There is emerging and accumulating evidence that heading injuries, including concussions, can result in an Auditory Processing Disorder.
Auditory Processing simply refers to what we do with sound once we “hear” it. A person with an Auditory Processing Disorder (APD) presents with a persistent limitation in their ability to recognize and process sounds and speech effectively that is not caused by language or cognitive factors. Auditory processing disorders have also been described as what happens when the brain can’t hear. APD can have a significant impact on a person’s ability to function during everyday activities.
Auditory processing disorders can be developmental or acquired. Acquired auditory processing disorders can be caused by traumatic brain injury, degenerative neurological diseases and exposure to certain chemicals as examples.
Individuals with traumatic brain injury can display a variety of impairments including cognitive, language, psychological and sensory deficits, all of which have a detrimental effect on the how the person interacts in their community (Lew et al. 2007). Traumatic brain injury can cause damage to both the peripheral and central auditory pathways. It has been estimated that over 50% of individuals with traumatic brain injury may have an auditory processing disorder (Musiek et al 2004) (Bergemalm & Burg 2001). In fact, the Canadian Guidelines on Auditory Processing Disorders indicate that auditory processing disorders are so prevalent for individuals with traumatic head injury that auditory processing testing should be routinely conducted for these clients (CAA 2010).
Case Study: So what does an auditory processing disorder from a head injury look like? In this case study, a woman is involved in a motor vehicle accident in which she sustains a “concussion”. She complains shortly after the accident that she can’t seem to hear as well in crowds and has difficulty understanding speech with foreign accents. She had a hearing test done and was told she had “normal” hearing. However, basic hearing tests only look at the peripheral part of our hearing system. When someone notices a change in their ability to understand and communicate after a head injury, we would want to assess how well a person can efficiently and accurately process sound when it travels from the inner ear, through the brain stem and up to the auditory portions of our brain, specialized tests can be conducted (APD Testing) In this case study, the woman’s APD test results confirmed that she has an auditory processing disorder that was likely the result of the “concussion” she sustained in her car accident. The woman is now receiving therapy including treatment to improve her ability to hear in the presence of background noise (a form of auditory training called Dichotic Listening Training).
There is much debate about therapy frequency and intensity. How long should sessions be and how frequently should they occur? There is no easy answer as the information can be different based on age (e.g. child or adult), type of disorder (e.g. speech or language), type of therapy approach used (e.g. cycles or constraint induced), as well as the individual needs of each client.
When looking at treatment for children with language disorders, again, clinicians need to consider the child’s age and his or her ability to tolerate therapy sessions. That said, a number of research studies have been completed to assess the progress children make with therapy durations and frequencies. When determining the length of a therapy sessions, young children typically do well with 30 minute sessions due to their attention span. Similarly, Ukrainetz et al. (2009), found that 30 minute sessions one to three times a week were sufficient because their research found that 4 hours of treatment were as effective as 11 hours. Duration for therapy can vary. Law et al. (2004) obtained great gains with treatment sessions lasting for more than 8 weeks. However, greater language gains are reported in preschoolers with concentrated sessions (e.g. 24 sessions over 6 weeks) instead of distributed sessions (e.g. 24 sessions over 24 weeks) (Barratt et al., 1992). That said, McGinty et al. (2011) found that both frequent sessions (e.g. four times a week) and less frequent sessions (e.g. two times a week) yielded similar outcomes for children as long as the number of trials obtained in a session was high. Therefore, from the available, current studies, we can determine that frequent sessions with a high number of trials over a concentrated amount of time will achieve the greatest results.
