OTE 18                Transcript
EPISODE 18


[INTRODUCTION]


[00:00:00] ANNOUNCER: Do you enjoy listening to On The Ear, but wish you could earn ASHA CEUs for it? Start today! SpeechTherapyPD.com has over 175 hours of audio courses on-demand, with an average of 19 new audio courses released each month. Here's the best part, each episode earns you ASHA Continuing Ed Credits. Oh, no, wait. This is the best part. As a listener of On The Ear, you can receive $20 off in annual subscription when you use code Ear21. Just head to SpeechTherapyPD.com to sign up and use code Ear21, E-A-R-2-1 for $20 off your annual subscription.


[00:00:48] DS: You're listening to On The Ear, an audiology podcast sponsored by SpeechTherapyPD.com. I'm your host, Dr. Dakota Sharp, Au.D, CCC-A, audiologist, clinical professor, and lifelong learner.


While I primarily work with pediatric cochlear implants and hearing aids, I am absolutely intrigued by the many areas of audiology and communication in general. This podcast aims to explore the science of hearing, balance, and communication with a variety of experts in hopes of equipping you to better serve your patients, colleagues, and students. Let's go. We are live and On the Ear, brought to you by SpeechTherapyPD.com.


[INTERVIEW]


[00:01:35] DS: Auditory Processing Disorder is one of the true enigmas in the world of communication disorders. Hearing healthcare professionals have adopted varying perspectives on the interpretation of the condition, including what exactly we should call it. There's ongoing debate regarding how to define, assess, and treat Auditory Processing Disorder, but today's guest is going to help demystify APD and provide some practical insights into better serving our patients.


Dr. Angela Alexander, Au.D, CCC-A, MNZAS, and I did my research y'all. It's MNZAS. I don't know if I got that exactly right. She can correct me there. She graduated from the University of Kansas in 2010 with her Doctor of Audiology. Angela's passion is in the treatment of Auditory Processing Disorder, also known as APD.


Angela was privileged to have been mentored by Jack Katz, PhD, a world-leading expert on APD. Angela worked with Katz for seven years between 2004 to 2012, building her knowledge and expertise. With the Auditory Processing Institute, Angela is looking to train her peers in the skills needed to provide effective APD diagnostic and therapeutic options. She's got a lot of fantastic insight she's going to share today.


She's hoping to double the number of SLPs and AuD professionals providing effective APD services through online APD master's courses by 2022. That goal is creeping up. I'm excited to hear how that's coming along. We are so fortunate to have Dr. Alexander on tonight. APD is a hot topic in the world of audiology and in the world of speech pathology. Thank you so much, Angela, for joining me.


[00:03:00] AA: I am thrilled to be here.


[00:03:02] DS: This is going to be a really interesting conversation. I'm going to be totally upfront and honest, right off the bat, okay. I did not get a lot of formal training on APD. I have a lot of questions.


[00:03:14] AA: That is completely fine. I think the most recent statistic I saw showed that 60% of AUD programs have a course in APD. Yeah, 40% don't even have a course. It could have a 100 times the prevalence in young children compared to permanent hearing loss.


[00:03:36] DS: Yeah. I think this is where the buck stops. Now that we are starting to learn more and more and we're starting to come to more of a consensus on what the problem is here, I think that, yeah, this is going to be a huge, huge aspect of training and education for audiologists.


[00:03:53] AA: I completely agree. I believe that this is the future of audiology.


[00:03:57] DS: I like that. Okay, so before we get too far ahead of ourselves, can you just introduce us to APD? For a listener who is totally – they're like me. Oh, I guess, I shouldn’t say totally unfamiliar, but I've heard conflicting things on what to call it. Is it CAPD? Is it APD? Does that even matter? How does this disorder manifest itself? What are we looking for here? Could you just give us that brief intro?


[00:04:21] AA: Absolutely. I'd say that those of us who are in the trenches now are calling it APD. CAPD was giving too much of a locus for where this is occurring. I think we just are calling it Auditory Processing Disorder just in general. I like to put it on the same continuum as hearing loss. I think a lot of people look at APD as this large, looming, complex issue, when actually, it's relatively simple if you can look at it in a specific framework.


I like to look at it using Erber’s Model. Erber’s Model is a model of auditory skill development. Let's look at this like it's a set of stairs. The very baseline, bottom stair is awareness. Are you aware of sound? If you're aware of sound, then you probably have, essentially, normal hearing sensitivity. If you are not aware of sound, we overcome those issues with cochlear implants, hearing aids, etc. Difficulties with awareness get devices.


The next level is discrimination. Not only are you aware of two sounds, can you hear the difference between them? Like ‘um’ and ‘unh’. The next level is identification. Can you hear the difference between them and can you identify what each one of those are? Then the last step is comprehension. I think a lot of audiologists think that as soon as you put a hearing aid on a person, they're going to go immediately from awareness all the way up to comprehension. It's this part in the middle that the brain is responsible for. I wish more people could see it like this, so that we realize, “All right, there's just a gap that we need to fill.”


[00:06:12] DS: Got it. Got it. Okay, so we've gone from awareness to – that's the problem. We're jumping from awareness all the way to full-on comprehension at the end of the book here. Where does APD then play into this hierarchy?


[00:06:26] AA: When I'm looking at APD, I'm looking for four different categories. The most basic category is called decoding. Decoding is the ability to quickly and accurately recognize and understand speech. It's being able to discriminate speech sounds to have good phonemic awareness, to know that a ‘um’ sound is M and ‘uhn’ is N, or whatever those sounds might be. 


