CAPD and the gifted child

Written by Kay Pittelkow Monday, 23 June 2008 12:30

Some gifted children learn most effectively through non-auditory channels. Because these children do not learn effectively in a traditional classroom they often perform well below their mental age. Additionally, because they are gifted, they are intrinsically aware of their own lack of achievement (particularly in respect to other less gifted children). They are "turned off" school and are often disruptive in class or at home showing many of the characteristics of the gifted learning disabled. The frustration, inner conflict, boredom, lack of a suitable peers and fragile self-esteem of such children translates into unruly and unsettling behaviour. These are children at risk.

However, before remediation of such problems can be effective, these children first need to experience success in learning. Success -or academic achievement- obtained by using their gifted abilities leads to an improvement in self-esteem that will underpin their future cognitive development.

These children can learn effectively if taught using strategies that do not rely on hearing and listening but instead use the type of visual /spatial or experimental/experiential strategies developed from the educational theory of Multiple Intelligences. (Pittelkow, 2001, Gifted, 118). As well as learning more effectively, such children also learn more easily when:

• They are taught using educational models or strategies which focus on the development of creativity/ lateral thinking,
• They participate in programmes that are aimed at teaching the hearing impaired, or
• They are taught how to use visual meditation/manipulation or gestalt (whole brain) thinking techniques.

Such techniques can help these children to engage analytical and evaluative thinking when required and also at times of "stress". These children become "spaced" out during auditory overload and need these techniques to overcome their stress. (Pittelkow, 2001, Gifted, 117).

This article looks at identification and attendant remedial strategies (both traditional and newer approaches) that can be used to improve auditory processing - a key area in assisting these gifted learning disabled children.

Characteristics/Identification and Prevention of CAPD

Central Auditory Processing Deficit (CAPD) is a diagnosis used by speech pathologists and audiologists. In this article I use Katz & Stecker's (1992) definition of Central Auditory Processing (CAP): What we do with what we hear.

CAP is what a child "does" with sounds that they hear. Therefore, it is important to establish, in the first instance, that a child can hear sounds normally. It should be emphasised at this point that before trying to identify if a child has CAPD their hearing must be checked and determined to be normal.

For further information on the different types of CAPD see my note on CAPD SubCategories.

Physiological characteristics of CAP

The physiological characteristics of CAP (from ASHA Task Force on CAP, 1996) are listed as:

Physiological Characteristics of CAP
Characteristic	Definition
Sound localisation and lateralisation	Ability to locate or know from where the sound(s) is coming.
Auditory discrimination	Ability to recognise the difference between different sounds.
Auditory pattern recognition	Ability to recognising patterns of sounds such as syllables and multi syllabic words.
Temporal aspects of audition Temporal resolution Temporal masking Temporal integration Temporal ordering	Ability to order (or time sequence) a series of sounds. This is necessary for sequential processing and is the basis of sequential organisational tasks.
Auditory performance with degraded acoustic signals	Ability to understand speech that is "soft", indistinct, low in volume or spoken with an accent.
Auditory performance with competing acoustic signals	Ability to listen to one person speaking when others are talking or there is background noise. (This is commonly defined as the "party syndrome".)

Behavioural characteristics of a CAPD child

The CAPD child may:

• Not participate in classroom discussions and/or respond inappropriately.
• Appear withdrawn or sullen.
• Appear not to hear (although hearing is normal).
• Be inattentive in class and may have trouble paying attention to auditory presentations.
• Be easily distracted.
• Work best in highly organised classrooms.
• Have trouble following complex verbal directions and localising sound.

Such children:

• Demonstrate verbal IQ scores that are often lower than their performance scores.
• Demonstrates significant scatter across sub-tests assessed by speech/language and/or psycho educational tests, with (relative) weaknesses in auditory dependent areas.
• May have poor reading and/or spelling skills.
• May have fine and/or gross motor skill deficits.
• May exhibit poor singing and music skills.
• May have significant history of middle ear pathology.
• May have a family history of similar problems.

