APD Mishearings Can Sometimes Be Hilarious

Today I thought I would try to post something light-hearted and humorous. Living with a child who has Auditory Processing Disorder has it's moments of downright belly jiggling laughter.  You see although all children mishear things some of the time, because APD makes it difficult to process what is said, children and adults with APD can do it a lot of the time.  Sometimes the results are hilarious.

Sometimes, we keep the laughter to ourselves as there are emotions involved.  Sometimes, we go right ahead and laugh as our daughter herself finds them funny and can see the humor in it all; of course we take her cues before laughing. (I think it might have accidentally become a game as well because sometimes I find all the kids saying things to make people laugh as if they misunderstood something. We all play along and laugh at our funny misunderstandings.)

So here are a handful of misunderstandings by our child and others that we found funny:  

• We were watching the show “The Middle” on television.  The oldest son in the show is named Axel.  Our daughter turns to us and asks, “Why did they name their son Asshole?”

• We were driving in the late afternoon and I said, "Oh no, we are in rush hour!" I heard my daughter’s little worried voice reply, "We’re in Russia?"

• I told my son to go and brush your teeth.   He said very excitedly, "We are getting a tent?”

• I was looking in the fridge and asked my son, “What happened to the cheese?” He replied, “I’m wearing my jeans!”

• I was covering my nose with my hand and heading towards the bathroom.  My daughter asked, “Why are you hiding your nose?”  I answered, “My nose is running.”  She tilted her head and with wide, expressive eyes said, “I don’t think your nose looks funny.”

But on a more serious note, these little misunderstanding are just the tip of the iceberg for people with auditory processing disorder.  They are funny examples of how they mis-process words they hear all the time and have to try to make sense of very mixed up language.

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(I'm adding on to this article whenever I find more funny moments.  So below are ones that I've heard of since the original publication of this post.  Enjoy!)

• My daughter asked, "Why do those hobo witnesses keep coming to our door?"

• I was trying to retrieve the word insane asylum or sanitarium
  What I retrieved instead: Insane aquarium

• My with APD asked, "Mom, what is an alibi?" So I gave her a definition. Her response was, "Oh, I thought it was the song you sing to a baby"

• Funny APD Moment: I was very crabby this morning. My mom told me to beware of Negative E. My response is who is Negative E? Is that an evil Santa Claus or the Boogeyman, or maybe an evil Easter bunny? Apparently I was getting flustered, because my mom laughed and explained that she'd said "Negativity".

• My child with APD used to tell me she was so afraid of the potato. I couldn't figure it until she was watching the weather channel one day and showed me what she was talking about - tornado!

• Child with APD: "Fear my raft!"
  Mother:  "... what?" 
  
  Child with APD: "Fear my raft!" 
  Mother:  "OH! It's wrath! Fear my wrath. Watch my lips.. W-R-A-T-H."  
  Child with APD:  "OOOHHHH! That makes so much more sense!
  
  
  
  

It Shouldn't Be This Hard: How One Girl with APD Learned to Read

“If I didn’t have Auditory Processing Disorder, I bet I would be able to read college level books by now.  I wish I didn’t have Auditory Processing Disorder.  It makes things so hard.  It’s not supposed to be this hard.”  Tear paths slowly appear on her cheeks as she lets out a barely auditable sigh.

Reading has been a horrendously difficult hurdle for my daughter with Auditory Processing Disorder (ADP).  You see one aspect of APD is auditory discrimination problems.  Auditory discrimination is the ability to detect the distinct and separate sounds in words.  Teachers call this phonemic awareness, and preschoolers and kindergarteners play games to identify the first consonant sound in a word or to rhyme small, one syllable words.  This, sensibly, leads to the skills needed to learn phonics.  Phonics is the method of teaching people to read through the recognition of letter patterns and the sounds they represent.  It is the most prevalent method to teach reading as it is highly effective.  With the knowledge of phonics, a person can read just about anything without having to have seen a particular word written before.

So with my daughter Hailey’s very real problems with auditory discrimination, she could not identify onset consonants, rhymes, or even hear the differences in many letter sounds.  For instance, /p/,/b/, /d/, /t/ and /g/ all sound the same to her.  As well as /nk/ and /ng/,  / f/, /s/, /v/, /sh/and /th/,  /a/, /e/ and /o/.  So no matter how many games we played, and no matter how much her private speech therapist worked with her on phonemic awareness, she could never distinguish the letter sounds.

