….then and now
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DESCRIPTION.Then and Now. Vicki M. Anderson, AuD, CCC-A Sarah Hanson, MS, CCC-S Roundtable Discussion, MSHA 2011. Multiple Models. Buffalo Model Bellis-Ferre Model MN Department of Education Model Chermak Model Walter Reed Model (Head Injury) HealthPartners Multidisciplinary Team Model - PowerPoint PPT Presentation
.Then and NowVicki M. Anderson, AuD, CCC-A Sarah Hanson, MS, CCC-SRoundtable Discussion, MSHA 2011
Multiple ModelsBuffalo Model Bellis-Ferre Model MN Department of Education Model Chermak Model Walter Reed Model (Head Injury) HealthPartners Multidisciplinary Team ModelDept. of Speech & Hearing Sciences, UMN (Research Model) Others?
ASHA 2006Preferred Practice PatternsASHA 2005CAPD Position Statement AAA 2010CAPD Clinical Practice GuidelineAAA 2000CAPD Consensus Statement
Guidelines and Positions
Few nor med tests Poor test-retest reliability Recommendations for interventions which cannot be implemented or are not available Poor reimbursement Lengthy testing Lengthy reports with non-specific recommendations
Concerns Frequently Heard in the Past
No procedure (testing or treatment codes) No diagnostic codes No Special Education (SPED) disability service category Effective, evidence-based therapies not availableRecommendations for interventions which cannot be implemented or are not available More Concerns Heard in the Past
Lack of modality specificitySpeech/language based tests confound resultsCo-morbidity (Looks like ADD/ADHD)Other confounding variablesNon-native English speaker (ELL, bilingual)Intellectual Disability/global delays Sensory integration/ASD
And, More Concerns Heard in the Past
AUDITORY PROCESSING: Cornerstone of Language and Literacy (Reading)AUDITORY PROCESSINGPHONOLOGIC AWARENESS ORAL LANGUAGE WRITTEN LANGUAGEReading and Spelling COMPREHENSION James W. Hall III, Ph.D. (2008). KSHA Conference.
APD DefinitionAmerican Speech-Language-Hearing Association (ASHA, 2005) (Central) auditory processing disorder [(C)APD] refers to difficulties in the processing of auditory information in the central nervous system (CNS) as demonstrated by poor performance in one or more of the following skills:
sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination (e.g., temporal gap detection), temporal ordering, and temporal masking;auditory performance in competing acoustic signals (including dichotic listening); and auditory performance with degraded acoustic signals.
APD Position StatementAmerican Speech-Language-Hearing Association (ASHA)It is the position of the American Speech-Language-Hearing Association (ASHA) that the quality and quantity of scientific evidence is sufficient to support the existence of (central) auditory processing disorder [(C)APD] as a diagnostic entity, to guide diagnosis and assessment of the disorder, and to inform the development of more customized, deficit-focused treatment and management plans. (C)APD is an auditory deficit; therefore, it continues to be the position of ASHA that the audiologist is the professional who diagnoses (C)APD.
American Speech-Language-Hearing Association. (2005). (Central) Auditory Processing Disorders The Role of the Audiologist [Position Statement]. Available from www.asha.org/policy.
Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children. JAAA 11: Nov. 2000.Definition: APD is broadly defined as a deficit in the processing of information that is specific to the auditory modality.Guidelines for screening strategies & diagnosis Screening strategies Diagnosis minimal test battery factors influencing test outcome and analysisJames W. Hall III, Ph.D. (2008). KSHA Conference. American Academy of AudiologyAPD CONSENSUS CONFERENCE 2000
Diagnosis, Treatment and Management of Children and Adults with Central Auditory Processing DisorderBuilds on the ASHA 2005 definition, which states that CAPD refers to difficulties in the perceptual processing of auditory information in the central nervous system and the neurobiologic activity that underlies that processing and gives rise to the electrophysiologic auditory potentials.Affects both children and adults, including the elderly Audiologic diagnosis based on behavioral and electrophysiologic test battery, observation and case history Multidisciplinary assessment and intervention Description of auditory strengths and weaknesses
American Academy of AudiologyClinical Practice Guidelines, 2010
ICD-9 Diagnostic codesAcquired Auditory Processing Disorder388.45Abnormal auditory perception388.40
