The Hearing Test & Treatment Advice

Dr. Xxxxx :
CENTRAL AUDITORY PROCESSING ASSESSMENT AND ADVICE

Sample Test Result
for an Imaginary Patient :Peter

ASSESSMENTS FOR HEARING: These form a basic initial assessment of a child who is believed to have dyslexia or speech/language difficulties.

Pure Tone Audiogram
Pure-tone audiometry checks hearing thresholds across the frequency range of 250Hz to 8 kHz in the left and right ears.

Impedance Audiometry
Impedance audiometry indicates middle ear pressure and tympanic membrane mobility in both ears. This result may change within minutes if air is popped into the ear.

Hearing Test results

AB Word Lists  
These Measure the ability to discriminate and repeat single words presented in quiet listening conditions.

E.g. Right Ear         
30dB SL presentation level   -    89% correct
50dB SL Presentation level   -    93% correct
E.g. Left Ear           
30dB SL presentation level    -    81% correct
50dB SL presentation level    -    95% correct Back to Dyslexia top 
Peter presents with normal hearing thresholds across the speech frequency range in both ears.

Peter scored within the acceptable range for speech discrimination – the identification of single words in quiet listening conditions. 
Dichotic Digits (DD): In this test pairs of numbers (1 to 9, except the number 7), are presented to both ears at the same time. This test measures the ability to process information presented to both ears simultaneously, with the sounds (numbers) being presented to each ear being different.

E.g. Right Ear 78 % correct
E.g. Left Ear 92% correct

In this result the right ear hearing test result is below average for age. This task examines the ability to integrate information (sounds) from both ears at the same time, so the result should be considered to possibly show an area of concern.

Word test list for hearing

Pitch Pattern sequence Test (PPS):
This test asks the child to report the pattern of three tone sounds presented to each ear individually, in one of six combinations e.g. low-high-low. It assesses the processing of frequency discrimination, temporal ordering and linguistic labeling. These skills relate to the child's ability to recognise acoustic contours such as rhythm, timing, stress and intonation, which are important in understanding the meaning of a sentence.

Result: The child performed very poorly on this test and the test had to be aborted. There were no correct results from either ear. The child was completely unable to identify the sequence pattern or to transfer this information across to the language area of the brain. The child was unable to correctly respond to questions about two tone sequences e.g. high-low 100% of the time.

Random Gap Detection Test (RGDT):
Several pairs of tones are presented to the child (via earmuffs). The child is required to indicate whether one or two sounds were heard. The silent pause between each pair of tones increases and decreases in duration, until the smallest time interval that can be identified between two tones is reached. This test explores the process of temporal resolution. This is important in phoneme recognition and thus the perception of speech.

Normal listeners have a gap detection threshold of between 2 to 20 msec.
Our test subject for example could not detect any gaps across the test range of 2 to 40 msec.

Selective Auditory Attention Test (SAAT):
This test assesses selective attention in hearing in a quiet environment and in the presence of a competing message e.g. a story about crocodiles. The child is required to discriminate between six similarly sounding words in these two different listening environments.
E.g. Score:
100% in quiet and 38% in noise
Percentile rank < 5%

With the addition of a competing noise source (speaker), the child's ability to discriminate between similar words was severely affected.

Paediatric Sentence Identification: (PSI):
A sentence describing one of five set pictures is presented to the listener. At the same time, a different sentence, not talking about the set picture is presented to the other ear. This monaural low redundancy speech tests assesses the ability; to perceive a whole message when a portion of the auditory signal is missing or distorted. E.g. When the speaker has an accent or is slurring their speech

Example Test Result
Right Ear:
95% Correct at 0dB Message/ Background Noise competition Ratio
55% Correct at –10dB Message/ Background Noise competition Ratio
Left Ear:
95% Correct at 0dB Message/ Background Noise competition Ratio
35% Correct at –10dB Message/ Background Noise competition Ratio

When the competing noise (Speaker) became louder than the “Task” voice, the child was unable to maintain focus and concentration. The child’s ability to “identify sentences” was significantly worsened despite the repetitive nature of the task, the small number of the test items and the assistance of picture clues and sentence cues. 

Time Compressed Sentence Test (TCST)
In this test, compressed sentences are presented to each ear. Compressed sentences are accelerated or “speeded up” without a change in pitch. This assessment explores the child’s ability to understand acoustically distorted (Sound distorted) speech or rapid rates of speech. This happens for example, when someone is speaking quickly.

Sample Test Result:
Right Ear
85% correct at 40% time compression
75% correct at 60% time compression
Left Ear
80% correct at 40% time compression
68% correct at 60% time compression

This child is scoring below the range of normal for each ear. This indicates a weakness in auditory closure. This is the ability to use context (speech environment) clues to understand speech that is difficult to listen to despite the lack of background noise.

