auditory processing disorders (apd) in children and adults ... · electrophysiologic measures of...

Auditory Processing Disorders (APD) in Children and Adults: Part 2. A Team Approach to Management

q Introduction q Counseling & Advocacyq FM technologyq Computer-based auditory trainingq Direct auditory remediationq Language-based options

Auditory Processing Disorders: Scope of Practice(American Academy of Audiology, 2004)

7/5/16, 3:26 PMScope of Practice

Page 2 of 4http://www.audiology.org/print/1664

An audiologist is a person who, by virtue of academic degree, clinical training, and license to practice and/orprofessional credential, is uniquely qualified to provide a comprehensive array of professional services related to theprevention of hearing loss and the audiologic identification, assessment, diagnosis, and treatment of persons withimpairment of auditory and vestibular function, and to the prevention of impairments associated with them.Audiologists serve in a number of roles including clinician, therapist, teacher, consultant, researcher andadministrator. The supervising audiologist maintains legal and ethical responsibility for all assigned audiologyactivities provided by audiology assistants and audiology students.

The central focus of the profession of audiology is concerned with all auditory impairments and their relationship todisorders of communication. Audiologists identify, assess, diagnose, and treat individuals with impairment of eitherperipheral or central auditory and/or vestibular function, and strive to prevent such impairments.

Audiologists provide clinical and academic training to students in audiology. Audiologists teach physicians, medicalstudents, residents, and fellows about the auditory and vestibular system. Specifically, they provide instruction aboutidentification, assessment, diagnosis, prevention, and treatment of persons with hearing and/or vestibularimpairment. They provide information and training on all aspects of hearing and balance to other professionsincluding psychology, counseling, rehabilitation, and education. Audiologists provide information on hearing andbalance, hearing loss and disability, prevention of hearing loss, and treatment to business and industry. They developand oversee hearing conservation programs in industry. Further, audiologists serve as expert witnesses within theboundaries of forensic audiology.

The audiologist is an independent practitioner who provides services in hospitals, clinics, schools, private practicesand other settings in which audiologic services are relevant.

Scope of PracticeThe scope of practice of audiologists is defined by the training and knowledge base of professionals who arelicensed and/or credentialed to practice as audiologists. Areas of practice include the audiologic identification,assessment, diagnosis and treatment of individuals with impairment of auditory and vestibular function, prevention ofhearing loss, and research in normal and disordered auditory and vestibular function. The practice of audiologyincludes:

IdentificationAudiologists develop and oversee hearing screening programs for persons of all ages to detect individuals withhearing loss. Audiologists may perform speech or language screening, or other screening measures, for the purposeof initial identification and referral of persons with other communication disorders.

Assessment and DiagnosisAssessment of hearing includes the administration and interpretation of behavioral, physioacoustic, andelectrophysiologic measures of the peripheral and central auditory systems. Assessment of the vestibular systemincludes administration and interpretation of behavioral and electrophysiologic tests of equilibrium. Assessment isaccomplished using standardized testing procedures and appropriately calibrated instrumentation and leads to thediagnosis of hearing and/or vestibular abnormality.



TreatmentThe audiologist is the professional who provides the full range of audiologic treatment services for persons withimpairment of hearing and vestibular function. The audiologist is responsible for the evaluation, fitting, and verificationof amplification devices, including assistive listening devices. The audiologist determines the appropriateness ofamplification systems for persons with hearing impairment, evaluates benefit, and provides counseling and trainingregarding their use. Audiologists conduct otoscopic examinations, clean ear canals and remove cerumen, take earcanal impressions, select, fit, evaluate, and dispense hearing aids and other amplification systems. Audiologistsassess and provide audiologic treatment for persons with tinnitus using techniques that include, but are not limitedto, biofeedback, masking, hearing aids, education, and counseling.

Audiologists also are involved in the treatment of persons with vestibular disorders. They participate as full membersof balance treatment teams to recommend and carry out treatment and rehabilitation of impairments of vestibularfunction.

Audiologists provide audiologic treatment services for infants and children with hearing impairment and their families.These services may include clinical treatment, home intervention, family support, and case management.

The audiologist is the member of the implant team (e.g., cochlear implants, middle ear implantable hearing aids, fullyimplantable hearing aids, bone anchored hearing aids, and all other amplification/signal processing devices) whodetermines audiologic candidacy based on hearing and communication information. The audiologist provides pre andpost surgical assessment, counseling, and all aspects of audiologic treatment including auditory training,rehabilitation, implant programming, and maintenance of implant hardware and software.

The audiologist provides audiologic treatment to persons with hearing impairment, and is a source of information forfamily members, other professionals and the general public. Counseling regarding hearing loss, the use ofamplification systems and strategies for improving speech recognition is within the expertise of the audiologist.Additionally, the audiologist provides counseling regarding the effects of hearing loss on communication and psycho-social status in personal, social, and vocational arenas.

The audiologist administers audiologic identification, assessment, diagnosis, and treatment programs to children ofall ages with hearing impairment from birth and preschool through school age. The audiologist is an integral part ofthe team within the school system that manages students with hearing impairments and students with centralauditory processing disorders. The audiologist participates in the development of Individual Family Service Plans(IFSPs) and Individualized Educational Programs (IEPs), serves as a consultant in matters pertaining to classroomacoustics, assistive listening systems, hearing aids, communication, and psycho-social effects of hearing loss, andmaintains both classroom assistive systems as well as students' personal hearing aids. The audiologist administershearing screening programs in schools, and trains and supervises non audiologists performing hearing screening inthe educational setting.

Hearing ConservationThe audiologist designs, implements and coordinates industrial and community hearing conservation programs. Thisincludes identification and amelioration of noise-hazardous conditions, identification of hearing loss, recommendation



TreatmentThe audiologist is the professional who provides the full range of audiologic treatment services for persons withimpairment of hearing and vestibular function. The audiologist is responsible for the evaluation, fitting, and verificationof amplification devices, including assistive listening devices. The audiologist determines the appropriateness ofamplification systems for persons with hearing impairment, evaluates benefit, and provides counseling and trainingregarding their use. Audiologists conduct otoscopic examinations, clean ear canals and remove cerumen, take earcanal impressions, select, fit, evaluate, and dispense hearing aids and other amplification systems. Audiologistsassess and provide audiologic treatment for persons with tinnitus using techniques that include, but are not limitedto, biofeedback, masking, hearing aids, education, and counseling.

