The team at SoundSkills congratulates our friend, colleague and APD research collaborator, Dr Suzanne Purdy from the University of Auckland, who has been awarded the American Academy of Audiology International Award for Hearing for 2021 to acknowledge her significant contribution to audiology internationally.
2020 was a promising year for participation at conferences with sessions on auditory processing disorder (APD), until a world pandemic resulted in the cancellation of most conferences internationally. Dr Bill Keith, Director of SoundSkills, was planning to report APD research findings at the Hearing Across the Lifespan (HeAL) conference in northern Italy, and the American Academy of Audiology annual conference in New Orleans, both at venues that were early Covid 19 hotspots. Both conferences were cancelled. The HeAL conference has been rescheduled for mid 2021 and the AAA 2021 Convention will be held as an online conference. An Australia-New Zealand online audiology conference was hastily arranged and Prof Suzanne Purdy and Dr Keith made a joint presentation on New Zealand APD research. Dr Keith also presented on APD at New Zealand conferences of paediatricians (live), educational psychologists (online), and Ear Nose and Throat Surgeons (live). APD teaching for audiology and speech-language students at the University of Auckland was all conducted online. SoundSkills staff conducted seminars for various groups including resource teachers for learning and behaviour (RTLBs), the Raukatauri Music Therapy Centre, and parent seminars.
Children with autism spectrum disorder (ASD) frequently also have auditory processing difficulties which affect their ability to hear and communicate especially in difficult listening situations such as when there is other conversation or noise going on. The auditory processing difficulties may also affect ability to hear prosody in speech, that is the changes in tone and emphasis that add meaning to spoken language and help us distinguish the emotion associated with a statement and whether or not it is a question or is spoken with humour. Complex auditory environments are stressful for children with ASD as they are also for many children with APD. SoundSkills is participating in a project with APD and ASD experts at the University of North Texas and the University of Melbourne to diagnose and treat auditory processing deficits in children with ASD. The project is supported by hearing instrument company Sonova.
Research at the University of Melbourne has shown that wearing remote microphone hearing aid systems in class reduces listening stress for children with ASD. Research at the University of North Texas has shown that children with ASD benefit from auditory training and the use of remote microphone hearing aid systems. Research by Dr Joan Leung at the University of Auckland has shown that children with ASD can improve their understanding of prosody with training, and that this training progresses faster if they wear remote microphone hearing aid systems. All this research shows that many children with ASD can be helped to hear and communicate better.
Dr Leung is also the ASD Adviser on the staff of SoundSkills and has been working with SoundSkills clinicians to develop their skills and protocols for working with children with ASD, and diagnosing and treating their auditory processing difficulties.
Data analysis for five research projects funded by the William Demant (previously Oticon) Foundation and carried out by SoundSkills and the University of Auckland has been completed and writing up the results for publication in scientific journals has begun. The projects investigated:
- actual and optimal duration of use of remote microphone hearing aid systems by children with APD
- actual and preferred listening levels of remote microphone hearing aid systems by children with APD
- the effects of different levels of loudness on auditory memory, the auditory brainstem response and speech perception in quiet by children with APD
- quantification of degree of disability for APD
- phonological perception training for children with APD both with and without remote microphone hearing aid systems
A project currently in progress is examining whether it is possible to correct amblyaudia, suppression of input from one ear by the brain in difficult listening situations (the auditory equivalent of ‘lazy’ eye), by gradually varying the loudness difference between the weak ear and strong ear over a matter of weeks in children with APD wearing remote microphone hearing aid systems. Professor Suzanne Purdy at the University of Auckland has a number of APD research projects underway including measuring brain function in children with APD using functional magnetic resonance imaging (fMRI), and benefits of auditory training for older adults with mild cognitive impairment. Auditory neuroscience colleagues in the Eisdell Moore Hearing and Balance Research Centre are measuring electrical brain responses to sounds in mice with autism traits to better understand the effects of autism on the central auditory nervous system of the brain.
Early intervention is a key tenet in audiology, except when it comes to Auditory Processing Disorder. This case study report argues that early intervention, with appropriate cautions, is also possible for children with APD.
Dr Bill Keith is Director of SoundSkills APD Clinic. Dr Suzanne Purdy is Professor and Head, Discipline of Speech Science, School of Psychology at the University of Auckland. The other co-authors are members of the SoundSkills APD Clinic multi-disciplinary team.
