AUDITORY PROCESSING DISORDERS AUDITORY PROCESSING DISORDERS AND THE ROLE OF THE SLPAND THE ROLE OF THE SLP

ASHA Ad Hoc Committee 2007-2009

Background Information

2005 – position statement on (Central) Auditory Processing Disorders generated by ASHA Working Group on Auditory Processing DisordersAudiologist primary professional for assessing (C)APDSLP important in assessment and management, but role of SLP beyond scope of that document2007- Ad Hoc Committee on the Role of the Speech-Language Pathologist in Identifying and Treating Children with Auditory Processing Disorders formed

Ad Hoc Committee Members

Gail J. Richard, ChairMarc E. FeyDonna GeffnerAlan G. KamhiLarry MedwetskyDeborah Ross-SwainSally ShawitzLynn Snyder (2007)Geraldine Wallach (2008-2009)Diane R. Paul, ex officioBrian B. Shulman (2007-2008); Julie Noel (2009) –monitoring ASHA Vice President

Challenge within Committee Charge

Considerable controversy surrounding topic of (C)APDDefinition of 2005 Working Group

“ the perceptual processing of auditory information in the CNS and the neurobiological activity that underlies that processing and gives rise to electrophysiological auditory potentials. (C)APD includes the auditory mechanisms that underlie the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal discrimination,temporal ordering, and temporal masking; auditory performance in competing acoustic signalsand auditory performance with degraded acoustic signals”

ASHA position statement: (Central) auditory processing disorders-The role of the audiologist, p.2 (2005)

Some Unfinished Business

2005 Working Group acknowledged children with (C)APD experience variety of learning and speech-language problemsComplicates research efforts to identify and characterize the relationship between discrete auditory abilities and higher –order language skills (e.g., reading, spelling)“although abilities such as phonological awareness, attention to and memory for auditory information, auditory synthesis, comprehension and interpretation of auditorily presented information, and similar skills may be reliant on or associated with intact auditory function, they are considered higher-order cognitive communicative and/or language-related functions and, thus are not included in the definition of (C)APD” (p. 2)

First Step for Ad Hoc Committee

Conduct evidence-based systematic review on efficacy of auditory interventions for children with (C)APD to facilitate addressing role of SLP with this populationContinuing uncertainty regarding role of SLP

ASHA, 1992 & 1996 – committee reportsDeBonis & Moncrieff, 2008

ASHA’s National Center on Evidence-Based practice in Communication Disorders (N-CEP) to conduct appraisal of literature regarding treatment efficacy with this disorder population

Parameters for Systematic Review

Committee accepted definition for (C)APD from 2005 Working Group

Distinction between auditory processing and higher-level language skillsDistinction not uniformly shared by researchers who study children with (C)APD

Systematic review considered all treatment studies involving school-age children diagnosed with APD regardless of criteria used for diagnosis

Also included auditory treatment studies involving children with language disorders – interest in auditory treatmentsBeyond scope of this review to include auditory interventions for reading, learning disabilities, autism, or other developmental disability diagnoses

Evaluate treatment programs- direct intervention of an auditory natureAuditory intervention distinguished from language intervention – progressive manipulation of auditory components of speech and non-speech stimuli

e.g., rate, interstimulus interval, frequency, intensity presence of background noiseContrasted with language intervention that manipulates form, content, useFastForWord considered auditory intervention – manipulates rate and intensity of speech segmentsEarobics considered primarily language intervention –manipulates consonants, vowels, syllables, written analogues as parts of words rather than the auditory features (Diehl, 1999)FM systems excluded – passive frequency modulation rather than active direct treatment

Fifteen Clinical Questions Developed Patient, Intervention, Comparison, Outcome (PICO)

Questions 1-6: effects / efficacy of auditory interventions on auditory, language, and academic outcomes in school-aged children with APD alone or with co-morbid language disorders

For school-age children with diagnosis of APD, what is effect of auditory intervention on auditory outcomes?auditory intervention on language outcomes?auditory intervention on academic outcomes?

For school-age children with diagnosis of APD and co-morbid LD, what is effect of

auditory intervention on auditory outcomes?auditory intervention on language outcomes?auditory intervention on academic outcomes?

Clinical Questions (con’t)

Questions 7-12: effects / efficacy of language interventions on auditory, language, and academic outcomes in school-aged children with APD alone or with co-morbid language disorders

For school-age children with diagnosis of APD, what is effect of

language intervention on auditory outcomes?language intervention on language outcomes?language intervention on academic outcomes?

For school-age children with diagnosis of APD and co-morbid spoken LD, what is effect of

language intervention on auditory outcomes?language intervention on language outcomes?language intervention on academic outcomes?

Clinical Questions (con’t)

Questions 13-15: effects /efficacy of auditory interventions on auditory, language, and academic outcomes in children with spoken language disorders

For school-age children with diagnosis of spoken LD, what is effect of

Auditory interventions on auditory outcomesAuditory interventions on language outcomesAuditory interventions on academic outcomes

MethodsSystematic search of 28 electronic data bases from March 2008 toJune 2008Key words related to central auditory processing or auditory processing interventionsPublished in peer reviewed journal from 1978-2008; written in English, original data, pertinent to one of 15 questionsInclusion criteria: school-age children, ages 6-12; diagnosis of auditory processing disorder and/or spoken language disorderExclusion

Written language disordersLearning disabilities (without co-morbid language)Reading disabilities/ dyslexiaAutism spectrum disordersHearing lossCognitive disability (IQ lower than 70)

Results of Systematic Review

192 article citations; 32 preliminarily accepted; 9 additional articles rejected; accepted 23 articles that addressed 25 studiesArticles categorized evaluated in critical appraisal

clinical research stage: Exploratory, efficacy, effectiveness, or cost-benefit/public policySeven quality indicators

Study protocolBlindingSampling/allocationTreatment fidelitySignificancePrecisionIntention to treat (when applicable)

Marc Fey

Evidence-Based Systematic Review

Auditory Processing Disorders and Its Treatment: An Evidence-

Based Systematic Review

Marc E. Fey, Ph.D.University of Kansas Medical Center

Intercampus Program in Communicative DisordersEmail: mfey@kumc.edu

2009 ASHA ConventionNew OrleansNovember 21

Question Set 1: The Effects of Auditory Interventions on Auditory,

Language, and Academic Outcomes in School-age Children with APD

Question Set 2: The Effects of Language Interventions on Auditory, Language, and Academic Outcomes

in School-age Children with APD

• A total of only 6 articles• Articles included 8 studies• APD dx typically based on SSW, SCAN-C,

and tests of speech in noise• Interventions represented

– Traditional auditory training (N = 4)– Auditory Integration Training (N = 1)– Fast ForWord (N = 2)– Earobics (N = 1)

Results of Our Search for Articles on TX for Children with Dx of APD

Number of Studies for Each Study Phase

Number of Treated and Control Subjects Participating Per Study

Study Quality Points Awarded

• Testers and analysts were not kept blind to the participants’ treatment protocols.

• The treatment was not adequately described and/or treatment fidelity was not reported.

• Participants were not assigned randomly to treatment group or schedule.

Most Common Problems with Quality Indicators

Significant Auditory Outcomes?

Significant Spoken Language Outcomes?

Significant Written Language Outcomes?

• A total of only 6 articles• Articles included 8 studies, none of which

earned more than 4 quality points.• There is weak, inconclusive evidence that

intensive short term interventions mayimprove some aspects of auditory function in children with primary APD.

Summary of Findings from Articles on TX for Children with APD

• Evidence to support use of auditory interventions designed to affect spoken or written language is especially limited.

• Earobics, an intervention we classified as language, had mixed effects on auditory and written language tasks.

• There is no evidence to support the use of AIT with children with APD.

Summary of Findings from Articles on TX for Children with APD

Question Set 3: The Effects of Auditory Interventions on Auditory

and Spoken and Written Language Outcomes in School-age Children with Primary Language Disorder

• A total of 17 articles• Articles included 19 studies• LD dx typically based on standardized tests with

varying criteria (e.g., below -1 SD)– Two studies required comprehension delays

• Most studies included only English-speaking American children– England, Scotland, Australia also included– One study included Dutch speakers

Results of Our Search for Articles on Auditory TX for Children Primary LD

• Interventions– Fast ForWord (N = 16)– Language interventions with FFW-like

acoustic modifications (N = 2)– Traditional auditory training (N = 1)

Results of Our Search for Articles on Auditory TX for Children Primary LD

Number of Studies for Each Study Phase

Number of Treated and Control Subjects Participating Per Study

Study Quality Points Awarded

• Testers and analysts were not kept blind to the participants’ treatment protocols.

• The treatment was not adequately described and/or treatment fidelity was not reported.

• Participants were not assigned randomly to treatment group or schedule.

• Study design did not include an “intention to treat” analysis.

Most Common Problems with Quality Indicators

Significant Auditory Outcomes?

• Alexander & Frost (1982) found that temporal processing of speech-like sounds improved as a result of a FFW prototype.– The improvement was significant only at the

.15 level.

Special Considerations Regardingthe Efficacy Studies of FFW

• Gillam et al. (2008) hypothesized that children who received FFW would improve more on a backward masking measure than would children who received language intervention or attention control procedures.– All groups made significant improvements in

backward masking over time.– There were no differences between groups,

however.

Special Considerations Findings of the Efficacy Studies of FFW

Significant Spoken Language Outcomes?

