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Hello, and welcome back to the podcast, everyone. Hey, today’s episode is on a topic that many of you might be confused about, interested in, dismissive of, who knows. It’s relatively controversial in our field. We’re talking about central auditory processing disorder with Dr. Michael Wolf. Let me tell you a little bit about Mike, and [00:01:00] then I’ll tell you what’s happening in this episode.
Michael is a clinical psychologist and board-certified neuropsychologist. He is the co-founder of Behavioral Resources And Institute for Neuropsychological Services (BRAINS), a private practice in Michigan. Dr. Wolff specializes in medical and congenital conditions and how they influence cognitive and daily functioning. He works with children, adolescents, and adults with medical, neurodevelopmental, and psychological disorders. He has authored numerous articles in neuropsychology and published a text on the Complexity of Autism Spectrum Disorder. He is a professional speaker and volunteers his time with several nonprofits as well.
Mike is a very dynamic speaker. You may have heard him at conferences in the past, and I am very grateful to have him here today to talk about central auditory processing disorder.[00:02:00] We talk about the definition of CAPD. So what it is. We talk about who can or should diagnose it especially in the context of psychologists diagnosing CAPD. We talk about how it may be similar or different to existing diagnoses, like ADHD, language disorders, and autism spectrum disorders among others. And we close with a discussion of available treatments for CAPD. The show notes have a number of resources if you’re interested in learning more.
And this is a good one. I, like I said, learned a lot and was surprised by some of the discussions and thoughts that came up during the episode. So really good one. I think it’ll make you think.
Before we transition to the episode, as always, I extend an open invitation to anyone who would like to enroll in one [00:03:00] of The Testing Psychologist Mastermind groups. These are accountability and coaching groups for folks at all stages of private practice. Whether you’re just starting out or you’re looking to hire your 10th employee, there’s a group for you. I facilitate all these groups and I love watching these groups go. It’s a cohort model. So people go through them together and grow over the course of 5 or 6 months toward their goals. If that’s interesting to you, you can get more information and schedule a pre-group call at thetestingpsychologist.com/consulting.
All right. I think that’s it for the intro. Let’s get to my conversation with Dr. Michael Wolf.[00:04:00] Hey, Mike, welcome to the podcast.
Dr. Michael: Thank you.
Dr. Sharp: I am glad to have you here. I have seen some of your work over the years and heard about your work from a number of folks in the field that I really respect. And I feel like this interview or this topic at least has been a long time coming. So I’m thrilled to have you. I know we have a lot to jump into with CAPD.
Right off the bat, I always just like to ask people, why this? In the field of neuropsychology, why care about this and put the energy into learning about and teaching about this particular subject?
Dr. Michael: Sure. I think as neuropsychologists, we often want to get caught up in the hospitals and want to get caught up in some of the hard medical factors that a lot of us do in our daily jobs, are epilepsy or tumor resections, different presurgical evaluations, or concussions and [00:05:00] TBI, but I think it’s easy to also forget that there are other conditions out there like CAPD that still warrant our attention. So warrant our research. And to know more about how these things come into fruition in terms of the evaluative process and in our role in considering and intervening in these types of conditions.
Dr. Sharp: I think that’s fair. We don’t specialize in it by any means, but it comes through our referral stream often. There are a lot of kids who either have had evaluations or want an evaluation for CAPD. And I know folks in the testing psychologist community have brought it up many, many times. So glad that you are focusing on it and can share some info with us.
Dr. Michael: Absolutely.
Dr. Sharp: Right off the bat, it’s a complicated topic. It’s a fraught topic in neuro-psychology maybe. There are [00:06:00] differences of opinion. I would love to start maybe with just some groundwork or background around some of this controversy or difference of opinion. There seem to be mixed opinions on the idea of sensory deficits in general and what that might mean. So, can you speak to that at all?
Dr. Michael: Absolutely. So let’s start out with just a general idea. I think a lot of times when you say sensory deficits like you just mentioned, I think half the neuropsychology world might cringe and go, “Oh gosh, here we go again.” The other half might go, “Yeah.” That’s where we’re going to get started in the sensory stuff. It is an everyday type of work.
When we look at sensory processing, it’s not necessarily always pathic pneumonic of anything specific. And I think that causes frustration in our field. If someone has a texture sensitivity, it’s like, “What part of the brain does that mean?” It doesn’t necessarily mean one [00:07:00] part of the brain, right? It’s a symptom that gives us a clue that something else might not be working right. And so, at the basic level, I think that part of the issue is that it doesn’t tell us something specific all the time.
But I think in reality, when you look at like a cranial nerve exam or something a neurologist is going to do, they’re essentially doing an evaluation to test stimuli or the perception of stimuli, and usually stimulate in motor movements, which then start to narrow down for them that process of understanding what might be occurring in the functioning of this individual and where do I start my investigation to then understand, is this a disease process? Is this deterioration? Is this developmental? Is this normal? Sensory stuff can be very normal for a lot of individuals. And when does it cross over into that world of pathology versus normality or developmental problems?
Dr. Sharp: Sure. I think that’s [00:08:00] something we all struggle with. When you say sensory issues in general, people get up in arms about that, right?
Dr. Michael: Yeah.
Dr. Sharp: There’s a lot to be concerned about. So, random question, you mentioned, there’s no part of the brain necessarily the maps directly to texture sensitivity. As far as we know, are there parts of the brain that map to other sensitivities: noise sensitivities, bright lights, food textures, anything like that? This term sensory processing is a tough one. I’ll just leave it at that.
Dr. Michael: Absolutely. All senses obviously come in through the environment. And I think the job of psychology and neurology and everything is to understand how the stimuli come in from the world because our job is to function in that world as best as we’re able to. But in doing that, we’re essentially functioning in response to [00:09:00] perception of stimuli or senses that are coming into us. Touch, taste, texture, sights, sounds, smells are those things that are coming at us. And then our response to those determines how well we perform in the world. And in neuropsychology, our job is to have a better functional outcome in order to improve or maximize everyone’s daily life activity as best as we can.
