Auditory processing disorders - National Acoustic Laboratories · 12 ASHA (2005) “()APD is a deficit in neural processing of auditory stimuli that is not due to higher order language,

Perspectives on the Diagnosis and Remediation ofAuditory Processing Disorders

Harvey Dillon

National Acoustic Laboratories,

University of Manchester

Macquarie University

Hearing CRC

Helen Glyde

Sharon Cameron

Carhart Memorial LectureAmerican Auditory Society

ScottsdaleMarch 2018

Kiri Mealings

Dani Tomlin

Mark Seeto

Pia Gyldenkaerne

1

MridulaSharma

Tony Sirimanna

What you might remember• Listening difficulties have multiple causes, which can be quantified.

• Diagnosing the type(s) and extent of auditory processing disorder present requires quantitative control of the effects of memory, attention, intelligence and language on auditory processing tests.

• Deficit-specific treatment can be highly effective in removing auditory processing deficits.

• Research is needed to:

• Better understand cause and effect between auditory processing, language and cognition

intervention studies;

• Create differential tests that identify more specific types of auditory processing disorders;

• Create a more efficient (hierarchical, adaptive) test battery than currently exists.

2

Talk outlineConcepts

NAL / Macquarie / Melbourne

specific data

Literature meta-analysis

What clinicians can do nowWhat researchers could do

3

APD concepts and other disorders

4

Four “controversies”

5

Controversy 1: What do we call it?

6

APD by any other name ….. Central auditory processing disorder

Sullivan (1976)

Central auditory dysfunctionBerry & Blair (1976)

Obscure auditory dysfunction Saunders & Haggard (1989)

Central presbycusisStach et al (1990)

King-Kopetzy syndromeHinchliffe (1992)

Auditory neuropathyStarr et al 1996

Hidden hearing lossSchaette & McAlpine (2011)

Auditory disability with normal hearing Stephens and Rendell (1988)

Auditory dysacusisJayaram, Baguley & Moffat (1992)

Auditory inferiority complexByrne & Kerr (1987)

Selective dysacusisNarula & Mason (1988)

Auditory processing disorderJerger & Musiek (2000)

(Central) Auditory processing disorderASHA (2005)

1. Auditory perception poorer than expected from hearing thresholds2. Definition sufficiently broad to include diverse types of deficits

Two things in common:

Auditory perceptual disturbanceMyklebust (1954)

7

Controversy 2: Does APD exist?

8

Does APD exist?

3. When something does go wrong with the way the auditory

system processes the neural signals initiated by sound, what

would you like to call such a disorder?

Language disorder

Cognitive disorder

General developmental disorder

1. Do you believe the brain transmits and analyses neural

signals after they leave the cochlea, or does auditory

perception occur by magic?

2. Can anything ever go wrong with the way the brain

transmits and analyses neural signals initiated by sound, or is

the system infallible and develops properly in every person?

Kaas & Hackett (2000)9

APD, Cognition and Language Brenneman, Cash, Chermak, Guenette,

Masters, Musiek, Brown, Ceruti, Fitzegerald, Geissler, Gonzalez & Weihing (2017).

Cognitive abilities

Language abilities

Auditory processing

abilities

29% shared variance

23% shared variance

35% shared variance

10

Controversy 3: What abilities does APD encompass?

11

12

ASHA (2005)“(C)APD is a deficit in neural processing of auditory stimuli that is not due to higher orderlanguage, cognitive, or related factors."

"When I use a word,' Humpty Dumpty said in rather a scornful tone, 'it means just what I choose it to mean — neither more nor less."

"The question is," said Alice, "whether you can make words mean so many different things."

Moore, Ferguson et al (2010)“What is currently called APD, for individuals without known neurologic lesions, should be redefined as primarily a cognitive disorder, rather than a sensory disorder.”

Views on the meaning of APD from around the worldProfessional Society Definition Comment

ASHA (2005) A deficit in neural processing of auditory stimuli that is not due to higher order language,

cognitive, or related factors.

Cognition and language out

AAA (2010) Difficulties in the perceptual processing of auditory information. (C)APD is frequently

comorbid with related language, learning and cognitive disorders.


Danish Medical Audiological

Society (2014)

The efficiency with which the central nervous system uses received auditory information. Cognition and language out

Canadian Interorganizational

Steering Group (2012)

A persistent limitation in the performance of auditory activities that originates in the

auditory system and is not caused by loss of auditory acuity or disorders of language,

attention, memory or cognition.


Belgian International Bureau

for Audiophonology (20070

… difficulties in listening and intelligibility …..can be the consequence of … cognitive and

memory functions, but also the functions provided by central auditory pathways.


NAL – Australia (Dillon &

Cameron, 2015)

An Auditory Processing Disorder (APD) is a deficit in the way the neural representation of

sounds are processed by the brain, resulting in a distorted neural representation of the

auditory signal within the auditory nervous system.


BSA (2017) Poor perception of speech and non-speech. Origins include the CANS and neural processing

systems for language, reading, speech, attention, executive function, memory, emotion,

vision and action.

