Auditive Verarbeitungs- und Wahrnehmungsstörungen (AVWS ... · (Central) Auditory Processing...

Auditive Verarbeitungs- und Wahrnehmungsstörungen (AVWS)

(Central) Auditory Processing Disorders ((C)APD)Dr. med. Stephanie Reetz, ORL-Klinik UniversitätsSpital Zürich, Abteilung Phoniatrie und Klinische Logopädie

Sommerschule 31.08.2019

1. Introduction2. Fundamentals of auditory processing and perception3. Term explanation: (Central) Auditory Processing

Disorders4. Etiology and pathogenesis5. Symptoms6. Diagnostics7. Differential diagnoses8. Therapy and management

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Index

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• Hearing and hearing processing can be affected in many ways.

• In some cases, the information is almost completely lost or "only" more difficult to recognize.

• (C)APD are deficits in neural processing and perception of auditory stimuli despite normal peripheral hearing and normal intelligence.

1. Introduction

Der PARITÄTISCHE Hessen: Hören - Hörschädigung, 3. Auflage, 2004, S.71.

Ch. Kiese-Himmel. Auditive Verarbeitungs- und Wahrnehmungsstörung (AVWS) im Kindesalter. 2011. Kindheit und Entwicklung, 20(1), 31-39. Auditive Verarbeitungs- und Wahrnehmungsstörungen. Konsensus-Statement. Überarbeitete und aktualisierte Version der DGPP.

• The diagnosis mainly concerns the primary school age

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1. Introduction

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• Referral of children due to school problems: „ unable to listen properly “ „ do not understand in noisy environment “ „ twisting letters during dictations “ „ cannot remember complex instructions “

Now, let's bake an omelette.

Why should I go to bed??

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1. Introduction

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Lisa tries hard to follow the explanations of the sports teacher in the gym. When all the other children run in the instructed direction, she doesn't know what to do. So she is oriented towards her girlfriend.

Mischa hears the teacher's instructions. „ Now get your red folder out of the school satchel and your pencil out of the pencil box.“Mischathinks for a while and takes a red pencil out of the pencil case.”

Tim works at his group table and occasionally exchanges ideas with a neighbour. The teacher is standing at the blackboard and calling hisname. Helpless and searching, Tim looks around the class and looks for the person who obviously wants something from him.

(Hammann, 2012, P. 9)

• Increasing attention and interest in various disciplines

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1. Introduction

Lehrbuch Phoniatrie und Pädaudiologie - Weidner, Seidner, Eyshold. 3. Auflage. Thieme.

(Central) auditory

processing disorders

Paediatrics

Child and youth psychiatry

Logopedics

Speech and/or hearing impaired

educationPhoniatrics, Paediatric audiology

Oto-Rhino-Laryngology

Psychology

Neuropaediatrics

• (C)APD affects functions that enable children to respond to auditory stimuli and/or understand speech at every level.

• There are different types of (C)APD, thus there is a great amount and variety of symptoms.

• Children with (C)APD can hear soft noises or sounds without problems, but what they hear is not processed in the correct manner.

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1. Introduction

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dgs Sprachheilpädagogik aktuell

Cat or pet?

• 1 - 3 % of children have difficulties in understanding what theyhear despite normal hearing thresholds in pure tone audiometry.

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1. Introduction

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M. Ptok, S. Miller, D.Kühn. Diagnostik auditiver Verarbeitungs- und Wahrnehmungsstörungen bei Kindern. HNO 2016. 64:271–286Auditive Verarbeitungs- und Wahrnehmungsstörungen. Konsensus-Statement. Überarbeitete und aktualisierte Version der DGPP.

• Hearing as a sensory function serves to detect and perceive acoustic signals from the environment, even in the presence of background noise, and to utilize them in a meaningful and targeted way.

