1	Current Assessment and Remediation Practices in Auditory Processing Disorders Robert W. Keith Ph.D. Seminar presented to the 34^th Annual Mid-South Conference on Communication Disorders March 11-12, 2004
2	Eight Year Old Girl with language delay and reading problems SCAN FW = 16 %ile AFG = 16 %ile CW = 3 %ile AFT-R = 120 msec. Time Compressed Speech RE = 20% LE = 10% SSW = 5 %ile
3	Eight Year Old Girl with language delay and reading problems TOLD = 25 to 50 %ile Token Test for Children = 16 %ile TAPS-Revised 18 - 50 %ile for memory tests 10 %ile for discrimination
4	Eight Year Old Girl with language delay and reading problems Recommendations: Multisensory approach to reading Refer to SLP for eval and Tx. Preferential Seating Slow rate of instructions and check for understanding Shorten directions into simple steps ID computer games for auditory and reading skills
5	18 YO Female w/ Question of APD W/ multiple complaints of difficulty learning through the auditory modality Moderate impairment in expressive and receptive language ability Possible ADD – on Adderall (but tested off Adderall) Student in a junior college
6	18 YO Female w/ Question of APD SCAN-A Composite SS= 65 for 1^st %ile SCAN-A ear advantage: Competing Words Subtest REF = 5, LEF = -4 Significant Competing sentences test EA = +3 (significant) SSW >2 SD below normal Dichotic Digits Total = 65% (cut-off = 88%) TCST -1.5 SD for 40 and 60% TC DPT Verbal 55% Hummed 100% RGDT 8 mSec. QuickSin = 15 dB SNR loss
7	18 YO Female w/ Question of APD: What are the implications of the APD findings: To assist this young lady to succeed in college? For decisions about vocational/occupational choices? For decisions about appropriate work sites/situations?
8	Purposes of this Seminar Define Auditory Processing Disorders Determine who should be referred for AP testing? Discuss the test battery approach to assessment of children with possible APD Interpret results of APD test batteries Describe remediation and management of children with APD
9	Some interesting issues in APD What is an appropriate diagnostic test battery? Why do we have so few standardized tests or tests with adequate norms in auditory processing? What is the clinical role of fMRI and EP in the assessment of APD? What is the relationship of specific language impairment or phonologic processing to temporal processing and frequency discrimination? What is the relationship between auditory processing and specific language impairment? and reading abilities? What guidelines exist for recommending FM systems in children with disorders of AFG? What are appropriate approaches for remediation of children with APD? Etc., etc!!!
10	Central Auditory Processing Disorders (CAPD) How would you define CAPD?
11	Two “Consensus” Conferences on the topic of (Central) Auditory Processing Disorders American Speech Language Hearing Association – 1996 Task Force on Central Auditory Processing Consensus Development, Amer. J. Audiology, 5: 41-54,1996 Bruton Conference- 2000 Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children. Jerger and Musiek, JAAA 11: 467-474, 2000
12	Categories of Tests to Measure (Central)Auditory Processes (ASHA, 1996) Sound localization and lateralization Temporal processes – ordering, discrimination, resolution (e.g. gap detection) Low redundancy monaural speech (TC, filtered, competing, etc. Performance with dichotic signals (syllables, digits, words, sentences) Electrophysiologic measures Speech and language assessment
13	Bruton Conference (Jerger and Musiek, JAAA 2000) Definition of APD An auditory processing disorder (APD) is … a deficit in the processing of information … specific to the auditory modality. The problem may be exacerbated in unfavorable acoustic environments … associated with difficulties in listening, speech understanding, language development and learning.
14	Bruton Consensus Conference on the Diagnosis of APD in School-Aged Children: Minimal APD Test Battery Behavioral measures Pure tone audiometry P-I functions for word recognition Dichotic task (digits, words, and/or sentences) Duration pattern sequence test Temporal gap detection Electrophysiologic measures Immittance audiometry Otoacoustic emissions ABR MLR P300 (optional)
15	Both Conferences discuss factors to consider when making a diagnosis of APD, including: Attention Auditory neuropathy Fatigue Hearing sensitivity Intellectual and developmental age Language age Medications Motivation Motor skills Native language
16	The Controversy: Clinical and Research Concerns Regarding the 2000 APD Consensus Report and Recommendations Katz, Johnson, Brandner, Delgrange, Ferre, King, Kossover-Wechter, Lucker, Medwetsky, Saul, Rosenberg, Stecker, Tillery Audiology Today March/April 2002 Volume 14 Number 2 2002
17	Clinical and Research Concerns: Philosophy APD requires an educational model rather than a diagnosis model Diagnosing APD versus describing behavior that promotes seeking remedies Insufficient research to document statements, cannot tell what is opinion Research on adults with lesions not appropriate to APD in children
18	Clinical and Research Concerns: Professional Physiologic Measures OAE ABR MLR Behavioral Measures PI-PB Dichotic Digits Duration Patterns Temporal Gap Detection
19	The Response: On the Diagnosis of Auditory Processing Disorder – a reply Jerger and Musiek Audiology Today Volume 14, Number 2 2002
20	The Jerger and Musiek Reply Disentangle diagnosis from treatment Disentangle APD from other problems such as attentional and linguistic factors Different approaches to diagnosis have unique advantages and disadvantages The diagnosis of APD lacks a gold standard Electrophysiological and electroacoustic measures are central to the diagnosis of APD There is time. You just have to take it.
