In many children, it is related to maturational delays in the development of the important auditory centers within the brain.Hence they have difficulties in following areas;

1. Sound localization and lateralization

2. Auditory discrimination

3. Temporal aspects of audition including: temporal resolution,
temporal masking, temporal integration and temporal ordering.

4. Auditory performance with competing acoustic signals

5. Auditory performance with degraded signals

THE BEHAVIORAL MANIFESTATIONS OF CAPD?

1. Difficulty hearing in noisy situations

2. Difficulty following long conversations

3. Difficulty hearing conversations on the telephone

4. Difficulty learning a foreign language or challenging vocabulary words

5. Difficulty remembering spoken information (i.e., auditory memory deficits)

6. Difficulty taking notes

7. Difficulty maintaining focus on an activity if other sounds are present child is easily distracted by other sounds in the environment

8. Difficulty with organizational skills

9. Difficulty following multi-step directions

10. Difficulty in directing, sustaining, or dividing attention

11. Difficulty with reading and/or spelling

12. Difficulty processing nonverbal information (e.g., lack of music appreciation)

Test for Central Auditory Processing?

1. Filtered Words

2. Auditory Figure-Ground

3. Competing Words

4. Competing Sentences

5. Electrophysiologic tests

6. Dichotic Speech Tests

7. Temporal Patterning Tests

Management of the Central Auditory Processing Disorders (Katz/Bellis diagnostic classifications)

• Auditory decoding deficit

• Integration deficit

• Prosodic deficit

• Auditory associative deficit

• Output-organization deficit

Auditory decoding management

• Processes affected

• Affects monaural separation, closure; speech sound discrimination, temporal processes, Binaural synthesis and integration

• Environmental

• Preferential seating, assistive listening devices, pre-teach new information, repetition, visual augmentation

• Compensatory

• Auditory closure, vocabulary building, problem-solving, active listening, schema induction

• Direct remediation

• Phoneme discrimination, temporal resolution and/or integration, phonological awareness, word attack (speech to print) skills

Management of Integration deficits

• Affected processes

• Binaural synthesis/integration; Localization

• Environmental

• Acoustic enhancements, avoid use of multi-modality cues

• Compensation

• Metalinguistic and metacognitive strategies as needed

• Direct remediation

• Interhemispheric transfer, binaural skills using dichotic stimuli, sound localization

Prosodic deficit management

• Processes affected

• Auditory pattern, temporal organization

• Non-speech sound discrimination

• Environmental

• Placement with “animated teacher”

• Compensatory

• Memory enhancement, schema induction, use of prosody and social judgment

• Direct remediation

• Prosody perception, temporal patterning, pragmataics

Memory rehabilitation/training

• Sensory store - initial signal processing

• development of encoding/discrimination skills – auditory training

• Speech recognition

• Working memory – affected by speed and accuracy of encoding, capacity, and duration of short term store

• Rehearsal, memorization, mnemonics, and strategies (grouping, singing, elaboration)

• Slow rate, use familiar terms, pauses for processing

• Pattern recognition as a bridge to long term memory

• Vocabulary building

• Semantic mapping/associations

• Compensatory strategies – slow rate, prior information about topic, preparation

Attention

• Assistive listening devices

• Improves S/N

• Metalinguistic skill development

• What are critical elements?

• Focus on suprasegmentals

Modifications to the learning environment

• Goal is to reduce noise and reverberation.

• Considerations in building design.

• Sound dampening techniques

• Carpets, draperies, cork boards and acoustic tiles

• Tennis balls, felt on chair/table legs

• Preferential seating

Modifications to the teaching approach

• Repetition

• Attention getting devices/markers

• Oral and written instructions

• Classroom buddy

• Use of clear, concise, explicit language

• Frequent breaks – reduce fatigue

• Reduce oral exams and brief timed tests

• Waive foreign language requirements or accept ASL or symbolic language (non-oral)

Auditory Training

Rationale underlying deficit-specific auditory skills training

Bellis (in press) identified three fundamental assumptions that are critical to the utility of deficit-specific intervention for CAPD.

1. Fundamental auditory mechanisms and processes underlie and are important to more complex listening, learning and communication behaviors.

2. We are able at present, to isolate and identify precisely those auditory mechanisms or processes that are dysfunctional in a child.

3. Improvement in fundamental auditory processes will lead to improvement in functional listening skills in daily life. That is ultimate goal of deficit specific auditory training is to improve children’s ability to comprehend spoken language.

Direct Remediation Activities

A primary purpose of direct remediation is to attempt to alleviate the disorder through specific therapeutic activities, either by training the recipient how to perform a specific auditory task, or by stimulating the auditory system in hopes of facilitating a structural, and concomitant functional, change. The degree to which the dysfunction will be ameliorated through these activities varies and, indeed, cannot be estimated a priori for any given child. In fact, many of the activities that here are based primarily on what is currently known about how the brain and auditory system function and have little documented efficacy at this time.

Just as lack of stimulation may result in structural and functional neurophysiological alterations within the CANS, increased stimulation may, likewise, result in structural changes and functional improvement. Just as an unused muscle will atrophy and wither, a muscle that is exercised regularly in a challenging manner will grow in size and strength. So it may be with structures within the brain, if recent findings in neuroplasticity are any indication. It should be remembered, however, that the degree to which any remediation technique will serve to remedy the dysfunction will depend on the individual child, and efficacy of treatment activities awaits further research and validation.

It should be remembered that therapeutic techniques typically utilized by speech-language pathologists and associated professionals may also be useful for children with CAPD, particularly if they exhibit a language-based disorder These activities are presented in order to provide clinicians with a staffing point for therapeutic intervention once a diagnosis of CAPD has been made.

Direct remediation activities seek to train fundamental auditory mechanisms and processes such as auditory discrimination, localization, and temporal processing that underlie more complex auditory behaviors.

A second purpose of direct remediation activities is to teach specific compensatory skills that focus on deploying auditory processes in listening and learning environments. For example, auditory closure training and vocabulary building—two of the direct remediation activities that will be discussed —teach children how to use context (either spoken or written) to fill in missing components of a message so that the meaning of the overall communication is understood. By employing activities at both the auditory input and compensatory skills levels, we are able to bridge the gap between bottom-up and top-down processing and help to ensure that generalization to environments outside the therapy room will take place.

Remediation Activities for Auditory Closure Deficits

Children with deficits in auditory closure tend to perform poorly on tests of monaural low-redundancy speech, such as band-pass filtered or time-compressed speech. Because the intrinsic redundancy of the auditory signal is reduced, any extraneous factor that renders the message less clear or more difficult to hear will significantly impact spoken language comprehension.

Auditory Closure Activities

The purpose of auditory closure activities is to assist children in "learning to fill in the missing parts in order to perceive a meaningful whole. As such, context plays an important role in auditory closure, because prediction of the complete word or message often depends on the surrounding context.

1. Missing Word Exercises

These exercises are designed to teach children 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 very young children, clinicians may wish to begin with familiar songs or nursery rhymes in order to familiarize them with the task of listening to the whole in order to predict the missing part.

The children’s task would be to fill in the missing word. It may surprise some clinicians 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.

A slightly higher-level activity might be prediction of rhyming words. For example, clinicians may ask, "Can you name an animal that rhymes with house?" If children are unable to perform the task, prompts should be given that guide them in solving the puzzle.

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 ( mother, brother).

Once mastery of these steps has been demonstrated, clinicians may move to new, unfamiliar messages in which children must utilize the context of the phrase, sentence, or paragraph in order to predict the missing component. When using this approach, clinicians should begin with simple sentences (e.g., When I'm hungry, I_______), then move to more complex material, such as paragraphs in textbooks or popular novels. In addition, clinicians should progress from omitting the subject or object of the sentence or phrase (e.g. Jill hit the _________ with a bat), to omissions of verbs, adjectives, and other portions of the message (e.g., Jill ___________ the ball with a bat; The water was so __________, it took his breath away.

Missing Syllable Exercises

Once children have demonstrated that they can predict missing words based on context, clinicians may move to omission of syllables.

Initially, the context should be familiar so that children are best able to fill in the missing components of the target word. Achieving closure for words in which the initial syllable is omitted is-a-more difficult task than for words in which the final syllable is omitted. Therefore, clinicians should begin by omitting the final syllable of the target word and, once mastery is achieved, move to omission of medial and initial syllables.

Clinicians may begin with sentences in which the target word is embedded (e.g., There are twenty-six 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 _________).

Missing Phoneme Exercises

Exercises in which specific phonemes are omitted may be carried out in a fashion similar 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 children have demonstrated mastery of the previous stage. Therefore, children 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 exercises, 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. With specialized equipment, phonemes can be electronically edited from isolated words or running speech, thus preserving the coarticulation characteristics of the surrounding phonemes—a situation that will most closely resemble real-life speech. Some of the computer-assisted auditory skills training programs currently available commercially already include such phoneme deletion auditory closure activities.

Speech-in-Noise Training

Virtually any method whereby the external redundancy of the acoustic signal is reduced may be utilized to train auditory closure skills. Therefore, auditory closure activities such as those discussed in the previous sections may be undertaken in distracting or noisy situations to increase the difficulty of the task further. In addition, variations in speakers, such as the introduction of regional dialects, misarticulations, and other speaker-related characteristics may be utilized to help train children to use context to achieve auditory closure.

Remediation Activities for Binaural Separation/Integration Deficits

Children with deficits in the processes of binaural separation or binaural integration exhibit difficulty processing auditory input in the presence of competing signals. Thus, performance on dichotic listening tasks typically is poor, with either ear-specific effects (e.g., left-ear deficit) or bilateral effects noted.

Furthermore, some children (e.g., those with Prosodic or Associative Deficit) may exhibit poor performance on dichotic listening tasks but have little or no functional difficulty in binaural listening environments. In these cases, the dichotic listening findings appear to be the diagnostic manifestations of cortical dysfunction but, because of intact auditory closure and related skills, they may pose little or no barrier to listening in noisy or competing environments. Therefore, it is important that clinicians analyze the presenting difficulties of children who perform poorly on tests of dichotic listening to determine precisely what, if any, intervention is indicated in the areas of binaural separation and/or integration. Two types of remediation activities for binaural separation/integration deficits will be discussed in this section: dichotic listening training and localization training.

Dichotic Listening Training

Dichotic Training

In dichotic listening training, the relative intensity of signals presented to each of the two ears is varied systematically while children are instructed either to attend to both ears (integration) or attend to the target ear only (separation). Because of the acoustic control necessary for this task, equipment capable of recording channel-specific information is required. Local radio stations can be extremely instrumental in providing assistance with digitizing channel-specific stimuli.