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2. Fundamentals of auditory processing and perception

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Ptok M, Kiese-Himmel Ch,, Nickisch A. Leitlinie „Auditive Verarbeitungs- und Wahrnehmungsstörungen“: Definition. S1-Leitlinie der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie. HNO 2019 · 67:8–14

• Acoustic signals can have various qualities: tones (sinus tone), sound (harmonic superposition of sinus tones), noises (non-harmonic superposition of sinus tones), bang.

• The acoustic signals/noises used for communication represent a special form: The actually realized acoustic speech signals are called phone.

• The smallest prototypical units of a speech system are phonemes.

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Petursson M, Neppert JMH (2002) Elementarbuch der Phonetik. Buske, HamburgPtok M, Kiese-Himmel Ch, Nickisch A. Leitlinie „Auditive VerarbeitungsundWahrnehmungsstörungen“: Definition . S1-Leitlinie der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie. HNO 2019 · 67:8–14

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How does auditory processing work?


• Intact peripheral hearing system

• Intact central hearing system

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Subdivision of the overall process of hearing into thefollowing subfunctions:

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• external ear • eardrum• middle ear• inner ear• auditory nerve• brainstem• auditory cortex

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Ptok M, Ptok A, Schönweiler R (1996) Audiometrie im Säuglings- und Kindesalter. HNO Aktuell. 4:209–216.

http://microtiaearsurgery.com/hearing-loss/what-is-atresia?lang=de

https://pennaudiology.com/hearing-loss

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Auditory processing = • Nerval transmission as well as preprocessing and filtering of auditory signals or information at different levels: cochlea, auditory nerve, brainstem, cortex

Auditive Verarbeitungs- und Wahrnehmungsstörungen. Konsensus-Statement. Überarbeitete und aktualisierte Version der DGPP.

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• processing of auditory evoked nerve impulses

• localization, summation, fusion, separation, discrimination, identification, differentiation and integration of sound signals

Brainstem


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• Planum temporale left: perception of spoken language

• Primary auditory cortex of the right hemisphere: music perception

Primaryauditory cortex Secondary,

tertiary auditory cortex

from the helicotrema

from the base

of the cochlea

Auditory Cortex

Phoneme and noise perception, sound and word comprehension, acoustic attention and storage of word, music and speech content

http://brainmind.com/PrimaryAuditoryArea.html

http://physiologie.cc/XVI.3.html


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Auditory Perception = • Part of cognition • On the one hand this comes about through signal

processing, i.e. "bottom-up processes", on the other hand through vigilance, attention and memory - "top-down processes".

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bottom-up processes

top-down processes

„I hear…“

• Strict distinction between hearing as an auditory process(= acoustic recording of frequencies and noise level) - andthe real recognition.

• „ I hear two people. A woman and a man.“ I recognize this only on the basis of my knowledge and

in my experience.This succeeds thanks to a complex interaction from physical and neuronal processes.

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Summery• Hearing in the sense of the meaningful and

purposeful utilization of acoustic signals is not a purely sensory process it takes place with the inclusion of cognitive abilities.

• “bottom-up processes” lead from bottom to top and begin with the absorption of stimuli. They lead up to the mental processes and are based on signal processing.

• In contrast: “top-down processes” involve higher mental processes: vigilance, attention, memory.

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• Hearing also includes the auditory memory phonetic storage

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In case of hearing impairment, all partial functions can be affected alone or in combination:

• Conductive hearing loss: Sound transport to the oval window disturbed

• Sensorineural hearing loss: Transformation of the mechanical energy of sound into a bioelectrical signal is disturbed.

• (C)APD : Disturbance of processing (brainstem level) and perception (higher auditory functions including cognitive functions) of nerve impulses.

3. Term explanation: (Central) Auditory Processing Disorders

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(Central) Auditory Processing Disorders is defined as an impairment of central hearing processes while peripheral hearing capacity is in the normal range.


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What are central hearing processes?

dgs Sprachheilpädagogik aktuell


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Central hearing processes:


central process example1.2.3.4.5.6.7.8.

