CSHA CAPD Task Force Document 1 California Speech-

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CSHA CAPD Task Force Document 1
California Speech-Language-Hearing Association’s
Guidelines for the Diagnosis & Treatment for Auditory
Processing Disorders
Page
I I NTRODUCTION……………………...……………………………...……… 2
A. Definitions …………………….……………………………………………… 3
B. Behaviors Present in APD…………………..………………………………… 4
C. Description of Auditory Skills….………………………...…………………... 5
II THE SPEECH-LANGUAGE PATHOLOGIST’S ASSESSMENT……….…….. 6
A. The Purpose of the SLP’s Assessment…………….…………………..….…… 6
B. Screening Tests for the Speech-Language Pathologist…………………………… 7
C. Suggested SLP Assessment Battery…………………...………………………… 8
III THE AUDIOLOGIST’S ASSESSMENT……... ..…………………………………. 11
A. The Purpose of the Audiologist’s Assessment…...……………………………… 11
B. Screening Tests for the Audiologist……………………………………………… 11
C Suggested Audiological Battery.…………… ………………………………….. 12
IV DIFFERENTIAL DIAGNOSIS FOR THE SLP AND AUDIOLOGIST…………… 14
A. Differentiating Language Processing from Auditory Processing Disorders… 14
B. Differentiating Attention Deficit Disorder from Auditory Processing Disorders…15
C. Assessing Bilingual Children………………………………………………… 16
D. Assessing Children with Autism Spectrum Disorder……….………………… 16
E. Interpretation of Test Results……………………………………………… 17
V DIAGNOSIS & TREATMENT IN THE SCHOOL SETTING……………..………... 18
A. Pre-Referral Strategies………………………………………………………...… 18
B. Current Practices in Determining Eligibility Criteria …………………………… 20
C. Related Special Education Laws………………………………………………… 21
D. The IEP…………………………………………………………………………. 22
E. Classroom/Teaching Modifications………………………………………… 24
VI DIAGNOSIS & TREATMENT IN THE CLINICAL/PRIVATE SETTING.…….. 24
A. Current Practices and Concerns: School Issues………………………………….. 24
B. Current Practices and Concerns: Medical Model…………...………………… 26
VII SUGGESTED APD INTERVENTION & MANAGEMENT……..………………… 26
A. Research……………………………………………………………….………. 27
B. Target Skills & Compensatory Strategies…………………………..………… 27
C. Language Intervention………………………………………………………….. 28
D. Commercial Programs……………………………………………………….. ... 28
E. Use of an FM System…………………………………………………….……… 29
F. Environmental Acoustic Modifications……………………………..…………… 30
Appendix A: Parent/Teacher Information (Questions/Answers)……………………………...….. 31
Appendix B: Tips for Parents………………………………………………………………….…. 34
Appendix C: Modifications for Teachers……………………………………………...………… 36
Appendix D: Modifications for Classroom Acoustics…………………………………………..… 37
Appendix E: Publishers of Tests…………………………………………………………………. 38
REFERENCES…………………………………………………………………………………… 40
CSHA CAPD Task Force Document 2
I. INTRODUCTION
The California Speech-Language-Hearing Association (CSHA) appointed a task force in
August 2002 to facilitate a more consistent approach to the diagnosis and treatment of
children with auditory processing disorders, also known as APD. The following
document is respectfully submitted in response to the charge. The Task Force consists of
the following members: Patricia Hamaguchi, M.A., CCC-SLP, Chair, June McCullough,
Ph.D., CCC-A, Jean M. Novak, Ph.D., CCC-SLP, Deborah Ross-Swain, Ed.D., CCCSLP,
CSHA Peer Reviewers Appointed to the Task Force: Jann Wilkerson, M.A., CCCSLP,
Stephen D. Roberts, Ph.D., CCC-A.
The task force participants agreed a priori to the following process. We reviewed the
reports from nationally recognized conferences (ASHA 1996, the Consensus Conference
on the Diagnosis of Auditory Processing Disorders in School-Aged Children; Jerger and
Musiek, 2000; ASHA 2003, Auditory Processing Disorders Conference; ASHA 2004,
Scope of Practice for Audiologists), the published guidelines of several states (Florida,
Colorado, and Minnesota), and guidelines developed by area school districts (San Diego
City, San Jose Unified, and Ventura). We examined published works by leading
professionals in peer-reviewed journals and books (see References) and sought formal
input from several leading professionals in the field of APD: Dr. Donna Geffner, Dr.
Frank Musiek, and Dr. Teri Bellis. Dr. Bellis is presently the chair of ASHA’s APD
Working Group, and Dr. Musiek is a member. The purpose of the review was to establish
areas of agreement among the leading researchers and practitioners of this very
specialized field. Areas of consensus form the framework for this document.
On the other hand, there are issues in auditory processing that have not been fully
defined, described, or remain fairly controversial. In examining this issue, we have
endeavored to present what we feel is the prevailing wisdom regarding the diagnosis and
treatment of this disorder. The reader should be aware that the area of APD is
controversial and changing rapidly. At this time there is no gold standard for “best
practices”, therefore, we are presenting this document as “professional guidelines” until
such time ASHA or another body feels the instruments and treatment for it are
sufficiently researched and proven to be reliable and valid for this purpose. When there is
significant disagreement in the literature or among leading professionals,
recommendations for further research are made.
Some of these issues are:
1. The nature of auditory processing: APD, what it is, and its relationship with
other concomitant disorders such as attention deficit disorder, with or without
hyperactivity (AD/HD), is still somewhat unclear at times.
2. Identifying APD by subtype: There is still is no official ASHA position as to
which model, if any, should be utilized.
3. APD and children with below average IQ scores: While most practitioners do
not feel an APD can be reliably diagnosed in children with globally depressed IQ
scores, there is some disagreement as to how and when it can be diagnosed in
CSHA CAPD Task Force Document 3
children with significant discrepancies between their verbal and non-verbal
cognitive abilities.
4. Treatment: There is a lack of consensus regarding the validity and reliability of
some commercially marketed products.
From a practical point of view, here in California, limited resources create a quandary for
the SLP who typically does not have adequate assessment tools, intervention materials, or
extended blocks of time to do assessments. Even more critical is the lack of access to an
audiologist, particularly one who has expertise in this specialized area of auditory
processing disorders. We recognize that more support, training, and resources may be
necessary for many professionals to implement these recommendations.
