The document discusses auditory processing disorders and central auditory processing. It describes the continuum of auditory processing from detecting sounds to organizing responses. It outlines different levels of central auditory processing including brainstem, temporal lobe, and executive functions. The document discusses different types of central auditory processing deficits including auditory decoding deficits, integration deficits, and prosodic deficits. It provides examples of tests used to assess central auditory processing skills and outlines approaches to differential diagnosis and intervention.

1. A rose by any other name… understanding
auditory processing disorders
Jeanane M. Ferre, PhD
Audiologist, CCC-A
Oak Park, IL
708.848.4363
Email: jmfphd@comcast.net
www.dr-ferre.com

3. Continuum of Processing
• Detect, analyze,
& synthesize
Acoustic processing
What we HEAR
• Attach meaning
& integrate
with other
information
Phonologic/linguistic
processing
What we KNOW • Organize,
execute a
response,
maintain focus
Linguistic /cognitive
processing
What we DO

4. Executive
functions
Language &
learning
Sensory processing

5. • Hearing sensitivity and reflex action
–Signal collection – outer ear
–Signal transmission – middle ear
–Signal detection – inner ear
–Signal transformation – 8th nerve

6. Central auditory processing
• neural processing of auditory/acoustic stimuli
– Auditory discrimination
– Temporal processing
– Binaural processing
• deficiency in skills subserved by CENTRAL
auditory mechanism in brainstem/brain =
CAPD

7. Brainstem level Central Auditory Functions
• Binaural interaction – how the two EARS
work together
– “additive” functions – provide a more robust
signal for higher centers
– “difference” functions – help with localization
and hearing in noise
• Acoustic feature extraction: timing and
frequency cues
– Assists in signal perception
– Different cells respond differently

8. • Auditory discrimination – ability to analyze
fine acoustic differences in signal spectra
• Occurs through the thalamic level AND
primary auditory cortex (Heschl’s gyrus)
• Perception of ACOUSTIC signal

9. • Dichotic listening – interaction between the
two HEMISPHERES
• Reflects integrity of the left hemisphere, right
hemisphere, and corpus callosum
–Binaural integration: process all
information presented to the two ears
–Binaural separation: “hear” what’s in both
ears BUT ignore one target or the other

10. • Temporal processing – ability to use timing
aspects of signal
–Temporal resolution- a left hemisphere skill
involving ability to perceive “1” versus “2”
targets
–Temporal patterning – a right hemisphere skill
involving ability to perceive order/sequence
• BOTH skills important for perception of
running speech

11. Impact of deficits in specific CAP skills
• CAPDs adversely academics, communication, and
psychosocial wellness
– Reading, writing, spelling, math
– Development of speech-language skills
– Sense of self
– Daily listening skills
• CAPDs can co-exist with, share symptoms of,
exacerbate and be exacerbated by other disorders

12. • Attention Deficit Disorder
– distractible, inattentive, disorganization
• Executive Function Difficulties
– poor working memory, strategy development
• Behavior Disorders
– opposition, perseveration, noncompliance
• Asperger’s Syndrome
– poor social language, impaired affect
• Nonverbal Learning Disability
– impaired prosody, use of nonverbal cues
• Speech-Language Impairment
– poor phonological awareness, pragmatic language
CAPDs can look like/exist with …

13. Differential Diagnosis Needed
• Differentiates among disorders having similar
symptoms/manifestations
• Audiologists examine specific CA processes
• SLPs examine phonetic-phonemic, linguistic,
memory, and related skills
• Psychologists/others probe listening and related
skills
• Patterns across tests identify DEFICIT-specific
processing disorders
• Results lead to DEFICIT-specific intervention

14. Differential Intervention
◦ Balance of treatment & management based on
neuroscience & derived from assessment
◦ Customized treatment and management plans to
treat skills & minimize impact on listener’s life
Neuroscience foundations
management
treatment

15. Central Auditory Processing Language Processing
Transition Area
Phonemic Processing
audiologist speech-language pathologist
audiologist and speech-language pathologist
Acoustic Linguistic

