i’m lost in this class! what’s wrong with me? i just can’t hear right. auditory processing...

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

Auditory Processing Disorders (APD) Diagnosis is Feasible and Management is Effective

James W. Hall III, Ph.D.James W. Hall III, Ph.D.

Clinical Professor and Associate ChairClinical Professor and Associate Chair

Department of Communicative DisordersDepartment of Communicative Disorders

College of Public Health & Health ProfessionsCollege of Public Health & Health Professions

University of Florida University of Florida

Gainesville, Florida, U.S.A.Gainesville, Florida, U.S.A.

[email protected]@phhp.uflufl..eduedu

8th cranial (auditory) nerve)

Internal auditory canal Shares space with vestibular nerves, facial nerves, efferent auditory nerves & internal auditory artery

Central auditory nervous system

Cochlear nuclei Superior olivary complex Lateral lemiscus Crossing pathways Infererior colliculus Reticular (activating) formation Thalamus Primary and secondary auditory cortex Corpus collosum

Behavioral Audiometry:True Measures of Hearing

Behavioral Audiometry: Sound Field versus Earphone Stimulation

The Audiogram: Hearing Sensitivity as aFunction of Pure Tone Frequency

AUDITORY PROCESSING DISORDERS (APD):Academic Underachievement & Failure

F

I must be stupid!

Age and Gender Distribution in an Unselected APD Population

in a Medical Center Audiology Clinic (N = 239)

Age in Years

5

N

um

ber

of

Pat

ien

ts

7 8 9 10 11 12 13 14 15 - 18

10

20

25 Male

(N = 160) Female(N = 79)

15

Average age = 9 Years

AUDITORY PROCESSING: Cornerstone of Language and Literacy (Reading)

AUDITORY PROCESSING

PHONOLOGIC AWARENESS ORAL LANGUAGE

WRITTEN LANGUAGEReading and Spelling

COMPREHENSION

Assessment and Management of Auditory Processing Disorders (APD)

Historical perspective … interest in APD dates back Historical perspective … interest in APD dates back over 50 yearsover 50 years

How APD became a household phrase in audiologyHow APD became a household phrase in audiology Neuroscience foundation for APDNeuroscience foundation for APD Disorders often co-existing with APD Disorders often co-existing with APD Risk factors for APDRisk factors for APD Current and future assessment strategies and Current and future assessment strategies and

proceduresprocedures Effective management strategies and proceduresEffective management strategies and procedures

Carlo Calearo, M.D.Otorhinolaryngologist

“Italian Pioneer in APD Assessment”

Bocca E, Calearo C, Cassinari V.Bocca E, Calearo C, Cassinari V. A new method for testing hearing in A new method for testing hearing in temporal lobe tumors. temporal lobe tumors. Acta Otolaryngologica 44: Acta Otolaryngologica 44: 19541954..

Helmer Myklebust, Ph.D. (in psychology)Northwestern University

“Pioneer in APD Assessment”

Myklebust HR.Myklebust HR. Auditory disorders in Auditory disorders in children: A manual for differential diagnosis. children: A manual for differential diagnosis. New York: Grune & Stratton, New York: Grune & Stratton, 19541954..

““hearing is a receptive sense … and hearing is a receptive sense … and essential for normal language behavior” (p. essential for normal language behavior” (p. 11)11)

““the diagnostician of auditory problems in the diagnostician of auditory problems in children has traditionally emphasized children has traditionally emphasized peripheral damage. It is desirable that he peripheral damage. It is desirable that he (sic) also include central damage.” (p. 54)(sic) also include central damage.” (p. 54)

Dichotic Listening Paradigm … A long-standing test strategy for assessment of auditory processing

1956: British PsychologistDonald E. Broadbent, Ph.D.

1961: Canadian PsychologistDoreen Kimura, Ph.D.

Dichotic Listening Paradigm

RIGHT TEMPORAL CORTEX

Association Cortex

Primary Auditory Cortex

Right Earair plane

1, 3

CorpusCallosum

LEFT TEMPORAL CORTEX

Association Cortex


Left Earbase ball

5, 9

Development of APD Assessment & Management:Principles & Procedures

Bocca & Calearo

Myklebust

1954 1960

KatzKimura

1975

WillefordJerger

1986

KeithAMLRstudiesMusiek

1982 19961990s

proceduresMRI

studies

ASHATask ForceTallalKraus

2000

APDConference

fMRIEarobics



How (C) APD became a household phrase in audiologyHow (C) APD became a household phrase in audiology Neuroscience foundation for APDNeuroscience foundation for APD Disorders often co-existing with APD Disorders often co-existing with APD Risk factors for APDRisk factors for APD Current and future assessment strategies and Current and future assessment strategies and


AUDITORY PROCESSING DISORDERS (APD):ASHA Task Force Consensus Statement (1996)

““A central auditory test battery should include measures that examine A central auditory test battery should include measures that examine different central processesdifferent central processes.”.”

Tests should generally include both Tests should generally include both nonverbalnonverbal and and verbalverbal stimuli to stimuli to examine examine different levels of auditory processingdifferent levels of auditory processing and the auditory and the auditory nervous system.”nervous system.”

FactorsFactors to consider in the selection of test procedures include to consider in the selection of test procedures include information on:information on: test sensitivity and specificitytest sensitivity and specificity reliability and validityreliability and validity age appropriatenessage appropriateness

The person administering and interpreting the test battery should have The person administering and interpreting the test battery should have both theoretical and practical knowledge … typically both theoretical and practical knowledge … typically audiologistsaudiologists.”.”

AUDITORY PROCESSING DISORDERS (APD):ASHA Task Force Consensus Statement (1996)

““Central auditory processes are the auditory system mechanisms and Central auditory processes are the auditory system mechanisms and processes responsible for:processes responsible for: sound localization and lateralizationsound localization and lateralization auditory discriminationauditory discrimination auditory pattern recognitionauditory pattern recognition temporal aspects of auditiontemporal aspects of audition auditory performance decrements with auditory performance decrements with competingcompeting acoustic signals acoustic signals auditory performance decrements with auditory performance decrements with degradeddegraded acoustic signals acoustic signals

““These mechanisms and processes are presumed to aply to These mechanisms and processes are presumed to aply to nonverbal nonverbal as as well as verbal signals … they have well as verbal signals … they have neurophysiologicneurophysiologic as well as behavioral as well as behavioral correlates.”correlates.”

