ArticlePublisher preview availableLiterature Review

It Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children

June 2015
24(2):124-136

DOI:10.1044/2015_AJA-14-0037

Source
PubMed

Authors:

Purpose The purpose of this article is to review the literature that pertains to ongoing concerns regarding the central auditory processing construct among school-aged children and to assess whether the degree of uncertainty surrounding central auditory processing disorder (CAPD) warrants a change in current protocols. Method Methodology on this topic included a review of relevant and recent literature through electronic search tools (e.g., ComDisDome, PsycINFO, Medline, and Cochrane databases); published texts; as well as published articles from the Journal of the American Academy of Audiology; the American Journal of Audiology; the Journal of Speech, Language, and Hearing Research; and Language, Speech, and Hearing Services in Schools. Results This review revealed strong support for the following: (a) Current testing of CAPD is highly influenced by nonauditory factors, including memory, attention, language, and executive function; (b) the lack of agreement regarding the performance criteria for diagnosis is concerning; (c) the contribution of auditory processing abilities to language, reading, and academic and listening abilities, as assessed by current measures, is not significant; and (d) the effectiveness of auditory interventions for improving communication abilities has not been established. Conclusions Routine use of CAPD test protocols cannot be supported, and strong consideration should be given to redirecting focus on assessing overall listening abilities. Also, intervention needs to be contextualized and functional. A suggested protocol is provided for consideration. All of these issues warrant ongoing research.

The recommended assessment and intervention process for children with listening and communication difficulties in the classroom.

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It Is Time to Rethink Central Auditory

Processing Disorder Protocols

for School-Aged Children

David A. DeBonis

Purpose: The purpose of this article is to review the

literature that pertains to ongoing concerns regarding the

central auditory processing construct among school-aged

children and to assess whether the degree of uncertainty

surrounding central auditory processing disorder (CAPD)

warrants a change in current protocols.

Method: Methodology on this topic included a review

of relevant and recent literature through electronic

search tools (e.g., ComDisDome, PsycINFO, Medline,

and Cochrane databases); published texts; as well

as published articles from the Journal of the American

Academy of Audiology;theAmerican Journal of Audiology;

the Journal of Speech, Language, and Hearing Research;

and Language, Speech, and Hearing Services in

Schools.

Results: This review revealed strong support for the following:

(a) Current testing of CAPD is highly influenced by nonauditory

factors, including memory, attention, language, and executive

function; (b) the lack of agreement regarding the performance

criteria for diagnosis is concerning; (c) the contribution of

auditory processing abilities to language, reading, and academic

and listening abilities, as assessed by current measures, is not

significant; and (d) the effectiveness of auditory interventions for

improving communication abilities has not been established.

Conclusions: Routine use of CAPD test protocols cannot

be supported, and strong consideration should be given

to redirecting focus on assessing overall listening abilities.

Also, intervention needs to be contextualized and functional.

A suggested protocol is provided for consideration. All of

these issues warrant ongoing research.

After many years of discussion, the reality of central

auditory processing disorder (CAPD) as a diag-

nostic construct is still far from any scenario that

would put an end to the ongoing questioning of both its

existence and its value. The concept of CAPD as a unique

diagnostic entity that could be assessed and treated in

school-aged children continues to engender controversy.

Cacace and McFarland (2005) described the current status

of CAPD construct as stalled; Cowan, Rosen, and Moore

(2009) referred to the auditory processing-related research

as “stagnating”(p. 188); and even proponents of CAPD

have admitted that the persistent lack of evidence validat-

ing the nature of the disorder and the most appropriate

test protocol threatens its viability as a diagnostic entity

(Bellis, 2002; Dawes & Bishop, 2009; DeBonis & Moncrieff,

2008).

The purpose of this article is to review the literature

that pertains to ongoing concerns regarding the central

auditory processing construct among school-aged children

and to assess whether the degree of uncertainty surrounding

CAPD warrants a change in current protocols.

CAPD and Auditory Processing

Disorder (APD)

It may be helpful to first clarify the use of the terms

central auditory processing disorder and auditory processing

disorder. CAPD was the original diagnostic term used for

individuals who were believed to “exhibit sensory process-

ing deficits that are more pronounced in the auditory mo-

dality”(American Speech-Language-Hearing Association

[ASHA], 2005, p. 2). Jerger and Musiek (2000), working

with 14 scientists and clinicians, recommended use of the

latter term in an effort to avoid attachment of specific ana-

tomic loci to the disorder and to better reflect peripheral

and central contributions to the auditory difficulties. Although

ASHA (2005) continued to support the use of the CAPD

terminology, they also conceded that the terms could be used

The College of Saint Rose, Albany, NY

Correspondence to David A. DeBonis: debonisd@strose.edu

Editor and Associate Editor: Larry Humes

Received July 31, 2014

Revision received December 10, 2014

Accepted January 11, 2015

DOI: 10.1044/2015_AJA-14-0037

Disclosure: The author has declared that no competing interests existed at the time

of publication.

