Perspectives on the Diagnosis and Remediation of Auditory Processing Disorders

Tony Perspectives on the Sirimanna Diagnosis and Remediation of

Auditory Processing Disorders Kiri Mridula Mealings Harvey Dillon Sharma Sharon Cameron National Acoustic Laboratories, University of Manchester Pia Dani Gyldenkaerne Tomlin Macquarie University Hearing CRC

Carhart Memorial Lecture Mark Helen American Auditory Society Seeto Scottsdale Glyde March 2018 1 What you might remember

• Listening difficulties have multiple causes, which can be quantified. • Diagnosing the type(s) and extent of auditory processing disorder present requires quantitative control of the effects of memory, attention, intelligence and language on auditory processing tests. • Deficit-specific treatment can be highly effective in removing auditory processing deficits. • Research is needed to: • Better understand cause and effect between auditory processing, language and cognition  intervention studies; • Create differential tests that identify more specific types of auditory processing disorders; • Create a more efficient (hierarchical, adaptive) test battery than currently exists.

2 Talk outline Concepts NAL / Macquarie / Literature Melbourne meta-analysis specific data

What clinicians can do now What researchers could do

3 APD concepts and other disorders

4 Four “controversies”

5 Controversy 1: What do we call it?

6 APD by any other name ….. Central auditory processing disorder Auditory perceptual disturbance Sullivan (1976) Auditory dysacusis Myklebust (1954) Jayaram, Baguley & Moffat (1992) Auditory processing disorder Jerger & Musiek (2000) Central auditory dysfunction King-Kopetzy syndrome Berry & Blair (1976) Hinchliffe (1992) (Central) Auditory processing disorder ASHA (2005) Auditory inferiority complex Central presbycusis Byrne & Kerr (1987) Stach et al (1990)

Selective dysacusis Obscure auditory dysfunction Narula & Mason (1988) Saunders & Haggard (1989)

Auditory disability with normal hearing Stephens and Rendell (1988)

Auditory neuropathy Hidden hearing loss Starr et al 1996 Schaette & McAlpine (2011)

1. Auditory perception poorer than expected from hearing thresholds Two things in common: 2. Definition sufficiently broad to include diverse types of deficits 7 Controversy 2: Does APD exist?

8 Does APD Language disorder exist? General developmental disorder Cognitive disorder

1. Do you believe the brain transmits and analyses neural signals after they leave the cochlea, or does auditory perception occur by magic?

2. Can anything ever go wrong with the way the brain transmits and analyses neural signals initiated by sound, or is the system infallible and develops properly in every person?

3. When something does go wrong with the way the auditory system processes the neural signals initiated by sound, what would you like to call such a disorder?

9 Kaas & Hackett (2000) APD, Cognition and Language Brenneman, Cash, Chermak, Guenette, Masters, Musiek, Brown, Ceruti, Fitzegerald, Geissler, Gonzalez & Weihing (2017).

Auditory 23% shared processing 29% shared variance abilities variance

Cognitive Language abilities abilities 35% shared variance

10 Controversy 3: What abilities does APD encompass?

11 "When I use a word,' Humpty Dumpty said in rather a scornful tone, 'it means just what I choose it to mean — neither more nor less."

"The question is," said Alice, "whether you can make words mean so many different things."

ASHA (2005) “(C)APD is a deficit in neural processing of auditory stimuli that is not due to higher order language, cognitive, or related factors." Moore, Ferguson et al (2010) “What is currently called APD, for individuals without known neurologic lesions, should be redefined as primarily a cognitive disorder, rather than a sensory disorder.” 12 Views on the meaning of APD from around the world

Professional Society Definition Comment ASHA (2005) A deficit in neural processing of auditory stimuli that is not due to higher order language, Cognition and language out cognitive, or related factors. AAA (2010) Difficulties in the perceptual processing of auditory information. (C)APD is frequently Cognition and language out comorbid with related language, learning and cognitive disorders. Danish Medical Audiological The efficiency with which the central nervous system uses received auditory information. Cognition and language out Society (2014) Canadian Interorganizational A persistent limitation in the performance of auditory activities that originates in the Cognition and language out Steering Group (2012) auditory system and is not caused by loss of auditory acuity or disorders of language, attention, memory or cognition. Belgian International Bureau … difficulties in listening and intelligibility …..can be the consequence of … cognitive and Cognition and language out for Audiophonology (20070 memory functions, but also the functions provided by central auditory pathways. NAL – Australia (Dillon & An Auditory Processing Disorder (APD) is a deficit in the way the neural representation of Cognition and language out Cameron, 2015) sounds are processed by the brain, resulting in a distorted neural representation of the auditory signal within the auditory nervous system. BSA (2017) Poor perception of speech and non-speech. Origins include the CANS and neural processing Cognition and language in systems for language, reading, speech, attention, executive function, memory, emotion, vision and action. Dutch position statement Listening difficulties can be caused by both disturbed bottom-up processes (sensory Cognition and language are the (2017) processing) and disturbed top-down processes (including cognition and language). most common problem in listening difficulties New Zealand (2017) Auditory processing disorder is a hearing disorder that results from atypical processing of Doesn’t say auditory information in the brain. 13 German (Nikissch et al, 2015) ???? ???? Controversy 4: Need APD be unimodal?

