Auditory Training: Principles and

Approaches for Remediating and Managing

Auditory Processing Disorders
Gail D. Chermak, Ph.D.,1 and Frank E. Musiek, Ph.D.2

ABSTRACT

Recent reports suggest that auditory training (AT) can serve as

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a valuable intervention tool, particularly for individuals with language
impairment and auditory processing disorder (APD). This article sug-
gests a continuum of AT approaches, including those that do not require
major instrumentation and can be implemented by speech-language
pathologists and audiologists through their clinical practices. AT ap-
proaches are categorized as formal and informal. Formal AT is con-
ducted by the professional in a controlled setting. Informal AT can be
conducted as part of a home or school management program for APD.
Formal AT employs acoustically controlled, bottom-up tasks using tones
and speech elements, as well as language-based or top-down tasks. Infor-
mal AT is designed to improve auditory perceptual skills through lan-
guage-based, predominantly top-down tasks. Coupling formal with in-
formal AT should maximize treatment efficacy as skills are practiced
toward mastery and automatism in real world settings that establish
functional significance and provide repeated opportunities for general-
ization of skills.

KEYWORDS: Auditory processing, auditory processing disorder,

auditory training

Learning Outcomes: Upon completion of this article, the reader will be able to (1) differentiate informal from
formal auditory training approaches, (2) identify at least three informal auditory training exercises and the audi-
tory process(es) targeted, and (3) identify at least three formal auditory training exercises and the auditory pro-
cess(es) targeted.

Management of Auditory Processing Disorders; Editor in Chief, Catherine V. Palmer, Ph.D.; Guest Editor, Gail D.
Chermak, Ph.D. Seminars in Hearing, volume 23, number 4, 2002. Address for correspondence and reprint requests: Gail
D. Chermak, Ph.D., Department of Speech and Hearing Sciences, Washington State University, Pullman, WA
99164–2420. E-mail: chermak@[Link]. 1Department of Speech and Hearing Sciences, Washington State University,
Pullman, Washington; 2Department of Communication Sciences and Otolaryngology, University of Connecticut, Storrs,
Connecticut. Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.
Tel: +1(212) 584-4662. 00734-0451,p;2002,23,04,297,308,ftx,en;sih00223x.
297
298 SEMINARS IN HEARING/VOLUME 23, NUMBER 4 2002

A uditory training (AT) is designed to and exercises we suggest reflect our opinion,
improve the function of the auditory system in clinical experience, and our interpretation of
resolving acoustic signals. There has been re- the literature reviewed in this article.
newed interest in AT recently driven by the
substantial body of literature demonstrating
the plasticity of the auditory system1–11 and AUDITORY PROCESSING
following reports that confirm the value of AT DISORDER
as an intervention tool, particularly for individ-
uals with language impairment and auditory APD is a complex and heterogeneous group of
processing disorder (APD).12–16 For an over- disorders usually associated with a range of lis-
view of the neurobiology of the central audi- tening and learning deficits despite normal
tory nervous system (CANS) and discussion of hearing sensitivity.18–21 Jerger and Musiek stated
the role of plasticity in AT, see the articles by that APD “may be broadly defined as a deficit
Phillips and Museik et al (this issue, pages in the processing of information that is specific
251–262, and pages 263–276, respectively). to the auditory modality.”21 More specifically,
The purpose of this article is to describe a Chermak and Musiek described APD as “a

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continuum of AT approaches, including those deficit observed in one or more of the central
that do not require major instrumentation, and auditory processes responsible for generating
can be implemented by speech-language pathol- the auditory evoked potentials and the follow-
ogists and audiologists through their clinical ing behaviors: sound localization and lateral-
practices. These approaches are designed pri- ization; auditory discrimination; auditory pat-
marily for children diagnosed with APD; how- tern recognition; temporal aspects of audition
ever, many exercises can be adapted for use including, temporal resolution, temporal mask-
with adults and for clients with other disor- ing, temporal integration, and temporal order-
ders, including peripheral hearing loss (see the ing; auditory performance with competing
section on Principles of Auditory Training, pre- acoustic signals; and auditory performance with
sented later in this article). Given the scarcity degraded acoustic signals.”19 Given the range
of published information about AT, coupled of listening and learning deficits associated
with the growing body of literature suggesting with APD, AT must be seen as only one com-
the potential benefit of some types of AT for ponent of a comprehensive management ap-
remediation and management of APD,5,8,12,14–17 proach to improving auditory processing. The
it is crucial that audiologists and speech-language reader is referred to companion articles in this
pathologists undertake AT to ascertain the rela- issue, as well as the authors’ other work on this
tive efficacy of the various approaches and ex- topic for a thorough discussion of the range of
ercises, including those outlined in this article. intervention approaches useful in managing
The approaches and tasks described in this ar- APD, including linguistic, metalinguistic and
ticle follow from the authors’ theoretical frame- metacognitive strategies, acoustic signal en-
work18,19 and professional consensus20 and are hancement, and environmental modifications.19
in use in the authors’ clinics. Preliminary data
reported by Musiek revealed improvements in
central auditory test scores, as well as improved PRINCIPLES OF AUDITORY
academic and communicative performance TRAINING
among 15 children between the ages of 8 and
13 years who underwent formal AT as described AT can be employed to improve auditory pro-
here.14 It must be emphasized, however, that cessing abilities in a number of clinical popula-
the approaches we suggest are among a num- tions presenting auditory deficits due to con-
ber of possible approaches that ultimately may firmed CANS pathology (e.g., traumatic brain
be deemed efficacious for the treatment of APD. injury, aphasia, progressive neurodegenerative
The principles we delineate and the approaches disorders), as well as in cases of suspected CANS
 AUDITORY TRAINING FOR AUDITORY PROCESSING DISORDERS/CHERMAK, MUSIEK 299

