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 didnt 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.)

From When the Brain Can't Hear by Teri James Bellis, Ph.D.. Copyright (c) 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. ISBN 0746428633 Pocket Books, 2002 pp. 239-246