21	Linear models of auditory processing and language disorder: A bottom up approach* Neurologic disorder Auditory Processing Disorder Language Learning Disorder Reception Perception Cognition * Reverse Conception and Perception and it becomes a top down approach
22	Bottom up processing Mortholinium Ethylsulfates Dimethyl Ethylbenzyl ammonium chloride Triethanolamine Isopropanolamine Cocoamphocarboxyglycinate 1-800-Call Bob
23	Top – Down Processing (or “top processing”) Bill Haste Music Flight Telephone Elephant Antidisestablishmentarianism
24	Linear models of auditory processing and language: Bottom Up Reception Perceptual Cognitive Disorder Disorder
25	Linear models of auditory processing and language: Bottom Up Reception Perception Cognitive Disorder
26	Linear models of auditory processing and language: Top Down Cognition Perceptual disorder* *No affect on reception
27	Which one is different?
28	Child with “bottom up” auditory processing problems. Fifth grade child with high IQ and 90+% ile on standardized tests – Poorly coordinated Excellent reader – math and science Difficulty “hearing” in noise and groups – no ADD Poor organization and listening skills Misses auditory directions though he tries hard Recently assigned some F’s in school
29	Child with “bottom up” auditory processing problems. SCAN-C Filtered Words = 75% Auditory Figure Ground = 37% Competing Words = 16% with REA = 2 % Competing Sentence = 9% Composite = 25% SSW LC = 1^st % RC = 10^th % Time Compressed Sentence Test in 12^th % RGDT – prolonged temporal processing @ 80 msec. DPT & FPT WNL
30	Child with “bottom up” auditory processing problems He is a bottom up APD because he is: Bright An excellent reader with good phonologic skills Good expressive language skills But he cannot process Speech in noise Acoustically degraded speech Has abnormal temporal processing
31	Child with “bottom up” auditory processing problems – Impression and Recommendations Delayed auditory maturation with normal hemispheric dominance for language Listening skills equal to those of younger child Partially compensated, especially in lower grades, by high intelligence – “guesses wrong” Recommend classroom management, provide teacher information, increased internal locus of control Consider FastForward for temporal processing
32	Central Auditory Testing What is your purpose?
33	Purposes of Central Auditory Testing Identify functional disorders of communication Identify site of Lesion Educational or Vocational Counseling Medical or Legal Evaluation Monitor Degenerative Disorder Better understanding of behavior* Removal of blame for poor performance* Development of remediation programs* Appropriate educational placement* *Cherry, 1993
34	Appropriate Referrals for CAP Testing: Using behavioral profiles. Normal hearing Inconsistent auditory responses Poor auditory localization Poor auditory discrimination Deficient phonemic skills Poor understanding in noise Poor auditory memory Poor listening skills Difficulty understanding rapid speech Frequently says “huh” or “what”
35	Appropriate Referrals for CAP Testing Children’s Auditory Performance Scale (CHAPPS)* Smoski, Brunt, and Tannahill (1998) Listening conditions: Noise, Quiet, Ideal, Multiple inputs. Range from less difficulty to cannot function at all. *Available from EAA 1-800-460-7322
36	Considerations prior to accepting a child for APD testing. Houston Referral Guidelines* Seven years old or older Passed a hearing test English as a primary language IQ of 85 or higher Recent psychoeducational assessment: is LD, ADD or emotional problem present Recent SLP assessment to evaluate auditory processing skills Intelligible speech Be able to follow instructions to complete APD testing
37	Houston Referral Guidelines* (cont.) APD considered after complete evaluation for LD, ADD, and SLP Referral must include IEP All previous assessments Diagnostic labels If on medication for ADD What special classrooms the child attends What modifications are in place What change in programming would result from APD diagnosis – if none then no test.
