Managing CAPDs while mitigating COVID-19: some considerations for accommodations

by Jeanane M. Ferre, PhD, Audiologist, CCC-A

We all are adapting our practices to meet the challenges of the COVID-19 pandemic including increased use of telehealth and implementation of safe in-person practice guidelines as recommended by the CDC, ASHA, AAA and our States’ Public Health Offices. As we move forward, we also need to revise our recommendations for educational accommodations for Central Auditory Processing Disorders (CAPDs).

Certainly, the presence of a central auditory processing disorder (H93.25) means that the school-age listener will experience significant challenges meeting grade level standards in Speaking and Listening and would be eligible for special education support per the Individuals with Disabilities in Education Act (IDEA, 2004), Every Student Succeeds Act (ESSA, 2015), and section 504 of the Rehabilitation Act (1973). However, what will some of those accommodations look like when education is provided via remote/distance learning? How will our recommendations change to accommodate CDC-recommended safety guidelines for in-person learning?

For any CAPD that affects the acoustic clarity of the signal, accommodations that enhance signal quality are recommended including access to Clear Speech and extrasensory visual cues. Use of facemasks has been shown to affect the acoustic quality of the target by reducing high frequency cues and attenuating speech by 3-12dB (Goldin, Weinstein, and Shiman, 2020). Additionally, solid medical-grade, N-95, or cloth facemasks eliminate access to lipreading and facial expression cues so important to our students with impairments in central auditory discrimination and/or temporal processing.

For a CAPD that affects binaural processing, we know these listeners feel overwhelmed by “too much” information that needs to be integrated and manipulated quickly, requiring accommodations to the quantity and structure of the incoming information. The substantial increase in remote education necessitated by the pandemic makes implementation of these accommodations more important than ever and, possibly, more challenging to accomplish.

As I have resumed conducting in-person evaluations, I have been rethinking recommendations for accommodations that previously I had taken for granted and have made some “tweaks” to my recommended accommodations that can be implemented for in-person or remote learning models. I hope you find them useful.

• For in-person learning, if possible, use a face shield or facemask with clear panel rather than a solid facemask to improve signal audibility and/or retain access to visual cues.

• Teachers must gain all students’ attention before giving instructions
• Use Clear Speech (speaking at a slightly reduced rate and slightly increased loudness with strategic pausing). – (exercises to enhance Clear Speech can be found here)
• Repeat information with associated visual cue and/or demonstration. With reduction of visual, i.e., lipreading cues/facial expressions resulting from use of facemasks, speakers should increase use of demonstration, cueing, gestures, body language, etc. to compensate.

• For multistep directions, provide number of steps, e.g., “I want you to do three things”, “tag” items, e.g., first, last, before, after, , and insert brief (1-2 second) pause between items.
• Allow “thinking time”, i.e., insert “wait time” of up to 10 seconds before expecting a response.

• Ask listener to paraphrase instructions to ensure that information was heard AND understood.

• Monitor your speaking rate. Children do not process speech as quickly as adults (Hull, 2014)
  • 3-5 yr-olds process speech at 120-124wpm
  • 5-7 yr-olds process at 128-130 wpm
  • 5-6^th graders at 135 wpm
  • Middle school-high school at 135-140 wpm
  • Adults process speech at 160-180 wpm

• Student should be seated facing the speaker.
• Provide advanced notice of material to become familiar with task demands, vocabulary and general concepts before “diving in” to task, e.g. give a study guide at outset of unit.

• Use audiobooks, copies of teachers’ texts, and Cliff’s Notes. Access to “hard” copies of all materials is essential for instruction provided via e learning.
• Supplement class lecture with visual aids.
• Limit oral exams. If used, supplement questions with written forms of questions.
• Use multiple choice or other closed set type tests rather than open-ended or true/false.
• Provide extended time for all examinations, including standardized and “high stakes” tests.
• Test questions should be read to student as needed to ensure that student has understood the question. Reading test questions assists student in perceiving question’s “point of view” and identifying key information.
• Provide recorded copy of remote lectures for reference.
• Provide listening breaks throughout the day to minimize auditory fatigue.

Encourage students to:

• Sit or stand facing the speaker. Use visual cues when/if available – look & listen.
• Listen for meaning. Wait for all instructions before beginning. Guess when possible.
• Ask for repetition, clarification and/or extra time as needed.
• Paraphrase instructions back to parent or teacher to ensure understanding.
• Use a digital recording device for note taking, e.g., “smart pen”, note-taking app.

It is well accepted that assistive listening devices improve the signal-to-noise ratio reaching the ear and can improve significantly the daily listening of some students diagnosed with CAPD. Students presenting with discrimination-based deficits are most likely to benefit from assistive listening technology and trial use of an FM system is a commonly recommended compensatory strategy.

With social distancing requirements, some of our students may need these devices more than ever. However, with the ubiquitous use of facemasks, is assistive listening device usage going to result in positive outcomes? The microphone cannot be placed underneath the mask and trying to affix it to the mask will be unwieldy, if not impossible. Therefore, the speaker’s microphone will be located below the mask. Thus, while our listener will receive that signal as the primary target, it may not be at an improved signal-to-noise ratio if the mask is reducing high frequency energy and signal loudness.

The takeaway- it will be necessary to monitor any FM system use for in-person learning more closely than it may have been monitored in the past. Alternatively, we may need to put FM system usage “on hold” for in-person learning until/unless facemasks are no longer required. In the latter case, recommendations focused on Clear Speech, access to other types of visual cues, and auditory training may result in the least restrictive learning environment for school-age learners.

REFERENCES

1. Every Student Succeeds Act of 2015. (2015). Retrieved from www.ed.gov/essa?src=rn
2. Goldin, A., Weinstein, B.E., & Shiman, N. (2020). How do medical masks degrade speech perception? Hearing Review, 27(5), 8-9.
3. Hull, R, (2014). The developing CNS auditory system in children- do we expect too much? Oral session, Annual Convention of the American Speech-Language-Hearing Association, Orlando, FL.
4. Individuals with Disabilities in Education Act of 2004. (2004) Retrieved from http://idea.ed.gov/explorev
5. Rehabilitation Act of 1973, Section 504. (1973). Retrieved from https://www2.ed.gov/about/offices/list/ocr/504faq.html

RESOURCES

1. Atcherson, S., Finley, E., McDowell, B., & Watson, C. (2020). More speech degradations and considerations in the search for transparent face coverings during the COVID-19 pandemic. Audiology Today, Retrieved from https/www.AudiologyToday/publications-resources/audiology-today.
2. Tucci, D. (2020). Cloth face coverings and distancing pose communication challenges for many. Retrieved from www.nidcd.nih.gov/sites/default/files/Documents/multimedia/NIDCD_mask_Infographic_Revised_-_508-073120.pdf.
3. Consideration of face shields as return to school option. (2020). Retrieved from www.edaud,org/#
4. Remote learning and teleaudiology: Resource information for educational audiology. (2020). Retrieved from www.edaud.org/#