““Report of the Consensus Conference on the Diagnosis of Auditory Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children”Processing Disorders in School-Aged Children” Journal of American Journal of American Academy of Audiology 11: Nov. 2000.Academy of Audiology 11: Nov. 2000.

Definition: “Definition: “APD is broadly defined as a deficit in the processing of APD is broadly defined as a deficit in the processing of information that is specific to the auditory modalityinformation that is specific to the auditory modality.”.”

GuidelinesGuidelines Screening strategiesScreening strategies DiagnosisDiagnosis

minimal test batteryminimal test battery factors influencing test outcome and analysisfactors influencing test outcome and analysis

CONSENSUS CONFERENCE 2000 ON APD

Assumptions in the diagnostic assessment of APD … possible Assumptions in the diagnostic assessment of APD … possible outcomesoutcomesa pure APDa pure APDan APD and a disorder or disorders in other modalities, an APD and a disorder or disorders in other modalities,

e.g., multi-sensorye.g., multi-sensorya disorder that appears auditory at first, but actually is non-a disorder that appears auditory at first, but actually is non-

auditoryauditorya disorder that appears at first to be non-auditory but is a disorder that appears at first to be non-auditory but is

actually auditoryactually auditory

2000 Consensus Conference on the Diagnosis of APD

Factors influencing diagnostic assessment of APDFactors influencing diagnostic assessment of APD

ADHDADHDLanguage impairmentLanguage impairmentReading disabilityReading disabilityLearning disabilityLearning disabilityAutistic spectrum disorderAutistic spectrum disorderReduced intellectual functioning (cognitive impairment)Reduced intellectual functioning (cognitive impairment)

2000 Consensus Conference on the Diagnosis of APD

Listener variables in the diagnostic assessment of APDListener variables in the diagnostic assessment of APDAttentionAttentionAuditory neuropathyAuditory neuropathyFatigueFatigueHearing sensitivityHearing sensitivityIntellectual and developmental ageIntellectual and developmental ageCognitive variables (e.g., memory, processing speed)Cognitive variables (e.g., memory, processing speed)MedicationsMedicationsMotivationMotivationMotor skillsMotor skillsNative language, language experience, language ageNative language, language experience, language ageVisual acuityVisual acuity

2000 Consensus Conference on the Diagnosis of APDs

www.www.ashaasha.org.org Definition of (C ) AP Definition of (C ) AP

Broad definition … “the efficiency and effectiveness by which the CNS utilizes Broad definition … “the efficiency and effectiveness by which the CNS utilizes auditory information”auditory information”

Narrow definition … “the perceptual processing of auditory information in the CNS Narrow definition … “the perceptual processing of auditory information in the CNS and the neurobiological activity that underlies that processing and gives rise to and the neurobiological activity that underlies that processing and gives rise to electrophysiologic auditory potentials.”electrophysiologic auditory potentials.”

Auditory processing includes the auditory mechanisms that underlie the following Auditory processing includes the auditory mechanisms that underlie the following abilities and skills:abilities and skills:

Sound localization and lateralizationSound localization and lateralization Auditory discriminationAuditory discrimination Auditory pattern recognitionAuditory pattern recognition Temporal aspects of auditionTemporal aspects of audition Temporal ordering and temporal maskingTemporal ordering and temporal masking Auditory performance in competing acoustic signals (includes dichotic listening)Auditory performance in competing acoustic signals (includes dichotic listening) Auditory performance with degraded acoustic signalsAuditory performance with degraded acoustic signals

Technical Report of ASHA Working Group on (Central) Auditory Processing Disorders (2005)

Definition of APDefinition of AP Nature of APDNature of APD Historical perspectiveHistorical perspective Knowledge base and ethical considerationsKnowledge base and ethical considerations The basic science connectionThe basic science connection

Neurochemistry and auditory processingNeurochemistry and auditory processing Screening for APDScreening for APD The APD case historyThe APD case history Diagnosis of APDDiagnosis of APD

Technical Report of ASHA Working Group on (Central) Auditory Processing Disorders (2)

Basic neuroscience advances in the decade of the brain (1990s) impacted understanding of APD

Different regions mature at different ratesDifferent regions mature at different ratesMaturation occurs along caudal to rostral gradientMaturation occurs along caudal to rostral gradient

Development of auditory pathways and centers involvesDevelopment of auditory pathways and centers involvesCell differentiation and migrationCell differentiation and migrationMyelinationMyelinationArborizationArborizationSynaptogenesisSynaptogenesis

Consistent and typical auditory stimulation (experience) within the first years after Consistent and typical auditory stimulation (experience) within the first years after birth shapes nervous system development birth shapes nervous system development (plasticity)(plasticity)

Perinatal and childhood factors influence development of auditory processing, Perinatal and childhood factors influence development of auditory processing, e.g.,e.g.,

Neurological risk factors (e.g., asphyxia, hyperbilirubinemia)Neurological risk factors (e.g., asphyxia, hyperbilirubinemia)Conductive hearing lossConductive hearing lossEnvironmental deprivationEnvironmental deprivation

Genetic factors play a role in etiology of auditory processing disordersGenetic factors play a role in etiology of auditory processing disorders

New Handbook of Auditory Evoked Responses Summary of AER findings in APD

Chapter 1: Overview of auditory neurophysiologyChapter 1: Overview of auditory neurophysiology Chapter 2: Anatomy and physiology principles of AERsChapter 2: Anatomy and physiology principles of AERs Chapter 3: Introduction to AER measurementChapter 3: Introduction to AER measurement Chapter 4: Electrocochleography (ECochG): Protocols and proceduresChapter 4: Electrocochleography (ECochG): Protocols and procedures Chapter 5: ECochG: Clinical applications and populationsChapter 5: ECochG: Clinical applications and populations Chapter 6: ABR Parameters, Protocols, and ProceduresChapter 6: ABR Parameters, Protocols, and Procedures Chapter 7: ABR analysis and interpretationChapter 7: ABR analysis and interpretation Chapter 8: Frequency-specific ABR and ASSRChapter 8: Frequency-specific ABR and ASSR Chapter 9: ABR: Pediatric clinical applications and populationsChapter 9: ABR: Pediatric clinical applications and populations Chapter 10: ABR: Adult diseases, disorders & clinical applicationsChapter 10: ABR: Adult diseases, disorders & clinical applications Chapter 11: Auditory middle latency responseChapter 11: Auditory middle latency response Chapter 12: Auditory late responseChapter 12: Auditory late response Chapter 13: P300 responseChapter 13: P300 response Chapter 14: Mismatch negativity (MMN) responseChapter 14: Mismatch negativity (MMN) response Chapter 15: Electrically evoked and myogenic responsesChapter 15: Electrically evoked and myogenic responses

Auditory Late Responseand P300 Response

500 ms

FrequentUnattendede.g., 1000 Hz

P2

A

mp

litu

de

(V

)

P2

P3 (300)

Infrequent(rare)Attendede.g., 2000 Hz

N1

Mismatch Negativity (MMN) Response:

“Unconcious Brain Response Elicited by Different Properties of Sound(Courtesy of Catharine Pettigrew, Ph.D.)

