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Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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To be considered OHI for IDEA, a disorder must
●
Be a chronic or an acute health problem
●
Due to the identified problem, the student has limited strength, vitality, or limited
alertness (including a heightened alertness to environmental stimuli that results in limited
alertness with respect to the educational environment)
Central Anatomy and Physiology Review
For a comprehensive discussion of CANS anatomy and physiology, please refer to Chapter 2. The
information provided in Table 6–7 is a brief review of important CANS structures relevant to (C)APD
in children.
Approaches in Audiology
Different approaches are used to categorize (C)APDs. The approach an audiologist chooses should be
founded in evidence-based practices that consider a clinical protocol based on age-based normative
data with a clear indication of what the inclusion criteria are and who should be excluded based on
other diagnoses. Currently, there are primarily two approaches to address (C)APDs. One is a model
approach that uses scores on specific diagnostics tests to categorize the type of disorder, while the other
uses deficit-specific areas to guide diagnosis and management.
Models of (Central) Auditory Processing
A model approach to examining auditory (central) processing includes testing that would place a child’s
performance into various categories of processing difficulties. These models are based on neurologic areas of
damage and infer functional components based on scores on specific diagnostic tests or test batteries. Two
common models include the Buffalo Model by Jack Katz and the Bellis/Ferre Model (Jutras et al., 2007).
The Buffalo Model
The Buffalo Model considers areas of CANS performance as measured test scores on the staggered
spondaic word test (SSW; a dichotic test), phonemic synthesis test (test that blends speech sounds to form
a word), and speech-in-noise test. Scores from these tests are used to divide children into four categories. Based on the category, functional skills are inferred, and therapy is conducted related to these areas.
n
Decoding: breakdown at the phonemic level
Test results include excessive errors in the SSW right competing and left noncompeting
conditions, and poor phonemic synthesis.
Projected area of dysfunction is the left posterior temporal lobe.
Possible functional difficulties include weakness is expected in oral reading, word accuracy,
and spelling skills due to difficulty at the phonemic level.
n
Tolerance fading memory: breakdown at the memory level
Test results include quick responses, “smushed” responses (using component of both
spondees to make a single word), repeating the carrier phrase, and omissions of words on
the SSW. Omissions are also seen on the phonemic synthesis test and these individuals have
difficulty on the speech-in-noise test.
CHAPTER 6 Pediatric Assessment and Differential Diagnosis
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TABLE 6 –7. Anatomical Structures Related to Auditory Processing and Sample Test Measures
ANATOMICAL STRUCTURE ROLE IN AUDITORY PROCESSING EXAMPLES OF (C)APD TESTS
Cochlear Nucleus Precise timing patterns Ipsilateral deficits on dichotic
listening
283
Superior Olivary Complex
(SOC)
Interaural timing MLDs
Figure-ground: reduction of
Acoustic reflexes
low-frequency, moderately loud
a
noise
Figure-ground
— reduction of
mid-high frequency, quiet noise
a
Suppression of OAEs
Inferior Colliculus Sound duration and gap detection Contralateral deficits on
dichotic listening and/or
degraded signals (e.g., filtered
speech, time-compressed
speech)
Medial Geniculate Body Localization interaural time and
intensity differences and beginning
Contralateral dichotic listening
deficits
processing of the natural speech
signal
Auditory Cortex right
hemisphere
Auditory Cortex left
hemisphere
Temporal skills, spatial
representation of stimuli, overall
meaning of the message
Language dominance and
organization, details within the
Dichotic tests — left ear scores
Temporal patterns of pitch and
duration, gap detection
Dichotic tests — right ear
scores
overall pattern of speech, perceive
subtle speech cues
Corpus Callosum Connection of the two hemispheres
a
Information from Liberman and Guinan (1998).
Source: Data primarily from Musiek and Baran (2020) and Rawool (2016).
Projected areas of dysfunction are the frontal lobes and anterior temporal region.
Possible functional difficulties include poor auditory memory and difficulty listening in
noise, expressive language difficulties, and impulsive responses.
n
Integration: integration of information from both sides of the brain
Test results include Type A SSW pattern, as well as long response time on SSW
Projected areas of dysfunction are the posterior corpus callosum and/or angular gyrus of the
parietal-occipital region. There is a secondary profile of integration that is more associated
with the anterior region of the corpus callosum.
of the brain to integrate auditory
information from both cerebral
hemispheres
Verbal labeling pitch or
duration patterns, significant
deficits on left ear during
dichotic listening
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Possible functional difficulties are poor reading skills, difficulty spelling, and difficulty with
visual\auditory association (e.g., dyslexia).
n
Organization: organizing what is heard
Test results include reversals on primarily the SSW but can be seen on the phonemic
synthesis test as well.
