, which is really not an answer at all.
Well, where to begin? If your purpose is to confuse and create territorial boundaries wherein you alone have the knowledge and insight into communication disorders to speak with accuracy and validity to issues which have auditory associations and bases: Congratulations! you have achieved your goal. Were it not such a shame that you seem determined to dominate what is supposed to be a multi-disciplinary, cooperative intervention approach, I guess you could revel in it. Unfortunately, you have such a divisive and and narrow-minded view, that you will, unfortunately do harm rather than good. I’m very thankful that the SLPs I work with are not so blind or biased. They would be horrified at your approach. It is your approach (dating back to Norma Rees and on to Kamhi, et al. who seem determined to take what is clearly a collaborative issue and rule it with arrogance and ignorance) which has perpetuated preventing patients with CAPD from finding the intervention they need. You likely shouldn’t even treat them at all if you find the diagnosis so hard to accept. Audiologists should do their best to find SLPs who have more interdisciplinary respect and perspective to send their clients to. As for you, by all means, continue to administer your top-down, cognitive, supramodal therapies through a system which has bottom-up irregularities (the input channel you must use most of the time) and then wonder why an otherwise bright 9th grade student has been working on the same speech sound for 7 years without success. Like it or not, almost all of the linguistic and cognitive “pages” in the “central library” were created through active interaction with sound: the auditory “fingerprint” is all over them and you can’t wipe it away, no matter how forcefully or dogmatically you oppose it. I only have to look at your reason #5 “Auditory deficits don’t cause speech, language, and academic learning difficulties,” to question your right or qualification to speak to this issue at all.
Michael,
Thank you for weighing in on this issue
My purpose for writing this post was not to ‘create territorial boundaries’ but rather provide up to date research preformed not just by some esteemed and highly accomplished speech language pathologists but also by highly influential audiologists all of which I have all exhaustively cited throughout my post and listed in my references. It must be very difficult for someone who considers himself the CAPD specialist to hear this but I must emphasize that none of the tests currently available on the market can confirm the so-called diagnosis of CAPD with appropriate reliability. Many children who are frequently diagnosed with CAPD actually present with legitimate language and learning disabilities, which need to be addressed. However, instead they receive so called CAPD treatments or “therapies aimed at particular processing deficits like noise sensitivity, phonemic awareness, auditory memory, dichotic training, speech in noise exercises; etc.” [as well as] “broad-spectrum” stimulation approaches [such as] “specially-mastered and filtered classical music selectively stimulates the brain through both air-conduction earphones, and a bone-conduction vibrator” (http://ear-central.com/capd-therapy/), which unfortunately completely lack validity and are ineffective. This brings me back to the original reason why I wrote the post and that is to ensure that these children receive appropriate and legitimate linguistically based interventions including those specifically addressing their comprehension, oral expression, social pragmatic abilities, as well as reading deficits to ensure that they actually receive services aimed at ameliorating their true deficits.
Best regards,
Tatyana
Tatyana, I think that you and I agree on many things. That is why the lion’s share of intervention with my CAPD patients is in the domain of the SLPs and educators I work closely with. It is very true that the goal is to ameliorate their true deficits. You said “instead, they receive…” [here you quoted from my website]. That is a blanket over-generalization and presumption based on limited knowledge. It’s not “either/ or” it’s “both/and” (when there is an auditory deficit which is a possible impediment to appropriate top-down intervention: e.g. dichotic asymmetry, spatial processing disorder, or hyperacusis; etc.). Where we would disagree is that the supra-modal areas are the only true deficits. And that approaching their remediation through impaired bottom-up channels is a wise course. Top-down therapies are very important. But if you don’t deal with the auditory deficiencies, you will likely diminish your own outcomes and subject a patient to prolonged therapeutic course and to extended need for out-of-proportion levels of auditory effort and difficulty processing important auditory information. As to “highly accomplished SLPs and influential audiologists”–you show me yours, I’ll show you mine. The research establishment is saddled by trying to force complex multi-modal human issues into a pharmaceutical research model. The sad result is a lot of babies littered in the bathwater. “Evidence-based” which can only honor these meager findings, totally ignoring intra-subject evidence which is a critical component of ongoing research, is merely a club which keeps both clinicians and patients lacking some very good sources of help. Until you have some personal experience with the things which you so easily denigrate second-hand, you may want to try to keep the attitude of a learner. You may find that not all issues lend themselves to a double-blind, study with control groups–though those can be very useful.
Cheers, Michael
To put it bluntly, I definitely have had first hand experience in the form of clients erroneously diagnosed with CAPD. They came to me and other SLP colleagues after years of receiving pointless CAPD driven therapies and general accommodations in the form of FM systems which did more harm than good by isolating these children even further and precluding them from full classroom participation. I also saw the huge difference targeted language intervention made on their lives after their started receiving appropriate therapies. To date I have saw zero “intra subject evidence” that the “treatments” you list on your website actually work. Furthermore, I saw quite a bit of evidence on other websites regarding their ineffectiveness.
