Early Auditory Reading Success (EARS)

Early Auditory Reading Success (EARS) James W. Hall III, Ph.D. Kristin N. Johnston, Au.D. Department of Communicative Disorders College of Public Health and Health Professions University of Florida Health Science Center Gainesville, Florida 32610 jhall@phhp.ufl.edu

Department of Communication Disorders College of Public Health & Health Professions Speech & Hearing Center Shands Hospital Department of Communicative Disorders

University of Florida EARS Project: Early Auditory Reading Success Significance Federal and State of Florida initiatives to improve early reading performance of children in public schools Putting Reading First (9/10/06) Reading First part of No Child Left Behind Research evidence Importance of phonologic (phonemic) awareness and auditory skills stressed by National Reading Panel (www.nationalreadingpanel.org)) and National Institute of Children s s Health and Human Development (NICDH)

EARS Program Rationale: Five Component Skills of Reading Phonemic Awareness (sound/speech sound skills) Phonics (phoneme/grapheme skills) Fluency Vocabulary Comprehension

Multiple Tiers of Reading Instruction Models: Conventional (e.g., Torgesen, 2005) Approach vs. Early Intervention (EARS) Reading Skills EARS Program Core Reading Program Powerful Intensive Intervention ( Struggling Readers ) APD? Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12 Grade

Definition of Auditory Processing Disorders: 2000 Consensus Conference on APD Journal of American Academy of Audiology 11: : Nov. 2000. Definition: APD is broadly defined as a deficit in the processing of information that is specific to the auditory modality. Levels of auditory processing, e.g., Detection of sound (threshold or hearing sensitivity) Discrimination of basic properties of sound Frequency Intensity Duration/temporal properties Speech (word) recognition Complex speech processing Speech sound discrimination Dichotic listening Speech perception in background noise or competing message

Technical Report of ASHA Working Group on (Central) Auditory Processing Disorders (2005) www.asha.org Definition of (C ) AP Broad definition the efficiency and effectiveness by which the CNS utilizes auditory information Narrow definition the perceptual processing of auditory information in the CNS and the neurobiological activity that underlies that processing and gives rise to electrophysiologic auditory potentials.

Screening for Auditory Processing Disorders (APD) in Kindergarten Children: Research Questions What combination of auditory measures (pure tone audiometry, tympanometry,, and otoacoustic emissions) is most efficient for hearing screening of kindergarten children? Can the outcome of screening for auditory processing disorders contribute to detection of children at risk for reading failure? Is intensive intervention for children with auditory, language, and reading readiness deficits effective in preventing reading failure?

EARS: Hearing & Auditory Processing Screening Screening Peripheral Hearing Image from the American Academy of Audiology

EARS: Hearing & Auditory Processing Screening New ASHA guidelines for audiologic screening of children ages birth to 5 include consideration of otoacoustic emissions (OAEs( OAEs) ) among other specific procedures and protocols (Diefendorf( Diefendorf,, 2005) No published investigations of screening for auditory function in kindergarten children (<( 5 years old) Auditory function in first grade children (>( 6 years old) is described by Lyons, et al. (2004) in DPOAEs in children at school entry: A comparison with pure- tone screening and tympanometry results. (N = 1003 children) When the results of a test protocol which incorporates both DPOAEs and tympanometry were used in comparison with the gold standard of pure tone screening plus tympanometry,, test performance was enhanced. The use of a protocol that includes both DPOAEs and tympanometry holds promise as a useful tool in hearing screening of schoolchildren, including difficult-to to-test test children (p. 702).

Screening for Auditory Processing Disorders in Kindergarten Children: Test Protocol Screening Procedure Otoscopy Pure tone audiometry Tympanometer Otoacoustic emissions Instrumentation Welch Allyn otoscope Inter-Acoustics 229e audiometer with insert earphones (ER-3A) GSI 38 auto tympanometer Bio-Logic AuDx distortion product device Central auditory processing Staggered spondaic word (SSW) test presented via portable CD player coupled to IA 229e audiometer

Screening for APD in Kindergarten Children: Pure Tone Hearing Screening (by Meghan Miller)

Screening for APD in Kindergarten Children: Distortion Product Otoacoustic Emissions

DPOAE Findings: Average DP and NF Data for kindergarten children who passed screening (average test time = 20 seconds per ear) DP Amplitude in db SPL.50 1K 2K 3K 4K 6K 8K 30 20 10 0-10.50 1K 2K 3K 4K 6K 8K DPgram (f 2 ) Right Ear Adult normal region DPgram (f 2 ) Left Ear

EARS: Hearing & Auditory Processing Screening Screening Auditory processing

Jack SSW Katz, Ph.D.

