Expanding the Role of the SLP in
Auditory Processing Disorder and
Autism Spectrum Disorder
The American Speech-Language and Hearing Association
2011
San Diego, California
Donna Geffner, Ph.D., CCC-SLP-AU
St. John’s University
Jamaica, New York
Deborah Ross-Swain, Ed.D., CCC-SLP
The Swain Center
Santa Rosa, California
Why Consider Expanding the Role of the
SLP in Auditory Processing Disorders?
Though ASHA (2005) recommends that APD be
diagnosed by an audiologist, it is typically the SLP that is
responsible for screening, selection, management and
treatment
Increased awareness of APD by general public
Extensive information on relationship of APD to
communication, learning, literacy and overall success
Treating APD typically does not include children with
ASD
How would treating APD in ASD affect overall
improvement with communication, learning and social
skills?
General Facts about Autism
Autism is a highly variable neurodevelopmental
disorder (Geschwind, 2006)
Overt symptoms gradually begin after six
months and become established by age 2 or 3
years (WHO, 2007)
It is distinguished not by a single symptom, but a
characteristic triad of symptoms: impaired social
interaction; impaired communication; and
restricted interests and repetitive behavior
(Filipek, Accardo, Baranek, et al, 2006).
The incidence of ASD continues to rise
Communication Problems in
Children with Autism
Approximately a third to a half of
children/individuals with autism do not
develop enough natural speech to meet
their daily communication needs (Noens,
van Berckelaer-Onnes, Verpoorten and
van Duijn, (2006).
Differences in communication may be present
from the first year of life, and may include
delayed onset of babbling, unusual gestures,
diminished responsiveness, and vocal patterns
that are not synchronized with the caregiver. In
the second and third years, autistic children
have less frequent and less diverse babbling,
consonants, words, and word combinations;
their gestures are less often integrated with
words. Autistic children are less likely to make
requests or share experiences, and are more
likely to use echolalia (Landa, 2007; TagerFlusberg, 2007).
Communication Behaviors
Associated with Children with Autism
Receptive Skills:
• Easily distracted primarily by noise
• Hyper/hypo sensitive to sounds or noise
• Looks away or avoids looking when
name is called
• Difficulty attending to voices
• Difficulty responding to simple or
age appropriate commands
• Difficulty responding to non-verbal cues
Communication Behaviors
Associated with Children with Autism
Expressive Skills:
• Limited expressive vocabulary
• Speaks with dysrhythmic patterns
• Echolalia
• Does not initiate communication; limited
communication intent
• Limited mean length of utterance
• Limited syntactical and grammatical patterns
• Difficulty shaking head for “yes” and “no”
• Difficulty with greetings
Autism and Auditory Behaviors
Autism is a neuro developmental spectrum
disorder described by its deficits in reciprocal
social interaction, impaired verbal and nonverbal
communication, and restricted, repetitive and
stereotyped patterns of behavior, interests and
activities (APA, 1994)
Autism comprises an array of disabilities that
may be displayed as:
– A social deficit in combination with severe mental
retardation and no spoken language.
– A handicap in social and communicative abilities but
with above normal IQ and language.
Paul, Chawarska, Fowler, Cicchetti & Volkmar, (2007)
Autism and Auditory Behaviors
The core characteristic of Autism is
displayed in the individual’s impaired
ability to socially interact.
For most parents the first symptom
typically noticed is the child’s inability to
develop and understand spoken language
and for speech initiation.
Paul, Chawarska, Fowler, Cicchetti & Volkmar, (2007)
Autism and Auditory Behavior
Autism is typically associated with
atypical auditory behavior which may
include aversion to everyday life sounds.
When these aversions affect children's
perception of speech like sounds, inadequate
behavioral response to sounds may occur.
Which may play a role into the language
impairments typical of Autism.
Boddaert et al., (2004)
Auditory Processing Defined
Auditory processing is the efficiency and
effectiveness by which the central nervous
system utilizes auditory information. It
encompasses the perceptible processing
of auditory information in the central
nervous system and the neurobiologic
activity that underlies that processing and
gives rise to electrophysiologic auditory
potentials (ASHA, 2005).
