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© Borgis - Postępy Nauk Medycznych 3/2020, s. 69-74 | DOI: 10.25121/PNM.2020.33.3.69
Magdalena Dunaj1, Anna Lobaczuk-Sitnik1, Malgorzata Rozanska2, *Emilia Duchnowska1, Bozena Kosztyla-Hojna1, Klaudiusz Nadolny3, 4, Maksim Wieliczko3, Jerzy Robert Ladny3
Auditory training in auditory processing disorders (APD)
Trening słuchowy w zaburzeniach przetwarzania słuchowego (APD)
1Department of Clinical Phonoaudiology and Speech Therapy, Medical University of Bialystok, Poland
2Department of Otholaryngology, Medical University of Bialystok, Poland
3Department of Emergency Medicine, Medical University of Bialystok, Poland
4Department of Emergency Medical Service, Strategic Planning University of Dabrowa Gornicza, Poland
Streszczenie
Zaburzenia przetwarzania słuchowego charakteryzują się obniżeniem sprawności funkcjonowania przetwarzania słuchowego, czego następstwem jest deficyt w identyfikowaniu i interpretacji dźwięków przez mózg. W 2017 roku zaburzeniom przetwarzania słuchowego przyznano indywidualny kod diagnostyczny. Objawy, które wskazują na występowanie zaburzeń przetwarzania słuchowego, są bardzo liczne i nieswoiste. Symptom podstawowy upośledzonego przetwarzania słuchowego to trudności ze zrozumieniem mowy w hałasie. Omawiane zaburzenie dotyka około 5-7% dzieci. Najczęściej za wyznacznik stanowiący podstawę do zdiagnozowania zaburzeń uznaje się niezgodny z przyjętą normą wynik minimum dwóch testów znajdujących się w zastosowanym zestawie.
W procesie diagnostycznym i terapeutycznym dzieci z zaburzeniami przetwarzania słuchowego kluczowe znaczenie ma postawienie prawidłowego rozpoznania, dzięki któremu możliwe będzie przeprowadzenie odpowiedniej terapii. Wszystkie metody terapeutyczne, zadania aktywizujące percepcję słuchową i zdolności językowe powinny być wybrane w sposób rzetelny, indywidualnie dla każdego uczestnika terapii. Normą powinno być stosowanie tzw. treningu słuchowego podczas zajęć korekcyjno-kompensacyjnych oraz logopedycznych, przeprowadzanych u dzieci z zaburzeniami ośrodkowego przetwarzania słuchowego. Jest to główna metoda terapii dzieci z ośrodkowymi zaburzeniami słuchu. Trening słuchowy zalicza się do wychowania słuchowego opierającego się na pobudzeniu predyspozycji słuchowych malca i na wykształceniu umiejętności ich stosowania, aby uzyskać lepszą orientację w otoczeniu.
W chwili obecnej w Polsce terapeuci mogą wykorzystywać różne rodzaje oddziaływań terapeutycznych mających pozytywny wpływ na kształtowanie umiejętności słuchowych dziecka.
Celem pracy jest omówienie treningów słuchowych i zaprezentowanie ćwiczeń logopedycznych pomocnych w procesie terapeutycznym dzieci z zaburzeniami przetwarzania słuchowego.
Summary
Auditory processing disorders (APD) are characterized by a reduction in the efficiency of auditory processing, which results in a deficit in identifying and interpreting sounds by the brain. In 2017, auditory processing disorders were awarded an individual diagnostic code. Symptoms that indicate the presence of auditory processing disorders are numerous and non-specific. The primary symptom of impaired auditory processing is difficulty understanding speech in noise. This disorder affects about 5-7% of children. Most often, the result of at least two tests included in the set is considered to be the determinant which constitutes the basis for the diagnosis of disorders.
In the diagnostic and therapeutic process of children with auditory processing disorders, the correct diagnosis is of key importance, thanks to which it will be possible to conduct an appropriate treatment. All therapeutic methods, tasks activating auditory perception and language skills should be selected reliably, individually for each participant of the therapy. The use of the so-called auditory training during corrective-compensatory and speech therapy classes in children with central auditory processing disorders should be the standard. It is the main method of treating children with central hearing impairment. Auditory training includes auditory education based on stimulating child’s auditory predispositions and on developing the ability to use them in order to gain better orientation in the environment.
