INTERVIEW WITH DOROTHY KELLY
Ricky W. Burk
Dorothy Kelly, D.A.., CCC-S, is a speech-language pathologist and teacher
of the hearing impaired with 28 years clinical and teaching experience.
She is Chair of the Department of Speech Communication at St. Joseph's
College in Patchogue, NY. Dr. Kelly is author of two books published by
Communication Skill Builders: Auditory Processing Disorders: Strategies
for Use with Children and Adolescents (1995), and A Winner's Workbook:
Reproducible Activities for Children With ADD (1998). She also has an inservice
program on Central Auditory Processing Disorder (CAPD) scheduled for publication
in January 1999. She serves as editorial consultant and occasional contributor
to Advance for Speech-Language Pathologists and Audiologists. Dr. Kelly
has worked in schools, hospitals, and rehabilitation settings. Her undergraduate
education focused on deaf education and elementary education; her Master's
and doctoral work was in speech-language pathology.
RB: Dr. Kelly, would you give us your definition of central auditory
processing disorder (CAPD)?
DK: The ASHA definition is very detailed, but a good way to summarize
the definition of CAPD is to say that it involves a disorder of the interpretation
of the verbal and nonverbal auditory stimuli. The person with CAPD has
difficulty utilizing auditory information.
RB: Are there gender differences in patients with CAPD?
DK: Yes. Although we do not have a tremendous amount of data on the
specifics, the caseloads are mostly male. The etiology of CAPD can range
from traumatic brain injury (TBI) to malformation of the corpus callosum
to lead poisoning, to chronic Otis media and many others. When we talk
about malformation of the corpus callosum, then we are possibly on the
track of talking about identifying gender differences. We know that the
structure of the corpus callosum of the male is different from that of
the female. In the normal individual, there are gender differences in terms
of using the right and left hemispheres. It is possible that the corpus
callosum is a part of the story in some cases; however, we certainly need
additional research on this issue.
RB: How about age differences?
DK: Age is certainly a parameter in terms of remediation. I hesitate
to use the term recovery because CAPD is not always a matter of catch-up.
There is often a qualitative difference in an individual with CAPD. The
younger child, especially before puberty, appears to respond to therapy
better than children past puberty. A major factor here would be neural
plasticity of the brain. In the older individual, there appears to be a
degeneration of processing skills.
RB: So, would it be fair to say that there are two categories of
CAPD: developmental and acquired?
DK: Yes. However, I believe that the term Central Auditory Processing
Disorder is too amorphous. Perhaps we should have several categories of
the disorder such as Central Auditory Processing Impairment, Central Auditory
Processing Disorder, and Central Auditory Processing Delay, especially
where the CAP is secondary to another disorder. I also think that we should
have a term called Specific Central Auditory Processing Disorder to describe
CAPD when it exists alone. CAPD exists in secondary form in the vast majority
of cases. I think that is one of the main reasons that the incidence estimates
we have are probably underestimated. In the school setting, for example,
CAPD is frequently applied to an academic school setting, which does not
deal with those terms. In the school, the primary diagnosis would be an
educational diagnosis such as Attention Deficit Disorder, Learning Disability,
and so forth. So, the diagnosis of CAPD may be missed because all symptoms
are lumped together under one disorder.
RB: I understand you deal with five skill areas in CAPD. Could you
describe those skill areas?
DK: I have been working on CAPD since about 1974. My first years in
practice were spent as a teacher of the deaf. My first group of students
was a group of Rubella children that first entered the school system in
the early 1970s. It was apparent to me at that time there were kids with
very similar audiograms that had very different uses of residual hearing
and there appeared to be a mismatch between hearing and perception. I came
across a wonderful book (Auditory Perceptual Disorders and Remediation;
1974, Springfield, IL: Charles C. Thomas) by Bernice Heasley. Heasley identified
fourteen areas of processing skills. As I studied these fourteen areas,
I began thinking of five key areas that impact on social and academic performance
and that is how I developed my five skill areas. The first area I would
mention is AUDITORY MEMORY. Auditory memory is often misunderstood and
misdiagnosed, especially in schools. We tend to think of it as a generic
skill involving repeating five numbers or five letters, or repeating a
direction. If they repeat well, we tend to think that they have a good
memory. Auditory memory if far more complex than that. It involves immediate
as well as deferred memory. It also involves a variety of units. For example,
a child may have good auditory memory for sentences, but not for numbers.
We also tend to think that if a child has a good auditory memory, then
the child should be able to carry out a direction. Carrying out a task
involves far more than just rote recall of information. It involves an
interpretation as well as an ability to carry out the direction. So, when
we give a direction and ask the child to repeat the direction, we tend
to assume that the child can carry out the task simply because the direction
was repeated correctly. We know many children will be able to repeat a
direction, but may have other programming problems (e.g., executive disfunction)
that will inhibit or prevent them from actually carrying out the task.