MISMATCH NEGATIVITY (MMN) RESPONSE:Investigations in clinical populations

Assessment of infant speech perception, including children at risk for disorders, Assessment of infant speech perception, including children at risk for disorders, e.g., language e.g., language (e.g., Leppanen & Lyytinen, 1997)(e.g., Leppanen & Lyytinen, 1997)

Hearing aid fitting of infants and young children with speech signals Hearing aid fitting of infants and young children with speech signals (e.g., (e.g., Kraus, et al)Kraus, et al)

Cochlear implant fitting infants and young children with speech signals Cochlear implant fitting infants and young children with speech signals (e.g., (e.g., Kraus, et al)Kraus, et al)

Documentation of auditory training and language treatment Documentation of auditory training and language treatment (e.g., Kujala et al, (e.g., Kujala et al, 2001)2001)

Description of Alzheimer’s disease Description of Alzheimer’s disease (e.g., Pekkonen et al, 1994)(e.g., Pekkonen et al, 1994) Electrophysiologic documentation of attention deficit hyperactivity disorder Electrophysiologic documentation of attention deficit hyperactivity disorder (e.g., (e.g.,

Barry, Johnstone, Clarke, 2003)Barry, Johnstone, Clarke, 2003) Prognosis of recovery from coma Prognosis of recovery from coma (e.g., Kane et al, 1993)(e.g., Kane et al, 1993) Diagnosis of frontal and auditory temporal lobe dysfunction in schizophrenia Diagnosis of frontal and auditory temporal lobe dysfunction in schizophrenia

(e.g., Michie et al, 2000)(e.g., Michie et al, 2000) Neurophysiologic documentation of auditory processing disorder (APD) and Neurophysiologic documentation of auditory processing disorder (APD) and

dyslexia in childrendyslexia in children

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

Right

TL

“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. Blau V, van Atteveldt N, Ekkebus M, Goebel R, Blomert L. Reduced Neural Integration of Reduced Neural Integration of Letters and Speech Sounds Links Phonological and Reading Deficits in Adult Dyslexia.Letters and Speech Sounds Links Phonological and Reading Deficits in Adult Dyslexia. Curr Biol. 2009 Mar 11.Curr Biol. 2009 Mar 11.

Leff AP, Iverson P, Schofield TM, Kilner JM, Crinion JT, Friston KJ, Price CJ. Leff AP, Iverson P, Schofield TM, Kilner JM, Crinion JT, Friston KJ, Price CJ. Vowel-Vowel-specific mismatch responses in the anterior superior temporal gyrus: An fMRI study.specific mismatch responses in the anterior superior temporal gyrus: An fMRI study. Cortex. 2009 Apr;45(4):517-26. Epub 2008 Feb 7.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. Warrier C, Wong P, Penhune V, Zatorre R, Parrish T, Abrams D, Kraus N. Relating Relating structure to function: Heschl's gyrus and acoustic processing.structure to function: Heschl's gyrus and acoustic processing. J Neurosci. 2009 Jan J Neurosci. 2009 Jan 7;29(1):61-9.7;29(1):61-9.

““Differential Diagnosis:Differential Diagnosis:

Diagnosis based on comparison of symptoms (signs) ofDiagnosis based on comparison of symptoms (signs) of

two or more similar diseases (disorders) to determinetwo or more similar diseases (disorders) to determine

which the patient is suffering from.”which the patient is suffering from.”

Auditory Processing Disorders:Differential Diagnosis

Shared Anatomy

Reading

Language

Auditory processing

Peripheral (conductive and sensory) hearing lossPeripheral (conductive and sensory) hearing loss Specific language impairment (SLI)Specific language impairment (SLI) Learning disabilities (LDs)Learning disabilities (LDs) Reading disorders (dyslexia)Reading disorders (dyslexia) Attention deficit/hyperactivity disorder (ADHD)Attention deficit/hyperactivity disorder (ADHD) Emotional and psychological disordersEmotional and psychological disorders Developmental delayDevelopmental delay Seizure disordersSeizure disorders PDD, autism, and autism spectrum disordersPDD, autism, and autism spectrum disorders

AUDITORY PROCESSING DISORDERS: Co-existing Disorders (Co-morbidity)

AUDITORY PROCESSING DISORDERS (APDs): Co-existing Disorders (Co-morbidity)

SLI

ADHD

dyslexiaAPD

Wright BA, Lombardino LJ, King WM, Puranik CS, Leonard Wright BA, Lombardino LJ, King WM, Puranik CS, Leonard CM, Merzenich MM.CM, Merzenich MM. Deficits in auditory temporal and Deficits in auditory temporal and spectral resolution in language-impaired children. spectral resolution in language-impaired children. Nature Nature 387: 176-178, 1997.387: 176-178, 1997.

““Here we report the results of psychophysical tests Here we report the results of psychophysical tests employing simple tones and noises showing that children employing simple tones and noises showing that children with specific language impairment (SLI) have severe with specific language impairment (SLI) have severe auditory perceptual deficits for brief but not long tones in auditory perceptual deficits for brief but not long tones in particular sound contexts.”particular sound contexts.”

