When the Brain Can't Hear: Unraveling the Mystery of Auditory Processing Disorder

by Teri James Bellis

Apgar score, a rating of the infant's basic appearance by one minute of life. In arriving at the Apgar, a score of 0, 1, or 2 is assigned for each of the following five areas: heart rate, respiration, muscle tone, reflex irritability (such as coughing or sneezing), and color. The maximum score is 10 (2 points for each of the five areas assessed).

This rapid assessment is repeated at five minutes after birth, leading to two Apgar scores. The second is expected to be higher than the first.

In general, the poorer the infant's health after birth, the more at risk he may be for difficulties later in life.

At birth, the child • Startles to loud or unexpected sounds • Cries when uncomfortable, hungry, or wet • May calm to a familiar, comforting voice • May cease behavior when he hears a new sound

At six months, the child • Makes many different sounds, including laughing, gurgling, and cooing

Reacts to tone of voice, especially if loud or angry • Turns (or localizes) in the direction of new sounds • Enjoys toys that make noise, such as rattles or squeakers, musical toys, and being sung to • Babbles to get attention, using consonants such as p, b, and m • Smiles when he...

At eight months, the child • Responds to ...

Says at least four or more different, distinct sounds • Uses syllables such as da, ba, ka • Listens to his or her own voice and others' voices • Tries to imitate some sounds • Responds to no • Enjoys ...

At ten months, the child • May say mama or dada, but does not necessarily apply the c...

Shouts, squeals, or uses some other vocal, noncrying sound to attract attention • Uses connected syllables that sound like real speech in their general intonation and consonant-vowel makeup, including both long and short groups of sounds ...

At one year, the child • Recognizes his name and turns to look when his name is called • Says mama and dada and may have two or thr...

Imitates familiar words and animal sounds • Understands simple instructions (such as “Give me . . .” or “Come here”) • Waves (and understands) bye-bye • Makes appropriate eye contact and shows affection for familiar people • Responds to sounds such as the doorbell ringing or the dog barking • Understands that words are symbols for objects (e.g., shows that the word dog refers to the furry, funny-looking beast beneath his high chair...

At eighteen months, the child • Uses at least five to ten words, including names of people and familiar things • Uses some words to express wants or needs (e.g., “More”), but also often points or gestures to the desired object • Begins to combine two words (e.g., “All gone”) • Points to familiar body parts • Recognizes pictures of familiar things and people • Gets a famil...

Hums or sings simple tunes • Hears and responds...

At two years, the child • Uses two- to three-word “sentences,” including negative sentences such as “No want” and “No go” • Has approximately two hundred to three hundred words in his vocabulary, uses at least fifty to one hundred words regularly • Expresses simple desires or needs for familiar things or actions through speaking rather th...

Asks wh questions (such as “What that?” and “Where kitty?”) • Understands simple questions and comma...

At two and a half years, the child • Has a four-hundred-word vocabulary and can name familiar objects and pictures • Says his first name and holds up fingers to show his age • Says no, but may mean yes • Refers to h...

Uses short sentences regularly, such as “Me do it” • Uses past tense and plurals, although not always correctly (e.g., drawed, foots) • Talks to other children and adults • Can m...

At three years, the child • Should be intelligible to strangers, even though many articulation errors may persist • Has a vocabulary of nearly a thousand words (that is, has a word for almost ev...

Names at least one color, can match all primary colors • Knows concepts such as night and day, boy and girl, big and little, in and on, up and down, go and stop • Follows two-step requests such as “Get the toy and put it in the box” • Can sing familiar songs • Talks a lot (to himself and others) • Expresses abstract thoughts, ideas, and concepts verbally and can tell a short sto...

Can hear the television or radio at the same level as ot...

Most behavioral tests for APD cannot be administered until the child is at least seven.

APD frequently does not become apparent until a child enters preschool or even elementary school. In some cases, APD does not fully manifest itself until language demands become much more difficult, such as in high school or even college. Even if the APD is identified early in life, the ways in which it impacts the child's ability to learn and communicate will be different depending on his or her age and school setting.