Speech sound disorders (e.g. articulation disorders and phonological processing disorders) vary from approach to approach. However, when looking at the research it’s clear that treatment can last from 7 months to 30 months of therapy from referral to dismissal (Gillam et al., 2012) depending on severity, approach, and client needs. Similar to language sessions, speech and language treatment sessions targeting speech sounds are about 30 to 45 minutes two to three times a week with a high number of trials in order to achieve the most progress (Williams et al., 2010). That said, when a child’s severity increases, there needs to be an increase in the intensity in both the number of sessions a week and number of trials obtained in order to make the most progress for that child (Gillam et al., 2012)
Studies targeting adult speech and language treatment post stroke or traumatic brain injury have found a variety of results in terms of how frequent and how long therapy sessions should be. This is likely because a clinician must consider the client’s arousal level, prognosis, stage in recovery, as well as ability to tolerate therapy sessions when determining the appropriate frequency, intensity, and duration of services for an individual post stroke or traumatic brain injury (TBI) (Cherney, 2010). This means more therapy may be beneficial for one person, but not for another because maybe they don’t have the attention span for intensive therapy or such a model would be too tiring for them at this point in treatment. The same applies to session length, someone may benefit from an hour or two of therapy daily, but this may not be feasible due to their current condition. That said, research has found that clients demonstrate significant gains when they received intensive treatment over a short amount of time rather than distributed sessions over longer periods of time (Bhogal et al., 2003), but a clinician must always consider the individual needs of the client.
Overall, we can see that more therapy and more trials is typically the gold standard in order to make the most progress in a short amount of time. That said, individual characteristics need to be considered with every client in order to determine the right approach for them.
Barratt, J., Littlejohns, P., & Thompson, J. (1992). Trial of intensive compared with weekly speech therapy in preschool children. Archives of Diseases in Childhood, 67, 106-108.
Bhogal, S., Teasell, R., & Speechley, M. (2003). Intensity of aphasia therapy, impact on recovery. Stroke, 34(4), 987 – 993.
Brandel, J., & Loeb, D. F. (2011). Program intensity and service delivery models in the schools: SLP survey results. Language, Speech, and Hearing Services in Schools, 42, 461–490.
Cherney LR, Patterson J, Raymer A, Frymark T, Schooling T., (2010). Updated evidence-based systematic review: Effects of Intensity of Treatment and Constraint-Induced Language Therapy for Individuals with Stroke-Induced Aphasia. Rockville Pike, MD: American Speech-Language-Hearing Association.
Gillam, R., Baker, E., Williams, A. (2012). How Much is Enough? Dosage in Child Language Intervention. American Speech-Language-Hearing Association Convention. Georgia: Atlanta.
McGinty, A. S., Breit-Smith, A., Fan, X., Justice, L. M., & Kaderavek, J. N. (2011). Does intensity matter? Preschoolers’ print knowledge development within a classroom-based intervention. Early Childhood Research Quarterly, 26, 255–267.
Ukrainetz, T.A., Ross, C.L., & Harm, H.M. (2009). An investigation of treatment scheduling for phonemic awareness with kindergartners who are at risk for reading difficulties. Language, Speech, and Hearing Services in Schools, 40, 86-100.
Warren, S. F., Fey, M. E., & Yoder, P. J. (2007). Differential treatment intensity research: A missing link to creating optimally effective communication interventions. Mental Retardation and Developmental Disabilities Research Reviews, 13(1), 70–77.
Williams, A. L., McLeod, S., & McCauley, R. J. (Eds.). (2010). Interventions for speech sound disorders in children. Baltimore, MD: Brookes.
When we think about academic difficulty for students, we often think of the curriculum or the subject matter (e.g. math, social studies, science, English, etc.), which can be remediated with tutoring. However, what most people don’t know, is that there is a lot more that impacts a child’s academic success than just the material being covered in the classroom. When we think of a classroom setting, children need to be able to master skills in a variety of domains. They must master:
The above skills are needed to simply participate in the classroom learning environment; therefore, difficulty in any of those areas is going to reduce a child’s academic success before we can progress to the subjects being taught. Luckily if students have difficulty, the speech-language pathologist can help raise awareness of the classroom environment and its demands as well as hone those specific skills in order to promote academic success.
Academic performance depends not only on a students’ ability to learn the material, but also on their ability to understand spoken and written language, their ability to convey their knowledge both verbally and written, as well as their literacy skills such as reading, writing, and spelling. Kids start developing the precursor skills needed to read, write, and spell as young as two years old. If those skills are later developing or do not develop, students’ performance will suffer. This is because reading and writing are both language-based academic skills (Gillam & Johnston, 1992).
