(Central) Auditory Processing Disorders

Question 1

Central Auditory
Nervous System (CANS
Overall pathway

Answer 1

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

Question 2

Development of Central Auditory Nervous
System (CANS)

Answer 2

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.

Question 3

Corpus Callosum

Answer 3

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)

Question 4

Right and Left Hemispheres

Answer 4

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

Question 5

Right Ear Advantage and CC

Answer 5

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

Question 6

Redundancy
External Redundancy
Internal Redundancy

Answer 6

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

Question 7

What Is Auditory Processing?

Answer 7

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

Question 8

What Is Auditory Processing?
How different professionals see it

Answer 8

“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.”

Question 9

Auditory Processing Continuum
Different areas in the brain

Answer 9

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

Question 10

Auditory Processing Continuum
How SLPs and aud see the phonemic and language processing

Answer 10

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.

Question 11

Auditory Processing
Disorder

Answer 11

Brain (not hearing) Disorder
Bellis: APD is when the brain can’t
hear

Question 12

ASHA – (C)APD

Answer 12

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.

Question 13

What is APD - ASHA

Answer 13

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

Question 14

Characteristics of Children with APD

Answer 14

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

Question 15

Skills
Affected

Answer 15

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

Question 16

Risk Factors for (C)AP Deficits

Answer 16

Chronic Otitis Media
Genetics
Concussion / head injuries
Lyme disease
Lead poisoning
Neurological issues / seizures
Premature and / or traumatic birth history

Question 17

SCREENING FOR
APD

Answer 17

Systematic observation of listening behavior and / or
performance of tests of auditory function to identify
those individuals who are at risk for APD

Question 18

s This Child At Risk For APD?

Answer 18

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?

Question 19

APD SLP Screening Protocols

Answer 19

1. 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
2. Speech and Language Evaluation
3. SCAN-3 for Children APD Screening Test
   -Gap Detection
   -Dichotic testing
   - Auditory figure ground

Question 20

1. Screening Questionnaires

Answer 20

• Children’s Auditory Processing Performance Scale
  (CHAPS)
• Screening Instrument for Targeting Educational Risk
  (S.I.F.T.E.R)
• Fisher’s Auditory Problems Checklist

Question 21

Children’s Auditory Processing Performance
Scale (CHAPS)

Answer 21

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

Question 22

Screening Instrument for Targeting Educational Risk
(S.I.F.T.E.R

Answer 22

• 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

Question 23

Fisher’s Auditory Problems Checklist

Answer 23

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

Question 24

2. SLP Evaluation

Answer 24

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

Question 25

LP EVALUATION

Answer 25

Celf – 4: Children with APD had the most difficulty with: Following directions Recalling sentences Formulation of sentence Forward number repetition (representing a memory task

Question 26

3. Screening Test for APD - SCAN 3: C/A Ages and the type of testing

Answer 26

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

Question 27

Multidisciplinary Screening Process

Answer 27

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 37 38

Question 28

APD Position Statement - ASHA

Answer 28

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.

Question 29

CAPD is listed as

Answer 29

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

Question 30

Criteria for Assessing APD

Answer 30

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

Question 31

Behavioral APD Assessment

Answer 31

Case History Audiological Assessment Auditory Processing Assessment

Question 32

Case History

Answer 32

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

Question 33

Auditory Processing Assessment What does it do

Answer 33

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)

Question 34

Auditory Processing Assessment Categories of the different tests

Answer 34

Dichotic Listening (Binaural Integration, Binaural Separation (BIBS)) o Temporal processing o Monaural Low Redundancy Speech o Test of Binaural Interactio

Question 35

Auditory Processing Assessment The tests under each category

Answer 35

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

Question 36

Auditory Processing Assessment Categories

Answer 36

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

Question 37

Dichotic Listening

Answer 37

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

Question 38

Dichotic Listening Test

Answer 38

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.

Question 39

Tests of Binaural Integration 2 ways to do it

Answer 39

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

Question 40

Tests of Binaural Separation

Answer 40

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

Question 41

Dichotic Listening Deficits

Answer 41

*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.

Question 42

Auditory Processing Assessment Test under each category

Answer 42

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

Question 43

Auditory Processing Assessment

Answer 43

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

Question 44

Temporal Processing How it relates to speech

Answer 44

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

Question 45

Temporal Processing Tests Gap detection

Answer 45

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

Question 46

Temporal Processing Tests Frequency pattern test What does it assess ?

Answer 46

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

Question 47

Frequency/Duration Pattern Test What does it tell us about their hemispheres ?

Answer 47

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.

Question 48

Temporal Processing Deficits

Answer 48

* 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.

Question 49

Auditory Processing Assessment

Answer 49

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

Question 50

Monaural Low Redundancy Speech Tests Auditory closure, what did it evaluate

Answer 50

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)

Question 51

Monaural Low Redundancy Speech Tests

Answer 51

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

Question 52

Monaural Low Redundancy Speech Tests Poor performance indicates ?

Answer 52

Poor performance may indicate a receptive language disorder and difficulty listening in noise or in adverse listening conditions

Question 53

Auditory Processing Assessment

Answer 53

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

Question 54

Binaural Interaction What does it evaluate?

Answer 54

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

Question 55

Binaural Interaction Tests

Answer 55

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

Question 56

Diagnosing APD

Answer 56

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)

Question 57

Information Processing Bottoms up and down

Answer 57

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

Question 58

Management of APD

Answer 58

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

Question 59

1. Environmental Modifications

Answer 59

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

Question 60

Environmental Modifications

Answer 60

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

Question 61

2. Compensatory Strategies

Answer 61

Teach communication repair strategies Auditory closure skills Vocabulary building Organizational skills (lists, outline, planners), Buddy system Study skills Record classes Self advocate

Question 62

3. Direct Therapy

Answer 62

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

Question 63

Types of Computerized Therapy

Answer 63

* 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

Question 64

Management of Temporal Deficits

Answer 64

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

Question 65

Management of Dichotic Deficits

Answer 65

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

Question 66

Management of Monaural Auditory Closure Abilities

Answer 66

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