14 Should APD be conceptualized as an auditory-specific disorder or as one aspect of a more generalized disorder? Not a practically useful question!!!!

Child 1 Identify the deficit Child 2 Give training to improve auditory skills in deficit

Improve input sound SNR

Manage or treat the other problem(s)

Deficit in auditory processing only Deficit in auditory processing + Deficit in visual processing

15 Four “controversies” dealt with

1. The name: APD, CAPD, or (C)APD? • Of course auditory processing happens in the cochlea 2. Does it exist? • Duh, yes! 3. Include or exclude deficits in cognition and language? • Excludes, by most definitions, but of course perception of speech needs cognition and language as well 4. Limited to unimodal problems? • Not limited. Problems involving audition should be identified and helped, irrespective of whether there are similar problems in other modalities

None are productive debates: more semantics than reality

16 One test, multiple abilities

17 Deficits (various) in cognition

Listening Deficits difficulties (various) in auditory processing Performance on tests of APD Deficits (various) in language 18 Deficits (various) in cognition

Deficits (various) in auditory processing Performance on tests of APD Deficits (various) in language 19 Example of a test that tests multiple abilities

• Dichotic digits test – Musiek (1983) - 293 citations • Easy to administer and score • Often failed by children seeking APD assessment • In many, many test batteries, including Australian Hearing

20 Dichotic Free Recall Paradigm

2, 4 1, 8

1, 2, 4, 8

21 Diotic Paradigm

Dichotic Digits 2, 4 2, 4 1, 8 1, 8 difference Test

2,4,1,8

22 Dichotic 100 Clinic School versus 90 r = 0.82 diotic 80 (%) 70

Diotic (%) 50

30 40 50 60 70 80 90 100 Dichotic free recall (%) 23 Attention Correlations (prudence) with cognition Attention 0.31 (vigilence) 0.21

Forward digit 0.53 Free recall span dichotic 0.36 Reverse digit span 0.27 Non-verbal IQ

25 Attention Correlations (prudence) with cognition Attention 0.26 (vigilence) 0.15

Forward digit 0.52 Diotic span 0.42 Reverse digit span 0.24 Non-verbal IQ

26 Dichotic 3 Clinic scores 2 School and 1 memory 0

-1

-2

-3 R=0.60

Dichotic free recall (z score) -4 The normal range! -5 -3 -2 -1 0 1 2 3 Number memory forward (z score)

27 Accounting Random measurement Dichotic for factors variance error 27% 9% Dichotic Memory test scores 64% 64% +27% Other 91% non-dichotic factors

28 .. And then there’s attention!

Fig 1 from Stavrinos (2018) 29 • Selective attention • Working memory Testing • Executive function cognitive • Aging ability • Mental Retardation

Application Information Dichotic to brain- about tests lesion hemisphere patients differences

Inferences Application to about auditory processing auditory disorder patients processing

30 Cognitive deficits

Brain “lesions” in Low dichotic Central Auditory CauseIndicate test scores Nervous System

31 What not to do in “sensitising” a test

Problem: A test gives ceiling performance for too many people

Usual solution: Make the test harder by demanding additional skills: • dichotic digits – make it two pairs, or three pairs  memory ↑ • speech tests – low-pass filter it  vocabulary ↑, phonetic awareness ↑ Result: Scores decrease below ceiling, but cause become uncertain

An alternative: Adaptively change inter-aural level

32 Diagnosing auditory processing disorders

33 Disentangling the disorders

Publications per year 35

30 25 Cognitive 20 disorder 15 10 Auditory Language 5 processing disorder

0 disorder

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year 34 Relation between APD and Attention Disorder

Auditory processing Auditory disorder attention 58 disorder 51

24 34 17

101 children with listening difficulties No disorder

Gyldenkaerne, Dillon, 26 35 Sharma and Purdy (2014); JAAA. Instead of “What disorder(s) does this person have” …. “How strong are the deficits in each of: cognition, auditory processing, and language”

With a common unit of measure! 36 Reported Listening difficulties

Suspected Suspected Language Cognitive Disorder Suspected Disorder Auditory Processing Disorder

Bornstein & Musiek (1992) Ahmed, Ahmed, Bath, Ferguson, Plack & Moore (2014) Vanniasegaram, Cohen & Rosen (2004) Gyldenkaerne, Dillon, Sharma, Purdy (2014) Dawes, Bishop, Sirimanna, Bamiou (2008) Boothalingam, Allan, Allen & Purcell (2015) Sharma, Purdy & Kelly (2009) Saxena, Allan & Allen (2015) Rosen, Cohen, Vanniasegaram (2010) Ahmed & Ahmed (2016) Umat, Mukari, Ezan & Din (2011) Neijenhuis, de Wit, Luinge (2017) 37 Reported Listening difficulties

Language Cognitive Deficits Auditory Processing Deficits Deficits

Dawes, Bishop, Sirimanna, Bamiou (2008): “Children diagnosed with APD reported similar symptoms and similarly had high rates of co-morbid learning problems”.

