tagline
WETA

Search LD OnLine

Get our free newsletter

Basic Principles of APD Management: All the World's a Stage: Environmental Modification at School

By: Teri James Bellis

Management of APD should incorporate three primary principles: (1) environmental modifications, (2) remediation (direct therapy) techniques, and (3) compensatory strategies. All three of these components are necessary for APD intervention to be effective. In addition, the details of each component should be deficit-specific; that is, they should be developed specifically for the person with APD and the unique circumstances of his or her learning or communicative difficulties and needs.

Environmental modifications consist of changing the learning or working environment so that access to verbally presented information is maximized. Remember, a child is in the classroom to learn, be it science, social studies, mathematics, or language arts. An adult is in the workplace to work, to get a job done, to further a career. These environments have their own intrinsic challenges. We do not want an additional challenge — such as coping with an auditory deficit-to interfere with the primary objectives of school or work. We don't want the person to be honing auditory skills when he or she should be focusing on learning the digestive system or developing an advertising campaign. Therefore, we must develop ways of making the information more accessible to the person with APD.

Remediation, on the other hand, should be challenging and should focus on the auditory deficit itself. Through clearly defined therapy techniques, we hope to train specific auditory and listening skills and change the way the brain processes auditory information, hopefully to ameliorate the disorder. The therapy environment should therefore be separate from the learning or work environment.

Finally, because some people with APD will continue to experience symptoms of their disorder even after remediation, it is important that they learn methods of living with the disorder. Thus, the teaching of compensatory strategies is an important, but often overlooked, component of the overall management program.

Author's note: All types of APD are discussed extensively in the book When the Brain Can't Hear. Recommendations for management should never be implemented without a formal diagnosis of APD. Some of the management techniques described will be inappropriate for some types of APD.

The first component of any APD management program should be to modify the environment. The modifications indicated will depend on whether the person with APD is in school, working for a living, or at home with family and friends. Remember, these environmental modifications are not intended to remediate, or fix, the disorder. They are employed to provide an environment that is user (or listener-) friendly so that access to information is improved.

The classroom modifications that are appropriate will depend on the specific type of APD. Although preprinted lists of "classroom suggestions for children with APD" do exist, we should recognize that not all of the suggestions included on such lists are appropriate for every child with APD. In fact, some that are quite beneficial for most children with APD may actually be harmful or, at the very least, ineffective for others. Common school-based management strategies for children with APD follow

Methods of improving the acoustic (or listening) environment

Pay special attention to seating

Children with APD should be seated where they can see the teacher clearly and are away from distractions or noise. Any child can benefit from this advice. We all hear and understand better if we can see the speaker's face. Being able to see the speaker is critical for the child with virtually any type of APD. Don't assume, however, that the best seat in the class is always in the front row. If, for example, the front row is too close to the teacher, the child may find himself looking up at the teachers chin rather than her face. And if the child is placed far away from the center of the front row so that only the side of the teacher's face is visible, the child will still have difficulties. The child with APD should sit as far back as he feels comfortable and off to the side up to about forty-five degrees, as long as the whole of the teacher's face is well lit and visible.

For classes in which traditional rows of seats are not used (Such as early- elementary-school classrooms in which desks may be in "pods" or small groups), finding the best seat can be more of a challenge. For instance, the teacher might designate a "speaker's throne" on which anyone (including the teacher) must sit when addressing the class. The throne can consist merely of a tall stool, and the children can decorate it in any way they like. The key is to place the throne in a spot where the child (or children) with APD can see the speaker clearly. This is a fun way of deciding preferential seating while not drawing undue attention to the child with APD. Some teachers have even reported that it brings more order to the class as a whole and increases turntaking behavior and class participation. And it can give the tired teacher a chance to rest her legs during the day! Remember, however, that this trick may not work in all elementary classrooms. Preferential seating and how to implement it should be determined class by class.

Teachers who like to roam while talking may need to remain within a predetermined area. Children with APD should be seated so that they can see the teacher easily no matter where she goes within this space. Although some teachers may feel restricted at first, they soon become accustomed to giving important information and directions from their "stages." Once the information is given, they can roam about the room, offering individual words of encouragement or further direction to their students as needed.

At all times, teachers should pay attention to the lighting in the room. They should make sure that they are not standing in front of open windows and talking when they are backlit and their faces are in shadow. They should also make sure they are always facing the students when giving important information, rather than writing on the chalkboard or looking down at their notes.

Finally, special attention should be given to sources of noise in the room. The hum of a radiator, the whir of an overhead projector fan, or the buzz of a fluorescent light may interfere with a child's ability to hear the teacher. Even if the child is seated where he can see the teacher well, the noise from these devices may negate any advantage from preferential seating. Either the device or the student should be moved.

Consider using an auditory trainer or other assistive listening device in the classroom.

The research is clear: all children in all classrooms benefit when they can hear the speaker clearly. Studies have shown that even children without learning or auditory deficits do better in classrooms that use amplification systems. In a perfect world, every classroom would have a sound-field amplification system installed. Children would be able to hear clearly without straining, and teachers' voices would be preserved. But this is not a perfect world, and the vast majority of children in our schools must contend with less-than-ideal listening conditions.

One of the most valuable aids for some children with APD is a personal amplification system to reduce background noise and allow the child to hear the teacher better. There are many different styles and types of these devices, referred to collectively as assistive listening devices.

Although commonly recommended for children with APD, these devices may not be appropriate in many, even most, situations.

Schools should determine which children will benefit most from assistive listening technology. Schools have limited funds, and they must distribute those funds wisely so that every child can obtain the services he or she truly needs. Fitting every child who has APD with an assistive listening device may not only be ineffective in many cases, but may divert money from other areas in which it is needed more.

How, then, do we determine which children really need assistive listening technology to function in school? We must consider the nature of the auditory deficit in each child. For example, the child with Auditory Decoding Deficit is similar to the child with a hearing loss in that many portions of the message are missing or heard incompletely or inaccurately. For these children, the clarity of the acoustic signal is of paramount importance, and an assistive listening device is often appropriate.

