Auditory Processing Disorders

1. Auditory Processing Disorders Christine A. Stevens, M.A., CCC-SLP

2. “Do not make the mistake of trivializing hearing problems triggered by the environment as compared to those innately physical. The effects are the same. The inability to hear (clearly) causes ALL children, even those with the best intentions to pay attention, to disengage themselves from auditory learning.”~The Institute for Enhanced Classroom Hearing (2008)

3. Definitions Auditory Processing: A term used to describe what happens when your brain recognizes and interprets the sounds around you. (NIDCD, 2008) OR “What we do with what we hear.”(Jack Katz, 1993) Auditory Processing Disorder: Difficulty in the recognition, processing, and/or interpretation of the sounds around you.

4. How does this all work? • The act of hearing does not end with our detection of sound. • “Between the arrival of speech at the eardrum and our perception of it, a very large number of mechanical and neurobiological operations intercede.”(Musiek & Chermak, 1997). • The Information Processing Theory describes that the processing of auditory information is made up of both “bottom-up” and “top-down” factors.

6. Definition, continued The American Speech-Language-Hearing Association Consensus Committee defines auditory processing as the auditory system mechanisms and processes responsible for the following behavioral phenomena: • Sound localization and lateralization • Auditory discrimination • Auditory pattern recognition • Temporal aspects of audition, including temporal resolution, temporal masking, temporal integration, temporal ordering • Auditory performance decrements with competing acoustic signals • Auditory performance decrements with degrading acoustic signals (ASHA,1996 in Stecker, 1998)

7. Auditory Processing Disorders: The Facts • Most individuals with A.P.D. have normal peripheral hearing. • Approximately 5% of school-age children have difficulty with auditory processing. • The ratio of males to females with processing difficulty is 2:1. • Interest in central auditory functioning as it related to communicative disorders first began in the 1950s and was referred to as “auditory imperception”. I wonder how we treated those with processing difficulty up until that point. . . • Most audiologists will not diagnose a child under the age of 7 with an auditory processing disorder.

8. What does a person with A.P.D. look like?

9. Potential Early Indicators of Processing Issues

10. The Buffalo ModelKatz, Stecker, & Masters (1993) • Decoding: Difficulty interpreting units of information. • Tolerance-Fading Memory (TFM): Difficulty storing items in short-term memory; part of the message “fades away”. • Integration: Severe decoding and TFM difficulties coexist. • Organization: Difficulty organizing and sequencing information. The following information/definitions adapted by Terri Cinotti, M.A., CCC-SLP, University at Buffalo, 1997.

11. Decoding: Observable Characteristics • General: Slow to respond Misinterprets words, directions, or questions Difficulty with speech-in-noise Phonics problems (translates to poor reading and spelling) Poor discrimination Poor sound blending Auditory fatigue • Speech-Language: Trouble with word-finding Articulation errors (/r/ and /l/ most commonly) Poor receptive language skills Difficulty with grammatical markers *Statistically significant history of ear infections

12. Decoding: Observable CharacteristicsContinued • Academic: Reading and writing difficulties Poor comprehension of phonics Difficulty following directions Difficulty with oral discussions Problems with group listening • PragmaticCharacteristics: Poor eye contact Difficulty participating in oral discussions Often allows others to “talk over” them Difficulty with topic maintenance

13. TFM: Observable Characteristics • General: Fast to respond(Auditory recall fades before the child’s ability to process the information. . .almost as though they don’t want to forget) Easily overstimulated Impulsive Distracted by noises Trouble with speech-in-noise tasks Poor short-term memory Poor handwriting (due in part to poor motor planning) • Speech-Language: Poor auditory recall Trouble with expressive language formulation Trouble with inferences Syntax issues (The child doesn’t get the full, appropriate model message all of the time) Articulation is normal in isolation; inconsistent errors in connected speech (cluttering is often observed)

14. TFM: Observable CharacteristicsContinued • Academic: Reading comprehension difficulties Difficulty following directions Distractibility and difficulty attending Impulsivity • Pragmatic Characteristics: Poor tolerance to noise “Erratic”, attention-seeking behaviors during “listening” situations

15. From National Institute of Mental Health ( 2008) Some signs of hyperactivity-impulsivity are: -Feeling restless, often fidgeting with hands or feet, or squirming while seated -Running, climbing, or leaving a seat in situations where sitting or quiet behavior is expected -Blurting out answers before hearing the whole question -Having difficulty waiting in line or taking turns.

16. Differential Diagnosis: Distinguishing between two or more conditions presenting with similar symptoms or attributes. American Speech-Language-Hearing Association. (2005). (Central) Auditory Processing Disorders [Technical Report]. Available from www.asha.org/policy.

17. The American Academy of Pediatrics “recommend a comprehensive assessment that relies on direct information from parents (or caregivers) and the classroom teacher (or other school professional) using developmental history, rating scales, observations, and available test results.”(Schwab Learning, 2008) Auditory Processing and AD/HD

18. AD/HD as a disorder of OUTPUT -Essentially the inability to control behaviors. Auditory processing disorders are then disorders of INPUT -The processing difficulty gets in the way of “selective and divided auditory attention.”(Chermack, Hall, and Musiak, 1998-1999 in Young, s.d.; Musiek and Chermack, 1997) Auditory Processing and AD/HD

19. Integration: Observable Characteristics • General: Extremely delayed responses Characteristics of Decoding and TFM-type classifications • Speech-Language: Severe receptive and expressive language difficulties Possible articulation/phonological delay • Academic: Poor phonics Severe reading and writing difficulties Difficulty with sound/symbol integration • Pragmatic Characteristics: Characteristics of both Decoding and TFM-type classifications

