AUDITORY PROCESSING DISORDERS (APD): A Common and Serious Problem I’m lost in this class! What’s wrong with me? I just can’t hear right. Auditory Processing Disorders (APD) Diagnosis is Feasible and Management is Effective James W. Hall III, Ph.D. Clinical Professor and Associate Chair Department of Communicative Disorders College of Public Health & Health Professions University of Florida Gainesville, Florida, U.S.A. email@example.com 8th cranial (auditory) nerve) Internal auditory canal Shares space with vestibular nerves, facial nerves, efferent auditory nerves & internal auditory artery Central auditory nervous system Cochlear nuclei Superior olivary complex Lateral lemiscus Crossing pathways Infererior colliculus Reticular (activating) formation Thalamus Primary and secondary auditory cortex Corpus collosum Behavioral Audiometry: True Measures of Hearing Behavioral Audiometry: Sound Field versus Earphone Stimulation The Audiogram: Hearing Sensitivity as a Function of Pure Tone Frequency AUDITORY PROCESSING DISORDERS (APD): Academic Underachievement & Failure I must be stupid! F Age and Gender Distribution in an Unselected APD Population in a Medical Center Audiology Clinic (N = 239) 25 Average age = 9 Years Male (N = 160) Number of Patients 20 Female (N = 79) 15 10 5 7 8 9 10 11 12 13 14 15 - 18 Age in Years AUDITORY PROCESSING: Cornerstone of Language and Literacy (Reading) COMPREHENSION WRITTEN LANGUAGE Reading and Spelling PHONOLOGIC AWARENESS ORAL LANGUAGE AUDITORY PROCESSING Assessment and Management of Auditory Processing Disorders (APD) Historical perspective … interest in APD dates back over 50 years How APD became a household phrase in audiology Neuroscience foundation for APD Disorders often co-existing with APD Risk factors for APD Current and future assessment strategies and procedures Effective management strategies and procedures Carlo Calearo, M.D. Otorhinolaryngologist “Italian Pioneer in APD Assessment” Bocca E, Calearo C, Cassinari V. A new method for testing hearing in temporal lobe tumors. Acta Otolaryngologica 44: 1954. Helmer Myklebust, Ph.D. (in psychology) Northwestern University “Pioneer in APD Assessment” Myklebust HR. Auditory disorders in children: A manual for differential diagnosis. New York: Grune & Stratton, 1954. “hearing is a receptive sense … and essential for normal language behavior” (p. 11) “the diagnostician of auditory problems in children has traditionally emphasized peripheral damage. It is desirable that he (sic) also include central damage.” (p. 54) Dichotic Listening Paradigm … A long-standing test strategy for assessment of auditory processing 1956: British Psychologist 1961: Canadian Psychologist Donald E. Broadbent, Ph.D. Doreen Kimura, Ph.D. Dichotic Listening Paradigm RIGHT TEMPORAL LEFT TEMPORAL CORTEX CORTEX Association Cortex Association Cortex Corpus Callosum Primary Auditory Cortex Primary Auditory Cortex Right Ear Left Ear air plane base ball 1, 3 5, 9 Development of APD Assessment & Management: Principles & Procedures AMLR Keith studies procedures ASHA Musiek MRI Task Willeford studies APD Force Jerger Conference Katz Tallal Kraus fMRI Kimura Earobics Bocca & Calearo Myklebust 1954 1960 1975 1982 1986 1990s 1996 2000 Assessment and Management of Auditory Processing Disorders (APD) Historical perspective … interest in APD dates back over 50 years How (C) APD became a household phrase in audiology Neuroscience foundation for APD Disorders often co-existing with APD Risk factors for APD Current and future assessment strategies and procedures Effective management strategies and procedures AUDITORY PROCESSING DISORDERS (APD): ASHA Task Force Consensus Statement (1996) “A central auditory test battery should include measures that examine different central processes.” Tests should generally include both nonverbal and verbal stimuli to examine different levels of auditory processing and the auditory nervous system.” Factors to consider in the selection of test procedures include information on: test sensitivity and specificity reliability and validity age appropriateness The person administering and interpreting the test battery should have both theoretical and practical knowledge … typically audiologists.” AUDITORY PROCESSING DISORDERS (APD): ASHA Task Force Consensus Statement (1996) “Central auditory processes are the auditory system mechanisms and processes responsible for: sound localization and lateralization auditory discrimination auditory pattern recognition temporal aspects of audition auditory performance decrements with competing