On the other hand, the child with Prosodic Deficit has a type of auditory difficulty that is not related to the clarity of the signal. Even under ideal listening conditions, these children still have problems understanding intent and extracting the key words from a message. Use of assistive listening technology will usually not benefit the child with Prosodic Deficit any more than it benefits any other child in the classroom. Similarly, for the child with Associative Deficit, the primary issue is meaning rather than clarity. Again, even if the information is heard quite clearly, the child may be unable to understand it.

Children with Integration or Output-Organization Deficit may experience significant difficulty hearing in noise. Assistive listening devices may help some of these children hear the information more clearly and may assist in learning. But, again, this decision should be made on an individual needs basis.

It is not enough merely to provide a child with an assistive listening device and assume that it will help the child listen and learn. Any child fitted with such a device should be monitored carefully to see if it is of benefit. Moreover, although hearing loss is unlikely, the child's hearing sensitivity should be tested regularly to make sure that no hearing loss is incurred from the use of the device. Finally, the device itself should be monitored to make sure that it remains in good working order. An assistive listening device that delivers a distorted signal or has a dead battery is no better-and probably worse-than no device at all.

When determining who should use assistive listening devices, we should also consider the age of the child. For the most part, assistive listening devices are accepted readily by children in elementary school. But once a child reaches middle or high school, priorities shift, and image becomes more important. Clothing, hairstyles, and jewelry take precedence over being able to hear clearly, especially if hearing clearly requires wearing something over the ears. Forcing the issue often leads to nothing but rebellion and a decrease in the adolescent's self-image. For these reasons, the use of personal assistive listening technology may be less appropriate and successful once a child reaches the later academic years.

Finally, I should mention that some other ear-related interventions, recommended by some professionals, may seem to make sense at first, but may actually be harmful. At one point, a frequent recommendation for children with APD was to plug one ear (usually the "weaker" or left ear) and allow the child to listen only through the right ear. This was usually recommended for children who exhibited left-ear deficits during dichotic listening tests. The inaccurate assumption was that, because the left ear was weaker during dichotic listening, only the right ear should be used during real-world listening. This assumption clearly reflects an incomplete or inaccurate understanding of the neurophysiology underlying binaural-or two-eared- listening. The use of an earplug in this manner is not recommended for children with APD. Indeed, this practice will likely be harmful to the child. Plugging one ear results in an undesirable reorganization of the auditory pathways. This practice, if followed consistently, may result in a worsening of binaural listening deficits that will persist long after the use of the earplug is discontinued.

Another potentially harmful practice I often see is children's use of assistive listening devices consistently in all classes and activities over many years. Although this may improve a child's access to information in the short term, it may have undesirable long-term results. The child may become overly dependent on the device and may lose (or simply never learn) the skills necessary for listening in real-world situations outside the school setting. Use of an assistive listening device should be carefully considered, and only for those classes or activities in which it is necessary. Children should have the opportunity to practice real world listening during recess, physical education, music, and art classes. We must carefully balance the need to improve the acoustic clarity of the signal with the potential for overdependence on assistive listening devices. If children with APD are only given opportunities to listen and learn under ideal, amplified, artificial conditions, they may find themselves unable to listen or learn in the less-than-ideal real world.

Analyze the listening environment. 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.

These characteristics help to reduce the amount of sound bouncing off floors, walls, and ceilings and decrease echoes (or reverberation) so that the signal is much clearer.

Schools with an open-classroom design — one in which partial walls are erected and noise spills over from adjacent classrooms — maybe particularly inappropriate for children with APD. Because noise affects hearing even for children who do not have APD, many schools in this country have moved away from the open classroom design, which was so popular a couple of decades ago. But this design remains, especially in some private or experimental schools or in school districts with limited funding.

The acoustic characteristics of every classroom should be analyzed carefully to ensure that children can hear the teacher clearly. If funding for changes is an issue, low-cost interventions such as the placement of cardboard egg cartons (empty, of course) on the ceilings and walls and inexpensive throw rugs on the floors can go a long way toward absorbing sound and reducing reverberation. Carpet squares, often available at little or no cost from the local carpet store's trash pile, offer a colorful, sound-absorbing alternative to hard walls. They can even be hung above partial walls in open classroom areas to decrease spillover of sound from adjacent rooms. Elementary-school students may enjoy decorating egg cartons or creating colorful banners to line the walls of the room. Making the room acoustically friendly can become a class art project that involves everyone, and the results can be as pleasing to the eye as to the ear.

Methods of improving students' comprehension and retention of information

Make frequent checks for understanding

Because children with APD often do not understand directions or instructions in the classroom, they should be monitored carefully to make sure that learning and comprehension are taking place. This does not mean asking "Do you understand?" in front of the entire class. Many children will nod their heads yes if asked this question point-blank, regardless of whether the understand the information. A better' way of checking might be to ask the child to rephrase what has been said. Rephrasing, rather than merely repeating, is important because some children with APD can repeat verbatim an entire message, yet still not get it. This strategy is most appropriate and effective in one-on-one interactions with the child because, if used too frequently in front of the entire class, it draws attention to the child and perhaps sets her up for embarrassment.

An even better way of checking for understanding is to observe the child and see if she is doing what was required. If not, she can be redirected, gently and discreetly. Perhaps a secret sign can be developed between the teacher and the child — for example, moving a finger in a circle, meaning, "Look around you and see what the other children are doing"-to alert the child that she is not on task without disrupting the rest of the class. In this manner, the child also begins to learn an important compensatory strategy, that of carefully observing what is going on around her as a guide to her own performance and behavior.

Provide a note-taker. Taking notes effectively is an important skill, usually taught in late elementary school or early middle school. Using a system of, "guided note-taking," teachers can help students learn to identify key information in a lecture and organize it in written notes. Under these circumstances, it usually is the note-taking itself, not the information presented in the lecture, that is the important skill being learned. When note-taking is the focus of the lesson in school, children with APD will benefit from such instruction just as their classmates will. However, in later grades in which note-taking is not the focus of the lecture, but rather a tool designed to help the child remember information, note-taking can actually get in the way of learning the key information for some children with APD.

