A sensory processing disorder (SPD) is a sensory impairment that affects an individual's ability to process sensory input efficiently and respond appropriately (Miller, Anzalone, Lane, Cermak, & Osten, 2007). One subtype of SPD is sensory modulation disorder. Miller et al. (2007) proposed that individuals with sensory modulation disorders show either over-responsiveness or under-responsiveness to sensory input or exhibit sensory-seeking behavior. Research suggests that auditory sensory over-responsiveness (ASOR) occurs in typically developing children who do not present with psychiatric disorders (Carter, Ben-Sasson, & Beriggs-Gowan, 2011; Gouze, Hopkins, LeBailly, & Lavigne, 2009; Van Hulle, Schmidt, & Goldsmith, 2012).
For some children, over-responsive reactions are elicited by auditory input. This condition is commonly called auditory defensiveness or ASOR. A child with this condition consistently shows intense negative reactions to certain sounds (Baranek, Foster, & Berkson, 1997). These negative reactions can impede engagement in daily activities and thus impair function (Bar-Shalita, Vatine, & Parush, 2008; Ben-Sasson, Carter, & Briggs-Gowan, 2009).
Sound-based interventions are sometimes used as a strategy in a variety of pediatric occupational therapy (OT) settings with children with SPD, ASOR, and other developmental conditions (Bazyk, Cimino, Hayes, Goodman, & Farrell, 2010; Gee, Devine, Werth, & Phan, 2013; May-Benson, Carley, Szklut, & Schoen, 2013). Several sound therapy systems with distinct differences are marketed under various names, including Berard Auditory Integration Training (AIT), Therapeutic Listening (TL), The Listening Program (TLP), Tomatis, and Integrated Listening Systems (iLs). The general premise behind these programs is that the auditory system can be used to help regulate other systems of the body through numerous neurological interconnections and neuroplasticity. This is similar to the Ayres Sensory Integration approach, which aims to change the processing of sensory information through elicited changes in neurophysiology (Watling & Hauer, 2015). Other sensory-based interventions that are not specifically included in the Ayres protocol strive to elicit a short-term change in self-regulation or behavior, based on a specific sensory task (Watling, Koenig, Schaaf, & Davies, 2011).
Frequently, OT clinicians, parents, and teachers report the benefits of sound-based interventions when combined with other intervention approaches. Further, clinicians frequently report the use of sound-based interventions with individuals with autism spectrum disorder (ASD), SPD, developmental coordination disorder, attention deficit hyperactivity disorder, central auditory processing disorder (APD), and developmental delay (Gee et al., 2013). However, many studies have focused on the role of sound-based interventions for individuals with ASD.
Bettison (1996) investigated the long-term effects of a sound-based intervention on children with ASD and found an improvement in behavior and “severity of autism” among an auditory intervention group compared with a control group of children who listened to typical music. This larger randomized study primarily included boys and did not control for therapy provided outside of school. Even with these limitations, improvements occurred in auditory sensitivity, verbal IQ, and behavioral measures in children with ASD (Bettison, 1996). Corbet, Shickman, and Ferrer (2008) examined the effect of sound therapy on language function among children with ASD and found no significant difference between treatment groups. In a 2015 study of the effect of AIT on sound integration in children diagnosed with ASD, treatment led to improved behavioral symptoms, including decreased irritability (Sokhadze, Casanova, Tasman, & Brockett, 2016).
Gee, Thompson, and St. John (2014) used a single-subject case-control design to examine the effect of 10 weeks of TLP on ASD and ASOR. After treatment, the participant showed fewer self-stimulating and negative behaviors (Gee et al., 2014). Another case study suggested that iLs treatment for a child diagnosed with pervasive developmental disorder, not otherwise specified, led to improved behavior and sensory tolerance (Nwora & Gee, 2009).