Based on Bellis (1996)

(Check here for a more detailed look at these characteristics and recommended traditional strategies. When interpreting this list keep in mind that a gifted child who performs in any area two years or more below their mental age (not their chronological age) should be given help. Therefore a 9 year old gifted child (say a mental age of 12 years) who performs at a 10 year old level requires intervention. This age difference increases with the giftedness of the child. When assessing remediation programmes check that the programme offers children a challenge. If it doesn't the programme will not be effective changing a child's his self-taught strategy.)

Prevention of CAPD

A child must be able to "hear" to develop auditory processing. If the ear and associated structures are intact then the cause of imperfect auditory processing may be:

• Intermittent or permanent physical damage or blockage of the hearing mechanism either by physiological events or mechanical objects.
• Physiological events include wax blockages of the outer ear, otitis media (middle ear infection) especially if associated with scarring or burst ears, glue ears or blockages of the Eustachian tube at top by swollen adenoids or stuffed noses and/or at the bottom by swollen tonsils.
• Children at risk are those who suffer from allergies, who have recently experienced a respiratory illness, who have suffered from foetal alcohol exposure, are deficient in certain minerals, vitamins and fatty acids, have suffered trauma at birth, or are genetically predisposed (such as Down Syndrome children).
• Environmental factors can be seasonal allergies, being surrounded by smokers or attending day care centres. Other environmental factors include early introduction to solids and children who live in a low socio-economic condition.
• Stress, yeast infections, and TMJ disorders (TMJ is the joint that hinges the lower jaw to the skull) are lesser known factors that lower the efficiency of the immune system. Interestingly this category includes blocked nerves at the first cervical vertebrae - which is why chiropractors can successfully treat some otitis media patients.
• Post head injury, hyperacusis, (An over-amplification of environmental sounds in the auditory pathways. Everyday sounds are heard as very loud and are intrusive.and a history of anti-depressant medication, such as Prozac which slows aural processing and exposure to neurotoxins (lead, carbon monoxide) can also lead to auditory processing problems.

Importantly, if parents of young children are aware of the correlation between these factors and learning disabilities they may avoid the disabling affects of CAPD [Footnote 1].

Auditory Diagnostic Testing - Identifying CAPD in Gifted Children

Since gifted children usually develop self-taught strategies or use prior knowledge to circumvent their deficit, they do not always demonstrate the typical characteristics of CAPD. It is only when they have to confront a new situation, for which they have not yet developed alternative strategies, that their deficits are exposed. In the classroom, gifted CAPD children most often use visual clues to establish what is required of them. Frequently these children already understand most of the classroom lessons having taught themselves at home using computers, television, or reference books (this is called "pre-teaching"). As a result, the fact that they can't follow what the teacher is teaching is missed. Children may "guess" what the teacher wants from what they did hear or from what they can see, copy or intuit. (Alternatively, a child may just sit quietly "turned off" from the activities surrounding them or become disruptive.)

This lack of clear, distinct behavioural characteristics for identifying gifted children with CAPD (as distinct from normal children with CAPD) makes audiological diagnosis an imperative for these children. Once correctly identified the appropriate intervention/ remediation can be implemented.

There are four categories of audiological tests for identifying children with CAPD:

1. Temporal Ordering Tasks

Temporal Ordering Tasks are tests designed to evaluate the child's ability to perceive a pattern of auditory events occurring over time. The functions tested are:

• Frequency and/or duration discrimination
• Temporal ordering and linguistic labelling

These tests can also distinguish between auditory processing requiring inter-hemispheric transfer of acoustic information and those that don't.

One example of this style of test is the Continuous Performance Test. The CPT measures the processing time for a single stimulus. It is administered as series of changing stimuli to which the child must respond as fast and as accurately as possible. It has been shown that children who have slow reaction speeds for naming letters and numbers tend to experience reading problems later on (Wolf , 1991) with the greater the speed deficit, the more severe the reading problems. This type of test can distinguish or point to learning disabilities, ADD, ADHD or depression.

