Auditory processing disorders 2

I’m lost in this class!What’s wrong with me?I just can’t hear right.

AUDITORY PROCESSING DISORDERS (APD):A Common and Serious Problem

Auditory Processing Disorders (APD) Diagnosis is Feasible and Management is Effective

James W. Hall III, Ph.D.

Clinical Professor and Associate Chair

Department of Communicative Disorders

College of Public Health & Health Professions

University of Florida

Gainesville, Florida, U.S.A.

[email protected]

mailto:[email protected]

8th cranial (auditory) nerve)

Internal auditory canal Shares space with vestibular nerves, facial nerves, efferent auditory nerves & internal auditory artery

Central auditory nervous system

Cochlear nuclei Superior olivary complex Lateral lemiscus Crossing pathways Infererior colliculus Reticular (activating) formation Thalamus Primary and secondary auditory cortex Corpus collosum

Behavioral Audiometry:True Measures of Hearing

Behavioral Audiometry: Sound Field versus Earphone Stimulation

The Audiogram: Hearing Sensitivity as aFunction of Pure Tone Frequency

AUDITORY PROCESSING DISORDERS (APD):Academic Underachievement & Failure

F

I must be stupid!

Age and Gender Distribution in an Unselected APD Population

in a Medical Center Audiology Clinic (N = 239)

Age in Years

5

N

um

ber

of

Pat

ien

ts

7 8 9 10 11 12 13 14 15 - 18

10

20

25 Male

(N = 160) Female(N = 79)

15

Average age = 9 Years

AUDITORY PROCESSING: Cornerstone of Language and Literacy (Reading)

AUDITORY PROCESSING

PHONOLOGIC AWARENESS ORAL LANGUAGE

WRITTEN LANGUAGEReading and Spelling

COMPREHENSION

Assessment and Management of Auditory Processing Disorders (APD)

Historical perspective … interest in APD dates back over 50 years

How APD became a household phrase in audiologyNeuroscience foundation for APDDisorders often co-existing with APD Risk factors for APDCurrent and future assessment strategies and

proceduresEffective management strategies and procedures

Carlo Calearo, M.D.Otorhinolaryngologist

“Italian Pioneer in APD Assessment”

Bocca E, Calearo C, Cassinari V. A new method for testing hearing in temporal lobe tumors. Acta Otolaryngologica 44: 1954.

Helmer Myklebust, Ph.D. (in psychology)Northwestern University

“Pioneer in APD Assessment”

Myklebust HR. Auditory disorders in children: A manual for differential diagnosis. New York: Grune & Stratton, 1954.

“hearing is a receptive sense … and essential for normal language behavior” (p. 11)

“the diagnostician of auditory problems in children has traditionally emphasized peripheral damage. It is desirable that he (sic) also include central damage.” (p. 54)

Dichotic Listening Paradigm … A long-standing test strategy for assessment of auditory processing

1956: British PsychologistDonald E. Broadbent, Ph.D.

1961: Canadian PsychologistDoreen Kimura, Ph.D.

Dichotic Listening Paradigm

RIGHT TEMPORAL CORTEX

Association Cortex

Primary Auditory Cortex

Right Earair plane

1, 3

CorpusCallosum

LEFT TEMPORAL CORTEX

Association Cortex


Left Earbase ball

5, 9

Development of APD Assessment & Management:Principles & Procedures

Bocca & Calearo

Myklebust

1954 1960

KatzKimura

1975

WillefordJerger

1986

KeithAMLRstudiesMusiek

1982 19961990s

proceduresMRI

studies

ASHATask ForceTallalKraus

2000

APDConference

fMRIEarobics



How (C) APD became a household phrase in audiologyNeuroscience foundation for APDDisorders often co-existing with APD Risk factors for APDCurrent and future assessment strategies and


AUDITORY PROCESSING DISORDERS (APD):ASHA Task Force Consensus Statement (1996)

“A central auditory test battery should include measures that examine different central processes.”

Tests should generally include both nonverbal and verbal stimuli to examine different levels of auditory processing and the auditory nervous system.”

Factors to consider in the selection of test procedures include information on: test sensitivity and specificity reliability and validity age appropriateness

The person administering and interpreting the test battery should have both theoretical and practical knowledge … typically audiologists.”

