multidisciplinary diagnosis of (c)apd: panel discussion teri james bellis, ph.d. the university of...

Case #1:

• Age 4 years, 1 month • History of chronic otitis media

beginning in first year of life; PE tubes precluded further OAE testing

• Play skills appropriate• Fine and gross motor skills

appropriate

• No apparent developing phonological system in place

• Could combine 2-3 ASL signs with verbalizations

• Verbalizations seemed to preserve prosodic qualities of speech

• Had had SLP intervention for 2 ½ years

• Imitation and/or approximation of speech sounds when looking at the clinician

• Significantly better imitation/ use of motor actions, including sign

• Behavior very similar to a child with a significant hearing impairment

• Normal peripheral hearing sensitivity confirmed through conditioned play audiometry/OAEs

Recommendation:

• Electrophysiologic evaluation to rule out auditory neuropathy or similar disorder

• ABR normal bilaterally

C4; R & L Ears

C3; R & L Ears

Pre-training MLRAge: 4 years, 2 months

Na

Pa

Normal Cortical Potentials in Children

From: Sharma, Kraus, McGee, & Nicol (1997). Electroenceph. Clin. Neurophys., 104, 540-545.

Pre-training Corticals

(C3)

(C4)

P1

N1b

Conclusions and Recommendations:

• Results suggested abnormal neurophysiologic representation of acoustic stimuli, consistent with (C)APD

• Recommended intensive computer-based auditory training, 45 minutes per day, 5 days per week throughout 8-week summer session

• Auditory training to focus on both perception and production of auditory stimuli

• Earobics training daily; Target = verbal imitation of stimuli, mouse controlled by clinician

• Goals:– Improve phonological

awareness (discrimination, synthesis, etc.) and phoneme production/ imitation skills simultaneously

Immediate Post-Training (4 years, 4 ½ months)

• Spontaneous eye contact during conversation 100% of the time

• Turned to voice 100% of the time

• Imitation of vowels, CV syllables with 100% accuracy

• Approximation of CVC words with some final phoneme deletions or appropriate inflection, but incorrect phonemes

At 4 years, 6 months

• Significant improvement in auditory comprehension

• 100% imitation of sounds, words, gestures

• Dozens of new words, including verbs, nouns, adjectives

• Semantic relations with 90% accuracy

• Plural /s/ and progressive /ing/ with 80% accuracy

• Use of “in” and “on” with 100% accuracy

• Imitation of multi-word sentences

Post-training MLR4 years, 9 months

Ipsilateral (C4/A2)

Contralateral (C3/A2)

Pa

Pa

Na

Na

C4; R & L Ears

C3; R & L EarsNa

Pa

Na

Pa

Post-training Corticals

(C4)

(C3)

P1

N1b

N1b

P1N1a

N1a

By 4 years, 10 months

• Spontaneous use of multi-word sentences with appropriate syntax

• Kahn Phonological Analysis:

– Phonological development at approximately 3.5 years of age

– Errors developmental in nature

Conclusions

• Intensive auditory training combining perception with production resulted in significant, rapid improvement in auditory comprehension and expressive skills.

• Behavioral observations were accompanied by a concomitant improvement in the neurophysiologic representation of acoustic stimuli.

Case #2

• P300 reduced, other electrophysiology normal

• Auditory fusion, speech and nonspeech discrimination probably normal, though some inconsistency in performance

• Continuous performance (auditory and visual) – high error rate

• Impression: Higher-order, likely attention-based disorder