Another example is the Time Order Processing Test. The TOP test measures the processing time for sequential stimuli - or "getting the sounds in the right order". Children who require a longer time to hear two sounds as distinct from each other and to tell which sound came first. Such children have problems with words such as "ticked" (pronounced tickt") where the consonants come one after the other in quick succession. They also have difficulty with sounds that differ in their length "eg one of the distinguishing characteristics of "da" and 'ta" is the length of time of the sound.

Children with problems in this area also tend to experience problems with tasks that involve organisation and sequencing. The neural pathway from the right ear to the left hemisphere of the brain is responsible for time ordering processing of fast changing sounds. It has been found to be relatively undeveloped in children with learning disabilities.

These children are usually slow to develop language and have difficulty with pronunciation, reading and spelling. Children who have greater than 60 msecs TOP time will experience spelling and reading difficulties (Sheil 2000). At about 100msecs normal processing of speech is not possible. (Dyson (2001) Children with these prolonged TOP will also have difficulty motor planning for fluent movement. (The importance of temporal processing was set out in Tallal, Miller and Fitch, 1993)

2. Monaural Low-Redundancy Speech Tests

These tests evaluate a child's ability to achieve closure when the auditory signal is not clear. ("Closure" is where a child "guesses" the word based on his experience - exposure and long-term memory of similar words - and the information he receives at the time.) Children who have problems in this area have difficulty understanding accents or speakers who do not articulate clearly. After about 7 years of age, when hearing of high frequencies starts to deteriorate, the ability to close becomes more and more important.

3. Dichotic Speech Tests

Dichotic speech tests evaluate the neuro-maturation (the natural development of auditory functions over your child's life) and inter-hemispheric transfer of auditory information. They then assess dysfunction with integration and separation of aural information received by either or both ears. Children who have problems in this area have difficulty in "hearing" the teacher in a noisy classroom. "Hearing" for such children is especially difficult if the child next to them whispers/makes noises or if there is extraneous noise from the classroom next door. Such children often scramble the two messages being received by each ear [Footnote 2].

4. Electrophysiological Tests.

There is a battery of neuro-audiological and radiological tests that assess the integrity of the central nervous system. They are auditory brainstem responses, middle latencies (MLR), late latency and event-related responses (P300, mismatched negativity MNN) and functional MRI. Diagnosis can then extend to auditory neuropathy where the cochlea of the ear is normal but the brain stem response is abnormal. The evoked brain potential (performed by neuroscientists) can provide invaluable information in the process of separating learning disability from AD(H)D and is often instrumental in diagnosing short-term memory problems or frontal lobe inefficiency. These tests are too complex to discuss here. Audiologists arrange and explain these tests in detail, if they are required.

5. Other Categories of Tests for CAPD

In addition the previously described tests there are another eleven categories of speech/language tests for CAPD:

• Speech Discrimination Surveys of Minimal Pairs.
• Auditory Perception Tests.
• Comprehension of Complex Grammatical Language Tasks.
• Auditory Attention.
• Auditory/Sequential Memory.
• Phonological Tests of Articulation.
• Phonological Awareness Tests.
• Expressive and Receptive Language/Vocabulary Tests.
• Reading and Writing Tests.
• Tests of Problem Solving.
• Comprehension of Figuration Language.

When to do the testing

Most tests are "normed" from about 7 to 12 but below age 7, assessment is affected by a high degree of variation. However, the new SCAN C is normed from 5 years. SCAN C is a composite test containing two tests for sensitised speech where the test items have been distorted in a specific way to reduce intelligibility and two tests which are dichotic listening tests in which different words or sentences are presented simultaneously, one to each ear.