Auditory Processing Disorder
Children and adults with APD are a
heterogeneous group of people who
have difficulty using the auditory
information to communication and learn
(Jerger & Musiek, 2000).
Central Auditory Processing
Disorder
Children with autism are more likely than
non-autistic children to suffer from
symptoms collectively known as auditory
processing disorders
Individuals with auditory processing
disorder are recommended to be screened
for communication difficulties associated
with Autism.
Dawes & Bishop, 2008; Tierney, 2004
Auditory Behaviors
Estimated that enhanced frequency
discrimination exists in approximately 20%
of ASD individuals and that clinicians must
attend to individual differences in the
presentation of auditory behaviors in this
population.
– For example, the subjects who performed
poorly on intensity discrimination tasks
engaged in higher levels of behaviors
intended to cope with loudness levels.
Jones et al., 2009
What is the Relationship
between APD and ASD?
We need to:
• Observe and document behaviors
• Evaluate
• Review the literature
• Study the research
Observe and Document
Behaviors
A variety of environments
Over a period of time
Communication and social behaviors
Consistency versus inconsistency of
behaviors
Results in a behavioral profile
Evaluate
Standardized batteries
What do the data tell you?
Share the results with other
professionals
Collaborate
Review the Literature
APD literature
ASD literature
Speech/language literature
Related fields literature
Study the Research
What is the research telling us about the
relationship between APD and ASD?
Assists in decision making about
treatment interventions
Assists in decision making about delivery
models
Encourages us to “rethink” our roles in
treating ASD
The Research
What We Already Know
Auditory Skills
Starting in early infancy hearing is a
fundamental basis for the orientation of
attention
Children with Autism have been shown to
have difficulties in extracting the linguistic
information received through auditory
perception.
– This information is vital for participating
in conversations.
Siegal & Blades, (2003)
Auditory Skills
Many of these children with Autism may
have subtle auditory impairments in which
asymmetrical patterns of activity may be
seen in the olivocohlear system involved in
detection of speech in noise.
Siegal & Blades, (2003)
Research
The research suggests that toddlers with Autism show a
reduced preference for child directed speech, compared
with typical peers.
Correlational analysis revealed that time spent listening
to child directed speech by children with autism was
related to their concurrent receptive language ability as
well as to receptive language abilities one year later.
Seri et al (2007) proposed that global deficits cause
autistic children to have heightened response in specific
brain regions to compensate for global deficits
Paul, Chawarska, Fowler, Cicchetti & Volkmar, (2007)
Autism and CAPD Prevalence
Children with Autism who experience
abnormal auditory perception may be
receiving the diagnosis of Auditory
Processing Disorder (APD).
– 9% of children referred for APD testing had a
formal diagnosis of Autism (Dawes et al.;
2008).
Dawes & Bishop, (2008)
Autism and CAPD Prevalence
It has been reported that 18% of 199
children with Autism have hyperacusis
Individuals with high functioning Autism
complain of difficulties listening in noise
and have poorer speech in noise
performance
Alcantara et al, 2004; Rosenhall et al., 1999
Impairment in Auditory Processing
Individuals with Autism react in an atypical
manner to their sensory environment.
– Auditory hypersensitivity
A response to sounds that most individuals
find tolerable (i.e. Fire alarm).
– Auditory hyposensitive
The individuals lack of response to one’s own name.
These Auditory paradoxes suggest that these
individuals process sounds in an atypical
fashion.
Bertone, Bonnel & Burack, (2009)
Auditory Skills
The auditory paradox is a complex, multilevel characteristic that is consistent with
the strengths and difficulties in auditory
processing for individuals with Autism.
– Strengths appear in the enhanced abilities to
discriminate between tones on the basis of
their pitch or height value.
– Weaknesses include difficulties in processing
words, and sentences in noisy backgrounds.
