Differential Diagnosis & Intervention of

Central Auditory Processing Disorders

Annette Hurley, PhD

November 21, 2014
Session 1405

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 Disclosure

Annette Hurley, PhD has no conflict of interest or financial

interest to disclose.

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 Agenda:
 Brief Historical Perspective of CAPD
 CAPD Screening
 CAPD Test Battery
 Test Interpretation
 CAPD vs Look-A-Likes
 Language Processing
 ADHD
 ANSD
 Autism
 Management
 Formal
 Informal
 CASES
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 In the News
 An auditory processing disorder constitutes an “other health
impairment” under the Individuals with Disabilities
Education Act, according to a recent court decision by the
U.S. Ninth Circuit Court of Appeals.

The ASHA Leader, September 2014, Vol. 19, online only.

doi:10.1044/leader.NIB6.19092014.14

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 When did CAPD begin?
 Mykelbust (1954) recognized a disorder of auditory
perception in children with normal hearing.
 Reported the children could hear sound, but are unable to
recognize the sounds they hear.
 Difficulty understanding in noise.

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 Brief History…
 1970s Central Auditory Dysfunction Symposium …name eventually became Central
Auditory Processing Dysfunction…CAPD.

 Work of Paula Tallal 1970’s children with “developmental dysphasia” also had
underlying temporal processing disorders…could not distinguish between stop
consonants.
 ASHA Working Group on CAPD (1996, 2005)

 Bruton Conference (2000) AAA: did not want to put an anatomical description

 AAA Clinical Practice Guidelines: Diagnosis, Treatment and Management of

Children & Adults with Central Auditory Processing Disorder

 Still no clear consensus on what is (C)APD…how is it

defined…how is it diagnosed…and how it is treated.

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 Area of Renewed Interest
 Is it real?
 Modality Specific? Is the brain modality specific?
 Area of Interest or Renewed Interest
 Does it truly exist?
 Who can diagnosis CAPD?
 No gold standard for assessment
 No gold standard for interpretation
 What constitutes a deficit?

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 CAPD Definitions…..
“ASHA (2005) Broadly stated, (Central) Auditory
Processing as referring to the efficiency and
effectiveness by which the central nervous system
(CNS) utilizes auditory information.

Narrowly defined, (C)AP refers to the perceptual

processing of auditory information in the CNS and
the neurobiologic activity that underlies that
processing and gives ride to electrophysiologic
potentials.”
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 What is (C)APD?
 (C)APD is a deficit in the neural processing of
auditory stimuli that is not due to higher-order,
cognitive, or related factors, yet (C)APD may be lead
to or be associated with difficulties in higher order
language learning, cognitive, and communication
functions.” (ASHA, 2005)

 (C)APD can coexist with other disorders such as

language impairment, ADHD, and learning
disabilities.

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 Other Definitions of (C)APD
“(C)APD is a deficit in the auditory pathways of
the brain that results in the inability to listen to or
to comprehend auditory information accurately
even though normal intelligence and hearing
sensitivity are documented (1986).”
Bob Keith, Ph.D.

“What we do with what we hear.”

Jack Katz, Ph.D.

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 The Nature of CAPD
 Who diagnoses CAPD?
 Other professionals
 Speech language pathologists
 Psychologists
 Educational Psychologists
 Physicians?

CAPD is not a “catch-all” term! Has overlapping

symptoms w/ language disorder, ADHD, and other
cognitive impairments.
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 Pre-testing considerations….
 Peripheral Hearing!!
 Age of the child (Chronological and Mental)
 Cognitive capacity
 Linguistic Capacity (native language)
 Attention
 Memory (7 year old who can only repeat 3
numbers
 Motivation

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 CAPD – Two Divergent Approaches

 Medical – Site of Lesion

 Educational – Auditory, Language,
Reading and Learning Disorders

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Whole Child
Development
Education
Difficulties
Coordination
Language
Temperament
Other….
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 Behavioral Characteristics noted:
 Difficulty hearing in noisy backgrounds
 Difficulty localizing the sound source
 Difficulty learning a foreign language
 Often asks for repetition
 Difficulty processing fast speech
 Inability to detect humor or sarcasm (prosody)
 Inappropriate responses
 Easily distracted by external stimuli
 Difficulty maintaining attention
 Difficulty following direction
 Poor musical ability
 Reading, spelling, and or learning problems.
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 A Boost to CAPD
 “Other health impairment”: A “chronic or acute health problem”
that “results in limited alertness with respect to the educational
environment” and that “adversely affects a child’s educational
performance” [34 C.F.R. 300.7(c)(9), (2005)].