At present, therapists in Poland may use various types of therapeutic interactions that have a positive impact on the development of a child’s hearing skills.
The aim of the work is to discuss auditory training and to present speech therapy exercises helpful in the therapeutic process of children with auditory processing disorders.
Introduction
Hearing is one of the most important human senses (1). Proper hearing depends, inter alia, on proper auditory processing (2). Despite normal peripheral hearing, it may be impossible to maximize the use of information coming from sound stimuli if central functions are disturbed (3). These disorders are called Auditory Processing Disorders (APD) (4, 5), also referred to as Central Auditory Processing Disorders (CAPD) (4, 6, 7). In the recently updated version of the ICD-10 (International Statistical Classification of Diseases and Related Health Problems) (8) of 2017, CAPD has been assigned a separate, specific diagnostic code, i.e. H93.25, and was defined as a disorder characterized by a reduced efficiency of auditory processing, which results in a deficit in identifying and interpreting sounds by the brain (9, 10).
In 2018, the British Society of Audiology (BSA) presented a new definition of auditory processing disorders, according to which they are characterized by poor perception of speech sounds as well as extra-linguistic sounds (9, 10).
There are many symptoms indicating APD. A key symptom of impaired central auditory processing is the inability to properly understand speech in a degraded sound environment (11). In addition, the typical symptoms reported by the patient himself and/or noticed during observation include:
– problems with localizing the sound source,
– trouble hearing when talking on the phone,
– frequent requests to repeat information,
– giving inconsistent or incorrect answers to questions,
– problems with fulfilling verbal commands,
– tendency to be easily distracted,
– learning difficulties, including reading and writing,
– difficulties in learning foreign languages (12).
It is estimated that auditory processing disorders affect approximately 5-7% of children. However, not all researchers agree on these values, as some of them report that this number is higher and reaches 10%. APD occurs twice as often in boys than in girls (11, 13).
Auditory processing disorders were first characterized over 60 years ago – the author of the earliest references to this issue was Mykelbust, whose publication on this subject appeared in the 1950s (9).
The history of formulating the definition, diagnosis and management of APD is not short or indisputable. Recently, the interest in APD, a health problem that has not been appreciated until recently, has increased significantly; scientists’ attention was strongly drawn to a more complete diagnosis of this disorder (9).
It is currently believed that there is no approved set of diagnostic criteria for APD (9, 14). Based on the recommendations of the AAA (American Academy of Audiology), during a detailed CAP analysis (Central Auditory Processing), the specialist should take into account the processes related to:
– localization of sounds,
– differentiation of sounds,
– time analysis of the acoustic impulse (recognition of sound patterns, determining the sequence of signals presented in a short time interval, finding short pauses between sounds),
– understanding of not very expressive speech (frequency filtered, limited or demonstrated in the presence of noise), as well as with both and split-ear listening (12).
It is advisable to select the minimum number of tests necessary to ensure the best possible sensitivity and accuracy while assessing the main auditory processes (12).
In most cases, the indicator that is the basis for the diagnosis of disorders is the abnormal result of at least two tests included in the kit used. In the light of current recommendations, each diagnosis of APD should have a description of the diagnostic criterion used (9).
In the diagnosis and speech therapy of children with auditory processing disorders, it is of key importance to make an appropriate diagnosis, which will then enable appropriate therapy. Accurate targeting of the deficiency of proper hearing functions, achieved through appropriate methods, significantly improves hearing. All therapeutic methods should be selected as carefully as possible, individually for each patient. Professional help is based on the cooperation of a multidirectional team of physicians and therapists. Therapy should cover both the child and his/her parents/guardians. Such a procedure leads to the maximum improvement of the functioning of a patient in everyday life (2, 15).
Auditory training is part of auditory education based on activating the child’s hearing capabilities and developing the ability to use them in order to better find themselves in the environment. This training should be a permanent part of corrective and compensatory classes, as well as speech therapy, conducted in children with APD (16).
Auditory training takes place in various forms. The opinion that computer games have many advantages is frequently. Nevertheless, it is recommended to limit the patient’s visual stimulation. The child may be offered games and aural games, using typical didactic aids, which will be easily found in educational institutions (16).