Bertone, Bonnel & Burack, (2009)
Auditory Skills
Studies have found that individuals with autism
generally have impaired auditory perception of
linguistic and social auditory stimuli
– This correlated with impaired language,
communication skills and social isolation among
these individuals with Autism.
Findings indicate enhanced auditory perception
abilities in pitch and music of individuals with
autism.
– This may correlate with the restrictive and highly
focused behaviors observed in individuals with Autism
Kellerman & Gorman (2005)
There was no generalized conclusions found
regarding findings on auditory perception of nonlinguistic, non-musical stimuli among autism
subjects.
The distinction between impaired global
processing and enhanced local processing may
prove useful in making sense of the discordant
findings on auditory abnormalities among
individuals with Autism.
Kellerman & Gorman (2005)
Impairment in Auditory Processing
Auditory processing disorder seen in
individuals with Autism are suggested by
the research to be heavily modulated by
the meaning of the stimuli.
– This is due to top down influences on auditory
processing and not caused by the primary
problem in detecting or discriminating auditory
features.
Dawes & Bishop, 2008
Auditory Processing Disorder
Both enhanced and impaired auditory skills have
been found in individuals with Autism.
– Enhanced or spared local processing (processing of
detail)
– Impaired global processing (processing of the whole)
The findings however have shown to be the
reverse of what is predicted.
– Enhancement of perception of musical affect
– Impairments in pitch discrimination
Dawes & Bishop, (2008)
Dawes and Bishop (2008) recommend:
– Individuals with a APD be screened for
communication difficulties associated with
Autism.
Children with Autism had enhanced
discrimination of pitch, as well as above average
response to changes in pitch for speech and
non-speech sounds, which they felt was related
to the increased sensitivity that autistic
individuals have to specific sounds.
Lepisto, Kujala, Vanhala, Alku, Huotinainen, & Naatanen, 2005
Temporal Processing
One of the central components of dysfunction in
APD is temporal processing.
Need for high functioning autistic individuals to
have a signal to noise ratio of 2.5 to 3 decibels
higher than for controls, particularly when there
were temporal dips in background sound
Alcantara, Weisblatt, Moore, & Bolton, 2004
Temporal Processing
The processing of acoustic stimuli over time
• This enables us to understand speech in
quiet and background noise and assist in
the acquisition in speech, language and
reading
• Binaural temporal processing is the
processing of stimuli over time by both
ears.
Auditory temporal processing includes:
– Temporal resolution
– Temporal asynchrony
– Temporal separation
– Temporal order
– Temporal masking
– Temporal summation
Vishakha Rawool, 2007
Temporal Integration/Summation is the
ability of the auditory system to add up
information over time or over duration up
to a critical duration.
Vishakha Rawool, 2007
Deficits in temporal processing and
atypical activation patterns are evident in
the autistic population.
Clinicians should be aware of the
challenges that this population faces with
specific tasks and skills, such as
multisensory auditory integration.
Lepisto, Kujala, Vanhala, Alku, Huotinainen, & Naatanen, 2005
Temporal complexity and primary auditory cortex
activity, particularly Heschel’s gyrus in autistic
versus anterolateral superior temporal gyrus in
non-autistics, was shown to vary directly.
Overall, more temporal complexity effects to parts
sensitive to acoustic features and reduced effects
in parts sensitive to abstract sound was
concluded to explain perception of speech
dysfunction in autism.
Children with Autism attend to more perceptual
parts of speech.
Samson et al., 2011
Another area of temporal processing in autistic
individuals was unisensory and multisensory
temporal activity, as measured by visual and
auditory temporal order judgment (TOJ) tasks,
where thresholds for TOJ tasks were higher for
ASD individuals for auditory tasks and there was
no difference in visual task activation.
Improvements were made in autistic auditory
processing in multisensory TOJ tasks over a
wide range of intervals, indicating that autistics
may need more time to process, or they may
have a delayed ability to integrate multisensory
auditory integration.
Kwakye, Foss-Feig, Cascio, Stone, & Wallace, 2011
Meta-analysis related to temporal auditory
processing, resulted in assertion that people
with ASD’s are likely right hemisphere dominant,
meaning they are more advanced in spectral
rather than temporal auditory processing and
that they have above average pitch and vowel
processing.
