auditory processing disorders - national acoustic laboratories · 12 asha (2005) “()apd is a...
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Perspectives on the Diagnosis and Remediation ofAuditory Processing Disorders
Harvey Dillon
National Acoustic Laboratories,
University of Manchester
Macquarie University
Hearing CRC
Helen Glyde
Sharon Cameron
Carhart Memorial LectureAmerican Auditory Society
ScottsdaleMarch 2018
Kiri Mealings
Dani Tomlin
Mark Seeto
Pia Gyldenkaerne
1
MridulaSharma
Tony Sirimanna
What you might remember• Listening difficulties have multiple causes, which can be quantified.
• Diagnosing the type(s) and extent of auditory processing disorder present requires quantitative control of the effects of memory, attention, intelligence and language on auditory processing tests.
• Deficit-specific treatment can be highly effective in removing auditory processing deficits.
• Research is needed to:
• Better understand cause and effect between auditory processing, language and cognition
intervention studies;
• Create differential tests that identify more specific types of auditory processing disorders;
• Create a more efficient (hierarchical, adaptive) test battery than currently exists.
2
Talk outlineConcepts
NAL / Macquarie / Melbourne
specific data
Literature meta-analysis
What clinicians can do nowWhat researchers could do
3
APD by any other name ….. Central auditory processing disorder
Sullivan (1976)
Central auditory dysfunctionBerry & Blair (1976)
Obscure auditory dysfunction Saunders & Haggard (1989)
Central presbycusisStach et al (1990)
King-Kopetzy syndromeHinchliffe (1992)
Auditory neuropathyStarr et al 1996
Hidden hearing lossSchaette & McAlpine (2011)
Auditory disability with normal hearing Stephens and Rendell (1988)
Auditory dysacusisJayaram, Baguley & Moffat (1992)
Auditory inferiority complexByrne & Kerr (1987)
Selective dysacusisNarula & Mason (1988)
Auditory processing disorderJerger & Musiek (2000)
(Central) Auditory processing disorderASHA (2005)
1. Auditory perception poorer than expected from hearing thresholds2. Definition sufficiently broad to include diverse types of deficits
Two things in common:
Auditory perceptual disturbanceMyklebust (1954)
7
Does APD exist?
3. When something does go wrong with the way the auditory
system processes the neural signals initiated by sound, what
would you like to call such a disorder?
Language disorder
Cognitive disorder
General developmental disorder
1. Do you believe the brain transmits and analyses neural
signals after they leave the cochlea, or does auditory
perception occur by magic?
2. Can anything ever go wrong with the way the brain
transmits and analyses neural signals initiated by sound, or is
the system infallible and develops properly in every person?
Kaas & Hackett (2000)9
APD, Cognition and Language Brenneman, Cash, Chermak, Guenette,
Masters, Musiek, Brown, Ceruti, Fitzegerald, Geissler, Gonzalez & Weihing (2017).
Cognitive abilities
Language abilities
Auditory processing
abilities
29% shared variance
23% shared variance
35% shared variance
10
12
ASHA (2005)“(C)APD is a deficit in neural processing of auditory stimuli that is not due to higher orderlanguage, cognitive, or related factors."
"When I use a word,' Humpty Dumpty said in rather a scornful tone, 'it means just what I choose it to mean — neither more nor less."
"The question is," said Alice, "whether you can make words mean so many different things."
Moore, Ferguson et al (2010)“What is currently called APD, for individuals without known neurologic lesions, should be redefined as primarily a cognitive disorder, rather than a sensory disorder.”
Views on the meaning of APD from around the worldProfessional Society Definition Comment
ASHA (2005) A deficit in neural processing of auditory stimuli that is not due to higher order language,
cognitive, or related factors.
Cognition and language out
AAA (2010) Difficulties in the perceptual processing of auditory information. (C)APD is frequently
comorbid with related language, learning and cognitive disorders.
Cognition and language out
Danish Medical Audiological
Society (2014)
The efficiency with which the central nervous system uses received auditory information. Cognition and language out
Canadian Interorganizational
Steering Group (2012)
A persistent limitation in the performance of auditory activities that originates in the
auditory system and is not caused by loss of auditory acuity or disorders of language,
attention, memory or cognition.
Cognition and language out
Belgian International Bureau
for Audiophonology (20070
… difficulties in listening and intelligibility …..can be the consequence of … cognitive and
memory functions, but also the functions provided by central auditory pathways.
Cognition and language out
NAL – Australia (Dillon &
Cameron, 2015)
An Auditory Processing Disorder (APD) is a deficit in the way the neural representation of
sounds are processed by the brain, resulting in a distorted neural representation of the
auditory signal within the auditory nervous system.
Cognition and language out
BSA (2017) Poor perception of speech and non-speech. Origins include the CANS and neural processing
systems for language, reading, speech, attention, executive function, memory, emotion,
vision and action.
Cognition and language in
Dutch position statement
(2017)
Listening difficulties can be caused by both disturbed bottom-up processes (sensory
processing) and disturbed top-down processes (including cognition and language).
Cognition and language are the
most common problem in
listening difficulties
New Zealand (2017) Auditory processing disorder is a hearing disorder that results from atypical processing of
auditory information in the brain.
