A rose by any other name… understanding auditory processing disorders

1. A rose by any other name… understanding auditory processing disorders Jeanane M. Ferre, PhD Audiologist, CCC-A Oak Park, IL 708.848.4363 Email: jmfphd@comcast.net www.dr-ferre.com

3. Continuum of Processing

4. Another way to “look” at process

5. Peripheral auditory function • Hearing sensitivity and reflex action • Signal collection – outer ear • Signal transmission – middle ear • Signal detection – inner ear • Signal transformation – 8th nerve

6. Central auditory processing • neural processing of auditory/acoustic stimuli • Auditory discrimination • Temporal processing • Binaural processing • deficiency in skills subserved by CENTRAL auditory mechanism in brainstem/brain = CAPD

7. Brainstem level Central Auditory Functions • Binaural interaction – how the two EARS work together • “additive” functions – provide a more robust signal for higher centers • “difference” functions – help with localization and hearing in noise • Acoustic feature extraction: timing and frequency cues • Assists in signal perception • Different cells respond differently

8. Auditory discrimination – ability to analyze fine acoustic differences in signal spectra • Occurs through the thalamic level AND primary auditory cortex (Heschl’s gyrus) • Perception of ACOUSTIC signal

9. Dichotic listening – interaction between the two HEMISPHERES Reflects integrity of the left hemisphere, right hemisphere, and corpus callosum Binaural integration: process all information presented to the two ears Binaural separation: “hear” what’s in both ears BUT ignore one target or the other

10. Temporal processing – ability to use timing aspects of signal • Temporal resolution- a left hemisphere skill involving ability to perceive “1” versus “2” targets • Temporal patterning – a right hemisphere skill involving ability to perceive order/sequence • BOTH skills important for perception of running speech

11. Impact of deficits in specific CAP skills • CAPDs adversely academics, communication, and psychosocial wellness • Reading, writing, spelling, math • Development of speech-language skills • Sense of self • Daily listening skills • CAPDs can co-exist with, share symptoms of, exacerbate and be exacerbated by other disorders

12. CAPDs can look like/exist with … • Attention Deficit Disorder • distractible, inattentive, disorganization • Executive Function Difficulties • poor working memory, strategy development • Behavior Disorders • opposition, perseveration, noncompliance • Asperger’s Syndrome • poor social language, impaired affect • Nonverbal Learning Disability • impaired prosody, use of nonverbal cues • Speech-Language Impairment • poor phonological awareness, pragmatic language

13. Differential Diagnosis Needed • Differentiates among disorders having similar symptoms/manifestations • Audiologists examine specific CA processes • SLPs examine phonetic-phonemic, linguistic, memory, and related skills • Psychologists/others probe listening and related skills • Patterns across tests identify DEFICIT-specific processing disorders • Results lead to DEFICIT-specific intervention

14. Differential Intervention • Balance of treatment & management based on neuroscience & derived from assessment • Customized treatment and management plans to treat skills & minimize impact on listener’s life treatment management Neuroscience foundations

15. Continuum of Processing Linguistic Acoustic Central Auditory Processing Language Processing audiologist speech-language pathologist Transition Area Phonemic Processing audiologist and speech-language pathologist

16. Differential Screening Test of Processing - DSTP Screens processing continuum 8 subtests delivered via CD 3 auditory processing 2 phonemic/phonic 3 language Identifies where to refer and/or spend more time in assessment Available from www.proedinc.com

17. Diagnostic CAPD Testing Battery • What? • Battery of tests to determine how efficiently CANS operates • How? • Overloading or overworking it • Who? • Children as young as 6 years • Results compared to age-matched peers Performance profiles yield insights into nature of CAPD

18. CAPD Test Assessment • Minimize influence of language, cognition & other sensory skills on performance • Results examined re: • central auditory processes being taxed • Auditory discrimination, binaural processing, temporal processing • anatomical sites subserving those skills • Brainstem, right/left hemispheres, corpus callosum

19. Considerations for testing • Hearing sensitivity • Sufficient expressive speech skills • Sufficient receptive language skills • Intelligence test results

20. Test Type Processes Assessed Underlying Site Puretone air & bone conduction Speech thresholds Word recognition hearing sensitivity acuity Tympanogram Acoustic reflexes OAEs signal transmission Binaural fusion Masking level difference LISN Low-pass filtered speech Time-compressed speech brainstem, primary auditory cortex peripheral mechanism peripheral/central interaction btw ears localization brainstem auditory closure, discrimination

21. Test Type Processes Assessed Underlying Site Dichotic digits Dichotic Rhyme Staggered Spondaic Words Dichotic Sentence Identification Binaural integration, closure ordering LH, RH, CC Competing Sentences Binaural separation LH, RH, CC Pitch patterns test Duration patterns test Random gap detection Gaps in noise Speech-in-noise tests Temporal patterning Temporal resolution RH, LH, CC varied varied

22. Test Interpretation • NOT CAPD • Below normal single test • Below normal on all tests • Contradictory findings • Evidence of CAPD • Poor scores on sets of tests taxing similar skills • Bellis/Ferre model describes 5 test profiles • Three primary • Two secondary

24. Interpretation • Primary CAPDs • Decoding deficit – LH • Integration deficit - CC • Prosodic deficit – RH • Represent true Central AUDITORY processing issues