pathology (e.g., learning disabilities, language deficits in the absence of auditory performance
impairment, attention deficit disorders). A com- deficits for degraded signals. Tasks should be
prehensive audiologic evaluation, supplemented presented systematically and graduated in diffi-
as needed with language and psychoeducational culty to be challenging and hence motivating,
evaluations, as well as feedback from parents but not overwhelming. We find that targeting
and teachers, must be conducted prior to im- accuracy between 30 to 70% allows for suffi-
plementing any AT program. These measures cient practice and challenge while maintaining
should be re-assessed periodically to ascertain the client’s motivation and on-task persistence.
progress, redirect therapy if necessary, and ter- Nonetheless, the clinician should determine the
minate therapy if the client has attained the criterion appropriate for each client. Detection
maximum benefit that can be expected. Gener- and discrimination tasks should precede more
ally, younger subjects can be expected to bene- demanding psychoacoustic tasks requiring iden-
fit from AT to a greater degree due to neural tification, recognition, and production. We rec-
plasticity.22 Children whose auditory deficit is ommend that clients attain a minimum of 70%
associated with a neuromaturational lag can be accuracy before proceeding to the more de-
expected to benefit from intense AT as stimu- manding tasks. To the extent possible, AT

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lation extends plasticity and the purported sen- should be conducted in an intensive manner,
sitive periods for learning, thereby maximizing scheduling multiple sessions, perhaps 5 to 7 ses-
the potential for successful rehabilitative ef- sions weekly.14 Generally, exercises should be
forts.3,23,24 Similarly, individuals with auditory presented at the client’s comfortable listening
deficits secondary to brain damage can profit level, although slightly louder presentations may
from AT that stimulates and challenges dam- produce more clear speech and ease the listening
aged neural networks and induces neural reor- task.25
ganization.24 In either case, the degree of neu- The ultimate goal of AT, and therefore the
ronal change and maturation is dependent on true measure of the efficacy of an AT program,
the quality and consistency of stimulation. is measured in functional abilities (i.e., improved
Auditory maturation must be considered listening comprehension, spoken language pro-
in designing auditory tasks and establishing cessing, and educational achievement).26,27 Data
criterion performance. Some of the AT tasks confirming treatment efficacy are derived from
reviewed in this article are appropriate for multiple measures that are sufficiently broad to
preschool-aged children (e.g., auditory dis- document the client’s progress in deploying the
crimination, auditory directives, and reading newly acquired or enhanced processing strate-
aloud); other AT tasks demand greater cogni- gies and skills in a variety of contexts.19 Repeat
tive sophistication and would be more appro- administration of auditory processing tests (e.g.,
priately used with older children and adults dichotic digits, pitch patterns, gap detection) are
(e.g., intensity and frequency training). less useful in establishing treatment efficacy and
A variety of stimuli and tasks should be may instead reveal a learning effect.28 Measures
used to train auditory processes. If the client of speech recognition in competition and recog-
presents an auditory deficit restricted to a spe- nition of time-compressed speech, for example,
cific auditory region or auditory process, a more provide more functional indices of the status of
narrowly designed AT program might be ap- binaural and temporal auditory processes than
propriate. For example, subjects with both tem- do dichotic digits and pitch pattern tests, re-
poral processing deficits and auditory perfor- spectively. Performance scales and inventories
mance decrements for degraded acoustic signals also may serve as useful outcome measures.29–31
might benefit from exercises requiring recogni- Musiek’s report of improved communication
tion of time-compressed speech. In contrast, function and academic performance in 9- to 11-
gap detection might be a more appropriate ex- year-old children following AT, as outlined in
ercise to specifically train temporal processing this article, illustrates the types of measures
for subjects presenting temporal processing needed to confirm efficacy of AT.14
300 SEMINARS IN HEARING/VOLUME 23, NUMBER 4 2002