We suggest this document be updated regularly, as new research or ASHA guidelines
become available that may help further define or clarify some of the issues contained
herein. The subject of auditory processing disorders is fairly new to our field, and as
such, still evolving.
The task force hopes that the guidelines proposed below will promote a more uniform
approach to the diagnosis and treatment of auditory processing disorders.
A. Definitions
An auditory processing disorder is a “deficit in the perceptual processing of auditory
information in the central nervous system.” (Bellis, 2004). Auditory processes are the
auditory system mechanisms and processes responsible for the following behavioral
phenomena:
• Auditory localization and lateralization
• Auditory discrimination
• Auditory pattern recognition
• Temporal aspects of audition, including temporal resolution, temporal masking,
temporal integration, and temporal ordering
• Auditory performance decrements with competing acoustic signals
• Auditory performance decrements with degraded acoustic signals
The Consensus Conference (2000) recommended labeling such problems as “auditory
processing disorder (APD),” as opposed to ‘central’ auditory processing disorder, in
order to avoid the imputation of anatomic loci and emphasize the interactions of disorders
at both peripheral and central sites. While there is still residual debate concerning this
issue, the majority of specialists in this field have transitioned to using the term, “APD”
in lieu of “CAPD”. As such, “APD” reflects current terminology and we recommend its
use in California.
An APD is specific to the auditory modality. That is, it may be associated with
difficulties in listening, speech understanding, language development, and learning, but in
its pure form, it is conceptualized as a deficit in the processing of auditory input. Yet, the
concept of the brain as a compartmentalized system is perhaps simplified, as there is a
CSHA CAPD Task Force Document 4
complex interactive neural network that makes a “pure” auditory processing disorder the
exception, rather than the rule. The differential diagnosis of APD from related problems,
including AD/HD, language impairment, reading disability, learning disability, autism
spectrum disorder, and reduced intellectual functioning is often challenging, but
important since children with these disorders may exhibit similar behaviors. In many
cases, the diagnosis of APD co-occurs with dysfunction in other modalities.
Because there is such a wide range of auditory skills assessed, one child with an auditory
processing disorder may present with a very different set of symptoms than another.
Many professionals in the field (e.g., Katz; Bellis and Ferre) prefer to use subcategories
when diagnosing an auditory processing disorder, depending upon the collective set of
symptoms and test results. For this reason, some view an “auditory processing disorder”
as a generic name for one of several specific disorders that have been further defined.
While this Task Force does not advocate for one type of model over another, we
recommend it may be helpful for the clinician to recognize that there are several different
profiles for children who could all conceivably be defined as having an auditory
processing disorder. Further research and consensus by ASHA and leading experts on the
topic of subcategories within the diagnostic label of an “auditory processing disorder”
should provide additional clarification on this aspect of auditory processing disorders.
In summary, APD is 1) a complex disorder; 2) specific to the auditory
modality; 3) should be differentially diagnosed from disorders with similar
symptoms, 4) may co-occur with other related disorders and 5) is often viewed as a
generic name for a heterogeneous set of auditory disorders.
B. Behaviors Present in APD
Children typically exhibit a wide range of behaviors when presenting APD, depending
upon the nature and severity of the disorder, as well as the presence of other co-morbid
conditions. However, the following list represents the most common symptoms:
• Poor listening skills
• Difficulty learning through the auditory modality
• Significant difficulty understanding or focusing in the presence of background
noise or competing conversations
• Frequently says “huh” or “what”
• Difficulty with phonics
• Poor auditory memory
• Processes verbal stimuli slowly
• Often complains the speaker is “talking too fast”
• Misunderstands what is said
• Difficulty understanding speech that has been muffled or distorted
• Difficulty “hearing” speech when presented via a PA system, telephone,
or electronically
• Require repetition or clarification of age level appropriate directions
• Difficulty following discussions, particularly in large rooms, with poor acoustics
CSHA CAPD Task Force Document 5
• Receptive language may or may not be weak when tested in a quiet, clinical setting
• Expressive language may or may not be weak; typical errors tend to be related to
morphology, syntax, word retrieval and sequencing
• Mumbly or indistinct articulation pattern
• Misinterpretation or confusion of vocal inflection, emphasis, sarcasm, etc.
• Difficulty using context clues when a part of a verbal message is distorted or
contains an unfamiliar word
• Reading, spelling and related academic problems
• Difficulty acquiring and articulating a foreign language in an academic
environment
C. Description of Auditory Skills
Auditory processing is not a singular skill, but rather an integration of skills that are basic
to the listening and communication process. The boundaries of each are not well defined,
resulting in overlap and are, essentially, inseparable.
The assessment tools should examine a variety of auditory skills. The areas to be
evaluated should be selected according to the presenting symptoms. The clinician should
not endeavor to assess each and every auditory skill during the evaluation, but should
note the following areas:
1. Sensation: The ability to perceive the presence of sound.
2. Perception and Discrimination of Tones: The process we use to discriminate among
sounds of different frequency, duration or intensity (e.g., high/low, long/short, loud/soft).
3. Perception and Discrimination of Speech Sounds: The ability to notice and
discriminate among words and sounds that are acoustically similar.
4.. Localization: The ability to determine the location of the acoustic signal relative to
the listener’s position in space.
5. AuditoryVigilance: The ability to direct and maintain attention to relevant acoustic
signals, particularly speech and/or linguistic stimuli and sustain that attention for age
level appropriate amounts of time.
6. Auditory Figure-Ground: The ability to identify the primary linguistic or nonlinguistic
sound source from background noise. This is affected by signal to noise ratio.
7. Auditory Closure: The ability to understand the whole word or message when a part
is missing.
8. Phonemic Awareness: The ability to auditorily identify phonemes, their position in
words, rhyming patterns, syllabication, and other associated phonemic awareness skills,
CSHA CAPD Task Force Document 6
including auditory synthesis (phonemic synthesis), the ability to auditorily blend isolated
phonemes into words.
9. Auditory Memory: Refers to the recall of the acoustic signal before the process of
storage (short-term auditory memory) as well as after it has been labeled, stored and
recalled (long-term auditory memory).
10. Auditory Latency: Refers to processing delays. This can be lapse, hesitation or
delay in response time when presented with auditory stimuli requiring a response.