• Both Gillam et al. (2008) and Cohen et al. (2005) observed significant gains in spoken language following FFW.

• Observed gains were no greater than observed for the language interventions or for the attention control group, however.• For Gillam et al., children in the FFW group

outperformed controls on a sound blending test.

Special Considerations Regarding the Findings of the 7-point Efficacy Studies

• Gillam et al. (2008) predicted that children with low backward masking scores would make greater language gains if they received FFW than if they received the language interventions or the attention control procedures. • Children with low backward masking scores

were at no advantage if they had FFW compared to either language intervention or the attention control procedures.

Special Considerations Regarding the Findings of the 7-point Efficacy Studies

• A total of 19 studies in 17 articles– All but three evaluated Fast ForWord

• In general, quality was better than studies of children with APD, with two efficacy studies receiving scores of 7.

Summary of Findings from Articles on Tx for Children with Primary LD

• Exploratory and efficacy studies provide weak evidence to indicate that children with PLD may improve their auditory function following FFW and traditional auditory processing treatments.

• There is no evidence that FFW’s acoustic modifications of speech and non-speech stimuli are responsible for these improvements.

Summary of Findings from Articles on TX for Children with Primary LD

• The largest and most rigorous efficacy studies of FFW with children with LD have found either no improvements on language measures or gains similar to other, equally intensive language interventions and control conditions with no auditory or language manipulations.– There is no evidence that children with PLD who

have weak auditory processing skills respond especially well to FFW.

Summary of Findings from Articles on TX for Children with Primary LD

• At present, there is no support for applying graded acoustic modifications , such as those found in FFW, to language interventions in an effort to enhance their efficacy.

Summary of Findings from Articles on TX for Children with Primary LD

To fill gaps in our understanding of children with APD and its treatment, we need research programs that:− more adequately identify APD and APD

subgroups using more rigorous test batteries.− carefully measure language as well as auditory

skills both before and as an outcome of tx.

Research Directions

To fill gaps in our understanding of children with APD and its treatment, we need research programs that:− based on evidence from high quality exploratory

studies, develop specific hypotheses about which auditory and language treatments should affect specific APD conditions.

− test these specific hypotheses in high-quality efficacy and effectiveness studies.

Research Directions

There is little evidence available to guide clinicians working with children with APD.A few recommendations are warranted.− Always carefully and comprehensively evaluate

the children’s language skills. − When language problems exist, they should be

treated with language interventions.

Some Clinical Guidelines

− If auditory interventions are planned as sole or adjuvant treatments, clinicians should carefully describe the nature of the auditory problems and select an intervention plan designed to target those specific deficits.

− Clinicians must keep careful records of auditory, language, and academic progress to evaluate the effects of the intervention choices.

Some Clinical Guidelines

Personal PerspectivesDespite committee’s strong commitment, not able to reach consensus regarding professional practice guidelines-minimal evidence in systematic reviewSLP faced with dilemma regarding interventionUse existing evidence and expert opinion to present variety of professional perspectives

Is auditory processing a unique and identifiable clinical entity?Do auditory intervention have an academic outcomes?Can auditory processing skills be separated from language, phonology, and literacy?Why is it so difficulty to reach professional consensus on a definition for identifying and treating APD?What guidance can be offered to practicing professional responsible for identifying and treating APD?

Alan Kamhi

Personal Perspective

The Problem with Processing-Based

Disorders

The Appeal of Processing Disorders

It is human nature to look for the easier ways to do things.

Watching videos (Baby Einstein) can make babies smarter.

Processing explanations provide easy solutions to complex learning problems like learning to talk, understand, read, write, spell, and reason.

Examples of Simple Solutions to Complex Problems

Give me the pillPay attention Just tryListenThinkRememberListen betterThink harderTry harder

If Only Learning Were So Simple

The pill—I don’t do drugs.Attention---What do I attend to? I hear birds.Just try---Why? When I try, I still don’t do well.Listen—I am listening. I don’t understand

what you’re saying.Think—Think about what? I think you don’t

know how to teach.Remember—I remember the ugly shirt you

wore yesterday.

Learning is Hard Work

Learning the specific language, conceptual knowledge, and reasoning skills required to talk, understand, read, write, spell well is hard even for typical learners.

It is incredibly challenging for students with language and learning disabilities.

There are no short cuts.

Processing Limitations

Working memory and speed of processing limitations account for 62% of the variance in composite language scores (Leonard et al., 2007).

Phonological processing limitations account for > 60% of the variance in word recognition ability (Wagner, Torgesen, et al. 1987, 1994).

The Disconnect Between Causation and Treatment

Processing limitations may contribute to language and reading problems, but attempting to improve these abilities has not led to significant changes in language and reading abilities (Our evidence-based review,, Fletcher, 2007).

It is often difficult to improve basic processing abilities like phonological memory, working memory, and speed of processing.

Processing-Based Treatments are Ineffective

When processing interventions are effective (e.g., Fast Foreword), it is often because they target knowledge or improve selective attention to speech and language.

Improvements in language knowledge often improves processing abilities (e.g., Alison in Germany).

Processing Assessments Have Little Predictive Value

Assumption: Knowledge about processing strengths or weaknesses predicts treatment outcomes.

Reality: No evidence that knowledge of processing strengths or weaknesses predicts treatment outcomes (Fletcher, 2007).

Predicting Treatment Outcomes

Processing measures provide no additional information about treatment outcomes that are not provided by measures of language or reading.

Measures of language (vocabulary, syntax, narrative) are the best predictors of language outcomes.

Measures of reading (word attack, word identification, fluency) are the best predictors of reading outcomes.

Most Processing Limitations Are Not Processing Disorders

Phonological processing disorderWorking memory disorderPhonological memory disorderSpeed of processing disorderRapid serial memory disorderWord retrieval disorderSyntactic processing disorderSemantic processing disorderVisual processing disorder

Criteria for a Processing Disorder

Need a professionAudiology---APDOccupational Therapy—SID Psychology---ADHD

Need a diagnostic battery (preferably expensive) that only one professional can administer.

Label needs to be a good meme (easy to understand, remember, and communicate to others).

Why Not a Phonological Processing Disorder?

Not in the domain of one profession.

Many professionals can administer the measures of phonological processing (e.g., CTOPP).

Poor meme– difficult to understand and communicate to others.

Why Not a Working Memory Disorder?

Not in the domain of one professionAssessment is too easy Too broad basedExplains too many disordersPoor meme—what is working memory?Intervention is not straightforward

Reasons for APD Referrals to Audiologist

difficulty following verbal instructions and answering questions

difficulty with reading

no diagnosed disorder and thus no services

a diagnosis, but parent is not satisfied with current level of functioning or services.

When the APD Student is Referred to an SLP

1. Perform a comprehensive assessment to evaluate child’s language and/or reading abilities.

2. Generate possible reasons for child’s listening/learning difficulties problems.

3. Develop management plan to target spoken and written language abilities.

Possible Reasons for (Listening) Comprehension Problems

Weak or distorted signalHearing impairmentWorking memory limitationLanguage disorder Concepts are too complexPoor inferencing skillsInattention (ADHD)Lack of motivation

Possible Comprehension Goals

Conceptual knowledgeLinguistic knowledge (e.g., vocabulary, syntax, conjunctions, figurative language)Inferencing skillsText/genre knowledgeDiscourse knowledge (e.g., rules for narrative and conversational discourse)

Possible Reading Goals

conventions of printpurposes of printletter knowledgephoneme awareness (sound knowledge)sound-letter correspondencesVocabularyWord attack skillsFluencycomprehension

Take-Home Message

Target language-based skills (e.g., comprehension, reading, writing) and knowledge deficits (science, history, math, literature).

Avoid goals that target general processing skills like auditory discrimination, auditory sequencing, phonological memory, or rapid serial naming. There is little or no evidence that targeting these skills improves language or reading ability (our evidence-based review, Fletcher, 2007)

Keep searching for more efficient and effective ways to improve language and reading abilities, but be wary of interventions that promise quick fixes.

Keep telling students to pay attention, try hard, listen, think, and remember.

But spend most of your time and effort teaching students the language and conceptual knowledge that will help them talk, listen, read, write, and reason better.

References

Fey et al. (2009). Evidence-based review of the efficacy of auditory intervention on auditory, language, and academic skills. ASHA Committee on the Role of the SLP.

Fletcher, J. (2007). Why RTI. Enhancing outcomes for all students. ASHA Convention.

Leonard, L. et al. (2007). Speed of processing, working memory, and language impairment in children. JSLHR, 50, 137-148.

Donna Geffner

Personal Perspective

Evidence Based PracticeEvidence Based Practice(C)APD Treatment:(C)APD Treatment:

A View From the ClinicianA View From the Clinician’’s s Desk Desk

Donna Geffner, Ph.D., CCC, SLP/ADonna Geffner, Ph.D., CCC, SLP/ASt. JohnSt. John’’s University, New Yorks University, New York

What is an auditory processing What is an auditory processing disorder?disorder?

The term APD is often loosely used by individuals The term APD is often loosely used by individuals from many disciplines and settings to mean many from many disciplines and settings to mean many different things. different things.

The label APD has been applied to many deficits which The label APD has been applied to many deficits which contribute to its confusion. Some even question its contribute to its confusion. Some even question its existence as a direct entity and other attribute to any existence as a direct entity and other attribute to any child or adult who has a listening problemchild or adult who has a listening problem-- not not recognizing that listening involves other cognitive and recognizing that listening involves other cognitive and language skills.language skills.

