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Diagnosis and Management:

Auditory Streaming Deficits in Children with

(Central) Auditory Processing Disorder

Sharon Cameron, PhD

[email protected]

8 November 2007 Sharon Cameron 2

Overview of Presentation

1. Review of CAP and (C)APD

2. Assessing auditory stream segregation deficits (ASSD)

3. General intervention strategies

4. Deficit-specific auditory training for ASSD

5. Monitoring training using CAEPs

6. Summary

7. Questions and answers


Central Auditory Processing

The efficiency and effectiveness by

which the central nervous system (CNS)utilizes auditory information

ASHA (2005)

What we do with what we hear

Katz (1992)


2/13


(Central) Auditory Processing Disorder

For children with (C)APD..

.. internal distortions degrade the auditorysignal so that top-down processing typicallypredominates in most listening situations,particularly those in which complex linguisticand cognitive demands are coupled withbackground noise

Putter-Katz et al (2002)


(C)APD

Said to affect 2% of children

Cellular degradation or immaturity; COM

Results in behaviours similar to hearing loss, inspite of normal hearing thresholds and normalintelligence

Predominant problem is difficulty listening inbackground noise

Becomes apparent when child enters school dueto change in listening environment, or increased

academic demands


Some Possible Contributing Factors to Listening Deficits

1. Peripheral hearing loss

2. Phonetic coding (segment, blend, delete, substitute)

3. Auditory STM (memory span & working memory)

4. Auditory processing speed (simple vs. complex)

5. Auditory attention (inattention & impulsivity)

6. Cloze ability (top-down processing)

7. Emotional factors (anxiety; depression)


3/13


Auditory Stream Segregation

1. The ability of the brain to tease apart allthe sounds that arrive simultaneously at

the ears and to form meaningfulrepresentations of the incoming acousticinformation

2. Auditory cues such as the location of thesound, or the pitch of a speakers voice,help us to segregating the total stream ofsound into its original sources


Listening in Spatialized Noise Sentences Test

LISN-S was developed specifically toassess how children use binaural cues,and differences between voices, toseparate target auditory stimuli fromdistracting auditory stimuli


Description of the LISN-S

1. Adaptive speech-in-noise-test

2. Target: sentences (designed for young children)

3. Competing speech: looped childrens stories

4. 3-D auditory environment under headphones

5. Offers alternative to free-field testing

6. No special hardware required


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LISN-S

Distracters

Target

Ave SRT


LISN-S Conditions

Same Voice - 0Condition

TARGET (0)D is tr ac te r A (0 ) D is tr ac te r B ( 0)

Same Voice -90Condition

TARGET (0)

DistracterA (+90) Distracter B (-90)

Different Voices -90Condition

TARGET (0)

DistracterA (+90) Distracter B (-90)

Different Voices - 0Condition

TARGET (0)D is tr ac te r A ( 0) D is tr ac te r B ( 0)

Talker Advantage

SpatialAdvantage

TotalAdvantage


LISN-S Measures Controls (n=82)

Better

Low-Cue SRT High-Cue SRT

5 6 7 8 9 10 11

Age Group

-16.0

-12.0

-8.0

-4.0

0.0

4.0

Low-CueSRT(d

B)

W

WW W

W W

W

1.1

0.1 -0.3 -0.4- 1. 4 - 1. 2

-1.8

5 6 7 8 9 10 11

Age Group

-18.0

-14.0

-10.0

-6.0

-2.0

2.0

High-CueSRT(dB)

W

W

W

WW

W

W

-9.1

-12.1-12.7

-14.4-14.8 -15.4

-16.0


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LISN-S Advantage Measures

Better

Talker Advantage Spatial Advantage

5 6 7 8 9 10 11

Age Group

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

TalkerAdvantage(dB)

WW

W

W W

WW

2.9 2.73.2

3.8 3.64.3

4.1

5 6 7 8 9 10 11

Age Group

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

SpatialAdvantage(dB)

W

W

W

W

W

W

W

8.7

10.1

11.3

12.6

11.512.1

12.9


LISN-S (C)APD Study

1. 20 children aged 6 to 11 years:

a) 9 children experiencing listening difficulties in class who had no learning orattention disorder (SusCAPDgroup)

b) 11 children with confirmed learning or attention disorders (LD group)