Cognition and language in

Dutch position statement

(2017)

Listening difficulties can be caused by both disturbed bottom-up processes (sensory

processing) and disturbed top-down processes (including cognition and language).

Cognition and language are the

most common problem in

listening difficulties

New Zealand (2017) Auditory processing disorder is a hearing disorder that results from atypical processing of

auditory information in the brain.

Doesn’t say

German (Nikissch et al, 2015) ???? ????13

Controversy 4: Need APD be unimodal?

14

Should APD be conceptualized as an auditory-specific disorder or as one aspect of a more generalized disorder?

Not a practically useful question!!!!

Deficit in auditory processing only

Child 1

Deficit in auditory processing+

Deficit in visual processing

Child 2

Give training to improve auditory skills in deficit

Improve input sound SNR

Manage or treat the other problem(s)

Identify the deficit

15

Four “controversies” dealt with

1. The name: APD, CAPD, or (C)APD?• Of course auditory processing happens in the cochlea

2. Does it exist?• Duh, yes!

3. Include or exclude deficits in cognition and language?• Excludes, by most definitions, but of course perception of speech needs

cognition and language as well

4. Limited to unimodal problems?• Not limited. Problems involving audition should be identified and helped,

irrespective of whether there are similar problems in other modalities

None are productive debates: more semantics than reality16

One test, multiple abilities

17

Deficits (various) in

auditory processing

Deficits (various) in language

Listening difficulties

Deficits (various) in cognition

Performance on tests of

APD

18

Deficits (various) in

auditory processing

Deficits (various) in language

Performance on tests of

APD

Deficits (various) in cognition

19

Example of a test that tests multiple abilities

• Dichotic digits test – Musiek (1983) - 293 citations

• Easy to administer and score

• Often failed by children seeking APD assessment

• In many, many test batteries, including Australian Hearing

20

1, 82, 4

1, 2, 4, 8

21

Dichotic Free Recall Paradigm

2, 41, 8

2, 41, 8

2,4,1,8

22

Diotic Paradigm

Dichotic Digits difference Test

Dichotic versus diotic

(%)

30 40 50 60 70 80 90 100

Dichotic free recall (%)

30

40

50

60

70

80

90

100

Dio

tic

(%)

Clinic

School

r = 0.82

23

Correlations with

cognition

Free recall dichotic

Attention (prudence)

Attention (vigilence)

Forward digit span

Reverse digit span

Non-verbal IQ

0.31

0.21

0.53

0.36

0.27

25

Diotic

Attention (prudence)

Attention (vigilence)

Forward digit span

Reverse digit span

Non-verbal IQ

0.26

0.15

0.52

0.42

0.24

26

Correlations with cognition

Dichotic scores and memory

27

-3 -2 -1 0 1 2 3

Number memory forward (z score)

-5

-4

-3

-2

-1

0

1

2

3

Dic

hotic fre

e r

ecall

(z s

core

)

Clinic School

The normal range!

R=0.60

Accounting for

variance

Dichotic test scoresMemory

Other non-dichotic

factors

9%

Dichotic factors

Random measurement

error

27%

64%64%

+27%91%

28

.. And then there’s attention!

Fig 1 from Stavrinos (2018) 29

Dichotic tests

Testing cognitive

ability

Application to brain-

lesion patients

Information about

hemisphere differences

Application to auditory processing

disorder patients

Inferences about

auditory processing

• Selective attention

• Working memory

• Executive function

• Aging

• Mental Retardation

30

Brain “lesions” in Central Auditory Nervous System

CauseLow dichotic test scores

Cognitive deficits

Indicate

31

What not to do in “sensitising” a test

Problem: A test gives ceiling performance for too many people

Usual solution: Make the test harder by demanding additional skills:• dichotic digits – make it two pairs, or three pairs memory ↑• speech tests – low-pass filter it vocabulary ↑, phonetic awareness ↑

Result: Scores decrease below ceiling, but cause become uncertain

An alternative: Adaptively change inter-aural level

32

Diagnosing auditory processing disorders

33

Disentangling the disorders

Cognitive disorder

Auditory processing

disorder

Language disorder0

5

10

15

20

25

30

35

20

00

20

01

20

02

20

03

20

04

20

05

20

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20

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20

09

20

10

20

11

20

12

20

13

20

14

20

15

20

16

20

17

Year

Publications per year

34

Relation between APD and Attention Disorder

35

Auditory attention disorder

51

Auditory processing

disorder

58

24 1734

26

No disorder

101 children with listening difficulties

Gyldenkaerne, Dillon, Sharma and Purdy (2014); JAAA.

“How strong are the deficits in each of: cognition,

auditory processing, and language”

Instead of “What disorder(s) does this person have” ….

