The Debate and Differential Diagnosis Flashcards
How long has the definition, etiology, sign and symptoms, treatment, and outcomes of CAPD been debated?
More than 70 years
What are the issues that complicate the diagnosis of CAPD?
There are many who question whether (C)APD is a separate and distinct disorder or a disorder of non-auditory processes
Such as cognition, language, memory, and attention that are not only tightly intertwined, but also closely integrated with auditory perception
Does CAPD remain universally ill-defined and poorly understood?
Yes
What has resulted from the uncertainty of a CAPD diagnosis?
(C)APD is not in DSM-V
(C)APD also is not a disability/disorder allowed under the Individualized Education Plan (IEP)
Children diagnosed only with (C)APD may receive accommodations under the 504 Plan
What is a 504 plan?
Section 504 of the Rehabilitation Act and Americans with Disabilities Act (ADA)
“No one with a disability can be excluded from participating in federally funded programs or activities, including elementary, secondary, or postsecondary schooling”
Spells out modifications/accommodations needed for students to have an opportunity to perform at the same level as their peers
(wheelchair ramps, blood sugar monitoring, peanut-free lunch, home instruction, keyboard for notetaking)
What is the difference between a 504 plan and an IEP?
A 504 plan, which falls under the civil-rights law, seeks to level the playing field so that those students can safely pursue the same opportunities as everyone else (temporary or permanent)
An Individualized Education Plan (IEP), which falls under the Individuals with Disabilities Education Act (IDEA), and is also federally mandated, is associated with providing educational services (more involved; only represent a small subset of all students with disabilities)
What are the 14 disabilities that are eligible for an IEP?
Autism
Deaf-blindness
Deafness
Developmental delay
Emotional disturbance
Intellectual disability
Multiple disabilities
Orthopedic impairment
Traumatic brain injury (TBI)
Visual impairment, including blindness
Hearing impairment
Speech or language impairment
Developmental learning disability (DLD)
Other health impairments that limit strength, vitality, or alertness (asthma, ADHD, diabetes, epilepsy, heart conditions, etc.)
What is lax criterion?
Abnormal performance on a single test (> 2 SD below mean)
What is strict criterion?
Abnormal performance on all tests (> 2 SD below mean)
What is intermediate criterion?
Abnormal performance on at least 2 tests (> 2 SD below mean)
Abnormal performance on at least 1 test (> 3 SD below mean)
*We will always follow this one because it is more sensitive
What is the AAA criteria?
Abnormal performance on at least one ear for 2 tests (> 2 SD below mean)
*Could be for different ears
Is there a gold standard for CAPD?
No
Essential to move the field forward
It is the best available method for establishing the presence or absence of CAPD (also called reference standard tests)
What is an index test?
A test under evaluation
Without a reference standard test, it is not possible to determine the diagnostic accuracy or validity of index tests
Do many diagnostic tests used to diagnose CAPD lack scientific basis or a well-defined utility?
Yes
These tests also are not used uniformly across professionals
Further, behavioral tests do not always differentiate or definitively diagnose (C)APD from other neurodevelopmental conditions
Have an efficiency (combined sensitivity and specificity) ranging from 68% to 90%
Is it difficult to make distinctions between CAPD and language-related issues?
Yes
Because most CAPD tests are based on verbal material/responses
BSA requires difficulty in both speech and non-speech sounds
Are there physiologic markers specific to CAPD?
No
Nothing that can be used to distinguish CAPD from other developmental disorders
What are non-auditory variables that may confound CAPD test interpretations?
Motivation
Attention
Cooperation
Test interpretation (performed the same way it was standardized, age appropriate, skill of the scorer in administering the test)
What are some criticisms of the CAPD test battery?
(C)APD tests tap into multi-modal processes such as attention, working memory, and cognition
Unimodal CAPD tests can not be validated from multimodal deficits in school age children
Some believe that CAPD tests should only assess auditory perceptual dysfunction (made with non-speech sounds so they are less likely to tap into memory and language)
What would happen if multiple modalities are shown to be impaired in those with CAPD?
It would argue for a supramodal problem
This would move it from the audiologic domain to the psychological domain and possibly outside our scope of practice
Do many disorders produce similar behavioral/academic profiles?