At four years, the child • Has a vocabulary of fifteen hundred words • Uses four-to-five-word sentences • Begins to use more complex sentences • Uses plurals, contractions, and past tense • Asks many questions, including “Why?” • Understands simple who, what, and where questions

Can follow commands and directions, even if the target object is not present • Can identify some basic shapes (e.g., circle, square) • Can identify primary colors • Can talk about concepts in the abstract and imaginary conditions (e.g., “I hope Santa brings me a scooter”) • Begins to copy patterns on a page (e.g., lines, circles) • Pays attention to a short story and may be able to answer questions about it • Hears and understands most of what is said at home and in school • Relates incidents that happened in school or at home (e.g., “Jimmy hit me”) At five years, the child • Has a vocabulary of two thousand words • Uses five-to-six-word sentences • Produces most speech sounds correctly (except for the later-developing ones) • Uses all types of sentences, including complex ones that describe cause and effect or temporal relations (e.g., “I'll get in trouble if I hit Jimmy” or “I can have a cookie after I eat my lunch”) and sentences that incorporate past, present, and future tense • Can count to ten (including counting number of objects)

Can tell what objects are used for and made of and knows spatial relations (e.g., on top of, behind, far, near) • Knows opposite concepts (hard/soft, long/short, same/different) • Asks questions for the purpose of gaining new information • Knows right and left on himself, but not necessarily on others • Can express feelings, dreams, wishes, and other abstract thoughts • Can copy basic capital letters when shown a model, may be able to w...

Ear infections are one of the most common conditions in preschool- and school-aged children, second only to the common cold.

Similarly, an ear infection can affect a child's hearing acuity, and the child may miss important information in school or at home. This is true even if the child's hearing has been tested previously and found to be completely normal. Therefore, it is important for parents and caregivers to keep an eye out for any signs that a child may be having difficulty hearing, such as saying “Huh?” or “What?” or requesting that the television be tuned louder.

is often possible to tell when a small child has an ear infection. The child may have a fever, complain of pain, or if too young to verbalize, may pull at his ears and cry. He may also exhibit other obvious signs of illness such as crankiness, lethargy, or lack of appetite. However, some ear infections are “silent” and may thus go undetected. Ear infections are associated with a buildup of fluid behind the eardrum, and if this fluid contains bacteria, other signs of infection and general illness will usually accompany the infection. However, if the fluid does not contain bacteria, a decrease in hearing acuity may be the only symptom, and that can easily go unnoticed. If an undetected ear infection persists for long enough, the fluid in the middle ear may become very thick, a condition known as glue-ear, and result in more serious effects on hearing sensitivity.

Children learn an incredible amount in a relatively short time in these formative years. Therefore, any condition that can affect their ability to hear clearly can, likewise, affect their speech, language, and auditory processing abilities.

Parents and caregivers should be vigilant in looking for signs that a child may have a middle ear problem that can affect hearing. Some of these symptoms include • Inattentiveness • Wanting the television or radio louder than usual • Pulling or scratching at the ears • Difficulty following directions or understanding what is being said that is not typical for the child, including saying “Huh?” or “What?” • Unexplained irritability • Making comments about how the ears feel strange (the first tip-off that my youngest son had an ear infection recently was his saying, “My ears are beeping.” I still don't know what he meant by that, but sure enough, he had an ear infection with fluid but without fever or pain)

Nevertheless, preschool-aged children with APD may • Demonstrate delayed speech and language abilities, or articulation errors that are not consistent with age or that suggest acoustic confusions (such as substituting d for g) • Have difficulty following directions at school or at home that other children of the same age are able to follow easily (e.g., “Put your crayons away and line up for play time”) • Have an easier time following daily routines (once they are learned), such as putting a coat in a cubby upon arriving at school or getting a blanket from the closet for quiet time, than following new, verbally presented information or instructions • Ask for repetitions frequently, such as “Huh?” or “What?” Of course, “Huh?” can mean a lot of things when coming from a small child, including, “I didn't hear you,” “I didn't understand you,” “I already forgot what you said,” “I really don't want to do that,” or even “I wasn't paying attention because the cartoon on TV is way more interesting than you are.” It may be difficult, if not impossible, to distinguish among these causes without paying close attention to the types of situations during which the child asks for repetitions • Demonstrate signs of frustration or confusion, running the gamut from refusing to participate to staring back with a completely blank face, when confronted with new instructions or activities • Perform better when a visual example of the expected activity or behavior is provided, that is, when shown...