This is an excellent post! I missed this when you originally posted it. I may be opening up a new can of worms, but I think that CAPD is often ‘diagnosed’ as a CYA (cover your ass) diagnosis particularly when kids score adequately on formal tests but present with generalized difficulties in the classroom. Jeremy raised this issue a while back in his post http://the-speechguy.com/2013/04/15/ill-have-a-sausage-and-people-pizza-the-controversy-over-auditory-processing-disorder/. My view is more on the language side – and I think that sometimes one just has to dig deeper to find the underlying deficit
This is an excellent post! I missed this when you originally posted it. I may be opening up a new can of worms, but I think that CAPD is often ‘diagnosed’ as a CYA (cover your ass) diagnosis particularly when kids score adequately on formal tests but present with generalized difficulties in the classroom. Jeremy raised this issue a while back in his post http://the-speechguy.com/2013/04/15/ill-have-a-sausage-and-people-pizza-the-controversy-over-auditory-processing-disorder/. I think that depending on which side of the coin your perceptions lie one needs to decide how to dig deeper.
Absolutely, Nikki, I completely agree with you! It’s all about “which side of the coin your perceptions lie”. Many people find it very difficult to accept that (C)APD is the Emperor with No Clothes. It sounds so legitimate when an audiologist diagnoses it, yet they don’t do anything about it, provide conflicting recommendations on how it should be treated and by whom and really contribute nothing truly helpful to the process. It’s been up to SLPs to treat it and obviously they will do it from linguistic perspective since they’re not working on the children’s comprehension of hoots and clicks. The bottom line is that (C)APD testing can expose a pattern of weaknesses however, these weaknesses are due to linguistic and not auditory deficits.
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This information has really shook me up. I just used your APD checklist recently to refer a student for CAPD testing. She does have dyslexia and was given the CELF5 and did not qualify for language services but only articulation services. Her teachers are very concerned about her listening & processing skills in the classroom. Should I have not recommended her since so many red flags were noted on the checklist by her teachers & her mother? I wanted to have her hearing checked first and then see about her processing. I should add I work in a Private school and her sending district did the previous testing. I know she has more than just dyslexia. She is going into the fourth grade but was very frustrated with tears & outbursts last school year because she wasn’t getting it.
I believe in researching as much as possible & always have an open mind to someones point of view. With that said, I am confused by your article & your “tone” comes across very arrogant. Dealing with a child’s Learning Differences is a delicate subject & very emotional & exhausting for parents to navigate the system to find an accurate diagnosis & treatment options. Your article offers a lot of information that will probably add to their frustrations. I think you should offer another point of view with solutions instead of discounting your professional peers.
I have a so many questions & comments for you in hopes to clarify what you mean by what you wrote. For some reason my first reaction was not a good one & I would like to know your thoughts on my questions.
Are you suggesting children that are dealing with the symptoms from your ” APD Symptomology” list do not have APD? What does these children have…a Language Disorder? How do you offer therapy/assistance solutions for a Language Disorder if you don’t know the “type” of disorder? It’s like having your Oncologist diagnose you with cancer & prescribes chemotherapy. Chemo for what type of cancer?
Are you suggesting a certified Audiologist is providing the wrong diagnosis? What is the point of all the tests our children are subjected to by Neuropsychologists, OT, Speech/Language Therapists, Developmental Pediatricians & Special Education-Academic Testing? What does is mean when all the tests results point to an Processing Issue? My daughter has taken at least 20 tests…BEHAVIORAL RATING INVENTORY OF EXECUTIVE FUNCTIONING, CONNERS CONTINUOUS PERFORMANCE TEST II, NEPSY-II, WISC-IV & V-Composite Scale & Subtest Scores,TAPS-3 (Test of Auditory Processing Skills), PHONOLOGICAL AWARENESS INVENTORY TEST & WJ-3 to just name a few.
You listed numerous programs (FM Systems, FastFoward) that you feel have little impact on APD. What about the parents witnessing actual improvements in their children after using these programs? What about the private schools that focus on Orton-Gilliam skills as well as other programs to assist student with decoding/phonics etc.? Are these schools really addressing a Language Disorder, Processing Disorder or both? Is it really a “medical” issue like you suggested?
