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Episode 78. The Ear-Brain Connection: Understanding Auditory Processing Disorder with Dr. Melissa Karp

Did you know that a problem accurately processing sound is often mistaken for an attention problem? What Is the relationship between ADHD and Auditory Processing Disorder (APD)? Who diagnoses APD? Is APD genetic? For those who may not be familiar with APD, of all the processing disorders, this one is most often missed or misdiagnosed. Dr. Melissa Karp, Au.D., and Lindsay discuss how hearing and processing sounds are interconnected and the different ways in which APD and ADHD can manifest.

Melissa Karp is a board-certified audiologist with special expertise in tinnitus treatment, auditory processing disorder (APD) evaluation, hearing aid fitting, and aural rehabilitation. 

Dr. Karp Links: Facebook | Instagram | LinkedIn | Website | TikTok

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Lindsay Guentzel (00:00):

Welcome back to Refocused. I’m your host, Lindsay Guentzel, and today we are talking all about the ear brain connection, understanding auditory processing disorder with Dr. Melissa Karp.

Dr. Melissa Karp (00:12):

People with ADHD can absolutely have APD. They can coexist. They’re both brain-based. With APD it’s harder to process sounds, with ADHD it’s harder to maintain your attention.

Lindsay Guentzel (01:04):

I’ve been led to believe throughout my entire life that I have terrible hearing. Now, I have to preface this by saying it is likely I have bad hearing. I’ve worked in radio and television for so many years with big earphones on my ears and lots of sound coming through them, but that’s more of a recent thing. I’m talking about going back to when I was very, very young and it was always that, “Are you listening? Do you have your ears on? Are your ears clean today? Did you hear what I said to you?” And I was led to believe I had terrible hearing. Now, fast-forward many years, we’re talking almost 35 of them, and I was diagnosed with attention deficit hyperactivity disorder. And after going through the process of talking with my therapist and my medical provider and getting on a great regimen of medication that has made my life so much better, one of the strange little things I’ve become aware of is I actually think I have pretty good hearing.

(02:01):

In fact, now that my brain is not as cluttered with so much stuff going on, stuff goes into my ears and processes in my brain in a much better fashion. Now it’s a complicated subject, so much so that when I reached out to today’s guest and was like, “Hey, we want to talk about ADHD and hearing.” She said, “I’m all in. But I have to tell you there’s a lot to it.” And then she said, “Why don’t we start with auditory processing disorder?” So that’s what we’re diving into with Dr. Melissa Karp on today’s episode of Refocused. Melissa is a board certified audiologist. She received her master’s of science from Vanderbilt University as well as a doctor of audiology from the University of Florida. And she shares her 25 years of experience with patients of all ages through her clinic, Audiology & Hearing Services of Charlotte. Auditory processing disorder is a communication disorder where the brain has difficulty processing sounds and a lot of the symptoms, well, they overlap with ADHD symptoms, meaning sometimes a misdiagnosis can happen.

(03:07):

You have APD, they give you ADHD. You have ADHD, they give you APD, but a person can have both APD and ADHD and as you’ll hear Melissa explain it’s her job to fine tune the diagnosis as much as possible. And she walks us through what that testing looks like, what her patient is doing during it, as well as what she’s looking for because treatment can work really well if the patient and their doctor know as much as they can about what they’re treating. And some of the treatment methods even have great benefits for people with ADHD whether you have APD or not. And the timing of our conversation couldn’t be better. Melissa was gracious enough to join us right after attending the American Academy of Audiology annual conference that was held last month in Seattle. And as we wrapped up our conversation, she shared some really exciting stuff coming out about the connection between hearing and speech and attention issues in people with autism.

(04:06):

There’s so much great stuff ahead. I’m already making a list of the next topics I want to talk to Melissa about. So sit back, relax, or do whatever you need to do to get into your own listening mode and enjoy episode 78 of Refocused with Lindsay Guentzel, the ear brain connection, understanding auditory processing disorder with Dr. Melissa Karp. I loved your excitement when I emailed you. You were like, “Yes, let’s do this, but here’s my thoughts on it.” And I have to tell you, one of the things that I’ve loved so much about working on this podcast is we sit down and we go, what do we want to talk about? And we threw out this idea of hearing, and it actually stemmed from my own realizations, but I’ll tell you it also kind of stemmed from a Super Bowl party I had where I was downstairs and there were maybe 10 people in the room.

(05:01):

It wasn’t some massive gathering, but at one point someone sheepishly looked around and said, “Could we turn on the subtitles?” Now we’re all in our mid-thirties and it was that moment where we’re like, oh yeah, no, we are at subtitle time of life. But there’s also so much also going on that being able to hear and read at the same time is it’s nice. So before we get too far into it, because I know there’s so much to get to, I thought it would be very important to just start by defining auditory processing disorder. So when we are talking about ADHD in hearing, it seems like there’s a lot of gray area and so I think just to make sure we’re starting from a really great structure, let’s begin right there.