With a common unit of measure!36

Suspected Auditory Processing

Disorder

Suspected Cognitive Disorder

Suspected Language Disorder

Reported

Bornstein & Musiek (1992)

Vanniasegaram, Cohen & Rosen (2004)

Dawes, Bishop, Sirimanna, Bamiou (2008)

Sharma, Purdy & Kelly (2009)

Rosen, Cohen, Vanniasegaram (2010)

Umat, Mukari, Ezan & Din (2011)

Ahmed, Ahmed, Bath, Ferguson, Plack & Moore (2014)

Gyldenkaerne, Dillon, Sharma, Purdy (2014)

Boothalingam, Allan, Allen & Purcell (2015)

Saxena, Allan & Allen (2015)

Ahmed & Ahmed (2016)

Neijenhuis, de Wit, Luinge (2017)


37

Auditory Processing Deficits

Cognitive Deficits

Language Deficits

Reported

Dawes, Bishop, Sirimanna, Bamiou (2008): “Children diagnosed with APD reported similar symptoms and similarly had high rates of co-morbid learning problems”.


3838

Noise Quiet Ideal Multiple Memory Attn Span

PROBLEM

-3.5

-3.0

-2.5

-2.0

-1.5

-1.0

-0.5

0.0

CH

AP

S s

co

res (

pare

nts

)

No APD

APD issues

APD diagnosed

Parents Teachers

Noise Quiet Ideal Multiple Memory Attn Span

PROBLEM

-3.5

-3.0

-2.5

-2.0

-1.5

-1.0

-0.5

0.0

CH

AP

S s

co

re (

teache

rs)

No APD

APD issues

APD diagnosed

CHAPS questionnaire results – Great Ormond Street APD Clinic, London

39

Slightly more

difficulty

More difficulty

Considerably more

difficulty

Same difficulty

CHildren’sAuditory Performance Scale

Speech understanding –what could go wrong?

Auditory processing

• Auditory filtering• Envelope analysis• Temporal fine structure• Spatial analysis

Complexsignals

analysed

Speech processing

• Comparison to stored templates (phonemes, syllables or words)

Phonemes, syllables or

words identified

Auditory (speech)

input

Noise

Spatial cues

Rate

Reverb

Phonemic and lexical neighbourhood

density

Language processing

Under-standing

• Morphology knowledge• Syntactic knowledge• Semantic knowledge• Prosody knowledge• Working memory• World knowledge

Syntactic cues

Semantic cues

Prosodic cues

Message length

SNR

Perc

ent

u

nd

ers

tan

din

g

Attention,Memory

Degrade the input

These enable auditory closure

40

Speech recognition – what has gone wrong?

Auditory processing Speech processing Language processing

• Auditory filtering• Envelope analysis• Temporal fine structure• Spatial analysis• Pitch contour analysis


ComplexSignals

analysed


words identified

Under-standing

Auditory (speech)

input

Spatial cues

NoiseReverb

Rate


Syntactic cues

Semantic cues

Prosodic cues

Message length

Test of auditory processing

Test of auditory and speech processing

Test of auditory and speech and language processing

Attention,Memory


density

41

Observations in relation to model• APD should be able to cause poor speech perception and language delay

(imagine consequences of a complete APD).

• Listening difficulties can be caused by any of auditory processing, speech processing, language processing or cognitive deficits, either alone or in combination.

• A deficit in language processing or auditory/speech processing can be expressed as an equivalent SNR loss

Auditory processing

Speech processing

Language processing



ComplexSignals

analysed


words identified

Under-standing

Auditory (speech)

input

Spatial cues

NoiseReverb

Rate


Syntactic cues

Semantic cues

Prosodic cues

Message length

Attention,Memory

Phonemic and lexical neighbourhood density

What to remediate

42

5

10

15

20

25

30

35

40

45

50

55

60

Age

-28

-26

-24

-22

-20

-18

-16

-14

-12

-10

-8

-6

-4

-2

Sp

ee

ch

re

ce

ptio

n t

hre

sh

old

(d

B S

NR

)

Importance of SNR: 1. Age

1.3 dB/year

Sound Scouts LiSN-S

5 10 15 20 25 30 35 40 45 50 55 60 65

Age

-22

-20

-18

-16

-14

-12

-10

-8

Hig

h C

ue

SR

T

1.0 dB/year

Sentences in competing babble

LiSN-U

5 6 7 8 9 10 11 12 13 14 15

Age

-20

-15

-10

-5

0

5

10

SR

T (

SV

90)

dB

2.4 dB/year

Nonsense syllables in competing nonsense syllables

6 y.o. re adult: 11 dB 6 dB 10 dB 43

Importance of SNR: 2. Hearing loss or APD

Condition Effect Increase in SRT

Mild hearing loss (35 dB 4FAHL)

1 dB increase for each 10 dB of 4FAHL above 5 dB

+3 dB

Spatial processing disorder

Same-age population standard deviation is 1.6 dB

+3.2 dB

Conclusion: A 6 year old, with mild hearing loss, or spatial processing disorder just outside normal limits needs 3 + 9 =12 dB better SNR than an average adult.

SNR = -4 dB SNR = -14 dB

44

How do we find the specific deficit(s)?

So, top-level testing to find the strength of deficit

in each area, but ….

45

How do we find the specific deficit(s) causing listening difficulties?

