Download Better Together--ASHA Leadership

March 13, 2012 Features: The ASHA Leader
Better Together
by Tena McNamara & Gail Richard
How do auditory processing disorders and deficits in language relate to one another—if at all?
It's a question that spurs endless debate. Some professionals believe that an auditory processing
disorder (APD) is nothing more than a reflection of a language disorder or delay. Others believe
true auditory processing difficulties exist that cause problems in language and academic skills.
They point to neuroscience research that links auditory processing skills to sites in the central
auditory nervous systems (e.g., Bamiou, Musiek, & Luxon, 2001; Musiek, Kibbe, & Baran,
1984; Musiek, Shinn Jirsa, Bamiou, Baran, & Zaidan, 2005). Abnormal functioning in these
areas, it is theorized, can lead to an auditory processing deficit—possibly triggering language
and learning difficulties.
What's challenging for professionals—apart from the limited evidence to date on APD treatment
efficacy (Fey et al., 2011, p. 254)—is that listening and language skills can be difficult to tease
apart in behavioral testing. For example, a problem with auditory input can compromise the
linguistic signal, which in turn can cause problems in the development of vocabulary, syntax,
and semantics.
That said, we believe it is more productive to focus on addressing the effects of auditory
weaknesses on school and home life than to expend energy debating whether poor performance
on auditory skills tests reflects an auditory processing deficit or a language deficit. Audiologists
are experts at investigating neurological components of auditory deficits. But when it comes to
meeting a child's educational needs, information on functional performance will be needed. For
example, behavioral tests for auditory processing often assess temporal processing—defined as
"the ability of the auditory system to represent and process changes in the acoustic signal that
occur over time and to its ability to process brief transient acoustic events" (Banai & Kraus,
2007, p. 91).
A child who performs poorly on temporal tasks may struggle to process rapid speech or longer
segments of information presented auditorily. In such a case, a simple recommendation from the
audiologist can make a big difference—just decreasing the time and length of utterances, for
example, may substantially boost that child's comprehension.
Similarly, if a child scores poorly on behavioral tests for low redundancy speech, it is likely that
poor classroom acoustics will impair that child's ability to interpret speech. Reducing excessive
classroom noise and seating the child away from noise sources could help a great deal.
Audiologists can and do offer such tips to teachers to help them improve children's
comprehension of speech in the classroom.
However, testing and intervention for APDs is not the sole domain of the audiologist. A speechlanguage pathologist also should be involved, providing key input on language abilities that may
be affected by deficits in auditory skills. Hence, intervention with APDs requires a close,
ongoing collaboration between the SLP and the audiologist. What should that collaboration look
like? We propose a model, but first we provide more justification.
Why Collaborate?
One major reason a cooperative model is so important is the large variability in how APDs affect
children's language behaviors. It is inappropriate to make general judgments about a child's
language skills based purely on auditory skills assessments. In turn, it is unrealistic to assume
that poor performance on language tests means that the same would be true for performance on
auditory processing tests.
Problems can emerge if clinicians try to categorize or infer language and learning deficits based
on results of the auditory processing evaluation alone. It is unrealistic to make recommendations
for intervention based on a "profile" of the child, rather than by actually focusing on the child's
unique needs.
By involving the SLP, information on the child's language abilities and educational can be
included in planning. While the audiologist identifies how deficits in auditory skills may affect
language development, the SLP investigates effects of auditory deficits on actual language
performance. Working together they can establish an intervention plan that better reflects the
educational needs of the child.
For a collaborative model to work efficiently, however, two aspects must be included:


The SLP needs to incorporate multiple evaluation tools that address not only basic
language skills, but also higher-level language function. As with any child who
experiences auditory deficits (because of deafness, hearing loss, or auditory processing
disorder), abstract language, critical thinking, and other language processing skills can
pose challenges. Metalinguistic analysis may be affected due to difficulty applying the
rules of language to auditory input. Also, testing should involve phonological/phonemic
awareness skills, as problems with speech discrimination may correlate with abnormal
auditory processes (Banai & Kraus, 2007).
The audiologist also needs to employ multiple evaluation tools to ensure the accuracy of
the diagnosis (Friberg & McNamara, 2010). Unfortunately, many tests have not been
adequately assessed for their diagnostic accuracy and validity. An important
consideration is the specific auditory challenges that children experience at home and in
the classroom. Valid and reliable measures of auditory processing in natural
environments are needed. No single assessment tool is likely sufficient for diagnostic
decision-making. Rather, a variety of approaches should be used, including tests of
dichotic listening, temporal processing/patterning, binaural interaction, and lowredundancy speech tasks (Musiek & Chermak, 2007). Collaboration with other
professionals and the interpretation of multiple cross-check testing data (including those
gathered from nonbehavioral tests), can help to yield a diagnosis.
An Ideal Partnership
Based on the need for frequent communication between the audiologist and SLP, an effective
diagnostic and intervention model for a child with a possible APD could look like this:




The audiologist and SLP consult when the client is first referred. After reviewing the
available case information, they can jointly identify possible deficits in areas such as
phonology, semantics, syntax/morphology, reasoning, discourse, pragmatics, and literacy.
Deficiencies in auditory skills would likely be reflected in one or more of these language
areas. Based on their analysis, the SLP and audiologist should agree on the extent and
type of testing needed.
The audiologist evaluates the client and shares the results with the SLP. Functional
performance on auditory tests may provide important insights into the deficits underlying
disordered language performance. As explained by Richard (2007), the audiologist's role
is to evaluate transmission of the acoustic signal through the peripheral and central
auditory system, whereas the SLP's role is to explore problems in analyzing the acoustic
signal to comprehend and respond.
The SLP now assesses the specific language skills of the child, armed with the auditory
skill performance data and the behavioral profile of language concerns.
The SLP discusses results and intervention strategies with the audiologist and, based on
the conversation, develops a tailor-made treatment plan to boost the child's performance
in school and daily living. The plan should include measurements to assess academic and
psychosocial progress.
Given that electronic media now connect us, teamwork between audiologists and SLPs is always
possible, even when they work at different sites. Ideally, audiologists who administer and
interpret auditory processing assessments should forge relationships with local SLPs. Both
professions need to understand the purpose of auditory processing assessment tools, the
implications of test results for auditory skill performance, the purpose and implications of the
various speech-language assessments, and the meaning of the results.
Getting Connected
With increased shared knowledge and collaboration between these professions, a child's auditory
deficits can be addressed more efficiently and effectively. Both the audiologist and the SLP play
an integral part in the diagnosis and treatment of children with these deficits, whether languageor auditory-related. Audiologists provide a unique perspective concerning why a child may not
interpret auditory information accurately; SLPs increase awareness of how language skills are
affected by the breakdown in auditory processing. As audiologists and SLPs, we address many
disorders in which the true underlying etiology is a mystery. However, we still have a
responsibility to treat the resulting deficits.
It is time for each discipline to move beyond debating etiology issues. We should focus on
working together to meet the pressing needs of children whose struggles to interpret and
comprehend auditory information result in compromised academic performance.
Tena McNamara, AuD, CCC-A/SLP, is assistant professor in the Department of Communication
Disorders and Sciences at Eastern Illinois State University and a member of ASHA's Special
Interest Groups 9 (Hearing and Hearing Disorders in Children) and 10 (Issues in Higher
Education). Contact her at [email protected].
Gail Richard, PhD, CCC-SLP, is professor and chair of the Department of Communication
Disorders and Sciences at Eastern Illinois State University and 2012–2014 ASHA vice president
for speech-language pathology practice. Contact her at [email protected].
cite as: McNamara, T. & Richard, G. (2012, March 13). Better Together. The ASHA Leader.
References
Banai, K., & Kraus, N. (2007). Neurobiology of (central) auditory processing disorder and
language-based learning disability. In F. Musiek & G. Chermak (Ed.) Handbook of (central)
auditory processing disorder: Auditory Neuroscience and Diagnosis. San Diego: Plural
Publishing.
Bocca, E. (1958). Clinical aspects of cortical deafness, Laryngoscope, 68, 301–309.
Bocca, E., & Calearo, C. (1963). Clinical aspects of cortical deafness. In J. Jerger (Ed.) Modern
developments in audiology. New York: Academic Press.
Bocca, E., Calearo, C., & Cassinari, V. (1954). A new method for testing hearing in temporal
lobe tumor. Acta Otolaryngologica, 44, 219–221.
Bocca, E. Calearo, C., Cassinari, V., & Migliavacca, F. (1955). Testing "cortical hearing" in
temporal lobe tumors. Acta Otolaryngologica, 42, 289–304.
Calearo, C., & Lazzaroni, A. (1957). Speech intelligibility in relation to the speech of the
message. Laryngoscope, 67, 410–419.
Clarke, J. M., Lufkin, R. B., & Zaidel, E. (1993). Corpus callosum morphometry and dichotic
listening performance: Individual differences in functional interhemispheric inhibition?
Neuropsychologica, 31, 547–557.
Fey, M.E., Richard, G. J., Geffner, D., Kamhi, A.G., Medwetsky, L., Paul, D., Ross-Swain,
D.,...Schooling, T. (2011). Clinical forum: The role of the speech-language pathologist in
identifying and treating children with auditory processing disorder. Language, Speech, and
Hearing Sciences in Schools, 42, 246–264.
Friberg, J. C., & McNamara, T. L. (2010). Psychometric validity of tests that assess central
auditory processing abilities. Journal of Educational Audiology, 16, 59–72.
Kimura, D. (1961). Some effects of temporal lobe damage on auditory perception. Canadian
Journal of Psychology, 15, 157–165.
Musiek, F. E. (1983). Assessment of central auditory dysfunction: Dichotic Digits Test
revisited, Ear and Hearing, 4, 79–83.
Musiek, F. E., & Chermak, G. D. (2007). Auditory neuroscience and (central) auditory
processing disorder: An overview. In F. Musiek & G. Chermak (Ed.) Handbook of (central)
auditory processing disorder: Auditory Neuroscience and Diagnosis. San Diego: Plural
Publishing.
Musiek, F. E., Kibbe, K., & Baran, J. (1984). Neuroaudiological results from split-brain
patients. Seminars in Hearing, 5, 210–229.
Musiek, F. E., Shinn, J. B., Jirsa, R., Bamiou, D. E., Baran, J. A., & Zaidan, E. (2005). The
GIN (Gaps-in-Noise) Test performance in subjects with confirmed central auditory nervous
system involvement. Ear and Hearing, 26, 608–618.
Richard, G. J. (2007). Language processing versus auditory processing. In D. Geffner & D.
Ross-Swain (Ed.) Auditory Processing Disorders: Assessment, Management, and Treatment. San
Diego: Plural Publishing.