Central auditory processing disorders in children

Central auditory processing disorders in children
Sharon Cameron Harvey Dillon Helen Glyde

Disclosure The National Acoustic Laboratories is a division of Australian Hearing, a Statutory Authority of the Australian Government. NAL licences the LiSN-S test to Phonak, and is paid a royalty on sales. NAL directly sells the LiSN & Learn training package through its web site and Sound Storm through iTunes.

Presentation Overview
Dillon: Deficit specific intervention Diagnosing, Treating and Managing CAPD Spatial processing disorder (SPD) What is it? How does it relate to CAPD? Diagnosis with the LiSN-S. Link to chronic otitis media. Remediation with the LiSN & Learn and Sound Storm. Dichotic digits testing Principles for test battery construction Impact of cognitive deficits ARC - Audiology Now! 2016

Central Auditory Processing Disorder (CAPD)
An Auditory Processing Disorder (APD) is a deficit in the way the neural representations of sounds are processed by the brain Central Auditory Processing Disorder (CAPD)

Disorders other than APD (e. g
Disorders other than APD (e.g. language disorders) can also create difficulty in listening Language disorders Attention deficit disorder Auditory working memory deficit Executive function deficit Autism spectrum disorder Low IQ

Diagnosis treatment and management of Auditory Processing Disorder:

Why diagnosing auditory processing disorders is complicated
Deficits in language Listening difficulties Deficits (various) in auditory processing Deficits (various) in cognition Performance on tests of APD

Diagnosing CAPD 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. Acts (inappropriately) based on what was heard Asks for repetition of instruction Does nothing Misbehaves Response by child Interpretation by observer Daydreams Badly behaved Can’t follow instructions Is not very smart Poor concentration Child fails to understand an instruction Event Cognition Language Auditory processing

Why diagnose CAPD at all?
To Manage it? To Treat it? (i.e. remediate, cure) To Compensate for it? (i.e. train some useful skill)

How is Management guided by a diagnosis?
Parent complains that child has difficulty hearing in the classroom or other noisy place It’s not! Administer a test battery Analyse test battery results Caveats: Diagnosis may be needed to get the funding needed for management Diagnosis may help teachers and/or parents “understand” reason for problems Write a report Commence management Sit at front of class Fit wireless remote microphone system Recommend clinician’s favourite training program Refer to a “therapist”

How is Treatment guided by diagnosis?
It can be: Example 1: Spatial processing disorder (LiSN-S)  spatial processing training (LiSN & Learn) Example 2: Dichotic deficit  dichotic training Dichotic Interaural Intensity Difference (DIID) Auditory Rehabilitation for Interaural Asymmetry (ARIA) Deficit in some specific ability diagnosed Train that specific ability Specific ability improved Training generalises to real-life listening in challenging situations Deficit-specific training should be the most efficient Non-specific training may also be effective  compensation

What should the diagnosis be based on?
Speech-based tests but… language disorder, or attention deficit, or working memory deficit, can cause low scores This can be solved with differential testing, as with LiSN-S Non-speech (psychoacoustic) tests but …. how good does one have to be in real life? cognitive deficits can cause low scores Are the right psychoacoustic abilities being measured?

Does any speech-in-noise test reveal a real-life deficit in speech understanding?
Not necessarily …. Deficit may be in: Spatial processing Vocabulary to achieve closure at word level Syntax or semantic knowledge, or working memory to achieve closure at sentence level Temporal processing to accurately parse speech in reverberation Speech in noise test

The elusive gold standard for CAPD?
Give up, because: CAPD has multiple causes, which very likely cannot be detected with a single test. Speech tests can have poor scores because of reasons other than CAPD Non-speech tests: are unlikely to assess all the skills needed to decode speech in challenging situations may assess skills not needed to decode speech in challenging situations Questionnaires can confirm difficulty in understanding, but not identify why the difficulty exists – type of CAPD, whether CAPD or something else.

