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Auditory and Language Processing Disorders: 

Assessment & Intervention

Gail J Richard, PhD, CCC‐SLPgjrichard@eiu.edu

Speaker Disclosure• Financial

o Receive royalties from ProEd publications• The Source ‐ Processing Disorders• The Language Processing Test• Language Processing Treatment Activities• Differential Screening Test for Processing Disorders• That’s Life Language Cards

o Revenue share from MedBridge courseso Royalties from Dynamic Resourceso Honorarium and travel reimbursement 

• Nonfinancialo Author of several book chapters and articles on  processing 

Historical Perspective1954 – Myklebust – “auditory processing” in Auditory Disorders in

Children

1962 – Vygotsky – “processing” in Thought and Language: relation between thought and words not a thing but a process -continuous back and forth movement from thought to word and word to thought

1978 – Weisenberg & Katz – “central auditory processing” inNeurological considerations in audiology:ability to receive and integrate auditory information

2005 – ASHA Working Group on Central Auditory Processing Disorders: perceptual processing of auditory information in the CNS and neural activity that underlies that processing

2007 – ASHA Ad Hoc Committee on Role of SLP in APD

2011 - LSHSS July Clinical Forum

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Clinical Forum – LSHSS 2011

• Kamhi – not a definitive clinical entity

• Wallach – processing layers –need to peel back and address functionally

• Medwetsky – auditory phenomena

Impact of Processing on Learning• 1967 ‐ Johnson & Myklebust: LD as disturbance in processing interfering with language comp. & verbal expression

• 1966 ‐ Cruickshank: most LD result of processing deficits

• 1981 ‐ Gerber & Bryen: processing difficulties result in school failure

• 2005 – ASHA Working Group: processing deficits may lead to or be associated with difficulties in learning

Major Points to Consider• The problem is NOT in reception of signal• Repeating the signal is minimally helpful• Individuals process stimuli in different

ways• Cues provide orientation, not the answer• Processing occurs ‘on top’ of basic

knowledge

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Auditory Processing Defined• Efficiency and effectiveness by which CNS utilizes auditory information 

(ASHA, 2005a) characterized by … • poor performance in one or more of the following skills

o Sound localization and lateralizationo Auditory discriminationo Auditory pattern recognitiono Temporal aspects of audition (e.g., temporal integration, 

discrimination, ordering, masking)o Auditory performance in competing acoustic signals (e.g., dichotic)o Auditory performance with degraded acoustic signals (ASHA, 2005b)

(Central auditory processing disorders: The role of the audiologist:a = Technical report; b = Position statement)

Definition: Language Processing• Ability to abstract meaning from an acoustic stimulus

(Massaro, 1983)

• Ability to interpret or attach meaning to auditorilyreceived information to then formulate an expressive response (e.g., behavior, gesture, verbal, written)

(Richard, 2017, 2001)

Typical  Problems Resulting from Processing

• Reading• Spelling• Splintered Academics• Written Language

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Language Processing /Top Downo Language info in mind of listener, not auditory

signal

• Listener uses knowledge of language and world to interpret speaker’s message

• Process acoustic signal using lexical/semantic knowledgeo familiar processed quickero discriminate significant features

Auditory Processing/Bottom Up• Auditory processing is a “pre-linguistic” skill

with acoustic info processed before linguistic

• Acoustic signal processed before being influenced by higher order knowledge

• Sound identification necessary prerequisite to speech-language development

• Tallal research: children with LD have deficits in rapid transition of both linguistic and non-linguistic signals

Resolution• Processing is actually INTERACTIVE• Type of processing depends on task

oTimes when focus on signal with minimal linguistic processing needed

oTimes when hear message but can’t understand message

• Most processing involves both signal processing & higher order processingoContinual fluctuation between signal

(auditory) and cognitive (language)• Different processing styles

Duchan & Katz, 1983

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TOP DOWNLanguage Processing

Knowledge of language& world to interpret

Semantic knowledge

Stress comprehensionand intake

BOTTOM UP

Auditory Processing

Acoustic Informationbefore linguistic interp

Acoustic knowledge

Stress productionand output

“Language shapes culture, language shapes thinking – and language shapes brains. The verbal bath in which a society soaks its children arranges their synapses and their intellects; it helps them learn to reason, reflect, and respond to the world.”

