Auditory Processing Disorders (APD) in Children and Adults: Part 2

Scope of Practice 7/5/16, 3:26 PM

An Auditoryaudiologist is a person Processing who, by virtue of academic Disorders degree, clinical (APD training,) andin license Children to practice and/orand professionalAdults: credential, Partis uniquely 2. qualified A Team to provide Approach a comprehensive array to of Management professional services related to the prevention of hearing loss and the audiologic identification, assessment, diagnosis, and treatment of persons with impairment of auditory and vestibular function, and to the prevention of impairments associated with them. Audiologists serve in a number of roles including clinician, therapist, teacher, consultant, researcher and administrator. The supervising audiologist maintains legal and ethical responsibility for all assigned audiology qactivitiesIntroduction provided by audiology assistants and audiology students. qTheCounseling central focus of the profession& Advocacy of audiology is concerned with all auditory impairments and their relationship to qdisordersFM technologyof communication. Audiologists identify, assess, diagnose, and treat individuals with impairment of either qperipheralComputer or central -auditorybased and/or auditory vestibular function, training and strive to prevent such impairments. qScopeAudiologistsDirect of Practice provide auditory clinical and remediation academic training to students in audiology. Audiologists teach physicians, medical7/5/16, 3:26 PM qstudents,Language residents, and-based fellows about options the auditory and vestibular system. Specifically, they provide instruction about identification, assessment, diagnosis, prevention, and treatment of persons with hearing and/or vestibular Treatmentimpairment. They provide information and training on all aspects of hearing and balance to other professions Theincluding audiologist psychology, is the counseling,professional rehabilitation, who provides and the education. full range ofAudiologists audiologic provide treatment information services onfor hearingpersons and with impairmentbalance, hearing of hearing loss and and disability, vestibular prevention function. ofThe hearing audiologist loss, and is responsible treatment to for business the evaluation, and industry. fitting, They and developverification ofand amplification oversee hearing devices, conservation including programs assistive listeningin industry. devices. Further, The audiologists audiologist serve determines as expert the witnesses appropriateness within the of amplificationboundaries of systems forensic foraudiology. persons with hearing impairment, evaluates benefit, and provides counseling and training regarding their use. Audiologists conduct otoscopic examinations, clean ear canals and remove cerumen, take ear canalThe audiologist impressions, is an select, independent fit, evaluate, practitioner and dispense who provides hearing services aids and in hospitals,other amplification clinics, schools, systems. private Audiologists practices assessand other and settings provide in audiologic which audiologic treatment services for persons are relevant. with tinnitus using techniques that include, but are not limited to, biofeedback, masking, hearing aids, education, and counseling. Scope of Practice Audiologists also are involved in the treatment of persons with vestibular disorders. They participate as full members ofThe balance scope oftreatment practice teams of audiologists to recommend is defined and by carry the outtraining treatment and knowledge and rehabilitation base of professionalsof impairments who of arevestibular licensed and/or credentialed to practice as audiologists. Areas of practice include the audiologic identification, function. assessment, diagnosis and treatment of individuals with impairment of auditory and vestibular function, prevention of hearing loss, and research in normal and disordered auditory and vestibular function. The practice of audiology Audiologists provide audiologic treatment services for infants and children with hearing impairment and their families. includes: These services may include clinical treatment, home intervention, family support, and case management.

Identification The audiologistAuditory is the member Processing of the implant team Disorders: (e.g., cochlear implants, Scope middle earof implantable Practice hearing aids, fully Audiologists develop and oversee hearing screening programs for persons of all ages to detect individuals with implantable hearing aids, bone anchored hearing aids, and all other amplification/signal processing devices) who hearing loss. Audiologists(American may perform speechAcademy or language of screening, Audiology, or other screening 2004) measures, for the purpose determines audiologic candidacy based on hearing and communication information. The audiologist provides pre and of initial identification and referral of persons with other communication disorders. post surgical assessment, counseling, and all aspects of audiologic treatment including auditory training, rehabilitation, implant programming, and maintenance of implant hardware and software. Assessment and Diagnosis Assessment of hearing includes the administration and interpretation of behavioral, physioacoustic, and The audiologist provides audiologic treatment to persons with hearing impairment, and is a source of information for electrophysiologic measures of the peripheral and central auditory systems. Assessment of the vestibular system family members, other professionals and the general public. Counseling regarding hearing loss, the use of includes administration and interpretation of behavioral and electrophysiologic tests of equilibrium. Assessment is amplificationScope of Practice systems and strategies for improving speech recognition is within the expertise of the audiologist. 7/5/16, 3:26 PM accomplished using standardized testing procedures and appropriately calibrated instrumentation and leads to the Additionally,diagnosis of hearingthe audiologist and/or vestibularprovides counselingabnormality. regarding the effects of hearing loss on communication and psychosocial status in personal, social, and vocational arenas. Treatment Thehttp://www.audiology.org/print/1664The audiologist audiologist administers is the professional audiologic identification,who provides assessment, the full range diagnosis, of audiologic and treatment treatment programs services to children forPage persons 2 of of 4 with allimpairment ages with hearing of hearing impairment and vestibular from birth function. and preschool The audiologist through school is responsible age. The audiologist for the evaluation, is an integral fitting, part of and verification theof amplificationteam within the devices, school system including that assistivemanages studentslistening with devices. hearing The impairments audiologist and determines students with the central appropriateness of auditoryamplification processing systems disorders. for persons The audiologist with hearing participates impairment, in the development evaluates benefit, of Individual and Familyprovides Service counseling Plans and training (IFSPs)regarding and theirIndividualized use. Audiologists Educational conduct Programs otoscopic (IEPs), serves examinations, as a consultant clean in mattersear canals pertaining and remove to classroom cerumen, take ear acoustics, assistive listening systems, hearing aids, communication, and psycho-social effects of hearing loss, and canal impressions, select, fit, evaluate, and dispense hearing aids and other amplification systems. Audiologists maintains both classroom assistive systems as well as students' personal hearing aids. The audiologist administers assess and provide audiologic treatment for persons with tinnitus using techniques that include, but are not limited hearing screening programs in schools, and trains and supervises non audiologists performing hearing screening in to, biofeedback, masking, hearing aids, education, and counseling. the educational setting.