APD refers to the how the central nervous system uses auditory APD refers to the how the central nervous system uses auditory information. information.

The CNS is responsible for function such as memory, attention, The CNS is responsible for function such as memory, attention, and language. and language.

However, that is not APD. However, that is not APD.

APD is an auditory deficit not the result of the other higherAPD is an auditory deficit not the result of the other higher--order order cognitive, language and related disorders (ASHA, Task Force 2005cognitive, language and related disorders (ASHA, Task Force 2005; ; Bellis, ASHA, 2009). Bellis, ASHA, 2009).

There are several disorders that affect the personThere are several disorders that affect the person’’s ability to s ability to understand auditory information. And several disorders counderstand auditory information. And several disorders co--exist exist with APD, i.e., AD/HD, language based disorders, and learning with APD, i.e., AD/HD, language based disorders, and learning disabilities (Geffner, 2007).disabilities (Geffner, 2007).

In many cases AD/HD coIn many cases AD/HD co--exists with APD (40%exists with APD (40%--80%, 80%, Dimaggo & Geffner, 2005) and language disorders Dimaggo & Geffner, 2005) and language disorders (Sharma, 2009).(Sharma, 2009).

It would be unfortunate to link them together as one It would be unfortunate to link them together as one but rather to recognize the heterogeneity of the but rather to recognize the heterogeneity of the population. population.

Given that mixture it is particularly difficult to sort out Given that mixture it is particularly difficult to sort out the APD from the population in order to study any the APD from the population in order to study any aspect of it.aspect of it.

How APD and Language Processing How APD and Language Processing are linked are linked

The impact of CAPD on language use is particularly The impact of CAPD on language use is particularly evident in spoken language comprehension. Because evident in spoken language comprehension. Because spoken language comprehension is determined by a spoken language comprehension is determined by a number of different factors, clinicians should be number of different factors, clinicians should be cautious in attributing spoken language comprehension cautious in attributing spoken language comprehension difficulties to CAPD in any simple fashion. difficulties to CAPD in any simple fashion.

Audiologic considerations as well, play a role. Thus, a Audiologic considerations as well, play a role. Thus, a diagnosis of CAPD requires comprehensive audiologic diagnosis of CAPD requires comprehensive audiologic assessment; such a diagnosis cannot be made solely on assessment; such a diagnosis cannot be made solely on the basis of poor comprehension of spoken language or the basis of poor comprehension of spoken language or any language based measure. any language based measure.

According to the ASHA Technical report According to the ASHA Technical report (ASHA, 2005), CAPDs have been reported in (ASHA, 2005), CAPDs have been reported in persons manifesting a large and diverse set of persons manifesting a large and diverse set of clinical problems. CAPD may have a role in clinical problems. CAPD may have a role in both language learning and language use both language learning and language use difficulties of clients with and without clear difficulties of clients with and without clear evidence of neuropathology. The report evidence of neuropathology. The report cautions clinicians not to infer the existence of cautions clinicians not to infer the existence of CAPD solely from evidence of learning CAPD solely from evidence of learning disability or language impairment. disability or language impairment.

Management and Treatments Management and Treatments

In studying efficacy of treatment, the ASHA In studying efficacy of treatment, the ASHA Task Force (2005) identified three conceptual Task Force (2005) identified three conceptual stumbling blocks for researchers and clinicians stumbling blocks for researchers and clinicians alike: alike:

heterogeneity of the populationheterogeneity of the populationtreatment goalstreatment goalsevaluating changeevaluating change

Management of CAPD entails two general and Management of CAPD entails two general and complementary approaches complementary approaches

a.a. The first approach is directed toward enhancing the The first approach is directed toward enhancing the client's own resourcesclient's own resources

b.b. The second approach is directed towards enhancing the The second approach is directed towards enhancing the auditory signal and improving the listening auditory signal and improving the listening environment. environment. Individuals with CAPD can benefit from Individuals with CAPD can benefit from interventions that help them increase their knowledge interventions that help them increase their knowledge of language and their ability to access that knowledge of language and their ability to access that knowledge in a timein a time--efficient manner for speech processing.efficient manner for speech processing.

Regardless of the nature of the processing deficit, most Regardless of the nature of the processing deficit, most persons who have difficulty with the comprehension of persons who have difficulty with the comprehension of spoken language will profit spoken language will profit bothboth from procedures that from procedures that enhance the acoustic signal and from procedures that enhance the acoustic signal and from procedures that increase the scope and control of central resources, increase the scope and control of central resources, particularly language resources. particularly language resources.

Given our current understanding of language disorders Given our current understanding of language disorders and of central auditory processing, techniques that and of central auditory processing, techniques that facilitate language competence are likely to improve the facilitate language competence are likely to improve the auditory processing of language and vice versa (Bellis, auditory processing of language and vice versa (Bellis, 2009).2009).

There are three general areas one focuses on There are three general areas one focuses on when doing treatment for APD. when doing treatment for APD. Bellis (ASHA, 2009) talks about:Bellis (ASHA, 2009) talks about:

Changing the learning or communication Changing the learning or communication environmentenvironmentRecruiting higher order skills to help compensate for Recruiting higher order skills to help compensate for the disorder, and the disorder, and Remediation of the auditory Remediation of the auditory processing deficit.processing deficit.

When one discusses altering the environment, When one discusses altering the environment, one usually refers to the use of:one usually refers to the use of:

sound altering devices or assistive listening devices, sound altering devices or assistive listening devices, electronic devices that help teachers deliver the electronic devices that help teachers deliver the information, and information, and devices that assist listening and clarity of the devices that assist listening and clarity of the message.message.

Such devices are FM systemsSuch devices are FM systems

FM SystemsFM Systems

It is generally agreed that the use of FM units has It is generally agreed that the use of FM units has increased a childincreased a child’’s discrimination skills and ability to s discrimination skills and ability to hear in classrooms and in a noisy situations. hear in classrooms and in a noisy situations. There have been many studies that have shown the There have been many studies that have shown the efficacy of using FM systems on youngsters who are efficacy of using FM systems on youngsters who are not hearing impaired. not hearing impaired. The following reports and research findings support the The following reports and research findings support the use of FM technology in both the classroom and as use of FM technology in both the classroom and as personal units.personal units.

The use of soundThe use of sound--field amplification system field amplification system provides a teacher with an opportunity to:provides a teacher with an opportunity to:improve academic achievement improve academic achievement for studentsfor students

decrease distractibility and decrease distractibility and increase onincrease on--task behaviortask behavior

increase attention to verbal increase attention to verbal instruction and activities and instruction and activities and improve understandingimprove understanding

decrease number of requests for decrease number of requests for repetitionrepetition

decrease frequency of need for decrease frequency of need for verbal reinforcers to facilitate verbal reinforcers to facilitate test performancetest performance

decrease testdecrease test--taking timetaking time

improve spelling ability under improve spelling ability under degraded listening conditions degraded listening conditions

increase sentence recognition increase sentence recognition abilityability

improve listening test scoresimprove listening test scores

increase language growthincrease language growth

improve student voicing when improve student voicing when speakingspeaking

Crandell, Smaldino, & Flexer, 1995

increase student length of increase student length of utteranceutterance

increase confidence when increase confidence when speakingspeaking

increase preference by increase preference by teachers and students for teachers and students for soundsound--field amplification in field amplification in the classroom the classroom

improve ease of listening and improve ease of listening and teachingteaching

reduce vocal strain and reduce vocal strain and fatigue for teachersfatigue for teachers

increase mobility for teachersincrease mobility for teachers

reduce special education reduce special education referral ratereferral rate

increase in seating options increase in seating options for students with hearing lossfor students with hearing loss

costcost--effective means of effective means of enhancing the listening and enhancing the listening and learning environmentlearning environment

SoundSound--field units provide amplification for the entire classroom field units provide amplification for the entire classroom through the use of two, three, or four wallthrough the use of two, three, or four wall-- or ceilingor ceiling--mounted mounted loudspeakers (Berg, 1987; Crandell, Smaldino, & Flexer, 1995). loudspeakers (Berg, 1987; Crandell, Smaldino, & Flexer, 1995).

All students in the room benefit from an improved S/N ratio of All students in the room benefit from an improved S/N ratio of approximately +10 to +20 dB, no matter where they or the approximately +10 to +20 dB, no matter where they or the teacher are positioned (Flexer, Millin, & Brown, 1990; Palmer, teacher are positioned (Flexer, Millin, & Brown, 1990; Palmer, 1997) (Flexer, 1999, p. 126).1997) (Flexer, 1999, p. 126).

Studies continue to show that soundStudies continue to show that sound--field FM systems facilitate field FM systems facilitate opportunities for improved academic performance (Crandell, opportunities for improved academic performance (Crandell, 1996; Flexer, Millin, & Brown, 1990; Neuss, Blair, & Veihweg, 1996; Flexer, Millin, & Brown, 1990; Neuss, Blair, & Veihweg, 1991; Palmer, 1996; Ray, Sarff, & Glassford, 1984; Zabel & 1991; Palmer, 1996; Ray, Sarff, & Glassford, 1984; Zabel & Tabor, 1993). Tabor, 1993).