AUDITORY PROCESSING DISORDERS (APD): Evidence of relation to language and reading

Wright BA, Lombardino LJ, King WM, Puranik CS, Leonard Wright BA, Lombardino LJ, King WM, Puranik CS, Leonard CM, Merzenich MM.CM, Merzenich MM. (continued) (continued)

““The present auditory tests may also aid in the diagnosis and The present auditory tests may also aid in the diagnosis and treatment of persons with reading difficulties … treatment of persons with reading difficulties …

Our results are in accord with the conclusion … that some Our results are in accord with the conclusion … that some but not all children with reading problems have difficulties but not all children with reading problems have difficulties accurately perceiving rapidly presented stimuli.”accurately perceiving rapidly presented stimuli.”

AUDITORY PROCESSING DISORDERS: Relation to language and reading

APD:Screening and Assessment in Pre-School Children

I can’t figure outwhat they are saying!

Risk Factors for APD:Team Work in Identification and Assessment

Neurological dysfunction and disorders Neurological dysfunction and disorders (physicians)(physicians), e.g.,, e.g., neonatal risk factors (e.g., asphyxia, CMV)neonatal risk factors (e.g., asphyxia, CMV) head injury head injury seizure disorders seizure disorders

Chronic otitis media in preschool years Chronic otitis media in preschool years (otolaryngologists)(otolaryngologists) Academic underachievement or failure Academic underachievement or failure (teachers and (teachers and

educational psychologists)educational psychologists) Family history of academic underachievement Family history of academic underachievement (parents)(parents) Co-existing disorders Co-existing disorders (multiple professionals)(multiple professionals)

Auditory Processing Disorders: Indicators in Early School Age Population

(e.g., kindergarten)

Behavior typical of peripheral hearing loss, but normal Behavior typical of peripheral hearing loss, but normal audiogramaudiogram

Scatter in results on psychological and language tests, with Scatter in results on psychological and language tests, with weakness in auditory domainsweakness in auditory domains

Verbal IQ score lower than performance IQ scoreVerbal IQ score lower than performance IQ score May have poor musical skillsMay have poor musical skills Problems with fine and/or gross motors skillsProblems with fine and/or gross motors skills Teacher and/or parent concern about hearing and listening Teacher and/or parent concern about hearing and listening

abilities (and the audiogram is normal)abilities (and the audiogram is normal)

Auditory Processing Disorders: Indicators in Early School Age Population (2)

Has difficulty following multi-step directionsHas difficulty following multi-step directions Poor reading and spelling skills (remediation not effective)Poor reading and spelling skills (remediation not effective) Responds inappropriately in the classroomResponds inappropriately in the classroom Reluctant to participate in class discussionsReluctant to participate in class discussions Positive history of middle ear disease and hearing loss Positive history of middle ear disease and hearing loss

Auditory Processing Disorders: Indicators in Early School Age Population and

Screening for At Risk Children (SIFTER)

Auditory Processing Disorders: Indicators in Early School Age Population and

Screening for At Risk Children (CHAPS)

SCAN-C and SCAN-A (Robert Keith, 1986):Undefined sensitivity and specificity

Low pass filtered words subtestLow pass filtered words subtest 40 monosyllabic words (20 for each ear)40 monosyllabic words (20 for each ear) low pass filtered at 1000 Hzlow pass filtered at 1000 Hz

Auditory figure-ground subtestAuditory figure-ground subtest 40 monosyllabic words (20 for each ear)40 monosyllabic words (20 for each ear) multi-talker babble noise at + 8 dB SNRmulti-talker babble noise at + 8 dB SNR

Competing wordsCompeting words 40 monosyllabic words (20 for each ear)40 monosyllabic words (20 for each ear) inter-word interval of inter-word interval of << 5 ms 5 ms initial response to right then left ear wordsinitial response to right then left ear words

Competing sentencesCompeting sentences 15 target and competing sentences15 target and competing sentences initial response to right then left ear sentencesinitial response to right then left ear sentences

Assessment of APD:Acquiring History and Background Information

Parents complete APD survey Parents complete APD survey Middle ear disease?Middle ear disease? Neonatal risk factors?Neonatal risk factors? Co-existing disorders?Co-existing disorders? Medical management for auditory or neurological disorderMedical management for auditory or neurological disorder Previous assessments, e.g., Previous assessments, e.g.,

Speech languageSpeech languagePsychological and psycho-educationalPsychological and psycho-educationalADHDADHD

Previous and current therapy and treatmentPrevious and current therapy and treatment

Assessment of APD:Peripheral Test Battery (< 20 minutes)

Otoacoustic emissions (OAEs)Otoacoustic emissions (OAEs)OAEs are abnormal in 35% of children undergoing APD assessmentOAEs are abnormal in 35% of children undergoing APD assessment

Aural immittance measuresAural immittance measurestympanometrytympanometryacoustic reflexes acoustic reflexes

crossed vs. uncrossed conditions … initial measure of CNS crossed vs. uncrossed conditions … initial measure of CNS functionfunction

Pure tone audiometryPure tone audiometryinter-octave frequencies (e.g., 3000 and 6000 Hz)inter-octave frequencies (e.g., 3000 and 6000 Hz)high frequency (> 8000 Hz) audiometry (as indicated)high frequency (> 8000 Hz) audiometry (as indicated)

Speech audiometrySpeech audiometryword recognition (use CD materials with 10 most difficult words word recognition (use CD materials with 10 most difficult words

first)first)

Assessment of APD:Central Auditory Test Battery (~ 80 minutes)

APD ASSESSMENT: Test Battery for Auditory Processes (1)

Sound localization and lateralizationSound localization and lateralization No clinical tests commercially-available for childrenNo clinical tests commercially-available for children Wxperimental techniques for earphone simulated signalsWxperimental techniques for earphone simulated signals

Auditory discrimination, e.g.,Auditory discrimination, e.g., Goldman-Fristoe-Woodcock Test of Auditory Discrimination Goldman-Fristoe-Woodcock Test of Auditory Discrimination (in (in

quiet and noise)quiet and noise) Temporal resolution/gap detection, e.g.,Temporal resolution/gap detection, e.g.,

Auditory Fusion Test (Revised)Auditory Fusion Test (Revised) Auditory Random Gap Detection (ARGD) testAuditory Random Gap Detection (ARGD) test Gap in Noise (GIN) testGap in Noise (GIN) test

Temporal ordering, e.g.,Temporal ordering, e.g., Pitch pattern sequence (PPS) testPitch pattern sequence (PPS) test Suration pattern sequence test Suration pattern sequence test

Dichotic Digits Procedure


Association Cortex


Right Ear2, 9

Left Ear1, 4

CorpusCallosum


Association Cortex


CAPD ASSESSMENT: Test Battery for Auditory Processes (2)

