controversy current issues in auditory processing...

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Current Issues in Auditory

Processing Disorders

Sarah Angerman, Ph.D., CCC-A

Dept. of Speech-Language-Hearing Sciences

University of Minnesota—Twin Cities

Controversy

� “…there is currently great divisiveness in the field of audiology concerning CAPD. There is no broadly accepted definition of CAPD. No one really knows what causes CAPD. Despite lofty claims to the contrary, there is no clear consensus concerning the battery of tests that lead to a diagnosis of CAPD. Similarly, there is no widely accepted auditory (re)habilitation program that has been conclusively shown to help those with CAPD…We are hamstrung by the lack of agreement in definitions and test batteries in the area of CAPD” (Burkard, 2009, p. vii).

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Kamhi (2011)

� “Given the lack of consensus about how to diagnose APD, it should not be

surprising that there is still some question about whether APD is truly a

distinct clinical entity…[the] alternative is to view auditory processing

problems as one of a number of deficits that are commonly found in

developmental disorders” (p. 268).

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ASHA (1996)—Definition

� “central auditory processes are the auditory system mechanisms and processes responsible for the following behavioral phenomena:

� sound localization and lateralization

� auditory discrimination

� auditory pattern recognition

� temporal aspects of audition: resolution, masking, integration, ordering

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ASHA (1996)—Definition

� auditory performance decrements with competing acoustic signals

� auditory performance decrements with degraded acoustic signals” (p. 5).

� “A Central Auditory Processing Disorder (CAPD) is an observed

deficiency in one or more of the above-listed behaviors” (p. 5).

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ASHA (2005a)—Definition

� (C)APD: “difficulties in the perceptual processing of auditory information in the CNS as demonstrated by poor performance in one or more of the above skills” (p. 2)

� referencing the same skills as ASHA (1996)

� the same auditory deficit will impact individuals differently

� some will show problems with speech, language, reading, spelling, or learning, and others will not

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ASHA (2005b)

� multidisciplinary assessment is appropriate

� audiologist, SLP, educational psychologist

� because it is an auditory deficit, audiologists should diagnose it

� SLPs may assist in determining other

language or communicative ramifications of (C)APD

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Bellis (2003)

� common indicators of APD (p. 173)

� behaves as if a peripheral hearing loss is present when it is not

� demonstrates scatter across the subtests of speech/language and cognitive tests

� verbal IQ lower than performance IQ

� requires a highly organized classroom

� difficulty following multistep directions

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Bellis (2003)

� poor reading and spelling skills

� refuses to participate in class discussions

� responds inappropriately during class discussions

� withdrawn or sullen

� positive history of otitis media or other otologic or neurologic disorders

� poor singing or music skills

� poorer gross and fine motor skills1010

Testing for APD

� “sensitized” tests employ auditory stimuli that are challenging to perceive

� limit stimulus redundancy or increase stimulus complexity

� the difficulty inherent in the tasks makes them susceptible to measuring

non-auditory factors

� e.g., sustained or divided attention, memory, linguistic processing, cognition

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Typical Categorization

� dichotic speech tests

� temporal processing tests

� monaural low-redundancy

� binaural interaction

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Screening Measures

� SCAN-3: C (ages 5 to 12 years)

� SCAN-3: A (ages 13 to 50 years)

� contain subtests assessing:

� gap detection

� speech-in-noise

� competing words

� filtered words

� competing sentences

� time-compressed sentences

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Screening Measures

� Differential Screening Test for Processing (DSTP)

� assesses three levels of processing:

� acoustic: dichotic digits, temporal patterning, auditory discrimination

� acoustic-linguistic: phonemic and phonic manipulation

� linguistic: antonyms, prosodic interpretation, language organization

� norms for ages 6 to 12 years14

Screening Measures

� Auditory Skills Assessment (ASA)

� assesses three areas of processing:

� speech discrimination: speech-in-noise and mimicry

� phonological awareness: blending and rhyming

� nonspeech processing: tonal discrimination and tonal patterning

� norms for ages 3:6 to 6:11 years

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Testing of Related Skills

� prior to or in conjunction with an auditory processing assessment, clients/parents should pursue assessments of any other areas of concern