Auditory Numbers Forward:
This test assesses rote memory of non-meaningful sounds in a sequence, such as in a list of numbers that gradually increases in length.
This child scored at the 5th percentile.

Auditory Numbers Reversed
This test assesses attention to and brain manipulation of heard material, such as a list of numbers that gradually increases in length. As the number sequences are dictated, the child needs to repeat them back to the speaker in reverse order. This reflects working memory skills, (a very short term of memory which stores memories such as numbers just long enough for us to understand them).
Percentile rank: 10% scored by this example child

Auditory Sentence Memory:
This test assesses rote recall of meaningful material in sequence, such as sentences. Sentences give context clues that assist memory
This child scored at the 5th percentile for this test, which is significantly below averages for children her age. Visual imagery and verbal rehearsal can be used and the test repeated. The poor sentence recall result indicates that the child is unable to utilize language contextual clues to assist memory function.

Percentiles:
For those of you have not run across this concept: A percentile is a value on a scale of one to one hundred that indicates a percentage of e.g. children who have scored lower than the given test result. Thus a percentile above 75th is considered above normal and a percentile below the 25th is regarded as below normal. The 50th Percentile is regarded as average or normal.

However Peter experienced difficulty across all other areas of assessment in Central Auditory Processing Testing 

Binaural integration – the ability to process information presented to both Ears simultaneously, with the information being presented to each ear being different.(i.e. Different sounds are given to each ear, with the brain required to combine the two separate sounds into one sound). 
Temporal resolution – the detection of subtle timing differences, which is essential for the ability to recognize "prosodic" aspects of speech such as  Rhythm and Stress patterns. 

Frequency discrimination and temporal ordering – the detection of subtle differences in pitch, and the correct labeling (appreciation or interpretation )of such changes. This is an Integral part of discrimination between similar words.

Auditory Closure – the ability to understand the whole word or message when a part of the word or message is missing.

Auditory Figure Ground – the ability to relegate certain sounds in the background (ignore them) whilst selecting others as the focus of attention. 

Auditory Memory – the recall of the acoustic signal after is has been stored labeled and manipulated.

Children's Paill Spectrum symptoms: a presentation.

In Summary, Peter's results indicate significant central auditory processing weaknesses in all areas of assessment, which would be considerably impacting on learning ability.

Results show the child can hear sounds, words and sentences and repeat them back.

However, the child falls well behind peers of similar age, when required to derive meaning from the speech and understand the gist of what has been said . 

Peter has poor temporal processing skills, which means he/she is unable to detect subtle timing, rhythm, stress and intonation changes.  These cues allow us to discriminate between similar words for example time/dime past/fast and can also mean the difference between a statement and a question.  Differences in stress patterns can help the listener identify key words as well as change the meaning of the message.  Intonation provides cues about the speaker’s intent and the emotional colour of a conversation.

Because of the inability to utilise prosodic cues embedded in our speech and language, conversation may well become a meaningless sequence of words. Hence, when the child gets tired, distracted or the listening environment is less than ideal, children with temporal processing weaknesses often misunderstand or misconstrue what they hear. This can result in them jumping to erroneous conclusions and having hurt feelings from the misunderstandings they experience.

Peter's results also indicated a weakness in interhemispheric communication within the brain.  The child had difficulty transferring information from the spatial area to the language area of the brain and showed a weakness in integrating and separating information presented to each side simultaneously. 

Behaviorally, children with binaural integration weakness have difficulty bringing information together, such as sound symbol association or a connection between their emotional affect and their speech.  They also take longer to answer questions and they need more time to integrate information to formulate and answer.  In response, the child will often ask for repeats to clarify intent and buy extra time, even though they actually heard the question or statement in the first place.

Peter experienced difficulty in the task of auditory closure. 
In the time compressed test, the child was required to repeat back sentences presented through the headphones.  The items were distorted not by the intrusion of noise, but by increasing the speed of the speech.  This means that natural and slight gaps that normally appear in the discourse are exaggerated.  Normal listeners use intrinsic redundancy to fill in missing or distorted parts of an auditory signal and so recognize the whole message. 

This Child’s results suggest a weakness in the ability to use such intrinsic redundancy.  If we are unfamiliar with the speaker, or the topic, or if it is a random question, those gaps are often too great to mentally fill and we ask for repeats, even though we have heard most of what was said.  This repeated request for repetition may become an annoying habit. 

