(Central) Auditory Processing Disorders Flashcards
Central Auditory
Nervous System (CANS
Overall pathway
Cochlear Nuclei through the Cortex
Brainstem – Integration of two signals
(binaural or dichotic processing) at level of
SOC
Corpus Collosum – Integrates auditory
information between 2 cerebral
hemispheres
Cortical level – Discrimination and
processing of phonetic and speech sounds
Development of Central Auditory Nervous
System (CANS)
Peripheral auditory system developed at birth
Central auditory system continues to develop through young
adulthood
Development proceeds from Brainstem to Cortex
Myelination occurs during maturation of the central auditory
system.
Corpus Callosum
Bundle of nerve fibers that connects the 2 cerebral
hemispheres that have complementary functions
Comprised mostly of myelin
The interhemispheric connections develop during the
first year of life but are not fully mature until early
adulthood (15-20 years of age)
Right and Left Hemispheres
Left Hemisphere
Dominant for comprehension
and production of language.
-Phonological analysis and
discrimination
-Sequencing auditory input
- Linguistic labeling
Right Hemisphere
Dominant for perception of
nonverbal sounds and musical and
prosodic stimuli
-Rhythm and stress
-Acoustic contour
-Auditory patterning and
temporal ordering
Handedness –
Right Handed - 96% are left brain dominant for language
Left handed – 70% are left brain dominant for language
15 % right brain dominant and 15% mixed brain dominant
Right Ear Advantage and CC
Language dominant hemisphere is usually the left
Both ears are ultimately connected to the left hemisphere, with input
from RE reaching left hemisphere slightly earlier than LE input
Information presented to the left ear must cross to the right hemisphere and
then across the CC to be perceived and labeled in the left hemisphere
Information presented to the right ear is directly transmitted to Left
hemisphere
Right ear advantage – More stimuli are successfully recalled from the
right ear than from the left.
REA decreases with age due to maturation of CC and pathways of
auditory nervous system
REA is observed in children until age 11
Redundancy
External Redundancy
Internal Redundancy
External Redundancy
Extrinsic - built into the
signal
Enhances
comprehension of signal
Syntax, morphology,
semantics
Internal Redundancy
Intrinsic - built into auditory
system
Multiple representations and
complex network
Cognitive capacity
What Is Auditory Processing?
Auditory = hearing
Processing = how the brain uses information
Katz: AP is not what we hear, but what we do with what we
hear
Musiek: AP is how well the ear talks to the brain and how well
the brain understands what the ear tells it
What Is Auditory Processing?
How different professionals see it
“The term “auditory processing” is used by speech language pathologists (SLPs),
psychologists and audiologist.
To a speech pathologist, the term is associated with linguistic processing.
To a psychologist, it refers to the auditory form of cognitive processing.
To an audiologist, it is deficit in the processing of auditory
input, specific to the auditory modality that occurs in the
auditory system prior to cognitive and linguistic operations.”
Auditory Processing Continuum
Different areas in the brain
Peripheral Auditory System – Perceive signal
CANS – Neurologic transmission of signal through brainstem to
upper cortex
Heschl’s Gyrus – Phonemic Processing to decode sounds and words
Temporal Lobe / Wernickes area - Language processing to decode
message. Attach meaning
Prefrontal/frontal lobe and motor strip – Executive function skills to
plan and execute a response
Auditory Processing Continuum
How SLPs and aud see the phonemic and language processing
Auditory Processing – Audiologist
Assesses audiological skill set associated with APD
Phonemic Processing – Audiologist and SLP
Audiologist focuses accurate reception of the phonemic signal (on non-
meaningful discrimination such as timing, patterns or competing signals
SLP focuses on accurate acquisition and discrimination of the phonetic code
to develop skills for reading, spelling and written language (phonemic
discrimination (b or p, rhyming)
Language Processing – SLP
Treats the functional impact of auditory processing disorders on language
and learning.