Temporal integration dichotic tests, e.g.,Temporal integration dichotic tests, e.g.,Dichotic digitsDichotic digitsStaggered spondaic word (SSW) testStaggered spondaic word (SSW) testDichotic sentence identification (DSI) testDichotic sentence identification (DSI) testSCAN competing words subtestSCAN competing words subtest

Auditory performance with competing acoustic signals, e.g.,Auditory performance with competing acoustic signals, e.g.,SSI-ICMSSI-ICMPediatric Speech Intelligibility (PSI) testPediatric Speech Intelligibility (PSI) testGFW Test of Auditory Discrimination (noise)GFW Test of Auditory Discrimination (noise)SCAN auditory-figure ground subtestSCAN auditory-figure ground subtest

Auditory performance with degraded acoustic signals, e.g.,Auditory performance with degraded acoustic signals, e.g.,Time-compressed words with reverberationTime-compressed words with reverberationSCAN filtered words subtestSCAN filtered words subtest

Auditory Continuous Performance Test (ACPT)Auditory Continuous Performance Test (ACPT) developed by Robert Keith developed by Robert Keith for children with suspected or diagnosed AD/HDfor children with suspected or diagnosed AD/HD rapid presentation of wordsrapid presentation of words task is to respond to target word “dog” onlytask is to respond to target word “dog” only analog to visual continuous performance testsanalog to visual continuous performance tests

Screening of phonologic awareness skillsScreening of phonologic awareness skillsPhonemic synthesis test Phonemic synthesis test

developed Jack Katzdeveloped Jack KatzTest of Auditory Analysis Skills (TASS)Test of Auditory Analysis Skills (TASS)

Say the word Say the word baseballbaseball … now say it again but don’t say … now say it again but don’t say basebaseSay the word Say the word smacksmack … now say it again but don’t say … now say it again but don’t say /m//m/

APD ASSESSMENT: Additional Components of Test Battery (as indicated)

General principlesGeneral principlesVerbal and non-verbal proceduresVerbal and non-verbal procedures

Non-verbal test materialsNon-verbal test materialsNon-verbal response modeNon-verbal response mode

Age appropriate tasksAge appropriate tasksPsychometrically well designedPsychometrically well designed

Sensitivity and specificitySensitivity and specificityAdequately large normative data across age rangeAdequately large normative data across age rangeStandard scores and percentilesStandard scores and percentiles

Adaptive test strategiesAdaptive test strategiesReduced test timeReduced test timeManipulation of test difficultyManipulation of test difficulty

Measures of major auditory processesMeasures of major auditory processes

APD ASSESSMENT: Ideas for New Procedures and Protocols

Gaps-in-Noise (GIN) test (Musiek, Shinn, Jirsa, Bamiou, Baran & Zaidan. Gaps-in-Noise (GIN) test (Musiek, Shinn, Jirsa, Bamiou, Baran & Zaidan. The GIN (Gaps-in-Noise) Test performance in subjects with confirmed The GIN (Gaps-in-Noise) Test performance in subjects with confirmed central auditory nervous system involvement. central auditory nervous system involvement. Ear & Hearing, 26Ear & Hearing, 26, 2005.), 2005.)Noise signals with gaps of silenceNoise signals with gaps of silence

Gaps of different durations and locations within noiseGaps of different durations and locations within noiseNon frequency specific signalsNon frequency specific signalsScores not influenced by hearing lossScores not influenced by hearing loss

Simple button pushing response Simple button pushing response Signal with either gap or no gapSignal with either gap or no gapYes or no response judgmentYes or no response judgmentMinimal influence of cognition (for patient Minimal influence of cognition (for patient and and tester)tester)

Gap detection is a traditional and accepted measure of Gap detection is a traditional and accepted measure of temporal temporal processingprocessing

APD ASSESSMENT: Creative Non-Verbal Test Procedures and Protocols (1)

Listening in Spatialized Noise (LISN) test The Listening in Spatialized Noise Test: Listening in Spatialized Noise (LISN) test The Listening in Spatialized Noise Test: An auditory processing disorder study. An auditory processing disorder study. JAAA, 17JAAA, 17, 2006. Cameron et al, 2006), 2006. Cameron et al, 2006)

The Listening in Spatialized Noise -- Sentences Test (LISN-S): Comparison to the The Listening in Spatialized Noise -- Sentences Test (LISN-S): Comparison to the prototype LISN and results from children with either a suspected (central) prototype LISN and results from children with either a suspected (central) auditory processing disorder or a confirmed language disorder. JAAA 19, 2008. auditory processing disorder or a confirmed language disorder. JAAA 19, 2008. Cameron & Dillon.Cameron & Dillon.

Three dimensional auditory environment under earphonesThree dimensional auditory environment under earphonesAssesses auditory stream segregation skills in childrenAssesses auditory stream segregation skills in childrenSpeech reception thresholds for sentences presented from 0Speech reception thresholds for sentences presented from 0oo azimuth in azimuth in

competing speech. Competing speech manipulated bycompeting speech. Competing speech manipulated by Location in auditory space (0Location in auditory space (0oo vs. 90 vs. 90oo)) Vocal quality of speakers (same as or different from target stimulus Vocal quality of speakers (same as or different from target stimulus

speaker)speaker) Advantage measured as benefit in dB with either spatial or talker cueAdvantage measured as benefit in dB with either spatial or talker cue


The Listening in Spatialized Noise -- Sentences Test (LISN-S): Comparison to the The Listening in Spatialized Noise -- Sentences Test (LISN-S): Comparison to the prototype LISN and results from children with either a suspected (central) prototype LISN and results from children with either a suspected (central) auditory processing disorder or a confirmed language disorder. JAAA 19, 2008. auditory processing disorder or a confirmed language disorder. JAAA 19, 2008. Cameron & Dillon.Cameron & Dillon.