Dr. Melissa Karp (05:43):

Right and that’s a really good point. So when we talk about auditory processing disorder, it’s important to realize that we hear with our ears and our brain. One of the ways that I describe it is the ear collects the information, but the brain connects the information. You can have perfectly good hearing when you go into one of those sound booths and you hear the beeping sounds and you can raise your hand for the beeps, but then you get to a Super Bowl party and you can’t follow a conversation. So that’s where more of the processing comes in. It’s how the brain is hearing. Where you get some overlap and some confusion between auditory processing disorder and ADHD is that in someone with ADHD sometimes because of the inattention sound doesn’t actually stay in the brain long enough to process so the symptoms can look very, very similar.

Lindsay Guentzel (06:39):

Let’s talk a little bit about how auditory processing disorder can show up in someone’s life. And I imagine that that is going to be different depending on where they are in life, children versus adults, whether they’ve been through an assessment and diagnosed or if they’re just living out there not knowing that this is going on.

Dr. Melissa Karp (06:56):

Usually there’s certain red flags and you can have an auditory processing disorder or an APD that’s developmental. You can also have one that’s acquired, for example, in my practice, I’m seeing a lot more adults right now, and that comes from things like concussion, traumatic brain injury, post-COVID type symptoms more auditory processing issues are popping up. But for someone, a child, usually it looks like, well, they can hear when they want to hear or there’s a lot of what and huh, but when they go to the doctor, their hearing comes out normal.

(07:37):

And sometimes when we look at things like invented spelling, it doesn’t make sense, they’re not hearing the sounds accurately. Sometimes when children are learning how to write, you’ll see their spelling and it may not be correct, but you can figure out what it is. In a child with APD, it might be completely all over the board and it’s just you have no idea what that means because it’s a really nice representation of what they’re getting in their brain at the time. These are the things that I see coming in, and it gets to the point where the parents are like, “We don’t know what’s going on. They’re having a really hard time following instructions. They are having a hard time in background noise, but sometimes they do just fine and we can’t figure it out so what’s that missing piece of the puzzle?”

Lindsay Guentzel (08:27):

You mentioned a little bit of the confusion with auditory processing disorder and ADHD and that there’s this gray area where a lot of the stuff can fit into both categories, but I’m wondering about the crossover and what you see as far as some of the things that are similar and can go hand in hand for a person at the same time.

Dr. Melissa Karp (08:46):

Yeah, it’s a great question. Typically, we look at an auditory processing test battery, and I describe it a lot of times as we’re peeling the onion. We have to figure out what’s global and the first thing I think about is attention because before, like I said, I want to make sure that sounds are getting in the brain long enough to process. So the first thing we ever do is an attention task. Can they pass that attention task? If they can, great. Let’s move on. The next thing I want to look at is is the hearing working, because I’ve had children come in with misdiagnosed or undiagnosed hearing loss, which is impacting their processing. So I want to make sure that they’re hearing accurately. And that’s a combination of objective tests and subjective tests. So once we’ve figured out that the attention is sufficient for the testing, the hearing is sufficient for the testing, then we start the actual auditory test battery.

(09:44):

But you’re right, people with ADHD can absolutely have APD, they can coexist, and then that’s very carefully teasing out, well, what’s from what and can you control for one and look at the other? But they’re both brain-based. So with APD it’s harder to process sounds, with ADHD, it’s harder to maintain your attention. With APD, it’s going to impact your language, your acceptive receptive language abilities. With ADHD, it’s going to impact your executive function. Both can look very tuned out in conversations, one because of inattention and the other because they’re not understanding what was said and they fall behind and then they’re trying to catch up. It can look like forgetfulness. It can look like struggling to keep up with the conversation, whether it’s from focus or because of decoding. Noise can really impact both populations. With noise it can distract your attention from speech if you’re ADHD.

(10:47):

It’s like, oh, well that conversation’s much more interesting over there and I’m going to focus over here and oh wow, there’s construction happening outside and oh, something’s at the door and oh my gosh, I forgot that I have my slippers on or all of these different things are competing for your attention. For someone with auditory processing disorder, they’re having a hard time hearing the difference between sounds and quiet. So when you add a level of noise, it wipes out more and more of those phonemes or those speech sounds, and it’s very effortful listening. By the time they figured out what was said, the conversation has moved on and then they’re lost. So there’s definitely social implications, anxiety implications. There’s definitely a big overlap. They can look very, very similar.

Lindsay Guentzel (11:36):

I’m nodding along. I mentioned that the realization that I think I have better hearing than I’ve always thought, but I will say the ADHD diagnosis and understanding how my brain works has also made me realize that I need to just give up trying to have meaningful conversations when I’m in a big gathering of people where I know everyone because as you’re saying, I can hear every conversation happening in the room and sometimes I’m able to focus in on the person that I’m speaking to, and it’s not because I’m not interested, it’s just that there is so much coming in from all different areas. It’s like big old surround sound of everyone’s conversations, and I’ve just decided that maybe this isn’t the best point to be having this massive heart-to-heart with someone where I’m trying to be really engaged.