Having more in my arsenal of techniques for teaching reading by having been a first grade teacher for many years, I decided to try the sight word approach.  So Hailey and I started playing games with flashcards.  We acted out words; traced words; made words with playdough; wrote words in the air; played memory with the cards; made stories with the cards; and similar type activities.  This was loads of fun, but it didn’t transfer over into reading.  Sure she could memorize a few words, but it took months to memorize just a few words.  Learning to read like this would be completely impractical.  You see, Auditory Processing Disorder (ADP) has another aspect: short term/working memory problems.  So Hailey has to repeat something, particularly something to do with auditory input, over and again until it finally is locked comfortably into her long term memory and the path to retrieving it is well defined.

So my spouse and I took her to see a neuro-psychologist.  We wanted to know what she could determine to help us teach Hailey to read.  Well, sadly we paid this woman way too much money for her to tell us that Hailey would probably never learn to read and we should focus on “life skills” instead.  Of course, we didn’t listen to her, and I started researching all I could find on reading.

I came upon a program called The Lindamood Phoneme Sequencing® (LiPS®) Program.  This program teaches children to learn the specific feeling of their lips, teeth, mouth, and breath when making each particular letter sound.  They also learn to identify the sound by “reading” other people’s mouths when they make the sound.  It seemed like it might work.   However, the program done at the Lindamood Bell Centers was extremely costly, and we really couldn’t afford it.  Knowing we would find the money some way if we had to, I started to look into private reading specialists first.

After scouring the Internet, I found a few people in my area who operate as private reading specialists and/or tutors.  I interviewed three and found the one I wanted to try.  She had been a reading specialist for the schools and was now retired.  She had been trained in the LiPS program and would love to work with Hailey.  So off we went to start the process.  It was amazing!  This program was the magic pill that enabled Hailey to read.  She took to it immediately and voila!  Her problem with auditory discrimination was not going to hold her back from reading.

So now Hailey has been reading for about two years.  She can decode absolutely any word and she loves to work in phonics based multisyllabic word workbooks.  As a bonus, her spelling is actually quite good due to her strong phonics skills, and she spends a great deal of time writing.  Of course, she still has the short term/working memory issues associated with Auditory Processing Disorder, so she spends a large amount of time phonetically spelling words and/or looking them up in the dictionary. 

So why is Hailey still crying about reading?  Simply this: she reads multiple times every day and yet it is still difficult.  As she puts it, “I see the word people and I have to sound it out every single time.  It just doesn’t stick in my head like it should.  I have to read a word hundreds of times to remember it.  My brother, he reads a word once and he remembers it.  He reads less than half the amount of time I read and he can read bigger words and faster.  It’s not fair.  It shouldn’t be this hard!”  This, again, is that short term/working memory problem that is a part of APD.

A third problem with Auditory Processing Disorder is filtering out background noise.  Hailey hears all those little sounds that are around us all the time: the furnace kicking in, the dog licking her paw, someone in the next room talking, a neighbor mowing his lawn,etc.  She finds it incredibly difficult to have to concentrate on reading when all those other sounds keep bombarding her.  So I finally broke down and bought her noise reduction ear muffs.  I was worried about her getting dependent on them and I wanted her to strengthen her ability to filter out background noises.  However, she wanted to focus on reading and she felt this would make a big difference to her.  They do help and she is much happier with them.

Surprisingly with all the intense work that it takes to read, Hailey still thoroughly enjoys reading.  She loves fiction and she finds that she remembers better the non-fiction that she reads versus what she has heard.  She has perseverance greater than I have ever witnessed in anyone before or since.  She is determined to not let her Auditory Processing Disorder stop her from doing all that she wants to do – including one day reading college level books.  For this, I admire her. 

So she says if she didn’t have Auditory Processing Disorder, she would already be reading college level books.  I say if we all worked half as hard as she does, it’d be amazing the things we could accomplish.  

What Can Psychologists Do Better When Working With Children With Special Needs?

I solicited some people on a couple of my Facebook communities for people or parents of children with Auditory Processing Disorder.  My purpose was to get input for my sister-in-law who supervises students practicing to be licensed therapists. 

