adhd/auditory processing eval question

[kirstenhill]

I've been thinking about evals for my DS6 for a few months, and we finally got in a well child check with a primary care doc we liked and who listened to my concerns. She agreed we should seek further evals. I don't think she has a lot of experience referring for evals though. She listed 3 places, and one was totally off -- it wasn't a clinic or a place for evals at all. I did some googling and I think she meant another place with a similar name. That place didn't do evals but did at least offer services for kids who already have diagnoses. LOL! The other two places were clinics within a large university hospital, and the doc said she didn't really know the difference between the two - and sure enough, only one did ADHD evals. I'm waiting for a call back from the scheduling desk of that place right now (I guess they all went to lunch?), to find out more info. I know there are plenty of other choices too, but I want to at least try talking to these people first.

 

When we discussed DS's auditory symptoms vs. the attention related symptoms, she said it was hard to tease out what was what and we would probably have to evaluate both...but she thought that the adhd eval would address the potential auditory issues too. Does that sound right? I am thinking that what I've read here and elsewhere is that an auditory processing eval would be with an audiology clinic of some sort.

[Tiramisu]

I've been thinking about evals for my DS6 for a few months, and we finally got in a well child check with a primary care doc we liked and who listened to my concerns. She agreed we should seek further evals. I don't think she has a lot of experience referring for evals though. She listed 3 places, and one was totally off -- it wasn't a clinic or a place for evals at all. I did some googling and I think she meant another place with a similar name. That place didn't do evals but did at least offer services for kids who already have diagnoses. LOL! The other two places were clinics within a large university hospital, and the doc said she didn't really know the difference between the two - and sure enough, only one did ADHD evals. I'm waiting for a call back from the scheduling desk of that place right now (I guess they all went to lunch?), to find out more info. I know there are plenty of other choices too, but I want to at least try talking to these people first.

 

When we discussed DS's auditory symptoms vs. the attention related symptoms, she said it was hard to tease out what was what and we would probably have to evaluate both...but she thought that the adhd eval would address the potential auditory issues too. Does that sound right? I am thinking that what I've read here and elsewhere is that an auditory processing eval would be with an audiology clinic of some sort.

 

Right about the auditory processing eval having to be done at an audiology clinic. One that specializes in pediatrics is best.

[PeterPan]

A psych can do an APD screening as part of your eval, but it's a specialty, even among audiologists, to get the full APD eval.  What you might want to do is so who you want to go to for the APD eval, get a real hearing eval and a screening with them, then you'll know if you want the full eval.  If you get into the psych sooner and the psych runs the APD screening, that would give you info too.  The psychs never bothered to do an APD screening on dd.  I took her in to the big state uni, who did a regular hearing exam and ran the APD screening, all for $35.  Private would have been $380 for the same thing.  And I could get into that university audiologist screening in 1-2 weeks.  Waiting for the psych is usually 1-4 months, depending.

 

I would take your time on the psych eval and not rush.  It really matters whether the psych is homeschool-friendly or not.  You can get a really nasty experience if they're not.  Personality matters and whether you feel comfortable talking with them.  They'll usually talk with you on the phone a couple minutes, allowing you to gauge this.  If you're paying for this yourself, cost will matter.  Around here hospital services are 3X the cost of the same service privately.  It's OUTRAGEOUS.  If you're paying for the eval yourself, that's huge.

 

Fwiw, my dd had *some* issues on the APD screening but not enough to get her an APD label.  I think it's worth doing the screening.  An OT eval will actually be a lot more enlightening, and if you need a referral to get your insurance to cover it you might want to go ahead and get that done too.  You might find there are retained reflexes, midline issues, sensory issues, etc. they could work on.  Even my dd's issues the audiologist turned up go back to the midline and OT issues.  An OT eval is always a good idea.

[Crimson Wife]

At 6, you're probably going to have difficulty finding an audiologist willing to do CAPD testing. Most clinics won't test until age 8.

 

Also, I do have to warn you that if there's a question of AD(H)D (and/or working memory deficit) vs. CAPD, the audiologist will probably send you to a neuropsych before doing the 2nd part of the CAPD battery. That's what happened to my oldest.

[PeterPan]

There are age-normed APD screening tools for younger kids that a psych can run.  The audiologist only had the main one they use (SCAN? I forget), but they could run portions of it even though he wasn't old enough for the whole thing.  They also just watched him and could tell things and have a pretty good sense.  They'll look at history as well. You're typically going to have issues with background noise, and with ds his behavior breaks down with lots of noise (the SPD), but he doesn't have issues actually comprehending with background noise.  (For instance, he does ok with verbal instructions in a loud gym during gymnastics, where a person with APD might be functionally deaf in that scenario, unable to distinguish or hear the instructions.)  The audiologists got to see some of the oddities we told them were happening (like his unresponsiveness if you're behind him and talk to him) and of course that really got their attention.  We later got the ASD label and had some odd results in his OT eval, both of which together explained it.  

