….Then and Now
Vicki M. Anderson, AuD, CCC-A
Sarah Hanson, MS, CCC-S
Roundtable Discussion, MSHA 2011
Multiple Models
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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?
Guidelines and Positions
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ASHA 2006
ASHA 2005
AAA 2010
AAA 2000
Preferred Practice Patterns
CAPD Position Statement
CAPD Clinical Practice Guideline
CAPD Consensus Statement
Concerns Frequently Heard in the Past
• 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
…More Concerns 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
…And, More Concerns Heard in the Past
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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
AUDITORY PROCESSING:
Cornerstone of Language and Literacy
(Reading)
COMPREHENSION
WRITTEN LANGUAGE
Reading and Spelling
PHONOLOGIC AWARENESS
ORAL LANGUAGE
AUDITORY PROCESSING
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:
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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 SpeechLanguage-Hearing Association (ASHA)
It is the position of the American Speech-LanguageHearing 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, deficitfocused 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.
American Academy of Audiology
APD CONSENSUS CONFERENCE 2000
 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.
American Academy of Audiology
Clinical Practice Guidelines, 2010
Diagnosis, Treatment and Management of Children and
Adults with Central Auditory Processing Disorder
Builds 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
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)
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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 Occurrence
ADHD
1. Inattentive
2. Distracted
3. Hyperactive
4. Fidgety/restless
5. Hasty/impulsive
6. Interrupts/intrudes
APD
1. Difficulty hearing in background
2. Difficulty following oral instructions
3. Poor listening skills
4. Academic difficulties
5. Poor auditory association skills
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-language
or 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
Collaborative Providers:
Educational Psychologist
Psychiatrist
Speech/Language
Pathologist
Primary Care Provider
Otolaryngologist
Other
Parent/School
Concerns
of (C)APD
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
INTERVENTION/THERAPIES:
(May not be covered by insurance)
-Auditory Training/Aural Rehabilitation
-Language Therapy -Cognitive Therapy
Multidisciplinary
(C)APD Team Model
Clinical/Educational Audiologist
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)
Diagnosed
(C)APD
Where abnormal, a second
test should be completed,
preferably using a different
modality (e.g., one speech,
one non-speech).
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
MLD
Result
Abnormal
Psychophysical correlate
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
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ENT evaluation for patients with abnormal retrocochlear findings
 e.g., abnormal acoustic reflexes,
abnormal word recognition rollover
Neuropsychology and/or
Educational Psychology evaluation
Developmental Vision evaluation
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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
References
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/Central
AuditoryProcessingDisorder.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.
References
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=3
96
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)