A three year study of sound field FM A three year study of sound field FM amplification revealed the following results amplification revealed the following results (Osborn, Graves, & VonderEmbse, 1989):(Osborn, Graves, & VonderEmbse, 1989):

The proportion of students requiring special services The proportion of students requiring special services decreased after 3 years with amplified classroomsdecreased after 3 years with amplified classrooms

Amplified kindergarten classes scored significantly Amplified kindergarten classes scored significantly higher on listening, language, and word analysis tests higher on listening, language, and word analysis tests than did children in unamplified classroomsthan did children in unamplified classrooms

Amplified classrooms had better onAmplified classrooms had better on--task behaviors task behaviors than students in unamplified classroomsthan students in unamplified classrooms

As reported by principals, in amplified classrooms, As reported by principals, in amplified classrooms, there were fewer teacher absences due to fatigue and there were fewer teacher absences due to fatigue and laryngitislaryngitis

Teachers in amplified kindergarten classrooms Teachers in amplified kindergarten classrooms tended to use less repetition and rephrasing in their tended to use less repetition and rephrasing in their instructioninstruction

The study began with 17 soundThe study began with 17 sound--field units; 3 years field units; 3 years later, 47 units were in use because teachers wanted later, 47 units were in use because teachers wanted them, parents demanded that their children be them, parents demanded that their children be placed in amplified classrooms, and administrators placed in amplified classrooms, and administrators were convinced that student performance improved.were convinced that student performance improved.

The advantages of soundThe advantages of sound--field amplification result from field amplification result from the use of a teacherthe use of a teacher--worn transmitter microphone that worn transmitter microphone that is positioned 4 to 6 inches from the speakeris positioned 4 to 6 inches from the speaker’’s mouth, s mouth, optimizing critical speech elements. optimizing critical speech elements.

All pupils are consistently closer to the speech source All pupils are consistently closer to the speech source (i.e., the loudspeaker), than they could be to a mobile (i.e., the loudspeaker), than they could be to a mobile teacher. teacher.

The speech signal is not only louder, but each student is The speech signal is not only louder, but each student is closer to the signal (loudspeaker), thereby improving closer to the signal (loudspeaker), thereby improving the S/N ratio. the S/N ratio.

However, a pupil cannot be as close to a However, a pupil cannot be as close to a loudspeaker as he or she can be to a personal loudspeaker as he or she can be to a personal FM receiver that directs the sound into the ear. FM receiver that directs the sound into the ear. Personal FM receivers can provide a speech Personal FM receivers can provide a speech signal superior to that provided by a soundsignal superior to that provided by a sound--field field unit and therefore may be more appropriate for unit and therefore may be more appropriate for some children (Flexer, 1999, pp. 128some children (Flexer, 1999, pp. 128--129).129).Children who have normal peripheral hearing Children who have normal peripheral hearing sensitivity but who have difficulty processing, sensitivity but who have difficulty processing, understanding, or attending to classroom understanding, or attending to classroom instruction could benefit from soundinstruction could benefit from sound--field FM field FM technology (Chermak & Musiek, 1997). technology (Chermak & Musiek, 1997).

What do FM systems do for children What do FM systems do for children in schools?in schools?

They allow the child to hear the teacherThey allow the child to hear the teacher’’s voice at an appropriate and s voice at an appropriate and constant intensity level regardless of the distance between the constant intensity level regardless of the distance between the child and child and the teacher.the teacher.

They allow the teacherThey allow the teacher’’s voice to be more prominently heard than s voice to be more prominently heard than background noise (toys, papers, chairs scraping, whispering, penbackground noise (toys, papers, chairs scraping, whispering, pencils cils being sharpened, feet shuffling).being sharpened, feet shuffling).

They allow for selfThey allow for self--monitoring of the childmonitoring of the child’’s own voice through the s own voice through the conventional hearing aid microphone. conventional hearing aid microphone.

They allow for the conventional hearing aid microphone to be turThey allow for the conventional hearing aid microphone to be turned ned off so that the child can concentrate only on the teacher. off so that the child can concentrate only on the teacher. ((www.asha.org/public/hearing/treatment/assist_tech.htmwww.asha.org/public/hearing/treatment/assist_tech.htm, 2009). , 2009).

Compensatory Strategies Compensatory Strategies

Include strengthening central resources such as Include strengthening central resources such as language and memory and other cognitive skills, so that language and memory and other cognitive skills, so that they can be used to overcome the auditory disorder. they can be used to overcome the auditory disorder.

Teach children to take responsibility for their own Teach children to take responsibility for their own listening success or failure and become an active listening success or failure and become an active participant in daily listening activities through a variety participant in daily listening activities through a variety of active listening and problemof active listening and problem--solving techniques. solving techniques.

Such strategies include asking for repetition and Such strategies include asking for repetition and clarification, repeating what was heard to verify clarification, repeating what was heard to verify accuracy, and to place oneself in the best position to accuracy, and to place oneself in the best position to listen (seating arrangement). listen (seating arrangement).

Direct TreatmentDirect Treatment

Involves remediation of the APD. Involves remediation of the APD.

Some programs in existence address phonemic Some programs in existence address phonemic awareness and some utilize computer based treatment. awareness and some utilize computer based treatment.

Many clinicians use the medical model of 1:1 to provide Many clinicians use the medical model of 1:1 to provide intervention. intervention.

In doing such direct treatment, it is important that the In doing such direct treatment, it is important that the type, frequency, and intensity of therapy be type, frequency, and intensity of therapy be individualized for the specific type of APD present. individualized for the specific type of APD present.

EarobicsEarobics

Earobics, (Earobics.com) has been a mainstay for SLPs Earobics, (Earobics.com) has been a mainstay for SLPs working to develop auditory phonological processing working to develop auditory phonological processing skills. skills.

Earobics is a multisensory reading intervention solution Earobics is a multisensory reading intervention solution designed to support atdesigned to support at--risk readers and foster a safe and risk readers and foster a safe and achievementachievement--orientated learning environment. orientated learning environment.

Earobics includes interactive software, guided Earobics includes interactive software, guided instruction, student resources, teachers guides, instruction, student resources, teachers guides, correlations and assessments, customized professional correlations and assessments, customized professional development, and schooldevelopment, and school--toto--home connections. home connections.

Evidence Studies for EarobicsEvidence Studies for EarobicsIn August of 2000, the Chicago Public Schools and Cognitive In August of 2000, the Chicago Public Schools and Cognitive Concepts, Inc. (CCI) completed a pilot study to evaluate the Concepts, Inc. (CCI) completed a pilot study to evaluate the effectiveness of Earobics in improving Chicago Public School effectiveness of Earobics in improving Chicago Public School studentsstudents’’ literacy performance in 12,000. literacy performance in 12,000.

Results showed that students in all grades achieved dramatic, Results showed that students in all grades achieved dramatic, statistically significant gains in the full range of phonologicastatistically significant gains in the full range of phonological l awareness skills, spelling and decoding. Some grades advanced awareness skills, spelling and decoding. Some grades advanced more than a full year in age and grade levels in only in 10 to 1more than a full year in age and grade levels in only in 10 to 12 2 weeks of using Earobics (Cognitive Concepts Inc., 2001).weeks of using Earobics (Cognitive Concepts Inc., 2001).

In Fall of 2000, Highland Elementary School in Owensboro, In Fall of 2000, Highland Elementary School in Owensboro, Kentucky conducted a pilot study to evaluate the performance of Kentucky conducted a pilot study to evaluate the performance of the the Kindergarten and first grade students using preKindergarten and first grade students using pre-- and postand post--test test assessments.assessments.

Results showed after 15 weeks of Earobic instruction, the first Results showed after 15 weeks of Earobic instruction, the first grade students showed significant gains in phonemic awareness grade students showed significant gains in phonemic awareness skills such as counting phonemes, comparing word lengths and skills such as counting phonemes, comparing word lengths and representing phonemes with letters (Cognitive Concepts Inc., representing phonemes with letters (Cognitive Concepts Inc., 2001). 2001).

In November of 200l, Cincinnati ChildrenIn November of 200l, Cincinnati Children’’s Hospital Medical s Hospital Medical Center conducted a study that involved 17 students who were Center conducted a study that involved 17 students who were referred for Central Auditory Processing Disorder (CAPD) referred for Central Auditory Processing Disorder (CAPD) testing. testing.

Results showed that students who received instruction with Results showed that students who received instruction with Earobics achieved statistically significant gains on overall Earobics achieved statistically significant gains on overall performance on the PAT and made statistically significant performance on the PAT and made statistically significant improvements on each of the eight early literacy skills improvements on each of the eight early literacy skills assessed by the PAT (Cognitive Concepts Inc., 2002). assessed by the PAT (Cognitive Concepts Inc., 2002).

In March of 2001, Polk County Public Schools in Florida In March of 2001, Polk County Public Schools in Florida conducted a pilot study on Earobics Literacy Launch. conducted a pilot study on Earobics Literacy Launch.

Results showed that the 5 Title I schools that had been Results showed that the 5 Title I schools that had been using Earobics with using Earobics with ““Open CourtOpen Court”” or or ““Success For AllSuccess For All””scored significantly higher gains than did 36 Title I schools scored significantly higher gains than did 36 Title I schools that used either literacy basal without Earobics (P<0.02) that used either literacy basal without Earobics (P<0.02) (Cognitive Concepts, Inc., 2002).(Cognitive Concepts, Inc., 2002).

In Spring of 2001, 178 kindergarten students In Spring of 2001, 178 kindergarten students from Newport News Public Schools in Virginia, from Newport News Public Schools in Virginia, were part of the study. were part of the study.

