Auditory Processing Disorders - Mayo · PDF fileAuditory Processing Disorders ... APD = 2...

2/17/2012

1

The Functional Significance of Diagnostic TestsPrudence Allen, Ph.D.

National Centre for AudiologyWestern Ontario UniversityLondon, Ontario, Canada

pallen@uwo.ca

The Functional Significance of Diagnostic TestsPrudence Allen, Ph.D.

National Centre for AudiologyWestern Ontario UniversityLondon, Ontario, Canada

pallen@uwo.ca

Auditory Processing DisordersAuditory Processing Disorders

ContributorsContributors

StudentsStudents• Chris Allan, Ph.D.

• Udit Saxena

• Alejandra Mendoza

• Blake Butler

• Chris Allan, Ph.D.

• Udit Saxena

• Alejandra Mendoza

• Blake Butler

FundingFunding• Networks of Centres of

Excellence

• CIHR

• NSERC

• CFI

• ORF-RE

Children, their families, our clinical colleagues

• Networks of Centres of Excellence

• CIHR

• NSERC

• CFI

• ORF-RE

Children, their families, our clinical colleagues

2/17/2012

2

WHAT IS REQUIRED OF A CHILD’S AUDITORY SYSTEM?WHAT IS REQUIRED OF A CHILD’S AUDITORY SYSTEM?

Real World NeedsReal World Needs

• Recognize familiar sounds quickly

• Learn new sounds

• Tolerate noise and stimulus degradation

• Form auditory objects and position them in space

• Listen to one sound and ignore another

• Recognize familiar sounds quickly

• Learn new sounds

• Tolerate noise and stimulus degradation

• Form auditory objects and position them in space

• Listen to one sound and ignore another

2/17/2012

3

What is Required of the Auditory System?

What is Required of the Auditory System?

• Signals must be audible

• Basic acoustic processing (discrimination and resolution) must be good: spectral and temporal clarity

• Binaural hearing must be functioning

• Selective, sustained and focused attention must be good

• Many signals must be well learned and predictable

• Integrity of the auditory nervous system must be intact

• Signals must be audible

• Basic acoustic processing (discrimination and resolution) must be good: spectral and temporal clarity

• Binaural hearing must be functioning

• Selective, sustained and focused attention must be good

• Many signals must be well learned and predictable

• Integrity of the auditory nervous system must be intact

Perceptual DevelopmentPerceptual Development

• Factors• Quality of sensory encoding• Ability to attend to and explore that

encoded information• Prior experience and knowledge• Environment

• Most easily recognized stimuli are those that are familiar and well learned – why?

• Factors• Quality of sensory encoding• Ability to attend to and explore that

encoded information• Prior experience and knowledge• Environment

• Most easily recognized stimuli are those that are familiar and well learned – why?

Gibson, E.J. 2000Gibson, E.J. 2000

2/17/2012

4

Processes of Perceptual Development

Processes of Perceptual Development

• Neural patterns are reinforced in response to frequently occurring stimuli (imprinting)

• Allows for rapid perception even with degradation

• Increased control over attention – selective and sustained (attentional weighting)

• When coded with prior knowledge stimuli are strengthened and thus can be degraded (unitization)

• Over time a finer level of detail is perceived (differentiation)

• Neural patterns are reinforced in response to frequently occurring stimuli (imprinting)

• Allows for rapid perception even with degradation

• Increased control over attention – selective and sustained (attentional weighting)

• When coded with prior knowledge stimuli are strengthened and thus can be degraded (unitization)

• Over time a finer level of detail is perceived (differentiation)

Goldstone, R., 1998Goldstone, R., 1998

CURRENT CLINICAL ASSESSMENT BEYOND AUDIBILITY

CURRENT CLINICAL ASSESSMENT BEYOND AUDIBILITY

What do pediatric audiologists have to help them?What do pediatric audiologists have to help them?

