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Use the clues: differential diagnosis and intervention for processing disorders

Jeanane M. Ferre, PhD1010 Lake Street, Suite 621

Oak Park, IL 60301708.848.4363

Fax:708.848.7233Email: [email protected]

disclosures

• Financial

– Invited speaker ‐receiving stipend and reg waiver

– Pro‐Ed author

– Consultant – school districts in IL, GA, WI, HI

– Adjunct Faculty‐

Northwestern University

Rush University

• Nonfinancial

– ASHA member

– ISHA member

Continuum of Processing

Acoustic Processing Linguistic Processing & Executive Functions

Transition AreaPhonemic/Phonetic Processing

Neuroscientific Bases of CAP

• perceptual processing of auditory stimuli, and neurobiological activity underlying that processing (ASHA, 2006)

• disorders of CAP cannot be attributed to higher‐order language, cognitive, or related confounds

• CAPDs may lead to/be associated with difficulties in higher‐order language, learning, and communication function

Differential diagnosis

• Differentiates among disorders having similar symptoms/ manifestations

• SLP’s, psychologists, neuropsychologists & others provide insights into auditory performance in various contexts

• Audiologists use well‐controlled, norm‐referenced tests that minimize influence of language, cognition & other sensory skills & maximize auditory system function

• Tests designed to tax CAP skills

• Patterns across tasks are used to diagnose specific CAPD

• Test results help professionals customize deficit‐specific differential intervention

• Differential Intervention:

– A balance of treatment and management based upon neuroscientific principles and derived from assessment results

– Customizes treatment and management plans in order to treat directly impaired skills and to minimize impact on listener’s life

Neuroscience foundations

management

treatment

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The “geography” of processing

• Peripheral auditory system

– Collect the sound

– Detect the sound

– Transform into a neural signal

• Brainstem processing

– Localization

– Selective/divided attention

– Preliminary acoustic feature extraction

The “geography” of processing

• Cortical AUDITORY processing

– Analyze/discriminate

– Synthesize/Integrate

• Cortical PHONOLOGIC‐LINGUISTIC processing

– Attach meaning

• Cortical EXECUTIVE processing

– Execute a response

Adequate Processing Involves Continuum of Skills

• Intact peripheral auditory system – receive acoustic stimulus

• Intact CANS – transmit through brainstem to upper cortex (Heschl’s gyrus)

• Phonemic knowledge to discriminate aspects of the acoustic stimulus

• Linguistic knowledge to decode message

• Executive function skills to attend, organize, execute behavioral response

Anatomic Structure/Site

Type of Processing

Peripheral Auditory System

External, Middle, Inner Ear, auditory nerve

Auditory Acuity;Reception of Signal

Central Auditory Processing

Central Auditory Nervous System-Brainstem through Heschl’s

Neurological Transfer of signal; analysis and synthesis of acoustic characteristics of signal

Phonemic Processing Heschl’s gyrus –temporal lobe

Analysis of phonemic characteristics of signal

Language Processing Temporal Lobe –Wernicke’s area and angular gyrus

Use of linguistic aspects of signal; attach meaning using code

Executive Functions Prefrontal/Frontal lobe areas; Motor Strip

Plan and execute a response (right or wrong)

Executive functions

Language & learning

Sensory processing

Another way to look at process

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Central Auditory Processing Language Processing

Transition AreaPhonemic Processing

audiologist speech-language pathologist

audiologist and speech-language pathologist

Acoustic Linguistic

Basic Principles

• Audiologists uniquely suited to diagnose CAPD

• SLP’s , psychologists, neuropsychologists & others provide insights into listener’s auditory performance in various contexts

• Results provide insights into listener’s strengths & weaknesses in academics, communication, and life skills

CAPD Assessment

• Screening determines those listeners at‐risk for CAPD

• Can screen by test, checklist, or record review

• NO standard screening protocol currently available

• Diagnostic testing determines presence/absence of disorder and specifies nature

• Audiologists diagnose CAPD

• Test battery recommended

CAPD Assessment• Screening by checklist

– CHAPS, SIFTER, LIFE, others

– not standardized or validated

– subjective

• Screening by record review

– look at academics and other test results

– not standardized or validated

• Screening by test

– SCAN‐C, SCAN‐A, SCAN‐3, ACPT

– DSTP – Differential Screening Test for Processing

CAPD Test Battery• What?