acoustic signals auditory performance decrements with degraded acoustic signals “These mechanisms and processes are presumed to aply to nonverbal as well as verbal signals … they have neurophysiologic as well as behavioral correlates.” CONSENSUS CONFERENCE 2000 ON APD “Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children” Journal of American Academy of Audiology 11: Nov. 2000. Definition: “APD is broadly defined as a deficit in the processing of information that is specific to the auditory modality.” Guidelines Screening strategies Diagnosis minimal test battery factors influencing test outcome and analysis 2000 Consensus Conference on the Diagnosis of APD Assumptions in the diagnostic assessment of APD … possible outcomes a pure APD an APD and a disorder or disorders in other modalities, e.g., multi-sensory a disorder that appears auditory at first, but actually is non- auditory a disorder that appears at first to be non-auditory but is actually auditory 2000 Consensus Conference on the Diagnosis of APD Factors influencing diagnostic assessment of APD ADHD Language impairment Reading disability Learning disability Autistic spectrum disorder Reduced intellectual functioning (cognitive impairment) 2000 Consensus Conference on the Diagnosis of APDs Listener variables in the diagnostic assessment of APD Attention Auditory neuropathy Fatigue Hearing sensitivity Intellectual and developmental age Cognitive variables (e.g., memory, processing speed) Medications Motivation Motor skills Native language, language experience, language age Visual acuity Technical Report of ASHA Working Group on (Central) Auditory Processing Disorders (2005) www.asha.org Definition of (C ) AP Broad definition … “the efficiency and effectiveness by which the CNS utilizes auditory information” Narrow definition … “the perceptual processing of auditory information in the CNS and the neurobiological activity that underlies that processing and gives rise to electrophysiologic auditory potentials.” Auditory processing includes the auditory mechanisms that underlie the following abilities and skills: Sound localization and lateralization Auditory discrimination Auditory pattern recognition Temporal aspects of audition Temporal ordering and temporal masking Auditory performance in competing acoustic signals (includes dichotic listening) Auditory performance with degraded acoustic signals Technical Report of ASHA Working Group on (Central) Auditory Processing Disorders (2) Definition of AP Nature of APD Historical perspective Knowledge base and ethical considerations The basic science connection Neurochemistry and auditory processing Screening for APD The APD case history Diagnosis of APD Assessment and Management of Auditory Processing Disorders (APD) Historical perspective … interest in APD dates back over 50 years How APD became a household phrase in audiology Neuroscience foundation for APD Disorders often co-existing with APD Risk factors for APD Current and future assessment strategies and procedures Effective management strategies and procedures Basic neuroscience advances in the decade of the brain (1990s) impacted understanding of APD Different regions mature at different rates Maturation occurs along caudal to rostral gradient Development of auditory pathways and centers involves Cell differentiation and migration Myelination Arborization Synaptogenesis Consistent and typical auditory stimulation (experience) within the first years after birth shapes nervous system development (plasticity) Perinatal and childhood factors influence development of auditory processing, e.g., Neurological risk factors (e.g., asphyxia, hyperbilirubinemia) Conductive hearing loss Environmental deprivation Genetic factors play a role in etiology of auditory processing disorders New Handbook of Auditory Evoked Responses Summary of AER findings in APD Chapter 1: Overview of auditory neurophysiology Chapter 2: Anatomy and physiology principles of AERs Chapter 3: Introduction to AER measurement Chapter 4: Electrocochleography (ECochG): Protocols and procedures Chapter 5: ECochG: Clinical applications and populations Chapter 6: ABR Parameters, Protocols, and Procedures Chapter 7: ABR analysis and interpretation Chapter 8: Frequency-specific ABR and ASSR Chapter 9: ABR: Pediatric clinical applications and populations Chapter 10: ABR: Adult diseases, disorders & clinical applications Chapter 11: Auditory middle latency response Chapter 12: Auditory late response Chapter 13: P300 response Chapter 14: Mismatch negativity (MMN) response Chapter 