James W. Hall III, Ph.D.

1
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_at_phhp.ufl.edu

2
Department of Communication DisordersCollege of
Public Health Health Professions
Speech Hearing Center
Shands Hospital
Department ofCommunicative Disorders
3
University of Florida EARS ProjectEarly
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 Childrens Health and Human
  Development (NICDH)

4
EARS Program RationaleFive Component Skills
of Reading

• Phonemic Awareness (sound/speech sound skills)
• Phonics (phoneme/grapheme skills)
• Fluency
• Vocabulary
• Comprehension

5
Multiple Tiers of Reading Instruction Models
Conventional (e.g., Torgesen, 2005) Approach vs.
Early Intervention (EARS)
Core Reading Program
Reading Skills
Powerful Intensive Intervention (Struggling
Readers) APD?
EARS Program
Pre-K K 1 2 3 4 5 6
7 8 9 10 11 12 Grade
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Definition of Auditory Processing
Disorders2000 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

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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.

8
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?

9
EARS Hearing Auditory Processing Screening

• Screening
• Peripheral Hearing

Image from the American Academy of Audiology
10
EARS Hearing Auditory Processing Screening

• New ASHA guidelines for audiologic screening of
  children ages birth to 5 include consideration of
  otoacoustic emissions (OAEs) among other specific
  procedures and protocols (Diefendorf, 2005)
• No published investigations of screening for
  auditory function in kindergarten children (lt 5
  years old)
• Auditory function in first grade children (gt 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-test
  children (p. 702).

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Screening for Auditory Processing Disorders in
Kindergarten Children Test Protocol

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

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Screening for APD in Kindergarten Children Pure
Tone Hearing Screening (by Meghan Miller)
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Screening for APD in Kindergarten Children
Distortion Product Otoacoustic Emissions
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DPOAE Findings Average DP and NF Data for
kindergarten children who passed screening
(average test time 20 seconds per ear)
8K
6K
4K
3K
2K
1K
.50
8K
6K
4K
3K
2K
1K
.50
30
20
DP Amplitude in dB SPL
10
0
-10
DPgram (f2) Left Ear
DPgram (f2) Right Ear
Adult normal region
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EARS Hearing Auditory Processing Screening

• Screening
• Auditory processing

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Jack SSW Katz, Ph.D.
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Staggered Spondaic Word (SSW) TestA dichotic
speech procedure
LEFT TEMPORAL CORTEXAssociation CortexPrimary
Auditory Cortex
RIGHT TEMPORAL CORTEXAssociation
CortexPrimary Auditory Cortex
CorpusCallosum
Right Earbase ball
Left Earhot dog
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Screening for APD in Kindergarten Children Pure
tone measurements
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Screening for APD in Kindergarten Children
Portable Audiology Facility
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Screening for Auditory Processing Disorders in
Kindergarten Children Refer Criteria

• Screening Procedure Pass Criteria
• Pure tone audiometry 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 gt 6 dB
  at
• 2K, 4K and 8K)
• SSW less than 11 errors (lt 1 std dev for 20
• items) for left ear competing condition

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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

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Title I Elementary Schools Noisy Learning
Environments
Circa 1955 Modular classroom design
AC Unit
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Early Auditory Reading Success (EARS) Small
Group or Individual Intensive Instruction(sequent
ial 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

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Literacy Outcome MeasureDIBELS (Dynamic
Indicator of Early Literacy Skills)

• Developed at the University of Oregon
  (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)

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Early Auditory Reading Success (EARS)Outcome by
DIBELS scores in pilot project

• EARS School Control
  School
• Outcome Initial Final Final
• (N52) (N63) (N48)
• Deficit 50 27 40
• Emerging 31 22 44
• Established 19 60 16

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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
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Correlation of APD Screening (SSW) Outcome with
Risk for Reading Failure (Early Reading Success
Indicator) Significant at p lt 0.05
ERSI Scores
Left Ear Competing Error Scores
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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

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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 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

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Screening for Auditory Processing Disorders in
Kindergarten Children Subjects

• Four elementary schools in Alachua County in
  Florida
• 1 rural
• 1 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

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Early Auditory Reading Success (EARS)
Expanded Program in Four Elementary Schools
(04-05)

• Audiologic screening for APD
• tympanometry
• distortion product otoacoustic emissions
  (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)

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Pure Tone Hearing ScreeningKindergarten
Children (N 268)
Right ear
97
96
100
94
96
95
95
94
90
87
82
80
Left ear
Percent Pass
60
40
20
500
1000
2000
3000
4000
Frequency in Hz
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DPOAE Screening for Right EarKindergarten
Children (N 268)
Pass
100
96
93
90
80
Fail
Percent
60
Noise
40
20
16
7
10
7
5
1
2000
3000
4000
Frequency in Hz
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Tympanometry for Kindergarten Children (N 260)
100
RE
84
86
LE
80
Percent
60
40
20
8
6
6
4
3
3
1
1
A
As
C
B
tube
Tympanogram Findings
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Kindergarten Auditory ScreeningPure tone (500
Hz) versus tympanometry findings

• Pure tone Findings
• Tympanometry Findings Pass Fail
• Pass 190 29
• Fail 30 13
• Ambient noise interfered with pass criterion of
  20 dB HL at 500 Hz. Difficulty screening a small
  proportion of kindergarten children also
  contributed to non-pass outcome.