� speech

� language and phonological processing

� auditory perception and memory

� literacy

� intelligence

� achievement

� attention16

Potential Contraindications to

Assessing (C)APD

� any degree of hearing loss

� mental age below 7 or 8 years

� young children or those with developmental delay

� significant traumatic brain injury

� veterans

� extreme hyperactivity

� emotional or behavioral disorders that limit cooperation

� non-native speaker of English

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Auditory Development

Whitelaw and Yuskow (2006), p. 30

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Neuroplasticity

� experience-expectant development

� stimulation is necessary during sensitive periods to ensure proper brain function and structure

� experience-dependent development

� unique personal experiences shape brain modifications throughout the entire lifetime

� if auditory skills are delayed, therapy may provide the stimulation necessary to improve brain function

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Etiology

� children may appear to have APD for one of the following reasons:

� delayed auditory development

• some children may “catch up” with age, whereas others may remain “disordered”

� lesion or disease

• seizures, TBI, concussion, demyelinating disease

� cerebral morphologic abnormalities

• genetic differences in brain morphology 20

APD in Older Adults

� even when audibility is accounted for, older adults show declines in auditory processing:

� speech recognition of fast speech or speech-in-noise

� temporal processing

� gap detection

� declines also occur for cognitive factors

� processing speed

� sustained and divided attention

� working memory20

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APD vs. ADHD

� significant overlap in the behaviors used to describe the two conditions

� possible options:

� separate clinical entities

� part of the same disorder

� comorbid disorders

� mistaken for one another

� causally related to one another

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Chermak et al. (2002)

� survey mailed to 100 audiologists and 100

pediatricians

� contained 58 behaviors compiled from checklists designed to evaluate APD or ADHD

� rating scale from 1 (never observed) to 5 (always observed)

� 26 pediatricians and 38 audiologists responded

� mean ratings calculated for each behavior

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Chermak et al. (2002)

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Conceptual vs. Diagnostic

Overlap of APD and ADHD

� Cacace and McFarland (2003) criticize the analysis of Chermak et al. (2002)

� when all the data is included in the statistical analysis (not just the top-ranked data), the data sets for the two disorders are highly correlated

� although Chermak et al. address the conceptual overlap of the disorders, their data do not adequately address the diagnostic overlap

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Medwetsky (2011)

� spoken language processing model

� acoustic signal transduction

� decoding

� short-term memory

� attentional allocation

� selective attention

� auditory-linguistic integration

� sequencing

� phonological awareness 26

Medwetsky (2011)

� processing breakdowns

� impaired neural transmission

� poor temporal resolution

� slow lexical-decoding speed

� lack of interhemispheric transfer to integrate linguistic and suprasegmental

information

� difficulty sequencing

� fading short-term memory

� issues with selective auditory attention

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Sharma et al. (2009), p. 714 Moore et al. (2010), p. e384

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FIGURE 1. Schematic diagrams of individual (BM0, BM50, SM, SMN, and FD)

and derived (TR and FR) AP tests. Each set of 3 boxes designates successive

sound presentation intervals of noise or quiet. Lines are target tones. The “odd

one out” is shown in the middle interval but could occur (randomly) in any

interval.

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Moore et al. (2010), p. e385

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FIGURE 2. Box plot distributions of AP thresholds among children 6 to 11 years of age

for 3 individual tests of AP (A) and derived tests of AP (B), demonstrating variations in

AP with age and across tests. Box plots show the median (horizontal line, the inter-

quartile range (25%–75%, box) and the minimum and maximum values (whiskers).

Moore et al. (2010), p. e386

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FIGURE 3. Reduced cognitive performance for children with poorer AP. Mean

standard scores and 95% confidence intervals for each cognitive test for

children in the upper 95% (typical) or lower 5% (poorer) of performance

(threshold) on each AP test are shown. NVIQ indicates nonverbal IQ; NW-rep,

nonword repetition test; TOWRE, Test of Word Reading Efficiency.

Moore et al. (2010), p. e387

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FIGURE 4. Reduced communication, listening, and speech-in-noise skills for

children with poorer AP. A, Histograms of standardized, whole-population scores

for each presentation test. B, Mean scores (or median CHAPPS scores) and 95%

confidence intervals for each test. Arrows in A mark the mean scores for the tests

in B with the greatest difference between typical (T) and poorer (P) performers.

