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The Hearing Journal April 2021

A uditory processing disorders (APD) in school-age children can lead to learning problems.1 Audiolo-gists may determine the presence or absence of APD in this population and make specific thera-

peutic recommendations. However, many therapies for APD have not been peer-reviewed or examined with statistical analysis to determine efficacy. The present study evaluates a therapeutic option called CAPDOTS-Integrated (also referred to as CAPDOTS), an online training program that aims to im-prove dichotic listening problems.

According to Jerger, “Dichotic listening (DL) tests are at the core of the diagnostic evaluation of auditory processing disorder... [Such tests] have been used for decades both as screening tools and as diagnostic tests in APD evaluation.”2 Thus, audiologists evaluating school-aged children for APD may find these children to have dichotic listening problems. Those diagnosed with dichotic listening problems are rec-ommended to try a dichotic listening training program, such as CAPDOTS-Integrated.1 Presently, CAPDOTS-Integrated claims to treat binaural auditory integration problems known as dichotic listening difficulties. CAPDOTS is a treatment program requiring access to the internet and good quality headphones. It can be completed in the trainer’s office, at school, or home.1 On their website, it states that CAPDOTS– Integrated “improves the ability to follow complex, multi-step directions, listening attention especially in distracting background noise, inferential listening and understanding of group instructions, auditory memory, academic perfor-mance especially for reading comprehension and spelling.”1 However, one may ask what evidence supports these claims?

EVALUATING THE SUPPORTING RESEARCH The CAPDOTS website cites two conference handouts on the changes after CAPDOTS training. Carol A. Lau dis-cussed mid-latency, electrophysiological responses in two

subjects.2 The 27-year-old subject identified as diagnosed with “binaural integration deficit” only completed 80 percent of the CAPDOTS training. The 16-year-old subject is re-ported diagnosed with a binaural integration (dichotic listen-ing) auditory processing disorder. Results of mid-latency electrophysiological measures revealed increased response findings after these subjects completed CAPDOTS. Quali-tative data discusses the Na-Pa amplitude changes and per-cent differences for each subject. Statistical analyses were not used so there is no indication whether these changes were significant.

The second conference presentation, also by Carol Lau, used only three subjects, all identified as having auditory pro-cessing problems based on scores from the SCAN and Dichotic Digits Tests.4 Number values are the only results pro-vided. There were no statistical analyses discussed.

A third reference is an article published in The Hearing Journal on a study involving three adults identified with co-morbid peripheral hearing loss and CAPD.5 Each subject was used as a single case study presenting results of auditory pro-cessing tests pre- and post- CAPDOTS training. Findings identified improvements after CAPDOTS training, but no sta-tistical analyses were provided.

Another study published in 2013 used individual case presentations including one of a second-grade boy with audi-tory processing problems, an older adult who suffered a head injury, a preteen with no history of educational or auditory pro-cessing concerns, two girls identified by qualitative observa-tions having problems following verbal interactions and directions, and an adult with a history of learning disabilities.6 All subjects were evaluated using the SCAN test as well as Dichotic Digits. Data compared pre- and post- CAPDOTS training with improvements noted, but no statistical analyses were provided.

Evaluating CAPDOTS Training for Children and Adolescents with APDBy Jay R. Lucker, EdD, CCC-A/SLP, FAAA; Cydney Fox, AuD; and Bea Braun, AuD

From left: Jay R. Lucker, EDD, CCC-A/ SLP, FAAA, is a professor and the director of the five-year accelerated master’s degree program in the de-partment of communication sci-ences and disorders at Howard University in Washington, DC. He

also has a part-time private practice specializing in issues related to audi-tory processing disorders. Cydney Fox, AUD, is a member of the Craniofa-cial Team at Orthopaedic Hospital and a full-time audiologist at Audiology Solutions LA. Bea Braun, AUD, is a clinical audiologist and a credentialed educational audiologist. She founded the Auditory Processing Center of Pasadena.