As with all assessments tests, results from gifted children should be related to mental age and not chronological age. If a child has a mental age of 12 and a chronological age of 9, then a test result showing of average 9 indicates a problem.

Under 5 years of age testing for CAPD should take place if there is/are:

• A history of recurrent and persistent otitis media
• Speech and language delays
• An inability to condition a child to age appropriate tasks
• An inability to localise in a controlled sound environment (soundfield)

Early intervention, while the neural network is still maturing and capable of easy change, is advisable. It must be noted here that auditory processing tests are still fairly new in Australia and few centres have the full range of tests. In Sydney, Northside Audiology is expected to have the full range later in 2001, otherwise the best course of action is to contact local speech pathologists. Some neuroscientists are also equipped to undertake testing.

Auditory re-training

In addition to traditional remediation programmes outlined above, the use of auditory re-training (sometimes called Auditory Integration or Auditory Training) therapies is gaining credibility and popularity. These therapies use high quality sound recordings that "exercise" the auditory pathways in a pattern that mimics the natural development of hearing. At the end of auditory re-training the underlying neural problem should no longer exist and the child should be in a position to learn effectively. However, they will still need to catch up on work they may have missed due to their CAPD.

What is auditory re-training

There are a number of programmes, each of which is biased towards a particular group or condition. There are two types of programmes. The first one originated in the work of Dr. Christian Volf and was later extended/ by Kjeld Johansen. The other type of programme originated in the work of Dr Alfred Tomatis, with his work inspiring further work by Dr, Guy Berard, Patricia Joudry and Ingo Steinbach. These programmes all have in common:

• Music - mostly Bach and Mozart are used. The music used induces the types of brain wave patterns which are associated with focusing and calm attention. The recordings are required to be of high quality and the programme is sequenced to accord with normal neurological development.
• The filtering or enhancement of certain frequencies. The programmes where frequencies are filtered out are for sound sensitive individuals. High frequencies are enhanced in order to stimulate the basic components of the auditory processing system, especially those of the temporal lobe. These specialised recording often require sound systems and ear phones that have specific qualities.
• A bias to the right ear. Music is louder in the right ear in order to train the right ear to be the dominant ear when listening - particularly when listening to complex fast changing patterns of sound.

Acceptance of audio re-training

There have been a number of factors contributing to the growing acceptance of auditory re-training strategies. These include:

• Availability of results of numerous case studies.
• Availability of accurate auditory diagnostic tests (as mentioned above) that identify which child is a suitable candidate for the therapies which also provide a means of monitoring the effectiveness of the treatment.
• The recognition by the medical profession of CAPD.

Results after auditory re-training show improvement in

• Processing of information (as measured by TOVA testing -a computerised test of variable attention often used to identify AD(H)D).
• The time interval which two separate sounds, closely following one another, can be heard as two distinct sounds (as measured by Warnke). The Warnke test is a Time Order Processing test in which the child is asked to repeat and write short randomly sourced consonants over a background of noise. Difficulty in this area could indicate reading and spelling problems, particularly in a situation where a student has to cope with extraneous noise or auditory signals coming from different directions. (Dyson (2001) quotes an approximate 300% increase after Somonas Sound Therapy (SST)- 95 children, average age 9.7yrs.)
• Discernment of just noticeable differences in sounds - thereby improving clarity and understanding of speech. (Keith's SCAN and Warnke's "Was Hanschen nicht Hort".) The Scan test has a number of subtests: it looks at a child's ability to interpret sounds or words that are distorted as with an accent or through sound systems. It also looks at whether children can "guess" (or affect closure) under these circumstances and also whether this ability is affected by background noise. Other subtests are dichotic listening tests (See earlier section.) (Dyson (2001) reports improvements of approximately 70% - filtered words, 20% - auditory figure-ground and 50% -competing words)
• Discrimination in the sound environment between what is wanted and what is not (such as hearing what the teacher says in a noisy classroom - measured by dichotic sound tests).
• Discernment and remembering complex sound patterns - such as the order of sounds in a word and the order of words in a song certain sounds.
• Supersensitivity to sudden loud sounds.
• Attention to sound.
• Response to sound after suffering from loss or diminished response such as in industrial deafness
• Tinnitus (in some people only) [Footnote 3]

Auditory re-training occurs at a basic neuro-physiological level. One research doctor from Sydney's Children Hospital excitedly told me that she could see the difference in the neural patterns before and after auditory re-training. Because it is at such a basic level, auditory re-training can have far reaching effect.