Auditory Processing
Disorder
Brain (not hearing) Disorder
Bellis: APD is when the brain can’t
hear
ASHA – (C)APD
Deficit in the processing of information that is specific to the
auditory modality
The deficit may be exacerbated in unfavorable acoustic
environments and that may be associated with difficulties in listening, speech understanding, language development, and learning
C)APD is a deficit in neural processing of auditory stimuli that
is NOT due to higher order language, cognitive, or related
factors.
Although (C)APD may co-exist with other disorders (e.g. ADHD,
LD, reading, language impairment, ASD), it is not the result of
these other disorders.
What is APD - ASHA
APD refers to difficulties in the processing of auditory information in the
central nervous system as demonstrated by poor performance in one or
more of the following skills:
Sound localization and lateralization
Sound discrimination
Temporal processing
- Auditory pattern recognition
- Temporal resolution
Auditory Performance Decrements with Competing Acoustic Signals and/or
with degraded acoustic signals
Characteristics of Children with APD
REPORTED DIFFICULTIES:
Following or understanding speech
In noisy situations
In poor acoustic situations
When the signal is fast or degraded
In the absence of multisensory supports
Localizing the source of a signal
Comprehending messages that rely on
tone of voice such as sarcasm or humor
Singing or appreciating music (e.g. nursery
rhymes)
Learning new or complex languages
RESULTING IN:
Delayed, inconsistent or inappropriate
responses in oral communication situations
Requests for repetitions (saying “huh” or “what”
often
Trouble following comiplex auditory directions
Inattention or distractibility in listening situations
Poor performance or auditory-dependent
multidisciplinary tests/subtests (e.g. receptive
language phonology)
Associated academic difficulties in reading,
spelling, and / or learning
Skills
Affected
Communication
May not speak clearly
May drop the ends of words
May not emphasize syllables
May confuse similar sounds (long after same-age peers)
Academic
May develop trouble reading, spelling, and/or writing
Phonetic awareness is difficult
Struggle with understanding instructions given verbally
May miss a great deal of information from class lectures
Easily distracted by background noises
Social Skills
May struggle telling stories and/or jokes
May have difficulty following conversations with peers
May take longer to respond to peer conversations
Risk Factors for (C)AP Deficits
Chronic Otitis Media
Genetics
Concussion / head injuries
Lyme disease
Lead poisoning
Neurological issues / seizures
Premature and / or traumatic birth history
SCREENING FOR
APD
Systematic observation of listening behavior and / or
performance of tests of auditory function to identify
those individuals who are at risk for APD
s This Child At Risk For APD?
8 y/o child on your caseload
demonstrates following
behaviors:
Difficulty following oral
directions
Difficulty hearing and
listening in BGN
Requires frequent repetition
of information
Does this child have:
Sensorineural HL?
Fluctuating conductive HL
related to OME?
Undiagnosed language
deficits?
Undiagnosed learning
disability?
Undiagnosed cognitive
deficits?
Disorder of attention?
Lack of motivation?
APD SLP Screening Protocols
- Questionnaires or checklists
-Children’s Auditory Processing Performance Scale (CHAPPS) by Smoski, 1998
-Screening Instrument for Targeting Educational Risk by Anderson 1989
(S.I.F.T.E.R)
-Fisher’s Auditory Problem Checklist (Fisher 1985) for Kdg to Grade 6 - Speech and Language Evaluation
- SCAN-3 for Children APD Screening Test
-Gap Detection
-Dichotic testing
- Auditory figure ground
- Screening Questionnaires
- Children’s Auditory Processing Performance Scale
(CHAPS) - Screening Instrument for Targeting Educational Risk
(S.I.F.T.E.R) - Fisher’s Auditory Problems Checklist
Children’s Auditory Processing Performance
Scale (CHAPS)
Assesses parent’s and/or a teacher’s judgment of a child’s
listening ability as compared to his or her peers.