Here is my original question and the wonderful, thoughtful responses I received.  I also left the number of Facebook likes to show how many people pushed “like” to show their agreement with the response.

“Please give me your thoughts: My sister-in-law is a supervisor of students practicing to be licensed therapists. She wants to know what things can therapists (as in psychologists) do better to help children with special needs?”

Yvonne:

“I think the most helpful thing any therapist can do - is to do their best to remove their biases - and remember although labeling may help get services - labels hurt kids/all people - correct diagnosis is so much more important.”

Facebook Likes : 2

Jennifer:

“It is important to look beyond the label and the list of recommended treatments and find out what the individual child needs. The label should only be a starting point as to what to look for. The therapist needs to dig and explore and figure out what is needed to treat and recover.”

Facebook Likes:  2

Kelseigh:

“Educate themselves. Yes, they're practicing and learning to be therapists, but that doesn't cover everything they're going to encounter out in the real world. If they weren't taught about a certain topic or forgot it, they still need to be responsible for that knowledge.”

Facebook Likes:  1

Hannah:

“Growing up with special needs I wish people would research the special need(s) more and try to better understand what it is like to have special needs.  My recommendation is to talk to someone who has the specific special need, if possible, to get a feel of what it's like in their shoes. Empathy is the best thing someone's ever given me.”

Facebook Likes:  3

Catherine:

“I would suggest they remember that behavior is communication. Everything a child does has a purpose. We have to figure out what they are trying to tell us, then teach them how to tell us more efficiently.”

Facebook Likes:  3

Nancy :

“Listen to parents and don’t disregard their feelings or thoughts or treat them like they know nothing, and don’t say negative things in front of the kids. Also follow up - maybe after a child has left care, a month later ring and ask how things are going.”

Facebook Likes:  5

Salina:

“Trust a parent's instincts.”

Facebook Likes:  6

Molly:

“Get hands on experience working with special needs children prior to becoming a qualified psychologist.  Also it would help to work with adults with special needs in order to get the bigger picture of our kids as adults!”

Facebook Likes:  5

Molly:

“Be prepared to commit to long-term therapy, as many of our kids can’t handle changes in staff.”

Facebook Likes:  4

If you have any other thoughts you would like to include, please post them in the comments.  Thank you.

She Will Find a Way to Make Herself Heard

Today I read a blog post which reminded me of my daughter when she was about five or six years old.  Her twin brother and she were working on learning to add as well as understand the concept of basic place value.  We had a hundreds chart taped to the wall which we used as a visual reference.  Of course, we also used other items and multi-sensory approaches, but the hundreds chart ended up playing a more significant role than I ever could have imagined.

My daughter, because of her auditory processing disorder and language issues, was still having a difficult time knowing the words for the numerals.  So she could see 5 and know that meant 5 objects, but she couldn't remember how to say "five".  She also couldn't identify the numeral 5 when I said "five".  It was frustrating for her, to say the least.

One day an amazing thing happened that really showed me how intelligent and creative my little girl really is.  She started pointing to numbers on the hundreds chart in a specific way.  She wanted me to watch her, and she was obviously trying to show me something.  So I kept watching and it finally dawned on me:  she was adding!  Yes, she was pointing to numbers in a sequence such as 4, 5, 9 or 3, 10, 13 and she kept doing this over and over again until she felt I understood her.

It was one of those enlightening moments in our lives.  I'll never forget it and since then, I have always trusted that she will find a way to make herself heard. 

Nurturing Self-Esteem in the Child with Special Needs

I recently solicited some friends on ideas for blog posts/articles.  One friend suggested writing about helping children with special needs build and maintain a good sense of self-esteem.

So off I went to research self-esteem and children with special needs.  I found a treasure trove of wonderful articles and eventually decided to focus my post around Maslow's hierarchy of needs and the article "The Need to Belong: Rediscovering Maslow's Hierarchy of Needs" by Norman Kunc.^*

As you can see from the diagram above, Maslow positioned that self-esteem is reliant upon a sense of belonging.  Norman Kunc, in his article mentioned above, explained, "Without a social context in which to validate a person's perceived worth, self-worth is not internalized.  The context can vary from small and concrete, as with babies, to universal and abstract, as with artists."^*

So a baby feels belonging by being loved and cared for by his or her family.  The baby is treated as a valuable member of the family.  A child belongs to a family as well as a group of friends, a team, a class, and others which provide a sense of community to that child. Adults belong to families, friends, neighborhoods, work groups, associations, etc.  It is through a secure sense of belonging that humans feel recognized, respected, and valued as members of that community.  These feelings are internalized as healthy self-esteem.

