Auditory processing disorders 2

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

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

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.
jwhall3@phhp.ufl.edu

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 a
Function of Pure Tone Frequency

Academic Underachievement & Failure

I must be
stupid!

F

Age and Gender Distribution in an Unselected APD Population
in a Medical Center Audiology Clinic
(N = 239)

25 Average age = 9 Years Male
(N = 160)
Number of Patients

20 Female
(N = 79)

15

10

5

7 8 9 10 11 12 13 14 15 - 18
Age in Years

AUDITORY PROCESSING:
Cornerstone of Language and Literacy (Reading)

COMPREHENSION

WRITTEN LANGUAGE
Reading and Spelling

PHONOLOGIC AWARENESS ORAL LANGUAGE

AUDITORY PROCESSING

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 audiology
 Neuroscience foundation for APD
 Disorders often co-existing with APD
 Risk factors for APD
 Current and future assessment strategies and
procedures
 Effective 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 Psychologist 1961: Canadian Psychologist
Donald E. Broadbent, Ph.D. Doreen Kimura, Ph.D.

Dichotic Listening Paradigm

RIGHT TEMPORAL LEFT TEMPORAL
CORTEX CORTEX
Association Cortex Association Cortex
Corpus
Callosum
Primary Auditory Cortex Primary Auditory Cortex

Right Ear Left Ear
air plane base ball
1, 3 5, 9

Development of APD Assessment & Management:
Principles & Procedures

AMLR Keith
studies procedures ASHA
Musiek MRI Task
Willeford studies APD
Force
Jerger Conference
Katz Tallal
Kraus fMRI
Kimura Earobics
Bocca &
Calearo

Myklebust

1954 1960 1975 1982 1986 1990s 1996 2000

Assessment and Management of Auditory
Processing Disorders (APD)

 Historical perspective … interest in APD dates back
over 50 years
 How (C) APD became a household phrase in audiology
 Neuroscience foundation for APD
 Disorders often co-existing with APD
 Risk factors for APD
 Current and future assessment strategies and
procedures
 Effective management strategies and procedures

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.”

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.”

CONSENSUS CONFERENCE 2000 ON APD

 “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

2000 Consensus Conference on
the Diagnosis of APD

 Assumptions in the diagnostic assessment of APD …
possible outcomes
 a pure APD
 an APD and a disorder or disorders in other modalities,
e.g., multi-sensory
 a disorder that appears auditory at first, but actually is non-
auditory
 a disorder that appears at first to be non-auditory but is
actually auditory

the Diagnosis of APD

 Factors influencing diagnostic assessment of APD

 ADHD
 Language impairment
 Reading disability
 Learning disability
 Autistic spectrum disorder
 Reduced intellectual functioning (cognitive impairment)

the Diagnosis of APDs

 Listener variables in the diagnostic assessment of APD
 Attention
 Auditory neuropathy
 Fatigue
 Hearing sensitivity
 Intellectual and developmental age
 Cognitive variables (e.g., memory, processing speed)
 Medications
 Motivation
 Motor skills
 Native language, language experience, language age
 Visual acuity

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

 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 (2)

 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

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

 Different regions mature at different rates
 Maturation occurs along caudal to rostral gradient
 Development of auditory pathways and centers involves
 Cell differentiation and migration
 Myelination
 Arborization
 Synaptogenesis
 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 loss
 Environmental 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 Response
and P300 Response

P2
Frequent
Unattended
e.g., 1000 Hz
Amplitude (mV)

P3 (300)
N1 P2 Infrequent
(rare)
Attended
e.g., 2000 Hz

500 ms

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.

Auditory Processing Disorders:
Differential Diagnosis

“Differential Diagnosis:

Diagnosis based on comparison of symptoms (signs) of

two or more similar diseases (disorders) to determine

which the patient is suffering from.”

Shared Anatomy

Reading

Language

Auditory processing

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

 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 (APDs):
Co-existing Disorders (Co-morbidity)

SLI

APD dyslexia

ADHD

Evidence of relation to language and reading

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:
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.”

