Utility of deficit-specific computer-based training on children with temporal processing deficit

Abstract

Purpose

Children with temporal processing deficits struggle to detect and discriminate syllables, phonemes, and stress patterns in speech. To overcome these deficits, computer-based auditory training programs have been widely used as one of the rehabilitation alternatives in recent years. The present study aimed to examine the usefulness of one such computer-based temporal processing training (CBTPT) module on children with temporal processing deficits.

Method

Sixteen children (8–15 years) with temporal processing deficits were enrolled in the study, further divided into active (CBTPT) and placebo (placebo training) groups. Further, 8 typically developing children (no training) were enrolled as a comparison group. The auditory outcome measures included Duration Pattern Test (DPT), Gap Detection Test (GDT), Dichotic CV (DCV), and Speech-in-Noise-Indian English (SPIN-IE) assessed before and after training for all three groups.

Results

Wilcoxon-sign rank test showed a statically significant difference between pre and post-test scores of DPT, GDT, and SPIN (p < 0.001) except DCV among the active group. However, no significant differences were noted in the pre and post-test scores among the placebo and TD groups. Mann Whitney U test showed a significant difference in DPT and SPIN post-training scores between active and placebo groups; active and TD group; placebo and TD group.

Conclusion

From the above finding, it is inferred that the CBTPT module is useful among children having temporal processing deficits.

Introduction

Central Auditory Processing Disorder (CAPD) is defined as the perceptual processing deficit of auditory information in the central auditory nervous system (CANS)and the neurobiological activity that underlies the processing. The deficit is in the neural processing of auditory information in the CANS, but not due to high-order language or cognition [1]. In India, it is estimated that 0.5–7% of school-aged children are affected due to CAPD [2]. The central auditory nervous system codes binaural information (lateralization &localization), and temporal cues (pattern & order) in a speech stimulus and also decodes speech in the presence of competing noise [3]. Among all the central auditory processes, temporal processing is one of the most affected processes [4]. Temporal processing abilities are essential for detecting and discriminating syllables, phonemes, and stress patterns in speech [5]. Disruption of temporal processes can affect the recognition and usage of prosodic aspects of speech. One of the management strategies used for temporal processing deficit is Auditory training (AT). Auditory training methods can help in overcoming processing deficits by bringing changes in the central auditory system due to the malleable and plastic nature of the same.

Auditory training improves the function of auditory processing deficit by directly targeting the specific central auditory processes [6]. It also improves the temporal processing ability of an auditory signal with repeated auditory experience, which brings a change in the auditory brainstem structure [7, 8]. Until recently, there have been some of the non-commercial auditory formal or informal training methods employed for targeting different processing deficits. There are shreds of evidence in the literature showing an improvement in the auditory processing skills of children with CAPD after the auditory training [9, 10]. Other researchers have also shown better improvement when the training was focused on the deficit-specific process [11, 12]. Due to the evolution of technology, to provide easy access to diagnosis and treatment, tele-mode of assessment and rehabilitation has taken over in recent years.

In recent years, computer-based training programs have come to light and are widely acceptable among children. An indication that individuals of all ages are interested in adopting interactive computer programs for learning is the abundance of applications that teach phonetics, vocabulary, academic curriculum, etc. Recently for training individuals with CAPD, computer-based auditory training programs have been implemented and have shown a positive effect on the auditory process [13, 14]. There is published literature on computer-based training programs that demonstrate improvements in auditory processing deficiencies as a result of training, including (1) Fast ForWord [15] which is an auditory language-based software targeting phonological awareness and temporal processing, (2) Earobics [17] similar to Fast ForWord but also targets auditory closure, (3) Listening in Spatialized noise-test (LiSN) [18, 19] targeting spatial processing and auditory closure, (4) Sound auditory training [6] focusing on temporal processing, binaural integration, binaural interaction, and auditory closure, (5) Zoo Caper Skyscraper and Insane Earplane programs [20]. The above training program utilizes both language-specific verbal and non-verbal stimuli, which limits the universal uses of the module. Further, there are limited numbers of CBAT module that focuses on temporal processing. Hence, the present study aimed to find the utility of computer-based temporal processing training (CBTPT) among children with temporal processing deficits using behavioural CAPD measures.