Note-taking requires a division of attention between auditory and visual modalities. When attention is focused on writing down information, less is available for listening to and comprehending the information in the first place. As a result of this division of attention, the child may neither hear the information nor write good, legible notes. In addition, for children with certain types of APD, note- taking relies on those very skills with which the child has great difficulty. For example, the child with interhemispheric Integration Deficit has difficulty with many crossmodality skills. Note-taking relies on listening and writing simultaneously, a task requiring both sides of the brain to work together effectively. The child with right-hemisphere Prosodic Deficit, on the other hand, may be unable to extract key words from the message, which is the essence of note-taking. Although the child with left- hemisphere Auditory Decoding Deficit may be able to take notes quite well, many of the words may be misspelled or the wrong words may be substituted because of the child's difficulty in hearing information clearly. These children are also trying to compensate for their auditory deficits by using their visual systems and watching the teacher's face. Note-taking requires them to look down at the page and to listen only with their ears, taking away the visual cues they rely on so heavily.

Children with Output-Organization Deficit may have difficulty organizing their notes logically so that they can be used for studying later on. They may need additional assistance to learn how to take notes in the first place, but can become quite adept at this task after training. Finally, note-taking may actually help some children with Associative Deficit to understand the information presented. By putting what is heard (but not necessarily completely understood at the time) into writing, then reading their notes later, these children often benefit from the dual modality augmentation that note-taking provides.

Allowing the child to obtain notes from another student or even from the teacher, or providing a note-taker hired for the purpose, should be considered for some children with APD in middle school, high school, or college. But this decision, like all others regarding management of APD, should be made on the basis of the individual child's auditory difficulties. If the need to take notes is detracting from the student's ability to learn the key information presented in class, a note-taker may be needed.

Repeat or rephrase information, when appropriate. On almost every central auditory assessment report that I see, the section on recommendations includes the following sentence: "The teacher should repeat or rephrase information." What is not always understood is that repetition is quite different from rephrasing. Whether repetition or rephrasing is appropriate depends entirely on the type of APD.

By definition, repetition means that the speaker presents the message again using precisely the same language used the first time. Rephrasing, on the other hand, means to say the same thing in a different way, using different terminology or shorter, clearer language.

The child with Auditory Decoding Deficit often benefits from direct repetition. He is able to fill in those portions of the message that were missed the first time around. If information is rephrased, however, this child now has an entirely new message to decode, with new missing pieces to figure out. Therefore, repetition is a more effective strategy for children with Auditory Decoding Deficit.

In contrast, repetition is rarely effective for the child with Associative Deficit. Indeed, you can repeat a message over and over, but if it was not understood the first time, it will probably not be understood the second, fourth, or tenth time. Instead, rephrasing using smaller linguistic units (Or chunks of information) and avoiding complex sentence forms (such as passive voice) is much more beneficial for the child with Associative Deficit. Similarly, children with Output-Organization Deficit will do better with smaller units of information, especially if they are allowed to act on each unit before the next is presented.

Children with Prosodic Deficit may benefit from either repetition or rephrasing, but only if key words in the message are emphasized strongly Likewise, either strategy may be beneficial for children with Integration Deficit, as long as the information is presented clearly and other distractions such as visual or tactile cues-are kept to a minimum.

This is an excellent example of why preprinted lists of suggestions for "all" children with APD should be avoided and management suggestions should be individualized for each child. Even a suggestion as seemingly innocuous as "repeat or rephrase information" can be implemented inappropriately unless the specific nature of the auditory deficit is taken into account.

Make appropriate use of visual cues and hands-on demonstrations. When a child has any type of hearing or listening difficulty, it is usually helpful if the information presented verbally is augmented by visual cues and hands-on, tactile demonstrations-what we call multimodality cues. This allows the child to obtain input through those modalities that are stronger and adds to the auditory information so that the whole message can be understood. Even children with no type of disorder at all benefit from actually seeing and touching what is being discussed. That's why employing multimodality cues is one of the most common recommendations made for children with APD.

There is, however, an exception to this rule. Many children with Integration Deficit have, by definition, difficulty integrating multimodality cues. When provided with visual, tactile' and auditory information all at once, these children may become more confused than they would have been if the information had been presented through only one modality. I have often heard frustrated teachers say, "The more I try to help her, the worse she does!" When I hear this' I often suspect that the child is being bombarded with information through a variety of modalities and is simply incapable of integrating all of that information into one, clear message.

Children with Integration Deficit often do far better when information is presented sequentially; that is, when the message is first delivered verbally, then a picture of the topic is introduced, and then tactile cues (such as touching the actual object) are added. For example, during teaching of early math skills, numbers and manipulables (objects to be counted or added together, such as blocks or apples) are often used to convey basic number concepts. For the child with Integration Deficit, saying the numbers and operation ("1 plus 2"), then seeing the written numbers on the page, and then watching as the blocks are moved around to represent both the numbers and the mathematical operation will probably be far more effective than doing all three of these simultaneously. The child with Integration Deficit may become confused and attempt to focus on one item at a time (the blocks or the numbers on the page). As a result, she will miss the overall message entirely. When central auditory testing indicates that a child has Integration Deficit, I always recommend that she be monitored carefully to see if multimodality cues result in confusion or clarification.

Finally, the use of multimodality cuing is only effective if the visual or tactile cues match the information being presented verbally. For example, if the teacher is presenting a unit on transportation and is discussing trains, a picture of a truck would be inappropriate, even though a truck falls into the general transportation category. Similarly, if an object is being passed around the classroom, the teacher should not move on to another topic while the children are still focused on the object at hand. Therefore, when discussing outer space during science class, the teacher should let all of the students see and feel the moon rock before beginning to talk about satellites or lunar craters.