AUDITORY PROCESSING DISORDERS (APD):ASHA Task Force Consensus Statement (1996)

“Central auditory processes are the auditory system mechanisms and processes responsible for: sound localization and lateralization auditory discrimination auditory pattern recognition temporal aspects of audition auditory performance decrements with competing acoustic signals auditory performance decrements with degraded acoustic signals

“These mechanisms and processes are presumed to aply to nonverbal as well as verbal signals … they have neurophysiologic as well as behavioral correlates.”

“Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children” Journal of American Academy of Audiology 11: Nov. 2000.

Definition: “APD is broadly defined as a deficit in the processing of information that is specific to the auditory modality.”

Guidelines Screening strategies Diagnosis

minimal test battery factors influencing test outcome and analysis

CONSENSUS CONFERENCE 2000 ON APD

Assumptions in the diagnostic assessment of APD … possible outcomesa pure APDan APD and a disorder or disorders in other modalities,

e.g., multi-sensorya disorder that appears auditory at first, but actually is non-

auditorya disorder that appears at first to be non-auditory but is

actually auditory

2000 Consensus Conference on the Diagnosis of APD

Factors influencing diagnostic assessment of APD

ADHDLanguage impairmentReading disabilityLearning disabilityAutistic spectrum disorderReduced intellectual functioning (cognitive impairment)

2000 Consensus Conference on the Diagnosis of APD

Listener variables in the diagnostic assessment of APD

AttentionAuditory neuropathyFatigueHearing sensitivityIntellectual and developmental ageCognitive variables (e.g., memory, processing speed)MedicationsMotivationMotor skillsNative language, language experience, language ageVisual acuity

2000 Consensus Conference on the Diagnosis of APDs

www.asha.org Definition of (C ) AP

Broad definition … “the efficiency and effectiveness by which the CNS utilizes auditory information”

Narrow definition … “the perceptual processing of auditory information in the CNS and the neurobiological activity that underlies that processing and gives rise to electrophysiologic auditory potentials.”

Auditory processing includes the auditory mechanisms that underlie the following abilities and skills:

Sound localization and lateralization Auditory discrimination Auditory pattern recognition Temporal aspects of audition Temporal ordering and temporal masking Auditory performance in competing acoustic signals (includes dichotic

listening) Auditory performance with degraded acoustic signals

Technical Report of ASHA Working Group on (Central) Auditory Processing Disorders (2005)

http://www.asha.org/

Definition of AP Nature of APD Historical perspective Knowledge base and ethical considerations The basic science connection

Neurochemistry and auditory processing Screening for APD The APD case history Diagnosis of APD

Technical Report of ASHA Working Group on (Central) Auditory Processing Disorders (2)





Basic neuroscience advances in the decade of the brain (1990s) impacted understanding of APD

Different regions mature at different ratesMaturation occurs along caudal to rostral gradient

Development of auditory pathways and centers involvesCell differentiation and migrationMyelinationArborizationSynaptogenesis

Consistent and typical auditory stimulation (experience) within the first years after birth shapes nervous system development (plasticity)

Perinatal and childhood factors influence development of auditory processing, e.g.,

Neurological risk factors (e.g., asphyxia, hyperbilirubinemia)Conductive hearing lossEnvironmental deprivation

Genetic factors play a role in etiology of auditory processing disorders

New Handbook of Auditory Evoked Responses Summary of AER findings in APD

Chapter 1: Overview of auditory neurophysiology Chapter 2: Anatomy and physiology principles of AERs Chapter 3: Introduction to AER measurement Chapter 4: Electrocochleography (ECochG): Protocols and procedures Chapter 5: ECochG: Clinical applications and populations Chapter 6: ABR Parameters, Protocols, and Procedures Chapter 7: ABR analysis and interpretation Chapter 8: Frequency-specific ABR and ASSR Chapter 9: ABR: Pediatric clinical applications and populations Chapter 10: ABR: Adult diseases, disorders & clinical applications Chapter 11: Auditory middle latency response Chapter 12: Auditory late response Chapter 13: P300 response Chapter 14: Mismatch negativity (MMN) response Chapter 15: Electrically evoked and myogenic responses

Auditory Late Responseand P300 Response

500 ms

FrequentUnattendede.g., 1000 Hz

P2

A

mp

litu

de

(mV

)

P2

P3 (300)

Infrequent(rare)Attendede.g., 2000 Hz

N1

Mismatch Negativity (MMN) Response:

“Unconcious Brain Response Elicited by Different Properties of Sound(Courtesy of Catharine Pettigrew, Ph.D.)