Yes
True (C)APD may coexist with these disorders but is not the result of these disorders
Who is in the CAPD team?
Audiologist
SLP
Classroom or special ed teacher
Pediatrician/physician
School counselor/psychiatrist
Social worker
Parents
Why does CAPD need a team?
Because it is heterogeneous
What is the general profile on children with CAPD?
Academic difficulties
Family history
Sporadic results on test batteries
Difficulties exacerbated in adverse listening conditions
Difficulty following multi-step directions, and so on
*This can also be said for other conditions
Is attention critical to higher level processing?
Yes
Is a greater comorbidity between ADHD and CAPD suspected?
Yes
The question is whether (C)APD causes some attention deficits or whether a more global ADHD negatively impacts auditory processing
(C)APD is considered a condition of bottom-up primarily auditory perceptual deficiencies
ADHD is considered a top-down global attention/executive function disorder
What is top-down processing?
Information processing that is guided by higher level cognitive processes that draw on experiences and expectations to construct perceptions
Top-down processing occurs any time a higher-level concept influences interpretation of lower-level sensory data
Cues are based on previous experience or knowledge
Example: light bulb over cartoon means idea, don’t need to be told what that means
What is bottom-up processing?
A form of information processing that is guided by input
Perception is data driven, therefore, most sensory information such as sound is an example of bottom-up processing
Senses allow us to interpret the scene around us
But how a person’s expectations, knowledge, and experience will shape that scene is the influence of top-down processing
Example: 15 people in a room hear the same song but there may be different emotions that song will evoke in each person based on their life experiences
Do many professionals believe that there can be a bidirectional interaction between central auditory processing and attention?
Yes
Both are essential for optimal speech processing
But CAPD and ADHD are distinct
How are CAPD and ADHD different?
ADHD is associated with more global disruption of sensory information whereas (C)APD is associated with disruption of processing of auditory information only
What is the one way to differentiate between CAPD and ADHD?
Test for both
For e.g., the Digit Span test on the Weschler Intelligence Scale (WISC) both in the auditory and visual modality
What is attention deficit hyperactivity disorder (ADHD)?
It is a common neurobehavioral childhood disorder that primarily affects children and often continues into adulthood
Prevalence: about 5% in children and about 2.5% in adults (a lot of adults with ADHD develop coping mechanisms, so they no longer think the diagnosis is necessary)
More frequent in males (2:1 ratio)
Females more likely to present primarily with inattentive features
What is a diagnostic feature of ADHD in the DSM-V?
Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
What are essential features of ADHD from the DSM-V?
Present before the age of 12 (requires clinical presentation during childhood)
Impairment observable in at least two settings (home and school, home and work, etc.)
Clear evidence of interference with developmentally appropriate social, academic, and/or occupational function
Observed independently of ASD, schizophrenia, or other intellectual disorders
What is ADHD characterized by?
Either inattention or hyperactivity-impulsivity
What is the inattention criteria for ADHD? (A1)
If six (or more) symptoms of inattention have persisted for at least six months to a degree that is inconsistent with developmental level and negatively and directly impacts social and academic/occupational activities
Example of inattention symptoms:
Often fails to give attention to details/makes careless mistakes
Often has difficulty sustaining attention in tasks or play activities (e.g., difficulty remaining focused during lectures, or lengthy reading)
Often does not seem to listen when spoken to directly
Often does not follow through on instructions/fails to finish schoolwork, chores
Often avoids/dislikes tasks requiring sustained mental effort (schoolwork/homework)
Often easily distracted by extraneous stimuli
Often has difficulty organizing tasks and activities
What is the hyperactivity-impulsivity criteria for ADHD? (A2)
If six (or more) symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is inconsistent with developmental level and negatively and directly impacts social and academic/occupational activities
Example of symptoms:
Often fidgets with or taps hands or feet or squirms in seat
Often leaves seat in classroom when remaining seated is expected
Often runs about or climbs in situations where it is inappropriate
Often unable to play or engage quietly in leisure activities
Often talks excessively
Often blurts out answers before questions have been completed
Often has difficulty awaiting turn
Often interrupts/intrudes on others (e.g., during conversations)
Can ADHD have a combined presentation (both inattention and hyperactivity)?