Preteach new information and vocabulary. This can be an appropriate strategy for most children with APD and is often helpful even for students with no disorder. In fact, I frequently employ this method in my own graduate-level college courses. Before a new topic is introduced in class, key vocabulary and critical concepts can be presented in writing (Or taught by a tutor) so that the student is already somewhat familiar with the words and ideas that will be presented. For example, the child with Auditory Decoding Deficit has problems filling in the missing pieces — or achieving closure — on some words even when they are familiar. Imagine the difficulty a child with this type of deficit would have when attempting to fill in the missing portions of a word he or she has never heard before. Provided the words in advance, the child will be ready for them during the classroom lecture and will be more likely to hear and understand them when they are spoken. Having students read the pertinent chapter in their textbook, familiarize themselves with new vocabulary, and learn basic concepts before the classroom lecture is an excellent way to enhance comprehension of new information for all students, from elementary school through college.

Author's note: All types of APD are discussed extensively in the book When the Brain Can't Hear. Recommendations for management should never be implemented without a formal diagnosis of APD. Some of the management techniques described will be inappropriate for some types of APD.

Basic principles of APD management:

Thinking outside the box: Environmental modifications at work

Management of APD should incorporate three primary principles: (1) environmental modifications, (2) remediation (direct therapy) techniques, and (3) compensatory strategies. All three of these components are necessary for APD intervention to be effective. In addition, the details of each component should be deficit- specific; that is, they should be developed specifically for the person with APD and the unique circumstances of his or her learning or communicative difficulties and needs.

Environmental modifications consist of changing the learning or working environment so that access to verbally presented information is maximized. Remember, a child is in the classroom to learn, be it science, social studies, mathematics, or language arts. An adult is in the workplace to work, to get a job done, to further a career. These environments have their own intrinsic challenges. We do not want an additional challenge — such as coping with an auditory deficit-to interfere with the primary objectives of school or work. We don't want the person to be honing auditory skills when he or she should be focusing on learning the digestive system or developing an advertising campaign. Therefore, we must develop ways of making the information more accessible to the person with APD.

Remediation, on the other hand, should be challenging and should focus on the auditory deficit itself. Through clearly defined therapy techniques, we hope to train specific auditory and listening skills and change the way the brain processes auditory information, hopefully to ameliorate the disorder. The therapy environment should therefore be separate from the learning or work environment.

Finally, because some people with APD will continue to experience symptoms of their disorder even after remediation, it is important that they learn methods of living with the disorder. Thus, the teaching of compensatory strategies is an important, but often overlooked, component of the overall management program.

Author's note: All types of APD are discussed extensively in the book When the Brain Can't Hear. Recommendations for management should never be implemented without a formal diagnosis of APD. Some of the management techniques described will be inappropriate for some types of APD.

APD in a working adult presents a unique set of challenges. An adult with APD does not have the same level of support afforded children at school. Furthermore, although the adult with a disability is guaranteed some rights, he or she is not guaranteed, by law, the job itself. The person with APD must find ways to meet job expectations despite the APD. This is a minor concern for some adults with APD, but a major impediment for others. A computer programmer may find that APD does not affect his ability to perform his job, while a teacher, receptionist, or stockbroker may find APD debilitating. Management of APD in adults, as in children, should take into account the particular needs, type of deficit, and task-related demands of the person with the disorder.

Finding alternative ways to perform

I once worked with a dental hygienist with APD. Genny performed all of her job duties just fine, unless the dentist was filling a tooth. Then, the noise of the drill, combined with her difficulties hearing in noise, made Genny virtually unable to understand any directions the dentist gave.

Genny didn't know that she had an auditory processing deficit. All she knew was that she had occasional hearing difficulties, which hadn't bothered her much during her training to become a dental hygienist. Her teachers and the training dentists with whom she had worked had made good use of visual cues (demonstrating, pointing to the desired instruments) and approached each dental patient step by step with the same basic procedure. Genny had always known what to expect and had done quite well in both her academic classes and in her clinical practicum.

The dentist with whom Genny was working now, however, did not approach his craft in such a methodical manner. Genny never quite knew which instrument he was going to ask for or what he was likely to do next. In addition, he had a beard and a mustache, which limited Genny's ability to read his lips when he was talking. Finally, he issued commands in a rapid, terse manner and sighed in exasperation when Genny asked him to repeat what he had said. Often, he would fix her with a glare and get the requested instrument himself By the time I first saw Genny, the dentist had become so frustrated with her that she had been relegated to answering the phone in the dental office which, given her auditory difficulties, was not much better.

Genny had come to our clinic for an audiological evaluation because she had begun to wonder if a hearing loss was to blame for her difficulties, even though she had always passed hearing screenings during school. Her hearing acuity was entirely normal, but further testing confirmed the presence of an Auditory Decoding Deficit type of APD. Based on Genny's history, I suspect that her disorder had been present most, if not all, of her life.

To make accommodations that would assist Genny in doing the job she had been hired to do, we decided to include Genny's employer in our management plan. Although Genny was initially reluctant to approach him about this, I explained that it would be difficult, if not impossible, to implement changes in the workplace if the one person with whom she worked most often was not on board.

Genny thought her boss was short-tempered and grumpy, but to her surprise, he actually proved cooperative once the nature of her disorder was explained. "Hmmph. Well, that explains a lot," he said. "Now, what do we do about this damn thing?"

The first thing we did was to fit Genny with an FM system — an assistive listening device in which the dentist wore a small lapel microphone and Genny wore a receiver that delivered his voice directly into her ears. The system works on FM radio waves, so no wires connected the two. They could move about the room freely without restriction. Even when Genny was in another room, she could still hear and understand the dentist's voice. And she could hear everything he said clearly - even when he was drilling.

The dentist also began to explain his procedures to Genny more clearly - a strategy akin to preteaching. As it turned out, he had been following specific, step-by-step procedures. They were just different from what Genny had come to expect during training. And he had a different procedure for different types of patients. Once Genny understood his methods, and the rationale behind them, she was better able to anticipate his needs.

We also worked on Genny's communication needs in general: the need for the dentist to slow down a bit and face her when speaking to her, the need to avoid a lot of background noise (or to use the FM system) when issuing directions or giving information, and the need for the two of them to work together in the communicative effort.