AUDITORY TRAINING APPROACHES ogist or educational audiologist, families, and

teachers who employ informal AT approaches
The authors categorize AT approaches as for- in the home or classroom setting.
mal and informal. Formal AT is conducted by A variety of habilitation techniques can be
the professional in a controlled setting (i.e., a employed to improve auditory processes, as illus-
clinic or laboratory). Informal AT can be con- trated in Table 1. Clinical decisions to target one
ducted as part of a home or school manage- or more auditory processes are based on the re-
ment program for APD. Coupling formal with sults of specific auditory tests and procedures, as
informal AT should maximize treatment effi- well as reports of functional, real-world deficits.
cacy as skills are practiced toward mastery and (The reader should note that interhemispheric
automatism in real world settings that establish transfer, while not a specific auditory perceptual
functional significance and provide repeated skill, is included in Table 1 because it underlies
opportunities for generalization of skills. binaural processing required for auditory separa-
tion and auditory integration.)
Some AT tasks target more than one audi-
Formal Auditory Training Tasks tory process. For example, intensity training

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may benefit localization and lateralization, au-
Formal AT employs rigorous, acoustically con- ditory vigilance, and auditory discrimination.32
trolled training paradigms using bottom-up (i.e., Similarly, training dichotic listening may
analytic) tasks with nonverbal signals (e.g., improve binaural separation and binaural inte-
tones) and simple speech elements (e.g., dis- gration. Perhaps most important, formal AT
criminating paired consonant-vowel [CV] syl- should benefit spoken language processing by
lables) to target specific auditory processes. improving the auditory processes essential func-
Formal AT to improve temporal processing tion in resolving auditory signals. For example,
might target gap detection and ordering of two improved temporal processing should strengthen
or three rapidly presented acoustic elements, resolution of prosodic detail underlying mean-
varying the interstimulus interval and/or stim- ingful distinctions between heteronyms, as well
ulus duration to alter task difficulty. Formal as distinctions of temporal cueing (e.g., “They
AT may involve language-based or top-down saw the car go on the ferry” vs. “They saw the
tasks (e.g., resolving semantic distinctions sig- cargo on the ferry.”). Targeting recognition of
naled by temporal cues; using a phonemic expanded or compressed words or speech seg-
analysis task to exercise auditory discrimination; ments should improve auditory closure.
resolving prosodic distinctions to challenge Examples of commercially available for-
temporal resolution). mal AT programs include Fast ForWord (avail-
Formal AT programs have many advan- able from Scientific Learning Corp., Berkley,
tages, including the ability to specify and pre- CA) and Earobics™ (available from Cognitive
cisely alter acoustic stimuli. The acoustic com- Concepts, Inc., Evanston, IL). Both programs
position of the stimuli, as well as their rate of involve computer-mediated presentations of
presentation, can be controlled using computers acoustically modified stimuli. The Earobics pro-
and other instrumentation. Presentation of con- gram, as well as Away We Go (also available
trolled stimuli through adaptive computer pro- from Scientific Learning Corporation), can be
grams engages the listener and ensures the task employed on the home computer (in support of
is maintained at the appropriate difficulty level. informal AT), as well as in the professional clin-
In addition, computer software can simplify the ical setting. See the articles by Musiek et al, and
monitoring of performance. Generalization of by Phillips (this issue, pages 263–276, and pages
auditory perceptual skills from clinic or labora- 251–262, respectively), for a discussion of soft-
tory to real-world settings (e.g., school, work- ware for AT. While these commercially available
place, playground) may not occur readily; how- tools for formal AT require instrumentation,
ever, unless formal AT is extended through other formal AT activities can be administered
collaboration with the speech-language pathol- in a clinical setting with minimal if any instru-
Table 1 Selected Formal and Informal Auditory Training Techniques Targeting Specific Auditory Processes
Process Assessment Test/Procedure (Re)Habilitation

Auditory discrimination Difference limens for intensity, frequency, and Auditory vigilance; Paired comparisons of phonemes,
duration; distorted speech recognition syllables, tones, or words; discriminate intensity
(e.g., filtered speech; compressed speech) increments; discriminate frequency
increments/transitions; discriminate duration
increments/gaps/differences for tones or CVs;
phonemic analysis, phonemic synthesis
Auditory closure Distorted speech recognition (e.g. filtered speech; Miller-Gildea vocabulary building; recognize words
compressed speech) and acoustically degraded words in sentence context
Temporal analysis/synthesis Two element ordering; pattern perception; click Gap detection; duration discrimination; sequencing
fusion or gap detection tasks; prosody training; heteronym differentiation;
identify word boundaries via temporal cueing; reading
poetry; follow auditory directives
Binaural separation Directed dichotic speech recognition; diotic Intensity altered dichotic listening; temporally altered
speech recognition in competition dichotic listening; speech recognition in competition;
listen to intensity imbalanced stereo music; auditory
vigilance
Binaural integration/summation Nondirected dichotic speech recognition Intensity altered dichotic listening; temporally altered
dichotic listening; speech recognition in competition;
listen to intensity imbalanced stereo music; auditory
vigilance
Localization, lateralization Dichotic rhyme; localization/lateralization Signal detection in sound-field with changing target
(binaural interaction) position
Interhemispheric transfer Pattern perception Verbal identification through tactile cues of objects
held in left hand; describe picture while drawing;
left-sided motor response to verbal command
AUDITORY TRAINING FOR AUDITORY PROCESSING DISORDERS/CHERMAK, MUSIEK
301

