In the News
Hail to Our Professors
I was returning from a workshop and used my time on the plane to begin my EAR column for this issue.
It was going to be what I regretted not having taught. The title was based on the saying, “Learning Never Shared Is Knowledge Stolen”.
My first regret was that, I think very few of my former students incorporated what I called the ‘sweep up” puretone threshold technique
even thought the resulting thresholds are essentially the same as with the typical approaches and it takes much less time. First, I start testing
at 8,000 Hz and work my way down. I indicated that this was because of my former professor Dr. Aubrey Epstein who explained that …
Eventually I gave up on the idea for the column because it got quite long and wondered whether it was a good venue for this topic.
When I got home I learned that my mentor Aubrey Epstein had died the day before at the age of 87. He was an extraordinary
human being and an extraordinary professor and an equally good audiologist. Perhaps it was fated that my previous idea did not
work out as an article about Aubrey might be quite interesting for the readers and certainly very appropriate.
Nature permits us to remember a lot of new things and to focus in on a narrow task as an older child and young adult.
But as we age our short-term memory tends to become weaker and our perspective becomes broader. Some people
say that is the reason older folks tend to become wiser. We fall back on our long term memory and consider the wider
view of the question at hand. Perhaps this explains why in more recent years I have been thinking more and more about
my old professors and how much I benefited from their teaching, philosophy and their stories. During my earlier years as
I was working on various projects I honed in one the specific topic at hand and not on the broad view. I used the information
that I had but did not think about who taught me that. Only as I have gotten older have I recognized how much I learn and
applied what my professors had handed me. For example, Dr. Robert West, who was the first ASHA president, one of the
first speech and hearing professors and the author of one of the earliest textbook was my first professor in the Introduction
to Speech Correction (or some such title back in 1954). He was a fascinating professor who taught us a great deal. Although
those who were “in the know” taught that everything is psychological. Autism was caused by lousy mothers, stuttering was
caused by demanding parents etc. Dr. West was of the opinion that the major factor was the central nervous system especially
the brain. He said that some people were more predisposed to stuttering than other, but that life situations could cause the
problem to emerge. His detractors scoffed at him but he was undeterred. Later on when I began to work with APD the brain model
was an easy step for me. Even the life experience part was so logical as the issues we encountered seemed to be so treatable.
That is, the brain and conditions led to the problems and the brain and conditions could lead to correcting the problems. But I am
sure that I did not make the connection between what Dr. West had taught just 4 years before. Only as I look back now (and for the
past few years) do I see the obvious connection.
My Mentor Aubrey Epstein
A graduate student mentioned all the great and famous professors in their Speech and Hearing Department at Pitt. When I
got to the university for my Ph.D. none of the famous ones were very helpful to my education and strangely some stood in
the way of my progress. I was primarily interested in speech but took two Audiology courses from Dr. Epstein, whom I had
not previously heard of. I found his classes fascinating and closely linked to underlying factors that I needed to understand
the material and to remember it. When many of the professors laughed at my ideas about Phonemic Synthesis as an important
tool for helping those with articulation problems and my desire to study it as part of my program (when everyone knew these
problems were psychological and could be corrected by non-directive counseling and not something as foolish as auditory training),
I decided to switch to Audiology. If Aubrey had not been there I would have gone to another university to continue my education in
Speech Pathology. So going into Audiology I owe to him.
I don’t remember him depending heavily on notes.
He just spoke pretty much extemporaneously telling a story as one topic led to the next and the wonders of science
were revealed in what he had to say. He never said a bad word about anyone, he just said what he thought was correct
and why. He was perfect for my learning limitations. He spoke slowly and clearly and drew diagrams on the board.
His exams were thought to be tough but if you understood the context of the phenomena the exams were kind of fun
and not that hard. Clearly, his style of teaching was perfect for me.
Dr. Epstein was an audiologist at a Hearing Society
that served mostly adults with hearing losses and perhaps at other facilities. Where he picked up his approaches and
procedures I do not know but I have never seen an audiologist like him. On the first day of clinic before he let us test a
patient he tested the first one to show us how he would do and how he would analyze the results. He looked at the audiometer
for a few moments and then in a slow motion turned the dial to the first frequency and then in an equally slow manner set the
intensity dial to where he wanted to begin. Then with some deliberation he pressed the presenter button to deliver the tone and
waited for a response and then after a brief delay he reset the intensity dial. It was as thought we were watching grass grow.
But as soon as he dismissed the patient he turned to us and said, “Now let me tell you about this patient”. He had only done
puretone testing (if I recall correctly), what could he possibly tell us that we did not see for ourselves?