38 38 CHildren’s CHAPS questionnaire results – Great Ormond Street APD Clinic, London Auditory Performance Scale Parents Teachers Same 0.0 0.0 difficulty No APD -0.5 APD issues -0.5 APD diagnosed Slightly -1.0 -1.0 more difficulty -1.5 -1.5

More -2.0 difficulty -2.0

CHAPS scoresCHAPS (parents)

CHAPS scoreCHAPS (teachers) -2.5 -2.5 Considerably -3.0 more -3.0 No APD difficulty APD issues APD diagnosed -3.5 -3.5 Noise Quiet Ideal Multiple Memory Attn Span Noise Quiet Ideal Multiple Memory Attn Span

PROBLEM PROBLEM

39 Speech understanding – Attention,

what could go wrong? Memory

Percent Percent understanding SNR

Auditory processing Speech processing Language processing Phonemes, Auditory Complex syllables or • Morphology knowledge (speech) signals words Under- • Auditory filtering • Comparison to • Syntactic knowledge input analysed identified standing • Envelope analysis stored templates • Semantic knowledge • Temporal fine structure (phonemes, • Prosody knowledge • Spatial analysis syllables or words) • Working memory • World knowledge

Degrade the input Phonemic and lexical neighbourhood Syntactic Message Noise Reverb density cues length Spatial Rate cues These enable Semantic Prosodic cues cues 40 auditory closure Speech recognition – what has gone wrong? Test of auditory and speech and language processing

Test of auditory and speech processing

Test of auditory processing

Auditory processing Speech processing Language processing Phonemes, Auditory Complex syllables or • Morphology knowledge (speech) Signals words Under- • Auditory filtering • Comparison to • Syntactic knowledge input analysed identified standing • Envelope analysis stored templates • Semantic knowledge • Temporal fine structure (phonemes, • Prosody knowledge • Spatial analysis syllables or words) • Working memory • Pitch contour analysis • World knowledge

Phonemic and lexical neighbourhood Syntactic Message Noise Reverb density cues length Spatial Rate cues Semantic Prosodic Attention, cues cues 41 Memory Observations in relation to model • APD should be able to cause poor speech perception and language delay (imagine consequences of a complete APD). • Listening difficulties can be caused by any of auditory processing, speech processing, language processing or cognitive deficits, either alone or in combination. What to • A deficit in language processing or auditory/speech processing can be expressed remediate as an equivalent SNR loss Auditory Speech Language processing processing processing Phonemes, Auditory Complex syllables or • Morphology knowledge (speech) • Auditory filtering Signals words Under- • Comparison to • Syntactic knowledge input • Envelope analysis analysed identified standing stored templates • Semantic knowledge • Temporal fine structure (phonemes, • Prosody knowledge • Spatial analysis syllables or • Working memory • Pitch contour analysis words) • World knowledge

Phonemic and lexical Noise Reverb neighbourhood density Syntactic Message cues length Spatial Rate cues Semantic Prosodic Attention, cues cues Memory 42 Importance of SNR: 1. Age

Sound Scouts LiSN-S LiSN-U

Sentences in competing Nonsense syllables in babble competing nonsense syllables

-2 -8 10 -4 -6 -10 2.4 dB/year 1.3 dB/year 1.0 dB/year 5 -8 -10 -12 0 -12 -14 -14 -16 -5 -18 -16

High Cue SRT

-20 SRT dB (SV90) -10 -22 -18

Speech reception threshold (dB SNR) -24 -15 -26 -20 -28 5 15 25 35 45 55 -22 -20 10 20 30 40 50 60 5 10 15 20 25 30 35 40 45 50 55 60 65 5 6 7 8 9 10 11 12 13 14 15 Age Age Age

6 y.o. re adult: 11 dB 6 dB 10 dB 43 Importance of SNR: 2. Hearing loss or APD

Condition Effect Increase in SRT Mild hearing loss 1 dB increase for each 10 dB +3 dB (35 dB 4FAHL) of 4FAHL above 5 dB Spatial processing Same-age population standard +3.2 dB disorder deviation is 1.6 dB

Conclusion: A 6 year old, with mild hearing loss, or spatial processing disorder just outside normal limits needs 3 + 9 =12 dB better SNR than an average adult.

SNR = -4 dB SNR = -14 dB

44 So, top-level testing to find the strength of deficit in each area, but ….

How do we find the specific deficit(s)?