11. Auditory Overload: Refers to the tenacity and effectiveness of the auditory system.
Individuals with APD are often overwhelmed with auditory input, exhibiting difficulty
screening out relevant from irrelevant auditory information, resulting in overload (Friel-
Patti, 1995: Katz, 1997; Sloan, 1998). Factors contributing to overload include:
• Brevity of the acoustic signal
• Fast rate of speech
• Rapid presentation rate of new information
• Increased phonemic complexity
• Reduced context
• Decreased word familiarity
• Increased length of de-contextualized material
• Poor listening conditions
• Temporal distortions
• Increasing task uncertainty (e.g., open responses)
• Poor acoustic environment
II. THE SPEECH-LANGUAGE PATHOLOGIST’S ASSESSMENT
A. The Purpose of the Speech-Language Pathologist’s Assessment
The purpose of the speech-language pathologist’s assessment is to determine if the child
has a language disorder, bilingual issue, or speech impairment. The SLP needs to
determine if these issues are contributing to the child’s presenting symptoms, as well as
impacting the child’s performance on speech and language-influenced auditory tests. This
background information is critical in formulating a differential diagnosis, both for the
audiologist, as well as the SLP.
Through the assessment, the speech-language pathologist may find that the child indeed
exhibits weaknesses or deficits in one or more auditory skill areas, not otherwise
explained by linguistic, speech output, cognitive or attentional issues. The SLP does not
need a formal confirmation from an audiologist in order to treat the presenting skill
deficits. However, the speech-language pathologist may not diagnose an auditory
processing disorder or utilize the previous diagnostic label, central auditory processing
disorder. The SLP report may state that the assessment reveals “auditory-based language
CSHA CAPD Task Force Document 7
deficits in the following areas: auditory memory, auditory discrimination, etc.” This type
of descriptive report may recommend further assessment by an audiologist.
A referral to an audiologist is preferable when any of the following conditions are
present:
• There is uncertainty as to the child’s peripheral hearing acuity
• The clinician feels the child’s speech or language issues require less
linguistically-loaded testing to properly assess auditory processing function
• The child requires a more acoustically-controlled testing environment
• A child’s school or insurance company requires a formal APD diagnosis for
treatment
• A consultation regarding FM or sound-field system is indicated
• A consultation regarding acoustic modifications in the class is indicated
B. Screening Tests for the Speech-Language Pathologist
Before a formal testing battery is initiated, the SLP should look qualitatively at the
presenting symptoms, behaviors, history, and other academic issues, which may point to
a possible auditory processing disorder. At this time, there are no reliable screening tests
for use by the SLP to identify an auditory processing disorder, therefore, we do not
recommend any specific tests for the SLP to use as a screening instrument for APD at this
time, as a limited use of standardized tests in this regard may very well miss an
underlying problem. Development of such a tool in the future would be welcome. Below,
please find a review of the pertinent information, which the SLP should gather in
determining the need for a comprehensive APD assessment.
1. Referral source and reason for referral
2. A thorough client history and/or parent interview to collect background
information such as:
a. Family history
b. Pregnancy and delivery history
c. Post natal history
d. Adoption history
e. Infancy and childhood history
f. Developmental milestones
g. Health history, including otologic history for middle ear fluid and allergies
h. Auditory developmental history
i. Visual developmental history
j. Motor and sensory developmental history
k. Social and behavioral developmental history
l. Speech and language developmental history
m. Previous evaluations and treatment with results
n. Educational history
o. School/Educational issues
p. Behavior
CSHA CAPD Task Force Document 8
q. Parent expectations
3. Behavioral Survey
a. Attending, focusing during auditory tasks
b. Requests for frequent repetition or clarification (“huh”)
c. Misinterpretation of what is said
d. Lack of response to name when called
e. Processes better in a quiet environment
f. Learns poorly through lecture-style teaching
g. Is easily distracted, primarily by noise
h. Sensitive to loud noises
C. Suggested SLP Assessment Battery
The following list represents examples of tests in each of the defined areas. We recognize
that there are additional assessments that may be appropriate, and more will continue to
be developed. While it is not a complete list, the following information will provide
SLP’s some guidance in selecting tests needed for a comprehensive battery. Not all areas
will require testing during each assessment. The clinician is cautioned to use judgment in
selecting tests that measure performance in those areas in which presenting symptoms
have been noted.
The speech-language pathologist should be extremely vigilant to avoid drawing
conclusions or using test scores in a vacuum, without consideration of the child’s other
speech and language or motor issues, which may adversely impact the validity of the test
scores. Tests selected should require output modalities that are not influenced by the
child’s other skill weaknesses whenever possible. For example, children with expressive
language difficulties may be more appropriately assessed for auditory weaknesses with
tests that require pointing or single-word responses rather than sentence formulations or
explanations. Here are just a few examples:
• A child’s score on an “auditory memory” subtest that requires repeating sentences
could be significantly low because his ability to reformulate the test prompt
verbatim is due to underlying syntax and morphological weaknesses rather than a
true auditory memory weakness.
• A child’s score on an “auditory memory” subtest that requires the repetition of a
series of words could be significantly low because he has auditory discrimination
difficulties and “misheard” the prompt words, resulting in similar sounding words
being repeated.
• A child’s score on an “auditory processing” subtest for following oral
directions could be significantly low because he is unfamiliar with the positional
concepts presented and therefore is unable to accurately perform the task.
CSHA CAPD Task Force Document 9
• A child’s low score on an “auditory processing” subtest that requires the child to
answer questions about a story or passage may be symptomatic of an underlying
expressive language disorder or confusion with linguistic concepts such as “why”
or “how”.
• A child’s slow “auditory processing speed” could be due to anxiety about possibly
answering incorrectly, a word retrieval deficit, apraxia, dysfluency, or expressive
language disorder.
• A child’s low score on the SCAN subtests may be influenced by a motor speech
problem that makes it difficult for the child to imitate certain words with clarity,
rather than an inability to perceive the word under degraded listening conditions.
• A child’s low score on the Token Test may be exacerbated by fine motor issues
that make manipulating objects challenging, resulting in the child forgetting the
direction.
Tests are listed in each section in alphabetical order. Appendix E contains contact
information for publishers of the tests listed below.