 

I'm saying it's worth it to go ahead and get that regular audiology eval done, because you'll at least get good information and an analysis of your situation.  You never, ever know what will pop up that you weren't expecting.  But that's easy for me to say, because we can get it done for $35.  I just felt like the age-normed APD screening by the SLP wasn't worth much.  It flagged him for half the test and not the other half, and then you're not sure if the things were skewed by the dyslexia or what.  

 

About the ADHD and APD overlapping.  I called one private audiologist who wanted full, recent psych and SLP evals before they'd see you for an APD eval.  I think she was in the camp of put them on meds first.  The univ. didn't care about the meds, so long as the ADHD was controlled behavior-wise, but they do a full screening before they put you on the year waiting list for the longer APD eval.  The 3rd audiologist I talked with, private, would do the regular eval and screening before a full booth eval.  Her twist and experience was that, for mild APD and areas of weakness, the results would shift with the ADHD meds, that someone would be screening with problems, start the meds, and the scores would normalize.  

 

Just interesting stuff that makes you go hmm.

[kirstenhill]

That's interesting. There's a lot to consider! I put in a call to a university dep't that does apd evals, but they haven't called me back yet either. Nobody returns calls on a summer Friday I guess...LoL.

 

While I feel like I have ideas and things I am trying (ideas from "smart but scattered" etc) for behavior issues that appear attention related, what is driving DH and I even more crazy on a daily basis is the fact DS is mishearing so much of what we say. I feel like this has gotten worse if anything in the last few months.

 

He passed the standard hearing screen at the well child appointment, but I suppose those are about as accurate as the vision screening in the ped office is? I haven't really felt like he can't hear us...just that he isn't hearing us correctly. I dont really understand how the hearing screen works, but I did find it curious that the nurse said to DS, "you're missing the beeps. Pay more attention and raise your hand when you hear them. We have to keep doing this until we get all of them." I was thinking that it sees rather odd and like he is having some trouble if he was missing the beeps. But ?? The nurse was in a hurry to run off somewhere else after the test so I didn't ask her, and the doctor just said, "well, he passed it."

[PeterPan]

I don't know.  My kids both have ADHD labels and both can pass a hearing screening just fine.  I'd get him in to the audiologist to see what's going on there and then head to the psych.  You'll probably be into the audiologist in 1-2 weeks, where a psych will be 1-4 months or more.

 

Hopefully it's nothing, but it's better to get it checked thoroughly.  

 

Adding: Our univ schedules large blocks, so they were able to be pretty responsive and take history, be thorough.  I was pleased with the experience.  Hopefully you will be too.  :)

[Crimson Wife]

 

He passed the standard hearing screen at the well child appointment, but I suppose those are about as accurate as the vision screening in the ped office is? I haven't really felt like he can't hear us...just that he isn't hearing us correctly. I dont really understand how the hearing screen works, but I did find it curious that the nurse said to DS, "you're missing the beeps. Pay more attention and raise your hand when you hear them. We have to keep doing this until we get all of them." I was thinking that it sees rather odd and like he is having some trouble if he was missing the beeps. But ?? The nurse was in a hurry to run off somewhere else after the test so I didn't ask her, and the doctor just said, "well, he passed it."

 

Hmm, I'd go to an audiologist for an eval where they put the electonic thingie in the ear because that will provide an objective measurement of his physical ability to hear the tones. IOW it won't matter if he consciously pays attention because the audiologist will be measuring the auditory system's response to the sounds. It's called a DPOAE test.

[PeterPan]

Yes, the univ we went to did that as part of ds' eval.  They have multiple ways to check and recheck/confirm, so the attention won't affect the accuracy of the results.  And while they're doing this, they're making observations on things that might indicate warrant for an APD eval later, etc., so even though he's too young for a full APD eval you're still getting some counsel there.  

 

Ds' eval was with 2 grad students and a professor, so it was especially interesting.  The ones who weren't interacting/leading the eval were observing, so you had even more observation and data gathering than normal.  It was a good experience.

[kirstenhill]

 I found a place that will do an auditory processing screening, and would do the full test after he turns seven (really, only six months from now) if the screen warranted it.   I don't know how soon they can get me in -- I left a message for scheduling but no call back, but I am assuming it won't be too long of a wait.