Finally, we helped Genny take responsibility for her own listening success. Prior to this, she had been timid and afraid to speak up when she didn't hear something that was said, particularly because this was her first "real" job, and she was nervous about others' perceptions of her. After the dentist groused, "Well, you should have told me you couldn't hear me," Genny felt much more comfortable letting him know when she didn't understand. Ultimately, Genny realized that the final responsibility for informing others about her needs and ensuring that she could hear and understand rested on her own shoulders.

Today, Genny is able to do the job she had been trained for. She still works for the same dentist, and now, when he grouses at her, she grouses right back. They have come to a mutual understanding and have a close working relationship. Genny loves her chosen career.

When a working adult has APD that interferes with her ability to perform a chosen job, it is important to identify alternative ways to do the job. In Genny's case, the solutions were relatively simple and the outcome completely favorable. This is not always the case. In some situations, no solution can be arrived at, and a change in job setting or career may be the only choice. However, before making a dramatic decision involving a job or career change, every attempt should be made to resolve the difficulties in the current job setting. Some steps that can be helpful follow.

  1. Analyze the environment. What is it about the job setting that, when coupled with the presence of APD, makes it so difficult to perform? Is there too much noise? Would an assistive listening device be helpful? Are certain coworkers easier to hear and understand than others? If so, what are they doing that others are not? Perhaps they speak more clearly or slowly. Perhaps they make sure their faces can be seen while talking. Perhaps they use clear, concise language. In any case, identify what works (and what doesn't) and make suggestions accordingly as to how supervisors and coworkers can best communicate.
  2. Involve employers, supervisors, and coworkers in the management effort. An adult with APD needs to overcome his natural tendency to hide the disorder. He must be forthright regarding the nature of the disorder and the ways in which others can assist.
  3. If hearing and understanding during staff meetings is difficult, consider some type of assistive listening or amplification device during these meetings. Alternatively, request minutes of each meeting so that information can be reviewed later. A written agenda given out before the meeting may also help orient an adult with APD to the topics that will be discussed.
  4. If employers or others often deliver rapid-fire, complex instructions involving several steps, request that the information be provided in a written memo to verify that each step is clearly understood.
  5. When in doubt, ask. Don't be afraid to request repetition or clarification when you don't understand. If you feel uncomfortable asking your supervisor or employer (or if such a move is simply impractical), ask a well-informed coworker to go over the information and clarify any questions.
  6. If an employer or coworker begins an important conversation at an inappropriate time — for example, while walking through a crowded hallway, during lunch in the cafeteria, or during another task — gently suggest that the conversation be moved to another location or scheduled for another time that would be more conducive to listening.
  7. If background noise makes talking on the phone difficult, consider plugging the ear that is not being used or requesting that calls be rerouted to another, less noisy room.
  8. Resist the urge to attribute all difficulties in the workplace to APD. Remember that many people without any type of disorder have difficulties with supervisors or coworkers. Try to determine which problems can be directly related to the auditory deficit.
  9. Similarly, do not use APD as an excuse not to perform a job adequately. If completing assigned job duties is not possible even with accommodations, perhaps a change in job setting should be considered.

Knowing your legal rights

Under the provisions of the Americans with Disabilities Act (ADA), an employer cannot discriminate against an employee on the basis of a disability. If a person with a disability needs accommodations to perform his or her job, the employer is lawfully required to implement those accommodations. An employee in a wheelchair who is completely capable of performing a given job if she could just get up the three steps into the office has the legal right to request that a wheelchair ramp or other means of access be supplied. Similarly, the person with diagnosed APD has the right to request reasonable accommodations.

An important distinction should be made here: there is a difference between needing accommodations because of a disability to do the job appropriately and being unable to do the job at all. There is also a difference between being afforded legal job rights as a person with a disability and being hired because of the disability. Under ADA, a qualified person cannot be discriminated against because of a disability. However, ADA does not guarantee the job itself If a disability renders a person unable to perform in a given career, that person is not entitled by law to be hired. Some jobs — bus driver, pilot, and radio dispatcher, for example — require a certain level of visual and auditory acuity before the person can even be hired. The key point is that the person should be able to complete the job duties once accommodations are in place.

Federal law affords every school-aged child a free and appropriate education. Federal law does not afford every adult a job. It does, however, ensure that a person cannot be discriminated against on the basis of a disability. If you feel that you have been passed over for promotion, treated unfairly in the workplace, or not hired at all solely because of a disability (and not because of lack of education, skills, or similar performance -related problems), you should seek legal aid.

Taking responsibility in the workplace

The responsibility for hearing, understanding, and following through on directions and information at work rests firmly on the shoulders of the employee. At school, a multidisciplinary team looks after the child with a disability and helps ensure that she learns. But no one watches over the adult with APD to make sure she does her job. In schools, team meetings are convened to make sure that everyone knows about the child's disorder and how to best meet the child's needs. At work, there is no team, no behind-the-scenes group of people whose job is to develop and implement a plan to meet the needs of the adult with APD. And no one informs significant coworkers, supervisors, and others about the nature of the APD and how to communicate with the person who has it. No one, that is, except the adult with APD.

If you are a working adult with APD, you must communicate your needs. You should also provide your employer written documentation of your disorder from your audiologist, along with suggestions for management, for placement in your personnel file. But don't approach the situation like an offensive linebacker barreling through the opponent's team. Couching your needs in the form of demands, telling the employer what he must do, and forcefully reminding him that federal law states that reasonable accommodations must be made will only alienate him. On the other hand, you should not be overly apologetic about your disorder, either.

You should explain the nature of your disorder matter-of-factly, describe how it affects your communication abilities (giving examples whenever possible), and present general ideas regarding the types of accommodations that are helpful. You should then enlist the employer as a team player in devising means specific to your workplace that can accommodate your needs effectively and efficiently At A times, you should endeavor to make your recommendations reasonable for your specific job setting, and you should explain why each accommodation is necessary. For example, providing written minutes and memos or an assistive listening device might be considered a reasonable accommodation. Provision of a personal secretary or aide to monitor your performance, keep you on target, manage your projects, and take on some of your tasks would not.