HearingAudiologists Conservation also are involved in the treatment of persons with vestibular disorders. They participate as full members Theof balance audiologist treatment designs, teams implements to recommend and coordinates and carryindustrial out andtreatment community and hearingrehabilitation conservation of impairments programs. Thisof vestibular includesfunction. identiﬁcation and amelioration of noise-hazardous conditions, identiﬁcation of hearing loss, recommendation

Audiologists provide audiologic treatment services for infants and children with hearing impairment and their families. http://www.audiology.org/print/1664 Page 3 of 4 These services may include clinical treatment, home intervention, family support, and case management.

The audiologist is the member of the implant team (e.g., cochlear implants, middle ear implantable hearing aids, fully implantable hearing aids, bone anchored hearing aids, and all other ampliﬁcation/signal processing devices) who determines audiologic candidacy based on hearing and communication information. The audiologist provides pre and post surgical assessment, counseling, and all aspects of audiologic treatment including auditory training, rehabilitation, implant programming, and maintenance of implant hardware and software.

The audiologist provides audiologic treatment to persons with hearing impairment, and is a source of information for family members, other professionals and the general public. Counseling regarding hearing loss, the use of ampliﬁcation systems and strategies for improving speech recognition is within the expertise of the audiologist. Additionally, the audiologist provides counseling regarding the eﬀects of hearing loss on communication and psychosocial status in personal, social, and vocational arenas.

The audiologist administers audiologic identiﬁcation, assessment, diagnosis, and treatment programs to children of all ages with hearing impairment from birth and preschool through school age. The audiologist is an integral part of the team within the school system that manages students with hearing impairments and students with central auditory processing disorders. The audiologist participates in the development of Individual Family Service Plans (IFSPs) and Individualized Educational Programs (IEPs), serves as a consultant in matters pertaining to classroom acoustics, assistive listening systems, hearing aids, communication, and psycho-social eﬀects of hearing loss, and maintains both classroom assistive systems as well as students' personal hearing aids. The audiologist administers hearing screening programs in schools, and trains and supervises non audiologists performing hearing screening in the educational setting.

Hearing Conservation The audiologist designs, implements and coordinates industrial and community hearing conservation programs. This includes identiﬁcation and amelioration of noise-hazardous conditions, identiﬁcation of hearing loss, recommendation

http://www.audiology.org/print/1664 Page 3 of 4 2010 AAA Clinical Guidelines on Auditory Processing Disorders: Terminology for Habilitation/Rehabilitation

q Intervention: “…encompassing term referring to one or more actions taken in order to produce an effect and to alter the course of a disease, disorder, or pathological condition.” q Treatment: “…any specific procedure used to prevent, remediate (I.e., cure), or ameliorate a disease, disorder, or pathological condition.” q Management: “…referes to compensatory approaches (e.g., strategies, technologies) used to reduce the impact of deficits that are resistant to remediation.”

2010 AAA Clinical Guidelines on Auditory Processing Disorders: Intervention q Bottom up “stimulus driven” approaches often implemented by audiologists, e.g., • Auditory training, e.g., ü Earobics ü LACE (Listening and Communication Enhancement) • Direct auditory skill remediation, e.g., ü Dichotic Interaural Intensity Difference (DIID) training ü Aural Rehabilitation for Interaural Asymmetry (ARIA) • Enhancement of listening environment ü Classroom acoustical modifications ü Classroom amplification (FM) systems ü Personal FM systems 2010 AAA Clinical Guidelines on Auditory Processing Disorders: Intervention q Top down “strategy driven” approaches often implemented by speech pathologists and other professionals • Language strategies • Cognitive/metacognitive strategies • Speaker modifications • Instructional modifications and strategies • Accommodations in the ü Workplace ü Home ü Recreational setting ü Religious setting

Auditory Processing Disorders (APD) in Children and Adults: Part 2. A Team Approach to Management

q Management: Appropriate Referrals lSpeech language pathologist üLanguage assessment üPhonological awareness assessment üReading remediation üTop-down therapy lPsychologist or neuropsychologist üAssessment of cognitive function üAssessment of ADHD üProfessional counseling üDiagnosis of other disorders (e.g., developmental disorders) Auditory Processing Disorders (APD) in Children and Adults: Part 2. A Team Approach to Management

q Management: Appropriate Referrals lOtolaryngologist üDiagnosis of ear disease üManagement of middle ear dysfunction üNeuro-radiological studies lNeurologist üAssessment of neurological functioning üRule out neurological disease (e.g., seizure disorders) lOccupational therapist üEvaluation of visual processing üEvaluation of motor processing üAssessment of sensory integration disorders

Auditory Processing Disorders (APD) in Children and Adults: Part 2. A Team Approach to Management

q Introduction q Counseling & Advocacy q FM technology q Computer-based auditory training q Direct auditory remediation q Language-based options Psychosocial Function in Children with APD Kreisman NV, John AB, Kreisman BM, Hall JW III & Crandell CC (deceased) (2012). Psychosocial status of children with auditory processing disorder. Journal of the American Academy of Audiology, 22, 222-233

Psychosocial Function in Children with APD: Initial BASC II Parent Report (Johnston et al, 2009)

•Externalizing Prob: Hyperactivity, Aggression, Conduct Problems •Internalizing Prob: Anxiety, Depression, Somatization •BSI: Atypicality, Withdrawal, Attentional Problems •Adaptive Skills: Adaptability, Social Skills, Leadership, Activities of Daily Living, Functional Communication Psychosocial Function in Children with APD: Initial BASC II Child Self Report (Johnston et al, 2009)

•Internalizing Prob: Atypicality, Locus of Control, Social Stress, Anxiety, Depression, Sense of Inadequacy, Somatization •School Prob: Attitude to School, Attitude to Teachers, Sensation Seeking •ESI: combination of Social Stress, Anxiety, Depression, Sense of Inadequacy •Personal Adjustment: Relations with Parents, Interpersonal Relations, Self-Esteem, Self Reliance

Patient/Family Counseling and Education in APD

“Knowledge is power.” (Nam et ipsa scientia potestas est.)

Francis Bacon (1561-1626)

Meditationes Sacrae [1597] Essentials of Counseling of Patients with APD and Parents/Family Members q General guidelines w Counsel in a quiet and private venue w Include spouse, “significant others”, and/or family members w Introduce yourself with eye contact and a firm (but comfortable) handshake w Use respectful titles (e.g., Mr. or Mrs.) w Give patient and family members the impression that you have plenty of time and nothing is more important than talking with them w Be accepting of statements, feelings, and attitudes but … w Gently clarify any misconceptions with factual information w Remember: Knowledge is power!