– Battery of tests to determine how efficiently CANS operates

• How?– Overloading or overworking it

– Minimize influence of language, cognition & other sensory skills on performance

– Maximize function of CANS

• Who?– Diagnostic tests available for children as young as 6 yrs

– Results compared to age‐matched peers– Look at processes taxed and underlying anatomical site

Performance profiles yield insights into nature of CAPD

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CAPD Test Battery

• Standard audiometrics

–Puretone air/bone

– Speech thresholds

–Word recognition

• Standard immittance tests

– Tympanogram

– Acoustic reflexes

• OAEs

Assessing brainstem level binaural processing

• Binaural interaction tasks

– Tap brainstem level interaction between ears

• Binaural fusion

• Masking level difference

• Localization – using interaural time and intensity differences

• RASP

• Stream segregation (listening in noise)

Cortical binaural processing –

assessing dichotic listening

• Binaural Integration Tasks

– Tap cortical level integration skills

• Dichotic digits

• Dichotic rhyme

• Staggered spondaic words

• Dichotic CVs

• Competing words

• DSI

Dichotic tests

• Binaural Separation Tasks

– Tap cortical separation skills

–Provide information re neuromaturation

• Competing sentence tests

• SSI‐CCM

Auditory discrimination assessment

• Monaural low redundancy tasks

– Tap cortical auditory closure/discrimination

• Low‐pass filtered speech

• Time‐compressed speech

• Speech in noise: SPIN, SCAN, and SSI‐ICM

Assessing temporal processing

• Tap LH, RH, interhemispheric function

– Resolution, ordering, masking, integration

– Temporal resolution tasks

• Random Gap Detection Test

• Gaps in Noise

– Temporal ordering tasks

• Pitch patterns sequence test

• Duration patterns sequence test

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brainsteminteraction between the ears;discrimination

binaural fusion, MLD RASPLISN

primary auditory cortex

auditory closure;auditory discrimination

low-pass filtered speech time-compressed speech

peripheral/centralsignal transmissiontympanogramacoustic reflexes

peripheral mechanism

hearing sensitivity/acuity

puretone air/bonespeech thresholdsword recognition

Underlying siteProcessassessed

Test Type

RH, LH, CCtemporal patterning

Temporal resolution

Discrimination

pitch patterns test, duration patterns test

Random gap detectionGaps in noise

Speech-in-noise tests variedvaried

Underlying SiteProcesses AssessedTest Type

LH, RH, CCneuromaturationseparation

separation tasks: competing sentences

LH, RH, CCclosure integrationordering

dichotic digits, dichotic rhyme, staggered spondaic words,dichotic CVs, competing words

Informal assessment of CAP skills

• Spelling

• Memory for words vs. sentences

• Music

• Alphabet

• Wepman, ITPA

• Multisyllabic words

Assessing phonological processing

• Phonological awareness test (PAT)

• Comprehensive Test of Phonological Processing (CTOPP)

• Sound blending and auditory closure tests

• Check spelling skills

Assessing language processing and related skills

• Check receptive vocabulary (e.g., PPVT)

• Assess hierarchy of language processing skills– LPT, CASL, WORD Test

• Assess multisensory and related executive function areas – Test of Problem Solving, CELF, Listening Test, Detroit

– Word retrieval – Test of word finding

– Memory for unrelated/related information –digit span, sentence memory tasks

Interpreting Diagnostic Results

• Remember your goal – evaluating integrity of auditory skills/systems, NOT just dxing CAPD

• Look at individual tests – absolute, norm‐referenced

• Look at the battery – relative, patterns

• Look at the “big picture” – impact of deficit on communication, academics, sense of self

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• Absolute analysis

– Norm‐referenced

– Compare to age‐matched peers

– Per test pass‐fail criterion: >2SDs below mean for age

• Relative analysis

– Examination of patterns across tests

• Ear differences

• “Ties that bind”

• Abnormal AND normal scores

• DON’T “diagnose” per test – use entire battery!

