School Management System in Visual Basic 6.0 by xoo79055

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									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.
                  jwhall3@phhp.ufl.edu
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
                       CT 10


                       CT 12
                             13
                            D3
                            D4
                            D5
                            D6
                            D8

                        AP 9
                        CT 1
                        CT 2
                        CT 3
                        CT 4
                        CT 5
                        CT 6
                        CT 7
                        CT 8
                       CT L9




                        AP 0
                        AP 2
                        AP 3
                        AP 4
                        AP 5
                              6
                            D
                           RL
                           RL
                           RL
                           RL
                           RL
                           RL
                           RL
                           RL




                           D1
                           D1
                           D1
                           D1
                           D1
                           D1
                         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 Behav ior
                                           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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