So are there specific regions that are mapped specifically to a particular type of sense? Well, some are. And we know more about some than others. We have that homunculus that maps over the motor and the somatosensory cortex neocortical. But that information doesn’t go directly from our hands, our lips, our eyes, our ears, right to this little guy sitting over the overfold of this amount of sensory in the primary motor cortex. It has to be filtered and come up through subcortical aspects of the neurological process before it gets to the higher-order levels.
And I think when we’re talking a sensory [00:10:00] basis older, like CAPD today, it’s what’s going on in that process or that evolution of perception of sound that then moves us toward the function in the world, whether it’s communication or reaction to, or sensitivity like kids who are afraid of loud sounds or TinEye is where there’s constant ear running. And we do know more about what might be relating to those types of things.
Dr. Sharp: Sure. I’m eager to dive into the specifics around CAPD. I know we’re going to get into that. I just want to talk a little bit more about the disagreement in the field, perhaps about these diagnoses. I was just looking over Pennington’s book, Diagnosing Learning Disorders, I forget the exact title. You’re shaking your head so you know what I’m talking about. So they include CAPD, [00:11:00] NVLD- nonverbal learning disorder, and sensory processing disorder in that chapter of, I think it’s less well-validated disorders.
And so, there’s been some back and forth about this. I’m curious. From your perspective, what do you think is so tough about this in our field? Why can we not figure this out? And why is there tension around these diagnoses?
Dr. Michael: I think there are two things that are occurring.
The first one, where are our boundaries? There’s neuro-psychology and then there’s the ASHA: American Speech-Language-Hearing Association. ASHA has typically taken that lead to say, both sound perception and sound process, which falls in the domain of both audiology, and that’s speech and language pathology. And if you follow some ASHA’s work, they’re saying, no one but an audiologist and or speech and language pathologists should really be diagnosing a central auditory [00:12:00] processing disorder.
So there is a boundary there that then takes neuro-psychology and saying, Hey, but we know how to assess and evaluate and look at a lot of this stuff too. And if we have covered all of our bases for making sure that there’s an individual’s past, a hearing test, and there are no other medical factors like tears and the tympanic membrane or Clessie OMAS or acoustic neuromas, or calcification of the ossicles, a lot of things that can change the conduction of sound initially coming in, and we’ve ruled out those mechanical processes already by medically evaluation, can neuropsychology come into that?
And then I think we also get neuro-psychology that starts to debate a little bit. Is auditory processing its own disorder, because it’s not obviously covered in the DSM? And is it its own entity because our supposedly diagnostic manual doesn’t include this as an option? And it can [00:13:00] be misdiagnosed very easily or included in, I guess, whichever way we want to look at it. Maybe this is an aspect of ADHD. Maybe this is an aspect of a semantic language type of disorder. Maybe this is a phonological articulation disorder. And is this an autism spectrum disorder?
And so we can lump aspects of CAPD into these other behavioral conditions, but I think a lot of us in neuropsychology recognize that the DSM is a behavioral math station or check-off list book that doesn’t really help us to understand and capably review other conditions that we now have tests and the sensitivity to look for that are actually more specific and more valid in many ways, in terms of symptom criteria to say, Hey, this isn’t actually ADHD. This is a specific subset of a condition that will mimic inattention problems but if you throw a psychostimulant at it, sure it might help.
A psychostimulant whether you have ADHD or not would probably help about [00:14:00] 95% of us at a low dose and whatnot. And that’s why it gets abused all over the place. But just because you get a response to that doesn’t mean it’s the right thing to do nor you’re treating the right condition. And for the developmental and then functional aspects of daily life, it still might not hit the mark. And we can be much more specific now than maybe we were 15, 20, some years.
Dr. Sharp: Yeah. I’m excited to figure out how we can do that. It’s good to know. There’s I think a lot of potential there and I hope this conversation will shed some light on that. I’m aware, maybe we should back up a little bit just in case somebody’s not aware of CAPD- central auditory processing disorder. If you had to do a 30 seconds definition or even a 15-second definition, what are we talking about here?
Dr. Michael: So a central auditory processing disorder is essentially a condition where an individual we’ve ruled out mechanical hearing issues, and so there’s no [00:15:00] conduction type of hearing issue, and we’ve ruled out any major sensory neural hearing loss- and so, we’ve ruled out again that mechanical factor, but then assuming a person has what would be considered to be normal hearing from a medical and an audiological sense, it then goes to the misperception of sound that then distorts the ultimate outcome of being able to function effectively in the world. Whether that’s because of the way that we talk and communicate and understand spoken language, or if that’s the way that we can’t ignore random background sounds and they start to really bother us and then we start to get edgy if someone is potentially chewing gum next to you, or swallowing a little bit louder, or making noises with their paper, pencil on the table in a way that then will disrupt our normal functioning.
Dr. Sharp: Yeah. I’m going to ask an off-script question right off the bat. When you talk about those things, [00:16:00] would you consider misophonia to be part of CAPD?
Dr. Michael: Yeah, it’s a qualitative feature. It might be so specific that it’s going to just stay in a misophonic camp, but essentially that’s abnormal auditory figure-ground. And as a result of that, it distorts an individual’s means of being successful in navigating the social and environment around them that causes agitation or anxiety, or avoidance. But misophonia is probably even more debatable as an isolated condition more than CAPD, I think.
Dr. Sharp: Yeah. I’m debating whether we want to go down that rabbit hole. There’s so much discussion about it and of course, it’s personally interesting as well, to me.
Dr. Michael: Not just you. I’m right there with you.
Dr. Sharp: Right. I’m like, what is it about these particular sounds that are so disruptive to folks and why can’t we gate those appropriately?
Dr. Michael: Great question.[00:17:00] Dr. Sharp: Yeah. You know what, let’s just do it. Do you know anything about that? Can you speak to that at all? Like where that’s coming from and why those particular noises are specifically activating for folks?
Dr. Michael: Yeah. So when we’re looking at that idea of misophonia, typically speaking, we’re going to see it maybe being disrupted as part of a couple of different core areas.