16. • Screens processing continuum
• 8 subtests delivered via CD
• 3 auditory processing
• 2 phonemic/phonic
• 3 language
• Identifies where to refer and/or spend more
time in assessment
• Available from www.proedinc.com

17. Diagnostic CAPD Testing Battery
• What?
–Battery of tests to determine how
efficiently CANS operates
• How?
–Overloading or overworking it
• Who?
–Children as young as 6 years
–Results compared to age-matched peers
Performance profiles yield insights into
nature of CAPD

18. CAPD Test Assessment
• Minimize influence of language, cognition & other
sensory skills on performance
• Results examined re:
–central auditory processes being taxed
–Auditory discrimination, binaural processing,
temporal processing
–anatomical sites subserving those skills
–Brainstem, right/left hemispheres, corpus
callosum

19. Considerations for testing
• Hearing sensitivity
• Sufficient expressive speech skills
• Sufficient receptive language skills
• Intelligence test results

20. brainstem,
primary auditory
cortex
Binaural fusion
Masking level difference
LISN
Low-pass filtered speech
Time-compressed speech
Underlying Site
Processes Assessed
Test Type
signal transmission
Tympanogram
Acoustic reflexes
OAEs
hearing sensitivity
acuity
Puretone air & bone
conduction
Speech thresholds
Word recognition
peripheral/central
auditory closure,
discrimination
peripheral
mechanism
interaction btw ears
localization
brainstem

21. RH, LH, CC
Temporal patterning
Temporal resolution
Pitch patterns test
Duration patterns test
Random gap detection
Gaps in noise
Speech-in-noise tests varied
varied
Underlying Site
Processes Assessed
Test Type
LH, RH, CC
Binaural separation
Competing Sentences
LH, RH, CC
Binaural integration,
closure
ordering
Dichotic digits
Dichotic Rhyme
Staggered Spondaic Words
Dichotic Sentence
Identification

22. Test Interpretation
• NOT CAPD
–Below normal single test
–Below normal on all tests
–Contradictory findings
• Evidence of CAPD
–Poor scores on sets of tests taxing similar skills
–Bellis/Ferre model describes 5 test profiles
–Three primary
–Two secondary

23. Primary CAPD
types
Auditory decoding
Deficit
LH
Integration
Deficit
CC
Prosodic deficit
RH

24. Interpretation
• Primary CAPDs
–Decoding deficit – LH
–Integration deficit - CC
–Prosodic deficit – RH
–Represent true Central AUDITORY
processing issues

25. Auditory decoding deficit
• Poor discrimination of fine acoustic
differences in signal
–Probable site: primary auditory cortex
–Signal distortion – poor neural
representation
–Exhibit impaired discrimination, closure, &
temporal resolution
–Poor scores on low redundancy tests, gap
detection, and (possibly) binaural
integration
–Behaviorally: they can’t “hear”

26. Integration Deficit
• Deficit in performing tasks requiring
interhemispheric communication
–Probable site: corpus callosum
–Insufficient development of corpus
callosum
–Poor integration skills
–Excessive LE suppression on dichotic tasks
AND poor labelling with good mimicking of
patterns
–“it’s too much” – not synthesizing inputs

27. Prosodic deficit
• Deficiency in use of prosodic (timing)
features of target
–Probable site: right hemisphere
–Inefficient RH pattern recognition
–Trouble with acoustic contours
–Exhibits poor temporal patterning
–Poor scores both labelled AND mimicked
on patterning tasks AND excessive LE
suppression on dichotic tasks
–Behaviorally: it’s all “blah, blah, blah”

28. Interpretation
• Secondary test patterns
–Associative deficit
• Likely reflects impaired language
processing
–Output-organization deficit
• Likely reflects cognitive/executive
function issues

29. Associative deficit
• NOT applying rules of language to acoustic signal
• May be due to poor communication between
primary and secondary (association) cortices
• Poor scores for both ears on dichotic tests, good
labelling/mimicking, adequate discrimination
• Poor “translators”, “I don’t get it”
• Issues manipulating multiple targets

30. Output-organization deficit
• Deficient ability to organize, sequence, plan
appropriate response
• May be due to deficient efferent, motor
planning, or executive function
• Exhibit difficulty with expression/execution
• Poor scores multiple target tasks, in noise,
sequencing errors
• Can’t get it back out

