When Hearing Isn’t Listening:
The ABCs of APD
Margaret’s beautiful baby boy Billy Ray was six months old when she began to sense that something wasn’t right. Why didn’t Billy Ray look at her, even when Margaret took him in her arms and murmured his name? Margaret had a powerful sense that the sounds her little boy made, so different in pitch and tone from her first child’s coos and giggles were just, well, wrong. And Margaret rarely had any sense that her son was making his baby sounds in response to the things his mom said or did.
Her doctor assured her there was nothing to worry about. “Boys start to talk later than girls,” he explained. “Besides, Billy Ray is the second child in the family. His need to communicate with you is not as great.” Well, he’s the doctor, Margaret thought. Yet in her heart, she just couldn’t accept these reasonable-sounding explanations. Margaret felt deep down that Billy Ray should be responding more to her and her husband’s voices and the sounds and noises in their home. Based on her experience with her first child, she sensed that the pre-speech vocalizations Billy Ray made should be different from what they were. Reaching for a box of rice one afternoon at home, Margaret impulsively rattled it behind Billy Ray’s head. When he again failed to react, Margaret knew what she had to do. The following day, she had Billy Ray’s hearing checked, fully expecting that her child had a hearing impairment.
The results came back normal.
Undeterred, Margaret arranged for consultations with two separate pediatric neurologists. After a battery of tests and examinations with Billy Ray and a lengthy interview with Margaret, both doctors concluded that Billy Ray had pervasive developmental disorder (PDD). Margaret had never heard of PDD, a condition involving developmental delays of socialization and communication skills. She tried to be as upbeat as possible as each neurologist explained what PDD was and described a therapeutic preschool and the necessary therapy that would accommodate Billy Ray’s special needs. Margaret was grateful for the diagnosis—having one gave her something new to focus her efforts on—but worried that the doctors were sentencing her beautiful little boy to a life of isolation. Nevertheless, Margaret did the research, fought with her insurance company, and adjusted her family’s budget so that Billy Ray could attend the school and receive the therapy that both doctors recommended.
But by age two Billy Ray was still uncommunicative. Worse, as he grew from infant to toddler, Billy Ray’s inability to listen began to be an educational and social ball and chain for him. Frustrated by an invisible wall that complicated and confused nearly everything he was asked to do, Billy Ray cried and acted out a lot. Unable to state his own needs or understand what other boys and girls asked for, he pushed and grabbed for toys, upsetting his peers and testing his teachers’ patience. As his mother looked on helplessly, Billy Ray increasingly retreated into a world of his own. Instead of each new day offering a chance to grow, develop, and interact more meaningfully and happily with the world around him, Margaret, Billy Ray, and their family faced a daily struggle simply to cope.
Margaret could see how much it hurt and confused Billy Ray when he misunderstood and was in turn misunderstood, but she was at a loss as to how best to help her son. It felt as if Billy Ray was on the other side of a door, knocking for her to unlock it, and Margaret simply didn’t have the key. Increasingly Margaret worried that if she couldn’t find a way to open the door and lead Billy Ray out into the full, rich world of experience, her little boy would never be able to play and connect with his sister, make friends in school, fall in love, go to college, or live on his own. Margaret redoubled the hunt for the key. There must be something she’d missed, someone she hadn’t consulted. She made calls, quizzed other parents, scanned parenting websites and chat boards, and read and reread everything she could find about Billy Ray’s diagnosed disorder, PDD.
Along the way she happened upon a website that described yet another three-letter syndrome. When she read the symptoms of APD or auditory processing disorder, she could scarcely believe it. Here was the exact list of what Billy Ray was going through. Children with APD:
•Have trouble listening and hearing, especially in noisy environments
•Struggle to distinguish between similar-sounding words and sounds
•Don’t follow directions well
•Frequently ask for clarification and to have words repeated
•Do poorly in reading and reading comprehension, spelling, and other classes where verbal directions are key
•Fare better in independent activities and classes where listening isn’t a central requirement
One other item made her sit bolt upright:
•Are often misdiagnosed with other disorders such as ADD (attention deficit disorder), ADHD (attention deficit hyperactivity disorder), and pervasive developmental delay (PDD)
Intrigued—and hopeful that perhaps there would be more that she could do for Billy Ray if this was his true problem—Margaret started to look further and asked more questions of the growing list of specialists she’d already consulted. She felt she was on the path to discovering how to unlock the proverbial door for her son.