Tactics to improve communication include removing oneself from a noisy environment and ensuring they know what is being discussed
For example,  referring to the exciting episode of Home and Away on TV last night- TV off, no other conversations nearby, and orienting people to the discussion before starting the discussion: one step at a time.

Learning in a classroom is affected by Paill Spectrum. From promise to disaster, all too often.

Learning Deficit / Dyslexia treatment

A helpful strategy for this child would be to paraphrase or even speak a little slower or clearer.

In the selective auditory attention test, the child was required to discriminate between sets of six similar words. For example: rocks socks box fox locks docks.  IN quiet listening conditions, the child was able to successfully identify each item across the test.  However when a background speaker was introduced, the child found the task of concentrating of the task, voice and using the auditory cues to identify the words difficult.  As this test involved words not sentences, the child did not have contextual cues or intrinsic redundancy to assist. 

If in a difficult listening environment, the child misunderstands a key word in a phrase or question, he/she may totally lose the thread of the discussion and become very confused. 

The child also demonstrated a significant weakness in auditory memory skills.  Auditory memory refers to the ability to retain, recall and sequence auditory material.  The 3 most important factors that influence auditory memory are meaning, length and complexity.  The more meaningful the material, the shorter the presentation and the simpler the language, the easier it will be to remember. 

An auditory memory deficiency may result in several difficulties, such as:
Remembering familiar names
Difficulty learning new information
Difficulty with rote memory of sequential information e.g. phone numbers or the alphabet
Difficulty following a series of steps or instructions

This child may also have difficulty with reading comprehension if he/she is not able to remember what was read in the previous passage, paragraph or chapter.  Auditory memory is also critical in developing and understanding of cause and effect or consequence, and one’s ability to mentally plan and organise one’s self and work. 

In view of the significant weaknesses observed across the auditory processing spectrum, further language and cognitive assessments are recommended for this child. 

So after all this incredibly complicated assessment of deficits and problems, no-one still knows what caused the problem with the child. The only treatment is education, which will obviously often fail due to "bad parenting", if the opinion of the educators is sought. The parents in turn generally blame poor teaching. Then again perhaps the kid is just another dumb kid.

Where can the real answers lie.

Sample Therapies

SO WHAT CAN BE DONE TO HELP THIS CHILD :
GENERAL CLASSROOM TIPS/MANAGEMENT STRATEGIES

Slow the rate of speech.  Slowing the speech rate may give the auditory system an opportunity to perceive features that may have been missed during more rapid productions.
Reduce Background Noise.  Sources of background noise can include fans, fish tanks, open doors or windows, TV and radio.  Open classrooms are poor environments for children with Central Auditory Processing difficulty. 

Preferential Seating.  Give good visual access to the teacher and avoid seating by open doors and windows.
Repetition rather than rephrasing.  Repetition allows for the filling in of any missing components, whereas rephrasing provides a whole new message with new holes to be filled in. 
Pre-teaching new information or new vocabulary.  It is easier to fill in the gaps of a message when more familiar with subject matter under discussion.
Gaining his/her attention before speaking.
Frequent checks for comprehension of instructions or directions. 
Generous use of positive reinforcement to maintain motivation.
Avoidance of auditory fatigue – using listening breaks or periods of time when listening is kept to a minimum.

Use of visual and /or multimodality cues and hands on demonstrations to supplement verbally presented information.  
Provision of a note taker and /or written notes before class.

Memory Improvement Strategies
The child may benefit from employing several memory strategies to enhance the retention of information.  These include:
Mnemonic techniques such as:
Chunking – breaking down long messages, lists, or information into smaller components and grouping similar concepts or objects together.
Elaboration – by using analogies and acronyms. 
Reading information into a pictorial representation.  This involves reducing the Overall Message into a picture that illustrates the main concept.  However, it is Important that the picture accurately reflects the main idea of the message.

Set steps of a task or information to music (tunes or rhythm) or motion.  Memory can be enhanced when the information is accompanied by a catchy tune or illustrative hand movements.  The verbal rehearsal involved in repeating the message this way serves to reinforce the memory

Interhemispheric Exercises for Assisting the Child

Interhemispheric exercises can be a fun way to practice at home with parent and/or sibling involvement.

Verbal to motor transfers: Children are instructed to find a particular object or  Shape with the left hand from a grab bag or behind a screen where they cannot see the object.

Motor to verbal transfer: This occurs when the above process is reversed.  Children find objects with their left hand and are instructed to verbally label their shape, texture etc.

Music therapy can assist dyslexic learning.

Music therapy can be a fun repetitive remediation activity.  Musical instruments that require  coordinated movement of both hands, such as the piano, are most useful.