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Ferguson et al. (2011), p. 221

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Wallach (2011)

� “Professionals may look at children and adolescents with language-

learning, literacy, and academic problems through different lenses, but

behind the lenses is the common goal of helping the children develop the

knowledge, skills, and strategies needed to survive and thrive in their

classrooms and communities” (p. 275).

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Kamhi (2011)

� current clinical categories: APD, ADHD, Sensory Integration Disorder (SID)

� processing abilities that most affect language and reading: working memory,

speed of processing, phonological memory, phonological awareness, and

rapid serial naming

� Why are these areas not labeled with their own clinical category? Professional territory and lack of “meme” status.

Richard (2011)

� “Do problems in accurately processing an acoustic signal always lead to language-learning difficulties? No. Can problems in accurately processing an acoustic signal lead to language-learning difficulties? Yes. The 2007 ad hoc committee members were in agreement that APD as a clinical entity probably served no purpose if educational or life functions were not negatively impacted. Individuals with diagnosed APD might compensate well, resulting in no experienced deficits or academic problems” (p. 299).

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ASHA Ad Hoc Committee

� in 2007, ASHA formed the Ad Hoc Committee on the Role of the Speech-

Language Pathologist in Identifying and Treating Children with Auditory

Processing Disorders

� LSHSS published a series of articles

in July 2011 regarding APD and SLPs

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Fey et al. (2011)

� systematic review of 25 studies documenting the effects of auditory vs. language interventions for children with APD or spoken language disorder

� auditory interventions: traditional auditory training, auditory integration training, Fast ForWord, and Earobics

� “…we found no compelling evidence that existing auditory interventions make any significant contributions to auditory, language, or academic outcomes…” (p. 254) 38

Fast ForWord vs. Traditional

Therapy

� Gillam et al. (2008)—four groups:• Fast ForWord

• academic enrichment

• computer assisted language intervention

• individualized language intervention

� all groups improved on global language testing and backward masking

• children with backward masking issues who engaged in Fast ForWord did not show differential effects

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Kamhi’s (2011) Suggestions

to SLPs (p. 270)

� “Do not assume that a child who has been diagnosed with APD needs to be treated any differently than children who have been diagnosed with language and learning disabilities.”

� “Do not provide auditory intervention for a child who has been diagnosed with APD…Language interventions are just as effective as auditory interventions in improving a child’s auditory abilities.”

� “Perform a comprehensive assessment of the child’s speech, language, and literacy abilities…” 40

Kamhi’s (2011) Suggestions

to SLPs (p. 270)

� “Consider non-auditory reasons for listening and comprehension difficulties, such as limitations in working memory, attention, motivation, language and conceptual knowledge, and inferencing abilities.”

� “Target speech, language, literacy, and knowledge-based goals in therapy.”

� “Avoid goals that target…auditory discrimination, phonological memory, working memory, or rapid serial naming. There is no compelling evidence that targeting these skills significantly improves a child’s language or reading ability.”

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Angerman & DeRuiter (2011)

� purpose:

� to examine the relationship between oral language skills and measures of auditory processing

� hypothesis:

� performance on tests of oral language will correlate highly with performance on tests of auditory processing, indicating that the disorders either commonly co-exist or are one in the same 4242


� participants:

� 18 children ages 8 to 17 years

(11 females and 7 males)

� 9 adults ages 19 to 44 years

(7 females and 2 males)

� all were self-referred or referred for testing by a professional in the community through word-of-mouth

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� preliminary testing:� audiological evaluation including pure-tone

audiometry and supra-threshold word recognition in quiet

� tympanometry and acoustic reflexes

� otoacoustic emissions

� auditory brainstem and middle latency responses

� vision screening

� Test of Nonverbal Intelligence-III

� Auditory Continuous Performance Test

� case history 4444


� auditory processing test battery:� SCAN-C or SCAN-A

� Dichotic Digits Test (DDT)

� Competing Sentences Test (CST)

� Staggered Spondaic Words Test (SSW)

� Time-Compressed Speech Test (TCS)

� Speech-in-Noise Difference (SND)

� Frequency or Duration Pattern Test (F/DPT)

� Random Gap Detection Test (RGDT)

� Spondee Binaural Fusion (SBF)

� Masking Level Difference-Spondees (MLD-S)

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� language processing test battery:� Expressive Vocabulary Test-2nd Edition (EVT)

� Peabody Picture Vocabulary Test-4th Edition (PPVT)