Spatial Processing Disorder:
Diagnosis, cause, remediation

Spatial Processing Disorder – Unique amongst CAPD because we:
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

Spatial Processing Disorder
Dillon: Deficit specific intervention Spatial Processing Disorder Noise Noise Speech Noise APD battery Noise ARC - Audiology Now! 2016 19

Dillon: Deficit specific intervention
What is Spatial Processing Disorder (SPD)? SPD is a deficiency in the ability to use binaural cues to selectively attend to sounds arriving from one direction while suppressing sounds arriving from other directions. One type of CAPD. A major cause of difficulty understanding speech in noise in a percentage of children with normal thresholds (Cameron & Dillon, 2008). Children with SPD need higher signal-to-noise ratios to understand speech in noise. SPD is a deficiency in the ability to selectively attend to sounds arriving from one direction while suppressing sounds arriving from another. A person with normal spatial processing ability uses the small interaural time and intensity differences to help them to segregate the speech from the background noise in a noisy environment, but a person with SPD is unable to make use of these cues. Previous research by Cameron & Dillon has shown that SPD is a major cause of difficulty understanding speech in noise for a percentage of normally-hearing children. ARC - Audiology Now! 2016

Assessing Spatial Processing Ability ARC - Audiology Now! 2016

LiSN-S Adaptive speech-in-noise test. Virtual auditory environment under headphones. Target sentences from 0°. Distracter stories at 55 dB(A) SPL from either 0º or ± 90º. Stops when SE < 1.0 dB, or max of 30 sentences. SPD is diagnosed using the Listening in Spatialized Noise- Sentences Test (LiSN-S). The LiSN-S is an adaptive speech in noise test conducted under headphones in a simulated auditory environment. The test uses sentences designed for young children as they target speech and that is heard as if it is coming from directly in front of the listener. At the same time looped children’s stories are presented from either directly in front of the speaker or from either side of the speaker depending on the condition. The SRT is calculated for four LiSN-S conditions and based on those scores 3 advantage measures or difference scores are also calculated. ARC - Audiology Now! 2016

LiSN-S Measurement Screen
Dillon: Deficit specific intervention LiSN-S Measurement Screen Version 2.4 Two Distracters at 55 dB A SPL SRT ≡ average SNR Level of Target (adaptive) ARC - Audiology Now! 2016

Four LiSN-S Conditions
Difference measures ! Same Voice Different Voices T D1 D2 Low Cue SRT T D1 D2 Same Direction Talker Advantage Spatial Advantage Total Advantage T D1 D2 D1 D2 T High Cue SRT Different Directions

LiSN-S Normative & Retest Data
Dillon: Deficit specific intervention LiSN-S Normative & Retest Data Normative data specific to language version of test: Australian norms: 202 people aged between 6 & 60 years Cameron et al (2011) North American norms: 192 people aged between 6 & 30 years. Brown et al (2010) Test-Retest reliability data provides a guide to whether performance at one test truly differs from retest. One-sided critical difference scores in dB used to determine whether an individual has genuinely improved on the LISN-S on retest taking into account mean practice effects and day-to- day fluctuations in performance. Lots!! ARC - Audiology Now! 2016

High Cue SRT p < 0.001 Better Moving on to the high cue SRT, this condition provides participants with both spatial and pitch cues to differentiate the target sentences from the distracter voices. ANOVA showed that a significant difference does exist between the groups. You can once again see that performance improves with age and then begins to plateau. However, like low-cue SRT performance starts to decline slightly –but not significantly – at about age 50 Planned comparisons revealed adult like performance was achieved by years of age for high cue SRT as well. Cameron et al. 2011 ARC - Audiology Now! 2016 26

Spatial Advantage (≡ Spatial Release from Masking)
Dillon: Deficit specific intervention Spatial Advantage (≡ Spatial Release from Masking) Nth America Australia Better This graph shows performance on the spatial advantage measure. Spatial advantage is calculated as the difference between the low-cue SRT and SV90 condition. Adult like performance on the spatial advantage measure is achieved earlier than on talker advantage. Children are able to use ITD and IID as well as adults by about 11 years of age. Again, there is no decline in spatial processing ability in older adults. ARC - Audiology Now! 2016 27

LiSN-S Cut-off Scores min (intercept + B-value * age, c) – (2 * SDs of the residuals from the age-corrected trend lines) Better Cameron et al. 2011 Level below which performance on a LiSN-S measure is considered outside normal limits. Two or three-part regression equations fitted to account for improvement with age Low Cue SRT: max ( * age, -1.61) + (2 * 0.96) ARC - Audiology Now! 2016

LiSN-S results profile: spatial processing disorder
Dillon: Deficit specific intervention LiSN-S results profile: spatial processing disorder ARC - Audiology Now! 2016

Explanation Screen Performance on LiSN-S consistent with spatial processing disorder as determined by pattern measure. ARC - Audiology Now! 2016