Interpreting CAP test results Test Interpretation

• NOT CAPD

– Performance below normal on single test

– Performance below normal on all tests

• Evidence of CAPD

– Poor scores on sets of tests tapping similar function

– Bellis/Ferre model describes 5 test profiles

– You are NOT obligated to use a specific model

Ask yourself…

• How did listener perform on degraded speech tests?

• How did listener perform on binaural processing tests?

• How did listener perform on temporal processing tests?

• Behaviors while testing?

Questions that you ask yourself

• What is status of conductive mechanism?

• Status of cochlear/retrocochlear mechanism?

• Evidence of deficient auditory discrimination? – how do you know?

• Evidence of impaired binaural processing?

– What is it? What type of bin proc issue?

• Evidence of impaired temporal processing?

– what is it? What type of problem?

• Other issues?

• Does it make sense? What does it mean?

Test Interpretation

PRIMARY CAPD

SUBTYPES

Auditory DecodingDeficit

IntegrationDeficit

Prosodic Deficit

• Poor discrimination of fine acoustic differences in signal

– Probable site: primary auditory cortex

– Signal distortion – poor neural representation

– Exhibit impaired discrimination, closure, & temporal resolution

– Poor scores on low redundancy tests, gap detection, and (possibly) binaural integration

– Behaviorally: they can’t “hear”

Auditory decoding deficit

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• Needs repetition – lots of “what?”

• Mishears information

• Fatigues easily

• Difficulty in noise esp. as noise gets louder

• Slow/inaccurate

• Reading decoding/comprehension

• Spelling

• Receptive language issues including vocabulary, syntax, semantics, second language acquisition

Decoding deficit ‐manifestations

• Deficit in performing tasks requiring interhemispheric communication

– Probable site: corpus callosum

– Insufficient development of corpus callosum

– Poor integration skills

– Excessive LE suppression on dichotic tasks AND poor labelling with good mimicking of patterns

– “it’s too much” – not synthesizing inputs

Integration Deficit

• Trouble multitasking

• Poor transitions

• Needs more time

• Slow but accurate

• Variable difficulty in noise

• “how to & how much”

• Reading decoding and/or comprehension

• Spelling, Written language

• Other sensory skills

• Syntactic and related language arts skills

Integration deficit manifestations

• Deficiency in use of prosodic features of target

– Probable site: right hemisphere

– Inefficient RH pattern recognition

– Trouble with acoustic contours

– Exhibits poor temporal patterning

– Poor scores both labelled AND mimicked on patterning tasks AND excessive LE suppression on dichotic tasks

– Behaviorally: it’s all “blah, blah, blah”

Prosodic deficit

• Poor direction following

• Loses focus after first few sentences

• May have flat affect

• Poor figure‐ground skills

• Misunderstands intent of message

• Social & pragmatic lang.

• Phonological processing

• Music perception/ appreciation

• Nonverbal communication

• Academic impact can be variable

Prosodic deficit manifestations Secondary CAP test profiles

• Likely to be “auditory” manifestations of more supramodal or neurocognitive disorder and NOT true CAPD

– Associative deficit

– Output‐Organization deficit

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• NOT applying rules of language to acoustic signal

• May be due to poor communication between primary and secondary (association) cortices

– Intra‐hemispheric impairment

• Poor scores for both ears on dichotic tests, good labelling/mimicking, adequate discrimination

• Poor “translators”, “I don’t get it”

Associative deficit

• Misunderstands meaning

• Linguistically inappropriate responses

• Poor peer relations

• May appear noncompliant

• Noise not a major issue

• May “daydream” while working

• Receptive, expressive, social, pragmatic, functional comm.