Audiologists also are involved in the treatment of persons with vestibular disorders. They participate as full membersof balance treatment teams to recommend and carry out treatment and rehabilitation of impairments of vestibularfunction.

Audiologists provide audiologic treatment services for infants and children with hearing impairment and their families.These services may include clinical treatment, home intervention, family support, and case management.

The audiologist is the member of the implant team (e.g., cochlear implants, middle ear implantable hearing aids, fullyimplantable hearing aids, bone anchored hearing aids, and all other amplification/signal processing devices) whodetermines audiologic candidacy based on hearing and communication information. The audiologist provides pre andpost surgical assessment, counseling, and all aspects of audiologic treatment including auditory training,rehabilitation, implant programming, and maintenance of implant hardware and software.

The audiologist provides audiologic treatment to persons with hearing impairment, and is a source of information forfamily members, other professionals and the general public. Counseling regarding hearing loss, the use ofamplification systems and strategies for improving speech recognition is within the expertise of the audiologist.Additionally, the audiologist provides counseling regarding the effects of hearing loss on communication and psycho-social status in personal, social, and vocational arenas.

The audiologist administers audiologic identification, assessment, diagnosis, and treatment programs to children ofall ages with hearing impairment from birth and preschool through school age. The audiologist is an integral part ofthe team within the school system that manages students with hearing impairments and students with centralauditory processing disorders. The audiologist participates in the development of Individual Family Service Plans(IFSPs) and Individualized Educational Programs (IEPs), serves as a consultant in matters pertaining to classroomacoustics, assistive listening systems, hearing aids, communication, and psycho-social effects of hearing loss, andmaintains both classroom assistive systems as well as students' personal hearing aids. The audiologist administershearing screening programs in schools, and trains and supervises non audiologists performing hearing screening inthe educational setting.

Hearing ConservationThe audiologist designs, implements and coordinates industrial and community hearing conservation programs. Thisincludes identification and amelioration of noise-hazardous conditions, identification of hearing loss, recommendation

2010 AAA Clinical Guidelines on Auditory Processing Disorders: Terminology for Habilitation/Rehabilitation

q Intervention: “…encompassing term referring to one or more actions taken in order to produce an effect and to alter the course of a disease, disorder, or pathological condition.”

q Treatment: “…any specific procedure used to prevent, remediate (I.e., cure), or ameliorate a disease, disorder, or pathological condition.”

q Management: “…referes to compensatory approaches (e.g., strategies, technologies) used to reduce the impact of deficits that are resistant to remediation.”

q Bottom up “stimulus driven” approaches often implemented by audiologists, e.g.,• Auditory training, e.g.,

ü Earobicsü LACE (Listening and Communication Enhancement)

• Direct auditory skill remediation, e.g., ü Dichotic Interaural Intensity Difference (DIID) trainingü Aural Rehabilitation for Interaural Asymmetry (ARIA)

• Enhancement of listening environmentü Classroom acoustical modificationsü Classroom amplification (FM) systemsü Personal FM systems

2010 AAA Clinical Guidelines on Auditory Processing Disorders: Intervention

q Top down “strategy driven” approaches often implemented by speech pathologists and other professionals• Language strategies • Cognitive/metacognitive strategies• Speaker modifications• Instructional modifications and strategies• Accommodations in the

ü Workplaceü Homeü Recreational settingü Religious setting

2010 AAA Clinical Guidelines on Auditory Processing Disorders: Intervention

q Management: Appropriate ReferralslSpeech language pathologist

üLanguage assessmentüPhonological awareness assessmentüReading remediationüTop-down therapy

lPsychologist or neuropsychologistüAssessment of cognitive functionüAssessment of ADHDüProfessional counseling üDiagnosis of other disorders (e.g.,

developmental disorders)


q Management: Appropriate ReferralslOtolaryngologist

üDiagnosis of ear diseaseüManagement of middle ear dysfunctionüNeuro-radiological studies

lNeurologistüAssessment of neurological functioningüRule out neurological disease (e.g., seizure

disorders)lOccupational therapist

üEvaluation of visual processingüEvaluation of motor processingüAssessment of sensory integration disorders




Psychosocial Function in Children with APDKreisman NV, John AB, Kreisman BM, Hall JW III & Crandell CC (deceased) (2012).

Psychosocial status of children with auditory processing disorder. Journal of the American Academy of Audiology, 22, 222-233

Psychosocial Function in Children with APD: Initial BASC II Parent Report

(Johnston et al, 2009)

•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

•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 Function in Children with APD:Initial BASC II Child Self Report

(Johnston et al, 2009)

Patient/Family Counseling and Education in APD

“Knowledge is power.”(Nam et ipsa scientia potestas est.)

Francis Bacon (1561-1626)

Meditationes Sacrae [1597]

Essentials of Counseling of Patients with APD and Parents/Family Members

q General guidelinesw Counsel in a quiet and private venuew Include spouse, “significant others”, and/or family membersw Introduce yourself with eye contact and a firm (but

comfortable) handshakew Use respectful titles (e.g., Mr. or Mrs.)w Give patient and family members the impression that you

have plenty of time and nothing is more important than talking with them

w Be accepting of statements, feelings, and attitudes but …w Gently clarify any misconceptions with factual informationw Remember: Knowledge is power!

q “Non-professional” counseling (by audiologists)lInformational (content) counseling* lPersonal adjustment counseling

q Professional counseling (by trained counselor, psychologist, or psychiatrist)lIdentifying unconscious behaviorslManaging major personality changes (e.g., clinical depression)

*Research shows that > 80% of audiologists and audiology students focus mostly on content counseling, even when the patient and family members express the need for help with psychosocial aspects of hearing loss

Essentials of Counseling Applied to APD:Types of Counseling



SNR improvement on the HINT in Normal Hearing Adults and Children Without and With APD: Three different FM system types

(Crandell & Hall, 2005)

Listening Condition

2

SNR

Impr

ovem

ent (

in d

B SP

L)

Adults (N = 10) Non-APD (N = 8) APD (N = 12)

4

6

8

Head set

Desk top7.5

4.0

7.4

3.8

9.5

6.5

10

Sound field4.7 4.3

7.2

Campus S

Transmitter

EduLink Receivers

Mini-Boom Microphone

Phonak EduLink FM System Use Improves Academic Performance and Psychosocial Status in Children with APD

Johnston, John, Kreisman, Hall & Crandell. (2009). Multiple benefits of personal FM system use by children with auditory processing disorder (APD).