Method

A total of 1180 school-going children aged between 8 to 15 years were initially screened for children at risk for CAPD based on a screening checklist of auditory processing (SCAP) [21] questionnaire and screening tests for auditory processing (STAP) [22]. There were 147 children out of 1180 identified at risk for CAPD based on SCAP and STAP. Out of 147 children, 17 children were confirmed with the diagnosis of CAPD with temporal processing deficit based on detailed CAPD diagnostic tests (Fig. 1). The diagnostic criteria for CAPD used in the present study were based on ASHA (2005) (1) recommendation. The 16 children with temporal processing deficits were randomly assigned in equal numbers to the CBTPT (Active) group (mean age: 12.25 ± 1.03 years) and placebo training group (mean age: 12.38 ± 0.91 years). In addition, 8 typically developing (TD) children (mean age: 12.75 ± 0.88 years) were recruited as the standard group for comparison with the active and placebo clinical group. There was no statistically significant difference observed between active, placebo, and TD children in terms of age.

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Fig. 1

Flow chart representing the study method. BLST Bankson Language Screening Test, ERS Early Reading Skill, MMSE Modified Mini-Mental State Examination, GDT Gap Detection Test, DPT Duration Pattern Test, SPIN-IE Speech Perception in Noise-Indian English; DCV: Dichotic CV

All 24 children had hearing thresholds ≤ 15dBHL across 250–8000 Hz frequencies with speech identification scores of 80% or higher in quiet; had 'A' type tympanogram with reflexes present below 100dBHL at 500 Hz, 1000 Hz and 2000 Hz; had presence of (SNR more than 6 dB in between 500 to 4000 Hz) transient evoked otoacoustic emission indicating normal outer hair cell function; had normal absolute latencies and inter-peak latencies on click-evoked ABR testing ruling out retro-cochlear pathology. In addition, reading (, language, and cognitive skills were assessed and the mean scores for the same are represented in Fig. 1 for active, placebo, and TD groups.

The present study included baseline evaluation where scores for duration pattern test (DPT) [23], gap detection test (GDT), speech perception in noise test in Indian English (SPIN-IE) [24], and dichotic CV test (DCV) [25] were obtained for all the subjects before initiation of training (Fig. 1). All the CAPD test materials were presented from the Dell-Inspiron all-in-one desktop via the TDH-39 headphones, which were routed through the calibrated two-channel GSI-61audiometer. All the above audiological tests were performed in sound treated room (ANSI S3.1 1991 [R2013]). The study was approved by the institutional ethical committee (DOR.9.1/ PhD/NM/913/2021–22) and written consent was obtained from each participant/ caregiver after explaining the procedure and purpose of the study.

Computer-based training module

A computer-based temporal processing (CBTP) training module, developed by Kumar and Singh (2020) was used in the current study. The temporal-based training module includes two sets of training activities i.e. duration pattern/ordering and gap detection training with choice-based closed set task changing in adaptive mode. The 3-alternate forced choice approach was used to present the gap detection training tokens with gap duration varying between 30 to 2 ms. There are a total of 17 levels and each level includes 10 trials. The module was interactive and adaptive. Similarly, the duration pattern training includes recognition of the pattern of the tones heard. Each level consisted of 10 trials. The short tone was 250 ms which was constant across the tokens whereas the duration of the long tone was 500 ms and varied up to 325 ms with the step size of 25 ms. The baseline was obtained before performing actual duration pattern training to set the initial level. The cutoff score to move from one level to the next level set by the developer was greater than 80% score.

The CBTPT was provided twice a week and each session lasted for 30 min. The placebo group was also exposed to the computer game (not deficit-specific) for 30 min per day and twice a week. The total number of sessions attended was between 7 and 10 sessions for the active as well as placebo groups. Whereas, TD children were informed not to engage in any computer-based game during the study period.