1. Differential testing

• DDdT (Dichotic digits difference test, Cameron et al, 2016)

• SPIN (Speech in noise test; Kalikow, Stevens & Elliott, 1977)

• LiSN-S (Listening in spatialized noise sentences test, Cameron & Dillon, 2007)

2. Allow for other abilities that affect test scores (just like we allow for age)

3. Use tests that rely only minimally on other abilities

46

Differential testing (e.g. SPIN – Kalikow, Stevens & Elliot, 1977)




ComplexSignals

analysed


words identified

Under-standing

Auditory (speech)

input

Spatial cues

NoiseReverb

Rate


Syntactic cues

Semantic cues

Prosodic cues

Message length

Attention,Memory


density

Test of auditory and speech and language processing (with semantic cues) SRT1

Test of auditory and speech and language processing (with no semantic cues) SRT2

∆SRT = SRT2 - SRT1

47

Pichora-Fuller (2008)

Diagnosing spatial processing disorder with the

Listening in Spatialized Noise Sentences (LiSN-S) test

SPD

APD

48

DisclosureLicensed to Phonak

Same

Direction

Different

Directions

Different Voices

Four LiSN-S Conditions

Same Voice

T

D1

D2

TD1 D2TD1 D2

Low

Cue

SRT

Sp

atia

l Ad

va

nta

ge

Talker Advantage

D1

D2

T

High

Cue

SRT

49

Difference measures !

6 7 8 9

10

11

12

-13

14

-15

16

-17

18

-19

20

-24

25

-29

30

-39

40

-49

50

-60Age Group

8

9

10

11

12

13

14

15

16

17

18

Spatia

l Advanta

ge (d

B)

Spatial Advantage (≡ Spatial Release from Masking)

Bett

er

Australia

Nth America

50

LiSN-S results profile: spatial processing disorder

51

SusCAPD Group

PP

S (

RE

)

PP

S (

LE

)

DD

(R

E)

DD

(LE

)

RG

DT

MLD

LC

SN

R

HC

SN

R

Talk

er

Adv

Spatial A

dv

Tota

l A

dv

-12

-10

-8

-6

-4

-2

0

2

4

6

Devia

tion f

rom

Mean N

orm

al P

erf

orm

ance

Median 25%-75% Min-Max

Cameron & Dillon (2008)

LiSN-S vs.Traditional Battery

52

Link between SPD and

Chronic Otitis Media (COM)

53

Link between SPD

and

Chronic Otitis Media (COM)

54

SPD and chronic otitis media (COM)

• 50% of children (24/49) diagnosed with SPD at NAL reported (unsolicited) a history of COM. (Dillon et al., 2012).

• 18% of children (18/82) previously diagnosed with COM at University of Melbourne were diagnosed with SPD. (Graydon et al., 2017).

• Degree of spatial loss at primary school age increases with degree of threshold elevationdue to COM in infancy. (Graydon et al, 2015)

• Spatial processing deficit worse for early onset age and longer duration of COM (n=35; Tomlin & Rance, 2014).

• 6 yo children with history of COM have below average spatial advantage (n=17; z= -1.0) (Kapadia et al, 2012).

• 13-17 yo adolescents with history of COM have below average spatial advantage (n=20; z= -0.75) (Kapadia et al, 2014).

• 10% of a population sample (9/90) of Aboriginal children from remote Australia diagnosed with SPD. (Unpublished data).

• 7% of a population sample (10/144) of Aboriginal children from regional Australia diagnosed with SPD. (Cameron et al., 2014).

Spatial Processing Disorder –

• Know its major cause

• Can diagnose it, unrelated to cognitive ability

• Have extensive normative and reliability data

• Can remediate it (blinded, randomized trial)

• Remediation generalizes to real life

55

SPD

APD

Unique amongst forms of APD because we:

Not all differential tests give immunity from cognitive deficits!

Right ear advantage in dichotic tests

56

An analogy

3+4

?

3,148-1,659

?

Percent correct

Cognitive resources applied to task

0%

100%

57

An analogy

Right

Left

Percent correct

Cognitive resources applied to task

100%

0%

58


1. Differential testing• DDdT

• SPIN

• LiSN-S


3. Use tests that rely only minimally on other abilities

59

A common recommendation:

Multi-disciplinary evaluation

Practicality!

60

Allowing for related abilities

APD test z-score = AP ability + c.(memory) + d.(attention)

Therefore:

AP ability = APD test z-score – c.(memory) – d.(attention)

61


62

-3 -2 -1 0 1 2 3


-5

-4

-3

-2

-1

0

1

2

3

Dic

hotic fre

e r

ecall

(z s

core

)

Clinic School


63

-3 -2 -1 0 1 2 3


-5

-4

-3

-2

-1

0

1

2

3

Dic

hotic fre

e r

ecall

(z s

core

)

Clinic School

Allowing for related abilities

AP ability = APD test z-score – c.(memory) – d.(attention)

But …….• Which type of “memory”?

• Echoic• Working memory

• Which type of attention?• Sustained?• Switching?• Selective?

• What are the values of c and d for each auditory processing test?

• Are the effects of memory and attention linear or non-linear?

• How accurately do we need to know memory and attention?

• Do we need to add non-verbal IQ or language ability to the modifiers?