ConclusionsConclusionsChildren with traditionally defined APD showed deficit on LISN-SChildren with traditionally defined APD showed deficit on LISN-SNo correlation of LISN-S with dichotic tests, PPS test, or gap detection testNo correlation of LISN-S with dichotic tests, PPS test, or gap detection testSpatial and non-spatial LISN-S test performance not correlatedSpatial and non-spatial LISN-S test performance not correlatedChildren with language impairment did not show LISN-S deficitsChildren with language impairment did not show LISN-S deficitsFindings support ASHA 2005 and AAA 2009 conclusions regarding the ability Findings support ASHA 2005 and AAA 2009 conclusions regarding the ability

to diagnose auditory specific deficitsto diagnose auditory specific deficitsChildren with spatial stream segregation deficits likely to require higher SNR, Children with spatial stream segregation deficits likely to require higher SNR,

e.g., personal FM devicese.g., personal FM devices


Auditory evoked responsesAuditory evoked responsesAuditory brainstem response (ABR)Auditory brainstem response (ABR)Auditory steady state response (ASSR)Auditory steady state response (ASSR)Auditory middle latency response (AMLR)Auditory middle latency response (AMLR)Auditory P300 response Auditory P300 response

oddball paradigmoddball paradigm active or passive subjectactive or passive subject

Mismatch negativity (MMN) response Mismatch negativity (MMN) response Auditory processes to be assessedAuditory processes to be assessed

Discrimination (e.g., frequency, duration, speech type sounds)Discrimination (e.g., frequency, duration, speech type sounds)Auditory figure groundAuditory figure groundTemporal processingTemporal processingTemporal orderingTemporal ordering

APD ASSESSMENT: Auditory Evoked Responses Evoked with

Non-speech and Speech Signals

Tallal P, Miller S, Merzenich M, et al.Tallal P, Miller S, Merzenich M, et al. Language Language comprehension in language-learning impaired children comprehension in language-learning impaired children improved with acoustically modified speech. improved with acoustically modified speech. Science 271: Science 271: 81-84, 1996.81-84, 1996.

““A speech processing algorithm was developed to create A speech processing algorithm was developed to create more salient versions of the rapidly changing elements in more salient versions of the rapidly changing elements in the acoustic waveform of speech that have been shown to the acoustic waveform of speech that have been shown to be deficiently processed by language-learning impaired be deficiently processed by language-learning impaired (LLI) children … LLI children received extensive daily (LLI) children … LLI children received extensive daily training with listening exercises ...”training with listening exercises ...”

Management of APD with Computer-Based Techniques: Scientific Bases of FastForword

APD MANAGEMENT: Computer-based Auditory Therapy(www.cogcon.com)

Earobics comes in two versions:

Earobics Foundations for pre-kindergarten, kindergarten, and first grade students • Earobics Connections for second and third grade students, and other struggling readers

Instructions available in 10 languages

Auditory, Phonological, and Pre-Reading SkillsAddressed by Earobics Program

Rhyming Phoneme identification Blending Segmentation

Ability to break word down into individual sounds Phonological manipulation Discrimination Auditory performance in competing noise Auditory sequential memory

Earobics: Comments from Website(www.cogcon.com)

Earobics is widely considered to be one of the most validated and quantifiable Earobics is widely considered to be one of the most validated and quantifiable reading intervention programs. States across the country have reviewed the reading intervention programs. States across the country have reviewed the program and approved its use in their schools to quickly and effectively build program and approved its use in their schools to quickly and effectively build student reading achievement.student reading achievement.

Independent industry reviewers, including the Florida Center for Reading Independent industry reviewers, including the Florida Center for Reading Research (FCRR), confirm these findings. As a vital source for districts and Research (FCRR), confirm these findings. As a vital source for districts and schools, FCRR regularly reviews reading programs to help teachers, principals, schools, FCRR regularly reviews reading programs to help teachers, principals, and district administrators make informed choices on effective instruction.and district administrators make informed choices on effective instruction.

Earobics was among the select few programs in the supplemental, intervention, Earobics was among the select few programs in the supplemental, intervention, and technology-based program categories to achieve the FCRR’s highest ranking and technology-based program categories to achieve the FCRR’s highest ranking in all five reading areas. in all five reading areas.

NOTE: FCRR = Florida Center for Reading Research (www.fcrr.org)NOTE: FCRR = Florida Center for Reading Research (www.fcrr.org)

AUDITORY PROCESSING DISORDERS (APDs): Incremental Deficits Model

AcademicAcademic

AchieverAchiever

AcademicAcademic

UnderachieverUnderachiever

> Intelligence> Intelligence Normal hearingNormal hearing Family supportFamily support GeneticsGenetics EnvironmentEnvironment Auditory stimulationAuditory stimulation

< Intelligence< Intelligence Conductive HLConductive HL ADD/ADHDADD/ADHD GeneticsGenetics SLISLI APDAPD

APD Management (Treatment): Preferred Practice Patterns for Audiology (ASHA)

CounselingCounseling Assistive listening devicesAssistive listening devices Acoustic enhancement and environmental modification of the Acoustic enhancement and environmental modification of the

listening environment listening environment Auditory training and stimulation (including computer-based Auditory training and stimulation (including computer-based

software programs)software programs) Communication and/or education strategiesCommunication and/or education strategies Meta-linguistic and meta-cognitive skills and strategiesMeta-linguistic and meta-cognitive skills and strategies Documentation of implementation of frequency and duration of Documentation of implementation of frequency and duration of

treatmenttreatment Documentation of outcomeDocumentation of outcome

APD Management Options and ApproachesAPD Management Options and ApproachesCounseling, case management, and advocacyCounseling, case management, and advocacyAudiologic management in school and the home, e.g.,Audiologic management in school and the home, e.g.,

FM technology (assistive listening devices)FM technology (assistive listening devices) Specific auditory training programs (e.g., DIID)Specific auditory training programs (e.g., DIID)

Computer based auditory training programs, e.g.,Computer based auditory training programs, e.g., Earobics (school wide license for 600 children)Earobics (school wide license for 600 children)

Multi-disciplinary management, e.g.,Multi-disciplinary management, e.g.,Multi-sensory reading instruction strategiesMulti-sensory reading instruction strategies

Management of Children with Auditory Processing Disorders (APD) in Educational Settings

Classroom Assistive Listening Devices

Personal FM

Headset Style

Desktop

Toteable FM Infrared Sound Field FM

Phonak EduLinkA viable option for all children, particularly adolescents

Campus S

Transmitter

EduLink Receivers

Mini-Boom Microphone

SNR improvement on the HINT in normal hearing adults and

children without and with APD:Three different FM system types

Listening Condition

2

S

NR

Im

pro

vem

ent

(in

dB

SP

L)