Balancing diagnostic considerations and the benefits of early intervention in the management of Auditory Processing Disorder: A case study report
Published in the New Zealand Audiological Society Bulletin, July 2014, 24:2, 11-22
William Keith, Suzanne C. Purdy, Anne Toth, Emma Russell, Chloe Young, Isabella Wojciechowski, Jenny Coutts, Jill Tyler
The SoundSkills project to develop a scalable model multi-disciplinary specialist auditory processing disorder (APD) clinic is in its fifth year. One of the many issues faced is the lower age limit at which APD can be diagnosed and intervention initiated. At our free monthly APD seminars for parents and professionals we often ask the question At what age have you heard APD can be diagnosed? The answer is usually seven years. This is a common belief and practice though some clinics in New Zealand and overseas only see APD cases from age eight. The belief that management of APD should be deferred until age seven is attributed to three factors. Firstly, some early APD tests were only normed on children down to age seven. Secondly, parts of the central auditory nervous system do not fully mature until adolescence or young adulthood, especially in the case of myelination of the corpus callosum which can continue into the early 20s (Yap et al, 2013). Thirdly, and in part because of these maturational factors, behavioural measures on young children show greater variability than behavioural measures on older children; hence behavioural test results on young children have to be interpreted with caution. However, these factors do not impede early intervention for other types of deafness.
In fact several APD tests and auditory skill assessment tools have norms for children younger than seven. These tools enable assessment of some auditory skills from age three or three years six months upwards with the proviso that it is important to keep in mind the variables mentioned above and cautions about making a definitive diagnosis in young children. Suspected diagnosis of APD in children below the usual age range for testing is qualified by SoundSkills as being at risk for, provisional, or criteria for diagnosis not met but auditory skill deficits are confirmed. Follow-up is scheduled to enable more comprehensive and definitive testing when the child is older.
Fortunately APD treatments are not harmful and generally are of benefit to most children. Hence early intervention when auditory deficits are suspected is very feasible. This paper presents two case studies on intervention in cases of suspected APD in young children.
It is well established that early intervention for hearing and learning disorders is critical if the effectiveness of treatment is to be maximised. This applies to auditory processing disorder (APD) just as much as to any other type of deafness. Yet it is also often stated that children cannot be assessed for APD until age 7 or even age 8. This viewpoint came about because some early APD tests only had norms for children from about age 7, and also because there is considerable variability in auditory performance on tests in young children.
At SoundSkills we believe that early intervention is critical. Not only does it enable early treatment of the hearing disorder, it helps the child to start learning more effectively as soon as possible. If children are not diagnosed and treated until after they have been at school for a number of years their impaired ability to hear and learn has led to them falling further and further behind.
Most APD tests can be administered from age 6. A number of assessments can be carried out at age 5. And more limited assessment can be carried out on even younger children. The youngest age at which we assess for APD is 4 years. Different tests and different norms are used according to age.
We make it clear that below age 6 we can only make a provisional diagnosis or a diagnosis of at risk for APD, with the necessity to follow up when the child is older. If the child does not perform well on tests it is important to observe whether there might be another explanation for the poor performance. It is also important to consider the test results in the broader context of observations by parents, teachers and other professionals. Usually children referred to us with suspicion of APD at ages 4 to 5 have quite clear and obvious hearing problems.
Fortunately treatments for APD are not harmful and in fact are usually generally beneficial to any child. Therefore a provisional diagnosis does not prevent a trial of intervention. We have seen good responses to intervention on the very youngest of our clients.
This is a helpful checklist if you’re a teacher working with APD in the classroom.
- Preferential seating
- Within 2m of teacher (unless wearing remote microphone hearing aids)
- Seated away from auditory distractions such as doorways or air conditioners
- Gain students attention before speaking
- Face student when speaking
- Limit distracting noises where possible
- Use clear speech with student
- Use a slightly reduced rate
- Use slightly increased volume
- Emphasise key words
- Pause often
- Repeat or rephrase as needed to ensure message has been understood
- When giving instructions:
- Give written as well as verbal instructions for home and class work
- Give clear and specific instructions without using too many words
- Link verbal instructions to visual cues to help the student remember
- Avoid multi-tasking (e.g writing while listening)
- Use a buddy who can then confirm what has been said
- Be aware that students who struggle to process information tend to fatigue more easily
- Consider having breaks in listening
- Consider the time of day when presenting auditory tasks
- Give adequate response time
- Allow the student time to work out the answer. For example, let the student know that you are coming back to them for an answer and ask someone else a question before coming back to them.
- Allow extended time to complete tasks More time is needed to comprehend
- Encourage the student to self-monitor the listening environment and identify any problems
The Ministry of Education was criticised for its discrimination against children with Auditory Processing Disorder (APD) by the CEO of the National Foundation for the Deaf, Louise Carroll, on TV1 News. The news item focused on ten year old Lachlan who needs remote microphone hearing aids to hear well in class.