• Memory issues, math

• Reading/language arts

• “Auditory” manifestations of LPD

Associative deficit manifestations

• Deficient ability to organize, sequence, plan appropriate response

• May be due to deficient efferent, motor planning, or executive function (frontal lobe, motor/pre‐motor cortex)

• Exhibit difficulty with expression/execution

• Poor scores multiple target tasks, in noise, sequencing errors

• Can’t get it back out

Output‐organization deficit• In the classroom

– May be disorganized – May be impulsive– May be poor planner – Poor task completion– Poor direction following

• At risk for deficits in – Speech production – Sequential memory– Recall, word finding– Executive function skills

Output‐organization manifestations

Summary of CAPD types

• Primary CAPDs

– Decoding deficit ‐ LH

– Integration deficit ‐ CC

– Prosodic deficit – RH

– Represent truly CENTRAL AUDITORY processing issues

• Secondary types


– Output‐organization deficit

– Represent language processing or executive function issues as opposed to central auditory issues

YOU make the call‐ CAP evaluation results

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Alaina – 13yrs

• Low‐pass filtered speech: bnl AU

• Time compressed with reverberation: bnl AU

• Dichotic Digits: wnl AD, bnl AS (by one digit)

• Dichotic Rhyme: wnl AD, bnl AS (by one word)

• Competing Sentences:wnl AU

• Pitch Patterns Sequencing:wnl labelling

• Duration Patterns Sequencing: wnl labelling

Sergio – 11yrs

• Low‐pass filtered speech: bnl AU

• Time compressed with reverberation: wnl AU

• Dichotic Digits: wnl AU

• Dichotic Rhyme: wnl AD, bnl AS

• Competing Sentences:wnl AD, bnl AS

• Pitch Patterns Sequencing: bnl labelling & mimicking

• Duration Patterns Sequencing: wnl labelling

Rachel – 9yrs

• Low‐pass Filtered Speech: wnl AU

• Time compressed Speech: wnl AU

• Dichotic Digits Test: wnl AD, bnl AS

• SSW Test: bnl AU with AS sig < than AD,

• Competing Sentences Test: wnl AD, bnl AS

• Pitch Patterns Sequencing: bnl labelling, normal mimicking

Ryan – 9 yrs

• Low‐pass Filtered Speech: within normal AU

• Time compressed speech:within normal AU

• Dichotic Digits: wnl AD, bnl AS

• Dichotic Rhyme Test: wnl AD, bnl AS

• Competing Sentences: wnl AD, bnl AS

• Pitch Patterns: bnl labelling, bnl mimicking

Marc – 12 yrs

• Low‐pass filtered speech: wnl AU

• Time compressed speech: wnl AU

• Dichotic Digits: wnl AD, bnl AS

• SSW test: bnl AU

• Competing Sentences: bnl AU

• Pitch Patterns Sequencing: wnl labelling

Alex – 8 yrs• Low‐pass filtered speech: wnl AU

• Time compressed speech: wnl AU

• Dichotic Digits Test: bnl AU

• Dichotic Rhyme Test: wnl AU

• SSW Test: wnl AU ‐ 19/40 items out‐of‐sequence

• Competing Sentences: wnl AU

• Pitch Patterns Sequencing: bnl due to >50% reversed labels, e.g., HHL for LLH, HLH for LHL, etc.

