Dr Judith Guedalia

The mother spoke to me with tears in her voice.  "We are having a lot of difficulty with my daughter in school.  She is eight years old, a very good girl and is trying, but the teachers are angry at her and keep saying that she isn't paying attention.   We have been to neurologists, psychologists and special education teachers who have all said she is fine, we even tried medication for ADHD - which didn't help and now they say it's all in MY head!!!"  Both the ‘angry at her' and ‘in my head', intrigued me.  One of my axioms is that there is no child that has a mother who wants to see a problem in with child.  It goes without saying, that if that child's mother does want to see a problem, then the child REALLY needs help! (An example thereof is Munchausen's-By-Proxy, but that's another article.)

When this cute 8 year old came in for Neuropsychological Assessment, it was hard to imagine that she made her teachers ‘angry' at her.  Maybe frustrated was a better word.  Another of my basic axioms in life is that: we are all trying our best to succeed.  That goes for ALL of us, children, parents, teachers, doctors etc., etc., etc.  So when that ‘success' eludes us we respond in different fashions depending on our personalities and our life history of dealing with success and failure.  Many people respond to a student's inability as a ‘thwarting' of their own success.  The converse example is seen in the famous Pygmalion Effect, where teachers were told that specific students were ‘gifted', when in reality they were average.   When these children achieved results that were ‘only' average or even poorer than that, the teachers understood the ‘gap' in expectation and result as their ‘fault' and attempted to teach them in a different fashion, sometimes even giving supplemental classes on their own time.  The end result was the children achieved higher scores than their ‘average' peers.

So I looked at Tikva's (not her real name) ‘condition' and especially the behavior she elicited from her teachers, as one of a ‘stumbling block' to the teacher's success.

How did her neuropsychological scores and the mother's and teacher's description differ and how were they the same, that was my challenge, since we were all seeing the same child, and we all wanted ‘to succeed'. 

When communicating with Tikva, and hearing her responses, one got the impression that she wasn't ‘paying attention'.  Well the tests for attentional abilities came out WNL (Within Normal Limits).  "She responds to a different question than the one asked."  Both her expressive vocabulary (naming pictures and concepts) and receptive vocabulary (understanding and pointing to the correct picture that described a word or concept) were very much below average.  Maybe she just wasn't intelligent?  Her IQ subtest scores were very disparate, showed strong (average to above average) abilities in tests that required abstract non-verbal abilities and very poor scores (on the impaired level) in sequencing and some language and short term memory encoding skills.

But they also reported that: "Tikva acts as though she doesn't understand what is being said".    When asked to respond to a task where there was ‘background noise', Tikva's function dropped significantly.  When told a story and asked to repeat it, and later retell it and answer questions about it, she couldn't ‘recall' it, and what she did recall did not make sense in relationship to the questions she was asked.  When questioned about the specifics, Tikva responded that the whole story she was told didn't make sense to her at the time either.  "You mean that was a story?  It just sounded like a ‘jumble' of words and sentences."

During the testing sessions I also noted that Tikva:

• Says "huh" or "what" frequently
• Inconsistent responses to auditory stimuli
• Often misunderstands what is said
• Requests that information be repeated
• Poor auditory attention
• Difficulty following oral instructions
• Difficulty listening in the presence of background noise
• Difficulty with phonics and speech sound discrimination
• Poor auditory memory span
• Poor sequencing skills
• Poor receptive and expressive language skills
• Slow or delayed response to verbal requests and instructions
• Reading, spelling and other academic problems
• Learns poorly through the auditory channel
• Exhibits behavior problems - well especially when she perceived she had gotten something wrong.

I began to get a glimmer of a hypothesis.  We did some more testing in the area of phonetic ability.  And the ‘picture' became clearer.  Maybe she had CAPD- Central Auditory Processing Disorder, which is a type of physical hearing impairment, a form of developmental aphasia. (Aphasia is any language impairment caused by brain damage, which is characterized by complete or partial impairment of language comprehension, formulation, and use; excludes disorders associated with primary sensory deficits, general mental deterioration, or psychiatric disorders. Partial impairment is often referred to as dysphasia." from: Terminology of Communication Disorders, Speech-Language-Hearing, Third Edition. By Lucille Nicolosi, Elizabeth Harryman and Janet Kresheck.)  Aphasia, which does not show up as a hearing loss on routine screenings or an audiogram, affects the hearing system beyond the ear, whose ‘job' it is to separate a meaningful message from non-essential background sound and deliver that information with good clarity to the intellectual centers of the brain (the central nervous system). When we receive distorted or incomplete auditory messages we lose one of our most vital links with the world and other people.

These "short circuits in the wiring" sometimes run in families or result from a difficult birth, just like any learning disability (LD).  In some cases the disorder is acquired from a head injury or severe illness. Often the exact cause is not known (it is also not a ‘common' disorder and so could easily be mistaken for other things that ‘go-bump-in-the-night', though Speech and Language Therapists and Neuropsychologists may be more familiar with aphasic disorders than other helping professionals). 

Tikva was sent for further testing to an audiologist and speech and language therapist who concurred with the diagnosis.  She, her parents, and teachers were ‘taught' about CAPD, and though she still is having some problems in the academic ‘sphere' (and may always be challenged in group ‘learning' situations), she and those around her understand the reason for her difficulties; specifically they know that they are all trying to succeed, and that they are complementing/complimenting each other's strengths and not ‘blaming' difficulties on the weaknesses, and especially not responding as though each is out to ‘fail' the other.   

Sometimes, the most we can do when attempting to ‘fix' a problem which is out of our hands is to identify it, and help all concerned understand behavioral responses that may be responses to frustration-of-success.

Originally published in the Jewish Press on April 12, 2006.

Tags: CAPD | Developmental Aphasia | Dysphasia | Jewish Press | Physical Hearing Impairment | Success