31. Processing
Level
Anatomic
location
Processing
skills
Assessment
examples
Acoustic Outer, middle, inner
ear; 8th nerve;
brainstem, Heschl’s
gyrus, RH, CC
Auditory Acuity;
Neurologic transfer;
Discrim/Integration of
acoustic cues
Pure tone hearing, word
recognition, patterning,
binaural recognition,
degraded speech
Phonologic Heschl’s gyrus,
temporal lobe
Discrim/recognition of
phonemic aspects of
signal
Word segmentation
Rhyming
Phoneme blending
Auditory closure
Linguistic Temporal Lobe –
Wernicke’s area and
angular gyrus
Discrim/recognition of
linguistic aspects of
signal; attach meaning
using code
Identifying objects
Identifying concepts
Semantics (synonym,
antonym, homonym)
Executive
functions
Prefrontal/Frontal
lobes; Motor Strip
Planning and executing
response
Pragmatic language
Problem solving/
reasoning
Prosodic Interpretation

32. Differential Intervention
◦ Balance of treatment & management based on
neuroscience & derived from assessment
◦ Customized treatment and management plans to
treat skills & minimize impact on listener’s life
Neuroscience foundations
management
treatment

33. Management Remediation
Modification of the
communicative
environment
Use of compensatory
strategies
Minimizes adverse
effect of disorder of
client’s life
Formal and informal
therapy to develop
deficient skills AND
Teach compensatory
strategies
Designed to reduce
or resolve deficit

34. • Bottom-up - stimulus driven
–Therapy: adaptive/repetitive skills
training
–Management: focus on access to signal
• Top-down - concept driven
–Therapy: use of cognitive/linguistic
strategies
–Management: focus on accommodations
& communication

35. message
medium
me
Communication

36. Intervention Tripod
Direct Remediation-
focus on listener
Compensatory Strategies –
focus on message
Environmental Modifications –
focus on environment

37. Focus on the environment
• Noise & reverberation
• Distance & lighting
• Direct Signal enhancement via ALD
• Educational accommodations

38. Noise & reverberation
• Listener’s ability to function in background
noise depends upon
– Type of noise
– Loudness of noise relative to target (signal-noise
ratio- SNR)
– Location of noise relative to target
– Task demands
• Reverberation (echo)
– Measured in reverberation time (RT)

39. Noise & reverberation
• ASHA recommends classroom SNR should exceed
+15dB with RT of <0.4 seconds
• Noise abatement
– Increase absorptive material
– Use baffles, damp reflective surfaces
– Eliminate open classrooms
– Floor plan changes
– Infrastructure changes
– Earplug/earphone use
– Noise abatement using “masking”

40. Distance & Lighting
• Sound intensity decreases with increasing distance
from source
• Sound may be direct or reverberant
– Direct reaches listener without obstruction
– Reverberant composed of reflected waves
• As distance increases from source, amount of
reverberant sound increases

41. Distance & Lighting
• Lighting can affect use of visual cues and
ability to maintain focus
• Optimal speaker-listener distance = 3-6 ft
• Optimizing distance/lighting
– Change lighting
– Avoid being backlit
– Use preferential seating to maximize auditory and
visual cues

42. Direct signal enhancement via ALDs
• Improves SNR reaching listener’s ear
–Personal wearable – FM, digital, PSAPs
–Soundfield systems
–Personal soundfield systems
• Can improve attention to, discrimination of, and
memory for signals
• NOT an option for all students

43. Other environmental considerations
• Change location for tests, studying
• Use of study/work carrels
• Consult with OT regarding type of seating and
sensory diet needs

44. Focus on the message
• Clear Speech
• Visual cues
• Clear Language
• Educational accommodations

45. Speed of processing
• 3-5 yr.-olds process speech at 120-124wpm
• 5-7 yr.-olds can handle 128-130 wpm
• 5-6th graders can process speech at 135 wpm
• Middle school-high school – 135-140 wpm
• Average wpm of most adults is 160-180 wpm and
may reach 190 wpm
• Check your rate – use Clear Speech