International Journal of Audiology, 48, 371 - 383

Hearing in Noise Test (HINT) Results(Mean SNR values without and with EduLink)

GroupTest 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 10.3with EduLink

* t = p < .08; ** t = .002

Typical Classroom SNR Range: +5 to -7 dBMarkides (1986); Finitzo-Hieber (1988); Crandell and Smaldino (1995)

BASC II Parent Report Results After EduLink Use (6 to 7 months): APD versus Control Subjects

(Source: Johnson, John, Kreisman, Hall & Crandell, 2009)

Normal Findings per Group (%)Domain Control APD

Aggression 92 100Conduct problems 92 100Anxiety 84 100Depression 92 100Internalizing problems 77 71Withdrawal 84 71Attention problems 92 29Adaptive skills 92 71 Functional communication 92 57

BASC II Student Report Results After EduLink Use (6 to 7 months): APD versus Control Subjects

(Source: Johnson, John, Kreisman, Hall & Crandell, 2009)

Normal Findings per Group (%)Domain Control APDAttitude toward teachers 100 86Attitude toward school 100 57School problems 100 71Conduct problems 92 100Atypicality 100 100Anxiety 100 100Social stress 92 100Depression 100 86Internalizing problems 100 100Sense of inadequacy 100 86Parent relationship 92 100Self esteem 100 100

q APD in school age children can have significant negative impact on:lAcademic performancelPsychosocial statuslQuality of life

q Early intervention for auditory processing deficits is indicated for all children, despite the age of identification

q The Phonak EduLink system is a feasible option for FM technology with adolescents (and persons of other ages)

q Management of APD with FM technology (enhancing the signal-to-noise ratio) improves:lSpeech perception in noise (with EduLink FM systemlAcademic performancelPsychosocial status lSpeech perception in noise without the benefit of FM technology

Multiple Benefits of Personal FM System Use for Children with APD

(Johnston, John, Kreisman, Hall, Crandell. 2009. International Journal of Audiology, 48, 371-383

Evidence Based Management of APD:Recent Research with FM Technology

q Hornickel J, Zecker SG, Bradlow AR & Kraus N (2012). Assistive listening devices drive neuroplasticity in children with dyslexia. PNAS (early edition). l “Classroom FM technology enhances acoustic clarity”l Assessed impact of classroom FM system use for 1 year on auditory

neurophysiology and reading skills in children with dyslexialFM system use reduced the variability of sub-cortical responses

(speech ABR)l Improvement was linked to increases in reading and phonological

awarenesslMatched control group of children with dyslexia didn’t show the

effectslConclusion: “Assistive listening devices can improve the neural

representation of speech and can impact reading-related skills


q Introduction q Counseling & Advocacyq FM technologyq Computer-based auditory trainingq Direct auditory remediationq Reading readiness trainingq Language-based options

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 ...”

Intervention for APD with Computer-Based Techniques:Scientific Bases of FastForword

q Earobicsl?????.com

q Lindamood Bell Learning Processesl LIPPS and Seeing StarslLindamoodbell.com

q Scientific Learning l FastForwordl scientificlearning.com

Selected Intensive & Computer-Based Programs for Development of Auditory Processing Skills

Earobics Program(Vendor: )

q Rhymingq Phoneme identificationq Blending

• Combining sounds into words)q Segmentation

• Breaking words down into individual sounds

q Phonological manipulationq Discriminationq Auditory performance in competing noiseq Auditory sequential memory

Computer-Based Auditory Training

Practice Guidance British Society of Audiology Management of APD 2011

© BSA 2011 18

ForWord also claims to improve the discrimination of brief sounds. Earobics and Fast ForWord have both been developed in the USA, and Phonomena has been developed in the UK. See Table 2 for a brief description of Earobics, Fast ForWord and Phonomena and the relevant websites. Further information and costs are available from the websites. Fast ForWord is significantly more expensive and professionals are required to complete a ‘Certified Practitioner’ training course before being able to purchase and use the software.

Table 2 Brief description of Earobics, Fast ForWord, Phonomena

Earobics www.earobics.com

Fast ForWord www.scilearn.com or

www.innovative-therapies.com (UK)

Phonomena www.mindweavers.co.uk

Earobics is underpinned by adaptive training technology to adjust the level of instruction to the child's level and progress, and primarily uses recorded but real speech. It is recommended that the child use Earobics for 15 to 20 minutes per day, three times a week. Earobics Step 1 is designed for developmental ages 4-7 and features six interactive games with over 300 levels of play. It purports to teach phonological awareness and introductory phonics skills required for learning to read and spell, and to develop general cognitive skills that support learning, such as attention and memory. Earobics Step 2 is designed for developmental ages 7-10 and features five interactive games with nearly 600 levels of play. Step 2 targets the same skills targeted in Earobics Step 1, but at more advanced levels, as well as language processing skills for extracting meaning from spoken language and written text. Earobics Adolescents & Adults provides sophisticated, game-style, multimedia instruction, designed to appeal to adolescents and adults who are struggling to

Fast ForWord is a series of computer based exercises (games) designed to improve auditory, language processing and reading abilities with the view to “train the brain to process at faster rates and help to create or modify the neural pathways”. It uses both speech and non-speech stimuli that have been acoustically modified to slow and amplify transient sounds. Fast ForWord Language Basics is a program aimed at 4-6 year olds and consists of 3 exercises that help to develop visual attention and auditory discrimination skills and sustained auditory attention, and aims to prepare for Fast ForWord Language. There are a number of products available such as: Fast ForWord Language v.2 (ages 5-12), Fast ForWord Middle & High School (adolescents and older learners), Fast ForWord Language to Reading v.2 (which targets the skills that require to make the link between spoken and written language). Fast ForWord Reading is a curriculum-based reading program. The child will usually work on these intensive computer based exercises 30 minutes a day, 5 days a week for 3-4 months (or more intensively for a

Phonomena is an interactive game, designed to improve auditory discrimination and phonemic awareness, and to build language skills. It consists of game-play and graphics designed to appeal especially to 6-12 year olds, while administrator controls give language professionals additional tools. “Phonomena” uses ‘phoneme contrasts’ which are selected from over 1,000 possible in English. At the start of the game, these 'sounds of words' are set as normally found in spoken language. Phonomena’s adaptive learning algorithms change the sounds in response to each player’s performance, making the choice more or less difficult, in order for the client to train at the ‘Edge of Competence’ therefore keeping the training at

Review of Computer-Based and Other Auditory Training Programs for APD

Semin Hear. 2015 Nov; 36(4): 199–215.doi: 10.1055/s-0035-1564458

PMCID: PMC4910543

Auditory Training for Central Auditory Processing DisorderJeffrey Weihing, Ph.D., Gail D. Chermak, Ph.D., and Frank E. Musiek, Ph.D.