Dr. Melissa Karp (12:18):

Right, absolutely. And changing your environment is huge, and that’s why sometimes we use things like FM systems or low-gain hearing aids with remote microphones. Using technology to bring down that background noise and bring the speaker to you, but that conversation environment with a big party, that’s hard for everybody and it’s really hard to focus on the conversation. That’s when we talk about strategies for, okay, well maybe we need to step to the side to have that conversation.

Lindsay Guentzel (12:46):

Well, I’m relieved to know that I’m not alone in that. I’m wondering if you could just take a minute to spend some time talking about sounds, because you say the word sounds and that is very wide and vast, and there’s a lot that goes into that. There’s noise and then there’s words and there’s music, and there’s all of the things that are happening around us. And a couple of days ago, we got my old Sega Genesis working and we’ve been playing it. It’s very fun to go back to our childhood, but I’m realizing we have always had soundtracks to our lives. There’s just always noise added into things, and it’s just gotten progressively more intense.

Dr. Melissa Karp (13:24):

It is a noisy, noisy world.

Lindsay Guentzel (13:26):

Yes.

Dr. Melissa Karp (13:26):

So typically when I’m talking about sound, especially when we’re talking about auditory processing, I’m talking about phonemes and phonemes are the smallest unit of speech, so it might be a b or a d sound. And when you think about that, they’re so rapid. We can have hundreds of sounds rapidly occurring and our brain has to take all of that, organize it and put it together and give it meaning. Whereas visually, we have a lot longer time to actually look at something and learn from it and take it in. It doesn’t change. There’s a great Nina Kraus book called Of Sound Mind, and she’s got this analogy in there where she talks about if vision and hearing were the same, it would almost be looking at something saying, “Poof, it’s a trailer, poof, it’s a genie, poof, it’s a bird.”

(14:18):

Because it moves so quickly, it’s so transient. So when we’re thinking about sound, our brains have to be working well and accurate and automatic. If we’re taking time to figure out what’s happening, we’re already getting behind. That’s the sounds that I’m talking about when I’m talking about speech. The other thing we need to think about is sound has rhythm and melody and temporal aspects to it. So sometimes it’s not just enough to hear the words, you have to infer the meaning. That’s how you can tell if someone’s joking or if it’s sarcasm or what’s the difference between your inside voice and your outside voice. All of those things, all that non-verbal bits of sound we use every day without thinking about it, yet there’s a group of children and individuals that really need to be taught, okay, well, when your voice does this, that’s a question.

(15:14):

When your voice does this, it’s a statement and really being taught those things. The other thing I like to think about is incidental learning. We are constantly listening. Our ears are constantly on. We don’t have ear lids, so even when we’re sleeping, our ears are open. We’re taking in all of this sound, and that’s how we learn. If you think about a toddler, no one ever taught a toddler how to say a bad word. That’s incidental learning from driving in the car with mom and coming up with, oh, darn it, but maybe not darn it. You didn’t teach that. That’s incidental. So if your auditory system isn’t doing what it’s supposed to do, you are missing out on a lot of social cues, conversations, information, and then that incidental learning.

Lindsay Guentzel (16:00):

You mentioned getting behind. If you are pausing to try in the moment as someone is talking to you, and keep in mind this can be a moment where you could say, “Hey, can you give me a second?” But most of the time in life it’s not. An alarm is going off at work and the emergency system’s going off and you’re trying to listen to something that is happening in real time and there’s not a pause button. You talked a little bit about some of the ways that it can hold somebody back, but how are you seeing it show up in life where it’s really becoming detrimental for a person?

Dr. Melissa Karp (16:29):

So a lot of times in education, we’re not set up for people that have hearing disorders typically, and even in work. So I see children and adults, and this is where technology can be a good thing, but I also think education for people who are speaking how to use something called clear speech, and that’s usually a recommendation for all speakers is if you are talking to a class, if you are teaching, think about talking to Alexa or Siri, you have to be a little bit slower, a little bit more deliberate, and your articulation has to be there, otherwise you’re not going to get the right signal. That’s really going to help your listeners.

(17:11):

Captioning has become wonderful. You mentioned that you wanted to put captioning on the television. I read something the other day that Netflix estimated that 80% of their viewers use captioning at one time or another because it’s great, it helps alleviate some of those listening demands, but captioning during recorded lectures or the ability to pause and go back, there’s even some devices or apps that will caption as you go. So if you’re in a situation where you have a meeting, you can put your app on the table and it will caption for you.