Staggered Spondaic Word (SSW) Test: A dichotic speech procedure LEFT TEMPORAL CORTEX Association Cortex Primary Auditory Cortex Corpus Callosum RIGHT TEMPORAL CORTEX Association Cortex Primary Auditory Cortex Left Ear hot dog Right Ear base ball

Screening for APD in Kindergarten Children: Pure tone measurements

Screening for APD in Kindergarten Children: Portable Audiology Facility

Screening for Auditory Processing Disorders in Kindergarten Children: Refer Criteria Screening Procedure Pure tone audiometry Pass Criteria Response at 20 db HL for 500 Hz, 1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz Tympanometry Type A (peak pressure with range of + 50 to - 150 dapa) Otoacoustic emissions DP NF difference > 6 db at 2K, 4K and 8K) SSW less than 11 errors (< 1 std dev for 20 items) for left ear competing condition

Early Auditory Reading Success (EARS): Pilot Project in One Elementary School (03-04) Children diagnosed with hearing, cognitive, attention, or other deficits referred for appropriate management Intervention components FM systems in each kindergarten classroom All kindergarten students complete Earobics Multi-sensory reading instruction strategies used by each kindergarten teacher Children diagnosed with APD and/or deficits in phonologic awareness receive intensive small group treatment by speech pathologist letter recognition phonologic awareness other basic reading skills

Title I Elementary Schools: Noisy Learning Environments Circa 1955 Modular classroom design AC Unit

Early Auditory Reading Success (EARS): Small Group or Individual Intensive Instruction (sequential during school year) Phonologic awareness (approximate time = 3 to 5 minutes) Rhyme recognition, generation, matching Phoneme detection Blending at different levels (word, syllable, onset, phoneme) Segmenting Deletion (elision) Vowel discrimination Based partially on LiPS program Alphabetic understanding (approximate time = 5 to 6 minutes) Writing (approximate time = 3 to 4 minutes) Spelling (approximate time = 7 to 8 minutes) Reading (approximate time = 6 to 7 minutes) introduce and review sight words Read decodable book

Literacy Outcome Measure: DIBELS (Dynamic Indicator of Early Literacy Skills) Developed at the University of Oregon (www.dibels.uoregon.edu( www.dibels.uoregon.edu) Required by Alachua County School System to monitor academic progress in kindergarten children Four measures of reading reading skills Initial sounds fluency (ISF) Letter naming fluency (LNF) Phonemic segmentation fluency (PSF) Nonsense word fluency (NSF) Administered four times in kindergarten year Early fall semester (September) Late fall semester (December) Early spring semester (January) Late spring semester (May)

Early Auditory Reading Success (EARS): Outcome by DIBELS scores in pilot project EARS School Control School Outcome Initial (N=52) Final (N=63) Final (N=48) Deficit 50% 27% 40% Emerging 31% 22% 44% Established 19% 60% 16%

Hearing Screening of Kindergarten Children: Correlation of APD Screening (SSW) Outcome with Risk for Reading Failure (N = 107) Right Ear Competing Error Scores Left Ear Competing Error Scores 20 25 20 15 Frequency 10 Frequency 15 10 5 5 0 5 10 15 RC Mean = 8.42 Std. Dev. = 3.354 N = 107 0 5 7.5 10 12.5 15 17.5 LC Mean = 11.79 Std. Dev. = 3.11 N = 107

Correlation of APD Screening (SSW) Outcome with Risk for Reading Failure (Early Reading Success Indicator) Significant at p < 0.05 Left Ear Competing Error Scores ERSI Scores 25 20 20 15 Frequency 15 Frequency 10 10 5 5 0 5 7.5 10 12.5 15 17.5 LC Mean = 11.79 Std. Dev. = 3.11 N = 107 0 10.0 20.0 30.0 40.0 ERSI Mean = 27.471 Std. Dev. = 8.0976 N = 107

