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| SSW Reports November 2005 - APD Testing in Children Below 7 |
| by Dr. Jay Lucker |
| Posted by Janis |
0000-00-00 |
Index
» by Dr. Jay Lucker
At What Age Depends on Your Approach
Jay R. Lucker
The last issue of SSW Reports discussed and presented strong arguments supporting the assessment of auditory processing deficits in children below the “cut-off” age often stated as being 7 years. As Katz pointed out in that issue, there was never any research that demonstrated that APD testing could not be conducted on children below this magical cut-off age. He further demonstrates that a number of stand-ardized tests of APD have norms going below 7 years, and a few have norms down to 3 years.
I have been involved in assessing children for APD for 35 years (I started when I was just a kid ). I never felt a need to consider a cut-off age because I always saw my role as a helping professional. When parents, pre-school teach-ers, speech-language pathologists or other pro-fessionals felt a young child presented with APD concerns, I wanted to be there to counsel and help to provide an assessment that would lead to the child receiving appropriate services. A number of years ago I even wrote an article for the National Coalition on Auditory Processing Disorders, Inc. (NCAPD; www. ncapd.org). The article was titled, “At What Age Can a Child Be Evaluated for APD?” In that article, I pointed out research on infant auditory processing (usually found under the area of speech per-ception). Thus, auditory processing has actually been investigated for years in infants, often in fields such as psychology, psycholinguistics, and acoustics. Little research in the field of audiology has focused on auditory processing in such young children. It is as if the magical cut-off age led audiologists to ignore auditory processing in very young children.
However, in the field of deafness and hearing loss, one of the most common factors discussed is the development of auditory skills in infants and young children. One of the most commonly referred to models of auditory development is Erber’s model. In this model, Erber discusses four stages of auditory development in children. These stages include (in order of development):
1. Awareness/Recognition
2. Discrimination
3. Identification
4. Comprehension
Awareness or recognition is the level at which the child is aware of the presence or absence of sound. It is the first level of auditory processing and is related directly to hearing. Yes, every time an audiologist tests a person’s hearing, that is every time the audiologist asks the client to “raise your hand,” the audiologist is assessing both the level of hearing and the client’s auditory processing abilities to make the decision whether or not the client heard (was aware of or re-cognized the presence of) the sound. Although this seems so simplistic that you wouldn’t think it were auditory processing, try assessing the hear-ing thresholds of children with developmental disabilities or those in the autistic spectrum. You will find that many of these children (regardless of being above or below a mental age of 7 years) show little or no awareness of the presence of sound demonstrating what Lucker has identified as his first level in his model of auditory processing, “Auditory Sensitivity.” Thus, audit-ory processing (awareness/recognition) is some-thing most pediatric audiologists have been assessing for years.
The discrimination level is one I believe we all would admit relates to auditory processing. In Erber’s model, this level is not only phonemic discrimination or the ability to distinguish be-tween words having minimal phonemic contrasts (e.g., cat vs. hat). Discrimination also relates to a person’s ability to know that any two sounds in that person’s listening environment are the same or different. Adding the level of memory, dis-crimination also relates to a listener hearing a series of sounds and knowing whether the successive sounds are the same or different from previous sounds. As research on speech per-ception (specifically categorical perception of stop consonants) has demonstrated, infants only a few weeks of age demonstrate differential be-havioral responses when sounds are within phonological categories (e.g., /p/ vs. /p/) or are from two different phonological categories (e.g., /p/ vs. /b/). Many of us will remember these voice onset time (VOT) studies from our acoustic phonetics courses.
We are also assessing auditory processing at this level of discrimination in standard pediatric sound field testing. Consider the following example. We notice a two year old showing no further responses to the fifth presentation of the same auditory stimulus, so we change the fre-quency (e.g., from 1000 Hz to 4000 Hz). Suddenly, we see a marked differential response to the change in the auditory stimulus. In reporting this noticeable change, we have as-sessed not only the child’s differential sensitivity (i.e., auditory processing) but also hearing. Such response differentiation can be recorded in a child as young as 6 months to 1 year of age.
I do not wish to drag out this issue further. I only hope that I made the point that we have been assessing auditory processing in children well below even 5 years of age for years. Thus, the question of whether we can or should be considering testing children below 7 years of age for auditory processing is really a function of the approach the audiologist chooses to take in as-sessment.
