RIDBC-Advanced Educational Audiology Lecture PowerPoint Presentation

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New Perspectives in Central Auditory Processing Disorder Sharon Cameron Harvey Dillon National Acoustic Laboratories

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Overview of Presentation New perspectives on CAPD Description of the LiSN-S Research behind LiSN-S LiSN-S and the traditional APD test battery How to interpret LiSN-S results Management options Description of LiSN & Learn Auditory Training Software LiSN & Learn Phase I and Phase II Clinicial Trial Results LiSN Screening Test – Sensitivity and Specificity Study LiSN-S “Prescribed Gain Amplifier” - HI Study 6-60+ Years Question time

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What is CAPD? For children with (C)APD….. “….. internal distortions degrade the auditory signal so that top-down processing typically predominates in most listening situations, particularly those in which complex linguistic and cognitive demands are coupled with background noise” Putter-Katz et al (2002)

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Operations Required for Comprehension of Speech in Noise Wingfield, A and Tun, P (2007). J Am Acad Audiol 18:548–558

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5 Source Discrimination aka Auditory Stream Segregation The ability of the brain to tease apart all the sounds that arrive simultaneously at the ears and to form meaningful representations of the incoming acoustic information Auditory cues such as the location of the sound, or the pitch of a speaker’s voice, help us to segregating the total stream of sound into its original sources

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LiSN-S was developed specifically to assess how children use: Spatial location cues (ITD, IID) Pitch differences between voices to separate target auditory stimuli from distracting auditory stimuli that arrive simultaneously at the ears LiSN-S Development

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LiSN-S Research – Spatial Processing Disorder 7 Speech Noise Noise Noise Noise

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Description Adaptive speech-in-noise-test Target sentences - 0º azimuth initially at 62dB SPL Competing speech - 0º or ±90º azimuth at 55dB SPL 3-D auditory environment under headphones Offers alternative to free-field testing No special hardware required Four LiSN-S conditions

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9 LISN-S Conditions

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LiSN-S SRT & Advantage Measures

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Client Screen

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Configure Language

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Client Session

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Diagnostic Screen

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Results Screen

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Explanation Screen

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Client Assessment Report

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NA LiSN-S Sentence Equivalence Study

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NA LiSN-S Sentence Equivalence Study

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Australian LiSN-S Normative Data 202 participants: 106 children - 6 yrs, 2 mths to 17 yrs, 7 mths 60 young adults - 18 yrs, 1 mth to 29 yrs, 10 mths 36 older adults – 31 yrs, 8 mths to 60 yrs, 7 mths English as a first language; no history of hearing disorders; no learning or attention disorders; normal pure tone audiogram and middle ear function.

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Low Cue SRT Better Low Cue SRT vs Age Group p < 0.000001

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High Cue SRT Better High Cue SRT vs. Age Group p < 0.000001

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Talker Advantage Better Talker Advantage vs. Age Group p < 0.000001

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Spatial Advantage Better Spatial Advantage vs Age Group p = 00005

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Total Advantage Better Total Advantage vs Age Group p = 0.003

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Conclusions LiSN-S SRT scores show that the ability to understand speech in noisy environments develops with age, is adult like by 14 years and starts to decline by 50 years of age. LiSN-S advantage measures show that ability to use spatial and pitch cues does not decline once adult-like performance is reached. The ability to use spatial cues matures well before the ability to use pitch cues and thus plays a greater role in how well children, in particular, are able to hear speech in noise.

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LiSN-S Cut-Off Scores Level below which performance on a LiSN-S measure is considered outside normal limits. Two and three-part regression equations fitted to account for improvement with age. Low and High Cue SRT: max (intercept + B-value * age, max (c, d + e * age) + (2 * SDs of the residuals from the age-corrected trend lines) Talker, Spatial and Total Advantage: min (intercept + B-value * age, c) – (2 * SDs of the residuals from the age-corrected trend lines)

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Cut-off Scores - Low Cue SRT

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Cut-off Scores - High Cue SRT

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Cut-off Scores – Talker Advantage

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Cut-off Scores – Spatial Advantage

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Cut-off Scores – Total Advantage

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LiSN-S Test-Retest Reliability 85 participants recruited from NA LiSN-S normative data studies. Retested on LiSN-S between 1 and 4 months after initial testing (average 2 months, 2 weeks). Mean test-retest difference ranged from 0.05 dB to 0.5 dB. RM ANOVA revealed no significant difference between test and retest (p = 0.307 to 0.974, age categorical variable). Correlation between test and retest significant for all measures (p = 0.006 to <0.00001; r ranged from 0.3 to 0.6)