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302 SEMINARS IN HEARING/VOLUME 23, NUMBER 4 2002

mentation required. Auditory vigilance training the modulation rates are the same or different
can be accomplished by presenting various stim- and, if different, to identify which of the two
uli (live voice or recorded), varying the time tones is modulated at a faster rate.
between presentations. Similarly, temporal or- Another frequency training task involves
dering can be targeted by asking clients to de- ascending and descending frequency sweeps of
termine the order in which tones or syllables are varying glide rates. The sweep range is usually
presented. The tasks outlined here are typically less than 10% of the frequency of the base tone.
presented in the sound field at a most comfort- The client’s task is to determine whether a
able listening level. change has occurred and if so in which direc-
tion (i.e., low to high or high to low frequency).

Intensity Training
Temporal Training
Intensity training may be indicated on the
basis of reduced difference limens for intensity. Temporal training tasks are indicated by poor

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Intensity discrimination training requires the performance on the Pitch Pattern Test and
client to discern an intensity increment that Duration Pattern Test.34 Cognate pairs (e.g.,
is superimposed on a continuous tone of the /pa/ vs. /ba/) that are distinguished by their
same frequency. We have found that an inten- voice-onset times (VOT) provide stimulus ma-
sity increment varied from 1 to 5 dB, approxi- terial for temporal training. Clients can be
mately 300 msec in duration, and with a 50 trained to discriminate and identify CV pairs
msec rise/fall time provides a success-to-failure as different (/ba/, /da/) or the same (/ba/, /ba/),
ratio needed to maintain challenge as well as varying the interstimulus interval to adjust dif-
motivation. ficulty level.16 Gap detection offers another ap-
proach to temporal training. Stimuli consist of
10 sec periods of broadband noise with two or
three interruptions (gaps). The gaps or silent
Frequency Training
intervals are systematically varied to permit the
appropriate range of performance. Ordering of
Training on frequency discrimination and tran-
two or three rapidly presented acoustic elements
sitions may be indicated by poor performance
also targets temporal processing. The clinician
on the Pitch Pattern Test.33 A frequency detec-
may alter the interstimulus interval and/or du-
tion task requires the client to detect frequency
ration of the stimuli to adjust task difficulty.
modulations (i.e., pitch variations) of continu-
ous tones (approximately 5 sec in duration).
The degree and rate of frequency modulation
are adjusted to attain the desired success-to- Speech Recognition Training
failure ratio. The frequency of the modulation
tone can be varied from session to session to Speech recognition training in various compet-
span across low, mid, and high frequencies. ing conditions builds on a number of auditory
Discriminating and identifying differences processes, including auditory discrimination
in modulation rates offers a more challenging and temporal processing. Poor performance on
task involving both frequency and temporal dichotic listening or compressed/reverberant
processing abilities. The client is asked to com- speech recognition tests suggests a need for
pare the modulation rates of two successive speech recognition training.
tones, each approximately 1 sec in duration with The speech recognition task can be con-
a 1 sec interstimulus interval. The degree of ducted to train binaural separation and binau-
frequency modulation is held constant at a fre- ral integration. In the first variation, the client
quency difference easily recognized by the client. is required to direct attention to the loudspeaker
The client’s task is to first determine whether delivering the less intense stimuli, while ignor-
 AUDITORY TRAINING FOR AUDITORY PROCESSING DISORDERS/CHERMAK, MUSIEK 303

ing the stimuli presented through the second training integrative functions. Moreover, infor-
loudspeaker (i.e., binaural separation). In the mal AT offers potential for broader impact, as
second variation, the client is asked to attend a number of informal techniques improve lan-
to both loudspeakers (i.e., binaural integra- guage skills as well as auditory skills. For exam-
tion). The intensity of the stimuli in both con- ple, discrimination and recognition of degraded
ditions varies in 10-dB steps, with 5 to 10 trials speech stimuli (e.g., time compressed or filtered
at each intensity. Words, sentences and conso- speech) can be used to improve auditory clo-
nant-vowel-consonant syllables (CVC) may be sure. These same speech stimuli presented in
used as stimuli. Stimulus intensity should be sentences can be used to build vocabulary (i.e.,
varied to achieve the desired success-failure context-derived vocabulary building).19 Simi-
rate. Competing speech may be added to the larly, prosody training with heteronyms target
binaural speech recognition task to increase temporal processing while also aiding vocabu-
difficulty. Stimuli should be presented at 50 dB lary development.19
HL, or comfortable listening level, and speech- Informal AT offers substantial opportunity
to-competition ratios should be adjusted to en- for generalization of newly learned skills and
sure challenge and maintain motivation. strategies. Informal AT provides a wide variety of