In a retrospective study, Brockett, Lawton-Shirley, and Kimball (2014) conducted chart reviews to investigate the effects of AIT on sensory behaviors in a sample of 54 children with disabilities. The study subjects had participated in AIT for 30 minutes daily for 10 consecutive days. The authors reported positive changes in behavior related to sensory modulation, but acknowledged that the study design did not control for several factors, such as a placebo effect (Brockett et al., 2014). Another study of the effect of TL and a sensory diet or program on children with SPD and visual-motor delays found that the intervention resulted in improved sensory-related behaviors and improved visual-motor skills (Hall & Case-Smith, 2007). In a qualitative study by Wink, McKeown, and Casey (2017), parents reported that a TL intervention calmed their child and led to improved child and family functioning.
The supporting evidence for sound-based interventions is limited and has focused primarily on children diagnosed with ASD, with no research available on sound-based interventions for the treatment of ASOR or auditory processing disorder (APD). The current study examined the effects of implementation of the iLs program on the functioning of a child with APD and ASOR. The American Speech-Language-Hearing Association (1993) defines APD as a deficit in the receptive signals processed by the individual separate from an impairment in peripheral hearing or another diagnosis. Those with APD can have a number of deficits in function, including attention to sounds, filtering information, and assigning meaning to sounds or groups of sounds (American Speech-Language-Hearing Association, 1993). We hypothesized that after 12 weeks of the iLs intervention, the child would show improved scores on the Test of Auditory Processing Skills-3 (TAPS-3) (Martin & Brownell, 2005) and fewer behaviors related to auditory defensiveness.
This study used a single-subject case study design to determine the effectiveness of the iLs intervention on auditory processing and auditory defensiveness.
The participant (pseudo-named “Joy”) was a 7-year-old White girl with diagnoses of APD and ASOR. She came from a middle-class family and was identified and diagnosed during a speech therapy evaluation. Joy was chosen for the study because her mother sought assistance with regulating her difficult behaviors around noises, such as avoiding the bathroom if a fan was operating, resisting the use of a hair dryer, and avoiding crowds and parties. She lived with her mother, and according to parental report, she was born full term with a birth weight of 6 pounds and 15 ounces, or 3.15 kg. Joy attained all motor milestones within normal limits. Joy's mother provided parental consent for her to participate in the current study, in accordance with the University of Tennessee Health Science Center Institutional Review Board procedures. Joy did not take any medications before or during the study. She was receiving one session of speech therapy per week in an out-patient rehabilitation setting specifically to improve speech articulation. The speech therapist made a diagnosis of APD and ASOR. Because the APD and ASOR were limiting Joy's engagement in daily occupations, the speech therapist recommended an OT consultation. Before the study, Joy had not undergone OT evaluation or treatment.
After an initial assessment that included a thorough sensory history and an interview with Joy and her mother, the OT clinician determined that Joy would be an appropriate candidate for integrated iLs. Throughout the duration of the study, Joy participated in direct speech therapy sessions to address her articulation issues.
Joy presented as a bright and engaging child. At the time of the study, she attended a private school, and her performance in daily occupations, such as socializing and carrying out activities of daily living, were negatively influenced by her difficulties with auditory processing and ASOR. Before initiation of the intervention, Joy's mother reported that Joy would not blow-dry her hair because she could not tolerate the sound of the hair dryer. Also, although Joy liked to cook, at times her participation in this occupation and her daily routines in general were disrupted by ASOR. For example, Joy needed to leave the kitchen if anyone used a mixer or a blender. Joy frequently covered her ears when exposed to sounds from small appliances or the bathroom fan. On particularly difficult days, Joy also had trouble tolerating ambient noise from others and often responded by turning the volume on the television or radio extremely high. Joy frequently craved oral input, as demonstrated by snacking or requesting snacks immediately after meals and by mouthing nonfood items. In particular, her mother expressed concern about times when Joy seemed to be snacking or chewing on non-food items as a response to other types of stimuli that she appeared to dislike, such as loud noises.
