1. Clinical Experience in (C)APD (Screening, Diagnosis, Intervention)*
07/16/96
Teri James Bellis, Ph.D.
The University of South Dakota
Vermillion, SD, USA *

2. Screening for (C)APD

3. Principles of (C)APD Screening
Purpose of Screening: To determine need for comprehensive central auditory assessment
Global or pan-sensory disorders (i.e., MR, ADHD, autism) must ALWAYS be addressed prior to evaluation for (C)APD

4. Bellis Screening Method
Screening involves review of multidisciplinary assessment results:
Cognitive
Psychoeducational/academic
Speech/language
Medical/neurologic
Other (e.g., questionnaires, auditory tests, other)

5. Screening is designed to answer four questions:
Are the current evaluations sufficient in scope?
Is there a likelihood of (C)APD?
Can the individual participate in the testing?
Will a diagnosis of (C)APD add significantly to the management/ treatment plan?

6. Outcomes of Screening Referral for comprehensive assessment
Referral for other testing/follow-up
Interim Recommendations
Other

7. Screening tools should never be used for diagnostic purposes, even if the term “auditory processing” is included in their titles!!!

8. Diagnosis of
(C)APD

9. Principles of (C)APD Diagnosis
Purpose of Diagnostic Testing: To identify presence and delineate characteristics/nature of central auditory deficit
Requires audiologist-administered diagnostic tests of central auditory function

10. Provides information regarding integrity of left-hemisphere, right-hemisphere, interhemispheric, and brainstem auditory structures

11. May include psychophysical and/or neuro(electro)physiologic tests of central auditory integrity
Leads directly to development of deficit-specific treatment and management plans

12. Diagnostic Tests for (C)APD
Must employ a test battery approach that assesses various levels/loci within the CNS, as well as different perceptual processes
The tests chosen should meet accepted psychophysical and scientific standards , should control for higher-order confounds, and should be appropriate to the individual being tested!

13. Most importantly:
The tests used should have been demonstrated to be sensitive, reliable, and efficient for identification of CANS dysfunction

14. Categories of Diagnostic Tests
Dichotic Speech Tests
Monaural Low-Redundancy Speech Tests
Temporal Patterning/ Processing Tests
Auditory Discrimination Tests

15. Binaural Interaction Tests
Electroacoustic Tests
Electrophysiologic Tests

16. Electrophysiologic and related measures may play an important role in the objective demonstration of neural deficits in the auditory system in many cases, as well as in the documentation of treatment efficacy

17. Test Battery Interpretation
Norm-referenced criteria
Using the patient as his/her own control (pattern analysis using neurophysiologic tenets):

18. Intra-test analysis (including ear differences)
Inter-test analysis
Cross-discipline analysis

19. Differential Diagnosis
Requires examination of multidisciplinary findings and functional sequelae
Diagnosis of (C)APD enabled ONLY when clear pattern of auditory deficits exists along with auditory-specific complaints OR
Pronounced deficit exists in one process accompanied by functional difficulties in that process

20. Lack of a pattern (e.g., poor performance on all measures) argues for more global or motivational deficit, not (C)APD
Multimodal (multidisciplinary) input is critical to fully explore functional deficits and confirm differential diagnosis

21. (C)APD should NEVER be diagnosed in a vacuum!!!

22. The key to interpretation and differential diagnosis:
Analysis of findings for neurophysiologically tenable PATTERNS consistent with CANS dysfunction

23. Relating Auditory Deficits to Functional Difficulties and Sequelae

24. Integrating Multidisciplinary Assessment Results
Examination of multidisciplinary findings for neurophysiologically tenable patterns
Subprofiling Methods

25. Utility of Subprofiling Methods
Useful guides to analysis of central auditory and multidisciplinary test findings for neurophysiologically tenable patterns
Not designed to be a catch-all, cookie-cutter approach to APD diagnosis and categorization