Lindsay Guentzel (17:46):

I love this idea. How would you speak to Alexa or Siri? Because we’ve all had the moment where you try to tell them to do something and they don’t understand you for whatever reason and it doesn’t work. And normally it’s because you are either speaking not clearly or you’re speaking too fast, and the frustration that comes from you when this machine doesn’t understand you. And now we’re talking about a large population of people, that statistic you mentioned about Netflix is staggering, but it’s a great reminder that every single one of us need to be thinking about accessibility in a much different way.

Dr. Melissa Karp (18:18):

Oh, absolutely. And it’s not just how we speak, it’s also things like movies and television. They’ve changed. The auditory settings have changed. Amazon Prime recently came out with a setting for some of their originals where you can increase the dialogue. They’re realizing that there’s a problem. Some of that has to do with putting more of the musical scores on. If you look at some of the older television programs, most of the times the actors were looking at the camera and they’ve changed that a lot. Sometimes it’s been changing in mics, having lapel mics on actors instead of the great big boom mics because they’re trying to keep it more authentic, but it takes away from some of the audio. So it’s not your imagination, it’s the audio quality on television and movies has changed over the years.

Lindsay Guentzel (19:08):

I want to go back for just a second to clear up some things on the ADHD confusion crossover area before we move on to talking about the different types of APD. You mentioned that a dual diagnosis can exist. And I’m wondering is it more likely that someone comes in misdiagnosed with ADHD and it’s actually APD, auditory processing disorder, or is it the other way around, or is it just totally dependent on their place in life, where they were raised, the age they’re at, the school system they were in, the care team they had around them, the support people?

Dr. Melissa Karp (19:43):

Yeah. So usually by the time someone sees me they’ve had several evaluations. So they’ve usually had a cognitive evaluation or a speech language evaluation. There’s been some reason why they’re being sent to my office. Some of them already have a diagnosis of ADHD and they say, “Well, you know what? Medication hasn’t worked. We’ve tried all these different medications.” And sometimes it breaks down to how they’re being diagnosed with ADHD because there are some objective tests like QbCheck, IVA-QS. There’s some other vigilance tasks that can be done, but then there’s questionnaire based testing where we’re talking about how closely some of these behaviors can mimic. It’s not necessarily unusual if diagnosis is based on questionnaires that a child might come to me with an ADHD diagnosis, they’re not on medication, we do the attention task and their attention is just fine on those screenings.

(20:43):

And it’s like, okay, well now let’s look at auditory processing. Okay, well here’s the issue. By the same token, I have people coming in, they think, oh, my child clicks every button on your list. They definitely have auditory processing disorder. They’re well-behaved, they’re not hyperactive at all. And there’s that misconception that everyone with ADHD is going to be hyperactive and bouncing off the walls. That’s not the case. And you get this very well-behaved person. They come in, they sit down, they look like they’re paying attention and they’re gone. It’s like they’re just phasing in and out. They cannot hold that information long enough to process, and then the recommendation changes.

(21:21):

We stop at that point, it’s like, okay, well let’s look at this first, and if problems persist, then let’s come in and look at the processing. And that seems to be about a 50/50 split, 50% of the time an undiagnosed ADHD. Once they’re treated appropriately like, “Oh wow, well now I can manage these things.” And then the other part of the time it’s like, “Well, okay, the attention piece is managed, there’s still problems. Now let’s look at auditory processing and oh, okay, yeah, so now we need to look at this too.” But that whole global attention piece is under better control, so we can really focus on working on the processing part of it.

Lindsay Guentzel (22:01):

I’m hoping we can move on to the different types of auditory processing disorder. And I want to clear up one thing before we jump into those because as I was doing research I saw that there’s auditory processing disorder and then there’s central auditory processing disorder. And are those the same things? Are they different? Are they used interchangeably? And then feel free to just jump right into the other different types and maybe explain a little bit about the differences between them.

Dr. Melissa Karp (22:25):

It’s really nice that you recognize that there are different types of auditory processing disorder, but the difference between APD and CAPD, it really depends on which article you read. Both are used interchangeably at this point. They both mean the same thing, but then inside the system they’re different types. So that’s why we have a whole battery of testing. So the most common type of auditory processing disorder is called decoding, and that’s really where the brain doesn’t hear sounds accurately. Most of these people are going to act like they have a hearing loss even though their hearing is fine, but you might see difficulty with phonics, articulation, accurately hearing the speech sounds, following multiple step directions. That’s where that invented spelling doesn’t make sense. There’s another type of auditory processing disorder called tolerance fading memory, and that’s a combination between auditory memory difficulty and speech and noise.

(23:22):

So when you put the two together, it oftentimes will look a lot like attention, difficulty, hard time following directions, speech and noise problems, a lot of distractability. There’s organization, which is how we organize and sequence what we hear and think. So expressing our ideas becomes more difficult. Spelling reversals, it’s a very labor-intensive process so these are the people that they’re thinking, they’re thinking, they’re thinking and they’ve got to get the information, figure out the order and have it make sense and spit it back out. And then there’s integration and that’s really looking at how either both hemispheres of the brain work together or how our vision and our auditory system work together. And that impacts things like localization where a sound coming from, hearing and noise, language deficits taking parts to whole and writing skills. So those are really the main types and each of them are treated a little bit differently so it’s important to when you have an evaluation, not just is it there, but what are the deficits and what are the areas that need to be improved?

