1. Auditory Processing Disorders
Christine A. Stevens, M.A., CCC-SLP

2. “Do not make the mistake of trivializing hearing problems triggered by the environment as compared to those innately physical. The effects are the same. The inability to hear (clearly) causes ALL children, even those with the best intentions to pay attention, to disengage themselves from auditory learning.” ~The Institute for Enhanced Classroom Hearing (2008)

3. Definitions
Auditory Processing: A term used to describe what happens when your brain recognizes and interprets the sounds around you. (NIDCD, 2008) OR
“What we do with what we hear.” (Jack Katz, 1993)
Auditory Processing Disorder: Difficulty in the recognition, processing, and/or interpretation of the sounds around you.

4. How does this all work?
The act of hearing does not end with our detection of sound.
“Between the arrival of speech at the eardrum and our perception of it, a very large number of mechanical and neurobiological operations intercede.” (Musiek & Chermak, 1997).
The Information Processing Theory describes that the processing of auditory information is made up of both “bottom-up” and “top-down” factors.

6. Definition, continued
The American Speech-Language-Hearing Association Consensus Committee defines auditory processing as the auditory system mechanisms and processes responsible for the following behavioral phenomena:
Sound localization and lateralization
Auditory discrimination
Auditory pattern recognition
Temporal aspects of audition, including temporal resolution, temporal masking, temporal integration, temporal ordering
Auditory performance decrements with competing acoustic signals
Auditory performance decrements with degrading acoustic signals
(ASHA,1996 in Stecker, 1998)
Auditory Processing Disorder is therefore defined as a deficiency in one or more of these areas.

7. Auditory Processing Disorders: The Facts
Most individuals with A.P.D. have normal peripheral hearing.
Approximately 5% of school-age children have difficulty with auditory processing.
The ratio of males to females with processing difficulty is 2:1.
Interest in central auditory functioning as it related to communicative disorders first began in the 1950s and was referred to as “auditory imperception”.
I wonder how we treated those with processing difficulty up until that point. . .
Most audiologists will not diagnose a child under the age of 7 with an auditory processing disorder.
A normal, pure-tone hearing screening will not yield information on APD!
The first study on pediatric APD came out in 1977 (KATZ!), therefore this is a relatively new area.

8. What does a person with A.P.D. look like?

9. Potential Early Indicators of Processing Issues
Parents of children with APD have reported that, as infants, the child was not particulary sensitive or responsive to noises or speech sounds, and didn’t attend very well to faces when the speaker was talking. On the other side of the coin, parents involved in this particular study whose children seemed almost hypersensitive to noise as infants grow to have difficulty with speech in noise tasks, which can really interfere with interactions with peers, and performance if he or she is a member of a large class

10. The Buffalo Model Katz, Stecker, & Masters (1993)
Decoding: Difficulty interpreting units of information.
Tolerance-Fading Memory (TFM): Difficulty storing items in short-term memory; part of the message “fades away”.
Integration: Severe decoding and TFM difficulties coexist.
Organization: Difficulty organizing and sequencing information.
The following information/definitions adapted by Terri Cinotti, M.A., CCC-SLP, University at Buffalo, 1997.

11. Decoding: Observable Characteristics
General:
Slow to respond
Misinterprets words, directions, or questions
Difficulty with speech-in-noise
Phonics problems (translates to poor reading and spelling)
Poor discrimination
Poor sound blending
Auditory fatigue
Speech-Language:
Trouble with word-finding
Articulation errors (/r/ and /l/ most commonly)
Poor receptive language skills
Difficulty with grammatical markers
*Statistically significant history of ear infections

12. Decoding: Observable Characteristics Continued
Academic:
Reading and writing difficulties
Poor comprehension of phonics
Difficulty following directions
Difficulty with oral discussions
Problems with group listening
Pragmatic Characteristics:
Poor eye contact
Difficulty participating in oral discussions
Often allows others to “talk over” them
Difficulty with topic maintenance

13. TFM: Observable Characteristics
General:
Fast to respond (Auditory recall fades before the child’s ability to process the information. . .almost as though they don’t want to forget)
Easily overstimulated
Impulsive
Distracted by noises
Trouble with speech-in-noise tasks
Poor short-term memory
Poor handwriting (due in part to poor motor planning)
Speech-Language:
Poor auditory recall
Trouble with expressive language formulation
Trouble with inferences
Syntax issues (The child doesn’t get the full, appropriate
model message all of the time)
Articulation is normal in isolation; inconsistent errors in connected speech (cluttering is often observed)

