Yes, you CANS! Assessing children’s central auditory processing skills

1. Yes, you CANS! Assessing children’s central auditory processing skills Jeanane M. Ferre, PhD, CCC-A Oak Park, IL 60301 708.848.4363 Fax: 708.848.7233 jmfphd@comcast.net www.dr-ferre.com

2. disclosures • Financial • Invited speaker – honorarium • Pro-Ed author • Consultant – school districts in IL, GA, WI, HI • Adjunct Faculty- Northwestern University Rush University • Nonfinancial • ASHA member • ISHA member

3. The “wh” questions about CAPDs • What is central auditory processing ? • Better Q- what ARE the central auditory processes? • What is a central auditory processing disorder? • Why should be assess these skills and/or treat these issues? • Who should be tested, and when?

4. Auditory processing is “what we do with what we hear” • Accurate definition? Yes • Diagnostically useful? Not so much • Why? Here’s the system with which we are dealing.

5. OUTPUT SYNTHESIS DISCRIMINATION

6. Continuum of Processing

7. Central auditory processing • neural processing of auditory stimuli • Auditory discrimination • Binaural processing • Temporal processing • A Central Auditory Processing Disorder (CAPD) is any deficiency in skills subserved by CENTRAL auditory mechanism in brainstem/brain

8. Outer, Middle, Inner, 8th nerve Peripheral Auditory System

10. Cortical system Right hemisphere Parietal lobe Frontal lobe Temporal lobe Occipital lobe Left hemisphere

12. Subcortical/cortical auditory functions • 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

13. Binaural processing - interaction between the two sides • Binaural fusion – interaction between ears • Reflects brainstem integrity • Assists listening in noise, localization, perception • Also referred to by some as binaural synthesis • Dichotic listening – interaction between hemispheres • Integration – process multiple targets • Separation – process one and ignore another • Reflects cortical integrity

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

15. Beyond CENTRAL auditory processing • Phonologic-phonemic processing • Relates to literacy/pre-literacy skills • Includes speech-to-print, spelling, writing • Linguistic Processing • Ability to interpret/attach meaning to signal • Foundation for metalinguistics/conceptual language • Executive Functions • Under control of frontal/pre-motor cortex • Planning, execution, regulation of a response

16. Another way to “look” at process

17. So, why test for CAPDs? • Auditory discrimination – analysis of fine differences in acoustic spectra • Binaural processing – recognition and manipulation of multiple acoustic targets • Temporal processing - using timing aspects of signals • Underlie ability to recognize/use speech • Necessary for active listening/ learning/ communication • Educationally relevant to ALL Common Core standards, including standard for Speaking and Listening

18. Processing disorders can co-exist with other disorders

19. 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

20. Differential diagnosis • Differentiates among disorders having similar symptoms/ manifestations • SLPs, psychologists, neuropsychologists & others provide insights re: listener’s auditory performance in various contexts • Audiologists use well-controlled, norm-referenced tests that minimize influence of language, cognition & other sensory skills & maximize auditory system function • Tests designed to tax CAP skills • Patterns diagnose specific CAPD • Test results help customize deficit-specific differential intervention

21. Differential Intervention • Balance of treatment and management based upon neuroscientific principles & derived from assessment results • Customizes treatment and management plans to treat impaired skills & to minimize impact on listener’s life treatment management Neuroscience foundations

22. Assessing processing skills

23. Continuum of Processing Aud & SLP Speech-language pathologist Audiologist

24. 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

25. CAPD Test Battery • Minimize influence of language, cognition & other sensory skills on performance • Maximize function of CANS • Results examined re: • central auditory processes being taxed • anatomical sites subserving those skills

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

29. Differential Screening Test of Processing Screen 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 LinguiSystems

30. Informal assessment of CAP skills • Spelling • Memory for words vs. sentences • Music • Alphabet • Wepman, ITPA • Multisyllabic words • Checklists and record review

31. Assessing skills beyond the CAPs • Phonologic Processing • Sound blending, auditory closure, spelling • Language Processing • Receptive/expressive vocabulary • Hierarchy of language processing • Multisensory and memory skills • Executive Functions • Flexibility, impulsivity, self-monitoring • Planning, problem-solving, attention/vigilance • Fluid thinking and divergent reasoning

32. Interpreting CAP test results • Absolute analysis • Norm-referenced • Compare to age-matched peers • Per test pass-fail criterion: >2SDs below mean for age • No “below average” CAP skills – skill set is normal or disordered • Relative analysis • Examination of patterns across tests • Ear differences • “Ties that bind” We DON’T “diagnose” per test – we look at battery!

33. Interpreting CAP test results • NOT CAPD • Performance below normal on single test • Performance below normal on all tests • Definition of a CAPD • Poor scores on sets of tests tapping similar function • Bellis/Ferre model describes 5 test profiles

35. 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”

36. Decoding deficit - manifestations • Needs repetition – lots of “what?” • Mishears information • Fatigues easily • Difficulty in noise esp. as noise gets louder • Slow/inaccurate • Reading decoding/comprehension • Spelling • Receptive language issues including vocabulary, syntax, semantics, second language acquisition

37. 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

38. Integration deficit manifestations • Trouble multitasking • Poor transitions • Needs more time • Slow but accurate • Variable difficulty in noise • “how to & how much” • Reading decoding and/or comprehension • Spelling, Written language • Other sensory skills • Syntactic and related language arts skills

39. Prosodic deficit • Deficiency in use of prosodic 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”

40. Prosodic deficit manifestations • Poor direction following • Loses focus after first few sentences • May have flat affect • Poor figure-ground skills • Misunderstands intent of message • Social & pragmatic lang. • Phonological processing • Music perception/ appreciation • Nonverbal communication • Academic impact can be variable

41. Secondary CAP test profiles • The “auditory” manifestations of more supramodal or neurocognitive disorder and NOT true CAPD • Associative deficit • Output-Organization deficit

42. Associative deficit profile • NOT applying rules of language to acoustic signal • Likely due to poor communication between primary and secondary (association) cortices (intra-hemispheric integration) • Poor scores for both ears on dichotic tests, good labelling/mimicking, adequate discrimination • Poor “translators”, “I don’t get it”

43. Associative deficit manifestations • Misunderstands meaning • Linguistically inappropriate responses • Poor peer relations • May appear noncompliant • Noise not a major issue • May “daydream” while working • Receptive, expressive, social, pragmatic, functional comm. • Memory issues, math • Reading/language arts • “Auditory” manifestations of LPD

44. 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

45. Output-organization manifestations • In the classroom • May be disorganized • May be impulsive • May be poor planner • Poor task completion • Poor direction following • At risk for deficits in • Speech production • Sequential memory • Recall, word finding • Executive function skills

46. Test results help professionals develop deficit-specific intervention strategiesEffective intervention includes management remediation Neuroscientific principles & test results

47. Assessment Summary Auditory processing Language Processing Is “on top of” basic language Develops in hierarchy from concrete to abstract Develops and refines throughout lifespan • Occurs before you “know” the target • Can adversely affect language • Is “adult-like” by early teens Any processing impairment can adversely affect learning & social-emotional health Differential diagnosis MUST be used to find the level of breakdown