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I’m lost in this class! What’s wrong with me? I just can’t hear right.

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

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I’m lost in this class! What’s wrong with me? I just can’t hear right.

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  1. 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.

  2. 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

  3. 8th cranial (auditory) nerve)Internal auditory canal Shares space with vestibular nerves, facial nerves, efferent auditory nerves & internal auditory arteryCentral auditory nervous systemCochlear nuclei Superior olivary complex Lateral lemiscus Crossing pathways Infererior colliculus Reticular (activating) formation Thalamus Primary and secondary auditory cortex Corpus collosum

  4. Behavioral Audiometry: True Measures of Hearing

  5. Behavioral Audiometry: Sound Field versus Earphone Stimulation

  6. The Audiogram: Hearing Sensitivity as a Function of Pure Tone Frequency

  7. AUDITORY PROCESSING DISORDERS (APD):Academic Underachievement & Failure I must be stupid! F

  8. 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) 20 Female(N = 79) 15 Number of Patients 10 5 7 8 9 10 11 12 13 14 15 - 18 Age in Years

  9. AUDITORY PROCESSING: Cornerstone of Language and Literacy (Reading) COMPREHENSION WRITTEN LANGUAGEReading and Spelling PHONOLOGIC AWARENESS ORAL LANGUAGE AUDITORY PROCESSING

  10. 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

  11. 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.

  12. 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)

  13. Dichotic Listening Paradigm … A long-standing test strategy for assessment of auditory processing 1956: British Psychologist Donald E. Broadbent, Ph.D. 1961: Canadian Psychologist Doreen Kimura, Ph.D.

  14. Dichotic Listening Paradigm RIGHT TEMPORAL CORTEXAssociation CortexPrimary Auditory Cortex LEFT TEMPORAL CORTEXAssociation CortexPrimary Auditory Cortex CorpusCallosum Right Earair plane1, 3 LeftEarbase ball5, 9

  15. Development of APD Assessment & Management:Principles & Procedures Keith AMLRstudiesMusiek WillefordJerger proceduresMRI studies KatzKimura ASHATask ForceTallalKraus APDConferencefMRIEarobics Bocca & CalearoMyklebust 1960 1975 1986 1954 1982 1990s 1996 2000

  16. 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

  17. 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.”

  18. 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.”

  19. 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

  20. 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

  21. 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)

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. Auditory Late Responseand P300 Response P2 FrequentUnattendede.g., 1000 Hz P3 (300) Amplitude (mV) N1 P2 Infrequent(rare)Attendede.g., 2000 Hz 500 ms

  29. Mismatch Negativity (MMN) Response: “Unconcious Brain Response Elicited by Different Properties of Sound(Courtesy of Catharine Pettigrew, Ph.D.)

  30. 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

  31. Neuroscience Evidence for APD: Functional Neuro-Imaging (fMRI)Left Handed 18 Year Old with Right Ear Deficit on Dichotic Tests RightTL

  32. “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.

  33. 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

  34. 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.”

  35. Shared Anatomy Reading Language Auditory processing

  36. 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

  37. AUDITORY PROCESSING DISORDERS (APDs): Co-existing Disorders (Co-morbidity) SLI APD dyslexia ADHD

  38. 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.”

  39. 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.”

  40. 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

  41. APD:Screening and Assessment in Pre-School Children I can’t figure outwhat they are saying!

  42. 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)

  43. 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)

  44. 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

  45. Auditory Processing Disorders: Indicators in Early School Age Population andScreening for At Risk Children (SIFTER)

  46. Auditory Processing Disorders: Indicators in Early School Age Population andScreening for At Risk Children (CHAPS)

  47. 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

  48. 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

  49. 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

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