Their speech perception problems and temporal
deficits are thought to be related to their
tendency to have less activation of the left brain.
Kwakye demonstrated that deficits in temporal
processing and atypical activation patterns exist
in ASD.
Haesen, Boets, & Wagemans, 2011
ABR Findings
Electrophysiological measures have
demonstrated explanatory evidence of
auditory processing difficulties in autistic
individuals.
Evoked Potentials
Children with autism were investigated regarding
their evoked potentials, random pitch changes
and random deletions of stimuli.
The findings were consistent with the view that
there are auditory deficits in autism
– Manifested by abnormalities in the brainstem that may
involve lower levels of neural transmission as well as
higher aspects of processing that involve the
registration and storage of stimulus information.
Severe language disorder in childhood autism
may be secondary to the basic deficits in high
auditory processing.
Novick et al (1980)
ABR
Kwon, (2007) investigated 121 children
with Autism using auditory brainstem
responses (ABR).
Results found that children with Autism
have a dysfunction or immaturity of the
central auditory nervous system.
Additional foundation for McClelland et al.’s
(1992) assertion of immaturity of the brainstem
has been found in recent years
– Kwon, Kim, Choe, Ko, & Park (2007) investigated the
auditory brainstem response of autistic children and
found significantly prolonged inter-peak latencies,
suggesting immaturity of the central auditory nervous
system.
Early research showed that brainstem auditory
evoked potentials resulted in central conduction
times beyond normal limits, indicating that the
myelination in autistic children’s brainstems were
immature, influencing cortical and subcortical
structures.
McClelland, Eyre, Watson, Calvert, & Sherrard, 1992
Neurophysiology
Neurophysiological studies of individuals with
autism have revealed atypicalities in structure
and functioning of portions of the auditory
system.
Concluded auditory behavioral deficits
seen in autistic individuals may be
explained through auditory brainstem
dysmorphia, such as:
– Poor responsiveness to speech
Which could be related to the decreased volume of
neurons in the medial superior olive
– Hyperacusis
Which may be related to the reduced amount of
neurons in the nuclei of the superior olivary
complex
(Kulesza, Lukose, & Stevens, 2011)
This research expands upon early studies,
such as:
– Research that insinuated dysfunction related
to decreased size of the entire brainstem, in
addition to the pons, in infantile autism
– (Gaffney, Kuperman, Tsai, & Minchin, 1988)
Neurophysiology
First comprehensive report of anatomical
differences between the auditory brainstem
regions of autistic versus control brains
– 67-77% decrease in the number of neurons in the
medial superior olive and lateral superior olive
– 57-58% decrease in the amount of neurons in the
superior paraolivary nucleus and lateral nucleus of
the trapezoid body
– 45% decrease in the number of neurons in the medial
nucleus of the trapezoid body
– Non-statistically significant decrease in the number of
neurons in the ventral nucleus of the trapezoid body
Kulesza, Lukose, & Stevens, 2011
Tested that some of the abnormal sensory
perceptions that characterize autism may be
explained by an abnormal activation of noclassical (extra lemniscal) pathways.
Results indicate that in the presence of crossmodal interaction in individuals with autism there
is a sign that autism is associated with abnormal
involvement of the non-classical auditory
pathways.
– This implies that sensory information is processed by
different populations of neurons than in individuals
without autism.
Moller et al, (2007)
MRI
Reported fMRI results showing that individuals
with autism failed to activate superior temporal
sulcus (STS) voice selective regions in response
to vocal sounds.
Results showed normal activation pattern in
response to nonvocal sounds.
Suggesting that there is abnormal cortical
processing of socially relevant auditory
information.
Gervais et al (2004)
Magnetoencephalogrphy
Researchers at The Children’s Hospital in
Philadelphia used an MEG machine to
Analyze and compare the brain’s changing
magnetic field in 30 children with ASD and
34 typically developing controls.
