Maximizing Outcomes for Children with Auditory Disorders: An Evidence-Based Approach to Managing Auditory Processing Disorders

Editor’s Note: This is an edited transcript of the third webinar in a 3-part webinar series.  The webinar series is also available as a text course - access the text course here.

Learning Objectives

After this course, readers will be able to discuss current evidence in cognitive science that supports treatment and management of auditory processing disorders, and list some specific strategies, current products and tools that have an evidence base as being effective in working with children with auditory processing disorders.

Introduction

Jane Madell, PhD:  This is part three of our pediatric workshop entitled Maximizing Outcomes for Children with Auditory Disorders. In the first session, Dr. Flexer presented information about the auditory brain.  She underscored how critical hearing is in the development of the auditory brain.  In the second session, I discussed what children need to hear in the classroom to be successful.  In the today's session, Dr. Gail Whitelaw will discuss an evidence-based approach to managing auditory processing disorders in children. To earn CEUs for this material, you can register for all three sessions as a recorded course or as a text course.

Dr. Whitelaw is the director of The Ohio State University Speech, Language and Hearing clinic, and she is an audiology faculty member on the Leadership Education in Neurodevelopmental and Other Disorders grant at the Nisonger Center of Ohio State University.

She is involved in a large range of professional issues, including preceptor education and training, clinical education and ethics education. She is the past president of the Ohio Academy of Audiology, past president of the American Academy of Audiology and a past chair of the Board of Governors of the American Board of Audiology. She currently teachers courses on ethics and audiology at The Ohio State University. 

Gail Whitelaw, PhD: Thank you, Jane.  Today, we'll look at some of the current evidence in cognitive science that supports treatment and management of auditory processing disorders (APD). How do we link what we know works or does not work to the current science? There is a lot of exciting current research on cognitive neuroscience and neuroplasticity that relates to our treatment of children with APD.

We are going to talk about specific strategies that are based in evidence, and then we will discuss some products and tools to help.  I have no financial relationships with any of the products I’ll discuss today; they are things that have worked effectively for us in our work with children with auditory processing disorders.

Auditory Processing Disorder

Auditory processing disorder, or central auditory processing disorder (CAPD) is a breakdown in auditory abilities resulting in diminished learning or comprehension through hearing, even though peripheral hearing sensitivity is normal.

Today we are not talking about children with peripheral hearing loss. We are talking about those children with normal peripheral hearing acuity who demonstrate auditory processing issues and who have been formally identified. We want to try to link those deficit areas to what is going to be successful for them from a management standpoint.

The ASHA statement (2005) talks about the fact that APD may lead to or be associated with difficulties in higher order of language, learning, and communication functions. Although APD may co-exist with other disorders, it is not the result of those disorders. People do not understand APD, because children can have attention deficit disorder or language impairment as co-existing conditions. That seems to be something that gets people concerned when they are planning management options.

The disorders under the APD umbrella are idiosyncratic. Dennis Phillips authored a very informative, foundational article in 2002 that covered APD from a basic science perspective.  He says that it should not bother us that kids or adults with APD are idiosyncratic because in most cases there are no identifiable origins at a structural level.

When I was first getting started in auditory processing about 30 years ago, people wanted to look at CT Scans or MRIs to look for lesions. We know in children, especially, that this is not how it works.  You very often do not find anything abnormal on an imaging test.

Phillips (2002) discusses the fact that brains are individualized and the central auditory nervous system pathology does not always respect functional neurological boundaries. In other words, these are very individualized issues and that is why individualized treatment or management is necessary.

Role of the Auditory System

The auditory system must prepare for adaptive demands faced by a listener, including processing variations in the speech of individual speakers, grasping auditory information presented in less than optimal listening environments and comprehending information on varying degrees of linguistic complexity. Our auditory systems have to be fast, and they have to be flexible.

One of the things often related to auditory processing the difficulty to listen in less-than-optimal listening environments. Obviously this includes when background noise is present or when there are multiple speakers or excess reverberation. Many kids with APD will also say that they cannot understand accents or dialects.  These conversations come up regularly in schools.

One of the questions we have related to management of APD is does APD really exist? ASHA in 2005 said that the quality and quantity of scientific evidence is sufficient to support the existence of APD as a diagnostic entity to guide the diagnosis and assessment of the disorder and to inform a development of more customized deficit focused treatment and management plan.