. The-steps of binaural separation dichotic training paradigm are as follows:

1. Determination of beginning target-to-competition intensity ratio. It is important to begin this exercise on a note of success, both to encourage children to participate willingly in the activity and to engage them in the story plot. Therefore, the initial ratio chosen should be one that allows the children to hear the target messages clearly while, at the same time, being aware of the competing message to the opposite ear. For some children, the competing message will need to be barely audible whereas others may begin at a more challenging target-to-competition ratio. The target message should be delivered to the weaker (usually left) ear while the competing message is delivered to the stronger (usually right) ear. Children are instructed to listen to the story presented in the target ear and told that they will be asked to summarize the story plot after the activity is completed.

2. Manipulation of target-to-competition ratio. Once children are engaged in the task and interested in the story line, the intensity of the competing signal is gradually increased to render the directed listening task more challenging. This increase usually takes place over several sessions, and the rapidity with which such increases can be implemented will differ from child to child. The goal is to increase the difficulty of the listening task while, at the same time, maintaining interest, motivation, and success on the part of the listeners.

3. Readjustment of target-to-competition ratio as needed. If children begin to exhibit significant frustration with the task or are unable to summarize the plot after each session, the intensity of the competing signal should be decreased to a manageable level for one or more sessions before increasing it once again. It should be noted that difficulty summarizing the plot may also occur if the language level of the material is too challenging for a child. Therefore, the choice of target material should be made with the specific child's language abilities in mind. For some children, novels can be used so that they are provided with the target message in the form of daily installments of an ongoing plot line. For others, however, short children's books that are written at elementary language levels and can be completed in a single sitting may be a more appropriate choice.

Binaural integration skills can also be trained in a similar manner. However, because of the need for attention to messages delivered to both ears, the signals should be equally interesting and far simpler than ongoing story material. As such, it’s more difficult to engage children's attention, interest, and motivation in binaural integration tasks. Furthermore, because children rarely need to listen to two competing signals simultaneously in their daily environments, binaural integration training may have far less ecological application than would training in binaural separation skills.

Auditory Language Training Approaches.

Two training programs serve as a good training for Auditory Language Training Approaches.

1. Work book based approach developed by Christine Sloan (Sloan, 1986).

2. Earobics – A well known computerized program.

These two general AT programs focus on basic phonemic awareness, and acoustic discrimination and identification using speech language tasks. Because these programs cover auditory language training in broad terms they can be used to treat some of the associate phonologic awareness deficits often presented by individuals diagnose with CAPD.

Earobics includes some exercises with time – and – intensity altered stimuli, which certainly supports temporal training. The focus of this program, however is directed to phonological awareness training. Several versions of Earobics are available for different age levels. ( 4- 7, 7- 10, adolescent and adult), as well as a version for home use. The home version is a valuable tool that allows the clinician to extend training in to the home.

AT with preschool children

Finding the target sound of a word

An adult read a story to a child or group of children. Before reading, the children are asked to listen for a certain word or sound that occurs in the story. The children are required to raise their hands each time a target word or sound is heard or to keep track of the number of times the target is heard and report at the story’s end. The later variation trains memory as well as selective attention. The former variation might interfere with comprehension; therefore it is important to encourage the listener to attend to the story and not only to the individual target.

Localization

The child is blindfolded and asked to point to the location of the person who is speaking while roaming across the room. Task difficulty can be increased by reducing the length or intensity of the speech segment produced at any given location.

Walking and Listening

While accompanying a child on an outdoor field trip, the child is encouraged to listen for sounds and to label these environmental sounds when heard. ( e.g; dog barking). This activity can be combined with localization requiring the child to point to location of the sound after labeling the sound.

Following Directives

The child is asked to follow one, two, or three step motor tasks verbally conveyed by a parent or teacher. ( e.g; go to the kitchen and turn on light). The child should be able to easily perform the required motor activity.

Interhemispheric Processing

Practice at transferring the information from one hemisphere to another can be a valuable training task – especially with the long maturational course of the corpus callosum. Playing” name that tune” likely requires activity between cortices. Also, having children close their eyes and name objects felt with their left hand also is an enjoyable game that likely requires information exchange between hemispheres.

Listening to Rhymes

Exposing young children to nursery rhymes, ad well as singing songs, helps develop temporal processes that underlie prosody. These activities are enjoyable, employ accessible and varied material, and can be done repetitively without the child tiring or becoming bored.

Musical Chairs

It requires a number of auditory, motor and cognitive processes. Sustained attention is pivotal to the multiple processes and skills trained through this game. Children walk around chairs ( equal to the number of children at the outset of the game) set in a circle while music plays in the background. The game can be modified to increase the challenge by having the children listen for specific targets with in the music.( eg., when the music becomes louder or softer sit down). Also, the time between musical segments can be varied greatly introducing unpredictability and challenge that should exercise the child’s ability to maintain attention to the task.

Localization Training

Sound source localization is fundamental to binaural hearing, including speech-in-noise, abilities. If children demonstrate little or no progress during speech-in-noise or dichotic listening training, or minimal carryover of binaural separation or integration skills to real-world listening situations, it may be necessary to train basic localization skills. This can be accomplished in a variety of ways. In the clinical environment, stimuli (either speech or nonspeech) can be delivered through multiple speakers set at various vertical and horizontal planes. Signals can be delivered either in isolation or in the presence of competing noise or multitalker babble. The child’s tasks simply to point to the speaker from which the target signal came.

Once again, because motivation and interest is critical to the success of any remediation activity, in which the task can be made to be fun and stimulating for the child enhances the opportunity for success. For example, children to use laser pointers to "zap" the target speaker once the sound source is localized or to allow children to change positions in a fun manner both to locate the sound source and to change the direction and S/N ratios of the localization cues.

Table 9.2

Summary of Binaural Separation/Integration Activities

· Dichotic listening training

· Establish beginning target-to-competition ratio

· Reduce target-to-competition ratio over time

· Readjust target-to-competition ratio as needed

· Localization training

· Sound room activities with speakers at various horizontal and vertical planes

· Children's games such as "Blind Man's Bluff" and "Marco Polo"

Several common children's games also train sound localization abilities. Chief among these are "Blind Man's Bluff and "Marco Polo," both of which involve blindfolding listeners and having them locate the other participants through voice cues alone. These games can provide an excellent opportunity for generalization of localization abilities to real-world listening environments in a fun, entertaining manner, especially for young children. Localization training may be indicated for any child with speech-in-noise or binaural separation, integration, or interaction deficits.

Remediation Activities for Temporal Patterning Deficits

Children with temporal patterning deficits may have difficulty perceiving subtle rhythm, stress, and other intonational (or suprasegmental) cue's in spoken language that provide illumination of the intent underlying the communication. As such, prosody training may be indicated for many of these children. Further, some children with temporal patterning deficits also exhibit difficulty in the perception and sequencing of basic sequential auditory patterns or contours, a skill that is fundamental to perception and use of prosody. For these children, training in sequencing basic rhythmic patterns may be indicated before specific training in the deployment of suprasegmental speech patterns for prosodic purposes can be undertaken. Therefore, this section describes two types of remediation activities for temporal patterning deficits: prosody training and basic temporal patterning training.

Remediation Activities for Auditory Discrimination and Temporal Processing Deficits

Children with CAPD may demonstrate deficits in auditory discrimination of speech or non speech signals. Certainly, the presence of discrimination deficits will affect many of the more complex auditory processes discussed in this and previous chapters. For example, phoneme discrimination is an important skill for achieving auditory closure in degraded or competing listening environments. A significant phoneme discrimination deficit will reduce the intrinsic redundancy of the signal, leading to greater reliance on external signal clarity. Similarly, the ability to discriminate between non speech sounds that differ in duration, frequency, or intensity is a prerequisite skill for the temporal patterning activities discussed in the previous section.

Temporal processing, is an even more basic auditory skill. Indeed, it has been hypothesized that auditory-based learning or language deficits may arise in some children because of a fundamental underlying deficit in the ability to process rapidly changing acoustic stimuli (e.g., Kraus et al., 1996; Tallal et al. 1996; Wright et al., 1997). Therefore, temporal processing training may be indicated for some children with CAPD, and many of the computer-assisted intervention programs are based largely on training children to process rapid acoustic stimuli.

Because both auditory discrimination and temporal processing are important to a wide variety of more complex auditory mechanisms and processes, they may need to be addressed either prior to or along with intervention focusing on skills such as auditory closure and temporal patterning. Although further research is needed in this area, it appears logical that children with such deficits would be served most efficaciously if direct remediation is directed toward these fundamental, basic underlying skill areas when needed, and that improvement in these areas will facilitate improvements in behaviors and skills that are reliant on auditory discrimination and temporal processing. Because discrimination and temporal processing are inextricably

Table 9-3.

Summary of Temporal Patterning Activities

· Prosody training

· Words in which change in syllabic stress alters meaning (e.g., convict versus convict)

· Sentences in which change in stress alters meaning (e.g., He saw the snowdrift by the window versus He saw the snow drift by the window)—exaggerated prosodic features

· Sentences as above—normal intonation

· Reading aloud with exaggerated prosodic features

· Key word extraction

· Role playing or charades games focusing on prosodic and nonverbal expression of emotion

· Basic temporal patterning training

· Same/different judgments of nonspeech or speech patterns differing in

· Pitch

· Stress

· Loudness

· Interstimulus interval

· Imitation of nonspeech or speech patterns differing in

· Pitch

· Stress

· Loudness

· Interstimulus interval

· Identification of stressed words within sentences (or stressed elements within a nonspeech pattern)

Environmental Modifications and class room based strategies

It should again be emphasized that the learning environment needs to be a highly redundant one. By this, children should be required to expend as little extra energy as possible in order to obtain critical information presented in the classroom. To accomplish this, classroom teachers and other involved individuals may need to be reminded that it is the ultimate desired outcome that is important , rather than the manner in which that

Classroom Management

For intervention to be effective, it is necessary to “ balance” treatment and management components.

The management team

The audiologist applies neuroscientific principles to assist in developing deficit specific treatment and management goals and strategies., to gauge the success of those strategies., and to extend intervention principles to all environments to maximize benefit.

Parents, family and other caregivers can offer important information regarding the disordr’s impact on the student’s day to day listening and wellbeing and, therefore, these individuals should also be considered integral to the intervention team.