Statistical analyses

The recorded data were tabulated and analysed using IBM SPSS Statistics (Version 20.0) (IBM Corp., Armonk, NY, USA). Descriptive statistics were done to obtain the mean, median, and standard deviation (SD) of the different CAPD tests (DCV, GDT, DPT, & SPIN-IE) before and after temporal-based training for each group (Active, placebo& TD). To observe the distribution of data, the Shapiro–Wilk test of normality was performed. Since the normality test result revealed a non-normal distribution of the data (p < 0.05) and hence non-parametric test was done. To compare the pre and post-test scores in each group, the Wilcoxon-sign ranked test was executed. To estimate the effect size (r) between pre and post-evaluation in each group, the following equation was used r = Z/ √ N (in which ‘Z’ is the Wilcoxon-sign ranked test and ‘N’ is the total number of samples in the study). Mann Whitney U test was done to compare between groups (Active versus Placebo; Active versus TD; Placebo versus TD) for post-temporal based training.

Results

Within-group comparison (Active, Placebo & TD children)

In the active group, the mean GDT score had reduced (improved) and the mean DPT score had (increased) improved after CBTPT respectively. However, the mean score of GDT and DPT in the placebo and TD group did not vary majorly as shown in Fig. 2A, B. Further, the Wilcoxon-sign rank test showed a statistically significant difference between before and after CBTPT scores for GDT and DPT for the active group. However, the Wilcoxon-sign rank test did not show a statistically significant difference between the before and after evaluation in the placebo as well as TD group for GDT and DPT as shown in Table 1.

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Fig. 2

A depicts the GDT mean scores; B depicts the DPT mean scores; C depicts the SPIN-IE mean scores; D depicts the DCV mean scores of pre (blue) and post (green) evaluation in active, placebo and TD group; *p < 0.01

Table 1. Mean, Median, and standard deviation of CAPD test scores across the group

Groups	Tests	Pre-training scores			Post-training scores			Z-Value	p-value	Effect Size (r)
		Mean	SD	Median	Mean	SD	Median
Active	GDT (ms)	5.27	4.70	3.58	3.14	1.02	2.70	– 2.68	0.007**	0.95
	DPT	12.63	4.80	10.50	18.25	5.03	17.00	– 3.52	0.001**	1.24
	SPIN-IE	11.63	3.14	10.50	18.38	3.92	20.00	– 3.41	0.001**	1.20
	DCV	11.25	2.31	11.50	13.38	4.65	15.00	– 1.43	0.153	0.50
Placebo	GDT (ms)	3.94	1.34	3.58	3.84	1.45	3.48	– 1.43	0.152	0.50
	DPT	13.38	5.15	15.00	13.50	6.45	13.00	– 0.71	0.475	0.26
	SPIN-IE	15.50	4.84	14.50	15.38	3.99	16.00	– 0.23	0.812	0.08
	DCV	11.38	3.20	11.50	11.88	3.35	12.50	– 0.84	0.398	0.29
TD	GDT (ms)	3.69	0.59	3.59	3.16	0.79	2.95	– 1.10	0.268	0.39
	DPT	26.00	2.00	26.00	26.17	2.13	25.50	– 1.58	0.112	0.56
	SPIN-IE	21.83	1.83	21.50	23.00	1.26	23.50	– 1.90	0.057	0.67
	DCV	13.17	2.22	14.00	16.67	4.41	16.50	– 1.61	0.107	0.57

GDT Gap Detection Test, DPT Duration Pattern Test; maximum possible score for DPT = 30, SPIN-IE Speech Perception in Noise- Indian English; maximum possible score for SPIN-IE = 25, DCV Dichotic CV test; maximum possible score for DCV = 30; *p < 0.05; **p < 0.01

Among other CAPD tests such as SPIN-IE showed a greater mean score after training in the active group as shown in Fig. 2C. Further, the Wilcoxon signed rank test showed a statistically significant difference between pre and post-training SPIN-IE scores for the active group as shown in Table 1. Whereas, the test did not show a significant difference between the baseline and after one-month evaluation for the placebo and TD group (Table 1).

For the Dichotic CV test, the Wilcoxon sign rank test did not show statistically significant differences between pre and post-training scores for the active group, placebo group, and TD children as shown in Fig. 2D (Table 1).

