Embed Size (px)
Citation preview
2/17/2012
1
The Functional Significance of Diagnostic TestsPrudence Allen, Ph.D.
National Centre for AudiologyWestern Ontario UniversityLondon, Ontario, Canada
The Functional Significance of Diagnostic TestsPrudence Allen, Ph.D.
National Centre for AudiologyWestern Ontario UniversityLondon, Ontario, Canada
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.