I will say this several times: a customized, deficit-focused treatment and management plan does not mean giving a pre-printed list of recommendations or a handout that talks about what kinds of things you might do for APD. It needs to be specific to that child and that child's deficit pattern.

As assessments are getting better, we should be able to do a better job of linking management to that diagnosis. A lot of people will still say that there is no evidence that APD is a disorder, or that it is some kind of attention deficit disorder. Those things are not true if we look at the evidence for APD.

Let's talk a bit more about some evidence-based approaches. The concept of CAPD as a unique diagnostic entity that should be addressed and treated in school-age children continues to engender controversy (DeBonis, 2015). Some people believe that the research is stagnating (Cowan, Rosen & Moore, 2009). This comes from the British Academy of Audiology, which takes a different approach than we would use in the United States for looking at APD and for treatment. There are number of reasons for this. They use a more basic science approach. It is hard to look at functional deficits that way.

After attending the Acoustical Society meeting in Indianapolis in 2014, I would debate the point that research is stagnating. You may think that basic science research does not have much to do with the kids that we see in our schools or the patients we see in our clinics.  I would debate that point and say that there is a lot of basic science that is truly leading us to some better diagnostic techniques and certainly better management techniques.

Management Myths

One management myth is that there is no such thing as an auditory processing disorder, and as we discussed, there is a clinical entity that falls in to that belief category. I conduct auditory processing assessments, develop treatment plans, and conduct treatment in the schools on the regular basis. It is a significant part of my clinical practice. However, another significant part of my clinical practice is working with children with hearing loss and those with educational audiology concerns. Our clinic consults to many school districts in Central Ohio. APD falls on a continuum.

Children with APD have more significant issues than some children with peripheral hearing loss. We seem to continue to want to make this into a peripheral hearing loss issue or an APD issue.  However, I often do not see it in my functional assessments or looking at children overall.

Another myth is that APD cannot be cured. I wrestle with this one because hearing aids do not cure hearing loss either.  The idea of treatment is not necessarily to cure.  I am discuss functional neuroplasticity and how we may make a bigger difference than we think we are making.

The last management myth is that we do the same thing for each person with APD.  If that is true, what is the point of doing an assessment or developing a management plan? As I discussed, treatment must individualized.

FM Systems

Anyone who has listened to an FM system can argue that it makes listening easier, but that does not necessarily make it the only or the most correct management technique that we would use. Treatment and management of APD has been happening for many years; it has been called aural rehabilitation or aural habilitation.

It supports this supposition that auditory processing disorders are on the continuum of functional listening disorders that are defined by the term hearing loss. I mentioned earlier that some of the children with APD we have seen have much more difficulty than those who are impaired because of their audiograms.  That is an important thing to remember when you consider functional issues with these children.

Tenants to Address APD Management in the Pediatric Population

Children are best evaluated and treated in an interdisciplinary team setting. APD is likely to overlap with other types of disorders for many children. They may have an Individualized Education Program (IEP) that addresses something else, like reading, attention or language, and we must address those functional listening deficits regardless of the ideology of the APD.

About 60% of children with hearing loss have another co-morbid condition. It should not surprise us that kids with APD may have multiple deficits. I look at kids as little pies, and my job is to carve out what part of the pie we as audiologists contribute to both in the assessment and in the treatment.

Sometimes APD is not even on anyone’s radar when children present with other more recognizable concerns.  For example, we see a lot of children with dyslexia or attention deficit disorder in our clinic, and we find that a big part of the pie is something related to either hearing loss or auditory processing disorder.

We know that we can have a separate disorder called APD, and we own that disorder in audiology. One of the things that seems to be a concern when I talk to school districts is that APD cannot be assessed clearly from ADHD, and we do not want to treat something that we are not supposed to be treating when it is not appropriate for us. This is why interdisciplinary teaming is important.

Gail Chermak and her colleagues (1998) have shown there is not much overlap between APD and something like attention deficit disorder. There may be some behaviors that have overlapped, but they are, in truth, fairly distinct disorders on their own.

It is critical is to consider the estimate of children presenting with APD is about 3%. The literature frequently cites between 2 to 5%, and that means this is a low incidence disorder.  It is not like you are going to be developing a treatment plan for 50% of the children in that classroom this. We should be able to screen these children out quite easily.