In order to determine the value of APD testing in children below 7 years of age, a comparison was made between actual test findings in a clinic population of children from 4 years through 11 years of age. It was hypothesized that if children below 7 years of age could not be assessed for APD for the reasons offered by many pro-fessionals who hold to the magic “cut-off” age, then either children below 7 years of age would have a greater incidence of APD problems or, from an objective point of view, children below 7 years of age would have a higher incidence of failing APD tests.
If the audiologist chooses what I would call a Test Battery Approach, then the youngest age at which that audiologist would test children for APD would be the youngest age for which norms are provided for the APD tests used in the test battery. If the audiologist chooses a neuro-physiological approach to APD, and the audio-logist determines that APD can only be identified when the developmental factors in the central auditory nervous system have stabilized, then, as pointed out in the NCAPD publication cited above, we may have to wait until the child is 12 years of age. In contrast, if the audiologist takes a developmental approach to assessing auditory processing, then auditory processing would be assessed using any appropriate measures the audiologist feels is suitable to obtain the be-havioral information regarding the child. These observations may tap into all aspects of auditory processing not just the few skills assessed on tests we call “tests of auditory processing.”
Lucker, J.R. (2002). At What Age Can A Child Be Evaluated for APD? NCAPD Newsletter.
What Do APD Test Results in Children
Below 7 Years Tell Us?
Jay R. Lucker
Since I have been assessing children for APD over the past 35 years, I have seen many children who are younger than 7 years. Using tests such as those discussed by Katz in the last issue of SSW Reports that have norms below 7 years of age, I have performed APD testing on children routinely down to 4 years of age. When assessing children down to this age level, I use tests having norms at the child’s age level and follow the standard test procedures for children at that age level. Additionally, for some tests, such as SSW, I often administer these tests to children below 5 years of age even though the lowest age norm I have had (until recently) has been that age level. What I have then done is compare these younger children’s performance to the youngest age norms for the test under consideration stating that this was what I was doing in the body of the report and on the test results summary page. Then, if the child scored within normal limits for the 5 year old age norms, I concluded that the child did not have problems in the areas of auditory processing assessed by that specific test. For example, I often administer the SSW to 4 year olds and compare their performance with the 5 year old norms
In order to determine the actual test findings in children as young as 4 years of age that I have tested, I decided to look back at my database of clients seen for APD testing between January 2002 and June 2005. I eliminated any children who had diagnoses of AD/HD or autism spectrum or children found to have mental deficiencies (i.e., IQ scores in the better area, typically performance vs. verbal) lower than 80 as these children could have developmental disabilities.
Following these criteria, I identified a group of 216 children aged 4 years – 1 month through 11 years – 11 months. Table 1 presents the breakdown by age and gender for my sample. To investigate the differences in performance between children above and below 7 years of age, I grouped the data for the 4, 5 and 6 year olds into the “younger” group (n = 78) and the remaining age groups into the “older” group (n = 138). Considering that the younger group consisted of only 3 age groups while the older group consisted of 5 age groups, it is not surprising that 36% of the entire sample were in the younger group while 64% were in the older group.
Table 1 Gender x Age at Evaluation
Age Group Males Females Total N
4 years 13 6 19
5 years 19 5 22
6 years 31 6 37
Younger Gr. 61 17 78
7 years 20 12 32
8 years 21 14 35
9 years 14 11 25
10 years 18 12 30
11 years 7 9 16
Older Gr. 80 58 138
Total 141 75 216
The battery of APD tests administered is summarized in Table 2. For each test in that table the percent of children in each age group (younger and older sample groups) who were found to fail (test results below the norms). For tests not having norms for that age group (e.g., SSW for the 4 year olds), the criterion described above was applied.