14. TFM: Observable Characteristics Continued
Academic:
Reading comprehension difficulties
Difficulty following directions
Distractibility and difficulty attending
Impulsivity
Pragmatic Characteristics:
Poor tolerance to noise
“Erratic”, attention-seeking behaviors during
“listening” situations

15. Some signs of hyperactivity-impulsivity are:
From National Institute of Mental Health ( 2008)
Some signs of hyperactivity-impulsivity are:
-Feeling restless, often fidgeting with hands or feet, or squirming while seated
-Running, climbing, or leaving a seat in situations where sitting or quiet behavior is expected
-Blurting out answers before hearing the whole question
-Having difficulty waiting in line or taking turns.

16. Differential Diagnosis:
Distinguishing between two or more conditions presenting with similar symptoms or attributes.
American Speech-Language-Hearing Association. (2005). (Central) Auditory Processing Disorders [Technical Report]. Available from

17. Auditory Processing and AD/HD
The American Academy of Pediatrics “recommend a comprehensive assessment that relies on direct information from parents (or caregivers) and the classroom teacher (or other school professional) using developmental history, rating scales, observations, and available test results.” (Schwab Learning, 2008)

18. Auditory Processing and AD/HD
AD/HD as a disorder of OUTPUT
-Essentially the inability to control behaviors.
Auditory processing disorders are then disorders of INPUT
-The processing difficulty gets in the way of “selective and divided auditory attention.” (Chermack, Hall, and Musiak, in Young, s.d.; Musiek and Chermack, 1997)

19. Integration: Observable Characteristics
General:
Extremely delayed responses
Characteristics of Decoding and TFM-type classifications
Speech-Language:
Severe receptive and expressive language difficulties
Possible articulation/phonological delay
Academic:
Poor phonics
Severe reading and writing difficulties
Difficulty with sound/symbol integration
Pragmatic Characteristics:
Characteristics of both Decoding and TFM-type classifications

20. Organization: Observable Characteristics
General:
Difficulty seen mainly in “output”
General disorganization (carries over into every area of the individual’s life)
Disorganized language, sentences, discourse, writing, workspace
Speech-Language:
Poor discourse skills
Poor sequencing skills
Difficulty with problem solving Poor syntax
Academic:
Poor writing skills
Sequencing problems
Disorganized work habits and work space
Pragmatic Characteristics:
Difficulty in taking his or her communication partners’ perspective

21. Assessment of A.P.D
Some of the cognitive and linguistic skills a child needs to complete testing for A.P.D. aren’t fully developed until 7 to 9 years of age.
. . . but we CAN identify students who may be at risk for processing difficulties based on established patterns of characteristics and change the way we interact with those children!
Identification/assessment takes on a TEAM approach:
-Classroom teacher
-Parents, grandparents, friends
-Therapists in the classroom
-Psychologist
-Speech-Language Pathologist
-Audiologist

22. Assessment of A.P.D., continued
“The Buffalo Model includes a comprehensive audiological and speech-language assessment, as well as a thorough case history, an educational questionnaire completed by the teacher [often the S.I.F.T.E.R.], and the Children’s Auditory Processing Performance Scale (CHAPPS) (Smoski et al., 1992) completed by both the parent and teacher.”
(Katz, Masters, and Stecker, 1993)
The audiological assessment will always include a complete peripheral hearing exam to rule out any underlying hearing loss.

23. Assessment of A.P.D., continued
The C.A.P. battery of tests include:
-Scattered Spondaic Word Test
-Phonemic Synthesis Test
-Speech-In-Noise Test
-Masking Level Difference Test
-Auditory Continuous Performance Test (as needed)
-Frequency Pattern Test (as needed)
-Duration Pattern Test (as needed)
-Compressed Speech Tests (as needed)
-Dichotic Digits Test (as needed)
The speech-language evaluation will include:
-Language sample
-Word-finding test
-Phonologic analysis
-Other expressive and receptive language tests (as needed)

24. The
AUDIOLOGIST can provide the actual diagnosis of A.P.D. after a comprehensive audiological assessment.

25. Strategies for Intervention
Management should be made up of three parts:
1. Direct therapeutic intervention
2. Environmental modifications
3. Development of compensatory strategies
Stimulation should be FREQUENT, INTENSE, and CHALLENGING (Bellis)

26. Direct Therapeutic Intervention
Auditory therapies
-Noise desensitization tasks (speech-in-noise)
-Computer programs to address A.P.
Speech-language therapy