26. ONE Subprofiling Method: The Bellis/Ferre Model
Involves integration and pattern analysis of auditory and multidisciplinary findings
Three primary profiles:

27. Auditory Decoding Deficit
Auditory deficits indicate left-hemisphere (primary auditory cortex) pattern:
Bilateral or right-ear deficit on dichotic speech tasks
Poor performance on auditory closure tasks
Poor phoneme discrimination
Reduced LH electrophysiologic responses (MLR, cortical)
Elevated gap detection thresholds

28. Associated difficulties in left-hemisphere functions:
Phonological decoding (word attack) difficulties
Speech-in-noise problems
Better performance with visual/multimodality cues
Other phonological and language-based concerns
Better Performance than Verbal IQ

29. Prosodic Deficit Auditory deficits indicate right-hemisphere pattern:
Left-ear deficit on dichotic speech tasks
Poor temporal patterning performance (BOTH humming and labeling)
Reduced RH electrophysiologic responses (MLR, cortical)
Elevated frequency, intensity, duration difference limens

30. Associated difficulties in right-hemisphere functions:
Sight word reading and other Gestalt patterning difficulties
Problems with prosody perception
Poor pragmatic skills
Sequencing difficulties
Other RH difficulties (e.g., visual-spatial skills, math calculation, better verbal than performance IQ)

31. Integration Deficit
Auditory deficits indicate inefficient interhemispheric transfer:
Left-ear deficit on dichotic speech tasks (opposite for nonspeech)
Poor temporal patterning performance (labeling ONLY)
Traditional electrophysiologic responses (MLR, cortical) often normal; may see reduced hemispheric asymmetry to speech stimuli

32. Associated interhemispheric difficulties:
Poorer performance with multimodality or visual cues
Sound-symbol association difficulties
Speech-in-noise and localization difficulties
May have subtle difficulties in other interhemispheric tasks (bimanual/bipedal activites, etc.) but not “true” sensory integration dysfunction

33. Intervention
for
(C)APD

34. Basic Principles
Intervention for (C)APD is a multidisciplinary endeavor
Treatment/intervention should be ecologically valid and based on the individual’s unique needs

35. The key to effective treatment is accurate diagnosis!

36. Intervention should employ “bottom-up” (e. g
Intervention should employ “bottom-up” (e.g., auditory training, signal enhancement) and “top-down” (e.g., compensatory strategies, instructional modifications) approaches
Should include three components:

37. Environmental Modifications (bottom-up and top-down)
To enhance access to and acoustic clarity of auditory information
To increase opportunity for effective listening/learning

38. 2. Compensatory Strategies (top-down)
To strengthen higher-order top-down processing skills (metacognition, metamemory, metalinguistic)
To overcome secondary/associated motivational and related deficits

39. 3. Direct Remediation Techniques (bottom-up)
To improve auditory performance by altering the way the brain processes sound
Involves targeted activities that maximize neuroplasticity

40. Maximizing Neuroplasticity
Auditory training activities must : Be
Frequent
Intense
Challenging
Involve active participation
Include salient reinforcement

41. Computer-Assisted Therapies
Allow for multisensory stimulation, sustained interest, reinforcement, and intense/frequent stimulation
BUT
Each program MUST BE analyzed for appropriateness of task demands targeted and adherence to principles of maximizing neuroplasticity

42. There is NO one-size-fits-all intervention/ treatment approach or program that is appropriate for ALL individuals with (C)APD!

43. Communicating Results and Recommendations

44. General Principles
View patient counseling sessions and reports (both screening and diagnostic) as educational opportunities
Focus on what (C)APD is AND what it is not
Make sure communications are individualized and appropriate to the patient in question

45. Elements of a “good” (C)APD Report
Clearly explains what was done and what was found
Delineates how findings relate (or do not relate) to reported symptoms and complaints
Provides comprehensive, individualized recommendations for intervention and/or follow-up

46. Assists reader in understanding why recommendations were made
Can be understood by anyone from any discipline

47. Questions???