Erber's Hierarchy (1982) states that the auditory hierarchy is like an upside-down pyramid, where mastery of one area leads to the next. The continuum is detection, discrimination, identification, and comprehension.  This is critical to our profession and for speech-language pathologists.  We spend a lot of time in detection, which is how we are able to hear and detect a sound.

Auditory processing looks at these higher-level functions, beginning with discrimination. This is important to guide our decision-making and how we might conduct management with some of the children that we see.

Neural Plasticity

Neural plasticity is considered brain flexibility. Specifically, it is alteration of nerve cells to better conform to the immediate environmental influences. The alteration is often associated with behavioral changes. We know that if something changes in the brain, we are likely to see something functional change as a result, also.

There are three types of neural plasticity. The first is developmental, and that happens naturally due to aging. Just as children grow in height, their brain grows in development. This is a challenge when looking at APD. Do we want to intervene or develop a management plan when we believe something is developmental? What can we do to help facilitate and support that development?

The second type is compensatory, which is something that might happen after a lesion, for example. Say you are working with a child who had a traumatic brain injury, a stroke or some other kinds of tissue compression. We might see some compensatory issues after that. The third type is learning related. We should take advantage of all three of those areas in our management.

Auditory Plasticity in Children

What do we know about auditory plasticity in children? The central auditory system in young children is highly plastic. The first year of life has the greatest promise in plasticity. The cortex is growing like crazy. When we identify children's hearing loss early and engage in early treatment early, the results are amazing and this is because we can take advantage of the plasticity in the cortex.

Because of cortex is highly plastic, intervention can produce some significant positive effects and outcomes, but at least two factors need to be considered.  One is the timing of the intervention and the other is the type of input/stimulus to be used. The positives are obvious, but there are some considerations that we need to think about.

Firstly, if there is insufficient stimulation of the auditory system during periods of plasticity, it can cause abnormalities of the auditory cortex (Sharma, Tobey, Dorman, Martin, Gilley, & Kunkel, 2004). Much of Sharma’s research is in regard to cochlear implants, but it is directly applicable to our discussion of changing the brain for children with APD. Without use, stimulation or treatment, does the unused auditory system lose the ability to function normally and mature?

Historically, we know that children who lack stimulation of the auditory system due to peripheral hearing loss have negative cortical changes.  However, we have never really applied that to auditory processing. Most audiologists, myself included, do not assess APD until age seven, and there are many valid reasons for that.  Because of this practice, APD is often not identified until much older than seven. For both peripheral hearing loss and APD, parental concern is one of the top reasons that we assess that, but it usually starts much younger than seven years.  I worked with 14, 15, and 16 year olds where parents were voicing concerns when the children were seven or eight, yet the parents were convinced not to obtain assessment or follow any treatment at that point in time.

Using the plasticity evidence to rethink the time frame of diagnosis in children, it is clear that we need some evidence-based testing and treatment that incorporates an earlier perspective for APD. There are a lot of reasons for not doing an assessment earlier, but now we have neural plasticity evidence suggesting why we may need to begin assessments earlier.

Our profession and the professions that interface with audiology that are interested in hearing and listening disorders have the opportunity to use this as a platform to take advantage of what we know and do a better job in assessment and management.

Evidence-Based Auditory Training

What evidence would we need to do auditory training? How do we change an auditory system? The treatment should include the following components (Smith, Housen, Yaffe, Ruff, Kennison, et al., 2009). We should have exercises or training that continuously adjusts to the difficulty of user performance to maintain a pre-determined percent-correct rate. This is called an adaptive approach. All of you probably have done some computer-based training at one time or another. If the material is too easy or too difficult for you, you lose interest quickly. An adaptive model says that if I aced my training today because it was so easy, tomorrow the program automatically adjusts for me so it is going to be a little bit more challenging, I'm going to have to work a little harder and I'm going to have to work to get that pre-determined percent-correct rate.

Correct trials should be rewarded. They might gain points or an animation might pop up so that they get excited about doing it.  The exercises should have a stimulus that addresses a range of acoustics of interest.  It may be listening in noise or temporal processing, but it is going to be a range of skills, not just one skill that we are focused on.