Table 2A SCAN
Group FW AFG CW CS
Younger 35% 37% 32% 18%
Older 42% 33% 32% 35%
Table 2B SSW
Group RNC RC LC LNC
Younger 58% 45% 64% 54%
Older 51% 65% 80% 63%
Table 2C SIN PS
Group SIN Quant Qual
Younger 36% 44% 41%
Older 18% 53% 48%
Table 2D TCST PPST
Group 40% 60% Say Point
Younger 19% 23% 6% 6%
Older 13% 21% 33% 28%
Table 2E ACPT
Group Total Vigilance
Younger 26% 27%
Older 33% 23%
Key to Test Names:
SIN = Speech-in-Noise
SCAN-C/FW = SCAN-C Filtered Words
SCAN-C/AFG = SCAN-C Auditory Figure-Ground
SCAN-C/CW = SCAN-C Competing Words
SCAN-C/CS = SCAN-C Competing Sentences
Revers = SSW Reversals
PST/Quant = Phonemic Synthesis Test Quantitative value
PST/Qual = Phonemic Synthesis Test Qualitative value
TCST/40% = Time Compressed Sentence Test 40% compression
TCST/60% = Time Compressed Sentence Test 60% compression
PPST/Say = Pitch Pattern Sequence Test Verbal Response
PPST/Point = Pitch Pattern Sequence Test Point Response
ACPT/Total = Audit. Continuous Perform. Test Total Error score
ACPT/Vigilance = Auditory Continuous Performance Test Vigilance measure
In order to make some comparisons, an apriori criterion needed to be established. It was decided that if the percent of children failing a test comparing the younger vs. older age groups was greater than 10%, the difference could be considered indicative of a difference in failure rate on that measure. Using this criterion, a similar percentage (within the 10% difference) of children in each age group failed 11 of the 19 measures. Thus, over 50% of all APD tests were failed by about the same percentage of children above and below age 7 years.
Of the remaining 9 tests, the following out-standing findings were noted. Twice the per-centage of children in the younger group failed the Speech-In-Noise (SIN) test using the standard SIN test (WRS word lists in quiet and noise at S/N+5 dB). About twice the percentage of older children failed the Competing Sentences subtest of SCAN-C. About an equal percentage of child-ren showed abnormalities for the NC conditions on the SSW, but about 20% more older children showed problems with the Competing conditions. Abnormal ear and order effects were more pronounced with the older group as were reversals and Type A pattern. However, none of the younger children showed significant Type A patterns and few have significant reversals to demonstrate a deficit.
Since the Phonemic Synthesis Picture Ident-ification (PSPI) test was used only with one child in the older group, comparisons could not be made. The same occurred for the Pitch (Fre-quency) Pattern Sequence Test that was admin-istered only to 5 children in the younger group. Furthermore, the Pediatric Speech Intelligibility (PSI) test was never administered to children above 5 years of age. Thus, results on this test also could not be compared between the two groups.
One interesting finding involved the results of the test of sustained auditory focal attention, the Auditory Continuous Performance Test (ACPT). This test has norms going down as low as 6 years of age. However, as stated earlier, I administered this test to many 5 year olds comparing their results to the 6 year old norms. If the children fell within the norms for 6 year olds, I deter-mined they did not fail the ACPT. Using this criterion along with the 10% difference between groups to indicate a difference between the groups, the same percentage of children in each age group failed the ACPT.
Some of the findings from this study were most interesting. It was expected that more of the younger children would fail the Competing conditions for the SSW because of the dev-elopmental factor well established for these conditions and the difficulty in repeating the two competing words. However, the present results indicate that 20% more older children failed the Competing conditions (Katz believes that the somewhat larger standard deviations for the younger children may help to explain why they were identified less often). Additionally, an equal number in each group failed the NC conditions. Thus, it appears that the SSW is a test that can be used with children down to 4 years of age providing information about aud-itory processing not just reflecting developmental factors. Another interesting finding for the SSW related to the Type A pattern and reversals. More older children than younger ones revealed Type A patterns and a significant number of reversals.
Attention is a factor felt to affect the younger children more than the older ones. The ACPT, a sensitive test of attention, was expected to be difficult for the younger children with the expectation that a higher percentage of these children would fail the test. However, from the present results, essentially the percentage of children in each group failing the ACPT for both the total score and the vigilance score was about the same (within 10%).
The area of phonemic awareness is of great concern related to APD in children. The test tapping into phonemic awareness reviewed for this study was the Phonemic Synthesis Test (PST). Because of the fact that there is a picture
version for younger children, the PST was only administered to children 5 years and above using the kindergarten age norms for these children. Children 4 years of age were administered the PSPI test. Therefore, a smaller number, and thus, percentage of the total sample of younger children were administered the PST. Yet, the findings from this study indicate that the percentage of children failing the PST in both age groups was similar (within 10%). If we remove the 19 4 year olds from the younger group and calculate the percentages of children failing in the younger group (now only representing 5 and 6 year olds), the results would show that 58% of the younger group failed the PST for Quant-itative analysis while 54% failed for Qualitative analysis. Compared with the older group (53% and 48%, respectively), the results still indicate that the percentage of children in both groups failing the PST was similar (within 10%).