Yes
If both criterion A1 (inattention) and A2 (hyperactivity-impulsivity) are met for the past six months
What is the predominantly inattentive presentation of ADHD?
If criterion A1 (inattention) is met but criterion A2 (hyperactivity-impulsivity) is not met for the past six months
What is the predominantly hyperactive-impulsive presentation?
If criterion A2 (hyperactivity-impulsivity) is met but criterion A1 (inattention) is not met for the past six months
Is there a known diagnostic biological marker for ADHD?
No
What are some risk factors/causes for ADHD?
Low birth weight (2 to 3 fold risk)
History of child abuse/neglect, multiple foster home placements
Neurotoxin exposure (lead, infections, in-vitro alcohol exposure)
Genetic and physiologic (increased risk if first degree biological relatives have it, visual and hearing impairment, and epilepsy)
*Exact causes are not understood, research suggests a combination of genetic and environmental factors
What is the treatment for ADHD?
Medication (stimulants and non-stimulants can help improve focus and reduce hyperactivity)
Therapy (coping skills)
Educational interventions (accommodations and modification in school)
*Could be one or a combination
What is phonemic awareness?
The ability to identify sound units that make up syllables and words
What is the point of overlap between auditory processing and language comprehension?
Phonemic awareness/processing
Begins to transition from primarily acoustic to linguistic
Happens in the temporal lobe
When the auditory processing transitions into linguistic interpretation, the SLPs assess for language deficits
Do many scientists and clinicians think that CAPD is a language disorder?
Yes
They believe that a diagnosis of (C)APD would not contribute anything to the child’s functioning beyond showing that the child is experiencing linguistically based deficits, which bear further language investigation
According to them, there is not enough empirical data to support that (C)APD is a disorder primarily auditory in nature
What is developmental language disorder?
Previously known as specific language impairment (SLI) or developmental dysphasia
A disorder that delays the mastery of language skills in children who have no hearing loss or other developmental delays
One of the most common childhood learning disabilities (affecting 7 to 8% of children in kindergarten)
Persists into adulthood
Affects reading and learning
Early signs often present in children as young as 3 years old
Is there a genetic link for DLD?
Yes
~ 50 to 70 percent of children have at least one other family member with the disorder
A recent study identified a gene mutation on chromosome 6 called the KIAA0319 gene that plays a key role in DLD
This mutation also plays a role in other learning disabilities (dyslexia, autism, speech sound disorders)
Do learning difficulties for DLD begin in school years?
Yes but they may not be fully present until demands increase beyond the individual’s capabilities for these skills as seen during high school and college
Times tests, writing complex lengthy reports, heavy academic load
In a study, what did they find when they tested for either CAPD or DLD on direct tests of intelligence, memory, language, phonology, literacy, and speech intelligibility?
They found no difference found between performance of children with DLD/SLI and (C)APD on any measure
But both groups consistently and significantly underperformed compared to the same-aged typically developing children
Speech intelligibility in both noise and quiet was unimpaired for both groups
Conclusion: The children were diagnosed based on their referral route vs. actual differences (audiologist, psychologist, or SLP)
What is dyslexia?
A learning disorder that primarily affects reading and writing skills
They have been suggested to experience deficits in both categorical perception (identifying word boundaries) and speech identification in noise
What were the results in the study testing categorical perception and SIN in children with dyslexia?
Inconsistent with the notion that children with dyslexia suffer from a low-level temporal processing deficit but, rather suggested a role of non-sensory (e.g., attentional) factors in the children’s speech perception abilities
Analyzing individual profiles suggested a lack of consistently poor individual performance in speech perception among the dyslexia group, with only a minority of children being impaired in both SIN perception and CP tasks
Are children with cultural and linguistic diversity diagnosed with CAPD frequently?
Not as much as native English speakers
Behavioral tests are standardized for native English speakers
Second-language learners lack necessary language experience and vocabulary, resulting in poorer performance on language-based tests
Using non-language-based (C)APD tests may alleviate this problem
When does a child’s correct identification of nonsense syllables in conditions of noise or reverberations develop?