2/17/2012

5

Auditory SkillsAuditory Skills

• Sound localization and lateralization

• Auditory discrimination

• Auditory pattern recognition

• Temporal resolution, masking, integration, and ordering

• Auditory performance decrements with competing or degraded signals

• Memory and attention

• Sound localization and lateralization

• Auditory discrimination

• Auditory pattern recognition

• Temporal resolution, masking, integration, and ordering

• Auditory performance decrements with competing or degraded signals

• Memory and attentionAsha, 2005Asha, 2005

Comprehensive Assessment Recommendations

Comprehensive Assessment Recommendations

• Thorough case history

• Non-standardized but systematic observation of auditory behavior (e.g. checklists)

• Behavioural evaluation of • Temporal process (ordering, discrimination, resolution

and integration)• Binaural processes (localization and lateralization)• Perception of low redundancy (filtered, compressed,

degraded) and dichotic speech

• Electrophysiologic evaluation

• Speech-language assessment

• Thorough case history

• Non-standardized but systematic observation of auditory behavior (e.g. checklists)

• Behavioural evaluation of • Temporal process (ordering, discrimination, resolution

and integration)• Binaural processes (localization and lateralization)• Perception of low redundancy (filtered, compressed,

degraded) and dichotic speech

• Electrophysiologic evaluation

• Speech-language assessment

2/17/2012

6

Clinical Practice, Emanuel et al., 2011, AJAClinical Practice,

Emanuel et al., 2011, AJA

Dichotic

• SSW - 144

• Digits – 115

• SCAN,CS – 100

• Competing Sentences – 91

Monaural low redundancy

• SCAN – AFG 101; FW 104

• Speech in Noise – 132

Dichotic

• SSW - 144

• Digits – 115

• SCAN,CS – 100

• Competing Sentences – 91

Monaural low redundancy

• SCAN – AFG 101; FW 104

• Speech in Noise – 132

Temporal Processing

• Pitch Pattern – 138

• Random Gap – 68

• Duration Pattern - 55

Binaural Interaction

• Binaural Fusion – 38

• MLD – 29

Electrophysiology

• ABR – 23

• MLR, Corticals - 13

Temporal Processing

• Pitch Pattern – 138

• Random Gap – 68

• Duration Pattern - 55

Binaural Interaction

• Binaural Fusion – 38

• MLD – 29

Electrophysiology

• ABR – 23

• MLR, Corticals - 13

Of the 195 respondents, # reporting use always or sometimesOf the 195 respondents, # reporting use always or sometimes

COGNITION, BRAINSTEM NEURAL INTEGRITY, DISCRIMINATION SKILLS, ETC.

COGNITION, BRAINSTEM NEURAL INTEGRITY, DISCRIMINATION SKILLS, ETC.

Our experiences with this battery…Our experiences with this battery…

2/17/2012

7

63 Children Referred for APD Evaluation

63 Children Referred for APD Evaluation

BehavioralBehavioral

Staggered Spondaic Word Test (SSW)

Auditory Fusion Test –Revised, a test of gap detection

Filtered Words

Pitch Pattern Sequence Test

Competing Words (words in noise)

APD = 2 tests > 2 sd below expectations

Staggered Spondaic Word Test (SSW)

Auditory Fusion Test –Revised, a test of gap detection

Filtered Words

Pitch Pattern Sequence Test

Competing Words (words in noise)

APD = 2 tests > 2 sd below expectations

ObjectiveObjective

Click evoked ABR at slow and fast rates

Acoustic Reflex Thresholds, ipsiand contra 500-2kHz

Also

Surveys

Cognitive Evaluation (Intelligence, academic achievement, language, phonology, memory, attention)

Click evoked ABR at slow and fast rates

Acoustic Reflex Thresholds, ipsiand contra 500-2kHz

Also

Surveys

Cognitive Evaluation (Intelligence, academic achievement, language, phonology, memory, attention)

Basis Auditory AbilitiesBasis Auditory Abilities

-10

0

10

20

23 Children with no APD diagnosis

-10

0

10

20250 500 1000 2000 4000 8000

40 Children with APD diagnosisRight Ear

Left Ear

80

85

90

95

100

Quiet Word Discrimination Score

Not APD

APD

Right Left

40 children met APD criteria23 did not40 children met APD criteria23 did not

2/17/2012

8

APD Test ResultsAPD Test Results

50556065707580859095

100

Per

cen

t C

orr

ect

Staggered Spondaic Word Test

Not APD

APD

0

10

20

30

40Thr

esho

ld (

ms)