38	Colorado Dept. of Educ: Team approach to CAPD* Observation To ID children with CAPD behaviors To ID interventions strategies To ID children who need further assessment Assessment Procedures: Screening and Dx. To determine presence of APD To develop IEP Classroom management Instructional modifications Amplification Additional Dx Procedures for organic-based problems
39	Colorado Dept. of Educ: Team approach to CAPD (cont.) All Screening and Assessment Procedures include protocols for Auditory Language Psychological Educational Other
40	Behavioral Tests of Auditory Processing Abilities Basic Considerations
41	The effects of linguistic background on results of tests of auditory processing disorders.
42	Factors to Consider When Testing for APD Age Peripheral hearing loss Linguistic background Ability to respond Reaction time Language and Cognitive abilities Auditory load of tests Motivation
43	Cognitive factors that may affect APD test results and interpretation Intelligence Memory - short and long term Speed of mental processing Attention Reaction time Social expectations Communication strategies
44	Assessment of Auditory Processing Disorders: Rule Number One Rule out middle ear disease and peripheral hearing loss!
45	Assessment of APD: Peripheral Test Battery Otoacoustic emissions (OAEs) Aural immittance measures Tympanometry Acoustic reflexes (crossed vs. uncrossed) Pure tone audiometry Speech audiometry Word recognition
46	Tests for Central Auditory Processing Disorders: Following the ASHA Model Tests for Temporal (timing) Processing Disorders Monotic Degraded (Sensitized) Speech Tests of functional listening and identification of cortical lesions Dichotic Tests for hemispheric dominance and cortical lesion Electrophysiologic measures of central function and attention
47	Temporal Processing Disorders Grammatical morphemes with short duration pose problems for speech-language impaired children (Drommi et al., 1993) We try to identify timing disorders in the auditory system to explain why some patients have difficulty with auditory discrimination, phonics, and reading. With this information appropriate remediation can be implemented.
48	Temporal Processing Disorders Time not Lobe!
49	Tests of Temporal Processing Abilities Masking Level Masking Level Differences (Wilson et al. 1994) Auditory Fusion Test-Revised (McCroskey and Keith 1996) Random Gap Detection Test (Keith 2000) Time Compressed Sentence Test (Keith2002)
50	Random Gap Detection Test Keith (2000) Purpose: To investigate temporal aspects of audition by measuring the auditory fusion threshold of tone pairs or clicks separated in time between 0 and 40 msec.
51	Random Gap Detection Test (RGDT) Keith (2000) Tone pairs at 500, 1000, 2000 and 4000 Hz and pairs of clicks. Time intervals (gaps) between stimuli range from 0 to 40 msec.
52	Random Gap Detection Test Keith (2000) Example of inter-stimulus interval (gap) order of presentation in msec: 20 - 2 - 40 - 5 - 10 - 25 - 15 - 0 - 30
53	Random Gap Detection Test 1000 Hz (Keith, 2000) Recorded by Auditec of St. Louis Bill Carver, Ph.D.
54	Random Gap Detection Test (RGDT) Keith (2000) The gap detection threshold is defined as the time interval at which the stimuli are detected as two tones rather than one. A gap detection threshold >20 msec. is considered abnormal for temporal processing disorder.
55	RGDT Normative Data (2001) Mean of each age group: age 5: 4.2 age 6: 3.5 age 7: 9.5 age 8: 5.5 age 9: 7.2 age 10: 9.6 age 11: 6.8 age 12: 8.7 SD of each age group: age 5: age 6: age 7: 4.1 age 8: 4.4 age 9: 4.5 age 10: 4.5 age 11: 2.7 age 12:
56	RGDT Normative Data (2001)
57	Pattern Recognition Tests
58	Duration Patterns Test Musiek et al (1990): A screening test for APD at the level of the auditory cortex.
59	Duration Patterns Test (Musiek, et al, 1990) Three 1000 Hz tones and two 300 msec inter-tone intervals Tones are 250 or 500 msec in duration Six possible combinations of the three-tone sequence: (LLS, LSL, LSS, SLS, SLL, SSL) Verbal or hummed responses may yield different results
60	Duration Patterns Test (Musiek, et al, 1990) LSS ^{__________ _____ _____} SLS ^{_____ __________ _____} SSL ^{_____ _____ __________} LLS ^{__________ __________ _____} LSL ^{__________ _____ __________} SLL ^{_____ __________ __________}
61	Duration Patterns Test Musiek et al (1990): Performance below 70% correct is considered abnormal, indicating cortical based APD.