One might just be sensitivity in the cochlear nerve itself. The second that loud screeching sound, that chewing, that swallowing sound comes in, it already in that noisy environment is sending the brain the signal of like, I don’t like this and we become hypersensitive to it. Sometimes that auditory figure-ground perception of misophonia and not being able to ignore those random sounds also might come from the lemniscal pathway, the processing of the perception of electrical stimulation of sound coming up to be processed in the medial geniculate nucleus of the brain.[00:18:00] And as a result of that, it’s also sending disrupting signals saying, Hey, we got to get away. We got to ignore this. And it’s kind of sending that fear-avoidance response that we’re usually going to get from the inferior colliculi conflicting with, now, we just got to ignore that because something’s being said, or I can’t get up and I can’t believe right now. In that conflict in neurological process between neighbors that should be working on similar types of clearing it up to get it to the higher-order processing or saying, no, we’re bailing, we’re getting out of here.
And so, as a result of that, now our emotions start to get provoked and our limbic system kicks into play. And in some way, even though it’s not puristic, it’s kind of that fight or flight, right? People who are really annoyed by certain specific stimuli of sound might have an outburst saying stop, or do you have to swallow louder? You’re annoying.
All of a sudden, we have this behavioral reaction because that whole [00:19:00] limbic system gears up as sensory perception, works its way up through what used to be believed in a very linear process. But now we know there can be conflict and there can be dual streams going simultaneously that will lead to conflict in the perception of sound.
Dr. Sharp: Yeah, I know there’s probably a lot to say about that. Maybe we could do a whole episode on misophonia, but that’s enough for me for now. I’m just very curious, and so, it’s something that I thought I might as well ask.
Dr. Michael: No problem.
Dr. Sharp: So as far as CAPD goes, you mentioned earlier that it often gets confused with ADHD. I’d say that’s probably the predominant question in our practice when we see it is, how do we separate those two? Can we separate those two? Is it worth separating those two? So are there other mental health diagnoses that we need to look out for that might masquerade as [00:20:00] CAPD or vice versa?
Dr. Michael: Yeah, we need to watch out. A lot of these kids can be easily misdiagnosed with an Autism Spectrum Disorder as well. They may misperceive the tone or the intent of language, not pair the non-verbal cue with the content of the language as effectively, we might also see them coming into language-based disorders, either receptive or expressive language disorder, which at its core is still a part of a central auditory processing issue.
But CAPD is going to be a little bit more encompassing of the functional aspects that will influence not only the perception of what’s being said, but the ability to have that auditory feedback loop keep up with what you’re saying to formulate your thoughts effectively to meaningfully engage interactively in conversation, which is why we have that social pragmatic language disorder, which added to the DSM in 2013, which could also be misdiagnosed or commonly diagnosed, potentially speaking [00:21:00] as CAPD. But I think ADHD is probably the most common misdiagnosed attribute of an auditory perceptual deficit. And yeah, I think it’s our responsibility to do as best as we can when we think it might be more specific to see and test the limits of that.
Dr. Sharp: Yeah, I don’t want to jump the gun too much and get into assessment, maybe that’s a nice segue. It’s hard to hold that back when it’s coming up right now.
My question is maybe a broad question in the diagnostic process. Let’s say we are evaluating for any of those things, autism or ADHD or social pragmatic, how do we know? That’s the question. How do we even know whether to consider CAPD as part of the picture or not, if the parents haven’t brought it up or the referral source hasn’t [00:22:00] brought it up because I don’t know that this is like automatically on people’s radars when these differential diagnoses pop up. Does that make sense?
Dr. Michael: Absolutely. I think the inquisitive nature of most neuropsychologists is where this all starts, right? So we start out with that clinical interview and when we’re working through that interview and we start to hear things that a lot of times it’s easy to ignore. My kid had chronic ear infections. They didn’t quite need tubes, maybe they did, but there’s always fluid there. There’s always wax there. And we know from that, that there still might be normal hearing especially once we treat those conditions, but when they’re in that fluid build-up, they’re hearing phonics and sound and speech at a very early age and this language develops very quickly for phonemic representation as though they’re hearing either underwater or there’s distortion from lax.
And so, I think as a neuropsychologist, I’m like, “Okay, that’s fine. It did make you sick. You [00:23:00] treated it. We’re good.” Or we hear there’s a chronic history of that should already set in motion to ask him a couple more questions about the pervasiveness of it. Was this just a couple of month interval of time or was this a couple of years? How long did they struggle with that?
Then we go to the tubes. And when we hear tubes again, it’s something so easy to overlook. That’s not our job. It’s not a role. That’s a medical thing. But tubes might fall out, but that doesn’t always mean that the whole and tympanic membrane is going to close over the way it should. Sometimes there can be scarring or scar tissue. I think my record at this point in time as an individual is that 14 sets of tubes. We start to look at like, how often, how many, what was the recovery process, complications? Because all of those things eventually may still result in a child with a normal audiological review but could have fundamentally changed the way that sound was transitioning from sound wave to electrical stimulation and perception in [00:24:00] the way that we perceive and process sound.
So, we finally get through those areas and we move through making sure that an audiologist or they’ve passed our school hearing tests. And then we can start to go, okay, but they had a phonological issue. Is that dyslexia? And was that early phony misrepresentation, or was there a different factor that might’ve been acquired in this process to lead to that misperception? We’ll know that from the history medically, and being more inquisitive initially from asking those other questions.
But if we’ve ruled those out now, we’re coming in. It’s like, no, they just can never say their phonics. Now they can’t read phonics. Okay, maybe we have more of dyslexia, just phonetic pattern. That’s bright. But then when we start to say, okay but wait, they didn’t just have that. They always seem to be slower to respond. I’d ask them a question, they’d respond, but there’s like this leg. And it was always so frustrating. I thought they just didn’t want to answer. Maybe they’re being deceptive.
And so we started asking questions about how well did they start to [00:25:00] engage in language use and mimicking sounds and the speed of maybe learning to sing along with songs, especially children with singing along with Disney songs or something that might be kind of fun, are they always a step or two or three behind?