Clinical study: Children with spatial processing disorder

LiSN-S CAPD Study (Cameron & Dillon, 2008)
Dillon: Deficit specific intervention LiSN-S CAPD Study (Cameron & Dillon, 2008) Nine children aged 6 to 11 years, who had no language, learning or attention disorder, but were experiencing listening difficulties in the classroom relative to peers (SusCAPD group). Eleven children with confirmed learning or attention disorders (LD group). Assessed on LISN-S and results compared to 70 age- matched controls. Assessed with a traditional APD test battery. ARC - Audiology Now! 2016

LiSN-S vs. Traditional Battery (LD Group)
Dillon: Deficit specific intervention LiSN-S vs. Traditional Battery (LD Group) Cameron & Dillon (2008) ARC - Audiology Now! 2016

LiSN-S vs. Traditional Battery – SusAPD Group
Dillon: Deficit specific intervention LiSN-S vs. Traditional Battery – SusAPD Group LiSN-S vs.Traditional Battery (sus CAPD Group) Cameron & Dillon (2008) ARC - Audiology Now! 2016

APD ? ? SPD ?

Link between SPD and Chronic Otitis Media (COM) ARC - Audiology Now! 2016

Interpretation Based on Numerous Studies
Chronic otitis media Fluctuating access to binaural cues reduced effectiveness in better-ear glimpsing

SPD and chronic otitis media (COM) 50% of children diagnosed with SPD at NAL reported a history of COM. (Dillon et al., 2012). 20% of children previously diagnosed with COM at University of Melbourne were diagnosed with SPD. (Graydon & Rance, ongoing). Degree of spatial loss at primary school age increases with degree of threshold elevation due to COM in infancy. (Gradyon 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 Australia diagnosed with SPD. (Cameron et al., in review). Indigenous Australian children experience, on average, 2.6 years of conductive hearing loss (vs. 3 months for non-Indigenous children). To OME summary ARC - Audiology Now! 2016

Remediation of SPD: The LiSN & Learn Auditory Training Software ARC - Audiology Now! 2016

LiSN & Learn Deficit-specific remediation for SPD.
Trains children to attend to a frontal target stimulus and filter out distracting talkers from left and right. Adapts to 70% performance level. Used in the home or schools/clinics). Provides detailed feedback, analysis and reporting.

Description of LISN & Learn
Dillon: Deficit specific intervention Description of LISN & Learn Five games presented on PC over headphones. Target sentences at 0º azimuth. Competing stories - same voice at ±90º - (55 dB SPL). Weighted up-down adaption of target level. SRT calculated over 40 sentences. 131,220 unique sentences. 50 training sessions (2 games x 5 days p/w x 10 weeks). Reward system. A weighted up-down adaptive procedure is used to adjust the signal level of the target based on participant’s response: decreased by 1.5 dB when target correctly identified increased by 2.5 dB if wrong target identified increased by 1.5 dB if the “unsure” response is made ARC - Audiology Now! 2016

LISN & Learn Game Target at 0˚: ARC - Audiology Now! 2016

Target: The horse kicked six wet shoes ARC - Audiology Now! 2016

LiSN & Learn – Preliminary Study
9 children with SPD (6 to 11 years) LiSN & Learn – 2 games/day, 5 days/week, 12 weeks 10 dB Better Average SRT First vs Last 30 Days p = LiSN & Learn SRT (dB) Cameron & Dillon (2011) Game Number

LiSN-S Results - Pre- vs. Post-Training
Dillon: Deficit specific intervention LiSN-S Results - Pre- vs. Post-Training LC SRT p = 0.158 Talker Advantage p = 0.981 HC SRT p = Spatial Advantage p = Total Advantage p = 0.001 Vertical bars denote 0.95 confidence intervals F(8, 64)=5.3847, p=.00003 Cameron & Dillon (2011) ARC - Audiology Now! 2016

Self-Report Questionnaire - Pre- vs. Post-Training
Very Hard Hard OK Easy Very Easy SSQ – Listening in Noise: Pre vs Post - p = * Post vs 3MP - p = 0.397 SSQ – Listening in Quiet: Pre vs Post - p = 0.103 Post vs 3MP - p = 0.529 Cameron & Dillon (2011)

