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Hearing with Your Brain: Auditory Processing Disorder in Children

Christine Rota-Donahue, PhD

Lehman College of the City University of New York

FLASHA, 2016

Disclosure

• Employed by the City University of New York

• Grant from the American Hearing Research Foundation

• Author of several articles and presentations on auditory perception

Introduction to Auditory Processing

Detection

Discrimination

Identification

Comprehension

Vision

Working memoryLanguage

Cognitive skills

Attention

Motivation

Emotions

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Outline

Auditory skills development:

- Structural maturation

- Behavioral responses to sounds

Definition:

- How is Auditory Processing Disorder (APD) defined today?

- Behavioral and brain bases of APD

Assessment and Treatment of pediatric APD:

- Case presentation supporting a multidisciplinary approach

Ascending auditory pathways

Decussation of the auditory pathways

Image from Neuroreille.com

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posterior Superior Temporal Gyrus (pSTG)

Image from Wikipedia

Behavioral auditory milestones

Lynn Werner (2007)What do children hear? How auditory maturation affects speech perception

Images from Google Images

Stage 1: 0-6 months

Newborns and young infants• react to loud sounds • can discriminate between speech sounds• recognize voices However•representations of sound are coarser than adults' •elevated detection thresholds •ability to separate sounds of different frequencies is immature

• limited precision in representation of speech

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Stage 2: 6 months - 5 years

Young children

• show interest in sounds

• follow stories

However

• detection thresholds still elevated

• listen in broad band way

• difficulty listening in noisy environment until age 5

Stage 3: 6 years - adolescence

School-aged children

• have mastered selective listening

• speech perception becomes automatic

However• less consistent than adults in categorization of speech

sounds.

• need multiple cues to identify phonemes

• requires attention

Models of speech perception

• Traditional models

• More recent model

Picture from Google Images

• The McGurk effect

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Processing model

The processing continuum model

Auditory processing Language processing

From: Gail Richard

Auditory skills development:

- Structural maturation

- Behavioral responses to sounds

Definition:

- How is Auditory Processing Disorder (APD) defined today?

- Behavioral and brain bases of APD

Auditory Processing Disorder

•3% of school-aged children (Musiek & Chermak, 2014)

•often associated with language impairment (e.g.

Rota-Donahue, 2014)

•other higher order deficits in attention and memory (e.g. Sharma et al. 2014)

• ‘is a deficit in neural processing of auditory stimuli’ (Musiek and Chermak, 2014)

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Symptoms of APD – ASHA 2005 and AAA 2010

Include difficulty in one or more of the following:

• sound localization and lateralization

• auditory discrimination

• auditory pattern recognition

• temporal aspects of audition

• auditory performance in competing acoustic signals

• auditory performance with degraded acoustic signals

Auditory Processing Disorder is NOT

• Poor sound detection

• Cognitive deficit

• Language impairment

• Age appropriate listening

• Attention deficit

Behavioral assessment

Pediatric APD is typically diagnosed if one of the following skills is affected:

- Perception of physical dimensions of sounds

- Localization or spatial listening

- Dichotic listening

- Speech in noise

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Brain bases of APD

• Electroencephalography (EEG)

P1N1P2 and Mismatch Negativity (MMN)

• fMRI

Pictures from Google Images

What is EEG?

• Recording of electrical activity at the level of the scalp

• Using caps with electrodes

• Spontaneous EEG

• Responses time locked to an event

Spontaneous EEG activity - waveform

From Google Images

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EEG spectral analysis

From pinterest.com

P1-N1-P2 complex

From: Neuroreille.com

ABR MLR P1-N1-P2 complex

P1-N1-P2 waveform in children with APD or SLI

At FCz

Rota-Donahue, 2014

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Differences in the P1N1P2 in children with APD

Rota-Donahue, 2010

AEP responses at FCZ at 500Hz and at 3000Hz for TD children (8-10 y.)

-2

-1

0

1

2

-2

-1

0

1

2

3120Hz

3060Hz

3030Hz

3015Hz

3007Hz

3003Hz

3000Hz

Group 500Hz base frequency 3000Hz base frequency

Latency in milliseconds

Am

plit

ude in m

icro

volts

0 100 200 300 400 500

-3

-2

-1

0

1

2

-3

-2

-1

0

1

2

-3

-2

-1

0

1

2

-3

-2

-1

0

1

2

-3

-2

-1

0

1

2

-3

-2

-1

0

1

2

-3

-2

-1

0

1

2

520Hz

510HZ

505HZ

502HZ

501HZ

500.7HZ

500HZ

0 100 200 300 400 500

-2

-1

0

1

2

- Large ∆ƒ: expected response clearly visible.

- ∆ƒ threshold: between .5 % and 1% of the base frequency

Rota-Donahue, 2010

Comparison ∆ƒ thresholds TD vs. APD

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

∆f

thre

sho

ld (

%)

Behavioral EEG

TD TD APDAPD

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Stimuli

Frequency changes (Rota-Donahue et al., JAAA, 2016)

Frequency discrimination, the detection of ∆ƒ

APD or SLI status affected frequency discrimination

Small ∆ƒ vs. Large ∆ƒ

The literature

Sensitivity index

• Hit rate (H) and false alarm rate (F) calculated for each participant for both tasks

• d’ determined for each participants using the formula d’= z(H) – z(F)

• Bias criterion c also calculated using the formula c = -1/2 [z(H) + z(F)]

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Preliminary data

fMRI

Boscariol et al, 2011

Auditory skills development:

- Structural maturation

- Behavioral responses to sounds

Definition:

- How is Auditory Processing Disorder (APD) defined today?