Elementary-school children with APD may • Behave as if a hearing loss is present, despite normal hearing acuity, especially in noisy environments • Demonstrate greater difficulty with verbal than nonverbal tasks, with verbal IQ lower than performance IQ • Demonstrate significant scatter, or fluctuation in ability levels, across tests of speech, language, or cognitive processes, with weaknesses in those areas considered to be more auditory in nature • Exhibit a delay in the content, use, or form of language • Exhibit articulation errors that persist longer than they should • Be distractible • Refuse to participate in classroom discussions or, conversely, offer inappropriate or off-topic contributions • Exhibit difficulty following multistep directions • Demonstrate poor reading or spelling skills • Have a history of chronic ear infections, head trauma, or other ear- or brain-related condition • Exhibit poor music or singing skills • Require a high degree of external organization in the classroom to begin and complete required tasks • Exhibit poor social communication skills or difficulty making and keeping friends • Rely heavily on memorization when learning new information or skills • Demonstrate inappropriate behavior, including withdrawal, acting out, tantruming, clowning, or playing instead of completing the task at hand • Express frustration with certain tasks, such as saying “I can't do this” or “I don't understand” • Demonstrate poor problem-solving skills • Perform ...

Behaving as if a hearing loss is present, despite normal hearing acuity, especially in noisy environments. This is considered the classic hallmark of APD. The most common complaint by far that we hear from children and adults with APD is difficulty hearing in backgrounds of noise, a complaint that is also common to people with hearing loss.

The child with an APD, like the child with a hearing loss, may hear a distorted or incomplete message.

Most often, a child with an APD will have difficulty with subjects such as reading and written language, social studies, and science.

The student with an APD will likely be compromised in his ability to listen to, comprehend, and answer questions about stories or topics presented in class.

These symptoms are most characteristic of children with APD involving the left hemisphere of the brain. This is because, for most people, the left hemisphere is dominant for language. In contrast, the right hemisphere is typically dominant for activities that are not as reliant on language. Therefore, an APD that involves the right hemisphere may lead to a completely opposite pattern of difficulties. Children with right-hemisphere-based APD may have problems with mathematics calculation, music, and art.

we must be aware that many types of APD co-occur with difficulties in areas not traditionally considered auditory-verbal in nature, especially APDs resulting from dysfunction in the right hemisphere or interhemispheric pathways of the brain.

Difficulty following multistep directions is a hallmark of APD. However, as with the other key indicators of APD, this type of difficulty can arise from many factors: Does the child not hear the directions in the first place? Does he hear them but not understand precisely what they mean? Does he both hear and understand, but forget them as soon as they are presented? Does he hear, understand, and remember them, but, somewhere in following through, become sidetracked by something else—a new toy, the sight of leaves blowing in the wind outside the window—and never complete the task as directed?

In addition, middle and high school students with APD may • Exhibit a reappearance of earlier complaints and symptoms or an entirely new set of difficulties because of the changing academic demands of higher grades • Demonstrate difficulties in classes at which they had excelled previously due to classroom acoustics, differing teacher styles, or a host of other factors • Have problems understanding concepts presented in lecture-based classes because of difficulty with note-taking and comprehending reading assignments • Earn poor grades in foreign-language classes because of the new speech sounds and vocabulary that must be learned • Exhibit difficulty with written tests, especially timed tests presented in multiple-choice or short-answer format, including college entrance exams • Refuse to employ management strategies that will set the student apart from peers, such as the use of an assistive listening device, even if such strategies were complied with willingly in lower grades • Withdraw from social communication or engage in self-destructive behavior; however, we must be careful not to attribute all undesirable behavior directly to the presence of an APD

The Americans with Disabilities Act (ADA) states that any individual with a physiologic disorder (which can include learning or communication disorders and APD) cannot be discriminated against in the educational arena, workplace, or other environments.

More recently, however, we have begun to acknowledge that adults suffer from the same types of APD that occur in children. That is why we now use the term auditory processing disorder to refer to these deficits in everyone, regardless of age.

They found that, for men, listening-related brain activity was focused exclusively in the left (or dominant) hemisphere. Women, on the other hand, also demonstrated activity in the right hemisphere of the brain while listening. Thus, men appear to listen with only one side of their brain and women appear to use both.

I found that women, like men, tend to exhibit decreased interhemispheric processing skills with aging. However, unlike men, the decrease in these processing skills occurs later in life—around the time of menopause.

counseling must focus on helping the person accept the presence of the disorder.

Certain classroom characteristics will make the room more listener-friendly to all students. These include carpeting on the floors, acoustic tiles on the ceilings, and the minimization of hard wall surfaces as much as possible.