1. Perception and Discrimination
• The Goldman-Fristoe-Woodcock Test of Auditory Discrimination: Quiet Subtest
• The Lindamood Auditory Conceptualization Test (LAC);
• Test of Auditory Perceptual Skills Revised-TAPS R: Word Discrimination
Subtest
• Test of Language Development-3 (TOLD-P:3) Supplemental Subtest 1
• Wepman’s Auditory Discrimination Test
2. Auditory Association/Receptive Vocabulary
• The Comprehensive Receptive and Expressive Vocabulary Test (CREVT-2)
• Peabody Picture Vocabulary Test (PPVT-3)
• Receptive Vocabulary Test (ROWPVT)
• CELF-4
3. Auditory Memory
• Auditory Processing Abilities Test (APAT) Subtests 2, 6, and 9
• Test of Auditory Perceptual Skills-Revised (TAPS-R): Memory for Words and
Numbers Forward Subtests
• The Token Test for Children
• Wepman’s Auditory Memory Battery
4. Phonemic Awareness
• The Comprehensive Test of Phonological Processing (CTOPP) Subtests 1, 2, 8,
10, 11, and 12
• The Lindamood Auditory Conceptualization Test (LAC)
CSHA CAPD Task Force Document 10
• The Phonemic Awareness Test (TAAS)
• The Phonemic Synthesis Test
• The Test of Phonological Awareness
5. Auditory Closure
• Comprehensive Assessment of Spoken Language: (CASL) Meaning from Context
Subtest
• Test of Language Competence: Subtest 3
6. Auditory Cohesion/ Comprehension of Sentence & Paragraph-Length Material
• The Auditory Processing Abilities Test (APAT): Passage Comprehension,
Sentence Absurdities, Complex Sentences Subtests
• Clinical Evaluation of Language Fundamentals-4 (CELF 4): Linguistic Concepts,
Sentence Structure, Concepts and Directions, Understanding Spoken Paragraphs
Subtests
• The Comprehensive Assessment of Spoken Language (CASL): Sentence
Comprehension, Paragraph Comprehension, Nonliteral Language, Ambiguous
Sentences, Inference, Subtests
• The Listening Test
7. Expressive Vocabulary
• The Comprehensive Receptive and Expressive Vocabulary Test (CREVT)
• The Expressive One Word Picture Vocabulary Test (EOWPVT)
• The Test of Language Development-Primary:3 (TOLD-3): Oral Vocabulary
Subtest
• DTLA-4 Story Construction
8. Word Retrieval
• CELF-4: Rapid Automatic Naming Subtest
• The Comprehensive Test of Phonological Processing (CTOPP) Rapid Object
Naming Subtest
• Test of Word Finding-2
9. Auditory/Speech Perception Under Degraded Listening Conditions
• Goldman-Fristoe-Woodcock Test of Auditory Discrimination: Noise Subtest
• SCAN or SCAN-C
• Woodcock-Johnson Tests of Cognitive Ability: Auditory Figure Ground Subtest
10. Behavioral Survey
• Children’s Auditory Performance Scale
• Children’s Home Inventory of Listening Difficulties (CHILD)
• Evaluation of Classroom Listening Behaviors
• Fisher’s Auditory Problems Checklist
• Listening Environment Profile
• Listening Inventory
CSHA CAPD Task Force Document 11
• Screening Instrument for Targeting Educational Risk (S.I.F.T.E.R.)
III. THE AUDIOLOGIST’S ASSESSMENT
A. The Purpose of the Audiologist’s Assessment
The purpose of the audiologist’s assessment is to determine if a child has an auditory
processing disorder. Both evaluation and management of APD are included in the
audiologist’s scope of practice (ASHA, 2004). Since a diagnosis of APD often involves
the elimination of, or co-morbidity of, other types of disorders exhibiting similar
symptoms such as peripheral hearing loss, AD/HD, language disorders, and auditory
neuropathy, a team approach to assessment is recommended. At a minimum, the team
should include an audiologist and a speech-language pathologist (Jerger and Musiek,
2000).
B. Screening Tests for the Audiologist
A diagnosis of APD cannot be made through screening tests alone. Rather, screening
tests determine if a listener demonstrates age-appropriate skills. If not, the listener may
be referred for a complete diagnostic evaluation.
A screening usually begins with a case history or questionnaire that includes observation
of suspect behaviors (Jerger and Musiek, 2000). Examples of suspect behaviors include:
• Difficulty in hearing and/or understanding in the presence of background noise or
reverberation,
• Difficulty in understanding degraded speech,
• Difficulty in following spoken instructions in the classroom in the absence of
language comprehension deficits,
• Difficulty in discriminating and identifying speech sounds, and
• Inconsistent responses to auditory stimuli or inconsistent auditory attention.
A standard audiological evaluation is recommended prior to the administration of
screening tests for APD so as to determine if peripheral hearing loss is present. The
standard battery includes pure tone air and bone conduction thresholds, speech
recognition threshold, word recognition in quiet and in noise (+5 or +10 S/N),
tympanometry, and acoustic reflex thresholds. Neither the ASHA guidelines (1996) nor
Jerger and Musiek (2000) support the practice of using audiometric “peaks and valleys”
(that is, pure tone thresholds that differ by as little as 5 dB), nor elevated or absent
acoustic reflexes, as a criterion for the diagnosis of APD.
Jerger and Musiek (2000) recommend that the screening test protocol for audiologists
include dichotic digits (i.e., two digits in each ear) and temporal gap detection. These
tests have the advantage of minimizing linguistic load, which may facilitate differential
diagnosis of APD from language disorders. Unfortunately, only dichotic digits have been
CSHA CAPD Task Force Document 12
standardized with children. Musiek (2004) indicates that a “true” gap detection test (as
opposed to auditory fusion, or random gap detection) is almost ready for distribution.
Another commonly used screening test for APD is the Test for Auditory Processing
Disorders in Children (SCAN-C) or Adolescents (SCAN-A). The SCAN subtests are also
appropriate diagnostic tests when administered in a controlled acoustic environment, such
as a sound-treated room. Audiologists may also wish to administer the Selective Auditory
Attention Test (SAAT) to facilitate the differential diagnosis of APD from AD/HD.
In summary, screening tests are intended to identify those individuals who need further
assessment. The Task Force recommends that 1) audiologists take a thorough case
history to determine if suspect behaviors are present and impact educational
performance, 2) a standard hearing evaluation be completed to determine if peripheral
hearing loss is present, and 3) audiologists utilize tests that minimize the effects of
language (e.g. dichotic digits) as part of the screening process.