45 How do we find the specific deficit(s) causing listening difficulties?

1. Differential testing

• DDdT (Dichotic digits difference test, Cameron et al, 2016)

• SPIN (Speech in noise test; Kalikow, Stevens & Elliott, 1977)

• LiSN-S (Listening in spatialized noise sentences test, Cameron & Dillon, 2007) 2. Allow for other abilities that affect test scores (just like we allow for age) 3. Use tests that rely only minimally on other abilities

46 Differential testing (e.g. SPIN – Kalikow, Stevens & Elliot, 1977) Pichora-Fuller (2008)

Test of auditory and speech and language processing (with semantic cues) SRT1

Test of auditory and speech and language processing (with no semantic cues) SRT2

∆SRT = SRT2 - SRT1

Phonemic and lexical neighbourhood Syntactic Message Noise Reverb density cues length Spatial Rate cues Semantic Prosodic Attention, cues cues 47 Memory Diagnosing spatial processing disorder with the Listening in Spatialized Noise Sentences (LiSN-S) test

APD

SPD

Disclosure

Licensed to Phonak 48 Four LiSN-S Conditions Difference measures !

Same Voice Different Voices

D1 T D2 D1 T D2

Same Direction

Talker Advantage Spatial Spatial Advantage

Low Cue SRT

High T T Cue Different SRT

Directions

D1 D1

49 50

50-60

40-49

30-39

25-29

20-24

18-19

16-17

14-15 AgeGroup 12-13

≡ Spatial Release from Masking) from Release Spatial ≡ 10 (

Nth America Nth 8 Australia 7

6 9 8 10 15 14 13 12 11 18 17 16

Spatial Advantage (dB) Better Spatial Advantage Spatial LiSN-S results profile: spatial processing disorder

51 LiSN-S vs.TraditionalSusCAPD Group Battery 6

-2

-4

-6

-8

Deviation from Mean Normal Performance Deviation from Normal Mean -10 Median 25%-75% Min-Max -12

MLD

RGDT

DD (LE) DD

LC SNR LC

DD (RE) DD

HC SNR HC

PPS (LE)

Total Total Adv

PPS (RE)

Talker Talker Adv

Spatial Adv Cameron & Dillon (2008) 52 Link between SPD and Chronic Otitis Media (COM) Link between SPD and Chronic Otitis Media (COM)

53 SPD and chronic otitis media (COM)

• 50% of children (24/49) diagnosed with SPD at NAL reported (unsolicited) a history of COM. (Dillon et al., 2012).

• 18% of children (18/82) previously diagnosed with COM at University of Melbourne were diagnosed with SPD. (Graydon et al., 2017).

• Degree of spatial loss at primary school age increases with degree of threshold elevation due to COM in infancy. (Graydon et al, 2015)

• Spatial processing deficit worse for early onset age and longer duration of COM (n=35; Tomlin & Rance, 2014).

• 6 yo children with history of COM have below average spatial advantage (n=17; z= -1.0) (Kapadia et al, 2012).

• 13-17 yo adolescents with history of COM have below average spatial advantage (n=20; z= -0.75) (Kapadia et al, 2014).

• 10% of a population sample (9/90) of Aboriginal children from remote Australia diagnosed with SPD. (Unpublished data).

• 7% of a population sample (10/144) of Aboriginal children from regional 54 Australia diagnosed with SPD. (Cameron et al., 2014). APD Spatial Processing Disorder –

Unique amongst forms of APD because we: SPD

• Know its major cause • Can diagnose it, unrelated to cognitive ability • Have extensive normative and reliability data • Can remediate it (blinded, randomized trial) • Remediation generalizes to real life

55 Not all differential tests give immunity from cognitive deficits!

Right ear advantage in dichotic tests

56 An analogy Percent correct

100% 3 +4 ?

3,148 -1,659 0% ? Cognitive resources applied to task

57 An analogy Percent correct

100% Right

Left

0% Cognitive resources applied to task

58 How do we find the specific deficit(s) causing listening difficulties?

1. Differential testing • DDdT • SPIN • LiSN-S 2. Allow for other abilities that affect test scores (just like we allow for age) 3. Use tests that rely only minimally on other abilities

59 A common recommendation:

Multi-disciplinary evaluation

Practicality!

60 Allowing for related abilities

APD test z-score = AP ability + c.(memory) + d.(attention)

Therefore:

AP ability = APD test z-score – c.(memory) – d.(attention)

61 3 Dichotic Clinic scores 2 School and 1 memory 0

-1

-2

-3

Dichotic free recall (z score) -4

-5 -3 -2 -1 0 1 2 3

Number memory forward (z score) 62 3 Dichotic Clinic scores 2 School and 1 memory 0

-1

-2

-3

Dichotic free recall (z score) -4

-5 -3 -2 -1 0 1 2 3

Number memory forward (z score) 63 Allowing for related abilities

AP ability = APD test z-score – c.(memory) – d.(attention)

But ……. AP ability • Which type of “memory”? • Echoic • Working memory

• Which type of attention? • Sustained? Memory • Switching? z-score • Selective?