Between-group comparison (Active, Placebo& TD group)

Mann–Whitney test was done to compare the groups (Active, placebo& TD group) for post-training scores. The post-training mean scores between the active and placebo group showed statistically significant differences for DPT (Z = – 2.75, p = 0.006) and SPIN (Z = – 2.48, p = 0.013) except DCV (Z = – 1.22, p = 0.222) and GDT (Z = – 1.20, p = 0.227). Further, post-training scores between the active and TD groups showed statistically significant differences for DPT (Z = – 4.11, p = 0.001), and SPIN (Z = – 3.81, p = 0.001), except DCV (Z = – 0.79, p = 0.426), and GDT (Z = 0.23, p = 0.812). Similarly, post-training scores between placebo and TD group children showed statistically significant differences for DPT (Z = – 4.17, p = 0.001), and SPIN (Z = – 4.48, p = 0.001), except DCV (Z = – 1.48, p = 0.130), and GDT (Z = – 1.11; p = 0.267).

Discussion

Effect of CBTPT module on temporal processing deficit

The present study compared the pre- and post-training CAPD test scores to evaluate the utility of the CBTPT module on children with temporal processing deficits. The results showed that the temporal processing (DPT & GDT) test scores significantly improved after 7–10 sessions of deficit-specific training using CBTPT in the active group. However, significant changes in the temporal processing domain were not noticed among the placebo group and in the TD group. These results are in line with previous studies that have shown an improvement in temporal processing tasks after deficit-specific intervention in children with CAPD [4, 16, 20, 26, 27]. Studies showed better scores on PPT [4, 20, 26], DPT, GDT [16, 27], and GIN [4] post CBAT on children with CAPD. These improvements in temporal processing scores can be attributed to auditory learning-induced due to training [28], reorganization of the auditory cortex [29], maturation, and neuroplasticity [4]. Repeated stimulation used in the CBTPT module probably led to the strengthening of the neural responses over a period in the auditory pathway and could also be retained due to long-term potentiation. This long-term potentiation could lead to a change in the neurons which in turn are reflected as a change in the scores of CAPD tests post-training.

The training module used in the present study was similar to the one mentioned in Ahmed et al. [26] and Moses [20] studies in which they used non-verbal stimuli for temporal-based training in a game format. Whereas Tawfik and colleagues did not focus on deficit-specific training, instead their design focused on the overall auditory process improvement. They used verbal as well as non-verbal stimuli for the training [4].In a similar line, Kumar and colleagues considered deficit-specific training focusing on speech perception in noise using verbal stimuli, but the improvement was also noted in other domains such as temporal processing skills [16]. These changes indicate that computer-based training modules are effective in improving the deficit-specific auditory processing changes among the younger population compared to the traditional approach. Incorporating non-verbal stimuli for training instead of verbal probably can eliminate the language barrier for a temporal-based training module as considered in the present study.

Effect of CBTPT module on other auditory processes

Statistically significant improvement was also noted for the SPIN-IE scores post-training among children in the active group. Similarly, a study by Ramezani and colleagues showed an improvement in the scores of SPIN after temporal processing-based training [30]. The training was based on sequencing skills and temporal resolution, which is similar to the training modules (duration pattern training & gap detection training) used in the current study. Adding to the literature, training programs focusing on improving pitch perception, including fundamental frequency [31, 32] and harmonics training [33] have shown improvement in SPIN along with pitch perception. On the contrary, Kumar et al. (2021b) showed an improvement in temporal processing skills along with SPIN scores after noise desensitization training. The noise desensitization training focused on the SPIN deficit but the positive impact was also noted on other central auditory processes such as temporal processing skills [16]. This can be attributed to the ability of temporal processing in our auditory system which helps in processing the minute auditory changes over time. This ability comes into action during the perception of speech in the presence of noise by utilizing the dips in background noise and assembling the pieces of fragments of the target stimuli [34, 35].