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Spatial Advantage

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NA LiSN-S Critical Difference Scores

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Australian LiSN-S APD Study Nine children aged 6 to 11 years experiencing listening difficulties in class relative to peers who had no learning or attention disorder (SusAPD group). Eleven children with confirmed learning or attention disorders (LD group). Assessed on LISN-S and results compared to 70 age-matched controls. Assessed with a traditional (C)APD test battery

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LiSN-S vs. Traditional Battery (LD Group) Cameron & Dillon (2008)

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LiSN-S vs. Traditional Battery – SusAPD Group Cameron & Dillon (2008)

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Low Cue SRT Better (LD)

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Spatial Advantage Better

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LiSN-S Results – Normal Male, 11 years, 10 months showing Normal Performance

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LiSN-S Results - SPD Male, 7 years, 5 months with Spatial Processing Deficit

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LiSN-S Results – Memory Deficit Male, 8 years, 3 months with Memory Deficit

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LiSN-S Results – Attention Issues Female, 7 years, 10 months with Attention Issues

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Goal of Management Strategies The ultimate goal of CAPD management in children is “… to maximize the auditory learning abilities so that communication and classroom learning experiences are more successful” Putter-Katz et al (2002)

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Managing Spatial Hearing Deficits Teacher-directed strategies Child-directed strategies Language training Classroom modification (+10 dB SNR) Assistive listening device Training in source discrimination

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Auditory Training Research Develop deficit-specific remediation for children with a spatial processing deficit. Trains children to use binaural cues – i.e. differences in the timing and intensity of signals arriving at the ears from various locations - to attend to a target stimulus and filter distracting auditory signals. Used in the home (as well as schools/clinics). Provides detailed analysis, reporting and feedback. Alternative/adjunct to ALD’s and other management strategies.

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Description of LISN & Learn Four games presented on PC over headphones Target sentences at 0º azimuth (initially 62 dB SPL) Competing stories at ±90º azimuth (55 dB SPL) Weighted up-down adaptive procedure used to adjust the signal level of the target SRT calculated over 40 sentences 131,220 unique sentences can be generated

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LISN & Learn Game The horse kicked six wet shoes Target at 0˚: Distracters at + and -90˚: Tamsin’s Blanket (-90˚) Eric’s Alarm Clock (+90˚)

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Target: The horse kicked six wet shoes

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Method 9 children (6 to 11 years) - LISN-S SA >2SD TOVA-A TAPS-3 memory sub-tests CAPD Pediatric SSQ LISN & Learn - 15 minutes per day; 5 days per week; over 12 weeks (120 games) Re-evaluate post-training; 3 months post-training

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LiSN & Learn - Performance Over Time (n=9) LiSN & Learn SRT (dB) Game Number 10 dB Better

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LiSN-S Results – Pre vs. Post (n=9) LC SRT - p = 0.158 Talker Advantage - p = 0.981 HC SRT - p = 0.0002 Spatial Advantage - p = 0.0002 Total Advantage - p = 0.001

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Additional Results – Pre- vs. Post Training CAPD SSQ: Listening in Quiet – p = 0.103 Listening in Noise – p = 0.0002 TOVA-A Omissions – p = 0.168 Commissions – p = 0.0004 TAPS-3 Memory Index – p = 0.003

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Conclusion LiSN & Learn training has the potential to strengthen or reorganize connections dedicated to binaural processing. Training results in enhanced ability to process speech in background noise.

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56 Method – Phase II Clinical Study 20 children - LISN-S spatial advantage >2SD from mean 10 x LiSN & Learn (experimental group) 10 x Earobics (control group) Questionnaire Participant (LIFE) Parent (Fishers) Teacher (LIFE) LiSN & Learn or Earobics training – 15 minutes per day Re-evaluate LiSN-S and questionnaires post-training Offer LiSN & Learn to control group.

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Phase II Study - LiSN & Learn Group (n=1) Pre-training Post-training SD from Mean

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Phase II Study - Earobics Group (n=1) Pre-training Post-training SD from Mean

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LiSN-S Screening Test Develop screening test to be used by teachers, speech pathologist, psychologists. Fully-automated instructional, testing, scoring and reporting functions. Accessible via internet. End-users own computer and headphones used. Aims to: Decrease time taken to refer children (and adults) with suspected CAPD for diagnostic testing with LiSN-S. Reduce inappropriate referrals. Reduced referral time will result in speedier implementation of management and remediation programs for those with SPD.