Results showed that students who used Earobics Results showed that students who used Earobics Literacy Launch achieved the targeted spring 2001 Literacy Launch achieved the targeted spring 2001 benchmark which was significantly higher in the benchmark which was significantly higher in the Earobics group (55.4%) than in the control group Earobics group (55.4%) than in the control group (36%) (Cognitive Concepts Inc., 2002).(36%) (Cognitive Concepts Inc., 2002).

In May of 2001, Shadow Oaks Elementary In May of 2001, Shadow Oaks Elementary School in Spring Branch Independent School School in Spring Branch Independent School District conducted a pilot study that involved a District conducted a pilot study that involved a classroom of 16 kindergarton students.classroom of 16 kindergarton students.

Results showed that the students achieved Results showed that the students achieved statistically significant gains in both the midyear statistically significant gains in both the midyear and endand end--ofof--year tests with the use of Earobic year tests with the use of Earobic instruction (Cognitive Concepts Inc 2001)instruction (Cognitive Concepts Inc 2001)

In December of 2002, Dr. Michael Pobanz of Los Angeles Unified In December of 2002, Dr. Michael Pobanz of Los Angeles Unified School District conducted a study with thirtySchool District conducted a study with thirty--nine students who nine students who received instruction with Earobics, and were compared to a contrreceived instruction with Earobics, and were compared to a control ol group who used the core reading program. group who used the core reading program.

Results showed that students in the Earobics group achieved Results showed that students in the Earobics group achieved significantly greater gains in phonological awareness, fluency asignificantly greater gains in phonological awareness, fluency and nd auditory memory than students who received instruction with auditory memory than students who received instruction with Open Court Reading alone (Cognitive Concepts Inc., 2003).Open Court Reading alone (Cognitive Concepts Inc., 2003).

In Spring of 2002, Seven Districts of Columbia elementary schoolIn Spring of 2002, Seven Districts of Columbia elementary schools s administered the Test of Phonological Awarenessadministered the Test of Phonological Awareness--Early Elementary Early Elementary (TOPA(TOPA--EE) which measured improvements in studentsEE) which measured improvements in students’’ early literacy early literacy skills. skills.

Results showed that students in the Earobics classrooms scored Results showed that students in the Earobics classrooms scored significantly higher on the TOPAsignificantly higher on the TOPA--EE than did students in the EE than did students in the nonnon--Earobics classrooms in first grade, second grade and third Earobics classrooms in first grade, second grade and third grade (Cognitive Concepts Inc., 2002). grade (Cognitive Concepts Inc., 2002).

At least three studies have examined the benefits of At least three studies have examined the benefits of Earobics compared to a control group that received no Earobics compared to a control group that received no treatment (Hayes, Warrier, Nicol, Zecker, & Kraus, treatment (Hayes, Warrier, Nicol, Zecker, & Kraus, 2003; Russo et al., 2005; Warrier, Johnson, Hayes, 2003; Russo et al., 2005; Warrier, Johnson, Hayes, Nicol, & Kraus, 2004).Nicol, & Kraus, 2004).

Results of each study confirmed significant benefits Results of each study confirmed significant benefits received by the experimental (treatment) group relative received by the experimental (treatment) group relative to the control group.to the control group.

It seems apparent that the intensity and frequency of It seems apparent that the intensity and frequency of treatment are perhaps the most important variables treatment are perhaps the most important variables influencing treatment outcomes.influencing treatment outcomes.

Challenges in Investigating Outcome Challenges in Investigating Outcome of Treatmentof Treatment

A select population can bias the number of A select population can bias the number of published studies reviewed and lead to a narrow published studies reviewed and lead to a narrow conclusion conclusion Subject population children with LD and Subject population children with LD and reading disorders were excludedreading disorders were excludedAdults should have been included Adults should have been included Animal studies excluded could have provided Animal studies excluded could have provided datadata

Challenges Challenges By excluding studies with dyslexic , the committee By excluding studies with dyslexic , the committee missed some strong evidence for effectiveness of missed some strong evidence for effectiveness of AT.AT.Temple et. al. (2003) found that FFW with dyslexic Temple et. al. (2003) found that FFW with dyslexic children resulted in improved language and reading children resulted in improved language and reading performance and increased activation in multiple performance and increased activation in multiple brain regions during phonological processing. brain regions during phonological processing. Jancke et al. (2001) found improved frequency Jancke et al. (2001) found improved frequency discrimination following training as reflected in discrimination following training as reflected in FMRI in the superior temporal gyrus bilaterally.FMRI in the superior temporal gyrus bilaterally.

Using music as stimuli for AT would have Using music as stimuli for AT would have shown effectiveness, shown effectiveness, Trainor et. al (2003) showed enhanced P2 Trainor et. al (2003) showed enhanced P2 following musical AT in children and adults. following musical AT in children and adults. Gabb et. al (2005) found enhanced pitch pattern Gabb et. al (2005) found enhanced pitch pattern processing and more efficient functional processing and more efficient functional network involving traditional language regions.network involving traditional language regions.

Animal studies show (Threlkeld et. al, 2009) that Animal studies show (Threlkeld et. al, 2009) that in rats auditory training improved auditory in rats auditory training improved auditory discrimination performance. discrimination performance. Although a number of studies that compare Although a number of studies that compare software AT programs found little advantage of software AT programs found little advantage of one over another, they nevertheless documented one over another, they nevertheless documented the effectiveness of these computerized AT the effectiveness of these computerized AT programs (Cohen et. al, 2005; Gillan et. al, 2001; programs (Cohen et. al, 2005; Gillan et. al, 2001; Gillan et. al, 2008).Gillan et. al, 2008).

The Five Steps of EBPThe Five Steps of EBP

Levels of EvidenceLevels of Evidence

According to Evidence Based Practice in the Health According to Evidence Based Practice in the Health Sciences, there are 6 levels of Evidence that include Sciences, there are 6 levels of Evidence that include research designs underlying evidence. Some provide research designs underlying evidence. Some provide stronger evidence than others based on their inherent stronger evidence than others based on their inherent characteristics. characteristics.

The hierarchy is as follows:The hierarchy is as follows:Systematic ReviewsSystematic ReviewsRandomized Controlled TrialsRandomized Controlled TrialsCohort StudiesCohort StudiesCaseCase--Control StudiesControl StudiesCase Series, Case reportsCase Series, Case reportsEditorials, Expert OpinionsEditorials, Expert Opinions

The order of the above reflects the quality of research designs The order of the above reflects the quality of research designs by by level, as well as the quantity of each study design in the body level, as well as the quantity of each study design in the body of of published literature. published literature.

The Oxford Centre for EvidenceThe Oxford Centre for Evidence--Based Medicine provides a Based Medicine provides a more detailed description of each level, the highest level beinmore detailed description of each level, the highest level being g the homogeneous systematic review of randomized controlled the homogeneous systematic review of randomized controlled trials to the least leveltrials to the least level-- expert opinion. expert opinion.

Systematic ReviewsSystematic ReviewsThe strongest type of evidence The strongest type of evidence

Randomized ControlledRandomized Controlled trials aretrials area compilation of an experimental prospective study in a compilation of an experimental prospective study in which the participants are randomly allocated into an which the participants are randomly allocated into an experimental group or a control group followed over experimental group or a control group followed over time or the variables of interest time or the variables of interest Cohort Studies are observational, prospective, and can Cohort Studies are observational, prospective, and can be retrospective studies. be retrospective studies. It involves identification of two groups (Cohorts) of It involves identification of two groups (Cohorts) of patients, one that receives the exposure of interest and patients, one that receives the exposure of interest and one that does not. one that does not.

Case Control StudiesCase Control Studies are observational and retrospective are observational and retrospective which involve which involve

identifying patients who have the outcome of interest and controidentifying patients who have the outcome of interest and control l patients without the same outcome and looking back to see if thepatients without the same outcome and looking back to see if they y had the exposure of interest. had the exposure of interest.

Case SeriesCase Series is a descriptive report on a series of patients with an is a descriptive report on a series of patients with an outcome of interest. outcome of interest.

No control group is involved. No control group is involved. The weakest evidence of the studies since they describe a relatiThe weakest evidence of the studies since they describe a relatively vely small number of patients and no experimental manipulation is small number of patients and no experimental manipulation is involved. involved.

Editorials and Expert Opinion Editorials and Expert Opinion The clinical experience, expertise and judgment of a respected The clinical experience, expertise and judgment of a respected healthcare professional plays an important role in evidence basehealthcare professional plays an important role in evidence based d practice. practice.

It is agreed that systematic reviews serve the profession well bIt is agreed that systematic reviews serve the profession well by its y its scrutiny and high standards. scrutiny and high standards.

Nevertheless, there are other measures of evidence that the LibrNevertheless, there are other measures of evidence that the Library ary of Health Sciencesof Health Sciences--Chicago, University of Illinois and the APA Chicago, University of Illinois and the APA uphold as reasonable courses of action in determining treatment uphold as reasonable courses of action in determining treatment efficacy. Such measures include clinical experience and expert efficacy. Such measures include clinical experience and expert opinions. opinions.

While the level of evidence approach is useful, this model was While the level of evidence approach is useful, this model was developed for bio statistical treatments and epidemiologic studideveloped for bio statistical treatments and epidemiologic studies, es, a different context than most studies relevant to audiology. a different context than most studies relevant to audiology.

The model rates group studies as superior to individual case The model rates group studies as superior to individual case studies. However, group studies present studies. However, group studies present ““averageaverage”” performance performance which may not apply directly to anyone particular person. which may not apply directly to anyone particular person.