MISMATCH NEGATIVITY (MMN) RESPONSE:Investigations in clinical populations

Assessment of infant speech perception, including children at risk for disorders, e.g., language (e.g., Leppanen & Lyytinen, 1997)

Hearing aid fitting of infants and young children with speech signals (e.g., Kraus, et al)

Cochlear implant fitting infants and young children with speech signals (e.g., Kraus, et al)

Documentation of auditory training and language treatment (e.g., Kujala et al, 2001)

Description of Alzheimer’s disease (e.g., Pekkonen et al, 1994) Electrophysiologic documentation of attention deficit hyperactivity disorder

(e.g., Barry, Johnstone, Clarke, 2003) Prognosis of recovery from coma (e.g., Kane et al, 1993) Diagnosis of frontal and auditory temporal lobe dysfunction in

schizophrenia (e.g., Michie et al, 2000) Neurophysiologic documentation of auditory processing disorder (APD)

and dyslexia in children

Neuroscience Evidence for APD: Functional Neuro-Imaging (fMRI)Left Handed 18 Year Old with Right Ear Deficit on Dichotic Tests

Right

TL

“fMRI” and “Auditory” Medline Citations:Thousands of Peer Reviewed Articles

Bernal B, Altman NR, Medina LS. Dissecting nonverbal auditory cortex asymmetry: an fMRI study. Int J Neurosci. 2004 May;114(5):661-80

Rowan A, Liegeois F, Vargha-Khadem F, Gadian D, Connelly A, Baldeweg T. Cortical lateralization during verb generation: a combined ERP and fMRI study. Neuroimage. 2004 Jun;22(2):665-75.

Okada T, Honda M, Okamoto J, Sadato N. Activation of the primary and association auditory cortex by the transition of sound intensity: a new method for functional examination of the auditory cortex in humans. Neurosci Lett. 2004 Apr 8;359(1-2):119-23.

Blau V, van Atteveldt N, Ekkebus M, Goebel R, Blomert L. Reduced Neural Integration of Letters and Speech Sounds Links Phonological and Reading Deficits in Adult Dyslexia. Curr Biol. 2009 Mar 11.

Leff AP, Iverson P, Schofield TM, Kilner JM, Crinion JT, Friston KJ, Price CJ. Vowel-specific mismatch responses in the anterior superior temporal gyrus: An fMRI study. Cortex. 2009 Apr;45(4):517-26. Epub 2008 Feb 7.

Warrier C, Wong P, Penhune V, Zatorre R, Parrish T, Abrams D, Kraus N. Relating structure to function: Heschl's gyrus and acoustic processing. J Neurosci. 2009 Jan 7;29(1):61-9.





“Differential Diagnosis:

Diagnosis based on comparison of symptoms (signs) of

two or more similar diseases (disorders) to determine

which the patient is suffering from.”

Auditory Processing Disorders:Differential Diagnosis

Shared Anatomy

Reading

Language

Auditory processing

Peripheral (conductive and sensory) hearing loss Specific language impairment (SLI) Learning disabilities (LDs) Reading disorders (dyslexia) Attention deficit/hyperactivity disorder (ADHD) Emotional and psychological disorders Developmental delay Seizure disorders PDD, autism, and autism spectrum disorders

AUDITORY PROCESSING DISORDERS: Co-existing Disorders (Co-morbidity)

AUDITORY PROCESSING DISORDERS (APDs): Co-existing Disorders (Co-morbidity)

SLI

ADHD

dyslexiaAPD

Wright BA, Lombardino LJ, King WM, Puranik CS, Leonard CM, Merzenich MM. Deficits in auditory temporal and spectral resolution in language-impaired children. Nature 387: 176-178, 1997.

“Here we report the results of psychophysical tests employing simple tones and noises showing that children with specific language impairment (SLI) have severe auditory perceptual deficits for brief but not long tones in particular sound contexts.”