Doesn’t say
German (Nikissch et al, 2015) ???? ????13
Should APD be conceptualized as an auditory-specific disorder or as one aspect of a more generalized disorder?
Not a practically useful question!!!!
Deficit in auditory processing only
Child 1
Deficit in auditory processing+
Deficit in visual processing
Child 2
Give training to improve auditory skills in deficit
Improve input sound SNR
Manage or treat the other problem(s)
Identify the deficit
15
Four “controversies” dealt with
1. The name: APD, CAPD, or (C)APD?• Of course auditory processing happens in the cochlea
2. Does it exist?• Duh, yes!
3. Include or exclude deficits in cognition and language?• Excludes, by most definitions, but of course perception of speech needs
cognition and language as well
4. Limited to unimodal problems?• Not limited. Problems involving audition should be identified and helped,
irrespective of whether there are similar problems in other modalities
None are productive debates: more semantics than reality16
Deficits (various) in
auditory processing
Deficits (various) in language
Listening difficulties
Deficits (various) in cognition
Performance on tests of
APD
18
Deficits (various) in
auditory processing
Deficits (various) in language
Performance on tests of
APD
Deficits (various) in cognition
19
Example of a test that tests multiple abilities
• Dichotic digits test – Musiek (1983) - 293 citations
• Easy to administer and score
• Often failed by children seeking APD assessment
• In many, many test batteries, including Australian Hearing
20
Dichotic versus diotic
(%)
30 40 50 60 70 80 90 100
Dichotic free recall (%)
30
40
50
60
70
80
90
100
Dio
tic
(%)
Clinic
School
r = 0.82
23
Correlations with
cognition
Free recall dichotic
Attention (prudence)
Attention (vigilence)
Forward digit span
Reverse digit span
Non-verbal IQ
0.31
0.21
0.53
0.36
0.27
25
Diotic
Attention (prudence)
Attention (vigilence)
Forward digit span
Reverse digit span
Non-verbal IQ
0.26
0.15
0.52
0.42
0.24
26
Correlations with cognition
Dichotic scores and memory
27
-3 -2 -1 0 1 2 3
Number memory forward (z score)
-5
-4
-3
-2
-1
0
1
2
3
Dic
hotic fre
e r
ecall
(z s
core
)
Clinic School
The normal range!
R=0.60
Accounting for
variance
Dichotic test scoresMemory
Other non-dichotic
factors
9%
Dichotic factors
Random measurement
error
27%
64%64%
+27%91%
28
Dichotic tests
Testing cognitive
ability
Application to brain-
lesion patients
Information about
hemisphere differences
Application to auditory processing
disorder patients
Inferences about
auditory processing
• Selective attention
• Working memory
• Executive function
• Aging
• Mental Retardation
30
Brain “lesions” in Central Auditory Nervous System
CauseLow dichotic test scores
Cognitive deficits
Indicate
31
What not to do in “sensitising” a test
Problem: A test gives ceiling performance for too many people
Usual solution: Make the test harder by demanding additional skills:• dichotic digits – make it two pairs, or three pairs memory ↑• speech tests – low-pass filter it vocabulary ↑, phonetic awareness ↑
Result: Scores decrease below ceiling, but cause become uncertain
An alternative: Adaptively change inter-aural level
32
Disentangling the disorders
Cognitive disorder
Auditory processing
disorder
Language disorder0
5
10
15
20
25
30
35
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
Year
Publications per year
34
Relation between APD and Attention Disorder
35
Auditory attention disorder
51
Auditory processing
disorder
58
24 1734
26
No disorder
101 children with listening difficulties
Gyldenkaerne, Dillon, Sharma and Purdy (2014); JAAA.
“How strong are the deficits in each of: cognition,
auditory processing, and language”
Instead of “What disorder(s) does this person have” ….
With a common unit of measure!36
Suspected Auditory Processing
Disorder
Suspected Cognitive Disorder
Suspected Language Disorder
Reported
Bornstein & Musiek (1992)
Vanniasegaram, Cohen & Rosen (2004)
Dawes, Bishop, Sirimanna, Bamiou (2008)
Sharma, Purdy & Kelly (2009)
Rosen, Cohen, Vanniasegaram (2010)
Umat, Mukari, Ezan & Din (2011)
Ahmed, Ahmed, Bath, Ferguson, Plack & Moore (2014)
Gyldenkaerne, Dillon, Sharma, Purdy (2014)
Boothalingam, Allan, Allen & Purcell (2015)
Saxena, Allan & Allen (2015)
Ahmed & Ahmed (2016)
Neijenhuis, de Wit, Luinge (2017)
Listening difficulties
37
Auditory Processing Deficits
Cognitive Deficits
Language Deficits
Reported
Dawes, Bishop, Sirimanna, Bamiou (2008): “Children diagnosed with APD reported similar symptoms and similarly had high rates of co-morbid learning problems”.