- Behavioral and brain bases of APD

Assessment and Treatment of pediatric APD:

- Case presentation supporting a multidisciplinary approach

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Test battery used in my lab

• Questionnaire to rule out known neurological deficits such as epilepsy or ASD

• Hearing screening

• Checklist to rule out ADHD based on the Connors’ checklist

• Test of non-verbal intelligence. TONI – 4

• Clinical Evaluation of Language Fundamentals CELF – 5

Word Class, Formulated Sentences, Recalling Sentences and Semantic Relations to get a core language score (CLS)

FOUR TESTS of AUDITORY PROCESSING

• LiSN-S

• DDT

• GIN

• SCAN3-C – A/F ground subtest

Preliminary data for 12 participants

Group TONI-4 CELF-5 CLS LiSN-S Dichotic

Digits (%)

Gaps in Noise

(ms)

SCAN

(AFG)

Typical (TD) 109.9 112.1 9.9 R: 93.6

L: 87.4

R: 4.4

L: 4

10.7

Atypical 99.3 74.7 5.3 R: 67.3

L: 54

R: 12.7

L: 12

8.7

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Case presentation supporting a multidisciplinary approach

Jane Vanessa

Assessment

• Questionnaire: known neurological deficits were ruled, medical history was unremarkable

• Hearing screening: pass bilaterally between 500Hz and 4000Hz

• Checklist to rule out ADHD based on the Connors’ checklist: pass

• Test of non-verbal intelligence. TONI – 4

Assessment (continued)

Clinical Evaluation of Language Fundamentals - CELF 5

Core Language Standard Score: 55Subtests Scaled Scores

Word Classes 3

Formulated Sentences 3

Recalling Sentences 4

Semantic Relations 0

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Assessment (continued)

Tests of Auditory Processing

• LiSN-S: below norms

• DDT: 54%, AD, 44% AS

• GIN: 20ms AU

• SCAN3-C – A/F ground subtest scaled score: 8

Treatment of processing problemsTreating the symptoms at each level: acoustic, phonemic, linguistic

ACOUSTIC

LINGUISTIC

PHONEMIC

Iden

tifi

cati

on

Au

dit

ory

M

emo

ry

Dis

crim

inat

ion

Au

dit

ory

A

tten

tio

n

Differential Processing Training Programby Kerry Winget (LinguiSystem)

Book 1 Acoustic Tasks

• Dichotic Listening

• Temporal Patterning

• Auditory Discrimination

Book 2 Acoustic-Linguistic Tasks

• Phonemic Manipulation

• Phonic Manipulation

Book 3 Linguistic Tasks

• Word Relationships

• Prosodic Interpretation

• Language Organization

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Jane’s first sessions of auditory training

Monaural

in noise

After 2 months of Auditory Training

SOAP notes from the SLP:- Jane is more attentive during sessions

- The mother is more motivated

- Jane is able to follow 3 steps commands (> 80% after 2 months of auditory training)

- However, Jane’s language comprehension and her reading skills are still very poor

- CTOPP, phonological memory (memory for digits and non word repetition), score: 88

- Future goals include working on word relationships and semantics

What can we learn from this case?

• Jane has both APD and SLI

• Auditory perception vs. language processing

• Speech perception

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Conclusion

Brain basis of APD and SLI

References

• American Academy of Audiology (2010) Clinical Practice Guidelines: Diagnosis, Treatment and Management of Children and Adults with Central Auditory Processing Disorder. Clinical Practice Guidelines, 1-51.

• American Speech-Language Hearing Association (2005) (Central) Auditory Processing Disorders. Technical Report, 1-20.

• Boscariol M, Guimaraes CA, Hage SRV, Garcia VL, Schmutzler KMR, CendesF, Guerreiro MM. (2011) Auditory processing disorder in patients with language-learning impairment and correlation with malformation of cortical development. Brain Develop 33:824-831.

• Musiek FE, Chermak GD. (2014) Handbook of Central Auditory Processing Disorder. Second Edition. San Diego: Plural Publishing.

• Richard G. (2001) The source for processing disorders. LinguiSystems• Rota-Donahue C. (2010) Neurophysiological and Behavioral Processing of

Small Frequency Changes in 8-11 Year-Old Children. AudiologyOnline, 7/12/ 2010.

References (continued)

• Rota-Donahue C. (2014) Neurophysiological Bases of Frequency Discrimination in Children with Auditory Processing Disorder or Specific Language Impairment. Ann Harbor, MI: ProQuest LLC.

• Rota-Donahue C. et al. (2016) in press

• Sharma M, Dhamani I, Leung J, Leung J. (2014). Attention, Memory, and Auditory Processing in 10- to 15-Year-Old Children With Listening Difficulties. J Speech Lang Hear Res 57,2308-2321.

• Werner L. (2007) What do children hear? How auditory maturation affects speech perception. ASHA Leader

• Winget K. (2007) Differential Processing Training Program. LinguiSystems

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Thank you