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LiSN Screening Test Client data End-user inputs client data Sound check Sets output level of computer soundcard Reference tone consists of “pulsed” speech-shaped broadband noise Reference tone is presented at 40 dB below level of combined distracters Listener adjusts volume control until he or she can “just hear” the reference tone Assumed to be at least 10 dB SPL Therefore level of distracters presented during test is approx 50 dB SPL

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LiSN Screening Test Word familiarization task (in quiet) 3 target words (red, blue, green) 12 “foils” (e.g. hat, doll, milk) Listener clicks on picture that matches word until all words correctly identified. LiSN Screening Test Distracters – looped stories (DV +/- 90º) Targets and foils: Female 1 at 0º initially presented at SNR of +4 dB 2 second ISI Listener clicks mouse when target heard. Adaptive procedure used to find SRT that yields 50% intelligibility. Level of word stimuli adjusted in 3 dB steps. At least 6 targets presented as practice. SRT calculated over up to 40 scored targets

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LiSN-S Screening Test Studies Target Stimulus Equalization Study 30 adults aged 18 to 29 years SRT of scored target words (red, blue, green) consolidated across participants and psychometric functions formulated Amplitude of target words adjusted for equal intelligibility Sensitivity and Specificity Study 40 children and adults with suspected CAPD Tested with LiSN Screening Test at referring centre Tested with LiSN-S no more than 3 weeks later at NAL Correlation between LiSN Screening Test and LiSN-S determined ROC analysis used to determine sensitivity and specificity Optimum criteria cut-off scores determined

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LiSN-S Prescribed Gain Amplifier

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CAPD and Hearing Impairment Studies LiSN-S Study 160 participants (40 x 6-17; 20 x 18-29; 20 x 30-59; 80 x 60+) Confirmed mild-to-moderately-severe SNHL (3FAHL of 65 dB) Assessment gools: LiSN-S + PGA LIFE Questionnaire (6-17 years) SSQ Questionnaire (18-60+ years) COGNISTAT (60+ years) “LiSN & Learn” Study 60 participants (10 x 6-17; 10 x 18-60; 10 x 60+) Confirmed mild-to-moderately-severe SNHL (3FAHL of 65 dB) Assessment tools: LiSN-S + PGA Memory Test LIFE Questionnaire (6-17 years) SSQ Questionnaire (18-60+ years) “LiSN & Learn” + PGA (120 games) then re-assess

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References Brown, D., Cameron, S. Martin, J., Watson, C., & Dillon, H. (in press). The North American Listening in Spatialized Noise – Sentences Test (NA LiSN-S): Normative data and test-retest reliability studies for adolescents and young adults. Cameron ,S., Brown, D., Keith, R., Martin, J., Watson, C., & Dillon, H. (2009). Development of the North American Listening in Spatialized Noise - Sentences Test (NA LISN-S): Sentence equivalence, normative data and test-retest reliability studies. Journal of the American Academy of Audiology, 20(2), 128-146. Cameron, S. & Dillon H. (2009) Listening in Spatialized Noise – Sentences test (LISN-S) (Version 1.013) [Computer software]. Murten, Switzerland: Phonak Communications AG. Cameron, S. & Dillon, H. (2008). The Listening in Spatialized Noise – Sentences Test: Comparison to prototype LISN test and results from children with either a suspected (central) auditory processing disorder of a confirmed language disorder. Journal of the American Academy of Audiology, 19(5), 377-391. Cameron, S. & Dillon, H. (2008). Spatial hearing deficits as a major cause of auditory processing disorders: Diagnosis with the LISN-S and management options. In R. Seewald & J. Bamford, eds. A Sound Foundation Through Early Amplification 2007. Proceedings of the Fourth International Conference: Phonak AG, Switzerland, 235-241. Cameron, S. & Dillon, H. (2007). Development of the Listening in Spatialized Noise - Sentences Test (LISN-S). Ear and Hearing, 28(2), 196-211. Cameron, S. & Dillon, H. (2007). The Listening in Spatialized Noise - Sentences Test (LISN-S): Test-retest reliability study. International Journal of Audiology, 46, 145-153.

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Acknowledgements and Q&A Dr Harvey Dillon Director of Research National Acoustic Laboratories Helen Glyde Research Audiologist National Acoustic Laboratories