2. Assessed with a traditional (C)APD test battery

3. Assessed on LISN-S and results compared to 70 age-matchedcontrols


A Control] SusCAPDX LD

Group

6 7 8 9 10 11 12

Age

-8

-6

-4

-2

0

2

4

6

Low-CueSRT(dB)

AA

AA

A

A

A

AA

A

AA

A

A

A

AA

A

A

A

A

A

AA

AA

AA

A

A

A

A

AA

A

A

A

A

A

AA

A

AA

AA

A

AA

A

AA

A

A A

A

A

A

A A

A

A

AA

A

A

AA

AA

]

]

]

]

]

]]]

]XXX

X

XX

XX

X

X

X

Mean = -0.8

Mean = -0.8Mean = -0.7

Results Low-Cue SRT

Better

Significance:

C ont ro l vs. LD : p = 0. 879

Control vs. SuSCAPD: p = 0.883

S us CAPDv s. LD: p = 0 .8 24

(LD)

(SusCAPD)


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A Control] SusCAPD

X LD

Group

6 7 8 9 10 11 12

Age

-20

-18

-16

-14

-12

-10

-8

-6

High-CueSRT(dB)

A

A

A

A

A

AA

A

A

A

AA

A

A

A

A

A

A

A

AA

A

A

A

A

A

A

A

A

A

AA

AA

AA

A

AA

A

A

A

A

AA

AA

AA

A

A

A

AA

A

A

A

A

A

A

A

A

AA

A

AAA

A

A

]

]

]

]

]

]]

]

]

X

X

X

X

XX

X

X

X

X X

71

75

7677

87

Mean = -14.2

Mean = -11.4

Mean = -13.6

Results High-Cue SRT

Better

Significance:


Control vs. SusCAPD: p = 0.001

S us CAPDv s. LD: p = 0 .0 25

n = 5 below 2SD (1 LD)

(LD)

(SusCAPD)


Results Talker Advantage

Better

Significance:


Control vs. SusCAPD: p = 0.883

S us CAPDv s. LD: p = 0 .2 30A Control]

SusCAPD

X LD

Group

6 7 8 9 10 11 12

Age

-4

-2

0

2

4

6

8

10

TalkerAdvantage(dB)

A

A

A

AA

A

AA

A

A

A

A

A

A

A

AA

A

A

A

A

A

A

A

A

A

A

AA

A

A

A

AA

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

A

AA

A

AA

AAA

A

A

AA

A

]

]

]

]]

]

]

]

]

X

X

X

X

X

X

X

X

X

X

X

Mean = 3.6

Mean = 3.6

Mean = 4.4 (LD)

(SusCAPD)


A Control] SusCAPD

X LD

Group

6 7 8 9 10 11 12

Age

2

4

6

8

10

12

14

16

SpatialAdvantage(dB)

A

A

A

A

AA

A

A AA

A

A A

A

A

A

A

A

A

A

A

AA

A A

A

A

A

A

A

A

AA

A

A

A

A

A

A

A

A

A

AA

A

A

A

A

A

A

A

A

A

A

A

AA

A

A

A

A

A

AAAA

AA

AA

]

]

]] ] ]

]]

]

XX

XX

X

X

X

X

XX

X

71

72

7375 76

87

Mean = 11.7

Mean = 7.8

Mean = 11.6

Results Spatial Advantage

Better

Significance:

Contr ol v s. LD: p = 0 .9 83

Control vs. SusCAPD:p < 0.0001

SusCAPDvs. LD: p = 0 .002

n = 6 below 2SD (1 LD)

(LD)

(SusCAPD)


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LISN-S and Traditional Battery LD Group

LD Group

PPS

(RE)

PPS(LE)

DD

(RE)

DD

(LE)

RGDT

MLD

LC

SNR

HC

SNR

TalkerAdv

SpatialAdv

TotalAdv

-12

-10

-8

-6

-4

-2

0

2

4

6

DeviationfromM

eanNormalPerform

ance

Median 25%-75 % Min-Max


LISN-S and Traditional Battery SusCAPD Group

SusCAPD Group

P

PS

(RE)

P

PS

(LE)

DD

(RE)

DD

(LE)