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Aidan – 9yrs

• Low‐pass filtered speech: wnl AU

• Time compressed –reverberation:wnl AU

• Dichotic Digits: wnl AU

• Dichotic Rhyme: wnl AD, bnl AS

• Competing Sentences: wnl AU

• Pitch Sequencing: bnl labelling, wnl mimicking

Summary• Use battery of CAP‐specific tests

• No one test taps into only one skill

• Base diagnosis on BATTERY. Don’t “diagnose” per test

• Look for the “tie that binds”

• Don’t ignore contradictory findings

• Does diagnosis “make sense” based on neuroscience

• Neither Dx nor Tx for CAPDs can be done using a “cookbook” approach

Intervention for CAPDs – it’s an “art” based on the science

ManagementRemediation

Knowledgeand principles

Effective Intervention

Intervention Tripod

Direct Remediation-focus on listener

Compensatory Strategies –focus on message

Environmental Modifications –focus on environment

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Management Remediation

Modification of the communicative environment

Use of compensatory strategies

Minimizes adverse effect of disorder of client’s life

Formal and informal therapy to develop deficient

skills AND

Teach compensatory strategies

Designed to reduce or resolve deficit

• Bottom‐up therapy and management is stimulus driven

– Therapy: adaptive and repetitive skills training

–Management: focus on access to signal

• Top‐down therapy and management is concept driven

– Therapy: teaches use of cognitive/linguistic strategies

–Management: focus on accommodations & communication

When choosing management strategies and/or remediation programs:

• Focus on the listener (remediation)

• Focus on the environment (modifications)

• Focus on the message (accommodations & strategies)

Focus on the listener: remediation

• Based on neural plasticity research

– Plasticity is brain’s ability to organize/reorganize in response to stimulation

• Includes bottom‐up programs to improve specific skills and top‐down programs to teach/reteach compensatory strategies

• CCSS.ELA‐literacy.CCRA.SL.1

– Prepare for and participate effectively in a range of conversations and collaborations with diverse partners, building on others’ ideas and expressing their own clearly and persuasively


– Integrate and evaluate information presented in diverse media and formats, including visually, quantitatively, and orally.


– Evaluate a speaker’s point of view, reasoning, and use of evidence and rhetoric

Listener: Remediation for CAPDs

• When choosing treatment program, consider

– Reported efficacy of program for specific populations – Does it work?

– Program’s neuroscientific foundations – Should it work?

– Appropriateness for type of deficit identified – Does it fit?

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Remediation for PDs

• Auditory ‐phonologic training – bottom‐up therapy, plasticity‐based

– auditory, although not exclusively, stimuli

– stimuli are repetitive

– max number of responses elicited

– feedback on accuracy provide

– activities adaptive, systematic, and varied

– nearly any CAP/phonologic skill can be trained‐discrimination, temporal processing, binaural processing

• Discrimination training • Phonemic Training • Dichotic listening training• Temporal resolution training• Localization training• Rhyming• Patterning ‐ diadochokinetics

Remediation for PDs

• Linguistic‐Cognitive therapy

– top‐down therapy

–based on neurocognitive theory

– concept‐driven – teaching “rules”

• Strategy‐based

– teaches compensatory strategies

• central resources training

• use of visual cues

• counseling

• Lipreading/speechreading

• Auditory closure (fill‐in‐the‐blank)

• Language processing treatment activities

• Teaching Meta‐memory strategies

– Reflexive strategies : verbal rehearsal, rote memory

– Explicit Declarative Strategies: visual imagery, chunking, mnemonics, rhymes

– Episodic Strategies: “mark” learning with places, circumstances, field trips

– Procedural Strategies: teach with movement, working models, songs

• Auditory vigilance training

• Interhemispheric transfer training

• Noise tolerance training

• Prosody training

• Active listening Strategies– Self‐monitoring

– Assertiveness training and self‐advocacy

Improving auditory discrimination • Designed to improve auditory system’s ability to extract acoustic

cues from within speech spectrum

• Targets include CVs/VCs, words, spondees/trochees, multisyllabic words, words in sentences, nonsense and real sentences, connected discourse, nonspeech targets

• Uses adaptive minimal pairs discrimination, identification and recognition training with targets altered to “tax” system

