….Then and Now

Vicki M. Anderson, AuD, CCC-A Sarah Hanson, MS, CCC-S

Roundtable Discussion, MSHA 2011

…….Then and Now.Then and Now

• Buffalo Model • Bellis-Ferre Model • MN “Department of Education” Model • Chermak Model • Walter Reed Model (Head Injury) • HealthPartners Multidisciplinary Team

Model• Dept. of Speech & Hearing Sciences,

UMN (Research Model) • Others?

Multiple Models

• ASHA 2006 Preferred Practice Patterns• ASHA 2005 CAPD Position Statement • AAA 2010 CAPD Clinical Practice Guideline• AAA 2000 CAPD Consensus Statement

Guidelines and Positions

• Few nor med tests • Poor test-retest reliability • Recommendations for interventions which

cannot be implemented or are not available

• Poor reimbursement • Lengthy testing • Lengthy reports with non-specific

recommendations

Concerns Frequently Heard in the Past

• No procedure (testing or treatment codes) • No diagnostic codes • No Special Education (SPED) disability

service category • Effective, evidence-based therapies not

available• Recommendations for interventions which

cannot be implemented or are not available

…More Concerns Heard in the Past

• Lack of modality specificity• Speech/language based tests confound results• Co-morbidity (Looks like ADD/ADHD)• Other confounding variables

– Non-native English speaker (ELL, bilingual)– Intellectual Disability/global delays – Sensory integration/ASD

…And, More Concerns Heard in the Past

AUDITORY PROCESSING: Cornerstone of Language and Literacy

(Reading)

AUDITORY PROCESSING

PHONOLOGIC AWARENESS ORAL LANGUAGE

WRITTEN LANGUAGE

Reading and Spelling

COMPREHENSION

James W. Hall III, Ph.D. (2008). KSHA Conference. James W. Hall III, Ph.D. (2008). KSHA Conference.

APD Definition—American Speech-Language-Hearing

Association (ASHA, 2005)

(Central) auditory processing disorder [(C)APD] refers to difficulties in the processing of auditory information in the central nervous system (CNS) as demonstrated by poor performance in one or more of the following skills:

• sound localization and lateralization; • auditory discrimination; • auditory pattern recognition; • temporal aspects of audition, including temporal integration,

temporal discrimination (e.g., temporal gap detection), temporal ordering, and temporal masking;

• auditory performance in competing acoustic signals (including dichotic listening); and

• auditory performance with degraded acoustic signals.

APD Position Statement—American Speech-Language-Hearing Association

(ASHA)It is the position of the American Speech-Language-Hearing Association (ASHA) that the quality and quantity of scientific evidence is sufficient to support the existence of (central) auditory processing disorder [(C)APD] as a diagnostic entity, to guide diagnosis and assessment of the disorder, and to inform the development of more customized, deficit-focused treatment and management plans. (C)APD is an auditory deficit; therefore, it continues to be the position of ASHA that the audiologist is the professional who diagnoses (C)APD.

American Speech-Language-Hearing Association. (2005). (Central) Auditory Processing Disorders— The Role of the Audiologist [Position Statement]. Available from www.asha.org/policy.

Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children. JAAA 11: Nov. 2000.

Definition: “APD is broadly defined as a deficit in the processing of information that is specific to the auditory modality.”

Guidelines for screening strategies & diagnosis • Screening strategies• Diagnosis

minimal test battery factors influencing test outcome and analysis

James W. Hall III, Ph.D. (2008). KSHA Conference.James W. Hall III, Ph.D. (2008). KSHA Conference.

American Academy of AudiologyAPD CONSENSUS CONFERENCE 2000

Diagnosis, Treatment and Management of Children and Adults with Central Auditory Processing DisorderBuilds on the ASHA 2005 definition, which states that “CAPD refers to difficulties in the perceptual processing of auditory information in the central nervous system and the neurobiologic activity that underlies that processing and gives rise to the electrophysiologic auditory potentials.” Affects both children and adults, including the elderly Audiologic diagnosis based on behavioral and electrophysiologic test

battery, observation and case history Multidisciplinary assessment and intervention Description of auditory strengths and weaknesses

American Academy of AudiologyClinical Practice Guidelines, 2010

ICD-9 Diagnostic codes

• Acquired Auditory Processing Disorder– 388.45

• Abnormal auditory perception– 388.40

CPT Procedure Codes• Complete audiological work-up is pre-requisite

– 92552 (air conduction pure tone thresholds)– 92556 (speech thresholds & word recognition

performance/intensity function)– 92570 (tympanograms, acoustic reflexes &

decay)– 92588 (otoacoustic emissions, comp.; with

contralateral suppression of OAE)– 92585 (auditory evoked potentials)