CPT Procedure CodesComplete audiological work-up is pre-requisite92552 (air conduction pure tone thresholds)92556 (speech thresholds & word recognition performance/intensity function)92570 (tympanograms, acoustic reflexes & decay)92588 (otoacoustic emissions, comp.; with contralateral suppression of OAE)92585 (auditory evoked potentials)Evaluation for CAPD 60 minutes + report 92620 (e.g., MLD, SIN, RGDT, PPT, DD, SIFTER)92621 (Each additional 15 minutes)
Behaviors of children "at risk" for APD (Adapted from Cohen,1980 & Fisher,1985)Frequently misunderstands oral instructions or questions Delays in responding to oral instructions or questions Says "Huh" or "What" frequently Frequently needs repetition of directions or information Frequently needs requests repetition Has problems understanding in background noise Is easily distracted by background noise May have problems with phonics or discriminating speech sounds May have poor expressive or receptive language May have spelling, reading, and other academic problems May have behavioral problems
Attention Deficit DisorderAlthough there was confusion in the past, it is now widely accepted that ADHD and APD are separate conditions, each of which may occur on their own, as well as together. Figuring out what is ADHD and what is APD can be challenging due to the similarities in symptoms between them. Nonetheless, there are some predominant behaviors that may help distinguish between the two. (Chermak et al., 1999)
Behaviors seen with ADHD vs. APD in Frequency of OccurrenceADHD APD 1. Inattentive 1. Difficulty hearing in background 2. Distracted 2. Difficulty following oral instructions 3. Hyperactive 3. Poor listening skills 4. Fidgety/restless 4. Academic difficulties 5. Hasty/impulsive 5. Poor auditory association skills 6. Interrupts/intrudes 6. Distracted
*From Auditory Processing Disorders, Minnesota Department of Education (2003).
APD can be evaluated in the presence of ADHD
If there is a question of ADD/ADHD: ADHD should be fully worked up & medications should be stable prior to APD evaluation. If medication does not appear effective or processing is still suspect, consider APD referral. An APD evaluation can be considered in the absence of ADHD.
Contraindications for APD TestingCognitive delay (IQ below 75)Autism Spectrum Disorder (ASD) Non-native English speakerUse non-languageor low-language based toolsMLD PPSTDichotic Digits RGGT
 Educational Audiology Association listserve (community standard), 10/09/03
Minimal Test Battery approach Jerger & Musiek (2000)Three possible approaches: Behavioral tests Electro-acoustic tests Neuro-imaging studies
Parent/School Concernsof (C)APD
Collaborative Providers: Educational Psychologist PsychiatristSpeech/Language PathologistPrimary Care Provider OtolaryngologistOther
Clinical/Educational Audiologist CRITERIA for REFERRAL: Rule out neurological problemRule out ADD/ADHD (or) If ADD/ADHD, medications stable Rule out vision loss (normal or corrected vision) Rule out cognitive delay (average or above cognitive quotient) Rule out phonological processing problem English as a Second Language excluded Minimum age of 7 years to allow for maturation of the CANS AUDIOLOGICAL EVALUTION:Pure tone audiogram Speech threshold & WordRecognition (PB/PI Function)OAE, with contralateral suppressionTympanogram & Acoustic Reflexes
BASIC (C)APD EVALUATION:Teacher checklist (e.g., SIFTER) Speech-in-Noise test (e.g., BKB-SIN)Binaural Processing test (e.g., MLD, Dichotic Digits)Temporal Processing test (e.g., RGDT)Pattern Processing test (e.g., PPST)Where abnormal, a second test should be completed, preferably using a different modality (e.g., one speech, one non-speech). Diagnosed (C)APDINTERVENTION/THERAPIES:(May not be covered by insurance)-Auditory Training/Aural Rehabilitation-Language Therapy -Cognitive Therapy
Multidisciplinary (C)APD Team Model
Use normed, peer-reviewed, non-verbal tests, where possibleThis protocol samples these domains:General screen for APD: MLD, SIFTERBinaural interaction/binaural integration: MLD, DDContralateral [efferent] suppression of OAEContralateral acoustic reflexes Localization/lateralization: MLDAuditory figure/ground: MLD, BKB- or QUICK-SINContralateral [efferent] suppression of OAETemporal processing/phonemic awareness: RGDTPattern processing: PPST
Narrative report must be readableSOAP formatA: Results from APD testing support the following: Procedure Result Psychophysical correlate
What about reliability? Where abnormal, we request another test of that domain, in a different modality (if possible) by another provider on the TeamTwo abnormal tests are required to diagnose an APD [in that domain]We believe this constitutes evaluationGreater validityMulti-disciplinary perspective
Follow-up on abnormal APD results ENT evaluation for patients with abnormal retro- cochlear findings e.g., abnormal acoustic reflexes, abnormal word recognition rollover Neuropsychology and/or Educational P