Interactive intervention approach

The goal of intervention for CAPD should be to maximize the listener’s access to and use of incoming auditory information. To that one must identify the components of communication event. For any communication event, the three key components are the listening environment, the message and the listener.

Focus on the environment

It is estimated that up to 60 % of classroom activities involve students listening to and participating in spoken communication with teachers or the students,. ( ANSI, 2002). Thus, it is essential that classrooms be free of acoustic barriers. When assessing the listening environment, consideration should be given to both acoustic and non acoustic variables that can affect speech perception. Acoustic variables include presence, nature and presence of visual and/ or distractions. ( Ferre, 1997).

Background Noise

Background noise refers to any auditory disturbance in a room that interferes with listening. (Crandell & Smaldino, 2002). Noise with in a room can come from internal sources ( in the building but outside the room)., external sources ( outside the building), and in room sources. Background noise can adversely affect speech perception by masking the acoustic and linguistic cues of a message and by distracting the listener from the communication event. ( Crandell & Smaldino, 2002).

The audiologist use a sound level meter to measure the intensity of noise, as well as its spectral and temporal aspects which also contribute to the degree to which the noise interferes with listening . Speech spectrum noise , multi talker babble and “ real life “ in room noise appear to affect more adversely the speech recognition skills of young children , college – age students, and adults with academic difficulties than does pink or no speech like noise.

SNR becomes less favorable; speech recognition becomes poorer for all listeners. ( Cooper & Cuts, 1971). For listeners with normal hearing, speech recognition is not severely reduced until the SNR reaches 0 dB ( Scrandell & Smaldino, 2002). For very young listeners and those with hearing impairment , speech language disorders , limited English proficiency, academic disabilities , or CAPD , SNR s that are at least 2 to 15 dB more favorable than those needed by normal hearing listeners are required. ( Maxwell & Evans, 2000).

Reverberation

For normal hearing adults, recognition is not adversely affected until the RT exceeds 1.0 sec ; however for children with disorderd hearing, language processing skills , speech perception may be compromised at RTs as low as 0.4 sec( Flexer, 1995).

Classroom Noise Abatement

Classroom noise abetment programs should seek to maintain an SNR of atleast +15 with reverberation time of 0.4 sec or less. ( ASHA, 1995; 2005). Reverberation times can be somewhat longer ( i.e; 0.6 sec) in small and mid size classrooms upto 0.7 sec in larger classrooms , without degrading speech intelligibility fror normal hearing listners , provided an SNR of +15 or better is maintained .( ANSI ., 2002).

Improving classroom acoustic includes: reduction or elimination of open classrooms; relocation of teaching spaces awy from play grounds, building infrastructure changes such as double- paned windows, noise control devices, use of smaller or less irregular shape class rooms, changes in lighting fixture type ( from flurescent to incandenscent) and location; and lowere ceiling levels. Simpler and less expensive classroom noise abatement can be accomplished by ; closing windows; carpeting rooms; using curtains, drapes and/ or acoustic ceiling tiles; placing baffles within the listening spaces; and damping highly reflective surfaces.

In the home , parents and caregivers should be reminded about simple ways to reduce and minimize acoustic barriers to listening such as closing doors and windows; reducing radio, stero and television volume; using carpet and drapes; rearranging furniture and changing lighting ; and minimizing the number of speaker’s talking at the same time.

Distance from source

As distance from the speaker increase, the amount of reverberant sound tends to increase and dominate te signal. Boothroyd ( 2004) noted that for students seated near the back of a class room the signal was composed almost entirely of reverberant sound while listeners near the front of the room received almost all direct sound. He suggested that a distance of 3 to 6 feet from the source would create optimal audibility, with speech recognition decreasing beyond the critical distance.

Non acoustic factors

When assessing the physical space, attention n als oshould be given to non acoustic factors such as lighting, presence of visual cues, and presence of visul and physical distractions. Room lighting can affect ability to use visual cues and maintain attention on task. Replacing flurscent llighting wit hincandescent lighting not only eliminates the hum often produced by these lights, it also improves access to visual cues by reducing harshness and glare. Speakers should avoid being backlit, that is, standing with the light coming from behind the speaker rather than the on the speaker’s face. Teachers should be reminde to speak after looking down at their notes or writing on a board rather than while writing or reading.

Preferential classroom seating can be used to counteract the adverse effects of distance and poor lighting and enhance the listener’s ability to use available relevant visual cues. In preferential seatig , an effort is mae to maximize both the acoustic and visul aspects of the signal based on the summative benefits of bimodal processing. ( Sanders & Godrich, 1971). Th elistener’s speech perception is enhanced when seated neare the speaker. Th student with CAPD should be encouraged to look and listen to maximize speech reading opportunities. Schow and Nerbonne ( 1996) noted that speech reading is optimal at a distance of 5 feet from the speaker, decreasing significantly as distance from the speaker increasese. By placing the listener near and facijng the speaker at no more than 45 degree angle and away from distracting noise , both signal audibility and accessibility of speech reading cues are optimized. ( Ferre, 1997).

Focus on the Message

In addition to enhancing the enviorenment, attention should be given to management strategies that enhance the acoustic, linguistic , and related instructional language aspects of the signal or message. Acoustic signal enhancement can be accomplished through assistive listening technology and by using “ clear speech” techniques. Linguistic modification include rephrasing in formation and adding non auditory sensory cues. Instructional modifications include using preview material , adjusting length and type of message, and modifying response time and response mode.

Assistive Listening Technology

The ALD is designed to improve the SNR reaching the listener’s ears. Unlike traditional amplification where both the speech signal and the ambient noise are both amplified., the physical configuration of the personal ALD selectively amplifies the signal and has the effect of pulling the target signal away from the noise via mild gain amplification , there by pushing the noise further into the perceptual background. This results in a significantly more favorable SNR and, in turn, improved speech reception. Sound field FM (systems enhance the target signal for groups of listeners. When used with proper diagnosis and monitoring, assistive listening technology can lead to improved auditory attention , short term memory , auditory discrimination , and speech perception .

The fitting of ALD should never be undertaken lightly. It should begin with a trial period in order to evaluate effectiveness. The trial period should begin with baseline information regarding listening and comprehension behaviors, as well as baseline audiogram obtained prior to fitting. The decision to use the device on a regular basis should be made only after post trial data indicate benefit. Serial audiograms should be obtained on a regular basis during equipment use to monitor for possible adverse effects on peripheral hearing sensitivity. Under no circumstances should an auditory trainer or other assistive listening device be provided simply on the basis of a diagnosis of CAPD, without further corroborating evidence of need and careful, document efficacy. Even when personal or sound field assistive listening devices are used properly , children shoud be given frequent opportunities through out the day to listen in real word enviorenment. Research on auditory neuro plasticity , clearly shows that sensory deprivation can result in undesireable changes in central auditory pathways and concomitant functional skills. In one sense, the use of an FM or similar assistive listening dvice can be thought of asa form of sensory deprivation of sound localization and auditory figure / ground cues. Thus it s possible that consistent use of such devices over expanded periods of time for many years actually result inCANS alterations that reduce the ability to process such cues.

Furthermore, because assistive devices require listeners to put forth less effort to listen , some children may gradually lose the motivation to expend extra effort in real world listening situations. ALD should be limited to content- base academic classes in which important information is being imparted. During other times, such as recess and lunch , and during art, music, physical education , and group discussions children with CAPD should go without their devices relying instead on their auditory figure/ ground and related abilities to in order to understand spoken language.

Children suffering from Auditory Processing Disorders (APD) can benefit tremendously from ear level FM technology. First introduced in 2004, the benefits of the “EduLink” have been researched in many scientific studies. These studies show that children diagnosed with APD improve not only significantly their speech-perception in noisy class

rooms but also their academic performance and psychosocial status. Some studies even suggest that after prolonged use, even unaided (i.e. no FM) speech perception is improved suggesting a therapeutic effect. This presentation will review the principle of

the technology and summarize some of the latest research findings. Towards the end of

the presentation, we will outline the benefits of a totally new FM technology, called

“Dynamic FM”. With respect to traditional FM technology, “Dynamic FM” increases

dramatically the SNR at the ear and therefore the speech intelligibility. First successfully

applied for hearing impaired children, this technology has recently been integrated in a new ear level “Dynamic FM” device, called “iSense”, for children suffering from APD.

Clear speech

In “clear speech” the focus is on the improving speech recognition by modifying the speech of the talker . Schuman (1997) noted that in typical conversational speech it is not uncommon for speaker’s to articulate quickly., fail to project the voice, omit unnecessary or redundant sounds , and to run word and sounds together. These behaviors can adversely affect speech recognition not only for normal hearing listeners. ( Helfer, 1997)., but also for those with hearing loss and auditory – based learning disabilities ( Schumann., 1996).

A common complaint among students with CAPD is mishearing parts or all of the message. In clear speech, the speaker I strained to speak at a slightly reduced rate and to use a slightly increased volume. In so doing, spectral boundaries and characteristics are enhanced. Signal timing and prosody improves, and relative consonant – to vowel intensities increase. ( Krause & Braida, 2004).

Linguistic Modification

Other beneficial changes in the message involve alterations to the non acoustic and nonverbal aspects of the signal. By rephrasing a “misheard signal, the presents the listener with a more linguistically familiar and less ambiguous target, there by fostering improved comprehension. Adding complementary visual cues , examples, demonstrations, and manipulatives can improve understanding, particularly for unfamiliar or abstract information. Limiting the overall amount of information given at one time, breaking long message into shorter sequences, and adding or emphasizing “tag” words enhances message salience and understanding.

Instructional Modification

Pre teaching or previewing material is designed to enhance familiarity, and there by scaffold the listener’s overall comprehension challenge. In general, the more familiar one is with the target, the easier the processing becomes. For children with CAPD, knowledge of the rules, structure, task demand up front can minimize overload. It is important to note that for many of these children this knowledge is not acquired through mere exposure, but through explicit instruction, repeated practice and review across a variety of contexts and settings. ( Ferre, 2006). Close set questions were better than open end questions for the CAPD children. Scheduling “ listening breaks” in which auditory message demands are limited, can minimize this reported auditory overload.

Focus on the Listener

Students with CAPD need to understand and be able to respond to the question “ How can I change the environment, the message , or myself to improve the listening condition?” This can be done by;

1. Encouraging the students to use rules for good communication. ( Ferre, 1997). These 10 simple “rules” can help students can learn to monitor the listening environment, message quality, and their own listening behavior to manage the impact of the CAPD. In addition, top down compensatory strategies or central resource training can teach the student to use specific compensatory strategies to improve access to and understanding of auditorly presented information.