Margaret is certainly not alone in her search to help unlock the door to healthy development for her son. If you’re reading this book, you likely suspect that your own child has one of these three-letter syndromes, or you already have a suggested diagnosis in hand and are trying to digest as much information as possible going forward.
Generally speaking, auditory processing disorder is a term for a group of conditions in which the parts of a child’s brain tasked with turning sound into language and hearing into listening don’t do their jobs right. How this issue develops and at what age it most often does so is little understood—we’ll discuss this more below—but it is estimated that between 1.5 million and 2.5 million children a year are diagnosed with this disorder. Because auditory pathways leading from the ear into the brain and the auditory processing centers within the brain itself are continuously developing throughout infancy and early childhood, it’s not possible to screen for and definitively establish the presence of an APD in a child until she or he is six or seven years old. A specific diagnosis detailing the magnitude of the APD as well as any related or concurrent problems such as ADD or ADHD and the right course of therapy and treatment cannot in turn be made until the child is seven or eight. But there are clearly many, many more younger children dealing with these listening difficulties. We think some children are even born with this issue. Unfortunately, because the development of auditory processing skills is linked with a growing child’s use of language and increasingly complex communications and social interactions and cannot be accurately measured until those skills develop, parents have to go without formal diagnosis and intervention for too long. The ideas in this book will help you understand what’s at stake in your child’s listening development and in turn help your child from the moment you begin to suspect that there may be a problem. You don’t need to wait for a formal diagnosis to begin to help.THE ABCS OF APD
In broad strokes, it’s easiest to understand hearing—the process of experiencing sound—as a two-stage phenomenon. First, sound vibrations are collected by the outer ear, funneled to the inner ear, where they become physical vibrations, and then sent on to the cochlea, where they are transformed into electrical impulses. Then these impulses travel along the eighth cranial nerve into the brain.
As the electrical impulses enter and go deeper into the brain, they pass through a series of relay stations in which the auditory information they carry is analyzed for timing (duration), intensity (volume), and frequency (pitch). The sound signals from each ear also get switched over like railcars changing tracks and are rerouted to the opposite side of the brain. Sound received in the right ear is sent to the left auditory cortex, while sound from the left ear goes to the right auditory cortex. The auditory cortex is a specialized area within the cerebral cortex that organizes, analyzes, and transforms sound information into the sensations and reactions that we recognize as language and speech. For most people the left cortex does the lion’s share of the work.
Once inside these brain centers, sound impulses are put through a highly sophisticated and detailed battery of analyses and examinations contoured by memory, instinct, thought, and various voluntary and involuntary reactions into the sensation we experience as hearing. It’s a complex process—one that simultaneously incorporates multiple locations of brain geography, a system of feedback to the cochlea to help narrow the focus of hearing, and a myriad of other analyses, impulses, gateways, functions, and processes. All this happens in a fraction of a second.
Most people recognize that birth defects, infections, blockages, eardrum punctures, tinnitus from loud noises, and various other things can adversely affect the middle and inner ear, important parts of the hearing equation. But a lot can also go wrong during a sound’s journey along the eighth cranial nerve through the relay stations and inside the auditory cortex. APD is a condition that affects that interior trip to the auditory cortex and the processing stage that transforms hearing into listening within the cortex itself.THE DEVELOPMENTAL LADDER
Since we don’t yet know what causes APD and can’t predict at what age it may develop, it’s important to understand the typical developmental milestones common to most young children. These developmental milestones are a loose guide. They can help you to zero in on your child’s listening development. If your child’s listening and speaking skills don’t come anywhere near the trajectory I describe, APD may be the problem. Keep in mind that the ideas, observations, and indications that follow are not one-size-fits-all. A child’s journey to developmental maturity is a ladder of many rungs. Your son or daughter can pause on one rung longer than another child the same age, skip one, or even go back a few and still be well within the range of “normal.” Always keep in mind that variation and individual timing is the natural order of things when it comes to growing children.Birth to Three Months
•Newborns listen to sounds that are close to them.
