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

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

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

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

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

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

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 8

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

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 10

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

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

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

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

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

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 16

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 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

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

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

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

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

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

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”

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

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”

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

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

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

Processing Level Anatomic location skills Assessment examples Acoustic Outer, middle, inner ear; 8th nerve; brainstem, Heschl’s gyrus, RH, CC Auditory Acuity; Neurologic transfer; Discrim/Integration of acoustic cues Pure tone hearing, word recognition, patterning, binaural recognition, degraded speech Phonologic Heschl’s gyrus, temporal lobe Discrim/recognition of phonemic aspects of signal Word segmentation Rhyming Phoneme blending Auditory closure Linguistic Temporal Lobe – Wernicke’s area and angular gyrus Discrim/recognition of linguistic aspects of signal; attach meaning using code Identifying objects Identifying concepts Semantics (synonym, antonym, homonym) Executive functions Prefrontal/Frontal lobes; Motor Strip Planning and executing response Pragmatic language Problem solving/ reasoning Prosodic Interpretation

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

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

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

Intervention for processing Disorders: the m3 model message medium me Communication 35

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

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

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)

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”

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

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

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

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

Focus on the message Clear Speech Visual cues Clear Language Educational accommodations

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

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

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

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

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

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

Direct Remediation for PDs Remediation based on research in neural plasticity. Plasticity is brain’s ability to organize/reorganize in response to internal/external changes. When choosing treatment program, consider Reported efficacy for specific populations – Does it work? Program’s neuroscientific foundations – Should it work? Appropriateness for deficit identified – Does it fit?

CAP Skills revisited Binaural processing Binaural interaction Binaural integration/separation Auditory discrimination Frequency analysis timing analysis Temporal processing Resolution (discrimination) Patterning (ordering)

Auditory Discrimination deficit Characterized by poor analysis of fine acoustic differences in speech spectra Management focuses on improving access to, clarity, and use of auditory signal Treatment focuses on improving perceptual skills

Auditory discrimination deficit Treatment needs Discrimination & closure Phonemic awareness Recognition in noise Use of visual cues Listening comprehension Impacts Phonological awareness Spelling Listening stamina Direction following Comprehension Language skills

Discrimination (auditory decoding) deficit Improving access Preferential seating near/facing speaker Need noise abatement Use Clear Speech Repeat information ALD trial Accommodations ASL - 2nd language Preteaching Adjust class schedule to minimize auditory overload Explicit multisensory environment Verbal info supplemented with written/graphic cues

Binaural processing – brainstem level Impacts Listening in noise Processing speed Localization Treatment needs Localization Training temporal/spatial recognition Recognition of speech in noise

Binaural processing – brainstem level Improving access Preferential seating Noise abatement Use Clear Speech Repeat information Accommodations Minimize auditory overload Explicit multisensory environment Verbal info supplemented with visuals

Binaural processing – cortical level Impacts Verbal comprehension Spelling Processing speed Direction following Task completion Note-taking Working memory Treatment needs Dichotic listening Interhemispheric communication Synthesis of multiple auditory targets Manipulation of auditory & non-auditory signals

Binaural processing deficit – interhemispheric integration type Characterized by poor synthesis and manipulation of multiple signals Management focuses on improving the quantity and structure of incoming signals Treatment focuses on improving interhemispheric communication

Integration deficit Accommodations Improving Access Extended time Write in test book not computer score sheet Audiobooks, study guides, Cliff’s Notes Music while studying “Wait/thinking” time Different room for tests Computer technology Movement breaks Explicit multisensory learning needs Provide structure Improving Access Look OR listen Look THEN listen Repeat with cue or demonstration DON’T rephrase Limit amount of information given Present information sequentially Use notetaker or recorder

Binaural processing deficit – intrahemispheric type Characterized by difficulty applying linguistic rules to incoming information (auditory-language Association deficit) Auditory tests reflect impact of language processing disorder Management focuses on improved linguistic quality of target and use of linguistic rules Treatment focuses on applying rules of language

Associative deficit Accommodations Improving Access Give parameters Use Clear Language Speak the “same” language Formatting Say what you mean- mean what you say Accommodations Give parameters Waive language req. Use non language-biased IQ instruments Audiobooks, study guides, Cliff’s Notes RULE-based learning

Intrahemispheric integration – associative deficit Impacts Verbal comprehension Spelling Processing speed Direction following Task completion Note-taking Working memory Treatment needs Manipulation of auditory & non-auditory signals Applying phonetic and linguistic rules Visualizing information Listening comprehension

Temporal processing deficit (prosodic) Characterized by difficulty analyzing, synthesizing, and attaching meaning to rapidly changing acoustic patterns Management focuses on improving quality and structure of incoming signal Treatment focuses on using temporal cues, e.g., patterning, temporal resolution

Temporal processing Impacts Treatment needs Comprehension – reading/listening Working memory Processing speed Social/pragmatic language Direction-following Reading fluency Treatment needs Pattern recognition Use of prosody Listening comprehension Use of visual cues Working memory Sequencing

Prosodic deficit Improving access Accommodations Repeat with emphasis on key words Clear Speech Preferential seating Consider ALD Noise abatement Seating Accommodations Explicit multisensory environment “Animated” teacher Previewing Notetaker, recorder Extended time Clear Language Provide structure Give parameters