Summary

The environment modifications include

1. Acoustic intervention to reduce reverberation or noise and enhance S/N ratio

2. Use of assistive Listening Devices.

3. Preferential seating with good visual access to the teacher at an angle of no greatr than 45 degrees.

4. Frequent checks for comprehension of instructions or directions.

5. Employment of multimodality cues and hands- on demonstrations to argument verbally presented information.

6. Repetition

7. Rephrasing

8. Pre teaching new information or new vocabulary

9. Provision of a note taker

10. Gaining children’s attention prior to speaking

11. Generous use of positive reinforcement.

12. Avoidance of auditory fatigue.

13. Placement with an animated teacher.

Computer Based Auditory Training ( CBAT ) for children with CAPD.

`Most are in agreement that auditory training can be an effective intervention for children with CAPD. As the term implies, such training requires some form of auditory/ i/ which could be naturally or electronically produced. In order to propose a model to support the use of CBAT, there are three area to consider: meaningfulness of the stimuli, active versus passive interaction, and frequency of training.

Meaningfulness of the Stimuli

Stimuli for auditory training vary along two dimensions: natural versus synthetic, and speech versus nonspeech. The easiest stimuli to produce quickly, of course, are natural speech and these stimuli are likely the most meaningful to most individuals, particularly children. Synthetic speech, however, allows for more accurate control of parameters such as duration and intensity. Natural, nonspeech sounds (e.g., environmental sounds) are used less frequently, perhaps because of the lack of or reduced cognitive, association evoked to maintain interest The final category, synthetically produced, nonspeech signals such as tones or noise bursts would be least interesting.

Natural Speech Stimuli

Human speech is the typical input for naturally produced auditory stimuli. Perhaps the earliest formal auditory training programs that involved natural speech were those designed to enhance communication skills of persons with hearing loss (Carhart, I960; Wedenberg, 1951)., These programs generally involved a hierarchy of skills moving from awareness, to discrimination, to identification, and finally to comprehension. Depending on the age of the child and residual hearing, the parent or teacher would provide activities involving vocabulary that was meaningful to the child at that time.

Synthetic Speech Stimuli

Auditory training specifically designed for children with (QAPD often involves a dimension of speech processing requiring central integration, such as dichotic listening, phonemic synthesis, and/or temporal processing. Training in these areas requires more precise stimulus control, which is enabled through the use of synthetic speech or non speech signals.

Merzenich et al., 1996; Tallal et al., 1996. Created CBAT programs in which children were presented synthetic speech with modified acoustic cues to aid recognition. For example, recognition training might begin using speech tokens with second-formant transitions with durations twice that found in normal speech. As the child responds correctly, the transitions can be shortened gradually to normal values.

Focused (Active) Versus Unfocused (Passive) Experience

The rationale for CBAT must also include consideration of the role of attention in training. Much acoustic information is processed without attention seemingly focused on particular stimuli. For example, one may recall hearing a radio commercial when asked about it even though there was no specific task to record information or respond to that information. Throughout a typical day, there are numerous unfocused (i.e., passive) auditory events that are processed by the auditory system, but not necessarily acknowledged unless circumstances require specific recall of that information.

Perhaps the most common example of unfocused or passive auditory training in humans is the process of learning language by a normally developing infant. By 12 months of age, infants show discrimination patterns specific to the language to which they have been exposed auditorily, (Kuhl & Meltzoff, 1996). Another common, unfocused, passive auditory training experience occurs when listeners with hearing impairment receive hearing aids or cochlear implants. Adjustment to the new sound provided by the assistive technology occurs over time as the individual continually acquires more auditory experience. This is referred to as acclimatization and can occur over six weeks to two years (Cox & Alexander, 1992; Gatehouse, 1992, 1993; Horwitz & Turner, 1997; Tyler & Summerfield, 1996).

Unlike this passive (unfocused) auditory stimulation, auditory training with focused attention employs various techniques that require the listener to actively direct attention input specific formation in the stimuli. For example, pairing a visual stimulus with an auditory stimulus that is made progressively more difficult in a discrimination task or providing a reward for attending increases the likelihood of active, focused attention. Typically, focused auditory attention involves selection of specific stimuli for training (e.g., nonspeech gap detection or speech comprehension of stories). Stemming from findings with animals, research with humans has shown that, as a result of brain plasticity, the cognitive processes that underlie perception of certain acoustic cues can be trained. Improvements in perception following focused auditory attention have been shown for adults with hearing aids (Walden et al., 1981), children with cochlear implants (Zwolan et al., 2000), and children with language impairments (Tallal et al., 1996).

Frequency of Training

They reported that nine, 20-minute training sessions over five days resulted in significantly improved discrimination of voice onset time cues in synthetic speech by adults with normal communication (Tremblay, Kraus, Carrell, & McGee, 1997). Interestingly, changes in the mismatched-negativity potential (MMN) occurred after only four consecutive days of training in all 10 subjects, and significant behavioral changes in speech discrimination occurred in 9 of the 10 listeners (with additional training) on day 10 (Tremblay, Kraus, & McGee, 1998).

Specifically, measures were made of neural timing in the brainstem in response to the presentation of the syllable "da." Children in the training group showed improved stimulus encoding precision relative to the controls. The authors concluded that the training resulted in improvements in neural synchrony concomitant with improvements in perceptual, academic, and cognitive measures. This research suggests that with frequent auditory training, the ability to code information into auditory patterns that may facilitate perception may be enhanced.

Benefits of CBAT

CBAT offers several advantages relative to these principles and thereby facilitates training. These advantages include stimulus control, hierarchy of activities, and the inherently interesting vehicle that computers offer to engage children in intensive training.

Precise Stimulus Control

Through the use of synthetic speech and nonspeech stimuli, precise acoustic features can be manipulated and presented in a graduated sequence of difficulty. For example, if the child's template for the word "hotdog" did not include a brief silent interval between the stop consonants IU and /d/, then training to recognize small gaps would be productive so that when "hotdog" or other similar two-syllable words are presented, the templates may be refined to include this brief silence between syllables. Training may begin widi noise bursts with easily perceptible gaps and through precise digital manipulation the gap duration could be altered in a sequential manner. This is known as an adaptively con-trolled paradigm where the difficulty level is based on the response to the previous stimulus. For example, if a gap is correctly detected, then the next trial would have a smaller duration gap. If the response to that trial is incorrect, the next gap would be longer in duration to facilitate perception. A typical adaptive gap detection paradigm involves stimulus manipulation so that the participant can correctly detect the gap with 70% accuracy. This type of graduated training could not be accomplished via natural speech, despite repeated presentations of the stimulus word. If the participant is not able to detect that silence, then no amount of repetition of that same interval would facilitate perception.

An example of manipulating the stimulus in the frequency domain that is possible in CBAT involves the perception of second-formant transitions. If the participant is unable to hear the difference between "bad" and "dad," it is likely that he or she is not discriminating differences between second-formant transitions that cue the difference between the bilabial and alveolar placement. Repeatedly presenting stimuli that the participant cannot discriminate will not strengthen the accuracy of internal auditory representations. Training should begin with stimuli incorporating large changes in frequency that are greater than that which occur in real speech (Thibodeau, Friel-Patti, & Britt, 2001).

Access to Levels and Games

Another advantage of CBAT is the easy access to an appropriate training level that the digital format provides. Because the selection of the stimulus to be presented can be chosen based on the previous response (i.e., adaptive training), training becomes more efficient as the participant does not have to sit through either multiple trials where there is no success or where trials are too easy and the participant achieves 100% success. Furthermore, to maintain interest CBAT also easily allows the clinician to hold the training objective constant while changing the game scene. For example, rather than continue selecting a balloon that corresponds to a change in frequency, the scene may change after 3 minutes so that the child is listening for the monkey that made a different sound. Variety helps to maintain the child's attention and continue practicing to strengthen the auditory representation.

Convenience of Training

Computers are available not only in educational settings, but in most homes. According to a U.S. survey (Rideout et al., 2003), 73% of homesL with young children have a computer.

Table 6-1. Areas of Training for Children with (C) APD

Training Area	Possible Stimuli	Software
Awareness	Nonspeech or Speech	Otto's World Earobics Brain Train
Memory	Nonspeech or Speech	Brain Train Earobics Fast For Word Learning Fundamentals continues
Temporal Processing, Including Sequencing	Nonspeech or Speech	Fast For Word Earobics
Localization	Nonspeech or Speech	None
Auditory Discrimination	Nonspeech or Speech	Fast For Word Otto's World
Auditory Pattern Perception	Nonspeech or Speech	Brain Train Earobics Fast For Word Learning Fundamentals
Phonologic Awareness	Speech	Conversation Made Easy Earobics Fast For Word Foundations in Speech Perception Learning Fundamentals
Auditory Synthesis	Speech	Learning Fundamentals Earobics
Dichotic Processing (Binaural Integration)	Nonspeech or Speech	None
Identification	Nonspeech or Speech	Brain Train Earobics Fast For Word Sound and Beyond
Degraded Speech Recognition (Filtered Speech, Compressed Speech, Speech-In-Competition/ Noise, Auditory Closure)	Speech	Conversation Made Easy Earobics Learning Fundamentals
Binaural Interaction	Nonspeech or Speech	None
Binaural Separation	Nonspeech or Speech	None
Comprehension	Speech	Brain Train Conversation Made Easy Earobics Fast For Word Learning Fundamentals
Auditory Vigilance	Nonspeech or Speech	Brain Train Learning Fundamentals

Table 6-2. Hierarchy of Training

				.VeryWicult \|
Stimuli	Natural Speech	Synthetic Speech	Natural Nonspeech	Nonspeech Synthetic
Competing Noise	No Noise	Single Noise	Two Talker Babble	Multitalker Babble
Noise Level	N/A	+10 SNR	OSNR	-10 SNR
Situation Cues	Pictures present	Pictures precede task	Single word cue	No Cue

