Last week I wrote a blog post entitled: “Why (C) APD Diagnosis is NOT Valid!” citing the latest research literature to explain that the controversial diagnosis of (C)APD tends to
a) detract from understanding that the child presents with legitimate language based deficits in the areas of comprehension, expression, social communication and literacy development
b) may result in the above deficits not getting adequately addressed due to the provision of controversial APD treatments
To CLARIFY, I was NOT trying to disprove that the processing deficits exhibited by the children diagnosed with “(C)APD” were not REAL. Rather I was trying to point out that these processing deficits are of neurolinguistic origin and as such need to be addressed from a linguistic rather than ‘auditory’ standpoint.
I’ve mentioned previously, the controversy regarding the validity of (C)APD has been going on for years with no end in sight. That means that speech language pathologists will continue to receive children on their caseloads diagnosed with (C) APD by audiologists.
So today I would like to offer some suggestions for SLPs asked to assess and treat students with “confirmed” or suspected (C) APD on their caseloads.
The first suggestion comes directly from Alan Kamhi, who states: “Do not assume that a child who has been diagnosed with APD needs to be treated any differently than children who have been diagnosed with language and learning disabilities.” (Kamhi, 2011, p. 270) In other words, if one carefully analyzes the child’s so-called processing issues, one will quickly realize that those issues are not related to the processing of auditory input (auditory domain) since the child is not processing tones, hoots, or clicks, etc. but rather has difficulty processing speech and language (linguistic domain).
Let’s quickly go over two major APD Models: The Buffalo Model (Katz) and the Bellis/Ferre Model, to prove this point.
The Buffalo Model by Jack Katz, PhD contains 4 major categories:
1. The Decoding Category – refers to the ability to quickly and accurately process speech, most importantly at the phonemic level (Since this involves speech sounds then this has nothing to do with the processing of auditory stimuli. In other words deficits in this area are of linguistic nature and the highly correlated with reading deficits characterized by weak/deficient phonemic awareness abilities/poor emergent reading abilities).
Here are a few examples of so called “decoding” deficits:
- Difficulty with processing what is heard accurately and quickly; tends to respond more slowly (indicative of weak language abilities)
- Problems keeping up with the flow of communication and running discourse (indicative of weak language abilities)
- Problems processing at a phonemic level (e.g, can’t blend ‘t,’ ‘u’ and ‘b’ together to make the word ‘tub’) (indicative of phonemic awareness deficits)
- Trouble reading and spelling (reading and writing deficits rather then APD)
- Receptive language problems and impairments in discrimination, closure abilities and temporal resolution (this one just explains itself)
2. Tolerance-Fading Memory (TFM) Category – refers to two skills that are often found together: “tolerance” – understanding speech in noise (processing of language) and “fading memory” – auditory short-term or working memory (memory= higher level cognitive skills vs. a pure auditory entity).
Here are a few examples of given of tolerance-fading memory deficits:
- Difficulty blocking out background noise so child’s performance suffers in a noisy classroom environment, may be labeled as distractible (clearly describes the child with poor language comprehension)
- Linked to poor reading comprehension, oral and written expression, poor short-term memory (in other words describes a learning disability)
3. Integration category
- difficulty bringing in information from different modalities, such as receiving auditory and visual information at the same time; these children are often labeled as learning disabled or even dyslexic (this one just explains itself)
- They may be poor readers, have trouble with spelling, and exhibit difficulty with multimodal tasks (clearly indicative of reading and writing deficits or students which will often get classified in the schools with specific learning disability)
4. Organization –disorganized thinking; sequencing errors (This appears to be indicative of the social communication / executive function deficits, as well as word-retrieval deficits)
Another major APD model is the Bellis/Ferre Model, which divides the above four categories into the following subtypes:
- Primary subtype
- Auditory decoding – listening difficulties in noisy environments
- Integration deficit – problems with tasks requiring both cerebral hemispheres to cooperate
- Prosodic deficits- difficulty understanding the intent of verbal messages
- Associative deficits- receptive language disorder
- Output organization deficits- attention and/or executive function disorder- might also be caused by an auditory efferent dysfunction
Similar to the Buffalo model, the Bellis/Ferre Model, describes deficits of linguistic versus auditory nature many of which are characteristic of a learning disability.
