Interview with James Jerger Ph.D., Distinguished Scholar in Residence
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AO/Beck: Good morning Dr. Jerger. Thank you for taking the time to speak with me this morning.
Jerger: You're welcome Doug. Thanks for the invitation.
AO/Beck: It goes without saying that you are a pioneer, a founding father of our profession, an amazingly productive scientist, a mentor and you've been instrumental in developing the profession and many of our clinical protocols. Nonetheless, perhaps we can start with a brief thumbnail sketch of the early days? Would you please tell me about your doctoral program?
Jerger: Well, that's going back a ways! I earned my doctorate in 1954 from Northwestern University. My mentor was the renowned Dr. Raymond Carhart. My dissertation was a study of intensity discrimination in persons with sensorineural hearing loss, using the quantal psychophysical method. Dr.Carhart was one of the experimental subjects. He had a high-frequency loss from aspirin. After I received my doctorate, I stayed on at Northwestern for another seven years. I left Northwestern in 1961 and moved to Washington, D.C.. I went to work at Gallaudet College and also worked for the Veterans Administration in DC.
AO/Beck: Dr. Jerger, I probably should know this, but I don't. What was Dr. Carhart's doctorate in?
Jerger: He got his degree around 1936 in speech science. His dissertation involved a mechanical model of the larynx. When Dr. Carhart was in the US Army, during WWII, they asked him to head the aural rehabilitation program at the Deshon Army Hospital in Butler, Pennsylvania, and that's where he got really interested in hearing aids, auditory training, various aspects of hearing and hearing loss and related matters. After that, he headed the audiology program at Northwestern until his death early in the 1970s. I had the good fortune to be one of his students.
AO/Beck: Thanks for the clarification. Let's continue with your story. How long were you at Gallaudet and the VA?
Jerger: I was there for about a year and a half and then I moved to Houston. In Houston I was the Director of Research at the old Houston Speech and Hearing Center. At that time, that Speech and Hearing Center was the largest autonomous Speech and Hearing Center in the country. I stayed there for 6 years. In 1968, I joined the faculty of the Baylor College of Medicine and I was there for the next 29 years. While I was at Baylor I ran the speech pathology and audiology services for The Methodist Hospital, which is one of the teaching hospitals for Baylor. In 1997, my wife and I moved to the University of Texas at Dallas.
AO/Beck: Are you currently teaching full-time?
Jerger: Currently I teach one seminar in audiology for the Au.D. program, which is administered by the Callier Center of UTD.
AO/Beck: Dr Jerger, this is a totally tacky question -- but in keeping with my reputation, I'll ask it anyway! How many books and articles have you published?
Jerger: Let's see, I believe I have 298 publications in all, and I've done 7 books.
AO/Beck: That is amazing. Please tell me, after all this time, what are your primary areas of interest within the profession?
Jerger:My primary interest currently is in improving the diagnosis of Auditory Processing Disorders (APDs). I am very interested in children with normal audiograms, no evidence of any auditory abnormality, but who have difficulty listening. Often these kids are referred in by the mom or the teacher because the child is not paying attention, or perhaps cannot follow directions in class, or the child doesn't seem to be entirely in the same time and space as his or her peers.
AO/Beck: I agree, those children are very interesting, and they are everywhere! I think many of the children you just described probably end up diagnosed as Attention Deficit Disorder (ADD), or perhaps Attention Deficit Hyperactivity Disorder (ADHD) or a similar diagnosis. Nonetheless, where are we and where should we be going with regard to APD?
Jerger:At the moment, we're not in very good shape regarding APD because much of the literature and research on APD comes from behavioral tests. The problem is that the child's performance on behavioral tests is subject to many non-auditory influences.
There is a chance that perhaps we are overdiagnosing APD in kids who perform poorly for other non-auditory reasons.
AO/Beck: Am I correct that your concern is essentially that we don't have objective data based on control versus experimental models for APD diagnosis and treatment?
Jerger: Yes, of course, that really is the heart of the issue and it causes me great concern.
AO/Beck: How do we overcome this problem?