Finally, you should always keep the job requirements themselves at the forefront of the conversation so that the employer gets the clear message that you are having this conversation so that you can be a better employee. You must always remember that, no matter how personable and caring an employer may be, his primary concern is whether your job will be done to specifications, not your personal happiness or satisfaction. You must be able to assure your employer that this is your primary concern, as well.

A disorder or disability should never be used as an excuse for performing a job poorly. If you are unable to perform your job because of your disorder, even with appropriate and reasonable accommodations in place, you and your employer should revisit the issue and determine whether different management approaches might be more effective. However, if you are still unable to perform after all options have been exhausted, it may be time to look for another job that does not involve the same communicative or auditory demands. We all have areas of relative strength and weakness., skills that we excel at and tasks that we find quite difficult. When we match our job or career decisions with our strengths and skills, it makes for a much happier and satisfying work experience for all concerned.

Author's note: All types of APD are discussed extensively in the book When the Brain Can't Hear. Recommendations for management should never be implemented without a formal diagnosis of APD. Some of the management techniques described will be inappropriate for some types of APD.

Basic principles of APD management:

Terri James Bellis, Ph.D. When The Brain Can't Hear Unraveling the Mystery of Auditory Processing Disorder ISBN 0746428633 Pocket Books, 2002 pp. 225-256 Reprinted with permission

Where they have to take you in: Environmental modifications at home

Management of APD should incorporate three primary principles: (1) environmental modifications, (2) remediation (direct therapy) techniques, and (3) compensatory strategies. All three of these components are necessary for APD intervention to be effective. In addition, the details of each component should be deficit- specific; that is, they should be developed specifically for the person with APD and the unique circumstances of his or her learning or communicative difficulties and needs.

Environmental modifications consist of changing the learning or working environment so that access to verbally presented information is maximized. Remember, a child is in the classroom to learn, be it science, social studies, mathematics, or language arts. An adult is in the workplace to work, to get a job done, to further a career. These environments have their own intrinsic challenges. We do not want an additional challenge — such as coping with an auditory deficit-to interfere with the primary objectives of school or work. We don't want the person to be honing auditory skills when he or she should be focusing on learning the digestive system or developing an advertising campaign. Therefore, we must develop ways of making the information more accessible to the person with APD.

Remediation, on the other hand, should be challenging and should focus on the auditory deficit itself. Through clearly defined therapy techniques, we hope to train specific auditory and listening skills and change the way the brain processes auditory information, hopefully to ameliorate the disorder. The therapy environment should therefore be separate from the learning or work environment.

Finally, because some people with APD will continue to experience symptoms of their disorder even after remediation, it is important that they learn methods of living with the disorder. Thus, the teaching of compensatory strategies is an important, but often overlooked, component of the overall management program.

Author's note: All types of APD are discussed extensively in the book When the Brain Can't Hear. Recommendations for management should never be implemented without a formal diagnosis of APD. Some of the management techniques described will be inappropriate for some types of APD.

When a person has a disability, the impact on the family can be even more devastating than on academics or work. Coping with and compensating for APD at school or work can be exhausting. Yet, many people with APD are far more successful at dealing with their difficulties when in a structured work or school environment or in public. At home, no one wants to work that hard. Home is a place for putting your feet up, letting your hair down, and being yourself. Even people who are adept at compensating for APD outside the home may find themselves having great difficulty communicating at the end of the day. Frustrations that were suppressed at school or work may be transferred to family members at home. Sheer exhaustion may make for a grumpy, tearful child; a sullen, withdrawn teenager; or an angry adult. Many of us have these tendencies after a hard day at work or school, but they may be much more pronounced in the person with APD.

Nevertheless, one has responsibilities at home. There are chores to be done, supper to be prepared, dishes to be washed. There is the need for conversation among family members. It can be a source of endless frustration when listening skills perfected at school or work are not employed at home. The unique nature of home and family dynamics requires different management approaches and considerations from those that are reasonable in other settings. A delicate balance must be struck between allowing the person with APD to take a break from it all and seeing that he meets expectations and responsibilities at home.

The need for acceptance

here is perhaps no place in the world where acceptance is more needed, and more expected, than at home among family and loved ones. Everyone needs to be accepted for who he or she is, bad habits and all. A person with APD must feel loved despite the disorder. Sometimes, however, parents, spouse, and others may unintentionally send the message that the person with APD is a burden, unloved and unappreciated.

Consider the following common scenario: Jimmy, a fourth-grader with APD, comes home from school on a Friday afternoon. He is elated that he passed his spelling test that day and proudly presents a note from the teacher that reads, "Jimmy is listening and following directions much better in the classroom and on the playground. He is working very hard to be a good listener and we think that the suggestions made at his IEP meeting are really having an excellent impact on his ability to understand and complete his schoolwork. He earned a 95% on his spelling test today and it is very apparent that Jimmy studied this week. We are quite proud of him!"

Jimmy's mother smiles and hugs him, telling him that she, too, is proud. She fixes him a snack and he goes into the family room to watch television for a while. He is looking forward to the weekend fishing trip that his father has promised him if he passed his spelling exam.

An hour later, Jimmy's mother calls from the kitchen, "That's enough television for now Your father will be home soon, so I'd like you to set the table. Oh, and you need to move your backpack and coat away from the front door so he doesn't trip over them when he comes in. Make sure you put knives out; we're having steak."

Jimmy slowly picks up his backpack and coat and tosses them onto the floor in front of the hall closet, his eyes never leaving the television screen. Task completed, he curls up on the sofa once again.

Fifteen minutes later, his mother calls again from the kitchen: "Jimmy? Where are you? I told you to set the table! Turn that television off now!"

Reluctantly, Jimmy turns off the set and makes his way into the kitchen. Carefully, he places three sets of plates, glasses, napkins, and forks onto the table. As he is helping his mother put the finishing touches on the dinner preparation, Jimmy's father enters the front door with jacket and briefcase in hand, makes his way to the closet, and promptly trips over Jimmy's backpack and coat.

"Jimmy!" he bellows. "'Come get your stuff right now and put it away where it belongs!"

