Editor’s note: After a number of requests to publish CAPD reports, we are pleased fulfill this demand. Louise Levy, a very busy, practicing clinician, has agreed to submit a CAPD report for the readership to view for this month’s Pathways article.
LOUISE LEVY M.S., CCC-A AUDIOLOGIST
Z was seen for an auditory processing evaluation in the past few months. Z was referred by an Occupational Therapist. At the time of this evaluation, she was in the 5th grade. There were 18 children and 1 teacher in the class.
Z is easily distracted by specific background noises. These noises included clicking from computer keys and the sound of knives and forks against dishes. Z reported that these sounds were “distressing”. The sounds at times made her extremely anxious, almost to the point of feeling sick. Z reported that she thinks that she has misophonia (about which she had read). Misophonia is a disorder whereby certain sounds trigger an emotional or physical response. Z also reported that when she is in an environment where there is a lot of activity, she becomes very anxious. This occurred in Times Square with her sisters. She had to subsequently leave the area. She also reported that the cafeteria can be distracting but that she can mostly manage that environment. Z and her parents reported that when multiple people speak at once, Z has difficulty with processing substantial auditory information. However, Z easily understands humor and sarcasm. Both contain acoustic contour including rhythm, stress and intonation, components of auditory processing. Interpretation of this information is key for assessing auditory processing.
Academically, with the completion of last year, Z did well. However, the first 2 months in 5th grade were challenging for her. Her teachers reported that she was having difficulty in math and history.; math was particularly difficult. She worked with a math tutor. Socially, Z reportedly had/has close friends.
Z was the product of a full-term, unremarkable pregnancy. Speech and language development and gross motor milestones evolved age appropriately. Medical history was unremarkable. Otologic history was also unremarkable. Z is right-handed. Family history was positive for anxiety.
AUDIOLOGICAL EVALUATION: Puretone tests results were consistent with normal hearing (i.e. 20 dB HL) sensitivity bilaterally from 250 Hz to 8000 Hz. Auditory hypersensitivity was noted at 2000 Hz and 4000 Hz bilaterally. Speech recognition results were judged excellent bilaterally at 35dB HTL. Immittance (tympanograms) findings were consistent with normal middle ear pressure, shape and compliance. Acoustic reflexes were absent @ 110 dB HL bilaterally for frequencies 500 – 4000 Hz. Transient otoacoustic emissions were present bilaterally supporting normal outer hair cell activity bilaterally.
CENTRAL AUDITORY PROCESSING EVALUATION
Test reliability of the session was judged as excellent. Z was very focused throughout the testing. All testing was performed at 55 dB HTL.
The central auditory test battery included the following: 1. Low Pass Filtered words/500Hz 2. Compressed Speech- NU 6 45% Compression & 0.3 reverberation 3. Pitch (Frequency) Patterns 4. GIN, 5. Dichotic Digits
- Auditory Closure
- Low Pass Filtered Speech Test
Right ear 36%
Left ear: 36%
Norms: > 70%
- Compressed Speech- NU6 45% Compression & 0.3 Reverberation
Right ear: CNT Left ear: CNT
- Temporal Ordering Tasks:
- Pitch Pattern Sequence Test
Z’s score was so strong that testing was completed after 15 sequences. Norms: 78 % bilaterally
Right Ear A.th = 5 msec.
Left Ear A.th. = 4 msec.=
(<8 msec. norm)
III. Dichotic Tests
- Dichotic Digits
Right ear 75% Left ear 87.5 %
Norm: Right ear 85% Left ear 78 %
The results for The Filtered Words 500 Hz test were below the norm bilaterally. The results suggested that when auditory information was distorted, decreasing the redundancy of the message, Z could not “fill” in the missing information (auditory closure) and determine what has been said. It should be noted based on the scores that Z had marked difficulty with this test. The recording needed to be stopped between words in order to give her more time to respond.
Z also had difficulty with the Compressed Speech test. She could not process the auditory information in either ear. She stammered and asked for repetition. Testing was so difficult that the test was terminated in each ear after 10 words per ear. Therefore no results could be obtained.
The results for The Pitch Pattern test were within the norms in the verbal mode. The results suggested that Z could auditorily sequence auditory information. In addition, she could process acoustic contour including stress, rhythm and intonation.
The results from the GIN were extremely strong bilaterally. The results suggested good temporal resolution skills. The results indicated that Z could easily decipher changes in timing between sounds so as to differentiate between one auditory stimulus and another.
The results for The Dichotic Digits test were slightly below the norm in the right ear and normal in the left ear. This information suggested that Z may have difficulty processing multiple auditory messages simultaneously. It should also be noted that typically at this age, the stronger ear should be the right ear. Z’s stronger score is her left ear.
Comments on Findings
Z presented with complaints of auditory hypersensitivity to certain environmental sounds. This caused her anxiety. Z reported that when multiple conversations were present, she could not understand the messages. Both Z and her parents stated that she could lose focus in these situations.
The auditory processing results were consistent with an auditory closure deficit and a mild dichotic listening deficit for binaural integration.