The training component should over-exaggerate what we are targeting so that the person gets the idea of what they are listening for. We may have to make it salient to them, because listening to recorded stimuli on a CD is not always engaging. The goal is to drive plasticity and increase effectiveness of how the stimuli engage the listener. We want to exaggerate it for whatever that issue is in the real world. Say it is listening in noise. Gradually remove that exaggeration so that the listener doing the auditory training will gain an opportunity to apply those skills in the real world.

Most importantly, consistency is important. Some programs, like LACE, only allow so many days to complete the program, and if you do not complete it in that amount of time, it closes it down because that consistency is important. I tell families that it is like having a personal trainer.  You cannot expect to reach a fitness goal if you only exercise once a year.  It takes a certain amount of continued focus.  

Treatment

Treatment looks at how the brain can recognize our ability to do things better. Many adults are participating in Posit Science or Luminosity activities and enjoy what they are doing. They understand that they are seeing some changes in brain function.

Plasticity depends on activity and stimulation, and intervention must be initiated in a timely manner. We want to try to identify their problem and get working on it at a much younger age than we have been previously been doing. Treatment has to be organized and progressively challenging. We have to know that we are trying to build a better auditory system based on all of this.

What does not work? Doing nothing, pre-printed lists of recommendations, and suggesting “preferential seating” as a fix for APD or hearing loss do not work. Carol Flexer would suggest that you recommend strategic seating, which opens a dialogue for what that means for each individual in their environment or classroom. One of the frustrations that I have when working with kids with APD is hearing how often people talk about preferential seating as if it is a panacea. From an auditory perspective, there is no evidence that it changes the acoustic environment for the child (Leavitt & Flexer, 1991). There are wonderful side benefits to preferential seating. The logistical access to a teacher is phenomenal; the teacher can see the child raising their eyebrows and saying, “I do not really know what that is,” or, “I didn't really get that.” They get good visual access to the information and they are at the front of the classroom, but there are a couple of issues with this.

First, acoustically, it does not have much value. It is very limiting for a child in a typical classroom in this day and age. There is often not really a preferential seat in front of the classroom; that may not be how the classroom is setup. I think we need to get over this global recommendation. I know that it has good face validity and it is not expensive to do, but it really does not take advantage of any of the issues of plasticity that I just talked about. Further, there is not any real evidence to support it.

Acoustical Modifications

If you are going to modify something in a classroom, you must make a measurement for it. If it is not measured, it does not happen.  Tennis balls on the bottom of chairs are a lovely idea if chairs scuff the floors and are loud when they are moving, but we do not know that they have any acoustic benefit if we do not measure it. If we are going to invest our time in something, we should make sure there is evidence that the modification did make a change in the classroom.

Another issue I have is with the use of sound field FM in the classroom. I was in a classroom a couple weeks ago and they had a system perhaps from the 1960s.  I would wager that if we made measurements, we would find that it is not doing what they think it is doing.

The other thing that does not work is using an FM system as a panacea for all. Kids with APD do not always need an FM system. As I said earlier, who does not want to listen to an FM or a looping system?  The sound quality is great, and it helps you to relax and takes stress off of listening.  These are all reasons we would want these for kids with hearing loss or APD, but that is not the only solution or best solution for children with APD.

What does work? We have some limited evidence, but it is strong. This is true with a lot of things in communication disorders. I always feel like I have to defend the APD, but there are a lot of parallels with other areas of communication disorders.  I do not want us to think that just because there are not a trove of studies that we cannot do anything. If we can do the right things, that is what is important. We also can collect our own evidence and verify and validate what we are doing. We can use programs that have been developed based on supporting plasticity, also.

Linking Assessment to Management and Treatment

There are three approaches we can consider for our APD patients: compensatory strategies, improving the acoustic environment, and direct intervention. Management issues can either be person-centered or context-centered. We are either addressing management of the person and their skills or we are looking to change and manage the context, for example, room acoustics.

The two key factors for anybody with APD is to look at increasing the predictability and redundancy of the signal. This is certainly something we should be doing when trying to change the brain.  If the underlying assumption is that APD is a breakdown in the redundancy of the auditory system, anything we can do to build that is a positive influence. 

Customizing a Treatment Program

There are a number of recommendations that are offered, but the number of recommendations we offer is irrelevant. We focus on the ones that are effective. Try to customize the treatment program to the person's deficit area. We might look at listening in noise, dichotic listening or temporal processing.