Case studies and retrospective studies (3 & 4 Case studies and retrospective studies (3 & 4 level evidence) can provide more evidence level evidence) can provide more evidence appropriate for a particular individualappropriate for a particular individual’’s profile s profile and intervention (Barlow & Herson, 1984).and intervention (Barlow & Herson, 1984).

We should not dismiss evidence because it is at a We should not dismiss evidence because it is at a lower level nor should we accept evidence as lower level nor should we accept evidence as infallible because it is assigned a higher level of infallible because it is assigned a higher level of evidence (Chemark, 2009). evidence (Chemark, 2009).

Expert OpinionExpert Opinion

Some of us are of the opinion that treatment Some of us are of the opinion that treatment does work and that evidence can be found does work and that evidence can be found substantiating successful management and substantiating successful management and treatment of children with APD over the years treatment of children with APD over the years by SLPs/Audiologists. by SLPs/Audiologists.

There are studies that have There are studies that have tackled the question. tackled the question.

Frank MusiekFrank Musiek

Treatment evidence is found in Neuroscience Treatment evidence is found in Neuroscience Journals Journals No question that AT is highly useful in CAPD No question that AT is highly useful in CAPD as seen in these articlesas seen in these articles““The sheer abundance of neuroscience literature The sheer abundance of neuroscience literature that supports the concept of AT for problems that supports the concept of AT for problems with auditory function and related issues is over with auditory function and related issues is over whelmingwhelming””..The basic science is extremely strongThe basic science is extremely strong

Agnew, Dorn, & Eden, 2004Agnew, Dorn, & Eden, 2004Cohen et al., 2005Cohen et al., 2005Gillam, Crofford, Gale, & Hoffman, 2001Gillam, Crofford, Gale, & Hoffman, 2001Gillam et al., 2008Gillam et al., 2008Hayes, Warrier, Nicol, Zecker, & Kraus, 2003Hayes, Warrier, Nicol, Zecker, & Kraus, 2003Kujala et al., 2001Kujala et al., 2001Moore, Rosenberg, & Coleman, 2005Moore, Rosenberg, & Coleman, 2005Russo et al., 2005Russo et al., 2005Tallal et al., 1996Tallal et al., 1996Temple et al., 2003Temple et al., 2003Warrier, Johnson, Hayes, Nicol, & Kraus, 2004Warrier, Johnson, Hayes, Nicol, & Kraus, 2004Katz et al., 1984Katz et al., 1984Devenyi, 1989Devenyi, 1989Jirsa, 1993Jirsa, 1993Alexander & Frost, 1982Alexander & Frost, 1982

Jack KatzJack KatzWorking with APD more than 50 years Working with APD more than 50 years Saw relationship between APD and reading Saw relationship between APD and reading problems in children esp. phonemic synthesisproblems in children esp. phonemic synthesisSkills improved as did oral readingSkills improved as did oral readingResults of Phonemic Synthesis Training (Katz, 2009) Results of Phonemic Synthesis Training (Katz, 2009) provides data from:provides data from:

1.1. Monitoring the therapy performanceMonitoring the therapy performance2.2. Test and retest of original test gatheringTest and retest of original test gathering3.3. Parent /teacher ratings of change in the areas of Parent /teacher ratings of change in the areas of

concernconcern

Parents of children realize how easy it is to Parents of children realize how easy it is to improve auditory skills with training in spite of improve auditory skills with training in spite of being told that there is no such thing as auditory being told that there is no such thing as auditory processing and there is no therapy for it! (Katz, processing and there is no therapy for it! (Katz, 2009)2009)

ExpertsExperts

Robert KeithRobert KeithExpert opinion is a nonscientific approach.Expert opinion is a nonscientific approach.

Teri BellisTeri BellisThe Science is strong with evidence for Auditory The Science is strong with evidence for Auditory training to benefit individuals with CAPD training to benefit individuals with CAPD

AAA Practice GuidelinesAAA Practice Guidelines

““While the level of evidence approach is useful, it should be While the level of evidence approach is useful, it should be understood that this model was developed primarily for understood that this model was developed primarily for biostatistical treatments and epidemiologic studies, a somewhat biostatistical treatments and epidemiologic studies, a somewhat different context than most studies relevant to audiology. different context than most studies relevant to audiology. Moreover, the model rates group studies as superior to individuaMoreover, the model rates group studies as superior to individual l case studies, however, this does not account for the fact that tcase studies, however, this does not account for the fact that the he results of group studies reflect results of group studies reflect ““averageaverage”” performance and might performance and might not directly apply to any particular individual. In fact, case snot directly apply to any particular individual. In fact, case studies tudies and retrospective studies (which are classified as level 3 or 4 and retrospective studies (which are classified as level 3 or 4 evidence) can often provide clinicians with evidence appropriateevidence) can often provide clinicians with evidence appropriatefor a particular individualfor a particular individual’’s profile and intervention (Barlow & s profile and intervention (Barlow & Hersen, 1984). A more pragmatic approach to evaluating evidence Hersen, 1984). A more pragmatic approach to evaluating evidence would be to not dismiss evidence simply because it is at a lowerwould be to not dismiss evidence simply because it is at a lowerlevel and conversely not to automatically accept evidence as level and conversely not to automatically accept evidence as infallible simply because it is assigned a higher level of evideinfallible simply because it is assigned a higher level of evidence.nce.””(Chermak, 2009)(Chermak, 2009)

AuthorAuthor’’s Opinionss OpinionsAlthough the final paper produced from the Although the final paper produced from the systematic study presents outcomes that are not systematic study presents outcomes that are not hopeful, evidence from clinicians on tried and true hopeful, evidence from clinicians on tried and true methods do give us hope. methods do give us hope. Studying other populations than those studied here do Studying other populations than those studied here do show evidence for effectiveness.show evidence for effectiveness.Further, because a systematic review involves Further, because a systematic review involves accepting only those studies that received the higher accepting only those studies that received the higher rankings, many studies were omitted because they rankings, many studies were omitted because they didndidn’’t meet the criteria, i.e., subject blinding, control t meet the criteria, i.e., subject blinding, control group , size, etc., for inclusion or they lacked sufficient group , size, etc., for inclusion or they lacked sufficient information.information.

Many studies, i.e., Gillam, et al., which did not show Many studies, i.e., Gillam, et al., which did not show benefits of any one program over the other in final benefits of any one program over the other in final outcome, nevertheless, did demonstrate that the outcome, nevertheless, did demonstrate that the programs understudy produced some reasonable programs understudy produced some reasonable outcomes. outcomes.

A distinction should be made when tackling such a goal A distinction should be made when tackling such a goal of evaluating treatments to a heterogenous and dynamic of evaluating treatments to a heterogenous and dynamic group. It cannot stand up to the same rigorous standards group. It cannot stand up to the same rigorous standards as an investigational drug study, where dosage and as an investigational drug study, where dosage and titrates are strictly controlled.titrates are strictly controlled.

Another distinction should be made between learners Another distinction should be made between learners and nonlearners. There are those who will not benefit and nonlearners. There are those who will not benefit regardless of the treatment used.regardless of the treatment used.

I believe that treatment has benefits and the SLPs I believe that treatment has benefits and the SLPs should be in the position of delivering treatments and should be in the position of delivering treatments and management, while continuing to collect data on management, while continuing to collect data on efficacy. efficacy.

The evidence for efficacy of FM usage is clear and The evidence for efficacy of FM usage is clear and beneficial in the classroom and in the individual therapy beneficial in the classroom and in the individual therapy sessionssessions-- even in quiet conditions! even in quiet conditions!

Teaching compensatory strategies and providing Teaching compensatory strategies and providing support/accommodations are helpful in the support/accommodations are helpful in the management. Such programs are hard to measure for management. Such programs are hard to measure for efficacy. efficacy.

Of concern is the methodology that is used to determine the Of concern is the methodology that is used to determine the presence of CAPD and the improvement following treatment presence of CAPD and the improvement following treatment based on such measures as backward masking. This measure may based on such measures as backward masking. This measure may not be appropriate. not be appropriate.

In some cases, the diagnosis may not be accurate and often the In some cases, the diagnosis may not be accurate and often the population is so heterogeneous, it is hard to tease out what is population is so heterogeneous, it is hard to tease out what is APD from language impairment. APD from language impairment.

When evaluating a heterogeneous population, there are so many When evaluating a heterogeneous population, there are so many confounding variables, it is hard to know what works and for confounding variables, it is hard to know what works and for whom. whom.

Further, the heterogeneity of such groups makes it virtually Further, the heterogeneity of such groups makes it virtually impossible to make any statement regarding treatment efficacy. impossible to make any statement regarding treatment efficacy.

There are many software programs on the market to help There are many software programs on the market to help clinicians and parents address their childclinicians and parents address their child’’s auditory weaknesses. s auditory weaknesses.

Some are language or phonologically based. Some deal with Some are language or phonologically based. Some deal with phonemic synthesis, memory training, auditory figure, group phonemic synthesis, memory training, auditory figure, group listening, prosody training and temporal processing. Cognitive listening, prosody training and temporal processing. Cognitive training is also available which may include language training, training is also available which may include language training, metalinguistic, vocabulary development and organization skills. metalinguistic, vocabulary development and organization skills.

The children we see all need a compilation of treatments dealingThe children we see all need a compilation of treatments dealingwith the myriad of deficits encountered in this population. with the myriad of deficits encountered in this population.