Essentials of Counseling Applied to APD: Types of Counseling q “Non-professional” counseling (by audiologists) lInformational (content) counseling* lPersonal adjustment counseling q Professional counseling (by trained counselor, psychologist, or psychiatrist) lIdentifying unconscious behaviors lManaging major personality changes (e.g., clinical depression)

*Research shows that > 80% of audiologists and audiology students focus mostly on content counseling, even when the patient and family members express the need for help with psychosocial aspects of hearing loss Auditory Processing Disorders (APD) in Children and Adults: Part 2. A Team Approach to Management

q Introduction q Counseling & Advocacy q FM technology q Computer-based auditory training q Direct auditory remediation q Language-based options

SNR improvement on the HINT in Normal Hearing Adults and Children Without and With APD: Three different FM system types (Crandell & Hall, 2005)

Head set 10 9.5

8 7.5 7.2 7.4 Desk top

6 6.5

4.7 4.3 Sound field 4 4.0 3.8

2 SNR Improvement (in dB SPL) dB (in Improvement SNR Adults (N = 10) Non-APD (N = 8) APD (N = 12) Listening Condition Phonak EduLink FM System Use Improves Academic Performance and Psychosocial Status in Children with APD

Johnston, John, Kreisman, Hall & Crandell. (2009). Multiple benefits of personal FM system use by children with auditory processing disorder (APD). International Journal of Audiology, 48, 371 - 383

EduLink Receivers

Mini-Boom Microphone

Campus S Transmitter

Hearing in Noise Test (HINT) Results (Mean SNR values without and with EduLink)

Group Test Condition Control APD

Unaided in Noise (SNR)* 7.9 dB 6.1dB

Aided in Noise (SNR) ** - 0.3 dB - 4.2 dB

Advantage in Noise 8.2 dB 10.3 with EduLink

* t = p < .08; ** t = .002

Typical Classroom SNR Range: +5 to -7 dB Markides (1986); Finitzo-Hieber (1988); Crandell and Smaldino (1995) BASC II Parent Report Results After EduLink Use (6 to 7 months): APD versus Control Subjects (Source: Johnson, John, Kreisman, Hall & Crandell, 2009)

Normal Findings per Group (%) Domain Control APD

Aggression 92 100 Conduct problems 92 100 Anxiety 84 100 Depression 92 100 Internalizing problems 77 71 Withdrawal 84 71 Attention problems 92 29 Adaptive skills 92 71 Functional communication 92 57

BASC II Student Report Results After EduLink Use (6 to 7 months): APD versus Control Subjects (Source: Johnson, John, Kreisman, Hall & Crandell, 2009)

Normal Findings per Group (%) Domain Control APD Attitude toward teachers 100 86 Attitude toward school 100 57 School problems 100 71 Conduct problems 92 100 Atypicality 100 100 Anxiety 100 100 Social stress 92 100 Depression 100 86 Internalizing problems 100 100 Sense of inadequacy 100 86 Parent relationship 92 100 Self esteem 100 100 Multiple Benefits of Personal FM System Use for Children with APD (Johnston, John, Kreisman, Hall, Crandell. 2009. International Journal of Audiology, 48, 371-383 q APD in school age children can have significant negative impact on: l Academic performance l Psychosocial status l Quality of life q Early intervention for auditory processing deficits is indicated for all children, despite the age of identification q The Phonak EduLink system is a feasible option for FM technology with adolescents (and persons of other ages) q Management of APD with FM technology (enhancing the signal-to- noise ratio) improves: l Speech perception in noise (with EduLink FM system l Academic performance l Psychosocial status l Speech perception in noise without the benefit of FM technology

Evidence Based Management of APD: Recent Research with FM Technology q Hornickel J, Zecker SG, Bradlow AR & Kraus N (2012). Assistive listening devices drive neuroplasticity in children with dyslexia. PNAS (early edition). l “Classroom FM technology enhances acoustic clarity” l Assessed impact of classroom FM system use for 1 year on auditory neurophysiology and reading skills in children with dyslexia l FM system use reduced the variability of sub-cortical responses (speech ABR) l Improvement was linked to increases in reading and phonological awareness l Matched control group of children with dyslexia didn’t show the effects l Conclusion: “Assistive listening devices can improve the neural representation of speech and can impact reading-related skills Auditory Processing Disorders (APD) in Children and Adults: Part 2. A Team Approach to Management

q Introduction q Counseling & Advocacy q FM technology q Computer-based auditory training q Direct auditory remediation q Reading readiness training q Language-based options

Intervention for APD with Computer-Based Techniques: Scientific Bases of FastForword

Tallal P, Miller S, Merzenich M, et al. Language comprehension in language-learning impaired children improved with acoustically modified speech. Science 271: 81-84, 1996.

“A speech processing algorithm was developed to create more salient versions of the rapidly changing elements in the acoustic waveform of speech that have been shown to be deficiently processed by language-learning impaired (LLI) children … LLI children received extensive daily training with listening exercises ...” Selected Intensive & Computer-Based Programs for Development of Auditory Processing Skills

q Earobics l?????.com q Lindamood Bell Learning Processes l LIPPS and Seeing Stars lLindamoodbell.com q Scientific Learning l FastForword l scientificlearning.com

Earobics Program (Vendor: ) q Rhyming q Phoneme identification q Blending • Combining sounds into words) q Segmentation • Breaking words down into individual sounds q Phonological manipulation q Discrimination q Auditory performance in competing noise q Auditory sequential memory Practice Guidance British Society of Audiology Management of APD 2011

ForWord also claims to improve the discrimination of brief sounds. Earobics and Fast ForWord have both been developed in the USA, and Phonomena has been developed in the UK. See Table 2 for a brief description of Earobics, Fast ForWord and Phonomena and the relevant websites. Further information and Computercosts are available-Based from the websites. Auditory Fast ForWord is significantly Training more expensive and professionals are required to complete a ‘Certified Practitioner’ training course before being able to purchase and use the software.