Compensatory Strategies

The first thing we want to do is build a team. We want to look to our intervention specialists, speech-language pathologists, and teachers of the hearing impaired because they have the evidence to know how to identify children's strengths and weaknesses. They know how to encourage children to use visual cues.  They know about assisting children in both hard and easy listening situations. They know about teacher strategy development, which is hugely important, because it focuses on how teachers speak in classrooms.

There is a series of functional research called clear speech. It talks about what I can do as a speaker without an FM system and without worrying about classroom acoustics to enhance the ability of the listeners to understand what is being said. One study by Payton and colleagues (1994) identified that normal hearing listeners using clear speech can increase speech intelligibility by about 28% for someone with deficits, which is not insignificant.

Rephrasing and repeating are strategies we have used routinely. Repetition is good, but only if it is in an acoustically better presentation than the first time. Rephrasing is helpful also, as long as there is information that is added and if the original information was misunderstood because the child did not have the vocabulary to understand what was said.  Instead of getting annoyed and repeating, we will give them different vocabulary and sentence structure even so that it is the same, but different.

Auditory fatigue is something we should acknowledge.  This happens for kids, and the evidence is there. The two largest factors I see with regard to functional listening is auditory fatigue and stress related to auditioning. Parents of children with APD will report that their child comes home exhausted.  They struggle to keep up with the class. This is a critical issue.

Technology Tools

We have several technological management tools available to us.  Speech-to-text software has come a very long way.  The Livescribe pen is amazing (https://www.livescribe.com/en-us/smartpen/). It allows the reader to create verbal notes with their pen, which can then be put into a Word file.  It learns the voice of the person using it, so there is a bit of a training curve involved, but it is a great product. 

CPRINT is another that provides closed captioning in certain situations for older kids.  This may provide some information and may not be useful in every situation. One of the things I want to stress is that we do not want to substitute one fatigue for another.  If we are taking away auditory fatigue through reading, we do not want to overburden the child by focusing heavily on reading, either.  Guided notes and PowerPoints are tried-and-true methods for providing written information for learning, also.

So who is responsible? I see these items listed in IEPs, but I do not see who is going to be responsible to accomplish them.  I am not in favor of merely copying another student’s notes for the child with APD or hearing loss either, as we do not know the quality of those notes over time.  Some of these technology tools are definitely better options to support their auditory input in a different way.

Evidence-Based Environment

We know that listening in noise is difficult for almost every child, regardless of APD or hearing loss. Listening in complicated environments extends well into adolescence. Johnson (2000) indicated that the typical normal-hearing child needs about a +6 dB signal-to-noise ratio. She goes on to say that the high-risk listener needs about a +12 to +20 dB signal-to-noise ratio.  I suggest making some measurements to verify that.

There is evidence as to an acoustical standard. Reverberation should be less than 0.4 seconds. Background noise should 35 dB or less, and signal-to-noise ratio +10 dB or greater.

You may ask if there is value in having a sound study. I would say yes, but now you can do a lot of these things yourself. Ostergren and Smaldino (2012) have a great article on using smartphone apps to make room measurements.

Listening Technology Options

I have already mentioned that FM is not necessarily the primary or only recommendation we should make for APD; it will depend on the type of APD. One of the things I hear from school districts is a call for sound field FM, which is now called a classroom audio distribution (CAD) system. That is great for all the kids. If we look at what happens with the CAD systems, we may want to re-think that for a child with APD. They may not get a significant enough signal-to-noise ratio enhancement. Conversely, they may not need that if signal-to-noise ratio is not their issue. If we include something like the BKB-SIN test as part of the assessment, it helps us to get some verification of signal-to-noise ratio loss (SNR loss). One good article from AudiologyOnline (Ostergren, 2013) answers many questions about CAD systems.

Considerations with FM Technology

When considering FM technology, we should perform some sort of authentic assessment and specific observations. Unfortunately, teachers are not always aware what an FM system is designed to do or why we might use it. I like to use questionnaires.  The LIFE was revised in 2011 (LIFE-R) and is available for use from this website: https://lifer.successforkidswithhearingloss.com.