Listeners who fail the screening tests should be referred for an APD diagnostic
evaluation.
C. Suggested Audiological Battery
A helpful way to categorize diagnostic tests for APD is by the underlying auditory
behaviors they seek to evaluate. Bellis (2004) recently constructed the following
categories of diagnostic tests for APD, based on auditory behaviors and skills:
1. Tests of Auditory Discrimination (to assess the ability to differentiate between
similar-sounding speech or non-speech stimuli, e.g., signals differing in
frequency, intensity, or duration; minimally contrasting speech sounds).
Example: Speech discrimination tests (WIPI, PB-K’s, as appropriate)
2. Tests of Auditory Temporal Processing (to assess the ability to analyze acoustic
events over time, e.g., gap detection, auditory fusion, temporal integration,
backward and forward masking).
Example: Auditory Fusion Test (AFT) (norms for children 5 – 11)
3. Dichotic Listening Tests (to assess the ability to separate or integrate competing
auditory stimuli, with different signals presented to each ear simultaneously, e.g.,
syllables, numbers, words, sentences).
Example: Dichotic Digits (norms for children 7 – 12+)
4. Tests of Auditory Temporal Patterning (to assess the ability to recognize and
sequence patterns of auditory stimuli, e.g., frequency patterns, duration patterns).
Example: Pitch Pattern Sequence Test (norms for children.)
5. Monaural Low-Redundancy Speech/Auditory Closure Tests (to assess recognition
of degraded speech stimuli presented to one ear at a time, e.g., filtered speech,
CSHA CAPD Task Force Document 13
time-compressed speech, speech in noise).
Example: SCAN-C, Filtered Words Subtest (norms for children 6 – adult)
6. Binaural Interaction Tests (to assess processing of binaurally presented signals
involving interaural intensity or time variations, e.g., masking level difference
(MLD), localization, lateralization).
Example: MLD, from the VA CD (no norms for children)
7. Electrophysiologic and related tests (to assess neurophysiologic representation of
auditory signals, e.g., auditory evoked potentials, topographical brain mapping,
neuroimaging). Example: ABR, MLR
Recent research has focused on describing a minimal and/or optimal test battery that is
sufficient for sampling the breadth of auditory behaviors and skills. Musiek (1998)
suggested that a test battery consist of dichotic digits, frequency patterns, competing
sentences, low-pass filtered or compressed speech, and evoked auditory brainstem and
middle latency responses. Jerger and Musiek (2000) proposed that, at minimum, the
diagnostic battery should include pure-tone audiometry to rule out peripheral hearing
loss; performance-intensity functions for word recognition; a dichotic task; duration
pattern sequence test; temporal gap detection; immittance audiometry; otoacoustic
emissions; and auditory brainstem and middle latency responses. On the other hand,
Bellis (2004) recommended that a diagnostic test battery not be specified, rather that test
components be individualized so as to be appropriate for the child in question.
Further research to describe an ideal test battery is needed. We recommend that the
audiologist construct a test battery that is sufficient to sample the various levels and
mechanisms of the auditory system.
We recommend that speech, language, learning and psychological evaluations be
obtained prior to the audiological assessment so that the audiologist can correctly
interpret a child’s performance on subsequent listening tasks.
We recommend that tests used to diagnosis APD be age-appropriate, both linguistically
loaded (speech tests) and linguistically limited (non-speech tests), and, if possible,
independently correlated with each other so as to assess separate auditory processes and
mechanisms with clinical efficiency.
Specific diagnostic criteria (i.e., the degree to which test scores must fall below agecorrelated
normal regions before a disorder is diagnosed) have not been clearly defined.
Generally, scores falling 2 or more standard deviations on more than one test, combined
with presenting symptoms that are not explained by other conditions would indicate an
APD. See the section on Differential Diagnosis for additional information on the
interpretation of test scores. Further research and consensus among leading professionals
is needed to establish universally accepted diagnostic criteria, as well as to establish
relationships between test results, deficit specificity, and subsequent treatment.
CSHA CAPD Task Force Document 14
IV DIFFERENTIAL DIAGNOSIS FOR THE SLP AND
AUDIOLOGIST
A. Differentiating Language Processing from Auditory Processing
Disorders
An auditory processing assessment focuses on evaluating how the child is receiving
speech sound(s), depending upon the auditory context, acoustic features of the speech
signal, and environment. It seeks to determine if the auditory speech signal is reaching
the child’s language centers intact, in the same way other people perceive it. For
example, if a child exhibits a significant left-ear weakness on auditory testing, it indicates
a discrepancy that is typical for a child with APD and probably not the result of a
language processing problem.
A language processing assessment focuses on how the child processes the verbal
information after if has been delivered by the auditory system. It focuses on evaluating if
the child is comprehending specific word meanings and sentence types such as those used
in following directions, passive voice, categorization, idioms, prepositions, "wh"
questions, etc.
An auditory processing disorder and a language disorder are not synonymous terms. Not
all APD’s lead to language disorders and not all language disorders are due to APD’s.
There are many reasons a child has difficulty with processing language aside from an
auditory processing disorder. Language comprehension tests should not be used to
diagnose an auditory processing disorder, although behaviors and response patterns
observed may indicate the need for further testing in the area of auditory processing.
Pure language processing (comprehension) tests only require the child to point to a
picture or follow a verbal direction. As soon as a verbal response is required, the answer
is affected by the child's expressive language and is then measuring two components, and
great care must be taken when interpreting test results to determine if the presence of an
expressive language disorder is present. Tests are listed alphabetically.
Tests that Assess Primarily Language Processing (Auditory Comprehension of
Language)
• CELF: Semantic Relationships Subtest
• Preschool Language Scale -3
• Test for Auditory Comprehension of Language (TACL)
Tests Given by an SLP that Assess Auditory Skills that May Show APD:
• The Phonemic Synthesis Test (Jack Katz)
• The Phonemic Synthesis Picture Test (Jack Katz)
• The SCAN-C (ages 5-12) and SCAN-A (ages 12 +) *Considered a screening test
unless administered by an audiologist
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• Goldman Fristoe-Woodcock Test of Auditory Discrimination
Tests Given by an SLP that Overlap Language and Auditory Processing:
• The Phonological Awareness Test
• Test of Auditory Perceptual Skills-R (TAPS-R)
• The Listening Test
• CASL (e.g. Third Book Subtests: Inferential Reasoning)
• CELF: Listening to Paragraphs Subtest
• The Token Test
Often children with APD need language processing intervention as well as auditory
processing intervention and management. It is still controversial as to whether these
deficits are co-existing throughout development or if the auditory disorder caused the
child’s language development to be disrupted, and eventually weakened. However, one
must logically assume than an improvement in a child’s auditory processing would be
beneficial to his language development. The clinician’s challenge is to determine where
the breakdown is occurring in the process, and direct the intervention accordingly.