Permission to carry out the study was granted by the University of Tennessee Health Science Center Institutional Review Board. After informed consent was obtained, an independent, blinded evaluator conducted all assessments. The evaluator had more than 22 years of pediatric OT experience and remained blinded to the purpose of the investigation throughout the study period.
Data were collected preintervention, midintervention, and postintervention with the TAPS-3 and preintervention and postintervention with the iLs Measure of Foundational Abilities (iLs, 2001a). During the initial interview, Joy and her mother discussed the sensory-related issues that caused stress and interfered with Joy's daily functioning. The following problem behaviors were identified: reacting negatively to the hair dryer, placing her fingers in her ears with noise, avoiding the bathroom because of the noise from the fan, turning the television volume extremely high, and mouthing items or requesting snacks immediately after eating. The OT clinician created a parental behavioral observation tally checklist or log for each of these behaviors, and Joy's mother was instructed to document the occurrence of these behaviors daily. Anecdotal information was gathered from the mother through e-mail at 8 months and again at 2 years and 10 months after the study ended.
The iLs program is designed to improve an individual's “concentration, cognitive skills, such as reading and writing, visual and auditory processing, and movement coordination” (Integrated Listening Systems, 2016, p. 6). An iLs-trained pediatric OT clinician with 24 years of practice experience instructed Joy and her mother in how to implement the iLs program and monitored the program implementation weekly over the course of the study.
The iLs Sensory Motor Playbook and User Guide (iLs, 2001b) includes a protocol of 10 sets of exercises and activities that gradually increase in complexity. The guide includes activity reference pages with descriptions and photographs of each activity, such as balancing tasks and jumping jacks. Joy was instructed to perform the first set of sensory motor exercises during week 1 of treatment, to perform the second set of exercises during week 2, and to follow this pattern through week 10. Joy was told to perform the tenth set of activities during weeks 11 and 12. The Sensory Motor Playbook and User Guide (iLs, 2001b) states that the listed activities occasionally could be supplemented with a task such as working a puzzle or engaging in a tracing or memory game, and the therapist explained this option to Joy and her mother.
Joy's intervention schedule consisted of following the protocol described earlier for at least one 20-minute session daily for at least 3 days per week. Joy was encouraged to strive for 45 minutes each session for 5 days per week, but if she became frustrated because of her challenges with sustaining attention, or if her schedule would not allow for a session that long, a minimum of a 20-minute session three times per week would be acceptable. Joy carried out all intervention sessions at home under the supervision of her mother. The treatment period was 12 weeks. Joy was generally compliant with the frequency of the protocol being carried out an average of 3.5 times per week, with an average session length of 27 minutes. The iLs Focus Series equipment used during the sessions included an iPod preloaded with iLs music programs, an amplifier with adjustable bone and air conduction volume, headphones with bone conduction capability, and the iLs Sensory Motor Play-book and User Guide (iLs, 2001b).
Data were collected preintervention, midintervention, and postintervention with the TAPS-3; preintervention and postintervention with the iLs Measure of Foundational Abilities; and daily with parental documentation of instances of aversive reactions to sensory input with the behavioral observation log. The iLs Measure of Foundational Abilities is a judgment-based questionnaire that is intended to document a caregiver's perceptions of a child's behaviors before and after program implementation. The measure has four sections: sensory and sensory motor, social/emotional, organization/attention/cognitive, and auditory/language (Table 1). The parent completes the iLs measure once before the intervention and again after the intervention to provide a potential measure of progress. For each item, the scale is 0 to 3, where 0 = does not apply, 1 = rarely, 2 = often, and 3 = always. The individual scores for the four sections are totaled to obtain a single numerical representation for that section. A reduction in the overall score indicates progress.
iLs Measure of Foundational Abilities
“The TAPS-3 is an individually administered assessment of auditory skills necessary for the development, use, and understanding of language commonly used in academic and everyday activities,” according to Martin and Brownell (2005, p. 5). The TAPS-3 provides an overall index standard score that is based on the sums of the sub-test scaled scores, with lower scores indicating increased auditory processing abilities. The test-retest reliability of the TAPS-3 is .96 for a child Joy's age.