46. Clear Speech
• Clear Speech improves perception/recognition
(Picheny, M., Durlach, N., & Braida, L. 1985)
• Speaking at slightly slower rate, including strategic use of
pausing and slightly increased loudness
• Simple repetition with Clear Speech ensures perception
for most listeners

47. Visual cues
• Couple clear speech with AV presentation
–Model look and listen
• Not all listeners can look and listen
–Use look or listen
• Add complementary visual cues
–Show me
• For teachers and parents
–Look then listen

48. Clear Language
• Improves comprehension
• Say what you mean and mean what you say
• Rephrase
• Minimize generic/ambiguous language
• Add “tag” words
• Consider overall amount of information
• Break instructions down
• Allow “waiting” and “thinking” time
• Verbal cueing
• Preteaching

49. Educational accommodations
• Extended time/Untimed tests
• Test reader
• Adjusting homework loads
• Using technology- “smart pens”, notetaking apps
• Changes in curriculum

50. Intervention Tripod
Direct Remediation-
focus on listener
Compensatory Strategies –
focus on message
Environmental Modifications –
focus on environment

51. Direct Remediation for PDs
• Remediation based on research in neural plasticity.
– Plasticity is brain’s ability to organize/reorganize in
response to internal/external changes.
• When choosing treatment program, consider
– Reported efficacy for specific populations – Does it
work?
– Program’s neuroscientific foundations – Should it
work?
– Appropriateness for deficit identified – Does it fit?

52. CAP Skills revisited
• Binaural processing
– Binaural interaction
– Binaural integration/separation
• Auditory discrimination
– Frequency analysis
– timing analysis
• Temporal processing
– Resolution (discrimination)
– Patterning (ordering)

53. Auditory Discrimination deficit
• Characterized by poor analysis of fine acoustic
differences in speech spectra
• Management focuses on improving access to,
clarity, and use of auditory signal
• Treatment focuses on improving perceptual
skills

54. Auditory discrimination deficit
• Impacts
– Phonological
awareness
– Spelling
– Listening stamina
– Direction following
– Comprehension
– Language skills
• Treatment needs
– Discrimination &
closure
– Phonemic awareness
– Recognition in noise
– Use of visual cues
– Listening
comprehension

55. Discrimination (auditory decoding) deficit
• Improving access
– Preferential seating
near/facing speaker
– Need noise abatement
– Use Clear Speech
– Repeat information
– ALD trial
• Accommodations
– ASL - 2nd language
– Preteaching
– Adjust class schedule to
minimize auditory
overload
– Explicit multisensory
environment
– Verbal info
supplemented with
written/graphic cues

56. Binaural processing – brainstem level
• Impacts
–Listening in noise
–Processing speed
–Localization
• Treatment needs
–Localization
–Training
temporal/spatial
recognition
–Recognition of
speech in noise

57. Binaural processing – brainstem level
• Improving access
– Preferential seating
– Noise abatement
– Use Clear Speech
– Repeat information
• Accommodations
– Minimize auditory
overload
– Explicit multisensory
environment
– Verbal info
supplemented with
visuals

58. Binaural processing – cortical level
• Impacts
– Verbal
comprehension
– Spelling
– Processing speed
– Direction following
– Task completion
– Note-taking
– Working memory
• Treatment needs
– Dichotic listening
– Interhemispheric
communication
– Synthesis of multiple
auditory targets
– Manipulation of
auditory & non-
auditory signals

59. Binaural processing deficit –
interhemispheric integration type
• Characterized by poor synthesis and
manipulation of multiple signals
• Management focuses on improving the
quantity and structure of incoming signals
• Treatment focuses on improving
interhemispheric communication

60. Integration deficit
• Improving Access
– Look OR listen
– Look THEN listen
– Repeat with cue or
demonstration
– DON’T rephrase
– Limit amount of
information given
– Present information
sequentially
– Use notetaker or
recorder
• Accommodations
– Extended time
– Write in test book not
computer score sheet
– Audiobooks, study guides,
Cliff’s Notes
– Music while studying
– “Wait/thinking” time
– Different room for tests
– Computer technology
– Movement breaks
– Explicit multisensory learning
needs
– Provide structure