62	Frequency Patterns Test (Musiek, 1994): A screening test for APD at the level of the auditory cortex.
63	Frequency Patterns Test (Musiek, 1994) Two tones of 1430Hz and 880 Hz. Tones are 200 msec in duration with silent interval of 150 msec between tones Six possible combinations of the three-tone sequence: (HHL, LHL, HLL, HLH, LHH, LLH) Verbal or hummed responses may yield different results
64	Frequency Patterns Test (Musiek, 1994): 8 YO = 40% Bilaterally 9 YO = 65% Bilaterally 10 YO = 72% Bilaterally 11 YO = 75% Bilaterally
65	23 YO female entertainer with complaints of poor listening skills (CF) Professional singer/dancer w/ BA Music Difficulty remaining focusing while listening Not daydreamer, but misses what is said Easily distracted by ambient sounds Has difficulty with musical tempos and rhythms Slow in processing, misses jokes Difficulty sounding out words and reading out loud Reverses numbers and word orders Needed extra time in school to finish exams Feels stupid, embarrassed and ashamed
66	23 YO female entertainer with complaints of poor listening skills (CF) Life-long history as “poor listener and not paying attention.” Second grade standard testing: KTEA SS=104 WRAT-R = ~ 104 (Rdg, Spell, Math) PPVT = 91 TOLD-P = 95 CELF = “above grade criterion” Iowa Test of Basic Skills Verbal = 43^rd %ile Quantitative = 71^st %ile Nonverbal = 97^th %ile
67	23 YO female entertainer with complaints of poor listening skills (CF): Auditory Processing Test Results SCAN-A AFG = SS 8 at 25^th %ile FW = SS 6 at 9^th PR CW = SS 9 at 37^th %ile CS = SS 9 at 37^th %ile Composite = 90 at 25^th %ile RGDT = Mean gap detection = 8 msec. FPT = 100% verbal response DPT = 60 % verbal response RE and LE
68	23 YO female entertainer with complaints of poor listening skills (CF): Auditory Processing Test Results Duration Patterns Test 60% with no pause between stimuli 90% with pauses between stimuli * Used tapping to reinforce stimulus interpretation
69	Time Compressed Sentence Test
70	FUNDAMENTALS OF AUDITORY ANALYSIS Frequency - Pitch Intensity - Loudness Duration - Time
71	Temporal Processing is a Cortical Function
72	Time Compressed Sentence Test: What does it measure? Test of temporal processing Inability to hear rapid format frequency transitions Inability to process auditory information at rapid rates of speech May correlate with gap detection thresholds Test of degraded speech Distorted speech similar in concept to filtered words and auditory figure ground
73	Time Compressed Sentence Test (Keith 2002) One list of practice sentences at 0% TC Two lists of sentences TC at 40% Two lists of sentences TC at 60% Each TC list preceded by 2 practice sentences
74	Time Compressed Sentence Test: Examples of test items The policeman / chased / the thief. Mother / cut / the bread. The boy / fell / in the water. The dog / caught / a rabbit. Father / drives / a car. The girl / helped / her mother The woman / washed / the floor. The cat / chased / a mouse. The baby / hurt / his finger. The duck / swam / on the water
75	Time Compressed Sentence Test 3.3 points scored for each correct sentence. One point deduced for each section missed. Score converted to percent (%) correct.
76	Scoring the Time Compressed Sentence Test: Example at 40% TC Mother / cut / the bread. - 0 The boy / fell - swam/ in the water. - 1 The dog / caught / a rabbit. - 1 Father / drives / a car. - 2 The girl / helped / her mother. -3
77	Time Compressed Sentence Test: Scoring and Interpretation Raw scores in number of errors Convert to percent correct Interpret as normal, borderline, or abnormal performance Look up Z-scores and percentiles Convert percentiles to Standard Scores Analysis of ear differences
78
79	Eight Year Old Girl with language delay and reading problems SCAN-C FW = 16 %ile AFG = 16 %ile CW = 3 %ile CS = 3^rd %ile RGDT = 120 msec. Time Compressed Sentence Test 40% TC = 1^st %ile 60% TC = 1^st %ile SSW = 5 %ile
80	Eight Year Old Girl with language delay and reading problems TOLD = 25 to 50 %ile Token Test for Children = 16 %ile TAPS-Revised 18 - 50 %ile for memory tests 10 %ile for discrimination
81	Eight Year Old Girl with language delay and reading problems Recommendations: Multisensory approach to reading Refer to SLP for eval and Tx. Preferential Seating Slow rate of instructions and check for understanding Shorten directions into simple steps ID computer games for auditory and reading skills Candidate for FastForward because of temporal processing disorder
82	23 YO female entertainer with complaints of poor listening skills (CF) Professional singer/dancer w/ BA Music Difficulty remaining focusing while listening Not daydreamer, but misses what is said Easily distracted by ambient sounds Has difficulty with musical tempos and rhythms Slow in processing, misses jokes Difficulty sounding out words and reading out loud Reverses numbers and word orders Needed extra time in school to finish exams Feels stupid, embarrassed and ashamed
83	23 YO female entertainer with complaints of poor listening skills (CF): Auditory Processing Test Results Time Compressed Sentence Test* RE @ 40% = 100% RE @ 60% = 80% = Z=-2 or 2^nd %ile LE @ 40% = 90% = Z = -3 LE @ 60% = 74% = Z = -3 or <1^st %ile No significant ear difference * TCST is normed to age 11 years