– Temporal and/or frequency discrimination, recognition in noise

• Computer‐assisted programs

– Fast ForWord

– HearBuilder

– Customized Learning: Exercises for Aural Rehabilitation (clEAR)

– Listening and Communication Enhancement (LACE)

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Computer‐assisted training

• HearBuilder (www.hearbuilder.com)

• clEAR‐ Customized Learning: Exercises for Aural Rehabilitation (www.clearworks4ears.com)

• LACE‐ Listening and Communication Enhancement (www.neurotone.com)

• Fast ForWord (www.scilearn.com)

• www.lipreading.org

Improving binaural processing

• Brainstem level binaural interaction training – Localization training/training temporal‐spatial skills

• Computer‐assisted LISN and Learn auditory training program (www.capd.nal.gov.au/lisn‐learn)

– Training with competing signals, e.g., speech‐in‐noise

• Cortical level dichotic listening training – Dichotic Interaural Intensity Difference (DIID)– Zoo Caper SkyScraper– CAPDOTS

Dichotic listening (DL) training• Addresses dichotic listening deficits due to impaired/

inefficient communication between right ‐left hemispheres

– Researchers theorize maturational delay in myelin development of the corpus callosum in learning disabled

• Impaired dichotic listening characterized by excessive left ear suppression on dichotic listening tasks

• Goal: improve interhemispheric communication by increasing score of “poorer” ear to normal‐near normal level and to level similar to that of stronger (usually right) ear

• Programs use words, numbers, animal sounds, sentences presented simultaneously, one or more to each ear

• Client responds to all targets – binaural integration OR to only one ear’s targets – binaural separation

• DIID, Zoo Caper, CAPDOTS

Computer‐assisted training

• Zoo Caper Skyscraper dichotic listening program (www.acousticpioneer.com)

• CAPDOTS dichotic listening training (www.capdots.com)

• www.clearworks4ears.com

• www.brainhq.com

• www.lipreading.org

Improving temporal processing

• Insane Earplane

– Targets lateralization and temporal pattern recognition

• clEAR

– Targets temporal resolution

• Fast ForWord

– Uses temporally altered speech

• LACE

– Increases rate of speech adaptively

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Diadochokinetics

• Puh

• Puh‐tuh

• Puh‐tuh‐kuh

• Pruh‐fuh‐guh

• Plu‐fru‐luh

• Plu‐glu‐gru

• Spuh‐stuh‐shuh

• Spruh‐struh‐skruh

Using visual cues‐ lipreading/speechreading

• Discriminate same‐different for visual‐only target with 90% accuracy

• Identify viseme group for target “sound” in initial/final position of word with 90% accuracy

• Identify target compound word visually only from closed set of (up to) 30 choices 90% accuracy

• Identify sentences/phrases from closed set of up to 10 choices with 90% accuracy

For all students

• Student will demonstrate ability to use active listening strategies

– Active listening ‐ taking responsibility for one’s listening success or failure by understanding impact of auditory impairment in one’s life, recognizing aspects of communication under listener’s control, displaying effortful listening behaviors, taking overt steps to avoid or correct potential communication mishaps.

• Student will maintain auditory vigilance for “X” amount of time

Active listening• Student will state two difficult listening situations that he/she has encountered

• For a self‐reported difficult listening situation, student will state (and practice) one strategy to minimize the listening difficulty

• Student will follow conditional directions, requesting clarification as needed

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Auditory vigilance

• Given a string of random words (or phonemes), student will indicate through hand signal each occurrence of pre‐determined “target” word

• Student will indicate through hand signal “rare” or different target from within a string of common targets (e.g., buh‐buh‐dee‐buh‐buh‐buh‐buh‐dee)

Computer programs: listening and related skills

• www.brainhq.com• www.interactivemetronome.com

• Apps from • www.superduperinc.com• www.smartyearsapps.com• www.virtualspeech.com• www.hamiguchiapps.com