15: Electrically evoked and myogenic responses Auditory Late Response and P300 Response P2 Frequent Unattended e.g., 1000 Hz Amplitude (mV) P3 (300) N1 P2 Infrequent (rare) Attended e.g., 2000 Hz 500 ms Mismatch Negativity (MMN) Response: “Unconcious Brain Response Elicited by Different Properties of Sound (Courtesy of Catharine Pettigrew, Ph.D.) MISMATCH NEGATIVITY (MMN) RESPONSE: Investigations in clinical populations Assessment of infant speech perception, including children at risk for disorders, e.g., language (e.g., Leppanen & Lyytinen, 1997) Hearing aid fitting of infants and young children with speech signals (e.g., Kraus, et al) Cochlear implant fitting infants and young children with speech signals (e.g., Kraus, et al) Documentation of auditory training and language treatment (e.g., Kujala et al, 2001) Description of Alzheimer’s disease (e.g., Pekkonen et al, 1994) Electrophysiologic documentation of attention deficit hyperactivity disorder (e.g., Barry, Johnstone, Clarke, 2003) Prognosis of recovery from coma (e.g., Kane et al, 1993) Diagnosis of frontal and auditory temporal lobe dysfunction in schizophrenia (e.g., Michie et al, 2000) Neurophysiologic documentation of auditory processing disorder (APD) and dyslexia in children Neuroscience Evidence for APD: Functional Neuro-Imaging (fMRI) Left Handed 18 Year Old with Right Ear Deficit on Dichotic Tests Right TL “fMRI” and “Auditory” Medline Citations: Thousands of Peer Reviewed Articles Bernal B, Altman NR, Medina LS. Dissecting nonverbal auditory cortex asymmetry: an fMRI study. Int J Neurosci. 2004 May;114(5):661-80 Rowan A, Liegeois F, Vargha-Khadem F, Gadian D, Connelly A, Baldeweg T. Cortical lateralization during verb generation: a combined ERP and fMRI study. Neuroimage. 2004 Jun;22(2):665-75. Okada T, Honda M, Okamoto J, Sadato N. Activation of the primary and association auditory cortex by the transition of sound intensity: a new method for functional examination of the auditory cortex in humans. Neurosci Lett. 2004 Apr 8;359(1-2):119-23. Blau V, van Atteveldt N, Ekkebus M, Goebel R, Blomert L. Reduced Neural Integration of Letters and Speech Sounds Links Phonological and Reading Deficits in Adult Dyslexia. Curr Biol. 2009 Mar 11. Leff AP, Iverson P, Schofield TM, Kilner JM, Crinion JT, Friston KJ, Price CJ. Vowel- specific mismatch responses in the anterior superior temporal gyrus: An fMRI study. Cortex. 2009 Apr;45(4):517-26. Epub 2008 Feb 7. Warrier C, Wong P, Penhune V, Zatorre R, Parrish T, Abrams D, Kraus N. Relating structure to function: Heschl's gyrus and acoustic processing. J Neurosci. 2009 Jan 7;29(1):61-9. Assessment and Management of Auditory Processing Disorders (APD) Historical perspective … interest in APD dates back over 50 years How APD became a household phrase in audiology Neuroscience foundation for APD Disorders often co-existing with APD Risk factors for APD Current and future assessment strategies and procedures Effective management strategies and procedures Auditory Processing Disorders: Differential Diagnosis “Differential Diagnosis: Diagnosis based on comparison of symptoms (signs) of two or more similar diseases (disorders) to determine which the patient is suffering from.” Shared Anatomy Reading Language Auditory processing AUDITORY PROCESSING DISORDERS: Co-existing Disorders (Co-morbidity) Peripheral (conductive and sensory) hearing loss Specific language impairment (SLI) Learning disabilities (LDs) Reading disorders (dyslexia) Attention deficit/hyperactivity disorder (ADHD) Emotional and psychological disorders Developmental delay Seizure disorders PDD, autism, and autism spectrum disorders AUDITORY PROCESSING DISORDERS (APDs): Co-existing Disorders (Co-morbidity) SLI APD dyslexia ADHD AUDITORY PROCESSING DISORDERS (APD): Evidence of relation to language and reading Wright BA, Lombardino LJ, King WM, Puranik CS, Leonard CM, Merzenich MM. Deficits in auditory temporal and spectral resolution in language-impaired children. Nature 387: 176-178, 1997. “Here we report the results of psychophysical tests employing simple tones and noises showing that children with specific language impairment (SLI) have severe auditory perceptual deficits for brief but not long tones in particular sound contexts.” AUDITORY PROCESSING DISORDERS: Relation to language and reading Wright BA, Lombardino LJ, King WM, Puranik CS, Leonard CM, Merzenich MM. (continued) “The present auditory tests may also aid in the diagnosis and treatment of persons with reading difficulties … Our results are in accord with the conclusion … that some but not all children with reading problems have difficulties accurately perceiving rapidly presented stimuli.” Assessment and Management of Auditory Processing Disorders (APD) Historical perspective … interest in APD dates back over 50 years How APD became a household phrase in audiology Neuroscience foundation for APD Disorders often co-existing with APD Risk factors for APD Current and future assessment strategies and procedures Effective management strategies and procedures APD: Screening and Assessment in Pre-School Children I can’t figure out what they are saying! Risk Factors for APD: Team Work in Identification and Assessment Neurological dysfunction and disorders (physicians), e.g., neonatal risk factors (e.g., asphyxia, CMV) head injury seizure disorders Chronic otitis media in preschool years (otolaryngologists) Academic underachievement or failure (teachers and educational psychologists) Family history of academic underachievement (parents) Co-existing disorders (multiple professionals) Auditory Processing Disorders: Indicators in Early School Age Population (e.g., kindergarten) Behavior typical of peripheral hearing loss, but normal audiogram Scatter in results on psychological and language tests, with weakness in auditory domains Verbal IQ score lower than performance IQ score May have poor musical skills Problems with fine and/or gross motors skills Teacher and/or parent concern about hearing and listening abilities (and the audiogram is normal) Auditory Processing Disorders: Indicators in Early School Age Population (2) Has difficulty following multi-step directions Poor reading and spelling skills (remediation not effective) Responds inappropriately in the classroom Reluctant to participate in class discussions Positive history of middle ear disease and hearing loss Auditory Processing Disorders: Indicators in Early School Age Population and Screening for At Risk Children (SIFTER) Auditory Processing Disorders: Indicators in Early School Age Population and Screening for At Risk Children (CHAPS) SCAN-C and SCAN-A (Robert Keith, 1986): Undefined sensitivity and specificity Low pass filtered words subtest 40 monosyllabic words (20 for each ear) low pass filtered at 1000 Hz Auditory figure-ground subtest 40 monosyllabic words (20 for each ear) multi-talker babble noise at + 8 dB SNR Competing words 40 monosyllabic words (20 for each ear) inter-word interval of < 5 ms initial response to right then left ear words Competing sentences 15 target and competing sentences initial response to right then left ear sentences Assessment and Management of Auditory Processing Disorders (APD) Historical perspective … interest in APD dates back over 50 years How APD became a household phrase in audiology Neuroscience foundation for APD Disorders often co-existing with APD Risk factors for APD Current and future assessment strategies and procedures Effective management strategies and procedures Assessment of APD: Acquiring History and Background Information Parents complete APD survey Middle ear disease? Neonatal risk factors? Co-existing disorders? Medical management for auditory or neurological disorder Previous assessments, e.g., Speech language Psychological and psycho-educational ADHD Previous and current therapy and treatment Assessment of APD: Peripheral Test Battery (< 20 minutes) Otoacoustic emissions (OAEs) OAEs are abnormal in 35% of children undergoing APD assessment Aural immittance measures tympanometry acoustic reflexes crossed vs. uncrossed conditions … initial measure of CNS function Pure tone audiometry inter-octave frequencies (e.g., 3000 and 6000 Hz) high frequency (> 8000 Hz) audiometry (as indicated) Speech audiometry word recognition (use CD materials with 10 most difficult words first) Assessment of APD: Central Auditory Test Battery (~ 80 minutes) APD ASSESSMENT: Test Battery for Auditory Processes (1) Sound localization and lateralization No clinical tests commercially-available for children Wxperimental techniques for earphone simulated signals Auditory discrimination, e.g., Goldman-Fristoe-Woodcock Test of Auditory Discrimination (in quiet and noise) Temporal resolution/gap detection, e.g., Auditory Fusion Test (Revised) Auditory Random Gap Detection (ARGD) test Gap in Noise (GIN) test Temporal ordering, e.g., Pitch pattern sequence (PPS) test Suration pattern sequence test Dichotic Digits Procedure LEFT TEMPORAL RIGHT TEMPORAL CORTEX CORTEX Association Cortex Association Cortex Corpus Callosum Primary Auditory Cortex Primary Auditory Cortex Left Ear Right