A series of recorded beeps, vowels and
sentences were presented to the children
through the MEG machine helmet that
surrounds the child’s head.
Magnetoencephalogrphy
The researchers indicated that Auditory
processing was abnormal in the children
with ASD due to a delay of 20 milliseconds
in the brain’s response to the sounds
presented.
Impaired Language and Communication
skills may be due to the difficulties that
ASD children experience processing
sounds and speech shown in this study.
(Roberts et al., 2008)
ERP
Genetic expression, or phenotype, of sound
encoding difficulties as measured by ERP’s are
similar between those with Asperger disorder
and their parents, while cortical auditory
discrimination as measured by prolonged
latency in mismatch negativity is similar between
these individuals and their fathers.
Jansson-Verkasalo et al., 2005
PET Scans
Investigated whether abnormal cortical
processing was present in children with autism.
PET scans were used to obtain the results
indicating significantly less activation localized in
left speech-related areas
Concluded that the abnormal cortical auditory
processing observed in children with autism
could be involved in inadequate behavioral
response to sounds and in language
impairments that are characteristic of children
with autism.
Boddaert et al (2004)
The researchers hypothesized that lowfunctioning autistic subjects present
abnormalities in discriminating simple auditory
stimuli at sensory system preconscious stages
of cortical processing.
Their finding suggest that low-functioning
subjects present a dysfunction at preconscious
stages of auditory discrimination, playing a role
in the abnormal processing of auditory
information.
Tecchio et al, (2005)
Several other studies have sought to
explore the auditory discrimination skills of
individuals with autism.
– An oddball paradigm was used to determine
that low functioning individuals with Autism
have preconscious deficits in cortical auditory
discrimination skills, which impair attention to
specific tasks
(Tecchio et al., 2003)
Russo et al., (2008) Found support for the
involvement of subcortical regions
Identified deficits in pitch tracking in autistic
subjects, concluding that prosody encoding
deficits resulted from subcortical involvement.
Evaluation
Emphasized the importance of evaluating
children on a case by case basis, conducting
comprehensive audiological testing when
necessary and acknowledging the difference
between APD and ASD when they occur in
isolation versus when they are comorbid.
State that APDs are due to “explicit auditory
discrepancies” rather than the global
communication deficits defined in the DSM-IV by
the American Psychological Association.
Neville, Foley, & Gertner, 2011
Intervention
In order to accomplish the best intervention
efforts, there must be a comprehensive
understanding of the commonalities of
neurophysiological, electrophysiological,
theoretical, and behavioral challenges between
those with autism and the apparent deficits that
are exacerbated by the existence of auditory
processing disorder.
– It is significant to note instances where auditory
therapy has been successful in treating individuals
with autism.
Treatment
Administered two 30 minute sessions of auditory
integration training for ten consecutive days and
conducted a follow-up three months later, when
the formerly abnormal P300 electrophysiological
measures showed immense improvement in a
sample of three autistic individuals.
They warn, however, that the deficits evident in
autistic individuals through language and
attention largely complicate valid administration
and evaluation of audiometric test batteries.
Edelson et al.,1999
Studies have shown that individuals with autism
have difficulties in auditory discrimination,
temporal aspects of audition, auditory
performance decrements with competing
acoustic signals and auditory decrements with
degraded acoustic signals have been presented.
It is very likely that the specific difficulties that
many autistic individuals have with attending to,
understanding, and processing both speech and
non-speech stimuli may be evidence of APD.
Further investigation is necessary in order to
fully aid in the identification and potential
treatment methods that may be helpful to autistic
populations.
Clinicians should be aware of global versus
specific deficits in auditory processing in order to
make the diagnosis of APD in ASD people.
Clinicians should be careful to ensure that their
assessment methods are valid given the
linguistic, communication, and social cue
difficulties that are often present in autistic
children.
FM Usage of Children with ASD
An open-fit, ear level FM received from
Phonak EduLink was worn by a total of 25
pupil with ASD
Staff members carried an FM microphone
(wireless), which increased volume and
signal-to-noise of the speakers voice
4 main focus areas were investigated with
9 subcategories
Study found an improvement in 7 out
of the 9 subcategories for 60% of the
children.
