What I have learned about the effects of Early Recurrent Otitis Media (EROM) and auditory processing: By Dr. Jack Katz 

  1. EROM can produce, what I refer to as, ‘The Otitis Media Dialect (OMD)’.  What is the OMD?
  2. The OMD is noted in those who have had (significant) histories of EROM (whether they knew it or not). You can often hear it in their phonemic errors and in their speaking-voice.
  3. I’m glad you asked for phonemes first. In 1983 Shriberg and Smith ran an amazing study at 2 separate universities.  Each one demonstrated the same thing.  Those with a significant history of O.M. showed a significant tendency to insert an /h/ at the beginnings of words (replacing the first sound or inserting /h/ in front of a vowel (“hand” for “tan” and “hose” for owes” on the W-22s in noise).  They also noted an Epenthetic Stop, I believe we see it when a person puts a stop-consonant at the beginnings of words (like on the W-22s they say “bahm” or something like it for “farm”.
  4. A very important phonemic error involves the /l/ and to a lesser extent /w/. We studied chinchillas, many years ago, and found that with middle ear fluid (similar to O.M.) that the middle formant of /l/ disappeared.  That is, a ramp from slightly higher to lower frequency vanished.  When there was fluid in the ear, even when we amplified the response to make up for the conductive loss, on the spectrogram, that ramp was gone!  That made the remaining 2 formants look exactly like the vowel.  Because of this and/or other reasons there are a lot of vowel confusions and/or vowel plus /l/ confusions in those we have seen with EROM.
  5. Oh yes, that’s not all. In addition, there were other phonemic problems.  Because fluid, especially thick fluid, greatly reduces the weak high frequency sounds like /p/ and /t/.  You may have heard of “H and Friends” and “Just the Friends”. They are therapies for /h/ /p/ /t/ and /k/ in the initial position with HaF and JtF for the 3 plosives in the final position.
  6. The other OMD characteristic that we have noticed are poor low-pitched voices, spoken from the back of the throat. In fact, if you ask the person to say /l/, you may hear a mumble from the back of the throat that sounds like a noisy short-u plus a weak noisy /l/.
  7. Why? On the spectrogram you will see the high frequency sounds faded-out and lots of noise that may, or may not, be associated with the speech.  When you speak with the words aimed at the side of the mouth, you get a kind of a noisy speech.  Unfortunately, when we speak from the back of our throats, we also minimize H-and-Friends sounds and other frontal sounds, so their speech is not clear. 
  8. Another thing I found is that the phonemic errors that are associated with EROM take longer to correct. That is how HaF came about.  I was curious what speech-in-noise errors were left at the end of WINT therapy.  The 4 HaF sounds on WINT represented 30% of the errors.  HaF and JtF have been most helpful.
  9. Itch Cards and Focus that we use in the Buffalo Model are also very helpful for stubborn speech sound confusions, like those above. I’ve added words to Itch Cards for the vowel+/l/ problems and also for Focus cards just the vowels+/l/.  My new Itch words to represent the /l/ errors are “old, pool, full, ultra, whittle” (the underline shows the /l/ confusion.  You may know that in some cases /l/ sounds like “ittl” to them.

Fascinated,  jack

About Buffalo Model Assessment and Intervention

About 35 years ago one of our graduate students checked to see how many SSW references he could find.  He found more than 60.  Now, I have also been working on a history of the SSW over the past 60 years.  I reference 60+ SSW studies (the majority more recent than 35 years. 

So just the ones he and I mentioned would be over 100 SSW reference for 50+ years.  They include studies in various languages and with many disorders, dealing with site of lesion and APD. 

SSW is so powerful, uses multidimensional scoring (so you get lots of details about the disorder).  It is reliable and sensitive.  It enables people with hearing loss to be tested effectively.  It was initially based on an NIH grant with more than 100 subjects with well localized lesions.  They were studied by audiologists, neurologists and a neurosurgeon as well as ENTs.  This was the basis for the Buffalo Model because those results enabled us to identify 4 major types of APD. 