However, as Norman Kunc points out, our communities must be accepting of diversity and find value beyond the currently narrow definitions of achievement, success, appearance, and other socially driven categories: “Yet in our society, we draw narrow parameters around what is valued and how one makes a contribution….Instead, we [need to] search for and nourish the gifts that are inherent in all people.”^*

So, how does this relate to nurturing and helping to maintain healthy self-esteem in children with special needs? 

Children with special needs often run into difficulty with self-esteem when they begin to realize that they are different from their peers.  Sometimes this comes in the form of bullying whereby the child is told he or she essentially does not belong to the group and is not wanted.  Sometimes this comes from the child him or herself identifying how different he or she is, and the child starts to isolate him or herself from the group out of fear of not belonging.  Both of these scenarios create the feeling of unworthiness and thus hinder self-esteem.

Another thing that happens to children with special needs is when the group to which the child belongs values only certain traits in its members.  This might be academic achievement in school, athletic achievement in a sport, or appearance in a social group.  The child who cannot achieve at the level required for these groups begins to not feel valued as a member of the group. This leads to doubts of self-worth.

These problems of being different and not being able to meet the goals defined as necessary to be a member of the group are how our current society fails in providing a sense of authentic belonging to all people.  To change this dynamic, society needs to encourage diversity and honor all the contributions people can make.

However, this post is not about changing society.  This post is about helping children today, in this society, maintain self-esteem.  So, if a sense of belonging and providing value to community is the building block upon which self-esteem sits, it only makes sense that we need to provide this for our children with special needs. 

So here are a dozen suggestions generated by myself and the ideas I garnered from my internet research:

1. Make sure you have a home life that values all members and all contributions without placing a hierarchy of value;
2. Provide a way for your child to contribute to the family in a way your child feels is valuable;
3. Find an activity or a group that your child can feel a welcome member of:
• A sport your child is good at;
• Chess club, book club, a role-playing game club, or any other activity your child enjoys;
• Drama, an art class, an environmental clean-up crew, etc.;
4. Talk to your child’s teacher or group facilitator about making a point of honoring diversity and multiple talents;
5. Make a point of having people in your child’s life who demonstrate respect for diversity and multiple talents;
6. Provide your child with a group identity to belong to such as artist, writer, good helper, etc.;
•  This can be done without having a specific group of people as in these groups one can be a member simply by doing art, writing, helping, etc.; 
• You as the parent can be the one expressing how valuable the child’s art, writing, helping, etc. is to you as a family member, as a person who likes art, writing, etc., and as a member of the greater society;
7.  Expose your child to the variety of ways in which people contribute to and are needed by the greater society and are valuable: street cleaners, doctors, artists, musicians, comedians, athletes, moms, dads, social workers, custodians, activists, therapists, dog lovers, environmentally conscious people, people who smile when we pass them in the store and they make everyone feel happier because of it, etc.;
8.  Find a way your child can contribute to a cause such as a favorite charity, helping at a soup kitchen, cleaning up the park, etc;
9. Educate your child on why people bully;
10. Help your child find value in identity as a member of his or her cultural, ethnic, or religious community;
11. Show your child other people with differences (disabilities/differing abilities) who are doing well and feeling happy with their lives.  They can be an excellent role model for your child; and
12.  Find a peer group of children with the same or similar differences to your child. It can be empowering to feel a part of this community as well.

This is a dynamic list and I welcome all suggestions to add to it.  Please post any you have in the comments as I would love to read them.  I hope you find some of them helpful. :)

^*Kunc, Norman.^”The Need to Belong: Rediscovering Maslow’s Hierarchy of Needs.” Broad Reach Training and Resources <www.normemma.com/articles/armaslow.htm>

Vibrating Chair

I started this blog with the intention of making it all about Auditory Processing Disorder, but as I've come to realize, I can't really isolate Auditory Processing Disorder from the other processing and learning differences that my sweet daughter has as well.  Like a lot of children with Auditory Processing Disorder, Hailey has other differences such as Sensory Processing Disorder, which is where this post on vibrating chairs fits in.