Ear 1, 4 2, 9 CAPD ASSESSMENT: Test Battery for Auditory Processes (2) Temporal integration dichotic tests, e.g., Dichotic digits Staggered spondaic word (SSW) test Dichotic sentence identification (DSI) test SCAN competing words subtest Auditory performance with competing acoustic signals, e.g., SSI-ICM Pediatric Speech Intelligibility (PSI) test GFW Test of Auditory Discrimination (noise) SCAN auditory-figure ground subtest Auditory performance with degraded acoustic signals, e.g., Time-compressed words with reverberation SCAN filtered words subtest APD ASSESSMENT: Additional Components of Test Battery (as indicated) Auditory Continuous Performance Test (ACPT) developed by Robert Keith for children with suspected or diagnosed AD/HD rapid presentation of words task is to respond to target word “dog” only analog to visual continuous performance tests Screening of phonologic awareness skills Phonemic synthesis test developed Jack Katz Test of Auditory Analysis Skills (TASS) Say the word baseball … now say it again but don’t say base Say the word smack … now say it again but don’t say /m/ APD ASSESSMENT: Ideas for New Procedures and Protocols General principles Verbal and non-verbal procedures Non-verbal test materials Non-verbal response mode Age appropriate tasks Psychometrically well designed Sensitivity and specificity Adequately large normative data across age range Standard scores and percentiles Adaptive test strategies Reduced test time Manipulation of test difficulty Measures of major auditory processes APD ASSESSMENT: Creative Non-Verbal Test Procedures and Protocols (1) Gaps-in-Noise (GIN) test (Musiek, Shinn, Jirsa, Bamiou, Baran & Zaidan. The GIN (Gaps-in-Noise) Test performance in subjects with confirmed central auditory nervous system involvement. Ear & Hearing, 26, 2005.) Noise signals with gaps of silence Gaps of different durations and locations within noise Non frequency specific signals Scores not influenced by hearing loss Simple button pushing response Signal with either gap or no gap Yes or no response judgment Minimal influence of cognition (for patient and tester) Gap detection is a traditional and accepted measure of temporal processing APD ASSESSMENT: Creative Non-Verbal Test Procedures and Protocols (2) Listening in Spatialized Noise (LISN) test The Listening in Spatialized Noise Test: An auditory processing disorder study. JAAA, 17, 2006. Cameron et al, 2006) The Listening in Spatialized Noise -- Sentences Test (LISN-S): Comparison to the prototype LISN and results from children with either a suspected (central) auditory processing disorder or a confirmed language disorder. JAAA 19, 2008. Cameron & Dillon. Three dimensional auditory environment under earphones Assesses auditory stream segregation skills in children Speech reception thresholds for sentences presented from 0o azimuth in competing speech. Competing speech manipulated by Location in auditory space (0o vs. 90o) Vocal quality of speakers (same as or different from target stimulus speaker) Advantage measured as benefit in dB with either spatial or talker cue APD ASSESSMENT: Creative Non-Verbal Test Procedures and Protocols (2) The Listening in Spatialized Noise -- Sentences Test (LISN-S): Comparison to the prototype LISN and results from children with either a suspected (central) auditory processing disorder or a confirmed language disorder. JAAA 19, 2008. Cameron & Dillon. Conclusions Children with traditionally defined APD showed deficit on LISN-S No correlation of LISN-S with dichotic tests, PPS test, or gap detection test Spatial and non-spatial LISN-S test performance not correlated Children with language impairment did not show LISN-S deficits Findings support ASHA 2005 and AAA 2009 conclusions regarding the ability to diagnose auditory specific deficits Children with spatial stream segregation deficits likely to require higher SNR, e.g., personal FM devices APD ASSESSMENT: Auditory Evoked Responses Evoked with Non-speech and Speech Signals Auditory evoked responses Auditory brainstem response (ABR) Auditory steady state response (ASSR) Auditory middle latency response (AMLR) Auditory P300 response oddball paradigm active or passive subject Mismatch negativity (MMN) response Auditory processes to be assessed Discrimination (e.g., frequency, duration, speech type sounds) Auditory figure ground Temporal processing Temporal ordering Assessment and Management of Auditory Processing Disorders (APD) Historical perspective … interest in APD dates back over 50 years How APD became a household phrase in audiology