The SSW does not stand alone.  There are 3 tests that provide 40 indicators of APD.  No APD test or battery has survived so many decades.  In the U.S. the SSW has been reported to be the most used central test (by an independent audiology group).    

The field of APD has had a history of many people saying that there is no such thing as APD (which has caused countless children and adults to suffer and under achieve in life).  Some interested in APD say that short-term auditory memory is not auditory processing.  Why do we do this to ourselves?  

In the Buffalo Model we work to make our test and test battery as beneficial to our patients as we can.  The parents of the children have been our biggest advocates.  They see what the benefits have been to their children and would like to see others benefit too. 

At 87 years I get such joy seeing my patients improve their lives and seeing their joy.  

Be well and keep doing this wonderful work! 

Jack

Professional Discussion about the significance of Auditory-Speech-Language Processing and Intervention

Hi, All,

I was very disheartened to have a seasoned SLP tell me that “auditory therapy doesn’t really work” because so many parents that come to her have had an evaluation for APD and completed all therapy recommended with little to no results. She claimed that “what they really need is an SLP to work on language” to see real results.  

So, please help!! If you can recall a specific study or article that comprehensively explains the need for many to have a full audiological evaluation for APD and treatment before and/or simultaneously with speech-language services or something similar, I would be so grateful. 

KL

Hi, I don’t have a study, but can suggest a short argument, and an entertainingly-documented case study

If the child has a language problem caused by anything other than some type of APD, language intervention is necessary and auditory training is useless.

If the child has a language problem caused by some type of APD, then auditory training to overcome the APD is necessary.  Once the APD remediated, the child may or may not need language intervention to catch up.  Without addressing the APD, the child may go through life continually having to exert more effort than his or her peers, just to understand what is being said.  That is fatiguing and leaves fewer cognitive resources available to learn, participate etc.

Because language problems, and doubtless causes of language problems, are so multifaceted, as are APDs, a study like you are after would be very hard to do.  Perhaps a professionally filmed case study of a child’s academic ability being changed by an auditory training program, delivered to address one specific type of APD, might help.  If so, please pass on this link to a TV Science show on this topic.   It goes for about 7 minutes and is easy to watch.

HD

Good explanation HD

Except for one sentence where you say APD therapy is useless 

In my experience i have found even those kids need help with extracting the key information and formulating responses based on what they heard

Teaching them listening skills to help language development  is important and APD therapy does foster that.

I don’t think we can separate auditory-speech -and language processing  with such distinct parameters 

In my experience they all spill into each other and we as professionals have to know where and when to support the specific deficits regardless of whether you are doing APD therapy or Speech and Language therapy

KK

Hi KK,

I agree with the intermingling of skills you refer to.  I think that any type of training probably has direct and indirect spill-over effects on things that the training is not actually designed to do.  Two examples:

Direct spill-over:  Children who were trained on spatial processing also significantly increased their scores on measures of  attention and memory.  I think this was a consequence of doing challenging auditory training for 15 minutes a day, 5 days a week, for 12 weeks (Cameron & Dillon, 2011, attached).  These changes would probably have occurred no matter what type of training was undertaken.  (But the much bigger changes in spatial hearing ability could only be achieved by spatial training.)   I think you refer to a similar spill-over where some types of auditory training might directly help language development.

Indirect spill-over: Good language ability helps with understanding in acoustically challenging situations, and good auditory processing ability helps develop good language.   So if auditory training improves auditory processing, it should eventually improve language, and hence even more improve listening ability in challenging situations.

HD

Fair analysis 

That is why I cringe when professionals try to compartmentalize the -auditory speech language processing conglomerate-like they are independent functions in the brain 

KK

Trivia: What are the only two fears humans are born with?

Answer: Falling and Loud Noises

Both the fears that humans are born with deal with our hearing-balance and listening systems (Inner ear and pathways that connect to the brain for listening and balance).
ONE more reason why intervention, for auditory weaknesses, is very important.
We do a lot of reflex integration work in our clinic and attribute this innate fear of sound and falling to the Moro (startle) reflex, which is necessary for protection and survival in newborns. Interestingly enough, we find signs of unintegrated Moro reflexes in many of the school-aged children that come to our clinic with auditory and vestibular sensitivities. This is a huge reason why we incorporate developmental reflex screenings and integration (when warranted) into our APD evaluations and therapy.
Just some more trivia and food for thought!

