Diagnosing processing disorders

Dr. Alisa Lipson (biography, no disclosures)

What I did before

As a general pediatrician, I see many children whose behaviour and/or development is not emerging as expected. A diagnosis such as autism or learning disability may be the obvious explanation; but frequently it is not so straightforward. Parents come armed with questions about ‘processing disorders’ and other developmental diagnoses that they read about online, see on TV and hear about from friends (e.g. ‘sensory, visual and auditory processing’ deficits, Dr. Daniel Amen’s ‘healing’ featured on PBS, ‘neuro-feedback’ touted for many psychiatric and developmental disorders). These are not topics taught in medical school or residency, yet parents expect their MD to be knowledgeable, especially if they are considering investing in an expensive treatment for their child. If the MD happens to parent a child with a neurodevelopmental disorder, questions can often be addressed from the point of view of an informed consumer. Otherwise MDs have had little guidance.

I did what I could to learn from my patients’ experiences, my own encounters with therapists in the various fields, and online searches – to sort out what seemed possible, sensible and effective from what seemed to be quackery. My knowledge was arbitrary, piecemeal and probably often wrong. Where were the opinion leaders?

What changed my practice

1. The DSM 5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), published in 2013, involved a comprehensive review of developmental disorders in children. The new broad category ‘Neurodevelopmental Disorders’ replaced the former ‘Disorders usually first diagnosed in infancy, childhood, or adolescence’. These are conditions separate from mental health disorders (1). The DSM5 represents the most up to date, evidence-based thinking about these conditions, and is a good guide and starting point for all the various developmental disorders. Why not just depend on it? The ‘processing’ disorders mentioned here are not to be found within DSM5.
2. So what about processing disorders?
   The three: Sensory Processing, Auditory Processing, and Visual Processing are within the domains of Occupational Therapy, Audiology and Developmental Optometry, respectively.

Sensory Processing Disorders: 

• defined by OT’s as “an inability for the brain to properly integrate sensory signals, resulting in an inappropriate motor or behavioural responses”(2);
• manifested by extreme sensory sensitivities; also learning challenges, motor awkwardness, lack of focus and hyperactivity, poor social skills (3);
• strongly endorsed by OTs; some support from pediatricians(4).

Auditory Processing Disorders:

• defined by audiologists as “difficulty in discriminating and interpreting speech sounds when listening caused by impaired bottom-up processing of sounds by the brain, in the central auditory system” (5,6); (where hearing itself is normal).
• manifested by poor listening skills, slow responses, learning and behaviour problems (7,8);
• audiologists themselves not in agreement how to test this; less pediatric support (5, 6, 7, 8).

Visual Processing Disorders: 

• defined by optometrists as “difficulties interpreting visual information, such as pattern recognition, whole/part, and foreground/background relationships” (9) (where vision itself is normal);
• manifested by poor attention to visual information, restlessness, learning difficulties, frustration (9);
• firmly entrenched in Developmental Optometry; strongly opposed by pediatric ophthalmologists (9, 10).

In recent years, pediatricians and various subspecialists have finally weighed in on whether these conditions are mere constructs and epiphenomena of other conditions or if they are real. In particular, there was a vigorous debate in the lead-up to DSM 5 as to whether Sensory Processing Disorder should be included as a diagnosable medical condition. The decision was NO, but there were many left unhappy (especially within the OT community) (4). Things may change with DSM 6. As for auditory processing, there is no consensus in how to test for this amongst audiologists. It is not accepted as a distinct disorder by speech therapists and psychologists, i.e. as distinguishable from such conditions as language disorders or ADHD (5, 6, 7, 8). For visual processing disorders, Pediatric Ophthalmologists are firmly opposed to the construct (10), while Developmental Optometrists are very actively advertising and promoting these treatments (9).

What I do now

• I look carefully for diagnoses within the categories of DSM 5 neurodevelopmental disorders to see if my patient’s clinical profile fits best here. OK, nothing new conceptually, except that the new categories do capture better, and within the one domain, most of what I am seeing in practice.
• I consider primary diagnoses that go beyond medicine. Sometimes. We may try on one diagnosis, but with time it seems wrong. Or nothing may truly fit from the outset. I do believe that there are children whose profiles do not best fit within DSM5, and may indeed be better explained by some type of processing disorder.

Consider Sensory Processing Disorder: Eg. In an angry child with marked irritation by sounds, touch and taste, or in a child with apparent anxiety and inflexible behaviour, who does not respond to good parenting and anxiety management. BUT many of these children actually have high functioning autism, which trumps, diagnostically, any ‘processing disorder’. So think of autism FIRST, and rule it out.

Consider Auditory Processing Disorder: Eg. In a child who may appear to have ADHD features, but not across domains (ie. only at school and at the skating arena), or in a child with behaviour dysregulation in noisy settings only.

BUT

• Though I consider, I do not make a diagnosis of a processing disorder, as this is not a medical diagnosis.

1. ‘Sensory Processing Disorders’ have the most medical support. I refer to a Pediatric OT with appropriate experience. For children under age 5, OT’s are accessible through local Child Development Centers; otherwise parents must pay for services (11).
2. ‘Auditory Processing Disorders’ remain controversial. Public services for testing are very limited. VCH audiology stopped assessments in 2007 (6); now only available at Surrey Memorial Hospital (for children in Fraser Health catchment). There are several private practitioners who offer assessment and treatment.
3. ‘Visual Processing Disorders’ are within the realm of alternative medicine. I neither suspect them nor refer for assessment.