Jerger: First, it requires a great deal of money! Then after we secure a funding source, we really need to initiate double blind studies with random assignment. But before we can do that, we need better measures of auditory-specific perceptual deficits. Currently, in our laboratory at UTD/Callier we are working on electrophysiological tests, such as event-related potentials in dichotic listening modes, and temporal gap detection paradigms, and other related phenomena, to see if we can define more objective measures of APD.
AO/Beck: I know this question has no hard and fast answer. Nonetheless, based on your best guess, how long will it be until we have better APD tests available?
Jerger: I've been telling people that it'll probably be three more years. Here at UTD we have opened a new laboratory specifically focused on these issues. We call it the Texas Auditory Processing Disorder Laboratory (web site: www.texasapd.org). We are trying to get at what are the actual brain mechanisms underlying the disorder, and we'd like to develop an electrophysiological test battery that will lead to more definitive diagnosis.
AO/Beck: And then, after the test is developed, then we might be ready to initiate the control versus experimental studies that we spoke about earlier?
Jerger: Yes, that's the most apparent route, and it makes sense.
AO/Beck: In the meantime, does it make sense to run children and adults through APD test batteries and aural rehabilitation protocols? I guess I'm asking -- is there any point in measuring auditory processing disorders if we're not sure we can positively impact the natural course of events?
Jerger: Yes, there is a point. And I'm glad you asked that because it's an important point. There certainly are intervention strategies that do work....But even if there weren't, it is extremely important for the parent of that child to know what's going on. If you're the parent, and it's your child having the difficulty, you want to know, and you need to know what's wrong. It is so important for the parent to know that the child is not dyslexic, or retarded, or hyperactive or whatever. And it is equally important for the parent to know if the problem is not APD. So yes, even if we could not provide effective intervention, the diagnostic process would still have value.
AO/Beck: Based on what you're saying, I wonder if we can draw the analogy that if you had a particularly horrible medical disease, and even if there was no cure or viable treatment, there is probably some solace in knowing the diagnosis?
Jerger: It is more than solace. The parent needs to know what is really wrong before intervention can be effective. Assistive Listening Devices (ALDs) have, indeed, been shown to be quite useful to these children, and of course there are many products and services and intervention techniques being studied, and many other avenues that remain to be pursued. So yes, identifying them as best we can is important for a number of reasons.
AO/Beck: Another issue I'd like to get your feedback on is the issue of specific therapy courses for specific APD issues. In other words, is it important to take each child (or adult) and their particular test results, and build a therapy program unique to that individual, based on their particular needs, or is it likely that a well founded, well rounded generic APD therapy approach might yield the same clinical outcomes?
Jerger: That too, is an important question. It opens up the issue of ... Are there really different types of APD? And if so, can we actually measure them and define them? The answer is that we don't really know just yet. It's an important issue that can only be resolved by some serious research efforts.
AO/Beck: Dr. Jerger, before I let you go, I wonder if you would address the issue of binaural interference with respect to fitting all bilateral hearing loss patients with binaural amplification? I recall you had a paper or two on this a few years back and I wonder if that work has progressed?
Jerger: Yes. The issue is that although most of the time it makes sense and is beneficial to fit bilateral hearing loss with binaural hearing aids, there are some patients for whom binaural interference may be an issue. In other words, for some of these identified older patients, we can observe that the interhemispheric transfer of information is problematic. Information doesn't cross from the left to the right, and the right to the left side as it should in a normal, healthy brain. It seems that the problem occurs at the level of the corpus callosum, and basically the information entering the left ear becomes an interference and detracts from the information entering the right ear. As I speak with more people across the country, I get more and more reports from professionals who have seen this in some of their patients too.
AO/Beck: And when you speak about observing this phenomena, I believe you are speaking about topographic brain mapping - is that correct?
Jerger: Yes, that's correct. These things can be detected by event related potentials, and we're still actively investigating these potentials as a tool in the identification of patients for whom binaural interference may be an issue.
AO/Beck: Dr. Jerger, it's always a pleasure to speak with you. Thanks for your outstanding contributions to the profession, and thanks for your time this morning.