 The symptoms, characteristics, and diagnosis of CAPD meet

these criteria: a chronic, medical condition; difficulty in
processing sound; and limited attention to oral communication
that can adversely affect a student’s ability to perform in a
classroom.
 The ASHA LEADER, September, 2014

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 A Boost…
 In further describing CAPD, court documents noted that it
encompasses an individual’s
 inability or difficulty to: identify the source of a sound;
 discriminate between sounds;
 determine similarities or differences in patterns of sound; sequence
sounds into words;
 understand speech when other sounds are present;
 understand sounds when part of the signal is missing or degraded
due to low frequency.
 In an educational or home setting, common symptoms of CAPD
are a child’s difficulty following oral instructions or directions,
difficulty hearing when there is background noise, poor listening
skills, distractibility, and inattention
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 Differential Diagnosis
 Often there are co morbid conditions
Difficulty with communication
 Academic Difficulties
 (ADHD/ADD)
 Language Disorders
 Learning Disorders
 Reading Disorders (dyslexia)

 Other Related Difficulties

 Acquired (CAPD)
 TBI

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 Things to Remember
 We are testing the auditory system at the acoustic level.
 The CAPD may not alone be the reason for the academic failure.
 Often see very bright individuals with CAPD--may have learned
to compensate for their difficulties.
 Often we see CAPD in existence with language processing,
phonological disorders, or dyslexia.

 We know that training can improve deficits noted in the auditory

system.

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 Screening for CAPD

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 Questionnaires
 Based upon the assumption that children and adults with
CAPD have distinctive behavioral profiles than can provide
useful screening information.

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 Screening: Behavioral Checklists
 Fisher’s Auditory Processing Checklist
 Preponderance of items are related to a language-based deficit-
comprehension; attention & memory
 Children’s Auditory Performance Scale
 Rate behavior in conditions
 Used by teachers and parents
 Evaluation of Classroom Listening Behavior
 Completed by a teacher in order to identify listening and academic
problems
 Children’s Home Inventory for Listening Difficulties (CHILD)
 “Family-centered parent survey that allows parents to assess a child’s
listening behavior within the home environment.
 Ages 3-12

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 Behavioral Screening Instruments
 SCAN-3C
 SCAN-3A
 Has 3 screening subtests:
 Gap Detection
 Auditory Figure Ground
 Competing Words (Free Recall)

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 Assessment for CAPD

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 Assessment Vs Diagnosis
 “ Assessment may be defined as a data-gathering process that
may include both formal and informal procedures to
document areas of strength and weakness (ASHA, 2005).

 Diagnosis, on the other hand, refers to the actual

identification and classification of a specific impairment.
(ASHA, 2005)

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 Behavioral Test Battery
 I. Monaural Low Redundancy
 Degraded Acoustic Signals
 Background noise
 Filtered Speech
 Time Compressed Speech

 II. Temporal Pattern Tests/ Temporal Processing Tests

 Discrimination and Patterning
 Frequency Pattern/Ordering Tests
 Duration Pattern/Ordering Tests
 Gap Detection

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 Behavioral tests..continued
III. Dichotic Listening
 Binaural Separation refers to the ability to process one message while ignoring
another at the same time.
 Binaural Integration refers to the ability to process information presented to
both ears at the same time when the information presented in each ear is
different. An important skills to classroom success and everyday functioning -
the ability to tune-in to the important auditory signals. Difficulty may be
indicated if the individual is having difficulty attending/hearing in noisy
environments.
 Competing Words
 Competing Sentences
 Dichotic Digits
 SSW
 SSI
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 Behavioral Tests
IV. Localization/Lateralization Tests/Binaural Interaction
 Masking Level Difference
 Rapidly Alternating Speech Perception

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 V. Electrophysiological Tests
 Electrophysiologic data validates the results of behavioral data when
abnormalities are shown in both behavioral and electrophysiological
tests
 Auditory Brainstem Response (ABR)
 Auditory Middle Latency Response
 Auditory Late Response (P300 & MMN)

 BioMARK: an ABR to Speech

 Approximately 30% of children with a language based learning
disability have an abnormal BioMARK recording.
 Normed for ages 3-4; 5-12; 18-28

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 Test Battery Approach
No Single test can diagnose CAPD.

 Monaural Low Redundancy Tests

 Binaural Interaction
 Tests of Temporal Processing
 Dichotic Tests
 Electrophysiological Tests

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 SCAN 3C (ages 5-12)
SCAN 3A (ages 13-50)
 Screening sub-tests-approximately 10-25 minutes.
 Administration for the diagnostic and supplementary tests is 20-30
minutes.

 Addition of:
 Gap Detection Test
 Filtered Words 750 Hz low pass
 Competing Words –Free Recall
 Auditory Figure Ground at 2 additional levels
 (all have option of 0, 8, & 12 dB SNR)
 Time Compressed Speech (60%)
 Competing Sentences are graded as number of words correct.

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 Popular Tests
 Auditory Figure Ground (Speech in Noise)
 Filtered Words
 Time Compressed Speech
 Dichotic Digits
 Duration Pattern
 Frequency Pattern
 Masking Level Difference
 Gap Detection
 SSW
 Phonemic Synthesis

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 Diagnosis
 Diagnosis of (C)APD generally requires performance deficits on
the order of at least two standard deviations below the mean on
two or more tests or three standard deviations on one test.
(ASHA, 2005).

 Deficits on all tests on the behavioral test battery may indicate a

higher order deficit.