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

4

6

8

Head set

Desk top

7.5

4.0

7.4

3.8

9.5

6.5

10

Sound field

4.7

4.3

7.2

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

GroupGroup

Test ConditionTest Condition ControlControl APDAPD

Unaided in Noise (SNR)*Unaided in Noise (SNR)* 7.9 dB7.9 dB 6.1dB6.1dB

Aided in Noise (SNR) **Aided in Noise (SNR) ** - 0.3 dB - 0.3 dB - 4.2 dB - 4.2 dB

Advantage in Noise Advantage in Noise 8.2 dB8.2 dB 10.310.3

with EduLinkwith EduLink

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

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

Educational Performance:Fisher’s Auditory Checklist Findings Completed by Parents

(Difference in scores between groups significant at p < .000)

Fisher's Score

0

10

20

30

40

50

60

70

80

90

100

Individual Control and APD Subjects

Perc

ent S

core

Fisher's Score

Educational Performance:Educational Performance:Listening Inventory For Education (Listening Inventory For Education (LIFE)

GroupGroup

QuestionQuestion ControlControl APDAPD Significance Significance

p < 0.05p < 0.05

11 8.68.6 5.25.2 ++

22 7.37.3 5.15.1 ++

33 6.66.6 4.74.7 --

44 5.55.5 21.521.5 --

55 4.94.9 3.03.0 --

66 8.48.4 6.86.8 --

88 7.17.1 6.06.0 - -

99 9.49.4 5.85.8 ++

1010 7.97.9 6.96.9 --

Educational Performance: SIFTER(Difference in scores between groups for all categories except

School Behavior [p < 0.57)]significant at p < .05)

SIFTER APD vs Control

0

2

4

6

8

10

12

14

Academics Attention Communication Class Participation School Behavior

SIFTER Categories

Sc

ore Control

APD

Psychosocial Questionnaires

Behavioral Assessment System for Children, Volume II (BASC-II)Behavioral Assessment System for Children, Volume II (BASC-II) A profile of adaptive and maladaptive behaviors and emotions of A profile of adaptive and maladaptive behaviors and emotions of

children and adolescents.children and adolescents. Social Skills Rating System (SSQ)Social Skills Rating System (SSQ)

A measure of positive and negative social skill behaviors of A measure of positive and negative social skill behaviors of students.students.

Dartmouth Cooperative Functional Health Assessment Charts (COOP)Dartmouth Cooperative Functional Health Assessment Charts (COOP) A screening tool for quality of life in adolescents in several A screening tool for quality of life in adolescents in several

functional domains/functional domains/

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

•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

““Scale scores in the Scale scores in the Clinically Significant Clinically Significant range range suggest a high level of maladjustment. suggest a high level of maladjustment.

Scores in the Scores in the At-RiskAt-Risk range may identify a range may identify a significant problem that may not be severe significant problem that may not be severe enough to require formal treatment or may enough to require formal treatment or may identify the potential of developing a problem identify the potential of developing a problem that needs careful monitoring.”that needs careful monitoring.”

Psychosocial Questionnaires:Interpretation

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

Normal Findings perNormal Findings per Group (%)Group (%)

DomainDomain ControlControl APDAPD

AggressionAggression 92 92 100 100

Conduct problems Conduct problems 92 92 100 100

AnxietyAnxiety 84 84 100 100

DepressionDepression 92 92 100 100

Internalizing problemsInternalizing problems 77 77 71 71

WithdrawalWithdrawal 84 84 71 71

Attention problemsAttention problems 92 92 29 29

Adaptive skillsAdaptive skills 92 92 71 71

Functional communicationFunctional communication 92 92 57 57

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

Normal Findings perNormal Findings per Group (%)Group (%)

DomainDomain ControlControl APDAPD

Attitude toward teachers 100Attitude toward teachers 100 86 86

Attitude toward schoolAttitude toward school 100 100 57 57

School problemsSchool problems 100 100 71 71

Conduct problems Conduct problems 92 92 100 100

AtypicalityAtypicality 100 100 100 100

AnxietyAnxiety 100 100 100 100

Social stressSocial stress 9292 100 100

DepressionDepression 100 100 86 86

Internalizing problemsInternalizing problems 100 100 100 100

Sense of inadequacySense of inadequacy 100 100 8686

Parent relationshipParent relationship 9292 100 100

Self esteemSelf esteem 100 100 100 100

Paper will appear in April 2009 issue of Paper will appear in April 2009 issue of International Journal of AudiologyInternational Journal of Audiology APD in school age children can have significant negative impact on:APD in school age children can have significant negative impact on:

Academic performanceAcademic performance Psychosocial statusPsychosocial status Quality of lifeQuality of life

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

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

Management of APD with FM technology (enhancing the signal-to-noise ratio) Management of APD with FM technology (enhancing the signal-to-noise ratio) improves:improves:

Speech perception in noise (with EduLink FM systemSpeech perception in noise (with EduLink FM system Academic performanceAcademic performance Psychosocial status Psychosocial status Speech perception in noise without the benefit of FM technologySpeech perception in noise without the benefit of FM technology

Benefit of Phonak EduLink FM Technology on Communication, Psychosocial Status, and Academic Performance of Children with

Auditory Processing Disorders (APD): Conclusions

Dichotic Intensity Increment Difference (DIID)


Association Cortex


Strong Earincreasingintensity

Weak Earfixed

intensity

CorpusCallosum


Association Cortex


Dichotic Intensity Increment Difference (DIID) Tasks

Binaural separationBinaural separation Ear directed targets (monaural)Ear directed targets (monaural) Ear directed targets (binaural)Ear directed targets (binaural) Ear directed manipulationsEar directed manipulations Ear directed judgmentsEar directed judgments Intensity, clarityIntensity, clarity Materials should be a mixture of dichotic materialsMaterials should be a mixture of dichotic materials

DigitsDigits Spondee wordsSpondee words Single syllable wordsSingle syllable words SentencesSentences

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

Context-derived vocabulary buildingContext-derived vocabulary building Visual imageryVisual imagery Visualizing and Verbalizing ProgramVisualizing and Verbalizing Program Auditory closure activitiesAuditory closure activities Speech/language therapySpeech/language therapy Multi-sensory reading strategies Multi-sensory reading strategies

Lindamood Bell Learning Processes (www.lindamoodbell.com)Lindamood Bell Learning Processes (www.lindamoodbell.com) Wilson Reading ProgramWilson Reading Program Orton Gillingham approachesOrton Gillingham approaches

Kindergarten children learn mostly through the auditory Kindergarten children learn mostly through the auditory modality, and learn best in an optimal acoustic environment.modality, and learn best in an optimal acoustic environment.