Division of Communicative Disorders, University of Louisville, Louisville, KentuckyDepartment of Speech and Hearing Sciences, Washington State University Spokane, Spokane, WashingtonSpeech, Language and Hearing Sciences, the University of Arizona, Tucson, Arizona

Address for correspondence Jeffrey Weihing, Ph.D. Division of Communicative Disorders, University of Louisville, Louisville, KY 40202,[email protected]

Copyright © Thieme Medical Publishers

Abstract

Auditory training (AT) is an important component of rehabilitation for patients with central auditoryprocessing disorder (CAPD). The present article identifies and describes aspects of AT as they relate toapplications in this population. A description of the types of auditory processes along with information onrelevant AT protocols that can be used to address these specific deficits is included. Characteristics andprinciples of effective AT procedures also are detailed in light of research that reflects on their value.Finally, research investigating AT in populations who show CAPD or present with auditory complaints isreported. Although efficacy data in this area are still emerging, current findings support the use of AT fortreatment of auditory difficulties.

Keywords: Auditory training, central auditory processing disorder

Learning Outcomes: As a result of this activity, the participant will be able to (1) describe characteristicsof effective AT protocols, including aspects related to the training schedule, training difficulty, maintainingmotivation, and transfer of learning and (2) describe results from current research investigating AT inpatients with CAPD or who present with auditory complaints.

Central auditory processing disorder (CAPD) refers to dysfunction of the central auditory nervous system(CANS) that contributes to difficulties with perceptual processing of auditory information and that isthought to contribute to delays in skills in which successful listening serves a fundamental role. CAPDaffects a variety of populations and has several suspected causes, including neuromaturational delay,neuroanatomical anomalies (e.g., ectopic cells), and neurologic insult of the CANS. Additionally, theterm central presbycusis has recently been adopted to describe CAPD that results from changes to theCANS that occur as a result of aging. CAPD is diagnosed using a test battery comprised of behavioral,electroacoustic, and/or electrophysiologic measures that have documented sensitivity and specificity toCANS dysfunction and that assess a range of CANS processes. The primary complaints and symptoms ofCAPD are auditory; however, due to the nonmodularity of brain organization, functional deficits canfrequently manifest in related areas of attention, language, communication, and learning.

A successful treatment plan for CAPD incorporates a variety of different approaches. These approaches

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Defi nitions of auditory processing disorder (APD) are based on impaired auditory skills, with the specifi c skills included in the defi -nition varying across publications (e.g. Putter et al, 2002; Sharma et al, 2009; Cameron & Dillon 2007a; Kuk et al, 2008). According to ASHA (2005), children with APD typically have poor speech understanding in adverse listening environments, misunderstand messages, respond inconsistently and/or inappropriately, often ask for information to be repeated, have diffi culty attending to verbal information, show delayed responses to oral communication, have diffi culty following complex and/or multiple oral directions and localizing sounds, and may have reduced musical and singing skills. When using an impaired skill to defi ne APD, diagnosis is based on performance falling two standard deviations below the normative mean on any task measuring auditory processing (AAA, 2010). The current study uses this criterion to defi ne APD, based on AAA (2010).

APD often co-occurs with language, reading, spelling, and other learning problems (ASHA, 2005; McArthur & Bishop, 2004a, 2004b; Richard, 2007; Sharma et al, 2009). Sharma et al (2009) found that about half of a group of 68 children diagnosed with APD according to the ASHA (2005) criteria had reading and language disorders, as well as APD. McArthur and Bishop (2004b) also found that a

subgroup of children with specifi c language disorder showed dif-fi culty on auditory discrimination (consistent with the view of APD as an impaired skill) and poor reading. Another subset of children in McArthur and Bishop ’ s study had poor sustained auditory attention and/or auditory memory as well as APD. Having two or three co-existing disorders has implications for intervention. Richard (2007, p. 282) recommended that management plans for children with APD with co-occurring language or reading disorder include strategies that target the co-occurring disorders, as well as the APD.

Management approaches for APD recommended in the literature are largely theoretical and lack a strong evidence base (Chermak & Musiek, 1997; Ferre, 1998). One of the proposed theoretical frame-works for APD intervention emphasizes brain reorganization or neu-roplasticity (Chermak & Musiek, 2007). Neuroplastic changes in the auditory system can occur as a result of auditory experience, passive listening, or active auditory training (Tremblay et al, 1998; Sheehan et al, 2005; Bosnyak et al, 2007). Another theoretical approach uses an information processing framework for APD interventions (Miller, 1956; Chermak & Musiek, 1997). This approach emphasizes the com-plex, multileveled nature of auditory processing, involving parallel and serial processing of information (Chermak & Musiek, 1992). A

Original Article

A randomized control trial of interventions in school-aged children with auditory processing disorders

Mridula Sharma * , Suzanne C Purdy* ,† & Andrea S Kelly ‡

* Department of Linguistics - Audiology, Macquarie University, Sydney, Australia , and Hearing Co-operative Research Center, Australia, † Department of Psychology - Speech Science, The University of Auckland, New Zealand , and ‡ Department of Audiology, Auckland District Health Board, Auckland, New Zealand

Abstract Objective: The primary purpose of the study was to compare intervention approaches for children with auditory processing disorder (APD): bottom-up training including activities focused on auditory perception, discrimination, and phonological awareness, and top-down training including a range of language activities. Another purpose was to determine the benefi ts of personal FM systems. Design: The study is a randomized control trial where participants were allocated to groups receiving one of the two interventions, with and without personal FM, or to the no intervention group. The six-week intervention included weekly one-hour sessions with a therapist in the clinic, plus 1 – 2 hours per week of parent-directed homework. Study sample : 55 children (7 to 13 years) with APD participated in the study. Intervention outcomes included reading, language, and auditory processing. Results: Posi-tive outcomes were observed for both training approaches and personal FM systems on several measures. Pre-intervention nonverbal IQ, age, and severity of APD did not infl uence outcomes. Performance of control group participants did not change when retested after the intervention period. Conclusions: Both intervention approaches were benefi cial and there were additional benefi ts with the use of personal FM. Positive results were not limited to the areas specifi cally targeted by the interventions.