Activities involving singing require both linguistic output (left hemispheric function) and melodic expression (right hemispheric function).  Also listening to songs and then answering comprehension questions about the lyrics is another Interhemispheric activity.

Drawing pictures from verbal directions is another verbal to motor transfer exercise.. Alternatively the child can describe the picture as he or she draws. Back to Dyslexia top 

Dyslexia writing test

Noise desensitization
This may benefit a child with poor speech discrimination in noisy environments.  It involves gradually building a tolerance for a variety of types and levels of noise and then having the child perform harder and harder tasks in those noises.

Begin with noise similar to that produced by an air conditioner (white noise) and progress to a middle ground type of noise that varies a little in frequency and volume but repeats a pattern, like the noise rain makes when falling or a dishwasher noise.  Finally with a cafeteria type noise, noisy playground type noise or noisy classroom type noise which is the most difficult to tolerate. 

Temporal Patterning Training
Children with temporal patterning deficits tend to have difficulties recognizing the acoustic contours of speech, the prosodic aspects of speech (such as rhythm, stress and intonation) and a general difficulty discriminating subtle changes in sound.  The following activities can be helpful.  Variations on the theme are encouraged, particularly if your child becomes bored with a particular activity.  Start with the simplest activity e.g. discrimination between same vs. different and move on once that task has been mastered. 

The goal of Temporal Patterning Training is for the child to first discriminate differences in and then analyse and imitate, rhythmic patterns of sound.  Begin with short (three elements) patterns that may be clapped, tapped on the table or done in any manner that will hold the child’s attention.  Play games or perform activities that involve listening to the differences in the sounds.

For example:
Get your child to indicate whether two patterns of sound are the same or different.  Alternatively, get your child to imitate the patter exactly.  Alter the patterns in terms of speed (by increasing or decreasing the interval between claps) relative loudness ( by placing more emphasis randomly on claps) and rhythm (by including silent intervals).  In addition, the rhythms may be made gradually more complex by adding more elements, up to seven or eight.

Once the child has mastered discrimination and imitation of nonverbal sounds, introduce sequences of words.  The child’s task may to be to determine which of three words was different e.g. tick tack tick.  Begin with words that are easiest to discriminate and them move to more difficult stimuli e.g. pen pin pen. 

Introduce sentences of three or four words, once of which has more stress placed on it, then the others.  The child’s task is not to derive meaning from the sentences but merely to indicate which of the four words was emphasized.  The same sentence may be used over and over again, each time stressing a different word e.g. YOU are going home, You ARE going home, you are GOING home, you are going HOME.  

Following work with words, focus on sentences in which subtle difference in stress temporal cuing or other prosodic features alter the meaning of the entire sentence e.g. Don’t touch that BOOK versus Don’t touch THAT book . At first the stress and rhythm characteristics of each sentence will need to be exaggerated. 

However, once the child becomes familiar with the task, the activities may be said in a more natural tone of voice.  The child should be led step by step by through the analysing the sentences for meaning depending on the stress and rhythm characteristics.  For example, in the sentence “Don’t touch that BOOK,” the implication is that the listener is not to touch books, although he may be permitted to touch other items.  However, in the sentence “Don’t touch THAT book,” it is clear that the listener is not touch one book in particular, although the touching of other books may be allowed. 

Directions following games are good tasks/activities helping to develop pattern recognition and order recognition. 

Auditory Closure Activities
Management of an auditory closure difficulty should include methods to improve access to auditory information through environmental modifications activities targeted at auditory closure, preteaching of new concepts and frequent repetitions of key messages.
The purpose of auditory closure activities is to assist the child is learning to fill in the missing parts of a message in order to perceive a meaningful whole.  The activities should be presented in a sequential fashion from least difficult to most difficult.  The child should demonstrate mastery of one level before moving to the next. Back to Dyslexia top 

Incomplete sentence test.

Missing word Exercises.
These exercises are designed to teach the child to use context to fill in the missing word in a message.  It is best to begin with very familiar subject matter and then move to new information.  For example, when working with a very young child, the teacher/parent may wish to begin with familiar songs or nursery rhymes in order to familiarize the child with the task of listening to the whole in order to predict the missing part.  For example, the following rhymes may be used:
Twinkle twinkle little ……………………………(star)
Little Jack Horner sat in the  ……………………. (corner)
Hey Diddle Diddle the cat and the …………………(fiddle)
In these examples, the child’s task would be to fill in the missing word.  It may surprise some teachers/parents  to find that, even with a great amount of external redundancy due to familiarity of the message, some children will exhibit difficulty with even this simple task.  In this case, and at all stages of auditory closure activities, the child should be talked through the process and prompted with questions such as, “what word comes next when you sing the song?”, “What word would rhyme with “Horner” and make sense of this sentence?”.

