….Then and Now

1. ….Then and Now Vicki M. Anderson, AuD, CCC-A Sarah Hanson, MS, CCC-S Roundtable Discussion, MSHA 2011

2. Multiple Models • 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?

3. Guidelines and Positions • ASHA 2006 Preferred Practice Patterns • ASHA 2005 CAPD Position Statement • AAA 2010 CAPD Clinical Practice Guideline • AAA 2000 CAPD Consensus Statement

4. 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

5. 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

6. 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

7. AUDITORY PROCESSING: Cornerstone of Language and Literacy (Reading) COMPREHENSION WRITTEN LANGUAGEReading and Spelling PHONOLOGIC AWARENESS ORAL LANGUAGE AUDITORY PROCESSING James W. Hall III, Ph.D. (2008). KSHA Conference.

8. 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 acousticsignals.

9. 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.

10. American Academy of AudiologyAPD 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.

11. American Academy of AudiologyClinical 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

12. ICD-9 Diagnostic codes • Acquired Auditory Processing Disorder • 388.45 • Abnormal auditory perception • 388.40

13. 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)

14. 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

15. Attention Deficit Disorder • Althoughthere 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)

16. Behaviors seen with ADHD vs. APD in Frequency of Occurrence ADHDAPD 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).

17. 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. APD can be evaluated in the presence of ADHD

18. 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

19. Minimal Test Battery approach— Jerger & Musiek (2000) Three possible approaches: • Behavioral tests • Electro-acoustic tests • Neuro-imaging studies

20. Collaborative Providers: Educational Psychologist Psychiatrist Speech/Language Pathologist Primary Care Provider Otolaryngologist Other Parent/School Concerns of (C)APD 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 • 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 • 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). INTERVENTION/THERAPIES: (May not be covered by insurance) -Auditory Training/Aural Rehabilitation -Language Therapy -Cognitive Therapy

21. 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

22. Narrative report must be readable • SOAP format • A: Results from APD testing support the following: Procedure Result   Psychophysical correlate

23. 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

24. 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

25. 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.

26. 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.

27. 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.

28. 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.

29. Environmental modification—managing classroom noise • iSenseis a miniaturized wireless communication system (FM system) that Phonak developed in the context of specific performance deficits. • iSenseenables the child to receive the teacher's voice without difficulty - even with environmental noise. • iSenseis 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

30. 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

31. 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.

32. 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=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.

33. 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)