Rated on a scale from -5 (cannot function at all) to a +1 (less
difficulty), the following listening conditions are assessed:
* Noise * Quiet * Ideal * Multiple Inputs
* Auditory Memory/ Sequencing * Auditory Attention Span
Screening Instrument for Targeting Educational Risk
(S.I.F.T.E.R
- The student’s classroom teacher completes the S.I.F.T.E.R, a rating scale
designed to “sift out” students who are educationally at risk, possibly as a
result of hearing or other auditory problems. - The S.I.F.T.E.R. compares the student to his or her classmates.
- Appropriate for Grades 1 -5
- Consists of 15 questions, 3 in each of 5 areas
Academics, Attention, Communication, Class participation, School Behavior
Fisher’s Auditory Problems Checklist
25 item checklist of auditory behaviors / characteristics associated with
13 categories of auditory processing skills
Can be completed by any referral source (parent, teacher, SLP)
Each item has value of 4%.
Observer places a checkmark next to each item that is consistent with
exhibited behavior of the child.
Items not selected are multiplied by 4 to determine total percentage.
Cut –off score of 72% to ID children at risk for (C)APD
- SLP Evaluation
Assessment of receptive and expressive language
o Comparing a student’s performance on tests that tap auditory perceptual
abilities and those that tap language abilities can assist in determining if a
referral for CAP testing is appropriate.
o Age-appropriate performance on speech and language tests and poor
performance on auditory perceptual tests suggests APD referral.
o Age-appropriate performance on auditory perceptual tasks and difficulty on
linguistic tasks may suggest need for comprehensive language assessment
LP EVALUATION
Celf – 4: Children with APD had the most difficulty with:
Following directions
Recalling sentences
Formulation of sentence
Forward number repetition (representing a memory task
- Screening Test for APD - SCAN 3: C/A
Ages and the type of testing
SCAN-3 for Children Ages 5-12
SCAN-3 for Adolescents & Adults Ages 13-50
Screens three Auditory Processing Skills:
1. Temporal Processing
2. Listening in Noise (Monaural Low Redundancy Test)
3. Dichotic Listening
Multidisciplinary Screening Process
Educational Psychologist - Rule Out Cognitive Difficulties
o Rule out attention, memory, and IQ-related disorders
o Assessment by an educational psychologist
o Verbal IQ is typically worse than performance IQ on WISC-IV
Verbal IQ – language expression, comprehension, listening and ability to
apply these skills to solving problems (Child responses
to oral questions)
Performance – non-verbal problem solving, visual-motor proficiency
(Puzzles, imitating designs, and analysis of pictures
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APD Position Statement - ASHA
It is the position of the American Speech-Language-Hearing Association
(ASHA) that the quality and quantity of scientific evidence is sufficient to
support the existence of (central)auditory processing disorder [(C)APD] as a
diagnostic entity, to guide diagnosis and assessment of the disorder, and to
inform the development of more customized, deficit-focused treatment and
management plans.
(C)APD is an auditory deficit; therefore, it continues to be the
position of ASHA that the audiologist is the professional who
diagnoses (C)APD.
CAPD is listed as
CAPD is listed in the ICD-10 under ear diseases (code H93.25) for both acquired and
congenital CAPD, which confirms the physiological nature of this disorder and supports the
medical necessity for care.
US Ninth District Circuit Court precedent-setting ruling13 that children with CAPD are
entitled to receive services in schools under the category of “other health impaired” (OHI).