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Background: Some individuals have a normal audiogram but have listening difficulties (LiD). As many studies have investigated the relationship between listening and developmental disorders, the traits of developmental disorders might explain the symptoms of LiD. In this study, we examined the traits of developmental disorders of adults with LiD to help clarify the cause of LiD symptoms. Methods: In total, 60 adults with LiD and 57 adults without LiD were included. Participants completed a questionnaire for the autism spectrum quotient (AQ) test, the Adult Attention-Deficit Hyperactivity Disorder Self-Rating Scale (A-ADHD), the Adolescent/Adult Sensory Profile (SP), and the severity of subjective LiD in daily life. Results: Before analysis, we excluded participants with LiD who were already diagnosed or met the criteria for autism spectrum disorder (ASD) or ADHD, and the results of the remaining 30 participants (50.0%) with LiD were analyzed. Adults with LiD showed higher scores than those without LiD in the AQ. Attention switching in the AQ and attention ability in the A-ADHD scale were correlated with the severity of LiD symptoms in everyday life. The AQ scores were also significantly correlated with subscales of the SP. Conclusions: Adults with LiD showed greater autistic traits than those without LiD; therefore, LiD symptoms are possibly related to autistic symptoms. Furthermore, adults with LiD might have attention disorder traits of both ASD and ADHD and sensory processing problems. These findings suggest that the attention problems in adults with LiD noted in previous studies might be related to these traits of developmental disorders.

Can emphasis on temporal processing inform literacy intervention design?

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The aim of this minireview is to explore the relationship between auditory (AP) and phonological processing and to probe potential ‘cascade effects’ on literacy development. The overall purpose of this study is to specify auditory deficits in language and literacy outcomes to inform intervention. Important underpinnings of language and literacy development and characteristics of AP, phonological processing, and phonological awareness in children with literacy disorders in light of auditory processing skills. Children with language and literacy impairments experience difficulties processing temporal and/or spectral changes in acoustic stimuli resulting from atypical neural synchronization. On a behavioural level, studies have revealed a relationship between temporal processing skills (e.g., rise time discrimination, frequency modulation sensitivity) and literacy development. While research remains inconclusive on intervention efficacy centred on auditory processing, this review serves as the stepping stone for investigating intervention methods focused specifically on temporal processing. Frameworks associated with literacy deficits and interventions may benefit from auditory modality-specific assessment and interventions.

Preliminary Validation of the Children's Auditory Performance Scale (CHAPS) and the Auditory Processing Domain Questionnaire (APDQ) in Greek Cypriot Children

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Background: Identification of auditory processing disorders is achieved using questionnaires along with linguistic, non-linguistic, and auditory processing tests. Notably, the questionnaires "Children's Auditory Performance Scale" (CHAPS) and "Auditory Processing Domain Questionnaire" (APDQ) are widely recognized and used. The current study investigated the psychometric properties of the CHAPS and APDQ in Greek Cypriot children. Methods: The CHAPS and APDQ questionnaires were completed by parents of 40 Greek Cypriot children, 16 typically developing (TD) children, and 24 children with a history of Speech Sound Disorders (SSDs). Results: There were significant differences between the two groups on both questionnaires. Cronbach's alpha was calculated at α = 0.922 for the CHAPS total score and α = 0.926 for the APDQ total score. The Receiver Operating Curve (ROC) analysis provided a cutoff point equal to −0.30 (AUC 0.849, p < 0.001) for CHAPS and a cutoff point equal to 90.00 (AUC 0.820, p < 0.001) for APDQ. Significant positive Spearman ρ correlations were observed between the CHAPS and APDQ (ρ = 0.639, p = 0.001). Conclusions: The CHAPS and APDQ can identify distinct auditory processing characteristics between in children with SSDs and TD children.

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A-Weighting for All? Acoustic Assessment for an Aurally Diverse Population