To me, auditory processing disorder is when a person is falling off that second step. It looks like a hearing loss, because the problem they have is so fundamental. It's so early on in the process. Decoding, when a person has difficulties with decoding, they may have troubles with spelling, they may have difficulties with articulating speech. One thing I wanted to mention is, if we think about speech and language without first thinking about auditory skills, it's like thinking about the digestive system without thinking about the food that is eaten. I'm going to totally quote Peggy Glenny on that one. I love that analogy.


[00:07:34] DS: Yeah, that's great. Honestly, I work a lot with children with cochlear implants. I completely agree that this basis of – I definitely think of Erber’s hierarchy, for sure, when it comes to those first auditory skills. Honestly, even the adults I see with cochlear implants, that's our starting point. I think that's a really helpful guide for anyone who works in that population to then translate that over into APD, where, hey, maybe a hearing loss isn't present, but we're still having this same problem with the fundamentals.


I think that's a really interesting point too, about decoding. I don't think I've heard it put that way before. Is there any relationship with that with reading? Because I know that reading involves decoding. Honestly, I don't know too much about literacy. My wife's a first-grade teacher. I've heard the term decoding used a lot in her classroom setting too.


[00:08:17] AA: Yes, absolutely. Decoding is what we're doing. We take sensory input, whether that's visual, reading it, or that's auditory, hearing it, we are putting it into the language portion of our brain, and we’re using that to decode language. Decoding is – that term is used a lot more when it comes to reading, but we're doing the exact same thing in the hearing system.


[00:08:42] DS: Wow. Okay. Wow. This is already such a great way to break this down to make it much – it makes so much more sense this way. I know there's some other terms that are used too. I think of things related to memory skills, things like binaural, different skills that we have when it comes to listening. Did those factor into this decoding or the Erber’s hierarchy? How do those things factor in?


[00:09:05] AA: Yeah. The four different categories of the buffalo model. Now, the buffalo model was created by Jack Katz. He created this construct. Basically, how he created the construct was he took in a whole bunch of kids who had a whole lot of different difficulties from a listening perspective, he did a bunch of tests on them, and then saw how those things seemed to categorize themselves based on the symptoms that they were mentioning when they were first referred, and he put them into different categories.


The first category is the decoding. That's being able to quickly and accurately digest speech. I think about it almost like trees. You know what a tree is based on the shape of the leaf. Can you decode that tree? Oh, that's an oak tree. I can tell what that is. All right. The second category is something called TFM, or tolerance fading memory. It’s the ability to tolerate background noise and it’s short-term memory abilities. There are two different things, but they're both located in the prefrontal cortex. When you see problems with one, you often see problems with another.


We are seeing, even in hearing aid research, that short-term auditory memory and speech and noise abilities seem to be linked. This is also a difficulty for people with ADHD, who have other prefrontal issues. TFM is the second category. It's almost you're walking past some trees, you and I are walking and I say, “What were the last three trees we passed?” You may not remember the first two trees. You only remember the last one.


The third category is organization, the ability to properly sequence what is heard. Now, there can be input problems with organization and output problems with organization, which can be tricky. You and I are walking past trees, and you may say that trees that we pass, but in a different order. Then the fourth one is integration. Integration is that ability to take different sensory inputs, or even inputs from both ears, integrate them into a cohesive whole. You and I might have walked past three trees and you might say, “What trees?” Yeah. That's the basic primer of the four categories of the buffalo model.


[00:11:17] DS: Got you. Does any one of those tend to stick out as the most common problem that you see? Honestly, when you're going through the diagnosis process, do you feel like, are they defined by one of these specific areas? Is it more just they're diagnosed with APD and maybe they're stronger at one or the other? How does that play into when it comes to thinking of a diagnosis?


[00:11:36] AA: I love this question. Brilliant. Decoding is probably the most prevalent category that we see in our clinic. That's also because the majority of people who are referred are having difficulties learning to read. They were doing really well in school, their child was from five to seven, they were really excelling in school, because they have really good visual memory and they were able to remember what a word looked like.


Then once they have to sound words out, they start really struggling. The kid is usually referred around seven years of age, although we will test as young as three and a half. We often see these decoding difficulties. I'm going to be honest with you, Dakota. I'm amped when I see decoding difficulties. If they completely fail on the decoding portions of the test, I believe we have the best chance of rectifying that, treating it, and having a huge difference in the quality of life of that person.


[00:12:32] DS: Wow. That's helpful, because that tends to be the most prominent one you see, too. That's perfect.


[00:12:37] AA: Yeah. I absolutely love it. When I see that I'm, yeah. It looks like the most severe problem, but it is the easiest to treat.


[00:12:45] DS: Interesting. Okay. I really want to talk more about that. I have to wait, until I ask you more about treatment, because I know I'm going to get to that later. If someone has the primary problem of that decoding, do you find that they're also struggling in the other areas? Can they be diagnosed with APD with only a decoding problem? Or how does that factor in?


[00:13:02] AA: A majority have two. A majority have at least two. Decoding and tolerance fading memory are the most common pair to get. I mean, there's a lot of heterogeneity when it comes to auditory processing disorder, which also makes some frustrations happen for people who want things really black and white. Decoding and tolerance fading memory are quite often interlinked.


[00:13:28] DS: Okay. That actually leads me to another question. As an audiologist, or we have people who are SLPs that listen in, or students, what behaviors – because I love the tree breakdown, but some of these different specific characteristics of APD, what would we be seeing in terms of the behavior, the listening behaviors, the educational behaviors at home, problem behaviors maybe? What are the things we should be looking out for that might be indicative of one of these problems?