25. Auditory decoding deficit • Poor discrimination of fine acoustic differences in signal • Probable site: primary auditory cortex • Signal distortion – poor neural representation • Exhibit impaired discrimination, closure, & temporal resolution • Poor scores on low redundancy tests, gap detection, and (possibly) binaural integration • Behaviorally: they can’t “hear”

26. Integration Deficit • Deficit in performing tasks requiring interhemispheric communication • Probable site: corpus callosum • Insufficient development of corpus callosum • Poor integration skills • Excessive LE suppression on dichotic tasks AND poor labelling with good mimicking of patterns • “it’s too much” – not synthesizing inputs

27. Prosodic deficit • Deficiency in use of prosodic (timing) features of target • Probable site: right hemisphere • Inefficient RH pattern recognition • Trouble with acoustic contours • Exhibits poor temporal patterning • Poor scores both labelled AND mimicked on patterning tasks AND excessive LE suppression on dichotic tasks • Behaviorally: it’s all “blah, blah, blah”

28. Interpretation • Secondary test patterns • Associative deficit • Likely reflects impaired language processing • Output-organization deficit • Likely reflects cognitive/executive function issues

29. Associative deficit • NOT applying rules of language to acoustic signal • May be due to poor communication between primary and secondary (association) cortices • Poor scores for both ears on dichotic tests, good labelling/mimicking, adequate discrimination • Poor “translators”, “I don’t get it” • Issues manipulating multiple targets

30. Output-organization deficit • Deficient ability to organize, sequence, plan appropriate response • May be due to deficient efferent, motor planning, or executive function • Exhibit difficulty with expression/execution • Poor scores multiple target tasks, in noise, sequencing errors • Can’t get it back out

32. Differential Intervention • Balance of treatment & management based on neuroscience & derived from assessment • Customized treatment and management plans to treat skills & minimize impact on listener’s life treatment management Neuroscience foundations

33. Management Remediation • Modification of the communicative environment • Use of compensatory strategies • Minimizes adverse effect of disorder of client’s life • Formal and informal therapy to develop deficient skills AND • Teach compensatory strategies • Designed to reduce or resolve deficit

34. Bottom-up - stimulus driven • Therapy: adaptive/repetitive skills training • Management: focus on access to signal • Top-down - concept driven • Therapy: use of cognitive/linguistic strategies • Management: focus on accommodations & communication

35. Intervention for processing Disorders: the m3 model Communication

36. Intervention Tripod Direct Remediation- focus on listener Environmental Modifications – focus on environment Compensatory Strategies – focus on message

37. Focus on the environment • Noise & reverberation • Distance & lighting • Direct Signal enhancement via ALD • Educational accommodations

38. Noise & reverberation • Listener’s ability to function in background noise depends upon • Type of noise • Loudness of noise relative to target (signal-noise ratio- SNR) • Location of noise relative to target • Task demands • Reverberation (echo) • Measured in reverberation time (RT)

39. Noise & reverberation • ASHA recommends classroom SNR should exceed +15dB with RT of <0.4 seconds • Noise abatement • Increase absorptive material • Use baffles, damp reflective surfaces • Eliminate open classrooms • Floor plan changes • Infrastructure changes • Earplug/earphone use • Noise abatement using “masking”

40. Distance & Lighting • Sound intensity decreases with increasing distance from source • Sound may be direct or reverberant • Direct reaches listener without obstruction • Reverberant composed of reflected waves • As distance increases from source, amount of reverberant sound increases

41. Distance & Lighting • Lighting can affect use of visual cues and ability to maintain focus • Optimal speaker-listener distance = 3-6 ft • Optimizing distance/lighting • Change lighting • Avoid being backlit • Use preferential seating to maximize auditory and visual cues

42. Direct signal enhancement via ALDs • Improves SNR reaching listener’s ear • Personal wearable – FM, digital, PSAPs • Soundfield systems • Personal soundfield systems • Can improve attention to, discrimination of, and memory for signals • NOT an option for all students

43. Other environmental considerations • Change location for tests, studying • Use of study/work carrels • Consult with OT regarding type of seating and sensory diet needs

44. Focus on the message • Clear Speech • Visual cues • Clear Language • Educational accommodations

45. Speed of processing • 3-5 yr.-olds process speech at 120-124wpm • 5-7 yr.-olds can handle 128-130 wpm • 5-6th graders can process speech at 135 wpm • Middle school-high school – 135-140 wpm • Average wpm of most adults is 160-180 wpm and may reach 190 wpm • Check your rate – use Clear Speech

46. Clear Speech • Clear Speech improves perception/recognition (Picheny, M., Durlach, N., & Braida, L. 1985) • Speaking at slightly slower rate, including strategic use of pausing and slightly increased loudness • Simple repetition with Clear Speech ensures perception for most listeners

47. Visual cues • Couple clear speech with AV presentation • Model look and listen • Not all listeners can look and listen • Use look or listen • Add complementary visual cues • Show me • For teachers and parents • Look then listen

48. Clear Language • Improves comprehension • Say what you mean and mean what you say • Rephrase • Minimize generic/ambiguous language • Add “tag” words • Consider overall amount of information • Break instructions down • Allow “waiting” and “thinking” time • Verbal cueing • Preteaching

49. Educational accommodations • Extended time/Untimed tests • Test reader • Adjusting homework loads • Using technology- “smart pens”, notetaking apps • Changes in curriculum

50. Intervention Tripod Direct Remediation- focus on listener Environmental Modifications – focus on environment Compensatory Strategies – focus on message