B. Differentiating Attention Deficit Disorder from Auditory Processing
Disorders
Children with attention deficit/hyperactivity disorder (AD/HD), including inattentive,
hyperactive, and mixed forms, may have a co-existing auditory processing disorder.
Great care must be given during the assessment process to ensure that the child’s
difficulty in responding to auditory stimuli is not strictly due to inattention. Keep in
mind:
• The most recent research (Tillery Study, 2000) indicates improvement in auditory
attention with 5 mg. of Ritalin, but not performance on APD assessment measures.
Therefore, whenever possible, it is recommended that children with AD/HD take their
medication before the administration of the test battery.
• Methods of inter-subject interpretation of test date (e.g. ear differences, patterns that
conform to established neurophysiological tenets, topographic hemispheric
differences) are often recommended to be a valid method of differentiating APD from
AD/HD.
• A child with AD/HD’s performance on standardized tests may deteriorate
throughout the testing session if his attention span is taxed too long. The results will
be more reliable and valid if the testing is broken into shorter segments rather than
one long, 1 ½-2 ½ hour battery.
• A child with AD/HD may frequently interrupt the test prompts with comments,
observations, and not sufficiently attend to the testing task. The clinician should note
these qualitative observations when determining whether the child’s performance is in
CSHA CAPD Task Force Document 16
fact an “input” disorder of the auditory channel, difficulty focusing on the auditory
stimuli, or in some cases, both.
• Children with AD/HD have difficulty attending not only to auditory tasks, but any
structured task, such as completing a worksheet or homework. A child with just an
auditory processing disorder typically should perform better on visual tasks, such as
worksheets. If the clinician suspects a pervasive problem with attending, a referral for
an attention deficit disorder assessment should be made before finalizing an APD
diagnosis
C. Assessing Bilingual Children
During the assessment of children who speak more than one language, great care needs to
be exercised in interpreting test results. Unfortunately, evaluating children in their nonnative
language is not always a valid way to determine the presence of an auditory
processing disorder, due to the lack of normative data and the confounding languageprocessing
issues that result. Depending upon the length of time the child has been
exposed to a second, or even third language, his native tongue may also be diminished
due to a reduction in conversational practice and exposure. Therefore, assessing auditorybased
language skills, particularly those with language-influenced tasks (e.g., repeating
words, sentences, following oral directions, listening to stories) is inappropriate in this
population unless their command of the testing language (English, typically) is such that
the examiner is confident the results are not influenced by the Limited English
Proficiency issue. The clinician should inquire as to whether or not the presenting
behavioral issues are observed in both languages, or just in one setting, such as school. A
true auditory processing disorder would be observable in both spoken languages.
A referral to an audiologist is recommended in order to provide additional testing using
instruments (e.g., frequency patterns, duration patterns, pitch pattern tests, gap detection,
gap fusion) that are less dependent upon language processing skills.
In many cases, a definitive diagnosis for a bilingual child may be elusive, and it is
recommended to defer a diagnostic label under these circumstances.
D. Assesssing Children with Autism Spectrum Disorders
Children with autism spectrum disorders are frequently referred for an APD assessment.
Clinicians are reminded that children with autism by definition have a severe receptive
language disorder, which is typically manifested by a severe deficit in responding to
auditory linguistic stimuli, sometimes coupled with hypersensitivity to loud noises
(hyperacusis). These auditory processing issues should be considered part of the
underlying condition, and not a separate diagnosis.
The nature of this population is such that standardized test responses are often unreliable,
depending upon their motivation, attention, familiarity with the task, cognition, and
CSHA CAPD Task Force Document 17
comfort level with the examiner. The Task Force recommends clinicians refrain from
diagnosing APD in this population.
However, in children with significantly milder presenting symptoms and normal
cognition, such as with a non-verbal learning disorder or Asperger’s Syndrome, a
separate and co-morbid diagnosis may be possible if the test responses are consistent and
reliable, and not confounded with cognitive, attention, or motivational issues.
F. Interpretation of Results
Once the audiological and other testing have been completed, the diagnosis of an APD
may be considered, based on the following criteria:
• Behavioral symptoms consistent across settings that correspond to APD
• Formal testing that shows a consistent significant weakness (i.e., 2 standard
deviations or more) on more than one APD measure given by the audiologist that
cannot be explained by other factors (e.g., cognition, attention, hearing
impairment, ESL issues)
• Inter- and intra-test patterns that indicate an auditory processing disorder,
including ear differences on behavioral assessments and hemispheric differences
on topographic physiologic tests. Poor and consistently low scores may in fact
indicate a global or other confounding condition rather than an APD. (Bellis,
2004)
Just as a mild hearing loss can impact each person differently, depending upon their
coping skills, support system and academic strengths, so it is with an auditory processing
disorder. Each child comes to us with a different collective gestalt, and we should not
underestimate the impact of even a mild auditory processing disorder on a child with comorbid
emotional, psychological, behavioral, or learning issues.
Caution should be used when interpreting any test results. Very often examiners fail to
remember that “tests do not diagnose, people do” and base their impressions,
interpretation and diagnoses exclusively on test results. When interpreting testing
regarding APD, there are a number of considerations other than test scores that must be
taken into account. These considerations, in combination with test scores, are what form
clinical impressions, interpretation and diagnosis. The following should be considered:
• Medical history: Premature birth; chronic ear infections; chronic upper respiratory
infections; delayed speech and language onset; jaundice; hyperbillirubin and
kernicterus; genetic predisposition; abnormal peripheral hearing.
• Parent and/or teacher observation: The use of the Listening Inventory or
S.I.F.T.E.R
• Clinician observation: Observation and documentation of response behaviors
during standardized assessment, in non-structured interaction; classroom
observation; social and behavioral interaction
CSHA CAPD Task Force Document 18
• Other professional reports: Audiology; psychology; RSP; physician; occupational
therapy
Many factors can contribute to a child’s performance on a test. It is essential
that a clinician have access to any and all information that may affect test performance
and make necessary adjustments to ensure that the results are valid and reliable. All
information should be included to ensure valid and reliable interpretation, impressions
and diagnoses.