Jane Healy, Endangered Minds (1990)

Neuropsychology:  Science of brain‐behavior relationships

• All behavior mediated by CNS• CNS composed of brain, brainstem, spinal cord• Impairment in CNS will interfere with learning • Brain dysfunction = interference in behavior

oneurological model of diagnosis more objectiveo intervention only as effective as diagnosisoneed to understand interference to remediate

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A.R. LURIAFunctional Organization of the Brain

• Brain structures all play highly specific  role & all under coordinated control

• Every mental activity affected through joint activity of discrete cortical systems

• When one system fails, behavior fails ‐ but other parts secondarily resume that functionobehavior returns in limited  wayo localization in diagnosis/remediationo individual differences as opposed to labels

Luria, 1970

FIRST  FUNCTIONAL  UNIT = RETICULAR FORMATION

• Neurological readiness to interact with environment

• Energy system for  cortex• Brainstem = midbrain, pons, medulla oblongata• Maintain attentive state to incoming signals• Awakens brain; keeps it alert; directs neural traffic

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SECOND  FUNCTIONAL UNIT = PARIETAL, OCCIPITAL, TEMPORAL LOBES

• Posterior two‐thirds of cortex• Isolate neural impulses into discrete areas for analysis, storage, coding, organizationoVisual stimuli = OccipitaloTactile stimuli  = Parietalo Auditory stimuli = Temporal

• Each cortical section further delineated into three zones

THIRD  FUNCTIONAL  UNIT =  FRONTAL LOBES

• Anterior one‐third of cortex, including frontal lobes, motor/pre‐motor cortex

• Active response through motoric expression to stimuli processed in second functional unit

• Planning and execution, managing of person’s behavior in relation to perceptions and knowledge ‐ through motor response

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PRIMARY  ZONE • Reception of incoming neural impulses

o Visual stimuli = Occipitalo Tactile stimuli = Parietalo Auditory stimuli = Temporal

• NOT involved in interpretation of meaningfulness of stimuli; only sensory analysis/sensation

• Impairment = sensory/perceptual impairment; not deficit in higher order processing

SECONDARY  ZONE• Organize incoming information according to rules of language ‐ attach meaning to input oVisual meaning = OccipitaloTactile meaning = ParietaloAuditory meaning = Temporal

• Interpretation through coding, organizing, associating, storing

• Integrate into meaningful experiences

TERTIARY  ZONE• Multisensory neural integration among sensory secondary zoneso integrate newly organized stimuli with stored information

o integrate discrete neural impulses between modality areas

• Coordinate higher level processingo integrate information from all corticesotransfer passive receptive input into active expressive output

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Second Functional Unit –Left Temporal Lobe

PRIMARY  SECONDARY TERTIARY

Auditory/acousticperception

Attach MeaningUse linguistic code

Integration/synthesis

What did I HEAR? What do I KNOW? What can I USE? (sensory) (language) (output)

Auditory  Language CorticalIntegration Integration Integration

new/oldx modal.rec/exp

analyzeorganizestore

MODEL  CONCLUSIONS• Model supports hierarchical integration of processing following neuromaturational order of zoneso zones develop maturationally in order ‐ primary, secondary, tertiary

o tertiary zone last to mature and most fragile• Progressive attachment of meaning to stimuli supports contribution of each level in hierarchy

• Concept integrates entire nervous system in thinking process

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CAP

• Most are male (75%)• Normal pure tone hearing• Trouble following directions• Short attention span• Poor memory• Don’t seem to pay attention• Poor listening in noisy environment• Trouble locating sound• Academic deficits• Behavior problems• Requests for repetition – “huh”• Otitis media

LANGUAGE PROCESSING• Word retrieval problems• Neutral generic language• Similar words• Original creative words• Response latency• “I don’t know”• Rehearsal• Inconsistent learning• Recognize but can’t fix errors• Incomplete expressive language• Pragmatic deficits; behavior problems• Age commensurate ability

Characteristics of Processing Disorders

• Overlap / Similarity in observed behaviors• Same behavioral symptom for different reasons

• Differential diagnosis important to determine appropriate intervention approach