Projected area of dysfunction is the anterior temporal/temporoparietal regions
Possible functional difficulties poor organization, planning, and sequencing
Bellis/Ferre Model
The Bellis/Ferre Model examines areas of CANS performance as measured on test scores for dichotic
measures (e.g., dichotic digits, SSW, competing words), temporal tasks (e.g., pitch or duration patterns),
low-redundancy speech (e.g., filtered words), and speech-in-noise tests. Scores from these tests are used
to divide children into three primary categories. Based on the category, functional skills are inferred
and therapy related to these areas.
n
Auditory decoding deficit: poor phonemic skills
Test results include poorer right ear scores on low-redundancy tests and speech-in-noise tests.
This is also associated with poor right ear scores (or both) on dichotic tests and/or
competing sentences.
Projected area of dysfunction is thought to be the primary auditory cortex in the left
hemisphere.
Possible functional difficulties include difficulty with phonemic skills, discrimination, and
sound blending.
n
Prosodic deficit: difficulty recognizing the prosodic components of speech (e.g., rate, rhythm,
inflection)
Test results include abnormal tonal patterns (e.g., pitch and duration), poor left ear skills on
dichotic testing, but good speech-in-noise.
Projected area of difficulty is the right hemisphere.
Possible functional problem areas: singing, social skills, flat tone of voice, and poor visual-
spatial skills
n
Integration: inter- or intrahemispheric skills
Test results include poor left ear on dichotic tasks and labeling of pitch or duration patterns.
Projected areas of difficulty would be the corpus callosum (interhemispheric transfer of
auditory information).
Possible functional problems would include drawing, understanding someone speaking
(when the child needs to take notes), and multimodality learning tasks.
Deficit-Specific Categorization
Assessing deficit-specific abilities is another viewpoint for classifying (C)APD. Some researchers suggest
that specific scores on specific tests do not always correlate with specific functional areas of deficit
(Gustafson & Keith, 2005). Considering tests that examine specific functional abilities is designed to
CHAPTER 6 Pediatric Assessment and Differential Diagnosis
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address concerns related to specific areas of observed deficit. Note, however, that these areas do not all
align with the specific auditory skills outlined by ASHA and AAA as underpinning auditory processing.
This method allows the provider to address specific difficulties experienced by the child and apply
them to the educational setting. A deficit-based “hierarchy” of auditory processing skills (adapted from
English, 2001) and examples of domain-specific tests include:
n
Awareness/localization: knowing that a sound has occurred and knowing where a sound
source is located
Testing includes pure-tone testing, Listening in Spatialized Noise–Sentences (LiSN-S) —
can be used to diagnose spatial processing disorder. Localization can also be assessed using
an informal method of having them point to a sound source when their eyes are closed.
n
Discrimination: ability to know if two sounds are the same or different
Tests include the Test of Auditory Processing Skills–4 (TAPS-4; subtest of discrimination)
and Lindamood Assessment.
n
Recognition: recognizing a word and being able to repeat it back correctly
Testing would include speech recognition testing at various levels such as syllables, words,
and sentences.
n
Auditory attention: skill of being able to attend to a particular auditory signal
Tests include the Auditory Continuous Performance Test (ACPT)
n
Figure-ground: ability to ignore background noise (both speech or nonspeech) and repeat the
desired signal; different types of noise and targets should be utilized.
Tests include word recognition in noise, but also the Selective Auditory Attention Task,
Synthetic Sentence Index Test (SSI), and the SCAN-3 (Child or Adolescents; figure-ground
section).
n
Synthesis: putting sounds together and taking them apart
Tests include Phonemic Synthesis, Phonemic Awareness Test, or TAPS-4 (Phonological
Deletion and Phonological Blending).
Note: when working in an interdisciplinary team, the speech-language pathologists often
assess this area.
n
Degraded signals: ability to fill in missing acoustic information in degraded auditory signals
Tests include filtered speech, SCAN-3 (Child or Adolescents; filtered speech and time
compressed sentences subtests), and time-compressed speech.
n
Dichotic listening tasks: examining the ability to separate and integrate information from
both sides of the brain and are a measure of language dominance
Tests include the SSW; SCAN-3 (Child or Adolescents, competing words and sentences
subtests); dichotic digits, words, or sentences; and binaural fusion.