AUDITORY PROCESSING DISORDERS (APD): Evidence of relation to language and reading

Wright BA, Lombardino LJ, King WM, Puranik CS, Leonard CM, Merzenich MM. (continued)

“The present auditory tests may also aid in the diagnosis and treatment of persons with reading difficulties …

Our results are in accord with the conclusion … that some but not all children with reading problems have difficulties accurately perceiving rapidly presented stimuli.”

AUDITORY PROCESSING DISORDERS: Relation to language and reading





APD:Screening and Assessment in Pre-School Children

I can’t figure outwhat they are saying!

Risk Factors for APD:Team Work in Identification and Assessment

Neurological dysfunction and disorders (physicians), e.g., neonatal risk factors (e.g., asphyxia, CMV) head injury seizure disorders

Chronic otitis media in preschool years (otolaryngologists) Academic underachievement or failure (teachers and

educational psychologists) Family history of academic underachievement (parents) Co-existing disorders (multiple professionals)

Auditory Processing Disorders: Indicators in Early School Age Population

(e.g., kindergarten)

Behavior typical of peripheral hearing loss, but normal audiogram

Scatter in results on psychological and language tests, with weakness in auditory domains

Verbal IQ score lower than performance IQ score May have poor musical skills Problems with fine and/or gross motors skills Teacher and/or parent concern about hearing and listening

abilities (and the audiogram is normal)

Auditory Processing Disorders: Indicators in Early School Age Population (2)

Has difficulty following multi-step directions Poor reading and spelling skills (remediation not effective) Responds inappropriately in the classroom Reluctant to participate in class discussions Positive history of middle ear disease and hearing loss

Auditory Processing Disorders: Indicators in Early School Age Population and

Screening for At Risk Children (SIFTER)

Auditory Processing Disorders: Indicators in Early School Age Population and

Screening for At Risk Children (CHAPS)

SCAN-C and SCAN-A (Robert Keith, 1986):Undefined sensitivity and specificity

Low pass filtered words subtest 40 monosyllabic words (20 for each ear) low pass filtered at 1000 Hz

Auditory figure-ground subtest 40 monosyllabic words (20 for each ear) multi-talker babble noise at + 8 dB SNR

Competing words 40 monosyllabic words (20 for each ear) inter-word interval of < 5 ms initial response to right then left ear words

Competing sentences 15 target and competing sentences initial response to right then left ear sentences





Assessment of APD:Acquiring History and Background Information

Parents complete APD survey Middle ear disease? Neonatal risk factors? Co-existing disorders? Medical management for auditory or neurological disorder Previous assessments, e.g.,

Speech languagePsychological and psycho-educationalADHD

Previous and current therapy and treatment

Assessment of APD:Peripheral Test Battery (< 20 minutes)

Otoacoustic emissions (OAEs)OAEs are abnormal in 35% of children undergoing APD assessment

Aural immittance measurestympanometryacoustic reflexes

crossed vs. uncrossed conditions … initial measure of CNS function

Pure tone audiometryinter-octave frequencies (e.g., 3000 and 6000 Hz)high frequency (> 8000 Hz) audiometry (as indicated)

Speech audiometryword recognition (use CD materials with 10 most difficult words

first)

Assessment of APD:Central Auditory Test Battery (~ 80 minutes)

APD ASSESSMENT: Test Battery for Auditory Processes (1)

Sound localization and lateralization No clinical tests commercially-available for children Wxperimental techniques for earphone simulated signals

Auditory discrimination, e.g., Goldman-Fristoe-Woodcock Test of Auditory Discrimination

(in quiet and noise)

Temporal resolution/gap detection, e.g., Auditory Fusion Test (Revised) Auditory Random Gap Detection (ARGD) test Gap in Noise (GIN) test

Temporal ordering, e.g., Pitch pattern sequence (PPS) test Suration pattern sequence test

Dichotic Digits Procedure


Association Cortex


Right Ear2, 9

Left Ear1, 4

CorpusCallosum


Association Cortex


CAPD ASSESSMENT: Test Battery for Auditory Processes (2)