Moro/Startle reflex which is associated with negative emotional reactions:

We learn in school about the CLASSICAL auditory pathway (Central Auditory Nervous System), but we NEVER learn much about or anything about the NON-CLASSICAL auditory pathway that goes from the upper auditory brainstem directly to the limbic system-emotional center of our brains.  REACTIONS to negative emotionality can involve the Moro reflex (and many of the emotional reactions starting with the limbic system are reflexive).
Possibly early MORO responses we see in young people and people with such Moro Reflex problems later in life might be tied in with the connection between the auditory system and the limbic system.
This could explain why over time we can help desensitize the person and reduce the reflexive reactions (Moro response) by reducing and (hopefully) removing the negative reactions to sounds, especially loud sounds.  My publications and research on this have also discussed the use of listening therapies like iLS and now SSP and Vital Links (therapeutic listening) and The Listening Program (TLP) to help reduce the negative emotional reactions between the non-classical auditory system and limbic system.
Dr. Jay  Lucker (apddrj@gmail.com)

 Help create a safe environment

 10 takeaways to help you create a safe environment and improve client outcomes:

  1. Movement can facilitate completion of an emotional response and nervous system discharge.
  2. Grounding techniques such as bilateral tapping can help down-regulate the amygdala and promote regulation.
  3. You can help your clients be in the present moment by utilizing grounding and orienting techniques that support the sense of Time and Space.
  4. Start the school day with listening therapy in order to help students feel safe.
  5. The SSP can help clients access “degrees of freedom” and improve their resilience.
  6. You can slow down and titrate a therapy session (in order to prevent flooding) by utilizing Pause and Grounding techniques
  7. Experiencing warmth is essential when one is working with trauma and attachment needs.  It can defragment and create the connections essential to healing.
  8. Use phrases such as “what was there for you?” and “what’s that about” when going through the protocol to check in. Non-judgmental and open questions.
  9. Giving clients a visual handout of feelings and sensations can help in tracking their felt sense throughout a session.
  10. “Felt Sense” is another word for sensation, and involves body and psychological self-awareness.

Ana do Valle’s website

Article posted on Integrated Listening Systems webpage

 

About commercially available programs

NBC put out a video about the commercially available program called Brain Balance. 

Here are some thoughts regarding commercially available programs that are being offered as a panacea to different learning disabilities including ADHD and Auditory Processing disorders.

Its not all black and white.  I think we need to make a distinction between enrichment and remediation. As well as a distinction between a tool and therapy. All programs are tools. The tool is just as effective as the professional delivering the program. Some professionals are trained to use the tool for remediation of a specific disorder, and some professionals are trained to use the tool just to complete the steps. But at completion, everyone benefits from the enrichment. Individuals who are on the fence between disorder and weakness will benefit most at completion of a set program,  because many times weaknesses can be improved with systematic enrichment. Consequently, everyone is happy and satisfied with the outcome.

On the other hand, there are ones who have a significant disorder and need remediation. Completing a program will not be significantly beneficial although the enrichment will offer some improvement. Parents often are disappointed because it was not cost effective enough to praise the program. At the end, every program has its benefits- depending on the child’s strengths, weaknesses and disabilities.

Often it may be an excellent plan to enroll kids in commercially available enrichment programs, post remediation/ therapy for purposes of maintaining and reinforcing the skills.  Programs like Brain Balance, Kumon, Mathnasium, Eye Level, etc are some examples. There are many more available in the market.

Tools and programs are not miracle pills. They can certainly not cure insufficient physiological and anatomical conditions. But they can always improve the abilities to the best of the individual’s potential when provided appropriately by a professional who is knowledgeable in the area of deficit.

Parents have to be aware of these facts and look for the appropriate professional to treat the appropriate disorder. A multidisciplinary approach is not the same as one stop shop- program like Brain Balance. Medical management including drugs may have to be part of the multidisciplinary approach (example ADHD- when diagnosed accurately). There are conditions such as APD that can be mistaken for ADHD often. And many times the 2 disorders do coexist.