84	23 YO female entertainer with complaints of poor listening skills (CF): Auditory Processing Test Results Time Compressed Sentence Test – Repeat test two months later* RE @ 40% = 100% RE @ 60% = 92% = 54%ile LE @ 40% = 100% LE @ 60% = 92% = 54%ile No significant ear difference * TCST is normed to age 11 years
85	SCAN-C: Test for Auditory Processing Disorders in Children Test for Auditory Processing Disorders in Children - Revised (2000) The next generation SCAN
86	SCAN-C is an auditory test battery consisting of four subtests Filtered Words: 1000 Hz @ 32 dB/octave Auditory Figure Ground: + 8 dB S/N Competing Words: 15 word pairs REF & LEF Competing Sentences: 10 sentence pairs RE & LE
87	1000 Hz low-pass filtered words from SCAN-C
88	Spectogram of “sing” filtered and unfiltered at 1000 Hz LP, 32 dB/octave from SCAN-C
89	Speech in Noise testing at +8 S/N ratio from SCAN-C
90	Hearing In Noise Test (HINT) Copyrighted by the House Ear Institute The HINT Test is a prerecorded test that measures sentence speech reception thresholds in quiet or in noise Subjects repeat short sentences presented in noise Signals presented sound field from front and side Reception Threshold for Speech is 50% level Intended for adults and children email: jorgec@maico-diagnostics.com
91	QuickSIN Speech-in-Noise Test Available from www.etymotic.com Sentence Materials Four-talker babble background Fourteen lists of 6 sentences, one each at 25, 20, 15, 10, 5, and 0 dB S/N ratio Five words scored in each sentence Words are said to be “not highly predictable from context” Performance-intensity function similar to NU-6 monosyllables Developing a test for children
92	23 YO female entertainer with complaints of poor listening skills (CF) Professional singer/dancer w/ BA Music Difficulty remaining focusing while listening Not daydreamer, but misses what is said Easily distracted by ambient sounds Has difficulty with musical tempos and rhythms Slow in processing, misses jokes Difficulty sounding out words and reading out loud Reverses numbers and word orders Needed extra time in school to finish exams Feels stupid, embarrassed and ashamed
93	23 YO female entertainer with complaints of poor listening skills (CF): Auditory Processing Test Results Differential threshold to intensity 500 to 3000 Hz = 1 dB Differential threshold to frequency 500 to 3000 Hz = 2 Hz RGDT to clicks = 2 msec. QuickSIN = 4.5 SNR “ mild SNR Loss”
94	10 YO Boy highly distracted in noise, attention,reading, writing. Pitch Pattern Sequencing - normal ACPT - normal WISC-III - Verbal =102, Performance = 95 Kaufman Test Educational Achievement Math = 93^rd %ile Reading = 21 and Reading Comp = 8^th %ile Spelling = 5^th %ile
95	10 YO Boy highly distracted in noise, attention, reading, writing. FW AFG CW CS Comp +2 SD Norm +1 SD Norm Mean X X X Norm -1 SD X Norm -2 SD Bord -3 SD X Dis
96	10 YO Boy highly distracted in noise, attention, reading, writing. Impressions: Not ADD, primary difficulty with AFG Recommendation: Classroom management Assistive Listening Device
97	Dichotic Speech Testing Presentation of different speech materials to opposite ears with simultaneous onset and offset times. Speech materials include CV’s, digits, words, spondees, sentences.
98
99	Purposes of Dichotic Speech Tests To identify hemispheric lesions To identify delays in the maturational development or damage to central auditory pathways To identify hemispheric dominance for language
100
101
102	Dichotic Consonant Vowels RE: ka LE: ba
103	Competing Words Test from SCAN-C and SCAN-A RE: Next LE: Frog
104	Competing Spondees Test (SSW) RE: Up Stairs LE: Down Town (RNC Comp LNC)
105
106	23 YO female entertainer with complaints of poor listening skills (CF) Professional singer/dancer w/ BA Music Difficulty remaining focusing while listening Not daydreamer, but misses what is said Easily distracted by ambient sounds Has difficulty with musical tempos and rhythms Slow in processing, misses jokes Difficulty sounding out words and reading out loud Reverses numbers and word orders Needed extra time in school to finish exams Feels stupid, embarrassed and ashamed
107	23 YO female entertainer with complaints of poor listening skills (CF): Auditory Processing Test Results SSW NOE analysis RNC = 0 Norm = 1 RC = 5 Norm = 2 LC = 10 Norm = 4 LNC = 1 Norm = 0 Total = 16 Norm = 4 (LC Z score=.03 or 1^st %ile
108	Competing Sentences Test from SCAN-C and SCAN-A RE: He caught the ball. LE: The box was full.
109
110
111	6 Year Old Child with Normal Auditory Processing
112	11 Year Old Child with Normal Auditory Processing
113	Dichotic Test Results in Normal Subjects A right ear advantage exists for all speech materials The right ear advantage is greater as linguistic content increases from CV’s to sentences The right ear advantage is maintained on directed right and directed left listening instructions
114	Dichotic Test Results in persons with Central Auditory Processing Disorders Poor overall performance Enhanced REA - directed right (right ear first) Enhanced LEA - directed left (left ear first) LEA under all listening conditions
115	Unusual Ear Advantage in a Six-Year Old, Bilingual Male A developmental evaluation was performed for a six-year-old, bilingual boy. His mother had concerns regarding his language skills in both Spanish and English.