Neuroscience foundation for APD Disorders often co-existing with APD Risk factors for APD Current and future assessment strategies and procedures Effective management strategies and procedures Management of APD with Computer-Based Techniques: Scientific Bases of FastForword Tallal P, Miller S, Merzenich M, et al. Language comprehension in language-learning impaired children improved with acoustically modified speech. Science 271: 81-84, 1996. “A speech processing algorithm was developed to create more salient versions of the rapidly changing elements in the acoustic waveform of speech that have been shown to be deficiently processed by language-learning impaired (LLI) children … LLI children received extensive daily training with listening exercises ...” APD MANAGEMENT: Computer-based Auditory Therapy (www.cogcon.com) Earobics comes in two versions: Earobics Foundations for pre-kindergarten, kindergarten, and first grade students • Earobics Connections for second and third grade students, and other struggling readers Instructions available in 10 languages Auditory, Phonological, and Pre-Reading Skills Addressed by Earobics Program Rhyming Phoneme identification Blending Segmentation Ability to break word down into individual sounds Phonological manipulation Discrimination Auditory performance in competing noise Auditory sequential memory Earobics: Comments from Website (www.cogcon.com) Earobics is widely considered to be one of the most validated and quantifiable reading intervention programs. States across the country have reviewed the program and approved its use in their schools to quickly and effectively build student reading achievement. Independent industry reviewers, including the Florida Center for Reading Research (FCRR), confirm these findings. As a vital source for districts and schools, FCRR regularly reviews reading programs to help teachers, principals, and district administrators make informed choices on effective instruction. Earobics was among the select few programs in the supplemental, intervention, and technology-based program categories to achieve the FCRR’s highest ranking in all five reading areas. NOTE: FCRR = Florida Center for Reading Research (www.fcrr.org) AUDITORY PROCESSING DISORDERS (APDs): Incremental Deficits Model > Intelligence < Intelligence Normal hearing Conductive HL Family support ADD/ADHD Genetics Genetics Environment SLI Auditory stimulation APD Academic Academic Achiever Underachiever APD Management (Treatment): Preferred Practice Patterns for Audiology (ASHA) Counseling Assistive listening devices Acoustic enhancement and environmental modification of the listening environment Auditory training and stimulation (including computer- based software programs) Communication and/or education strategies Meta-linguistic and meta-cognitive skills and strategies Documentation of implementation of frequency and duration of treatment Documentation of outcome Management of Children with Auditory Processing Disorders (APD) in Educational Settings APD Management Options and Approaches Counseling, case management, and advocacy Audiologic management in school and the home, e.g., FM technology (assistive listening devices) Specific auditory training programs (e.g., DIID) Computer based auditory training programs, e.g., Earobics (school wide license for 600 children) Multi-disciplinary management, e.g., Multi-sensory reading instruction strategies Classroom Assistive Listening Devices Personal FM Headset Style Desktop Sound Field FM Toteable FM Infrared Phonak EduLink A viable option for all children, particularly adolescents EduLink Receivers Mini-Boom Microphone Campus S Transmitter SNR improvement on the HINT in normal hearing adults and children without and with APD: Three different FM system types Head set SNR Improvement (in dB SPL) 10 9.5 8 7.5 7.2 7.4 Desk top 6.5 6 4.7 4.3 Sound field 4.0 3.8 4 2 Adults (N = 10) Non-APD (N = 8) APD (N = 12) Listening Condition Hearing in Noise Test (HINT) Results (Mean SNR values without and with EduLink) Group Test Condition Control APD Unaided in Noise (SNR)* 7.9 dB 6.1dB Aided in Noise (SNR) ** - 0.3 dB - 4.2 dB Advantage in Noise 8.2 dB 10.3 with EduLink * t = p < .08; ** t = .002 Typical Classroom SNR Range: +5 to -7 dB Markides (1986); Finitzo-Hieber (1988); Crandell and Smaldino (1995) Educational Performance: Fisher’s Auditory Checklist Findings Completed by Parents (Difference in scores between groups significant at p < .000) Fisher's Score 100 90 80 Percent Score 70 60 50 Fisher's Score 40 30 20 10 0 CT 11 D3 D4 D5 