61. Binaural processing deficit –
intrahemispheric type
• Characterized by difficulty applying linguistic rules to
incoming information (auditory-language Association
deficit)
• Auditory tests reflect impact of language processing
disorder
• Management focuses on improved linguistic quality
of target and use of linguistic rules
• Treatment focuses on applying rules of language

62. Associative deficit
• Improving Access
– Use Clear Language
– Speak the “same”
language
– Formatting
– Say what you mean-
mean what you say
• Accommodations
– Give parameters
– Waive language req.
– Use non language-biased
IQ instruments
– Audiobooks, study guides,
Cliff’s Notes
– RULE-based learning

63. Intrahemispheric integration –
associative deficit
• Impacts
– Verbal
comprehension
– Spelling
– Processing speed
– Direction following
– Task completion
– Note-taking
– Working memory
• Treatment needs
– Manipulation of
auditory & non-
auditory signals
– Applying phonetic
and linguistic rules
– Visualizing
information
– Listening
comprehension

64. Temporal processing deficit (prosodic)
• Characterized by difficulty analyzing,
synthesizing, and attaching meaning to rapidly
changing acoustic patterns
• Management focuses on improving quality
and structure of incoming signal
• Treatment focuses on using temporal cues,
e.g., patterning, temporal resolution

65. Temporal processing
• Impacts
– Comprehension –
reading/listening
– Working memory
– Processing speed
– Social/pragmatic
language
– Direction-following
– Reading fluency
• Treatment needs
– Pattern recognition
– Use of prosody
– Listening
comprehension
– Use of visual cues
– Working memory
– Sequencing

66. Prosodic deficit
• Improving access
– Repeat with
emphasis on key
words
– Clear Speech
– Preferential seating
– Consider ALD
– Noise abatement
– Seating
• Accommodations
– Explicit multisensory
environment
– “Animated” teacher
– Previewing
– Notetaker, recorder
– Extended time
– Clear Language
– Provide structure
– Give parameters

67. Ordering-sequencing issues
• Characterized by difficulty organizing,
sequencing, and executing a response
(output-organization deficit)
• Management focuses on adjusting quantity
and structure and teaching organization rules
• Treatment focuses on executing response/
expressive skills

68. Output-organization deficit
• Improving Access
– Consider ALD if
difficulty in noise
– Minimize
distractions
– Notetaker, recorder
– Limit amount of
information given
– Break tasks down
• Accommodations
– Preteach rules
– Outlines/checklists
– Closed-set tests
– Oral responses on
written tests
– Keyboarding/word
processing
– Extended time
– Answers written in
test booklet-not score
sheet

69. Level System Task Management Treatment examples
Acoustic
(AUD)
Receiving the
signal/intact
transmission –
I “hear it”
Focus on quality
of ACOUSTIC
signal and
environment
Discrimination training
Patterning training
Lipreading
Active listening
Dichotic listening
Phonologic
(AUD & SLP)
Analyzing signal
– discrimination
& recognition –
I “know” it
Focus on quantity
and structure
ACOUSTIC
Sound Blending
Analysis-synthesis
Closure
Sound-symbol association
Linguistic
(SLP)
Attaching
meaning
- I “get” it
Focus on
comprehension /
communication
LANGUAGE
Concept Development
Word/Object Association
Answering wh questions
Compare/Contrast Tasks
Executive
Functions
Managing and
organizing a
response –
I can “use” it
Focus on ease of
expression,
speed of
processing
Role-play pragmatics
Work on impulse control
Judgment and interpretation
Active listening

70. Resources for therapy
• www.proedinc.com - Differential Processing Training
Program – auditory, phonologic and linguistic goals
• www.acousticpioneer.com – dichotic listening and
temporal patterning training
• www.neurotone.com – LACE: Listening & Communication
enhancement – for adults
• www.clearworks4ears.com – activities for auditory
processing & related skills
• www.brainHQ.com- enhances auditory, visual and
thinking/reasoning skills