And so we started to pick up on, oh, so there is some lag here. So now we need to know, we need to add at least some more language tests. But now I can start to add some simple little things. Let’s do a WRAML attention measure. Right? We got visual figure-ground and auditory attention. I’m not going to go completely in testing here, but we can start to target. Quick little things to tell us, oh, something’s a little bit unique here.
But then as they get a little bit older, it’s like, okay, they learned to read, this is great. They still do some articulation stuff. That’s a little bit unique. But for some reason they can’t when we’re in a noisy environment, they never listen. When the coach yells at them on the field, they don’t hear it. When they’re in a work meeting, they’re taking notes and they’re trying to do this, but if I all of a sudden whisper next to them, they can’t pick me up. And now they’re getting a little bit of [00:26:00] trouble. They’re uncomfortable in group interactions. Something still is abnormal. They could do all this other stuff relatively well, but we can’t do meetings or groups, or we can’t ignore those misophonic sounds that are bothering us. They’re all triggering symptoms to tell us, oh, oh, this might be auditory processing adepts that I need to flush out a little bit further.
Dr. Sharp: Sure. I love these questions that you’re throwing out there. You’ve given us a decent list, but are there other things that we can be kind of looking for or asking during that clinical interview that can help at least tip us off that we might need to do some testing in this area. And I mean, if there’s anything that you didn’t already cover.
Dr. Michael: Yeah. So similar specific things that I would typically ask families when I am in my diagnostic interview is looking for, when you call their name, would they respond and would they acclimate their head [00:27:00] in the right direction? If you’re on the right side and you call their name and they look to the left, that’s an atypical response. They should be able to know, hey, they’re over here and I can shoot spatially locate. And so, we’ll have families telling us symptoms like that.
It’s also common for me to ask things to the family in terms of how long would they respond? And would the answer the question accurately? Which gives me a flavor of, is this a receptive language issue, which it well could be, but if they would pause, start to respond, and then respond to accurately, okay, well, they are receptive there, but for some reason, there’s a slowing in the perception of the process, which also gives me an indication of what’s going on.
And I think probably that one of the bigger tales that we have from families is they’ll tell us, like, even from infancy all the way through it, and sometimes we’re hearing this even from adults who are coming in from CAPD evaluations or at least questioning other’s processes, for some reason, at no point in my development [00:28:00] could I really engage in a conversation. There wasn’t a back and forth. And so if they’re of an age where a baby should coup and look and smile on cue back if they’re at an age where we should be going back and forth, but there’s always those lags. That’s also another sign of either language or an auditory processing deficit of some type.
And people are very annoyed by those because even if I do something unique to you and all of a sudden I took a three-second pause there on you, you’re going to think, oh, Mike just had a stroke. While, in fact, I didn’t, it was just that lag. And that’s very uncomfortable. And so, we can rule out language versus CAPD are our next steps moving toward the evaluatory process.
Dr. Sharp: Yeah, as we talk about this, it seems very hard to separate auditory processing issues from perceptive language issues. I’m [00:29:00] just being honest. So, I’m very curious how that might happen, but I’m going to save that for a little bit.
I’m curious about the order of operations, so to speak, and when or if you involve other allied health professionals. Let’s say you’re doing a diagnostic interview with a family and you get some of these signs. So you’re suspicious. What happens from there? Are you moving straight to testing or are you pulling in other people? What does that look like?
Dr. Michael: So we automatically start pulling in some other people or at least case history. So when we’re hearing some of those triggering things that might throw me into language versus CAPD or other diagnostics, I’ll ask them, have you ever been to an audiologist? Have they done a hearing test? Or if they’re an infant, did we do the BAER for brainstem auditory vote a response? Do we know that stuff [00:30:00] is getting into, through the brain stem to the brain to be processed?
And so if they say no, Hey, okay, I’m going to refer you to an audiologist to make sure that we at least have normal sound perception from an external mediated environment. If they’re saying, yes, we got that but we still have fluid buildup. Well, okay. Then I’m asking their doctor, can we get an ENT referral? Are we at a point now where maybe that canal is too small or maybe we need to open it up or do we need to do tubes? Is there something else going on that’s causing them to have glue ears? Is there something else that we can do to help mitigate the routine wax buildup? And so ENT consultation might be coming into play.
If those two things either have been done before or are managed and whatnot, then it’s coming into the next phases of going, okay, well, did you get it early on, and at least in Michigan, it’s called early enough. Did a speech pathologist consult with you regarding an early language screen, or if you’re in school, [00:31:00] has a speech and language pathologist met with you to look at your language aspects and had they said anything?
Often with CAPD, we’ll find kids being able to pass through core language testing, whether it’s a cell for other measures, that the mechanics of basic language use and perception and receptive language are there, but there still seems to be something a little bit atypical. But often they have a speech and language pathologist are involved is very important. And then sometimes, but not always in the early phase of CAPD, an occupational therapist who might specialize in things like listening programs or whatnot could become involved at some level if they have toolkits that also look at various sounds.
So let’s say those are your biggest ones, your audiologists, your ENT, your speech and language pathologist should be working alongside us at some level or have already done as we move into the journey.
Dr. Sharp: Yeah, I’m just thinking [00:32:00] logistically. I might be getting too granular here, but I’m a concrete thinker. So, how do you handle something like this when there are such waitlists for a lot of these services? I mean, just like procedurally, you do an interview and then you refer to X person audiologist, or maybe try to pull in or get some records which can take forever and then get them back in for testing. I don’t know if you have any thoughts on how to manage, just coordinating all these pieces when it can possibly get drawn out over so much time.
Dr. Michael: So in my view, neuro-psychology can still keep moving forward with their evaluation even as you wait for the other pieces. Sometimes, we can simply ask, have they pass our hearing screen at school and we know that all kids have to do that every couple of years, especially in their early academics, not once they get into late elementary and beyond. We can ask if doctors that were taking tuning forms.[00:33:00] As a neuropsychologist, we should also be able to do basic sound perception testing: walking behind an individual and putting their hands up next to their ears and having them raise their hand when you’re just gently rubbing your fingers together to see can they perceive some of those early sounds just from the finger rubbing in the ears and how loud do you have to rub? You have to start snapping them. That’ll give us a sign like, oh, this actually seems to be a hearing issue not even a perception of audition and beyond that. And so now, I’m going to wait. But if they’re passing through those screens, if they’re oriented in their head, if they’re in your office, and even an infant who hears someone walk by loudly might be startled and look like, “What was that?”
