1. Yes, you CANS! Assessing children’s central auditory processing skills
Jeanane M. Ferre, PhD, CCC-A
Oak Park, IL 60301
Fax:

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
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.

6. 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

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
Executive functions
Language & learning
Sensory processing

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 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

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 skills22

23. 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

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

27. 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

28. 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

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 29

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

47. 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