In the November 2018 issue of The Hearing Journal, Rosenzweig, Smolen, and Hartman published a notable article1 on the importance of addressing hearing loss in adopted children (https://bit.ly/3gYpQkS). But other than hearing loss, another critical concern affecting adopted children is auditory processing disorder (APD).2 Many adopted children with normal hearing and fluency in the language used may still have difficulty understanding speech, not do well in school, and be found to have attention or behavior problems that could reflect an underlying, unidentified APD. Many adoptive parents go to online forums to find answers to questions such as, “How can I find out if my child has an auditory processing disorder?” or “Where can I go to get an evaluation of my child's listening and auditory processing abilities?”3,4 These questions inspired the primary author of this paper (Lucker) to further investigate his observations of adopted children seen in his audiology practice that specializes in APD.
STUDY 1: IDENTIFYING APD
In a case file review, the primary author identified 114 adopted children with normal hearing and normal middle ear function via standard audiological evaluation, who were brought to his clinic for auditory processing evaluations. Of note, 102 children were from other countries (two from India, two from Lithuania, two from the Philippines, four from Bulgaria, six from China, four from Guatemala, four from Kazakhstan, six from Ukraine, 14 from Korea, 58 from Russia), and 12 were from the United States. The children lived in metropolitan areas in Washington, DC, Maryland, and Northern Virginia.
The children were found to have normal hearing (thresholds below 20 dB HL) and normal middle ear functioning (normal tympanogram and present acoustic reflexes at levels below 100 dB HL). However, findings from the auditory processing evaluation battery indicated that each child met the recommended criteria to be diagnosed with APD.5,6 Thus, these findings indicate that the communication and learning problems reported by the adoptive parents could be due, at least in part, to APD.
Considering the findings of the auditory processing evaluations, one concern was whether the children had APD or underlying attention issues such as attention deficit hyperactivity disorder (ADHD). Interestingly, all 114 children had been seen by a clinical neuropsychologist for evaluation, and only 28 (25%) were diagnosed with ADHD. Thus, the overwhelming majority of these children (75%) were not found to have attention problems.
The results of the auditory processing tests showed no consistent pattern, but all 114 failed at least two measures of auditory processing, identifying them to have APD that required intervention based on professional guidelines.4,5 However, no specific type of APD was found.
STUDY 2: EFFECTS OF TREATMENT
Just as important as identifying whether an adopted child has APD is determining how to improve the child's listening and auditory processing abilities. With the help of Brain Train America, 12 of the 114 adopted children underwent brain training exercises. For many years, Brain Train America has provided science-based programs to help improve listening, attention, and related processing issues affecting children, adolescents, and adults. Of the children in this study who were given brain training exercises, seven were male and five were female, and their ages ranged from 8 to 19 years old, with a mean age of 11 years and 9 months and a standard deviation of 2 years and 10 months. Ten of the participants were internationally adopted (three from Korea, three from Russia, two from China, one from Lithuania, and one from the Philippines), while the remaining two were from the United States. All were fluent speakers of Standard American English (SAE). The auditory processing tests consisted of a standard audiometric evaluation of hearing and middle ear functioning, which found all 12 children to have normal hearing and middle ear functioning for both ears before and after receiving the brain training treatments. The auditory processing tests included a speech understanding in noise evaluation using W-22 word lists (pre-recorded) and comparing quiet versus noisy (S/N+5) conditions,7 the SCAN-3 test,8,9 the SSW Test,7 the Comprehensive Test of Phonological Processing Second Edition (CTOPP-2),10 and the Auditory Continuous Performance Test (ACPT).11
All participants underwent the same brain training exercises, which included listening therapy (Integrated Listening Systems; iLS), Interactive Metronome (IM), and Fast ForWord exercises (www.scilearn.com). The children were given programs appropriate for their age level and were monitored by a training staff member from Brain Train America. The testing order was the same for all participants, and the pre- and post-treatment results were compared (Table 1).
Pre-treatment results were found to be abnormal in at least two areas of auditory processing of the adopted children diagnosed with APD. Post-training results on the children's hearing and middle ear functioning remained normal, but their auditory processing abilities differed. Comparative results presented in Table 1 show improvements after brain training. Two-tailed, paired sample t-tests were calculated to determine if these improvements (p < 0.05) were significant. Significant findings were classified into three categories, the first being speech understanding in noise (SIN). Findings for both ears on the quiet/noise difference measure of the SIN yielded significant results (RE SIN p =.014; LE SIN p =.015). The second category was auditory integrative, which involved dichotic listening and putting pieces of verbal Hymessages heard together to form a meaningful whole. RC and LC on the SSW were significant (RC, p =.007; LC, p =.017), as was the finding for Competing Words – Free Recall (p =.048). For the phonemic integration measures, the Blending Nonwords and Segmenting Nonwords subtests of the CTOPP-2 were significant (BNW p =.003; SNW p =.026).
The third category was attention and memory. Attention was measured using the Competing Sentences measure of the SCAN-3 and the ACPT. Results of the ACPT (p =.006) showed significant improvements, indicating that brain training led to gains in the children's listening/auditory attention abilities. For working memory, the Memory for Digits measure from the CTOPP-2 showed a significant improvement (p =.004). Thus, brain training exercises also improved the children's memory skills.
A trend toward being very close to significant was also found in the speed of processing of auditory information (auditory temporal processing). The Time Compressed Sentences were close to significant (p =.051). Thus, we can conclude that improvements were found in this area. As such, brain training resulted in significant improvements in 10 of 19 auditory processing factors, including overall listening, attention, learning, and understanding (based on the significant categories identified), among adopted children with APD.
Editor's note: Test results for 25 of the 114 participants were made available to support the study one findings.
1. Rosenzweig EA, Smolen ER, Hartman M (2018). Serving families who have adopted children with hearing loss. The Hearing Journal, 71
5. American Speech-Language-Hearing Association (ASHA) (2005). (Central) auditory processing disorders [Technical Report]. Retrieved from www.asha.org/policy
6. American Speech-Language-Hearing Association (ASHA) (2005). (Central) auditory processing disorders [Technical Report]. Retrieved from www.asha.org/policy
7. Katz J (2007). APD evaluation to therapy: The Buffalo Model. Audiologyonline
. Retrieved from: https://www.audiologyonline.com/articles/apd-evaluation-to-therapy-buffalo-945
8. Keith RW (2009a) SCAN-3 Test for Auditory Processing Disorders in Children. San Antonio, TX: Pearson.
9. Keith RW (2009b) SCAN-3 A Test for Auditory Processing Disorders in Adolescents and Adults. San Antonio, TX: Pearson.
10. Wagner RK, Torgesen JK, Rashotte CA, Pearson NA. (2013). Comprehensive Test of Phonological Processing – Second Edition (CTOPP-2). San Antonio, TX: Pearson.
11. Keith RW (1994). Auditory Continuous Performance Test (ACPT). San Antonio, TX: Pearson.