• I consider, (but do not make) concurrent diagnoses, at times: A primary DSM5 diagnosis may not satisfy all of the child’s needs: For instance, children diagnosed with autism frequently have sensory sensitivities. An OT may concurrently diagnose a Sensory Processing Disorder and provide useful therapy. But autism is the primary medical diagnosis.
  
• I do diagnose Developmental Coordination Disorder (DCD): Defined as functional motor impairment where there is no underlying neurological disorder, this is in the DSM5 under Motor Disorders, and hence within our purview as physicians. Diagnosed in conjunction with an OT or PT.  Tread with care, however, as it is a diagnosis of exclusion.
• The desperation and frustration parents feel regarding unsolved issues in their child inspires action. But this is no reason to endorse spending valuable time and money on unproven treatments. For such parents with or without financial resources to invest, I stick to tried and true methods: for learning challenges: Orton-Gillingham tutoring, specialized private schools (Kenneth Gordon Maplewood, Fraser Academy, St. John’s, Mediated Learning Academy, etc in Vancouver area); speech-language assessment and treatment, ADHD assessment and treatment, behaviour therapy for a child with autism, parenting programs and support through Alan Cashmore Center, Community Health Centers, Family Services of Greater Vancouver for challenging behaviour; psychological counseling and Child and Youth Mental Health for anxiety and emotional issues. OT can be part of the mix, as, less commonly can be audiology.
• For other possible conditions and treatments: I do not have an informed opinion on Dr. Amen’s concepts, neurofeedback, or other alternative approaches. My negative view is based on anecdotal information only. When asked by parents I give them this honest answer.

References:

1. Diagnostic and statistical manual of mental disorders: DSM-5 by American Psychiatric Association. DSM-5 Task Force; American Psychiatric Association, 2013, 5th ed. (Request with CPSBC or view UBC)  DOI: 10.1176/appi.books.9780890425596
2. Zimmer, Michelle, et al. Sensory integration therapies for children with developmental and behavioral disorders. Pediatrics 129.6 (2012) View
3. Webpage: Regulation Disorder of Sensory Processing, Early Childhood Mental Health Fact Sheet. Minnesota Association for Children’s Mental Health. Accessed from http://www.macmh.org/publications/ecgfactsheets/regulation.pdf on May 31, 2016.
4. The American Occupational Therapy Association comment on DSMV and SPD.pdf View
5. Moore, D. R., Ferguson, M. A., Edmondson, M.  A., Ratib, S., Riley, A. Nature of Auditory Processing Disorder in Children. Pediatrics 126(2): e382-e390 (2010) (View with CPSBC or UBC)   DOI: 10.1542/peds.2009-2826
6. Vancouver Coastal Health Position Statement. Auditory Processing Disorder Testing at Vancouver Coastal Health (2007). And The Canadian Interorganizational Steering Group for Speech-Language Pathology and Audiology. Canadian Guidelines on Auditory Processing Disorder in Children and Adults: Assessment and Intervention. (2012) View
7. Lovett, B.  J. Auditory processing disorder: School psychologist beware? Psychology in the Schools 48(8): 855-867 (2011). (View with CPSBC or UBC) DOI: 10.1002/pits.20595
8. DeBonis, David A. It Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children. American Journal of Audiology 24(2): 124-136 (2015). (View with CPSBC or UBC) DOI: 10.1044/2015_AJA-14-0037
9. Webpage: Understood for learning & attention issues. Understanding Visual Processing Issues. Accessed from: https://www.understood.org/en/learning-attention-issues/child-learning-disabilities/visual-processing-issues/understanding-visual-processing-issues on May 31^st 2016.
10. Lueder, G. T., et al. Joint statement-learning disabilities, dyslexia, and vision. Pediatrics 124(2): 837-844 (2009). (View with CPSBC or UBC) DOI: 10.1542/peds.2009-1445
11. College of Occupational Therapists of BC: http://cotbc.org

Additional Readings:

1. Kamhi, A, G. What speech-language pathologists need to know about auditory processing disorder. Language, Speech, and Hearing Services in Schools 42(3): 265-272 (2011). (View with CPSBC or UBC) DOI: 10.1044/0161-1461(2010/10-0004)
2. Wilson, W. J., and Arnott, W. Using different criteria to diagnose (central) auditory processing disorder: How big a difference does it make? Journal of Speech, Language, and Hearing Research 56(1): 63-70 (2013). (View with CPSBC or UBC)  DOI: 10.1044/1092-4388(2012/11-0352)
3. Canadian Guidelines on Auditory Processing Disorder in Children and Adults:  Assessment and Intervention (2012). View
4. Missiuna, C., Gaines, R.,  & Soucie, H. Why every office needs a tennis ball: a new approach to assessing the clumsy child. Canadian Medical Association Journal 175(5): 471-471 (2006). (View with CPSBC or UBC) DOI: 10.1503/cmaj.051202

Resources for Parents:

1. CAPD assessment and Management Booklet. View
2. SPD Building Resilience. View

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Diagnosing processing disorders

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