Reaches adult like until >14 years old
For combined noise and reverberation conditions, performance does not reach adult-like levels until later teens
Even in quiet control conditions, compared to adults, children score poorly at all intensity levels
Do typically developing younger children score poorly on these CAPD tonal tests?
Yes
Tests were also very variable in younger children
Typically developing children don’t have very good auditory skills to begin with
According to the researchers, it was unclear how these tests related to everyday listening skills (because they weren’t having issues in everyday life)
What is executive function?
A metacognitive component that controls processes ensuring behavior that is adaptive and goal-oriented, including listening
Coordinates knowledge (cognition) and metacognitive knowledge (awareness and understanding of one’s own thought processes)
Needed for task analysis, planning, reflective decision-making, paying attention, learning and problem solving, self-regulation of emotions and behavior (pragmatics)
Can brain damage or disease (TBI or tumors) affect executive function?
Yes
Has a causal role of executive dysfunction been proposed for children with ADHD and learning disability without apparent structural damage?
Yes
Unlike ADHD, a causal role of executive dysfunction for (C)APD has not been fully examined
But a key component of executive function, working memory deficits, have been reported in a subset of children with (C)APD
Working memory supports auditory processing including localization, speech recognition in noise, pattern processing, and dichotic listening
Based on the bottom-up model for (C)APD, however, executive dysfunction could be a secondary feature but not a primary cause of listening difficulties in (C)APD
What is cognition?
Cognition is the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses
It is finite
When multitasking, no task is performed maximally because of divided attention
The net result is the individual has fewer cognitive resources to allocate for either primary or secondary goals
Children with hearing loss have to use their cognitive resources to overcome the classroom noise (they will start to have a great difficulty paying attention)
Do children with lower IQ have a harder time in noisy listening situations?
Yes
Attention and receptive language weaknesses can play a part too
Could manifest as CAPD
Less cognitive reserve in these environments to attend to what is said
Could cognition be impaired if the brain was not receiving appropriate sound input (hearing loss or CAPD)?
Recent studies with older adults with hearing loss have shown us that there is at least a correlational if not a causal effect between hearing loss and risk of dementia
It’s a two-way street
Do children with minimal or mild hearing loss have a higher risk of cognitive and attention problems than those with normal hearing?
Yes
In a study
Subjective and objective assessments of auditory processing revealed that the auditory processing ability of children with MMHL was also poorer than that of children with NH
Research shows a significant correlation between scores of auditory processing tests and cognitive tasks
What is non-verbal IQ?
Performance IQ
Assesses cognitive abilities that do not rely heavily on language skills
It measures a person’s ability to reason, solve problems, and think abstractly using visual and spatial information
What are the three types of memories?
Short term, working, and long-term
Can short-term memory impairment be a marker for CAPD?
Maybe
Short term memory is the ability to remember and process information at the same time
It is sometimes referred to as “the brain’s Post-it note“
It holds a small amount of information (typically ~ 7 +2 items) in an active, readily-available state for a short period of time (typically ~ 10 to 15 seconds or up to a minute)
Necessary step toward the next stage (long-term memory)
Do short term memory impairments limit working memory?
Yes
What is working memory?
A system that’s designed to manipulate and use short-term memories
Manipulating information is essentially the difference between short-term and working memory
WM retains and uses, while short-term just retains
Is working memory often linked to intelligence, information processing and executive function?
Yes
Working memory and attention together play a major role in thought processes
What is long-term memory?
Intended for storage of information over a long period of time
Motivation is also a consideration (information that is of strong interest to a person is more likely to be retained in long term memory)
It is likely that long-term memory decays little over time, and can store unlimited amount of information almost indefinitely
There is some debate as to whether humans ever “forget” anything at all, or whether it just becomes increasingly difficult to access/retrieve certain items from memory as seen with aging
Does short-term memory and long-term memory describe how memory is stored?
Yes
And working memory is how you process memory to complete tasks
When should a person not be diagnosed with CAPD?
When they have hearing loss, executive function deficits, or another global condition that accounts for the auditory deficit