The TAPS-3 includes the following subtests: (a) word discrimination, which assesses the student's ability to discern phonological differences and similarities within word pairs; (b) phonological segmentation, which determines how well a student can manipulate phonemes within words; (c) phonological blending, which determines how well the student can synthesize a word, given the individual phonemes; (d) number memory forward, which shows how well the student can retain simple sequences of auditory information; (e) number memory reversed, which shows how well the student can retain simple sequences of auditory information; (f) word memory, which shows how well the student can retain simple sequences of auditory information; (g) sentence memory, which shows how well the student can retain details in sentences of increasing length and grammatical complexity; (h) auditory comprehension, which shows how well the student understands spoken information; and (i) auditory reasoning, which reflects higher-order linguistic processing (Martin & Brownell, 2005, pp. 24–33).
To establish a baseline level of functioning, the TAPS-3 was administered 1 month before the initiation of treatment and again 3 days before the initiation of treatment. The assessment was also administered during week 5 of treatment and again 3 days after the iLs intervention was discontinued.
The following preintervention information was used to determine a baseline level of functioning for Joy: results of the second administration of the TAPS-3, the parental behavioral observation log, and the preintervention iLs Measure of Foundational Abilities. The initial TAPS-3 index of scaled scores obtained 1 month before the initiation of treatment was 100. The index of scaled scores was 102 when obtained 3 days before treatment was initiated. The blinded evaluator reported that Joy appeared to be less anxious during the second evaluation and hypothesized that this difference was caused by an increased comfort level with the evaluator, who had first met the child minutes before the initial evaluation, and with the format of the test. Based on this information, the score of 102 appeared to provide a better baseline picture and a more accurate account of the child's abilities than the initial testing session (Figure 1).
Test of Auditory Processing Skills-3 total standardized scores from baseline to postintervention. This test was completed four times over the course of the study. Baseline scores were obtained 1 month and again 3 days before the start of the intervention. Based on the individual's reaction to the examiner and the testing, the test at 3 days was determined to be the better baseline score. The test was conducted at week 5 of treatment to determine whether there was a need to adjust the treatment protocol. The final test was completed 2 days after the final intervention session, with a final score of 121. This total shows a change from 102 at 3 days before the start of the intervention to 121 at the completion of the intervention (95% confidence interval [88.61, 115.39]).
The TAPs-3 index was administered by the blinded evaluator, who was not aware of the type of intervention being administered, according to the study design. This information was kept separate from the data documented or collected by the parent and the other clinician involved in the study. Hence, data from the parental documentation log and the iLs Measure of Foundational Abilities were not included in the discussion of midintervention measurement procedures.
The information in the parental behavioral observation log showed that Joy had consistent challenges with auditory defensiveness. She regularly resisted having her hair dried and covered her ears when exposed to the noise from small appliances and the bathroom fan. The log also showed that Joy regularly showed oral sensory-seeking behaviors, including mouthing her shirt and book (Figure 2).
Results of the parental behavioral observation log of sensory responses. The parental log was completed daily over the 12 weeks of the intervention. For each behavior cited by the parent at the initiation of the study, a log of the number of times that the undesirable behavior occurred was totaled for each week. The Figure shows a sampling of the study weeks, showing the noticeable change in undesirable behaviors to virtual elimination of these behaviors by the end of week 7.
Joy's caregiver rated the following preintervention iLs Measure of Foundational Abilities statements as always: (a) bothered by background noise, loud, unexpected sounds; (b) has difficulty sitting still, wiggles a lot, especially if trying to pay attention; (c) cannot follow directions in a noisy environment; (d) anxious, bites nails, face and body not relaxed; and (e) is distracted easily. The following items were also rated as always: (a) not able to stay on task; (b) has poor short term memory, can't remember sequential tasks; (c) often fails to begin or to complete tasks or projects unless helped; (d) difficulty following what others say; (e) misuses or confuses words and sounds; (f) difficulty with spelling; (g) needs to be given directions repeatedly before responding; and (h) lack of understanding what is said, needs explanations.