Also reiterated that audiologists are the professionals qualified to diagnose CAPD, the
legitimacy of CAPD diagnosis for children is extremely well -supported and established for a
population who has long been underserved in our schools, as well as for adults seeking help
for CAPD
Criteria for Assessing APD
Minimum of 7 years of age
Near-normal to normal IQ
Adequate Speech and Language Skills
Sufficient attention abilities to perform assessment task
Normal or near normal hearing
Behavioral APD Assessment
Case History
Audiological Assessment
Auditory Processing Assessment
Case History
Auditory and/or communication difficulties
Family history of HL and/or (C)APD
Medical history
Speech-language history
Educational and/or work history
Existence of comorbid conditions
Social development
Linguistic background
Auditory Processing Assessment
What does it do
Evaluates the ability to respond under
different conditions of auditory signal
distortion and competition
An intact auditory system can tolerate
mild distortions of speech and still
understand it
An individual with APD will encounter
difficulty when the auditory system is
stressed by signal distortion and
competing messages (Keith, 1995)
Auditory Processing Assessment
Categories of the different tests
Dichotic Listening (Binaural Integration, Binaural Separation
(BIBS))
o Temporal processing
o Monaural Low Redundancy Speech
o Test of Binaural Interactio
Auditory Processing Assessment
The tests under each category
o Dichotic Listening (Binaural Integration, Binaural Separation
(BIBS))
* Interaction of right & L hemispheres and maturation of auditory system
o Temporal processing
* Pattern perception
* Gap detection
o Monaural Low Redundancy Speech
* Auditory Closure
* Auditory figure ground
* Filtered Words
o Test of Binaural Interaction
* Ability of BS to synthesize partial auditory information presented to each
ear into a complete message
Auditory Processing Assessment
Categories
o Dichotic Listening (Binaural Integration, Binaural Separation
(BIBS))
o Interaction of right & L hemispheres and maturation
of auditory system
o Temporal processing
o Monaural Low Redundancy Speech
o Test of Binaural Interaction
Dichotic Listening
Speech is processed more efficiently by RE
which is directly connected to left hemisphere
Speech presented to LE reaches right
hemisphere and crosses to left hemisphere
via corpus callosum
Right Ear Advantage (REA) observed in children
and I decreases with age
Compare results to age matched norms
Dichotic Listening Test
o Neuro-maturation and interhemispheric transfer of
information system
o Different sounds are presented to the 2 ears
o Binaural integration – Repeat everything
o Binaural separation - Repeat only from one ear.
Tests of Binaural Integration
2 ways to do it
o Dichotic Digits Test
- Two digits presented to each ear
- Repeat all 4
- Binaural integration
o Staggered Spondaic Work Test (SSW)
- Dichotic presentation of 2 spondees
- Repeat both words
- Binaural Integration
Tests of Binaural Separation
SCAN: 3
* Competing Sentences, Directed Ear
* 2 different sentences are presented to each ear.
* Repeat sentence in the directed ear (right then left)
* Binaural Separation
Dichotic Listening Deficits
*Dysfunction of R hemisphere or CC would impact
message coming from left ear only. Poor
performance suggests auditory immaturity or
dysfunction.
*Atypical large right ear advantage may indicate
delayed development of the auditory nervous system.
*Atypical left ear advantage indicates right cerebral
hemisphere language dominance, mixed dominance
for language, or neurologically based language or
learning disability.
*Behavioral symptoms may suggest difficulty hearing
in BGN, or difficulty listening to two conversations at
the same time.
Auditory Processing Assessment
Test under each category
o Dichotic Listening (Binaural Integration, Binaural Separation
(BIBS))
* Interaction of right & L hemispheres and maturation of auditory system
o Temporal processing
* Pattern perception
* Gap detection
o Monaural Low Redundancy Speech
* Auditory Closure
* Auditory figure ground
* Filtered Words
o Test of Binaural Interaction
* Ability of BS to synthesize partial auditory information presented to each
ear into a complete message
Auditory Processing Assessment
o Dichotic Listening (Binaural Integration, Binaural
Separation (BIBS))
o Temporal processing
* Pattern perception
* Gap detection
o Monaural Low Redundancy Speech
o Test of Binaural Interaction
Temporal Processing
How it relates to speech
Timing Related Aspect of Speech
*Auditory pattern recognition, Temporal order, Temporal resolution
* Perception of music
* Perception of speech
* Voicing, discrimination of similar words (bill / pill - Delay is 1/20 of
a second of silence!)