• A gold standard for the diagnosis of (C)APD is not yet available internationally.

• A number of expert opinions have been published: • German Society for Phoniatrics and Pedaudiology (DGPP)• American Speech and Hearing Association (ASHA)• American Academy of Audiology (AAA) • British Society of Audiology (BSA)

• German term “AVWS" was introduced by the DGPP in 2000, based on the Anglo-American expression “Auditory Processing Disorder” (APD), but supplemented by linguistic auditory processing and short-term memory.

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M. Ptok, S. Miller, D.Kühn. Diagnostik auditiver Verarbeitungs- und Wahrnehmungsstörungen bei Kindern. HNO 2016. 64:271–286Auditive Verarbeitungs- und Wahrnehmungsstörungen. Konsensus-Statement. Überarbeitete und aktualisierte Version der DGPP.


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„Eine Auditive Verarbeitungs- und/oder Wahrnehmungsstörung (AVWS) liegt vor, wenn bei normalem Tonaudiogramm zentrale Prozesse des Hörens gestört sind.

Zentrale Prozesse des Hörens ermöglichen u. a. die vorbewusste und bewusste Analyse, Differenzierung und sowie Prozesse der binauralen Identifikation von Zeit-, Frequenz- und Intensitätsveränderungen akustischer oder auditivsprachlicher Signale sowie Prozesse der

binauralen Interaktion (z. B. zur Geräuschlokalisation, Lateralisation, Störgeräuschbefreiung, Summation) und der dichotischen Verarbeitung. Hierbei können sowohl efferente

als auch afferente Bahnen betroffen sein.“

Konsensus-Papier der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie, DGPP 2016


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„Deficits in the processing of auditory information in the central nervous system (CNS) as demonstrated by poor performance in

one or more of the following skills: sound localization and lateralization; auditory discrimination; auditory pattern

recognition; temporal aspects of audition including temporal integration, temporal discrimination (e.g., temporal gap

detection), temporal ordering, and temporal masking; auditory performance with competing acoustic signals (including

dichotic listening); and auditory performance with degraded acoustic signals.“

American Speech-Language-Hearing Association (ASHA) -Working Group on Auditory Processing Disorders (2005a): (Central) Auditory Processing Disorders (Position Statement) -The Role of the Audiologist.www.asha.org


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„APD is characterised by poor perception of both speech and non-speech stimuli. Auditory “perception” is the awareness of acoustic

stimuli, forming the basis for subsequent action. Perception results from both sensory activation (via the ear) and neural processing that

integrates “bottom up” information with activity in other brain systems (e. g. vision, attention, memory). Insofar as difficulties in perceiving and

understanding speech sounds could arise from other causes (e. g. language impairment, non-native experience of a particular language), poor perception of speech alone is not sufficient evidence of APD. APD

has its origins in impaired neural function. The mechanisms underlying APD can include both afferent and efferent pathways in the auditory system, as well as higher level processing that provides “top-down” modulation of such pathways. (. . . ). APD is a collection of

symptoms that usually co-occurs with other neurodevelopmental disorders (. . . ) (poor language, literacy or attention, autism). APD is often

found alongside other diagnoses.“

British Society of Audiology (2011) Position statement: auditory processing disorder (APD).http://www.thebsa.org.uk/wp-content/uploads/2014/04/BSA_APD_PositionPaper_31March11_FINAL.pdf.


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What is missing in the position of ASHA and BSA in contrast to the German consensus?