Some of the necessary skills fall under the term phonological awareness (PA), which is the awareness of sounds, syllables, and words (Hedge & Pomaville, 2008). There are different levels of PA (Weinrich & Fay, 2007):
Studies have shown that phonological awareness is a strong predictor of literacy development in school-age children. This means that if a child does not grasp these earlier concepts, they will have difficulty learning to read, spell, and write. This is because concepts like sequencing sounds or separating sounds are skills that we may learn at a young age; however, we continue to implement them as adults when we are reading and writing.
You might ask, how does rhyming and sequencing help with spelling and reading? Spoken forms of language like rhyming and alliteration (e.g. repetition of the same sound like Peter Piper) allow children to develop pre-literacy skills and awareness that they can later apply when learning to read and write. They are able to make connections between words that share common sounds (e.g. sun and soup both have “s” sound) and spelling patterns. Similarly, the ability to segment words into sounds (e.g. soup=s-ou-p) is a strong predictor of spelling ability as we continue to use such skills as adults when writing (Weinrich & Fay, 2007).
We know early intervention is key to helping children be successful, but this doesn’t mean we can’t help beyond the preschool and elementary school age. Yes, classroom demands may change from preschool with circle time, show and tell, snack time, and clean-up, to primary grades with reading groups, homework, and workbooks, on to middle and upper grades where there are oral reports, written reports, test taking, following lectures, and note taking (Westby, 1997). Language is involved in all these learning environments, whether it’s understanding spoken or written language, using spoken or written language, or understanding and participating in social interactions.
A speech-language pathologist can help assess and remediate the underlying language skills that may be impacting a student’s academic performance at any grade level. There is always room for improvement; SLPs work on phonological awareness with a child in kindergarten, expanding vocabulary and concept knowledge with a third grader, or working with a high schooler on higher level thinking skills such as self-monitoring and goal setting or higher level language skills like metaphors and inferencing to help improve understanding. Similarly, SLPs are uniquely equipped with the knowledge and skills to teach students proper compensatory strategies for classroom use (e.g. organization, planning, and sequencing tools) that will help them be self-advocates and successful in school.
Speech-language pathologists (SLP) are highly trained in the areas of
These areas underlie every topic in every class at every grade level; therefore, difficulty with language, can result in poor academic performance. Remediating underlying concepts such as understanding vocabulary or grammatical concepts like plurals verb tenses, will help a child’s performance in the classroom.
If you or someone you know is having difficulty in school, give us a call and we can discuss the evaluation process and if it’s right for you and your child. Following the evaluation, you and the speech-language pathologist will create an individualized treatment plan with specific goals to help improve your child’s language skills in order to increase academic success.
Gillam, R. B. & Johnston, J. R. (1992). Spoken and written language relationships in language/learning-impaired and normally achieving school-age children. Journal of Speech and Hearing Research, 35, 1303 – 1315.
Hedge, M. & Pomaville, F. (2008). Assessment of communication disorders in children: Resources and protocols. San Diego, CA: Plural.
Weinrich, B. & Fay, E. (2007). Phonological awareness/literacy predictors of spelling abilities for first-grade children. Contemporary Issues in Communication Science and Disorders, 34, 94 – 100.
Westby, C. (1997). There’s more to passing than knowing the answers. Language, Speech, and Hearing Services in Schools, 28, 274 – 287.
Parkinson disease (PD) is a neurodegenerative disease that deteriorates parts of the brain over time because of a loss of dopamine (Suchowersky et al., 2006). Parkinson disease impacts a variety of motor movements including those necessary for speech (e.g. tongue, lips, or jaw movement), swallowing, and limb movements including legs and arms can become impaired with the progression of the disease (Fox et al., 2006).
Studies have shown that individual’s with PD consider the reduced ability to communicate one of the disease’s most difficult aspects, but only 2-3% of people diagnosed with the disease seek speech and language services (Fox et al., 2002). Due to the impaired motor movements, individuals with PD have specific voice characteristics such as:
Reduced loudness
All of these features can impact intelligibility and understanding for listeners. This can become frustrating for a person with PD and they may withdraw from social activities or communicating with others all together, but there is another option!
Yes, the disease will continue to impact more and more of the neurological system, but speech-language pathologists (SLP) have a unique understanding of motor learning and the speech system needed for communication. This means, SLPs are prepared with research-backed therapy approaches designed to help improve some of the voice characteristics associated with PD in order to help the individuals with successful communication.