V. DIAGNOSIS & TREATMENT IN THE
SCHOOL SETTING
A. Pre-Referral Strategies
Schools are required to employ pre-referral strategies to address an identified academic
weakness with regular-ed interventions before seeking a formal evaluation. Initially,
other explanations should be ruled out when considering an APD diagnosis:
Some possible reasons children have difficulty "listening" in the classroom include:
1. They are bored because the work is too easy.
2. They are overwhelmed because the work is too hard.
3. They are worried about any number of other things (from family issues to whether
there is going to be pizza left at lunchtime)
4. The teacher is speaking too quietly.
5. The acoustics in the room are poor.
6. They are tired from lack of sleep.
7. They are hungry.
8. They are not from an English-speaking family and therefore do not process the
instructions or information well.
9. They have a hearing impairment in one or both ears.
10. They have fluid in their ears from a recent cold or allergies.
11. They are allergic to something they ate at breakfast or lunch.
12. They are taking medications for allergies, asthma, seizures, depression, or any
number of things that cause a child to be "jumpy", somewhat sedated or “spacey”.
13. They don't feel well.
14. A child sitting near them is engaging in behaviors that are distracting.
15. The teacher has a monotonous voice.
16. The content of the lesson is not interesting.
17. The child has been sitting for too long and needs to move around.
18. The teacher's expectations of the class’s auditory attention are overestimated for their
age and development.
19. The teacher is not using a good mix of visual/ auditory/ and "hands-on" methods.
20. The child has little previous preschool experience listening in large groups.
21. The child has poor balance and trunk control resulting in difficulty staying seated,
causing him/her to be distractible.
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22. The child has a learning disability, AD/HD or other language processing delay or
disability.
Below are some additional examples of pre-referral problem-solving steps to address
specific concerns, prior to pursuing a formal APD assessment:
Symptom: Child’s attention during verbal instructions wanders.
Rule out the following: fatigue, internal distractibility (ADD), hunger, lack of sleep,
location of seat near another child whose behavior is distracting, ESL issues, reaction to
prescription or over-the-counter medications, weak receptive language/vocabulary
affecting ability to extract meaning from verbal information. Pure-tone threshold
audiogram conducted (not a screening) in order to rule out a mild hearing loss (above
20DB) or the presence of fluid through tympanometry.
If none of the above issues are present, try the following:
• Preferential seating near the teacher or have the teacher move closer to the child
during direct instructions
• Teacher to use visual cues whenever possible.
• Have the child/class listen for specific purposes. Write the important questions to be
answered on the board. (“What is camouflage?”/ “Who helped Arthur find his
frog?”)
• Cue the child by name, then pause before asking a question. (“Peter..., what sound
does ‘boat’ begin with?”)
• Teacher to use a slower rate of speech when asking the child questions.
• Teacher to repeat important concepts/new vocabulary several times.
• Reduce ambient noise by closing windows, doors.
• Incorporate a class-based listening program
• Reduce the amount of concentrated listening time to shorter intervals.
Symptom: Child misinterprets what is heard.
Rule out: Hearing loss or middle ear fluid (see above), ESL issues, weak
vocabulary/receptive language.
If none of the above issues are present, try the following:
• Teacher to move closer to the child, gain eye contact, and repeat the
instructions/directions.
• Close windows and doors to minimize ambient noise.
• Write down and repeat important key words and phrases.
Symptom: Child says “Huh?” or “What?” often.
Rule out: Hearing loss or middle ear fluid, noisy class or teacher with unusually quiet
voice or strong foreign accent.
If none of the above issues are present, try the following:
• Move the child’s seat away from windows or doors
• Move the child’s seat closer to the teacher
CSHA CAPD Task Force Document 20
• Alert the child to important instructions by name or physical prompt (e.g. a tap on
the child’s desk)
• Incorporate a class-based listening program to improve listening behaviors and
facilitate the use of repair strategies.
If the pre-referral strategies are unsuccessful or if the child’s problematic
behaviors/symptoms are severe and/orcontinue, a speech-language pathologist should
assess the child, including appropriate auditory tests that might indicate a possible APD.
The IEP team should make a referral to an audiologist, based on behavioral observations
of APD symptoms in the classroom and/or social school environment, if they feel there is
sufficient cause for ruling this disorder in or out.
B. Current Practices in Determining Eligibility Criteria
Presently, Colorado, Florida and Minnesota have adopted guidelines through their state
departments of education for the diagnosis and treatment of auditory processing disorders
in the schools. Their IEP teams, with an audiologist’s confirmation, using set criteria,
determine this diagnosis. In the state of California, some individual school districts have
chosen to formulate their own guidelines for this purpose.
At this time, many school districts in California do not diagnose or treat this disorder.
Some do, but often only if a parent applies pressure from outside professionals or utilizes
legal resources. There is an understandable caution in over-referring, over-diagnosing,
and over-treating any disorder. Additional reasons for the schools’ reluctance to identify
and treat auditory processing disorders are varied, but include: a lack of financial
resources, access to audiological services, staff training, ideological concerns about the
validity of the disorder itself, unavailability of diagnostic tools, intervention materials;
and a lack of consistent professional criteria to properly identify and treat the disorder.
This document seeks to address the latter issue, but recognizes that the former issues
expressed will need to be appropriately addressed at the local and state level before
widespread changes can take place.
According to the US Dept. of Education, Special Education Division, the educational
categorization of this disorder is diverse across the country, depending on the state and
local school district’s own guidelines. It is reportedly more often defined as a learning
disability or a hearing impairment, depending on the school district. For children with comorbid
conditions, it is often a secondary deficit, and thus the category issue is a moot
one. The question lies in determining eligibility for those children who do not present
with other areas of deficit (e.g. a speech or language delay) but do exhibit problematic
symptoms, diagnosed as an APD, that adversely affects their ability to function in a largegroup
environment.
CSHA CAPD Task Force Document 21
C. Related Special Education Laws
The present California Regulations and Laws (Part 30. Special Education Programs,
Article 3.1 3030) that pertain to this issue read as follows:
30 EC 56337 - Specific Learning Disability; Discrepancies
56337. A pupil shall be assessed as having a specific learning disability which makes
him or her eligible for special education and related services when it is determined that
all of the following exist:
(a) A severe discrepancy exists between the intellectual ability and achievements in
one or more of the following academic areas:
(1) Oral expression.