 Models: May be confusing because of over-lapping terminology

 Bellis/Ferre & Buffalo Model

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 Process Based Interpretation
 Targets the underlying strengths and weakness of the
underlying auditory process

 What auditory area(s)/process(s) are deficient?

 What should we do to remediate?

 Differential Diagnosis

Central Auditory Processing Disorders from

Other Co-morbid Conditions

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 Differential Diagnosis
 Most often consider young children
 Academic Difficulties (ADHD/ADD)
 Language Disorders
 Reading Disorders (dyslexia)
 ANSD
 Other?
 ASD

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 APD vs ADHD
 Can you test a child diagnosed with ADHD?

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 What is ADHD?
 Initially identified in Heinrich Hoffman’s 19th century descriptions
of “Fidgety Phil”
 DSM-IV describes 3 classifications:
 ADHD-HI: predominantly hyperactivity-impulsivity
 ADHD-IA: predominantly inattention
 ADHD-C: combined subtype
 Diagnosis is based on an accumulation of at least 6 symptoms,
some of which were present before the age of 7.

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 Other signs
 Academic difficulty, especially in reading and math
 No significant memory deficits
 Difficulties in social functioning
 IQ 10-20 points below average
 Learning disability
 Language disorder

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 Diagnostic Difficulty
 Subjectivity
 Questionnaire filled out by parent or teacher
 Hyper dreamy shy energetic withdrawn daydreamer
tomboy …
 High comorbidity with other conditions
 Learning disabilities (15-25%)
 mood disorders (15-20%)
 Language disorders (30-35%)
 anxiety disorders (20-25%)
 Conduct disorder (15-20%)
 tic disorders (10-15%)
 Oppositional defiant disorder (40%)

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 Etiology - Biological
 Overall brain size 5% smaller
 Smaller amounts of brain tissue
 Smaller anterior cortices, corpus callosum
 Metabolic dysfunction in sub-cortical regions projecting to
frontal lobes of brain
 Lower cerebral metabolic rates for glucose reported in girls
with ADHD, using PET scan

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 Rank Order of Behavioral Measures

ADHD CAPD
 Difficulty hearing in
 Inattentive background noise
 Distracted  Difficulty following oral
 Hyperactive instructions
 Poor listening skills
 Fidgety or restless
 Academic difficulties
 Hasty or impulsive
 Poor auditory association
 Interrupts or intrudes skills
 Distracted
42  Inattentive
From Chermak et al, 1998
 Conclusion
 ADHD-HI – easy to tell because they exhibit hyperactive
symptoms

 ADHD-IA – hard to tell without testing

 Typical audiological results:
 Inconsistent PT
 NL SRT
 Poor to fair WRS in quiet and in noise
 If noise much poorer than quiet, suspect CAP!
 NL tymps
 And … just don’t seem to be paying attention

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 ANSD: CAPD?
 Definition: A form of hearing impairment in which the outer
hair cell function works properly, but neural transmission in
the auditory pathway is disordered.
 Approximately 7% of permanent childhood hearing loss have
ANSD.

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 (C)APD vs ANSD
 Management Differences:
 Current Research determining site of dysfunction pre vs post
synaptic
 Hearing aids may not be of benefit. Increasing amplitude
without overcoming pathologic condition.

 Cochlear implants- may be beneficial for some patients

**Most patients with ANSD have difficulty

listening in background noise.
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 HEARING LOSS AN/AD (C)APD
Family History Family History Family History
Infections: Infections: Infections:
[Toxoplasmosis, Rubella, [Toxoplasmosis, Rubella, [Toxoplasmosis, Rubella,
Cytomegalovirus (CMV), Cytomegalovirus (CMV), Cytomegalovirus (CMV),
Herpes Virus, Syphilis] Herpes Virus, Syphilis] Herpes Virus, Syphilis]
Hyperbilirubinemia Hyperbilirubinemia Hyperbilirubinemia
Craniofacial Anomalies Immune Disorders RH Incompatibility
(Type 1 Diabetes)
Low Birth Weight Uremia Difficulty During Birth
Other Syndromes Genetic/Syndrome Toxic Exposures
Ototoxic Medications Ototoxic Medications
Prematurity Prematurity
Anoxia Anoxia
Infections after Birth Infections after Birth
Mechanical Ventilation Head Trauma
Bacterial Meningitis Cerebrovascular Disorders
Metabolic Disorders
Epilepsy
Recurrent Otitis Media
Meningitis/Encephalitis
Developmental Disorders (e.g.
Dyslexia, Learning Disability,
46 Language Impairment, Attention
Deficit Hyperactivity Disorder)
 Audiometric Test/Procedure Auditory Neuropathy (C)APD
Pure Tone Thresholds Various degrees of hearing Usually within normal limits
loss and configurations

Tympanometry
Acoustic Reflexes Elevated or Absent Usually within normal limits
Speech Recognition in Quiet depending upon site(s) of central
Speech Recognition in Noise Poor auditory nervous system (CANS)
dysfunction
Variable, depending upon site(s)
of CANS dysfunction

Otoacoustic Emissions Present Present

Gap Detection Abnormal Often abnormal, depending upon
site(s) of central auditory nervous
system (CANS) dysfunction

ABR Absent Usually normal

MLR Questionable Depending upon site(s) of central
ALLR/P300 Questionable auditory nervous system (CANS)
dysfunction
Variable, depending upon
site(s) of CANS dysfunction
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 Other Auditory Problems
 Temporal Processing Difficulties
 Gap Detection
 Localization
 Frequency discrimination abilities

FM system or other assistive listening device to

increase Signal/Noise Ratio.
‘Most’ individuals with ANSD will have auditory
processing disorder.