In short, there is no straight forward answer to a highly complex organ such as the Brain. Brain’s functions and its disorders/ weakness are not easy to discern. Especially since it is so resilient and versatile. It is always trying to compensate in every which way it can. Any insufficiency in the brain’s connections result in learning disabilities. So don’t throw the baby with the bath water, understanding the learning disability and treating it appropriately is very important.

Dr.Kavita Kaul

Quotes about auditory skills and related issues

About IQ

Carl U. Weitman, PhD.  Clinical Neuropsychology

IQ can be useful, but is more frequently misused.
With regard to Auditory Processing Disorder (APD), IQ may set a ceiling on what to expect even with normal function or with improvement.
Some aspects of Auditory Processing (AP) are sufficiently narrow as to operate independently of IQ, some interact with it.
Within large groups, IQ successfully predicts school and vocational success fairly well.
Within small groups or within individuals, IQ landmarks a variety of (likely) clinical problems.
One problem with most of the IQ tests and achievement tests is that they are calibrated to national norms.
Accordingly, a child with a “normal” IQ, e.g. SS = 100 +/- 15 may nonetheless struggle in an advanced suburban school, but still not qualify for special services.
Many people mistakenly equate “verbal” with “auditory,” and this is not always correct.
For example, although Digit Span items are orally delivered to the subject, solution requires (cognitive) visual rotation.
As to some other tasks, it would not be a surprise to discover that a child whose listening has improved, will also know more reportable facts within a year or two.
Finally, a “standard deviation” does not by itself render the Full Scale I.Q. “invalid,” although it does provide important clinical information.

In complex cases you do have to look in many direction.  IQ would be of interest but…

My experience with children and adults with low IQ’s, has reinforced, over and over again, to consider the IQ test as ‘an achievement test’ and not a measure of the person’s potential. My favorite patient was a man with Down Syndrome with a 31 IQ.  Although his IQ remained essentially unchanged, in 2 1/2 years he learned to speak, read, sing a bit, make little jokes and he was my assistant giving part of the Phonemic Training  Program to another person with a 40 IQ.

About Therapy

Regardless of IQ levels a child struggling with listening issues in the real world will benefit from Auditory only based therapies

We should include auditory skills training along with speech- cognitive- linguistic intervention
Granted some need more Auditory intervention and some may need minimal brush up
The potential to improve overall skills is huge when the auditory intervention is also included
Carl U. Weitman, PhD.  Clinical Neuropsychology
Everyone benefits, some from therapy, some from enrichment

About malingering:

Carl U. Weitman, PhD.  Clinical Neuropsychology

Fake Bad for some secondary gain, legal advantage or medical advantage or disability advantage.

Fake Good (although the term is not often used this way) to obtain tangible advantage or social approval. There is also the so-called Munchausen Syndrome, faking by proxy i.e. on another person’s behalf. At the more normal level, there is the so-called cry for help (e.g. exaggerate in an Emergency Room to avoid being consigned to the long term waiting room).

At the even more normal level, there is performance anxiety or stage fright.

Malingering is usually measured by failures on “simple” items that are inconsistent with failures on more complex items that subsume the content and process of the easier items.

At the less deliberate level, there is either innocent false conclusion or self-deception

Errors may be due to:

  1.   A person does well on a complex test, then blows it on a subsequent easy task…often due to fatigue from the hard test.
  2. A person does well on a complex test, marked by forced coherence in the items, then does poorly on an easy task, because an element of the easy task is not easy for the subject. This happens in variant verbal vocabulary tasks all the time

“Leave Almost No Child Behind (LANCB)”

Jack Katz

60 years ago, when working in 3 central schools, I found that Phonemic Synthesis Program works better than I could have imagined. I used it with 16 of the 17 kids who took the PS test (1 kid passed with flying colors).  When I saw such great improvement, so quickly, for some reason I thought that all the kids in 1st grade should get this help.  In those days we did not have phonics, as reading was done visually only, so this was a virgin group.  The 1st grade teacher let me work with her kids 30 minutes a week for the rest of the semester.  At the end of the term I thanked her for letting me work with her children.  I said next semester I’d be working with the kindergartners.  She looked so disappointed and said, “You mean you are not going to be working with my children?” I was so surprised and asked why she was so disappointed.  She said all the wonderful things that she saw (I don’t remember the specifics as I was shocked). The next semester I worked again with the Kindergarten kids but still didn’t realize the broad potential for this training. I had to leave the school as I started my PhD program in another state.