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AT stimuli, contexts, and tasks, all of which foster
generalization of skills. Because these programs
Informal Auditory Training can be undertaken at home and in school, infor-
mal AT allows for additional practice that pro-
Employing verbal stimuli and emphasizing the motes mastery and generalization of skills and
use of linguistic context to benefit auditory func- maximizes the efficacy of the treatment program.
tion, informal AT offers a complementary and In addition to the specific methods below,
more synthetic approach to AT. Informal AT is the professional may adapt many tests of cen-
designed to improve auditory perceptual skills tral auditory processing for use as therapy ma-
through language-based, predominantly top- terials. For example, temporal gap detection
down tasks. Because required instrumentation may be trained using the Auditory Fusion
is minimal, AT can be conducted in the home Test-R.35 (or the revised form, the Random
or school, as well as by the speech-language Gap Detection Test). Temporal sequencing may
pathologist or the educational audiologist in the be trained using the Duration Patterns Test.34
clinic. The speech-language pathologist can use Auditory directives may be trained using the
informal AT to train the same auditory pro- Token Test for Children.36 Auditory vigilance
cesses targeted by the audiologist, who, because may be targeted using the Auditory Continu-
of access to particular instrumentation, would ous Performance Test.37 The speech-language
more likely administer formal AT techniques. pathologist should make the decision to use test
For example, binaural separation (i.e., selective materials for therapy in collaboration with the
listening) and binaural integration (i.e., divided audiologist who may plan to re-administer these
attention) can be trained through formal AT tests as one measure of progress in therapy.
using intensity altered and temporally altered Using the same test for assessment and therapy
dichotic tasks. These same skills can be trained could lead to a situation where the subject’s
informally with a two-channel stereo system, performance on repeat testing reflects familiar-
using the balance control to adjust the inten- ity with the test (i.e., learning effect) rather than
sity of the two channels. Similarly, informal a true measure of auditory function.
tasks requiring the following of sequenced, au- The following informal AT methods rely
ditory directives can be paired with formal tasks on equipment readily available to most speech-
requiring ordering of rapidly presented acous- language pathologists and educational audiol-
tic elements of varying interstimulus interval ogists. Preliminary data support the potential
and/or duration to target temporal processing. of these methods to improve the communica-
Informal AT programs tap multiple pro- tion and academic performance of children
cesses concurrently, which can be helpful in with APD.14
304 SEMINARS IN HEARING/VOLUME 23, NUMBER 4 2002

Auditory Discrimination Training blends. Consonant pairs sharing few acoustic

features will be easiest to discriminate. Training
Auditory discrimination is perhaps the most can be extended to sentence contexts, providing
fundamental auditory processing skill underly- a transition to therapy directed to auditory clo-
ing spoken language comprehension.19 The sure and vocabulary building.19 Construction of
ability to perceive acoustic similarities and dif- a confusion matrix of vowel, consonant, and word
ferences between sounds is essential (but not discrimination errors can help direct training
sufficient) for segmentation skills and phone- toward more frequently occurring errors. As
mic analysis and synthesis. the child masters these errors, these sounds are
Children with APD often experience diffi- removed from the high-error pool and atten-
culty discriminating and identifying vowels, per- tion is directed to discriminating items that re-
haps reflecting an interaction between classroom main challenging to the child.
acoustics and auditory perception.14 Because the As noted previously, auditory discrimi-
background or ambient classroom noise has a nation exercises also tax and therefore train au-
spectrum that is often similar to many of the low ditory attention. Similarly, auditory discrimi-
frequency vowels,38,39 many distinctive acoustic nation tasks can be used to train temporal

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elements that are key to distinguishing and iden- processing by requiring the child to distinguish
tifying vowels are masked. Auditory discrimina- heteronyms and identify vowels in proper se-
tion training for vowels should be conducted in a quence. Sloan’s four-part AT program devel-
quiet environment, without visual cues, although ops auditory discrimination, sound analysis,
it may be necessary to initially provide visual in- and phoneme-grapheme association skills and
formation that is then removed as the client applies these skills to reading and spelling of
achieves some success. words.40
The clinician must ascertain that the child
understands metalinguistic concepts (e.g., the
meaning of long versus short vowels, sound Auditory Discrimination Training
position in words, phoneme-grapheme corre- for Young Children.
spondence rules, etc.) before proceeding. In-
formal vowel training progresses through a For most preschool children, discriminating
hierarchy of steps. First the child is asked to differences among sounds is a challenging, yet
identify the sound corresponding to each of engaging, task. Environmental sounds differ-
the vowel graphemes, as these graphemes are ing in intensity, frequency, duration, and qual-
written for the child. Next, the clinician pre- ity can be used to develop auditory discrimina-
sents the vowel sounds auditorily, asking the tion. The child might be asked to state which
child to point to or state the corresponding of three bells of different pitch has the highest,
grapheme, denoting long or short. Vowels may middle, and lowest pitch or to identify differ-
then be presented for identification in context ent, familiar voices. To increase task difficulty,
using CV and CVC stimuli and words. speakers can alter their voices, speak quickly,
Once the child’s understanding of pho- say short words or CV combinations, or use a
neme-grapheme correspondence has been es- combination of these modifications.41 Playing
tablished, auditory discrimination training com- games with toy animals (“The cow says moo,
mences with paired (same-different judgments) the sheep says baaa.”) and picture or sticker
comparisons of vowels. The task can be gradu- pointing games (“Show me the cat.”) also train
ated in difficulty by presenting vowels with in- auditory discrimination and identification.42
creasingly more similar acoustic structure (i.e.,
those closer together in the vowel quadralat-
eral). The child should be directed to listen for Prosody Training
the subtle acoustic changes that mark vowels
coarticulated in syllabic and word (rhyming) con- Prosody guides attention to the most informa-
texts. Auditory discrimination training can be tive parts of the message, provides information
focused on single consonant and consonant about lexical, semantic, and syntactic aspects of
 AUDITORY TRAINING FOR AUDITORY PROCESSING DISORDERS/CHERMAK, MUSIEK 305