In summary, baseline functioning for Joy indicated auditory defensive behaviors, oral sensory-seeking behaviors, challenges with maintaining attention, and difficulty following directions. These issues made it difficult for Joy to socialize and carry out activities of daily living.
After 5 weeks of intervention, the TAPS-3 index of scaled scores was 119, compared with the baseline score of 102, suggesting a slight improvement in auditory processing. Retesting was conducted at the midpoint of the study to determine the need for adjustment in the intervention and to assess alignment or malalignment with the qualitative data; this procedure is in accordance with the typical flow of the OT process. Figure 2 shows a marked reduction in Joy's aversive reactions to auditory input, such as noise from a hair dryer, bathroom fan, or small appliance 5 weeks into the intervention, as documented by the parental observation log.
The postintervention observation log showed that, after the iLs intervention, Joy had fewer instances of resisting use of the hair dryer, decreased instances of putting her fingers in her ears with noise, and fewer occurrences of avoiding the bathroom fan noise. She also had reduced instances of turning the television volume extremely loud and a reduction in the frequency of mouthing items or requesting snacks immediately after eating (Figure 2).
The postintervention iLs Measure of Foundational Abilities clearly showed improvement with sensory and sensory motor skills, with the score for this section dropping from a preintervention Measure of Foundational Abilities score of 26 to a postintervention score of 9. The following two items decreased from always to rarely: (a) bothered by background noise, loud, unexpected sounds and (b) cannot follow directions in a noisy environment. The rating decreased from often to never for the following item: difficulty finding numbers or words on a page. Joy's social/emotional skills score on the iLs Measure of Foundational Abilities decreased from 10 to 4. The score that showed the greatest decrease for this section was for one item: anxious, bites nails, face and body not relaxed. For this item, the rating changed from often to does not apply. For the organization/attention/cognitive section, Joy's score decreased from 18 to 8 after treatment. The ratings dropped from always to rarely for the following two items: (a) has poor short term memory and (b) can't remember sequential tasks. The auditory/language score was cut in half after the intervention, decreasing from 25 to 12.5. Three items changed from rankings of always to rarely: (a) difficulty following what others are saying, (b) difficulty with spelling, and (c) needs to be given directions repeatedly before responding (Table 1).
After 12 weeks of intervention, the TAPS-3 index standard score was 127, compared with a baseline score of 102 (95% confidence interval [88.61, 115.39]), suggesting an improvement in Joy's auditory processing skills from baseline to postintervention. The results of the scores across time are shown in Figure 2.
Results from baseline to postintervention subtest scores are shown in Table 2. With the subtest scores, standard difference, and the reliable change index included in the TAPS-3 manual (Martin & Brownell, 2005), the researchers calculated a Jacobson's reliable change index score for each subtest (Jacobson & Truax, 1991). A score of greater than 1.96 suggests a significant change. These results indicate that the observed changes in the following scores are clinically and statistically significant (p < .05): number memory forward, sentence memory, auditory comprehension, and auditory reasoning.
Test of Auditory Processing Skills-3 Subtest Baseline and Postintervention Scores With Reliable Change Index
The current findings provide preliminary evidence that a 12-week iLs intervention is effective in reducing the symptoms of auditory sensitivity in a child with APD and ASOR. The information from the postintervention observation log shows an overall decrease in ASOR. The parental report of continued improvement in auditory sensitivity at 2 years and 10 months postintervention was called “a life-changing improvement.” During the course of the study, Joy progressed from being intolerant of the hair dryer to drying her hair independently, which is an age-appropriate activity of daily living. Her negative reactions to the noise of the bathroom fan also improved. The results from the parental report mirror the scores on the iLs Measure of Foundational Abilities, showing a clear decrease in auditory sensitivity after the protocol was completed. According to parental report, this change facilitated a decrease in stress at home during activities of daily living and family interactions. This finding is consistent with the results of Wink et al. (2017), which showed that parents reported improvements in family life and the child's social and daily participation after TL treatment.