Temporal integration dichotic tests, e.g.,Dichotic digitsStaggered spondaic word (SSW) testDichotic sentence identification (DSI) testSCAN competing words subtest

Auditory performance with competing acoustic signals, e.g.,SSI-ICMPediatric Speech Intelligibility (PSI) testGFW Test of Auditory Discrimination (noise)SCAN auditory-figure ground subtest

Auditory performance with degraded acoustic signals, e.g.,Time-compressed words with reverberationSCAN filtered words subtest

Auditory Continuous Performance Test (ACPT) developed by Robert Keith for children with suspected or diagnosed AD/HD rapid presentation of words task is to respond to target word “dog” only analog to visual continuous performance tests

Screening of phonologic awareness skillsPhonemic synthesis test

developed Jack KatzTest of Auditory Analysis Skills (TASS)

Say the word baseball … now say it again but don’t say baseSay the word smack … now say it again but don’t say /m/

APD ASSESSMENT: Additional Components of Test Battery (as indicated)

General principlesVerbal and non-verbal procedures

Non-verbal test materialsNon-verbal response mode

Age appropriate tasksPsychometrically well designed

Sensitivity and specificityAdequately large normative data across age rangeStandard scores and percentiles

Adaptive test strategiesReduced test timeManipulation of test difficulty

Measures of major auditory processes

APD ASSESSMENT: Ideas for New Procedures and Protocols

Gaps-in-Noise (GIN) test (Musiek, Shinn, Jirsa, Bamiou, Baran & Zaidan. The GIN (Gaps-in-Noise) Test performance in subjects with confirmed central auditory nervous system involvement. Ear & Hearing, 26, 2005.)Noise signals with gaps of silence

Gaps of different durations and locations within noiseNon frequency specific signalsScores not influenced by hearing loss

Simple button pushing response Signal with either gap or no gapYes or no response judgmentMinimal influence of cognition (for patient and tester)

Gap detection is a traditional and accepted measure of temporal processing

APD ASSESSMENT: Creative Non-Verbal Test Procedures and Protocols (1)

Listening in Spatialized Noise (LISN) test The Listening in Spatialized Noise Test: An auditory processing disorder study. JAAA, 17, 2006. Cameron et al, 2006)

The Listening in Spatialized Noise -- Sentences Test (LISN-S): Comparison to the prototype LISN and results from children with either a suspected (central) auditory processing disorder or a confirmed language disorder. JAAA 19, 2008. Cameron & Dillon.

Three dimensional auditory environment under earphonesAssesses auditory stream segregation skills in childrenSpeech reception thresholds for sentences presented from 0o azimuth in

competing speech. Competing speech manipulated by Location in auditory space (0o vs. 90o) Vocal quality of speakers (same as or different from target stimulus

speaker) Advantage measured as benefit in dB with either spatial or talker cue


The Listening in Spatialized Noise -- Sentences Test (LISN-S): Comparison to the prototype LISN and results from children with either a suspected (central) auditory processing disorder or a confirmed language disorder. JAAA 19, 2008. Cameron & Dillon.

ConclusionsChildren with traditionally defined APD showed deficit on LISN-SNo correlation of LISN-S with dichotic tests, PPS test, or gap detection testSpatial and non-spatial LISN-S test performance not correlatedChildren with language impairment did not show LISN-S deficitsFindings support ASHA 2005 and AAA 2009 conclusions regarding the ability

to diagnose auditory specific deficitsChildren with spatial stream segregation deficits likely to require higher SNR,

e.g., personal FM devices


Auditory evoked responsesAuditory brainstem response (ABR)Auditory steady state response (ASSR)Auditory middle latency response (AMLR)Auditory P300 response

oddball paradigmactive or passive subject

Mismatch negativity (MMN) response Auditory processes to be assessed

Discrimination (e.g., frequency, duration, speech type sounds)Auditory figure groundTemporal processingTemporal ordering

APD ASSESSMENT: Auditory Evoked Responses Evoked with

Non-speech and Speech Signals





Tallal P, Miller S, Merzenich M, et al. Language comprehension in language-learning impaired children improved with acoustically modified speech. Science 271: 81-84, 1996.

“A speech processing algorithm was developed to create more salient versions of the rapidly changing elements in the acoustic waveform of speech that have been shown to be deficiently processed by language-learning impaired (LLI) children … LLI children received extensive daily training with listening exercises ...”