[00:13:57] AA: Awesome question. All right, so with decoding, you're going to be seeing a child who has really indistinct speech, like things sound really mumbled, because they don't actually realize they're using speech sounds, that it's just this jumbled mess of sounds. For decoding, if you see somebody confusing speech sounds, if you see that they're getting words wrong quite often, if their spelling is a problem, if they're struggling to read, I mean, decoding is really a potential concern there. If they're often looking really blank or lost, that would be decoding for me.


The next one is tolerance fading memory. These kids get really frustrated in background noise. They have a really hard time remembering instructions. It's almost like, decoding is how quickly they get there. Then TFM is how long they can hold onto something afterwards. They're a bit opposite. Organization is interesting. We can see this one physically manifests itself. These people have difficulties even keeping their belongings organized. They may just be a total mess.


Then integration, these difficulties can be a little bit harder to spot. A person with an integration delay may have a long pause before they respond to something, but they're completely unaware that they've paused. I had a kid once who came into the clinic, and I would ask him a question. Then I would start almost following up with a question to help him understand what I was asking before I realized that he was – it was actually just taking time for his brain to process what I was saying.


I mean, sometimes if they're taking a small amount of time and it's a high degree of effort, that's more decoding. If it's a long amount of time, low amount of effort, they're just waiting for things to cross the corpus callosum, that's more of an integration issue. You'll see kids who have problems learning how to ride a bike, or crossing midline, things like that.


[00:15:53] DS: Wow, that's really interesting. Okay, and those are all behaviors that I think, honestly can be obvious. If it was in the case history, I think the parent would jump and say, “Oh, my gosh. Yes, they do have that problem. I see that all the time.” Or having the teacher involved, I think you could get a lot of good feedback on those things.


[00:16:09] AA: Absolutely.


[00:16:11] DS: I don't know how nerdy we want to go here, but do you have any – this is more like just personal curiosity. You mentioned some of the things that are more related to frontal processing. Could you speak to any of the other anatomical things that are going on here, just for the real nerdy crowd who wants to hear a little bit of that?


[00:16:26] AA: Absolutely. Just blow it. I would say, it's funny, because a lot of people ask like, do you feel you've become a really good diagnostician, figuring out anatomically, where in the brain each one of these things is happening? For me, I feel I'm a better diagnostician because I know how to treat certain things as opposed to that.


However, I mean, we can look at things, like there's different contributions to auditory processing based on the auditory structure that's involved. Auditory nerve breaks down the incoming signal from the cochlea into specific components for relay higher in the cans. Then we've got cochlear nuclei, which contrast enhancements of modulations and transients in the signal. I mean, we can get super nerdy.


 [00:17:11] DS: You're definitely scratching that itch. Yeah. That's definitely what I was trying to see, like, where those things factor in. I mean, if there's anything to it, honestly, maybe with decoding, if there's anything that sticks out to you as one of those, because I'm sure you get families after a diagnosis and they're like, “Okay, but what is going on in their head when I say to do this and they don't do it? Or when I try to get them to respond to a question and they say the wrong thing?” That's definitely the question I was asking there.


Is there anything to decoding anatomically that just jumps out at you that's a quick explanation that can help someone understand that mechanism a little bit better?


[00:17:50] AA: Well, Jack Katz always talks about phonemic boundaries. While this is a little less pure anatomical, I really like this idea. It's almost like our brain has little buckets of what each sound is. We know what the boundaries of those are. These kids have really indistinct phonemic boundaries. They overlap. Somehow, some of these kids can approximate a sound between an M and an N. Every now and then, I'm looking at them, trying to figure out how they're articulating that. I don't even know.


[00:18:21] DS: They're creating new phonemes.


[00:18:24] AA: You have just created a new phoneme. Look at you. Look at you, little buddy.


[00:18:29] DS: Yeah, that's awesome. Okay, so that actually makes me think, when we're thinking of these kiddos, how do we differentiate when we're thinking of – because at some point, someone told me, well, if they have any hearing loss at all, they cannot also be diagnosed with APD. Then I read a different study that does not say that. I'm just trying to get a better sense of, is there a continuum between hearing loss and APD? Do they merge? How do we tease those things and make sense of the two?


[00:18:55] AA: I mean, wouldn't you expect that a person who has an actual problem with their peripheral hearing system would be more likely to have problems further up the system?


[00:19:06] DS: I would think that makes sense.


[00:19:08] AA: Right? I mean, it's so funny. I mean, I think the initial definition of Auditory Processing Disorder was “a hearing disorder that occurs without a hearing loss.” However, I have worked with a lot of people who have cochlear implants who have poor decoding. By just increasing their decoding abilities, we can actually make their auditory skills much better.


Anybody who has a cochlear implant for the first time can tell you the process they've gone through to help themselves hear and understand better. It's really interesting. Yes, absolutely, you can have an auditory processing issue at the same time as a hearing loss. They can certainly be related and comorbid.


[00:19:55] DS: I think that makes total sense. Part of me feels like, whatever strategies we get to with the buffalo model later on in our conversation here, I'm like, how can I integrate those into my oral rehab process for my patients with cochlear implants? Because it sounds invaluable, that not only I'm ensuring that their map or their programming is appropriate, but also that we're building up these central auditory skills that will help them later on.


Hold on, I want to get to treatment so bad. I don't know if I've made that clear enough. Before we get there, that's my question there with the hearing loss thing. How do we know, or I mean, maybe if we don't, it doesn't matter. When the problem is, okay, let's say someone has a severe hearing loss and they wear hearing aids, but we know their hearing aids aren't really providing them everything super clearly. Does it even matter if we tease out between if their problems are more related to a central processing thing, or if it's more just – that their peripheral system is not working as well, because the limitations of their hearing technology. Have you run into that situation before?