• What are the values of c and d for each auditory processing test? Non- Language Attention • Are the effects of memory and attention linear or non-linear? verbal IQ z-score z-score • How accurately do we need to know memory and attention? • Do we need to add non-verbal IQ or language ability to the modifiers? 64

Cognitive ability (of some sort) Auditory processing test score test processing Auditory

65 But which cognitive or language abilities affect which auditory processing tests?

66 Correlations !

1000

320

160

20 0 -1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1 Correlation coefficient

67 Cognitive APD APD Outcomes (NVIQ, memory, attention) (dichotic, non-speech) (speech tests) (reading, questionnaires, language)

Competing Competing Combined Receptive Expressive Overall Div Aud Vis Sus RGDT or Filtered words sentences LiSN-S Spat WARP or reported language language academic NVIQ NMF NMR NMF+NMR Prudence Vigilance Tten Atten DDT-L DDT-R DDT-Avg FPT SSW MLD GIN words (Scan)(Scan) (Scan) AFG (Scan) VCV LiSN-S HC Adv TOWRE listening CHAPS SIFTER Life Fishers CCC-2 SLI CCC-2 PLI CCC-2 GCC (CELF-4) (CELF-4) ability NVIQ 1.00 0.27 0.32 0.19 0.28 0.25 0.27 0.31 0.16 0.36 0.38 0.09 0.12 -0.04 -0.03 -0.02 0.09 -0.08 0.22 0.08 0.34 0.40 0.21 0.24 0.60 NMF 0.27 1.00 0.45 0.86 0.18 0.15 0.07 0.32 0.27 0.37 0.31 0.16 0.12 0.04 0.09 0.15 -0.01 0.44 0.24 0.08 0.06 0.03 0.29 0.44 NMR 0.32 0.45 1.00 0.83 0.22 0.26 0.26 0.26 0.22 0.31 0.35 -0.05 0.04 0.11 0.21 0.16 0.02 0.53 0.36 0.26 0.27 0.07 0.36 0.59 NMF+NMR 0.19 0.86 0.83 1.00 0.29 0.19 0.32 0.27 0.40 0.35 0.06 0.08 0.20 0.34 0.33 0.15 0.22 0.18 0.01 0.47 0.35 0.24 0.17 0.43 0.59 Prudence 0.28 0.18 0.22 1.00 0.54 0.37 0.22 0.36 0.18 0.42 0.55 0.49 0.12 -0.08 Vigilance 0.25 0.15 0.26 0.29 0.54 1.00 0.76 0.62 0.25 0.22 0.26 0.33 0.21 0.02 0.17 -0.10 0.01 -0.17 0.12 0.07 0.39 0.31 0.19 0.22 0.53 0.16 0.15 0.03 0.31 Div Aud Tten 0.76 1.00 0.68 0.08 -0.03 0.66 0.24 Vis Sus Atten 0.27 0.07 0.26 0.19 0.62 1.00 0.24 0.20 0.22 0.19 0.07 -0.01 0.00 0.01 0.30 0.20 0.18 0.16 0.28 DDT-L 0.31 0.32 0.26 0.32 0.37 0.25 0.24 1.00 0.47 0.85 0.37 -0.02 0.13 0.20 0.36 0.17 0.21 0.29 0.21 0.18 0.24 0.11 0.31 0.06 0.18 0.48 DDT-R 0.16 0.27 0.22 0.27 0.22 0.22 0.20 0.47 1.00 0.76 0.29 -0.04 0.11 0.20 0.32 0.17 0.18 0.20 0.34 0.09 0.15 0.08 0.31 0.16 0.33 0.36 DDT-Avg 0.36 0.37 0.31 0.40 0.36 0.26 0.68 0.22 0.85 0.76 1.00 0.36 -0.11 0.09 0.18 0.18 0.41 0.32 0.11 0.38 0.00 0.19 0.52 FPT 0.38 0.31 0.35 0.35 0.33 0.19 0.37 0.29 0.36 1.00 -0.02 0.25 0.21 0.26 0.12 0.12 0.36 0.20 0.11 0.14 0.01 0.21 0.34 0.30 0.39 SSW 0.18 0.21 1.00 0.64 0.57 0.26 MLD 0.09 0.16 -0.05 0.06 0.02 0.07 -0.02 -0.04 -0.11 -0.02 1.00 0.01 -0.08 0.02 -0.03 -0.14 -0.07 -0.05 0.21 0.07 0.08 RGDT or GIN 0.12 0.12 0.04 0.08 0.17 -0.01 0.13 0.11 0.09 0.25 0.01 1.00 0.13 0.18 0.30 0.10 -0.07 0.12 0.03 0.05 0.07 Filtered words (Scan) -0.04 0.04 0.11 0.20 0.42 -0.10 0.20 0.20 0.21 0.64 1.00 0.35 0.33 0.38 0.20 0.08 0.20 0.19 0.11 Competing words (Scan) -0.03 0.34 0.55 0.01 0.57 0.35 1.00 0.48 0.32 0.21 0.21 0.15 0.10 Competing sentences (Scan) -0.02 0.09 0.21 0.33 0.36 0.32 0.26 0.33 0.48 1.00 0.26 0.25 0.17 0.19 0.14 0.07 0.25 0.25 AFG (Scan) 0.09 0.15 0.49 -0.17 0.26 0.38 0.32 0.26 1.00 0.14 0.00 0.13 VCV -0.08 0.22 0.20 0.21 0.25 0.14 1.00 0.28 LiSN-S HC 0.22 0.15 0.16 0.18 0.12 0.08 0.00 0.17 0.17 0.18 0.12 -0.08 0.13 1.00 0.35 0.34 0.20 0.27 0.08 0.24 -0.15 0.15 LiSN-S Spat Adv 0.08 -0.01 0.02 0.01 0.07 -0.03 0.01 0.21 0.18 0.18 0.12 0.02 0.18 0.35 1.00 0.12 0.07 0.03 0.08 0.09 -0.01 0.03 WARP or TOWRE 0.34 0.44 0.53 0.47 0.39 0.30 0.29 0.20 0.41 0.36 -0.03 0.30 0.08 0.21 0.17 0.00 0.34 0.12 1.00 0.54 0.13 0.30 0.38 0.67 Combined reported listening 0.40 0.24 0.36 0.35 0.31 0.20 0.21 0.34 0.32 0.20 -0.14 0.10 0.20 0.07 0.54 1.00 0.62 0.80 0.62 CHAPS 0.08 0.26 0.24 0.18 0.09 0.11 0.20 0.15 0.19 0.28 0.13 1.00 0.66 SIFTER 0.06 0.27 0.24 0.15 0.14 0.19 0.14 0.66 1.00 Life 0.21 0.03 0.07 0.17 0.12 0.19 0.18 0.11 0.08 0.11 0.01 -0.07 -0.07 0.27 0.03 0.30 0.62 1.00 0.14 0.29 Fishers 0.24 0.29 0.36 0.43 -0.08 0.22 0.16 0.31 0.31 0.38 0.21 -0.05 0.12 0.08 0.08 0.38 0.80 0.14 1.00 0.56 CCC-2 SLI 0.53 0.66 0.24 0.09 1.00 0.59 CCC-2 PLI 0.15 0.24 -0.15 -0.01 0.59 1.00 CCC-2 GCC 0.11 0.10 0.07 0.13 1.00 Receptive language (CELF-4) 0.15 0.06 0.16 0.00 0.34 0.21 0.03 0.25 1.00 Expressive language (CELF-4) 0.03 0.18 0.33 0.19 0.30 0.07 0.05 0.25 1.00 Overall academic ability 0.60 0.44 0.59 0.59 0.31 0.28 0.48 0.36 0.52 0.39 0.08 0.07 0.15 0.03 0.67 0.62 0.29 0.56 1.00