Memory z-score

AP ability

Attention z-score

Language z-score

Non-verbal IQ

64

Cognitive ability (of some sort)

Au

dit

ory

pro

cess

ing

test

sco

re

65

But which cognitive or language abilities affect which auditory

processing tests?

66

Correlations !

0

-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1

320

20

40

80

160

1000

Correlation coefficient

67

Ahmed (2017)Ahmed & Ahmed (2016)Brenneman et al (2017)Cameron et al (in prep)Cameron et al (2015)

Cameron et al (2016)Gyldenkaerne et al (2014)Harris et al (1983)Maerlander (2010)Maerlander et al (2004)

Riccio et al (2005)Dillon & Sirimanna (2014)Sharma et al (2009)Stavrinos et al (2018)Tomlin et al (2015)

Weihing et al (2015)Wilson et al (2011)

NVIQ NMF NMR NMF+NMR Prudence VigilanceDiv Aud Tten

Vis Sus Atten DDT-L DDT-R DDT-Avg FPT SSW MLD

RGDT or GIN

Filtered words (Scan)

Competing words (Scan)

Competing sentences (Scan) AFG (Scan) VCV LiSN-S HC

LiSN-S Spat Adv

WARP or TOWRE

Combined reported listening CHAPS SIFTER Life Fishers CCC-2 SLI CCC-2 PLI CCC-2 GCC

Receptive language (CELF-4)

Expressive language (CELF-4)

Overall academic ability

NVIQ 1.00 0.27 0.32 0.19 0.28 0.25 0.27 0.31 0.16 0.36 0.38 0.09 0.12 -0.04 -0.03 -0.02 0.09 -0.08 0.22 0.08 0.34 0.40 0.21 0.24 0.60

NMF 0.27 1.00 0.45 0.86 0.18 0.15 0.07 0.32 0.27 0.37 0.31 0.16 0.12 0.04 0.09 0.15 -0.01 0.44 0.24 0.08 0.06 0.03 0.29 0.44

NMR 0.32 0.45 1.00 0.83 0.22 0.26 0.26 0.26 0.22 0.31 0.35 -0.05 0.04 0.11 0.21 0.16 0.02 0.53 0.36 0.26 0.27 0.07 0.36 0.59

NMF+NMR 0.19 0.86 0.83 1.00 0.29 0.19 0.32 0.27 0.40 0.35 0.06 0.08 0.20 0.34 0.33 0.15 0.22 0.18 0.01 0.47 0.35 0.24 0.17 0.43 0.59

Prudence 0.28 0.18 0.22 1.00 0.54 0.37 0.22 0.36 0.18 0.42 0.55 0.49 0.12 -0.08

Vigilance 0.25 0.15 0.26 0.29 0.54 1.00 0.76 0.62 0.25 0.22 0.26 0.33 0.21 0.02 0.17 -0.10 0.01 -0.17 0.12 0.07 0.39 0.31 0.19 0.22 0.53 0.16 0.15 0.03 0.31

Div Aud Tten 0.76 1.00 0.68 0.08 -0.03 0.66 0.24

Vis Sus Atten 0.27 0.07 0.26 0.19 0.62 1.00 0.24 0.20 0.22 0.19 0.07 -0.01 0.00 0.01 0.30 0.20 0.18 0.16 0.28

DDT-L 0.31 0.32 0.26 0.32 0.37 0.25 0.24 1.00 0.47 0.85 0.37 -0.02 0.13 0.20 0.36 0.17 0.21 0.29 0.21 0.18 0.24 0.11 0.31 0.06 0.18 0.48

DDT-R 0.16 0.27 0.22 0.27 0.22 0.22 0.20 0.47 1.00 0.76 0.29 -0.04 0.11 0.20 0.32 0.17 0.18 0.20 0.34 0.09 0.15 0.08 0.31 0.16 0.33 0.36

DDT-Avg 0.36 0.37 0.31 0.40 0.36 0.26 0.68 0.22 0.85 0.76 1.00 0.36 -0.11 0.09 0.18 0.18 0.41 0.32 0.11 0.38 0.00 0.19 0.52

FPT 0.38 0.31 0.35 0.35 0.33 0.19 0.37 0.29 0.36 1.00 -0.02 0.25 0.21 0.26 0.12 0.12 0.36 0.20 0.11 0.14 0.01 0.21 0.34 0.30 0.39

SSW 0.18 0.21 1.00 0.64 0.57 0.26

MLD 0.09 0.16 -0.05 0.06 0.02 0.07 -0.02 -0.04 -0.11 -0.02 1.00 0.01 -0.08 0.02 -0.03 -0.14 -0.07 -0.05 0.21 0.07 0.08

RGDT or GIN 0.12 0.12 0.04 0.08 0.17 -0.01 0.13 0.11 0.09 0.25 0.01 1.00 0.13 0.18 0.30 0.10 -0.07 0.12 0.03 0.05 0.07

Filtered words (Scan) -0.04 0.04 0.11 0.20 0.42 -0.10 0.20 0.20 0.21 0.64 1.00 0.35 0.33 0.38 0.20 0.08 0.20 0.19 0.11