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 CAPD vs Language Processing

Auditory Processing Language Processing

Acoustic Signal Meaning

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 What if a child did not reply
 Signal was blocked  Unfamiliar language
 Chose not to answer  Thinking about something
 Could not remember the else
question  Signal was not
 Was not sure what the compromised and not
question meant. clear.
 Signal was not received
(HOH)
 Not capable of replying
 Apraxia, neuro-motor From.. C. Richard in Geffner & Ross-Swain
Central Auditory Processing Disorders.

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 Language Processing vs CAPD
Upon hearing a phrase, ask the following questions
Did you hear it? Can you explain what it means?
Can you repeat it? Will saying it slower help?
Can you identify the first sound? Will repeating it multiple times help?
Can you identify another sound you heard? Will making it louder help?
If the answer to these questions is “yes,” If the answer to these questions is “no,”
Then the problem is language processing, not auditory processing

From Richard
 Processing disorder…
 Generic term used to describe a variety of communication
disorders: language processing, language perception, sensory
processing, central auditory processing.

 Audiologists, SLPs, and OTs?

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Auditory Problems
 Frequently says “huh? or “what”
 Misunderstands or misinterprets what is being said
 Needs information to be repeated or rephrased
 Hass difficulty following conversations or discussions
 Has difficulty following spoken directions
 Has difficulty listening in the presence of background noise
 Confuses words that sound alike “mishears”
 Has poor short-term memory
 Inability to retain information
 Has difficulty localizing sound sources
 Has difficulty discriminating among sounds
 Has trouble blending sounds to form words
 Phonological Processing
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 Language Problem Behaviors
 Difficulty ‘getting to the point’ in conversation
 Difficulty organizing and expressing thoughts
 Difficulty ‘getting started’ with open-ended questions
 Uses vague language
 Difficulty knowing what to say
 Difficulty reading and responding to social cues
 Experiences word-finding problems
 Difficulty remembering lengthy directions
 Has pronounced differences between measures of verbal and
performance abilities

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 LP vs AP continued
 Audiologists are responsible for evaluating and diagnosing
problems in the reception and/or transference of an
acoustic signal in the peripheral auditory system and central
auditory nervous system.
 SLPS are responsible for evaluating and diagnosing problems
in analyzing an acoustic signal in phonological awareness
and/or linguistic interpretation.
 Treatment for processing disorders cannot be effective
unless the specific skills in deficit are carefully
differentiated.

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 Guide for Interpretation
 Identify the presence or absence of auditory processing skill
weaknesses
 Identify specific auditory processing skill weaknesses (auditory
discrimination, or auditory memory)
 Determining the effects of the weakness…spelling, following
directions, etc
 Determining which treatment/interventions will be beneficial

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 What to do after diagnosis?
Treatment & Intervention

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 Important to Remember
 Patients/Clients come to our clinic because of
listening difficulties/academic concerns

 Normal hearing thresholds

 Academic Difficulties
 Co-existing Reading or Language Problems
 Risk Factors
 History of OME
 Jaundice
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 Diagnosis:
Now you have to look at all of the results, look for patterns,
point of breakdown, differences between ears, strengths,
compensatory strategies.

Remember, if there is a deficit, you haven’t helped anyone if

you don’t have information for treatment!!!!

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 Successful remediation of APD/CAPD
has three crucial components:

1. Environmental Modifications
2. Developing Compensatory Strategies
3. Specific Remediation

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 1. Environmental Modifications
 Reduce distractions
 Be aware of your delivery style
 Plan carefully for transitions
 Check frequently for auditory exhaustion
 Be supportive
 Consider acoustic modifications and other
classroom/academic modifications
 FM system?

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 II. Compensatory Strategies
 Rehearsal (silent, physical, etc.)
 Pre-tutoring academic tasks, directions, projects, etc.
 Networking of ideas, webbing, mind mapping
 Imagery
 Cognitive monitoring
 Chunking
 Mnemonics

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 Some Specific Skills to Teach
 Analysis of key ideas
 Task analysis
 Analysis of errors
 Systematic retrieval of information
 Organization skills (environment, notebooks, thoughts,
how to take notes, etc…)
 Vocabulary Building

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 More Specific Skills to Teach
 How to calendar
 HOW to DO a project
 Study skills
 Direction following strategies
 Memory boosters (Computer Programs? Cog Med)

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 Plasticity
 Changes (reorganization) in the CANS due to experience or
stimulation which leads to reorganization of the cortex.