Management of APD with Computer-Based Techniques: Scientific Bases of FastForword

APD MANAGEMENT: Computer-based Auditory Therapy(www.cogcon.com)

Earobics comes in two versions:

Earobics Foundations for pre-kindergarten, kindergarten, and first grade students • Earobics Connections for second and third grade students, and other struggling readers

Instructions available in 10 languages

Auditory, Phonological, and Pre-Reading SkillsAddressed by Earobics Program

Rhyming Phoneme identification Blending Segmentation

Ability to break word down into individual sounds Phonological manipulation Discrimination Auditory performance in competing noise Auditory sequential memory

Earobics: Comments from Website(www.cogcon.com)

Earobics is widely considered to be one of the most validated and quantifiable reading intervention programs. States across the country have reviewed the program and approved its use in their schools to quickly and effectively build student reading achievement.

Independent industry reviewers, including the Florida Center for Reading Research (FCRR), confirm these findings. As a vital source for districts and schools, FCRR regularly reviews reading programs to help teachers, principals, and district administrators make informed choices on effective instruction.

Earobics was among the select few programs in the supplemental, intervention, and technology-based program categories to achieve the FCRR’s highest ranking in all five reading areas.

NOTE: FCRR = Florida Center for Reading Research (www.fcrr.org)

AUDITORY PROCESSING DISORDERS (APDs): Incremental Deficits Model

Academic

Achiever

Academic

Underachiever

> Intelligence Normal hearing Family support Genetics Environment Auditory stimulation

< Intelligence Conductive HL ADD/ADHD Genetics SLI APD

APD Management (Treatment): Preferred Practice Patterns for Audiology (ASHA)

Counseling Assistive listening devices Acoustic enhancement and environmental modification

of the listening environment Auditory training and stimulation (including computer-

based software programs) Communication and/or education strategies Meta-linguistic and meta-cognitive skills and strategies Documentation of implementation of frequency and

duration of treatment Documentation of outcome

APD Management Options and ApproachesCounseling, case management, and advocacyAudiologic management in school and the home, e.g.,

FM technology (assistive listening devices) Specific auditory training programs (e.g., DIID)

Computer based auditory training programs, e.g., Earobics (school wide license for 600 children)

Multi-disciplinary management, e.g.,Multi-sensory reading instruction strategies

Management of Children with Auditory Processing Disorders (APD) in Educational Settings

Classroom Assistive Listening Devices

Personal FM

Headset Style

Desktop

Toteable FM Infrared Sound Field FM

Phonak EduLinkA viable option for all children, particularly adolescents

Campus S

Transmitter

EduLink Receivers

Mini-Boom Microphone

SNR improvement on the HINT in normal hearing adults and

children without and with APD:Three different FM system types

Listening Condition

2

S

NR

Im

pro

vem

ent

(in

dB

SP

L)

Adults (N = 10) Non-APD (N = 8) APD (N = 12)

4

6

8

Head set

Desk top

7.5

4.0

7.4

3.8

9.5

6.5

10

Sound field

4.7

4.3

7.2

Hearing in Noise Test (HINT) Results(Mean SNR values without and with EduLink)

Group

Test Condition ControlAPD

Unaided in Noise (SNR)* 7.9 dB6.1dB

Aided in Noise (SNR) ** - 0.3 dB - 4.2 dB

Advantage in Noise 8.2 dB10.3

with EduLink

* t = p < .08; ** t = .002

Typical Classroom SNR Range: +5 to -7 dBMarkides (1986); Finitzo-Hieber (1988); Crandell and Smaldino (1995)

Educational Performance:Fisher’s Auditory Checklist Findings Completed by Parents

(Difference in scores between groups significant at p < .000)

Fisher's Score

0

10

20

30

40

50

60

70

80

90

100

Individual Control and APD Subjects

Perc

ent S

core

Fisher's Score

Educational Performance:Listening Inventory For Education (LIFE)

Group

Question Control APD Significance

p < 0.05

1 8.6 5.2+

2 7.3 5.1+

3 6.6 4.7-

4 5.5 21.5-

5 4.9 3.0-

6 8.4 6.8-

8 7.1 6.0 -

9 9.4 5.8+

10 7.9 6.9-

Educational Performance: SIFTER(Difference in scores between groups for all categories except