Competing words (Scan) -0.03 0.34 0.55 0.01 0.57 0.35 1.00 0.48 0.32 0.21 0.21 0.15 0.10

Competing sentences (Scan) -0.02 0.09 0.21 0.33 0.36 0.32 0.26 0.33 0.48 1.00 0.26 0.25 0.17 0.19 0.14 0.07 0.25 0.25

AFG (Scan) 0.09 0.15 0.49 -0.17 0.26 0.38 0.32 0.26 1.00 0.14 0.00 0.13

VCV -0.08 0.22 0.20 0.21 0.25 0.14 1.00 0.28

LiSN-S HC 0.22 0.15 0.16 0.18 0.12 0.08 0.00 0.17 0.17 0.18 0.12 -0.08 0.13 1.00 0.35 0.34 0.20 0.27 0.08 0.24 -0.15 0.15

LiSN-S Spat Adv 0.08 -0.01 0.02 0.01 0.07 -0.03 0.01 0.21 0.18 0.18 0.12 0.02 0.18 0.35 1.00 0.12 0.07 0.03 0.08 0.09 -0.01 0.03

WARP or TOWRE 0.34 0.44 0.53 0.47 0.39 0.30 0.29 0.20 0.41 0.36 -0.03 0.30 0.08 0.21 0.17 0.00 0.34 0.12 1.00 0.54 0.13 0.30 0.38 0.67

Combined reported listening 0.40 0.24 0.36 0.35 0.31 0.20 0.21 0.34 0.32 0.20 -0.14 0.10 0.20 0.07 0.54 1.00 0.62 0.80 0.62

CHAPS 0.08 0.26 0.24 0.18 0.09 0.11 0.20 0.15 0.19 0.28 0.13 1.00 0.66

SIFTER 0.06 0.27 0.24 0.15 0.14 0.19 0.14 0.66 1.00

Life 0.21 0.03 0.07 0.17 0.12 0.19 0.18 0.11 0.08 0.11 0.01 -0.07 -0.07 0.27 0.03 0.30 0.62 1.00 0.14 0.29

Fishers 0.24 0.29 0.36 0.43 -0.08 0.22 0.16 0.31 0.31 0.38 0.21 -0.05 0.12 0.08 0.08 0.38 0.80 0.14 1.00 0.56

CCC-2 SLI 0.53 0.66 0.24 0.09 1.00 0.59

CCC-2 PLI 0.15 0.24 -0.15 -0.01 0.59 1.00

CCC-2 GCC 0.11 0.10 0.07 0.13 1.00

Receptive language (CELF-4) 0.15 0.06 0.16 0.00 0.34 0.21 0.03 0.25 1.00

Expressive language (CELF-4) 0.03 0.18 0.33 0.19 0.30 0.07 0.05 0.25 1.00

Overall academic ability 0.60 0.44 0.59 0.59 0.31 0.28 0.48 0.36 0.52 0.39 0.08 0.07 0.15 0.03 0.67 0.62 0.29 0.56 1.00

Cognitive(NVIQ, memory, attention)

APD(dichotic, non-speech)

APD (speech tests)

Outcomes(reading, questionnaires, language)

68

DDTavg

FPT

GIN

LiSNSA

MemavgAttenavg

NVIQ

NMF

NMR

Prudence VigilanceDivided aud

attention

DDT-L

DDT-R

SSW

LiSNHC

Visual attention

CW

CS

FW

AFG VCV

Language ability

Reported Listening

ability

Academic or reading

ability

Speech in noise

MLD

69

DDTavg

FPT

GIN

LiSNSA

MemavgAtten

NVIQ

CW

CS

FW

Reported Listening

ability

Academic or reading

ability

Speech in noise

MLD

0.1

0.2

0.3

0.4

0.5

Correlation Scale

Observed correlations

70

FPT

GIN

LiSNSA

NVIQNMF NMR

Prudence Vigilance

DDT-L

DDT-R

LiSNHC

Visual attention

CW

CS

FWAFG

VCV

Listeningability

LIFEFishersSIFTER

CHAPS

Constrained SEM Model

71

Atten

0.1

0.2

0.3

0.4

0.5

Path strength scale

FPT

GIN

LiSNSA

NVIQNMF NMR

Prudence Vigilance

DDT-L

DDT-R

LiSNHC

Visual attention

CW

CS

FWAFG

VCV

Constrained SEM Model

72

Atten

Reading ability


1. Differential testing• DDdT

• SPIN

• LiSN-S


3. Use tests that rely only minimally on other abilities • LiSN-U

73

Speech without language?




ComplexSignals analysed


words identified UnderstandingAuditory (speech)

input

Spatial cues

NoiseReverb

Rate


density


Syntactic cues

Semantic cues

Prosodic cues

Message length

Auditory and speech processing

Attention,Memory 74

LiSN-U

Listening in SpatialisedNoise -Universal

75

LiSN-U

Listening in SpatialisedNoise -Universal

76

LiSN-U preliminary

data

(Test still under development)

-22 -20 -18 -16 -14 -12 -10 -8 -6 -4 -2 0 2 4

LiSN-S High Cue SRT (dB)

-20

-18

-16

-14

-12

-10

-8

-6

-4

-2

0

2

4

6

8

LiS

N-U

SV

90 S

RT

(dB

)

R=0.70

77

Building an assessment battery

78

79

Traditional approach to APD testing

History Audiometry

Is there a problemthat APD

might explain?

