BAA Conference 19.11.13

Characteristics of cognition, language, listening and auditory

processing abilities in children with specific language

impairment and autistic spectrum disorder

NIHR Nottingham Hearing Biomedical Research Unit, UK

Mel Ferguson

To prevent future

publishing conflict all

unpublished data have

been removed

BAA Conference 19.11.13

How comorbid is APD with Language Impairment and Autistic

Spectrum Disorder?

NIHR Nottingham Hearing Biomedical Research Unit, UK

Mel Ferguson

Ear Central Auditory System Hearing

The auditory brain

Ear Central Auditory System Listening

Vision

Attention Memory

Learning

The auditory brain

“We hear with our ears…

but listen with our brains”

Ear Central Auditory System Listening

Vision

Attention Memory

Learning

The auditory brain

“It’s not what you hear, it’s what you do

with what you hear”

Jack Katz

Clinical presentation of

auditory processing disorder

• Difficulties hearing in noisy surroundings

• Difficulties following verbal instructions

• Language and communication difficulties

• Inattention

• Distractibility

• Academic difficulties

(Keith, 1994, 2000; Bamiou et al, 2001)

APD symptoms are similar to other

developmental disorders

Dyslexia

Specific Language

Impairment

Attention Deficit Hyperactivity Disorder

Autistic Spectrum

Disorder

Behavioural

problems

Communication:

no difference between SLI and APD

Group APD SLI MS

GC

C

90

80

70

60

50

40

30

p < .001

(Ferguson et al, JSLHR, 2011)

Children’s Communication Checklist-2 (CCC-2)

General communication composite (GCC)

120 100 80 60 40 20 0

So

cia

l in

tere

acti

on

devia

nce

co

mp

osit

e (

SID

C)

30

20

10

0

-10

-20

-30

APD

SLI

MS SLI

ASD Typical

Error bars = mean +/- 95% CI

Conclusions from clinical case study

• APD and SLI for all practical purposes are indistinguishable

o APD and SLI groups were poor on all cognitive tests

o APD and SLI groups were poor on listening (CHAPPS)

• Referral route central to diagnostic labelling

o Similar cognitive and behavioural profiles can have different

diagnostic labels

• What might be a useful functional test of APD?

o CCC-2, validated, well-constructed, and would identify functional

communication problems associated with APD**

**see Dillon et al (2012, JAAA)

(Ferguson et al, JSLHR, 2011)

Challenges of APD

• Lots of clinical tests of APD available – many of these are:

• based on a clinical case approach

• poorly validated

• speech-based

• Diagnosis label useful.....but only to a point

– standard diagnostic test batteries for APD cannot effectively

distinguish between disorders like APD, SLI, dyslexia

• Appropriate to focus on presenting symptoms

– to understand more about an individual child’s strengths, weaknesses

and clinical needs

– to make decisions about best route of referral

• Need for robust research to understand what APD is, how it is

characterised, then how it can be diagnosed and managed

Research approaches to developing

and validating tests of APD

• Case control approach

Examine two samples of listeners,

one with and one without a

diagnosis of APD

Addresses the ‘clinical

presentation’

Currently no validated APD

tests in UK

Assumes unbiased sampling

of APD (and control) group

• Population approach

Poor auditory performance

identified on the basis of

auditory/non-speech abilities

Makes no assumption about

the link between presenting

symptoms and APD

Can lose track of clinical

presenting symptoms

Prevalence of APD unknown

(estimate 5%)

IHR Multi-centre Auditory

Processing study (IMAP)

Population study, May 07-July08

n = 1638 children, 6-11 y.o.

n = 1476 normally hearing

Stratified by age, sex and socioeconomic group

Nottingham

Exeter

Cardiff

Glasgow

Testing in

schools

Conclusion:

APD is primarily a result of poor

engagement with sounds.

We suggest that APD is primarily an

attention problem, and that clinical

diagnosis and management … should

be based on that premise.