[00:20:58] AA: I've got a hot take.


[00:21:00] DS: I want to hear it so bad.


[00:21:02] AA: My hot take is when we are telling people that they need to have realistic expectations, we are actually forgetting that we should be able to involve the brain more. I think, audiologists will often tell a client who's not able to “meet their realistic expectations.” I think we're doing those clients a disservice. We are actually limiting ourselves and what is the potential, because there are clients that I've worked with with severe hearing losses and with hearing aids.


I often find that decoding is actually their problem. Because over time, as the auditory signal has changed to them, their brain has not kept up. If we can help them create better phonemic boundaries, we can actually improve their decoding abilities. It's funny, because we think it's speech and noise quite a lot, which it could still be some speech and noise difficulties, of course. If we can fundamentally change their ability to decode what they're hearing, we can get great outcomes from that too.


[00:22:00] DS: Wow, that's a hot take, but that’s a hot take that makes a lot of sense. That really is a really good perspective on that. Okay. Wow. Okay, thank you for sharing that. Honestly, everything keeps leading me back to, okay, so what do we do when we're in the situation? How do we treat it? Before we get there, I got to ask at least a few more things. 


Actually, you know what? We need to figure out if someone has APD. Before we're going to treat them, what does diagnosis look like? What assessments are you using? Are there assessments that audiologists who don't primarily work with APD can start utilizing, or maybe even just a screener or a questionnaire that could be helpful?


[00:22:35] AA: Absolutely. All right. Here's the deal. The client comes into your office, have every one of them do an HHIA, which, of course, is a free form, the Hearing Handicap Inventory for Adults. I like to just call it the Hearing Inventory for Adults. I have those forms available and I can share a link to you as well. It is a free 25-item questionnaire. You answer yes, no, or sometimes. Based on that score, you get a score out of a 100 of how this person's social, emotional score, their psychosocial score for how their hearing is affecting their lives.


Now, with APD, I would say the biggest impact APD has is on the psychosocial wellbeing. Basically, if you have somebody come into your clinic and they say, “I've got a hearing loss,” and you have them fill out the HHI and let's say, their score is 80 out of 100. 100 being awful, zero being great. 80 is going to be pretty bad, right?


Then you put them in a hearing test booth. Let's say, there's two different situations. One time in one situation, they have a really bad hearing loss. That makes sense with the HHIA. All right. Let's say, they don't have hearing loss. Well, maybe this is a red flag that a person has an auditory processing issue. You fit the person who has a hearing loss with hearing aids. After they come back to your clinic with properly fitted hearing aids, do another HHIA. Has that score dropped substantially? If it hasn't dropped substantially, you could be looking at another red flag of APD in addition to hearing loss.


[00:24:16] DS: Wow.


[00:24:17] AA: Yeah. Yeah.


[00:24:18] DS: That's a really simple tool that we can be using. I guess, it wasn't intended to be an APD screener, but it does seem pretty relevant in that discussion.


[00:24:27] AA: 100 percent. You know what? I would rather see a clinician who's not doing any APD work referring based on an HHIA score than a quick send any day.


[00:24:38] DS: Wow.


[00:24:39] AA: Yeah. 100%.


[00:24:41] DS: Good. Okay, so we've got the HHIA for our clinicians who aren't doing as much APD, but that can be a really good starting point. Let's say, they're referred to your center, or if there's a clinician who wants to start incorporating some diagnostic criteria, what does it take to complete that kind of assessment?


[00:24:58] AA: For an auditory processing assessment that I do in my clinic, based on the buffalo model, it's a one-hour long assessment. There's another misnomer that you need to test somebody for four hours. If you're testing somebody for four hours, you're not testing auditory processing abilities anymore. You're testing fatigue and, yeah, lots of other things. Yeah. I also really like to use Acoustic Pioneer’s Feather Squadron. Have you heard of this?


[00:25:24] DS: I've never heard of that before.


[00:25:25] AA: Okay. It's actually an iPad app that tests for auditory processing abilities. It's ingenious.


[00:25:32] DS: That's awesome.


[00:25:34] AA: I know. It's not the most sensitive thing, in my opinion. I wouldn't diagnose based on it, but it is a brilliant way to get really good information on tonal processing, some dichotic skills, even word memory. It tests eight or nine different things. Yeah, it's bright and fun, like Angry Birds. The kid plays it for 45 minutes. I get a lot of information out of it. I like to have it, because I can use it as a pre and post for my therapy, because I want to see something that doesn't have my bias on it to prove that significant changes have happened in the auditory system based on the therapy we've done.


[00:26:11] DS: Sure. That's great. Is that the number one assessment tool that you're using? You know what? I'm going to go ahead and be honest, I was under the impression that an APD assessment did take two, at least two, more like three hours. It's really making me feel better to know, okay, we're not doing that. That's not important in this scenario.


[00:26:29] AA: I mean, those kids, if you keeping them there for four hours, they're not going to want to come back to you for therapy.


[00:26:35] DS: That’s true.


[00:26:36] AA: All right. For me, I like to do the Feather Squadron. Feather Squadron is not my number one tool, but I do really, really like it. Matt Barker who created it actually has a code that you can go in as an audiologist, or a speech language pathologist, and you can give the test to yourself for free to see what it looks like, what the responses look like.


[00:26:58] DS: Oh, that's really cool.