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ONLINE EXCLUSIVE

April 2021 The Hearing Journal

PURPOSE OF THE PRESENT STUDYStudies have looked at changes in auditory processing after completing CAPDOTS training. However, none provides sta-tistical analyses, and all use small samples. The present looked at a large sample of children and adolescents diag-nosed with APD. The researchers measured what changes occur when statistical analyses are used. The research ques-tions asked whether auditory processing test findings re-vealed significant improvements after completing CAPDOTS training, and for what specific measures, as well as investigat-ing the degree of improvement following training.

STUDY METHODSForty-six children and adolescents (26 males and 20 females) participated in the study. Two of the authors (CF and BB), both licensed clinical audiologists, evaluated participants identifying all having significant APD. Participants ranged from 6 years to 18 years with a mean age of 10.0 years (standard deviation of 2.70 years). Participants had normal hearing which would not influence their auditory processing or treatment.

Auditory Processing Tests: Auditory processing was as-sessed via the SCAN-3 C for children7 and A for adolescents8 Dichotic Digits (DDT),9 Frequency Patterns and Duration Pat-terns,10 Competing Sentences,11 Low Pass Filtered Speech,12 SSW Test,13 and the Phonemic Synthesis Test (PST),14 using the specific scores for each ear or individual measure on the tests.

CAPDOTS Training: CAPDOTS is a web-based therapy based on a Staggered Dichotic Listening Training (SDLT) paradigm, using words, digits, and syllables. SDLT uses a difference in the timing presentation of targets in each ear

Table 1. Ranges, Means, and Standard Deviations for each of the Measures of Auditory Processing used in the Present Study (N = 46)

Test Measure Range MeanStandard Deviation

Competing Sentences

Right ear-pre 80-100% 93.9% 6.58%

Right ear-post 88-100% 97.4% 4.44%

Left ear-pre 50-100% 78.6% 15.97%

Left ear-post 30-100% 80.4% 19.17%

Dichotic Digits

Right ear-pre 50-95% 84.7% 13.61%

Right ear-post 73-100% 92.9% 7.33%

Left ear-pre 35-95% 74.0% 14.20%

Left ear-post 40-100% 82.4% 50.58%

Duration Patterns

Pre 40-73% 50.6% 18.44%

Post 17-84% 56.0% 20.09%

Frequency Patterns

Pre 10-100% 58.5% 24.59%

Post 50-100% 84.7% 16.27%

Low Pass Filtered

Right ear-pre 32-90% 71.6% 17.36%

Right ear-post 64-92% 82.9% 8.90%

Left ear-pre 32-86% 66.4% 16.32%

Left ear-post 40-96% 79.4% 14.03%

Phonemic Synthesis

Quantitative-pre

0-23 16.2 5.51

Quantitative-post

16-24 20.6 2.98

Qualitative-pre 2-23 13.9 5.73

Qualitative-post

8-24 18.8 4.51

SSW RNC-pre 0-10 2.6 2.61

RNC-post 0-4 0.6 0.99

RC-pre 0-27 8.6 5.95

RC-post 0-15 3.1 3.42

LC-pre 5-34 14.3 6.93

LC-post 2-22 8.3 5.09

LNC-pre 0-19 3.9 4.18

LNC-post 0-7 1.2 1.39

SCAN-3

Competing Sentences

RE-pre 6-35 12.3 8.67

RE-post 12-35 12.6 7.19

LE-pre 4-34 8.2 8.14

LE-post 10-22 9.2 6.03

SCAN-3

Competing Words- Directed Ear

Right Ear First

RE-pre 3-14 10.7 2.49

RE-post 7-14 11.5 2.03

LE-pre 1-12 6.8 2.86

LE-post 5-14 8.8 2.52

Table 1. Continued...

Test Measure Range MeanStandard Deviation

Left Ear First RE-pre 4-15 10.3 2.88

RE-post 8-15 12.3 1.62

LE-pre 3-13 8.2 2.57

LE-post 5-14 10.1 2.23

SCAN-3

Auditory Figure-

Ground +8 RE-pre 17-20 18.6 1.1

RE-post 16-20 18.7 1.4

LE-pre 13-20 18.1 1.9

LE-post 16-20 18.8 1.1

SCAN-3

Time Compressed

RE-pre 17-30 25.7 3.7

Sentences RE-post 22-30 27.8 2.9

LE-pre 19-29 24.9 2.7

LE-post 22-30 26.9 2.2

ONLINE EXCLUSIVE

The Hearing Journal April 2021

starting with a gap between stimuli presented to each ear with the gap decreasing until the two stimuli are presented simultaneously.