"I told you to put that away so your father wouldn't trip over it," Jimmy's mother scolds. "Get in there right now and do what I told you!"

A few minutes later, Jimmy and his parents sit down for dinner. Excitedly, Jimmy tells his father about his spelling test. "I got an A! And the teacher wrote a note and said I was listening real good! So that means we'll go fishing this weekend, right?" His mother interrupts him: "Jimmy, where are the knives?" "The what?"

"The steak knives. I told you we're having steak and to put knives on the table."

"I didn't hear you."

Exasperated, his mother shakes her head. "No, you just weren't listening. You were too busy watching television. You never listen."

"'But my teacher says I'm a good listener now." "Maybe at school, but not here. I'm your mother. Don't I deserve the same respect you give your teacher? Why can't you listen to me the way you listen to her? You — didn't hear me because the television was just too important." "Until you start following directions at home and listening to your mother, there'll be no more TV for you," says Jimmys father sternly. "Your mother and I are sick and tired of the way you ignore us. You come home with notes talking about how great you're doing in school, but we sure don't see any of that great stuff You still can't listen to your own mother when she tells you to do something as simple as put knives on the table. I'll tell you, things are gonna change around here, buddy, right now. And you're not setting one foot outside of this house until they do!"

"What about the fishing trip?" Jimmy whispers.

"You can forget about that until you start pulling your own weight in this family and doing what you're told. Now, go to your room and think about it. Your mother and I want to eat in peace."

Scenarios such as this one are not entirely uncommon in households with young children. But when a child has APD, they occur much more frequently and can be even more frustrating for everyone. In some ways, Jimmy was behaving like a typical kid on a Friday afternoon: lounging in front of the television and "ignoring" his mother. On the other hand, that Jimmy's mother issued her commands from the kitchen without first making sure that she had obtained his attention and could be heard clearly may have set Jimmy up for failure. Adding to his parents' frustration is the glowing report from Jimmy's teacher concerning his much improved listening skills at school, which seems to be in stark contrast to the current home situation. What began as something to be proud of (improvement in listening at school) has become a point of contention and unfavorable comparison when the same good listening skills were not displayed at home. Finally, Jimmy's hard-earned reward- the fishing trip-was revoked because of an incident that was unrelated to the behavior that had earned him the reward in the first place: his good grade on the spelling exam.

Parents get frustrated with children — that is a fact of life. Children don't always listen — that, too, is a fact of life. But when a child has APD and a great deal of attention has been given to listening skills, this typical, common argument can evolve into something much more significant and serious. Jimmy may have come away with the conviction that his parents only love the "'good-listener Jimmy" and not the "bad-listener Jimmy." In addition, the good-listener Jimmy must be present at all times, at home and at school, for his parents to truly accept and love him. Good listening at school doesn't count, no matter how much effort he exerts or how successful he is. If it did, the wonderful note from his teacher and the A on his spelling test would not have been forgotten just because of the missing steak knives. But Jimmy knows he cant be a good listener all the time. No child can, especially a child with an auditory processing deficit. Therefore, Jimmy may well be left with the feeling that he will never be completely acceptable to his parents, no matter how hard he tries.

This type of situation occurs not only between parents and children. It is perhaps even more common between spouses. Even when an APD is known to and understood by both parties, there will inevitably be times when frustration or anger is expressed because of something that wasn't heard or understood. Comments made in the heat of anger, such as "I can't stand it anymore". I'm so tired of having to tell you things over and over again before you hear me — may be taken as "I don't love you anymore" by the person with APD.

To avoid this type of misconception and to help ensure that the person with APD feels accepted in spite of his disorder, bear in mind-and, where possible, act upon-the following tips:

  1. Blame the disorder, not the person. Instead of saying, "I am so angry at you because you never listen to me," express your anger at the disorder itself This allows the person with APD to agree and say, "Yeah, this thing is frustrating for me, too." Battle the common enemy of APD. Don't battle each other.
  2. Separate the person from the disorder. APD does not define a person; however, the incredible amount of attention devoted to diagnosing and managing APD can make someone feel as if nothing else about her is important. Try to focus equally on good skills, not just on the listening - related negative behaviors. Make it clear that disliking APD is not the same as disliking the person with APD.
  3. Let the punishment fit the crime. Try to avoid the roller coaster of praising the person with APD for good listening one minute, then rejecting him for poor listening the next. If a child does something that is unacceptable, address that behavior accordingly. Do not take away a reward previously earned for good behavior.
  4. Avoid saying "You never…" When you are frustrated, it may be difficult to remember that the person with AP D is trying and does exhibit good listening skills some of the time. Make sure to acknowledge that good listening behaviors do occur. "You never…" may eventually become a self-fulfilling prophecy. After all, if previous, successes are continually negated in this manner, why try to succeed at all? Along these same lines, keep the discussion to the situation at hand and do not bring up past miscommunications. Listing previous failures only serves to further the feeling that the person is unacceptable, unloved, and a failure.
  5. Avoid comparing listening environments. Remember that most people with APD will perform better when in a structured situation such as at school or work. They need to feel free to relax and be themselves at home. Don't expect the same type of focused effort at home as at work or school.
  6. Analyze problem situations and talk about them. What was it that led to the misunderstanding? What was due to inattention or behavior, and what was due to the disorder?
  7. Avoid overemphasizing auditory behavior. Everyone misunderstands or mishears at times. Not every situation requires an in depth analysis or full-blown confrontation. Sometimes, it is more important just to clarify the message, let go, and move on. Try not to turn every miscommunication into an extended diatribe on APD.

Generalization of skills to the home environment

Despite the need for acceptance in the home, it is still important for the person with APD to put forth an effort. Skills implemented in the more structured environments of school or work should, to some degree, be carried over to the home. Only then will chores, instructions, rules, and other communications be understood and acted upon. The child or adult with APD is not off the hook completely once he or she walks through the front door. The unstructured home environment may make this generalization of skills difficult, so different strategies will be needed at home.