RGDT

MLD

LC

SNR

HC

SNR

Ta

lkerAdv

Sp

atialAdv

T

otalAdv

-12

-10

-8

-6

-4

-2

0

2

4

6

DeviationfromM

eanNormalPerformance

Median 25%-75% Min-Max


LISN-S (C)APD Study Participant 1

Central Auditory Processing Test Results - P1

-7.0

-6.0

-5.0

-4.0

-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

PPS

-RE

PPS

-LE

Dich

otic

Digits

-RE

Dich

otic

Digits

-LE

RGDT

MLD

LISN

-S:L

ow-C

ueSR

T

LISN

-S:H

igh-

CueS

RT

LISN

-S:T

onal

Adv

LISN

-S:S

patia

lAdv

LISN

-S:T

otal

Adv

Tests

StandardDeviationsfro

mMea

2StandardDeviations Below

Mean

NormalisedScore

OutsideNormalRange

WithinNormalRange


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Personal Strategies

1. Recognise and anticipate difficult listeningsituations:

a) overhead fans; children outside classroom

2. Find a solution:

a) advise teacher; move position; ask for repetition

3. Whole body listening techniques


Strengthen General Language Skills

1. Auditory closure training

2. Vocabulary building

3. Drills in speech-to-print skills to improve

any spelling and reading deficits


Deficit-Specific Auditory Training

1. Compelling neurophysiologic evidence suggests that auditorytraining can alter neural activity in the auditory system.

2. Cortical plasticity of the auditory system has been established in

animals, in children, and in adults.

3. Auditory training may play a future role in our adjustment to

background noise.

4. It is clear that auditory training may be the most powerful,

underutilized, and not completely understood tool in theaudiologist armamentarium.

Kricos and McCarthy (2007)


10/13


Example of LISN & LearnGame


Example of LISN & LearnGame

Target: The horse kicked six wet shoes


Central Auditory Processing Test Results - P1 - Pre-Training

-7.0

-6.0

-5.0

-4.0

-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

LISN

-S:L

ow-C

ueSR

T

LISN

-S:H

igh-

Cue

SRT

LISN

-S:T

alker

Adv

LISN

-S:S

patia

lAdv

LISN

-S:T

otal

Adv

Tests

StandardDeviation

sfrom

Mea

2StandardDeviations Below

Mean

NormalisedScore

OutsideNormalRange

WithinNormalRange

LISN & Learn Participant 1 (Pre-Training)


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Monitoring Pre-, Post- and 3m-Post Training

1. LISN-S one-sided critical difference scores fromre-test study

2. TOVA-A

3. TAPS-R memory sub-tests

4. (C)APD Pediatric Speech, Spatial and Qualities ofHearing Scale(SSQ)

5. Cortical auditory evoked potentials to spatializedstimuli


Cortical Auditory Evoked Potential Study


Adult Control Group Active P300 TaskN1 and P2 to Standard Stimulus at Cz

ms

-200.0 50.0 300.0 550.0 800.0

V 0.0

2.5

5.0

7.5

10.0

-2.5

-5.0

-7.5

-10.0

-6.4V

2.9V

-4.6V

___

2.1V

Background Noise

_______ 0

_______ 90


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Age Matched Control - Passive P300 TaskN1 and P2 to Standard Stimulus at Cz

ms

-200.0 50.0 300.0 550.0 800.0

V 0.0

2.5

5.0

7.5

10.0

-2.5

-5.0

-7.5

-10.0-9.1V

5.9V

-7.8V

___

1.7V

Background Noise

_______ 0

_______ 90


Spatial Deficit (Pre-Training) Passive P300 TaskN1 and P2 to Standard Stimulus at Cz

ms

-200.0 50.0 300.0 550.0 800.0

V 0.0

2.5

5.0

7.5

10.0

-2.5

-5.0

-7.5

-10.0

-4V

3.9V

-6.4V

6.9V

___Background Noise

_______ 0

_______ 90


Questions and Answers


13/13


Acknowledgements

Dr Harvey DillonDirector of ResearchNational Acoustic Laboratories

Australia

Speech, Hearing and LanguageResearch Centre

Macquarie University

National Health and Medical

Research CouncilAustralia

Documents

0129 Cameron Sharon