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>"When the Brain Can’t Hear"

April 21, 2011

>Integrated Listening Systems or iLs has been on my radar for a few years since my friend Dorothy began using it with her children. (Dorothy’s experience with iLs is here.) I was reminded of iLs early this year, when Hope’s OT evaluation indicated a “probable difference from peers” in auditory integration or auditory processing, which is the brain’s ability to make sense of sensory input that comes in through the ears. The ears hear just fine. But the brain cannot accurately comprehend what the ears hear. And if the brain cannot adequately decipher auditory input, it cannot translate it into an appropriate response.

Auditory processing disorders exist independent of FASD. People can have auditory processing differences with zero prenatal exposure to alcohol. But auditory processing differences can co-exist with FASD. In the case of FASD, the common (70%) co-occurrence of ADHD may add another reason why the brain can’t hear: it checked out. While the attention switch is toggled to “off,” the proverbial tree can fall in the forest and even though Hope is there and her ears hear it, her brain isn’t engaged so she essentially hears nothing.

We did not make a lot of progress with Hope in traditional Occupational Therapy –and now that we know her diagnosis, we know why. But we learned a helpful vocabulary for helping Hope recognize her level of energy and very helpfully, worked through a very long list of calming strategies and identified the ones that most help her.

The biggest benefit of OT from my point of view was being able to interact with her therapists. It took Hope several weeks to relax down out of good behavior during therapy. (She has the ability to contain herself for a few hours at a stretch on a good day when she’s motivated. That is how she skated through two years of preschool without raising any red flags with her teachers for ADHD.) But once she relaxed enough to be herself, her therapists had some keen insights into her behaviors.

Like this: “What do you think of the idea that Hope has a much easier time attending to things than to people?”

That is one of the things about Hope that made me feel crazy for wondering if she had ADHD. In some cases, like free play or even doing an assignment like a page of handwriting, Hope seems to be able to stay on task. But other times, getting her to attend is like trying to catch a butterfly without a net. I am too close to  her too much of the time to see the bigger picture like her therapists could. They observed a pattern to her inattention that I did not.

While Hope is very social and according to the recent testing, her ability to read and respond to non-verbal social cues (like facial expression and body language) is not impaired, she still has a harder time interacting appropriately with grown-ups. Maybe because her interactions with grown-ups almost always require her to accurately perceive and decode auditory input: what they are saying.

*****

Hope’s reaction to verbal requests is unpredictable. But auditory processing differences might partially explain it. Here’s an example. With bedtime approaching, I may say, “Hope, it is time to go upstairs, put on your pajamas, and brush your teeth. Then I will read you bedtime stories.” In fact we follow that same routine every night so it is hardly news to her –unless she rarely hears (understands) it the same way twice. Listen to how loaded that ordinary request might be depending upon what part of it she hears.

“Go upstairs.” She thinks she is being sent to her room (a safe space for collecting herself when she’s overwhelmed) which feels like she’s being punished which feels unjust because she isn’t aware she did anything wrong so she melts down, unable to comply.

“I will read you bedtime stories.” But then I don’t, waiting for her to comply with the pajama and tooth brushing requests, which she did not hear. It feels like mommy made a promise but didn’t keep it so Hope melts down, unable to comply.

“Put on your pajamas and brush your teeth.” Hope has no natural sense of time so isn’t aware bedtime is approaching. And mommy seems to be giving arbitrary orders with none of the accustomed relationship words, which must mean she is really mad at me about something. But I didn’t do anything. So Hope, wounded and angry, melts down, unable to comply.

*****
So what if Hope has a much harder time attending to people because she has auditory processing deficits?
One approach would be to deliver the message some other way than through her auditory system. Like we could make a visual picture schedule labeled “Bed Time,” point to the schedule and say “Bed Time” and let the pictures cue her to put on  pajamas, brush teeth and read stories in that order.
But in Hope’s case, we know from testing that she doesn’t have problems with other key parts of social communication, like non-verbal cues. So she’s not confused because people, while talking, also gesture and make facial expressions. She may be struggling in part because she’s overly dependent on her non-verbal strengths, which doesn’t get her very far in a world driven by spoken language.
Her non-verbal strength suggests another intervention. Rather than issue the bedtime instruction from the other room, I need to engage her non-verbally: be near her, touch her to get her attention, establish eye contact, gesture to my watch and point to upstairs, sign putting on pajamas, brushing teeth, reading stories while I say the words to ensure my spoken message gets across in a way that is meaningful to her.
Yet another intervention is auditory processing therapy: we can make an attempt to help Hope re-wire her neural circuitry to more efficiently process auditory input including spoken language. iLs is one  of several therapies for auditory processing deficits.

In the process of evaluating iLs, I read two books on Auditory Processing Disorder (APD), Karen Foli’s memoir of her son’s journey with APD, Like Sound Through Water, and When the Brain Can’t Hear by Teri James Bellis. I thought I was reading to find out if auditory integration therapy was worth the investment (in time and money) for Hope. But I came away impressed that Mercy and Joy  –neither one exposed –may have even clearer signs of auditory processing deficits for reasons I’ll discuss in my next post.

So we’re going ahead and starting iLs today with Hope, not quite certain what the results will be (with organic ADHD in play), but willing to try since we are sure it will help Mercy and it may be the only form of auditory processing therapy accessible to Joy.

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