The entire family should help come up with ideas on how to manage APD at home. Modifications and communication strategies that have been found to be effective in school or at work can be adapted for the home. Remember, though, that the ultimate goal of home management of APD is to facilitate communication while, at the same time, maintaining the warm, friendly, accepting atmosphere of safety and family. Therefore, the home environment shouldn't be too structured or it will seem less like a place to escape to at the end of the day and more like just another job or school setting.

Following are some tips that may help:
  1. Family members should agree on when and where important information will be conveyed. It is difficult for anyone to hear and understand someone talking when the television is blaring and the baby is crying. It is even more difficult for a person with APD. Simply stepping into another room or turning off the television and gaining the person's visual attention can go a long way toward preventing misunderstandings.
  2. In spy movies, key characters get together and synchronize their watches before a caper. Football players gather in the locker room and go over game plans before the big game. These types of activities can be very useful when a family member has APD. Set a time to get together and make plans, assign chores, and handle important business. This may be a daily or weekly event, depending on the circumstances. Write everything down on a notepad or, even better, a reusable write-on/wipe-off board. As decisions are made, list who is responsible for what and the expected timeline. The board then serves several functions: it clarifies any potential misunderstandings, serves as a visual reminder of expectations and responsibilities, and provides a convenient means of follow-up.

    Remember, different types of APD require different types of communication strategies

    1. If someone in your family has Auditory Decoding Deficit, pay special attention to the acoustic environment. Make sure that you have visual attention before speaking, and whenever you can, make sure you demonstrate visually what is expected. If a message is not heard or understood, repeat it or write it down. Do not try to carry on a conversation when someone is vacuuming, washing dishes, or engaged in another activity that involves competing noise.
    2. 'If the family member has a Prosodic Deficit, pay special attention to how you say things and make sure to explain your intentions whenever possible. Don't hint. Spell out your meaning. To avoid miscommunications, misunderstandings, and hurt feelings, avoid being too subtle or abstract. Don't use long, complicated sentences in which the main point is hidden in a lot of unnecessary language. Pay special attention to saying (and explaining, when needed) precisely what you mean. Remember, too, that sarcasm, humor, and subtle hints may go unnoticed or be misinterpreted by someone with Prosodic Deficit.
    3. For children or adults with Interhemispheric Deficit, remember that visual or tactile distractions may be just as destructive to comprehension as auditory distractions. Try not to carry on important conversations while engaged in distracting activities such as putting groceries away or exercising together or while the person is writing or doing homework. In addition, make sure that you give critical information via one modality at a time. For example, if you are helping a child build a model airplane, don't try to explain the next step while, at the same time, pointing to the instruction sheet and holding the pieces together as a demonstration. Read the instruction together first, then explain it (if necessary), and then demonstrate how the pieces should fit together.
    4. For family members, especially children, with more language based or executive-function-based auditory deficits such as Associative or Output-Organization Deficit, remember to keep your communications simple. If several steps are to be completed or several chores done, you may need to provide them one at a time and allow the child to complete each one before presenting the next. To avoid needing to call the child again and again for each chore, which is often frustrating for everyone, you might want to tell him, "Check back when you're done for your next job." If you make that a general rule, you won't continually need to regain the child's attention for each and every step. If the child does not understand the message, don't just repeat it. Instead, rephrase using simpler language. Finally, as with many other types of APD, writing down the steps, chores, or expectations sequentially and posting them where the child can refer to them will save time and energy for everyone.
  3. Always remember that people with APD may not know when they aren't hearing or understanding correctly Although they may sometimes ask for clarification (Or respond with a look of confusion), don't count on it. Indeed, children or adults with APD often complete a task proudly, only to find that what they thought they were supposed to do was inaccurate. Try not to punish or reject them for this. Instead, realize that they may have honestly thought that they were doing the right thing. Ask the person to retell you what you've said and/or monitor the behavior (at least initially) to see that she is on task. Finally, never discourage someone from asking for repetitions by saying, "Again? Weren't you listening?" You want them to request repetition or clarification when something is not heard or understood. If requests for repetition occur far too frequently, examine how you are communicating to determine how you can convey the message more clearly in the first place.
  4. Collaborate with family members with APD to determine what communication modifications work best. Ask directly how best to communicate. They, may say, "I understand best when you…" or "I have a hard time hearing or understanding you when…" Once those criteria are identified, make every effort to abide by them. For example, my husband has told me clearly over and over that he cannot hear me when there is noise (Such as water running) nearby He has requested that I wait until he turns the water off before talking to him. I don't always remember to honor his request, but when I don't, I try to accept the responsibility for any miscommunications that occur during those times. I knew the rules. I broke them. It's no one's fault but my own.
  5. Finally, and most importantly, keep a sense of humor. The miscommunications that accompany APD can be incredibly frustrating. But they can also be terribly funny at times, too. A mother once told me a story about her son, who had an Auditory Decoding Deficit type of APD. It was a lovely summer day. Many of the neighbors were out in their yards barbecuing or just sitting and enjoying the soft breeze. This mother had instructed her son to go outside and play with their new puppy while she finished putting away the laundry. A few minutes later, she heard her sweet little boy yelling a particularly profane word at the top of his lungs, over and over. She ran to the back door, threw it open, and was excruciatingly aware of the shocked looks on the neighbors' faces as she yelled to her son, "Stop that and come here, right now!" Fully prepared to give him a thorough tongue lashing, she asked him what in the world he thought he was doing and who had taught him that horrible language. He replied, "Mr. Carver, next door. He was watching Alfie jump all over me and he said that I should tell him to shit. I tried, but he just wouldn't listen. Maybe he has APD, too?"

Author's note: All types of APD are discussed extensively in the book When the Brain Can't Hear. Recommendations for management should never be implemented without a formal diagnosis of APD. Some of the management techniques described will be inappropriate for some types of APD.

When the Brain Can't Hear by Teri James Bellis, Ph.D. Copyright © 2002 by Teri James Bellis, Ph.D.. Reprinted by permission of Pocket Books, a division of Simon & Schuster, Inc., N.Y.Terri James Bellis, Ph.D. pp. 225-256