• auditory attention• auditory memory• phonological awareness• auditory synthesis• understanding and interpreting auditory information


Ptok M, Miller S, Kühn D. Diagnostik auditiver Verarbeitungs- und Wahrnehmungsstörungen bei Kindern. HNO 2016. 64:271–286

Ptok M, Kiese-Himmel C, Nickisch A. Leitlinie „Auditive Verarbeitungs- und Wahrnehmungsstörungen“: Definition. S1-Leitlinie der Deutschen Gesellschaft fürPhoniatrie und Pädaudiologie. HNO 2019. 67:8–14

exclusion criteria:• peripheral hearing

impairment• general intelligence

reduction• general perceptive

dysfunction• intermodality memory

disorder

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inclusion criteria:• evidence of impaired

processes of the auditory processing and perception

Diagnosis (C)APD/AVWS is based on:


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Video examplehttps://www.youtube.com/watch?v=eOL7-wlnKOc&list=PLpWNrNPbmU3byd3W66TGCldl0nDcJpada&index=4&t=0s

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• ? • neurobiological disorder with genetic background• pre-, peri- and postnatal damages• reduced verbal-auditive input• conductive hearing loss (maturation dysfunction of the

central auditory system)• environment

4. Pathogenesis and Etiology

ASHA -Working Group on Auditory Processing Disorders (2005a): (Central) Auditory Processing Disorders (Position Statement) -The Role of the Audiologist.www.asha.orgAuditive Verarbeitungs- und Wahrnehmungsstörungen. Konsensus-Statement. Überarbeitete und aktualisierte Version der DGPP. Ch. Kiese-Himmel. Auditive Verarbeitungs- und Wahrnehmungsstörung (AVWS) im Kindesalter. 2011. Kindheit und Entwicklung, 20(1), 31-39

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5. Symptoms: (Central) Auditory Processing Disorders

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To hear and yet not to hear!impaired despite proven proper cochlear function:

• problems understanding auditory information• misunderstandings of verbal prompts• slower processing of verbal information• delayed response to auditory or verbal stimuli• weak auditory memory• disturbed detection and differentiation of sound stimuli• disturbed sound source localization• limitations of speech understanding and focusing in background

noise• limitations in understanding altered speech signals (e.g.

incomplete or reduced redundancy speech signals)• impairment of auditory attention

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6. Diagnostics: (Central) Auditory Processing Disorders

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• No equivalent recognized (C)APD screening in Anglo-american and European regions.(no diagnostic gold standard)

• The international scientific literature reported uniformly that the reliable diagnosis of (C)APD is only possible from the age of 7 onwards.

Nickisch A, Gross M, Schönweiler R et al. Auditive Verarbeitungs- und Wahrnehmungsstörungen (AVWS): Zusammenfassung und aktualisierter Überblick. Leitlinie. HNO 2015; 63: 434–38Jerger J, Musiek F. Report of the consense conference on the diagnosis of auditory processing disorders in school-age children. J Am Acad Audiol. 2000; 11: 467–74American Academy of Audiology Clinical practice guidelines. Diagnosis, treatment and management of children and adults with central auditory processing disorders. BSA (2011): British Society of Audiology. Position statement: Auditory processing disorder (APD).

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(C)APD (= deficits in the neuronal processing of auditory stimuli) can occur together with further dysfunctions in

other modalities, but is not primarily caused by this.


American Academy of Audiology (2010) Clinical practice guidelines: diagnosis, treatment and management of children and adults with central auditory processing disorder. http://audiology-web.s3.amazonaws.com/migrated/CAPD%20Guidelines%208-2010.pdf_ 539952af956c79.73897613.pdf.

Ptok M, Buller N, Kuske S, Hecker H. Untersuchungen zur subjektiven Einschätzung der Beeinträchtigung auditiver Verarbeitungs- und Wahrnehmungsleistungenbei Kindern. 2005. HNO 53, 568-572.


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Assessments of speech, language, learning ability, intelligence and development should be made prior to

comprehensive audiological evaluation so that the results can be correctly interpreted in the hearing tests.

American Academy of Audiology (2010) Clinical practice guidelines: diagnosis, treatment and management of children and adults with central auditory processing disorder.


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• To diagnose (C)APD, there must be a clear discrepancy between the child's auditory and other cognitive abilities.