The second skill area is AUDITORY DISCRIMINATION. This is also an area
that is underestimated in terms of its importance in the classroom. It
impacts on following directions as well as spelling, reading, writing,
and phonology skills. It is my belief that an auditory discrimination test
should be a part of every reading program in schools. I feel that poor
auditory discrimination is often a key factor when a child is not reading
on target. There is a hierarchy involved in addressing auditory discrimination
skills in therapy. Paula Tallal's work in the neurophysiological aspects
of timing give us a lot of information on how to conceptualize a hierarchy
for auditory discrimination tasks within a program. The third area is AUDITORY
FIGURE-GROUND, which involves background noise. We know that auditory figure-ground
in a normally developing child doesn't really mature until about age eight.
If we have very noisy, unstructured, open classrooms in kindergarten through
third grade, we may be asking a child to do more than he is capable of
doing. Planning a program of intervention for the child with poor auditory
figure-ground skills should start with building a tolerance for a variety
of types and levels of noise and then having the child perform harder and
harder tasks in those noises. We could begin with noise similar to that
produced by an air-conditioner (white noise) and progress to a middle-ground
type of noise that varies a little in frequency and volume but repeats
a pattern, like the noise rain makes when falling or a dish-washer makes,
and finally we could work with a cafeteria-type noise, noisy playground-type
noise or the noisy classroom type noise, which is the most difficult type
of noise to tolerate. Another factor that is not really auditory figure-ground,
but is related to it is reverberation. We know that children don't do well
perceiving speech within reverberant environments until as late as age
thirteen. So, classroom acoustics is certainly something that we should
be aware of and fine tune as far as possible. The fourth skill area, AUDITORY
COHESION, is a higher order linguistic processing skill. It relates to
such skills as complicated conversations as well as understanding jokes,
riddles, inferences, and abstractions. It also impacts the child's ability
to do note-taking. AUDITORY ATTENTION, the fifth skill area is the key
skill. We come into the world with some ability to auditorily attend. We
see in very young infants momentary attention to auditory stimuli. The
auditory attention skill grows with maturation in the child. If there is
delay in development of auditory attention, the everything else for the
child is at risk in terms of performance in the classroom. Auditory attention
is the glue that holds all the other auditory processing skills together.
The skill areas are interrelated and hierarchial in nature. A child with
CAPD may have any combination of difficulties to varying degrees of severity.
RB: Let's move to the topic of assessment of CAPD.
DK: The speech-language pathologist should certainly assess the five
skill areas we just talked about and look at the impact of performance
in those skill areas on spelling, reading, following directions, phonology,
writing, vocabulary, and other language and language-dependent behaviors.
Before I see a child for assessment, I send home a checklist for the parents.
I have the teacher fill out a questionnaire on reading and a checklist
of symptoms exhibited in the classroom. When I see the child, I will look
at those five skill areas, and administer a reading decoding test. I think
that how a child fails a task is just as important as what he fails. In
spelling, for example, I am interested in the pattern of errors. Does he
do better with sight vocabulary than with words with which he has to apply
work-attack strategies? Does he do better with logically spelled words
than with illogically spelled words? You can get a great deal of programming
direction for intervention by observing the pattern of error in a variety
of tasks. I typically spend two to two and a half hours of on-site testing.
Following the formal assessment, I will spend six to seven hours putting
the pieces of this assessment puzzle together and writing the report of
six to seven pages. The issue of auditory discrimination is very important
in the assessment. The possibility for a false negative on assessment of
auditory discrimination is very real. If only the auditory discrimination
subtest of the Test of Auditory Perceptual Skills (TAPS) is administered
we could get the impression that the child's auditory discrimination is
quite good. If we compare the performance on auditory discrimination subtest
of the TAPS, which involves only auditory stimuli, with another test that
involves visual stimuli (e.g., Goldman-Fristoe Woodcock Test of Auditory
Discrimination) we may see many children who will do very well on the TAPS,
but very poorly on the Goldman-Fristoe Woodcock. This may mean that the
child has good auditory discrimination, but poor auditory-visual integration
discrimination. I feel that some children with CAPD have hidden auditory-visual
integration difficulties. The assessment of a child with CAPD is not a
formula, not a specific protocol. Assessment involves looking at the relationship
between the child's performance and the impact of auditory processing skills
on that performance. Audiological evaluation must precede all assessment.
CAPD assessment by both an audiologist and a speech-language pathologist
is ideal. I also feel that screening for CAPD should be completed at the
preschool or kindergarten level.
Dr. Kelly will appearing at the 1999 MSHA Annual Continuing Education
Conference in a six-hour presentation on Central Auditory Processing Disorder.
You may contact Dr. Dorothy Kelly by email at kelly@sjcny.edu
or at 44 Long Meadow Place, S. Setauket, NY 11720
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