Listening difficulties
3838
Noise Quiet Ideal Multiple Memory Attn Span
PROBLEM
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
CH
AP
S s
co
res (
pare
nts
)
No APD
APD issues
APD diagnosed
Parents Teachers
Noise Quiet Ideal Multiple Memory Attn Span
PROBLEM
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
CH
AP
S s
co
re (
teache
rs)
No APD
APD issues
APD diagnosed
CHAPS questionnaire results – Great Ormond Street APD Clinic, London
39
Slightly more
difficulty
More difficulty
Considerably more
difficulty
Same difficulty
CHildren’sAuditory Performance Scale
Speech understanding –what could go wrong?
Auditory processing
• Auditory filtering• Envelope analysis• Temporal fine structure• Spatial analysis
Complexsignals
analysed
Speech processing
• Comparison to stored templates (phonemes, syllables or words)
Phonemes, syllables or
words identified
Auditory (speech)
input
Noise
Spatial cues
Rate
Reverb
Phonemic and lexical neighbourhood
density
Language processing
Under-standing
• Morphology knowledge• Syntactic knowledge• Semantic knowledge• Prosody knowledge• Working memory• World knowledge
Syntactic cues
Semantic cues
Prosodic cues
Message length
SNR
Perc
ent
u
nd
ers
tan
din
g
Attention,Memory
Degrade the input
These enable auditory closure
40
Speech recognition – what has gone wrong?
Auditory processing Speech processing Language processing
• Auditory filtering• Envelope analysis• Temporal fine structure• Spatial analysis• Pitch contour analysis
• Comparison to stored templates (phonemes, syllables or words)
ComplexSignals
analysed
Phonemes, syllables or
words identified
Under-standing
Auditory (speech)
input
Spatial cues
NoiseReverb
Rate
• Morphology knowledge• Syntactic knowledge• Semantic knowledge• Prosody knowledge• Working memory• World knowledge
Syntactic cues
Semantic cues
Prosodic cues
Message length
Test of auditory processing
Test of auditory and speech processing
Test of auditory and speech and language processing
Attention,Memory
Phonemic and lexical neighbourhood
density
41
Observations in relation to model• APD should be able to cause poor speech perception and language delay
(imagine consequences of a complete APD).
• Listening difficulties can be caused by any of auditory processing, speech processing, language processing or cognitive deficits, either alone or in combination.
• A deficit in language processing or auditory/speech processing can be expressed as an equivalent SNR loss
Auditory processing
Speech processing
Language processing
• Auditory filtering• Envelope analysis• Temporal fine structure• Spatial analysis• Pitch contour analysis
• Comparison to stored templates (phonemes, syllables or words)
ComplexSignals
analysed
Phonemes, syllables or
words identified
Under-standing
Auditory (speech)
input
Spatial cues
NoiseReverb
Rate
• Morphology knowledge• Syntactic knowledge• Semantic knowledge• Prosody knowledge• Working memory• World knowledge
Syntactic cues
Semantic cues
Prosodic cues
Message length
Attention,Memory
Phonemic and lexical neighbourhood density
What to remediate
42
5
10
15
20
25
30
35
40
45
50
55
60
Age
-28
-26
-24
-22
-20
-18
-16
-14
-12
-10
-8
-6
-4
-2
Sp
ee
ch
re
ce
ptio
n t
hre
sh
old
(d
B S
NR
)
Importance of SNR: 1. Age
1.3 dB/year
Sound Scouts LiSN-S
5 10 15 20 25 30 35 40 45 50 55 60 65
Age
-22
-20
-18
-16
-14
-12
-10
-8
Hig
h C
ue
SR
T
1.0 dB/year
Sentences in competing babble
LiSN-U
5 6 7 8 9 10 11 12 13 14 15
Age
-20
-15
-10
-5
0
5
10
SR
T (
SV
90)
dB
2.4 dB/year
Nonsense syllables in competing nonsense syllables
6 y.o. re adult: 11 dB 6 dB 10 dB 43
Importance of SNR: 2. Hearing loss or APD
Condition Effect Increase in SRT
Mild hearing loss (35 dB 4FAHL)
1 dB increase for each 10 dB of 4FAHL above 5 dB
+3 dB
Spatial processing disorder
Same-age population standard deviation is 1.6 dB
+3.2 dB
Conclusion: A 6 year old, with mild hearing loss, or spatial processing disorder just outside normal limits needs 3 + 9 =12 dB better SNR than an average adult.
SNR = -4 dB SNR = -14 dB
44
How do we find the specific deficit(s)?
So, top-level testing to find the strength of deficit
in each area, but ….
45
How do we find the specific deficit(s) causing listening difficulties?