 Can be positive or negative

 Improved synaptic efficiency, increased neural density and

behavioral changes.
 Long-lasting
(From : Musiek, Chermak & Weihing, 2007)

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 Three Types of Plasticity
 Developmental- results from the maturation of the nervous
system…more connections, myelination….Stimulation

 Compensatory- occurs after damage as other parts of the brain

take over

 Learning-related: habilitation/rehabilitation efforts

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 Considerations
 Age appropriate materials
 (cognitive, language, & communication skills)

 Maintaining motivation
 Vary the tasks

 Progression of AT
 Difficult/Challenging; Accuracy between 30-70% correct before
increasing difficulty (Musiek & Schochat, 1998)

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 III. Direct Auditory Remediation
 Targeting the area of auditory weakness

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 Auditory Training
 Utilizing Residual Hearing

 Dates back to the 6th century- doctors used large bells to

stimulate a hearing response in people who were deaf (Musiek,
Chermak, Weihing, 2007)

 Auditory training to help with hearing aids-1950s -

 Listening and Communication Enhancement (LACE™)

 Cognitive Training during Aural Rehabilitation

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 Auditory Training

 Informal: Speech-language pathologists, educational

audiologists, reading tutors, other school professional, parents

 Listening Activities, Target Words, Localization activities, Following

Directions, Rhymes, Musical chairs, etc.

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 Auditory Training
Improve speech encoding

 Populations for children with

 language disorders (Kraus, et al 2005, 2006)
 brain injury, (Musiek et al, 2004)
 stroke (Willis & Hurley, 2014; Weinhing et al, 2006; Hurley &
Billiet, 2008)

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 Auditory Training
 Passive: acoustic stimulation
Music Programs
Controversial
 Very little published research with control group
or blinded
 Active: Probably more effective
Patient is involved
Reinforcement
Challenging, but not frustrating!

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 Auditory Training
 Formal: Controlled acoustic environment
Dichotic Interaural Intensity Training (Musiek & Schochat,
1998)
Constraint Induced Auditory Therapy (Hurley & Davis,
2011)
Interaural Asymmetry Dichotic Listening (Moncrief &
Wertz, 2008)
Backward Masking
Frequency Discrimination
 Informal: SLPs, educational audiologists, reading tutors,
other school professional, parents, etc.
73 Listening Activities/Games etc.
 How much Time?
 Intensive therapy time (daily vs weekly)
 Intrinsic Factors- attention, fatigue, performance
 Extrinsic Factors: cost, caseload, schedule
 Termination of therapy
 Motivation/Determination of the patient

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 Is this working?
 Evidence Based….progress?
Psychophysical
Electrophysiologic
Questionnaires and scales

 Reinforcement/Feedback-
Adaptive procedures- may change the difficulty level
with patient response

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 What’s available?
 Computer Mediated Programs
Fast ForWord
Earobics
Brain Train
Brain Fitness (Adults)
Play Attention

 Traditional Therapy
Phonemic Training

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 Computer-Mediated Auditory Training
Programs
 Convenient
 Hold interest for young children
 Standardization of stimuli/ Precise Control
 Must consider what deficit/skill are we training
 Some programs may actually be auditory language
programs
 Length of training

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 Fast ForWord
 Poor temporal processing may underlie reading and
language difficulties.
 Program designed to improve :
Underlying temporal processing skills
Memory
Attention
Phonologic awareness/language structures
Reading Comprehension

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 Fast ForWord…(cont.)
 Intensive
 60-100 hours
 Reinforcement and novelty
 Based upon principles of neuroscience

 Positive Outcomes
 Merzenich et al, 1996; Tallal, et al, 1996; Schopmeyer et al, 1998; Friel-
Patti, DesBarres, & Thibodeau, 2001; Loeb, Stoke, & Fey, 2001; Gilliam,
et al, 2001; Temple et al, 2003;

 Other studies have shown no differences between FF and other

auditory training programs

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 Earobics
Auditory Language Program
 Phonemic awareness
 Sound discrimination
 Sequencing
 Sound/symbol association
 Decoding
 Complex directions with and without background noise
 Auditory memory
 Auditory Comprehension

80
 Earobics…
 May be purchased by parents for home
 Reasonable price
 Great computer graphics
 Directions may be set in 10 native languages
 Positive outcomes in peer review studies
 Increased amplitude of auditory evoked responses
 Hayes et al, 200; Warrier et al, 2004; Russo et al, 2005

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 Phonemic Awareness Training
Dr. Jack Katz
 Phonemic Training Program - for Decoding problems
 Phonemic Synthesis Program - for Decoding that supports PTP
 Word-in-Noise Training - for Speech in Noise problems.
 Short-Term Auditory Memory Training - for digit, word and
working memory problems.