� Comprehensive Assessment of Spoken Language (CASL Comp)

� Comprehensive Test of Phonological Processing (CTOPP)

• Phonological Awareness (CTOPP PA)

• Phonological Memory (CTOPP PM)

• Rapid Naming (CTOPP RN) 4646


� language processing test battery (cont.):� Gray Oral Reading Test-4th Edition (GORT

ORQ)

� Test of Auditory-Perceptual Skills-Revised (TAPS-R APQ)

� Woodcock-Johnson-3 Test of Achievement

� Token Test or Revised Token Test

� Symbol Digit Modality Test

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� categorizing test results:

� auditory processing testing

• “failure” is defined as below normal performance on multiple tests designed to assess the same auditory skill

• “borderline” performance is defined as failure on several tests, but passing scores on other tests designed to assess the same auditory skills

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� categorizing test results:

� language processing testing

• “failure” is defined as full-scale performance greater than or equal to 2 SD below the mean on two or more tests

• “borderline” performance is defined as failure on one test accompanied by failure on a cluster score from a second test

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Pass Borderline Fail

Children 8 3 0

Adults 4 1 3

Children 0 3 1

Adults 0 0 0

Children 1 1 1

Adults 0 0 1

Pass

Borderline

Fail

Auditory Tests

Language

Tests

Matrix showing the number of children and adults who passed,

failed, or showed “borderline” results for the auditory processing and language tests.

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� 9 of the 18 children passed the auditory

testing, 7 were considered “borderline,”and 2 failed

� 11 of the 18 children passed the language

testing, 4 were considered “borderline,”and 3 failed

� 4 of the 9 adults passed the auditory

testing, 1 was considered “borderline,” and 4 failed

� 8 of the 9 adults passed the language testing and 1 failed

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Angerman & DeRuiter (2011)Auditory Processing Test Performance

0

10

20

30

40

50

60

SCAN DDT CST SSW TCS SND FPT DPT RGDT SBF MLD-S

Auditory Processing Measures

Pe

rce

nta

ge

of

Fa

ilu

res

child

adult

Histogram showing the percentage of children and adults who

failed each auditory processing test. Numbers in the bars indicate

the number of participants who were administered the test.

18 9 18 9 18 9 18 9 18 9 13 5 9 18 9 14

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Angerman & DeRuiter (2011)Language Test Performance

0

10

20

30

40

50

60

EVT PPVT CASL Comp CTOPP PA CTOPP PM CTOPP RN GORT ORQ TAPS-R APQ

Language Measures

Pe

rce

nta

ge

of

Fa

ilu

res

child

Histogram showing the percentage of children who failed each

language test. Numbers in the bars indicate the number of

children who were administered the test.

13 18 17 18 18 18 14 15

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� as a group, the children showed more difficulty with expressive than

receptive vocabulary (EVT vs. PPVT)

� the language measures that produced

the greatest difficulty for children involved rapid naming (CTOPP RN),

reading (GORT APQ), and auditory memory (TAPS-R APQ)

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� anecdotal findings:

� two of the child participants who had IQ scores in the superior range (144 and >160) showed normal results for all auditory and language measures

• they were referred by teachers who were concerned about distractibility in the classroom

• these children may have simply been under-challenged, and therefore more inclined to become off-task

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� two of the adults who failed the auditory processing testing reported a history of concussion during a motor vehicle accident, which suggests the presence of traumatic brain injury

• both participants showed normal language findings, but auditory processing deficits

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� one of the child participants demonstrated inconsistent results suggestive of malingering

• pseudohypacusis

• the child then showed conflicting results on the auditory processing assessment (e.g., time-compressed word recognition scores that were 20% higher than the word recognition scores obtained for words presented at the normal rate)

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� clinical implications:

� communication difficulties may be misinterpreted by parents, professionals, and patients

• what may appear to be an auditory processing weakness may actually be a language impairment or vice versa

� evaluations of auditory processing should be paired with speech-language assessments to confirm the true deficit

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Acknowledgments

� principal investigator:

� Mark DeRuiter, MBA, PhD, CCC-A/SLP

� speech-language colleagues

� Marilyn Fairchild, MA-TESL, MA, CCC-SLP

� Linda Hinderscheit, MA, CCC-SLP

� Becky Lulai, MA, CCC-SLP

� data analysis

� Mary Carpenter, SCSU graduate student

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References

� American Speech-Language-Hearing Association. (1996).