 

First two places I called to see what the wait is like for an adhd eval were about six months and I have two more places to call tomorrow.  I am definitely not in a rush, but if one had a shorter wait I might go for that. 

 

What is the best way to figure out what my actual out of pocket cost will be at each place?  Do you suppose my insurance company will give me a list of tests they do or don't cover? Or do I need to get a list of what the provider wants to do and run that list by the insurance company?  I've never had any medical situations like this before where we could really take our time figuring out where we want to go, how much we might spend.  Emergencies you don't get to choose who/where you get care typically and pregnancy/birth was going to cost about the same no matter where we went...but it seems like there could be some vast differences in cost here potentially.  

 

I tried to ask about cost at one place and they really wouldn't say much of anything about it and just suggested calling my insurance company.

[Tiramisu]

 I found a place that will do an auditory processing screening, and would do the full test after he turns seven (really, only six months from now) if the screen warranted it.   I don't know how soon they can get me in -- I left a message for scheduling but no call back, but I am assuming it won't be too long of a wait.

 

First two places I called to see what the wait is like for an adhd eval were about six months and I have two more places to call tomorrow.  I am definitely not in a rush, but if one had a shorter wait I might go for that. 

 

What is the best way to figure out what my actual out of pocket cost will be at each place?  Do you suppose my insurance company will give me a list of tests they do or don't cover? Or do I need to get a list of what the provider wants to do and run that list by the insurance company?  I've never had any medical situations like this before where we could really take our time figuring out where we want to go, how much we might spend.  Emergencies you don't get to choose who/where you get care typically and pregnancy/birth was going to cost about the same no matter where we went...but it seems like there could be some vast differences in cost here potentially.  

 

I tried to ask about cost at one place and they really wouldn't say much of anything about it and just suggested calling my insurance company.

 

We went to a major children's hospital. They had to get an authorization from the insurance company prior to testing. In my case, it was covered so I went in without any worries. My friend's insurance did not cover it. But she was still able to go in knowing exactly what it would cost. It's good to call the insurance company, but it's also nice to have a place that checks it all out ahead of time so there are no surprises.

 

One thing about the screening. We had one that dd passed despite being diagnosed at the children's hospital years later. If you decide to go with the screening, make sure you get the results and keep them. When it only became clearer over time that my dd's problems were audiological, I could refer to the old test results and see that there could be a problem that the first audiologist didn't think was a problem. Sure enough, with more complete testing, that continued to be the area of dd's difficulty and it was significant enough for her to get a CAPD dx. 

 

My dd also was found to have another audiological abnormality, and it was nice that she was at a facility that they could check it out to make sure it didn't indicate other problems.

[Targhee]

I was told by developmental pediatrician and two different SLPs that if ADHD is present that tests for CAPD would be invalid because they couldn't tease out what was missed from processing bs they were distracted at the moment. At this point my child was taking Meds for ADHD, doing VT, and remediation some fine motor things with OT. She was having trouble with understanding spoken directions (meaning) somewhat and difficulties with clear expression (after a year of speech therapy they still couldn't decide if it was a stutter, a tic, or an LD - or if she heard sound the same way she was expressing them, she also has terrible rhythm and repeats notes occasionally while playing piano just as she repeats middle and end sounds in words). I asked if we couldn't do therapy for CAPD anyway and was told no. It was very frustrating to hear, but I understand the reason behind it. At no time was I told that addressing ADHD would address CAPD. That doesnt make sense to me.

[Targhee]

That's interesting. There's a lot to consider! I put in a call to a university dep't that does apd evals, but they haven't called me back yet either. Nobody returns calls on a summer Friday I guess...LoL.

 

While I feel like I have ideas and things I am trying (ideas from "smart but scattered" etc) for behavior issues that appear attention related, what is driving DH and I even more crazy on a daily basis is the fact DS is mishearing so much of what we say. I feel like this has gotten worse if anything in the last few months.

 

He passed the standard hearing screen at the well child appointment, but I suppose those are about as accurate as the vision screening in the ped office is? I haven't really felt like he can't hear us...just that he isn't hearing us correctly. I dont really understand how the hearing screen works, but I did find it curious that the nurse said to DS, "you're missing the beeps. Pay more attention and raise your hand when you hear them. We have to keep doing this until we get all of them." I was thinking that it sees rather odd and like he is having some trouble if he was missing the beeps. But ?? The nurse was in a hurry to run off somewhere else after the test so I didn't ask her, and the doctor just said, "well, he passed it."