Table 6-3. Hardware Requirements for Operating Fast ForWord® Training Programs

Operating Systems	Windows 98SE Windows 2000 Professional Service Pack 4 Windows XP Home or Professional Service Pack 2 or later
Processor	500 MHz Intel or AMD Processor
Memory	256 MB RAM or higher
CD-ROM Drive	8x or faster
Video Card/Monitor	Maximum supported resolution of 800 x 600 with thousands of colors
Sound Card	Any Creative Labs or 100% compatible sound card, including Sound Blaster 16 (or 32), PCI 64, or 16-bit VIBRA series products Note: Integrated sound cards are not recommended
Mouse	Any Microsoft or compatible mouse (required)
Keyboard	Any Microsoft or compatible keyboard (required)
Hard drive space needed for installation	1. Approximately 40 MB for a one-product installation 2. Approximately 10 MB for each additional installation 3. Optional space for installing multimedia content: 100 MB for Fast ForWord Language Basics 510 MB for Fast ForWord Language 460 MB for Fast ForWord Middle and High School 410 MB for Fast ForWord Language to Reading 100 MB for Fast ForWord to Reading Prep 360 MB for Fast ForWord to Reading 1 310 MB for Fast ForWord to Reading 2 175 MB for Fast ForWord to Reading 3 300 MB for Fast ForWord to Reading 4 250 MB for Fast ForWord to Reading 5
Hard drive space needed to run the product	1. 1 MB per participant, per product for backup creation 2. 1 MB per participant, per product for entire machine archive 3. 1 MB per participant, per session to expand files and creation of data files
Internet connection, if needed	56 k.p.s. or faster Note: Direct connection is recommended Note: Internet connection is required for Progress Tracker

Considerations for CBAT in Schools

The use of CBAT in the schools has been addressed in previous sections regarding interfacing with FM systems, avoiding distracting ambient noise, and group training arrangements. There are three other important considerations, however, which involve the actual installation of the soft-ware, licensing, and interfacing with the current service delivery options.

An important consideration for CBAT in schools is knowing how many students will use the software. Multiple site licenses will be more cost-effective for large group applications. Prior to adding software to school-based computers that may be part of a network, technical support for the network should be consulted regarding installation requirements. In many cases, there are designated personnel to manage software installations to be sure that compatibility requirements are met. As mentioned above, CD ROM-dependent software may be more difficult to manage as young children or busy teachers have to organize data disks or software CD's for training sessions.

Communication strategies

· Cognitive & Language management

· Recording improvement in therapy

Definitions

In recent years, there has been a dramatic upsurge in professional and public awareness of Auditory Processing Disorders (APD), also referred to as Central Auditory Processing Disorders ((C) APD).

Broadly stated, (Central) Auditory Processing [(C) AP] refers to the efficiency and effectiveness by which the central nervous system (CNS) utilizes auditory information. Narrowly defined, (C) AP refers to the perceptual processing of auditory information in the CNS and the neurobiological activity that underlies that processing and gives rise to electrophysiological auditory potentials.

(C)AP includes the auditory mechanisms that underlie the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination (e.g., temporal gap detection), temporal ordering, and temporal masking; auditory performance in competing acoustic signals (including dichotic listening); and auditory performance with degraded acoustic signals (ASHA, 2005; Bellis, 2003; Chermak & Musiek, 1997).

Non-modality-specific cognitive processing and language problems may manifest themselves in auditory tasks (i.e., as listening problems); however, diagnosis of (C)APD requires demonstration of a deficit in the neural processing of auditory stimuli that is not due to higher order language, cognitive, or related factors. This working group concluded after a comprehensive review of the literature that any definition of (C)APD that would require complete modality-specificity as a diagnostic criterion is neurophysiologically untenable; however, one should expect the sensory processing perceptual deficit in (C)APD to be more pronounced, in at least some individuals, when processing acoustic information. (C)APD is best viewed as a deficit in neural processing of auditory stimuli that may coexist with, but is not the result of, dysfunction in other modalities.

(C)APD can also lead to or be associated with difficulties in learning (e.g., spelling, reading), speech, language, attention, social, and related functions. Because of the complexity and heterogeneity of (C)APD, combined with the heterogeneity of learning and related disorders, it is to be expected that a simple, one-to-one correspondence between deficits in fundamental, discrete auditory processes and language, learning, and related sequelae may be difficult to demonstrate across large groups of diverse subjects. This underscores the need for comprehensive assessment and diagnostic procedures that fully explore the nature of the presenting difficulties of each individual suspected of having (C)APD.

Intervention

Intervention for (C)APD typically requires an interdisciplinary approach involving the audiologist, speech-language pathologist, and other professionals, and should be implemented as a collaborative effort by the audiologist and speech-language pathologist (and possibly others) as soon as possible following the diagnosis to exploit the plasticity of the CNS, maximize successful therapeutic outcomes, and minimize residual functional deficits. Treatment and management goals are deficit driven and are determined on the basis of diagnostic test findings, the individual's case history, and related speech-language and psychoeducational assessment data.

Treatment and management of (C)APD should incorporate both bottom-up (e.g., acoustic signal enhancement, auditory training) and top-down (i.e., cognitive, metacognitive, and language strategies) approaches delivered consistent with neuroscience principles (e.g., training should be intensive, exploiting plasticity and cortical reorganization; training should be extensive, maximizing generalization and reducing functional deficits; training should provide salient reinforcement to induce learning).

Bottom-up approaches are designed to enhance the acoustic signal and to train specific auditory skills. Top-down approaches provide compensatory strategies designed to minimize the impact of (C)APD through the strengthening of higher order central resources (i.e., language, memory, attention) that individuals with (C)APD may draw upon to buttress deficient auditory processing skills not fully remediated through auditory training.

Introduction to management

A number of broad, guiding themes appear in the current APD intervention literature (ASHA, 2005; Bellis, 2003, 2006; Ferre, 2006). One of the themes is that the intervention for (C) APD should be implemented as soon as possible following the diagnosis to exploit the plasticity of the CNS, maximize successful therapeutic outcomes, and minimize residual functional deficits. Also the intervention must be comprehensive.

The Recommended Professional Practices for Educational Audiologists (1997) include the following in the statement regarding the role of Educational Audiologists in the assessment and management of (C) APD:

· Provide identification and assessment information, ideally as a member of the interdisciplinary team, for students suspected of having (C) APD.

· Provide information to the student, parents, Teachers, and other school personnel concerning auditory strengths and limitations of the student. As well as possible learning and teaching strategies for the classroom and other learning environments that assist the student with APD to learn & manage the auditory environment to the best of his advantage.

· Counseling parents about what an (C) APD actually is helps the child inadvertently and therefore may be one of the audiologists most important to the overall process.

COMPENSATORY METHODS

Central resources training

METACOGNITIVE STRATEGIES

Metacognition refers to the active monitoring and consequent regulation and orchestration of attention, memory, learning and language processes in the service of some goal (Flavell, 1976). Although (C)APD by definition isn’t a metacognitive disorder, the experiential deficit surrounded by individuals with (C)APD in processing the auditory signal can lead to metacognitive deficits, as metacognition develops through experience in a skill based context, such as spoken language processing (Harris, Reid, & Graham, 2004).

Strategies used for listening comprehension rely upon the followings kills and processes:

1) Understanding task demands

2) Appropriately allocating attention

3) Identifying important parts of the message

4) Self monitoring

5) Self questioning

6) Deployment of debugging strategies (Chermak & Musiek, 1997)

Individuals with (C) APD may require direct instruction and opportunities for application and reinforcement. (C)APD intervention programs may incorporate several metacognitive approaches, all of which promote active, self regulation and share several distinctive features (Chermak & Musiek, 1997).

Ø Attribution training

Chronic listening problems and the often associated academic or workplace failure, as well as the social frustrations places individuals with CAPD at risk for developing motivational problems. Attribution problems occur, then, when these individuals attribute successes to luck, an easy task, or the benevolence of co- worker or clinician (Bryan, 1991).

Components:

It is a 2 step procedure. The client is confronted with some failure. The key component involves teaching the client to attribute the failure to insufficient effort. The clinician might tell the client that his or her answer wasn’t correct, that he or she is working hard but he should listen even more carefully. In a parallel manner, the clinician should attribute successes to effort, providing feedback that the response was correct and acknowledging that the listener was listening carefully and trying hard. The wording of attribution statements should acknowledge hard work while urging even greater effort (Miller. Brickman, & Bolen, 1975.)

Ø Cognitive Behavior Modification

It depends on a client’s use of strategies, notably executive and task specific strategies (Lloyd, 1980) with the goal of self control through a reflexive processing and response style, a client instructed in Cognitive Behavior Modification employs monitors, checks and evaluated behavioral strategies (Brown et al, 1981). Critical to this approach is the informed and active client.

It is classified into 3 categories: Self Instruction, Problem Solving And Self Regulation (Whitman, Burgio, & Johnson, 1984). All Cognitive Behavior Modification procedures include:

1) Client involvement as active collaborators

2) Target strategies modeled during training

3) A reflective processing and response style

4) Analysis of the relationship between the client’s actions and the task outcome (Meichenbum, 1986)

Also shared across the procedures is the use of daily logs or diaries.

Self Instruction: it trains clients to formulate adaptive and self directing verbal cues before and during a task or situation. In addition to listening training, self instruction is particularly useful in addressing academic difficulties, including reading comprehension problems, and impulsive and hyperactive behaviors (Wong, 1993). 5 sequential steps are outlined:-

a) The clinician performs the task while self verbalizing aloud

b) Client performs the task while the clinician verbalizes

c) Client performs the task while self instructing aloud

d) Client performs the task while whispering.

e) Client performs the task while self instructing silently.

Cognitive problem solving: It offers clients opportunities to resolve problems through systematic analysis and self regulation. Basically a 5 stage process, the clinician serves as a consultant as the client learns to reconceive the potentially anxiety-producing listening situation as a problem to be solved.

Perhaps the most important stage of problem solving, the process begins with by familiarizing oneself with the nature of the problem (D’Zurilla1986). The second stage requires the generation of hypotheses regarding the solutions to the problem. In the third stage, one evaluates the solution options, considers their utility and predicts possible costs or consequences, and selects the best one. The fourth stage is bifurcated. If a viable solution is found, it’s implemented; if no solution is deemed tenable, the incubation phase is expended towards solving the problem. 5^th stage is the process which involves the monitoring and evaluation of one’s performance in relation to solving the problem. Self monitoring homework assignments are useful in measuring progress. Self reinforcement for successful problem solving should lead to enhanced self efficacy and generalization of the process (Haaga & Davidson, 1986).