Table 2 Brief description of Earobics, Fast ForWord, Phonomena Earobics Fast ForWord Phonomena www.earobics.com www.scilearn.com or www.mindweavers.co.uk www.innovative-therapies.com (UK) Earobics is underpinned by Fast ForWord is a series of Phonomena is an adaptive training technology to computer based exercises (games) interactive game, adjust the level of instruction to designed to improve auditory, designed to improve the child's level and progress, and language processing and reading auditory discrimination primarily uses recorded but real abilities with the view to “train the and phonemic speech. It is recommended that brain to process at faster rates and awareness, and to build the child use Earobics for 15 to 20 help to create or modify the neural language skills. It minutes per day, three times a pathways”. It uses both speech and consists of game-play week. Earobics Step 1 is designed non-speech stimuli that have been and graphics designed to for developmental ages 4-7 and acoustically modified to slow and appeal especially to 6-12 features six interactive games with amplify transient sounds. Fast year olds, while over 300 levels of play. It purports ForWord Language Basics is a administrator controls to teach phonological awareness program aimed at 4-6 year olds and give language and introductory phonics skills consists of 3 exercises that help to professionals additional required for learning to read and develop visual attention and tools. “Phonomena” uses spell, and to develop general auditory discrimination skills and ‘phoneme contrasts’ cognitive skills that support sustained auditory attention, and which are selected from learning, such as attention and aims to prepare for Fast ForWord over 1,000 possible in memory. Earobics Step 2 is Language. There are a number of English. At the start of designed for developmental ages products available such as: Fast the game, these 'sounds 7-10 and features five interactive ForWord Language v.2 (ages 5-12), of words' are set as games with nearly 600 levels of Fast ForWord Middle & High School normally found in spoken play. Step 2 targets the same (adolescents and older learners), language. Phonomena’s skills targeted in Earobics Step 1, Fast ForWord Language to Reading adaptive learning but at more advanced levels, as v.2 (which targets the skills that algorithms change the well as language processing skills require to make the link between sounds in response to for extracting meaning from spoken and written language). Fast each player’s spoken language and written text. ForWord Reading is a curriculum- performance, making the Earobics Adolescents & Adults based reading program. The child choice more or less provides sophisticated, game- will usually work on these intensive difficult, in order for the style, multimedia instruction, computer based exercises 30 client to train at the ‘Edge designed to appeal to adolescents minutes a day, 5 days a week for 3- of Competence’ therefore and adults who are struggling to 4 months (or more intensively for a keeping the training at

18 © BSA 2011

Review of Computer-Based and Other Auditory Training Programs for APD

Semin Hear. 2015 Nov; 36(4): 199–215. PMCID: PMC4910543 doi: 10.1055/s-0035-1564458

Auditory Training for Central Auditory Processing Disorder

Jeffrey Weihing, Ph.D.,1 Gail D. Chermak, Ph.D.,2 and Frank E. Musiek, Ph.D.3

1Division of Communicative Disorders, University of Louisville, Louisville, Kentucky 2Department of Speech and Hearing Sciences, Washington State University Spokane, Spokane, Washington 3Speech, Language and Hearing Sciences, the University of Arizona, Tucson, Arizona Address for correspondence Jeffrey Weihing, Ph.D. Division of Communicative Disorders, University of Louisville, Louisville, KY 40202, [email protected]

Abstract Auditory training (AT) is an important component of rehabilitation for patients with central auditory processing disorder (CAPD). The present article identifies and describes aspects of AT as they relate to applications in this population. A description of the types of auditory processes along with information on relevant AT protocols that can be used to address these specific deficits is included. Characteristics and principles of effective AT procedures also are detailed in light of research that reflects on their value. Finally, research investigating AT in populations who show CAPD or present with auditory complaints is reported. Although efficacy data in this area are still emerging, current findings support the use of AT for treatment of auditory difficulties.

Keywords: Auditory training, central auditory processing disorder

Learning Outcomes: As a result of this activity, the participant will be able to (1) describe characteristics of effective AT protocols, including aspects related to the training schedule, training difficulty, maintaining motivation, and transfer of learning and (2) describe results from current research investigating AT in patients with CAPD or who present with auditory complaints.

Central auditory processing disorder (CAPD) refers to dysfunction of the central auditory nervous system (CANS) that contributes to difficulties with perceptual processing of auditory information and that is thought to contribute to delays in skills in which successful listening serves a fundamental role. CAPD affects a variety of populations and has several suspected causes, including neuromaturational delay,1 neuroanatomical anomalies (e.g., ectopic cells),2 3 and neurologic insult of the CANS.4 Additionally, the term central presbycusis has recently been adopted to describe CAPD that results from changes to the CANS that occur as a result of aging.5 CAPD is diagnosed using a test battery comprised of behavioral, electroacoustic, and/or electrophysiologic measures that have documented sensitivity and specificity to CANS dysfunction and that assess a range of CANS processes.6 The primary complaints and symptoms of CAPD are auditory; however, due to the nonmodularity of brain organization, functional deficits can frequently manifest in related areas of attention, language, communication, and learning.7

A successful treatment plan for CAPD incorporates a variety of different approaches. These approaches Review of Computer-Based and Other Auditory Training Programs for APD

International Journal of Audiology 2012; 51: 506–518

Original Article

A randomized control trial of interventions in school-aged children with auditory processing disorders

Mridula Sharma * , Suzanne C Purdy* ,† & Andrea S Kelly ‡

* Department of Linguistics - Audiology, Macquarie University, Sydney, Australia , and Hearing Co-operative Research Center, Australia, † Department of Psychology - Speech Science, The University of Auckland, New Zealand , and ‡ Department of Audiology, Auckland District Health Board, Auckland, New Zealand

Abstract Objective: The primary purpose of the study was to compare intervention approaches for children with auditory processing disorder (APD): bottom-up training including activities focused on auditory perception, discrimination, and phonological awareness, and top-down training including a range of language activities. Another purpose was to determine the benefi ts of personal FM systems. Design: The study is a randomized control trial where participants were allocated to groups receiving one of the two interventions, with and without personal FM, or to the no intervention group. The six-week intervention included weekly one-hour sessions with a therapist in the clinic, plus 1 – 2 hours per week of parent-directed homework. Study sample : 55 children (7 to 13 years) with APD participated in the study. Intervention outcomes included reading, language, and auditory processing. Results: Posi- tive outcomes were observed for both training approaches and personal FM systems on several measures. Pre-intervention nonverbal IQ, age, and severity of APD did not infl uence outcomes. Performance of control group participants did not change when retested after the intervention period. Conclusions: Both intervention approaches were benefi cial and there were additional benefi ts with the use of personal FM. Positive results were not limited to the areas specifi cally targeted by the interventions.