This is common in ADHD kids. Very common. I've been to audiology with two of my ADHD kids for this (and one for additional reasons). I'm not saying don't pursue audiology. I really wish I could have got more answers for my dd with an LD. But when you only partially pay attention (your mind is driving on with other things) you don't get the message clearly, and "can you get me the remote" becomes "can you get another goat" to the ADHD listener.

 

Try requiring a reiterative response to clear up miscommunication and unmet/not understood expectations.

[kirstenhill]

Thanks, Targhee.  That's good to know.  I'll probably at least try the screen for the CAPD just to see...Since I don't actually know for sure at this point what we are dealing with, I don't want to rule anything out.  Unless it turns out that just doing the screening is super pricey...I am hoping it won't be though.

 

[kirstenhill]

We got in for an audiology screen later next month.  And I called the insurance company and they were extremely helpful in getting the step by step of how to figure out what my cost is going to be.  I'm not sure the steps work very well without going further down the road toward an actual appointment some place, but at least it wouldn't be a surprise when I got the bill.   So, I am feeling good about making progress here.  :-)

[PeterPan]

I was told by developmental pediatrician and two different SLPs that if ADHD is present that tests for CAPD would be invalid because they couldn't tease out what was missed from processing bs they were distracted at the moment. At this point my child was taking Meds for ADHD, doing VT, and remediation some fine motor things with OT. She was having trouble with understanding spoken directions (meaning) somewhat and difficulties with clear expression (after a year of speech therapy they still couldn't decide if it was a stutter, a tic, or an LD - or if she heard sound the same way she was expressing them, she also has terrible rhythm and repeats notes occasionally while playing piano just as she repeats middle and end sounds in words). I asked if we couldn't do therapy for CAPD anyway and was told no. It was very frustrating to hear, but I understand the reason behind it. At no time was I told that addressing ADHD would address CAPD. That doesnt make sense to me.

These were audiologists I was talking with.  The professor at the state uni didn't care if they were on meds or not so long as their behavior seemed controlled.  The private audiologist was the one who told me she had before and after data showing improvement of the CAPD symptoms with ADHD meds.  And this fits with geodob's theories about auditory attention as a cause of APD symptoms.  It would also explain the strong overlap in ADHD and APD and why you have scenarios with ADHD and *some* APD symptoms but not enough to get to a diagnosis.  I'm not saying there aren't more opinions out there among audiologists on how to handle it.  I just think the differences are interesting.

 

I'm not really an expert on it, but the cases I've known of for APD all had issues with figure-ground.  My dd is *right on the line* for tipping over to needing a full eval on that parameter on the SCAN3 (is that the right name? slips my mind) but her other parameters were ok.  I'm just saying you're describing language processing and maybe some kind of motor planning issues, and those aren't necessarily APD.  Those could have other explanations.  Did they do a CELF or other detailed language testing to help you target her weaknesses?  Has the speech issue improved?  The rhythm is EF, at least in our house.  My dd just has poor rhythm, but my ds has nasty, nasty rhythm issues, not able to clap to a beat AT ALL before interventions.  We did on-hand clapping, mine over his, just to get him able to do a single clap.  That extreme impulsivity and inability to control shows up with his basketball dribbling (or lack of dribbling, lol) too.  We just started working on it.  EF is interesting stuff.

[PeterPan]

This is common in ADHD kids. Very common. I've been to audiology with two of my ADHD kids for this (and one for additional reasons). I'm not saying don't pursue audiology. I really wish I could have got more answers for my dd with an LD. But when you only partially pay attention (your mind is driving on with other things) you don't get the message clearly, and "can you get me the remote" becomes "can you get another goat" to the ADHD listener.

 

Try requiring a reiterative response to clear up miscommunication and unmet/not understood expectations.

Does she also have dyslexia as part of her mix?  

 

I need to see if my straight ADHD dd does that.  She's such a slow processor, you wouldn't know if she did, lol.  And you could even have differences that occur with having multiple kids in the house.  You'd have more background noise, so there would be more occasions for that.  My dd, indeed, does test as borderline on the figure-ground and does get frustrated with it.  Not enough to get her a diagnosis, but enough that the audiologist said it's a relative weakness and to understand it and work around it.  

 

That's where I don't think the disease model to this is helpful, because it's not like some lightswitch, yes/no, kwim?  It's weaker, weaker, till you get enough going on that they give you the label.  But they ran the SCAN screening tool thing on her so we could see the areas that were weaker.  The one we thought was indeed was.  The audiologist said since you already have the ADHD label, use that as your pretext to get better seating (up close, less distracting noise around you), etc. even without the APD label.