Exclude APD;Refer elsewhere

No

Test result interpretation & diagnosisNon-specific remediation and management:• Classroom placement• FM use• Instruction style• Soundfield amplification• Auditory training

Detailed test battery

Yes

Caveats:

1. Diagnosis may be needed to get the funding needed for management

2. Diagnosis may help teachers and/or parents “understand” reason for problems

Deficit-specific remediation

Why diagnose APD at all?

To Manage it?

To Treat it?

(i.e. remediate, cure)

To Compensate for it?

(i.e. train some useful skill)

80

Hierarchical assessment




ComplexSignals

analysed


words identified

Under-standing

Auditory (speech)

input

Spatial cues

NoiseReverb

Rate


Syntactic cues

Semantic cues

Prosodic cues

Message length

Test of auditory processing

Test of auditory and speech processing

Test of auditory and speech and language processing

Attention,Memory


density

81

Cognitive abilities

Speech under-standing

Speech sound recognition

Action

Good Good Good None

Good Good X Should not occur

Good X Good Language testing & intervention

Good X X Auditory processing testing & intervention

X Good Good Should not occur

X Good X Should not occur

X X Good Cognitive testing & intervention

X X X Cognitive testing & intervention

Dealing with listening difficulties

Questionnaire / history

Audiometry

Measure of attention

Language testing &

interventions

Auditory processing

testing

Measure of speech understanding in noise

(TOLD-U)

No auditory problem

Measure of speech sound recognition in noise

(~ LiSN-U)

Measure of working memory

Evaluate resultsCognitive testing &

interventions

82


Audiometry



Language testing &

interventions

Auditory processing

testing


(TOLD-U)

No auditory problem

?


(~ LiSN-U)



interventions

Temporo-frequency resolution

Time

Freq

uen

cy

Time

Freq

uen

cy

Gap detection

Time

Freq

uen

cy

Order detection

Time

Freq

uen

cy

Localization

Dichotic

Spatial processing

Time

Freq

uen

cyFPT DPT

PIT

GIN, RGDT, ParSE

LiSN

83


Audiometry


Non-specific remediation and management:• Classroom placement• FM use• Instruction style• Soundfield amplification


(TOLD-U)


(~ LiSN-U)

No auditory problem




interventions

Language testing &

interventions

Auditory processing & interventions


Time

Freq

uen

cy

Time

Freq

uen

cy

Gap detection

Time

Freq

uen

cyOrder detection

Time

Freq

uen

cy

Localization

Dichotic

Spatial processing

Deficit-specific remediation

84

Criteria for selecting an assessment test

1. Established test validity, meaning that scores below the cut-off value chosen are usually associated with listening problems in real life.

2. Adequate normative data and information on retest reliability and critical differences.

3. Minimal or controlled effects of memory, attention and non-verbal intelligence

4. The existence of remediation options specific to the deficit revealed by the test, and for which evidence of benefit in real-life exists.

5. Affected by known lesions in the brainstem or auditory cortex.

85

University of MelbourneSPD: 3 / 105

3%

Tomlin et al (2015)

Auditory Processing

Deficits

Cognitive Deficits

Language Deficits

ReportedListening difficulties?

? ?

Australian HearingSPD: 130 / 666

20%

Cameron et al (2015)

P=0.000 000 000 000 1

Are listening difficulties mostly: Language, Auditory processing, or Cognition ?

86

Questionnaires

?87

Child fails to understand

an instruction

Event

Acts (inappropriately) based on what

was heard

Asks for repetition of instruction

Does nothing

Misbehaves

Response by child

Interpretation by observer

Daydreams

Badly behaved

Can’t follow instructions

Is not very smart

Poor concentration

88

Questionnaires (or other ways to gather symptoms) might be able to confirm there is a problem, but can’t tell us the cause.

Diagnosing APD by symptoms?

Cognition

Language

Auditory processing

Questionnaires (self-report, other-report)

89

APDQ

BMQQ

CHAPS

CHILD

CCC-2

FAPC

LIFE

SAB

SIFTER

TEAP

TLI

ECLiPS

90

The Auditory Processing Domains

Questionnaire

O’Hara and Mealings (submitted)

50 items, 3 scales

AttentionLanguage abilities

Auditory processing abilities

Separation of groups using the attention and auditory processing scalesAPDQ.NAL.gov.au

Att

enti

on

Auditory processingA

tten

tio

nAuditory processing

Electrophysiology testing

Yes, probably!