D6 D8 AP 9 CT 10 CT 12 13 AP 0 AP 2 AP 3 AP 4 AP 5 6 CT 1 CT 2 CT 3 CT 4 CT 5 CT 6 CT 7 CT 8 CT L9 D D1 D1 D1 D1 D1 D1 RL RL RL RL RL RL RL RL RL RL RL RL R AP AP AP AP AP AP CT Individual Control and APD Subjects Educational Performance: Listening Inventory For Education (LIFE) Group Question Control APD Significance p < 0.05 1 8.6 5.2 + 2 7.3 5.1 + 3 6.6 4.7 - 4 5.5 21.5 - 5 4.9 3.0 - 6 8.4 6.8 - 8 7.1 6.0 - 9 9.4 5.8 + 10 7.9 6.9 - Educational Performance: SIFTER (Difference in scores between groups for all categories except School Behavior [p < 0.57)]significant at p < .05) SIFTER APD vs Control 14 12 10 Score 8 Control 6 APD 4 2 0 Academics Attention Communication Class Participation School Behavior SIFTER Categories Psychosocial Questionnaires Behavioral Assessment System for Children, Volume II (BASC-II) A profile of adaptive and maladaptive behaviors and emotions of children and adolescents. Social Skills Rating System (SSQ) A measure of positive and negative social skill behaviors of students. Dartmouth Cooperative Functional Health Assessment Charts (COOP) A screening tool for quality of life in adolescents in several functional domains/ Psychosocial Function in Children with APD: Initial BASC II Parent Report •Externalizing Prob: Hyperactivity, Aggression, Conduct Problems •Internalizing Prob: Anxiety, Depression, Somatization •BSI: Atypicality, Withdrawal, Attentional Problems •Adaptive Skills: Adaptability, Social Skills, Leadership, Activities of Daily Living, Functional Communication Psychosocial Function in Children with APD: Initial BASC II Child Self Report •Internalizing Prob: Atypicality, Locus of Control, Social Stress, Anxiety, Depression, Sense of Inadequacy, Somatization •School Prob: Attitude to School, Attitude to Teachers, Sensation Seeking •ESI: combination of Social Stress, Anxiety, Depression, Sense of Inadequacy •Personal Adjustment: Relations with Parents, Interpersonal Relations, Self-Esteem, Self Reliance Psychosocial Questionnaires: Interpretation “Scale scores in the Clinically Significant range suggest a high level of maladjustment. Scores in the At-Risk range may identify a significant problem that may not be severe enough to require formal treatment or may identify the potential of developing a problem that needs careful monitoring.” BASC II Parent Report Results After EduLink Use (6 to 7 months): APD versus Control Subjects Normal Findings per Group (%) Domain Control APD Aggression 92 100 Conduct problems 92 100 Anxiety 84 100 Depression 92 100 Internalizing problems 77 71 Withdrawal 84 71 Attention problems 92 29 Adaptive skills 92 71 Functional communication 92 57 BASC II Student Report Results After EduLink Use (6 to 7 months): APD versus Control Subjects Normal Findings per Group (%) Domain Control APD Attitude toward teachers 100 86 Attitude toward school 100 57 School problems 100 71 Conduct problems 92 100 Atypicality 100 100 Anxiety 100 100 Social stress 92 100 Depression 100 86 Internalizing problems 100 100 Sense of inadequacy 100 86 Parent relationship 92 100 Self esteem 100 100 Benefit of Phonak EduLink FM Technology on Communication, Psychosocial Status, and Academic Performance of Children with Auditory Processing Disorders (APD): Conclusions Paper will appear in April 2009 issue of International Journal of Audiology APD in school age children can have significant negative impact on: Academic performance Psychosocial status Quality of life Early intervention for auditory processing deficits is indicated for all children, despite the age of identification The Phonak EduLink system is a feasible option for FM technology with adolescents (and persons of other ages) Management of APD with FM technology (enhancing the signal-to-noise ratio) improves: Speech perception in noise (with EduLink FM system Academic performance Psychosocial status Speech perception in noise without the benefit of FM technology Dichotic Intensity Increment Difference (DIID) LEFT TEMPORAL RIGHT TEMPORAL CORTEX CORTEX Association Cortex Association Cortex Corpus Callosum Primary Auditory Cortex Primary Auditory Cortex Weak Ear Strong Ear fixed increasing intensity intensity Dichotic Intensity Increment Difference (DIID) Tasks Binaural separation Ear directed targets (monaural) Ear directed targets (binaural) Ear directed manipulations Ear directed judgments Intensity, clarity Materials should be a mixture of dichotic materials Digits Spondee words Single syllable words Sentences Examples of “Top-Down” and Multi-Sensory Reading Intervention Options for Children with APD