Early Auditory Reading Success (EARS): Assumptions Kindergarten children learn mostly through the auditory modality, and learn best in an optimal acoustic environment Academic success is dependent on reading success Reading failure a product largely of auditory processing and phonemic awareness deficits Auditory processing and phonemic awareness deficits must be identified early through screening of all kindergarten children Early and intensive intervention for auditory processing and phonemic awareness deficits is necessary reading and academic success

Early Auditory Reading Success (EARS) : Expanded Program in Four Elementary Schools (04-05) Collaborative service and research project by Department of Communicative Disorders at University of Florida and Alachua County School District in Gainesville Florida Funded by SBAC ($126,000) Auditory, language and reading readiness screening in kindergarten children Intensive intervention of children at risk for reading failure by b auditory and language screening Goals: Early intervention for auditory processing disorders Reading and academic success for all kindergarten children Reduction of children referred for exceptional student education (ESE), i.e., special education, in the school district

Screening for Auditory Processing Disorders in Kindergarten Children: Subjects Four elementary schools in Alachua County in Florida 11 rural 11 inner city 2 diverse population Each school met Title I criteria (free breakfast and lunch for majority of children) N = 268 children 137 male 129 female Children were 5 years old

Early Auditory Reading Success (EARS) : Expanded Program in Four Elementary Schools (04-05) Audiologic screening for APD tympanometry distortion product otoacoustic emissions (DPOAEs( DPOAEs) pure tone screening (20 db HL) dichotic speech task (SSW) DIBELS = Dynamic Indicators of Basic Early Literacy Skills Letter naming Initial sound Phonemic sequencing fluency Non-sense word fluency Language screening Reading readiness/phonologic screening ERSI (Early Reading Screening Inventory)

Pure Tone Hearing Screening: Kindergarten Children (N = 268) Percent Pass 100 80 60 40 87 82 94 90 96 95 97 95 96 94 Right ear Left ear 20 500 1000 2000 3000 Frequency in Hz 4000

DPOAE Screening for Right Ear: Kindergarten Children (N = 268) 100 96 93 90 Pass Percent 80 60 40 Fail Noise 20 7 16 7 5 10 1 2000 3000 Frequency in Hz 4000

Tympanometry for Kindergarten Children (N = 260) Percent 100 80 60 40 84 86 RE LE 20 4 3 6 3 6 8 1 1 A As C B tube Tympanogram Findings

Kindergarten Auditory Screening: Pure tone (500 Hz) versus tympanometry findings Tympanometry Findings Pure tone Findings Pass Fail Pass 190 29 * Fail 30 13 * Ambient noise interfered with pass criterion of 20 db HL at 500 0 Hz. Difficulty screening a small proportion of kindergarten children also contributed to non-pass pass outcome.

Kindergarten Auditory Screening: Pure tone (4000 Hz) versus DPOAE (4000 Hz) findings DPOAE Findings Pure tone Findings Pass Fail Pass 222 5 * Fail 26 4 * None of the subjects at hearing loss on follow up assessment. Difficulty screening a small proportion of kindergarten children also contributed to non-pass pass outcome.

Screening for Auditory Processing Disorders in Kindergarten Children (N = 278*) Screening Procedure Pass Fail* Pure tone audiometry 79% 21% Tympanometry 74% 26% Otoacoustic emissions 77% 23% SSW 54% 46% * Unilateral or bilateral, and at any frequency for pure tone and d DPOAE measures

EARS: Kindergarten Hearing Screening: Pure Tone vs. Tymp/DPOAE Findings (N= 303)* Tymp/DPOAE Findings Pure Tone Findings Pass Fail* Pass 62% 11% ** Fail 16% 11% * Screening outcome for both ears. Relation highly significant. ** Includes CNT outcomes and failures at 500 Hz only. None of the subjects had hearing loss on follow up assessment.