1. Differential testing
• DDdT (Dichotic digits difference test, Cameron et al, 2016)
• SPIN (Speech in noise test; Kalikow, Stevens & Elliott, 1977)
• LiSN-S (Listening in spatialized noise sentences test, Cameron & Dillon, 2007)
2. Allow for other abilities that affect test scores (just like we allow for age)
3. Use tests that rely only minimally on other abilities
46
Differential testing (e.g. SPIN – Kalikow, Stevens & Elliot, 1977)
Auditory processing Speech processing Language processing
• Auditory filtering• Envelope analysis• Temporal fine structure• Spatial analysis• Pitch contour analysis
• Comparison to stored templates (phonemes, syllables or words)
ComplexSignals
analysed
Phonemes, syllables or
words identified
Under-standing
Auditory (speech)
input
Spatial cues
NoiseReverb
Rate
• Morphology knowledge• Syntactic knowledge• Semantic knowledge• Prosody knowledge• Working memory• World knowledge
Syntactic cues
Semantic cues
Prosodic cues
Message length
Attention,Memory
Phonemic and lexical neighbourhood
density
Test of auditory and speech and language processing (with semantic cues) SRT1
Test of auditory and speech and language processing (with no semantic cues) SRT2
∆SRT = SRT2 - SRT1
47
Pichora-Fuller (2008)
Diagnosing spatial processing disorder with the
Listening in Spatialized Noise Sentences (LiSN-S) test
SPD
APD
48
DisclosureLicensed to Phonak
Same
Direction
Different
Directions
Different Voices
Four LiSN-S Conditions
Same Voice
T
D1
D2
TD1 D2TD1 D2
Low
Cue
SRT
Sp
atia
l Ad
va
nta
ge
Talker Advantage
D1
D2
T
High
Cue
SRT
49
Difference measures !
6 7 8 9
10
11
12
-13
14
-15
16
-17
18
-19
20
-24
25
-29
30
-39
40
-49
50
-60Age Group
8
9
10
11
12
13
14
15
16
17
18
Spatia
l Advanta
ge (d
B)
Spatial Advantage (≡ Spatial Release from Masking)
Bett
er
Australia
Nth America
50
SusCAPD Group
PP
S (
RE
)
PP
S (
LE
)
DD
(R
E)
DD
(LE
)
RG
DT
MLD
LC
SN
R
HC
SN
R
Talk
er
Adv
Spatial A
dv
Tota
l A
dv
-12
-10
-8
-6
-4
-2
0
2
4
6
Devia
tion f
rom
Mean N
orm
al P
erf
orm
ance
Median 25%-75% Min-Max
Cameron & Dillon (2008)
LiSN-S vs.Traditional Battery
52
54
SPD and chronic otitis media (COM)
• 50% of children (24/49) diagnosed with SPD at NAL reported (unsolicited) a history of COM. (Dillon et al., 2012).
• 18% of children (18/82) previously diagnosed with COM at University of Melbourne were diagnosed with SPD. (Graydon et al., 2017).
• Degree of spatial loss at primary school age increases with degree of threshold elevationdue to COM in infancy. (Graydon et al, 2015)
• Spatial processing deficit worse for early onset age and longer duration of COM (n=35; Tomlin & Rance, 2014).
• 6 yo children with history of COM have below average spatial advantage (n=17; z= -1.0) (Kapadia et al, 2012).
• 13-17 yo adolescents with history of COM have below average spatial advantage (n=20; z= -0.75) (Kapadia et al, 2014).
• 10% of a population sample (9/90) of Aboriginal children from remote Australia diagnosed with SPD. (Unpublished data).
• 7% of a population sample (10/144) of Aboriginal children from regional Australia diagnosed with SPD. (Cameron et al., 2014).
Spatial Processing Disorder –
• Know its major cause
• Can diagnose it, unrelated to cognitive ability
• Have extensive normative and reliability data
• Can remediate it (blinded, randomized trial)
• Remediation generalizes to real life
55
SPD
APD
Unique amongst forms of APD because we:
Not all differential tests give immunity from cognitive deficits!
Right ear advantage in dichotic tests
56
How do we find the specific deficit(s) causing listening difficulties?
1. Differential testing• DDdT
• SPIN
• LiSN-S
2. Allow for other abilities that affect test scores (just like we allow for age)
3. Use tests that rely only minimally on other abilities
59
Allowing for related abilities
APD test z-score = AP ability + c.(memory) + d.(attention)
Therefore:
AP ability = APD test z-score – c.(memory) – d.(attention)
61
Dichotic scores and memory
62
-3 -2 -1 0 1 2 3
Number memory forward (z score)
-5
-4
-3
-2
-1
0
1
2
3
Dic
hotic fre
e r
ecall
(z s
core
)
Clinic School
Dichotic scores and memory
63
-3 -2 -1 0 1 2 3
Number memory forward (z score)
-5
-4
-3
-2
-1
0
1
2
3
Dic
hotic fre
e r
ecall
(z s
core
)
Clinic School
Allowing for related abilities
AP ability = APD test z-score – c.(memory) – d.(attention)
But …….• Which type of “memory”?
• Echoic• Working memory
• Which type of attention?• Sustained?• Switching?• Selective?
• What are the values of c and d for each auditory processing test?
• Are the effects of memory and attention linear or non-linear?
• How accurately do we need to know memory and attention?
• Do we need to add non-verbal IQ or language ability to the modifiers?
Memory z-score
AP ability
Attention z-score
Language z-score
Non-verbal IQ
64
Correlations !