Dichotic tests are often examined not just as overall scores, but by comparing the ears’
performance to each other. If one ear outperforms the other, this is referred to as an ear
advantage. Right ear advantages are typical to a degree.
n
Memory and sequencing: remembering acoustic information and keeping it sequenced in order
Tests include the TAPS-4, or pitch and duration pattern sequence.
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n
Temporal resolution: processing the auditory information to identify rate, pitch, and duration,
at an appropriate speed
Tests include gap detection (Gaps in Noise, Random Gap Detection), pitch pattern
sequence, and duration pattern sequence.
Q & A
Question: A 9-year-old girl with difficulty retelling a story she has heard was
tested for (C)APD using dichotic measures. She shows a right ear advantage
(REA) typical of a much younger child. What does a REA tell you about her
auditory development?
Answer:
She still appears to be on a typical developmental path but is delayed
in acquiring dichotic listening skills. Depending on the other findings, she may
be diagnosed with integration-type (C)APD with training efforts focused on
dichotic listening.
Testing Factors
The selection of tests used depends on the approach (model or deficit specific) used and what information is desired. An audiologist should consider the implications for the child and what information tests
will supply the other members of the multidisciplinary team.
n
Factors that impact whether a child should be tested and/or influence test results
Age: scores are variable below age 7 with large confidence intervals so testing is not
recommended.
Language: children for whom English is a second language should be tested in the child’s
primary language. Also, the language level of the task when testing needs to be considered
for a child. Children with lower language skills may require nonverbal tasks.
Global function: it is recommended that the child’s global functioning (IQ) be 85 or
greater. If that is not possible as a total score, a nonverbal IQ of 85 or greater could be used
as the criterion. Any known executive function difficulties (e.g., working memory) should
also be considered related to concerns for whether a child should be tested and/or which
tests may be inappropriate to use because the skills required for testing would be highly
impacted by poor executive function.
ADHD: children with ADHD should be tested on medication to try to control attention
impact. Later testing can be done off of medications (working with the child’s doctor) to see
if ADHD makes the symptoms worse or if (C)APD was the primary concern.
Multidisciplinary team: a team is needed to address all areas of functional concern and
coordinate management.
Hearing: in pursuing a diagnosis of (C)APD, hearing needs to be within normal limits; by
and large, testing norms are based off of individuals with normal hearing.
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Speech/language disorders: a child’s speech/language abilities need to be considered so that
test results will not be impacted by errors due to articulation or by language skills impacting
the child’s understanding of the task.
Neurological disorders: since (C)APD is examining the CANS, children with known
lesions of the CANS should have difficulty on the test measures, so a diagnosis of (C)APD
cannot be definitively made.
The information above is related to diagnosis of (C)APD as the primary disorder. (C)APD tests of
function may be given to individuals with comorbid disorders to examine the individual’s functional
abilities but should not change their primary diagnosis.
n
Case history risk factors (C)APD
History of otitis media
History of hyperbilirubinemia
Family history
Medical issues during pregnancy such as anoxia, bacterial/viral illness, maternal drug or
alcohol abuse
Severe childhood illness
Neurologic issues
Maternal smoking during pregnancy
Smoking in the home (contribution to otitis media)
Anesthesia use recently
n
Checklists can be used to get an idea of the difficulties experienced by a child with (C)APD.
The Screening Instrument for Targeting Educational Risk (SIFTER) and Children’s
Auditory Performance Scale (CHAPS) are two that can be used. These are discussed later in
the chapter in the Educational Audiology section.
Fisher’s Auditory Problems Checklist is a checklist of auditory characteristics where the
teacher or parent checks off applicable behaviors.
Children’s Home Inventory for Listening Difficulties (CHILD) by Anderson and Smaldino
(2011) is a checklist that parents and the child answer regarding how difficult 15 different
listening situations are for the child.
Other tests can be found in resources listed in the Educational Audiology section.
n
Factors to consider when testing for (C)APD
Test difficulty
If a lower-level problem is seen in the auditory skills hierarchy, testing at the higher levels
may not be performed as they build on each other as a foundation.
Functional implications in educational settings
Test scores
●
Some tests do not have standard scores and/or the scores have large confidence intervals,
which makes diagnosis difficult. This is reflective of the fact that auditory development
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of complex skills varies widely as children development, with marked variability at
younger ages.
