A RATIONALE FOR SCREENING FOR CENTRAL AUDITORY PROCESSING DIFFICULTIES AT THE KINDERGARTEN AND SECOND-GRADE LEVELS: CONSIDERATIONS FOR THE SPEECH-LANGUAGE PATHOLOGIST

by

Dorothy A. Kelly, DA, LSP/CCC-Teacher of the Hearing Impaired

Submitted: September, 2001.

Note: Some of the article content reflects information contained in Screening for Central Auditory Processing Difficulties (Kelly, 2001, Academic Communication Associates, Oceanside, CA; with permission).

According to the American Speech-Language-Hearing Association (ASHA), central auditory processing disorder (CAPD) is an observed deficiency in one or more of a group of mechanisms and processes related to a variety of auditory behaviors (1996). It involves difficulty in processing or interpreting verbal and/or nonverbal auditory stimuli usually in the absence of a peripheral hearing loss. CAPD is associated with a lesion somewhere in the central auditory nervous system (CANS). It’s what we do with what we hear (Katz, 1992).

Children with auditory perceptual limitations may experience difficulties with: 1) localizing sound sources; 2) comprehending the meaning of environmental sounds; 3) discriminating among sounds and words; 4) reproducing the pitch, rhythm, and melody of music; 5) distinguishing important sounds from other sounds; or 6) combining syllables to form words and sentences (Barr, 1976), among other areas.

CAPD can appear on a primary diagnostic level or in combination with another disorder such as learning disabilities, cluttering, or attention deficit disorder. A hearing loss (an acuity rather than perceptual problem) can complicate CAPD.

Chermak and Musiek (1997) estimate that CAPD affects approximately 3% of the school-age population. Goldberg (1998) maintains that auditory processing deficits may affect as much as 5% of children. Estimates are higher for the special education population. It is difficult to project incidence as a function of early identification. However, it is reasonable to assume that estimates would decrease over time.

The impact of central auditory processing difficulties upon language and language-dependent behaviors has been widely examined (Rampp, 1977; Cohen, 1980; Lasky and Cox, 1983; Sanger, Freed, and Decker, 1985; Tallal, 1990; Friel-Patti, 1994; Mody, Studdert-Kennedy and Brady, 1997; Cacace and McFarland, 1998). However, it is clear that additional research is needed.

Although many clinicians agree that central auditory processing disorders exist (and can negatively affect language performance), there is disagreement concerning identification and intervention. Audiologists often support a signal-based/bottom-up processing/perceptual disorder/pathway model, while speech-language pathologists tend to advocate a language-driven/top-down processing/language disorder/network model.

As in many such discussions, there is merit in both perspectives. An integrated approach is consistent with the American Speech-Language-Hearing Association’s (1996) inclusive definition of CAPD, as well as its recommendations for assessment and intervention.

Many children with CAPD are misdiagnosed or not diagnosed at all. When CAPD presents as a secondary diagnosis (e.g., to learning disabilities or attention deficit disorder), symptoms may be incorrectly associated with the more apparent diagnosis.

Not all children who display deficits in central auditory processing skills are diagnosed with CAPD. The term central auditory processing difficulties may describe a composite of behaviors that can negatively impact upon language and language-dependent behaviors (e.g. literacy skills/spelling, reading, writing, and so on). Such difficulties may also affect processing performance within different settings (e.g., home and play contexts) to varying degrees of severity. Central auditory processing difficulties may be a preferred term at the kindergarten level (and beyond) in many cases.

Approximately 98% of children in the United States attend kindergarten before entering first grade (Zill, Collins, West, and Hausken, 1995). This population is increasingly diverse in ethnic background, income levels, and family status, and readiness. Factors that impact on preparedness include language abilities and auditory processing skills.

Auditory processing is involved in many academic tasks. Some children with CAPD may experience difficulty in reading aloud due to an inability to associate visual and auditory symbols. Difficulties with auditory discrimination, (important to reading and spelling), may be due to the distortions of speech sounds at the cortical level (Mencher, Gerber, and McCombe, 1997). Typical kindergarten screening protocols do not identify possible auditory processing difficulties.