Staggered Spondaic Word (SSW) Test: Percent Correct Scores Percent Correct 100 80 60 40 Normal Limit EARS 20 RNC RC LC LNC

Follow Up of Hearing Screening Failures: Kindergarten Children (N = 268) Initial Screening (September) Fail? Follow Up Screening (November) Fail? 11 CHL (4%) 3 SNHL (1%) Pure Tone Audiometry (in school) Medical Referral

EARS: Outcome at the End of the Kindergarten Year Measured by DIBELS Scores Dynamic Indicators of Basic Early Literacy Skills (DIBELS) Benchmark Goals: 1. Initial Sound Fluency 2. Letter Naming Fluency 3. Phoneme Segmentation Fluency 4. Nonsense Word Fluency http://dibels.uoregon.edu/measures/isf_tutorial.php

Early Auditory Reading Success (EARS): Outcome by DIBELS scores (Scores in 03-04 below 25%ile in 4 schools) National %ile 100 80 60 40 85 74 63 40 20 LNF ISF PSF NWF

Ear Auditory Reading Success (EARS): Outcome by DIBELS scores (Scores in 03-04 below grade level in 4 schools) DIBELS Score 50 40 30 20 Grade Level EARS 10 LNF ISF PSF NWF

Early Auditory Reading Success (EARS): Final Outcome 2005 by DIBELS scores (Williams Elementary School) Established 04 100 96 92 94 National %ile 80 60 40 20 HR MR LR AA Est HR MR LR AA Est HR MR LR AA Est Letter Sound Phonemic Sequence Nonsense Word Fluency Fluency Fluency

Screening for Auditory Processing Disorders (APD) in Kindergarten Children: Conclusions Tympanometry and DPOAEs,, in combination, offer an efficient strategy for hearing screening of kindergarten children. The results of auditory processing can be used to determine children at risk for reading and academic failure. Intensive intervention for auditory processing and phonologic awareness deficits improves early literacy skills conclusion based on analysis of short-term term outcome (DIBELS scores at end of kindergarten year).

EARS: Five Components 1. All kindergarten children are screened for hearing sensitivity and auditory processing 2. Soundfield amplification systems are installed in all kindergarten classrooms 3. All kindergarten children complete Earobics computer based program for developing auditory pre-reading reading skills 4. Classroom teachers receive in-service training on phonological awareness and auditory skills, which they focus on for 15 minutes daily with students in small groups 5. Children with abnormal performance on the Staggered Spondaic Words test (SSW) receive intensive one-on on-one one or small group instruction on auditory and pre-reading reading skills

EARS: Screening Screenings are conducted during the first part of the academic year y for: Auditory status Peripheral hearing Auditory processing Language and Reading Readiness (optional) Early Reading Screening Inventory (ERSI) (Lombardino,, et al., 1999) Well accepted measure of reading readiness found to correlate highly with results of auditory processing screening Dynamic Indicators of Basic Early Literacy Skills (DIBEL Measure of reading readiness given at four intervals to all kindergarten children in the state of Florida

EARS: Hearing & Auditory Processing Screening Peripheral auditory function Otoscopy Tympanometry Otoacoustic emissions Puretone audiometry Auditory processing Dichotic procedure (first 20 test items of Staggered Spondaic Word (SSW) Test

EARS: Auditory Processing Screening SSW Normative Data

EARS: Intervention All Children: FM Assistive Listening Systems installed in the classrooms of participating kindergarten classes Image from http://www.connevans.com/soundfield/index.shtml

EARS: Intervention All Children: Receive computer based training for auditory processing and phonological awareness skills (Earobics) Images from http://www.earobics.com/index.cfm

EARS: Intensive Intervention Children at Serious Risk for academic failure: Receive individual or group instruction for auditory processing and phonological awareness skills by a speech pathologist e.g., Lindamood Bell LiPS Program

EARS: Screening Reading Readiness Dynamic Indicators of Basic Early Literacy Skills (DIBELS) Benchmark Goals: 1. Initial Sound Fluency 2. Letter Naming Fluency 3. Phoneme Segmentation Fluency 4. Nonsense Word Fluency http://dibels.uoregon.edu/measures/isf_tutorial.php

EARS: DIBELS Analysis DIBELS Findings for the original cohort of kindergarten children at the end of their first grade year Performance on the DIBELS for 6 schools ( 3 with EARS program and 3 control schools) Comparison of mean scores Comparison of national %ile% rank