Auditory Fusion Test - Revised

405060708090

100

ppsr ppsl wicr wicl fsl fsr

Per

cent

Cor

rect

Other Central Auditory Tests

RELATION TO COGNITIVE SKILLSRELATION TO COGNITIVE SKILLS

2/17/2012

9

Intelligence (WISC) & Achievement (WRAT)Intelligence (WISC) & Achievement (WRAT)

70

85

100

115

130S

tan

dar

d S

core Not APD

APD

Language (OWLS) & Phonology (CTOPP)Language (OWLS) & Phonology (CTOPP)

70

85

100

115

130

Sta

nd

ard

Sco

re

OWLS CTOPP

Not APD

APD

2/17/2012

10

Language Diagnosis By APD Diagnosis

Language Diagnosis By APD Diagnosis

0 20 40 60 80 100

Typically developing

Receptive

Expressive

Receptive andExpressive

Percent occurrence

APD

Not APD

Attention (TEA-Ch) and Memory (WRAML)

Attention (TEA-Ch) and Memory (WRAML)

4

7

10

13

16

Sta

nd

ard

Sco

re

WRAML

4

7

10

13

16

Sta

nd

ard

Sco

re

TEA-Ch Composite Scores

2/17/2012

11

RELATION TO OBJECTIVE MEASURES – BRAINSTEM NEURAL INTEGRITY

RELATION TO OBJECTIVE MEASURES – BRAINSTEM NEURAL INTEGRITY

Click ABR Wave Latencies:APD & Non-APD

Click ABR Wave Latencies:APD & Non-APD

1.0

2.0

3.0

4.0

5.0

6.0

7.0

5 10 15 20 25

Late

ncy

(ms)

Age (years)

Left ear

1.0

2.0

3.0

4.0

5.0

6.0

7.0

5 10 15 20 25

Late

ncy

(ms)

Age (years)

Right ear

2/17/2012

12

Wave I LatenciesAPD & Non-APD Wave I LatenciesAPD & Non-APD

1.00

1.50

2.00

2.50

5 10 15 20 25

Adults

Wave V latenciesAPD & Non-APD

Wave V latenciesAPD & Non-APD

5.00

5.20

5.40

5.60

5.80

6.00

6.20

6.40

5 10 15 20 25

Adults

2/17/2012

13

V/I Amplitude RatioAPD & Non-APD

V/I Amplitude RatioAPD & Non-APD

0.00

0.50

1.00

1.50

0.00 0.50 1.00 1.50

Wav

e V

am

plit

ud

e

Wave I amplitude

Acoustic ReflexesAPD & Non-APD

Acoustic ReflexesAPD & Non-APD

80

85

90

95

100

105

110

Ref

lex

Th

resh

old

2/17/2012

14

Ipsi-Contra Threshold Differences

APD & Non-APD

Ipsi-Contra Threshold Differences

APD & Non-APD

70

80

90

100

110

120

130

70 80 90 100 110 120 130

Ave

rag

e co

ntr

alat

eral

th

resh

old

Average ipsilateral threshold

RELATION TO SUPRA-THRESHOLD DISCRIMINATIONRELATION TO SUPRA-THRESHOLD DISCRIMINATION

2/17/2012

15

Frequency & Level Discrimination

APD & Non-APD

Frequency & Level Discrimination

APD & Non-APD

0

5

10

15

20

25

5 10 15 20Le

vel d

L(d

B)

Age (years)

Maxon & Hochberg(1982)

Jensen & Neff (1993)

He, Dubno & Mills(1998)

Berg & Boswell (2000)

1

10

100

1000

0 10 20 30

Fre

quen

cy d

L at

1 k

Hz

(Hz)

Age (years)

Jensen & Neff 1993

(Maxon & Hochberg, 1985

Freyman & Nelson, 1991

Temporal ResolutionAPD & Non-APD

Temporal ResolutionAPD & Non-APD

0

5

10

15

20

25

30

35

0 10 20 30

Gap

th

resh

old

(m

s)