Two approaches (among others) to identify children at risk for central auditory processing disorder (CAPD) are: (1) the use of checklists and, (2) referral on the basis of observed behaviors (Keith, 1999). Checklists include: The Kindergarten Auditory Screening Test (Katz, 1971); The Auditory Perceptual Check List (Barr, 1976); Fisher’s Auditory Problems Checklist (Fisher, 1976); Checklist of Classroom Observations For Children With Possible Auditory Processing Problems (Sanger, Stick, and Smith, 1985); and The Children‘s Auditory Processing Performance Scale (Smoski, Brundt, and Tannahil, 1992).

Keith (1999) identifies 10 behaviors of children with CAPD. These markers include, (but are not limited to): difficulties with auditory discrimination; auditory figure-ground (background noise); and auditory memory. According to Keith (1999), children with CAPD may display some of these behaviors. Such children are candidates for central auditory testing.

Specific correlates are associated with possible central auditory processing difficulties: a family member with similar difficulties (Kinsbourne, 1983; Willeford and Burleigh, 1985); auditory distractibility; and hypersensitivity to loud sounds. Other risk factors include: a large difference between verbal and performance IQs (Musiek and Geurkink, 1980); academic underachievement; poor listening skills; phonological disorder; attention disorder; learning disability; language impairment; neurological insult; difficulty with directions; reading disorder; pervasive developmental disorder; difficulties with auditory closure; difficulties with rapidly produced speech; and hearing difficulties often in the presence of a normal audiogram, among others.

A history of recurrent otitis media is also associated with possible central auditory processing difficulties (Keith, 1995). Inconsistent auditory input may negatively affect the central auditory maturational process. Martin and Clark (2000) describe minimal auditory deficiency syndrome, a language-learning condition associated with erratic auditory input. Among other effects, fluctuating hearing loss may affect a child’s categorical perceptions (Clarkson, Eimas, and Marean (1989; Werner and Marean, 1996).

Observations of CAP Skills at the Kindergarten Level With Possible Follow-up at the Second -Grade Level (or Age Seven)

In general, a multi-dimensional system which includes input from several knowledgeable sources (i.e. parents, teachers, speech-language pathologist, school nurse, and so on) is less likely to produce false negatives or positives. Checklists and brief assessment procedures (commercially available) may form the foundation of such a system. {Auditory and tympanometric screenings should precede all observations of central auditory functioning}.

A screening protocol designed to identify children at risk for central auditory processing difficulties at the kindergarten level, appears logical from several perspectives. Preliminary observations of verbal (e.g., can repeat an 8 syllable sentence; can follow a two-step command) and nonverbal (e.g., loud and soft tones; can identify long and short tones) auditory processing skills could help identify children with at risk behaviors for central auditory processing disorder. Such children may also be at risk for difficulties in reading, spelling, writing, and following directions, among other concerns related to language and academic functioning.

For children identified as possibly at risk at the kindergarten level, nonintrusive recommendations could be made at that time. Auditory processing skills may be stimulated using computer programs (designed to improve auditory discrimination, auditory memory, auditory closure skills, and so on). In addition, there are many opportunities during the typical class day that classroom teachers, music teachers, special educators, reading teachers, and speech-language pathologists, could provide helpful auditory experiences (e.g., listening games, rhythm activities, direction games, sound recognition activities discrimination and sequencing activities, and so on).

Such children could also be monitored (and stimulated) for listening, phonemic awareness, phonological processing, and pre-reading skills, among other areas. Additional recommendations may include preferential seating, small group interactions, and intervention options for otitis media.

Maturational gains may (or may not) be realized between kindergarten and second-grade (or at age seven). A second, and more rigorous observation could be completed in second-grade (or at age seven) for children who presented as possibly at risk at the kindergarten level. At this point, more input from teachers (and others) is usually available in the areas of following directions, phonological/phonemic awareness, sound/symbol associations, auditory discrimination, and tolerance to background noise, among other areas. Children who continue to display at risk behaviors at the second-grade level (or age seven) may be considered probably at risk and referred to audiologists for a full diagnostic evaluation. Many audiologists are comfortable in completing a CAP battery at this point.

