Working Memory and Auditory Processing

When attention deficit disorder or attention deficit hyperactivity disorder has been identified, concomitant problems with phonologic or auditory processing when hearing tests are normal can lead to serious deficiencies in learning that will persist into adulthood.

In my experience, these often are comorbid and can both mask and magnify each other. Attention deficits can mimic phonologic or auditory processing impairments because deconstructing words for meaning and developing meaning out of the context of the usage of the word both require attention and working memory. Conversely, the inability to perceive phonemic or auditory information produces functional limitations with learning that occur in the context of increasing levels of anxiety in the child, causing frustration that appears to the casual observer to be hyperactivity or distraction that is a strategy the child employs to minimize his or her frustration.

Fortunately, once appropriately identified both of these types of impairment can be relatively easily improved through integrated treatment. Optimally, this can be done at home over summer vacation under the direction of a team involving the parent, speech/language therapist, reading resource teacher, and pediatrician. Before summer vacation starts, the pediatrician can work with the parent to provide to the child a brief introduction to ADD/ADHD medications, identifying the optimal medication, dosage, and timing.

Baseline testing using sophisticated measures by the reading resource teacher and speech language therapist should be obtained under the optimal medication regimen. During summer vacation, the medication regimen can be used with daily computer-based drills at the child’s home using software such as that provided by Posit Science and Lumosity, under the direction of the speech language therapist, no more than one hour each day. As the child moves towards competence with auditory processing, recreational reading is introduced with a meaningful reinforcement schedule involving another hour each day.

Near the end of summer vacation, the speech/language therapist and reading resource teacher should retest the child under the medication regimen and one week later without the medication. Using this information, an appropriate strategy for the new school year can be determined for the child.

Executive Function: Working Memory

I am always amazed when I recall that Albert Einstein developed his theories of relativity with what he called thought experiments (Einstein, 1920).

Einstein was not only very intelligent, he had excellent working memory, defined as “the set of mental processes holding limited information in a temporarily accessible state in service of cognition” (Cowan et al., 2005). The laboratory in which he conducted his thought experiments was his working memory. As a child, his intellectual development was enabled by his gradual accretion of knowledge, supported by the development of his working memory capacity, both in terms of his ability to attend and maintain focus, and in terms of his ability to consider an increasing breadth of ideas and facts.

Working memory is crucially dependent on minimally adequate levels of attentional capacity (Saults & Cowan, 2007). In turn, aptitudes and intellectual capacity are dependent on working memory; “[i]ndividual differences in the measured scope of attention are important for individual differences in aptitudes” (Cowan et al., 2005).

Attention is necessary but not sufficient for the full development of working memory, beginning in early childhood, and becoming extremely important at age 8 or 9, with the advent of complex reasoning tasks involving the integration of information obtained aurally, through reading and visual encoding of pictorial information, and by demonstration. To the degree that task complexity and rate of information flow increases in school and in later work settings, the importance of working memory capacity accelerates.

Individual differences in working memory capacity development are related to differences in educational development. To the degree that attention is impaired by attention deficit disorder or attention deficit hyperactivity disorder (ADD/ADHD), working memory capacity will be limited, leading to problems with reasoning that persist even after the attention decrement has been successfully addressed with medication. This is important because, although working memory imposes a ceiling on intellectual capacity, it can be considered a skill, a feature of the person that can be developed. As such, once the ADD/ADHD problem has been addressed, remediation of working-memory deficits should be undertaken. As working memory improves, the child should be encouraged to re-visit challenging intellectual tasks and will find that these are more easily handled.

  • Cowan, N., Elliott, E. M., Scott Saults, J., Morey, C. C., Mattox, S., Hismjatullina, A., et al. (2005). On the capacity of attention: its estimation and its role in working memory and cognitive aptitudes. Cogn Psychol, 51(1), 42–100.
  • Einstein, A. (1920). Relativity: The Special and General Theory. London: Methuen & Co, Ltd.
  • Saults, J., & Cowan, N. (2007). A central capacity limit to the simultaneous storage of visual and auditory arrays in working memory. Journal of Experimental Psychology: General, 136(4), 663–684.

Executive Function: Development in Rehabilitation

After a brain injury, a useful alternative to the natural development of executive functions (EF) having to do with inhibition and emotional self-control is the reinforcement of rules that prohibit target behaviors.

Using prohibitions to develop self-control is useful because it simulates the down-regulation of the limbic system by the orbital-frontal cortex (OFC). The OFC is linked to the amygdala such that it provides appraisal-based inhibition (ABI) after arousal.

When the person with ABI doesn’t have enough “self-control”, one likely cause is an imbalance between the OFC and the limbic system, which had been gradually developed through mid-childhood and early adolescence, but has been disrupted by the ABI. One helpful way to think of this is to evaluate these executive functions in terms of age equivalence and then to design rules and procedures that would be appropriate in a school setting for people of that age.

Get started with the Behavior Rating Inventory of Executive Function—Adult (Roth, Isquith, & Gioia, 2005) administered to both the person and a significant other. Because age-based normative data are available, you can help the client and family understand that this is a developmental issue, which is often greatly appreciated. Once the emotional self-control level has been identified, functional-age-equivalent rules can be developed that are more likely to be successful in eliciting appropriate behavior.

Care should be taken to not over-restrict the client because the “just-right challenge” is found at the interface between his or her immediate capacity and the demands of their occupations and environmental contexts. You want to continue to challenge the client so that self-reliance is able to gradually develop. One way to do this is with motivational interviewing (Miller & Rose, 2009). MI is a strategy that was developed for counseling persons with drug and alcohol dependence to assist with sobriety. It has been found to be useful whenever ambivalence pertains, which is usually the case with ABI intervention. The beauty of a vocational context for MI is that the “urge towards competence” (White, 1959; White, 1971) is always operative, reinforcing the clinician’s efforts.