APD:
Screening and Assessment in Pre-School Children

I can’t figure out
what 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)

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)

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

Indicators in Early School Age Population and
Screening for At Risk Children (SIFTER)

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
 multi-talker babble noise at + 8 dB SNR
 Competing words
 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 language
 Psychological and psycho-educational
 ADHD
 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 measures
 tympanometry
 acoustic reflexes
 crossed vs. uncrossed conditions … initial measure of CNS
function
 Pure tone audiometry
 inter-octave frequencies (e.g., 3000 and 6000 Hz)
 high frequency (> 8000 Hz) audiometry (as indicated)
 Speech audiometry
 word 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
LEFT TEMPORAL RIGHT TEMPORAL
CORTEX CORTEX
Corpus
Callosum

Left Ear Right Ear
1, 4 2, 9

CAPD ASSESSMENT:
Test Battery for Auditory Processes (2)
 Temporal integration dichotic tests, e.g.,
 Dichotic digits
 Staggered spondaic word (SSW) test
 Dichotic sentence identification (DSI) test
 SCAN competing words subtest
 Auditory performance with competing acoustic signals, e.g.,
 SSI-ICM
 Pediatric Speech Intelligibility (PSI) test
 GFW Test of Auditory Discrimination (noise)
 SCAN auditory-figure ground subtest
 Auditory performance with degraded acoustic signals, e.g.,
 Time-compressed words with reverberation
 SCAN filtered words subtest

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

 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 skills
 Phonemic synthesis test
 developed Jack Katz
 Test of Auditory Analysis Skills (TASS)
 Say the word baseball … now say it again but don’t say base
 Say the word smack … now say it again but don’t say /m/

APD ASSESSMENT:
Ideas for New Procedures and Protocols

 General principles
 Verbal and non-verbal procedures
Non-verbal test materials
Non-verbal response mode
 Age appropriate tasks
 Psychometrically well designed
Sensitivity and specificity
Adequately large normative data across age range
Standard scores and percentiles
 Adaptive test strategies
Reduced test time
Manipulation of test difficulty
 Measures of major auditory processes

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

 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 noise
 Non frequency specific signals
 Scores not influenced by hearing loss
 Simple button pushing response
 Signal with either gap or no gap
 Yes or no response judgment
 Minimal influence of cognition (for patient and tester)
 Gap detection is a traditional and accepted measure of temporal
processing

APD ASSESSMENT:

 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 earphones
 Assesses auditory stream segregation skills in children
 Speech 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

APD ASSESSMENT:

 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.
 Conclusions
 Children with traditionally defined APD showed deficit on LISN-S
 No correlation of LISN-S with dichotic tests, PPS test, or gap detection test
 Spatial and non-spatial LISN-S test performance not correlated
 Children with language impairment did not show LISN-S deficits
 Findings support ASHA 2005 and AAA 2009 conclusions regarding the ability
to diagnose auditory specific deficits
 Children with spatial stream segregation deficits likely to require higher SNR,
e.g., personal FM devices

APD ASSESSMENT:
Auditory Evoked Responses Evoked with
Non-speech and Speech Signals

 Auditory evoked responses
 Auditory brainstem response (ABR)
 Auditory steady state response (ASSR)
 Auditory middle latency response (AMLR)
 Auditory P300 response
 oddball paradigm
 active or passive subject
 Mismatch negativity (MMN) response
 Auditory processes to be assessed
 Discrimination (e.g., frequency, duration, speech type sounds)
 Auditory figure ground
 Temporal processing
 Temporal ordering

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

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 ...”