Academic success is dependent on reading success.Academic success is dependent on reading success. Reading failure a product largely of auditory processing and Reading failure a product largely of auditory processing and

phonemic awareness deficits.phonemic awareness deficits. Auditory processing and phonemic awareness deficits must be Auditory processing and phonemic awareness deficits must be

identified early through screening of all kindergarten children.identified early through screening of all kindergarten children. Early and intensive intervention for auditory processing and Early and intensive intervention for auditory processing and

phonemic awareness deficits is necessary reading and phonemic awareness deficits is necessary reading and academic success.academic success.

The Early Auditory Reading Success (EARS) Program:Assumptions

Developed at the University of Oregon (www.dibels.uoregon.edu)Developed at the University of Oregon (www.dibels.uoregon.edu) Required by Alachua County School System (and in state of Florida) to Required by Alachua County School System (and in state of Florida) to

monitor academic progress in kindergarten childrenmonitor academic progress in kindergarten children Four measures of reading reading skillsFour measures of reading reading skills

Initial sounds fluency (ISF)Initial sounds fluency (ISF)Letter naming fluency (LNF)Letter naming fluency (LNF)Phonemic segmentation fluency (PSF)Phonemic segmentation fluency (PSF)Nonsense word fluency (NSF)Nonsense word fluency (NSF)

Administered four times in kindergarten yearAdministered four times in kindergarten yearEarly fall semester (September)Early fall semester (September)Late fall semester (December)Late fall semester (December)Early spring semester (January)Early spring semester (January)Late spring semester (May)Late spring semester (May)

Literacy Outcome Measure:DIBELS (Dynamic Indicator of Early Literacy Skills)

DIBELS (Reading Readiness) Outcome in the Initial EARS Project (2002-2003)

DIBELS DIBELS EARS School EARS School Control School Control SchoolOutcomeOutcome EarlyEarly FinalFinal Final Final

N = 52N = 52 N = 63N = 63 N = 48 N = 48

DeficitDeficit 50%50% 27%27% 40% 40% EmergingEmerging 31%31% 22%22% 44% 44% EstablishedEstablished 19%19% 60%60% 16% 16%

Phonemic Awareness (sound/speech sound skills)Phonemic Awareness (sound/speech sound skills) Phonics (phoneme/grapheme skills)Phonics (phoneme/grapheme skills) FluencyFluency VocabularyVocabulary ComprehensionComprehension

EARS Program Rationale:Five Component Skills of Reading

Children diagnosed with hearing, cognitive, attention, or other Children diagnosed with hearing, cognitive, attention, or other deficits referred for appropriate managementdeficits referred for appropriate management

Intervention componentsIntervention componentsFM systems in each kindergarten classroomFM systems in each kindergarten classroomAll kindergarten students complete Earobics All kindergarten students complete Earobics Multi-sensory reading instruction strategies used by each Multi-sensory reading instruction strategies used by each

kindergarten teacherkindergarten teacherChildren diagnosed with APD and/or deficits in phonologic Children diagnosed with APD and/or deficits in phonologic

awareness receive intensive small group treatment by speech awareness receive intensive small group treatment by speech pathologistpathologist letter recognitionletter recognitionphonologic awarenessphonologic awarenessother basic reading skillsother basic reading skills

The Early Auditory Reading Success (EARS) Program:

Intervention based on screening outcome

Multiple Tiers of Reading Instruction Models: Conventional (e.g., Torgesen, 2005) vs. Early Intervention (EARS)

Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12Grade

Rea

din

g S

kill

s

Core Reading Program

Powerful Intensive Intervention

(Struggling Readers)

EARS Program

EARS Program (2005-2006): Early (Kindergarten) Intervention Program for At Risk Struggling Children

Core ReadingProgram(Tier 1)

All kindergarten children in Title I schools undergo

auditory and language screening

Intensive Intervention(Tier 3)

Small group inclusive instructionPre-reading skills

Phonologic awareness instruction

At risk?

Monitor Outcome(DIBELS)

National 70%ile?

Not at risk?

Phonologic Awareness Enhancement(Tier 2)

Classroom FM systemClassroom instruction

Earobics program

Early Auditory Reading Success (EARS):Final Outcome 2005 by DIBELS scores

(Williams Elementary School)

Nat

ion

al %

ile

Letter Sound Fluency

20

40

60

80

10096

9294

Phonemic Sequence Fluency

Nonsense Word Fluency

HR MR LR AA Est HR MR LR AA Est HR MR LR AA Est

Established 04

EARS: DIBELS National %ile rank in final test interval of First Grade for EARS participants (2005/2006)

40

21

57

38

0102030405060

OLV ReadingComp

EARS(n=180)

Control(n=143)

OLV Oral Language VocabularyReading Comp Reading Comprehension

The results of auditory processing can be used to determine The results of auditory processing can be used to determine children at risk for reading and academic failure.children at risk for reading and academic failure.

All kindergarten children in Title I schools benefit from All kindergarten children in Title I schools benefit from Adequate acoustic learning environment (classroom)Adequate acoustic learning environment (classroom)Enhancement of phonologic awareness instruction in by the Enhancement of phonologic awareness instruction in by the

classroom teacherclassroom teacherTherapy for auditory processing and pre-reading skills Therapy for auditory processing and pre-reading skills

(Earobics)(Earobics) Intensive intervention for auditory processing and phonologic Intensive intervention for auditory processing and phonologic

awareness deficits improves early literacy skills.awareness deficits improves early literacy skills. The EARS program offers effective early intervention for The EARS program offers effective early intervention for

kindergarten children at risk for reading failure.kindergarten children at risk for reading failure. To date, the benefits of EARS program for reading are To date, the benefits of EARS program for reading are

documented through 2documented through 2ndnd grade grade

The Early Auditory Reading Success (EARS) Program: Conclusions

MANAGEMENT OF APD: Facilitating academic achievement & success

I must be smart!

i’m lost in this class! what’s wrong with me? i just can’t hear right. auditory processing...

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