Validity of testing
●
Test protocol is required and testing should be performed in a controlled environment.
Language load
Tests contain varying language loads (language difficulty) and these need to be considered
prior to testing to be sure the instructions and stimuli are appropriate for a child’s language
skills and cognitive level.
n
Peripheral audiological testing should be completed prior to (C)APD testing to not only rule
out peripheral hearing loss but also examine results that impact the auditory processing. A
peripheral test battery should include:
Pure-tone audiometry, including interoctave frequencies
Speech recognition in quiet and noise
Immittance measures
OAEs
Use of electrophysiology
●
There are no agreed-upon criteria as to when electrophysiology should be included in
the clinical evaluation of (C)APD. However, electrophysiology assessment should be
considered when results of neurologic concern are obtained, such as hearing asymmetries,
abnormal MEMRs, large asymmetry between ears for word recognition scores, switching
ear advantages on right ear first versus left ear first reporting of dichotic tasks, large left
ear advantages, and so on.
●
Limited evidence exists to support the inclusion of these tests in cases of normal
peripheral findings, with the exception of the ABR. When used with OAEs, the ABR is
necessary in identifying ANSD.
●
MLR and later potentials (like the P300) can provide insight into thalamocortical and
cortical functioning, respectively.
n
Not all testing requires an audiometer; there have been an increasing number of computer or
app-based (C)APD measures recently.
Feather Squadron (Acoustic Pioneer) is an app-based system to assess auditory processing
skills. Based on results, therapy programs to address areas of functional difficulties exist.
CAPDOTS (capdots.com) is an online system that includes an assessment for auditory
processing disorders designed to work with children with binaural integration and
separation difficulties.
n
Speech and language testing may cover some of the same areas, such as phonemic skills, and
can be used in conjunction with (C)APD testing to look at more functional areas. Following
or concurrent with (C)APD testing, advanced language assessment may help in developing
strategies and determining if bottom-up or top-down training may be best. Advanced
language assessment may include phonemic skills, executive function, problem-solving, theory
of mind, reading skills.
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Management Overview
Management of (C)APD can be grouped into modification of the environment, compensatory strategies, and direct rehabilitative services, which include perceptual/auditory training as well as cognitive
training. Components of management include:
n
Modifications of the environment
Improvement of the signal-to-ratio (SNR) by:
●
Increasing the signal loudness by increasing the teacher’s loudness or decreasing the
child’s distance from the speaker
●
Decreasing the background noise through improving classroom acoustics (including
reverberation) and controlling noise in the classroom
Train student to listen better by using whole-body listening, increasing the child’s
motivation to listen and teaching the child to advocate when struggling.
Hearing assistive technology systems (HATS), where the teacher is wearing a microphone
that transmits to some form of receiver the child is wearing, can be used to improve
environmental listening by improving SNR. (A more in-depth discussion is in the
Educational Audiology section later in this chapter.)
n
Compensatory strategies for children with (C)APD include improving acoustics/environment,
accommodations, modifying presentation methods, providing support, maximizing other
sensory cues, and providing encouragement.
n
Direct services can be provided by audiologists and/or speech-language pathologist and
include both perceptual and cognitive training.
Perceptual/auditory training is a bottom-up style therapy based on perceptual auditory skills
using training to strengthen skills. It utilizes several principles in training (Musiek et al.,
2014). It relies on the fact that the central auditory system is plastic and can learn auditory
skills through exposure to auditory stimuli either through increased natural exposure
or planned therapy. It includes the principle that active exposure for the child is more
efficient when the child is active and motivated. Evidence-based research supports different
perceptual trainings (Musiek et al., 2014).
●
Dichotic Interaural Intensity Training (DIID) (Moncrieff & Wertz, 2008)
●
Speech-in-noise training
●
Discrimination training
●
Temporal processing training
●
Commercial computer-based training programs
CAPDOTS (capdots.com)
Insane Airplane, Zoo Caper, Elephant Memory (Acoustic Pioneer)
Cognitive training is a top-down style using cognition concepts to facilitate processing.
Often this is performed in collaboration with the speech-language pathologist on the team.
It uses cognitive strategies, metacognitive strategies, and metalinguistic strategies to train
the child to perform top-down tasks. For more information about different strategies, the
reader is directed to Chermak (2014).
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●
Cognitive strategies include training in auditory attention and vigilance, auditory
memory, mnemonics strategies, and mind-mapping.