To continue, if you get a child with confirmed or suspected (C)APD on your caseload begin at the beginning by administering a comprehensive battery of testing to determine the scope of their linguistic deficits. And no, I am not recommending that you administer one general language test such as the Clinical Evaluation of Language Fundamentals-5 and call it a day. I am saying that in order to expose all the deficits you have to dig deep and make sure that the following major areas of language are assessed:
- Listening Comprehension (for stories not just sentences) (Suggestions: consider administering the Listening Comprehension Test -2, the Listening Comprehension Test-Adolescent or assess their skills informally through presentation of science or social studies -related grade level passages when applicable)
- Comprehension of Ambiguous and Figurative Language (idioms, ambiguous expressions, etc.) (Suggestion: administer portions of Clinical Evaluation of Language Fundamentals -5 Metalinguistics)
- Semantic Flexibility Skills (can the student easily generate definitions, synonyms, antonyms, multiple meaning words, etc.) (Suggestions administer portions of the WORD Test 3 Elementary, WORD Test 2 Adolescent; The Expressive Language Test-2)
- Narrative Abilities (can the student coherently and cohesively summarize books or movies) (Suggestion: Obtain an informal narrative sample)
- Critical Thinking and Problem Solving (Suggestions: Test of Problem Solving-2,Test of Problem Solving-3)
- Social Communication Skills (Suggestion: administer portions of Social Language Development Test Elementary, Social Language Development Test Adolescent, Informal Social Thinking Dynamic Assessment Protocol®)
- Executive Function Abilities (Suggestion: administer portions of The Executive Functions Test-Elementary; use the free Situational Awareness STOP Observation Tool)
(Please note that I am not even including: Reading, Writing, and Spelling in the above list but just asking you to review and seriously consider the results of learning evaluations in order to see the whole child and not just their limited functioning in select areas of oral language comprehension, expression and use.)
Sorry folks, there’s no other way around it! You take shortcuts and you will continue getting kids diagnosed with the (C)APD label and not know what to do with them! Now I know what you’re going to say. You are in dreamland, there is no way school-based SLPs will have the time, the resources, and the opportunity to assess the above abilities in each student with suspected or confirmed (C) APD. It will never happen! That’s unfortunate because that is exactly what needs to happen in either school setting or via use of independent evaluations in order for you to comprehensively understand and adequately address the student’s linguistic based deficits! And yes it can be accomplished given some creativity.
For starters, if available, try to review the results of educational and psychological testing prior to performing language testing in order to determine areas of academic weaknesses. Thorough learning and psychological evaluations have much to offer in revealing the students existing deficit areas. Their testing score breakdowns can also reveal significant discrepancies in functioning which may need to be addressed. Try to make your assessments as targeted as possible especially because children with language disorders do not necessarily display weaknesses in all of the above areas but may only display difficulties in selected few (e.g., social communication, reading impairment, etc.) Thus instead of administering general language testing, after reviewing the child’s educational and psychological reports, the SLP may elect to administer select specialized testing to specifically pinpoint the student’s areas of difficulty, based on parental/teacher’s checklists.
In other words, consider non-auditory reasons for listening and comprehension difficulties, such as limitations in working memory, language knowledge, conceptual abilities, attention, and motivation (Kamhi & Wallach, 2012) vs. jumping to conclusion that its (C)APD.
After performing a comprehensive assessment formulate language goals based on determined areas of weaknesses. Keep in mind that a systematic review by Fey and colleagues (2011) found no compelling evidence that auditory interventions provide any unique benefit to auditory, language, or academic outcomes for children with diagnoses of (C)APD or language disorder. As such it’s important to avoid formulating goals focused on targeting isolated processing skills like auditory discrimination, auditory sequencing, working memory, etc., as they would not assist with improving the student’s abilities in the affected areas in any way (Fey et al., 2011 ).
Instead focus on the linguistic underpinnings of the above skills and turn them into linguistic goals. Child presents with phonemic awareness deficits? Figure out where in the hierarchy of phonemic awareness they are and formulate goals based on the remaining areas in need of mastery. Received a description of the child’s deficits from the audiologist in an accompanying report? Turn them into language goals as well! Turn “prosodic deficits” or difficulty understanding the intent of verbal messages into “listening for details and main ideas in stories” goals. In other words figure out the linguistic correlate to the ‘auditory processing’ deficit and replace it.
I realize how very tempting it is to use dubious practices which promise a quick fix for your child/student’s “APD deficits” instead of labor intensive language therapy sessions. But you have to realize something as well: acquiring higher order language abilities takes a significant period of time, especially for those children whose skills and abilities are significantly below those of age matched peers.
So here it is “Your Moment of Zen” (forgive me Jon Stewart for I have sinned): Work on language because it’s all DUE to language! Whatever the dubious diagnosis has been given to the child, I can assure you: his/her deficits have a linguistic origin and as such need to be dealt with by following language-based remediation models. Anything else is just a great show of smoke and mirrors!
So to all SLPs, healthcare professionals, and parents out there who already know and understand this, keep fighting the good fight and keep educating others regarding this information. For all others out there, don’t be so hasty in dismissing this post out of hand, mull it over, trust me it’s worth your time!