[Targhee]

Does she also have dyslexia as part of her mix?

 

I need to see if my straight ADHD dd does that. She's such a slow processor, you wouldn't know if she did, lol. And you could even have differences that occur with having multiple kids in the house. You'd have more background noise, so there would be more occasions for that. My dd, indeed, does test as borderline on the figure-ground and does get frustrated with it. Not enough to get her a diagnosis, but enough that the audiologist said it's a relative weakness and to understand it and work around it.

 

That's where I don't think the disease model to this is helpful, because it's not like some lightswitch, yes/no, kwim? It's weaker, weaker, till you get enough going on that they give you the label. But they ran the SCAN screening tool thing on her so we could see the areas that were weaker. The one we thought was indeed was. The audiologist said since you already have the ADHD label, use that as your pretext to get better seating (up close, less distracting noise around you), etc. even without the APD label.

No dyslexia - she is a precocial reader, and when she focuses she does well enough in spelling (her handwriting is pretty sad though). There is still a piece to her puzzle missing htough. No one - doc, psych, SLP, OT, dev ped doc - has been able to figure out what it is for sure. They ruled out a number of things (dyspraxia, ASD, mild CP), and have tried looking at it as anxiety-related, and like to fall back on "it may just be the difference between her IQ and her processing speed" (normal processing speed but IQ is almost 3 standard deviations above). Right now she's in an OK place, so I feel like I shouldn't be dissatisfied even though there is a part of me that thinks "if I only knew what the piece of the puzzle is we could help her get to a really good super awesome place."

[PeterPan]

Targehee, I don't have a great answer for you, and my dd is not yet up to ask her if she does that.  (She was up crazy late for driver's ed, woo-woo!)  One interesting thing though is our brains do predictive vision.  That's probably not what it's called, lol.  Basic idea though is that you see (literally see) what you think you're going to see.  It's one of the things they talk about in VT, because the brain will use it to create a false sense of depth perception.  The brain calculates out what it expects and bam.  Same deal with color, where your color perception will be affected by what you anticipate.  

 

So whether there's some auditory prediction going on and then the processing speed affecting that and making the results even more off, dunno.  I need to ask dd.  I think sometimes it's fair game to do some general things and see if they might hit some of the parameters and together get things to move.  Have you done any cognitive therapies?  Many of the cognitive therapies will bring together vision, auditory processing, working memory, etc.  Some of the things recommended for APD can in fact be good across labels.  With each cognitive therapy type thing I've done with my dd I've felt like we got some benefit.  Sometimes they're even free or relatively low cost.  I'm particular keen on metronome work, but audiblox, PACE, Cogmed, other software programs, there are tons of things out there.

 

If you want an odd idea, BalavisX attempts to improve auditory processing and attention using the rhythmic bouncing of the balls.  Neurofeedback is another that is good for attention and anxiety that also supposedly can affect/improve auditory processing and language.  Some of these are more global in effect and good for the mix.  You can't be guaranteed they'd help the auditory symptoms, but even if they just help the ADHD and anxiety you're still ahead.  

 

For disclosure, my ds is getting BalavisX right now with the OT and I hope to start him on neurofeedback in the next month.  My dd has had a month of neurofeedback.  What's interesting is now that my ds is back in speech therapy (thanks to the scholarship, hallelujah), we're finding that LIPS/Barton was ROCKET FUEL for his speech!!  I think it's because it both improved his working memory (HUGE) and his discrimination. He's able to do these long strings of words and sounds now, where she was constantly limited before with what she could do with him.  She was totally BLOWN AWAY.  

 

So these areas overlap so much, I think it's ok to think globally and do things for midline, working memory, attention, etc., and see if the affect carries over.

[PeterPan]

Ok, I'm back and had a chance to ask her.  She has figure/ground issues right on the line to needing the full eval, and of course the ADHD.  She said it's usually with background noise and it goes to jibberish, not actual word replacements.  

 

There's an interesting book It's On the Tip of My Tongue that goes into word retrieval errors.  Not that it directly applies, but there are patterns to word retrieval errors.  Interesting to ponder if there are patterns to her word replacements.  There's also a phonological processing disorder in the DSM that is distinct from reading disorder.  

[PeterPan]

I was just going through my browser tabs and found someone had mentioned this.  http://www.amazon.com/Train-Brain-Hear-Understanding-Processing/dp/1627340033/ref=pd_cp_14_2?ie=UTF8&refRID=1ZASZAM2WDTHAY0VMQD4