* * * * * * * *
This interview was from 2005. My attitude has not changed in the 6 years since.
Getting to Know Jack Katz
In this issue of the EAR, I am delighted to introduce you to a new columnist. He is someone we all know of, but most know little about. Dr. Jack Katz has agreed
to write a column focusing on auditory processing disorders to discuss his work and research efforts for which he is recognized worldwide.
Best known as Professor Emeritus at the University at Buffalo in New York, Dr. Katz is also the distinguished editor of The Handbook of Clinical Audiology,
and developer of the popular SSW test.
When speaking with Dr. Katz, I realized that he is passionate about audiology and about helping others, especially other audiologists. I anticipate his columns will
be informative, fascinating and encouraging. I was completely privileged to visit with Dr. Katz and ask him a few questions for the EAR. Now we can all get to know
him better, after all, we all have that handbook!
Let’s start with the basics, where did you get your degrees?
I received my Bachelor’s degree from Brooklyn College in Speech with an emphasis in Speech and Hearing, a Master of Science degree in
Audiology and Speech Pathology at Syracuse University in New York, and later my Ph.D. in Audiology from the University of Pittsburgh, Pennsylvania.
What do you think of the AuD movement?
I love it! I believe it is one of the most important things that has happened to our profession in the past decade or more. For the long-time
audiologists going back for the Au.D. it has been so very positive as they have gotten up-dated and often branch into new clinical areas.
It seems to have kindled some research and development interests as well. I believe the regular Au.D. graduates have a broader and
deeper understanding of audiology when they get out than their predecessors. But what is more impressive as a group they seem to
have a great enthusiasm for this work and the opportunity to help others. I suspect that the NAFDA organization has been a positive
influence in this regard.
What originally peaked your interest in the speech and hearing professions?
When I was a senior in high school my English teacher suggested that I look into Speech & Hearing as a possible career choice. Wow, what a great
suggestion Miss Carlton gave me back in 1948. Once I learned about this gratifying and exciting field I never looked back (to biology).
Although I have worked as a Speech and Hearing Therapist and then as an Audiologist for over 45 years, I have never lost my interest or enthusiasm.
What inspired you to edit The Handbook of Clinical Audiology?
I was on vacation (ca 1969) and decided to do some writing. But for each topic I decided to write about I lacked critical information. I thought what we need in
audiology is a handbook where you can have all the basic information available. “Hmmm” I said to myself, “that’s a good idea!” Then I wondered who would I
like to write a chapter for me? I’d love to have Neil Goetzinger write a chapter on word recognition and Bill Hodgson to write one on evaluating young children… and so it went.
It turned out that what the contributors wrote was also of interest to many others in the field (although I must admit it was originally a selfish choice of authors).
I had the second edition in my Master’s program, it is now in what edition?
We (Bob Burkard, Linda Hood, Larry Medwetsky and I) are now working on the 6th edition.
Tell me more about the developments of the Staggered Spondaic Word (SSW) test for processing disorders.
The test is now 45 years old and is still one of the most widely used APD tests. I believe it has remained valuable because
we had many years to develop it and so many people have used and contributed to its development and acceptance. The SSW
has had important additions both in scoring (e.g., qualifiers) and as well as in the methods of analysis (e.g., NOE). The third (of 5)
versions, List EC, is still the best one because it has the simplest words, does not have a great signal-to-noise ratio, has less than
highest quality recorded speech plus the staggered presentation and everything is counterbalanced. Despite these minor challenges
it is quite an easy task for normals but often quite difficult for those with APD. It took us years to puzzle out what the SSW was telling us.
In his spare time, Dr. Katz edits (now with three colleagues) a newsletter for professionals dealing with APD called SSW Reports. This quarterly
publication deals with diagnosis and rehabilitation issues and even features “Dear Ackie” who tries her best to field questions from professionals
and the public. To subscribe for 2-years ($15) contact Nancy Stecker at 122 Cary Hall in Buffalo, NY, 14214.
Can you briefly describe the Buffalo Model?
I’ll try. The Buffalo Model is a total approach to Auditory Processing Disorders (AP) that can be considered from many
standpoints starting with anatomical-physiological, central test battery, test signs, CAP categories, as well as recommendations
for management/therapy. Because one can go from any level in this model to any other level we refer to it as a coherent approach.
The Buffalo Model is strongly grounded in research and clinical experience over the years starting in the 1960’s. For example, so far as I know it was the first APD test to have norms for children (1965). Currently all diagnostic factors for APD have statistical norms. We obtained great insights into what the test was telling us from the site-of-lesion research and mapping out the SSW regions of the brain. Over the past 25 years the emphasis has been almost exclusively on APD and not brain damage. For example, Katz & Smith (1991) tie the site-of-lesion work and APD together and Katz (1992) provides information about the Buffalo-Model Categories.