Lindsay Guentzel (24:34):

We’re going to jump to that just a second, but I want to ask really quick a follow-up on decoding. I heard you say phonics.

Dr. Melissa Karp (24:40):

Yes.

Lindsay Guentzel (24:40):

And it immediately brings me back to learning to read and learning to write and speech and I’m wondering how a person is taught that, does that play a role in potentially how their brain processes things?

Dr. Melissa Karp (24:54):

Right and I am not a reading specialist, so I have to defer to my better educated colleagues on that area, but what I can tell you is making sure that children understand and can hear the difference in sounds that they’re not being told to guess, that they’re not being told to look at pictures, that they’re really hearing them and sounding them out. A lot of times people who had multiple ear infections in childhood, and even if they’re not infections, even if they just have fluid in the middle ear space, they have these times of temporary hearing loss. And when you have these areas of neural growth pattern and those auditory pathways are growing and being created and you have this temporary hearing loss, this auditory deprivation at times, it can really change how you’re able to hear and understand these sounds. The good news is that decoding actually responds very favorably to training. So that is a good thing.

Lindsay Guentzel (25:53):

Let’s talk about what gets somebody to this assessment. I remember going through the hearing test as a kid in school, but I imagine that it’s much deeper than that. The hearing test tells us one thing, teachers tell us another, the people we engage with on a day-to-day basis. And I’m saying this all about children, but that’s not only the people that you are treating. So tell me a little bit about the referral assessment pipeline. How does a person find themselves in your office? What typically leads them there?

Dr. Melissa Karp (26:20):

A lot of times, either word of mouth or they find me online. They’re Googling their symptoms like we all do now. And once you start putting all these things in, they go, “Oh, what’s this auditory processing disorder?” Sometimes I will get siblings and parents of a child that I’ve tested because the parent will look at the report and go, “This is me. Maybe I have this.” And I’ll get them in my office that way. We get referrals from psychologists, we get referrals from the schools, other audiologists who don’t do the testing. And that’s a distinction too, that not every audiologist tests for auditory processing disorder. You might go to an audiologist and they go, “Okay, hearing’s normal, that’s great.” But if you’re having those functional deficits, it’s something to ask about or it’s something to look at and see where can I find an audiologist that’s trained to do this testing?

Lindsay Guentzel (27:13):

You mentioned families. Is there anything that points to a genetic connection for something like auditory processing disorder?

Dr. Melissa Karp (27:20):

I can tell you that I see it. I don’t know that we’ve identified a specific genome or pattern, but we have an awful lot of families that come in and it’s like family discount day. I’ve got three siblings, one parent, and they’re all pointing fingers at each other. But it is kind of neat because then you’ve got these families that are working on strategies together.

Lindsay Guentzel (27:43):

Well, I mean the same could be said for ADHD. It can always be a family discount day when one person gets diagnosed. The snowball effect. And I think again, it’s just not knowing certain things. You mentioned people Googling things. The internet can be a very messy place, but it’s great for a lot of things like this. We didn’t have access to things like this and we weren’t able to just see things laid out in front of us. It was much more of a difficult path for people to go down.

Dr. Melissa Karp (28:11):

Absolutely. If you pop into some of these Facebook groups now, like you said, good and bad, there are some Facebook groups that have audiology professionals in there and they’re moderated a bit and you can get some really good information. You’ve got other Facebook groups that I actually tell patients, yeah, let’s not look at that one. That one’s pushing their own program. Let’s let’s keep it to the things that we know and that we know that are effective.

Lindsay Guentzel (28:40):

I want to ask one thing. If you see this, let’s say a person is missed in this diagnostic process as a child and then they come in as an adult and it’s obviously something that’s been around for a while, what do you typically see? Is there anything that stands out as kind of maybe patterns they’ve fallen into or things they’ve adopted or just is it that everything is a little bit more higher up on the scale of severity?

Dr. Melissa Karp (29:06):

Yeah, so people who are smart are really good at compensating and they use a lot more effort to figure things out. I actually saw a college student and most of her college career she’s done great. She’s looking at going to grad school, but the way she gets through school is she reads the notes beforehand, she reads her text before, she goes into class with a recording device, and then she goes home and she listens to it multiple times and that’s how she takes her notes and she teaches herself.

(29:37):

So she is spending three to four times as much effort to learn the same information because it’s not an intellectual disability, it’s a communication disability, but that’s her compensation strategy. I’ll see other people who they’re always known as thinking before they speak because they have this delayed response, but in that delay, they’re taking time to go, well, what exactly was said? Or they need a little bit extra time for their thoughts. Or sometimes I might see people that they tend to dominate the conversation because if they’re dominating the conversation, they know what the topic is and it’s more comfortable and it’s easier for them to have the conversation.