[00:26:59] AA: Yeah, it's really good. I do not recommend doing that after a glass of wine. A friend said she totally bombed it, because she had a bit of a buzz. There's the Feather Squadron, which that one was so bright and fun that kids don't seem to mind it. That would be about an hour. Then I usually have them leave for a few hours, go do something fun, have some lunch. They'll come back for the last hour.


Then as a part of the buffalo model central test battery, they do speech and quiet, speech and noise, 25 words to each ear. The speech and noise part is at a 5 DB SNR. It seems to be where people fall apart with auditory processing difficulties. Even with the signal being 5 DB over the noise. Then the second part is the SSW test, which you're familiar with, the Staggered Spondee Word Test. A couple words go in one ear, couple words go in the other ear, and the second and third word overlap in time. Then the last test is something called the phonemic synthesis test. Have you ever heard it before?


[00:27:59] DS: Phonemic synthesis. I feel like, I must have, because I had to do one of these, but it's been a long time.


[00:28:05] AA: Oh, man. On the phonemic synthesis test, you take phonemes and you blend them together. E is she, right? The first time I heard it, I thought it was crazy town. I also think I had auditory processing issues. That being said, I really like doing something like the phonemic synthesis test with people who have hearing loss, just to see what their decoding abilities look like.


[00:28:30] DS: I remember, I've watched a video of yours where you've got some real client video. I remember just being in awe, because to me, it just seems it would be so easy. It was like, buh-oat. Then they would say like, “Shoe.” Or me maybe not shoe, but some – they would rearrange the phonemes, like tobe, or tub. I was like, “Where are they getting this?” I do remember that one now. I guess, that is a perfect example of decoding. It's that breakdown of phoneme by phoneme and where that can just fall apart.


[00:29:01] AA: Absolutely.


[00:29:03] DS: Yeah. Does it take someone doing poorly on multiple tests, or – this is where my memory gets a little foggy, because I haven't done this in a while. I remember, it used to be something like, a score of a certain number of standard deviations or something below on two different tests. What is really the diagnostic criteria at this point?


[00:29:22] AA: Yeah. The diagnostic criteria was set by that ASHA 2015 consensus paper. Then also, the AAA guidelines also doubled down a little bit there. What the old standard was, is you have to fail two probes by two standard deviations, or a single probe by three standard deviations.


Then we need to realize that two standard deviations means that 98% of the population of the same age are scoring better than this person. The National Acoustic Laboratories here in Australia, actually put out a statement in 2015, saying that a standard deviation cut off is completely arbitrary and does not identify that a person is or is not having difficulties in the real world. I think that is a major discussion that's occurring now. Would it make more sense to drop it to one standard deviation, where 86% of the population may be performing better than you? Yeah. It is a little bit arbitrary. I do like the central test battery. I do think it is quite sensitive. It is probably more sensitive than specific. A lot of audiologists prefer specific testing, because you want that black and white, really clear.


I think that it's really important that these people are coming to us because they say, “I have a problem.” Every time, when I use the buffalo model test, I can see the problem in one way or another because we don't just use quantitative data. We also look at how many times a person pauses, how many times a person reverses their response. We're looking at these things that are super segmental. I think that it has a lot of relevance to what's happening in their day-to-day lives.


[00:31:18] DS: Wow, that's great. It actually reminds me, I know, something you talk about really often is this more qualitative impact. We talked about some of the behaviors we might see in someone who could be a good referral. When it comes from an assessment standpoint, what other qualitative things are you looking at? I mean, I feel the HHIA is a great indicator of some of those quality of life impacts. What are some of the other things you're seeing?


I like how you mentioned the specifics during the assessment. Is there anything else? Because I feel like, you do a really good job of promoting - this is way more than just a documentable problem with binaural integration. This is a huge quality of life thing. They're coming in to see us for a reason. They say they have a problem. How else do you see that factoring in, in this process, like, pre-therapy and the diagnosis and in the referral process?


[00:32:06] AA: Yeah. Other qualitative things that we're looking for. We're looking for a quick response. Did somebody respond really quickly because they were afraid they were going to forget it? Or is it because it's an executive functioning issue? Once again, both prefrontal cortex, right? Does the person quietly rehearse what has said before they’re going to respond? That is a decoding issue. They're not quite certain what they heard, so they're repeating it on their lips in order to encode it further.


It's very interesting. I think the crux of the issue, as far as I can tell, is that a lot of people, even audiologists have a hard time realizing that these things can change. I feel like, I have this weird superhero power. When a person walks into the clinic, I immediately can see how much of an impact this seems to be happening for them. I can also see what potential they've got to overcome those difficulties.


For me, I love seeing severe cases. The more severe, the more excited I get. I think that my hope for audiology is to be able to unveil that a bit, to show more people what the potential is to change lives with better auditory processing.


[00:33:23] DS: Yeah, that's amazing. That's amazing. You have a lot of good cases. Honestly, I think it would be awesome here, once we talk about therapy a little bit too, maybe if you have a couple of cases that come to mind that can be a great – I've found through this podcast that oftentimes, when we talk through a case, that's where I'll get the feedback is, I thought of that case when I saw this person. It was that instant reminder that they might be good for this. I think that's a really great tool, so just to get you brainstorming already if there's anyone that you want to share about in a little bit.


Now we have a better understanding of why they came in, how they received a diagnosis, and what the assessments look like. Now what? How do you decide what therapy looks like for that person? Is it going to target those specific skills? Is the therapy more global? How does that process get started?