Thus, the main purposes of such a two-part system are to flag children who present at risk behaviors, describe specific behaviors, and make recommendations to parents and teachers. These purposes appear consistent with recommendations made by Martin and Clark (2000). Specifically, they maintain that technical diagnostic statements are less useful when communicating with teachers than those that describe kinds of difficulties a child experiences in learning. Martin and Clark (2000) further state that perhaps the diagnosis of site of lesion is less important than descriptions of how the child functions in different settings.

It is suggested that all children should be screened at the kindergarten level. Standards for Pass and At Risk may be sensitive to institutional needs and determined using auditory developmental milestones, published checklists, and relevant research. Other children should be screened on an as need basis. For example, children who display reading or spelling difficulties, children identified as learning disabled, and kindergarteners who enter school system mid-year may benefit from screening. In addition, some children may pass kindergarten screening assessments and present questionable skills later.

In general, screening procedures of central auditory processing skills should be sensitive to neuromaturational factors. Many aspects of auditory perception develop as a function of maturation and experience (see Development of Auditory Perceptual Behaviors). Some children identified with CAPD appear to eventually outgrow it (suggesting a neuromaturational profile).

This does not imply that a "wait and see" attitude should be adopted. Critical time should not wasted especially in view of what is known about neuroplasticity. Specifically, experience changes the brain’s architecture. The brain can rewire itself with appropriate stimulation. This is particularly true in young children. For example, there appears to be a window of opportunity between ages five and seven when foundation skills of reading are most easily learned (Kantrowitz and Underwood, 1999).

Some children who display central auditory processing difficulties do not appear maturational in nature. Traumatic brain injury, aphasia, dyslexia, cluttering, and learning disabilities (and other diagnoses) are often associated with this group. Early identification of these children is also important in order to facilitate neuroplasticity, as well as to provide targeted therapy and coping strategies. Although such children may not outgrow their difficulties, some of the challenges may be alleviated in this manner. In such cases where central auditory processing difficulties are noted, referrals should be made for a diagnostic evaluation by an audiologist as early as possible.

Development of Auditory Perceptual Behaviors

Screening protocols for CAP skills should be sensitive to auditory developmental milestones. Research focusing upon developmental aspects of auditory perception is somewhat limited. The following represents a brief summary of recent findings:

Speech sound awareness and language-specific abilities are apparent within the first year of life (Kuhl, 1993). Newborns are not only capable of detecting auditory stimuli, but can also make gross discriminations on the basis of frequency and intensity. (Moffitt, 1971; Eimas, 1975; Eisenberg, 1976). Four- to 17 week-old infants can discriminate between the vowels {u} and {i}, and {a} and{I}. Two-month-old infants can discriminate between {ba} and {ga} (Roseberry-McKibbin and Hegde, 2000). The infant’s ability to discriminate sounds contained in languages other than their own appears to decline around age one (Roseberry-McKibbin and Hegde, 2000).

However, according to Martin (1994), structures within the auditory nervous system continue to mature until age nine. Many aspects of perception of speech and nonspeech auditory stimuli are largely mature by school-age (Olsho, 1985; Allen and Wightman, 1992). Siegenthaler (1969) maintained that children experienced the most significant gains in central auditory processing development between ages three and seven.

According to Kendler (1995), very young children appear to process auditory information more generally (non-selectively) than older children. However, as they progress through childhood, they gradually increase their abilities to extract relevant information rapidly and efficiently. Wightman and Allen (1992) estimated that preschool-aged children were inattentive at least half of the time. Like other auditory skills, the ability to localize sound and process binaural cues appears to improve throughout the infancy and preschool periods (Werner and Marean, 1996).

According to Torgesen and Mathes (1998), by the beginning of kindergarten, children should be able to tell whether two words rhyme and to generate rhymes for simple words.  At the kindergarten level, children should also be able to blend sounds to make words (e.g., m+ a+ n=man) and to connect some sounds and letters (Wingert, 1999).

Kraus, Burton-Koch, and McGee (1999) found that auditory discrimination skills are largely developed by age six. This finding is supportive of an earlier study by Templin (1957), which found that auditory discrimination skills mature early and are well established by ages six to seven. In the first and second grades children can count syllables in words (Wingert, 1999).