Jerger: Thanks Doug. I appreciate the opportunity to address the Audiology Online audience. Best regards to you too.
Jerger: You're welcome Doug. Thanks for the invitation.
AO/Beck: It goes without saying that you are a pioneer, a founding father of our profession, an amazingly productive scientist, a mentor and you've been instrumental in developing the profession and many of our clinical protocols. Nonetheless, perhaps we can start with a brief thumbnail sketch of the early days? Would you please tell me about your doctoral program?
Jerger: Well, that's going back a ways! I earned my doctorate in 1954 from Northwestern University. My mentor was the renowned Dr. Raymond Carhart. My dissertation was a study of intensity discrimination in persons with sensorineural hearing loss, using the quantal psychophysical method. Dr.Carhart was one of the experimental subjects. He had a high-frequency loss from aspirin. After I received my doctorate, I stayed on at Northwestern for another seven years. I left Northwestern in 1961 and moved to Washington, D.C.. I went to work at Gallaudet College and also worked for the Veterans Administration in DC.
AO/Beck: Dr. Jerger, I probably should know this, but I don't. What was Dr. Carhart's doctorate in?
Jerger: He got his degree around 1936 in speech science. His dissertation involved a mechanical model of the larynx. When Dr. Carhart was in the US Army, during WWII, they asked him to head the aural rehabilitation program at the Deshon Army Hospital in Butler, Pennsylvania, and that's where he got really interested in hearing aids, auditory training, various aspects of hearing and hearing loss and related matters. After that, he headed the audiology program at Northwestern until his death early in the 1970s. I had the good fortune to be one of his students.
AO/Beck: Thanks for the clarification. Let's continue with your story. How long were you at Gallaudet and the VA?
Jerger: I was there for about a year and a half and then I moved to Houston. In Houston I was the Director of Research at the old Houston Speech and Hearing Center. At that time, that Speech and Hearing Center was the largest autonomous Speech and Hearing Center in the country. I stayed there for 6 years. In 1968, I joined the faculty of the Baylor College of Medicine and I was there for the next 29 years. While I was at Baylor I ran the speech pathology and audiology services for The Methodist Hospital, which is one of the teaching hospitals for Baylor. In 1997, my wife and I moved to the University of Texas at Dallas.
AO/Beck: Are you currently teaching full-time?
Jerger: Currently I teach one seminar in audiology for the Au.D. program, which is administered by the Callier Center of UTD.
AO/Beck: Dr Jerger, this is a totally tacky question -- but in keeping with my reputation, I'll ask it anyway! How many books and articles have you published?
Jerger: Let's see, I believe I have 298 publications in all, and I've done 7 books.
AO/Beck: That is amazing. Please tell me, after all this time, what are your primary areas of interest within the profession?
Jerger:My primary interest currently is in improving the diagnosis of Auditory Processing Disorders (APDs). I am very interested in children with normal audiograms, no evidence of any auditory abnormality, but who have difficulty listening. Often these kids are referred in by the mom or the teacher because the child is not paying attention, or perhaps cannot follow directions in class, or the child doesn't seem to be entirely in the same time and space as his or her peers.
AO/Beck: I agree, those children are very interesting, and they are everywhere! I think many of the children you just described probably end up diagnosed as Attention Deficit Disorder (ADD), or perhaps Attention Deficit Hyperactivity Disorder (ADHD) or a similar diagnosis. Nonetheless, where are we and where should we be going with regard to APD?
Jerger:At the moment, we're not in very good shape regarding APD because much of the literature and research on APD comes from behavioral tests. The problem is that the child's performance on behavioral tests is subject to many non-auditory influences.
There is a chance that perhaps we are overdiagnosing APD in kids who perform poorly for other non-auditory reasons.
AO/Beck: Am I correct that your concern is essentially that we don't have objective data based on control versus experimental models for APD diagnosis and treatment?
Jerger: Yes, of course, that really is the heart of the issue and it causes me great concern.
AO/Beck: How do we overcome this problem?