Self-Regulation procedures: It leads clients towards self control through self monitoring, self evaluation, and self reinforcement. Training begins by increasing awareness of the behavior targeted for control and proceeds by teaching goal setting and self monitoring skills for behavioral chance. Qualitative monitoring of performance involves the client noting factors such as attitude and emotional state, whereas quantitative monitoring measures successful performance. The client self evaluates favorably if information obtained through self monitoring matches his or her standards or listening comprehension goals.

Ø Reciprocal Teaching

The client and the clinician alternate roles in reciprocal teaching, allowing the client to take the role of teacher as well as student (Chermak, Curtis, &Seikal, 1996). Reciprocal teaching has produced demonstrated gains in reading comprehension, self-monitoring, memory, and health education, including hearing conservation (Aarnoutse et al., 1998; BrandGruwel et al., 1998; Chermak et al., 1996)

The following principles and procedures underlie it:

a) Modeling of the target behavior by the clinician –teacher

b) Contextual modeling of strategies

c) Verbal analysis of the strategies used by the client to comprehend the message

d) Clinician’s feedback

e) Transfer of responsibility for comprehension from clinician to client once competence in demonstrated by client (Harris & Spay,1990)

Ø Cognitive Style and Reasoning

Effective listening requires reasoning to critically evaluate and ultimately reconstruct the messages we hear, as well as the flexibility to invoke the cognitive style that best meets changing task demands (Chermak & Musiek, 1997). Inflexible reasoning and sole reliance on any one cognitive style is ineffective in meeting the diverse processing demands of a complex linguistic signal often presented in challenging (and unfavorable) listening environments (e.g., noisy and reverberant). Dependence on a single cognitive style such as overreliance on literal interpretation, for instance, could lead to failure to comprehend figurative language such as metaphors, idioms, and proverbs (Bard, Shillcock, & Altmann, 1988)

Individuals with (C)APD should be trained to take advantage of specific information revealed through bottom-up processing (e.g., auditory segmentation, auditory discrimination, pattern recognition), as well as more global information extracted from top-down processes that facilitate auditory and grammatic closure, inferencing, and recognition of conceptual nuances (Chermak & Musiek, 1997).

Individuals with (C)APD may benefit from exercises that reveal the advantages of analysis and reflection prior to synthesizing information and converging on an interpretation of a complex message. Given the importance of cognitive style flexibility for spoken language comprehension, training individuals with (C)APD to vary their cognitive styles provides them the opportunity to become appropriately responsive listeners (Chermak & Musiek, 1997).

Deductive and Inductive Inferencing

Effective listening requires use of the full range of cognitive approaches to information processing and reasoning, including both deduction and induction and analysis and synthesis (Chermak & Musiek, 1997).

Inductive inferencing involves generalization, reasoning from the particulars to the general; deductive inferencing involves reasoning from the general to the particular (Nickerson, 1986). Spoken language comprehension often requires that individuals infer information not specifically presented in the message, but which may be implied and induced or deduced from the available patterns of information.

Inferencing skills can be developed through the context derived vocabulary building technique described later in this chapter. Also useful are short stories requiring inferencing on the basis of perceptual information, logic, and/or evidence. Attention to the appropriate use of diverse cognitive styles (e.g., divergent/convergent, impulsive/reflective, adaptive/innovative, synthetic/analytic, field dependent/field independent) should also be introduced in therapy (Chermak & Musiek, 1997).

Ø Assertiveness Training

It empowers individuals and advances all intervention goals. Assertion can be defined as “self expression through which one stands up for one’s own basic human rights without violating the basic human rights of others” (Kelley, 1979).

It typically involves a verbal exchange, whereby the individual formulates and delivers an assertive message (Kelley,1979). Non verbal skills also influence message impact. The non verbal aspects of the message, including paralinguistics elements (vocal intensity, intonation, rhythm), kinesics (facial expressions, posture, gestures), and proxemics (distance between parties, seating arrangement); reinforce assertiveness [Chermak, & Musiek, 1997]. Assertiveness training techniques involve modeling, guided practice, coaching, homework and self management, readings, small group discussion (Kelley,1979).

COGNITIVE STRATEGIES

Cognition refers to the automatic and unconscious processes that underlie the activity of knowing (Nickerson,1986). Cognitive processes allow the listener to transform, reduce, elaborate, store, recover, and use sensory input. Attention and memory are 2 primary and highly interdependent and interactive cognitive resources (deFockert, Rees, Frith, & Lavie; 2001).

Attention

It is a multi dimensional psychological construct, which when viewed from an information processing point of view includes sustained attention or vigilance, selective attention, and divided attention.

Management can be grouped into 2 categories depending upon nature of the deficit.

· The first involves management strategies for addressing deficits in metacognitive skills essential to the success of an attention task. One such strategy is to focus on the crucial elements when listening to a presentation. Or focusing on differentiating between suprasegmental cues specific to the target talker as from the competing talkers.

· The second category is related to when the processing load exceeds the person’s capacity. A successful management strategy would be to increase the SNR.

· Auditory vigilance:

The individual is required to sustain attention to a continuous stream of auditory stimuli, such as environmental sounds, syllables, or words, and to respond when a particular stimulus is heard.

Demonstrating the powerful role of attention for learning, Solan, Shelley Tremblay, Silverman, and Larson (2003) reported that 12 one hour sessions of computer assisted attention therapy improved reading comprehension in a group of adolescents with reading disabilities compared to the control group which showed no significant improvement in reading comprehension scores. The capacity for selective attention is fully developed in children by age 7 years of age, whereas sustained attention (i.e., vigilance) continues to develop throughout adolescence (McKay, Halperin, Schwartz, & Sharma, 1994).

The individual is required to sustain attention to a continuous stream of auditory stimuli, such as environmental sounds, syllables, or words, and to respond (e.g., by raising a hand, tapping a table) when a particular stimulus is heard. Failure to detect the target stimulus reflects inattention. False positive errors (i.e., responding to a stimulus other than the target stimulus) may reflect impulsivity.

Memory

Exercises to strengthen memory should benefit individuals with (C)APD given the essential role of memory for spoken language processing and learning. Metamemory, or knowledge and awareness of one's own memory systems and strategies (Flaveli & Wellman, 1977), provides one focus for memory improvement (Chermak & Musiek, 1997). A number of direct memory enhancement techniques provides a second group of approaches.

Although some drugs have been shown to improve memory losses associated with neurodegenerative diseases such as Alzheimer's disease (Giacobini & Becker, 1989; Hock, 1995), pharmacologic therapies are not available yet nor recommended to enhance memory in individuals with (C)APD (Chermak & Musiek, 1997; Musiek & Hoffman, 1990).

· Mnemonics

A mnemonic is any learning technique that aids memory. Mnemonics are artificial or contrived memory aids for organizing information that operate through the application of basic learning principles (e.g., association, organization, meaningfulness, attention) (Harris, 1992; Loftus & Loftus, 1976). Mnemonics can employ acronyms, rhymes, verbal mediators, visual imagery, and drawing, among other devices.

Commonly, mnemonics are verbal (such as a very short poem or a special word used to help a person remember something) but may be visual, kinesthetic or auditory. Mnemonics rely on associations between easy-to-remember constructs which can be related back to the data that is to be remembered. This is based on the principle that the typical human mind much more easily remembers spatial, personal, surprising, sexual, humorous or otherwise meaningful information than arbitrary sequences.

The 4 most frequently

1. Elaboration:-

Elaboration is the most basic of all memory techniques. Elaboration entails assigning meaning to items to be remembered by recasting them in meaningful sentences, analogies, or acronyms. For example, the sentence "Richard Of York Gained Battles In Vain" is an example of elaboration in which the first letter of each word represents the first letter of the colors of the spectrum of light (i.e., red, orange, yellow, green, blue, indigo, and violet) (Chermak & Musiek, 1997).

The acronym TORCH (i.e., toxoplasmosis, rubella, syphilis, cytomegalovirus, and herpes) represents the most common perinatal infections that raise the risk of morbidity, especially auditory morbidity.

The more meaning you are able to give to the thing-to-be-remembered the more successful you will be in recalling it later. It has been shown that it is more effective to emphasize higher-levels of meaning. This is achieved by

· Converting the word or name into meaningful words that sound similar

· Bizarre, humorous, or other memorable visualization of the words

· Involvement of other modalities in the mental image, such as feeling, hearing, and smelling

· Make the words active and vivid!

2. Transformation:-

It involves reconstituting complicated material into a more basic form that can be more easily remembered. E.g. pythogoras theorem --> a² +b²=c²

3. Chunking:-

Chunking is a technique used when remembering numbers, although the idea can be used for remembering other things as well. When you use "chunking" to remember, you decrease the number of items you are holding in memory by increasing the size of each item. In remembering the number string 64831996, you could try to remember each number individually, or you could try thinking about the string as 64 83 19 96 (creating "chunks" of numbers).

4. Coding:-

It involves recasting the form in which information is presented. Creating mental images (e.g., real scenes or diagrams) or drawing pictures to capture information presented auditorily are examples of coding (Chermak & Musiek, 1997). Drawing may be a particularly useful coding technique for individuals experiencing spoken language processing difficulties because as a nonlinguistic mnemonic drawing activates the primary motor cortex of the right hemisphere and thereby applies bihemispheric processing to a verbal memory task (Musiek & Chermak, 1995).

· Auditory Enhanced Memory (AME)

Musiek, 1999

The AME procedure promotes concept development and listening (reading) comprehension through the use of generative processes, inter-hemispheric transfer, and multimodal integration. The AME also provides a useful strategy for note taking and for interpreting complex auditory information and in this regard is similar to mind mapping techniques, which employ drawings supplemented by words to enhance relationships and anchor concepts.

The 3 key steps are: Listening or reading (verbal/analytic), Sketching (spatial/gestalt), Discussing or writing. After listening to several paragraphs pr pages o information, the client is asked to sketch (within no more than 2-3 minutes) the main concepts presented. This process may be repeated until the entire story or written material is reviewed and sketched. In the final stage of this procedure, the client is asked to review the sketches and convey to the clinician, either orally or in writing, the entire story, including all the main concepts.

Sketching activates the visual spatial sketch pad, a subsystem of working memory, whereas the verbal information in its analytic form activates another working memory subsystem, the phonologic loop (Schacter & Tulving, 1994). The multiple representations (i.e., verbal, spatial, auditory, visual, somatic, and motor) should improve memory processes (Massaro, 1987). The transfer of analytic, verbal based information (i.e., primarily left hemisphere) to a more gestalt representation (i.e., primarily right hemisphere) depends upon the use of mental imagery, which has been shown to enhance recall and information processing

· Mind mapping

It is a visually based approach, involving the drawing of pictures, usually supplemented by words, as an alternative to note taking or outlining (Margulies, 1991). Like the AME procedure described above, mind mapping fosters retention and comprehension through the concurrent interplay of auditory, visual, somatic, and motor modalities, as well as activation of analytic/ verbal and gestalt/spatial processes and representations.