Key Words: Auditory processing disorder (APD); top-down; bottom-up; personal FM; management; randomized control trial (RCT); discrimination; language; phonological awareness; reading

Correspondence: Mridula Sharma, Department of Linguistics, Room C5A 518, Macquarie University, NSW 2109, Australia. E-mail: [email protected]

(Received 4 September 2011; accepted 20 February 2012)

ISSN 1499-2027 print/ISSN 1708-8186 online © 2012 British Society of Audiology, International Society of Audiology, and Nordic Audiological SocietyDOI: 10.3109/14992027.2012.670272

International Journal of Audiology 2012; 51: 506–518


(Sharma, Purdy & Kelly, 2012)

514 M. Sharma et al.

also produced signifi cant improvements for four of the CELF-4 language measures (concepts and following directions, sentence recall, receptive language, core language). If discrimination training is effective, improvements would be expected for both discrimina-tion alone as well as discrimination training plus FM groups. This pattern was only seen for the core language measure which showed robust improvements for both discrimination training groups. Varia-tions in outcomes between the two discrimination training groups for FPT scores and the other language measures may refl ect participant differences at baseline. Overall, the clearest benefi t of discrimina-tion/bottom-up training was evident in the CELF-4 core language scores, which improved signifi cantly for both discrimination training alone (average standard score improvement of 7.8) and discrimina-tion plus FM (average standard score improvement of 8.8) groups. These differences refl ect an overall improvement in core language scores of 0.5 – 0.6 standard deviations, indicating a large effect size (Cohen, 1988).

Children in the language training groups improved on auditory processing, language and reading measures (FPT; CELF-4 sentence recall, formulating sentences, and core language; WARP; QUIL nonword spelling & spoonerisms). As was seen for the discrimina-tion training, many of these changes were inconsistent across the two language training groups, which may be due to the heteroge-neous nature of the sample and a lack of statistical power. Two mea-sures, CELF-4 sentence recall and QUIL nonword spelling, showed robust improvements when language training was combined with FM use. For the language training plus FM group, sentence recall and nonword spelling standard scores improved by 0.6 – 0.7 standard deviations, indicating large effect sizes. Neither measure showed a signifi cant change with language training alone, suggesting that enhanced classroom listening provided by the personal FM systems was required to demonstrate these gains.

Discussion

Although anecdotal evidence suggests that the APD interventions investigated here are commonly used clinically, there are few ran-domized controlled trials of these interventions. An RCT design was used to investigate effects of discrimination/bottom-up and lan-guage/top-down training and personal FM in children with auditory

processing, reading, and language disorders, using a variety of out-come measures including reading, phonological awareness, language, and auditory processing tasks. Previous studies have shown that FM systems can benefi t children with APD (see Table 1), however, to our knowledge, no studies have investigated FM and training together. Hence a second purpose of the current study was to determine how training and FM approaches interact to assist children with APD.

One of the limitations of the current study is the relatively small number of participants that were divided across fi ve groups. Despite the lack of statistical power, signifi cant differences were observed after intervention for several measures. Positive features of the study that strengthen the conclusions include the lack of statistical differ-ences between the control and intervention groups at baseline and the stability of the measures for the control group, which showed no signifi cant test-retest differences. Of the nine measures that showed changes post-training, six showed improvement for the groups that were not the worst performers, thus the observed benefi ts cannot be explained solely on the basis of regression to mean effects. Of the nine measures that showed improvement post-training, only core language improved for both FM and non-FM intervention groups receiving the same kind of training (discrimination). The benefi cial effect of discrimination training on core language scores is the clear-est fi nding in the study. Core language scores are composite scores based on performance on the CELF subtests that best discriminate typical language performance from disordered language (Conti-Ramsden et al, 2010), and hence they may also be more sensitive to treatment effects than other CELF subtest scores.

A number of outcome measures showed statistically signifi cant improvements only for the non-FM groups (FPT, concepts and direc-tions, formulated sentences, receptive language, and QUIL spoo-nerisms). Table 6 shows that for each of these measures there was improvement for the FM groups receiving the same training and hence it is possible that the lack of signifi cance for the non-FM groups may be due to differences between the groups at baseline or may refl ect a specifi c outcome of FM use. For lack of statisti-cal power, research is needed to determine whether training has a reliable effect on these outcome measures. Two of the phonologi-cal awareness measures (QUIL nonword spelling and phonological awareness) and one language measure (sentence recall) only showed improvement for the FM groups, not for the training-alone groups.

Table 6. Means and standard deviations for the outcome measures for the fi ve intervention groups that were signifi cant (p ! 0.01). Values shown in bold indicate measures that showed signifi cant improvement post-intervention.

Control Discrimination Discrimination & FM Language Language & FM

Pre Post Pre Post Pre Post Pre Post Pre Post

FPT (R) 35.5 (21.5) 40.5 (22.2) 18.3 (10.1) 44.6 (28.4) 38.8 (26.4) 51.8 (28.3) 41.2 (21.8) 54.7 (17.1) 42.0 (22.4) 43.5 (21.8)FPT (L) 30.0 (19.0) 31.3 (19.5) 25.1 (10.9) 49.3 (27.9) 40.6 (31.9) 52.2 (30.0) 38.0 (18.9) 50.0 (22.7) 42.4 (14.8) 42.2 (21.3)Concepts and

directions7.3 (3.1) 7.6 (1.8) 6.0 (3.1) 7.5 (4.1) 4.7 (1.9) 6.1 (3.0) 7.2 (3.2) 7.8 (3.0) 5.6 (2.8) 7.2 (3.3)

