BAA Conference 19.11.13
Characteristics of cognition, language, listening and auditory
processing abilities in children with specific language
impairment and autistic spectrum disorder
NIHR Nottingham Hearing Biomedical Research Unit, UK
Mel Ferguson
To prevent future
publishing conflict all
unpublished data have
been removed
BAA Conference 19.11.13
How comorbid is APD with Language Impairment and Autistic
Spectrum Disorder?
NIHR Nottingham Hearing Biomedical Research Unit, UK
Mel Ferguson
Ear Central Auditory System Hearing
The auditory brain
Ear Central Auditory System Listening
Vision
Attention Memory
Learning
The auditory brain
“We hear with our ears…
but listen with our brains”
Ear Central Auditory System Listening
Vision
Attention Memory
Learning
The auditory brain
“It’s not what you hear, it’s what you do
with what you hear”
Jack Katz
Clinical presentation of
auditory processing disorder
• Difficulties hearing in noisy surroundings
• Difficulties following verbal instructions
• Language and communication difficulties
• Inattention
• Distractibility
• Academic difficulties
(Keith, 1994, 2000; Bamiou et al, 2001)
APD symptoms are similar to other
developmental disorders
Dyslexia
Specific Language
Impairment
Attention Deficit Hyperactivity Disorder
Autistic Spectrum
Disorder
Behavioural
problems
Communication:
no difference between SLI and APD
Group APD SLI MS
GC
C
90
80
70
60
50
40
30
p < .001
(Ferguson et al, JSLHR, 2011)
Children’s Communication Checklist-2 (CCC-2)
General communication composite (GCC)
120 100 80 60 40 20 0
So
cia
l in
tere
acti
on
devia
nce
co
mp
osit
e (
SID
C)
30
20
10
0
-10
-20
-30
APD
SLI
MS SLI
ASD Typical
Error bars = mean +/- 95% CI
Conclusions from clinical case study
• APD and SLI for all practical purposes are indistinguishable
o APD and SLI groups were poor on all cognitive tests
o APD and SLI groups were poor on listening (CHAPPS)
• Referral route central to diagnostic labelling
o Similar cognitive and behavioural profiles can have different
diagnostic labels
• What might be a useful functional test of APD?
o CCC-2, validated, well-constructed, and would identify functional
communication problems associated with APD**
**see Dillon et al (2012, JAAA)
(Ferguson et al, JSLHR, 2011)
Challenges of APD
• Lots of clinical tests of APD available – many of these are:
• based on a clinical case approach
• poorly validated
• speech-based
• Diagnosis label useful.....but only to a point
– standard diagnostic test batteries for APD cannot effectively
distinguish between disorders like APD, SLI, dyslexia
• Appropriate to focus on presenting symptoms
– to understand more about an individual child’s strengths, weaknesses
and clinical needs
– to make decisions about best route of referral
• Need for robust research to understand what APD is, how it is
characterised, then how it can be diagnosed and managed
Research approaches to developing
and validating tests of APD
• Case control approach
Examine two samples of listeners,
one with and one without a
diagnosis of APD
Addresses the ‘clinical
presentation’
Currently no validated APD
tests in UK
Assumes unbiased sampling
of APD (and control) group
• Population approach
Poor auditory performance
identified on the basis of
auditory/non-speech abilities
Makes no assumption about
the link between presenting
symptoms and APD
Can lose track of clinical
presenting symptoms
Prevalence of APD unknown
(estimate 5%)
IHR Multi-centre Auditory
Processing study (IMAP)
Population study, May 07-July08
n = 1638 children, 6-11 y.o.
n = 1476 normally hearing
Stratified by age, sex and socioeconomic group
Nottingham
Exeter
Cardiff
Glasgow
Testing in
schools
Conclusion:
APD is primarily a result of poor
engagement with sounds.
We suggest that APD is primarily an
attention problem, and that clinical
diagnosis and management … should
be based on that premise.