Participant CAPDOTS therapy at home with monitoring by the audiologist. Upon completion of CAPDOTS training, the auditory processing evaluation was re-administered. Thus, pre- and post- training scores were available and were com-pared allowing for statistical analyses of the data.

Data Analyses: A paired (also called dependent) samples t-test was calculated for each measure. Performance for the right ear was compared separately from performance for the left ear when appropriate. -test scores yielding probability values less than 0.05 identified that the change was signifi-cant. Significant t-test findings were then evaluated by Cohen’s d.

Table 2. Results of Paired (Dependent) Samples t-tests on all Measures

Test Measure t p

Competing Sentences Right ear 1.550056 0.1494

Left ear 0.547209 0.59516

Dichotic Digits Right ear 5.887257 <0.00001*

Left ear 2.531742 0.01743*

Duration Patterns 1.234108 0.24288

Frequency Patterns 5.803375 <0.00001*

Low Pass Filtered Right ear 2.61608 0.02134*

Left ear 3.585902 0.00332*

Phonemic Synthesis Quantitative 5.809389 <0.00001*

Qualitative 8.102465 <0.00001*

SSW RNC -5.946805 <0.00001*

RC -8.836471 <0.00001*

LC -8.986836 <0.00001*

LNC -4.690867 0.00003*

SCAN-3

Competing Sentences RE 0.2470897 0.78585

LE 0.79106 0.43699

SCAN-3

Competing Words-Directed Ear

Right Ear First RE 1.603042 0.12051

LE 2.845347 0.00941*

Left Ear First RE 5.013774 0.00003*

LE 4.66104 0.00008*

SCAN-3

Auditory Figure-

Ground +8 RE 0.722672 0.47749

LE 1.636319 0.12015

SCAN-3

Time Compressed RE 3.231994 0.00559*

Sentences LE 4.552721 0.00025*

* significant at p<0.05

RESULTS & DISCUSSIONA total of 24 measures were completed in the study. Table 1 presents the results of the pre- and post- CAPDOTS meas-ures, indicating large differences between the post- and pre-therapy findings.

Table 2 shows the t-test statistical analyses results, which reveal significant findings for 16 of the 24 measures. Only one dichotic measure (Right Ear for Competing Words- Directed Ear Right Ear First) was not significant. The remain-ing 7 dichotic measures were significant. Thus, significant findings were found for 7 of the 8 dichotic measures of audi-tory processing.

Surprisingly, CAPDOTS training not only significantly im-proved dichotic listening but also made significant improve-ments in other areas of auditory processing. Nine measures were also found to have significant t-test results. Therefore, the present study indicates that CAPDOTS therapy can show significant improvements in dichotic listening as well as in other areas of auditory processing.

To determine how much change was found after CAP-DOTS training, a post hoc analysis was conducted for the 16 significant measures found. This analysis determined the ef-fect size of change using Cohen’s d for dependent samples. Table 3 presents the results of these calculations.

Cohen’s d values range from no significant effect (less than .20) to a small effect (from .20 to .49), a medium effect (from .50 to .79), a large effect (from .80 to 1.0), and very large effect (greater than 1.0). These values are measures of the number of standard deviation change occurring. A review of Table 3 indicates that only one measure revealed a small improvement and three showed a medium improvement. Large improvements were found for six measures and very large improvements for six other measures. Thus, the majority of improvements were found to be large and very large.