Sentence recall 7.8 (1.8) 8.6 (2.1) 5.3 (3.1) 6.9 (2.8) 6.8 (2.7) 8.3 (2.4) 6.8 (2.1) 7.7 (2.6) 5.4 (2.4) 7.2 (3.3) Formulated sentences 7.3 (3.5) 8.4 (1.9) 6.3 (1.8) 7.8 (2.9) 6.3 (2.8) 8.4 (2.3) 6.3 (2.8) 9.1 (2.4) 6.1 (2.3) 7.6 (3.8)Receptive language 88.0 (13.7) 90.3 (10.3) 79.3 (16.3) 88.3 (14.9) 82.7 (10.4) 88.0 (14.2) 88.1 (12.0) 93.3 (12.7) 81.4 (9.0) 87.6 (12.7)Core language 84.8 (12.1) 89.7 (9.3) 75.1 (14.2) 86.7 (13.8) 80.2 (11.9) 88.0 (12.5) 83.4 (10.7) 92.2 (11.3) 78.8 (12.9) 82.3 (15.9)WARP 56.1 (42.5) 65.4 (45.9) 77.3 (39.6) 88.3 (33.5) 83.4 (39.6) 87.2 (36.3) 75.8 (47.2) 91.0 (50.6) 67.4 (42.7) 73.0 (45.4)Nonword spelling 4.6 (2.2) 5.0 (2.3) 3.8 (1.8) 4.1 (2.1) 3.6 (1.6) 5.2 (3.3) 5.2 (2.1) 5.5 (2.5) 3.3 (1.0) 5.1 (3.1) Syllable segment 7.5 (3.5) 9.4 (3.2) 7.8 (3.3) 9.8 (3.2) 7.1 (3.0) 10.2 (3.2) 9.1 (3.8) 10.6 (3.6) 8.1 (3.6) 9.9 (3.4)Spoonerisms 6.1 (3.4) 7.9 (4.0) 6.7 (3.7) 8.7 (3.7) 6.2 (3.8) 8.8 (3.6) 6.8 (4.0) 10.4 (2.0) 5.2 (3.7) 7.8 (4.1)



Dichotic Intensity Increment Difference (DIID)

LEFT TEMPORAL CORTEX

Association Cortex

Primary Auditory Cortex

Strong Earincreasingintensity

Weak Earfixed

intensity

CorpusCallosum

RIGHT TEMPORAL CORTEX

Association Cortex

Primary Auditory Cortex

Selected Papers Reporting Benefit of DIID Auditory Training Programs

q Musiek F, Weihing J, Lau C (2008). Dichotic interauralintensity difference (DIID) training: a review of existing research and future directions. J Acad Reh, 41, 51–65.

q Weihing J, Musiek F (2014). Dichotic interaural intensity difference (DIID) training. San Diego, CA: Plural Publishing

q Musiek F, Schochat E (1998). Auditory training and central auditory processing disorders: a case study. Seminars in Hearing, 19, 357–365.

Direct Auditory Remediation:Auditory Rehabilitation for Interaural Asymmetry (ARIA)


Original Article

Diagnosis of amblyaudia in children referred for auditoryprocessing assessment

Deborah Moncrieff1, William Keith2, Maria Abramson3 & Alicia Swann4

1Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pennsylvania,USA, 2SoundSkills APD Clinic, Auckland, New Zealand, 3Hear Now / Abramson Audiology, Laguna Niguel, California, USA, and 4AuditoryProcessing Center, LLC, MS, Clinton

AbstractChildren (n¼ 141) referred to 5 clinical sites for auditory processing disorder assessment were tested with two dichotic listening tests, one

with word pairs and the other with pairs of digits, as part of a comprehensive diagnostic battery. Scores from the Randomized Dichotic

Digits Test and the Dichotic Words Test were compared to age-appropriate norms and used to place children into one of four diagnostic

categories (normal, dichotic dysaudia, amblyaudia, or amblyaudia plus) or to identify them as undiagnosed. Results from the two dichotic

tests led to diagnosis of 56% of the children tested, leaving 44% undiagnosed. When results from a third dichotic listening test were used as

a tie-breaker among originally undiagnosed children, a total of 79% of the children’s scores were placed into diagnostic categories (13%

normal, 19% dichotic dysaudia, 35% amblyaudia, 12% amblyaudia plus). Amblyaudia, a binaural integration deficit evident only from

dichotic listening test results, was most prevalent (35% + 12%¼ 47%) in this population of children suspected of auditory processing

weaknesses. Since amblyaudia responds to treatment with Auditory Rehabilitation for Interaural Asymmetry (ARIA), clinicians are guided

through the protocol for identifying diagnostic categories so that they can make appropriate referrals for rehabilitation.

Key Words: Auditory processing disorder, binaural integration, dichotic, audiology

Introduction

Amblyaudia is a type of auditory processing disorder (APD)characterized by deficits in the binaural integration of verbalinformation (Moncrieff, 2011) that is diagnosed by results fromdichotic listening (DL) tests. The hallmark pattern of amblyaudia isan abnormally large asymmetry between the two ears during DLtasks with either normal or below normal performance in thedominant ear. The underlying mechanisms of amblyaudia areunknown, but they may be similar to the neural mechanisms ofamblyopia or ‘lazy eye’ in the visual system. In amblyopia,activation in the dominant pathway suppresses information in thenon-dominant pathway, leading to an indistinct encoding of visualinformation at the level of the cortex (Doshi & Rodriguez, 2007). Asimilar suppression by the dominant ascending pathway mayinterfere with clear encoding of the auditory signal during routinebinaural listening in amblyaudia. Suppression of the ipsilateralsignal by the dominant contralateral pathway was evident in earlystudies with competing digits and served as the basis of thestructural model of DL proposed by Doreen Kimura (1961). She

noted that individuals identify more verbal material presented to theear that transmits through more abundant contralateral fibers to theirlanguage-dominant hemisphere. Because of its direct contralateralpathway to the left cortical hemisphere, the right ear typicallyperforms better during DL testing in listeners who process languagein the left hemisphere. In those who process language in their righthemisphere, the left ear performs better during DL tests (Denes &Caviezel, 1981).