• It is possible to have both: attention deficit and (C)APD at the same time. a child with untreated attention deficit may not be able to concentrate enough on (C)APD testing

American Academy of Audiology (2010) Clinical practice guidelines: diagnosis, treatment and management of children and adults with central auditory processing disorder.


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The German Society for Phoniatrics and Pedaudiology (DGPP) recommends the following diagnostics:

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• detailed, preferably structured patient history interview

• Questionnaire: patient history and assessment questionnaire for entering auditive processing andperceptual disturbances of the DGPP (http://www.dgpp.de/cms/media/download_gallery/FragAVWS.pdf)

only supplement does not replace patient history no screening

patient history:

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www.dgpp.de/cms/media/download_gallery/FragAVWS.pdf „general questions“

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www.dgpp.de/cms/media/download_gallery/FragAVWS.pdf „localization“

„auditory discrimination“

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www.dgpp.de/cms/media/download_gallery/FragAVWS.pdf

„selection ability/hearing in background noise“

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www.dgpp.de/cms/media/download_gallery/FragAVWS.pdf „auditory memory“

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www.dgpp.de/cms/media/download_gallery/FragAVWS.pdf

„ hypersensitivity to noise“

• Otoscopy• external ear • eardrum• tympanic cavity

• Peripheral articulation organs• tongue mobility • cleft lip and palate

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Clinical examination:

https://www.denochearing.com/outer-ear-diseases-related-to-it/ https://is.muni.cz/do/med/mimsa/12840881/24067852/24067855/OTOSCOPY___OPTHALMOSCOPY.pdf

https://www.facebook.com/MB.Dentistry/posts/anatomy-of-the-oral-cavity/1390547474364327/

• tympanometry

• tone audiogram (side-separated, air and bone conduction)

• speech audiogramm

• otoacoustic emissions, possibly brainstem audiometry

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Audiometric tests:

https://www.semanticscholar.org/paper/Tympanometry-in-children-with-Down-syndrome-Heeren/cc2bd627bcb4bd7050b6a35864cec28ccf2e6b81

https://www.hno.uniklinik-bonn.de/patienten/diagnostik/tonaudiometrie.html

https://yasminroohi.com/otoacoustic-emission-test-instrument https://www.ggzbern.ch/

https://www.indiamart.com/hitone-hearing/basic-audiology.html

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language-free tests:

• Pitch discrimination, “gap detection” show deficits in basal auditory processing and perception.

• language-free intelligence test

Dichotic speech audiometry

• to assess the ability to separate or integrate auditory stimuli, presenting different signals simultaneously to the right and left ear, e.g. syllables, numbers, words, sentences).

Dichotischer Test nach Uttenweiler

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Tests for understanding in background noise• Selection: Is it possible to distinguish meaningful

information from background noises?• Child covers his ears hearing loud noises.• Child asks more often in case of background noises.

Binaural interaction tests• Localization: From which direction and distance does the

acoustic signal come? (classroom, traffic)• Binaural hearing enables orientation in the room by

evaluating time and intensity differences between both ears.

HSM: Satztest im Störlärm

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Phoneme differentiation tests

• to assess the ability to differentiate phonemes• Discrimination: Are the perceived auditory stimuli different

or the same or similar?

Phoneme identification tests

• to assess the ability to correctly recognize phonemes

H-LAD

Checking reading and writing skills

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Short-term auditory memory tests

• Is it possible to keep the sentence which was said earlier in the working memory for a short time or to store that in the working memory in a certain order?

• Child cannot keep verbal orders and has difficulty writing dictations.

Mottier test (repetition of nonsense syllables/words)

HSET(text memory capacity)

das-hoerhaus.de

The little mouse is hunted by the lion.

Before you play, you must clear the table.

That wardrobe I bought myself is beautiful.

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Tests for phonological awareness• to assess the ability to make use of the knowledge of the

phonetic structure of the language• Synthesis: Ability to construct a complex acoustic form

from single elements.

Example: Child can hardly combine single letters to a word. Child can form single phonemes correctly, but cannot

speak them correctly in one word with other phonemes.