One area where we want to use caution is in recognizing that FM systems are transparent systems – they improve the signal-to-noise ratio but do not provide amplification per se.  The quality of sound is excellent. The ease of use is outstanding and now they can be fit more like a hearing aid, with a slim tube and a dome.  While they are easy for us to use, someone at school has to have the ability to change the dome, remove wax from the tubing and change batteries.

School personnel frequently tell us the system is not working.  Sometimes that is because they do not want to handle the system for fear of breaking parts; other times it can be because they do not like touching small pieces that have come into contact with ear wax.  While that may not bother us, it is unfamiliar to others outside of audiology. We have to talk about some of those issues upfront so they know what they are dealing with.

The option of the receiver may keep the child using the system longer into teenage years, and the option of some of the current transmitters may do that, too. The ear-level device is specifically designed for those that are have normal peripheral hearing.  Both Phonak and Oticon offer such a device and both are compatible with the other’s transmitter.

The Phonak Roger Focus can be paired with either the Roger Pen, which allows children to use it in a small group situation or as a teacher transmitter.  It does not have the same distance of transmission as a classroom transmitter would have (e.g. Roger Inspiro).  There is also a clip mic. These provide a lot of flexibility for kids with APD. It is easily transferrable and, from many children’s perspectives, it is more discreet, which may be something that matters to them as they get older.

The Oticon Amigo Star looks very similar to the Roger Focus.  A lot of teachers like the Amigo Star because it has a red indicator light that tells you when it is working. The T30 or T31 Amigo transmitter can be used for this device. Both Phonak and Oticon devices have ear-level volume controls if needed.

Hearing Aids

One thing to consider and something we have done quite often is to enhance the signal-to-noise ratio by using hearing aids. I have two teenage girls that I can credit for helping me see this one.  One was a girl who had a dodge ball accident.  We put an FM on her and she reported that it worked well in school, but it provided little benefit outside of school. She wanted something she could use wherever she was.  We reluctantly tried hearing aids on her, but that is what she wanted. Her mother told me that her daughter wanted the hearing aids after trying her grandmother’s for a weekend; she loved them so much, that she for them for her 16th birthday. 

Her first spring break home from college, she visited us and said being able to hear had made all the difference.  It is one of the reasons I bring this up.  If we are going to say that APD and hearing loss are on the same continuum, we cannot be afraid of hearing aids. For instance, Francis Kuk (2011) published data on using hearing aids on children with APD.  We are doing some of that research here in both younger and older adults.

I have not fit anybody under the age of 12 or 13, and we always get medical clearance from their physician. We do real-ear measures and extensive authentic assessment. We collect data for listening in noise, and we are very cautious to look at the real-ear measures from the aspect of a transparent system where we are providing very minimal gain.

A hearing aid does allow better options than an ear-level FM receiver like the Focus or Star.  We can run a hearing aid through a streaming device, which is very attractive to the teens who are using phones and music players.  These kids often report that they do not understand well on their cell phone or in other environments, so the Bluetooth capability Because of the fact that they do not hear well on their cellphone or they do not hear well in other environments, so it allows us to Bluetooth something for that to and go through the hearing aids and for them, that is often a life saver.

All technology requires training, and evidence shows that when people know what they are doing, the outcomes are better.  We have known that for years. The audiologist should be the one who leads this.  A lot of questions will come up from the schools.  Who provides batteries? Where do the domes from? How is the cord or tubing changed? What kinds of things should we watch for?

It is important for the success of this to make sure that people who are well trained and educated about the FM are available in the school district.  We need a few people to see the buy-in so that they can advocate with us.  I sat in on a meeting where one teacher said they were going to give up on the system because it was not working most all of the time.  We found out that it was two days without the use of the system because it was not put on the charger properly.  This, to some people, means that a system will not be successful.  We need this teacher to have some buy-in on the system and, obviously, better training.

Direct Therapeutic Approaches

Recent evidence supports the impact of training on neuroplasticity. Phillips (2002) points out that changes in the auditory cortex as a result of behavioral training are well documented in animal models.  It is just that we can do some things in lab animals that we cannot do to humans, but we are going to make the assumption that those changes are also happening in the plastic auditory system with children.

Thompson (2000) described how treatment or therapy can enhance what we call representational plasticity of the central auditory nervous system. That results in building new neuropathways post-treatment. That might be important if you have a lesion, but we do not know right now how important that might be in terms of development.