Blinded Randomized Control Study
Dillon: Deficit specific intervention Blinded Randomized Control Study 10 children (aged 6 yrs 0 mths to 9 yrs, 9 mths) diagnosed with LiSN-S as having SPD: 5 x LiSN & Learn (experimental group) 5 x Earobics (control group) Questionnaires Participant (LIFE) Parent (Fishers) Teacher (LIFE) LiSN & Learn or Earobics training – 15 minutes p/d x 60 sessions Re-evaluate LiSN-S and questionnaires post-training Class 1 evidence SSQ = Speech, Spatial and Qualities of Hearing Scale LISN-S one-sided critical difference was calculated as (Mean Test-Retest Difference) - (1.64 x SD of Mean Test-Retest Difference). This represents the decrease in dB needed to infer that there has been a genuine improvement in auditory performance on retest, taking into account mean practice effects and day-to-day fluctuations in performance. Mean difference between test and retest was 0.5 dB for Low-cue SRT, 1.1 dB for High-cue SRT, 0.9 dB for talker advantage, 0.1 dB for spatial advantage, and 0.7 for total advantage. A critical difference on the spatial advantage measure is 2.8 dB, and on the Low-cue SRT it is 2.5 dB 54 ARC - Audiology Now! 2016 54

LiSN-S Results – Pre vs. Post Training
Earobics (n = 5) Lisn & Learn (n = 5) p = 0.03 to p = 0.5 to 0.7 Cameron, Glyde & Dillon (2012)

Questionnaires – Post Training Improvements
L&L = 15.8 pts; Earobics = 6.6 pts where 0 pts = “no improvement”. Teachers Parents Children L&L = 31%; Earobics = 9% (p = 0.028) L&L = 22%; Earobics = 9% Skip quizz

Time for quick check: True or false?
The LiSN-S test: Detects all forms of CAPD (T/F ?) Is suitable for children down to the age of 4 years Can detect spatial processing disorder in children and adults Gives much better scores on retest than on initial test Must be performed in an echo-free sound environment Gives several sub-scores some of which may be affected by language disorders, attention, and cognition, and some of which shouldn’t. Detects spatial processing disorder, which causes most cases of CAPD Reliably tests localization of speech sounds. Is a validated intervention tool.

Time for quick check: True or false?
The LiSN-S test: Detects all forms of CAPD - False Is suitable for children down to the age of 4 years - False Can detect spatial processing disorder in children and adults - True Gives much better scores on retest than on initial test - False Must be performed in an echo-free sound environment - False Gives several sub-scores some of which should be affected by language disorders, attention, and cognition, and some of which shouldn’t - True Detects spatial processing disorder, which causes most cases of CAPD - False Reliably tests localization of speech sounds - False Is a validated intervention tool - False

In review Spatial processing disorder (SPD) can unambiguously be diagnosed SPD is very often caused by protracted otitis media in infancy Generalized auditory training appears to be much less effective than deficit specific training for SPD SPD can be remediated … but boring!

LiSN & Learn Soundstorm
An app for tablet devices

Your turn Spatial processing disorder:
Is caused by chronic otitis media and cannot be overcome through training. Is different from CAPD. Is remediable in children aged 6 to 12 years of age.

What causes fails in dichotic testing? … and how do they impact on real life listening ability? … and how should dichotic deficits best be remediated or managed? ARC - Audiology Now! 2016

Existing dichotic tests
Dillon: Deficit specific intervention Existing dichotic tests Dichotic paradigms are the most commonly used tests of CAPD. Intended to assess binaural interactions Dichotic Digits Test (DDT) results correlated with academic outcomes and listening difficulty. 1, 8 2, 4 1, 2, 4, 8 The other auditory processing test we include in our test battery is the DDT. This test is widely used and research has shown that poor performance on the DDT is correlated with greater reported listening difficulty, greater academic difficulty and poorer reading. The DDT is a simple test to administer but some research suggests that it can be affected by memory and attention so monitoring the child’s attention during this test is important. ARC - Audiology Now! 2016

So what’s the problem? DDT is affected by more than binaural interactions Dichotic free recall scores correlate with: non-verbal intelligence (r = 0.49; Tomlin et al., 2015) attention (r = 0.36; Cameron et al., 2016) working memory (r = 0.38; Cameron et al., 2016) Failing DDT doesn’t tell us what the problem is, only that a problem exists. The other auditory processing test we include in our test battery is the DDT. This test is widely used and research has shown that poor performance on the DDT is correlated with greater reported listening difficulty, greater academic difficulty and poorer reading. The DDT is a simple test to administer but some research suggests that it can be affected by memory and attention so monitoring the child’s attention during this test is important. ARC - Audiology Now! 2016

The Dichotic Digits difference Test (DDdT)
Dillon: Deficit specific intervention The Dichotic Digits difference Test (DDdT) Modified version of the DDT Four different test paradigms: Dichotic integration Dichotic directed left & right Diotic Computer scored Norms based on exact age The other auditory processing test we include in our test battery is the DDT. This test is widely used and research has shown that poor performance on the DDT is correlated with greater reported listening difficulty, greater academic difficulty and poorer reading. The DDT is a simple test to administer but some research suggests that it can be affected by memory and attention so monitoring the child’s attention during this test is important. ARC - Audiology Now! 2016