Encouraging students to use visual and auditory input for better comprehension is central to academic success; however, note taking (or mind mapping) precludes watching the teacher, forcing students with (C)APD to rely solely on their compromised auditory system for all information. Because these youngsters are often poor writers, their pedestrian note taking skills exacerbate an already difficult situation as their transcription lags behind the spoken message (Chermak & Musiek, 1992).

WORKING MEMORY

Working memory deficits have been documented in individuals diagnosed with attention deficit hyperactivity disorder (ADHD), language impairment, learning disability, and those with histories of chronic otitis media (Daneman & Merikle, 1996). It is uncertain whether individuals diagnosed with (C)APD exhibit working memory deficits, although the common connection through chronic otitis media underscores the need for additional research into this potential association. Indeed, Mody, Schwartz, Gravel, and Ruben (1999) found poorer retention and recall of consonant vowel syllables among subjects with positive histories of otitis media, which they attributed to underspecified coding of phonetic features in working memory. Working memory deficits likely result in difficulties maintaining relevant information simultaneously and integrating information, inefficient resource allocation, and listening comprehension deficits (Daneman & Blennerhasett, 1984).

Working memory can be exercised through a variety of activities, including formulating sentences, sentence combining or assembly, sentence completion, word associations, trail making, digit span, and verbal fluency. (Sentence completion also trains auditory closure.)

· Daneman and Carpenter (1980) designed a working memory span paradigm in which subjects listen to increasingly longer sets of sentences, and at the end of the set, they attempt to recall the final word of each sentence in the set.

· Ellis Weismer, Evans, and Hesketh (1999) described a rather standard approach to working memory in which subjects demonstrate comprehension by answering questions following a sentence, and demonstrate working memory by recalling the last word of each sentence after all the sentences in the series have been presented.

· Another common task that exercises working memory requires a client to answer a question about the set of rhyming words before reciting those words. For example, the clinician would present a series of rhyming words (e.g., fun, run, sun) and ask the client to recognize whether one or more words were among those on the list (e.g., was bun or sun presented) before recalling and reciting the rhyming words.

METALINGUISTIC STRATEGIES

These comprise the final type of central resources training approaches.

Ø Discourse cohesion devices:

These linguistic forms that connect propositions into more complex messages (Halliday & Hassan,1976). They establish relationships between ideas and build cohesive chains through the devices that are either explicit or must be inferred.

Ø Auditory Closure Activities

Auditory closure (AC) is an aspect of auditory processing that is crucial for understanding speech in background noise. It is a set of abilities that allows listeners to understand speech in the absence of important information, both spectral and temporal. The purpose is to assist in learning to fill in the missing parts in order to perceive a meaningful whole. As such context plays an important role in auditory closure, because prediction of the complete word or message often depends on the surrounding context. Children should demonstrate mastery of one level before moving on to the next.

· Missing word exercises

These are designed to teach children 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 initially familiar nursery rhymes can be used.

E.g.: twinkle, twinkle, little _____ (star).

The children should be talked through the process and prompted with questions such as “what is the sentence talking about?”, “what word comes next when you sing the song?”

A slightly higher level activity might be prediction of rhyming words.

E.g.: can you name an animal that rhymes with ‘house’?

Prompts can be given to solve the puzzle. For example, they 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.

Once mastery of these steps has been achieved, clinicians may move to newer unfamiliar messages in which they must utilize the context of the phrase, sentence, or paragraph in order to predict the missing component. The clinicians must begin with simple sentences (when I am hungry, I ___), then move to more complex stimuli like paragraphs. In addition, the clinician should progress from omitting the subject or object, to omission of verbs, adjectives etc.

· Missing Syllable Exercises

- In the beginning, the context should be familiar so that the child is best able to fill in the missing components of the target word.

- Achieving closure for words in which the initial syllable is omitted is more difficult than words in which the final syllable is omitted.

o Begin with omission of final syllables and then move on to omission of medial and initial syllables.

- Begin with sentences in which the target word is imbedded (e.g., “There are 26-letters in the al-pha-______.”)

- Move on to single words in which the contextual cue may be a category designation (e.g., “Sports: base_____, soc____, ten___.”)

· Missing Phoneme Exercises

- May be carried out in a similar way as missing syllable exercises

- Begin with sentences in which the child can supply the missing phonemes in words with contextual cues (e.g., “I like to (w)atch (t)ele(v)ision.”), before moving onto isolated words.

- 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.

- It is helpful to provide general categories as a contextual cue (e.g., “Animals: ti(g)er, (m)on(k)ey.”).

- Mastery with final phonemes prior to moving on to medial and initial phonemes.

Ø Vocabulary Building

§ Requires the listener to use context to predict the word.

§ 1^st – Reauthorization – saying the word aloud a few times

§ 2^nd – child should be encouraged to attempt a definition of the new word based on the context in which it appears

§ 3^rd – the actual definition of the word should be provided to the child.

**Immediate problem solving in the form of providing the definition, rather than telling the child to look it up in the dictionary, is necessary.

§ 4^th – encourage the child to define the new word in his or her own way, thus assuring that comprehension of the provided definition has been achieved.

Ø Speech-in-Noise Activities

Once the child has mastered a given activity (any of the auditory closure activities listed above) in quiet listening situations, noise of varying levels is added to make the activity more challenging.

Ø Segmentation

Segmental training exercises temporal processing, albeit within the context of phonological awareness. The client is asked to recognize how many syllables are there in a word. It is more appropriate for older preschoolers. Visual support (e.g. block per syllable) or motor accompaniments (eg tapping on a table) is used.

Ø Auditory discrimination

Auditory discrimination is one of the most fundamental central auditory processing skills underlying spoken language comprehension (Chermak & Musiek, 2002). The ability to perceive acoustic similarities and differences between sounds is essential to segmentation skills, which require the listener to recognize the acoustic contrasts among contiguous phonemes (Chermak & Musiek, 1997). In this way, auditory discrimination is fundamental to phonemic analysis and phonemic synthesis. Auditory discrimination and phonemic segmentation are so crucial to spoken language comprehension that treatment programs for (C)APD have been designed around them (Sloan, 1986).

Ø Phonemic Analysis And Synthesis

These provide 2 reciprocal approaches to phonological awareness and segmentation training. The primary goal of Phonemic analysis is to develop phonemic encoding and decoding skills using either multisyllabic nonsense sequences or single syllables and multisyllabic words (Sloan,1986). The listener identifies which sound is heard and the position in the syllable or word. Commercially available programs are Sloan’s (1986) treatment program and Lindamood Phoneme sequencing program for reading spelling and speech (lindamood & lindamood, 1975).

Phoneme synthesis stresses on the blending of discrete phonemes into the correctly sequenced co articulated sound patterns. The phonemic synthesis program developed by Katz and Harmon (1982) is one such example.

· Prosody

In contrast to segmental analysis, prosody involves the supra-segmental aspects of spoken language. Prosody refers to the dynamic melody, timing, rhythm, and amplitude fluctuations of fluent speech. Prosodic information is integral to spoken language processing at a number of levels. Prosody links phonetic segments (Goldinger, Pisoni, & Luce, 1996). Furthermore, prosody provides information about the lexical, semantic, and syntactic content of the spoken message (Goldinger, Pisoni, & Luce, 1996; Studdert Kennedy, 1980).

A number of approaches may be useful in targeting perception of prosody in the context of spoken language (Chermak & Musiek, 1997). As mentioned above in the section on vocabulary building and the construction of meaning, heteronyms require focus on prosody (specifically accent or stress pattern) to resolve semantic distinctions. Ambiguous phrases also can be used to draw attention to prosodic detail while training context derived vocabulary building skills (Chermak & Musiek, 1992). For example, durational contrasts and context allow the listener to disambiguate sentences with identical surface structure (e.g., The girl saw the boy with the binoculars that she purchased for a birdwatching expedition. The girl saw the boy with the binoculars that she hoped to purchase for herself- some day).

Intonation is used as an aid to resolve ambiguous messages where prosody changes meaning. As illustrated by Musiek and Chermak (1995), the sentence, "Look out the window," can be parsed and interpreted differently depending on the speaker's intonation and timing. It could mean "Look out!, the window" or simply the simple imperative statement "Look out the window." Parsing of words and phrases based on duration and juncture (e.g., nitrate vs. night rate, it sprays vs. it's praise) and reading poetry and noting the location of the emphasis and stress in sentences and words also promote this appreciation and may improve perception of prosody (Chermak & Musiek, 1997).

DOCUMENTING TREATMENT EFFICACY

It is important for professionals working with individuals with (C)APD to be able to document patient outcomes. As the health care industry works to control rising costs, it is demanding evidence of the effectiveness of treatment procedures.

Following Bocca and his colleagues' findings (1954, 1955) that individuals with temporal lesions experience auditory deficits in spite of normal peripheral audiological findings, much of the clinical research that followed has involved the investigation of the nature of the auditory deficits in patients with confirmed lesions of the CANS as assessed by a number of auditory tasks/tests (Baran & Musiek, 1999). These investigations served to increase our understanding of normal and abnormal brain function and to link specific auditory processes with an area (or areas) of the brain.

· Although no large scale studies have examined the efficacy of intervention approaches with adults, there have been some case studies that have shown changes in behavioral and electrophysiologic measures in adults with (C)APD following intervention (e.g., Musiek et al., 2004). In addition, there have been a number of studies with normal adults that have used various auditory evoked potential measures to see if neurophysiologic changes could be documented following training on novel auditory perceptual tasks (Kraus et al., 1995; Tremblay & Kraus, 2002; Tremblay, Kraus, Carrell, & McGee, 1997; Tremblay, Kraus, & McGee, 1998; Tremblay, Kraus, McGee, Ponton. & Otis, 2001).

· Each of these studies documented one or more electrophysiologic changes associated with the training, and as such, provide some evidence that behavioral interventions can result in physiologic changes in adults.

· Additional studies with adolescents and adults with (C)APD using similar methodologies (i.e., behavioral training approaches and electrophysiologic assessment measures) are likely to demonstrate similar findings—thus, supporting the efficacy of these approaches with adults despite the anticipated reduced plasticity of the mature brain.