Focus on the environment• Noise & reverberation (echo)

• Distance & lighting

• Direct signal enhancement via assistive listening technology (ALDs)

• Test‐taking

• Workload, note‐taking, homework

• Technology

• Curriculum

Focus on the message

• Clear speech

• Visual cues

• Clear Language

Message: clear speech

• Characteristics of typical speech

• Clear Speech improves perception and recognition

• Training to speak at slightly slower rate and slightly increased loudness

• Simple repetition with clear speech ensures perception for most listeners

Message: visual cues

• Couple clear speech with AV presentation

– Model look and listen

• Not all listeners can look and listen

– Use look or listen

• Add complementary visual cues

– Show me

• For teachers and parents

– Look then listen

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Message: Clear language

• Improves comprehension• Say what you mean and mean what you say• Rephrase • Minimize generic and ambiguous language• Add “tag” words• Consider overall amount of information• Break instructions down• Allow “waiting” and “thinking” time• Verbal cueing• Preteaching

Summary of deficit specific intervention for CAPDs – back to our

cases

Auditory decoding deficit

• Characterized by poor analysis of fine acoustic differences in speech spectra

• Management focuses on improving access to, clarity, and use of auditory signal

Decoding deficit

• Improving access

– Preferential classroom seating near and facing speaker

– Need noise abatement

– FM system trial

– Use Clear Speech

– Repeat information as needed

• Accommodations

– American Sign Language for 2nd

language req.

– Preteaching

– Adjust class schedule to minimize auditory overload

– Multisensory environment –verbal info supplemented with written/graphic cues

Auditory discrimination – inefficient analysis of acoustic cues

• Impacts

– Phonological awareness

– Spelling

– Listening stamina

– Direction following

– Comprehension

– Language skills

– Foreign language acquisition

• Treatment needs

– Sound discrimination

– Auditory closure

– Phonemic awareness

– Recognition in noise

– Use of visual cues

– Comprehension

Integration deficit

• Integration deficit is characterized by poor synthesis and manipulation of multiple incoming signals

• Management focuses on improving the quantity and structure of incoming signals

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Integration deficit

• Improving Access

– Look OR listen, look THEN listen

– Repeat with cue or demonstration

– DON’T rephrase

– Limit amount of information given

– Present information sequentially

– Tape recorder, notetaker

• Accommodations

– Extended time tests

– Write in test book not computer score sheet

– Books on tape, study guides, Cliff’s Notes

– Music while studying

– “Wait/thinking” time

– Different room for tests

– Computer technology

– Movement breaks

– Explicit multisensory learning needs

Binaural processing‐ interhemispheric

• Impacts

– Reading comprehension

– Spelling

– Listening comprehension


– Task completion

– Note‐taking

• Treatment needs

– Dichotic listening

– Interhemispheric communication

– Synthesis of multiple auditory targets

– Manipulation of auditory & non‐auditory signals

Prosodic deficit

• Prosodic deficit characterized by difficulty analyzing, synthesizing, and attaching meaning to rapidly changing acoustic patterns

• Management focuses on improving quality and structure of incoming signal

Prosodic deficit

• Improving access

– Repeat with emphasis on key words

– Clear Speech

– Preferential seating

– Trial use of FM system

– Noise abatement

• Accommodations

– Explicit multisensory learning environment

– Placement with “animated” teacher

– Preteaching

– Notetaker, as needed

– Untimed or extended time for tests and assignments

Temporal processing‐receptive

• Impacts


– Memory


– Social & pragmatic language

– Direction‐following

• Treatment needs

– Pattern recognition

– Use of prosody



– Working memory

– Sequencing

Associative deficit

• Associative deficit characterized by difficulty applying linguistic rules to incoming information

• Management focuses on improving the linguistic quality of the target and use of linguistic rules

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Associative deficit


–Rephrasing

–Clarification

–Clear Language

– Speak the “same” language

– Formatting

• Accommodations

–Preteaching rules and vocabulary

–Waive language req.