School age childrenSchool age children’’s auditory perception of speech and non s auditory perception of speech and non speech continue to develop during school age years which can be speech continue to develop during school age years which can be modified by auditory experience (Kraus et al., 1999)modified by auditory experience (Kraus et al., 1999)

ConclusionConclusion

There is much work to do ahead in deciphering There is much work to do ahead in deciphering just what the nature of APD is in a particular just what the nature of APD is in a particular childchild-- since no two children are alikesince no two children are alike-- and to and to determine which programs are more appropriate determine which programs are more appropriate for each child. We have a long journey ahead in for each child. We have a long journey ahead in determining what works and for whom.determining what works and for whom.

Geraldine Wallach

Personal Perspective

THE ROLE OF THE SLP IN THE ROLE OF THE SLP IN APD:APD:

PEELING THE ONIONPEELING THE ONION

GERALDINE P. WALLACHGERALDINE P. WALLACHDept of Communicative DisordersDept of Communicative Disorders

California State University at Long California State University at Long BeachBeach

THE APD COMMITTEETHE APD COMMITTEE

A MODEL OF A MODEL OF COLLABORATIONCOLLABORATION

WHAT IS BUNNY # 2WHAT IS BUNNY # 2’’S REAL S REAL PROBLEM?PROBLEM?

GRADE 5 CONNECTED TEXTGRADE 5 CONNECTED TEXTThe The colonistscolonists knew that their actions would have knew that their actions would have very serious consequences, or results. very serious consequences, or results. AfterAfterhearing about the Boston Tea Party, Parliament hearing about the Boston Tea Party, Parliament decided to punish the decided to punish the colonycolony of Massachusetts. of Massachusetts. A law was passed saying A law was passed saying thatthat no ship carrying no ship carrying colonialcolonial goods could leave Boston Harbor goods could leave Boston Harbor untiluntilthe the colonistscolonists had paid for all of the tea had paid for all of the tea thatthatwas destroyed. To enforce the new law, was destroyed. To enforce the new law, Parliament ordered the Royal Navy to blockade Parliament ordered the Royal Navy to blockade Boston Harbor.Boston Harbor.

Social Studies: The Early United States (2000) p. 280Social Studies: The Early United States (2000) p. 280

A GRADE 5 COMPREHENSION A GRADE 5 COMPREHENSION CHALLENGE: SENTENCE LEVELCHALLENGE: SENTENCE LEVEL

The Boston Tea The Boston Tea Party was the Party was the colonistscolonists’’response to an response to an unfair tax unfair tax instituted the instituted the prior year by prior year by the British the British ParliamentParliament

SCIENCESCIENCEWHAT KIND OF ENERGY IS INVOLVED WHAT KIND OF ENERGY IS INVOLVED

WHEN MATTER CHANGES STATE?WHEN MATTER CHANGES STATE?

RECALL WHAT YOU KNOW ABOUT RECALL WHAT YOU KNOW ABOUT CHANGES OF STATECHANGES OF STATE

EXPLAIN WHAT PROPERTIES HELP KEEP EXPLAIN WHAT PROPERTIES HELP KEEP AIR IN REFRIGERATOR COLDAIR IN REFRIGERATOR COLD

Science Discovery Works, p.b37Science Discovery Works, p.b37

WHAT DO WE KNOW FOR WHAT DO WE KNOW FOR SURE: CURRICULAR CONTENTSURE: CURRICULAR CONTENT

UNFAMILIAR UNFAMILIAR TOPICS/ABSTRACTTOPICS/ABSTRACTEMBEDDED IN EMBEDDED IN COMPLEX FORMSCOMPLEX FORMSDECONTEXTUALIZEDDECONTEXTUALIZED

WHAT ELSE DO WE KNOW: WHAT ELSE DO WE KNOW: DERIVED LITERACIESDERIVED LITERACIES

EACH SUBJECT HAS EACH SUBJECT HAS ITS OWN ITS OWN LANGUAGE, E.G. LANGUAGE, E.G. HISTORY = VERY HISTORY = VERY INFERENTIAL; INFERENTIAL; SCIENCE = SCIENCE = TECHNICAL TECHNICAL LANGUAGELANGUAGE

SO WHATSO WHAT??

LANGUAGE LANGUAGE DISORDERS DISORDERS RESIDE INSIDE RESIDE INSIDE AND OUTSIDE AND OUTSIDE KIDSKIDS’’ HEADSHEADS

INSIDE/OUTSIDE CONCEPT INSIDE/OUTSIDE CONCEPT AT SCHOOL AGE LEVELSAT SCHOOL AGE LEVELS

DEMANDS OF THE CURRICULUM DEMANDS OF THE CURRICULUM AND THE INSTRUCTIONAL AND THE INSTRUCTIONAL REQUIREMENTS OF TEACHERS REQUIREMENTS OF TEACHERS PLUS STATE STANDARDS MUST BE PLUS STATE STANDARDS MUST BE PART OF THE ASSESSMENT AND PART OF THE ASSESSMENT AND INTERVENTION PROCESS FOR INTERVENTION PROCESS FOR STUDENTS WITH APD/LLDSTUDENTS WITH APD/LLD

A KEY QUESTIONA KEY QUESTION……

WHAT DO I AS WHAT DO I AS AN SLP DO WHEN AN SLP DO WHEN AN AUDIOLOGIST AN AUDIOLOGIST OR TEACHER OR TEACHER SENDS ME AN SENDS ME AN APD REPORT OR APD REPORT OR REFERRAL?REFERRAL?

OPTIONSOPTIONS……

IGNORE ITIGNORE ITTOSS REPORT IN TOSS REPORT IN SHREDDERSHREDDERCONSIDER A CONSIDER A ““RED RED FLAGFLAG””CREATE CREATE INTERVENTION THAT INTERVENTION THAT DEALS DIRECTLY WITH DEALS DIRECTLY WITH AUD SKILLAUD SKILL

MY PERSONAL OPTIONMY PERSONAL OPTIONMORE LIKELY SEE THE DIAGNOSIS MORE LIKELY SEE THE DIAGNOSIS AS A RED FLAG (IDENTIFICATION)AS A RED FLAG (IDENTIFICATION)HAVE TO PROCEED TO THE HAVE TO PROCEED TO THE CONTEXTS IN WHICH LANGUAGE CONTEXTS IN WHICH LANGUAGE AND ACADEMIC LEARNING ARE AND ACADEMIC LEARNING ARE PROBLEMATICPROBLEMATICFIND FUNCTIONAL FIND FUNCTIONAL MANIFESTATIONS OF AUDITORY MANIFESTATIONS OF AUDITORY FINDINGSFINDINGS

WHERE WE ARE COMING FROM?WHERE WE ARE COMING FROM?

1. CREATE A VIABLE SET 1. CREATE A VIABLE SET OF LANGUAGE OF LANGUAGE INITIATIVES FOCUSED INITIATIVES FOCUSED TOWARDS CONTENT TOWARDS CONTENT AREA LEARNINGAREA LEARNING

2. HELP KIDS DEVELOP 2. HELP KIDS DEVELOP THE LANGUAGE THE LANGUAGE KNOWLEDGE, SKILLS, KNOWLEDGE, SKILLS, AND STRATEGIES AND STRATEGIES NEEDED NEEDED

(EHREN (EHREN ’’06; WALLACH ETAL 06; WALLACH ETAL ‘‘09)09)

KNOWLEDGE, SKILLS, AND KNOWLEDGE, SKILLS, AND STRATEGIESSTRATEGIES

PARAPHRASING:PARAPHRASING:---- A COMPREHENSION A COMPREHENSION STRATEGYSTRATEGY

---- ONE NEEDS A ONE NEEDS A KNOWLEDGEKNOWLEDGE OF WORDS OF WORDS (SYNONYMS)(SYNONYMS)

---- ONE ALSO NEEDS SYNTACTIC ONE ALSO NEEDS SYNTACTIC SKILLSSKILLS

EHREN, 2006EHREN, 2006

DOES CAP INTERVENTION DOES CAP INTERVENTION MEASURE UP?MEASURE UP?