0
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
320
20
40
80
160
1000
Correlation coefficient
67
Ahmed (2017)Ahmed & Ahmed (2016)Brenneman et al (2017)Cameron et al (in prep)Cameron et al (2015)
Cameron et al (2016)Gyldenkaerne et al (2014)Harris et al (1983)Maerlander (2010)Maerlander et al (2004)
Riccio et al (2005)Dillon & Sirimanna (2014)Sharma et al (2009)Stavrinos et al (2018)Tomlin et al (2015)
Weihing et al (2015)Wilson et al (2011)
NVIQ NMF NMR NMF+NMR Prudence VigilanceDiv Aud Tten
Vis Sus Atten DDT-L DDT-R DDT-Avg FPT SSW MLD
RGDT or GIN
Filtered words (Scan)
Competing words (Scan)
Competing sentences (Scan) AFG (Scan) VCV LiSN-S HC
LiSN-S Spat Adv
WARP or TOWRE
Combined reported listening CHAPS SIFTER Life Fishers CCC-2 SLI CCC-2 PLI CCC-2 GCC
Receptive language (CELF-4)
Expressive language (CELF-4)
Overall academic ability
NVIQ 1.00 0.27 0.32 0.19 0.28 0.25 0.27 0.31 0.16 0.36 0.38 0.09 0.12 -0.04 -0.03 -0.02 0.09 -0.08 0.22 0.08 0.34 0.40 0.21 0.24 0.60
NMF 0.27 1.00 0.45 0.86 0.18 0.15 0.07 0.32 0.27 0.37 0.31 0.16 0.12 0.04 0.09 0.15 -0.01 0.44 0.24 0.08 0.06 0.03 0.29 0.44
NMR 0.32 0.45 1.00 0.83 0.22 0.26 0.26 0.26 0.22 0.31 0.35 -0.05 0.04 0.11 0.21 0.16 0.02 0.53 0.36 0.26 0.27 0.07 0.36 0.59
NMF+NMR 0.19 0.86 0.83 1.00 0.29 0.19 0.32 0.27 0.40 0.35 0.06 0.08 0.20 0.34 0.33 0.15 0.22 0.18 0.01 0.47 0.35 0.24 0.17 0.43 0.59
Prudence 0.28 0.18 0.22 1.00 0.54 0.37 0.22 0.36 0.18 0.42 0.55 0.49 0.12 -0.08
Vigilance 0.25 0.15 0.26 0.29 0.54 1.00 0.76 0.62 0.25 0.22 0.26 0.33 0.21 0.02 0.17 -0.10 0.01 -0.17 0.12 0.07 0.39 0.31 0.19 0.22 0.53 0.16 0.15 0.03 0.31
Div Aud Tten 0.76 1.00 0.68 0.08 -0.03 0.66 0.24
Vis Sus Atten 0.27 0.07 0.26 0.19 0.62 1.00 0.24 0.20 0.22 0.19 0.07 -0.01 0.00 0.01 0.30 0.20 0.18 0.16 0.28
DDT-L 0.31 0.32 0.26 0.32 0.37 0.25 0.24 1.00 0.47 0.85 0.37 -0.02 0.13 0.20 0.36 0.17 0.21 0.29 0.21 0.18 0.24 0.11 0.31 0.06 0.18 0.48
DDT-R 0.16 0.27 0.22 0.27 0.22 0.22 0.20 0.47 1.00 0.76 0.29 -0.04 0.11 0.20 0.32 0.17 0.18 0.20 0.34 0.09 0.15 0.08 0.31 0.16 0.33 0.36
DDT-Avg 0.36 0.37 0.31 0.40 0.36 0.26 0.68 0.22 0.85 0.76 1.00 0.36 -0.11 0.09 0.18 0.18 0.41 0.32 0.11 0.38 0.00 0.19 0.52
FPT 0.38 0.31 0.35 0.35 0.33 0.19 0.37 0.29 0.36 1.00 -0.02 0.25 0.21 0.26 0.12 0.12 0.36 0.20 0.11 0.14 0.01 0.21 0.34 0.30 0.39
SSW 0.18 0.21 1.00 0.64 0.57 0.26
MLD 0.09 0.16 -0.05 0.06 0.02 0.07 -0.02 -0.04 -0.11 -0.02 1.00 0.01 -0.08 0.02 -0.03 -0.14 -0.07 -0.05 0.21 0.07 0.08
RGDT or GIN 0.12 0.12 0.04 0.08 0.17 -0.01 0.13 0.11 0.09 0.25 0.01 1.00 0.13 0.18 0.30 0.10 -0.07 0.12 0.03 0.05 0.07
Filtered words (Scan) -0.04 0.04 0.11 0.20 0.42 -0.10 0.20 0.20 0.21 0.64 1.00 0.35 0.33 0.38 0.20 0.08 0.20 0.19 0.11
Competing words (Scan) -0.03 0.34 0.55 0.01 0.57 0.35 1.00 0.48 0.32 0.21 0.21 0.15 0.10
Competing sentences (Scan) -0.02 0.09 0.21 0.33 0.36 0.32 0.26 0.33 0.48 1.00 0.26 0.25 0.17 0.19 0.14 0.07 0.25 0.25
AFG (Scan) 0.09 0.15 0.49 -0.17 0.26 0.38 0.32 0.26 1.00 0.14 0.00 0.13
VCV -0.08 0.22 0.20 0.21 0.25 0.14 1.00 0.28
LiSN-S HC 0.22 0.15 0.16 0.18 0.12 0.08 0.00 0.17 0.17 0.18 0.12 -0.08 0.13 1.00 0.35 0.34 0.20 0.27 0.08 0.24 -0.15 0.15