Key Words: Auditory processing disorder (APD); top-down; bottom-up; personal FM; management; randomized control trial (RCT); discrimination; language; phonological awareness; reading

D e fi nitions of auditory processing disorder (APD) are based on subgroup of children with specifi c language disorder showed dif- impaired auditory skills, with the specifi c skills included in the defi - fi culty on auditory discrimination (consistent with the view of APD nition varying across publications (e.g. Putter et al, 2002; Sharma et al, as an impaired skill) and poor reading. Another subset of children in 2009; Cameron & Dillon 2007a; Kuk et al, 2008). According to ASHA McArthur and Bishop ’ s study had poor sustained auditory attention (2005), children with APD typically have poor speech understanding and/or auditory memory as well as APD. Having two or three co- in adverse listening environments, misunderstand messages, respond existing disorders has implications for intervention. Richard (2007, inconsistently and/or inappropriately, often ask for information to be p. 282) recommended that management plans for children with APD repeated, have diffi culty attending to verbal information, show delayed with co-occurring language or reading disorder include strategies responses to oral communication, have diffi culty following complex that target the co-occurring disorders, as well as the APD. and/or multiple oral directionsReview and localizing sounds,of andComputer may have Management approaches-Based for APD recommended and in the literature reduced musical and singing skills. When using an impaired skill to are largely theoretical and lack a strong evidence base (Chermak & defi ne APD, diagnosis is based on performance falling two standard Musiek, 1997; Ferre, 1998). One of the proposed theoretical frame- deviationsOther below the normative Auditory mean on any task measuring Training auditory works for APD Programs intervention emphasizes brain reorganizationfor APD or neu- processing (AAA, 2010). The current study uses this criterion to defi ne roplasticity (Chermak & Musiek, 2007). Neuroplastic changes in the APD, based on AAA (2010). (Sharma, Purdyauditory & system Kelly, can occur as a2012) result of auditory experience, passive APD often co-occurs with language, reading, spelling, and other listening, or active auditory training (Tremblay et al, 1998; Sheehan learning problems (ASHA, 2005; McArthur & Bishop, 2004a, 2004b; et al, 2005; Bosnyak et al, 2007). Another theoretical approach uses Richard, 2007; Sharma et al, 2009). Sharma et al (2009) found that an information processing framework for APD interventions (Miller, about half of a group of 68 children diagnosed with APD according 1956; Chermak & Musiek, 1997). This approach emphasizes the com- to the ASHA (2005) criteria had reading and language disorders, plex, multileveled nature of auditory processing, involving parallel 514 M. Sharmaas well et asal. APD. McArthur and Bishop (2004b) also found that a and serial processing of information (Chermak & Musiek, 1992). A

Table 6. MeansCorrespondence: and standard Mridula Sharma, deviations Department offor Linguistics, the outcome Room C5A 518, measures Macquarie University, for theNSW 2109,fi ve Australia. intervention E-mail: [email protected] groups that were signifi cant (p Ͻ 0.01). Values shown in bold indicate measures that showed signifi cant improvement post-intervention. (Received 4 September 2011; accepted 20 February 2012) ISSN 1499-2027 print/ISSN 1708-8186 online © 2012 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2012.670272Control Discrimination Discrimination & FM Language Language & FM Pre Post Pre Post Pre Post Pre Post Pre Post

FPT (R) 35.5 (21.5) 40.5 (22.2)18.3 (10.1) 44.6 (28.4) 38.8 (26.4) 51.8 (28.3)41.2 (21.8)54.7 (17.1) 42.0 (22.4) 43.5 (21.8) FPT (L) 30.0 (19.0) 31.3 (19.5) 25.1 (10.9) 49.3 (27.9) 40.6 (31.9) 52.2 (30.0)38.0 (18.9)50.0 (22.7) 42.4 (14.8) 42.2 (21.3) Concepts and 7.3 (3.1) 7.6 (1.8)6.0 (3.1) 7.5 (4.1) 4.7 (1.9) 6.1 (3.0) 7.2 (3.2) 7.8 (3.0) 5.6 (2.8) 7.2 (3.3) directions Sentence recall 7.8 (1.8) 8.6 (2.1)5.3 (3.1) 6.9 (2.8) 6.8 (2.7) 8.3 (2.4) 6.8 (2.1) 7.7 (2.6)5.4 (2.4) 7.2 (3.3) Formulated sentences 7.3 (3.5) 8.4 (1.9) 6.3 (1.8) 7.8 (2.9) 6.3 (2.8) 8.4 (2.3)6.3 (2.8) 9.1 (2.4) 6.1 (2.3) 7.6 (3.8) Receptive language 88.0 (13.7) 90.3 (10.3)79.3 (16.3) 88.3 (14.9) 82.7 (10.4) 88.0 (14.2) 88.1 (12.0) 93.3 (12.7) 81.4 (9.0) 87.6 (12.7) Core language 84.8 (12.1) 89.7 (9.3)75.1 (14.2) 86.7 (13.8) 80.2 (11.9) 88.0 (12.5) 83.4 (10.7) 92.2 (11.3) 78.8 (12.9) 82.3 (15.9) WARP 56.1 (42.5) 65.4 (45.9) 77.3 (39.6) 88.3 (33.5) 83.4 (39.6) 87.2 (36.3)75.8 (47.2) 91.0 (50.6) 67.4 (42.7) 73.0 (45.4) Nonword spelling 4.6 (2.2) 5.0 (2.3) 3.8 (1.8) 4.1 (2.1) 3.6 (1.6) 5.2 (3.3) 5.2 (2.1) 5.5 (2.5)3.3 (1.0) 5.1 (3.1) Syllable segment 7.5 (3.5) 9.4 (3.2) 7.8 (3.3) 9.8 (3.2)7.1 (3.0) 10.2 (3.2) 9.1 (3.8) 10.6 (3.6) 8.1 (3.6) 9.9 (3.4) Spoonerisms 6.1 (3.4) 7.9 (4.0) 6.7 (3.7) 8.7 (3.7) 6.2 (3.8) 8.8 (3.6)6.8 (4.0) 10.4 (2.0) 5.2 (3.7) 7.8 (4.1)