1. LANGUAGE INTERVENTION AT 1. LANGUAGE INTERVENTION AT SCHOOL AGED LEVELS = SCHOOL AGED LEVELS = CURRICULAR CONTENT WITH CURRICULAR CONTENT WITH LANGUAGE SKILLS TO GET LANGUAGE SKILLS TO GET KIDS THEREKIDS THERE

2. KEEPING IDEAS AS CLOSE TO 2. KEEPING IDEAS AS CLOSE TO CONTENT AREA AS POSSIBLE CONTENT AREA AS POSSIBLE (DERIVED LITERACIES)(DERIVED LITERACIES)

3. WATCH THE COMPETING 3. WATCH THE COMPETING RESOURCES (TOO MANY RESOURCES (TOO MANY FACTORS INTERACTING)FACTORS INTERACTING)

GUIDING PRINCIPLES: GUIDING PRINCIPLES: METAPHORS FOR METAPHORS FOR CONSIDERATIONCONSIDERATION

---- GETTING TO THE GETTING TO THE CORE OF PROBLEMCORE OF PROBLEM

---- MUST KEEP MUST KEEP PEELING THE PEELING THE LAYERS OF THE LAYERS OF THE ONIONONION

PEELING THE ONION OF PEELING THE ONION OF SENTENCE MEMORY TASKSSENTENCE MEMORY TASKS

METALINGUISTIC METALINGUISTIC DECONTEXTUALIZEDDECONTEXTUALIZEDPRAGMATICALLY BIZARREPRAGMATICALLY BIZARREINFLUENCED BY LEXICAL INFLUENCED BY LEXICAL FAMILIARITYFAMILIARITYHAS A PRODUCTION HAS A PRODUCTION COMPONENT (COMPETING COMPONENT (COMPETING RESOURCES)RESOURCES)

METAPHORS CONTDMETAPHORS CONTD……(KEEP CORE IN MIND)(KEEP CORE IN MIND)

METAPHORS CONTDMETAPHORS CONTD……(CHICKEN(CHICKEN--EGG QUESTION)EGG QUESTION)

ONE WAY MAPPINGONE WAY MAPPING(THE CAUSE EFFECT (THE CAUSE EFFECT

DIRECTION)DIRECTION)

---- AP AP --> L > L ---- S S --> W> W---- C C --> L> L---- R R --> E> E

CHICKEN CHICKEN –– EGG ONE WAY MAPPING EGG ONE WAY MAPPING CONTCONT’’D: LANGUAGE KNOWLEDGE D: LANGUAGE KNOWLEDGE

HAS POWERHAS POWER---- LEARNERS CREATE EXPECTANCIES FOR LEARNERS CREATE EXPECTANCIES FOR

WHAT THEY ARE LIKELY TO HEARWHAT THEY ARE LIKELY TO HEAR---- THEIR EXPECTANCIES INFLUENCE THEIR EXPECTANCIES INFLUENCE

WHAT IS WHAT IS ATTENDED TOATTENDED TO, , PERCEIVEDPERCEIVED, , AND AND REMEMBEREDREMEMBERED

---- CHILDREN GET BETTER CHILDREN GET BETTER ““SEQUENCINGSEQUENCING””WHEN NARRATIVE STRUCTURE WHEN NARRATIVE STRUCTURE IMPROVESIMPROVES

(GILLAM, ET AL (GILLAM, ET AL ‘‘02; LAHEY AND BLOOM, 02; LAHEY AND BLOOM, ’’94; NITTROUER, 94; NITTROUER, ‘‘02)02)

THINGS ARE NOT ALWAYS THINGS ARE NOT ALWAYS WHAT THEY SEEMWHAT THEY SEEM

DYNAMIC PROCESSINGDYNAMIC PROCESSING(E.G. TWO STEP COMMANDS)(E.G. TWO STEP COMMANDS)

---- BEFORE YOU EAT DINNER, BEFORE YOU EAT DINNER, WASH YOUR HANDSWASH YOUR HANDS

---- TAKE OUT YOUR MATH TAKE OUT YOUR MATH BOOKS BEFORE YOU START BOOKS BEFORE YOU START YOUR READINGYOUR READING

---- TOUCH THE BIG RED TOUCH THE BIG RED TRIANGLE AFTER YOU PICK TRIANGLE AFTER YOU PICK UP THE SMALL RED SQUAREUP THE SMALL RED SQUARE

PROCESSING IS NOT LINEARPROCESSING IS NOT LINEAR

““A LAW WAS PASSED SAYING THAT NO A LAW WAS PASSED SAYING THAT NO SHIP CARRYING COLONIAL GOODS SHIP CARRYING COLONIAL GOODS COULD LEAVE BOSTON HARBOR UNTIL COULD LEAVE BOSTON HARBOR UNTIL THE COLONIST HAD PAID FOR ALL OF THE COLONIST HAD PAID FOR ALL OF THE TEA THAT WAS DESTROYED.THE TEA THAT WAS DESTROYED.””

FROM SOCIAL STUDIES: THE EARLY U.S. FROM SOCIAL STUDIES: THE EARLY U.S. 2000, P. 280 (SEE ALSO NIPPOLD2000, P. 280 (SEE ALSO NIPPOLD’’S WORK)S WORK)

THINGS ARE NOT ALWAYS THINGS ARE NOT ALWAYS THE WAY THEY SEEMTHE WAY THEY SEEM

AUD DISCRIM TASKS = META AUD DISCRIM TASKS = META JUDGEMENTS/PHONEMICJUDGEMENTS/PHONEMICLINDAMOOD TASKS = CLOSER TO LINDAMOOD TASKS = CLOSER TO PRINT KNOWLEDGEPRINT KNOWLEDGE

GUIDING PRINCIPLESGUIDING PRINCIPLES1. GET TO THE CORE OF WHAT OUR KIDS 1. GET TO THE CORE OF WHAT OUR KIDS

WITH LLD NEED (BE RELEVANT AND WITH LLD NEED (BE RELEVANT AND FUNCTIONAL)FUNCTIONAL)

2. UNDERSTAND THE COMPLEX CAUSE/EFFECT 2. UNDERSTAND THE COMPLEX CAUSE/EFFECT RELATIONS AMONG DISCRETE SKILLS AND RELATIONS AMONG DISCRETE SKILLS AND ““HIGHER ORDERHIGHER ORDER”” SKILLSSKILLS

3. KNOW THAT THINGS AREN3. KNOW THAT THINGS AREN’’T ALWAYS T ALWAYS WHAT THEY SEEM (LABELS CAN DECEIVE)WHAT THEY SEEM (LABELS CAN DECEIVE)

4. RECOGNIZE THAT AUDITORY, LINGUISTIC 4. RECOGNIZE THAT AUDITORY, LINGUISTIC AND ACADEMIC PROBLEMS ARE BOTH AND ACADEMIC PROBLEMS ARE BOTH ““INSIDEINSIDE”” AND AND ““OUTSIDEOUTSIDE”” KIDSKIDS’’ HEADSHEADS

SOME FINAL THOUGHTSSOME FINAL THOUGHTS---- CLAIM OF CAUSECLAIM OF CAUSE--EFFECT EFFECT RELATIONS OF CAP DISORDERS RELATIONS OF CAP DISORDERS AND OTHER PROBLEMS REJECTED AND OTHER PROBLEMS REJECTED BY MANY (E.G., BISHOP and BY MANY (E.G., BISHOP and NITTROUER)NITTROUER)

---- APPRECIATE INTRICATE LINKS APPRECIATE INTRICATE LINKS BETWEEN VARIOUS ASPECTS OF BETWEEN VARIOUS ASPECTS OF LANGUAGE PROCESSING FOR LANGUAGE PROCESSING FOR DESIGNING BETTER TOOLSDESIGNING BETTER TOOLS

FINAL THOUGHTS CONTFINAL THOUGHTS CONT’’DD……---- LANGUAGE INTERVENTION LANGUAGE INTERVENTION STRUCTURED WITH KNOWLEDGE, STRUCTURED WITH KNOWLEDGE, SKILLS AND STRATEGIES IN THE SKILLS AND STRATEGIES IN THE CONTEXTS RELATED TO CONTEXTS RELATED TO ““THE THE REAL WORLDREAL WORLD””

---- EVEN IF CAP DISORDERS EXIST, EVEN IF CAP DISORDERS EXIST, WE NEED TO GET AT THEM BY WE NEED TO GET AT THEM BY CREATING STRATEGIC LANGUAGE CREATING STRATEGIC LANGUAGE INTERVENTION PROGRAMS INTERVENTION PROGRAMS (EHREN)(EHREN)

THE IMPORTANT QUESTIONTHE IMPORTANT QUESTION

WHAT ARE THE WHAT ARE THE LANGUAGELANGUAGEUNDERPINNINGS OF UNDERPINNINGS OF THE ACADEMIC THE ACADEMIC TASKS FACING OUR TASKS FACING OUR KIDS?KIDS?

(NORRIS (NORRIS ’’97; EHREN 97; EHREN ’’00; WALLACH 00; WALLACH ’’08)08)

THINK OF WAYS TO HELP OUR THINK OF WAYS TO HELP OUR KIDS CONSTRUCT KNOWLEDGEKIDS CONSTRUCT KNOWLEDGE

““WATER UPWATER UP”” THE THE CURRICULUM CURRICULUM (ED ELLIS (ED ELLIS ’’97)97)

---- ELABORATE ON ELABORATE ON IDEASIDEAS

---- BROAD CONCEPTSBROAD CONCEPTS

THINK OF WAYS TO HELP OUR THINK OF WAYS TO HELP OUR KIDS WORK THE LANGUAGEKIDS WORK THE LANGUAGE

---- DEVELOP AND USE DEVELOP AND USE STRATEGIES TO STRATEGIES TO COMPREHEND COMPREHEND LANGUAGELANGUAGE

---- DEVELOP WAYS TO DEVELOP WAYS TO ORGANIZE INCOMING, ORGANIZE INCOMING, SPOKEN, AND SPOKEN, AND WRITTEN LANGUAGEWRITTEN LANGUAGE

DONDON’’T BUY APPLES IF YOU T BUY APPLES IF YOU WANT TO MAKE ORANGE WANT TO MAKE ORANGE

JUICEJUICE

CAPD: THE MOTHER OF CAPD: THE MOTHER OF ALL MYTHS?ALL MYTHS?

---- DIALOGUE DIALOGUE NEEDED ABOUTNEEDED ABOUTTHE TOPICTHE TOPIC

---- VARYING VIEWS VARYING VIEWS AMONG AMONG PROFESSIONALSPROFESSIONALS

---- CAN WE FIND CAN WE FIND COMMON COMMON GROUND?GROUND?

Summary Comments

It all depends on how you look at it!

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