Testing for Central Auditory Processing Disorders

1. Testing for Central Auditory Processing Disorders Harvey Dillon With thanks to: Pia Gyldenkaerne Sharon Cameron Helen Glyde Dani Tomlin Mridula Sharma Wayne Wilson

2. On the basis of evidence, what should CAPD testing and remediation services consist of? What gaps in evidence are there that our research should fill in the future? Suggestions to Pia and Dani in the interpretation of their data

3. A clinician’s question • Does this child have a problem hearing or understanding sound that adversely affects him or her, and that I or anyone else can do something about? • What is the specific nature of the problem? • Is there a specific remediation for that problem? • Are there general management techniques that might minimize its effects?

4. Impact of criterion on diagnosis of CAPD Binaural fail Monaural fail Wayne Wilson

5. What is a fail on one test? Proportion of children Test score Z-score

6. Test score sensitivity relative to functional listening ability • Can estimate from correlation between test scores and functional ability • Questionnaire scores of listening ability • Educational attainment scores Test A Test B

7. Test score sensitivity relative to functional ability: • Sensitivity

8. Criteria for adopting a CAPD test • Test is associated with variation in functional ability • High sensitivity ) • Deviant results common in clinical population • Attributes tested minimally shared with other tests in battery • Test result indicates specific remediation necessary (and remediation affects real life) • Time taken is small • Test is minimally affected by attention, intelligence, motivation, working memory • Associated with a known anatomical site and neural mechanism

9. First a brief background on the LiSN-S

10. (LiSN-S) Conditions Same Voice - 0° Condition Different Voices - 0° Condition Low cue Talker Advantage Spatial Advantage Total Advantage High cue Different Voices - ±90° Condition Same Voice - ±90° Condition Sharon Cameron

11. Results profile: spatial processing disorder

12. LiSN & Learn training software Target: The horse kicked six wet shoes Cameron & Dillon, JAAA, 2011

13. Effect of training on LiSN-S scores Follow-up Post Pre Cameron & Dillon, JAAA, 2011

14. LiSN & Learn - Performance Over Time (n=9) 10 dB Better LiSN & Learn SRT (dB) Cameron & Dillon, JAAA, 2011

15. Randomized Control Trial Earobics Lisn & Learn N = 5 N = 5 Cameron et al

16. Experiment 1 Dani Tomlin current PhD study • Two subject recruitment groups: • Children referred to Uni of Melbourne Audiology Clinic due to suspected APD (n=65) • Teachers, parent, speech pathologist referral • Normative group (n=47) • School enrolment, open invitation • Age range of 7–12 years • Both groups to complete full test battery • Results converted to Z scores (derived using age specific norms)

17. Measures obtained • Dichotic Digits Test (DDT): Binaural integration (Musiek, 1993) • Frequency Pattern Test (FPT): Temporal sequencing (Musiek et al, 1990) • Gaps in Noise (GIN): Temporal resolution (Musiek et al, 2005) • MLD: Binaural interaction (Bellis, 2003) • LiSN-S: Binaural integration – spatial listening ability (Cameron & Dillon, 2006) • MemoryCELF-4: Forward and reverse digits • Attention:BrainTrain®: Continuous Performance Test: Sustained auditory and visual attention • Cognition -TONI-4: Nonverbal cognitive assessment • Questionnaires and interview: • Child completed LIFE questionnaire & recorded interview • Parent completed Fisher checklist & written interview • Teacher Evaluation of Auditory Performance (TEAP) & written interview • Academic Performance - NAPLAN & WARP (reading fluency)

18. Relations between outcome variables

19. Test score sensitivity relative to functional abilities Freq pattern - right Dichotic digits - left Dichotic digits - right Freq pattern - left Listening capabilities Literacy Reading fluency Dani Tomlin

20. Test score sensitivity relative to functional abilities Digit span - Reversed Gaps in noise - left Gaps in noise - right Digit span - Forward Listening capabilities Literacy Reading fluency Dani Tomlin

21. Test score sensitivity relative to functional abilities LiSN-S Low Cue LiSN-S High cue MLD z score attention Listening capabilities Literacy Reading fluency Dani Tomlin

22. Sensitivity: Effect on outcome variable of being 1 SD below the mean on test score

23. P<0.01 Correlations – outcomes and test scores

24. NAPLAN literacy

25. What is affecting listening capabilities? TONI 0.27 DS Fwd 0.10 Listening capabilities 0.19 LDD 0.10 DS Rev 0.20 N=59 Adj R2 = 0.31 Att