Temporal processing abilities (e.g., gap detection, duration discrimination, and temporal integration) mature at about six years of age (Werner and Marean, 1996). Selective listening for tones in noise appears to mature by six to eight years of age (Greenberg, Bray, and Beasley, 1970).

The Roswell-Chall Auditory Blending Test (1963) assessed a child’s ability to combine sounds to produce words when the sounds were presented orally (e.g., c-u-p/cup). The test was norm-referenced on children in first through fourth grades, as well as on older children who exhibited reading difficulties (Barr, 1976). Findings suggested that fundamental integration abilities are present in first grade. Sound/syllable associations approach adult levels after fifth grade.

Some auditory perceptual skills mature later in childhood. Temporal acuity does not mature until age ten (Werner and Marean, 1996). Neuman and Hochberg (1983) discovered that the ability to identify consonants within reverberant environments continued to mature until age 13. In noise, these skills may mature between ages 13 and 15 years of age (Elliott, 1979). When reverberation is combined with noise, speech recognition is more challenging (Nabelek and Mason, 1981), and may not mature until the mid-to-late teens (Johnson, 2000).

It appears that many central auditory processing skills (for speech and nonspeech stimuli) are largely functional by school-age (Kraus, Burton-Koch, and McGee, 1999). Therefore, a preliminary observation (without subsequent direct intervention) of basic auditory processing skills at the kindergarten level with possible follow-up at second-grade/age seven, appears appropriate. Observations of behaviors that mature later (e.g., auditory figure-ground skills) should be observed relative to the performance of peers. For example, parents and teachers may be asked how well the child functions in noise as compared to other children of the same age. Minor differences should not be considered significant.

Psychological Issues

Children with auditory processing difficulties suffer from psychological burn out over time. Sustained academic failure, strained peer and family relationships, and pronounced frustration may result in depression. Some children grow to dislike school, exhibit low self-esteem, socially withdraw, or act out. Early identification and appropriate intervention may prevent some of these unfortunate results.

Early identification of children with central auditory processing difficulties has practical benefits, as well. Education institutions are likely to realize considerable savings over time. The provision of misguided services is likely to continue longer then better designed services. These expenditures include direct/indirect services (e.g., speech-language therapy), as well as those associated with the ripple effect (e.g., possible psychological services).

Emergent Literacy

Auditory processing skills, particularly auditory discrimination abilities, are associated with emergent literacy. According to Lane and Molyneaux (1992), other skills include letter naming, context-dependent word recognition, storybook orientation, writing, and interest in writing. Stimulation of faulty auditory discrimination abilities could strengthen early literacy skills.

Phonological/phonemic awareness is also associated with emergent literacy. Such awareness involves an ability to detect rhymes and alliteration, segment and blend syllables, categorize sounds, sequence phonemes, and otherwise manipulate phonemes within words. This awareness is important to various aspects of literacy, especially reading. Catts (1993) maintained that metalinguistic abilities, including phonological awareness, were the best predictors of reading success. According to Gilbertson and Bramlett (1998), phonological measures were better predictors of at risk readers than other types of assessment. Temporal processing (i.e., perception of tonal patterns and sequences) is also associated with reading and spelling skills (Pinheiro, 1976). CAP screening at the kindergarten level could survey phonological/phonemic awareness and temporal processing abilities.

Speakers perceive messages in terms of the phonological rules of their native language. Therefore, when such speakers engage in auditory discrimination tasks, they may be at a disadvantage. If the phoneme contrasts are not part of their phonological system, they are apt to make errors (Shames, Wiig, and Secord, 1998). The speech-language pathologist may erroneously conclude that the child is delayed in auditory discrimination. When speakers of non-standard dialects are screened, the speech-language pathologist should be aware of these influences.

It appears that early identification of nonverbal and verbal central auditory processing difficulties in kindergarten and second-grade children (and others) is warranted on academic, maturational. psychological, and economic bases. Early identification could reduce overall intervention costs for children with central auditory processing limitations. While a diagnosis of central auditory processing disorder is made under specific conditions (by the audiologist, often at age seven or later), the term central auditory processing difficulties may be applied more broadly (although carefully) to children with verified processing deficits (e.g., auditory discrimination, auditory figure-ground, or auditory memory). This term may be particularly useful with younger children.

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