School Behavior [p < 0.57)]significant at p < .05)

SIFTER APD vs Control

0

2

4

6

8

10

12

14

Academics Attention Communication Class Participation School Behavior

SIFTER Categories

Sc

ore Control

APD

Psychosocial Questionnaires

Behavioral Assessment System for Children, Volume II (BASC-II) A profile of adaptive and maladaptive behaviors and emotions of

children and adolescents. Social Skills Rating System (SSQ)

A measure of positive and negative social skill behaviors of students.

Dartmouth Cooperative Functional Health Assessment Charts (COOP) A screening tool for quality of life in adolescents in several

functional domains/

Psychosocial Function in Children with APD:Initial BASC II Parent Report

• Externalizing Prob: Hyperactivity, Aggression, Conduct Problems• Internalizing Prob: Anxiety, Depression, Somatization• BSI: Atypicality, Withdrawal, Attentional Problems• Adaptive Skills: Adaptability, Social Skills, Leadership, Activities of Daily Living, Functional Communication

• Internalizing Prob: Atypicality, Locus of Control, Social Stress, Anxiety, Depression, Sense of Inadequacy, Somatization

• School Prob: Attitude to School, Attitude to Teachers, Sensation Seeking• ESI: combination of Social Stress, Anxiety, Depression, Sense of Inadequacy• Personal Adjustment: Relations with Parents, Interpersonal Relations, Self-Esteem, Self Reliance

Psychosocial Function in Children with APD:Initial BASC II Child Self Report

“Scale scores in the Clinically Significant range suggest a high level of maladjustment.

Scores in the At-Risk range may identify a significant problem that may not be severe enough to require formal treatment or may identify the potential of developing a problem that needs careful monitoring.”

Psychosocial Questionnaires:Interpretation

BASC II Parent Report Results After EduLink Use (6 to 7 months): APD versus Control Subjects

Normal Findings per Group (%)

Domain ControlAPD

Aggression 92 100

Conduct problems 92 100

Anxiety 84 100

Depression 92 100

Internalizing problems 77 71

Withdrawal 84 71

Attention problems 92 29

Adaptive skills 92 71

Functional communication 92 57

BASC II Student Report Results After EduLink Use (6 to 7 months): APD versus Control Subjects

Normal Findings per Group (%)

Domain ControlAPD

Attitude toward teachers 100 86

Attitude toward school 100 57

School problems 100 71

Conduct problems 92 100

Atypicality 100 100

Anxiety 100 100

Social stress 92 100

Depression 100 86

Internalizing problems 100 100

Sense of inadequacy 100 86

Parent relationship 92 100

Self esteem 100 100

Paper will appear in April 2009 issue of International Journal of Audiology APD in school age children can have significant negative impact on:

Academic performance Psychosocial status Quality of life

Early intervention for auditory processing deficits is indicated for all children, despite the age of identification

The Phonak EduLink system is a feasible option for FM technology with adolescents (and persons of other ages)

Management of APD with FM technology (enhancing the signal-to-noise ratio) improves:

Speech perception in noise (with EduLink FM system Academic performance Psychosocial status Speech perception in noise without the benefit of FM technology

Benefit of Phonak EduLink FM Technology on Communication, Psychosocial Status, and Academic Performance of Children with

Auditory Processing Disorders (APD): Conclusions

Dichotic Intensity Increment Difference (DIID)


Association Cortex


Strong Earincreasingintensity

Weak Earfixed

intensity

CorpusCallosum


Association Cortex


Dichotic Intensity Increment Difference (DIID) Tasks

Binaural separation Ear directed targets (monaural) Ear directed targets (binaural) Ear directed manipulations Ear directed judgments Intensity, clarity Materials should be a mixture of dichotic materials

Digits Spondee words Single syllable words Sentences

Examples of “Top-Down” and Multi-Sensory Reading Intervention Options for Children with APD

Context-derived vocabulary building Visual imagery Visualizing and Verbalizing Program Auditory closure activities Speech/language therapy Multi-sensory reading strategies

Lindamood Bell Learning Processes (www.lindamoodbell.com) Wilson Reading Program Orton Gillingham approaches

Kindergarten children learn mostly through the auditory modality, and learn best in an optimal acoustic environment.