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Semantic  Confusion• Processing• Auditory processing• Central auditory processing• Language processing

Adjunct Problems“Although abilities such as phonological awareness, attention to and memory for auditory information, auditory synthesis, comprehension and interpretation of auditorilypresented information, and similar skills may be reliant on or associated with intact auditory function, they are considered higher order cognitive communicative and/or language related functions and, thus are not included in the definition of (C)APD”  (ASHA 2005a)

APD vs. CAPD?• Myklebust, 1954 – “auditory disorder” – very broad term

o Intact peripheral hearingo Deficit ‐ability to listen and meaningfully respond to acoustic stimuli

o “central deafness” – problem in higher neurological levels of auditory system

o Auditory agnosia: can’t attend or comprehend  auditory input

• Weisenberg & Katz, 1978 – “Central auditory processing”o Post‐peripheral auditory deficito Difficulty in ability to receive and integrate auditory information 

• ASHA 2005 working group – (central) auditory processing disorder (C)APD – synonymous terms

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Consensus Definition of APD?• Multiple auditory skills encompassed within APD

o Diagnose by specific deficit skill or global APD?o How many auditory skills in deficit = APD?

• Battery of tasks/test for assessment of APDo Specific battery not specifiedo Variability among audiologists diagnosing APD

• Lack definitive standard for interpretation of APD testo Combination of observed clinical impressions and performance 

outcomes on assessment testso Recommendation: child perform 2 standard deviations below mean on 

two or more tests for APD diagnosis• Issues with specificity and validity of APD assessments• Need some guidelines for relationship between cognition, language skills, 

and performance on (C)AP tests (Friberg & McNamara, 2010)

Relationship of APD and LD?• Introduction of APD as clinical entity acknowledged impact of 

auditory deficits on language development (Myklebust, 1954; Johnson & Myklebust, 1967).

• Premise – address auditory perceptual deficits before languageo Challenged by Rees (1973) – futile effort to isolate specific auditory 

abilities as essential to language; artificial effort to make fito Continue to question auditory deficits as significant risk factor for 

compromised language development (Kamhi, 2011; Watson & Kidd, 2009)

• Influence of auditory perceptual abilities on language development in pre‐literacy skills (e.g., sound‐symbol recognition, discrimination)

• Acknowledge dynamic interaction between perception of acoustic signal and linguistic decoding to interpret meaning

Erroneous Diagnosis of APD?• Language developmental level influences performance on APD assessment 

tasks (e.g., directions of dichotic assessment task)• Referrals from adjunct professional disciplines (e.g., teacher, school 

psychologist)o Observe deficits in listening, auditory comprehension, discrimination for 

spellingo Assessment tasks or screening checklists that resulted in APD

• Failure to recognize global profile of child (e.g., ADHD, ASD, EF)• Early APD in conjunction with developmental delays resolved but diagnosis 

not changed• Imperative that AUD and SLP work together to determine primary deficits 

negatively impacting academic and functional performance (McNamara & Richard, 2012)

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Treatmentondiscreteauditoryskills=language/academicimprovement?• Evidence‐based systematic review (Fey et al., 2011)

• School‐aged children with diagnosed APD• Auditory –based treatment• Functional outcomes in auditory, language, or academic 

• Encountered challenges in conducting research review• Lack of standard definition for diagnosis of APD• APD co‐exists with reading, writing, learning disabilities• Intervention programs include both auditory and language aspects

• Most studies exploratory case studies• Gains in some specific isolated auditory skills, but no functional impact on language or reading measurements

• Failed to provide direction for SLPs responsible for treatment

TreatmentefficacyinAPD?• Heterogeneity of APD

• AP encompasses wide variety of skills• Co‐morbidity of APD with other spoken & written communication disorders (Sharma, Purdy, & Kelly, 2009)

• Treatment gains across all aspects of APD difficult• Lack of definitive assessment battery

• Fail to differentiate subtypes within APD• Treatment will be minimal across all types of APD

• Treatment programs combination of auditory and language • Difficult to attribute gains to auditory aspects of program• Confounding variables mitigates against significant results

GoalofTreatment?• Language / academic deficits rarely resolved through treatment focused only on isolated auditory skills

• APD may be diagnosis, but functional language objectives will yield more functional outcomes

• Goal of intervention – address presenting deficits• Major deficit in APD is difficulty abstracting encoded linguistic message – involves variety of competencies

• Will improvement in auditory skills have significant impact on functional language?