(2) Listening comprehension.
(3) Written expression.
(4) Basic reading skills.
(5) Reading comprehension.
(6) Mathematics calculation.
(7) Mathematics reasoning.
(b) The discrepancy is due to a disorder in one or more of the basic psychological
processes and is not the result of environmental, cultural, or economic disadvantages.
(c)The discrepancy cannot be corrected through other regular or categorical services
offered within the regular instructional program.
30 EC 56363 - Designated Instruction and Services
56363. (a) Designated instruction and services as specified in the individualized
education program shall be available when the instruction and services are necessary for
the pupil to benefit educationally from his or her instructional program. The instruction
and services shall be provided by the regular class teacher, the special class teacher, or
the resource specialist if the teacher or specialist is competent to provide such instruction
and services and if the provision of such instruction and services by the teacher or
specialist is feasible. If not, the appropriate designated instruction and services specialist
shall provide the instruction and services. Designated instruction and services shall meet
standards adopted by the board.
(b) These services may include, but are not limited to, the following:
(1) Language and speech development and remediation. The language and speech
development and remediation services may be provided by a speech-language pathology
assistant as defined in subdivision (f) of Section 2530.2 of the Business and Professions
Code.
(2) Audiological services.
5 CCR 3030 - Eligibility Criteria
3030. A pupil shall qualify as an individual with exceptional needs, pursuant to Section
56026 of the Education Code, if the results of the assessment as required by Section
CSHA CAPD Task Force Document 22
56320 demonstrate that the degree of the pupil's impairment as described in Section 3030
(a through j) requires special education in one or more of the program options authorized
by Section 56361 of the Education Code. The decision as to whether or not the
assessment results demonstrate that the degree of the pupil's impairment requires special
education shall be made by the individualized education program team, including
assessment personnel in accordance with Section 56341(d) of the Education Code. The
individualized education program team shall take into account all the relevant material,
which is available on the pupil. No single score or product of scores shall be used as the
sole criterion for the decision of the individualized education program team as to the
pupil's eligibility for special education. The specific processes and procedures for
implementation of these criteria shall be developed by each special education local plan
area and be included in the local plan pursuant to Section 56220(a) of the Education
Code.
(a) A pupil has a hearing impairment, whether permanent or fluctuating, which impairs
the processing of linguistic information through hearing, even with amplification, and
which adversely affects educational performance. Processing linguistic information
includes speech and language reception and speech and language discrimination.
(b) A pupil has concomitant hearing and visual impairments, the combination of which
causes severe communication, developmental, and educational problems.
Determining the best IEP category for an auditory processing disorder is challenging, but
the mechanism for special education eligibility is already present in the California special
education laws under the category of learning disability (3030 j). Because there is an
aspect to APD that is largely perceptual in nature, this category may be appropriate,
particularly in the absence of an audiologist on staff.
However, because APD is an impairment of the auditory system, confirmed by an
audiologist, one can also make a case to use the label hearing-impaired to describe this
disorder. This is the most common category used by private practitioners using a medical
model, and sometimes used in schools. We recommend that, in the absence of defined
local guidelines, school districts select either the category of “specific learning
impairment” or “hearing impairment” to qualify a child with APD for special services.
D. The IEP
Upon receiving an APD assessment and diagnosis from the audiologist, the team needs to
examine this data in the context of the child’s presenting symptoms, observations in the
classroom, and other formal testing. The team then determines eligibility for special
education services and develops an individualized, appropriate IEP, if indicated. Since
APD is often a secondary educational label to other conditions, several specialists may
need to be involved in the implementation of the IEP.
Upon determining an APD diagnosis, you will need to develop an appropriate I.E.P. In
California, IEP team members typically include the SLP, resource specialist, school
psychologist, classroom teacher, and program specialist. In cases where an APD
CSHA CAPD Task Force Document 23
diagnosis is being considered, an audiologist trained in this area should be included in the
IEP team.
1. As a team, decide what other special education services are necessary for this
child to succeed. (e.g. resource, reading specialist, psychologist, OT)
2. Make sure all staff that has contact with the child is aware of the child's auditory
weaknesses as one would with a hearing impairment.
3. Identify appropriate teaching and testing modifications.
4. Make recommendations for modifying the classroom environment.
5. Determine if assistive listening devices (FM or Sound-Field) are necessary or
should be utilized on a trial basis.
6. Implement direct services by the SLP and/or other trained personnel specifically
to improve auditory skills.
7. Select supportive technology that could supplement or compensate for the child’s
deficits.
The role of the speech-language pathologist: The SLP should provide language testing,
preliminary auditory-based language skills testing, direct intervention, as well as
facilitating classroom management and communicating with other professionals to insure
goals are being coordinated. He or she may also monitor the need or use of assistive
listening devices if trained, recommend acoustic or teaching modifications, and refer for
supportive academic/technology services.
Case manager: The SLP or audiologist should be the “manager” for a child with a
primary diagnosis of APD if it is the sole or primary handicapping condition, however
the case manager is typically the resource specialist if the child qualified under the
“specific learning disability” category.
The role of the audiologist: The audiologist diagnoses the disorder, may make specific
therapeutic recommendations, carry out therapy, monitor the need or use of assistive
listening devices, recommend acoustic or teaching modifications, and refer out for
supportive academic and technology services in keeping with the ASHA scope of
practice statement (2004).
The Recommended Professional Practices for Educational Audiologists (EAA, 1997)
states that audiologists: “1) provide identification and assessment information, ideally as
a member of an interdisciplinary team, for students suspected of having APD; and 2)
provide information to the student, parents, teachers, and other school personnel
concerning auditory strengths and limitations of students with APD, as well as possible
learning and teaching strategies for the classroom and other learning environments that
assist the student with APD to learn and manage the auditory environment to his or her
best advantage.” In other words, the audiologist must interpret the results of the APD
evaluation for all interested parties, determine areas of deficit for specific intervention,
and monitor the classroom environment of students with APD.
CSHA CAPD Task Force Document 24
The 504 Plan At some point, a child may no longer require direct intervention, but
continue to require acoustic and/or educational modifications in order to function in a
school setting. A 504 plan is set up to ensure that appropriate modifications are
implemented in order to compensate for