A slightly more advanced activity is to predict rhyming words.  For example the teacher/parent may ask the child, “Can you name an animal that rhymes with house?” If the child is unable to perform the task, prompts should be given that guide the child in solving the puzzle.  For example, the child may be instructed to begin at the beginning of the alphabet and substitute the initial consonant of the word with different letters until the correct consonant is reached. (aouse, bouse, couse, douse etc.).  If the child is demonstrating difficulty with the concept of rhyming, the initial consonant of the target word, in this case "M", may be provided for the child, requiring him/her to add it to the remainder of the word "ouse" to derive the whole “mouse”.  A third method is prompting.

Alphabet = Symbolic Speech Symbols

A useful strategy for when the child correctly chooses an initial consonant and combine it with the remainder of the word to derive a meaningful, but incorrect word (e.g. douse), may be to draw the child’s attention to the key word or words in the clue.  In this situation, the teacher/parent would remind the child that while douse is indeed a word that rhymes with house, what is wanted here is an animal. 

Some examples of stimuli that may be used in this activity are as follows:
Colour that rhymes with bed (red)
Family member that rhymes with other. (Brother or mother)
Fruit that rhymes with beach (peach)
Once mastery of these steps has been demonstrated, the teacher/parent may move to new unfamiliar messages in which the child must us the context of the phrase, sentence, or paragraph in order to predict the missing component. 
When using this approach the teacher/parent should begin with simple sentences (e.g. “When I’m hungry, I ……………”), then more to more complex material, such as paragraphs in text books or popular novels. 

In addition, the teacher/parent should progress from omitting the subject or object of the sentence of phrase e.g. “Jill hit the ………..with a bat”, to omissions of verbs, adjectives and other parts of the message e.g. “Jill ……….. The ball with a bat”; “The water was so ………………, it took his breath away”. 

 The child should be prompted continually to use context to predict missing components, as well as to derive meaning from the whole message.  In addition, materials appropriate for this exercise can be taken from classes in which the child is demonstrating difficulty, in order to assist the child further in the understanding the class material. 

Vocabulary deteriorates in Paill Spectrum Dyslexia.

Missing Syllable Exercises
Once the child has demonstrated that he/she can predict a missing word based on context, the teacher/parent may move to omission of syllables. As with missing words, missing syllable exercises should be presented in a progression from least to most difficult.  Initially, the context should be familiar so that the child is best able to fill in the missing components of the target word. 

The teacher/parent may find that, even if the child is able to predict an entire missing word from a sentence easily, she may have great difficulty when only a portion of the target word is omitted.   In addition, achieving closure of words in which the initial syllable is omitted is a more difficult task than for words in which the final syllable is omitted.  Therefore, the teacher/parent should begin by omitting the final syllable of the target word and, once mastery is achieved, move to omission of middle and initial syllables. 

The teacher/parent may begin with sentences in which the target word is embedded e.g. there are 26 letters in the al-pha-….., and then gradually move to single words in which the only contextual cue may be a category designation e.g. sports: base……, soc……., ten…….  Gradually the child learns to become less dependent on hearing and decoding every component of the target word and more aware of the need  to use the surrounding context of the message if parts of it are unclear.

Missing Phoneme Exercises
Exercised in which specific phonemes are omitted may be carried out in a similar fashion to the missing syllable exercises.  Again, it is best to use a progression of least to most difficult, moving to the next stage only when the child has demonstrated mastery of the previous stage.  Therefore, the child should be able to supply the missing phonemes in words with contextual cues e.g. “I like to (w)atch (t)ele(v)ision”, before moving on to isolated words.  With these exercised, tape-recording the target sentences or words may be useful, as it may be difficult to perform the necessary phonemic omissions using a live voice approach. 

Again, when focusing on isolated words, it is helpful to provide general categories as a contextual cue e.g. Animals: ti(g)er, (m)on(k)ey, and to require master with final phonemes prior to moving on to middle and initial phonemes.

Other Auditory Closure Activities
Auditory closure activities may be performed in distracting or noisy situations to increase the difficulty of the task further.  In addition, variations in speakers, such as the introduction of accents, pronunciation errors, and other speaker-related characteristics may be utilized to help train the child to use context to achieve auditory closure.

 Vocabulary Building
An Activity that falls within the category of auditory closure activities is Vocabulary Building.  Just as a word may be indecipherable due to missing syllables or phonemes, requiring the listener to use context to predict the word, a word may be indecipherable due to the child’s lack of familiarity with the word or subject itself.  

Dyslexia test