Dichotic Free Recall Paradigm
Dillon: Deficit specific intervention Dichotic Free Recall Paradigm 1, 8 2, 4 1, 2, 4, 8 In the DDT the child is presented with two digits to each ear simultaneously and is required to repeat back all the numbers they heard. It doesn’t matter what order the digits are repeated in but the two ears are scored separately. So in this exampe the number 2 and 9 have been presented to the right ear and 1 and 5 to the left ear. The child responds 1, 2, 9, 5 so you would mark them correct for each number. ARC - Audiology Now! 2016

Diotic Paradigm 2, 4 1, 8 2, 4 1, 8 2,4,1,8 In the DDT the child is presented with two digits to each ear simultaneously and is required to repeat back all the numbers they heard. It doesn’t matter what order the digits are repeated in but the two ears are scored separately. So in this exampe the number 2 and 9 have been presented to the right ear and 1 and 5 to the left ear. The child responds 1, 2, 9, 5 so you would mark them correct for each number. ARC - Audiology Now! 2016

Dichotic vs diotic perception
Dichotic presentation Dichotic ability Auditory working memory Attention IQ Diotic condition

Dichotic vs diotic perception
Dichotic presentation Dichotic ability Auditory working memory Attention IQ Diotic condition Auditory working memory Attention IQ

Correlations – DDDT and cognition
Dichotic Diotic Attention - Prudence 0.37 0.32 Attention - Vigilance 0.34 0.24 Number memory forward 0.35 0.41 Number memory reverse 0.47 Non-verbal IQ 0.26

Interpreting results 1, 8 2, 4 1, 2, 4, 8 Dichotic Free Recall 2, 4, 1, 8 1, 2, 4, 8 Diotic Free Recall Right ear advantage (free) Dichotic advantage 1, 8 2, 4 Dichotic Directed Left Attention Advantage 1, 8 2, 4 Dichotic Directed Right Right ear advantage (dir) ARC - Audiology Now! 2016

DDDT report The DDT is a recorded test presented over headphones via either the Medrx. The test is presented at 50 dB (dial) for all normlly hearing children. In the case of children with a mild conductive loss the presentation level should be 50 dB (HTL). The DDT is only normed for children aged 7 years and above so 6 year olds seen in our service cannot be given this test. ARC - Audiology Now! 2016

Conclusions – dichotic testing
None yet, but some observations …. Dichotic scores related to attention and memory (and NVIQ) Dichotic scores strongly related to diotic scores DDdT provides a basis for separating dichotic factors from other factors affecting dichotic scores

Principles for test battery construction ARC - Audiology Now! 2016

Principles in constructing a test battery
Keep the battery as short as possible Attention Accumulating type I error Include tests for which: suitable normative data and reliability measures exist poor results are associated with poor listening in real life evidence-based remediation exists NAL position statement on CAPD:

Dealing with problems in understanding speech
Questionnaire / history Audiometry Measured disability Is there a problem that CAPD might explain? Exclude CAPD; Refer elsewhere No Master test battery Yes Detailed test battery Test result interpretation leading to a disorder-specific diagnosis Disorder-specific remediation

Dealing with problems in understanding speech
Questionnaire / history Audiometry Measured disability Is there a problem that CAPD might explain? Exclude CAPD; Refer elsewhere No Master test battery Yes Non-specific remediation and management: Classroom placement FM use Instruction style Soundfield amplification FPT Verbal DDDT Dichotic SPIN Hi Cont LiSN-S High Cue Detailed test battery FPT Hum DDDT Diotic SPIN Lo Cont LiSN-S Spatial Advantage Talker Low Cue Test result interpretation leading to a disorder-specific diagnosis ? Integration Deficit Closure skill deficits Undiag- nosed deficit SPD Pitch deficit Disorder-specific remediation ? ARIA / DIID Top-down training LiSN & Learn

Clinical results from the Australian Hearing CAPD Service ARC - Audiology Now! 2016

Australian Hearing’s CAPD Service Operating in 42 Australian Hearing centers around Australia since May 2012. Diagnosis, assessment and management of specific aspects of CAPD. Recruitment targets children experiencing difficulty hearing in background noise. Tests are chosen which: Have been shown to be associated with difficulties in real life. Are reliable, repeatable and relatively quick to administer. Lead to remediation that is backed by research evidence. ARC - Audiology Now! 2016