• Evaluation for CAPD 60 minutes + report – 92620 (e.g., MLD, SIN, RGDT, PPT, DD, SIFTER)– 92621 (Each additional 15 minutes)

Behaviors of children "at risk" for APD (Adapted from Cohen,1980 & Fisher,1985)

• Frequently misunderstands oral instructions or questions • Delays in responding to oral instructions or questions • Says "Huh" or "What" frequently • Frequently needs repetition of directions or information • Frequently needs requests repetition • Has problems understanding in background noise • Is easily distracted by background noise • May have problems with phonics or discriminating speech sounds • May have poor expressive or receptive language • May have spelling, reading, and other academic problems • May have behavioral problems

http://www.capdtest.com/capd.cfm

Attention Deficit Disorder• Although there was confusion in the past,

it is now widely accepted that ADHD and APD are separate conditions, each of which may occur on their own, as well as together. Figuring out what is ADHD and what is APD can be challenging due to the similarities in symptoms between them. Nonetheless, there are some predominant behaviors that may help distinguish between the two. (Chermak et al., 1999)

Behaviors seen with ADHD vs. APD in Frequency of

OccurrenceADHD APD

1. Inattentive 1. Difficulty hearing in background 2. Distracted 2. Difficulty following oral instructions 3. Hyperactive 3. Poor listening skills 4. Fidgety/restless 4. Academic difficulties 5. Hasty/impulsive 5. Poor auditory association skills 6. Interrupts/intrudes 6. Distracted

*From Auditory Processing Disorders, Minnesota Department of Education (2003).

APD can be evaluated in the

presence of ADHD If there is a question of ADD/ADHD:

ADHD should be fully worked up & medications should be stable prior to APD

evaluation. If medication does not appear effective or

processing is still suspect, consider APD referral.

An APD evaluation can be considered in the absence of ADHD.

Contraindications for APD Testing

• Cognitive delay (IQ below 75)• Autism Spectrum Disorder (ASD) • Non-native English speaker

– Use non-languageor low-language based tools

– MLD – PPST– Dichotic Digits – RGGT

[3] Educational Audiology Association listserve (community standard), 10/09/03

Minimal Test Battery approach— Jerger & Musiek (2000)

Three possible approaches: 1. Behavioral tests 2. Electro-acoustic tests

3. Neuro-imaging studies

Parent/School Concernsof (C)APD

Collaborative Providers: Educational Psychologist PsychiatristSpeech/Language PathologistPrimary Care Provider OtolaryngologistOther

Clinical/Educational Audiologist

CRITERIA for REFERRAL: •Rule out neurological problem•Rule out ADD/ADHD (or) •If ADD/ADHD, medications stable •Rule out vision loss (normal or corrected vision) •Rule out cognitive delay (average or above cognitive quotient) •Rule out phonological processing problem •English as a Second Language excluded •Minimum age of 7 years to allow for maturation of the CANS

AUDIOLOGICAL EVALUTION:•Pure tone audiogram •Speech threshold & Word•Recognition (PB/PI Function)•OAE, with contralateral suppression•Tympanogram & Acoustic Reflexes

BASIC (C)APD EVALUATION:•Teacher checklist (e.g., SIFTER) •Speech-in-Noise test (e.g., BKB-SIN)•Binaural Processing test (e.g., MLD, Dichotic Digits)•Temporal Processing test (e.g., RGDT)•Pattern Processing test (e.g., PPST)

Where abnormal, a second test should be completed, preferably using a different modality (e.g., one speech, one non-speech).

Diagnosed (C)APD

INTERVENTION/THERAPIES:(May not be covered by insurance)-Auditory Training/Aural Rehabilitation-Language Therapy -Cognitive Therapy

Multidisciplinary (C)APD Team Model

Use normed, peer-reviewed, non-verbal tests, where possible

• This protocol samples these domains:– General screen for APD: MLD, SIFTER– Binaural interaction/binaural integration: MLD, DD

• Contralateral [efferent] suppression of OAE• Contralateral acoustic reflexes

– Localization/lateralization: MLD– Auditory figure/ground: MLD, BKB- or QUICK-SIN

• Contralateral [efferent] suppression of OAE

– Temporal processing/phonemic awareness: RGDT– Pattern processing: PPST

Narrative report must be readable• SOAP format• A: Results from APD testing support the following:

Procedure    Result    Psychophysical correlate   MLD Abnormal Possible brainstem binaural

interaction problem (functions such as sound localization, spatial sound separation),  Possible speech-in-noise difficulty

BKB-SIN Abnormal Supports mild SNR loss, mild speech-in-noise difficulty 

RGDT Normal Supports normal temporal or speed of auditory processing, normal processing for timing information in speech