Recently Hailey has been having more difficulties falling asleep and staying asleep at night.  When she was an infant and young child, we went through tons of vibrating bouncy chairs and then vibrating pads for her to lie on.  She loved the feeling of being vibrated, and it was the best way she could get calmed enough to fall asleep.

When she was an infant, we happened upon the vibrating effect quite by accident.  We found that she would actually cry to be put in her vibrating bouncy chair.  She would sit in it and happily play with toys; interact better with us by making eye contact and smiling; and then would drift peacefully off to sleep in it.

Of course, the chairs would eventually stop working and we would buy another one.  Once she got too big for them, we started buying vibrating pads to lie on, however she didn't like them as much and really only used them before bedtime to get more sleepy.

Around age five, her last vibrating pad stopped working and since she hadn't been using it as much anymore, we decided not to replace it; she was getting to sleep on her own without it.  (She still had vibrating chew toys that she used when she felt stressed out.)

Now, five years later, she is starting to have difficulties with sleep again.  Maybe it's the onset of puberty causing it, maybe it's the stress of transitioning from being a child to a pre-teen, or maybe it's the social difficulties of the pre-teen/teen years.  Who knows really?

So we bought her a vibrating chair. (Comfort Products 60-0582) It's one marketed as a massage chair and it has eight rotating gears that provide a vibrating sensation.   She loves it!  Not only does it help her to sleep, she also uses it to just relax when she's feeling stressed or overwhelmed.

Auditory Processing Disorder: "A Manifestation of Impaired Neurocognitive Processes" and "One Factor in the Overall Profile of Different Developmental Disorders"

After weeks of intense researching on Auditory Processing Disorder, I finally found an article that takes all that research and makes a cohesive analysis.  Yippee!  I love it.  It is titled "Communication Disorders: Auditory ProcessingDisorders."¹

Why The Intense Research:

So, let’s start from the beginning.  I wanted to research what the current thinking is on Auditory Processing Disorder because it seems to me that my daughter, as well as many of the other children I am learning about through my Auditory Processing Disorder (APD) groups, seems to have more than just auditory processing problems. Moreover, the label Auditory Processing Disorder is controversial and not recognized in the United States as a disability in and of itself.  My concern is that my daughter, and all other people with the diagnosis APD, will not get the accommodations she needs at places such as school (not related to us as we homeschool), college (possibly in the future), and work (when she's an adult).

My daughter has all the usual problems associated with APD: difficulty localizing sounds in space, discriminating sounds, recognizing auditory patterns, responding to the temporal aspects of sounds (integration, discrimination, ordering, and masking), and extracting auditory information in less than ideal auditory environments.  She also has the common attributes of APD of short term memory deficit and auditory recall problems – including word retrieval. 

Like many children with APD, she has also been given additional diagnoses that coincidentally are the same diagnoses given to many other children also diagnosed with APD:  Mixed Receptive-Expressive Language Disorder, Phonological Disorder, Attention Deficit Hyperactivity Disorder (ADHD) - only inattentive type, Sensory Processing Disorder, Visual Processing Disorder, Dyslexia, and the very broad term neurologically atypical.  She was also suspected of Autism when younger by two pediatricians and ruled not Autistic by a pediatric psychologist. 

Like a lot of children with special needs, she has had a variety of diagnoses and probably could have a variety more if we only brought her to the right specialist who would somehow find a way to make her fit the categories he or she is looking for.  Personally, I find all these labels just weird little note tags at this point that all say: She has a problem with her brain and it affects her academically and socially.  We notice it affects these particular areas and we don’t know what causes it or what to call it.  It seems similar enough to these diagnoses and not similar enough to these.

Moreover, when researching each of these specific diagnoses, it is readily apparent that there is a lot of overlap among them.  So how can one really differentiate where one begins and the other ends?  This has been a question that has plagued me for some time. 