Academic success is dependent on reading success. Reading failure a product largely of auditory processing and

phonemic awareness deficits. Auditory processing and phonemic awareness deficits must be

identified early through screening of all kindergarten children. Early and intensive intervention for auditory processing and

phonemic awareness deficits is necessary reading and academic success.

The Early Auditory Reading Success (EARS) Program:Assumptions

Developed at the University of Oregon (www.dibels.uoregon.edu) Required by Alachua County School System (and in state of

Florida) to monitor academic progress in kindergarten children Four measures of reading reading skills

Initial sounds fluency (ISF)Letter naming fluency (LNF)Phonemic segmentation fluency (PSF)Nonsense word fluency (NSF)

Administered four times in kindergarten yearEarly fall semester (September)Late fall semester (December)Early spring semester (January)Late spring semester (May)

Literacy Outcome Measure:DIBELS (Dynamic Indicator of Early Literacy Skills)

DIBELS (Reading Readiness) Outcome in the Initial EARS Project (2002-2003)

DIBELS EARS School

Control SchoolOutcome Early Final

FinalN = 52 N = 63

N = 48

Deficit 50% 27%

40% Emerging 31% 22%

44% Established 19% 60%

16%

Phonemic Awareness (sound/speech sound skills) Phonics (phoneme/grapheme skills) Fluency Vocabulary Comprehension

EARS Program Rationale:Five Component Skills of Reading

Children diagnosed with hearing, cognitive, attention, or other deficits referred for appropriate management

Intervention componentsFM systems in each kindergarten classroomAll kindergarten students complete Earobics Multi-sensory reading instruction strategies used by each

kindergarten teacherChildren diagnosed with APD and/or deficits in phonologic

awareness receive intensive small group treatment by speech pathologistletter recognitionphonologic awarenessother basic reading skills

The Early Auditory Reading Success (EARS) Program:

Intervention based on screening outcome

Multiple Tiers of Reading Instruction Models: Conventional (e.g., Torgesen, 2005) vs. Early Intervention (EARS)

Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12Grade

Rea

din

g S

kill

s

Core Reading Program

Powerful Intensive Intervention

(Struggling Readers)

EARS Program

EARS Program (2005-2006): Early (Kindergarten) Intervention Program for At Risk Struggling Children

Core ReadingProgram(Tier 1)

All kindergarten children in Title I schools undergo

auditory and language screening

Intensive Intervention(Tier 3)

Small group inclusive instructionPre-reading skills

Phonologic awareness instruction

At risk?

Monitor Outcome(DIBELS)

National 70%ile?

Not at risk?

Phonologic Awareness Enhancement(Tier 2)

Classroom FM systemClassroom instruction

Earobics program

Early Auditory Reading Success (EARS):Final Outcome 2005 by DIBELS scores

(Williams Elementary School)

Nat

ion

al %

ile

Letter Sound Fluency

20

40

60

80

10096

9294

Phonemic Sequence Fluency

Nonsense Word Fluency

HR MR LR AA Est HR MR LR AA Est HR MR LR AA Est

Established 04

EARS: DIBELS National %ile rank in final test interval of First Grade for EARS participants (2005/2006)

40

21

57

38

0102030405060

OLV ReadingComp

EARS(n=180)

Control(n=143)

OLV Oral Language VocabularyReading Comp Reading Comprehension

The results of auditory processing can be used to determine children at risk for reading and academic failure.

All kindergarten children in Title I schools benefit from Adequate acoustic learning environment (classroom)Enhancement of phonologic awareness instruction in by the

classroom teacherTherapy for auditory processing and pre-reading skills

(Earobics) Intensive intervention for auditory processing and phonologic

awareness deficits improves early literacy skills. The EARS program offers effective early intervention for

kindergarten children at risk for reading failure. To date, the benefits of EARS program for reading are

documented through 2nd grade

The Early Auditory Reading Success (EARS) Program: Conclusions

MANAGEMENT OF APD: Facilitating academic achievement & success

I must be smart!

Documents

Auditory processing disorders 2