EARS: DIBELS Summary of Findings DIBELS Component* Mean Score National %ile% Rank School PSF NWF ORF OLV Reading Comp EARS (n=180) A 40 64 59 57 62 B 55 66 33 31 53 C 59 64 51 33 56 Average 51 65 48 40 57 CONTROL (n=143) A 46 57 39 26 54 B 52 70 31 18 30 C 54 60 50 18 38 Average 51 62 40 21 38 *PSF = phoneme segmentation fluency; NWF = nonsense word fluency; ORF = oral reading fluency; OLV = oral language vocabulary; Reading Comp. = reading comprehension

EARS: DIBELS Final Grade Assessment 2005/2006 First Grade 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EARS Control EARS Control EARS Control PSF NWF ORF Established Emerging Deficit

EARS: DIBELS Final Grade Assessment 2004/2005 Kindergarten 100% 80% 60% 40% 20% 0% EARS C EARS B EARS A Crontrol C Control B Control A Established Emerging Deficit

PSF Phoneme Segmentation Fluency NWF Nonsense Word Fluency ORF Oral Reading Fluency EARS: DIBELS Mean Score in last test interval of first grade for EARS participants 70 60 50 40 30 51 51 65 62 48 40 EARS (n=180) Control (n=143) 20 10 0 PSF NWF ORF

EARS: DIBELS National %ile rank in final test interval of First Grade for EARS participants (2005/2006) 60 50 40 30 20 10 0 40 21 OLV 57 38 Reading Comp EARS (n=180) Control (n=143) OLV Oral Language Vocabulary Reading Comp Reading Comprehension

EARS: DIBELS Initial Grade Assessment 2006/2007 Second Grade 100% 80% 60% 40% 20% 0% EARS C EARS B EARS A Control C Control B Control A Established Emerging Deficit

Early Auditory Reading Success (EARS): 2006-2007 School Year Modified EARS program: The School Board of Alachua County has made EARS a formally funded part of the county s s core curriculum for reading Approved by the Florida Center for Reading Research (www.fcrr.org) Nine schools meeting Title 1 and Reading First criteria are currently participating in the EARS program for the 2006/2007 academic year EARs components implemented Sound field FM systems in all kindergarten classrooms All kindergarten children complete web-based based Earobics program Some classroom instruction on phonologic awareness skills No intensive intervention to date (dearth of speech pathologists in school system)

Modified EARS Incorporated into Kindergarten Curriculum in 9 Title I Schools in Alachua County (2005-2006) Core Reading Program (Tier 1) All kindergarten children in Title I schools undergo auditory and language screening Phonologic Awareness Enhancement (Tier 2) Classroom FM system Classroom instruction Earobics program Not at risk? At risk? Monitor Outcome (DIBELS) National 70%ile? Intensive Intervention (Tier 3) Small group inclusive instruction Pre-reading skills Phonologic awareness instruction

EARS: Conclusions The results of auditory processing screening can be used to identify children at risk for reading and academic failure. All kindergarten children in Title I schools benefit from Adequate acoustic learning environment (classroom) Enhancement of phonologic awareness instruction by the classroom teacher Therapy for auditory processing and pre-reading reading skills (e.g., Earobics) Intensive intervention for auditory processing and phonologic awareness deficits improves early literacy skills. The EARS program offers effective intervention for kindergarten children at risk for reading failure.

Selected References Diefendorf,, A. O. (2005, April 12). Early hearing detection and intervention: New ASHA guidelines available on children, ages birth to 5. The ASHA Leader, p. 4. Jerger,, J. & Musiek,, F. 2000. Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children. Journal of the American Academy of Audiology 11: 467-474. 474. Lombardino,, L.J., Morris, D., Mercado, L., DeFillipo,, F., Sarisky,, C., & Montgomery, A. 1999. The Early Reading Screening Inventory: a method for identifying kindergarteners at risk for learning to read. International Journal of Communicative Disorders, 34(2): 135-50. 50. Lyons A, Kei J & Driscoll C. DPOAEs in children at school entry: A comparison with pure-tone screening and tympanometry results. JAAA 15: 2004 (Univ. of Queensland, Brisbane, Australia) www.connevans.com/soundfield/index.shtml www.earobics.com/index.cfm www.lblp.com/index.shtml dibels.uoregon.edu

Thank you Questions?