26. What is affecting literacy? TONI But only 14 clinic participants with NAPLAN so far. 0.24 DS Fwd 0.30 0.18 NAPLAN Literacy LDD 0.16 DS Rev 0.29 N=35 Adj R2 = 0.64 Att

27. Importance of the presenting symptoms?

28. Importance of presenting symptoms MANOVA analysis: p=0.94

29. Importance of presenting symptoms Response by child Interpretation by observer Event Acts (inappropriately) based on what was heard Is not very smart Can’t follow instructions Child fails to understand an instruction Asks for repetition of instruction Poor concentration Does nothing Daydreams Misbehaves Badly behaved

30. Experiment 2 PiaGyldenkaerne current PhD study • Children referred to Macquarie Uni Audiology Clinic due to suspected APD (n=119) • Teachers, parent, speech pathologist referral • Age range of 7–13 years

31. Measures obtained • Dichotic Digits Test (DDT): Binaural integration (Musiek, 1993) • Frequency Pattern Test (FPT): Temporal sequencing (Musiek et al, 1990) • Gaps in Noise (GIN): Temporal resolution (Musiek et al, 2005) • MLD: Binaural interaction (Bellis, 2003) • MemoryCELF-4: Forward and reverse digits • Attention:BrainTrain®: Continuous Performance Test: Sustained auditory and visual attention • Cognition -TONI-4: Nonverbal cognitive assessment • Questionnaire: • Purpose designed – yes/no answers to 18 questions asking about difficulties in listening and its possible consequences • Academic Performance: WARP (reading fluency)

32. Test score sensitivity relative to functional ability: Reported difficulties and reading fluency Reported difficulties Freq pattern - right Dichotic digits - left Dichotic digits - right Freq pattern - left Reading speed PiaGyldenkaerneand Mridula Sharma

33. Test score sensitivity relative to functional ability: Reported difficulties and reading speed Reported difficulties Gaps in noise - right Brain Train attention quotient Brain Train response control quotient Binaural masking level difference Reading speed PiaGyldenkaerneand Mridula Sharma

34. Simple correlation matrix – outcome scores and test scores P<0.01

35. Reported Difficulties

36. Current approach to CAPD testing Yes No Exclude CAPD; Refer elsewhere Test result interpretation • Non-specific remediation • and management: • Classroom placement • FM use • Instruction style • Soundfield amplification • Auditory training software Detailed test battery History Audiometry Is there a problem that CAPD might explain?

37. Dealing with problems in understanding speech Is there a problem that CAPD might explain? Yes No Exclude CAPD; Refer elsewhere Master test battery Test result interpretation leading to a disorder-specific diagnosis Detailed test battery • Non-specific remediation • and management: • Classroom placement • FM use • Instruction style • Soundfield amplification Disorder-specific remediation Questionnaire Audiometry Measured disability

38. Dealing with problems in understanding speech Is there a problem that CAPD might explain? Yes No Exclude CAPD; Refer elsewhere Master test battery Test result interpretation leading to a disorder-specific diagnosis Detailed test battery • Non-specific remediation • and management: • Classroom placement • FM use • Instruction style • Soundfield amplification Disorder-specific remediation Questionnaire Audiometry Measured disability LiSN-S High Cue FPT Verbal SPIN Hi Cont SPIN Lo Cont LiSN-S Talker Advantage LiSN-S Low Cue LiSN-S Spatial Advantage FPT Hum ? Undiag- nosed deficit Pitch deficit Closure skill deficits SPD ? Top-down training LiSN & Learn

39. Criteria for adopting a CAPD test • Test is associated with variation in functional ability • High sensitivity ) • Deviant results common in clinical population • Attributes tested minimally shared with other tests in battery • Leads to a specific diagnosis, for which remediation exists, and remediation affects real life functional ability • Time taken is small • Test is minimally affected by attention, intelligence, motivation, working memory, and language ability • Known high reliability and critical differences • Associated with a known anatomical site and/or neural mechanism

40. Comparison of tests against criteria

41. Test structure???? Parental / teacher report of difficulties Low DD LiSN - HC Low Low DS rev LiSN remainder Low Low Att TONI Psych Strategies, FM Strategies, FM Psych Psych SA low: LiSN&Learn HC low: Strategies, FM

42. Thanks for listening www.NAL.gov.au

43. Detection of an APD in the presence of hearing loss Auditory processing neurons Deficient auditory skill Life consequences Consequent disabilities Hearing loss Trauma or failure to develop Visual processing neurons Life consequences Deficient visual skill

44. LiSN-S Prescribed Gain Amplifier

45. Changes in LiSN-S scores with hearing loss Better Helen Glyde and Sharon Cameron