Before the intervention, the iLs Measure of Foundational Abilities indicated that Joy's social/emotional skills were affected by her inability to tolerate certain types of auditory input. For example, she consistently became anxious and attempted to avoid settings, activities, and interactions that might trigger her auditory defensiveness, and she frequently experienced anxiety. An item on the iLs Measure of Foundational Abilities indicated that Joy always showed anxiety before the intervention; the occurrence decreased to rarely by the end of the treatment period. This result is also consistent with the study of Wink et al. (2017), which noted parental reports of their children appearing calmer postintervention.
The iLs Measure of Foundational Abilities also showed changes in Joy's functional memory, with improvements in short-term memory, following directions, attending during conversations, and completing sequential tasks. These findings align with the results of Schoen, Miller, and Sullivan (2015), who reported that children showed improvement in following directions and timeliness with completing day-to-day tasks after iLs treatment. The decrease in Joy's ASOR likely allowed for better selective attention for tasks requiring memory because she was no longer overwhelmed or attending to the distractions of other noises in the environment, which is consistent with improved scores on the TAPS-3.
A comparison of the participant's TAPS-3 index scaled scores shows improvement in the scores over time. Some of this upward trend may have been the result of a practice effect, especially for items with a phonological focus. If Joy learned or memorized a word during an early test administration, she may have recalled the word from memory on subsequent tests rather than sounding the word out phonetically. Increases in the TAPS-3 index standard scores also may be related to the decrease in Joy's auditory defensiveness over time, which may have allowed her to focus and attend better during the testing sessions, improving her performance. Further, progress made as a result of speech therapy, as was provided before, during, and after the iLs intervention, could have contributed to the gains made, but the speech sessions addressed Joy's articulation issues.
Implications for Practice
The effectiveness of this case study in improving Joy's auditory defensiveness shows the usefulness of auditory training programs for individuals with SPD, independent of other sensory interventions. This opens new possibilities for treatments that differ from typical practice, where sound-based interventions are frequently used in combination with other interventions as opposed to the use of sound interventions alone (Gee et al., 2013). The ability to conduct treatment sessions at home, after an initial training session followed by minimal guidance from the therapist, may provide a level of flexibility that was not present in many earlier studies (Bettison, 1996; Corbett et al., 2008; Gee et al., 2014). However, the prescribing therapist should take care to identify the individual needs of the client when determining the most effective use of auditory training.
Parental reports show the attainment of goals in the child's participation in activities of daily living. Our study is unique in that anecdotal feedback from Joy's mother was obtained well beyond the treatment protocol itself, at 8 months and at nearly 3 years after completion, showing the long-term effect of the intervention. This long-term benefit builds on the evidence of therapeutic benefits for auditory training alone, as seen in the pilot study by Schoen et al. (2015). Further, the significance of the data obtained through parental reporting underscores the importance of the use of narrative accounts and qualitative data captured by researchers and clinicians in addition to test scores and other quantitative information.
The current results cannot be generalized because of the case study design. In addition, the success with a home program that was shown in this study may not translate to similar success with sound-based interventions provided by therapists alone. Use of a standardized measure for auditory defensiveness would have strengthened the study. In addition, a potential testing effect on the specific test items with a phonological focus may have helped to improve the TAPS-3 scores. Finally, asking the child directly about perceived changes may have been beneficial and should be considered for future research.
The current findings show preliminary evidence of a positive effect of a standalone iLs intervention for a child diagnosed with auditory defensiveness. Additional studies of this intervention are needed to substantiate the effectiveness of this treatment.