[00:34:12] AA: According to the buffalo model, we always start with decoding anyway. We start with decoding, because it is that second step on the ladder. Even if it looks like, okay, we may have integration difficulties, let's make sure that the phonemic boundaries are really clear before we keep going. It's just creating those early foundational skills, especially if the child has grown up having a whole lot of middle ear infections and they've been essentially hearing underwater for a long time, we need to help their brain understand what speech sounds are.


For the buffalo model, we do a round of about 12 to 14 sessions. One-hour sessions once a week. Over three months, we see usually our biggest gains. Then, I do more deficit-specific stuff. Now, I mean, people say, not everyone with auditory processing issues will have the same issues. That's correct. Also, we only have a finite number of speech sounds in the language. Doesn't it make sense to make sure that we've got all of those locked down before we move forward?


[00:35:14] DS: Yeah, absolutely.


[00:35:15] AA: We do those 12 to 14 sessions. We can also do something called a phonemic error analysis. On the buffalo model battery, there are 926 speech sounds. It's a nice little language sample. We can go in. Every time a person substitutes a sound for another, omits one, or adds one, we add that to the analysis, and we can figure out which phonemes are most often an error.


It's really surprising to me, because sometimes the phonemes that are most often in error are in their first names. I need to do a study on that to – I'm like, “How is it that you don't know these sounds?” I don't know. Anyway. We go through and we can analyze the sounds that are most in error. Maybe the first four sounds that we're going to work on in a session, or in their therapy round. Maybe that made up for 26% of the errors on their test. You can see that if we can increase the phonemic awareness on those four speech sounds that, wow, that's really going to help give them a boost, a leg up.


[00:36:15] DS: Wow. Yeah, that's great. I really love that setup. It sounds pretty intensive. I mean, that's a long time to be committed to that therapy. Do you find that the follow up is pretty good? Do people stick with their sessions for the most part?


[00:36:28] AA: Oh, yeah. Definitely.


[00:36:30] DS: Yeah. You guys probably make it pretty fun.


[00:36:33] AA: Well, yeah, yeah, yeah, yeah. Definitely have to make it fun. Definitely want to engage that amygdala as much as possible, because the amygdala is going to help us, or the limbic system is going to help us take things from short-term memory to long-term memory. The weirder I am – sometimes when I'm working with adults, I like to throw bad words in. I was working with a 14-year-old and I threw the word piss in today, and I thought he was going to wet himself. Yeah. Especially, my favorite part is when I see a teenager start to engage in the process because they feel things changing. That's a powerful moment.


[00:37:09] DS: Yeah. That's great. Making it fun. Making sure it sticks. I'd love to talk a little bit more specifically about some of the strategies in just the therapy treatment options you guys are doing. Are you working with SLPs and audiologists? Is there oral rehab involved? If someone, if you feel their programming isn't right, if it's more they're missing out on sounds that they were getting before just fine and you're worried there was a change in their hearing, how does that process usually work?


[00:37:35] AA: Absolutely. I actually sold my dispensing practice in May of last year, which actually doesn't feel it was that long ago, but that’s all right. In my clinic, I mean, we were always trying to work on the hearing aid first and then processing second. It was, let's make sure that that person is actually getting the awareness, they're getting the input, and then working on hearing from there and retesting hearing as needed. We've seen some amazing people come through the clinic. A woman who had a cochlear concussion, which I had never even heard of before that.


[00:38:08] DS: Wow. What?


[00:38:10] AA: Yeah. She was standing next to a cannon that went off next to her ear and had a concussion in her cochlea. She only has one category on her APD testing. It's tolerance fading memory. It's all short-term auditory memory stuff. It's really, really interesting and tolerance to background noise. That's super interesting.


[00:38:33] DS: Yeah, that is interesting. Before we transition into talking about some cases, if you've got any that you want to share, what does some of that treatment look like? I'm going to be honest, I did see a video of some of the things you have done, including there was a video of you working with your daughter and it just blew me away. I think that was really more on phonemic decoding and things like that. What are some of the strategies that you guys are utilizing?


[00:38:54] AA: Yeah. We generally have four parts to each auditory training session. The very first part is to train somebody to quickly and accurately digest the speech sounds. We use a visual filter in front of our face, so somebody is not actually using their vision. It's a visual filter. Filters out the vision, but the auditory signal is still maintained. You say the sound.


I have a deck of cards that has the graphemes on them, the written speech sounds. I say the phoneme to them, they tap the card. We start with just a few sounds, three or four sounds. Then the next week, we bring in four new sounds. I think the best way for me to explain it is to say that, like my husband and I went dancing, to dance lessons, and we started a new dance. The next week we came back in, they're like, “Okay, let's review the dance we did last week and then we're going to add a new dance.” Wait. Then we left again. Next week we came in, we started with the dance we did the week before, then the dance we already knew from two times before, and a new dance. That's the way that we bring sounds into the system. We are constantly cycling over and over and over the speech sounds that have been difficult for them.


The first thing we do is phonemic training, speech sound training. The second thing we do is called words and noise training. That's where they hear words and background noise and have to repeat them back. The level of background noise goes from no noise at all, then from a 12 Db signal to noise ratio down to zero. Then we do a little bit of auditory memory work. Then we do phonemic synthesis training. Yeah, it's really cool. It's just this process. The kid gets on the top of the slide and I know where they're going.


[00:40:43] DS: Sure.


[00:40:43] AA: Yeah, super fun.


[00:40:46] DS: How are you guys tracking some of the qualitative things that you mentioned? Are you asking probing questions at each therapy session? Or how do you have a sense of how they're progressing in the more qualitative ways?