20. Organization: Observable Characteristics • General: Difficulty seen mainly in “output” General disorganization (carries over into every area of the individual’s life) Disorganized language, sentences, discourse, writing, workspace • Speech-Language: Poor discourse skills Poor sequencing skills Difficulty with problem solvingPoor syntax • Academic: Poor writing skills Sequencing problems Disorganized work habits and work space • Pragmatic Characteristics: Difficulty in taking his or her communication partners’ perspective

21. Assessment of A.P.D • Some of the cognitive and linguistic skills a child needs to complete testing for A.P.D. aren’t fully developed until 7 to 9 years of age. • . . . but we CAN identify students who may be at risk for processing difficulties based on established patterns of characteristics and change the way we interact with those children! • Identification/assessment takes on a TEAM approach: -Classroom teacher -Parents, grandparents, friends -Therapists in the classroom -Psychologist -Speech-Language Pathologist -Audiologist

22. Assessment of A.P.D., continued • “The Buffalo Model includes a comprehensive audiological and speech-language assessment, as well as a thorough case history, an educational questionnaire completed by the teacher [often the S.I.F.T.E.R.], and the Children’s Auditory Processing Performance Scale (CHAPPS) (Smoski et al., 1992) completed by both the parent and teacher.” (Katz, Masters, and Stecker, 1993) • The audiological assessment will always include a complete peripheral hearing exam to rule out any underlying hearing loss.

23. Assessment of A.P.D., continued • The C.A.P. battery of tests include: -Scattered Spondaic Word Test -Phonemic Synthesis Test -Speech-In-Noise Test -Masking Level Difference Test -Auditory Continuous Performance Test (as needed) -Frequency Pattern Test (as needed) -Duration Pattern Test (as needed) -Compressed Speech Tests (as needed) -Dichotic Digits Test (as needed) • The speech-language evaluation will include: -Language sample -Word-finding test -Phonologic analysis -Other expressive and receptive language tests (as needed)

24. The AUDIOLOGIST can provide the actual diagnosis of A.P.D. after a comprehensive audiological assessment.

25. Strategies for Intervention Management should be made up of three parts: 1. Direct therapeutic intervention 2. Environmental modifications 3. Development of compensatory strategies Stimulation should be FREQUENT, INTENSE, and CHALLENGING (Bellis)

26. Direct Therapeutic Intervention • Auditory therapies -Noise desensitization tasks (speech-in-noise) -Computer programs to address A.P. • Speech-language therapy

28. Environmental Modifications Improve signal-to-noise ratio: • Adding carpets to classrooms to improve the acoustic environment. • Place tennis balls on the feet of classroom chairs to decrease noise. • Computers turned off when not in use • Preferential seating (close to teacher or near a student “buddy” who can provide cues) • Indirect lighting (fluorescent lighting may buzz)

29. FM Systems Boost the sounds of the speaker’s voice above the classroom noise Completely in Canal Campus SX Behind the Ear Edu Link (Designed specifically for those with A.P.D) Zoom Link Transmitter

31. Compensatory Strategies • Teaching children to be “active” rather than “passive” listeners. • Teaching “chunking” of information • Developing “brain tricks” • Teaching older children and adults note-taking strategies • Helping the individual to be a self-advocate • Develop linguistic and metacognitive skills

32. Food for Thought “While some APD children develop compensatory skills enabling them to thrive in school, it is still not easy for them. Compensatory skills take up working memory, and working memory then suffers.” Auditory Processing Disorder: The Hidden Disability By Robbie Woliver with Mo Ibrahim.

33. What Can I Do?

34. When Speaking to a Child with A.P.D. • Establish eye-to-eye position with the child • Gain the child’s attention when giving directions • Speak in a slow, clear manner, but do not over-exaggerate speech • Give simple, clear directions and be mindful of the number of steps you are giving

35. When Speaking to a Child with A.P.D. • Give directions in a logical, time-ordered sequence. Include words that make the sequence clear, such as “first”, “next”, and “then” • Use visual aids (or write out instructions for older students) to supplement spoken information • Emphasize key words when presenting new information. Pre-instruction with emphasis on the main ideas to be presented may also be effective.

36. Speaking to a Child with A.P.D., continued • Use gestures that will add to the information you present • Vary speech volume to increase the student’s attention • Encourage students to ask questions to clarify information (may need to teach them the language of asking questions) • Make transition times clear with both auditory and visual cues • Review previously learned material • Recognize signs of fatigue and give breaks as necessary • Avoid showing frustration when the child misunderstands the message

37. Speaking to a Child with A.P.D., continued • Avoid asking the child to listen and complete another task at the same time (writing, putting on shoes and coat, etc.) • Paraphrase instructions and information into shorter, simpler, and more direct sentences rather than just repeating the initial instruction • Check for comprehension by asking the child questions or asking for a brief summary after key ideas have been presented to be sure that the child understands.

38. Auditory Processing and Autism • Bauman & Kemper’s 1994 study found that the hippocampus is “neurologically immature” in people with Autism. • Since auditory information is processed in the hippocampus, information may not be transmitted to long-term memory in those with Autism in an effective way.

39. Auditory Processing and Autism • Auditory processing problems may be linked to characteristics of those with autism. Consider implementation of programs rich in visual supports. -Use of picture symbols -Object representations

40. Take-Home Messages “The key to effective treatment and management is accurate diagnosis!”~Teri Bellis Management of processing disorders should be specific to the individual’s area of deficit.

41. Questions?