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iLs Measure of Foundational Abilitiesa
|Sensory and sensory motor|
| Bothered by textures on body, face, or hands, having nails cut, hair combed||1||0|
| Bothered by background noise, loud, unexpected sounds||3||1|
| Avoids movement activities (swings, climbing, playground activities)||0||0|
| Doesn't feel pain, doesn't notice when touched||0||0|
| Avoids eye contact||0||0|
| Unaware of body sensation such as hunger, hot, cold, need to use toilet||1||1|
| Doesn't seem to notice sensory stimuli (smells, noisy crowded places)||0||0|
| Constantly on the move, seeks intense crashing or rough play||1||1|
| Has difficulty sitting still, wiggles a lot, especially if trying to pay attention||3||2|
| Makes disruptive noises or sounds||1||0|
| Has poor balance, fall easily, avoids balance-related activities (bike riding)||0||0|
| Has poor endurance, is weak and gets tired easily, avoids physical activity||0||0|
| Slumps when sits in a chair or on floor, uses arms/hands to support self||0||0|
| Difficulty learning new motor activities or those requiring steps||1||0|
| Clumsy, awkward, accident prone, bumping into people or objects||1||0|
| Difficulty organizing/takes a long time to perform daily life tasks||2||1|
| Struggles with fine motor skills, like handwriting||0||0|
| Dislikes or avoids group sports||2||1|
| Visual difficulty, often loses place, eyes skip one or more lines||1||1|
| Cannot follow directions in a noisy environment||3||1|
| Has difficulty completing puzzles||1||0|
| Has difficulty identifying different sounds or letters||1||0|
| Has difficulty judging force required for a task||1||0|
| Cannot find pictures hidden in background||1||0|
| Difficulty finding numbers or words on a page (esp. math or reading tasks)||2||0|
| Irritable, short-tempered||0||0|
| Easily overwhelmed, frustrated by daily life activities||1||0|
| Does not transition smoothly from one activity to another||0||0|
| Has difficulty making and keeping friends||1||0|
| Does not sleep well, can't get enough rest||0||0|
| Lacks confidence with new environments and new tasks||1||0|
| Has frequent mood fluctuations||0||0|
| Is not affectionate, not touching or hugging||0||0|
| Is needy, lacks independence, low self-reliance, low self-esteem||0||0|
| Lack of tactfulness, acts impulsively||2||2|
| Response to situation appears immature for age||2||1|
| Anxious, bites nails, face, and body not relaxed||3||1|
| Is distracted easily, not able to stay on task||3||2|
| Has poor short-term memory||3||1|
| Must re-read schoolwork several times to comprehend||2||1|
| Has difficulty finding clothes, getting dressed in the AM||0||0|
| Planning ahead is difficult, prefers to avoid planning at all||2||0|
| Disorganized with school assignments, belongings, schedule||2||1|
| Can't remember sequential tasks – e.g. do A, then B, then C||3||1|
| Often fails to begin or to complete tasks or projects unless helped||3||2|
| Difficulty following what others are saying||3||1|
| Misuses or confuses words and sounds||3||2|
| Needs instructions repeated, needs visual cues (What? Huh?)||2||1|
| Difficult to understand, can't speak clearly||1||0|
| Difficulty with spelling||3||1|
| Unable to recognize or repeat rhymes or songs||1||1|
| Does not like to sing or hum||0||0|
| Difficulty interpreting tone of voice – e.g. angry vs. joking||1||2|
| Tendency to ramble, can't “get to the point”||2||0|
| Poor grammar, doesn't speak in complete sentences||2||2|
| Mumbles, has monotone voice||0||0|
| Slow to react to speech||1||0|
| Needs to be given directions repeatedly before responding||3||1|
| Lack of understanding what is said, needs explanations||3||1.5|
Test of Auditory Processing Skills-3 Subtest Baseline and Postintervention Scores With Reliable Change Indexa
|Behavior/response||Baseline score||Follow-up score||Difference in scores||Standard difference||Reliable change index|
|Number memory forward||18||23||5||2.19||2.28*|
|Number memory reversed||8||10||2||2.63||0.76|