And so, we can always use our observations. We should all be able to do some of the basics of cranial nerve exams in my opinion. I have been trained on those, sometimes in-depth, and then also have all tool kits that we can use for sound or sound disruption [00:34:00] to at least rule out the basics of, they’re definitely hearing, so I can already rule that in. Now, what’s next?
At the end of our reports, we might say things like, I’m pretty confident this is X but we’re still waiting for similar findings first. And when those come in, we may change our final diagnoses and recommendations, or these will be consistent with them. We’re already moving forward into the next steps.
Dr. Sharp: Sure. Yeah, that’s good to know. So then let’s talk about the evaluation process and what that might look like. So feel free to dive in. I’m curious about specific measures and what we might be looking for, but you’re welcome to take that in whatever direction you might want to. How do you approach the evaluation process?
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All right, let’s get back to the podcast.[00:36:00] Dr. Michael: So approaching evaluation, here in our company, BRAINS, we always look at the balance of, what do we need to do and not what do we all want to do because neuropsychological evaluations could be 15 to 20 hours. But at that point in time, it’s almost cruel and unusual punishment for anyone to go through that much testing. And so, it’s picking and choosing enough to give us information and then starting to chase a little bit of, is this just a Mulligan or is this in fact clustering as a dataset to say this as a concern?
So as we start out with the basics, if we know there’s a possible CAPD question, I am going to do the basics. I’m going to do a basic phonic test. That might be as simple as a pseudoword decoding on a WIAT. I might look at pulling out that WRAML attention index. I can get a quick split between visual working memory and auditory working memory. It’s so easy to [00:37:00] pull a WISC out and look at auditory retention in terms of digital banner reversal or resequencing information.
I’ll do some simple sentence tests. To add, I’m just going to say something, repeat it after me. And I might not even use a formal test, but I’m just going to do simply like an MMSE, no ifs, and, or buts, or John, cross the road to go look at and I’ll make some things up to see, can they just mimic my language? And if they’re younger and we’re not quite to fully talking, can I get them mimicking the sounds that I might be making? And are they the right sounds?
But it’s not just the right sounds, when you’re working with an individual, you got to be observers, right. We’re neuropsychologists. Did their mouth move in the way it should or am I looking at an oral motor issue that caused him to distort what they just said? Or am I looking at no, it looks like the mechanisms of everything I’m saying, it might not be perfect yet, but look right? But boy, that still wasn’t what I [00:38:00] said or that wasn’t the sound that I made. So we can do those types of things.
From there, if they’re still concerned, we use the SCAN here. And in the SCAN has both a pediatric and adult test to it. And that will start to break out for us. Auditory filtered words, auditory figure-ground, binaural hearing as well as selective auditory attention or dichotic listening. And so, that gives us a pretty good sense of what might be going on. And as a general baseline for me, if I see an auditory filtered word that isn’t performing well, that does raise more questions for me about, do they have a hearing issue? Because that’s just someone mumbling a little bit and you got to hear it and then clarify it a little bit more.
So if they don’t pass that one, I might say, okay, if you haven’t had a hearing test, I’m going to send you your hearing test. But if they pass out with flying colors or at least average or above, I pretty much [00:39:00] know, if I send you an audiologist, you’re going to pass an audiological exam. You’re picking these things up.
We like to use the IVA- the integrated visual and auditory continuous performance test. Even though I know there are debates about the validity of that one and a lot of people have their preferences for CPTs, it’s simultaneously tasked visual and auditory attention, and it’s amazing with CAPD individuals where you can easily see this huge split where visual attention is like solid and right on an auditory is doodling, if not pretty significantly impaired.
And I’ll ask him, how did it go? I think I did great. Well, great, you did in one area, now we have to watch out for the video game kids that are really attuned to paying attention, visually gear screens, and then maybe not as much auditory, but that’s there. We also have the sound perceptions from the tops. We have the test of auditory processing (TAPS).
And then if it does seem to be more language, then we can [00:40:00] start to bridge into broader language tests, our castle and the SLDT and many other phonic tests that we can break into to just say, this might be dyslexia. This might be phonics only. This might be […] only. And then that opens up a huge fund of tests once we get to those higher-order processing types of things.
Dr. Sharp: Sure. As you list all these measures, one, just honoring that process of being able to think on your feet and be flexible as you go and add when you need to add and stop when you need to stop, know what you’re looking for. But another thought that occurred to me was just stepping into the others’ realms potentially. I wonder if you’ve ever gotten pushback from a speech-language pathologist or audiologist? We touched on this at the beginning, but I’m curious to bring it to [00:41:00] the real world a little bit and just ask if people ever are like, “Hey, you can’t do that. That’s our realm. Why are you giving those tests?” Whatever it might be.
Dr. Michael: Yeah, it’s interesting that you ask that. During the pandemic, all of our typical audiology clinics closed. They stopped seeing patients. But I continued to see individuals who needed evaluations to delineate, so essential patients, but sometimes that became part of the question. And I actually had a conversation back and forth with ASHA. I emailed them specifically, and then they sent me to their ideological department and we had some conversations back and forth.
I think that they had put that provision of saying, we’re the ones who diagnose CAPD. If anyone can do it, no one else. And when I pushed them, it’s like, “Okay, you’re right. As a neuropsychologist, you actually are doing tests that we actually don’t know that should maybe be [00:42:00] considered in this process as well. Cognitive testing, memory testing, different types of exposures and how do prenatal alcohol or drug exposure or trauma, or concussions and these things also affect what might be misperceived as CAPD.
And I think at the end of our conversation, it came down to, well, as long as an audiologist has ruled in normal auditory function, then yeah, neuro-psychology actually does do a lot of these things.
In our office, I’m privileged to have speech and language pathologists that work right alongside us. And we work together all the time. They can do a lot of the tests that I can do, but they’ve even said to their training along with speech and language pathology, they weren’t trained on a lot of what’s needed to look at a CAPD evaluation.