* Length of time between sounds
* The cat sat vs the cats at
* Look out the door vs Look out! The door!
* Perception of emotional content of speech
* Irony, sarcasm
Temporal Processing Tests
Gap detection
Gap Detection Test – Test of Temporal Resolution
Define smallest interstimulas interval (ISI) where
person hears 2 stimuli
Listener is required to listen and identify whether
one or two tones are heard as the silence interval is
varied in msec
Temporal Processing Tests
Frequency pattern test
What does it assess ?
Frequency Patterns Test or Duration Patterns Tests
Assesses temporal patterning/order and inter-hemispheric transfer
via the corpus callosum.
Requires pitch discrimination, memory, and sequencing
Listener reports pattern of 3 tone bursts of different frequencies
or durations.
Ex. high, low, high or low, high, high
Ex. Long, short, short or long, long, short
Response may be verbal, humming or motoric
Sensitive to R or L hemisphere dysfunction
Frequency/Duration Pattern Test
What does it tell us about their hemispheres ?
Right Hemisphere – Hum the 3 pitch/duration sequence
Left hemisphere – Label the 3 pitch/duration sequence.
If patient able to label responses, left cortical function is okay.
Left hemisphere lesion - Patient can only use motoric gesture or hum
the response but not label. R hemisphere discerns pattern, but L
hemisphere cannot label it.
Right hemisphere Lesion – Bilateral deficit Listener is unable to
perceive the pattern which then cannot be recognized and labeled by
the left hemisphere.
Temporal Processing Deficits
- Poor performance in tests of temporal processing may
influence phonemic awareness skills, speech
discrimination, short term auditory tasks, and
suprasegmental / prosody cues of language. - Difficulty in temporal patterning may be expressed in
misinterpretation of an oral message and difficulties
extracting key words from a message.
Auditory Processing Assessment
o Dichotic Listening (Binaural Integration, Binaural
Separation (BIBS))
o Temporal processing
o Monaural Low Redundancy Speech
* Auditory Closure
* Auditory figure ground
* Filtered Words
o Test of Binaural Interaction
Monaural Low Redundancy Speech
Tests
Auditory closure, what did it evaluate
Evaluates auditory closure when signal is not clear.
Auditory closure - Ability to recognize speech even
when parts of the signal are distorted or missing
Redundancy in language and CANS allows for auditory
closure, even when signal is degraded (missing, or
distorted signal, or BGN)
Monaural Low Redundancy Speech Tests
Auditory Figure Ground – Scan 3
Filtered Speech – Scan: 3 Frequencies higher than
750kHz are filtered out
Time Compressed Sentences – Scan: 3
Compresses speech by 60%
Synthetic Sentence ID –Ipsilateral Competing Message
Nonsense sentence & continuous discourse in same
ear
Monaural Low Redundancy Speech
Tests
Poor performance indicates ?
Poor performance may indicate a receptive
language disorder and difficulty listening in noise
or in adverse listening conditions
Auditory Processing Assessment
o Dichotic Listening (Binaural Integration, Binaural
Separation (BIBS))
o Temporal processing
o Monaural Low Redundancy Speech
o Test of Binaural Interaction
o Ability of BS to synthesize partial auditory information
presented to each ear into a complete message
Binaural Interaction
What does it evaluate?
oEvaluates how two ear work together: Binaural Fusion
o The ability to fuse incomplete information presented to each ear to
a meaningful message
o Localization, Lateralization
o Hearing in Noise
oBinaural Advantage – easier to hear in noise with 2
functioning ears.
