1. A rose by any other name… understanding auditory processing disorders
Jeanane M. Ferre, PhD
Audiologist, CCC-A
Oak Park, IL

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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 16

17. 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

18. 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

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

20. 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

21. 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

22. 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

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

25. 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”

26. 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

27. 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”

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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

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

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

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

38. 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)

39. 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”

40. 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

41. 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

42. 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

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

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

45. Speed of processing 3-5 yr.-olds process speech at 120-124wpm
5-7 yr.-olds can handle wpm
5-6th graders can process speech at 135 wpm
Middle school-high school – wpm
Average wpm of most adults is wpm and may reach 190 wpm
Check your rate – use Clear Speech

46. 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

47. 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

48. 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

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

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

51. 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?

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

53. 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

54. 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

55. 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

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

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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

66. 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

67. 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

68. 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

69. 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

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

71. Resources for therapy
– Fast ForWord program discrimination, temporal/phonologic processing
– dichotic listening program
– phonologic awareness, discrimination, memory for auditory info, usage
– using visual cues
– multisensory training, enhances sequencing, speed, attention
- enhances spatial listening and auditory vigilance

72. Resources for therapy Apps from www.superduperinc.com
Central Auditory Processing Disorder. ASHA Practice Portal

73. 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

74. 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

75. 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

76. 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

77. 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

78. 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

79. 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

80. 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