So we’ve worked alongside and now they do some of it. I do the rest of it. And we come together for a consensus opinion of what is this looking like, and what do we think before we make that final diagnosis. So it’s [00:43:00] really nice to work alongside allied professionals. And they really haven’t had too much kickback. ASHA did initially. When I pointed out some of the pitfalls of a standard CAPD evaluation from an ASHA side, they hadn’t considered the other factors themselves either, which could also, again, result in them misdiagnosing something that should be looked at in a different way.
Dr. Sharp: Right. If I remember right, that is one of the primary criticisms of ASHA and their perspective is that initially the criteria maybe still the criteria for CAPD is only based on tests that they can administer. And that seemed a little bit limited in scope and less well-defined than maybe we would like.
Dr. Michael: Yes, that’s correct.
Dr. Sharp: So let’s think about, how does this all come together? This could just be me, it takes me a while sometimes. So I’m curious if you can delineate a little bit more [00:44:00] how you might separate “attention issues” from a CAPD? A lot of those measures you mentioned: auditory attention, visual attention, auditory memory, visual memory. I’m just curious, like, if you can even give any more specifics about what you might be looking for, differences in those profiles that might help us make that distinction.
Dr. Michael: So in our trying to distinguish between CAPD and ADHD is a good example here. ADHD is a mutual opportunity attention pathology. And so it should affect most aspects of attentional regulation, not select aspects. In some rare cases, we can argue, okay, well, you can make an ADHD diagnosis if only one potential area of attention is influenced, but in our opinion, ADHD should influence some executive functioning skills. Maybe they can get through a working memory task, but divided attention testing or distractibility is going to be off, sustaining [00:45:00] simple attention should be off, and we’re going to see that difficulty shifting focus. So, we should be able to see ADHD influencing these multiple domains.
We can do Go/No-go tasks. We can do a Stroop test. We can do the Decafs colored inference, and we’re looking at that disinhibition and disinhibition switching. We’re probably going to see some vulnerability in an ADHD individual whereas in a CAPD individual, those tests are probably going to be absolutely fine. And they’re not going to show that dis-inhibited quality.
We’re also going to be looking at the Trails, quick down and dirty, easy, right? ADHD, might have trouble with trails B and shifting their focus. CAPD, that should be a rare finding if at all of a deficit therein. And with ADHD, often when we’re testing other components of language perception like on the SCAN, they’re going to pass the SCAN all right, at least low average or average or above. CAPD individuals, they’re going to be pulling out the headphones. They’re going to be looking at you like, [00:46:00] “It’s not talking.” It’s fine. I got it on my headphones here too. It’s right where it needs to be. And they’re going to start to tell you things that aren’t there or when we’re looking at binaural hearing, an ADHD kid might not correctly get the word or because you’re supposed to say you right ear first, then your left ear, your left your first and your right ear. So I might mix that up, but they’re going to get the words. A CAPD individual might completely suppress a right ear, left ear, and get everything right in one ear, but they can’t listen to both simultaneously. And so we’re going to see that process.
Obviously, on the IVA, we already mentioned that split of visual-auditory performance. That’s not a classic ADHD profile. ADHD should have both suppressing and looking very troublesome and showing scatter, and we’re not going to see that. And of course, with ADHD, communication and talking, and back and forth, sometimes they’re going to go really fast and they’re just boom, boom, boom and right there with it clicking fast, while that individual with an auditory [00:47:00] processing, it might be like, “Oh, give me a minute.” And you can feel like you’re overwhelming them by going too much.
So those are some things that we’ll look at both in profile testing as well as then functional probation and outcome.
Dr. Sharp: I like that. I appreciate that. I like how you articulated that. And for anyone who doesn’t know, I did want to ask, myself included, you mentioned the SCAN two times. What is that acronym and what does that test?
Dr. Michael: That was an unfair question.
Dr. Sharp: Well, I don’t know. Why?
Dr. Michael: Let me say it. I’m going to Google that one quickly. I don’t know what the SCAN stands for.
Dr. Sharp: It’s so funny how we live by these acronyms. I’ve gotten caught in this very situation many times in the past by supervises. “What’s that? I don’t know. Let me think about it for a second.”
Dr. Michael: Yeah, I don’t know if Pearson actually spells out what the SCAN stands for.
Dr. Sharp: Oh, okay.[00:48:00] Dr. Michael: Yeah. Just a SCAN- test of auditory processing disorders for children, but the acronym SCAN doesn’t break into its own specific words.
Dr. Sharp: Okay. Fair enough. Well, that really was an unfair question then.
Dr. Michael: Yeah, that was a tricky question.
Dr. Sharp: An unintentional trick question.
Dr. Michael: Yeah.
Dr. Sharp: So can you describe that test for us in a little bit more?
Dr. Michael: So you asked about the SCAN. It’s a test where you both have headphones on. It’s this prerecorded CD. This test has four different subsets of auditory perception to it. It’s got auditory filtered words where it sounds like you’re listening to a muted sound, almost as though you’re having a conversation across the gym, or if you both have hats on and they’re trying to have a conversation. So the language isn’t pronounced very clearly, but the brain can easily pick up the sound patterns to make it into a word very easily.
Then [00:49:00] it goes through the auditory figure-ground. And this is the one where it seems like you’re in an airport or subway or something like that. There are random extraneous sounds going on around you, not language sounds, but people walking by, little noises that might throw an individual off, and the job of the individual is to listen. It might say, “Say the word big,” but all those random sounds are going on around you. And can you ignore those sounds and still pay attention to the words that you’re hearing?
Then it goes into a dichotic listening task competing for words. In competing words, it gives you two different words simultaneously in each ear, and your job is to say both words, but for half a test, you say a right ear first and your left ear and then the other half of the test to say your left ear first and then your right ear. So you can accurately delineate between and on which side is, is functioning. And the test does a pretty decent job at letting you know, was there a strong ear dominance, left ear or right ear dominance? And most of us are going to be right ear dominant because left hemispheres [00:50:00] predominantly, are for our language perception of at least core language itself, not the tones and sounds and other appreciable qualities, which are more right, but it does go contralaterally.