Think of a sand picture (coloured sand held between two glass plates) - if you knock an air bubble out of the bottom of the pile of sand, the sand above it shifts in an almost unpredictable fashion. This is similar to what happens when basic level neural problems are solved.

After or during auditory re-training, changes occur, not only in the basic auditory pathways but also in the higher neural levels eventually reaching the top of the sand picture - where academic skills are affected. Sangster, (2000) and Dyson (2001) state that auditory re-training (sound therapy) has been shown to improve motor co-ordination (not surprising if you consider the role the vestibular system of the ear plays in balance and co-ordination), visual perception and visual/motor skills. The improvement in motor co-ordination is also thought to be a result of a general improvement in time order processing time - children now having time to motor plan for fluent movement before the next stimulus.

Individual case studies provide data on educational gains - Dyson (2001) reports on 13 to 27 month spelling gain, 24 to 40 month gains in reading comprehensive and 25-month gain on reading accuracy. Sheil (2000) gives mean improvements of 18 months in spelling age 11 month in reading accuracy,47% auditory processing speed, and 58.5% visual processing speed 58 (First 18 students with mean therapy time of 5.7 months). Sangster, in same paper gives another 13 case studies showing gains comparable to Dyson.

Auditory re-training can improve or remove the underlying neural problem thereby giving children the ability to learn more effectively when taught by auditory strategies. Some children may suffer from side effects when undergoing auditory re-training. It is important to suspend the therapy until the underlying problem (usually neural for example retention of primitive reflexes, or cellular such as allergies) has been attended to. After or during auditory re-training effort needs to be put into your child's education to teach them how to use their re-trained ears, to unlearn their old ineffective strategies and to catch up on curriculum they may have missed.

In Conclusion

The development of accessible auditory diagnostic tests has, for the first time, made diagnosis of CAPD in gifted children possible. Once diagnosed, strategies can be used to improve the effectiveness of learning for these children in a traditional auditory teaching classroom. However, the availability of proven auditory tests and benchmarks has also given the previous "alternative" auditory re-training programmes the chance to quantify their effectiveness. Auditory re-training, if successful, is said to "cure" CAPD.

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Kay is the co-author of a recently published book (2000) Discovering the Gifts and Talents in Your Child. After completing the book Kay found she still had extensive research material on gifted children, particularly underachieving gifted children that was too technical for general publishing. Her aim, by publishing this article is to make relevant research on medical and education issues more accessible to parents and non-academic educators. Click to read her personal experience with auditory re-training.

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Footnotes

1. 1. For actions a parent can take to promote healthy development of the vestibular (ear) system in the first 15 months of a child's life investigate "Why Does My Boy Scientist Not Want to Read?" (Gifted, 114). Additionally, to prevent or at least limit the effects of the factors above, the other most important positive intervention a parent can assist with is to ensure that their child is physically active and has plenty of exposure to meaningful interpersonal verbal communication. [Return]
3. 2. The right ear links to the left hemisphere in which the bulk of the language processing is performed. The neural pathway is neurologically different to the left ear link that goes first to the right hemisphere and then to the left brain. (Tomatis, 1991) In learning disabled children this right ear pathway is not as developed as in normal children. Tomatis and others have all recognised that for optimal language development in the young child the right ear should be dominant. The dichotic speech test and the time ordering tests are important diagnostic tools for evaluating this feature. [Return ]
5. 3. Check the internet references to review of research results (for and against) the success of auditory re-training. Otherwise type "CAPD" or "Central Auditory Processing Deficit" into your favourite web search engine. The references cited in Sangster (2000) and Dyson (2001) give further research results and case studies supporting the above claims. The literature is full of claims and counterclaims. However, at this time the most compelling claims for auditory retraining comes from case studies and testimonials. [Return]