In conclusion, stimulating the auditory
sense improved the pupil’s attention
span, concentration, eye contact,
stereotypical body movements,
language usage and communication.
FM Usage of Children with ASD
Important prerequisite for the development of
social skills include attention
It’s concept involves the ability to gain and
maintain attention, and focus one’s attention on
specific stimuli, while excluding distracting
stimuli
Attention, concentration, and perception are
fundamental to optimal cognitive functioning.
Phonak (2011)
FM Usage of Children with ASD
Hypothesis
Hypotheses of this study were formulated based
on observations from an earlier pilot project
– Phonak EduLink was used by children with ASD
– Only two older studies on FM systems and ASD have
been published
Results of these studies were highly positive:
children with ASD had improved attention,
accompanied by more appropriate behavior and
reduced sensory arousal
Phonak (2011)
Auditory processing deficits largely impact
the academic achievement of those with
autism, therein highlighting the need for
further research in the area of auditory
processing in this population so that early
intervention efforts can be implemented
more thoroughly
(Griswold, Barnhill, Smith, Myles, Hagiwara, & Simpson, 2002).
Case Study
Scott R.
DOB : 10/00
Classified PDD/Autism
Had first CAPD
evaluation 6/23/07 –
significant CAPD,
Phonological Processing
dx, Receptive and
Expressive language
disorder
Provided in school
with:
– Accommodations
– Speech-language
therapy
– FM system- ear level
Test Results
WIAT-III-3/11
Test Standard Score
Word Reading 86
Reading
Comprehenesion 61
Pseudoword Decoding 79
Numerical Operations 63
Math Problem Solving 32
Spelling 86
Oral expression 23
Listening Comprehension
63
Oral Reading Fluency 32
Essay Composition 77
CELF-4, Speech-Language Scores
(10)
(11)
(07)
(08)
SS
SS
Core Language-
6
70
2
76
05
88
21.
Receptive Language
6
86
18
81
10
88
21
Expressive Language 65
67
1
80
09
95
37
Language Content
100
50
106
66
110
75
75
5
85
16
91
27
Test
76
Working Memory Index 88
Percentile
SS Percentile SS
Percentile
Fitted with a binaural FM units, Speech-Language therapy
services 5x week
Monitored carefully annually
Auditory Processing Scores
SCAN-C
2010SS
Percentile
4/2011 SS
AFG
2
0.4
7
FW
12
75
CW
2
CS
TCS
Percentile
10/2011
Percentile
16
4
2
12
75
13
84
0.4
2
0.4
2
0.4
4
2
3
1.0
3
1
5
5
6
9
10
50
Overall Composite Standard Score
2010= 67, Percentile 1
4/2011 =72, Percentile 3
10/2011= 70 percentile 2
Where do We go from Here?
We all need to contribute to the ongoing fund of
information
Submit case studies
Consider auditory processing interventions for
the ASD population that are different from
traditional speech-language therapy
Consider mulit-modality interventions
that would be appropriate for individual
children
Study and understand the difference
between “top-down” and “bottom-up”
therapy approaches and their benefits for
effective treatment
Summary of Key Points
The role of the SLP continues to expand in
terms of evaluating and treating different
disorders and populations
Auditory processing disorder is a recognized as
a specific disorder warranting intervention by
SLPs
Children with ASD have communication
disorders of varying severities warranting SLP
intervention
Summary cont.
– Research indicates that children with ASD
frequently have co-morbid APD
– Decision making for treatment intervention of
the ASD population should involve bottom-up
interventions for APD
– The fund of information and research findings
are always changing thus the scope of practice
for SLPs will continue to change
Summary of Auditory Processing
Comorbid APD in
– Speech discrimination
– Speech discrimination in noise
– Temporal processing deficit
– Hyperacusis
– Higher TOJ thresholds
– Poor prosody encodings
Q & A and Discussion
References
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