the spoken message, and also helps establish Reading poetry is another useful activity
auditory memory patterns important to lan- to improve temporal processing of speech
guage.43–47 Also known as acoustic contour rhythms.14 Having the child mimic a cadence
recognition, discrimination and identification of simple finger tapping or sequence of notes
of prosodic features (e.g., intonation, rhythm, on a piano also can be used as a form of tempo-
and acoustic stress) require the perception of ral training.
rather subtle and rapid temporal, frequency,
and intensity changes.47 Because individuals
with APD often do not have good frequency, Auditory Directives
temporal or intensity discrimination,48,49 prosody
and intonation cannot be appreciated fully. The ability to follow auditory directions is an
Informal auditory training for recognition essential life skill and is key to academic success.
of rhythm, prosody, and intonation can be ac- Following auditory directives can be trained
complished in a variety of ways. One approach within naturally occurring (i.e., authentic) con-
similar to the temporal tasks employed by Tal- texts in which the individual must follow se-
lal and colleagues16 is to require clients to audi- quenced directives to successfully complete a

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torily define word boundaries and intervals be- task, as well as through the use of games that
tween words. The client is given words with require the child to follow directions presented
one segment stressed and asked to identify the auditorily.41
stressed segment and repeat the word with The child should be asked to repeat the di-
stress on the appropriate syllable. For example, rective before executing the motor task to en-
a city in Ohio can be said in three different hance reauditorization and auditory memory.
ways with stress on three different syllables, as Requesting motor activity rather than simply
follows: Ashtabula, Ashtabula, Ashtabula. requiring repetition of the directive ensures that
Sentences with varying prosodic cues can the client integrated the auditory input with rel-
be used as therapy material to demonstrate how evant knowledge and motor commands in com-
prosodic changes alter meaning. For example, pleting the required task. Moreover, the motor
the meaning of the following phrase changes task will channel excessive motor activity pre-
as emphasis is placed on different words: Look! sented by children whose APD co-exists with
out the window; Look out! the window; Look attention deficit hyperactivity disorder (ADHD).
out the window. The pitch, intensity, and dura- The impulsivity of children with ADHD should
tion variations that signal proper segmentation be counteracted by instructing them not to
and change meaning should be discussed. perform the motor task until the directive(s)
Sentences in which temporal cues signal has been completed.
word boundaries and change meaning also pro- Auditory commands should progress in
vide opportunity to train auditory closure and difficulty level from simple to complex, involv-
build vocabulary. Subtle timing cues mark dis- ing one or multiple sequenced actions.14,41
tinctive differences in meaning as illustrated in Group actions requiring cooperation among
the following sentences, taken from Cole and children may be used, and children can be given
Jakimik.50 Resolution of prosodic detail is neces- the chance to act as clinicians (i.e., reciprocal
sary to properly segment and derive the correct teaching) by generating directives for others to
meaning of ambiguous words in these sentences. follow. Reciprocal teaching expands practice
opportunities while building confidence and
“The doctor said that nose drops will help self-esteem.19
the cold.” Directives can be presented in the context
“The doctor said that he knows drops will of a game format. The Token Test for Children
help the cold.” can be used as material for auditory directives.36
Incorporating this type of therapy outside the
“He just hated forgetting the right number.” clinical setting (e.g., in the classroom, at home in
“He was noted for getting the right the context of chores, or in recreational settings)
number.” should maximize generalization. An example of
306 SEMINARS IN HEARING/VOLUME 23, NUMBER 4 2002

the latter would be in teaching a child how to ered optimal for remediating APD, it is now
swing a tennis racket or a golf club while also recognized that regular and consistent practice,
teaching the game of tennis or golf, respectively. perhaps even for 10 to 15 minutes daily for a
number of weeks, provides the intensity of focus
and training needed to maximize success.16 Al-
Auditory Vigilance Training though economic, time, and motivational fac-
tors certainly influence the length of time ther-
Auditory vigilance involves sustaining a high apy can be provided, optimally, progress toward
level of auditory attention for necessary peri- meeting therapy objectives should be the pri-
ods of time in anticipation of a target stimulus. mary guide to decisions regarding scheduling
Auditory vigilance is usually trained by asking and terminating therapy.
a client to listen for a target stimulus presented
at random or at pseudo-random intervals within
a series of other auditory events. One might,
for example, read a story to a child (or group of ABBREVIATIONS
children), designating a target item (e.g., all