Auditory Training

Building new pathways could be a critical aspect, following a use-it-or-lose-it theory.  Some of the best evidence for change in auditory function comes from cochlear implants. All cochlear implant recipients are expected to do auditory training. We do not do that with people with hearing loss, and we certainly do not do that with people with APD. We have great information on cochlear implant outcomes with auditory training, so perhaps some of the assumptions we are making when it comes to pursuing it (or rather NOT pursuing it) with APD may be wrong.

We know that the improvements in communication behavior following implantation are influenced by the rate of plastic changes in the central nervous system pathway (Sharma, Dorman, & Kral, 2005).  In order to make this interesting and exciting, it has to be varied and challenging and developmentally appropriate.

Historically, many of the therapeutic approaches were pre-printed worksheets, and the kids thought that those were really boring. We have to set up a favorable listening and learning environment to make that plasticity develop, not just due to natural development, but rather because we helped it along.  Now we are designing auditory training programs based on this.

Specifics

Our training materials have to be adaptive. They have to be acoustically enhanced and evidence based. The older program Fast ForWord used those principles and was a foundational piece in these kinds of training programs.  Fast ForWord had great success with regard to temporal processing. Earobics was similar and is still available, often used for reading.

One well-documented program for adults that now we can apply to kids with APD is the LACE program (Listening and Communication Enhancement). This program takes advantage of those things related to plasticity and focuses on listening in background noise. I have had many kids and teens do this very cost effectively, even at home.  They find it very useful and say that they see differences in their own listening abilities.

LisN and Learn is another program that came out of Australia. It is attached to the LisN-S test, which is available from Phonak. LisN and Learn does a great job of looking at speech in noise and dichotic listening issues.  Its primary focus is temporal processing and localization to help listeners learn where sound is coming from.

Dichotic listening training helps to get the two ears working together. Both Frank Musiek and Deb Moncrief have programs that are available to look at that. That is a critical aspect of what we need to do.

Hear Builder is another program that incorporates phonological awareness, auditory memory, sequencing, and following directions. This has components of an evidence-based listening program, but it is more of a complement to APD than a program to target APD, although there is nothing wrong with that. It uses a top-down versus a bottom-up approach, so it may enhance some skills related to language processing.

One tool that is no longer on the market, but that I wanted to point, is a protocol called BioMARK, originally called BioMAP. It used to be available in the Biologic Navigator PRO family of equipment, but it has been discontinued.  It measured an electrophysiological response from the brainstem that mimicked characteristics of speech with remarkable fidelity. The BioMARK training program allowed people to become better at temporal processing. Even though this is not currently being used, it will be used again in the future, because all of this is new again, just within a different context.

Many people feel that if you cannot measure it, you cannot prove it. One of the benefits of measuring electrophysiologically is that it shows a change to the brain. It is a biomarker.  This looks at how we might change the brain and how we might prove that we did something, which would be better than the criticisms of some of the early auditory training programs.

Empirical Question of the Effectiveness of APD Programs

All learning involves plastic changes in the brain, thus newer training strategies are not unique that way. What may makes them “special” is the effectiveness of what they can do to target the impaired process. That links us as individual listeners, but my prediction is that we are going to see some changes in that when we look at electrophysiology.

Summary

There is significant evidence for plasticity in children, and that plasticity benefits those APD children significantly; we just have to figure out how to consistently do it better.

We need to keep questioning how we create a new future for children with APD. How do we create better assessment protocols and better treatment protocols? As technology changes, we have to think outside the box and use that technology to support and enhance auditory development.

APD is on the same continuum as hearing loss. It is a low-incidence population, and there is no reason why we should not be exploring some of the technologies that are already available. Predictability and redundancy are important, as are technology and programs based on development and plasticity. While there are a small number of assessment and management tools currently on the market, it is growing.  We have to demand it, and we are no longer recommending things that we can measure at the exclusion of things that work. Preferential seating is not what we should be using over technology.

Think about trying things you originally would have dismissed, like hearing aids. Think about pushing for new electrophysiology measures.  A growing knowledge of plasticity allows us to grow our programs to align with the child's weaknesses or deficit areas to support area that might make some brain changes. Additional references have been provided for you as a resource.

References

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