Ahmed (2017) Cameron et al (2016) Riccio et al (2005) Weihing et al (2015) Ahmed & Ahmed (2016) Gyldenkaerne et al (2014) Dillon & Sirimanna (2014) Wilson et al (2011) Brenneman et al (2017) Harris et al (1983) Sharma et al (2009) Cameron et al (in prep) Maerlander (2010) Stavrinos et al (2018) 68 Cameron et al (2015) Maerlander et al (2004) Tomlin et al (2015) Divided aud Visual Prudence Vigilance attention attention

NMR Memavg NVIQ Attenavg NMF

Language MLD ability SSW

DDT-L DDTavg Reported Listening DDT-R CW ability

CS Academic FPT or reading ability GIN

FW Speech in noise LiSNSA AFG VCV LiSNHC 69 Observed correlations 0.1 Correlation 0.2 0.3 Scale Memavg NVIQ 0.4 Atten 0.5

MLD

DDTavg Reported Listening CW ability

CS Academic FPT or reading ability GIN

FW Speech in noise LiSNSA

70 Visual Constrained SEM Model Prudence Vigilance Path strength scale attention 0.1 0.2 0.3 NMF NMR NVIQ Atten 0.4 0.5

LIFE SIFTER Fishers

DDT-L CHAPS

DDT-R Listening ability CW

FPT

GIN VCV

FW AFG

LiSNSA LiSNHC 71 Visual Constrained SEM Model Prudence Vigilance attention

NMF NMR NVIQ Atten

DDT-L

DDT-R Reading ability CW

FPT

GIN VCV

FW AFG

LiSNSA LiSNHC 72 How do we find the specific deficit(s) causing listening difficulties?

1. Differential testing • DDdT • SPIN • LiSN-S 2. Allow for other abilities that affect test scores (just like we allow for age) 3. Use tests that rely only minimally on other abilities • LiSN-U

73 Speech without language?

Auditory and speech processing

Auditory processing Speech processing Language processing Phonemes, Auditory Complex syllables or • Morphology knowledge (speech) Signals analysed words identified • Understanding • Auditory filtering • Comparison to stored Syntactic knowledge input • • Envelope analysis templates (phonemes, Semantic knowledge • • Temporal fine structure syllables or words) Prosody knowledge • Spatial analysis • Working memory • Pitch contour analysis • World knowledge

Phonemic and lexical neighbourhood Syntactic Message Noise Reverb density cues length Spatial Rate cues Semantic Prosodic Attention, cues cues Memory 74 LiSN-U

Listening in Spatialised Noise - Universal

75 LiSN-U

Listening in Spatialised Noise - Universal

76 8 LiSN-U 6 R=0.70 preliminary 4 data 2 0 -2 (Test still under -4 development) -6 -8 -10 -12