LiSN-S Spat Adv 0.08 -0.01 0.02 0.01 0.07 -0.03 0.01 0.21 0.18 0.18 0.12 0.02 0.18 0.35 1.00 0.12 0.07 0.03 0.08 0.09 -0.01 0.03
WARP or TOWRE 0.34 0.44 0.53 0.47 0.39 0.30 0.29 0.20 0.41 0.36 -0.03 0.30 0.08 0.21 0.17 0.00 0.34 0.12 1.00 0.54 0.13 0.30 0.38 0.67
Combined reported listening 0.40 0.24 0.36 0.35 0.31 0.20 0.21 0.34 0.32 0.20 -0.14 0.10 0.20 0.07 0.54 1.00 0.62 0.80 0.62
CHAPS 0.08 0.26 0.24 0.18 0.09 0.11 0.20 0.15 0.19 0.28 0.13 1.00 0.66
SIFTER 0.06 0.27 0.24 0.15 0.14 0.19 0.14 0.66 1.00
Life 0.21 0.03 0.07 0.17 0.12 0.19 0.18 0.11 0.08 0.11 0.01 -0.07 -0.07 0.27 0.03 0.30 0.62 1.00 0.14 0.29
Fishers 0.24 0.29 0.36 0.43 -0.08 0.22 0.16 0.31 0.31 0.38 0.21 -0.05 0.12 0.08 0.08 0.38 0.80 0.14 1.00 0.56
CCC-2 SLI 0.53 0.66 0.24 0.09 1.00 0.59
CCC-2 PLI 0.15 0.24 -0.15 -0.01 0.59 1.00
CCC-2 GCC 0.11 0.10 0.07 0.13 1.00
Receptive language (CELF-4) 0.15 0.06 0.16 0.00 0.34 0.21 0.03 0.25 1.00
Expressive language (CELF-4) 0.03 0.18 0.33 0.19 0.30 0.07 0.05 0.25 1.00
Overall academic ability 0.60 0.44 0.59 0.59 0.31 0.28 0.48 0.36 0.52 0.39 0.08 0.07 0.15 0.03 0.67 0.62 0.29 0.56 1.00
Cognitive(NVIQ, memory, attention)
APD(dichotic, non-speech)
APD (speech tests)
Outcomes(reading, questionnaires, language)
68
DDTavg
FPT
GIN
LiSNSA
MemavgAttenavg
NVIQ
NMF
NMR
Prudence VigilanceDivided aud
attention
DDT-L
DDT-R
SSW
LiSNHC
Visual attention
CW
CS
FW
AFG VCV
Language ability
Reported Listening
ability
Academic or reading
ability
Speech in noise
MLD
69
DDTavg
FPT
GIN
LiSNSA
MemavgAtten
NVIQ
CW
CS
FW
Reported Listening
ability
Academic or reading
ability
Speech in noise
MLD
0.1
0.2
0.3
0.4
0.5
Correlation Scale
Observed correlations
70
FPT
GIN
LiSNSA
NVIQNMF NMR
Prudence Vigilance
DDT-L
DDT-R
LiSNHC
Visual attention
CW
CS
FWAFG
VCV
Listeningability
LIFEFishersSIFTER
CHAPS
Constrained SEM Model
71
Atten
0.1
0.2
0.3
0.4
0.5
Path strength scale
FPT
GIN
LiSNSA
NVIQNMF NMR
Prudence Vigilance
DDT-L
DDT-R
LiSNHC
Visual attention
CW
CS
FWAFG
VCV
Constrained SEM Model
72
Atten
Reading ability
How do we find the specific deficit(s) causing listening difficulties?
1. Differential testing• DDdT
• SPIN
• LiSN-S
2. Allow for other abilities that affect test scores (just like we allow for age)
3. Use tests that rely only minimally on other abilities • LiSN-U
73
Speech without language?
Auditory processing Speech processing Language processing
• Auditory filtering• Envelope analysis• Temporal fine structure• Spatial analysis• Pitch contour analysis
• Comparison to stored templates (phonemes, syllables or words)
ComplexSignals analysed
Phonemes, syllables or
words identified UnderstandingAuditory (speech)
input
Spatial cues
NoiseReverb
Rate
Phonemic and lexical neighbourhood
density
• Morphology knowledge• Syntactic knowledge• Semantic knowledge• Prosody knowledge• Working memory• World knowledge
Syntactic cues
Semantic cues
Prosodic cues
Message length
Auditory and speech processing
Attention,Memory 74
LiSN-U preliminary
data
(Test still under development)
-22 -20 -18 -16 -14 -12 -10 -8 -6 -4 -2 0 2 4
LiSN-S High Cue SRT (dB)
-20
-18
-16
-14
-12
-10
-8
-6
-4
-2
0
2
4
6
8
LiS
N-U
SV
90 S
RT
(dB
)
R=0.70
77
79
Traditional approach to APD testing
History Audiometry
Is there a problemthat APD
might explain?