•Unexpected or loud sounds may startle them or make them cry.
•New and interesting sounds may calm them or cause them to stop movement and “listen” or attend. Recognizing attention in a newborn can be tricky at first. Sometimes it’s visible only in an interruption of sucking on a pacifier or a bottle.
•The baby begins to localize and turn in the direction of a sound source.
•A familiar voice gets greeted with a familiar expression, sound, or gesture.
•The baby responds to soft, comforting tones.
In the first ninety days of life, a newborn infant is fully occupied by the basic needs for comfort, food, rest, hygiene, and love. During these first beautiful months your baby spends most of his or her day sleeping and being kept clean, fed, and adored. At the same time that your baby begins to develop a sense of touch she also begins to respond to the trust and warmth she soaks up from the people who care for her. By the third month your baby begins to grasp and hold things such as rattles and stuffed animals, and fully expects that her comfort and contact needs will be met.
Initially your baby communicates by crying. You and the other adults around her begin to read her signals and recognize that the specific cry for being hungry is different from the cry for being wet. Soon she will start making other sounds and playing with her growing ability to vocalize; she will repeat sounds that get your attention and approval.Three to Six Months
•Sounds begin to have meaning.
•A child begins to respond to “no.”
•The baby recognizes changes in a voice’s loudness and pitch.
•He or she starts to associate word meaning with sound.
•The baby listens to his or her own voice.
•Rhythm and music draw their own reaction.
•The baby shows an interest in toys that pair sound with movement, such as rattles, musical mobiles, or anything else designed to make noise when it moves or is moved.
•The baby demonstrates increased attention to more varied environmental sounds, such as a vacuum cleaner, a fan, or a door slamming in another room.
At the ninety-day mark, your baby is now ready to play. She is awake for longer periods of time, is more physically active and clearly enjoys interacting with you. She can now grasp objects and bring them to her mouth for more sensory exploration. If your play involves language, your baby is ready to experience that, too. At this age a child can create vowel-like (“a,” “e,” “o”) and consonant-like (“p,” “b,” “m”) sounds.Six to Twelve Months
•The child begins to listen and pay attention when spoken to.
•He or she responds to his or her name by turning.
•He or she is able to focus on listening for longer periods of time.
•The baby begins to like and play games that pair voice with movements.
•Familiar words (names of daily used objects and frequently seen people) are recognized in familiar contexts.
•The baby responds to familiar requests, such as waving bye-bye or being asked to give something to the parent.
•The child recognizes sounds paired with objects, such as an animal sound with the appropriate animal.
Your baby is awake even more and therefore more available to play. At six to twelve months a baby loves to look at books and pictures with you and is becoming much more physically active. She’s developing a longer attention span, sitting by herself, crawling, pulling herself up to standing, and possibly even taking her first steps. She shows off her developing fine motor skills while playing with blocks and stacking rings. As the twelve-month mark approaches, she clearly understands more about the world around her.One to Two Years
•The child begins to show specific comprehension of words.
•He or she can point out and identify pictures and objects by their names.
•He or she can also point to simple body parts on themselves and others.
•The child will now imitate words he or she hears.
•The child can follow one-step commands or questions such as “Throw the ball” or “Where’s the kitty?”
•He or she likes listening to simple stories.
•The child loves to listen to songs and rhymes and can incorporate body and hand movements to go with some of them.
During this time your baby’s speech makes a big leap forward. Over the course of year one to two, most children go from babbling to creating nonsense words to learning and using real words and finally to using real words in two-word combinations. Increasingly your child enjoys playing with things that represent actual objects, such as using a block as a truck. She also explores her environment, learning how to walk and even how to climb stairs and using fine motor skills to manipulate simple one-piece puzzles.
Excerpted from The Sound of Hope by Lois Kam Heymann, MA, CCC-SLP. Copyright © 2010 by Lois Kam Heymann. Excerpted by permission of Ballantine Books, a division of Random House LLC. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.