Annotated References

Cummings, Martha and Heithaus, D. (2000). From Central Auditory Processing Skills to Language and Literacy. Speech Pathology Australia National Conference. Adelaide May 8-12. Not published but can be obtained from the presenter, Dorsey Heithaus: email This e-mail address is being protected from spambots. You need JavaScript enabled to view it  It has an excellent reference section. For co-presenter Martha Cummins: This e-mail address is being protected from spambots. You need JavaScript enabled to view it at the Children's Hospital Medical Center, Cincinnati, Ohio.

Dyson, M.D. (2001). Submission to the Inquiry into Early Intervention into Learning Disabilities. 22 May 2001. Submission by the Samonas Sound Therapy Association of Australasia. The transcript can be read at www.parliament.nsw.gov.au then find the relevant Legislative Council standing committee on social issues. The committee's report is not yet published. The submission is extensive covering the role of CAPD in learning disabilities and results using Samonas sound therapy both in Australia and overseas. Phone/fax Dr. M. Dyson on 9983 0484 for copies.

McPhillips, M., Hepper, P.G., Mulhern, G. (2000). Effect of Replicating Primary-Reflex Movements on Specific Reading Difficulties in Children: A Randomised, Double-Blind Controlled Trial. Lancet. 355, 537-541. Links the presence of primary reflex to reading disabilities in children. Should be read in conjunction with Sangster & Carson's submission (see below).

Pittelkow, K. (2000). Why Does My Boy Scientist Not Want to Read?. Gifted. 114, 22-27.

Pittelkow, K. (2001). A New Look at Strategies for Visual Spatial Learners. Gifted. 117, 15-18, 23-25.

Pittelkow K. (2001). Variety is the Spice of Life: Multiple Intelligences and the Gifted. Gifted. 118, 1,1-18, 23-27.

Sangster, S and Carson, B. (2001). Submission to the Inquiry into Early Intervention into Learning Disabilities. Legislative Council Standing Committee of Social Issues. 22 - 23 May 2001. Looks at the successful inhibition of primary reflex by the use of N.O.T., a branch of kinesiology. Contact the Committee or fax Sangster on Fax: 9456 5309 for a copy.

Schmidt, Dr, M. A. (1966). Healing Childhood Ear Infection. North Atlantic Books, Berkeley California, USA. About Otitis Media. A little out of date when the book ventures out of the medical into the relationship between ear infections and learning disabilities but well worth reading.

Sheil, Dr M. L., Dyson, Dr M. Ed: Joudry, R. (2000) Samonas Sound Therapy. Rationale and Results. An explanation for parents and therapists with Case Histories by Sangster, S. Privately published. Contact Shanagh Sangster Fax: 9456 5309.

References and Further reading on CAPD

Bellis, T. (1996). Assessment and Management of Central Auditory Processing Disorders in the Educational Setting: From Science to Practice. San Diego, Singular Publishing Group.

Ferre, J.M. (1997). Processing Power: A Guide to CAPD Assessment and Management. The Psychological Corporation, San Antonio, Texas.

Kartz, J. (1992). Classification of Auditory Processing Disorders. In Katz, J., Stecker, N.A. Henderson, D. (Eds). Central Auditory Processing: A Transdisciplinary View. Mosby Year Book, St Louis, 81-92.

Tomatis, Alfred. (1991). The Conscious Ear. Station Hill Press.

Wolf, M. (1991). Naming speed and Reading. The Contribution of the Cognitive Sciences Reading Research Quarterly. 26, 123-141.