· Although much of the interest recently has been in using an objective measure (e.g., MLR, mismatched negativity, etc.) to document changes in neurophysiologic function associated with behavioral changes affected by auditory training, this is by no means the only approach to documenting treatment efficacy. Equally as important are ecological or functional measures that document changes in the individual's performance in a variety of contexts (e.g., school, home, work, and community). For these types of documentation, other measures would be needed. These could include various types of behavioral rating scales, communication effectiveness measures, and other performance measures that probe listening, communication, and academic achievement, and so forth.

DOCUMENTING EFFECTIVENESS FOR AN INDIVIDUAL

Absent large scale investigations that document treatment efficacy for the various approaches that are being used in remediation and management of (C)APD with adolescents and adults, it is important for the professional to document on an individual basis the changes that are occurring, presumably as a result of intervention.

Electrophysiologic measures as well as behavioral test measures can be used to document these changes; however, additional quantitative and qualitative measures should be included. Data collected should include measures that would document changes (or lack thereof) in a variety of contexts in which the individual would need to use the newly acquired processing skills and/or strategies. For adolescents in structured environments, these could include teacher questionnaires that probe for changes in auditory behaviors and academic performance.

For the adult patient who is not in a structured environment, this could include a journal or a checklist where the individual indicates when a desired strategy or behavior was used. Additionally, the journal could include some type of evaluation or rating of the success of the strategy or behavior. The use of these latter techniques can also encourage self-monitoring and the use of executive processes, which can further enhance the treatment program (Chemak & Musiek, 1997).

CENTRAL RESOURCES TRAINING WITH PRESCHOOL AGED CHILDREN

Early identification and diagnosis of (C)APD in children is crucial given the potential adverse impact of (C)APD for communication, academic achievement, and social function (ASHA, 2005; Bellis, 2003; Musiek & Chermak, 1995). Unfortunately, few tests with sufficiently documented sensitivity and specificity for (C)APD are available for young children, rendering diagnosis of (C)APD difficult at best (Chermak & Musiek, 1997). Nonetheless, it is prudent to involve preschool children suspected of, or at risk for, (C)APD (e.g., children with histories of recurrent and persistent otitis media with effusion; prematurity and low birth weight; prenatal drug exposure; associated developmental disorders) in programs designed to promote development of auditory perceptual skills.

· Central resource training for children at risk for and suspected of (C)APD should emphasize the principles of natural language learning (Norris & Damico, 1990).

· An enriched language environment involving activities that engage young children and provide natural opportunities for listening and communication fosters the development of auditory perceptual and auditory language skills (Chermak & Musiek, 1997). For example, repetition of daily routines creates a sense of familiarity, allowing the child to focus attention on new auditory information.

· Collaboration between speech and hearing professionals, preschool teachers, and families maximizes the transfer of skills to daily routines and other settings (Chermak, 1993).

Strategies used to enhance the acoustic signal and the listening environment for individuals with hearing impairment also are appropriate for children suspected of, or at risk for, (C)APD.

· In addition to auditory strategies, maximizing access to visual information (e.g., pictures, facial expression, gestures and other nonverbal cues) supports and reinforces auditory information and thereby enhances the saliency of the acoustic signal (Chermak & Musiek, 1997).

· Strategies to enhance the acoustic signal and the listening environment, including personal FM and sound field technology.

1. Listening to Stories

Reading aloud to children promotes concept learning, vocabulary building, and practice in vigilance and selective listening (Musiek & Chermak, 1995). The child might also be encouraged to listen for subtle prosodic cues (e.g., intonation, stress), while focusing on target words. Posing comprehension questions at the end of the story promotes listening for meaning (i.e., comprehension) while still exercising targeted or selective listening (Chermak & Musiek, 1997).

Concurrently, multisensory integration can be encouraged by allowing the child to examine the accompanying pictures and words as the story is read aloud (Chermak & Musiek, 1997). Having the caregiver and the child jointly elaborate on the pictures in a book or sections of the text that are of particular interest to the child fosters vocabulary development and reading skills (Ninio, 1980;Teale, 1984, Wells, 1985).

2. Following Directions

Following directions engages a number of central resources, including attention and working memory, as well as basic central auditory processes, most notably temporal processing.

Chermak and Musiek (1997) outlined a range of directives of varying complexity and difficulty. Oral directives may be made more complex by inserting adjective sequences, prepositions, and a number of facts, or by using more sophisticated linguistic concepts (e.g., use of suspensive phrasing such as "Point to the pictures of animals, but only if they live on farms, after you point to the pictures of toys").

3. Inferencing

Activities that require the drawing of inferences can be entertaining and appropriate for younger clients. In addition to promoting cognitive style flexibility, inferencing also challenges memory, as stored knowledge is essential to the inferencing process (Chermak & Musiek, 1997).

4. Executive Function

By age 5 years, children have begun to develop metacognitive knowledge and executive strategies (Kreitler & Kreitler, 1987). As these strategies underlie attention and listening comprehension, activities to reinforce and cultivate these strategies are worthwhile (Chermak & Musiek, 1997). Preschool aged children have developed metacognitive message evaluation skills and respond well to self-regulation training that involves asking questions and evaluating message ambiguity (Pratt & Bates, 1982)

5. Metalinguistic Skills and Vocabulary Building

Discussed previously.

CENTRAL RESOURCES TRAINING FOR ADULTS AND OLDER ADULTS

Age is one of the most significant sources of individual variability. The individual's response to the variety of developmental, situational, environmental, social, and economic factors influencing that individual at various periods throughout life is dynamic (Chermak & Musiek, 1997). Just as children experience increasing and more complex central auditory processing demands as they face more intellectually and linguistically challenging academic and social situations, the central auditory processing demands facing the older adult in retirement differ from the demands he or she confronted as a young, ambitious professional (Chermak & Musiek, 1997).

However, in contrast to children with (C)APD who may never have developed efficient processing skills, older adults with (C)APD are experiencing loss or disruption of processing functions that were previously intact (Chermak & Musiek, 1997). Moreover, the older adult with (C)APD typically presents a complex clinical profile due to the difficulties caused by comorbid conditions, including peripheral hearing loss and cognitive deficits, as well as the diminished plasticity of the central nervous system. Older adults also may present differences in cognitive style that may affect processing outcomes.

Clinical Profile

Estimates of (C)APD in older adults range from 23% to 76% (Cooper & Gates, 1991; Golding, Carter, Mitchell, & Hood, 2004; Stach, Spretnjak, & Jerger, 1990). (C)APD is seen in older adults due to aging, or associated with neurologic diseases, disorders and insults, including neurodegenerative diseases (Baran & Musiek, 1991; Bellis, Nicol, & Kraus, 2000). Approximately one in three adults 65 years of age and older present with peripheral hearing loss (Ries, 1994).

Although peripheral hearing loss, particularly at the high frequencies, accounts for some of the difficulties older adults experience understanding speech in competing noise backgrounds, other factors including CANS changes and/or senescent changes in cognition may also contribute to reduced speech understanding in noise among older adults (CHABA Working Group on Speech Understanding and Aging, 1988; Pichora Fuller & Souza, 2003)

Following an extensive literature review, Bellis concludes that older adults experience a variety of central auditory processing deficits due to aging that exacerbate the speech understanding difficulties attributed to peripheral auditory dysfunction and that can lead to speech understanding difficulties even in the absence of peripheral hearing loss. Moreover, noting the absence of correlation between degree of cognitive deficit and perceived self-assessment of hearing handicap in older listeners.

Neurophysiology of (C)APD in Older Adults

· A neurobiology disorder is suspected in the majority of youngsters with (C)APD, possibly involving inefficient interhemispheric transfer of auditory information and/or lack of appropriate hemispheric lateralization, atypical hemispheric asymmetries, imprecise synchrony of neural firing, or other factors (Jerger et al., 2002; Kraus et al., 1996).

· In contrast, the central auditory processing deficits of older adults are acquired, resulting from accumulated damage or deterioration to the CANS due to neurologic diseases, disorders and insults, including neurodegenerative diseases, which may or may not involve fairly circumscribed and identifiable lesions of the CANS (Baran & Musiek, 1991; Musiek & Gollegly, 1988; Musiek et al., 1990), or from the aging process (e.g., less synchrony and time-locking, slower refractory periods, decreased central inhibition, and inter-hemispheric transfer deficits) (Bellis et al., 2000; Jerger et al., 2000; PichoraFuller & Souza, 2003; Tremblay et al., 2003; Wiliott, 1999; Woods & Clayworth, 1986).

Intervention

· Management must begin by considering amplification, as the primary complaint of the older adult with (C)APD is difficulty understanding spoken language in the presence of background noise, as well as the frequent co-occurrence of peripheral hearing loss in this population (Chmiel & Jerger, 1996; Stach et al., 1990).

· Hearing aids and personal hearing assistive technology (e.g., personal frequency modulation [FM] systems) should be fitted in advance of intervention directed toward the (C)APD. The remote microphone technology employed in FM systems is more effective than hearing aids in reducing background competition, which interferes with the older adult's ability to understand spoken language (Stach et al., 1990)

· When fitting hearing aids to older adults with mixed peripheral and central hearing problems, consideration should be given to the possibility that a monaural fitting may be more effective than a binaural fitting due to interhemispheric transfer problems (Bellis et al., 2000; Jerger et al., 2000)

· The intervention program should also include communication repair strategies and auditory visual speech perception training (i.e., speech-reading), particularly when the older adults presents with both peripheral and central auditory disorders.

· Home based therapy programs may be particularly appropriate for older adults. One such program designed specifically for adults with peripheral hearing impairment, LACE (Listening and Communication Enhancement), trains auditory-visual communication via an interactive computer program (Sweetow & Henderson Sabes, 2004)

OUTCOMES

Differences in intellectual, cognitive, linguistic, and psychosocial state will influence treatment outcomes across individuals, and must, therefore, be taken into consideration in planning and delivering intervention. Key to successful outcomes with older adults, as with children, is the collaborative involvement of family, other communicative partners, and related professionals in the comprehensive intervention program

REFERENCES:

· Chermak, Gail D.; Musiek, Frank E., ( Ends). Handbook of (Central) Auditory Processing Disorder : Comprehensive Intervention, Volume II . San Diego, CA: Plural Publishing, Inc. (2007)

· Bellis,T.,J.Assessment and Management of Central Auditory Processing Disorders in the Educational setting.(2^nd edn).

· http://www.neuroaudiology.com/ASHA_Position.pdf

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