How This Article Helps To Shed Light On the Confusion:

Now, on to this article which seems to make sense to me:  Karen Banai and Rachel Yifat, the authors of the article, “Communications Disorder: Auditory Processing Disorder,” have gathered the loads of research results from various testing being done on APD as well as similar disorders around the world, and written their interpretation.  To my understanding of their article, it seems that APD is most likely a “manifestation of impaired neurocognitive processes”² and it seems to mostly be related to impaired attention processing and impaired context processing.³   APD relates to ADHD in the impaired attention processing.⁴   APD relates to Dyslexia and other language disorders, such as Specific Language Impairment (SLI), in impaired context processing.⁵

Furthermore, it is believed a possibility that APD is “one factor contributing to the overall profile of symptoms in different developmental disorders.”⁶   This makes huge amounts of sense to me as it seems to me that many children with APD also have other issues, i.e. Sensory Processing Disorder, Visual Processing Disorder, Autism Spectrum Disorder, and those that seem to overlap with APD such as ADHD, SLI, and Dyslexia.

All of this research, in my opinion, suggests that it does not matter what diagnosis you give to a child and that perhaps the diagnoses themselves are flawed and limited in their criteria.  What matters is that you do what you can to provide the interventions and support each child needs to be as successful as possible at academics, as well as living life in general, including socializing.  As Banai and Yifat put it, “The reservations… concerning the necessity of the separate diagnosis of APD should not obscure the troubling fact that no matter what diagnosis they have received, the outcomes for many children with learning disabilities (estimated at 25% by Hatcher et al., 2006) even following gold standard interventions are not encouraging.” 

My Lesson Learned as a Parent:

The experts haven't figured it all out and really don't understand the brain and its processes well enough at this point to agree upon proper labels, categories, causes, etc.  So, stop worrying about the diagnoses and concentrate on helping my child academically, socially, and with life in general.  Look at her particular needs and address them on an individual basis.  When she gets ready to go to college, get a job, or do anything else that requires us getting special accommodations, well, let's hope the rules are less stringent than they are now, and they'll look at her as an individual and what she can/cannot do, rather than as a list of diagnoses.

Citations:

^{1Banai K, Yifat R. 2011. Communication Disorders: Auditory Processing Disorders. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation. Available online: http://cirrie.buffalo.edu/encyclopedia/en/article/249/}

^{2”Another option is that what appears as APD is merely a manifestation of impaired neurocognitive processes such as auditory attention or memory which lead to difficulties in challenging listening conditions.”}

^{3”Taken together, it seems that auditory processing deficits are part of the clinical picture of several developmental disorders, including dyslexia and SLI, even though causal relationships are poorly understood. Theoretically, this clinical picture suggests several possibilities. One option is that poor auditory processing is one factor contributing to the overall profile of symptoms in different developmental disorders (Dawes and Bishop, 2009). Another option is that what appears as poor auditory processing actually reflects a problem in other cognitive processes such as attention or context processing.”}

^{4”Finally, the findings of one study suggest that children diagnosed with APD were distinguishable from children diagnosed with ADHD in terms of their verbal memory spans (Maerlender, 2007), but neither auditory attention data, nor information on other aspects of performance were provided. Therefore, the lower memory spans in the APD children could have been a part of a more general disorder involving both language and attention. Indeed, it has been shown that both ADHD and APD are associated with high incidences of inattentive and distracted behaviors (Chermak, 2007).”}

^{“However, a careful analysis of performance on the auditory tasks revealed that poor performance typically results from poor auditory attention, rather than from a specific deficit in the spectral or temporal analysis of sound (Ferguson, Riley, Ratib, Edmondson-Jones, and Moore, 2009).”}

^{5”Furthermore, there are few apparent differences between children diagnosed with APD and those diagnosed with dyslexia or language problems on measures of both auditory and language processing (Dawes et al., 2009; King, Lombardino, Crandell, and Leonard, 2003)”.}

^{“In particular, individuals with dyslexia perform poorly on tasks in which performance in the general population benefits from the consistent presentation of repeated anchor stimuli, consistent with the idea that individuals with dyslexia are not making as efficient use of the context of recently presented stimuli as does the general population (Ahissar, Lubin, Putter-Katz, and Banai, 2006).”}

^{6”Taken together, it seems that auditory processing deficits are part of the clinical picture of several developmental disorders, including dyslexia and SLI, even though causal relationships are poorly understood. Theoretically, this clinical picture suggests several possibilities. One option is that poor auditory processing is one factor contributing to the overall profile of symptoms in different developmental disorders (Dawes and Bishop, 2009). Another option is that what appears as poor auditory processing actually reflects a problem in other cognitive processes such as attention or context processing.”}