also produced signifi cant improvements for four of the CELF-4 processing, reading, and language disorders, using a variety of out- language measures (concepts and following directions, sentence come measures including reading, phonological awareness, language, recall, receptive language, core language). If discrimination training and auditory processing tasks. Previous studies have shown that FM is effective, improvements would be expected for both discrimina- systems can benefi t children with APD (see Table 1), however, to our tion alone as well as discrimination training plus FM groups. This knowledge, no studies have investigated FM and training together. pattern was only seen for the core language measure which showed Hence a second purpose of the current study was to determine how robust improvements for both discrimination training groups. Varia- training and FM approaches interact to assist children with APD. tions in outcomes between the two discrimination training groups for One of the limitations of the current study is the relatively small FPT scores and the other language measures may refl ect participant number of participants that were divided across fi ve groups. Despite differences at baseline. Overall, the clearest benefi t of discrimina- the lack of statistical power, signifi cant differences were observed tion/bottom-up training was evident in the CELF-4 core language after intervention for several measures. Positive features of the study scores, which improved signifi cantly for both discrimination training that strengthen the conclusions include the lack of statistical differ- alone (average standard score improvement of 7.8) and discrimina- ences between the control and intervention groups at baseline and tion plus FM (average standard score improvement of 8.8) groups. the stability of the measures for the control group, which showed no These differences refl ect an overall improvement in core language signifi cant test-retest differences. Of the nine measures that showed scores of 0.5 – 0.6 standard deviations, indicating a large effect changes post-training, six showed improvement for the groups that size (Cohen, 1988). were not the worst performers, thus the observed benefi ts cannot Children in the language training groups improved on auditory be explained solely on the basis of regression to mean effects. Of processing, language and reading measures (FPT; CELF-4 sentence the nine measures that showed improvement post-training, only core recall, formulating sentences, and core language; WARP; QUIL language improved for both FM and non-FM intervention groups nonword spelling & spoonerisms). As was seen for the discrimina- receiving the same kind of training (discrimination). The benefi cial tion training, many of these changes were inconsistent across the effect of discrimination training on core language scores is the clear- two language training groups, which may be due to the heteroge- est fi nding in the study. Core language scores are composite scores neous nature of the sample and a lack of statistical power. Two mea- based on performance on the CELF subtests that best discriminate sures, CELF-4 sentence recall and QUIL nonword spelling, showed typical language performance from disordered language (Conti- robust improvements when language training was combined with Ramsden et al, 2010), and hence they may also be more sensitive to FM use. For the language training plus FM group, sentence recall treatment effects than other CELF subtest scores. and nonword spelling standard scores improved by 0.6 – 0.7 standard A number of outcome measures showed statistically signifi cant deviations, indicating large effect sizes. Neither measure showed improvements only for the non-FM groups (FPT, concepts and direc- a signifi cant change with language training alone, suggesting that tions, formulated sentences, receptive language, and QUIL spoo- enhanced classroom listening provided by the personal FM systems nerisms). Table 6 shows that for each of these measures there was was required to demonstrate these gains. improvement for the FM groups receiving the same training and hence it is possible that the lack of signifi cance for the non-FM Discussion groups may be due to differences between the groups at baseline or may refl ect a specifi c outcome of FM use. For lack of statisti- Although anecdotal evidence suggests that the APD interventions cal power, research is needed to determine whether training has a investigated here are commonly used clinically, there are few ran- reliable effect on these outcome measures. Two of the phonologi- domized controlled trials of these interventions. An RCT design cal awareness measures (QUIL nonword spelling and phonological was used to investigate effects of discrimination/bottom-up and lan- awareness) and one language measure (sentence recall) only showed guage/top-down training and personal FM in children with auditory improvement for the FM groups, not for the training-alone groups. Auditory Processing Disorders (APD) in Children and Adults: Part 2. A Team Approach to Management

q Introduction q Counseling & Advocacy q FM technology q Computer-based auditory training q Direct auditory remediation q Language-based options

Dichotic Intensity Increment Difference (DIID)

LEFT TEMPORAL RIGHT TEMPORAL CORTEX CORTEX Association Cortex Association Cortex Corpus Callosum Primary Auditory Cortex Primary Auditory Cortex

Weak Ear Strong Ear fixed increasing intensity intensity Selected Papers Reporting Benefit of DIID Auditory Training Programs

q Musiek F, Weihing J, Lau C (2008). Dichotic interaural intensity difference (DIID) training: a review of existing research and future directions. J Acad Reh, 41, 51–65. q Weihing J, Musiek F (2014). Dichotic interaural intensity difference (DIID) training. San Diego, CA: Plural Publishing q Musiek F, Schochat E (1998). Auditory training and central auditory processing disorders: a case study. Seminars in Hearing, 19, 357–365.

Direct Auditory Remediation: Auditory Rehabilitation for Interaural Asymmetry (ARIA)

International Journal of Audiology 2016; 55: 333–345

Original Article

Diagnosis of amblyaudia in children referred for auditory processing assessment

Deborah Moncrieff1, William Keith2, Maria Abramson3 & Alicia Swann4

1Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pennsylvania, USA, 2SoundSkills APD Clinic, Auckland, New Zealand, 3Hear Now / Abramson Audiology, Laguna Niguel, California, USA, and 4Auditory Processing Center, LLC, MS, Clinton

Abstract Children (n 141) referred to 5 clinical sites for auditory processing disorder assessment were tested with two dichotic listening tests, one ¼ with word pairs and the other with pairs of digits, as part of a comprehensive diagnostic battery. Scores from the Randomized Dichotic Digits Test and the Dichotic Words Test were compared to age-appropriate norms and used to place children into one of four diagnostic categories (normal, dichotic dysaudia, amblyaudia, or amblyaudia plus) or to identify them as undiagnosed. Results from the two dichotic tests led to diagnosis of 56% of the children tested, leaving 44% undiagnosed. When results from a third dichotic listening test were used as a tie-breaker among originally undiagnosed children, a total of 79% of the children’s scores were placed into diagnostic categories (13% normal, 19% dichotic dysaudia, 35% amblyaudia, 12% amblyaudia plus). Amblyaudia, a binaural integration deficit evident only from dichotic listening test results, was most prevalent (35% + 12% 47%) in this population of children suspected of auditory processing ¼ weaknesses. Since amblyaudia responds to treatment with Auditory Rehabilitation for Interaural Asymmetry (ARIA), clinicians are guided through the protocol for identifying diagnostic categories so that they can make appropriate referrals for rehabilitation.