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 Skills
Addressed 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

 > Intelligence  < Intelligence
 Normal hearing  Conductive HL
 Family support  ADD/ADHD
 Genetics  Genetics
 Environment  SLI
 Auditory stimulation  APD

Academic Academic
Achiever Underachiever

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

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

 APD Management Options and Approaches
 Counseling, case management, and advocacy
 Audiologic 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

Classroom Assistive Listening Devices

Personal FM
Headset Style

Desktop
Sound Field FM
Toteable FM Infrared

Phonak EduLink
A viable option for all children, particularly adolescents

EduLink Receivers

Mini-Boom Microphone

Campus S
Transmitter

SNR improvement on the HINT in normal hearing adults and
children without and with APD:
Three different FM system types

Head set
SNR Improvement (in dB SPL)

10 9.5

8 7.5 7.2
7.4 Desk top

6.5
6
4.7 4.3
Sound field
4.0 3.8
4

2

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

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

Group
Test Condition Control APD

Unaided in Noise (SNR)* 7.9 dB 6.1dB

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

Advantage in Noise 8.2 dB 10.3
with EduLink

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

Typical Classroom SNR Range: +5 to -7 dB
Markides (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

100
90
80
Percent Score

70
60
50 Fisher's Score
40
30
20
10
0
CT 11

D3
D4
D5
D6
D8

AP 9
AP 0
AP 2
AP 3
AP 4
AP 5
6
CT 10

CT 12
13
CT 1
CT 2
CT 3
CT 4
CT 5
CT 6
CT 7
CT 8
CT L9

D
RL
RL
RL
RL
RL
RL
RL
RL

D1
D1
D1
D1
D1
D1
RL
RL

RL
RL
R

AP
AP
AP
AP
AP
AP
CT

Individual Control and APD Subjects

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

14
12
10
Score

8 Control
6 APD
4
2
0
Academics Attention Communication Class Participation School Behavior
SIFTER Categories

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

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

•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 Questionnaires:
Interpretation

“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.”

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

Normal Findings per Group (%)
Domain Control APD

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 Control APD
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

Benefit of Phonak EduLink FM Technology on Communication,
Psychosocial Status, and Academic Performance of Children with
Auditory Processing Disorders (APD):
Conclusions

 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

Dichotic Intensity Increment Difference (DIID)

LEFT TEMPORAL RIGHT TEMPORAL
CORTEX CORTEX
Corpus
Callosum

Weak Ear Strong Ear
fixed increasing
intensity intensity

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

The Early Auditory Reading Success (EARS) Program:
Assumptions

 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.

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

 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 year
 Early fall semester (September)
 Late fall semester (December)
 Early spring semester (January)
 Late spring semester (May)

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

DIBELS EARS School Control School
Outcome Early Final Final
N = 52 N = 63 N = 48

Deficit 50% 27% 40%

Emerging 31% 22% 44%

Established 19% 60% 16%

EARS Program Rationale:
Five Component Skills of Reading

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

Intervention based on screening outcome

 Children diagnosed with hearing, cognitive, attention, or other
deficits referred for appropriate management
 Intervention components
 FM systems in each kindergarten classroom
 All kindergarten students complete Earobics
 Multi-sensory reading instruction strategies used by each
kindergarten teacher
 Children diagnosed with APD and/or deficits in phonologic
awareness receive intensive small group treatment by speech
pathologist
 letter recognition
 phonologic awareness
 other basic reading skills

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

Core Reading
Program
Reading Skills

EARS
Program Powerful Intensive
Intervention
(Struggling Readers)

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

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

Core Reading All kindergarten children in Title I
Program schools undergo
(Tier 1) auditory and language screening

Phonologic Awareness Enhancement
(Tier 2) Not at risk? At risk?
Classroom FM system
Classroom instruction
Earobics program

Intensive Intervention
(Tier 3)
Monitor Outcome Small group inclusive instruction
(DIBELS) Pre-reading skills
National 70%ile? Phonologic awareness instruction

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

Established 04

96 94
100 92
National %ile

80

60

40

20

HR MR LR AA Est HR MR LR AA Est HR MR LR AA Est
Letter Sound Phonemic Sequence Nonsense Word
Fluency Fluency Fluency

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

60 57
50
40 40 38
30 EARS
21 (n=180)
20
10 Control
(n=143)
0
OLV Reading
Comp

OLV Oral Language Vocabulary
Reading Comp Reading Comprehension

Conclusions

 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 teacher
 Therapy 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

MANAGEMENT OF APD:
Facilitating academic achievement & success

I must be
smart!

Auditory processing disorders 2

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