Jerger: First, it requires a great deal of money! Then after we secure a funding source, we really need to initiate double blind studies with random assignment. But before we can do that, we need better measures of auditory-specific perceptual deficits. Currently, in our laboratory at UTD/Callier we are working on electrophysiological tests, such as event-related potentials in dichotic listening modes, and temporal gap detection paradigms, and other related phenomena, to see if we can define more objective measures of APD.
AO/Beck: I know this question has no hard and fast answer. Nonetheless, based on your best guess, how long will it be until we have better APD tests available?
Jerger: I've been telling people that it'll probably be three more years. Here at UTD we have opened a new laboratory specifically focused on these issues. We call it the Texas Auditory Processing Disorder Laboratory (web site: www.texasapd.org). We are trying to get at what are the actual brain mechanisms underlying the disorder, and we'd like to develop an electrophysiological test battery that will lead to more definitive diagnosis.
AO/Beck: And then, after the test is developed, then we might be ready to initiate the control versus experimental studies that we spoke about earlier?
Jerger: Yes, that's the most apparent route, and it makes sense.
AO/Beck: In the meantime, does it make sense to run children and adults through APD test batteries and aural rehabilitation protocols? I guess I'm asking -- is there any point in measuring auditory processing disorders if we're not sure we can positively impact the natural course of events?
Jerger: Yes, there is a point. And I'm glad you asked that because it's an important point. There certainly are intervention strategies that do work....But even if there weren't, it is extremely important for the parent of that child to know what's going on. If you're the parent, and it's your child having the difficulty, you want to know, and you need to know what's wrong. It is so important for the parent to know that the child is not dyslexic, or retarded, or hyperactive or whatever. And it is equally important for the parent to know if the problem is not APD. So yes, even if we could not provide effective intervention, the diagnostic process would still have value.
AO/Beck: Based on what you're saying, I wonder if we can draw the analogy that if you had a particularly horrible medical disease, and even if there was no cure or viable treatment, there is probably some solace in knowing the diagnosis?
Jerger: It is more than solace. The parent needs to know what is really wrong before intervention can be effective. Assistive Listening Devices (ALDs) have, indeed, been shown to be quite useful to these children, and of course there are many products and services and intervention techniques being studied, and many other avenues that remain to be pursued. So yes, identifying them as best we can is important for a number of reasons.
AO/Beck: Another issue I'd like to get your feedback on is the issue of specific therapy courses for specific APD issues. In other words, is it important to take each child (or adult) and their particular test results, and build a therapy program unique to that individual, based on their particular needs, or is it likely that a well founded, well rounded generic APD therapy approach might yield the same clinical outcomes?
Jerger: That too, is an important question. It opens up the issue of ... Are there really different types of APD? And if so, can we actually measure them and define them? The answer is that we don't really know just yet. It's an important issue that can only be resolved by some serious research efforts.
AO/Beck: Dr. Jerger, before I let you go, I wonder if you would address the issue of binaural interference with respect to fitting all bilateral hearing loss patients with binaural amplification? I recall you had a paper or two on this a few years back and I wonder if that work has progressed?
Jerger: Yes. The issue is that although most of the time it makes sense and is beneficial to fit bilateral hearing loss with binaural hearing aids, there are some patients for whom binaural interference may be an issue. In other words, for some of these identified older patients, we can observe that the interhemispheric transfer of information is problematic. Information doesn't cross from the left to the right, and the right to the left side as it should in a normal, healthy brain. It seems that the problem occurs at the level of the corpus callosum, and basically the information entering the left ear becomes an interference and detracts from the information entering the right ear. As I speak with more people across the country, I get more and more reports from professionals who have seen this in some of their patients too.
AO/Beck: And when you speak about observing this phenomena, I believe you are speaking about topographic brain mapping - is that correct?
Jerger: Yes, that's correct. These things can be detected by event related potentials, and we're still actively investigating these potentials as a tool in the identification of patients for whom binaural interference may be an issue.
AO/Beck: Dr. Jerger, it's always a pleasure to speak with you. Thanks for your outstanding contributions to the profession, and thanks for your time this morning.
Jerger: Thanks Doug. I appreciate the opportunity to address the Audiology Online audience. Best regards to you too.
James Jerger, PhD
Distinguished Scholar in Residence