Lindsay Guentzel (30:19):

Let’s move into the battery test. Explain this to me like you would explain it to a five-year-old.

Dr. Melissa Karp (30:25):

If I have a five-year-old or a seven-year-old come into my office, the first thing I do is I say, “Do you know why you’re here?” And a lot of times they go, “No.” So I say, “Okay, this is really cool. Your ears and your brain hears. So we’re going to check both of them today. So the first thing we’re going to do is we’re going to make sure that your ears are hearing all the sounds. So you’re going to raise your hand for these beeps. Okay, great. So now we’re going to see how your brain hears words. So we’re going to copycat, I’m going to say a word and you’re going to say the word back to me and, oh, you did that so great so now I’m going to put some noise in. Don’t let me trick you. Tell me the word you hear back.” And basically I just walk them down this task.

(31:10):

So each thing looks a little bit different. So I want to see how is the left hemisphere working? How is the right hemisphere working? Can they combine information from both ears at the same time? Can they separate information out? How do they do in background noise? How do they do when the background noise moves around like that cocktail party effect? And then there’s other tests that are very objective that they just get to sit and they can look at an iPad and relax while I’m doing tests to see what does this reflex look like in their ear. Electrophysiology, what’s their brain’s response to sound that they don’t have to do anything for, which is great. So everything we do, I try to be just as warm and fun and oh my gosh, this is so silly. I want you to say these words back and they make no sense at all. You just tell me what you hear, and that’s pretty much what it is.

Lindsay Guentzel (32:06):

Well, and I have to imagine with children there is also this feeling of wanting to make sure that you aren’t making them feel different because it’s so hard to be a kid or an adolescent already, and then you throw in this thing where they feel like, oh no, something’s wrong with me. And I think a lot of people who were diagnosed with ADHD, whether they were kids or adults, have dealt with that shame. And I think one of the things that’s so wonderful about having conversations about this is acknowledging that as much as we would like to think that every single human, body, brain, nervous system, all of it is the same as the person standing next to us, we just know now that is not the case. And the quicker we get around to accepting it, the better it’s going to be for those young kids who come into your office who feel like they’re different.

Dr. Melissa Karp (32:51):

Yeah, and I think one of my favorite things about doing this testing is finding out what are they good at? What are they excited about? Because then how can we use that when we start talking about treatment and therapy? I might have a kid that comes in and they’re an incredible artist. Okay, great. Well, they’re having a really hard time with reading comprehension or listening comprehension. So what we want them to do is use their art because in order to draw a picture, you need to completely understand what’s happening. I can tell you how to set a table, that’s a bunch of words, but if I draw you a picture of where’s the plate and where’s the fork and where’s the knife, oh my gosh, that makes so much more sense.

(33:31):

And they can really get into, “Oh, well this is something I’m good at. Well, I’m going to use that.” And scaffolding and using things that they enjoy. We use music and rhythm, anything that they like. If someone’s very active in sports working on auditory memory, we might throw a ball back and forth. So finding things that are individual and enjoyable and that they can have a really good sense of self-worth and importance because no one wants to feel like there’s something wrong. And sometimes we talk about what the younger ones, like we’re going to get them some magic ears so they can hear better.

Lindsay Guentzel (34:09):

I could use some magic ears at 37, I’ll be honest.

Dr. Melissa Karp (34:12):

Yeah, when I was at that conference, for an audiology conference there were definitely some places where it was hard to hear and I was sitting next to another audiologist and she said, “Oh yeah, I just grabbed a pair of hearing aids and programmed them for the conference.” I was like, that was brilliant. I should have done that. I’m going to do it next time.

Lindsay Guentzel (34:28):

Being in a big room of people and there’s a lot going on, it doesn’t matter if the topic is your favorite topic or something you’re incredibly passionate about, it is very easy to just completely lose yourself. You mentioned a little bit about some of the therapy options that you do with children. How does that change when you’re working with adults who are maybe coming in, whether it’s a later in life diagnosis or it’s something completely new and they’re adjusting to this new normal?

Dr. Melissa Karp (34:51):

So in my personal area, what I have found is that adults tend to prefer technology. They don’t necessarily want to do the auditory training piece of it. Now some do and some do a great job with it, but more of them are likely to say, “Well, is there a device or is there something else I can use?” They don’t want to necessarily put in the auditory training. They tend to be more device heavy or device dependent, and that’s fine. With children and adolescents we really try to work with them on the training because my goal is to get them as independent as possible. So if we can actually remediate a decoding deficit, let’s do that. Let’s get them on a good path and that way they don’t need anything else. But yeah, adults are funny. They’re like, “Oh gosh, I’m busy. I’ve got to go to work. I don’t have time for this. I don’t necessarily want to go to therapy.” Or they want a computer-based program that they can do at home and then they’re terrible at up. Adults are more challenging than kids. Kids are easier I think.

