Considerations for treatment and management of individuals with co-morbid CAPD and ADHD

Chermak, Gail D. PhD

doi: 10.1097/01.HJ.0000403504.42347.3c

Gail D. Chermak, PhD, is a Professor and Chair of the Department of Speech and Hearing Sciences at Washington State University.

Article Outline

Individuals diagnosed with attention deficit hyperactivity disorder (ADHD) frequently have difficulties performing tasks that challenge the central auditory nervous system (CANS). While the integrated brain presents a challenge to those responsible for diagnosing central auditory processing disorder (CAPD), audiologists working as a part of a multidisciplinary team have developed strategies and documented cross-test patterns that assist in diagnosing co-morbid CAPD and ADHD.1,2

Patients with CAPD and ADHD have auditory modality or perceptual deficits due to CANS compromise and supramodal deficits due to frontal-striatal involvement. These co-morbid diagnoses require adjustments to interventions, which for individuals with co-morbid CAPD and ADHD should have a strong metacognitive component, just as is recommended for those presenting with only CAPD. Metacognitive engagement promotes efficient allocation of perceptual and higher-order (central) resources (e.g., language, memory, and attention), facilitates development of self-esteem through self-empowerment, and may reduce passivity often seen in individuals with ADHD, all of which are likely to enhance the success of interventions.3

Two metacognitive approaches, self-control and planning, which underlie executive control and typically are compromised in ADHD, are key interventions for these individuals. Because sustained attention deficits in ADHD are secondary to behavioral disinhibition and self-regulation deficits, strengthening self-monitoring is one key to managing ADHD. Some planning and self-control exercises (e.g., freezing to stick-figure poses when the music stops and role playing) may also exercise working memory and auditory vigilance, two other key intervention areas for individuals with both conditions.

Of the various linguistic and metalinguistic skills and strategies recommended for intervention with CAPD, focusing on building vocabulary and auditory-verbal closure (contextual derivation and semantic network expansion) and teaching listening strategies are especially helpful. Current models of comprehension emphasize lexical processing. Based on strong correlations between vocabulary and comprehension, words are considered the building blocks of understanding, with vocabulary a strong predictor of self-regulation ability, underscoring its relevance for managing co-morbid CAPD and ADHD.4

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Researchers have documented in ADHD and some CAPD patients that working memory supports normal auditory processing, including listening in noise, and this clearly should be a focus of intervention programs for these individuals.5,6

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Noise and reverberation pose challengest for individuals with CAPD and ADHD. Children require better listening environments to achieve performance comparable with adults, and children with a hearing loss, who are learning in a second language or who have CAPD or ADHD require even more favorable acoustics, because background noise and sound competition are exacerbated for these individuals.7-9 Bottom-up approaches must be used to complement top-down strategies including environmental modifications to control noise and enhance acoustics (assistive listening systems, clear speech, improved room acoustics) and auditory training (direct auditory skills remediation to reorganize the CANS).

Several modifications to intervention programming are recommended for individuals with co-morbid CAPD and ADHD:

* Therapy should be conducted with children in their typical state, which may be medicated, to enhance cooperation, motivation, understanding, and attention to task.

* Optimally, therapy should be scheduled in the morning. Shorter sessions with breaks to minimize off-task behavior may be required.

* Background noise and other distractions should be minimized and the use of assistive listening devices to increase access to the acoustic signal should be considered.

* The interval between stimuli (interstimulus interval) should be lengthened, and more time should be allowed for responses due to slower cognitive tempo (slow reaction time and slow processing speed) and reduced speed of information processing often seen in ADHD.

* More immediate and frequent feedback should be provided to increase motivation.

* Effective behavior management (token economy, time-out, and response cost) systems should be implemented.

* The clinician should monitor and intervene if a client's responses (especially during computerized therapy) appear to be impulsive (commission errors).

* Skills trained should be over-learned because individuals with memory and attention problems require more practice or rehearsal to mastery.

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1. Bellis TJ, Ross J: Performance of normal adults and children on central auditory diagnostic tests and their corresponding visual analogs. J Am Acad Audiol (in press).
2. Chermak GD: Differential diagnosis of (central) auditory processing disorder and attention deficit hyperactivity disorder. Handbook of (Central) Auditory Processing Disorder: Vol. 1. Auditory Neuroscience and Diagnosis (p. 365-394). San Diego, CA: Plural Publishing; 2007.
3. Chermak GD: Central resources training: Cognitive, metacognitive and metalingustic skills and strategies. Handbook of (Central) Auditory Processing Disorder: Vol. 2. Comprehensive Intervention (p.107-166). San Diego, CA: Plural Publishing; 2007.
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5. Diamond A: Attention-deficit disorder (attention-deficit/hyperactivity disorder without hyperactivity): a neurobiologically and behaviorally distinct disorder from attention-deficit/hyperactivity disorder (with hyperactivity). Dev Psychopathol 2005;17(3):807-825.
6. Bamiou D, Free SL, et al: Auditory interhemispheric transfer deficitis, hearing difficulties, and brain magnetic resonance imaging abnormalities in children with congenital anaridia due to PAX6 mutations. Arch Pediatr Adolesc Med 2007;161(5):463-469.
7. Breier JI, Gray LC, et al: Dissociation of sensitivity and response bias in children with attention deficit/hyperactivity disorder during central auditory masking. Neuropsychology 2002;16(1):28-34.
8. Crandell C: Speech recognition in noise by children with minimal degrees of sensorineural hearing loss. Ear Hear 1993;14(3):210-216.
9. Nelson P, Kohnert K, et al: Classroom noise and children learning through a second language: Double jeopardy? Lang, Speech, Hear Serv Sch 2005;36(3):219–229.
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