There are a few ways to approach the speech and language therapy for an individual with PD. Following an initial assessment, the client and the speech-language pathologist will sit down and create an individualized treatment plan tailored to their goals and needs. This will take into account the length or duration of therapy, available time commitment, voice use, and personal goals.
Speech therapy for degenerative neurological diseases is controversial because therapy will not recover speech and language to its original state; however, we can provide strategies to improve communication for as long as possible (Ramig et al., 2007).
In addition to the focus on voice, speech and language therapy can address any cognitive strategies that may help the individual function in daily living. With PD, an individual may notice more difficulty with higher level learning such as memory and sequencing (Voyzey, 2012). Therefore, the speech-language pathologist can introduce different strategies to improve their functional status in everyday life. Such strategies may include:
Such cues can help a person complete sequencing tasks (e.g. the steps to getting ready in the morning), planning an activity/day, and performing different daily tasks.
Similarly, complex tasks like balancing a checkbook, creating a budget, shopping, using the telephone, as well as processing and manipulating information may be difficult. However, in speech-language therapy, the clinician can provide strategies to aid in the completion of these tasks such as
(Voyzey, 2012)
Augmentative and alternative communication is when we use a means other than speech to communicate. It can be via alphabet boards, text-to-speech software, sign language, etc. In terms of PD, attending therapy four days a week or even once a week may not feasible; however, there are other options because of AAC. Depending on the progression of the PD, individuals may find some benefit in amplifiers, which would be like a hand held device with a microphone that would allow them to project their voice louder than they could independently. Similarly, if the disease is more progressed, there are different technologies, either low or high-tech, that may be beneficial. Research surrounding AAC and PD is small and has mixed results (Mathy, 2002), but by creating an individualized treatment plan the client and speech-language pathologist can determine which device would be suited for that person’s needs.
If you or someone you know has been diagnosed with Parkinson’s disease, contact us to talk about your options or to set up an appointment for a full comprehensive assessment. We are committed to providing you with individualized service that meets your needs and goals for successful communication.
Fox, C., Morrison, C., Ramig, L., Sapir, S. (2002). Current Perspectives on the Lee Silverman Voice Treatment (LSVT) for individuals with idiopathic Parkinson disease. American Journal of Speech-Language Pathology, 11, 111 – 123.
Fox, C., Ramig, L., Ciucci, M., Sapir, S., McFarland, D., & Farley, B. (2006). The science and practice of LSVT/LOUD: Neural plasticity-principled approach to treating individuals with Parkinson disease and other neurological disorders. Seminars in speech and language, 27(4), 283 – 299.
Mathy, P. (2002). Augmentative and alternative communication intervention in neurogenic disorders with acquired dysarthria. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 12(4), 11 – 19.
Ramig, L. & Fox, C. (2007). Voice treatment for individuals with Parkinson’s disease. Perspectives on Gerontology, 12, 2 – 11.
Suchowersky, O., Reich, S., Perlmutter, J., Zesiewisz, T., Gronseth, G., & Weiner, W. (2006). Practice parameter: Diagnosis and prognosis of new onset Parkinson disease (an evidence-based review). American Academy of Neurology, 66, 968 – 975.
Trail, M., Fox, C., Ramig, L., Sapir, S., Howard, J., & Lai, E. (2005). Speech treatment for Parkinson’s disease. NeuroRehabiliatation, 20, 205 – 221.
Voyzey, G. (2012). Cognitive strategies for individuals with Parkinson’s disease. Perspectives on Gerontology, 17, 60 – 68.
When we hear and understand speech, our auditory system has to perform a rather complex task of recognizing and interpreting sound. The process of recognizing and interpreting sound or speech involves the entire auditory pathway from the ear itself on through the brainstem and finally up to the temporal area of our brain. Auditory Processing is the term used to describe what we do with sound once we “hear “ it.
When an audiologist assesses a person’s auditory processing skills they are basically looking at the how effectively and efficiently they perform skills such as:
Sound Localization and Lateralization: the ability to know where sound has occurred in space, to identify the source of sound.
Auditory Discrimination: the ability to distinguish one sound from another.
Binaural Interaction: the ability to integrate information heard in each ear.