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Kindergarten Auditory ScreeningPure tone (4000
Hz) versus DPOAE (4000 Hz) findings

• Pure tone Findings
• DPOAE 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 outcome.

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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 DPOAE measures

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EARS Kindergarten Hearing Screening Pure Tone
vs. Tymp/DPOAE Findings (N 303)

• Pure Tone Findings
• Pass Fail
• Tymp/DPOAE Findings
• 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.

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Staggered Spondaic Word (SSW) TestPercent
Correct Scores
Normal Limit
100
80
EARS
Percent Correct
60
40
20
RNC
RC
LC
LNC
40
Follow Up of Hearing Screening FailuresKindergar
ten Children (N 268)
InitialScreening(September)
Follow UpScreening(November)
Fail?
Fail?
Medical Referral
Pure Tone Audiometry (in school)
11 CHL (4) 3 SNHL (1)
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EARS Outcome at the End of the Kindergarten
Year Measured by DIBELS Scores

• Dynamic Indicators of Basic Early Literacy Skills
  (DIBELS)
• Benchmark Goals
• Initial Sound Fluency
• Letter Naming Fluency
• Phoneme Segmentation Fluency
• Nonsense Word Fluency

http//dibels.uoregon.edu/measures/isf_tutorial.ph
p
42
Early Auditory Reading Success (EARS)Outcome by
DIBELS scores (Scores in 03-04 below 25ile in 4
schools)
100
85
80
74
63
National ile
60
40
40
20
LNF
ISF
PSF
NWF
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Ear Auditory Reading Success (EARS)Outcome by
DIBELS scores (Scores in 03-04 below grade level
in 4 schools)
Grade Level
50
40
EARS
DIBELS Score
30
20
10
LNF
ISF
PSF
NWF
44
(No Transcript)
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Early Auditory Reading Success (EARS)Final
Outcome 2005 by DIBELS scores (Williams
Elementary School)
Established 04
96
94
100
92
80
National ile
60
40
20
HR MR LR AA Est
HR MR LR AA Est
HR MR LR AA Est
Letter Sound Fluency
Phonemic Sequence Fluency
Nonsense Word Fluency
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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 outcome (DIBELS scores at end of
  kindergarten year).

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EARS Five Components

• All kindergarten children are screened for
  hearing sensitivity and auditory processing
• Soundfield amplification systems are installed in
  all kindergarten classrooms
• All kindergarten children complete Earobics
  computer based program for developing auditory
  pre-reading skills
• 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
• Children with abnormal performance on the
  Staggered Spondaic Words test (SSW) receive
  intensive one-on-one or small group instruction
  on auditory and pre-reading skills

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EARS Screening

• Screenings are conducted during the first part of
  the academic year 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

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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

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EARS Auditory Processing Screening

• SSW Normative Data

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EARS Intervention

• All Children
• FM Assistive Listening Systems installed in the
  classrooms of participating kindergarten classes

Image from http//www.connevans.com/soundfield/ind
ex.shtml
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EARS Intervention

• All Children
• Receive computer based training for auditory
  processing and phonological awareness skills
  (Earobics)

Images from http//www.earobics.com/index.cfm
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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

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EARS Screening Reading Readiness

• Dynamic Indicators of Basic Early Literacy Skills
  (DIBELS)
• Benchmark Goals
• Initial Sound Fluency
• Letter Naming Fluency
• Phoneme Segmentation Fluency
• Nonsense Word Fluency

http//dibels.uoregon.edu/measures/isf_tutorial.ph
p
55
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

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EARS DIBELS Summary of Findings
PSF phoneme segmentation fluency NWF
nonsense word fluency ORF oral reading
fluency OLV oral language vocabulary Reading
Comp. reading comprehension
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EARS DIBELS Final Grade Assessment2005/2006
First Grade
PSF
NWF
ORF
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EARS DIBELS Final Grade Assessment 2004/2005
Kindergarten
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EARS DIBELS Mean Score in last test interval of
first grade for EARS participants
PSF Phoneme Segmentation Fluency NWF Nonsense
Word Fluency ORF Oral Reading Fluency
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EARS DIBELS National ile rank in final test
interval of First Grade for EARS participants
(2005/2006)
OLV Oral Language Vocabulary Reading Comp
Reading Comprehension
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EARS DIBELS Initial Grade Assessment2006/2007
Second Grade
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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 countys 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
  Earobics program
• Some classroom instruction on phonologic
  awareness skills
• No intensive intervention to date (dearth of
  speech pathologists in school system)

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

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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.
• 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.
• 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

66
Thank you Questions?