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

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

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?

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.

OUTPUT SYNTHESIS DISCRIMINATION This is the system with which we are dealing. The ear here represents the peripheral auditory mechanism- outer ear, middle ear, inner, and auditory nerve. This system collects the sound, detects it, and turns it into something the brain can use. The central auditory nervous system are the centers in the brain and brainstem that help us interpret what the ear sends up to the brain. As listeners, we must do all five of these skills – and pretty quickly. Attention here, refers to brainstem level “channel capacity” that allows us to listen with both ears at the same time or to listen to one target and ignore a competing signal – supporting divided and selective attention. Discrimination refers to the system’s ability to extract the pitch, loudness, and timing cues that make up every sound so that by the time the signal reaches the auditory cortex you have the “c”, “a”, “t”. Integration is essentially the opposite of discrimination. Instead of piece-piece-piece, the auditory centers on the right side and the auditory centers on the left side work together to synthesize all the targets so the c-a-t turns into cat or act or tac, depending upon order of signals. After we have analyzed and synthesized the targets, the signal, literally, moves to the language centers – the association cortex and our language kicks in and our brain’s say “hey, you said cat, I KNOW what a cat is.” Then we are able to execute a response or “output” – an umbrella term that refers to our ability to say the word, point to the picture, sing the song, laugh at the joke, organize, sequence, recall information. So, it really is a process that starts at the ear and ends when we execute a response – right or wrong. Dysfunction at the peripheral level is hearing loss, ANY breakdown in the central system is a processing problem.

Continuum of Processing Detect, analyze, & synthesize Acoustic processing Attach meaning & integrate with other information Phonologic/linguistic processing Organize, execute a response, maintain focus Linguistic /cognitive processing

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

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

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

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

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

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

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

Another way to “look” at process Executive functions Language & learning Sensory processing

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

Processing disorders can co-exist with other disorders

Attention Deficit Disorder Executive Function Difficulties 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

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

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

Assessing processing skills 22

Continuum of Processing Detect, analyze, & synthesize Acoustic processing Attach meaning & integrate with other information Phonologic/linguistic processing Organize, execute a response, maintain focus Linguistic /cognitive processing Aud & SLP Speech-language pathologist Audiologist

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

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

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

Test Type Process assessed Underlying site hearing sensitivity/acuity standard audiometric: puretone air/bone speech thresholds word recognition hearing sensitivity/acuity peripheral mechanism standard immittance: tympanogram acoustic reflexes signal transmission peripheral/central monaural low redundancy: low-pass filtered speech time-compressed speech auditory closure; auditory discrimination primary auditory cortex binaural interaction binaural fusion masking level difference LISN interaction between the ears brainstem

Test Type Processes Assessed Underlying Site binaural integration dichotic digits dichotic rhyme staggered spondees dichotic CVs competing words closure integration ordering LH, RH, CC binaural separation competing sentences neuromaturation separation temporal processing random gap detection gaps-in-noise pitch patterns test duration patterns test temporal resolution patterning RH, LH, CC speech-in-noise tests varied

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 29

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

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

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!

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

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”

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

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

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

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”

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

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

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”

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

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

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

Neuroscientific principles & test results Test results help professionals develop deficit-specific intervention strategies Effective intervention includes management remediation Neuroscientific principles & test results

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