Age (years)

Wightman, Allen, Dolan, Kistler, &Jamieson (1998)Irwin, Ball, Kay, Stillman, & Rosser (1985)

Fitzgibbons & Wightman (1982)

2/17/2012

16

Spectral ResolutionAPD & Non-APD

Spectral ResolutionAPD & Non-APD

40

50

60

70

80

0 10 20 30

Th

resh

old

(d

B S

PL

)

Age (years)

Flat

0 10 20 30Age (years)

Notched

Allen, Wightman,Kistler, & Dolan(1989)

Veloso, Hall, & Grose(1990)

Hall & Grose (1991)

Masking Level DifferenceAPD & Non-APD

Masking Level DifferenceAPD & Non-APD

02468

101214161820

6 11 16 21

S0N

0 -

SπN

0(d

B)

Age (Years)

MLD

25

30

35

40

45

50

55

25 30 35 40 45 50 55

SπN

0

S0N0

Thresholds

2/17/2012

17

TYPICALLY DEVELOPING CHILDREN AND THOSE WITH APD

TYPICALLY DEVELOPING CHILDREN AND THOSE WITH APD

Other projects using this diagnostic criterionOther projects using this diagnostic criterion

Speech Evoked ABR/ya/ with Rising and Falling

Intonation

Speech Evoked ABR/ya/ with Rising and Falling

Intonation

0.3

0.4

0.5

0.6

0.7

0.8

0.9

7 10 13 16 19

Pit

ch S

tren

gth

Age (years)

RISING

0.3

0.4

0.5

0.6

0.7

0.8

0.9

7 10 13 16 19

Pit

ch S

tren

gth

Age (years)

FALLING

2/17/2012

18

Follow Up: Acoustic Reflexes Growth Functions

Follow Up: Acoustic Reflexes Growth Functions

Factors causing shallower ARGF

a. Decreased static compliance

b. Retrocochlear, brainstem pathology

Factors causing shallower ARGF

a. Decreased static compliance

b. Retrocochlear, brainstem pathology y = 0.0068x + 0.029

y = 0.0072x + 0.056

y = 0.0136x + 0.038

0

0.05

0.1

0.15

0.2

0.25

0.3

0 5 10 15

Aco

ust

ic r

efle

x m

agn

itu

de

(in

mm

ho)

Stimulus intensity (in dB SL)

0.4 ml

0.6 ml

1.6 ml

Shallower Growth in Contralateral Reflexes for

Children with APD

Shallower Growth in Contralateral Reflexes for

Children with APD

2/17/2012

19

Inhibition of OAEsInhibition of OAEs

Butler et al., IJA, 2011Butler et al., IJA, 2011

Temporal Integration at Threshold

Temporal Integration at Threshold

Children with APDChildren with APD

05

1015202530354045

1 10 100 1000

Th

resh

old

(d

B D

PL

)

Signal duration (ms)

Adults & Typically developing childrenAdults & Typically developing children

05

1015202530354045

1 10 100 1000

Th

resh

old

(d

B S

PL

)

Signal duration (ms)

2/17/2012

20

REFLECTIONS ON OUR DIAGNOSTIC BATTERYREFLECTIONS ON OUR DIAGNOSTIC BATTERY

Summary and final commentsSummary and final comments

How Useful is a Diagnosis of APD Made Based Upon This

Conventional Battery?

How Useful is a Diagnosis of APD Made Based Upon This

Conventional Battery?

• Results only loosely related to the skills/abilities important to perceptual development.

• Co-morbidity with other disorders is going to be high.

• Underlying auditory neural integrity is often compromised, both with and without the diagnosis.

• Basic encoding abilities and often reduced, with and without the diagnosis.

• Results only loosely related to the skills/abilities important to perceptual development.

• Co-morbidity with other disorders is going to be high.

• Underlying auditory neural integrity is often compromised, both with and without the diagnosis.

• Basic encoding abilities and often reduced, with and without the diagnosis.