71. Resources for therapy
• www.scilearn.com – Fast ForWord program
discrimination, temporal/phonologic processing
• www.capdots.com – dichotic listening program
• www.hearbuilder.com – phonologic awareness,
discrimination, memory for auditory info, usage
• www.lipreading.org – using visual cues
• www.interactivemetronome.com – multisensory
training, enhances sequencing, speed, attention
• www.capd.nal.gov.au/lisn-learn - enhances spatial
listening and auditory vigilance

72. Resources for therapy
• Apps from
• www.superduperinc.com
• www.smartyears.com
• www.virtualspeech.com
• www.hamaguchiapps.com
• Central Auditory Processing Disorder. ASHA Practice
Portal www.asha.org/Practice-Portal/Clinical-
Topics/Central-Auditory-Processing-Disorder/

73. A word about treatment outcomes
• Studies of CAP tx efficacy note improved performance
pre- and post TX in specific auditory skill (i.e., “if you drill
it, it will come”)
• Some evidence of improved phonologic awareness
• Very few published reports of generalizability of
improved auditory-specific processing to academic
and/or learning skills
• Some reports of improved language-learning-cognition
following use of multi-modal training programs
• Virtually all report improved “hearing”, listening ease
and listening stamina

74. Why do outcome data look so discouraging?
• Some therapies not grounded in “good science”
• Poorly defined experimental groups with respect
to diagnosed deficits/needs
• Logistics associated with matched group
treatment efficacy studies- how “matched”
• Lack of consistent experimental methods
• AT rarely done in isolation - difficult to gauge
effects of AT (many interaction effects)
• Few studies designed to examine generalizability
to language-learning

75. Games that enhance processing and related skills
Game Processing skills taxed
• Battleship listening, patterning, integration
• Boggle pattern recognition, integration
• Bopit, integration, vigilance
• Catch Phrase integration, vocabulary, output
• Clever Endeavour language strategies, listening
• Feely Bag interhemispheric communication
• Ending sound game auditory discrimination
• Mad Gab temporal patterning, language
• Marco Polo localization, binaural interaction

76. Game processing skills taxed
• Musical Chairs vigilance
• Name that tune interhemispheric integration
• Password vocabulary, linguistic skills
• Plexers metalinguistic strategies
• Rags to Riches metalinguistic skills (idioms)
• Read My Lips lipreading/speechreading
• Scattergories vocabulary, linguistic strategies
• Simon auditory-visual patterning
• Simon Says vigilance, active listening
• Taboo vocabulary, linguistic strategies
• Twister integration, critical listening
• UpWords integration, visual patterning
• Wheel of Fortune auditory closure

77. M33 -9 tips to enhance processing
• Attention all shoppers – gain listeners’ attention
• If I told you once… - children NEED repetition
• Show me! - use pictures, demos, examples
• Say what you mean and mean what you say
• I’m listening as fast as I can – children DO NOT process
speech at the same rate as adults
• TMI – break lengthy info into smaller units
• Are we there yet? – give parameters
• Tag, you’re it – use “tag” words (first, then)
• Gimme a break – provide listening breaks

78. M33 – 9 self-help processing tips
• Twice is nice - ask for repetition
• Mind over mutter – use the clues, take a guess
• Wait for it… - wait for all instructions
• I’ll be watching you – look and listen
• Noise annoys – stay away from noisy spaces
• Oh dear, it’s not clear – ask for clarification/help
• Be the tortoise, not the hare – take your time
• ABC/123, going in order will set you free – start at
beginning and go step by step
• Go with the flow – listen for key words and changes in
tone of voice

79. Summary
• It really is a PROCESS
• Deficit in one or more skills subserved by CANS
• Adversely affects communication, learning, and
psychosocial wellness; Can co-exist with other
conditions
• Audiologic tests available to reliably assess skills
with adjustment to protocol as needed
• Results help define nature and clarify impact of
deficit to ensure deficit-specific intervention

80. Summary
• Effective intervention MUST be deficit-specific
AND include remediation and management
• Bottom-up strategies focus on access to clear
signal, top-down focus on functional
communication- you MUST know deficit type
• TX for CAPDs typically includes both bottom-up
training and top-down strategies
• Monitor skills at periodic intervals