Lindsay Guentzel (36:00):

I’m wondering if you could touch on the benefits of doing both at once. I imagine that there’s some great benefits to doing both.

Dr. Melissa Karp (36:07):

There are, and one of the nice things is being able to look at some of that objective data that how auditory training can actually change the brain. Taking the time and learning how to do these things and hearing the sounds accurately. So learning your phonemes, those speech sounds and getting them quick and accurate. It’s kind of like when you were in math class and you were forced to learn your times tables and memorize them and you had to get them super quick, and the reason you had to do that was you wanted it super quick and super accurate so that when you went on to higher level math it was one less piece of cognitive information you had to hold.

(36:47):

You could solve your math problems so much easier because you didn’t have to think about it. That’s the same thing with auditory training is we’re training the brain to hear those sounds quickly and automatically so that you can follow rapid conversations so that you’re not stuck trying to figure out, ooh, did they say death or did they say death? And which one makes more sense? And how can I pull from my receptive vocabulary to fill in those blanks? Being able to do that without a device is awesome. Having a device, there’s no shame to that. I think it’s great to have that with it, but everything that you can do in your own power, changing your brain for the better is always a good idea.

Lindsay Guentzel (37:31):

You mentioned empowering children, young adults to be able to do it on their own. I’m wondering how that looks as they start to grow into adulthood and how that therapy continues and when it starts to change and what it might look like for someone in the sense of continuous care.

Dr. Melissa Karp (37:50):

There are certain types of auditory processing disorder that work really well with therapy and it’s a set course of therapy and they graduate. There are other types of deficits that will require more training in compensation mechanisms and strategies and accommodations. So where you might have someone that just has a decoding deficit and they can go through training and graduate, you may have someone that has an organization deficit and they may always need a little bit of extra time, or they may always want to do some pre-learning before they go into a situation or with integration they may always have a harder time with some of these skills, so they may want to use a device or they may always want to sit at the front of the classroom. That’s something that we always talk about, what’s prognosis and when you have that test result in front of you, this is the map and this is where we’re going to go.

(38:53):

These are the things that I think they’re going to do really well with. These are the things that we’re going to teach your child and you need to work with your child to advocate for themselves, advocate for where they need to sit, be able to comfortably say, I heard x, y, z, what was that last word? And make sure that they get all of the information. Certain things don’t show up as much in elementary school, but once they go to middle school, high school, college, the classes get bigger, the information gets faster. So someone that may not need as much accommodations in middle or high school when they go to college, they might go, “Oh wow, there’s a hundred people in this class. I haven’t used FM before. I think now I really need some help.” And having them recognize that there are going to be these times that what’s available, how to go about getting it, who to talk to at the university level or at work, who to talk to for accommodations because there are accommodations.

Lindsay Guentzel (39:58):

I love that you are empowering people and educating them on their accommodations. I want to ask one thing really quick on the crossover. So you have somebody who has a dual diagnosis with ADHD and auditory processing disorder. Are there specialized treatment plans that combine certain things that will help on both sides of it?

Dr. Melissa Karp (40:17):

Well, there’s going to be certain things that help regardless, someone that speaks clearly, reducing the background noise, working on the speech sounds, working on taking breaks. There’s something very real called auditory fatigue where if you’re working hard to focus, whether if you’re working hard to focus from ADHD or you’re working hard to focus because you’re listening to these speech sounds, you need breaks. Our patients are aware of how can you tell when your attention’s starting to wane? How can you tell when you need a break and what do you need to do at that point? There’s going to be strategies that are helpful for everyone. The main thing we think about with ADHD is as much as possible, how can that be controlled? What are the pieces that you can control? So for some people it’s medication.

(41:10):

For other people, it might be, okay, before I sit down and study, I’m going to go lift weights or I’m going to take a run because that helps get me centered and I can focus better. So it really depends, and that’s where so much of it’s individual. I do see some people have these lists of here’s your accommodations for APD, here’s your accommodations for ADHD. It’s not a homogeneous population. We really want to make sure that we’re fitting the deficit to the therapy or to the accommodations and the recommendations because it’s not going to work for everyone.

Lindsay Guentzel (41:46):

As I mentioned, you just returned from the American Academy of Audiology annual conference in Seattle, and I want to hear about some of the stuff that you’re excited about. But I do also want to ask, is that something where the connection and the possible crossover with ADHD, is it mentioned, is it talked about, because you have to kind of be on your toes to be able to distinguish some of these things, and so I’m just wondering from a big picture if that’s being mentioned.