In the early days of Learning Disability- LD, they said that 20% of all school children had it.  We did a study in a middle-income group district in the Kansas City area. The head of the counselors in the district applied for a grant from the state of MO to fund our study.  She trained counselors, teachers and parents about LD and then she asked the teachers to indicate which children they thought had LD.  She reviewed the submissions to be sure and then referred those kids to our medical center for Psychological, Speech, Language, Hearing, Auditory Processing evaluations.  We used SSW and PS as our APD battery.  Of the various tests the Auditory Processing Disorders-APD procedures were more significant than the other 4 types of tests.  77% of the children tested were LD (that was 20% of the school population).  In those days they did not think that children with psychological disorders, autism, neurological conditions, hearing loss, etc. could also be considered LD, so they were never evaluated.  So, when considering those higher risk children, it accounted all together to about 20% of the entire district with APD!  In the 50 years since then I have seen nothing to make me question about 20%.

If LANCB, would be given to each Kindergarten or 1st grade class, it would give this valuable training to all children, quickly, and I think, inexpensively at an ideal time to form important foundations in their brains.  It will not solve all the problems but will help the average kids, the mild-moderate kids even more, and even the severe kids to some extent.  It could have some value to the above-average kids too.

The training could directly affect speech, reading, spelling and be reflected in memory, language, and academically because of improved decoding (thereby opening new opportunities for them). The therapy would not need to be limited to Decoding.  Speech-in-Noise would be possible and perhaps memory.  Working with one class would help to figure out what would work best.  E.g., the students with more challenge would be seated close to the front and middle. If this program works well in Kindergarten, then some aspects could be used with preschool children also (that would be super!).

This would eventually to make a huge difference in almost all children in the state or country.  It would have to start somewhere. This is the first thing I would recommend as the most economical approach with the broadest effect!

 

 

Accommodations and Modifications for Auditory Processing Weaknesses

General Recommendations

  1. Speech leaves the speaker’s mouth and thins out in all directions. So, distance from the speaker’s mouth to the listener’s ears is extremely important.
  2. Most of the energy goes forward from speaker’s mouth.  So, when possible speak close by and face-to-face with her to give her the most and most accurate speech message.
  3. Speech from another room is dramatically reduced by the walls and the small opening.  This is especially true for the high pitched (extremely important) speech sounds.
  4. The person who initiates the conversation must go to the listener.  But, if the person with auditory weakness talks to you from another room remind them to come to you using any predetermined code (Example: you can say “Rule 32”)
  5. When looking at one another, they should be able to see your lips, facial expressions as well as gestures.  This should be especially helpful because they depend so much on vision.
  6. Clear Speech is how you speak when it is very noisy.  It is slower and more distinct.  It is also a louder, but with no noise competition it could be just a little louder.  With people who are hard-of-hearing, it increases understanding by 20%.  It will likely have a similar effect with those with auditory weakness.
  7. Background noise is harder for everyone, but especially for people who have APD (or hearing loss). When conversing reduce/turn off TV, ask people to quiet down, or move away from noise.
  8. If they are otherwise preoccupied, touch them on the shoulder and when attention is established, say/ask what you wanted.
  9. When reading a book, if the child is on the left lap, the next time have the child on the right lap (so that both ears get the benefit).
  10. Especially when giving instructions, try to use clear speech and pause after each instruction (to let it sink in and not be erased by the next one) and then give the next. Don’t hesitate to briefly reiterate what you told her, or ask her to tell you what she is going to do. You could put up one finger and give the first instruction etc. to give some visual support.