The present study result showed that there was no statistically significant difference between pre and post-test scores of DCV in all three groups (active, placebo& TD). This could be because the score of the DCV test was within the normative range before training for the majority of the subjects and hence there were no changes noted post-training. The placebo group was used in this study to understand whether placebo training rather than deficit-specific training is effective in this population or not. The placebo group (placebo training) did not show a significant difference between the pre and post-evaluation of the CAPD test.

The present finding is in agreement with the literature showing no improvement among the placebo group pre and post-placebo training [36, 37]. This indicates that the improvement observed in these children with temporal processing deficit of the active group is only due to CBTPT (deficit-specific training) and not because of placebo training or, other non-audiological factors such as attention, or any visual-based training. In addition, the typically developing group was considered for a standard comparison purpose and helped in monitoring the test–retest effect, and changes if any consequences of the maturation or developmental changes over the period in these children [38]. Therefore, based on the CBTPT efficacy, it is observed that only the deficit-specific training led to the changes in performance which were statistically significant in comparison to the placebo training and without training for the TD group.

Between group comparison (Active, Placebo& TD group)

The children diagnosed with temporal processing deficits were included in the active and placebo groups. The CAPD test results of the groups before training did not differ significantly from one another. However, the mean score of the active group on DPT, GDT, and SPIN-IE was found to be greater than that of the placebo group following CBTPT in the active group. This indicates that there is an effect of deficit-specific training on CAPD. The study is in line with ElShafaei and colleagues [39] study that assessed 52 children with CAPD with dyslexia. These children were randomly assigned to a ‘differential processing training program’ (DPTP) and a ‘computer-based training program” (CBTP) which included components of temporal-based tasks. The results showed that there were significantly higher scores on PPT and DPT seen in children who underwent CBTP compared to DPTP [39]. There are constrained shreds of evidence on CBTPT studies; hence we compare the outcome with the deficit-specific auditory training. The results of the present study are in agreement with Maggu and Yathiraj (2011) [16] study where they considered 10 children diagnosed with CAPD who were randomly assigned to experimental and control groups. The experimental group in the study underwent temporal-deficit training. The results of the study showed a significant improvement in the test scores of DPT and RAMST in the experimental group compared to the control group post-training. The improvement was due to temporal-based training and also the authors concluded by stating that direct remediation is essential to focus on the target process affected. Overall, this indicates that the CBTPT has effectively shown improvement in the active group.

Between-group comparisons showed that there were significant differences between the active versus placebo group (for DPT& SPIN test scores); active group versus TD group (for DPT & SPIN test scores); and placebo versus TD group (for DPT & SPIN test scores). In contrast, Strehlow and colleagues, who assessed children with dyslexia with temporal processing deficits, did not show a significant difference between the dyslexia group and the normal group. The authors used a CBTP consisting of a temporal training program and a phoneme training program [40]. The difference in results seen could be attributed to the difference in sample, and the training module used and also might be due to the shorter duration of training in the present study. Though there was an improvement in the mean scores of DPT, GDT, and SPIN-IE in the active group, these scores are yet to reach within the normative range. However, the lesser number of sessions, and small sample size in the present study limits the generalization of the results. Further validation on a larger sample and a longer duration of training is required before implementing the present finding.

Conclusion

The present study highlights the improvement observed in temporal processing abilities using a computer-based training module in CAPD children having temporal-based deficits. This also reflects the importance of deficit-specific intervention among CAPD children. The similar performance among placebo and TD groups further strengthens the importance of the computer-based training module used in the study.

Acknowledgements

We would like to thank the Director, of All India Institute of Speech and Hearing (AIISH), Mysore for permitting us to carry out this study. We also would like to thank the Head of the Department of Audiology for providing the necessary support to conduct the research. The authors would also like to thank the Department of Science and Technology (DST) Govt. of India for the CBTPT module. We would like to thank all the participants for their valuable time and co-operation.

Author contributions

Ms. Nayana M: She was involved in the design of the study, data collection, statistical analysis, and writing the manuscript. Dr. Prawin Kumar: He was involved in the design of the study, statistical analysis, correction of the manuscript, and overall supervision in finalizing the manuscript.

Declarations

Conflict of interest

The authors have no conflict of interest to disclose.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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