What about reliability? • Where abnormal, we request another test

of that domain, in a different modality (if possible) by another provider on the Team

• Two abnormal tests are required to diagnose an APD [in that domain]

• We believe this constitutes “evaluation”– Greater validity– Multi-disciplinary perspective

Follow-up on abnormal APD results ENT evaluation for patients with abnormal retro-

cochlear findings e.g., abnormal acoustic reflexes,

abnormal word recognition rollover Neuropsychology and/or Educational Psychology evaluation Developmental Vision evaluation

R/o dyslexia, 50% correlation w/ APD Speech/Language evaluation

Phonological processing/phonemic awareness PCP/Medical Home APD expanded evaluation/re-evaluation

Effective interventions & therapies are available

The referring provider may coordinate referrals for assessments & interventions. School SPED or 504 case manager may provide oversight in some cases.

Recommendations for treatment should include services & therapies that are readily available in the community, & interventions supported by peer reviewed studies.

Evidence-based “minimal” interventions are recommended by the audiologist when auditory-based APD results are positive (e.g., preferential seating, ALD).

Other APD team members make recommendations for appropriate interventions per their area of expertise.

If not covered by schools or insurance, parents/patients may need to pay for these services out-of-pocket.

There are effective & proven interventions for APD

• Comprehensive intervention management typically is accomplished through three component approaches that are employed concurrently: – direct skills remediation, – compensatory strategies, and – environmental modifications.

American Speech-Language-Hearing Association. (2005). (Central) Auditory Processing Disorders—The Role of the Audiologist [Position Statement]. Available from www.asha.org/policy.

There are effective & proven interventions for APD

• Treatment and management goals are deficit driven and are determined on the basis of diagnostic test findings, the individual's case history, and related speech-language and psycho-educational assessment data.

American Speech-Language-Hearing Association. (2005). (Central) Auditory Processing Disorders—The Role of the Audiologist [Position Statement]. Available from www.asha.org/policy.

There are effective & proven interventions for APD

• Bottom-up approaches are designed to enhance the acoustic signal and to train specific auditory skills.

American Speech-Language-Hearing Association. (2005). (Central) Auditory Processing Disorders—The Role of the Audiologist [Position Statement]. Available from www.asha.org/policy.

Environmental modification—managing classroom noise

• iSense is a miniaturized wireless communication system (FM system) that Phonak developed in the context of specific performance deficits.

• iSense enables the child to receive the teacher's voice without difficulty - even with environmental noise.

• iSense is used to complement existing therapies in children with Auditory Processing Disorders (APD), Attention Deficits Disorders (ADD), ADD with Hyperactivity (ADHD) and Learning Disabilities.

http://www.speechpathology.com/channels/iSenseProfessionalBrochure.pdf

Environmental modification—managing classroom noise

•Lightspeed holds the state contract for school sound field FM systems•Figure $900/system

http://www.lightspeed-tek.com/products.aspx

ReferencesReferences

American Academy of Audiology (2010). Diagnosis, treatment and management of children and adults with central auditory processing disorder [Clinical Practice Guidelines]. Retrieved from http://www.audiology.org/resources/documentlibrary/Pages/CentralAuditoryProcessingDisorder.aspx

American Speech-Language-Hearing Association. (2006). Preferred practice patterns for the profession of audiology. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2005). (Central) auditory processing disorders— The role of the audiologist [Position Statement]. Available from www.asha.org/policy.

Hall, J.W., III. (2000). Contra lateral & ipsilateral acoustic suppression. In Handbook of otoacoustic emissions (pp. 204-220). San Diego, CA: Singular Publishing Group.

ReferencesReferences Keith, RW. (2000). Random Gap Detection Test [CD]. St Louis, MO: AUDiTEC.

Moncrieff, D. (2002). Binaural Integration: An Overview. http://www.audiologyonline.com/articles/article_detail.asp?article_id=396

Musiek, F. (1999). Habilitation and management of auditory processing disorders: Overview of selected procedures. Journal of the American Academy of Audiology, 10(6), 329-342.

Wilson, RH, McArdle, RA, Smith, SL. (2007). An evaluation of the BKB-SIN, HINT, QuickSIN, and WIN Materials on listeners with normal hearing and listeners with hearing loss. Journal of Speech, Language, and Hearing Research, 50, 844-856 .

Wilson, RH, Moncrieff, DW, Townsend, EA, Pillion, AL (2002). Development of a 500-Hz Masking-Level Difference Protocol for Clinical Use. Journal of the American Academy of Audiology, 4(1), 1-8.

Contact Information• For more information, please contact:

– Vicki M. Anderson, AuD, CCC-A, FAAA * vicki.m.anderson@healthpartners.com* ander214@tc.umn.edu * 612-209-8223 (cell)