Context-derived vocabulary building Visual imagery Visualizing and Verbalizing Program Auditory closure activities Speech/language therapy Multi-sensory reading strategies Lindamood Bell Learning Processes (www.lindamoodbell.com) Wilson Reading Program Orton Gillingham approaches The Early Auditory Reading Success (EARS) Program: Assumptions Kindergarten children learn mostly through the auditory modality, and learn best in an optimal acoustic environment. Academic success is dependent on reading success. Reading failure a product largely of auditory processing and phonemic awareness deficits. Auditory processing and phonemic awareness deficits must be identified early through screening of all kindergarten children. Early and intensive intervention for auditory processing and phonemic awareness deficits is necessary reading and academic success. Literacy Outcome Measure: DIBELS (Dynamic Indicator of Early Literacy Skills) Developed at the University of Oregon (www.dibels.uoregon.edu) Required by Alachua County School System (and in state of Florida) to monitor academic progress in kindergarten children Four measures of reading reading skills Initial sounds fluency (ISF) Letter naming fluency (LNF) Phonemic segmentation fluency (PSF) Nonsense word fluency (NSF) Administered four times in kindergarten year Early fall semester (September) Late fall semester (December) Early spring semester (January) Late spring semester (May) DIBELS (Reading Readiness) Outcome in the Initial EARS Project (2002-2003) DIBELS EARS School Control School Outcome Early Final Final N = 52 N = 63 N = 48 Deficit 50% 27% 40% Emerging 31% 22% 44% Established 19% 60% 16% EARS Program Rationale: Five Component Skills of Reading Phonemic Awareness (sound/speech sound skills) Phonics (phoneme/grapheme skills) Fluency Vocabulary Comprehension The Early Auditory Reading Success (EARS) Program: Intervention based on screening outcome Children diagnosed with hearing, cognitive, attention, or other deficits referred for appropriate management Intervention components FM systems in each kindergarten classroom All kindergarten students complete Earobics Multi-sensory reading instruction strategies used by each kindergarten teacher Children diagnosed with APD and/or deficits in phonologic awareness receive intensive small group treatment by speech pathologist letter recognition phonologic awareness other basic reading skills Multiple Tiers of Reading Instruction Models: Conventional (e.g., Torgesen, 2005) vs. Early Intervention (EARS) Core Reading Program Reading Skills EARS Program Powerful Intensive Intervention (Struggling Readers) Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12 Grade EARS Program (2005-2006): Early (Kindergarten) Intervention Program for At Risk Struggling Children Core Reading All kindergarten children in Title I Program schools undergo (Tier 1) auditory and language screening Phonologic Awareness Enhancement (Tier 2) Not at risk? At risk? Classroom FM system Classroom instruction Earobics program Intensive Intervention (Tier 3) Monitor Outcome Small group inclusive instruction (DIBELS) Pre-reading skills National 70%ile? Phonologic awareness instruction Early Auditory Reading Success (EARS): Final Outcome 2005 by DIBELS scores (Williams Elementary School) Established 04 96 94 100 92 National %ile 80 60 40 20 HR MR LR AA Est HR MR LR AA Est HR MR LR AA Est Letter Sound Phonemic Sequence Nonsense Word Fluency Fluency Fluency EARS: DIBELS National %ile rank in final test interval of First Grade for EARS participants (2005/2006) 60 57 50 40 40 38 30 EARS 21 (n=180) 20 10 Control (n=143) 0 OLV Reading Comp OLV Oral Language Vocabulary Reading Comp Reading Comprehension The Early Auditory Reading Success (EARS) Program: Conclusions The results of auditory processing can be used to determine children at risk for reading and academic failure. All kindergarten children in Title I schools benefit from Adequate acoustic learning environment (classroom) Enhancement of phonologic awareness instruction in by the classroom teacher Therapy for auditory processing and pre-reading skills (Earobics) Intensive intervention for auditory processing and phonologic awareness deficits improves early literacy skills. The EARS program offers effective early intervention for kindergarten children at risk for reading failure. To date, the benefits of EARS program for reading are documented through 2nd grade MANAGEMENT OF APD: Facilitating academic achievement & success I must be smart!
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