CONCLUSIONSResults of the present study indicated significant improve-ments in dichotic listening with 7 of the 8 measures showing large and very large effect sizes. What was surprising was that 9 non-dichotic measures of auditory processing revealed significant changes after CAPDOTS therapy. Thus, the con-clusion drawn is that CAPDOTS therapy not only can make a significant improvement in dichotic listening but can also change other auditory processing factors. Changes were found in auditory temporal processing (Frequency Patterns and Time Compressed Sentences for each ear), understand-ing distorted speech (Filtered Speech), and auditory phono-logical processing (Phonemic Synthesis). Thus, professionals recommending CAPDOTS training for children and adoles-cents with auditory processing disorders should not only ex-pect improvement in dichotic listening and auditory integrative processing but also in other areas identified above.

One important outcome from the present study relates to what is stated on the CAPDOTS website1 that CAPDOTS training should lead to improvements in a variety of areas which include listening in noise, understanding verbal mes-sages in groups (which may relate to listening in noise), read-ing and spelling abilities. The findings from the present

ONLINE EXCLUSIVE

evaluation indicated significant improvements in auditory phonological processing which would be related to reading decoding and spelling abilities. However, no improvements were evidenced for listening in noise. Results of the Auditory Figure-Ground measures used were not significant (p>0.05) for either the right or left ears. Although the CAPDOTS web-site does not address auditory temporal processing skills which are important, the results of the present study indicate significant improvements in this auditory process. Perhaps this is due to the subject’s ability to more rapidly process (time compression) and be better able to understand the pro-sodic features of the verbal message (frequency pattern pro-cessing). Additionally, integrative processing (dichotic listening) can contribute to other aspects of listening be-cause it involves processing the meaning of what is spoken to the listener.

LIMITATIONS & FUTURE RESEARCHAs with any study, there can be limitations leading to recom-mendations for further research. One limitation could be considered the number of participants used. This study in-cluded 46 participants all identified with auditory processing disorders. However, the specifics of each participant’s audi-tory processing issues were not identified. Some partici-pants might have had additional issues such as attention disorders (ADHD) or autism spectrum disorder (ASD) that were not identified. However, if participants had ADHD or ASD, findings from the present study suggest that even for

Table 3. Results of Cohen’s d Effect Size analysis for measures that showed significant differences on the paired sample t-tests.

Test Measure Cohen’s d Effect Size

Dichotic Digits Right ear 0.931 Large

Left ear 0.462 Small

Frequency Patterns 1.117 Very Large

Low Pass Filtered Right ear 0.699 Medium

Left ear 0.918 Large

Phonemic Synthesis Quantitative 1.094 Very Large

Qualitative 1.505 Very Large

SSW RNC 0.897 Large

RC 1.332 Very Large

LC 1.355 Very Large

LNC 0.707 Medium

SCAN-3

Competing Words-Directed Ear

Right Ear First LE 0.593 Medium

Left Ear First RE 0.948 Large

LE 0.881 Large

SCAN-3

Time Compressed RE 0.808 Large

Sentences LE 1.440 Very Large

people with these diagnoses, CAPDOTS therapy might be beneficial in improving their auditory processing abilities. Further research may wish to look at subjects diagnosed with ADHD or with ASD and compare these participants with subjects not found to have neither of these psychologi-cal issues.

Another limitation of the present study relates to the spe-cific auditory processing tests used. Other tests used by au-diologists may need to be statistically evaluated to determine if there are significant changes following CAPDOTS training. Areas such as auditory (listening) attention were not evalu-ated. It would be interesting to see what changes might occur on a measure of auditory attention such as the Auditory Con-tinuous Performance Test (ACPT)15 following CAPDOTS therapy.

One other limitation of the present study relates to age. Participants were children from 6 to 12 years old as well as adolescents from 13 to 18 years old. It is likely that children performed differently from adolescents. Thus, future research may wish to compare findings for children versus adolescents to determine if differences may be found based on age.

Whatever the limitations, the present investigation looked carefully at a large group of children and adolescents who completed CAPDOTS-Integrated training online. The findings indicated very significant changes in dichotic listening as well as in other areas of auditory processing not specific to di-chotic listening. The conclusion is that after CAPDOTS train-ing, one should expect to see significant improvements in various aspects of auditory processing.

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April 2021 The Hearing Journal