And then there’s competing sentences where you get two different sentences simultaneously in each ear and your job, it’ll say, Hey, for the next 10, ignore your right year or for the next 10, ignore your left ear.
And then there are different subtests within the SCAN that go through different Hertz of listening, different Hertz of sound that you can go through, but I also like the one at the end that’s time-compressed language. Now, the SCAN is giving words very quickly, or not words but even sentences. So it might say very quickly, […] Can the individual hear that when someone might be talking quickly and accurately understand what sentence was said, and then repeat that back to you?
So, we get both receptive language. We get sound environments. We get dichotic [00:51:00] listening. We get the ability to perceive sound when it has a muffled or muted quality. And then you can do different decibels or Hertz that are going to come into, is there a particular one that seems to be harder for an individual than not if you do the full test? A lot of times we’ll do the core foreign time-compressed and see what that’s looking like.
Dr. Sharp: Very nice. Thank you. It sounds like a cool test. I’m going to go look that up after we’re done. I feel like I should take that test.
Dr. Michael: Caution. If you have a possible auditory perception issue, some people have come away from that going, Oh, Oh! I have 2 colleagues here that are like, “So just because I have it,” but now they won’t administer the test anymore because to administer, you have the headset on to make sure that it’s not skipping, but then they can’t score the test because they can’t do or process the test.
Dr. Sharp: Oh, that’s interesting. Well, so let’s think about treatment. So assuming that [00:52:00] results are pointing in this direction, you’ve gotten all the data, the history, everything you need. Well, first of all, are we the ones that are recommending treatment for this or? Okay. You’re shaking your head. Yes. So, okay, I’ll take that.
Dr. Michael: In my opinion, neuropsychology for identifying areas of vulnerability, it’s also for us to give specificity of care, to know some of the treatments that are out there even if they’re not the best research, as long as they’re: 1, not detrimental, 2) not cost-prohibitive. Our job is not to sell miracle cures for other people to go and spend exorbitant amounts of money. If we have a solid foundation and what we’re recommending and enough knowledge to suggest that it makes sense and it meets a litmus test, then yeah, we do make recommendations for these areas.
Dr. Sharp: Okay. The next question, of course, is what are the valid treatments that you would consider for something like this? And are there [00:53:00] multiple treatments?
Dr. Michael: There are multiple treatments. I think validity becomes a problem. And I think that’s true. So many things are in our treatment environment. These aren’t pharmacological companies that are inventing these treatments for so many things in our field. And so they don’t have the financial leverage to do really solid controlled studies. Some of the things are pretty easy though.
In my opinion, if we have an individual that has difficulty with phonic sound representation, which usually is going to sit either subcortically coming up through the alumnus skull pathway or from the medial geniculate nucleus to the primary auditory cortex, and through the insula, we’ve got to make sure that we’re hearing those sounds accurately.
So lots of times when I work with speech pathologists, if I think it’s more of a sound perception versus an articulation or motor movement, I’ll tell him, “Look, I don’t want the […] necessarily because it’s not a motor or a motor apparatus issue. I want you to say the sounds and I want you to [00:54:00] record the sounds for them so they can hear the accurate phonic as best as they can. We know that hearing is not a part of this. We don’t need some amplification or anything like that, but I don’t want them representing the sounds as much as hearing the sounds accurately and saying I’m slower, slow on our cadence of speech. Make sure that we’re not overwhelming them because we want them to make sure that they can participate in what’s happening.”
So for speech and language pathologists, we might slow down on Orton-Gillingham Approach. We might target a little bit differently. So it’s not a dyslexic type of intervention, but it’s an auditory processing phonological recognition type of task. And we might do a lot more of saying the sound and have them point to the sound. And eventually, then they say the phonics that they’re seeing on the page, and then we can start to blend that into. So it’s a little bit different than a traditional Orton-Gillingham.
I think the most debatable aspect in making recommendations is, do therapeutic listening [00:55:00] programs work? That’s where a lot of money can be spent. You got Berard who’s the most popular in terms of integrated listening types of things. And then here we will sometimes recommend Integrated Listening Systems (ILS). They’re similar. Usually, it’s listening to classical music and that classical music, when we have normal hearing, but if we know their suppression of the right ear, left ear, we can’t do the binaural hearing. You can choose soundtracks that might do specific sound representation in the right ear for a while or the left ear for a while, or bring it together where if they don’t hear both simultaneously, the music will be a little bit more kickoff.
And then, in Integrated Listening (ILS), we also feel stuff. And so, the ILS system and its headset also have a bone conduction type of play that allows that feeling of what it’s like to have that vibration. It’s subtle. It’s not like we’re putting them through some sort of vibrant vibrating rock tumbler, [00:56:00] but it is subtle, but sound waves can startle by feel just as much as I can by sound. And so letting them feel what that’s like when things are amplifying or diminishing. So we don’t have unusual soccer responses.
There are things like neuro tone and lays, which are additional auditory acoustic sounds for people who might have Misophonia, like you mentioned, or Tinnitus for sound blending and matching of those types of things. So we know that lipo-flavonoids has come out in some of the scientific literature to suggest this might be healthy for the auditory acoustic nerve in the perception of sound and reducing particular tinnitus, but maybe it has something more to do with. And so sometimes recommending a lipo-flavonoid. It’s not well validated for CAPD, but we do know it’s working for another area of missed sound representation or excess excitation of sound in tinnitus.
And then there’s [00:57:00] also things that we can do, like a cadence of speech, duration of the speech. I’m starting to work with them on memory. You’re using context memory, like story memories versus rope memory where you just memorize words. And we’re trying to then challenge the system to function better function longer, to move into a more normal type of representation of auditory perception.
Dr. Sharp: Thank you. You went a totally different direction with that than I thought you were going to. So that’s super helpful.
Dr. Michael: Which direction did you think I was going to go?
Dr. Sharp: Well, so when you started to say, and the most controversial, I thought we were headed down the route of filters, like in-ear filters because that…
Dr. Michael: Oh, I can talk about those too.