Key Words: Auditory processing disorder, binaural integration, dichotic, audiology

Introduction noted that individuals identify more verbal material presented to the ear that transmits through more abundant contralateral fibers to their Amblyaudia is a type of auditory processing disorder (APD) language-dominant hemisphere. Because of its direct contralateral characterized by deficits in the binaural integration of verbal pathway to the left cortical hemisphere, the right ear typically information (Moncrieff, 2011) that is diagnosed by results from performs better during DL testing in listeners who process language dichotic listening (DL) tests. The hallmark pattern of amblyaudia is in the left hemisphere. In those who process language in their right an abnormally large asymmetry between the two ears during DL hemisphere, the left ear performs better during DL tests (Denes & tasks with either normal or below normal performance in the Caviezel, 1981). dominant ear. The underlying mechanisms of amblyaudia are Kimura proposed that because listeners could simultaneously unknown, but they may be similar to the neural mechanisms of identify information heard at the opposite ear, ipsilateral to their amblyopia or ‘lazy eye’ in the visual system. In amblyopia, language-dominant hemisphere, information must connect contral- activation in the dominant pathway suppresses information in the aterally to the opposite cortex and then transfer to the language- non-dominant pathway, leading to an indistinct encoding of visual dominant hemisphere via the corpus callosum. The inter-hemi- information at the level of the cortex (Doshi & Rodriguez, 2007). A spheric transfer of information aspect of Kimura’s structural model similar suppression by the dominant ascending pathway may was supported by evidence of a near-complete extinction of a interfere with clear encoding of the auditory signal during routine listener’s ability to identify verbal material presented to the binaural listening in amblyaudia. Suppression of the ipsilateral ipsilateral, non-dominant ear following surgical separation of the signal by the dominant contralateral pathway was evident in early corpus callosum (Springer & Gazzaniga, 1975; Damasio, 1976; studies with competing digits and served as the basis of the Springer, 1978; Pollmann, 2002). Post-surgical patients later structural model of DL proposed by Doreen Kimura (1961). She

Correspondence: Deborah Moncrieff, Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, 4033 Forbes Tower, Pittsburgh, PA 15260, USA. E-mail: [email protected]

(Received 10 April 2015; revised 15 October 2015; accepted 30 November 2015) ISSN 1499-2027 print/ISSN 1708-8186 online ß 2016 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.3109/14992027.2015.1128003 Direct Auditory Remediation: Auditory Rehabilitation for Interaural Asymmetry (ARIA) (www.dichotics.com)

International Journal of Audiology 2017; 56: 580–588

Original Article

Evidence of binaural integration benefits following ARIA training for children and adolescents diagnosed with amblyaudia

1 2 3 4 Deborah Moncrieff , William Keith , Maria Abramson & Alicia Swann Evidence of binaural integration benefits 585 1Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA, 2SoundSkills APD Clinic, Auckland, New Zealand, 3Hear Now/Abramson Audiology, Laguna Niguel, CA, USA, and 4Auditory Processing Center, LLC, Clinton, MS, USA

Abstract Objective: The purpose of this study was to demonstrate the efficacy of Auditory Rehabilitation for Interaural Asymmetry (ARIA) to improve dichotic listening scores in children and adolescents diagnosed with amblyaudia and other binaural integration deficits. Design: The study is a field experiment without randomisation. Study: Participants placed into groups based on dichotic listening test scores received four sessions of ARIA training. Baseline scores were compared to performance during the final session of training and to scores obtained 2 or more months after completion of ARIA. Sample: A total of 125 children participated at five different clinical sites. Results: Dichotic listening scores improved across all participants. Post hoc analyses demonstrated highly significant gains in non-dominant ear performance and reductions of interaural asymmetry among participants diagnosed with amblyaudia at both post-ARIA measurements. Participants in other diagnostic groups also showed significant benefits for some post-ARIA measures. Conclusions: Results demonstrate that ARIA training is an effective method for improving binaural integration skills among children and adolescents identified with dichotic listening weaknesses during assessments for auditory processing disorder (APD), especially for those diagnosed with amblyaudia. Benefits achieved following ARIA training remain stable across several months.

Key Words: Auditory processing; amblyaudia; dichotic listening; behavioural measures; paediatric; psychoacoustics/hearing science; speech perception

Amblyaudia is a type of auditory processing disorder (APD) hemisphere, which is the right ear in 65–80% of normal listeners characterised by deficits in the binaural integration of verbal (Hiscock et al, 2000; Moncrieff, 2011) and the left ear in others information (Moncrieff, 2010). The hallmark pattern of amblyaudia (Denes & Caviezel, 1981). Because either the left or right ear can be Evidenceis an abnormally of binaural large asymmetry integration between the two benefits ears during dominant585 during DL tests, a diagnosis of amblyaudia is based on dichotic listening (DL) tasks with either normal or below normal comparison to norms developed without regard to which ear is performance in the dominant ear (Moncrieff et al, 2016). Children superior (Moncrieff, 2011; Moncrieff et al, 2016). with listening, learning and reading difficulties have produced When assessed under earphones, normal listeners can readily symmetrical deficits in binaural integration (Hynd et al, 1979; identify information presented to their non-dominant ear during DL Keefe & Swinney, 1979; Pelham, 1979; Tobey et al, 1979; Harris et tasks, long thought to be primarily through cortical connections via al, 1983; Roush & Tait, 1984; Grogan, 1986; Vanniasegaram et al, the corpus callosum because after sectioning of the corpus 2004; Pinheiro et al, 2010) as well as an abnormally large callosum, a listener’s ability to identify material presented to the asymmetry duringDirect DL tasks due to low performanceAuditory in their non- non-dominant Remediation: ear is extinguished (Sparks & Geschwind, 1968). In dominant ears (Ayres, 1977; Johnson et al, 1981; Dermody et al, those patients, however, the performance improves following a 1983; Aylward, 1984; Berrick et al, 1984; Asbjornsen et al, 2000; reorganisation of the auditory pathways despite the absence of AuditoryVanniasegaram Rehabilitation et al, 2004; Moncrieff & Black, 2008).for The Interauralcallosal transmission (Milner et al,Asymmetry 1968; Levitsky & Geschwind, (ARIA) structural model of DL (Kimura, 1961) predicts enhanced perform- 1968; Springer et al, 1978). This suggests that binaural integration ance in the ear that is contralateral(Moncrieff to the language dominant cortical ofet dichotic al, material 2017) engages both contralateral and ipsilateral Correspondence: Deborah Moncrieff, Ph.D., Department of Communication Science and Disorders, University of Pittsburgh, 6035 Forbes Tower, Pittsburgh, PA 15260. Tel: (412) 648-0156, Fax: (412) 383-6555. E-mail: [email protected]

(Received 15 July 2016; revised 4 February 2017; accepted 15 February 2017) ISSN 1499-2027 print/ISSN 1708-8186 online ß 2017 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.1080/14992027.2017.1303199

gains in both ears following ARIA training, suggesting that children Benefits are maximal, though, for children and adolescents whose and adolescents who perform poorly and symmetrically on DL tests binaural integration skills are consistently weak across two different may also benefit from participation. DL tests, especially when the pattern leads to the diagnosis of Results from this study suggest that ARIA training benefits amblyaudia. As the ARIA training paradigm requires that the individuals whose performance on a DL test falls below normal clinician continually adjust the relative intensity of material which is not surprising since the training focuses on dichotic tasks. presented through the sound-field speakers, participants with poor