116
117
118	Electrophysiology The Auditory Brainstem Response was normal on the right and left ears for latency and amplitude of waves I, II, and V. The P-100, N1, P2, and P-300 response was present for both the right and the left ears. The latency of the P-100, P-200 was completely normal. The P-300 latency was “slightly prolonged” at approximately 350 msec. The amplitude of the response was normal.
119	Sagital MRI
120	Tests of Auditory Processing: A Quasi Hierarchy of Anatomic Site Temporal Integration Cochlea Auditory Brainstem Response Brainstem Gap Detection BS to Cortex Time Compressed Speech Cortex Duration Patterns Test Cortex Frequency Patterns Test Cortex Monaural Sensitized Speech Cortex Dichotic Speech Tests Cortex & CC Electrophysiologic Tests BS to Assn Areas
121	The effects of linguistic background on results of tests of auditory processing disorders.
122	Some Non-Linguistic Tests of Central Auditory Function Threshold Temporal Integration Tests Differential Thresholds for Frequency and Intensity Median Plane Localization Masking Level Differences Frequency and Duration Patterns Tests Auditory Fusion Test - Revised Random Gap Detection Test Otoacoustic Emissions Electrophysiology (ABR, MLR, LVR, P-300)
123	Observation of Auditory Behaviors
124	What Is the Current Role of Electrophysiologic and Imaging Techniques in the Assessment of Auditory Processing Disorders?
125	Purposes of Electrophysiological Testing To obtain additional “objective” physiologic information regarding central auditory nervous function To provide a “gold standard” against which behavioral tests are compared.
126	Electrophysiologic Procedures to Measure Central Auditory Processing Exogenous - Independent of cognition Auditory brain stem responses (ABR), Middle latency responses (MLR), Endogenous – Due to perception or cognition Event related potentials (P-300) Mismatch negativity (MMN).
127	Electrophysiologic Measures of Auditory Processing Otoacoustic Emissions (OAE) Auditory Brainstem Response (ABR) Middle Latency Response (MLR) N-100 P-200 P-300 Mismatch Negativity (MMN) Brain Mapping Functional MRI (fMRI)
128	15 YO Male w/ Sig. Language, Learning, and APD - CJ Delay in language development When 5 YO Dx w/ HL and fit with binaural HA Placed in Hearing Impaired Classroom When 10 YO ABR and OAE Dx Hearing WNL and HA discontinued
129	15 YO Male w/ Sig. Language, Learning, and APD - CJ Pleasant, good looking, “deaf-like” speech Interested in his learning disorder Aggressive grandmother seeking appropriate educational placement for this young man
130	15 YO Male w/ Sig. Language, Learning, and APD - CJ WISC Verbal IQ of 54 Performance IQ = 104 Visual Motor Integration Test = 120 PPVT = SS 40 Expressive One Word Vocab Test = SS 55 CELF-4^th Ed = Core Lang Score = 50, Receptive = 54 Expressive = 57 Woodcock-Johnson Psycho-Educational Battery = SS 68 Etc. on Wechsler Individual Achievement Test and several other tests
131	15 YO Male w/ Sig. Language, Learning, and APD - CJ Mild HF SNHL W/ Hearing Thresholds
132	15 YO Male w/ Sig. Language, Learning, and APD - CJ MCL = 55 to 60 dB HL LD = 85 dB HL Does not instantly or accurately localize the source of sound Delta I @ 70 dB HL = 3 dB at 1 and 2 K Hz No Threshold Tone Decay PB-MAX Quiet = 84% RE and 66% LE w/ PB rollover LE
133	15 YO Male w/ Sig. Language, Learning, and APD - CJ
134	15 YO Male w/ Sig. Language, Learning, and APD - CJ Dichotic digits, single digit = 100 % RE; NR LE FW = 40% RE and 15% LE AFG = No Response CW = 100 RE and 0% LE CS = 100% RE and 0 % LE
135	15 YO Male fMRI for Tones (left) and Speech (right)
136	15 YO Male w/ Sig. Language, Learning, and APD - CJ OAE normal ABR normal to clicks and 500 Hz tone pip ABR normal LI function ABR normal at slow and fast click rates MLR and Late Cortical EP normal MRI normal fMRI abnormal – “unable to differentiate between auditory stimulation with or without semantic content.”