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words that end in the “d’ sound or any word ADHD attention deficit hyperactivity disorder
that has to do with food). The more random APD auditory processing disorder
the target presentation and the greater the in- AT auditory training
terval between targets, the more challenging CANS central auditory nervous system
the task. This type of activity is appropriate CV consonant-vowel syllables
for children in preschool or early elementary CVC consonant-vowel-consonant syllables
grades and can be adapted for use with older
clients as well. For example, the target might
be subtle prosodic elements, thereby training
REFERENCES
prosody in the context of an auditory vigilance
exercise. The option to use a wide variety of 1. Edeline JM, Weinberger NM. Thalamic short-term
target stimuli gives the auditory vigilance para- plasticity in the auditory system: associative retun-
digm flexibility to train other auditory pro- ing of receptive fields in the ventral medial genicu-
cesses while accommodating clients of varying late body. Behav Neurosci 1991;105:618–639
age and ability. 2. Elbert T, Pantev C, Wienbruch C, Rockstroh B,
Taub E. Increased cortical representation of the
fingers of the left hand in string players. Science
1995;270:305–306
CONCLUSIONS 3. Hassamannova J, Myslivecek J, Novakova V. Ef-
fects of early auditory stimulation on cortical areas.
Given the range of listening and learning deficits In: Syka J, Aitkin L, eds. Neuronal Mechanisms of
associated with APD, AT must be seen as only Hearing. New York: Plenum Press; 1981:355–359
4. Irvine DRF, Rajan R, McDermott HJ. Injury-
one component of a comprehensive manage-
induced reorganization in adult auditory cortx and
ment approach to improving auditory process- its perceptual consequences. Hearing Res 2000;
ing. Coupling formal with informal AT should 147:188–199
maximize treatment efficacy. Collaboration 5. Knudsen EI. Experience shapes sound localization
among professionals administering these ther- and auditory unit properties during development
apies is crucial to the success of AT. The in- in the barn owl. In: Edlman G, Gall W, Kowan W,
volvement of families in home practice is cru- eds. Auditory Function: Neurobiological Basis of
cial because many children with APD do not Hearing. New York: John Wiley; 1988:137–152
6. Merzenich M, Jenkins W. Cortical plasticity,
qualify for special services in many school dis-
learning and learning dysfunction. In: Julesz B,
tricts. Those who do qualify may not receive Kovacs I, eds. Maturational Windows and Adult
sufficient school-based therapy to achieve their Cortical Plasticity: SFI Studies in the Sciences of
potential. Although there is little empirical Complexity, vol. XXIII. Reading, PA: Addison-
data relating to the amount of practice consid- Wesley; 1995: 247–272
 AUDITORY TRAINING FOR AUDITORY PROCESSING DISORDERS/CHERMAK, MUSIEK 307

7. Moore DR. Plasticity of binaural hearing and some 24. Black JE. How a child builds its brain: some lesions
possible mechanisms following late-onset depriva- from animal studies of neural plasticity. Prev Med
tion. J Am Acad Audiol 1993;4:227–283 1998;27:168–171
8. Recanzone GH, Schreiner CE, Hradek G, et al. 25. Picheny M, Durlach N, Braida L. Speaking clearly
Functional reorganization of the primary auditory for the hard of hearing: intelligibility differences
cortex I adult owl monkeys parallel improvements in between clear and conversational speech. J Speech
performance in an auditory frequency discrimina- Hear Res 1985;28:96–103
tion task. Soc Neurosci 1991;17(213.2):534 (Abst) 26. Bain B, Dollaghan C. Treatment efficacy: the no-
9. Recanzone GH, Schreiner CE, Merzenich MM. tion of clinically significant change. Lang Speech
Plasticity in the frequency representation of primary Hear Serv School 1991;22:264–270
auditory cortex following discrimination training in 27. Olswang LB, Bain B. Data collection: monitoring
adult owl monkeys. J Neurosci 1993;13:87–103 children’s treatment progress. Am J Speech Lang
10. Weinberger NM, Diamond DM. Physiological Pathol 1994;3(3):55–66
plasticity in auditory cortex: rapid induction by 28. Yencer KA. The effects of auditory integration
learning. Prog Neurobiol 1987;29:1–55 training for children with central auditory process-
11. Willott JF, Aitken LM, McFadden SL. Plasticity ing disorders. Am J Audiol 1998;7:32–44
of auditory cortex associated with sensorineural 29. Anderson KL. S.I.F.T.E.R.: Screening Instrument
hearing loss in adult mice. J Comp Neurol 1993; for Targeting Educational Risk. Austin, TX: Pro

Downloaded by: University of Florida. Copyrighted material.