Age Distribution N=618

(digits forward and reverse)
Test structure LiSN-S high cue LiSN-S Remediate (L&L) Auditory memory (digits forward and reverse) Remediate (Memory booster) Remediate (FM …..) Dichotic digits

LiSN & Learn LiSN - HC LiSN 20% Memory 26% Memory Booster Age 11%
666 Mild conductive 26 4 Sensorineural loss Hearing screening Pass 636 LiSN & Learn Z < -1 Fail Goal setting and recommendations LiSN - HC LiSN 349 130 20% Z ≥ -1 317 Pass (not SPD) 219 Fail 174 Goal setting and recommendations Memory 26% Pass 362 Memory Booster < 7 years 77 Age Testing discontinued 11% ≥ 7 yrs 285 Wireless remote mic Fail 104 Goal setting and recommendations DDT 16% Pass 181 27% Cameron et al (2015) Sem in Hearing

National CAPD service results: LiSN & Learn effects

LiSN & Learn training: COSI results

Effect of Memory Booster training

COSI scores for Memory Booster training

Addition to structure: Questionnaire
Auditory processing disorder questionnaire (APDQ) Brian O’Hara 52-item questionnaire Mostly APD, short subscales for autism, attention For example Has no problem hearing your words clearly when paying close attention in noisy conditions. Does not say “huh?” “what?” or need “repeats” when conversing (with interest) in a quiet place. Does not “mishear” and mistake similar sounding words (“fifty-fifteen,” “thirsty-Thursday”, "ships-chips") Norwegian?

Auditory processing disorders and dyslexia
Current research Auditory processing disorders and dyslexia

Auditory processing and dyslexia
Auditory processing ability Consonant categorical perception Syllable segmentation Non-word (phonetic) reading ability Brain-wave oscillations Cont to ephys To mechanisms To cognitive effects To cognitive conclusions

Locus of Spatial processing

Cortical Auditory Evoked Potential Study
Dillon: Deficit specific intervention Cortical Auditory Evoked Potential Study CAEP’s are voltage fluctuations associated in time with some physical or mental occurrence. They are recorded from the human scalp using surface electrodes. They are extracted from the ongoing electroencephalogram (EEG) by filtering and signal averaging. Our CAEPs are evaluated in the time domain, that is the waveforms plot the change in voltage over time. Standard stimulus /i/ occurred 80% of the time. A rare stimulus /u/ occurred 20% of the time. Both stimuli were presented over insert earphones at 0˚ azimuth. In one condition the stimuli were presented in background noise at either 0˚ azimuth or ±90˚ azimuth. Adult study used an active P300 paradigm where participant pressed a response button each time he or she heard the rare stimulus. Child study used a passive P300 paradigm where the participant watched silent TV. 11 November 2018 Sharon Cameron ARC - Audiology Now! 2016

Adult Control Group – Active Task N1 and P2 to Standard Stimulus at Cz
Dillon: Deficit specific intervention Adult Control Group – Active Task N1 and P2 to Standard Stimulus at Cz ms -200.0 50.0 300.0 550.0 800.0 µV 0.0 2.5 5.0 7.5 10.0 -2.5 -5.0 -7.5 -10.0 -6.4μV 2.9μV -4.6μV ___ 2.1μV Background Noise _______ 0˚ _______ ±90˚ Adult control group study (n=10). Age ranged from 19.5 yrs to (mean age 25.9 years). Active P300 paradigm – press response button when target heard. MANOVA run on Cz-M1 for 0˚ vs. ±90˚ conditions for time window of msec for standard stimulus. 6 of the 10 participants significantly different (p < to p=0.010). 6 of the 10 participants showed larger N1-P2 in 90˚ condition than 0˚ condition. Other 4 participants showed same amplitudes. 11 November 2018 Sharon Cameron ARC - Audiology Now! 2016

Age Matched Control - Passive Task N1 and P2 to Standard Stimulus at Cz ms -200.0 50.0 300.0 550.0 800.0 µV 0.0 2.5 5.0 7.5 10.0 -2.5 -5.0 -7.5 -10.0 -9.1μV 5.9μV -7.8μV ___ 1.7μV Background Noise _______ 0˚ _______ ±90˚ Female, 11.7 years. Passive P300 paradigm. MANOVA analysis of Cz-M1 for standard stimulus in 0˚ vs. ±90˚ conditions with a time window of msec. No significant difference (p=0.480). 11 November 2018 Sharon Cameron ARC - Audiology Now! 2016

Frequency following response
Krishnan et al 2012

MECHANISMS IN Spatial processing AND ITS DISORDERS

Relative importance of ILD and ITD cues?
Better

Spatial processing mechanisms Signal + + Left Right SNR differences ITDs ILDs Reduced informational masking Reduced energetic masking ARC - Audiology Now! 2016

Caution: heterogeneous!
How do APD scores, cognitive abilities and reported listening capability connect? Caution: heterogeneous!