Ordering-sequencing issues Characterized by difficulty organizing, sequencing, and executing a response (output-organization deficit) Management focuses on adjusting quantity and structure and teaching organization rules Treatment focuses on executing response/ expressive skills

Output-organization deficit Accommodations Preteach rules Outlines/checklists Closed-set tests Oral responses on written tests Keyboarding/word processing Extended time Answers written in test booklet-not score sheet Improving Access Consider ALD if difficulty in noise Minimize distractions Notetaker, recorder Limit amount of information given Break tasks down

Level System Task Management Treatment examples Acoustic (AUD) Receiving the signal/intact transmission – I “hear it” Focus on quality of ACOUSTIC signal and environment Discrimination training Patterning training Lipreading Active listening Dichotic listening Phonologic (AUD & SLP) Analyzing signal – discrimination & recognition – I “know” it Focus on quantity and structure ACOUSTIC Sound Blending Analysis-synthesis Closure Sound-symbol association Linguistic (SLP) Attaching meaning - I “get” it Focus on comprehension / communication LANGUAGE Concept Development Word/Object Association Answering wh questions Compare/Contrast Tasks Executive Functions Managing and organizing a response – I can “use” it Focus on ease of expression, speed of processing Role-play pragmatics Work on impulse control Judgment and interpretation 69

Resources for therapy www.proedinc.com - Differential Processing Training Program – auditory, phonologic and linguistic goals www.acousticpioneer.com – dichotic listening and temporal patterning training www.neurotone.com – LACE: Listening & Communication enhancement – for adults www.clearworks4ears.com – activities for auditory processing & related skills www.brainHQ.com- enhances auditory, visual and thinking/reasoning skills

Resources for therapy www.scilearn.com – Fast ForWord program discrimination, temporal/phonologic processing www.capdots.com – dichotic listening program www.hearbuilder.com – phonologic awareness, discrimination, memory for auditory info, usage www.lipreading.org – using visual cues www.interactivemetronome.com – multisensory training, enhances sequencing, speed, attention www.capd.nal.gov.au/lisn-learn - enhances spatial listening and auditory vigilance

Resources for therapy Apps from www.superduperinc.com www.smartyears.com www.virtualspeech.com www.hamaguchiapps.com Central Auditory Processing Disorder. ASHA Practice Portal www.asha.org/Practice-Portal/Clinical-Topics/Central-Auditory-Processing-Disorder/

A word about treatment outcomes Studies of CAP tx efficacy note improved performance pre- and post TX in specific auditory skill (i.e., “if you drill it, it will come”) Some evidence of improved phonologic awareness Very few published reports of generalizability of improved auditory-specific processing to academic and/or learning skills Some reports of improved language-learning-cognition following use of multi-modal training programs Virtually all report improved “hearing”, listening ease and listening stamina

Why do outcome data look so discouraging? Some therapies not grounded in “good science” Poorly defined experimental groups with respect to diagnosed deficits/needs Logistics associated with matched group treatment efficacy studies- how “matched” Lack of consistent experimental methods AT rarely done in isolation - difficult to gauge effects of AT (many interaction effects) Few studies designed to examine generalizability to language-learning

Games that enhance processing and related skills Game Processing skills taxed Battleship listening, patterning, integration Boggle pattern recognition, integration Bopit, integration, vigilance Catch Phrase integration, vocabulary, output Clever Endeavour language strategies, listening Feely Bag interhemispheric communication Ending sound game auditory discrimination Mad Gab temporal patterning, language Marco Polo localization, binaural interaction

Musical Chairs vigilance Name that tune interhemispheric integration Game processing skills taxed Musical Chairs vigilance Name that tune interhemispheric integration Password vocabulary, linguistic skills Plexers metalinguistic strategies Rags to Riches metalinguistic skills (idioms) Read My Lips lipreading/speechreading Scattergories vocabulary, linguistic strategies Simon auditory-visual patterning Simon Says vigilance, active listening Taboo vocabulary, linguistic strategies Twister integration, critical listening UpWords integration, visual patterning Wheel of Fortune auditory closure

M33 -9 tips to enhance processing Attention all shoppers – gain listeners’ attention If I told you once… - children NEED repetition Show me! - use pictures, demos, examples Say what you mean and mean what you say I’m listening as fast as I can – children DO NOT process speech at the same rate as adults TMI – break lengthy info into smaller units Are we there yet? – give parameters Tag, you’re it – use “tag” words (first, then) Gimme a break – provide listening breaks

M33 – 9 self-help processing tips Twice is nice - ask for repetition Mind over mutter – use the clues, take a guess Wait for it… - wait for all instructions I’ll be watching you – look and listen Noise annoys – stay away from noisy spaces Oh dear, it’s not clear – ask for clarification/help Be the tortoise, not the hare – take your time ABC/123, going in order will set you free – start at beginning and go step by step Go with the flow – listen for key words and changes in tone of voice

Summary It really is a PROCESS Deficit in one or more skills subserved by CANS Adversely affects communication, learning, and psychosocial wellness; Can co-exist with other conditions Audiologic tests available to reliably assess skills with adjustment to protocol as needed Results help define nature and clarify impact of deficit to ensure deficit-specific intervention

Summary Effective intervention MUST be deficit-specific AND include remediation and management Bottom-up strategies focus on access to clear signal, top-down focus on functional communication- you MUST know deficit type TX for CAPDs typically includes both bottom-up training and top-down strategies Monitor skills at periodic intervals