I am surprised that your article comes across very one-sided and basically disregards Audiologists & companies that are trying to offer solutions for our children to be successful. What do you suggest/offer? What type of testing do you suggest our children should have to receive an accurate diagnosis? Should we rush to your office for proper testing, diagnosis & treatment plan? You made it clear in your article what is “wrong” with an APD diagnosis & parents should be careful to only focus on APD. I understand one should not put all their eggs into one basket. But, it does make me wonder if in fact your child does have APD especially when you have the results of over 20 tests given throughout the year by different professionals that have the same conclusion…Auditory Processing Disorder & the type of Processing Disorder that needs to be focused on.
First, I want to say that I think it’s AWESOME that a parent is reading this blog post. I really hope more do. I have been following this page for some time now, and I know the main audience for this page is other SLPs, and AUDs, so I don’t “read” into the tone the same way as maybe a parent would. But what I really wanted to say is that this is not actually the first time I am hearing/reading this information. In fact, very similar information was presented at the ASHA’s Schools conference two years ago. There I heard for the first time that over the past DECADE or so, AUDs and SLPs were beginning to see how the dx of (C)APD is far too broad and is not lending itself to appropriate or accurate treatment plans. In fact, what is presented above is not this author’s opinion but facts based on the information from all the resources mentioned at the bottom of the post and as far as what I have learned over the past two years, she isn’t wrong.
I will admit, like you, I was taken aback by this information when I initially heard it. What? (C)APD is not an accurate diagnosis? What does that really mean? What does it mean for the children walking through my therapy room door? Have I been providing them with appropriate treatment plans? I’ll admit, it did rock my world a bit. BUT, it got me thinking, that if ASHA (American Speech-Language and Hearing Association) is not even sure of the validity of (C) APD, well then I better look into this further.
Here is what I have found, what is stated above is actually correct. The (C)APD assessment (and you can read the problems with assessment above) conducted does not necessarily translate into true deficits (academic or otherwise), OR (and I think this is even WORSE), the (C)APD assessment does not actually diagnose the underlying problem which could range from so many causes (such as various medical causes as stated in #6 above or other disorders or deficits such as working memory issues, semantic mapping issues, poor receptive vocabulary, cognition issues, poor higher level functioning, lack of ability to predict or inference, etc. …and the list can go on and on). Here’s my biggest problem with a broad dx such as (C)APD, the recommendations that are often recommended have not been proven to be effective at an acceptable rate. Yes FM systems are recommended or specific programs, but meta-analysis of the research literature is showing how little these programs or accommodations actually are not enhancing a child’s ability to compensate for their deficits nor are they closing the gap between the child’s functioning and his/her peers. Why? I have come to learn, it’s because, the treatment being provided is actually the wrong treatment. It never addresses the underlying issue.
Now there is quite a bit of anectdotal reports from teachers, parents or other professionals who do believe certain programs or FM systems help. However, this type of information is subjective and is considered the least reliable when it comes to research based evidence as it cannot be standardized across persons, nor can subjective feelings be measured. Therefore, the results from the meta-analysis done regarding these treatments is considered far more reliable.
Another big problem I have with (C)APD dx is that SLPs have in the past said it’s an AUD dx therefore it’s out of their scope of practice (yes, I’ve actually worked with some SLPs who have said this), and will not provide therapy. So if as a professional, I am taking the information presented to me (whether it be (C)APD dx or any other dx) from an assessment and NOT looking at underlying causes, I will never be providing the correct treatment. And WHAT a disservice would be done to the child!
Let us not throw out the baby with the bath water. There are still a number of very good accommodations that can be used for children who have been labeled with (C)APD such as checking for comprehension of directions, having child repeat directions or key points, etc. However, if I look at these specific accommodations, I can say to myself, these are strategies I have successfully used with my language delay kiddos as well. Therefore, is the (C)APD dx even necessary? Or is it truly a language delay?
I am not familiar with your child’s specific case but I didn’t see any true language tests reported above. Maybe your child’s receptive and expressive language skills as well as vocabulary and higher level language skills have been tested but I cannot answer your questions regarding what your child’s underlying issue could possibly be. In fact, no one could without being familiar with your child and testing her themselves. What I can tell you, is that once I learned this information about the validity issues with (C)APD dx and the programs recommended, I have begun to look at my clients in a completely different way and have been able to find underlying issues that I was able to successfully identify and target. What you want to see, is your child’s therapy targeting skills that will then translate to improved functioning. If the correct weaknesses are targeted, you will see that improvement.
Now there is still controversy over this topic. Some AUDs refuse to believe in the issues with the (C)APD dx or with their recommendations. But others feel so strongly about it’s weakness that they are presenting on it to SLPs and AUDs around the US. So will the controversy continue? Sure. But in the meantime, I feel as though, if SLPs are taught to always look and see if there is something MORE, some underlying cause, masked by various behaviors or results of other tests that can be addressed, AND if they address it using evidence based practice, then we will be doing all we can for our clients.
I hope that helps clear up some of your questions.