28. Environmental Modifications
Improve signal-to-noise ratio:
Adding carpets to classrooms to improve the acoustic environment.
Place tennis balls on the feet of classroom chairs to decrease noise.
Computers turned off when not in use
Preferential seating (close to teacher or near a student “buddy” who can provide cues)
Indirect lighting (fluorescent lighting may buzz)
GOAL IS TO ENHANCE LISTENING

29. FM Systems Boost the sounds of the speaker’s voice above the classroom noise
Completely in Canal
Campus SX
FM systems boost the volume of the speaker’s voice above classroom noise. Research shows that wearers perform approximately 40% better on tasks when speech is amplified in both ears. The optimal level of amplification would be 20 decibles above the classroom noise.
hearing aids amplify all of the noise around the wearer. What we really want is one speaker’s voice to be highlighted against a background of noise
Individuals with Disabilities Education Act (IDEA) requires that children with disabilities be provided with a free and appropriate public education that includes special education and related services.
Behind the Ear
Edu Link
(Designed specifically for those with A.P.D)
Zoom Link Transmitter

31. Compensatory Strategies
Teaching children to be “active” rather than “passive” listeners.
Teaching “chunking” of information
Developing “brain tricks”
Teaching older children and adults note-taking strategies
Helping the individual to be a self-advocate
Develop linguistic and metacognitive skills
GOAL IS TO STRENGTHEN RELATED, HIGHER LEVEL SKILLS SUCH AS MEMORY
-Tricks
Count out the number of directions on your fingers
2. Turn steps into a song
3. Pick out however many poker chips
4. Younger kids, teach them to watch others
Self Advocate
Teach them to RAISE THEIR HAND!!! How would they know to do that?”
Linguistic- Give them the vicabulary for first, next, then, last, finally

32. Food for Thought
“While some APD children develop compensatory skills enabling them to thrive in school, it is still not easy for them. Compensatory skills take up working memory, and working memory then suffers.”
Auditory Processing Disorder: The Hidden Disability
By Robbie Woliver with Mo Ibrahim.

33. What Can I Do?

34. When Speaking to a Child with A.P.D.
Establish eye-to-eye position with the child
Gain the child’s attention when giving directions
Speak in a slow, clear manner, but do not over-exaggerate speech
Give simple, clear directions and be mindful of the number of steps you are giving

35. When Speaking to a Child with A.P.D.
Give directions in a logical, time-ordered sequence. Include words that make the sequence clear, such as “first”, “next”, and “then”
Use visual aids (or write out instructions for older students) to supplement spoken information
Emphasize key words when presenting new information. Pre-instruction with emphasis on the main ideas to be presented may also be effective.

36. Speaking to a Child with A.P.D., continued
Use gestures that will add to the information you present
Vary speech volume to increase the student’s attention
Encourage students to ask questions to clarify information (may need to teach them the language of asking questions)
Make transition times clear with both auditory and visual cues
Review previously learned material
Recognize signs of fatigue and give breaks as necessary
Avoid showing frustration when the child misunderstands the message

37. Speaking to a Child with A.P.D., continued
Avoid asking the child to listen and complete another task at the same time (writing, putting on shoes and coat, etc.)
Paraphrase instructions and information into shorter, simpler, and more direct sentences rather than just repeating the initial instruction
Check for comprehension by asking the child questions or asking for a brief summary after key ideas have been presented to be sure that the child understands.

38. Auditory Processing and Autism
Bauman & Kemper’s 1994 study found that the hippocampus is
“neurologically immature” in people with Autism.
Since auditory information is processed in the hippocampus, information may not be transmitted to long-term memory in those with Autism in an effective way.

39. Auditory Processing and Autism
Auditory processing problems may be linked to characteristics of those with autism.
Consider implementation of programs rich in visual supports.
-Use of picture symbols
-Object representations
Auditory processing problems may also be linked to several characteristics of autism. Autism is sometimes described as a social-communication problem. Processing auditory information presented by one’s communication partner is a hugely important part of social-communication. Other characteristics that may be associated with auditory processing problems include: anxiety or confusion in social situations, inattentiveness, and poor speech comprehension.

40. Take-Home Messages
“The key to effective treatment and management is accurate diagnosis!”~Teri Bellis
Management of processing disorders should be specific to the individual’s area of deficit.
My goal in presenting on this topic is to make all of you aware of APD and hopefully give you the tools to identify students who may have processing issues.

41. Questions?