137	The status of electrophysiologic and imaging techniques in APD, an opinion!
138	Differentiation of ADD versus CAPD
139	Behavioral Symptoms that Differentiate ADHD vs CAPD* ADHD CAPD Inattentive Difficulty hearing in background noise Distracted Difficulty following oral instructions Hyperactive Poor listening skills Fidgety or restless Academic difficulties Hasty or impulsive Poor auditory association skills Interrupts or intrudes Distracted Inattentive *Chermak et al (1998) JAAA 9:78-84
140	Attention Deficit Disorders Attentional Processes Quickly identify important information Sustain attention Access relevant memories Shift attention to new information
141	Auditory Continuous Performance Test (Keith, 1995) Standardization: Subjects Age = 6 to 11 years N = 510: 85 in each year Hearing < 15 dB HL Male/Female = 48.8 / 52.2 %
142	Example of Auditory Continuous Performance Test. Monosyllable words are presented at 1 per second. The entire test takes approximately 10 minutes. The ratio of the target word “dog” to the foils is 1 in 20.
143	ACPT Scoring Inattention errors + Impulsitivity errors = Total error score
144	ACPT Scoring: Vigilance Decrement Difference in correct responses: Presentation 1 versus 6 for ages 6-8 and 9-11 years
145	Results of ACPT testing in children
146	ACPT Changes in response over 6 trials (EG)
147	ACPT Changes in response over 6 trials (JQM)
148	ACPT Changes in response over 6 trials (AB)
149	“Speed of Auditory Processing” Characterized by difficulty maintaining the “pace” of ordinary conversation Borderline but not profoundly abnormal auditory processing abilities
150	18 YO Female with borderline AP Abilities - PA Family history of APD with affected father and brother Complaint of “distracted by noise”, difficulty listening in the classroom and following directions, requests repeat of information frequently, difficulty following conversations.
151	18 YO Female with borderline AP Abilities - PA IQ = 114 Duration Patterns Test = 100% Frequency Patterns Test = 100% RGDT = 2 msec. Time Compressed Sentence Test = SS of 55 SSW NOE = normal All responses to speech stimuli were delayed, with “last minute responses.”
152	18 YO Female with borderline AP Abilities - PA
153	18 YO Female with borderline AP Abilities - PA Impression: Borderline auditory processing skills with delays in speed of auditory processing
154	18 YO Female with borderline AP Abilities - PA Recommendations: Maintain perspective relative to many talents against her auditory processing skills Direct methods of coping by managing her acoustic environment Use of direct eye contact Follow compensatory recommendations that have worked for her father Continue to ask questions when she misses auditory information Do not limit college choices because of mild auditory processing deficits
155	Speech-Language Pathology Measures What is an appropriate test battery?
156	Speech and Language Testing Discrimination Phonology Analysis Synthesis Closure Memory Span Sequence Receptive language Expressive language Prosody Pragmatics
157	Test of Auditory Perceptual Skills (TAPS)* Auditory : Number memory Word memory Sentence memory Word discrimination Interpretation of directions Processing (thinking and reasoning) *Includes parent questionnaire Gardner 1985
158	Clinical Evaluation of Language Fundamentals - 3rd Ed. (CELF-3) Receptive language score Expressive language score Total language score Subtest scores Sentence structure Concepts and directions Word classes Word structures Formulated sentences Recalling sentences Listening to paragraphs
159	Token Test for Children Assesses receptive language disorders Normed in children age 3 to 12.5 years Normed by age and grade Norms include means, SD, and Standard Scores for 5 subtests and total score
160	Lindamood Auditory Conceptualization Test (LAC) Measures auditory perception and conceptualization of speech sounds. Encoding task similar to reading and spelling to: discriminate speech sounds perceive and compare the number and order of sounds within spoken patterns www.lblp.com
161	Speech and Language Assessment Scatter of performance Intelligibility Phonologic Difficulties Atypical prosody Poor sound discrimination Syntactic Difficulties Variable vocabulary Poor imitation
162	Psychological Measures Verbal, Performance, and Full Scale IQ
163	Summary: What is an Adequate Test Battery? Rule out peripheral hearing loss Test of temporal processing Tests of degraded speech AFG FW Time-Compressed Dichotic speech testing Electrophysiology for neurologically based APD Speech Language Measures Intelligence Testing
164	What is an adequate method of interpreting AP test results? Determine auditory test standard scores including percentile ranks and confidence intervals Determine ear differences Determine atypical or abnormal auditory processing abilities Develop standard score profile for tests of Intelligence Language Auditory Processing
165	Child with primary language disorder and dyslexia of the dysphonetic type Showing, not all language problems exhibit auditory processing, just as not all children with APD have language disorders.