It is felt that these results are very significant in support of the value for testing children below the age of 7 years old for APD issues. Findings from the present study do indicate that some tests (like the SIN) appear to be more difficult for younger children and may not be appropriate for them. This factor would not eliminate the audiologist’s ability to assess speech under-standing in noise in such young children. The PSI has norms for this age group as does the SAAT. Additionally, there are other tests that could be used such as the new BKB-SIN test that has norms for children down to 5 years of age, but no clinical findings reported using this test as a measure of APD in children. I have a test that also looks at speech understanding in various noise backgrounds that is in the process of being standardized and may have components indi-cating speech discrimination abilities as well as speech understanding in noise vs. in the presence of competing messages that may differentiate between children with APD auditory distrac-tibility and children with attention problems such as children with AD/HD.
It is hoped that audiologists and other pro-fessionals concerned with young children’s aud-itory processing abilities will look at this and the previous SSW Reports and realize that we can test children’s auditory processing abilities below the magic cut-off age of 7. Perhaps future researchers will find ways to assess auditory processing even in children younger than the 4 year olds reported in this study. One day we may even be able to find clinical utility for the experimental measures that have looked at auditory processing abilities in infants as described earlier.
Sample Case – A 5-Year-Old
This child presented with problems listening and attending. A neuropsychological assessment indicated a verbal IQ= 102 & performance IQ= 124 with grade appropriate academic skills. A rating scale indicated her to be ‘at risk,’ but showing no specific indication of inattention or hyperactivity. The psychologist felt there was “something more” going on than just an attention problem.
The school psychologist confirmed normal cog-nitive abilities with the verbal/performance discrepancy. The school speech-language pathologist found her to have comprehension and some verbal information problems. The team concluded that she had attention deficit, offering a 504 Plan & encouraging the use of medication.
The parents expected the 504 Plan accommodations to “cure” their daughter, but she continued to have the same problems. Eventually, she slipped behind her peers in early reading skills. The parents decided to go to their pediatrician.
The pediatrician felt the girl had more than just attention problems and discussed APD. The pedi-atrician had heard about APD and felt that the parents should first get an APD assessment before pre-scribing Ritalin.
Comprehensive auditory processing testing at age 5yr–6mo showed abnormalities for: Speech-in-Noise, SCAN-C/AFG, significant ear difference on the CW although total CW score was normal, SSW LC condition, Time Compressed Sentences Test using 6yr norms, and significant problems on children’s Token Test, parts 3 & 4. Normal 6yr results norms on the ACPT were found for total errors, but not for vigilance.
The conclusion was no support for attention pro-blems on AP testing. However, with background noise auditory distractibility was found. Good scores on the PSPT indicated good phonemic awareness skills raising questions about why she was having reading readiness problems.
School was ending so auditory training was started during the summer using Sound Based Therapy program as well as background noise tolerance training. She completed the summer program and started 1st grade, but only continuation of her 504 Plan at school because the school district insisted that she had only an attention deficit disorder. Despite fighting for an FM system, the school refused to give it to the child.
The parents continued with private auditory training for background noise tolerance and some phonemic awareness work because of parental insistence as they felt their daughter would fall behind in reading skills. First grade came to an end with the schools continuing to push the parents to get their daughter medicated.
APD testing was recently completed for an up-date at age 6 yrs – 11 mos. Results indicated only a weaknesses in speech-in-noise (SIN) under-standing but normal results on the SCAN-C/ AFG and the noise subtests of the LAD (Lucker’s test). Thus, improvements in dealing with back-ground noise were found.
SSW results continued to show integration prob-lems got worse since both RC & LC results were down. Phonemic Synthesis test yielded 100% correct similar to the perfect score on the PSPT.
Results of the TCST were normal showing either improvement in temporal processing or that 6-yr norms were inappropriate previously. The Token Test for Children continued to be below normal. Thus, it was concluded that she always had auditory overloading, as the information to be processed increased, she fell down in processing accuracy. Likely this led to behaviors viewed as inattentiveness. ACPT scores were normal for both the total score and the vigilance.
APD testing supported the Psychologist and Ped-iatrician’s views that she did not have an attention problem. Background noise tolerance was found and following training improvement was shown in auditory distractibility. The con-tinued problems on the Token Test suggest over-loading resulting in a need to reduce her verbal
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