By Deborah Swain, EdD, CCC
The Swain Center specializes in treating auditory processing, reading, and spelling disorders, which affect children across the United States. In 1985, I opened the Swain Center for Listening, Communicating and Learning to treat auditory processing, reading, and spelling disorders. The center now employs five speech-language pathologists (SLPs), an educational tutor, and a speech assistant. Dedicated to treating auditory processing disorders and coexisting reading and spelling problems, the Swain Center serves hundreds of clients each year. Previous to opening my own practice, I was the Chief of Speech Pathology at the University of California, Davis, Medical Center. Changes in insurance regulations influenced my decision to open a practice that could offer comprehensive speech-language services without restrictions. The practice was established as a fee-for-service center without the need for insurance authorization and targeted clients whose problems were not covered by insurance. I focused on a segment of the population that was not being served, wrote a marketing plan, and established a highly specialized practice. Initially, I was the sole clinician, but within 6 months, I had a waiting list and my first associate. My chosen specialization is treating auditory processing disorders (APDs), which affect as many as 25% of school-aged children in the United States with a ratio of 2:1 boys to girls. It is quickly reaching epidemic proportions. APD is one of the most misdiagnosed or undiagnosed language problems, yet it is the primary cause of reading and spelling problems. Left unidentified and untreated, children are at risk for lifelong literacy problems that affect their personal, professional, social, and psychological well-being. The relationship between literacy and APD is well established, but it is not currently identified and addressed in the public school system. I wanted to open a clinic that specialized in APD because it enables us to diagnose and treat the underlying problem while establishing literacy skills. APD is a serious national problem affecting the overall literacy rate of our nation. I want to be a part of the solution. What is an Auditory Processing Disorder? APD is not a hearing problem. The American Speech-Language Hearing Association (ASHA) defines APD as: "the inability or decreased ability to attend to, discriminate, recognize, or understand auditory information." Most language is learned by listening. In order to learn, a student must be able to attend to, listen to, and separate important speech from all the other noises present at school and home. There is a hierarchy of skills that are basic to the listening and communication process. Although sequential in development, these skills overlap and are essentially inseparable: Sensation. The ability to identify the presence of sound. Discrimination. Determining differences in sounds—essential in reading, spelling, and following directions. Localization. Ability to determine the origin of the acoustic signal. Auditory attention. The ability to direct and sustain attention to auditory stimuli. Auditory figure-ground. The ability to identify signal over other signals. Auditory discrimination. Necessary to discriminate among words and sounds that are similar. Auditory closure. The ability to understand the whole word or message when a part is missing. Auditory synthesis. The ability to blend isolated phonemes into words. Auditory analysis. The ability to identify phonemes or morphemes in words. Auditory association. The attachment of meaning. Auditory memory. The recall of the acoustic signal after it has been labeled and stored and then recalled. When auditory skills are weak, the student may experience auditory overload. This makes learning more challenging and sometimes too difficult without special assistance, particularly in reading and spelling problems. Most people with APD have normal or above normal intelligence and normal hearing sensitivity. Auditory processing is considered a receptive language skill. A deficit with these skills is presumed to be due to dysfunction of the central nervous system, specifically at the cortical level. Secrets to success In order to ensure the success of such a specialized clinic, I scheduled many speaking engagements with groups, on the radio, and on television to discuss the services and the need for parents and professionals to know and understand the effects of auditory processing disorders on literacy and learning. We offered free screenings to local private schools and preschools. Most important, the entire staff provided superb customer service to all clients and their families. We provided ongoing support and advocacy when needed. I found that educating the public is one of the fastest ways to develop a "waiting list practice." Initially, most of our referrals came from pediatricians and family practice physicians. As the clinic's reputation grew, referrals were generated from word of mouth, tutors, educators, and counselors. Currently, 90% of the clinic referrals are from word of mouth. Keeping a healthy bottom line is also of the utmost importance. Most insurance companies will pay for the initial evaluation—called a language processing evaluation, which