[00:40:57] AA: Yeah. I'll usually tell the parents that, “Keep your eyes open around maybe session four or five. I want to see if you start noticing that they're a little bit more aware. They're not asking ‘huh?’ or ‘what?’ as often, that their speech may sound a little bit clearer.” That's not what we're working on, but it's a secondary benefit. I do start asking about those things. The boy that I saw today for therapy, he said to me, “I'm able to listen more easily,” which was really exciting. It's always cool when teenagers say nice things.


[00:41:29] DS: It's got to be a rarity. When it does happen, that's a treasured moment. Yeah, that's really cool. Who is administering the assessments and the therapies in your center? I'm curious, because, I mean, just from what you've shared so far, I do definitely see the benefit. I'm just curious how a clinician, whether that's an audiologist, or an SLP, or another professional, how they could start to get more involved in providing this service?


[00:41:57] AA: Absolutely. I am only an audiologist. My team is, at the current moment, it’s just me. Basically, I don't have a multi-disciplinary approach. I do think it is important to be able to take all those in, if that can be done in a way that's financially possible, especially if you actually have a socialized healthcare system. Oh, my gosh. It's amazing the teams that they can bring together. I'm only an audiologist. I can only see what's going on from an auditory skill perspective. If I see that there are things that we can change with auditory skills that may also have some other improvements for someone else, then I'll give those recommendations in the therapy and we'll see how we go.


I mean, that's tough, because I think a lot of people are so unsure on what to do with APD. They want to add as many voices to the discussion as possible. For me, I want to look at things from a practical perspective. Which one of us is going to be able to make some really practical changes happen? Because auditory skills are such a foundational point of learning, I feel it's a great place to start.


[00:43:04] DS: Wow. Yeah, that's great. That's great. I do think there is space for a team. You're right that sometimes, if we're unsure, it feels easier to just invite as many other people on board as possible and maybe hope that they have a little bit more to say on the topic. I think the way that you've broken it down, it's a lot more digestible as an audiologist to see where the skills overlap here. I'm sure our SLP listeners would agree as well that some of these phonemic breakdowns and things like that are things that they see, whether they're working on literacy or just early language development.


[00:43:35] AA: Absolutely. I have to say, I have tremendous respect for SLPs. I honestly believe, anybody who is dually qualified, number one, they should be doing this. This is the most awesome way that audition and speech crossover. I always wondered in grad school, why we shared a hallway with the speech language people, but we never interacted. I have a huge amount of respect for SLPs and I love what they add to things. I also like working with them when they're like, “Oh, we haven't made progress with this kid.” Just by changing it, changing the route of delivery to more of an auditory skill thing can be what unlocks the code for some kids.


[00:44:18] DS: Yeah, that's awesome. I can see where this is totally a place for those worlds to merge and collide. I think that you're right, the dual SLP-AuDs, this sounds exactly like what they need to be doing. This feels like a perfect blend of skills here.


[00:44:32] AA: Super cool.


[00:44:34] DS: Yeah. I teach SLP students and I get this question a lot. They're hearing about APD in other spaces. They're hearing about it in the school system. Wherever they go, no one seems to really be quite certain. Are we supposed to be talking about this? Who is the professional and who is responsible for this? I do think, as we've started to reach a better consensus on what it is and how we can help it, I think that audiologists are definitely starting to step up and this is starting to become a much more common part of our practice.


[00:45:03] AA: Richard Tyler said that if audiology doesn't own tinnitus, another profession will. I would say the same is true of APD. If we don't step up and own this, then another profession will. A lot of other professions are trying, between psychology and OT. For psychologists, it's like, “Oh, yeah. I can clearly see this person has an auditory processing issue.” Although, if they would miss the hearing loss, that would be pretty awful.


I think that this does, this is in the audiologist’s domain, but the last ASHA survey that asked, said that 1.4 percent of our colleagues are doing this testing regularly. When there's approximately 300 million English speakers in the world who may have auditory processing issues from a low estimate and there's only 300 people doing the work, we're just not feeling the need. The idea that some people think that auditory processing is over-diagnosed is the most ludicrous thing I've ever heard in my life.


[00:46:01] DS: Sure. How do you feel current audiologists can start to implement some of these things into their practice?


[00:46:07] AA: That HHIA form, I also am developing an HHIC, just to get that standard number too. Only problem is, I have one client who had an HHIA score that got really got a lot better with therapy. Then, at retest, I checked her HHIA and it dropped. I was like, “Wait. What happened?” Then I asked a few questions and I realized that the questions she had answered, there were two questions that were totally changed based on COVID. She was like, “Oh, I haven’t [inaudible 00:46:41] people.” And do you feel that a difficulty with your hearing limits or hampers your personal or social life? She was like, “Oh, yeah. No, I haven't had either of those two things happen.” That was hilarious.


[00:46:53] DS: Oh, gosh.


[00:46:54] AA: Watch out for the effects of COVID on HHIA.


[00:46:57] DS: We need the COVID edition.


[00:46:59] AA: Yeah. I mean, I think the first part is caring. The first part is when you notice that a person is struggling on a hearing test, don't get your hackles up and get angry because you feel they're trying to pull something over on you. Because a hearing test is actually quite difficult for a person who has an auditory processing difficulty.


Number one, try not to let your ego get in the way of seeing what a person is actually struggling with. Two, find a person who's great at doing this work and refer to them. If there's no one close, be that person.


[00:47:31] DS: How can they go about getting started with that?


[00:47:34] AA: They can always contact me at auditoryprocessinginstitute.com. Hello, pitch. No, just kidding. I do teach online masterclasses on how to evaluate and how to treat auditory processing. It's really cool, because it's an online group of professionals. We have an online community, we meet once a week with speakers and have meetings.