Causation …….. unknown Cognitive abilities
Auditory processing abilities Language abilities Academic abilities Reported listening ability

Relation between APD and Attention Disorder
Auditory processing disorder 58 Auditory attention disorder 51 19 13 2 20 14 5 4 Visual attention disorder 25 24 No disorder 101 children with listening difficulties Gyldenkaerne et al. (2015)

Subjects Clinical Group: (n=105) Control group: (n=50) Dani Tomlin
Children referred for clinical AP assessment Aged 7.0 to 12.9 years (Mean Age 8.9 yrs, ± 1.5) Control group: (n=50) No reported auditory, listening or academic difficulties Aged 7.0 to 12.2 years (Mean age 9.1 yrs. ± 1.4) Peripheral hearing assessments all normal Dani Tomlin

Measures obtained AP Academic Results Listening Ability Cognition
Frequency Pattern Test (%) Dichotic Digits Test (%) Gaps In Noise (msec) Listening in Spatialised Noise Sentences test (LiSN-S) (dB) Masking Level Differences (dB) Cognition Non verbal IQ Auditory Working Memory Sustained Attention (Quotient Scores) Academic Results Reading Fluency –WARP NAPLAN (Numerical scores) Listening Ability Questionnaires: LIFE (child) Fisher (Parent) TEAP (Teacher) (Total item scores) Results need to allow for development & comparison of measures  z scores Source: Dani Tomlin

Relationships between variables in different domains Path analysis

(model; no latent variable)
Path analysis (model; no latent variable) Memavg Attenavg NVIQ DDTavg Reading fluency Listening ability Remove the latent variable but allow the cognitive skills to share some variance with each other and to affect the AP test scores. Propose that each of the “cognitive” and “AP” variables affect listening ability and that the cognitive variables and listening ability affect reading fluency. How strong do the paths need to be to fit the observed relationships? (Model 0A structure) FPTavg GINavg LiSNavg

(results; no latent variable)
Path analysis (results; no latent variable) Memavg Attenavg Reading fluency NVIQ 66% DDTavg 49% Listening ability is significantly affected only by NVIQ, not by any AP scores. Reading fluency is affected by listening ability (but reverse is probably also true). DDT, FPT and LiSN all affected by both Memory and NVIQ. GIN not much related to anything! (Model 0A results) 77% FPTavg Listening ability GINavg 97% P=0.12 Most metrics OK 88% LiSNavg 76%

Path analysis (delete link from AP to Listening ability)
Memavg Attenavg NVIQ 66% DDTavg Reading fluency 49% Deleting the paths from all the AP variables to listening ability does not produce a significant change in the fit of the model . (Model 0F relative to model 0A) 77% FPTavg Listening ability GINavg 97% P=0.19 All metrics OK Deletion causes no sig change in fit 88% LiSNavg 76%

(reverse listening ability to reading fluency)
Path analysis (reverse listening ability to reading fluency) Memavg Attenavg NVIQ 66% DDTavg Reading fluency 49% Back to original. What happens if we reverse the arrow from Listening ability to Reading fluency? Only change in significance of links is the NVIQ to LA becomes a little weaker and hence not significant. Overall fit is just as good. (Model 0G relative to model OA) 77% FPTavg Listening ability GINavg 97% P=0.11 Most metrics OK 88% LiSNavg 76%

Conclusions Performance on many AP tests affected by cognitive abilities (caution … causation!). Teacher & parent reports of listening problems much more related to cognitive ability and academic performance than to auditory processing test scores. Need for auditory processing tests less affected by cognitive abilities.  Intervention studies  Difference tests

Conclusions … for the moment
A score on a CAPD test reflects more than just the child’s auditory processing ability. Limiting the size of test batteries limits the chances of spurious test results. Select tests that are minimally affected by higher order cognitive factors. Select tests that have evidence-based remediation available. Stay up-to-date with literature as recommendations will continue to change!