Central auditory processing: Current status of research and

implications for clinical practice [Technical Report]. Retrieved

from http://www.asha.org/docs/pdf/TR1996-00241.pdf

� American Speech-Language-Hearing Association. (2005a).

(Central) auditory processing disorders [Technical Report].

Retrieved from http://www.asha.org/docs/pdf/TR2005-00043.pdf

� American Speech-Language-Hearing Association. (2005b).

(Central) auditory processing disorders—The role of the

audiologist [Position statement]. Retrieved from

http://www.asha.org/docs/pdf/PS2005-00114.pdf

� Angerman, S.K., & DeRuiter, M. (2011, November). Auditory

and language processing correlates in children and adults.

Poster presented at the American Speech-Language-Hearing

Association Annual Convention, San Diego, CA.

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References

� Bellis, T.J. (2003). Assessment and management of central

auditory processing disorders in the educational setting: From

science to practice (2nd ed.). San Diego: Singular.

� Burkard, R. (2009). Foreword. In A. Cacace & D. McFarland

(Eds.), Controversies in central auditory processing disorder

(pp. vii-viii). San Diego, CA: Plural.

� Chermak, G.D., Tucker, E., & Seikel, J.A. (2002). Behavioral

characteristics of auditory processing disorder and attention-

deficit hyperactivity disorder: predominantly inattentive type.

Journal of the American Academy of Audiology, 13, 332-338.

� Ferguson, M.A., Hall, R.L., Riley, A., & Moore, D.R. (2011).

Communication, listening, cognitive and speech perception

skills in children with auditory processing disorder (APD) or

specific language impairment (SLI). Journal of Speech,

Language, and Hearing Research, 54, 211-227.

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References

� Fey, M.E., Richard, G.J., Geffner, D., Kamhi, A.G., Medwetsky,

L., Paul, D., Ross-Swain, D., Wallach, G.P., Frymark, T., &

Schooling, T. (2011). Auditory processing disorder and

auditory/language interventions: An evidence-based systematic

review. Language, Speech, and Hearing Services in Schools,

42, 246-264.

� Gillam, R.B., Loeb, D.F., Hoffman, L.M., Bohman, T., Champlin,

C.A., Thibodeau, L., Widen, J., Brandel, J., & Friel-Patti, S.

(2008). The efficacy of Fast ForWord language intervention in

school-age children with language impairment: A randomized

controlled trial. Journal of Speech, Language, and Hearing

Research, 51, 97-119.

� Kamhi, A.G. (2011). What speech-language pathologists need

to know about auditory processing disorder. Language, Speech,

and Hearing Services in Schools, 42, 265-272.

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References

� Medwetsky, L. (2011). Spoken language processing model:

Bridging auditory and language processing to guide

assessment and intervention. Language, Speech, and Hearing

Services in Schools, 42, 286-296.

� McFarland, D.J., & Cacace, A.T. (2003). Potential problems in

the differential diagnosis of (central) auditory processing

disorder (CAPD or APD) and attention-deficit hyperactivity

disorder (ADHD). Journal of the American Academy of

Audiology, 14, 278-280.

� Moore, D.R., Ferguson, M.A., Edmondson-Jones, A.M., Ratib,

S., & Riley, A. (2010). Nature of auditory processing disorder in

children. Pediatrics, 126, e382-e390.

� Richard, G.J. (2011). The role of the speech-language

pathologist in identifying and treating children with auditory

processing disorder. Language, Speech, and Hearing Services

in Schools, 42, 297-302.

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References

� Sharma, M., Purdy, S.C., & Kelly, A.S. (2009). Comorbidity of

auditory processing, language, and reading disorders. Journal

of Speech, Language, and Hearing Research, 52, 706-722.

� Wallach, G.P. (2011). Peeling the onion of auditory processing

disorder: A language/curricular-based perspective. Language,

Speech, and Hearing Services in Schools, 42, 273-285.

� Whitelaw, G.M., & Yuskow, K. (2006). Neuromaturation and

neuroplasticity of the central auditory system. In T.K.

Parthasarathy (Ed.), An introduction to auditory processing

disorders in children (pp. 21-38). New York: Lawrence

Erlbaum Associates.

controversy current issues in auditory processing...

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