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Executive summary 1. The aim of this report is to review whether A-Weighting accurately represents the hearing of the whole UK population, to explore the consequences if it does not, and to make recommendations for future research to address the problems identified. 2. The approach taken was to first research the construction of A-Weighting from its root in early research on loudness perception and the development of the equal loudness contours. We then identified three groups of interest, who may not be well represented by A-Weighting. These are people with age-related hearing loss, neurodivergent people, and noise-sensitive people. These groups were chosen because they each represent a different kind of hearing difference, and they are all a substantial size. 3. A detailed literature review was conducted to examine the available evidence of hearing differences in the three groups and to discuss how these relate to A-Weighting and its uses. We reviewed 540 papers and cite 182 in this report. This dataset was then analysed to identify significant research gaps and suggest future research to fill them. 4. A-Weighting was found to be a significant way in which the assumption of normal hearing is embedded in a very wide range of acoustic assessment and legislation. This is because A-Weighting was developed from the equal loudness contours, and the contours are produced from measurements on a relatively small sample of otologically normal people-18-25-year-olds with no hearing impairment. This is important because A-Weighting extends far beyond its original use to convert sound levels into loudness estimates and is now found in most assessments and control of noise worldwide, from product design to environmental noise. 5. People with age-related hearing loss represent 7.9% of the UK population. Age-related hearing loss is caused by degradation of the hair cells' transducer mechanism in the inner ear. Among other effects, this typically causes problems with masking, where it becomes harder to pick a target speech sound out of a noisy background. Because background noise is usually quantified using A-Weighting, and A-Weighting models normal hearing, this may mean that the enhanced need for reduced background interference is often not met for this group. 6. Neurodivergent people (who include autistic people, those with attention deficit hyperactivity disorder (ADHD), dyslexia, dyspraxia, dysgraphia, dyscalculia, and Tourette's) make up about 10% of the UK population. Evidence was found of auditory processing differences for autistic people, and for people with ADHD and dyslexia. The auditory processing differences occur at a low level in the brain and can result in difficulty separating out sound signals, especially when trying to listen to someone speak against a background of competing speech. It is likely that enhanced background noise targets would improve the experience of this group, but it is currently difficult to translate the laboratory findings on auditory processing into new noise assessment methods. There is too little evidence for people with dyspraxia, dyscalculia, dysgraphia and Tourette's to base a conclusion on. 7. People who are noise-sensitive represent 17-50% of the population. In this report, this group included people who are more sensitive to general noise, people with misophonia and people with hyperacusis. For this group, the widespread use of A-Weighted sound level to predict noise annoyance is likely to significantly underpredict their heightened response. Hyperacusis is very common in autistic people, and it is particularly likely that A-Weighted levels do not represent the experience of this group. 8. It is not possible to simply adapt the A-Weighting curve to better fit any of the groups at this time. Partly this is because of lack of data on how to adjust, but mostly it is because most of the differences in sound perception are not equivalent to a simple transformation in loudness. The exception is for people with hyperacusis, where more detailed data on their loudness responses might enable a new weighting to be derived. 9. The overarching research gap identified is a lack of translational research. There is a need for research that builds on existing laboratory studies of hearing differences and translates them into guidelines for practitioners to assess sound and design spaces suitable for people with atypical hearing. 10. We also identify nine specific research gaps and projects to address them: a. Acoustic guidelines for spaces for people with a hearing impairment b. Acoustic design guidelines for people with auditory processing problems c. Accurate estimate of the numbers of noise sensitive people in the UK d. Loudness for people with age-related hearing impairment e. Loudness functions for autistic people with hyperacusis f. Equal loudness contours for autistic people with hyperacusis g. Demographic factors as a modulating effect on neurodivergent hearing h. Loudness functions for people with hyperacusis i. Psychoacoustic factors in misophonia Of these, we suggest that the first three are the most important. 11. This report represents an initial exercise in a much larger project for acoustics to respond to the aural diversity movement-the idea that a wide range of different kinds of hearing differences exist, in contrast to the assumed binary division of normal hearing and impaired hearing. This project could be repeated with other groups of people, such as those with noise-induced hearing loss, Meniere's disease, or many other conditions.

Masking Effects Caused by Contralateral Distractors in Participants With Versus Without Listening Difficulties

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Objectives To examine the effects of distractor sounds presented to the contralateral ear on speech intelligibility in patients with listening difficulties without apparent peripheral pathology and in control participants. Design This study examined and analyzed 15 control participants (age range, 22 to 30 years) without any complaints of listening difficulties and 15 patients (age range, 15 to 33 years) diagnosed as having listening difficulties without apparent peripheral pathology in the outpatient clinic of the Department of Otolaryngology-Head and Neck Surgery, Tohoku University Hospital. Speech intelligibility for 50 Japanese monosyllables presented to the right ear was examined under the following three different conditions: “without contralateral sound,” “with continuous white noise in the contralateral ear,” and “with music stimuli in the contralateral ear.” Results The results indicated the following: (1) speech intelligibility was significantly worse in the patient group with contralateral music stimuli and noise stimuli; (2) speech intelligibility was significantly worse with contralateral music stimuli than with contralateral noise stimuli in the patient group; (3) there was no significant difference in speech intelligibility among three contralateral masking conditions (without contra-stimuli, with contra-noise, and with contra-music) in the control group, although average and median values of speech intelligibility tended to be worse with contralateral music stimuli than without contralateral stimuli. Conclusions Significantly larger masking effects due to a contralateral distractor sound observed in patients with listening difficulties without apparent peripheral pathology may suggest the possible involvement of masking mechanisms other than the energetic masking mechanism occurring in the periphery in these patients. In addition, it was also shown that the masking effect is more pronounced with real environmental sounds, that is, music with lyrics, than with continuous steady noise, which is often used as a masker for speech-in-noise testing in clinical trials. In other words, it should be noted that a speech-in-noise test using such steady noise may underestimate the degree of listening problems of patients with listening difficulties in their daily lives, and a speech-in-noise test using a masker such as music and/or speech sounds could make listening problems more obvious in patients with listening difficulties.

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