In order for the auditory training aimed at a child with APD to be effective, it should be long-term, and at the same time intense (e.g. 30 minutes, 3-4 times a week, for a period of 6 weeks), tailored to his individual abilities. Moreover, the period of the therapy depends on the chosen method, as well as on the effort put into training by the participant of therapy (7, 16, 17).
During the exercises, it is necessary to work on various sounds – on non-linguistic material (sounds of the environment, nature, etc.), and on linguistic material (sounds/phonemes, syllables, words, sentences, phrases) (16). Auditory training may either be deficit-oriented or improve the ability to compensate for existing disorders. It is advisable that the training of children with APD should not only include auditory exercises, but include games and activities supporting coordination or language skills (18).
Currently, specialists in Poland have at their disposal various variants of therapeutic interventions that favorably influence the development of a child’s hearing skills. These impacts include, among others:
– the Tomatis method,
– Warnke’s method (15),
– Neuroflow training (16),
– training focused on the hearing deficit (7),
– SPS-S method (Stimulation of Auditory Perception using the Skarzynski method) (19),
– interactive metronome,
– speech therapy and pedagogical aural training (15).
The aim of the study is to review auditory training used in the therapy of children with auditory processing disorders and presenting proposals for speech therapy exercises performed while working with a child with APD.
The Tomatis method
In Poland, the Tomatis method has been used for over 20 years. Children’s qualification is based on the auditory attention test, auditory lateralization and interview. When starting therapy, patients are subjected to a large number of complementary tests (functional laterality study, transformed psychological tests). The therapy itself includes sessions during which, using special headphones, the sound material is properly developed – based on Mozart’s music and Gregorian chants. In addition, the above-mentioned material is filtered and the weight of listening is gradually transferred to the right ear (1, 15).
The therapy schedule is individually prepared to enhance the child’s perception of those frequency bands that are responsible for the development of communication and the ability to listen and understand. This training influences, inter alia, the enrichment of the vocabulary range, fluency of speech, communication skills (3).
The method consists of two phases: passive and active. During the passive phase, the patient only listens to the audio material. In the active phase, the child is stimulated with speech sounds and activated to play them (15).
The training in question is relatively intense. Professionals recommend eight to ten sessions per cycle of two hours each. These cycles should be separated with several-week breaks in order to assimilate the effects achieved by using the discussed method. The number and length of cycles depend on the nature of the problem the child is struggling with (15, 20).
One of the modifications to the Tomatis method is the Warnke method (1).
Warnke’s method
The purpose of the Warnke’s method is to help children with dyslexia, learning difficulties, support them in speech therapy and in problems related to auditory processing disorders (3, 21).
In the therapy of a child carried out by this method, tasks resembling simple computer games are used, during which – when the patient can cope with them, the degree of difficulty is gradually increased (15).
The Brain-Boy Universal (BBU) is a device intended primarily for individual, daily training at home. The therapy participant, on the basis of play, trains eight functions of central hearing, visual perception and motor skills, achieving excellent results – this is the training of basic functions (21). Rehabilitated basic functions are:
1. Establishing the threshold of visual order – the patient sees one flash on the left and on the right. His task is to decide which side of the impulse came first.
2. Auditory sequence thresholding – the patient hears one click on the left and one click on the right. Its task is to answer the question from which side the signal appeared at the beginning. The degree of difficulty is constantly increasing. Children with poor results in this test show difficulty in differentiating stop-blasts (p, b, t, d, k, g), and this is reflected in problems with understanding speech.
3. Directional hearing – the patient hears one click and then decides which side it came from. Children whose results in this test are lower than the accepted norm are not able to follow the course of activities in the vicinity of disruptive stimuli (standard range between 50 dB and 60 dB).
4. Tone differentiation – the patient hears two sounds of unequal pitch, and then he should specify the order in which they appeared.

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otrzymano: 2020-07-13
zaakceptowano do druku: 2020-08-03

Adres do korespondencji:
*Emilia Duchnowska
Department of Clinical Phonoaudiology and Speech Therapy Medical University of Bialystok
ul. Szpitalna 37, 15-295 Bialystok, Poland
tel.: +48 603330294
emilia.duchnowska@umb.edu.pl

Postępy Nauk Medycznych 3/2020
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