Dr. Melissa Karp (42:09):

Sometimes. Sometimes it is, and we actually had, one of the most valuable sessions we had was this great round table of audiologists who are all talking about adults with APD and evaluating and treating, and that was fantastic because you had people in this field who have been in this field for a very long time, and we got to share what are we doing? What tests are we using? Oh, this is a really great questionnaire type tool that helps us narrow things down. Oh, here’s some cool technology that we’ve been trying. That’s really neat. I love that sort of thing. As far as new research coming out, one of the talks I really enjoyed was actually not necessarily about APD and ADHD, it was more about speech and noise and people on the autism spectrum and how some of the neurological gating, they were checking some of these electrophysiology measures and they could see that in people with autism who were having problems with speech and noise, that there was less attention there.

(43:13):

So the theory is that if you treat attention in someone with autism that you might be able to help with speech and noise. So again, preliminary, but it was nice to see that we’re branching out behind just what is APD, and we’re looking at all of these other conditions that can overlap. But whether it’s autism, sensory processing, ADHD, specific learning disability, there is so much out there. And also I would say that when an audiologist writes a report about auditory processing, yes, there are different types of APD, but it’s so important that you write your report and you make sure that it’s understandable for the educators and the people in that person’s life, and that you talk about what are their strengths and what are their weaknesses so that educators have a better idea of what they can be doing on their side.

(44:08):

Psychologists have a better idea of what they can be working on. If you’ve got OT involved, they know what they need to be working on. So it can be a really good multidisciplinary group, but everyone has to try and get on the same language. So yes, we have all of these different terms and acronyms and things like that, but at the end of the day, really describing where the breakdown happens and coming at it from any direction we need to is what’s important for the patient.

Lindsay Guentzel (44:37):

Well, I’m really glad to know that all of those things are being talked about. I love the connection with autism because right now we’re seeing an influx of people who found themselves on the neuro diverse spectrum because of an ADHD diagnosis and are now seeking out an autism diagnosis. It just makes me so excited about the future and just being able to make things better for people because we know what it’s like when people are treated properly, and it’s so important to get them there. And so Melissa, thank you so much. This was wonderful and we’d love to have you back on Refocused again.

Dr. Melissa Karp (45:09):

Oh, well, thank you so much. I really enjoyed talking with you. I hope a lot of people get some clarity and figure out where they need to be and who to help.

Lindsay Guentzel (45:25):

There was so much good stuff in our conversation with Dr. Karp on auditory processing disorder. I cannot wait to have her back on the show. In the meantime, I’m going to be doing some digging on the whole ear infections as a kid news that she delivered because that was definitely me. I do want to wrap up this episode by quickly sharing some of the strategies Melissa mentioned when it comes to dealing with noisy environments. The first, eliminate as much background noise as possible. If you’re in a class or a conference, Melissa suggests sitting in the front of the room close to the person speaking and make sure to utilize FM systems whenever possible. Ask about accommodations. They are there. Record your meetings or your classes or lectures and listen back to it while reading your notes.

(46:14):

And it’s incredibly important to work on developing a comfort level with asking people to repeat what they said until you’re clear. You shouldn’t have to guess. Which leads me to the importance of using clear speech. I talk too fast. I know it, and it’s something I’ll be working on from here on out. Remember, when you’re speaking, pretend like you’re delivering instructions to Alexa or Siri and then think of how annoying it is when they don’t understand you. That’s what it can be like for a person with auditory processing disorder, and we can easily ease that frustration by making small meaningful changes right now.

(46:59):

Refocused is a collaboration between me, Lindsay Guentzel, and ADHD online, a telemedicine mental healthcare company that provides affordable and accessible ADHD assessments and treatment plans, including medication management and teletherapy. To find out how they can help you on your journey head to adhdonline.com. A huge thanks to our managing editor, Sarah Platanitis, who was instrumental in building this conversation on auditory processing disorder with Dr. Melissa Karp. Sarah is the ying to my ADHD brain yang and we’re so lucky to have her working on the team. Our coordinating producer, Phil Rodemann makes recording and producing these interviews a breeze and I am so happy he came out of retirement to give podcast life a go.

(47:50):

Al Chaplain is our go-to for all things social media, and I love what they’ve been creating for us. Make sure to go check it out and give it a like @refocusedpod. A big thanks to Mason Nelle over at DEKSIA, in Grand Rapids, Michigan for all of us help in getting our videos ready to share with you guys. Refocused couldn’t happen without my partner’s turned friends at ADHD Online. High-fives and hugs to the ones I bug the most. Keith Boswell, Claudia Gotti, Melanie Meyrl, Susanne Spruit, Tricia Merchant Dunny, and the entire team at Mentavi Health and ADHD online.

(48:30):

Our show art was created by Sissy Yee of Berlin Grey, and our music was created by Louis Inglis, a singer-songwriter from Perth, Australia who was diagnosed with ADHD in 2020 at the age of 39. Links to all of the partners we work with are available in the show notes. To connect with the show or with me, you can find us online @refocusedpod as well as @LindsayGuentzel, and you can email the show directly, [email protected]. That’s [email protected]. Take care of yourselves and please, in an effort to reduce the unbelievable amount of stress we all carry around with us unnecessarily be a little kinder to yourself this week.

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