329:402–411 Ed, 1989
12. Jirsa RE. The clinical utility of the P3 AERP in chil- 30. Anderson KL, Smaldino J. Listening Inventories
dren with auditory processing disorders in school- for Education (L.I.F.E.). Tampa, Fl: Educational
aged children. J Speech Hear Res 1992;35:903–912 Audiology Assoc; 1998
13. Merzenich MM, Jenkins WM, Johnston P, et al. 31. Smoski WJ, Brunt MA, Tannahill JC. Listening
Temporal processing deficits of language-learning characteristic of children with central auditory pro-
impaired children ameliorated by training. Science cessing disorders. Lang Speech Hear Serv School
1996;271:77–80 1992;23:145–152
14. Musiek FE. Habilitation and management of audi- 32. Schlanger B. Effects of listening training on audi-
tory processing disorders: overview of selected pro- tory thresholds of mentally retarded children.
cedures. J Am Acad Audiol 1999;10:329–342 ASHA 1962;4:273–274
15. Musiek FE, Schochat E. Auditory training and 33. Pinheiro ML. Auditory pattern reversal in audi-
central auditory processing disorders: a case study. tory perception in patients with left and right
Semin Hear 1998;19:357–366 hemisphere lesions. Ohio J Speech Hear 1977;12:
16. Tallal P, Miller S, Bedi G, et al. Language compre- 9–20
hension in language-learning impaired children 34. Musiek FE, Baran JA, Pinheiro ML. Duration
improved with acoustically modified speech. Sci- pattern recognition in normal subjects and in pa-
ence 1996;271:81–84 tients with cerebral and cochlear lesions. Audiol-
17. Katz J, Chertoff M, Sawusch J. Dichotic training. J ogy 1990;29:304–313
Audiol Res 1984;24:251–264 35. McCrosky RL, Keith RW. The auditory fusion
18. Chermak GD, Musiek FE. Managing central au- test-revised. St. Louis, MO: Auditec; 1996
ditory processing disorders in children and youth. 36. DiSimoni FG. The Token Test for Children.
Am J Audiol 1992;1:61–65 Allen, TX: University Park Press; 1978
19. Chermak GD, Musiek FE. Central Auditory Pro- 37. Keith RW. The Auditory Continuous Perfor-
cessing Disorders: New Perspectives. San Diego, mance Test. San Antonio, TX: The Psychological
CA: Singular; 1997 Corp; 1994
20. American Speech-Language-Hearing Association 38. Sanders DA. Aural Rehabilitation. Englewood
Task Force on Central Auditory Processing Devel- Cliffs, NJ: Prentice Hall; 1971
opment. Central auditory processing: current status 39. Hetu R, Gagnon-Ttuchon C, Bilideau S. Problems
of research and implications for clinical practice. of noise in school settings: a review of literature
Am J Audiol 1996;5(2):41–54 and the results of an exploratory study. J Speech
21. Jerger J, Musiek F. Report of the consensus confer- Pathol Audiol 1990;14:31–39
ence on the diagnosis of auditory processing disor- 40. Sloan C. Treating Auditory Processing Difficulties in
ders in school-aged children. J Am Acad Audiol Children. San Diego, CA: College Hill Press; 1986
2000;11:467–474 41. Musiek FE, Chermak GD. Three commonly asked
22. Kolb B. Brain Plasticity and Behavior. Mahwah, questions about central auditory processing disor-
NJ: Lawrence Erlbaum; 1995 ders: management. Am J Audiol 1995;4:15–18
23. Kalil R. Synapse formation in the developing 42. Tye-Murray N. Foundation of Aural Rehabilita-
brain. Sci Am 1989;261:76–87 tion. San Diego, CA: Singular; 1998
308 SEMINARS IN HEARING/VOLUME 23, NUMBER 4 2002

43. Goldinger SD, Pisoni DB, Luce PA. Speech per- 48. Bornstein SP, Musiek FE. Implication of temporal
ception and spoken word recognition: research and processing for children with learning and language
theory. In: Lass NJ, ed. Principles of Experimental problems. In: Beasley D, ed. Contemporary Issues
Phonetics. St. Louis, MO: Mosby; 1996:277–327 in Audition. San Diego, CA: College-Hill Press;
44. Cutler A, Foss DJ. On the role of sentence stress in 1984:25–65
sentence processing. Lang Speech 1977;20:1–10 49. Thompson M, Abel S. Indices of hearing in pa-
45. Studdert-Kennedy M. Speech perception. Lang tients with central auditory pathology. II: Choice
Speech 1980;23:46–66 response time. Scand Audiol 1996;21:17–22
46. Valett RE. Developing linguistic auditory memory 50. Cole R, Jakimik J. A model of speech perception.
patterns. J Lear Disabil 1983;16:462–466 In: Cole R, ed. Perception and Prediction of Fluent
47. Handel S. Listening: An Introduction to the Per- Speech. Mahwah, NJ: Lawrence Erlbaum; 1980:
ception of Auditory Events. Cambridge, MA: 133–160
MIT Press; 1989

Downloaded by: University of Florida. Copyrighted material.