–Use non language‐biased IQ instruments

–Books on tape, study guides, Cliff’s Notes

–RULE‐based learning

Binaural processing‐ intrahemispheric

• Impacts


– Spelling



– Task completion

– Note‐taking

• Treatment needs

– Synthesis of multiple auditory targets

– Manipulation of auditory & non‐auditory signals

– Speech‐to‐print skills

– Strategy application

Output‐organization deficit

• Output‐organization deficit characterized by difficulty organizing, sequencing, and executing a response

• Management focuses on adjusting quantity and structure and teaching organization rules

Output-organization deficit


– Consider FM system if student exhibits excessive difficulty in noise

– Minimize distractions

– Notetaking service– Limit amount of information given

– Break tasks down

• Accommodations

– Preteaching rules – Outlines and checklists

– Closed‐set tests – Oral responses on written tests

– Keyboarding/word processing

– Extended time – Answers written in test booklet‐not score sheet

Temporal processing‐ expressive

• Impacts


– Memory


– Task completion

– Direction‐following

– Expressive skills

• Treatment needs

– Patterning

– Verbal rehearsal



– Working memory

– Sequencing

– Noise tolerance

• Primary CAPDs

– Decoding deficit ‐ LH

– Integration deficit ‐CC

– Prosodic deficit – RH

– Probably represent truly CENTRAL AUDITORY processing issues

• Secondary test profiles


– Output‐organization deficit

– Probably represent language processing or executive function issues as opposed to central auditory issues

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INTERVENTION SUMMARY

Effective Intervention MUST be deficit‐specific AND include modifications, compensation, remediation

Bottom‐Up management

• Noise abatement

• Clear Speech

• Visual cues

• Seating

• Assistive Listening Technology

Top‐Down management

• Clear Language

• Familiarity & redundancy

• Curricular changes

• Technology

Assessment of & Intervention for CAPDs – summary

• Deficit in one or more of skills subserved by CANS

• Can adversely affect academics, communication, well‐being

• Can co‐exist with other conditions

• Audiologic tests available to reliably assess skills for listeners as young as 6 years

• Results help define nature and clarify impact of deficit

Assessment of & Intervention for CAPDs –summary

• Effective intervention MUST be deficit‐specific AND include modifications, compensation, and remediation

• Should reassess skills at periodic intervals to monitor

• Urgent need for more research: assessment, treatment, and interrelationships among skills

Great games to enhance processing skills

Game Processing skill taxed

• A Rhyme in Time sound discrimination, auditory closure• Battleship listening, visual patterning, integration • Blind Man’s Bluff localization, binaural interaction• Boggle pattern recognition, integration• Bopit, integration, vigilance, patterning• Brain Warp vigilance, integration, problem‐solving• Card games pattern recognition, sequencing• Catch Phrase integration, vocabulary, output • Clever Endeavour metalinguistic strategies, critical listening• Feely Bag interhemispheric communication

Game processing skills taxed

• Ending sound game auditory discrimination

• Mad Gab temporal patterning, language

• Marco Polo localization, binaural interaction

• Musical Chairs vigilance

• Name that tune interhemispheric integration

• Password vocabulary, linguistic skills

• Plexers metalinguistic strategies

• Read My Lips lipreading/speechreading

• Red Light‐Green light vigilance, active listening

20

Game Processing skills taxed

• Rummikub patterning, problem solving, integration• Scattergories vocabulary building, linguistic strategies• Scrabble integration, language, visual patterning• Simon auditory‐visual patterning, integration• Simon Says vigilance, active listening• Taboo vocabulary, metalinguistic strategies• Telephone game attention, active listening, discrimination• Twister integration, critical listening• UpWords integration, visual patterning• Wheel of Fortune auditory closure

disclosures - showmemsha.org · acoustic reflexes peripheral mechanism hearing sensitivity/acuity...

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