Figure 3. Left column displays results from the group of participants whose scores were measured at the fourth session of ARIA (words, n 119; digits, n 117): Outcomes measured during the pre-ARIA evaluation (grey bars) and during the 4th ARIA session (black bars) for participants¼ in each¼ diagnostic group (a) for non-dominant ears from the 2-pairs condition of dichotic digits; (b) for non-dominant ears from dichotic words and (c) for interaural asymmetry measured from digits and words; Right column displays results from the subgroup of participants whose scores were measured at pre-ARIA (grey bars) and post-ARIA (black bars) evaluation (words, n 67; digits, n 70); (d) for non-dominant ears from the 2-pairs condition of dichotic digits; (e) for non-dominant ears from dichotic words;¼ (e) for interaural¼ asymmetry measured from digits and words. Significance values are represented by bars, p50.001***, p50.01**, p50.05*. gains in both ears following ARIA training, suggesting that children Benefits are maximal, though, for children and adolescents whose and adolescents who perform poorly and symmetrically on DL tests binaural integration skills are consistently weak across two different may also benefit from participation. DL tests, especially when the pattern leads to the diagnosis of Results from this study suggest that ARIA training benefits amblyaudia. As the ARIA training paradigm requires that the individuals whose performance on a DL test falls below normal clinician continually adjust the relative intensity of material which is not surprising since the training focuses on dichotic tasks. presented through the sound-field speakers, participants with poor Auditory Processing Disorders (APD) in Children and Adults: Part 2. A Team Approach to Management

q Introduction q Counseling & Advocacy q FM technology q Computer-based auditory training q Direct auditory remediation q Language-based options

Relation Between Auditory Processing Disorders (APD) and Specific Language Disorder

q Fey et al. (2011). Auditory processing disorder and auditory/language interventions: An evidence-based systematic review. Language, Speech and Hearing Services in Schools, 42, 246–264. q Bellis Chermak, Weihing, & Musiek (2012). Efficacy of auditory interventions for central auditory processing disorder: A response to Fey et al (2011). Language, Speech and Hearing Services in Schools, 43, 381-386. q Kamhi AG. (2011). What speech-language pathologists need to know about auditory processing disorder. Language Speech Hearing Services in the Schools, 42, 265-272 q Murphy CF & Schochat E (2013). Effects of different types of auditory temporal training on language skills: A systematic review. Clinics (Sao Paulo), 68, 1364-1370 q Specht K. (2013). Neuronal basis of speech comprehension. Hearing Research, pre-print Auditory Processing and Language

J Am Acad Audiol 28:758–769 (2017)

The Relationship between Central Auditory Processing, Language, and Cognition in Children Being Evaluated for Central Auditory Processing Disorder DOI: 10.3766/jaaa.16119

Lauren Brenneman* Elizabeth Cash*†‡ Gail D. Chermak§ Linda Guenette ** { Gay Masters* Frank E. Musiek|| Mallory Brown { Julianne Ceruti { Krista Fitzegerald { Kristin Geissler { Jennifer Gonzalez { Jeffrey Weihing*

Abstract

Background: Pediatric central auditory processing disorder (CAPD) is frequently comorbid with other childhood disorders. However, few studies have examined the relationship between commonly used CAPD, language, and cognition tests within the same sample.

Purpose: The present study examined the relationship between diagnostic CAPD tests and ‘‘gold standard’’ measures of language and cognitive ability, the Clinical Evaluation of Language Fundamentals (CELF) and the Wechsler Intelligence Scale for Children (WISC).

Research Design: A retrospective study.

Study Sample: Twenty-seven patients referred for CAPD testing who scored average or better on the CELF and low average or better on the WISC were initially included. Seven children who scored below the APDCELF and/orIndividualized WISC inclusion criteria were Management then added to the dataset for aStrategies second analysis, yielding a (Chermak &sample Musiek size of 34. , American Journal of Audiology 1, 1992) Data Collection and Analysis: Participants were administered a CAPD battery that included at least the following three CAPD tests: Frequency Patterns (FP), Dichotic Digits (DD), and Competing Sentences (CS). In addition, they were administered the CELF and WISC. Relationships between scores on CAPD, language (CELF), and cognition (WISC) tests were examined using correlation analysis.

Functional DeficitResults: DD and FP showed signiﬁcant correlationsStrategies with Full Scale Intelligence Quotient, and the DD left ear and the DD interaural difference measures both showed signiﬁcant correlations with working mem- q Distractibility/inattentionory. However, z80% or more of the varianceIncrease in these CAPD SNR tests was unexplained by language and q Poor memory Meta-language external aids *Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders, University of Louisville School of Medicine, Louisville, KY; q Restricted†James Graham vocabulary Brown Cancer Center, Louisville, KY; ‡DepartmentImprove of Psychological andclosure Brain Sciences, University of Louisville, Louisville, KY; §De- partment of Speech and Hearing Sciences, Washington State University Health Sciences Spokane, Spokane, WA; Department of Speech, Language, q CognitiveHearing Sciences,inflexibility University of Connecticut, Storrs, CT; ||DepartmentDiversify of Speech, Language, cognitive Hearing Sciences, style{ University of Arizona, Tucson, AZ Corresponding author: Jeffrey Weihing, Department of Otolaryngology-Head and Neck Surgery and Communicative Disorders, University of q Poor listeningLouisville School of comprehension Medicine, Louisville, KY 40202; E-mail: [email protected] formal schema to aid This research was supported by the Royal Arch Research Assistance (RARA) group. **Deceased organization & integration q Reading & spelling problems Enhance multisensory integration q Maladaptive758 behaviors Cognitive behavior modification Delivered by Ingenta to: ? q Poor motivation IP : 73.35.92.174Internal On: Mon, 20 Novlocus 2017 17:56:48 of control attribution retraining Examples of “Top-Down” and Multi-Sensory Reading Intervention Options for Children with APD

q Context-derived vocabulary building q Visual imagery q Visualizing and Verbalizing Program (Lindamood) q Auditory closure activities q Speech/language therapy q Multi-sensory reading strategies l Lindamood Bell Learning Processes (www.lindamoodbell.com) l Wilson Reading Program l Orton Gillingham approaches

Auditory Processing Disorders (APD) in Children and Adults: Part 2. A Team Approach to Management

Thank You! Questions?