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 Reading Programs
 Lindamood-Bell
 Reading
 Spelling
 Language Comprehension
 Math Reasoning
 Orton-Gillingham
 Other programs:
 Wilson Reading Program
 Davis Reading Program

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 APPs
 Phonetic Birds ($1.99) an auditory training app that uses
game play to help children learn to listen for changes in
sound patterns
 Sound Match: Auditory memory trains the ear- not the eyes
 Hear Coach is a suite of listening games developed by Starkey
Laboratories; it features games that challenge both your
cognitive and auditory sharpness.
 Auditory Processing Studio by Virtual Speech Center Inc.
2,400 audio exercises $29.99)

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 Lindamood-Bell Programs
 Reading
 Spelling
 Language Comprehension
 Math Reasoning

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 Auditory Closure Ideas
 Adapted from Bellis

 Missing word exercises

 Missing syllable
 Missing phoneme exercises
 After these are completed in quiet, try completing them in the
presence of background noise

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 Prosody Training Ideas
 from Bellis & Sloan
 Syllabic stress in words, sentences, stories, etc.
 Normal tone, rising intonation, falling intonation
 Identifying the key words in sentences
 Reading aloud with exaggerated prosodic features
(expression)
 hot dog vs. hotdog green house vs. greenhouse

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 Temporal Patterning Training

 Clapping to patterns
 Tapping to patterns
 Loudness and rhythm patterns
 Boost vs Boost

 The goal is to start simple and progress to more complex

patterns.

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 Interhemispheric Exercises
 Singing
 Humming
 Verbal to motor
 Motor to verbal
 Twister, Name That Tune,
Feely Bag, etc.

 The idea is to support the areas of deficit and to improve the

interhemispheric transfer of information. It’s one of the most fun to
do!!

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 Dichotic Training
 Dichotic Interaural
Intensity Difference
Training. (Musiek)

 Dichotic Interaural
Asymmetry Listening
(Moncrief & Wertz, 2008)

 Constraint Induced
Auditory Training (CIAT)
(Hurley & Davis, 2011)

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91
92
 INTEGRATION/ INTERHEMISHPEHRIC
(C)APD
 The two cerebral hemispheres are not working
together.
 Difficulty transferring information from one part of
the brain to another.
 Lag in maturation of the central nervous system
auditory pathway (corpus callosum).
 Often left-ear deficits are found in dyslexia patients.
 Adults with lesions due to stroke or head injury.

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 Therapy for Integration/Inter-
hemispheric (C)APD
Formal Auditory Training:
 Must be done in a clinic or laboratory
 Clinician routes 2 different signals (Dichotic)
to each ear through an audiometer. Ear that
is not performing well gets a stronger
intensity, increases the opposite ear over time.

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 Formal Digits Auditory Training
4, 8 6, 1

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 Informal Training
 Two different sound sources are used:
 One generates a story/ One generates noise.
 Example: Harry Potter book going to the deficit ear- talk
radio in the opposite ear.
 Over time, increase the noise in the opposite ear.

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 Informal Training
Right: Story Left : Competing Noise

No standardization of volume controls for either ear.

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 What is CIAT?
 Auditory Training Program
 Specifically Addresses Deficit Ear
 Dichotic Auditory Training Exercises
 Sentences (3,4,5,6 & 7 syllables)
 Semantically Related Words (yes/no; sun/set; read/book)
 Digits (1-9 with the exception of 7)
 Consonant-Vowel Syllables (pa, ba, ga, da, ka, ta)
 Stories (Public domain literature)

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 Key Point to Remember
 “…Select an intervention that appears well designed to treat
the child’s auditory deficit” (Fey et al.,2011)

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 Informal Listening Activities

Listening is an important skill. Listening Activities are

used to help improve auditory memory and help
individuals with attention or central processing
disorders.

“Do You Hear What I Hear? Listening Activities” by

Judith Maginnis Kuster, ASHA LEADER, June 16, 2009.

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 Informal Activities
 Managing Children’s Central Auditory Processing Deficits in
the Real World (2002) Seminars in Hearing
J.M.
 Smart Mom Toy Box: Brain Buzz: www.learningrx.com

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 Wii-habilitation to enhance Listening
Skills
• Nintendo Wii reports over 84 million units have been
sold worldwide, with over 41 million in the United
States alone. In March, 2011, over 454,00 Wii units were
sold2. This system remains popular.

• It is important to note that games should not replace

formal rehabilitation techniques but may be used as a
supplement to therapy.
List of video games in What’s in Your ToyBox?
Hearing Journal.

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 Self-auditorization
 Having the person repeat/read aloud
 Automatic feedback look….

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 Self-Auditorization
 Having the person repeat/read aloud
 Humans instinctively endeavor to hear their own speech more clearly
by resorting to subvocalization or “self-talk” to enhance the auditory
feedback loop.
 Subvocalization activates both the auditory loop and tactile
proprioceptive loop.
 Behaviors cannot be changed unless the individual is made aware of the
behavior
 The mind learns what the body does, whether it is accurate or
innacurate…..
 Training the client to simultaneously hear, feel, see, and say phonemes
accurately provides a multisensory, self-monitoring scaffold for
accurate discrimination, analysis and automaticity of phonological
processing
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 Formal Music Training
 Music & Auditory Training (Chermak, G. 2010). The
Hearing Journal.
 Better discrimination
 Facilitates learning
 Attention
 Ability to hear in noise
 Brains are different!