Dr. Sharp: Okay. Yeah, I’d love to touch on that because we see a fair number of kids who have had filters or have filters or are considering them. So I’m curious what the research says about filters and how they work and are they helpful?
Dr. Michael: Yeah. I’m glad you brought that up [00:58:00] and I forgot to mention. So, there are two sound filters. DUBS is one, or I think they’re called one DUBS and there’s a couple of others out there on the market.
Original research started out at the University of San Francisco, at least that I know of, and that was probably about a decade ago. And they’re trying to compare that with smart technology to say, hey, if we implant these filters, which are smart filters, can we then on your phone say, hey, there’s a screaming individual next to me? Can I control my phone, these filters to screen out that individual screaming next to me?
And what they were finding is there is that possibility to in fact do that. And so, they, I think the University of San Francisco had relinquished some of the research and it sold the concept off is my understanding, but I’m not exactly sure how that happened, but so there are earbuds out there that do suggest they can sync with our technology to pick up what is going on in a complex sound environment. [00:59:00] And you can effectively look at your smart technology and move your bars to minimize some of those other extraneous sounds in those.
Now, sound blocking in and of itself, usually that’s going to be more of an autism spectrum disorder thing. That’s your headsets. So, that’s just putting something in your ear to suppress all sounds so that they’re not as acute coming in at the same time. Those ones probably aren’t going to be as helpful, unless there’s just very sound sensitive, but they probably won’t do much else.
And then there are now some computer programs and interfaces that do suggest that they can introduce sound filters to then desensitize your system. And again, particularly for misophonia, to desensitize particular sounds that you seem to be hypersensitive to by the introduction of them through a controlled sound environment, which does make sense. I mean, that’s kind of like deconditioning or flooding almost for an obsessive-compulsive germaphobe type of thing or whatnot, but we’re doing it to a [01:00:00] different modality.
And so I think we’ll find some good outcomes as these things are published or as the technology comes online, or even if it’s not Bible technology, but it’s using clinics that they can take some of these sounds that are bothersome and in fact, decondition them to some extent, but will we ever get good controlled studies? It’ll be a long time coming is my guess because again, funding source for them is limited. So families might be putting financial risk out there for some of these things that are newly hitting the market and we don’t know enough about them to know if they work.
Dr. Sharp: That’s fair. I feel like you have shared a wealth of information with us today. This interview really flew by. What did we not cover? What’s still hanging out there? Anything that you want to share or clarify or even resources if people want to learn more?
Dr. Michael: Yeah. So, I’ll try to send you some resources. I was actually [01:01:00] testing when I was emailing today. So if I had patients back to back, but sometimes when a patient’s doing a bordering tests, I can email.
Dr. Sharp: I love it. Multitasking.
Dr. Michael: Multitasking at its best. The only thing I would, it goes way back to the beginning of our discussion here, in my opinion, neuropsychologists, our job is to understand not only medical complexity in what’s happening medically neurodevelopmentally and in terms of circumstance, but it’s also to translate all these different conditions and all these different types of ways that the body can perceive senses, and then they transitioning to function in order to optimize the outcome of life.
I think if we’re too dogmatic to say, “Nope, that doesn’t exist. Nope, that’s not in the DSM,” it puts us at risk of missing the complexity of the human condition to some extent. I think a lot of times we end up in arguments that say, is this valid or not valid, but then when we’re saying [01:02:00] it’s not valid, okay, that’s great. But what other option is there? Wait and see? And will that come around in 5 years, 10 years, 15 years? Will people just ignore it because it’s not polarizing enough to get energy?
And so now we just leave patients with something that we know is problematic or saying good luck with that. And that does bother me sometimes. So I think we need to be more diligent in our own field to recognize that we are responsible to understand and to move forward, not to necessarily stagnate cluster and then minimize some of these challenges that our patients do have.
Dr. Sharp: Well said. Yeah, I think that happens in many cases in our field. We do like to get dogmatic and maybe self-righteous occasionally.
Dr. Michael: Every now and again. I see that daily.
Dr. Sharp: Well I appreciate this. I really do. It’s funny when we were way back [01:03:00] trying to schedule this interview, I think I phrased it in email. I was like, “Are you in the camp of, this is a thing, or this is not a thing?” And you thankfully wrote back with a very nuanced response and I think presented a pretty compelling case that this was something worth looking into and something that we could potentially help with and distinguish from some of these other disorders that get mixed up in the picture.
Dr. Michael: Absolutely.
Dr. Sharp: Yeah, I really appreciate it. This is fun, Mike.
Dr. Michael: I appreciate it. If there’s anything else you ever need, I’m a wealth of some prevalence knowledge. Hopefully, you found someone for lifespan neuropsychology because you had asked me about that initially too. And there’s a lot of us out there in the field, but I know that that’s probably if you haven’t found someone yet, that’s worth finding someone for because I think in neuropsychology it’s like you can’t do lifespan, right?
It’s too [01:04:00] complex. You got to know your pediatric, your Mirabelle, your geriatric. It’s not feasible to really do it all well, but there are certainly people doing it well or even the neuropsychologists at blend clinical practice with forensic practice and they can have free or renals or a couple of big wigs out there explaining how did you mitigate that in your career? So there are some more really interesting things there to keep people not reified in their own profession.
Dr. Sharp: I like that. Well, and thanks for providing a little teaser for some future episodes here. These are all good things that I want to talk about. So yeah. Grateful for you. Thanks. I hope our paths cross again soon.
Dr. Michael: I look forward to it. Take care of, Doc.
Dr. Sharp: All right, y’all, thank you so much for tuning in as always. I really appreciate you. I appreciate all of the new subscribers that I’m seeing showing up in the numbers. It’s great to see the word [01:05:00] spread for testing and neuropsychology. There’s a number of resources in the show notes today. So check those out as always.
And like I said at the beginning, if you are interested in a group coaching experience, you can get more information at thetestingpsychologist.com/consulting.
Okay. Hope you all are doing well. And I’ll look forward to talking to you on Thursday with another business episode. Take care.
The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for [01:06:00] professional, psychological, psychiatric, or medical advice, diagnosis, or treatment. Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.