Environmental Modification of APD at Home

By: Teri James Bellis

Basic principles of APD management

Management of APD should incorporate three primary principles: (I) 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

There 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 Jimmy's 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 APD 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.
  3. Remember, different types of APD require different types of communication strategies
    • 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.
    • '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.
    • 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.
    • 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.
  4. 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.
  5. 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.
  6. 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 sit. 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.)

From When the Brain Can't Hear Terri James Bellis, Ph.D. ISBN 0746428633 Pocket Books, 2002 pp. 246-256.