Binaural Separation: the ability separate information arriving at each ear.
Temporal Sequencing: the ability to process two or more sounds in their correct order.
Temporal Resolution: the ability to detect small changes in sound over time.
Temporal Integration: the ability to sequence and process sounds over time by both ears.
Auditory Performance with Degraded Acoustic Speech: the ability to understand speech when some of the information is missing or compressed in time: the ability to perceive speech or other sounds when another signal (noise or speech) is present.
(ASHA 2005, CAA 2012)
When a person has difficulty and reduced performance on any of the above auditory skills, they are said to have an Auditory Processing Disorder (APD). In the real world it means they may have difficulty understanding speech in certain contexts and this can have a significant impact on communication and learning. Check out our section on APD for more information.
Parents and families are key to helping children develop speech and language skills.
Children learn a large portion of what they know through indirect teaching (e.g. watching their parents or people in their environment), so it is important to consciously focus on the way you interact with your child.
Consider some of the following techniques that will promote early speech and language development:
Reading is also a great way to help your child develop their speech and language skills. Try reading with enthusiasm by talking like the characters, making sound effects, and reading with expression because this will keep your child interested. Similarly, try to talk as you are reading – make comments, point to pictures, and talk about what’s happening. Again, these techniques will draw your child’s attention to important things in the story and keep them engaged.
Remember, the more you read the more interested your child becomes in the activity. Try to set aside special times for reading, even just 5 to 10 minute will make a difference.
Library programs are a great opportunity to help develop a child’s speech and language skills. For example, the Moncton Public Libraries offer a variety of children’s programs such as Babies in the Library for children 0 to 18 months, Toddler Time for children 18 months to 3 years of age, as well as Storytime for children 3 to 5 years of age.
These programs focus on books, nursery rhymes, songs, and fun activities with parents and their child. These are great activities to foster speech and language skills in children while having fun with books. In addition, to these recurring events, the libraries also offer seasonal programs related to different holiday’s or events (e.g. Halloween, first day of kindergarten, etc.). Check out their website for more information.
Our voice is produced when our two vocal cords, located in our voice box or larynx, vibrate together. This vibration happens when air comes up through our vocal cords and produces sound. If one or both of the cords are not working properly, you will experience a voice problem.
To help minimize vocal chord irritants, try the following:
Call your doctor if your voice sounds hoarse or different for more than 2-3 weeks, you lose your voice, or if you have difficulty speaking loud enough to be heard.
Communicating with older adults can often be difficult due to the physical, psychological, and social changes associated with aging; however, this difficulty also occurs when communicating with an adult with a speech or language disorder.
Some great rules of thumb when communicating include:
When interacting with someone with a speech and language disorder or an older adult, be sure to speak slowly and clearly, to allow more processing time and to ensure they are understanding your message. In order to ensure successful communication, be sure to use short and concise sentences or questions, frequently check the person’s understanding, and provide them with time to speak while resisting the urge to finish their sentences/words.
“My son is in grade three and is having difficulty in school with reading, spelling and math. His teacher suggested we have him tested for APD? Is this a good idea?”
Auditory Processing Disorders can significantly affect a child’s listening, communicating and learning. Research has shown that APD can in some cases, can be the underlying cause of deficits in reading, spelling and math (especially word problems).
Although there is no “rule of thumb” for determine when to refer a child for comprehensive APD testing, the decision to refer should be based on a few considerations:
If the answer to any of these questions is “Yes”, a referral for comprehensive APD testing is recommended.
Check out common APD Red Flags to help identify if your child is at risk for APD.
The diagnosis and treatment of APD is best done with a collaborative approach involving the audiologist, speech language pathologist, educational psychologist, resource teacher and classroom teacher. You may want to discuss a possible referral for APD testing with your school or simply contact our office and we can help guide you through the process of determining if APD testing is recommended.
Metro Hearing & Speech Center is unique in that we offer both Audiology and Speech Language Pathology services to diagnose and treat Auditory Processing Disorders (APD).
Children with auditory processing disorders (APD) display a number of symptoms. Geffner (2013) provides a summary list of 16 behaviors that are considered red flags for APD in children. Not all children with APD will display the same types of behaviors, but this list gives a good indication of what APD can look like in children.