92

Remediation of auditory processing disorders

1. Deficit-specific training

2. Generalised auditory trainingManagement by improved SNR

+

93

LISN & Learn Game

Target at 0˚:

94

Target: The horse kicked six wet shoes

95

LiSN & Learn – Preliminary Study

• 9 children with SPD (6 to 11 years)

• LiSN & Learn – 2 games/day, 5 days/week, 12 weeks

LiS

N&

Le

arn

SR

T (

dB

)

Bett

er

Game Number

10 dB

Cameron & Dillon (2011)

Average SRT

First vs Last 30 Days

p = 0.000052

96

Experiment 1: Effect of training on LiSN-S scores

Low cue

High Cue

Talker advantage

Spatial advantage

Total advantage

LiSN-S scale

-3.0

-2.5

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

LiS

N-S

sco

re (p

op

n S

D u

nits

)

Pre

Post

Follow-up

97

Experiment 2: Blinded randomized controlled trial

Earobics (n = 5) Lisn & Learn (n = 5)

98 Cameron, Glyde & Dillon (2012)

p = 0.5 to 0.7 p = 0.03 to 0.0008

Questionnaire results

Parents Children

L.I.F.E. Student pre L.I.F.E. student post

TIME

40

60

80

100

120

140

160

180

200

DV

_1

Group L&L

Group Earobics

L&L Earobics

Group

-10

-5

0

5

10

15

20

25

30

35L

.I.F

.E T

ea

che

r p

ost

Fisher pre Fisher post

TIME

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

DV

_1

Group L&L

Group Earobics

Parents Children

Teachers

99

Effectiveness of remediationCameron & Dillon (2011)Cameron et al (2012)Cameron et al (2014)Cameron et al (2015)Graydon et al (2018)

Necessary steps to show that remediation is effective

• Test scores increase

• Increase in test scores is not due to:• Practice effects on the test known test-retest statistics

• Regression to the mean double baseline testing

• Placebo effect randomized controlled trial

• Increase in age age-adjusted scores, control group

• Similarity of training to test independent outcome test

• Improved listening ability generalizes to real life, evidenced by• Speech understanding in realistic acoustic conditions, and/or

• Self-report or others-report

100

Research suggestions

101

1. Universal test of listening difficulties

Test must require:• All the signal analysis skills needed to identify speech

• Attention, working memory and language skills needed to understand speech

Test could comprise:• Sentence material, with syntactic, semantic & prosodic cues available

• Competing talkers, spatially separated from target

• Fast speaking rate

• Reverberation (typical amount)




ComplexSignals analysed


words identified Under-standingAuditory (speech)

input

Spatial cues

NoiseReverb

Rate

• Linguistic knowledge• Morphology knowledge• Syntactic knowledge• Semantic knowledge• Prosody knowledge• Working memory• World knowledge

Syntactic cues

Semantic cues

Prosodic cues

Message length

Attention,Memory

Phonemic and lexical neighbourhood density

Test of Listening Difficulties – Universal (ToLD-U)Auditory, speech and language processing (Told-U)

102

2. Objective versus subjective assessment of listening difficulties

Test of speech understanding

(ToLD-U)

Self- or parent report(APDQ, ECLiPS)

Electrophysiological measure

(cABR, CAEP in noise,)

103

3. Create and norm new adaptive tests (where needed)


Time

Freq

uen

cy

Time

Freq

uen

cyGap detection

Time

Freq

uen

cyOrder detection

Time

Freq

uen

cy

Localization

Dichotic

Spatial processing

104

4. Which types of auditory processing deficits correlate with poor speech perception and listening difficulties?


Time

Freq

uen

cy

Time

Freq

uen

cyGap detection

Time

Freq

uen

cyOrder detection

Time

Freq

uen

cy

Localization

Dichotic

Spatial processing

Test of speech understanding

(ToLD-U)

Self- or parent report

(APDQ, ECLiPS)

105

5. Correcting AP test results for cognition and language• Determine impact of memory and attention

(and IQ and language) on each age-corrected test.

• Derive corrections needed for each APD test in battery.

Memory z-score

AP ability

Attention z-score

Language z-score

Non-verbal IQ

AP2

AP5

AP6

AP8

Memavg AttenavgNVIQ

AP1

AP3

AP4

AP7correlation and slope!

106

Causation …….. unknown

Cognitive abilities

Language abilities

Auditory processing

abilities

Academic abilities

Reported listening ability

107

6. What is the effect of cognitive vs auditory training?

Auditory processing score

Memory score

Attention score

Listening difficulty score

Auditory processing score

Memory score

Attention score

Listening difficulty score

Language training

Does Cog APD, or APD Cog, or something else cause both?

Ditto for language training

108

7. Miscellaneous ideas

• Create a clinical test of backward masking, and measure normative performance and performance in kids with SLI.

• Create a sensitive dichotic test without challenging memory or executive function

• Compare behavioural results to electrophysiological results for stimuli chosen to expose specific deficits & examine sensitivity for individuals

• Explore relationship between temporal order perception (FPT and DPT), cognitive abilities, speech intelligibility, and reported listening difficulties.

109

Questions?

CAPD.NAL.gov.au

Thanks to Australian Department of Health for sustained funding.

110

Documents

Auditory processing disorders - National Acoustic Laboratories · 12 ASHA (2005) “()APD is a deficit in neural processing of auditory stimuli that is not due to higher order language,