1. Sh-oe; 2. th-i-n; 3. a-d-e-l-m-a-t (nonsense word); … Child should repeat this in connected way.PET (Psycholinguistischer Entwicklungstest)

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Tests that primarily examine speech comprehension• to assess the ability to understand speech and to

evaluate the differential diagnoses (C)APD and speech understanding disorder

TROG-D

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Criteria for diagnosis of CAPD


exclusion of peripheral hearing impairment

≥ 2 auditory partial performance regions affected (with significant norm deviations, preferably 2 standard deviations)

considering intellectual abilities (non-verbal IQ), speech development (e.g. pronunciation, speech comprehension, etc.), attention (ADHS)

Nickisch et al. Auditive Verarbeitungs- und Wahrnehmungsstörungen (AVWS): Zusammenfassung und aktualisierter Überblick. HNO June 2015, Volume 63, Issue 6, pp 434–438Auditive Verarbeitungs- und Wahrnehmungsstörungen. Konsensus-Statement. Überarbeitete und aktualisierte Version der DGPP.

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(C)APD is an interdisciplinary challenge !

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• speech development disorders• reading and spelling disorders• Autism (limited communication behavior)• attention disorders (top-down disturbed also for

auditory processing)• general developmental anomalies• no age-appropriate average intelligence

Auditory processing and perception impaired !

7. Differential diagnoses


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• only a few studies about the success of therapeutic interventions or prognosis in (C)APD

• the methods of treatment have not yet been empirically tested; controlled intervention studies are still needed

8. Therapy and management

S1 Leitlinie Auditive Verarbeitungs- und Wahrnehmungsstörung. Herausgegeben von der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie. Aktueller Stand 09/2015.

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• counselling parents, teachers, educators, therapists http://www.dgpp.de/cms/media/download_gallery/Praxishil

fen-AVWS.pdf

• exercising / compensatory procedures therapy and training of speech and language skills, if not

age adequate sound discrimination phonetic - letter assignment phonological awareness (synthesis - analysis) speech auditory short-term memory compensatory strategies (visual, writing)


S1 Leitlinie Auditive Verarbeitungs- und Wahrnehmungsstörung. Herausgegeben von der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie. Aktueller Stand 09/2015.Schönweiler, R., Nickisch, A., am Zehnhoff-Dinnesen, A. (2012). Auditive Verarbeitungs- und Wahrnehmungsstörungen – Vorschlag für Behandlung und Management bei AVWS. Leitlinien der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie. HNO, 60, 359-368.Ptok, M. & Leonhardt, A. (2009). Wie können Kinder in der Schule besser zuhören? Elterninformation. Sprache Stimme Gehör, 33, Patienteninformation.

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• modification of the acoustic environment reduction of noise

close windows and doors heating systems, air conditioners, clocks, etc.

reduction of echo back wall covering, curtains, window shades carpeting, acoustic ceiling cladding

structural planning of classrooms “audibility", reverberation time <0.55s no too big rooms

• wireless transmission system hearing in difficult hearing situations (classroom)

FM system


S1 Leitlinie Auditive Verarbeitungs- und Wahrnehmungsstörung. Herausgegeben von der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie. Aktueller Stand 09/2015.Schönweiler, R., Nickisch, A., am Zehnhoff-Dinnesen, A. (2012). Auditive Verarbeitungs- und Wahrnehmungsstörungen – Vorschlag für Behandlung und Management bei AVWS. Leitlinien der Deutschen Gesellschaft für Phoniatrie und Pädaudiologie. HNO, 60, 359-368.Ptok, M. & Leonhardt, A. (2009). Wie können Kinder in der Schule besser zuhören? Elterninformation. Sprache Stimme Gehör, 33, Patienteninformation.

www.hagebau.com

https://www.pixcove.com/

http://www.hoerkomm.de/fm-anlagen.html

Thank you for your attention!

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