Children with hearing loss due to any other cause receive free hearing aids from the Ministry of Health. However under current government policy, children with APD are singled out and may only apply to the Ministry of Education for hearing aid funding. The problem is that the Ministry of Education disallows applications in the majority (90% or more) of cases. This is a major inequity compared to other children who need hearing aids, and to adults. Even the wealthiest of adults with hearing impairment are entitled to a subsidy of $1022.22 towards hearing aids.
Critics believe that hearing aid fitting is a health matter, that the Ministry of Education is not an appropriate organisation to be fitting or funding hearing aids, and that hearing aids for children with APD should be managed and funded by the Ministry of Health on the same basis as hearing aids for children with other types of deafness.
At least one child in every New Zealand classroom is believed to have a hearing problem that can seriously affect their ability to learn.
Auditory processing disorder (APD) is believed to affect from three to 15 per cent of children and can be difficult to detect as it is not picked up by a normal hearing test.
As a result, many children continue to struggle with reading, writing, spelling and often lose interest in school altogether.
Dr Bill Keith is an audiologist with 40 years’ experience who now deals solely with APD.
He said the problem is worse in boys than girls and can be caused by birth trauma or early history of glue ear.
In the past year Dr Keith has seen nearly 100 children, mostly from Auckland, who struggled in school before being diagnosed with APD.
He said he is now getting about half a dozen new referrals each week, many from friends and relatives of diagnosed children.
Children with the disorder are not deaf – which is why it’s not picked up in normal hearing tests.
Their ears process sounds normally but the brain struggles to understand what is being said, especially when there are competing noises, such as in a classroom.
As a result children have trouble following instructions that are lengthy or require more than one task and that is often reflected in problems with reading, spelling and language.
“APD can present as a learning or behavioural problem and can cause underachievement because these children are missing out on vital information,” said Dr Keith.
“The problem lies in the hearing pathways and centres in the brain. Children are unable to extract the message they need from all the sounds and noise around them.”
Professor Suzanne Purdy, head of speech science and senior researcher in the Centre for Brain Research at Auckland University, said APD was often overlooked or mistaken for another condition that affects learning and behaviour.
“It is important that children who appear to have poor classroom listening skills, and who are struggling with literacy in particular, be assessed by an audiologist to determine whether APD is an underlying factor.”
Help was available from a FM device which blocked out background noise, enabling children to focus on what they were being told by a parent or teacher.
Over time FM use could also lead to an improvement in auditory skills.
Vauxhall Primary principal Aaron Kemp, who has a child diagnosed with APD in his school, said the FM devices made a huge difference in helping children to follow instructions.
He said children had hearing and vision tests when they start school.
If teachers felt there was still something wrong they usually asked parents to get more comprehensive tests which would hopefully identify something like APD.
Making Sense of Messages to the Brain
Thomas Crook’s reading wasn’t bad, but he wasn’t as good as his twin brother Alex and he was “hopeless” at following instructions, especially ones that involved doing more than one thing.
While many might put that down to different personalities, his mother Helen was worried there was more to it and starting making inquiries that would eventually make a huge difference in Alex’s school life.
“I was chatting to my sister who is a primary teacher in the UK and Thomas’ reading level was certainly not up to the level Alex was reading,” said Mrs Crook.
Her sister quizzed her further on a few subjects, such as whether he was very good at following multiple tasks.
“I said he’s absolutely hopeless at that. You ask him to brush his teeth and put his shoes on and he’ll come back with a sweater. I kind of thought that was just a boy thing and first thing in the morning but evidently there could be more to it than that.”On her sister’s recommendation she took Thomas to have his ears and eyes tested.
These tests found no problems, but staff at the ear-test clinic suggested Mrs Crook take Alex to the Sounds Skills unit at Auckland University if she was still concerned.
Several tests later, Thomas was diagnosed with auditory processing disorder – a problem in which the ear processes the sound but the brain struggles to interpret the message.
To help him, he now wears a discreet FM device at school – two tiny pieces behind his ears which enable him to hear his teacher’s voice more clearly while blocking out other classroom noises.
Thomas’ teacher Zane Cooper said he noticed a big improvement once he started wearing the device last year.
“You suddenly start seeing his hand going up and putting his ideas forward.
“The biggest improvement that I saw in him was his enjoyment at school.
“Once a child can get a full enjoyment out of being in the classroom, the learning follows.”
Mr Cooper encouraged parents to get their children tested if they were worried about possible hearing difficulties.
“You don’t want kids missing three or four years of learning because they can’t process instructions.”
by Elizabeth Binning, New Zealand Herald (Mar 2011)
(Published with permission)