 Kraus, et al, Experience-induced Malleability in Neural

encoding of Pitch, Timbre, and Timing: Implications for
Language and Music

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 CASES

DX and Intervention

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Jack: 5 year old Screening
 Born 5 weeks early.  Jack is in the first grade.
 Mechanical ventilation was School performance is
required at birth. described as “poor.”
 Developmental milestones  He is demonstrating poor
were achieved at phonemic skills, difficulty
appropriate ages. learning to read, difficulty
 Positive history of middle
hearing in group situations,
ear infections and three and mispronounces many
sets of PE tubes words.
 There is a family history of
 Passed language screening
dyslexia.
 Recommendations: Jack was referred for a speech-language
evaluation. Results of this assessment indicated a phonological
disorder. Jack began weekly speech therapy sessions. A computer
mediated software program, Earobics, was started at home. A list of
informal listening activities was also provided.

 Intervention: Jack returned to the clinic after one year at age 6.

Follow-up screening results are shown in Table 21-11 and are within
normal limits. The cABR improved, but remained abnormal
 Jack’s mother reports significant improvement in his performance at
school. This improvement is also reported by Jack’s teachers. Jack has
been discharged from speech-language therapy as phonological skills
are within normal limits. Jack’s progress will continue to be followed
annually.
 cABR 1 year follow-up Normal.
Carrie: 15 year old Female
 Normal birth & developmental history
 Referred by psychologist
 Psycho-educational assessment revealed
 average intelligence,
 deficits in reading comprehension,
 deficits in language processing,
 deficits in auditory processing.
 Attention deficit disorder was ruled out.
 She reports difficulty with reading comprehension and has previously
completed reading tutoring at a commercial learning center, with
success.
 Carrie will be entering the 10th grade at a private school.
 Qualifies for Fast ForWord Summer Program
Test Results

 Fast ForWord “helped her process information quicker.”

 Pre and post ALER recordings for the right and left ears from Cz to the
ipsilateral ear are shown in this figure. A summed response from two
individual recordings is depicted.
Pre & Post ALER amplitude
Edward: Ages 7-9
 Referred for a (C)APD assessment SLP.
 Dx severe receptive and profound expressive language delay.
 Speech therapy since age 3. Currently 2x/week school and
private therapy
 Normal birth history, with the exception of speech, gross motor
skills were achieved at appropriate times.
 History of otitis media and pressure equalization tubes were
previously placed.
 Normal peripheral hearing.
 Edward is currently in the 2nd grade with average to poor
performance. He receives speech services twice weekly at school.
 A diagnosis of ADHD was made; however, pharmaceutical
management has not begun.
  Completed Earobics Step 1
& 2 at age 7.
 Began medication for
ADHD at age9. Significant
improvement in
confidence, grades,
performance.
 This case demonstrates the
results of a maturing
central auditory nervous
system and effective
speech-language therapy
and successful
pharmaceutical
management. Results of
recent speech-language
evaluation indicate normal
speech-language abilities
Normal ABR and cABR
Debbie: 30 year old SLP grad student
 Self referred for a (C)APD assessment after an audiological
assessment established normal peripheral hearing.
 Experiencing difficulty transcribing and
distinguishing/discriminating phonemes required as part of a
phonetics course.
 She reports normal developmental history. She has never
experienced academic difficulties before.
 Of interest, are Debbie’s history of protracted middle ear
infections and the placement of pressure equalization tubes as a
young child.
Results of this assessment indicate difficulty listening in
degraded acoustic environments
 Intervention…
 A list of environmental modifications and compensatory strategies
were provided. The Listening and Communication Enhancement
(LACE) program was recommended for Debbie for home use.
Additionally, Debbie will begin Dichotic Listening Therapy three times
per week for four weeks.