One thing I did not anticipate is how many people are creating their own products from this. We have people who are creating therapy programs. We have people who are creating software to help make the evaluation faster to score. I mean, this is a very, very exciting time to be a part of the movement. I hope anybody who's listening here who feels called to do so will join the movement.


[00:48:24] DS: Absolutely. Just taking it back to what you're saying about being caring, a few episodes ago, we had Dr. Maria Morrison on and she was talking about incorporating tinnitus care. She had a lot of – just like you, a lot of very practical specific things that people can start doing, whether it's just the THI, or some inventory, or questionnaire, something. Her number one piece of advice was just letting people know that there's hope for them, that it's not this hopeless thing, because I feel like the same goes for APD. When it’s not well-understood, our response is, “I'm really sorry. That's it. I'm sorry you have that problem, but that's about it.”


[00:49:03] AA: You know whose fault it is? It's ours as a profession. We have let these people down.


[00:49:09] DS: Absolutely. Yeah, just coming from that caring perspective and letting them know, they're not alone. There's something we can do to help. Even if it's not you, even if you're not that expert who's going to help diagnose or treat, there is someone out there who can help and letting them know that it's not just too bad, so sad, because I do feel that's really been the response for a long time.


[00:49:27] AA: Right. It's an absolute shame. I completely agree. Maria is awesome.


[00:49:32] DS: Really cool. Okay. Well, we've only got a couple of minutes left. Is there any one case that comes to mind that you could give us a quick breakdown of where they were in life when you met them? Then their process through everything, then where they are today? Could you give us something just to be that reminder for clinicians in the future who think back to this episode?


[00:49:51] AA: Absolutely. There's a woman named Jackie that I used as a case study. She came into our clinic. She had had her hearing tested over and over again, and they said her hearing was normal. Then she came into our clinic and she had an HHIA score of 82. We did auditory processing testing and found out that she had a severe auditory processing disorder.


She had actually had a QuickSIN done by another audiologist prior to this. She had passed the QuickSIN and the audiologist had recommended no further testing. She went to an otologist, who sent her to us. I mean, she was struggling in all areas of her life, because she was struggling so much to listen, to hear, and understand and remember what she had heard. We did therapy with her. We did one round of therapy. Afterward, she had an HHIA score of 30.


[00:50:45] DS: Wow.


[00:50:45] AA: Yeah, 30, after one round of therapy. At her six-month follow up, it was at 14. She continued to show improvement after the therapy concluding. That was a night and day situation. I thought that was really important. Then the other little case studies I wanted to highlight is we evaluate people at three and a half years and older in our clinic.


Now, I think people think that you're not supposed to test younger than seven. A lot of people choose not to diagnose until after seven. They don't want to put that label on the child until after seven. I don't think that the public understands that testing and diagnosis aren't the same thing, so I think it's really dangerous for people to say that we can only test over seven years of age. That was because certain tests were only norm for over seven years of age. Now unfortunately, there's lots of people who think it's not possible.


There was a kid that was five years of age, her parents contacted a clinic for APD testing. They said to call back when the child was seven or eight. They called back at seven or eight, got the child tested and the kid had a hearing loss. It’s really dangerous. Doing harm there. I also have a client who contacted me, because she's been turned down for APD testing from a university, because her child has too low of an IQ.


Auditory processing is one of the easier things to change, to improve. I will definitely be doing testing with that child and we'll be treating her as well. Same thing with autism and ADHD and things. I don't think that that needs to prevent – we would never prevent doing a hearing test on somebody who has depression. We wouldn't prevent – we should be able to figure out what the auditory skills are there in deficit and make these better.


[00:52:36] DS: That's great. Angela, thank you so much. That was all so helpful. Those illustrations, I think those are really going to stick with me for sure. Those are really great. I love hearing about Jackie. That's so awesome. I love having the HHIA, is that – It wasn't maybe built for looking at people who didn't have specifically a hearing loss, but they do have a hearing difficulty that's impacting their life in a really severe way. That's a really great reminder.


[00:53:01] AA: Yeah. Like Gail Whitelaw said, audiograms don't talk. Patients do. Listen to your patients.


[00:53:09] DS: That's so good. That's so good. I feel like audiologists, we really struggle with the numbers game. We keep it too black and white, but it really is about the people that we're serving. That's great.


[00:53:20] AA: Thanks a lot. It’s a good chat.


[00:53:24] DS: All right. I think, that about brings us to the end of our time. Before we go, if someone wanted to reach out to you, honestly, no, before we even – if you have your email and you want to share that, but you're all over the place. I see you rocking it out on Clubhouse, making big waves for audiology, just around the world. Where can people find you?


[00:53:42] AA: Yeah. Anywhere. My email address is angela@APD. You should know how to spell that now, I guess. support.com. APDsupport.com. I have an online searchable map for providers to find people in their area who are doing this work, both on the diagnostic and therapy side. Yeah, auditoryprocessinginstitute.com. Yeah, hit me up. I'm happy to have a chat. 


[00:54:10] DS: That's awesome. Thank you so much again, for joining me. This has just been a really eye-opening and really helpful conversation. I really appreciate you taking the time.


[00:54:17] AA: Great questions.


[END OF INTERVIEW]


[00:54:20] DS: That's all for today. Thank you so much for listening, subscribing, and rating. This podcast is part of an audio course offered for continuing education through SpeechTherapyPD. Check out the website if you'd like to learn more about the CEU opportunities available for this episode, as well as archived episodes. Just head to speechtherapypd.com/ear. That’s speechtherapypd.com/ear.


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