Exclude APD;Refer elsewhere
No
Test result interpretation & diagnosisNon-specific remediation and management:• Classroom placement• FM use• Instruction style• Soundfield amplification• Auditory training
Detailed test battery
Yes
Caveats:
1. Diagnosis may be needed to get the funding needed for management
2. Diagnosis may help teachers and/or parents “understand” reason for problems
Deficit-specific remediation
Why diagnose APD at all?
To Manage it?
To Treat it?
(i.e. remediate, cure)
To Compensate for it?
(i.e. train some useful skill)
80
Hierarchical assessment
Auditory processing Speech processing Language processing
• Auditory filtering• Envelope analysis• Temporal fine structure• Spatial analysis• Pitch contour analysis
• Comparison to stored templates (phonemes, syllables or words)
ComplexSignals
analysed
Phonemes, syllables or
words identified
Under-standing
Auditory (speech)
input
Spatial cues
NoiseReverb
Rate
• Morphology knowledge• Syntactic knowledge• Semantic knowledge• Prosody knowledge• Working memory• World knowledge
Syntactic cues
Semantic cues
Prosodic cues
Message length
Test of auditory processing
Test of auditory and speech processing
Test of auditory and speech and language processing
Attention,Memory
Phonemic and lexical neighbourhood
density
81
Cognitive abilities
Speech under-standing
Speech sound recognition
Action
Good Good Good None
Good Good X Should not occur
Good X Good Language testing & intervention
Good X X Auditory processing testing & intervention
X Good Good Should not occur
X Good X Should not occur
X X Good Cognitive testing & intervention
X X X Cognitive testing & intervention
Dealing with listening difficulties
Questionnaire / history
Audiometry
Measure of attention
Language testing &
interventions
Auditory processing
testing
Measure of speech understanding in noise
(TOLD-U)
No auditory problem
Measure of speech sound recognition in noise
(~ LiSN-U)
Measure of working memory
Evaluate resultsCognitive testing &
interventions
82
Questionnaire / history
Audiometry
Dealing with listening difficulties
Measure of attention
Language testing &
interventions
Auditory processing
testing
Measure of speech understanding in noise
(TOLD-U)
No auditory problem
?
Measure of speech sound recognition in noise
(~ LiSN-U)
Measure of working memory
Evaluate resultsCognitive testing &
interventions
Temporo-frequency resolution
Time
Freq
uen
cy
Time
Freq
uen
cy
Gap detection
Time
Freq
uen
cy
Order detection
Time
Freq
uen
cy
Localization
Dichotic
Spatial processing
Time
Freq
uen
cyFPT DPT
PIT
GIN, RGDT, ParSE
LiSN
83
Questionnaire / history
Audiometry
Dealing with listening difficulties
Non-specific remediation and management:• Classroom placement• FM use• Instruction style• Soundfield amplification
Measure of speech understanding in noise
(TOLD-U)
Measure of speech sound recognition in noise
(~ LiSN-U)
No auditory problem
Measure of attention
Measure of working memory
Evaluate resultsCognitive testing &
interventions
Language testing &
interventions
Auditory processing & interventions
Temporo-frequency resolution
Time
Freq
uen
cy
Time
Freq
uen
cy
Gap detection
Time
Freq
uen
cyOrder detection
Time
Freq
uen
cy
Localization
Dichotic
Spatial processing
Deficit-specific remediation
84
Criteria for selecting an assessment test
1. Established test validity, meaning that scores below the cut-off value chosen are usually associated with listening problems in real life.
2. Adequate normative data and information on retest reliability and critical differences.
3. Minimal or controlled effects of memory, attention and non-verbal intelligence
4. The existence of remediation options specific to the deficit revealed by the test, and for which evidence of benefit in real-life exists.
5. Affected by known lesions in the brainstem or auditory cortex.
85
University of MelbourneSPD: 3 / 105
3%
Tomlin et al (2015)
Auditory Processing
Deficits
Cognitive Deficits
Language Deficits
ReportedListening difficulties?
? ?
Australian HearingSPD: 130 / 666
20%
Cameron et al (2015)
P=0.000 000 000 000 1
Are listening difficulties mostly: Language, Auditory processing, or Cognition ?
86
Child fails to understand
an instruction
Event
Acts (inappropriately) based on what
was heard
Asks for repetition of instruction
Does nothing
Misbehaves
Response by child
Interpretation by observer
Daydreams
Badly behaved
Can’t follow instructions
Is not very smart
Poor concentration
88
Questionnaires (or other ways to gather symptoms) might be able to confirm there is a problem, but can’t tell us the cause.
Diagnosing APD by symptoms?