oPoor performance may indicate difficulty using information that
arrives at the two ears at different times to recognize direction and
Binaural Interaction Tests
The ability of the two ears to merge auditory input alternating
between the RE and LE
* Filtered CVC/spondee words - HF to one ear, LF to other ear
OR
* Consonants to one ear, vowels to other ear
* RASP –Rapidly Alternating Speech Perception
* Listener identifies alternating presentation of words heard by both ears into
an intelligible sentence
Diagnosing APD
A diagnosis of APD can be made when the individual scores two standard
deviations or more below the mean in at least one ear on two or more
tests within the battery (AAA 2010)
* A diagnosis of CAPD is enabled only when performance on > 2 tests is
abnormal AND the pattern of findings is consistent with underlying
neuroscience tenets (ASHA, 2005)
Information Processing
Bottoms up and down
Bottom Up Processing
* How information is carried from ear to
brain
* Prior to higher order cognitive or
linguistic operations
Top down Processing
* How information is acted on once it gets
to the brain
* Attention, memory, linguistic
competence
o Both bottom up and top down factors work
together for processing of auditory input
Management of APD
o Environmental modifications
Adjust environment to minimize noise and improve the child’s ability to
process auditory information.
Bottom-up approach
o Compensatory Strategies
Teach strategies to compensate for the auditory deficit, and strategies for
coping in daily life.
Top-down approach
o Deficit Driven Auditory Training
Direct remediation techniques
Bottom-up approach
- Environmental Modifications
Classroom Modifications to improve SNR:
o Acoustical treatment
Decrease reverberation by covering hard surfaces, strategically placed
acoustic dividers, use absorption materials in open spaces.
o Preferential (strategic) seating
Reduce distance between speaker and listener’s ear
o Amplification
Soundfield amplification
Personal DM (Can increase SNR to +15 dB
Environmental Modifications
o Instructional Accommodations to improve access to verbally
presented information
-Pre teaching of new material
-Clear speech
- Establish eye contact
-Rephrase/repeat
-Check for comprehension
-Provide visual teaching and supplements
-Teach whole body listening skills
- Compensatory Strategies
Teach communication repair strategies
Auditory closure skills
Vocabulary building
Organizational skills (lists, outline, planners),
Buddy system
Study skills
Record classes
Self advocate
- Direct Therapy
Direct treatment that targets specific deficits
o Exploits neuroplasticity
o Training must be adaptive, challenging and intensive
o Formal auditory activity
o Language training, auditory memory exercises, vocabulary
building. Listening training in BGN, auditory closure activities
o Computer based activity
o Must be individualized and deficit specific
Types of Computerized Therapy
- Acoustic Pioneer
- Dichotic Listening (Zoo Caper Skyscraper)
- Pitch pattern/Tonal activities – (Insane Airplane)
- Auditory Memory: (Elephant Memory)
- CapDots
- Binaural Integration Deficits
- Binaural Separation Deficits
- CLEARworks4ear
- Phoneme Discrimination
- Auditory Attention, Auditory, Memory, Processing speech
- Sound Storm
- Spatial Processing, Listening in Noise
Management of Temporal Deficits
Auditory Pattern – Temporal Ordering
Reading aloud with exaggerated emphasis
Reading poetry
Musical training
Prosody - Listening for how meaning changes with stress change
(subject vs. subject or e.g. You are going home. You are going home.
You are going home. )
Segmenting and duration- “nitrate” vs. “night rate” “it sprays” vs.
“its praise”
Commercial training programs
Management of Dichotic Deficits
Formal dichotic listening training
Listening activities:
Repeat back stimuli presented in both ears
Ignore one ear and repeat back target (weaker)
side
Task is to describe target message
SNR can be increased or decreased.
Localization activities
Management of Monaural Auditory Closure
Abilities
Auditory closure Training Activities
o Missing word, missing syllable, missing phoneme exercises
Words: Mary had a little _____ . We put rugs on the _____
Syllable: He hit the nail with the ha______.
oKey word extraction
Following directions - Listen for what you do first, next, what to do last
oPhoneme discrimination
Minimal pair contrasts (/t/ vs. /d/)
Phrases: had some coke vs had some cake
Verb endings: play, plays, played, playing
Speech in noise training
o Start with favorable SNR which gets progressively more challenging
Commercially available programs
oEarobics and Fast ForWord