Kimura proposed that because listeners could simultaneouslyidentify information heard at the opposite ear, ipsilateral to theirlanguage-dominant hemisphere, information must connect contral-aterally to the opposite cortex and then transfer to the language-dominant hemisphere via the corpus callosum. The inter-hemi-spheric transfer of information aspect of Kimura’s structural modelwas supported by evidence of a near-complete extinction of alistener’s ability to identify verbal material presented to theipsilateral, non-dominant ear following surgical separation of thecorpus callosum (Springer & Gazzaniga, 1975; Damasio, 1976;Springer, 1978; Pollmann, 2002). Post-surgical patients later

Correspondence: Deborah Moncrieff, Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, 4033 Forbes

Tower, Pittsburgh, PA 15260, USA. E-mail: [email protected]

(Received 10 April 2015; revised 15 October 2015; accepted 30 November 2015)

ISSN 1499-2027 print/ISSN 1708-8186 online ! 2016 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society

DOI: 10.3109/14992027.2015.1128003


(www.dichotics.com)


Original Article

Evidence of binaural integration benefits following ARIA trainingfor children and adolescents diagnosed with amblyaudia

Deborah Moncrieff1, William Keith2, Maria Abramson3 & Alicia Swann4

1Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA,USA, 2SoundSkills APD Clinic, Auckland, New Zealand, 3Hear Now/Abramson Audiology, Laguna Niguel, CA, USA, and 4Auditory ProcessingCenter, LLC, Clinton, MS, USA

AbstractObjective: The purpose of this study was to demonstrate the efficacy of Auditory Rehabilitation for Interaural Asymmetry (ARIA) to

improve dichotic listening scores in children and adolescents diagnosed with amblyaudia and other binaural integration deficits. Design:

The study is a field experiment without randomisation. Study: Participants placed into groups based on dichotic listening test scores

received four sessions of ARIA training. Baseline scores were compared to performance during the final session of training and to scores

obtained 2 or more months after completion of ARIA. Sample: A total of 125 children participated at five different clinical sites. Results:

Dichotic listening scores improved across all participants. Post hoc analyses demonstrated highly significant gains in non-dominant ear

performance and reductions of interaural asymmetry among participants diagnosed with amblyaudia at both post-ARIA measurements.

Participants in other diagnostic groups also showed significant benefits for some post-ARIA measures. Conclusions: Results demonstrate

that ARIA training is an effective method for improving binaural integration skills among children and adolescents identified with dichotic

listening weaknesses during assessments for auditory processing disorder (APD), especially for those diagnosed with amblyaudia. Benefits

achieved following ARIA training remain stable across several months.

Key Words: Auditory processing; amblyaudia; dichotic listening; behavioural measures; paediatric;psychoacoustics/hearing science; speech perception

Amblyaudia is a type of auditory processing disorder (APD)characterised by deficits in the binaural integration of verbalinformation (Moncrieff, 2010). The hallmark pattern of amblyaudiais an abnormally large asymmetry between the two ears duringdichotic listening (DL) tasks with either normal or below normalperformance in the dominant ear (Moncrieff et al, 2016). Childrenwith listening, learning and reading difficulties have producedsymmetrical deficits in binaural integration (Hynd et al, 1979;Keefe & Swinney, 1979; Pelham, 1979; Tobey et al, 1979; Harris etal, 1983; Roush & Tait, 1984; Grogan, 1986; Vanniasegaram et al,2004; Pinheiro et al, 2010) as well as an abnormally largeasymmetry during DL tasks due to low performance in their non-dominant ears (Ayres, 1977; Johnson et al, 1981; Dermody et al,1983; Aylward, 1984; Berrick et al, 1984; Asbjornsen et al, 2000;Vanniasegaram et al, 2004; Moncrieff & Black, 2008). Thestructural model of DL (Kimura, 1961) predicts enhanced perform-ance in the ear that is contralateral to the language dominant cortical

hemisphere, which is the right ear in 65–80% of normal listeners(Hiscock et al, 2000; Moncrieff, 2011) and the left ear in others(Denes & Caviezel, 1981). Because either the left or right ear can bedominant during DL tests, a diagnosis of amblyaudia is based oncomparison to norms developed without regard to which ear issuperior (Moncrieff, 2011; Moncrieff et al, 2016).

When assessed under earphones, normal listeners can readilyidentify information presented to their non-dominant ear during DLtasks, long thought to be primarily through cortical connections viathe corpus callosum because after sectioning of the corpuscallosum, a listener’s ability to identify material presented to thenon-dominant ear is extinguished (Sparks & Geschwind, 1968). Inthose patients, however, the performance improves following areorganisation of the auditory pathways despite the absence ofcallosal transmission (Milner et al, 1968; Levitsky & Geschwind,1968; Springer et al, 1978). This suggests that binaural integrationof dichotic material engages both contralateral and ipsilateral

Correspondence: Deborah Moncrieff, Ph.D., Department of Communication Science and Disorders, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260. Tel: (412)

648-0156, Fax: (412) 383-6555. E-mail: [email protected]

(Received 15 July 2016; revised 4 February 2017; accepted 15 February 2017)

ISSN 1499-2027 print/ISSN 1708-8186 online ! 2017 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society

DOI: 10.1080/14992027.2017.1303199


(Moncrieff et al, 2017)

gains in both ears following ARIA training, suggesting that childrenand adolescents who perform poorly and symmetrically on DL testsmay also benefit from participation.

Results from this study suggest that ARIA training benefitsindividuals whose performance on a DL test falls below normalwhich is not surprising since the training focuses on dichotic tasks.

Benefits are maximal, though, for children and adolescents whosebinaural integration skills are consistently weak across two differentDL tests, especially when the pattern leads to the diagnosis ofamblyaudia. As the ARIA training paradigm requires that theclinician continually adjust the relative intensity of materialpresented through the sound-field speakers, participants with poor

Figure 3. Left column displays results from the group of participants whose scores were measured at the fourth session of ARIA (words,n¼ 119; digits, n¼ 117): Outcomes measured during the pre-ARIA evaluation (grey bars) and during the 4th ARIA session (black bars) forparticipants in each diagnostic group (a) for non-dominant ears from the 2-pairs condition of dichotic digits; (b) for non-dominant ears fromdichotic words and (c) for interaural asymmetry measured from digits and words; Right column displays results from the subgroup ofparticipants whose scores were measured at pre-ARIA (grey bars) and post-ARIA (black bars) evaluation (words, n¼ 67; digits, n¼ 70);(d) for non-dominant ears from the 2-pairs condition of dichotic digits; (e) for non-dominant ears from dichotic words; (e) for interauralasymmetry measured from digits and words. Significance values are represented by bars, p50.001***, p50.01**, p50.05*.