Cognition
Language
Auditory processing
Questionnaires (self-report, other-report)
89
APDQ
BMQQ
CHAPS
CHILD
CCC-2
FAPC
LIFE
SAB
SIFTER
TEAP
TLI
ECLiPS
90
The Auditory Processing Domains
Questionnaire
O’Hara and Mealings (submitted)
50 items, 3 scales
AttentionLanguage abilities
Auditory processing abilities
Separation of groups using the attention and auditory processing scalesAPDQ.NAL.gov.au
Att
enti
on
Auditory processingA
tten
tio
nAuditory processing
Remediation of auditory processing disorders
1. Deficit-specific training
2. Generalised auditory trainingManagement by improved SNR
+
93
LiSN & Learn – Preliminary Study
• 9 children with SPD (6 to 11 years)
• LiSN & Learn – 2 games/day, 5 days/week, 12 weeks
LiS
N&
Le
arn
SR
T (
dB
)
Bett
er
Game Number
10 dB
Cameron & Dillon (2011)
Average SRT
First vs Last 30 Days
p = 0.000052
96
Experiment 1: Effect of training on LiSN-S scores
Low cue
High Cue
Talker advantage
Spatial advantage
Total advantage
LiSN-S scale
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
0.5
1.0
LiS
N-S
sco
re (p
op
n S
D u
nits
)
Pre
Post
Follow-up
97
Experiment 2: Blinded randomized controlled trial
Earobics (n = 5) Lisn & Learn (n = 5)
98 Cameron, Glyde & Dillon (2012)
p = 0.5 to 0.7 p = 0.03 to 0.0008
Questionnaire results
Parents Children
L.I.F.E. Student pre L.I.F.E. student post
TIME
40
60
80
100
120
140
160
180
200
DV
_1
Group L&L
Group Earobics
L&L Earobics
Group
-10
-5
0
5
10
15
20
25
30
35L
.I.F
.E T
ea
che
r p
ost
Fisher pre Fisher post
TIME
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
DV
_1
Group L&L
Group Earobics
Parents Children
Teachers
99
Effectiveness of remediationCameron & Dillon (2011)Cameron et al (2012)Cameron et al (2014)Cameron et al (2015)Graydon et al (2018)
Necessary steps to show that remediation is effective
• Test scores increase
• Increase in test scores is not due to:• Practice effects on the test known test-retest statistics
• Regression to the mean double baseline testing
• Placebo effect randomized controlled trial
• Increase in age age-adjusted scores, control group
• Similarity of training to test independent outcome test
• Improved listening ability generalizes to real life, evidenced by• Speech understanding in realistic acoustic conditions, and/or
• Self-report or others-report
100
1. Universal test of listening difficulties
Test must require:• All the signal analysis skills needed to identify speech
• Attention, working memory and language skills needed to understand speech
Test could comprise:• Sentence material, with syntactic, semantic & prosodic cues available
• Competing talkers, spatially separated from target
• Fast speaking rate
• Reverberation (typical amount)
Auditory processing Speech processing Language processing
• Auditory filtering• Envelope analysis• Temporal fine structure• Spatial analysis• Pitch contour analysis
• Comparison to stored templates (phonemes, syllables or words)
ComplexSignals analysed
Phonemes, syllables or
words identified Under-standingAuditory (speech)
input
Spatial cues
NoiseReverb
Rate
• Linguistic knowledge• Morphology knowledge• Syntactic knowledge• Semantic knowledge• Prosody knowledge• Working memory• World knowledge
Syntactic cues
Semantic cues
Prosodic cues
Message length
Attention,Memory
Phonemic and lexical neighbourhood density
Test of Listening Difficulties – Universal (ToLD-U)Auditory, speech and language processing (Told-U)
102
2. Objective versus subjective assessment of listening difficulties
Test of speech understanding
(ToLD-U)
Self- or parent report(APDQ, ECLiPS)
Electrophysiological measure
(cABR, CAEP in noise,)
103
3. Create and norm new adaptive tests (where needed)
Temporo-frequency resolution
Time
Freq
uen
cy
Time
Freq
uen
cyGap detection
Time
Freq
uen
cyOrder detection
Time
Freq
uen
cy
Localization
Dichotic
Spatial processing
104
4. Which types of auditory processing deficits correlate with poor speech perception and listening difficulties?
Temporo-frequency resolution
Time
Freq
uen
cy
Time
Freq
uen
cyGap detection
Time
Freq
uen
cyOrder detection
Time
Freq
uen
cy
Localization
Dichotic
Spatial processing
Test of speech understanding
(ToLD-U)
Self- or parent report
(APDQ, ECLiPS)
105
5. Correcting AP test results for cognition and language• Determine impact of memory and attention
(and IQ and language) on each age-corrected test.
• Derive corrections needed for each APD test in battery.
Memory z-score
AP ability
Attention z-score
Language z-score
Non-verbal IQ
AP2
AP5
AP6
AP8
Memavg AttenavgNVIQ
AP1
AP3
AP4
AP7correlation and slope!
106
Causation …….. unknown
Cognitive abilities
Language abilities
Auditory processing
abilities
Academic abilities
Reported listening ability
107
6. What is the effect of cognitive vs auditory training?
Auditory processing score
Memory score
Attention score
Listening difficulty score
Auditory processing score
Memory score
Attention score
Listening difficulty score
Language training
Does Cog APD, or APD Cog, or something else cause both?
Ditto for language training
108
7. Miscellaneous ideas
• Create a clinical test of backward masking, and measure normative performance and performance in kids with SLI.
• Create a sensitive dichotic test without challenging memory or executive function
• Compare behavioural results to electrophysiological results for stimuli chosen to expose specific deficits & examine sensitivity for individuals
• Explore relationship between temporal order perception (FPT and DPT), cognitive abilities, speech intelligibility, and reported listening difficulties.
109