 Intervention: Debbie completed ten sessions of dichotic listening

therapy. Additionally, Debbie completed the LACE program Debbie
reports positive changes from therapy and using environmental
modifications to move to the front of the classroom and request that
the classroom speakers be turned on. She also reports these exercises
were important to personally complete to have first-hand knowledge
of aural rehabilitation training programs.
James
 James is 12 year old male who was a participant in a study examining
pre and post behavioral and electrophysiological measures after Fast
ForWord® training, provided by a local school system.
 James was the product of a normal pregnancy and birth. All
developmental milestones were developing appropriately until the age
of three. At that time, it was noted by his parents that James’ speech and
language skills regressed. Initially, this decline was attributed to sibling
jealousy as it coincided with the birth of a younger sibling and a family
relocation.
 James also had a history of otitis media, the lack of progression in
speech and language was next related to his history of ear infections. A
pure tone hearing evaluation indicated normal hearing thresholds,
bilaterally.
 Subsequently, autism and pervasive developmental disorder were also
erroneously diagnosed. Seizure activity began at the age of three and a
half years; the diagnosis of Landau Kleffner Syndrome (LKS) was made
after a characteristic spiking EEG. Nocturnal seizure activity continued
until James was eleven years old.
 James attended speech/language therapy and occupational therapy
through early intervention programs in order to address expressive and
receptive language delay and verbal apraxia.
 He sporadically uses sign language as needed when he experiences
difficulty with word finding or speech production.
 He has been in special education classes and is receiving
speech/language therapy at school two times per week, thirty minutes
per session.
 A speech-language assessment indicated a moderate to severe receptive
and expressive language disorder, characterized by moderately impaired
receptive language skills, severely impaired expressive language skills,
and severely impaired language memory skills.
 Expressive language skills were significantly weaker than receptive
language skills. Articulation skills were also impaired and consistent
with a diagnosis of verbal dyspraxia.
 Speech intelligibility was fair in known contexts and fair to poor in
unknown contests. James is taking anti-convulsion medication for
seizures and is medically managed for ADHD.
 Because of James’ apraxia and speech difficulty, only the Dichotic
Digits Test, a low- linguistically loaded behavioral test was
administered. James could not repeat any numbers presented to
the right ear (0%), but had a left ear score of 92%.
 Normal temporal resolution was found.
 James had a 2 msec gap detection threshold and scored 100% by
verbal response on the Frequency Pattern and Duration Pattern
Test.
 A Masking Level Difference of 10 dB was obtained. An
electrophysiological study including the auditory brainstem
response (ABR), complex ABR (cABR), Auditory Middle Latency
Response (AMLR), and Auditory Late Evoked Response (ALER)
and P300 were recorded.
 James completed an eight-week program of Fast ForWord,
provided by James’ school district. He received dichotic listening
therapy, once per week for two semesters for a total of twenty-
two sessions. Additional therapy sessions could not be scheduled
due to James’ geographical distance from the clinic. James
continued to receive speech and language therapy two times per
week for thirty minutes per session at his school.
 No change in the right dichotic scores was noted after Fast
ForWord. Progress was made during dichotic listening therapy.
Binaural separation scores for the right ear are shown Listed also is
the intensity level of the signal to the left ear.
James
ABR
 This figure shows a normal auditory brain stem response
(ABR) recorded pre Fast ForWord and post Fast ForWord
and Dichotic Listening training for the right and left ears.
cABR
 Pre and Post cABR recordings are depicted for the left and
right ears. Also depicted is a normative waveform.
 AMR
Figure 21-3. Pre auditory middle latency response (AMLR) recordings with
right ear stimulation are shown for electrodes Cz, C3 and C4 in tracings 1, 2,
and 3. Post Fast ForWord® recordings are shown in tracings 4, 5 and 6, and
recordings after Dichotic listening training are shown in tracings 7, 8 and 9.
 ALER
Pre and post Auditory Late Evoked Response (ALER) for the left and right ears are shown. Pre recordings are shown in
tracings 4 and 1, post Fast ForWord® recordings are shown in tracings 5 and 2, and post Dichotic listening training
therapy recordings are depicted in tracings 6 and 3.
 Follow-up
 Although binaural separation scores were within normal limits, binaural
integration was still difficult. Because of the geographical distance from
James’ home and clinic, therapy was discontinued and dichotic exercises
were provided for James to continue at home. In addition to objective
evidence of improvement in the central auditory pathway, unsolicited
parental reports were positive. They reported extended family
members, as well as James’ teachers, commented that James’ speech
was improving and that he was speaking in complete sentences and
thoughts, rather than in a telegraphic-type speech. He was also initiating
phone conversations, something he had never done in the past. They also
reported that he rarely used signs anymore.
 James has not returned for formal follow-up evaluation. James
completed NeuroFeedback training.
 He is no longer taking ADHD medication and is not any special
education classes, nor does he qualify for any resource services through
the school system at this time.
 Questions
[email protected]

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 Selected References
 American Academy of Audiology (2010). Diagnosis, treatment and management of children and adults with
central auditory processing disorder [Clinical Practice Guidelines]. Retrieved from
www.audiology.org/resources/documentlibrary/Documents/CAPD Guidelines 8-2010.pdf.
American Speech-Language Hearing Association (2005b). (Central) auditory processing disorders [Technical
Report]. Retrieved from www.asha.org/docs/html/tr2005-00043.html.
 ASHA Leader, September 2014, Vol. 19, online only. doi:10.1044/leader.NIB6.19092014.14
 Bellis, T. (2003). Assessment and management of central auditory processing disorders in the education setting: From
science to practice. New York: Delmar Learning.
 Chermak, G.D.,Somers, E.K., Siekel, J.A., (1998). Behavioral signs of central auditory processing disorder
and attention deficit hyperactivity disorder. JAAA1: 78-45.
 Geffner, D. Ross-Swain, D. (2007). Auditory Processing Disorders: Assessment, Management and
Treatment. Plural Publishing Company.
 Musiek, F., Chermak, G., & Weihing, J. (2007). Auditory training. In G. Chermak & F. Musiek (Eds.),
Handbook of (central) auditory processing disorders: Comprehensive intervention (Vol. II). San Diego: Plural
Publishing.

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