LiSN-U SV90 SRTSV90 (dB) LiSN-U -14 -16 -18 -20 -22 -20 -18 -16 -14 -12 -10 -8 -6 -4 -2 0 2 4

LiSN-S High Cue SRT (dB) 77 Building an assessment battery

78 Traditional approach to APD testing

Caveats: History Audiometry 1. Diagnosis may be needed to get the funding needed for management 2. Diagnosis may help No Is there a problem teachers and/or parents that APD Yes might explain? “understand” reason for problems

Exclude APD; Refer elsewhere Detailed test battery

Non-specific remediation and management: Test result interpretation & diagnosis • Classroom placement • FM use • Instruction style • Soundfield amplification • Auditory training Deficit-specific remediation 79 Why diagnose APD at all?

To Manage it?

To Treat it? (i.e. remediate, cure)

To Compensate for it? (i.e. train some useful skill)

80 Hierarchical assessment Test of auditory and speech and language processing

Test of auditory and speech processing

Test of auditory processing

Phonemic and lexical neighbourhood Syntactic Message Noise Reverb density cues length Spatial Rate cues Semantic Prosodic Attention, cues cues 81 Memory Dealing with listening difficulties Cognitive Speech under- Speech sound Action abilities standing recognition Questionnaire / history Good Good Good None

Audiometry Good Good X Should not occur Good X Good Language testing & intervention Measure of speech No auditory Good Auditory processing testing & understanding in noise X X problem intervention (TOLD-U) X Good Good Should not occur Measure of speech sound X Good X Should not occur recognition in noise (~ LiSN-U) X X Good Cognitive testing & intervention

Cognitive testing & intervention Measure of attention X X X

Measure of working memory Cognitive Auditory testing & Evaluate results processing interventions testing

Language testing & 82 interventions Dealing with listening difficulties Temporo- PIT frequency

Questionnaire / history resolution Frequency Time GIN, RGDT, ParSE Audiometry Gap

detection

Frequency Frequency

No auditory Measure of speech Time Time problem understanding in noise ? (TOLD-U) FPT DPT Order

detection Frequency Measure of speech sound Frequency recognition in noise Time Time (~ LiSN-U) LiSN

Measure of attention Spatial processing

Measure of working memory Cognitive Auditory Dichotic testing & Evaluate results processing interventions testing

Language Localization testing & 83 interventions Dealing with listening difficulties Temporo- frequency

resolution Frequency Questionnaire / history Time Gap

detection

Frequency Frequency

Time Time Audiometry Order

detection Frequency Measure of speech Time No auditory understanding in noise problem Spatial (TOLD-U) processing

Measure of speech sound Dichotic recognition in noise (~ LiSN-U) Localization Measure of attention

Measure of working memory

Cognitive Auditory testing & Evaluate results processing & interventions Non-specific remediation interventions and management: • Classroom placement Deficit-specific remediation Language • FM use testing & • Instruction style interventions • Soundfield amplification 84 Criteria for selecting an assessment test

1. Established test validity, meaning that scores below the cut-off value chosen are usually associated with listening problems in real life. 2. Adequate normative data and information on retest reliability and critical differences. 3. Minimal or controlled effects of memory, attention and non-verbal intelligence 4. The existence of remediation options specific to the deficit revealed by the test, and for which evidence of benefit in real-life exists. 5. Affected by known lesions in the brainstem or auditory cortex.

85 Are listening difficulties mostly: Language, Auditory processing, or Cognition ?

Reported ? Listening difficulties ? Language ? Cognitive Deficits Auditory Deficits Processing Deficits

University of Melbourne Australian Hearing SPD: 3 / 105 SPD: 130 / 666 3% P=0.000 000 000 000 1 20% Tomlin et al (2015) Cameron et al (2015)

86 Questionnaires

87 Diagnosing APD by symptoms? Questionnaires (or other ways to gather symptoms) might be able to confirm there is a problem, but can’t tell us the cause.

Event Response Interpretation by child by observer Cognition

Acts Is not very (inappropriately) smart based on what Auditory was heard processing Can’t follow instructions Child fails to Asks for understand repetition of an instruction Poor instruction concentration Does nothing Daydreams

Language Misbehaves Badly behaved

88 Questionnaires (self-report, other-report)

APDQ TLI

BMQQ TEAP CHAPS SIFTER CHILD

CCC-2 SAB

ECLiPS LIFE

FAPC 89 The Auditory Processing Domains Questionnaire O’Hara and Mealings (submitted)

50 items, 3 scales

Auditory processing Language Attention abilities abilities

Separation of groups using the attention and auditory processing scales APDQ.NAL.gov.au

Attention Attention

Auditory processing Auditory processing Electrophysiology testing Yes, probably!