166	Ten YO Girl with Dyslexia of the Dysphonetic Type Lifelong history of difficulty reading Problems with short term memory Model student Sensitive about educational problems Private tutor for 2 years No evidence of ADD
167	Ten YO Girl with Dyslexia of the Dysphonetic Type CELF-3 Total language score = 82 No receptive/expressive discrepancy Test of Written Language SS = 83 Wide Range Achievement Test Reading = 78 Spelling = 77 Arithmetic = 87 Cognitive ability composite score of 98
168	Ten YO Girl with Dyslexia of the Dysphonetic Type: Scan-C
169	Ten YO Girl with Dyslexia of the Dysphonetic Type Scan-C composite = 100 TCST = Normal RDGT = 8 msec TAPS memory = 94 TAAS = 2^nd grade performance Boder = dysphonetic pattern LAC = 36 (cut-off = 81)
170	Ten YO Girl with Dyslexia of the Dysphonetic Type
171	Ten YO Girl with Dyslexia of the Dysphonetic Type
172	Remediation!
173	What is the contribution of the APD, SLP, and Psychological test battery? Identifies strengths and weakness in auditory, language, and intelligence abilities and describes the relationships that exist among them Identifies specific areas of strength or weakness in auditory processing abilities Identifies areas of need for classroom accommodation and individual remediation Identifies the level of intervention required to allow the child to achieve at his/her potential
174	Levels of remediation Parent and teacher counseling Classroom management Teach compensatory strategies Develop auditory subskills Traditional language therapy Computer based remediation Tutoring Special classroom placement Psychological counseling
175	Remediation: Basic Treatment Strategies Medical Intervention Compensatory techniques, e.g. Perceptual training Teaching specific skills, e.g. sound blending Cognitive training, e.g. Vocabulary Organizational skills Schema theory Alter physical and psychological environment
176	ASHA Task Force Recommendations on Intervention Approaches Improve quality of acoustic signal Reduce competing signals Boost intensity of signal by preferential seating or FM Improve quality of linguistic signal; communication partners speak more slowly, pause more often, emphasize key words Use of visual aids or graphic displays
177	Task Force Recommendations on Intervention Approaches Enhance Language Resources Teach vocabulary Extended practice with new grammatical patterns or words Teach to monitor comprehension Pay attention to speech sounds Use of prosody Predictive quality of language to deduce meaning Enhance Signal Quality
178	Identifying Barriers to Auditory Processing Quiet speech Distorted speech Competing speech Noise Acoustic Environment - reverberation
179	Modifications to the Speech Signal Increase loudness Slower rate Smaller language units Frequent language units Reauditorization
180	Strategies for Management of CAPD: Preferential Seating for: Better hearing and vision Minimize background noise with improved S/N ratio Enable teacher monitoring
181	Classroom Management Use of Classroom Amplification and Assistive Listening Devices to Improve S/N Ratio
182	Remediation Auditory Discrimination Auditory Memory Auditory Analysis and Synthesis Auditory Figure Ground Prosody Training Temporal Processing Deficits
183	Remediation Katz - Phonemic synthesis Tallal - Perceptual training Butler - Selective attention and mnemonic strategies Secord - Adaptation of education approaches to specific needs Lasky and Cox - SPERS Johnson - Classroom acoustics Psychological intervention
184	A Decision Tree for Management or Remediation (Keith, 1999) Disorders of temporal processing Perceptual training Slowing rate Disorder of auditory figure ground Reduce noise in environment Preferential seating FM system or other ALD Disorders of binaural separation/maturation Receptive and expressive language training
185	CAPD Management Avoid humiliation Recognize learned helplessness Prepare for long term residual deficits Provide parent and family support
186	CAPD Management Suggestions for teachers Provide information for teachers Seek the child’s attention Frequently check comprehension Rephrase and restate Use short information “bites” Provide buddy system and notetaker Give additional time to process information
187	CAPD Management Suggestions for teachers Understand the nature of the disorder and behavioral implications Understand the different approaches which may be required Recognize the social isolation due to communication difficulties Use teaching strategies which include visuals and handouts
188	CAPD Management Suggestions for parents Examine the grief cycle and work toward acceptance Give recognition to gradual accomplishments Give accurate information Provide on-going evaluation Locate family assistance when needed Assist in realistic expectations for their child
189	Lindamood-Bell Learning Processes* Lindamood-Bell® has pioneered programs to develop the sensory cognitive processes that underlie reading, spelling, language comprehension, math, and visual motor skills. Our research-based programs are for individuals ranging from severely learning disabled to academically gifted–ages 5 years through adult *Quote from www.lblp.com
190	Computer Assisted Remediation FastForward www.scilearn.com Earobics www.cogcon.com ????
191	Validity of Construct Difficulties with rapid temporal processing necessary for perceiving the transition between various speech sounds Foundation of FastForWord (Mike Wynne – 2001)
192	Studies Supporting FastForWord (Mike Wynne – 2001)
193	Studies Confronting FastForWord (Mike Wynne – 2001)
194	Earobics* “Earobics uses scientifically based and clinically proven techniques to teach listening and language skills (including phonologic awareness, auditory processing and phonics skills) that make children better readers, listeners, and learners.” Quote from www.earobics.com
195	What’s on the web?? Audiology.org Asha.org Edaud.org Addwarehouse.com Scilearn.com Cogcom.com Ldonline.com Capdtest.com Lblp.com Lots of junk