●
Metacognitive strategies areas include attribution retraining, self-instruction, cognitive
problem-solving, self-regulation, cognitive strategies, cognitive style and reasoning,
reciprocal teaching, and assertiveness training.
●
Metalinguistic strategies include discourse cohesion devices, schema, auditory verbal
closure, vocabulary building, phonologic awareness, and prosody training.
There is a complementary nature of bottom-up and top-down processing. Bottom-up
focuses on strategies to deal with novel or degraded incoming signals, whereas top-down
uses prior knowledge for structure to process the incoming message.
Educational Audiology
Children with hearing loss are included as individuals who may need to receive services under the
Individuals with Disabilities Act (IDEA) and Section 504 of the Rehabilitation Act. To qualify, a
“specialist” in hearing/deafness needs to provide evidence the child has a significant difficulty in an
educational system due to their hearing status. Though there are several professionals who could be a
“specialist” (e.g., otolaryngologist, teachers of the deaf, speech-language pathologists), audiologists are
trained to recognize the specific impact of hearing difficulties. To meet the growing needs of students
with varying levels and types of hearing loss, audiologists are being more frequently employed by, or
contracted with, local school districts or educational service centers to provide audiological services to
children in the school systems. The audiologist will determine the nature and degree of hearing loss as
well as how the child processes speech information. They will also examine amplification the child is
using, as well as make recommendations for HATS. This information will help determine the level of
concern for the child’s educational need.
n
Educational implications of hearing loss: children who are deaf or hard of hearing are at risk
for educational difficulty. Educational implications vary according to degree of hearing loss;
however, degree of loss does not address all listening situations. Factors not reflected on the
audiogram will affect each child differently. Educational recommendations should be created
based on assessment and individual needs.
n
Some factors associated with children who are Deaf/Hard of Hearing (DHH):
Poor speech production (articulation)
Problems with expressive and receptive language skills (especially high-level skills)
Difficulties with language often lead to delays in reading and writing.
Poor understanding of speech in noise
Difficulty focusing and paying close attention so as to fill in missing information
Experience fatigue by the end of the day as hearing loss may impact listening effort, or
how much effort is exerted to be able to understand speech, or listening fatigue (Hicks &
Tharpe, 2002)
Negative effects to Theory of Mind (ToM) skills
Notable changes for mental health have been noted, as well as the impact of bullying due to
being considered different by other children
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One item that is NOT a result of hearing loss is cognitive ability. Hearing loss does
not lower a child’s cognitive ability. As seen above, the deficit relates more to effectively
communicating thoughts and developing cognitive skills due to language deprivation.
Relevant Legislation
Much of the current legislation is based on laws regarding children with disabilities in the 1970s.
Example legislation, from the 1970s to current, includes:
n
Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination and protects
individuals, including children in the schools
n
PL 94-142, The Education for all Handicapped Children Act (1975)
Ensured “free appropriate publication in the least restrictive environment”
First to delineate Individualized Education Programs (IEPs) in the schools
n
PL 99-457 Education of the Handicapped Act Amendments (1986)
Extended 94-142 to include children from 3 to 5 years of age
Included option for early intervention services for birth to 2 years and Individualized
Family Service Plans (IFSPs) for the early intervention services
n
Americans with Disabilities Act (ADA)
Protects against discrimination
n
Individuals with Disabilities Education Act (IDEA)
Combined 94-142 and 99-457
Services for birth to 5 and preschool/school age children are included as well.
IDEA has different sections for school-aged children and early childhood intervention with
different eligibility requirements.
Eligibility and Services
Eligibility should be determined using a multidisciplinary team to obtain information about if the child
meets criteria for the description of significant hearing loss. This hearing loss needs to show an impact
on educational performance, leading to a need for special education. Once a child has been identified
as having hearing difficulties by a “specialist” in hearing/deafness, information will be examined by a
team to determine if the child qualifies for services and, if so, what services. Using this information,
the educational system (and/or early childhood program) will determine if the child qualifies under
IDEA. In the educational setting, a team would comprise an administrator, a general education teacher,
a special education teacher, and the child’s parent(s)/legal guardian(s) but can include others such as
the audiologist, teacher of the deaf, speech-language pathologist, and so on. The team members vary
by state requirements.
n
504 Services
Considerations for 504 accommodations and modifications would be included in the
IDEA determination. However, a child found to not qualify for IDEA still qualifies for
504services.
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