(Moore, Ferguson et al, Pediatrics, 2010)
IHR Multi-centre Auditory
Processing study (IMAP)
Population study, May 07-July08
n = 1638 children, 6-11 y.o.
n = 1476 normally hearing
Stratified by age, sex and socioeconomic group
Nottingham
Exeter
Cardiff
Glasgow
Testing in
schools
Aims: To identify the characteristics of normally
hearing children who had:
• communication problems
• listening problems
(Moore, Ferguson et al, Pediatrics, 2010)
Functional difficulties not diagnosis
• Children’s Communication Checklist
– n=70 questions n=10 scales 3 subscales
• Structural language
– Language structure, vocabulary and discourse
» Speech production, syntax, semantics
• Pragmatic language
– Difficulties in pragmatic, everyday use of language, in relation to the
communication context e.g. difficulties interpreting figurative language,
poor accounting of the perspectives of others
» Inappropriate initiation, use of context, stereotyped language
• Autistic behaviours
– Triad of symptoms: communication disorders, social impairment,
restricted stereotyped behaviours
» Social relations, interests
(Bishop, 2003)
CCC-2: communication difficulties
SLI ASD PLI
Based on Norbury et al, 2004
Clinical labels most closely aligned to.
Main difference between ASD and Asperger Syndrome = ASP do not have
delayed language when younger
CCC-2 suitable for children aged 4+ years who speak in sentences (HFA)
n=818
CHAPPS: listening difficulties
SLI ASD PLI
n=818
6 scales on listening in:
• Noise • Quiet
• Ideal
Poorest 5%
n=45 Not ideal because:
• Lack theoretical basis
• Not psychometrically robust
• Not validated
• Leptokurtic distribution
But best we had at the time –
more of that later!
• Attention
• Memory
• Multiple inputs
Children’s Auditory Processing Performance Scale (Smoski et al, 1992)
Summary of results
• Compared to the typically developing children:
– The listening difficulties group (APD) had poorer scores for all the
CCC-2 subscales (structural, pragmatic and autistic)
– Listening was poorer for all the ‘clinical’ groups
– Cognition, language and reading were poorer for all the ‘clinical’ groups
who had general communication or listening difficulties, except ASP
– Frequency discrimination was poorer for those with structural language
and listening abilities
– The group mostly aligned to Asperger’s syndrome were virtually the
same as TD on all measures, with the exception of listening, poorer in
about 10%
Clinical implications
• Symptoms of children with listening difficulties (or APD) are very
similar to those with communication problems aligned to language
impairment (LI) and autistic spectrum disorder (ASD)
– does APD co-occur with other developmental disorders? Yes
– is APD a separate disorder? Probably not
– does APD fall along a dimension? Probably yes
• Children presenting to Audiology with listening difficulties should be
assessed for communication difficulties (e.g. SLI, PLI, or ASD)
– How? Questionaires such as CCC-2, CAST, ADOS,
– Or, ECLIPS, developed by Johanna Barry at IHR
www.ihr.mrc.ac.uk
IMAP team
Dave Moore
Alison Riley
Sonia Ratib
Sally Hind
Anna Phillips
Karen Baker
Nicola Bergin
Leanne Mattu
Ruth Lewis
Kelvin Wakeham, Royal Devon and Exeter Hospital, Exeter
Juan Mora, Royal Hospital for sick children, Glasgow
Veronica Kennedy, University Hospital, Cardiff
Clinical implications
• Symptoms of children with listening difficulties (or APD) are very
similar to those with communication problems aligned to language
impairment (LI) and autistic spectrum disorder (ASD)
– does APD co-occur with other developmental disorders? Yes
– is APD a separate disorder? Probably not
– does APD fall along a dimension? Probably yes
• Children presenting to Audiology with listening difficulties should be
assessed for communication difficulties (e.g. SLI, PLI, or ASD)
– How? Questionaires such as CCC-2, CAST, ADOS,
– Or, ECLIPS, developed by Johanna Barry at IHR
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