(Moore, Ferguson et al, Pediatrics, 2010)

IHR Multi-centre Auditory

Processing study (IMAP)

Population study, May 07-July08

n = 1638 children, 6-11 y.o.

n = 1476 normally hearing

Stratified by age, sex and socioeconomic group

Nottingham

Exeter

Cardiff

Glasgow

Testing in

schools

Aims: To identify the characteristics of normally

hearing children who had:

• communication problems

• listening problems

(Moore, Ferguson et al, Pediatrics, 2010)

Functional difficulties not diagnosis

• Children’s Communication Checklist

– n=70 questions n=10 scales 3 subscales

• Structural language

– Language structure, vocabulary and discourse

» Speech production, syntax, semantics

• Pragmatic language

– Difficulties in pragmatic, everyday use of language, in relation to the

communication context e.g. difficulties interpreting figurative language,

poor accounting of the perspectives of others

» Inappropriate initiation, use of context, stereotyped language

• Autistic behaviours

– Triad of symptoms: communication disorders, social impairment,

restricted stereotyped behaviours

» Social relations, interests

(Bishop, 2003)

CCC-2: communication difficulties

SLI ASD PLI

Based on Norbury et al, 2004

Clinical labels most closely aligned to.

Main difference between ASD and Asperger Syndrome = ASP do not have

delayed language when younger

CCC-2 suitable for children aged 4+ years who speak in sentences (HFA)

n=818

CHAPPS: listening difficulties

SLI ASD PLI

n=818

6 scales on listening in:

• Noise • Quiet

• Ideal

Poorest 5%

n=45 Not ideal because:

• Lack theoretical basis

• Not psychometrically robust

• Not validated

• Leptokurtic distribution

But best we had at the time –

more of that later!

• Attention

• Memory

• Multiple inputs

Children’s Auditory Processing Performance Scale (Smoski et al, 1992)

Summary of results

• Compared to the typically developing children:

– The listening difficulties group (APD) had poorer scores for all the

CCC-2 subscales (structural, pragmatic and autistic)

– Listening was poorer for all the ‘clinical’ groups

– Cognition, language and reading were poorer for all the ‘clinical’ groups

who had general communication or listening difficulties, except ASP

– Frequency discrimination was poorer for those with structural language

and listening abilities

– The group mostly aligned to Asperger’s syndrome were virtually the

same as TD on all measures, with the exception of listening, poorer in

about 10%

Clinical implications

• Symptoms of children with listening difficulties (or APD) are very

similar to those with communication problems aligned to language

impairment (LI) and autistic spectrum disorder (ASD)

– does APD co-occur with other developmental disorders? Yes

– is APD a separate disorder? Probably not

– does APD fall along a dimension? Probably yes

• Children presenting to Audiology with listening difficulties should be

assessed for communication difficulties (e.g. SLI, PLI, or ASD)

– How? Questionaires such as CCC-2, CAST, ADOS,

– Or, ECLIPS, developed by Johanna Barry at IHR

www.ihr.mrc.ac.uk

IMAP team

Dave Moore

Alison Riley

Sonia Ratib

Sally Hind

Anna Phillips

Karen Baker

Nicola Bergin

Leanne Mattu

Ruth Lewis

Kelvin Wakeham, Royal Devon and Exeter Hospital, Exeter

Juan Mora, Royal Hospital for sick children, Glasgow

Veronica Kennedy, University Hospital, Cardiff

Melanie.ferguson@nottingham.ac.uk

Clinical implications

• Symptoms of children with listening difficulties (or APD) are very

similar to those with communication problems aligned to language

impairment (LI) and autistic spectrum disorder (ASD)

– does APD co-occur with other developmental disorders? Yes

– is APD a separate disorder? Probably not

– does APD fall along a dimension? Probably yes

• Children presenting to Audiology with listening difficulties should be

assessed for communication difficulties (e.g. SLI, PLI, or ASD)

– How? Questionaires such as CCC-2, CAST, ADOS,

– Or, ECLIPS, developed by Johanna Barry at IHR