Evidence of binaural integration benefits 585

gains in both ears following ARIA training, suggesting that childrenand adolescents who perform poorly and symmetrically on DL testsmay also benefit from participation.

Results from this study suggest that ARIA training benefitsindividuals whose performance on a DL test falls below normalwhich is not surprising since the training focuses on dichotic tasks.

Benefits are maximal, though, for children and adolescents whosebinaural integration skills are consistently weak across two differentDL tests, especially when the pattern leads to the diagnosis ofamblyaudia. As the ARIA training paradigm requires that theclinician continually adjust the relative intensity of materialpresented through the sound-field speakers, participants with poor

Figure 3. Left column displays results from the group of participants whose scores were measured at the fourth session of ARIA (words,n¼ 119; digits, n¼ 117): Outcomes measured during the pre-ARIA evaluation (grey bars) and during the 4th ARIA session (black bars) forparticipants in each diagnostic group (a) for non-dominant ears from the 2-pairs condition of dichotic digits; (b) for non-dominant ears fromdichotic words and (c) for interaural asymmetry measured from digits and words; Right column displays results from the subgroup ofparticipants whose scores were measured at pre-ARIA (grey bars) and post-ARIA (black bars) evaluation (words, n¼ 67; digits, n¼ 70);(d) for non-dominant ears from the 2-pairs condition of dichotic digits; (e) for non-dominant ears from dichotic words; (e) for interauralasymmetry measured from digits and words. Significance values are represented by bars, p50.001***, p50.01**, p50.05*.

Evidence of binaural integration benefits 585



q Fey et al. (2011). Auditory processing disorder and auditory/language interventions: An evidence-based systematic review. Language, Speech and Hearing Services in Schools, 42, 246–264.

q Bellis Chermak, Weihing, & Musiek (2012). Efficacy of auditory interventions for central auditory processing disorder: A response to Fey et al (2011). Language, Speech and Hearing Services in Schools, 43, 381-386.

q Kamhi AG. (2011). What speech-language pathologists need to know about auditory processing disorder. Language Speech Hearing Services in the Schools, 42, 265-272

q Murphy CF & Schochat E (2013). Effects of different types of auditory temporal training on language skills: A systematic review. Clinics (Sao Paulo), 68, 1364-1370

q Specht K. (2013). Neuronal basis of speech comprehension. Hearing Research, pre-print

Relation Between Auditory Processing Disorders (APD) and Specific Language Disorder

Auditory Processing and Language

Delivered by Ingenta to: ?IP : 73.35.92.174 On: Mon, 20 Nov 2017 17:56:48

The Relationship between Central AuditoryProcessing, Language, and Cognition inChildren Being Evaluated for Central AuditoryProcessing DisorderDOI: 10.3766/jaaa.16119

Lauren Brenneman*Elizabeth Cash*†‡Gail D. Chermak§Linda Guenette{**Gay Masters*Frank E. Musiek||Mallory Brown{Julianne Ceruti{Krista Fitzegerald{Kristin Geissler{Jennifer Gonzalez{Jeffrey Weihing*

Abstract

Background: Pediatric central auditory processing disorder (CAPD) is frequently comorbid with otherchildhood disorders. However, few studies have examined the relationship between commonly usedCAPD, language, and cognition tests within the same sample.

Purpose: The present study examined the relationship between diagnostic CAPD tests and ‘‘gold stan-dard’’ measures of language and cognitive ability, the Clinical Evaluation of Language Fundamentals(CELF) and the Wechsler Intelligence Scale for Children (WISC).

Research Design: A retrospective study.

Study Sample: Twenty-seven patients referred for CAPD testing who scored average or better on theCELF and low average or better on theWISCwere initially included. Seven children who scored below theCELF and/or WISC inclusion criteria were then added to the dataset for a second analysis, yielding asample size of 34.

Data Collection and Analysis: Participants were administered a CAPD battery that included at least thefollowing three CAPD tests: Frequency Patterns (FP), Dichotic Digits (DD), and Competing Sentences(CS). In addition, they were administered the CELF andWISC. Relationships between scores on CAPD,language (CELF), and cognition (WISC) tests were examined using correlation analysis.

Results:DD and FP showed significant correlations with Full Scale Intelligence Quotient, and the DD leftear and the DD interaural difference measures both showed significant correlations with working mem-ory. However, z80% or more of the variance in these CAPD tests was unexplained by language and

*Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders, University of Louisville School of Medicine, Louisville, KY;†James Graham Brown Cancer Center, Louisville, KY; ‡Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY; §De-partment of Speech and Hearing Sciences, Washington State University Health Sciences Spokane, Spokane, WA; {Department of Speech, Language,Hearing Sciences, University of Connecticut, Storrs, CT; ||Department of Speech, Language, Hearing Sciences, University of Arizona, Tucson, AZ

Corresponding author: Jeffrey Weihing, Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders, University ofLouisville School of Medicine, Louisville, KY 40202; E-mail: [email protected]

This research was supported by the Royal Arch Research Assistance (RARA) group.

**Deceased

J Am Acad Audiol 28:758–769 (2017)

758

Functional Deficit Strategiesq Distractibility/inattention Increase SNRq Poor memory Meta-language external aids q Restricted vocabulary Improve closureq Cognitive inflexibility Diversify cognitive styleq Poor listening comprehension Induce formal schema to aid

organization & integrationq Reading & spelling problems Enhance multisensory integrationq Maladaptive behaviors Cognitive behavior modificationq Poor motivation Internal locus of control

attribution retraining

APD Individualized Management Strategies (Chermak & Musiek, American Journal of Audiology 1, 1992)

Examples of “Top-Down” and Multi-Sensory Reading Intervention Options for Children with APD

q Context-derived vocabulary buildingq Visual imageryq Visualizing and Verbalizing Program (Lindamood)q Auditory closure activitiesq Speech/language therapyq Multi-sensory reading strategies

l Lindamood Bell Learning Processes (www.lindamoodbell.com)l Wilson Reading Programl Orton Gillingham approaches


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