If It’s NOT CAPD Then Where do SLPs Go From There?

In July 2015 I wrote a blog post entitled: “Why (C) APD Diagnosis is NOT Valid!” citing the latest research literature to explain that the controversial diagnosis of (C)APD tends to

a) detract from understanding that the child presents with legitimate language based deficits in the areas of comprehension, expression, social communication and literacy development

b) may result in the above deficits not getting adequately addressed due to the provision of controversial APD treatments

To CLARIFY, I was NOT trying to disprove that the processing deficits exhibited by the children diagnosed with “(C)APD” were not REAL. Rather I was trying to point out that these processing deficits are of neurolinguistic origin and as such need to be addressed from a linguistic rather than ‘auditory’ standpoint.

In other words, if one carefully analyzes the child’s so-called processing issues, one will quickly realize that those issues are not related to the processing of auditory input  (auditory domain) since the child is not processing tones, hoots, or clicks, etc. but rather has difficulty processing speech and language (linguistic domain).

Let us review two major APD Models: The Buffalo Model (Katz) and the Bellis/Ferre Model, to support the above stance.

The Buffalo Model by Jack Katz, PhD contains 4 major categories:

1. The Decoding Category – refers to the ability to quickly and accurately process speech, most importantly at the phonemic level (Since this involves speech sounds then this has nothing to do with the processing of auditory stimuli. In other words deficits in this area are of linguistic nature and the highly correlated with reading deficits characterized by weak/deficient phonemic awareness abilities/poor emergent reading abilities).

Here are a few examples of so-called “decoding” deficits:

• Difficulty with processing what is heard accurately and quickly; tends to respond more slowly (indicative of weak language abilities)
• Problems keeping up with the flow of communication and running discourse (indicative of weak language abilities)
• Problems processing at a phonemic level (e.g, can’t blend ‘t,’ ‘u’ and ‘b’ together to make the word ‘tub’) (indicative of phonemic awareness deficits)
• Trouble reading and spelling (reading and writing deficits rather then APD)
• Receptive language problems and impairments in discrimination, closure abilities and temporal resolution (this one just explains itself)

2. Tolerance-Fading Memory (TFM) Category – refers to two skills that are often found together: “tolerance” – understanding speech in noise (processing of language) and “fading memory” – auditory short-term or working memory (memory= higher level cognitive skills vs. a pure auditory entity).

Here are a few examples of given of tolerance-fading memory deficits:

1. Difficulty blocking out background noise so child’s performance suffers in a noisy classroom environment, may be labeled as distractible (clearly describes the child with poor language comprehension)
2. Linked to poor reading comprehension, oral and written expression, poor short-term memory (in other words describes a learning disability)

3. Integration category 

• difficulty bringing in information from different modalities, such as receiving auditory and visual information at the same time; these children are often labeled as learning disabled or even dyslexic (this one just explains itself)
• They may be poor readers, have trouble with spelling, and exhibit difficulty with multimodal tasks (clearly indicative of reading and writing deficits or students which will often get classified in the schools with specific learning disability)

4. Organization –disorganized thinking; sequencing errors (This appears to be indicative of the social communication / executive function deficits, as well as word-retrieval deficits)

Another major APD model is the Bellis/Ferre Model, which divides the above four categories into the following subtypes:

• Primary subtype

1. Auditory decoding – listening difficulties in noisy environments
2. Integration deficit – problems with tasks requiring both cerebral hemispheres to cooperate
3. Prosodic deficits- difficulty understanding the intent of verbal messages

• Secondary

1. Associative deficits- receptive language disorder
2. Output organization deficits- attention and/or executive function disorder- might also be caused by an auditory efferent dysfunction

Similar to the Buffalo model, the Bellis/Ferre Model, describes deficits of linguistic versus auditory nature many of which are characteristic of a learning disability.

Consequently, if an SLP is referred a student with confirmed or suspected (C)APD, the first thing they should do is to administer a comprehensive battery of testing to determine the scope of the student’s linguistic deficits. To test general language abilities, consider using the Test of Integrated Language & Literacy Skills (TILLS) (Review HERE). But SLPs shouldn’t just stop there! They need to dig deeper to make sure that the following major areas of language are assessed:

• Listening Comprehension (for stories not just sentences)
  • Listening Comprehension Test -2 (ages 6+)
  • Listening Comprehension Test-Adolescent (ages 12+)
  • Assess skills informally through presentation of science or social studies -related grade level passages when applicable
• Comprehension of Ambiguous/Figurative Language(idioms, ambiguous expressions, etc.)
  • Clinical Evaluation of Language Fundamentals -5 Metalinguistics (ages 9+)
• Semantic Flexibility Skills(can the student easily generate definitions, synonyms, antonyms, multiple meaning words, etc.)
  • Expressive Language Test-2 (ages 5+)
  • WORD Test 3 Elementary (ages 6+)
  • WORD Test 2 Adolescent (ages 12+)
• Narrative Abilities(can the student coherently and cohesively summarize books or movies)
  • Obtain an informal narrative sample
• Critical Thinking and Problem Solving
  • Test of Problem Solving-3 (ages 6+)
  • Test of Problem Solving-2 (ages 12+)
• Social Communication Skills
  • Social Language Development Test Elementary (ages 6+)
  • Social Language Development Test Adolescent (ages 12+)
  • Informal Social Thinking Dynamic Assessment Protocol® (ages 8+)
• Executive Function Abilities 
  • The Executive Functions Test-Elementary (ages 7+)
  • Situational Awareness STOP Observation Tool (ages 8+)

The above list doesn’t even reference assessment of Reading, Writing, and Spelling, all areas which play a crucial role in academic language as any deficits displayed in those areas may also present as CAPD symptoms.  If literacy testing is not performed, it is still important for SLPs to review and seriously consider the results of learning evaluations in order to see the whole child and not just their limited functioning in select areas of oral language comprehension, expression, and use.

It is very important for SLPs to understand that without a comprehensive language and literacy assessment of deficit areas it is very difficult to adequately address the student’s linguistically-based deficits! Thus, if testing shortcuts are taken then the referral of students diagnosed with the (C)APD will not cease, and SLPs will continue to be in the dark regarding which goals should be addressed with these students in therapy.

Related Posts:

• Why (C) APD Diagnosis is NOT Valid!
• C/APD Update: New Developments on an Old Controversy
• How Early can “Dyslexia” be Diagnosed in Children?
• Components of Comprehensive Dyslexia Testing: Part I- Introduction and Language Testing 
• Part II: Components of Comprehensive Dyslexia Testing – Phonological Awareness and Word Fluency Assessment
• Part III: Components of Comprehensive Dyslexia Testing – Reading Fluency and Reading Comprehension
• Part IV: Components of Comprehensive Dyslexia Testing – Writing and Spelling
• Review of the Test of Integrated Language and Literacy (TILLS)
• Special Education Disputes and Comprehensive Language Testing: What Parents, Attorneys, and Advocates Need to Know
• What do Auditory Memory Deficits Indicate in the Presence of Average General Language Scores?
• Why Are My Child’s Test Scores Dropping?
• Comprehensive Assessment of Adolescents with Suspected Language and Literacy Disorders