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Adequate Processing Involves Continuum of Skills

• Intact peripheral auditory system – perceive and receive acoustic stimulus

• Intact CANS – transmit through brainstem to upper cortex

• Phonemic knowledge to discriminate aspects of the acoustic stimulus

• Linguistic knowledge to decode message• Executive function skills to attend, organize, execute behavioral response

Continuum  of  Processing

Auditory Processing Language Processing

Transition AreaAcoustic / Phonemic Processing

audiologist speech-language pathologist

audiologist and speech-language pathologistRichard, 2017, 2001

• American Speech‐Language‐Hearing Association (2005). Technical Report from the Working Group on (Central) Auditory Processing Disorders. ASHA: Author.  

• Boswell, S., Bellis, T. & Richard, G. (2004) “Redefining Auditory Processing Disorder”. The ASHA Leader. Vol. 9:6, pp 7 & 21.• Ferre, J. M. (1997). Processing Power: A Guide to CAPD Assessment and Management. San Antonio, TX: The Psychological Corporation.• Ferre, J.M. (2002). Managing children's central auditory processing deficits in the real world: What teachers and parents want to know. 

Seminars in Hearing, 23(4):319‐26.• Fahy, J. &  Richard, G. (2017). The Source: Development of Executive Functions, 2nd ed. Austin, TX: ProEd.• Fey, M., Richard, G., Geffner, D., Kamhi, A., Medwetsky, L., Paul, D., Ross‐Swain, D., Wallach, G., 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.

• Friberg, J., & McNamara, T. (2010). Evaluating the reliability and validity of (Central)  Auditory Processing Tests: A preliminary investigation. Journal of Educational Audiology, 2

• Healy, J. (1990). Endangered Minds: Why Our Children Can’t Think. NY, NY: Simon & Schuster.• Jensen, E. (1998) Teaching with the Brain in Mind. Association for Supervision and Curriculum Development. Alexandria, VA..• Johnson,D., & Myklebust, H. (1967). Learning disabilities: Educational principles and practices. New York: Grune and Stratton, Inc.• Kamhi, A. (2011).   What speech‐language pathologist need to know about auditory processing disorder. Language, Speech, and Hearing 

Services in Schools, 42, 265‐272. • McFarland (Eds.), Controversies in central auditory  processing disorder  (pp. 218‐242). San Diego, CA: Plural. • McNamara, T. & Richard, G. (2012). Better together. The ASHA Leader. Vol.17:3, pp 12‐14.• Myklebust, H.R. (1954). Auditory Disorders in Children – A Manual for Differential Diagnosis. NY, NY: Grune & Stratton.• Richard, G. (2017). The Source: Processing Disorders, 2nd ed. Austin, TX: ProEd.• Richard, G. (2013). “Language Processing versus Auditory Processing”. In Auditory Processing Disorders: Assessment, Management and 

Treatment – 2nd ed  (D Geffner & D. Ross‐Swain). Plural Publishing; San Diego, CA.• Richard, G. (2012). Primary issues for the speech‐language pathologist to consider in regard to diagnosis of  auditory processing 

disorder. Perspectives on Language Learning and Education, 19, 78‐86. • Richard, G. (2011). Prologue: The role of the speech‐language pathologist in identifying and treating children with auditory processing 

disorder. Language, Speech, and Hearing Services in Schools, 42, 241‐245• Richard, G. (2011). Epilogue: 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.• Richard, G. (2009). That’s Life! Language Cards. East Moline, IL: LinguiSystems/ProEd.• Richard, G. & Hanner, M. (2007). Language Processing Treatment Activities. East Moline, IL: LinguiSystems/ProEd• Richard, G. & Ferre, J. (2006). Differential Screening Test for Processing. East Moline, IL: LinguiSystems/ProEd.• Richard, G. & Hanner, M. (2005). The Language Processing Test 3. East Moline, IL: LinguiSystems/ProEd.

• Saxe, J.G. (1816‐1887). The Blind Men and the Elephant. 

REFERENCES

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