92 Remediation of auditory processing disorders

1. Deficit-specific training Management by + 2. Generalised auditory training improved SNR

93 LISN & Learn Game

Target at 0˚:

94 Target: The horse kicked six wet shoes

95 LiSN & Learn – Preliminary Study

• 9 children with SPD (6 to 11 years) • LiSN & Learn – 2 games/day, 5 days/week, 12 weeks

10 dB Average SRT First vs Last 30 Days

p = 0.000052

Better

& Learn SRT (dB) Learn & SRT LiSN

Cameron & Dillon (2011)

Game Number96 Experiment 1: Effect of training on LiSN-S scores

1.0

0.5 Follow-up

0.0

Post -0.5

-1.0

-1.5 Pre

-2.0

LiSN-S score (popn SD units) (popn score LiSN-S

-2.5

-3.0 Low cue Talker advantage Total advantage High Cue Spatial advantage LiSN-S scale 97 Experiment 2: Blinded randomized controlled trial

Earobics (n = 5) Lisn & Learn (n = 5)

p = 0.5 to 0.7 p = 0.03 to 0.0008

98 Cameron, Glyde & Dillon (2012) 35

30 Teachers

25 Effectiveness of remediation 20 Cameron & Dillon (2011) 15 Questionnaire Cameron et al (2012) 10 Cameron et al (2014)

L.I.F.E Teacher post L.I.F.E Teacher results 5 Cameron et al (2015) Graydon et al (2018) 0

-5

-10 L&L Earobics Group 1.0 200

0.9 Parents 180 Children

0.8 160

0.7 140

0.6 120

DV_1

0.5 100

0.4 80

Group L&L 0.3 Group L&L 60 Group Earobics Parents Group Earobics Children

0.2 40 Fisher pre Fisher post L.I.F.E. Student pre L.I.F.E. student post 99 TIME TIME Necessary steps to show that remediation is effective

• Test scores increase • Increase in test scores is not due to: • Practice effects on the test  known test-retest statistics • Regression to the mean  double baseline testing • Placebo effect  randomized controlled trial • Increase in age  age-adjusted scores, control group • Similarity of training to test  independent outcome test • Improved listening ability generalizes to real life, evidenced by • Speech understanding in realistic acoustic conditions, and/or • Self-report or others-report

100 Research suggestions

101 1. TUniversalest of Listening test of Dlisteningifficulties difficulties – Universal (ToLD-U) Auditory, speech and language processing (Told-U)

Auditory processing Speech processing Language processing Phonemes, Auditory Complex syllables or • Linguistic knowledge (speech) Signals analysed words identified • Morphology knowledge Under-standing • Auditory filtering • Comparison to input • Syntactic knowledge • Envelope analysis stored templates • Semantic knowledge • Temporal fine structure (phonemes, • Prosody knowledge • Spatial analysis syllables or words) • Pitch contour analysis • Working memory • World knowledge

Phonemic and lexical Noise Reverb neighbourhood density Syntactic Message cues length Spatial Rate cues Semantic Prosodic Attention, cues cues Memory Test must require: • All the signal analysis skills needed to identify speech • Attention, working memory and language skills needed to understand speech Test could comprise: • Sentence material, with syntactic, semantic & prosodic cues available • Competing talkers, spatially separated from target • Fast speaking rate

• Reverberation (typical amount) 102 2. Objective versus subjective assessment of listening difficulties

Test of speech Self- or parent report understanding (APDQ, ECLiPS) (ToLD-U)

Electrophysiological measure (cABR, CAEP in noise,)

103 Temporo- 3. Create and norm new adaptive frequency

resolution Frequency tests (where needed) Time

Gap

detection

Frequency Frequency Time Time

Order

detection Frequency Time

Spatial processing

Dichotic

Localization

104 4. Which types of auditory processing Temporo- frequency resolution deficits correlate with poor speech Frequency perception and listening difficulties? Time Gap

detection

Frequency Frequency Test of speech Time Time understanding Order

(ToLD-U) detection Frequency Time

Spatial Self- or parent processing report (APDQ, ECLiPS) Dichotic

Localization

105 5. Correcting AP test results for cognition and language • Determine impact of memory and attention Mem (and IQ and language) on each age-corrected avg NVIQ Attenavg

test. AP1 • Derive corrections needed for each APD test in AP2 battery. AP ability AP3

AP4

AP5 Memory AP6 z-score correlation and slope! AP7 Non- Attention Language AP8 verbal IQ z-score z-score 106 Causation …….. unknown

Auditory processing abilities

Cognitive Language abilities abilities

Academic Reported abilities listening ability

107 6. What is the effect of cognitive vs auditory training?

Auditory Auditory processing score processing score

Memory score Memory score

Language training Attention score Attention score

Listening difficulty Listening difficulty score score

Does Cog  APD, or APD Cog, or something else cause both? Ditto for language training

108 7. Miscellaneous ideas

• Create a clinical test of backward masking, and measure normative performance and performance in kids with SLI. • Create a sensitive dichotic test without challenging memory or executive function • Compare behavioural results to electrophysiological results for stimuli chosen to expose specific deficits & examine sensitivity for individuals • Explore relationship between temporal order perception (FPT and DPT), cognitive abilities, speech intelligibility, and reported listening difficulties.

109 Thanks to Australian Department of Health for sustained funding.

Questions?

CAPD.NAL.gov.au 110