is considered a speech and language evaluation. The diagnostic code is auditory discrimination or perception. Many will not pay for therapy because the disorder does not derive from a neurological problem. However, careful report writing often persuades underwriters to consider payment. The Role of Speech-Language Pathologists Whether in a school or clinical setting, speech-language pathologists play a crucial role in the identification and treatment of APD. However, knowledge and expertise are key to initiating an assessment procedure. When interpreting testing results and responses, the experienced clinician will know that a client is experiencing auditory processing problems. However, guidelines established by ASHA state that a diagnosis of APD cannot be made by an SLP. A referral to an audiologist with a specialty in APD testing may be warranted when testing indicates a client has the following: difficulty retaining age level appropriate information at the immediate memory level, cannot follow directions, is unable to conceptualize information through the auditory modality, cannot filter extraneous noise, has difficulty focusing, cannot segment or blend sounds, or requires numerous repetitions of instructions or stimulus items. For purposes of treating auditory processing as well as coexisting reading and spelling problems, the Lindamood Phoneme Sequencing (LiPS) program is quite effective. Patti Hamguchi, CCC-SLP, offers an excellent metacognitive approach to treating APD. Other multisensory programs are effective. However, whatever program is selected for intervention purposes, it must be research-based and built on a neurolinguistic model. Traditional language-based therapy models for treating APD provide individual therapy sessions a minimum of two to three times weekly. The duration of therapy will vary depending on which therapy program is selected. Group therapy sessions are not appropriate for treating APD. A note of caution—quick fix programs never work. Therapeutic Listening Therapeutic listening is based on the pioneering work of Alfred Tomatis, MD, a French ear, nose, and throat specialist. Tomatis began his work in the mid-1900s with the therapeutic application of sound to treat specific symptoms and behaviors related to communication disorders. Therapeutic listening is a combination of art, science, and engineering that improves the ability to perceive the full range of auditory frequencies, which results in active listening. Active listening improves auditory tonal processing, which helps the ear and brain better support auditory sequential processing as well as language processing. The integration of auditory function in the ear with the brain achieves changes in listening, communicating, and learning. The focus of therapeutic listening is on reeducating the ear and the auditory pathways. This is done through the modification and/or modulation of classical music when presented in either clinical or home program models. Auditory reeducation is based on the neurological effect of filtered and gated music on the nervous system. A cortical change takes place from the direct application of sound frequencies when applied through headphones. Sound therapy uses soothing, balanced classical music with the primary purpose of delivering filtered and nonfiltered high-frequency sounds to the ear and brain. The Swain Center offers several methods of therapeutic listening for its clients. Used to supplement and enhance traditional speech and language therapy, therapeutic listening has stimulated impressive results. How does therapeutic listening work? Following a thorough speech and language evaluation and parent interview, the clinician recommends a specific listening protocol based on the unique needs of the client. Home programs are typically 30 minutes a day, 5 to 7 days a week of listening to CDs via headphones. Typical listening protocols are 8 to 12 weeks in duration. Clinic models are more intensive and listening times vary depending on the specific program. Client progress is closely monitored and supervised through weekly parent interviews. Training and certification are required to use therapeutic listening and SLPs, occupational therapists, physical therapists, physicians, and other health care professionals are seeking out that training, although it can be difficult to find. Training program length varies depending on the specific methodology. The Swain Center staff are certified in one or more therapeutic listening methodologies, including the Tomatis Method, Samonas Sound Therapy, The Listening Program, and Listening EarsTM. Because Tomatis is so specialized and requires highly specialized equipment, not many clinics or practitioners offer this method. Our center is the only facility north of Pasadena, Calif, to offer it. Therapeutic listening has been used successfully in Europe for more than 50 years. It has slowly made its way to the United States in the past 10 years. We have offered therapeutic listening since the fall of 1999. Deborah Swain, EdD, CCC, is the founder, owner, and director of the Swain Center, Santa Rosa, Calif. She is also the current president of California Speech Pathologists and Audiologists in Private Practice. She can be reached at (707) 575-1468.