 In School

  1. They will do best facing the teacher less than 10-12 feet away.
  2. Depending on how much the person can understand or retain, it might be helpful for the teacher to write things on the white board.  This will be more helpful as she is able to read more.
  3. These may be more difficult to carry out in a Montessori setting, it would be best to provide face-to-face instructions, in a quiet/quieter area.
  4. Children who have APD are working much harder than the other children and so they tend to tire more quickly.  A little time in a quiet/quieter area a few times a day (especially toward the end of the school day or when they look tired/stressed) would be very helpful
  5. Preferential seating
  6. Quiet classroom
  7. Loud with clear speech
  8. Provide extra time for processing and response
  9. Verbal rehearsal of oral directions prior to execution of directions
  10. Chunking of information
  11. Use gestures
  12. Repeat rather than rephrase
  13. Repetition of new material for long term retention
  14. Avoid multi-level processing, multi-tasking, and/ or multi-step directions. Limit information input with new material for better comprehension and retention
  15. Provide appropriate pauses in conversations
  16. Pre-teach new vocabulary to increase familiarity, provide visual list on the board
  17. Assistive listening device- FM system
  18. Frequent breaks
  19. Buddy or peer helper
  20. Testing in a quiet room or in small group
  21. Teach organizational skills by an educational specialist
  22. Present information at a slow pace for effective information processing (Like Mr. Rogers!!)

How were degrees of hearing loss first measured and determined?

Hearing regarding what is normal, etc. has ABSOLUTELY NOTHING to do with standard deviations.  The normal category was NEVER subjected to testing thousands of people with and without hearing loss and identifying a MEAN hearing value for normal and one standard deviation for the cut-off of normal.
During World War II, many veterans came home complaining of hearing loss.  It was decided to determine a NORMAL level of hearing.  Based on hearing science, it was identified two things:  One was that the dB scale is logarithmic and not linear, so means and SD cannot be used.  Second, it was measured that human beings identified a DOUBLING of loudness every 10dB (based on research done in the 1930s duplicated many times.  Whispered speech- the softest level of speech an AVERAGE person with normal hearing could detect and understand was at 30dBHL.  Thus, it was originally decided that normal hearing would be the first step BELOW a whisper meaning a person with normal hearing CAN hear a whisper and a person with the first level called a MILD hearing loss could barely detect a whisper.  Thus, the original CUT-OFF of normal was 25dBHL.
ASHA modified this YEARS  ago maybe in the 1960s.  It was decided to use half the loudness of a whisper rather than one step below a whisper.  A whisper is 30dBHL so half the loudness is 20dBHL.  Thus, it was decided that normal hearing would be UP TO 20dBHL.  The other decisions of mild, moderate, etc. were developed by a combined group of audiologists (more in the hearing sciences) and sound scientists and they identified the various categories with were then set by the American National Standards Institute or ANSI in the 1960s with the agreement that 20dBHL would be the cut-off of normal and the other categories as is.  ANSI and ASHA working with ANSI also identified that it would be best NOT to test hearing above 120dBHL since the thresholds of PAIN from hearing is 130dBHL so 120dBHL is half the loudness of pain.
Dr. Jay R. Lucker, Ed.D., CCC-A/SLP, FAAA

Certified/Licensed Audiologist & Speech-Language Pathologist
Specializing in Auditory Processing Disorders &
Language Processing Disorders
also
Professor
Dept. of Communication Sciences & Disorders
Howard University
Washington, DC
contact: 301-254-8583 or via this email address

How can you tell when you are nervous?

“When your heart becomes 2”

Recently in my clinic, my 5 year old patient was asked come back to his seat to work on phonemic synthesis. He had not yet seen my dog in the clinic at that time. As he hesitatingly came to sit at his seat he noticed my puppy and said, “My heart is 1 again!”. I was perplexed and asked him what he meant. He said, “You know when you asked me to come to do the sound game, my heart became 2, but when I saw Pinto, my heart became 1 again.”

Wow, only then I realized that he was anxious about doing the phonemic synthesis work, and probably felt like he skipped a heartbeat when I told him that it is time to work.

Dr.Kavita Kaul