References & Resources References Brown, D., Cameron, S. Martin, J., Watson, C., & Dillon, H. (2010). The North American Listening in Spatialized Noise – Sentences Test (NA LiSN-S): Normative data and test-retest reliability studies for adolescents and young adults. J Amer Acad Audiol, 21(10), Buchholz, J., Dillon, H., & Cameron, S. (2013). Toward a listening in spatialized noise test using complex tones. Proceeding on Meetings of Acoustics, 19, , 1-7. Cameron ,S., Brown, D., Keith, R., Martin, J., Watson, C., & Dillon, H. (2009). Development of the North American Listening in Spatialized Noise - Sentences Test (NA LISN-S): Sentence equivalence, normative data and test-retest reliability studies. Journal of the American Academy of Audiology, 20(2), Cameron, S., & Dillon, H. (2013). Remediation of spatial processing issues in CAPD. In G. D. Chermak & Frank E. Musiek (Eds.) Handbook of Central Auditory Processing Disorders. Comprehensive Intervention (Vol. II, pp ). San Diego, CA: Plural Publishing. Cameron, S. & Dillon, H., (2011). Development and evaluation of the LiSN & Learn Auditory Training Software for Deficit-Specific Remediation of Binaural Processing Deficits in Children: Preliminary Findings. J Amer Acad Audiol 22(10): Cameron, S., & Dillon, H. (2012). LISN & Learn Auditory Training Software (Version 3.0.0) [Computer software]. Sydney, NSW: National Acoustic Laboratories. Cameron S, Dillon H. (2009) Listening in Spatialized Noise – Sentences test (LISN-S) (Version 2.2) [Computer software]. Murten, Switzerland: Phonak Communications AG. Cameron, S. & Dillon, H. (2008). The Listening in Spatialized Noise – Sentences Test: Comparison to prototype LISN test and results from children with either a suspected (central) auditory processing disorder of a confirmed language disorder. Journal of the American Academy of Audiology, 19(5), ARC - Audiology Now! 2016

References (Continued)
Cameron, S. & Dillon, H. (2008). Spatial hearing deficits as a major cause of auditory processing disorders: Diagnosis with the LISN-S and management options. In R. Seewald & J. Bamford, eds. A Sound Foundation Through Early Amplification Proceedings of the Fourth International Conference: Phonak AG, Switzerland, Cameron, S. & Dillon, H. (2007). Development of the Listening in Spatialized Noise - Sentences Test (LISN-S). Ear and Hearing, 28(2), Cameron, S. & Dillon, H. (2007). The Listening in Spatialized Noise - Sentences Test (LISN-S): Test-retest reliability study. International Journal of Audiology, 46, Cameron, S., Glyde, H., Dillon, H., Kanthan, S., & Kania, A. (2014). Prevalence and remediation of spatial processing disorder (SPD) in Indigenous children in regional Australia. International Journal of Audiology. Early Online: 1–10. Cameron, S., Glyde, H., & Dillon, H., (2012) Efficacy of the LiSN & Learn auditory training software: Randomized blinded controlled study. Audiol Res 2(1): e15. Cameron, S., Glyde, H. & Dillon, H. (2011). Listening in Spatialized Noise- Sentences Test (LiSN-S): Normative and retest reliability data for adolescents and adults up to 60 years of age. J Amer Acad Audiol, 22(10), Dillon, H., Cameron, S., Glyde, H., Wilson, W., & Tomlin, D. (2012). Opinion: Re-designing the process of assessing people suspected of having central auditory processing disorders. Journal of the American Academy of Audiology, 23, Glyde, H., Cameron, S., Dillon, H., Hickson, L. & Seeto, M. (2013) The effects of hearing impairment and aging on spatial processing. Ear Hear, 34(1), Glyde, H.V. (2013) The effects of ageing and hearing impairment on spatial processing. (Doctoral dissertation, University of Queensland, 2013). Kapalia, S., Godden, D., Harvey, J., Satyanarayana, N. & Morley, A. (2012). Spatial listening in children with a history of otitis media with effusion. Poster presentation. Global Perspectives on CAPD. American Acadamy of Audiology Conference, Boston. Tomlin, D., & Rance, G. (Under Review). Long-term hearing deficits following childhood middle-ear disease. Developmental Medicine & Child Neurology.

Any questions? Additional resources & references ARC - Audiology Now! 2016

Spatial processing disorder on Catalyst
Sophie’s story CAPD.NAL.gov.au Spatial processing disorder on Catalyst

SPD in Other Populations ARC - Audiology Now! 2016

Friedreich Ataxia Rating Scale vs LiSN-S spatial advantage
Source: Rance (Neuroscience, 2012)

LiSN-S Prescribed Gain Amplifier

Changes in LiSN-S scores with hearing loss
Better Glyde et al (2013) Ear Hear

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