Specifically, the results from The Filtered Word test were below the norm. Z could not complete The Compressed Speech test. As alluded to earlier, the information from both tests indicated that she may have an auditory closure deficit. Auditory closure is defined as the ability to utilize intrinsic (auditory/cognitive) and extrinsic cues (environmental) to “fill” in what has been said when the auditory information has been reduced usually by distortion in some way, such as when the speaker has an accent, speaks unclearly, when background noise is present or when speech is presented rapidly. Consequently, when Z is in a noisy classroom, when her teachers speak rapidly or if her teacher speaks unclearly, she would likely have a difficult time with understanding the information. Z reported that when multiple messages are present, she could not follow the auditory information. This is likely due to the fact that the additional messages act as background noise which therefore makes it difficult to interpret the auditory information because of the auditory closure deficit. This may mean that during active conversation in the classroom, Z could not be follow the information. Z’s Dichotic Digit scores also supported her complaints. The score was below the norm in the right ear. This indicated that Z could not integrate multiple messages that were presented simultaneously. Therefore, when 2 or more people are speaking at the same time, Z may only partially follow the auditory messages. This could impact her in the classroom and in social situations. In small group discussions, with multiple speakers, Z may have difficulty following both speakers. In social situations, this will likely also occur. As Z ages, more and more social situations will arise necessitating her need to quickly integrate multiple messages. Without intervention, she will likely retreat from these situations. Z’s auditory closure deficit will further exacerbate the ability to perform binaural integration (an important process). As stated above, Z’s scores for The Dichotic Digits test are not typical. With most right handed children at her age, the right ear advantage should prevail. Thus, information that is presented to the right ear travels contralaterally to the left brain. This route is the most efficient means for information to arrive at the left brain, the language and dominant auditory hemisphere. As a result, the right ear is typically the stronger ear and performs better than the left dichotically. Z demonstrates a left ear advantage/ right ear deficit. This may be typical if there is a weakness within the corpus callosum. However, Z’s scores for the Pitch Pattern subtest are very strong. These scores support a very intact interhemispheric function. Therefore the scores from The Filtered Word test, The Compressed Speech test and The Dichotic Digits test suggest an auditory processing deficit as 3/5 test scores were below the norm.
Z’s temporal processing skills were very solid. As stated above, her results from the Pitch Pattern subtest suggested an intact interhemispheric transfer and sequencing skills. Consequently, when auditory directions or auditory information were presented to her, she did use acoustic contour (rhythm, stress and intonation) to remember the sequence. Acoustic contour was also necessary to interpret pragmatic (social) language including sarcasm and humor. Based on her results, she could easily interpret subtle cues that exist as a result of acoustic contour. The results from the GIN test suggested strong temporal resolution skills. Temporal resolution is defined as the ability to process time related aspects of speech. Successful temporal resolution is necessary for subtle cues within speech discrimination including discrimination of similar words and subtle cues such as voicing. It is also important for melody perception. Speech discrimination between two speech sounds that have rapidly changing spectro temporal acoustic features requires precise temporal resolution. It is timing changes between phonemes (sounds) that assist with altering the differences between sounds and make for successful speech discrimination. Successful temporal resolution or timing related aspects of auditory function are crucial to many tasks requiring auditory processing. Given the strong performance on temporal tasks, one may ponder the possibility of less than adequate processing of spectral information. However at this point this notion is only speculative.
Z’s auditory processing test results likely identified auditory processing deficits. These deficits must be addressed with intervention. Therefore, specifics of intervention should be further explored by a Speech/Language Pathologist or educational audiologist who is skilled in auditory processing (see recommendations below). Z also presented with significant sensitivity to specific sounds. Her sensitivity resulted in anxiety and physical symptoms. This area should also be addressed. Consequently, Z should be evaluated by a sensory based Occupational Therapist. For social reasons and for academic reasons, this is a necessary area to receive the intervention. It is likely that when the anxiety presents, it further contributes to her auditory processing deficit.
The absence of the acoustic reflex needs to be considered and weighed. Could it simply be a false positive? Could it play a role in the reported tolerance issues?
1.In light of Z’s auditory closure deficit, classroom modifications should be made. This support includes strategic seating. Strategic seating will enhance listening and minimize distractions. This includes the following:
- Full visual access to her teacher so as to obtain all visual cues. The visual cues will supplement her listening and facilitate learning.
- Z should sit away from computers, ventilation systems and open doors. This will minimize the unwanted background noise and improve focus and listening.
- A personal Roger (Phonak) system should be trialed in the classroom. The Roger system will improve her auditory access to her teachers and facilitate listening. It will also improve her focus and reduce auditory fatigue, a condition commonly accompanying CAPD.
- An evaluation with a Speech/Language Pathologist/educational audiologist to address the auditory closure deficit. Intervention in this area includes:
- Missing Word Exercises
- Missing Phoneme Exercises
- Speech-In-Noise Training
- Vocabulary Building – Miller – Gildea vocabulary building approach to work on closure.
- Within the classroom, if Z misunderstands what has been said, the information should be repeated in the same format. It should not be rephrased.
- Verbal information should be supplemented with written and graphic information to aid in the educational process.
- In light of the auditory closure deficit, a multi-sensory environment should be present whenever possible. Until the auditory closure deficit has improved, the more visual information that is present, the easier learning will be for her.
- Pre-Teaching of academic information whenever possible. If Z is familiar with the auditory material, auditory closure will be easier for her (the Miller – Gildea approach mentioned earlier integrates pre-teaching for vocabulary enhancement and could be used as a general model)
- Dichotic Listening Training (DIID). is a possibility but not necessarily a priority. —If pursued, re-evaluation in 6 months to determine if progress has been made.
- Trends of Z’s scores are suspect for a possible language processing deficit. Further probing in this area is indicated with a speech and language pathologist.
- In light of Z’s auditory sensitivity which clearly gets in her way and can make her physically ill, it is strongly recommended that K have an evaluation with a sensory based Occupational Therapist. Pending the results, the family may also want to consult with a Psychologist. Misophonia may also be due to anxiety and therefore this should be addressed.