Where do you reside now?
We now live in the Greater Kansas City area, where we enjoy being close to our children and grandchildren.
How do you spend most of your time?
My professional time is divided between my private practice, writing, research, and presenting. Initially when we moved
here I found the Kansas City area to be underserved in the area of APD, so at the age of 70, I opened my own private practice;
specializing in auditory processing testing and therapy. I also work with students and teach a bit at the University of Kansas
as a Research Professor. Frankly, it is not how I envisioned retirement, but I wouldn’t change a thing.
What kind of research are you doing?
Having day-to-day responsibility for my patients has brought to light new research needs. Am working on some new diagnostic
procedures for refining our current information and new therapeutic options to broaden our assistance.
At what age can children be tested for auditory processing disorders?
I prefer to work with them early as possible and test them by age five. That is ideal right now with our current test in order
to take advantage of neuromaturation and to reduce the academic and communicative struggle these children experience.
Any child who is at risk at 2½ to 5 years of age is likely to have a very significant APD so the sooner we can evaluate them
and start needed habilitation the better. Even before the age of five, parents and others can be working with children in developing
better auditory skills. Although this exposure may make later evaluations somewhat more challenging for the audiologist it is too
important to put off. The importance of early identification and training is no different for the child with APD than for the hard of hearing child.
The special focus of this issue of the EAR is working with other professionals. What words of advice do you have based on your experience
about working with other professionals?
I’m sure that my experience is similar to others working with those who have auditory problems. Many of the children we work with have
multiple problems and sometimes rather complex problems and occasionally present with problems with which we have little experience.
If you want to be successful and help these patients then referrals to other professionals is necessary. I often refer to speech-language
pathologists (for obvious reasons), and when the children present with otitis media they are referred to an otolaryngologist or family physician.
In addition, children benefit from psychologists, allergists occupational therapists specializing in sensory integration and psycho-education
specialists. I also refer to other audiologists who have expertise or equipment that I lack.
Of course those of you who work in the schools have a much simpler task as you can refer among yourselves, although I have heard that this
differs from school to school or system to system. Referrals to others is like developing “group genius”. Often we are not able to resolve a child’s
issues all by ourselves, but working together we can all look very smart. Having a good relationship and knowing what the others do enables us to
plan effectively. If our colleagues do not know what audiologists do and vice versa you can be sure there will be miscommunication and problems.
Do you have any suggestions for correcting such a problem?
Through education we can correct many problems. The best approach is to educate everyone! I started with my receptionist before I had any patients so she
knew who we work with, what we do, and what we can’t do. I try to educate each parent and even the kids that I see for evaluations or therapy. More about
that in a future column. Of course educating colleagues is critical. Offer to do an in-service, speak to professional groups, hospitals and your own school
personnel or parents. Another way to communicate is to have lunch with other professionals and also teach while you “staff” a child.
Does this mean other professionals are your best advocates?
No, actually the parents are my best promoters. Once their child improves, they want to reach out to other families and
help them.
What do you anticipate for the future of audiology?
If I could just focus on one aspect I would mention rehabilitation. We started as a rehab field during WWII and got as far away as we
could for next 25-30 years during the important period of test development. Only when audiologist began dispensing did the emphasis
begin to shift back. Each year we see more and more audiologists dispensing, counseling, providing cochlear implant services, as well
as tinnitus, APD and vestibular training. There is even a return to lipreading and auditory training with the hard-of-hearing. No doubt this
trend toward greater involvement in rehabilitation will continue. This will make audiology stronger because we will be providing additional
and even better services.
To learn more about Dr. Katz, log on to his website at JackKatzPhD.com.
* * * * * *
Are Auditory Memory and Auditory Organization Part of Auditory Processing?
At the excellent Summer Conference of EAA in New Orleans an audiologist said to me that she was thoroughly confused – are auditory
memory and organization part of auditory processing or not? She said that some authorities are suggesting that they are not part of auditory processing.
The Questions
1. Because auditory memory is processed along with other sensory modalities (pan-sensory) should it be excluded as an auditory processing concern and
thereby not specifically relevant to audiology?
2. If organization of auditory information is an output (or efferent) function does that mean that it is not part of auditory processing and therefore not of
specific concern to audiology?
These are important questions because they reflect on our scope of practice and the work that we do with our patients. Anytime we relinquish a piece
of our profession we must make sure that it is for both important and valid reasons and that there is a professional consensus regarding the exclusion.
Once cutting it loose it may not be so easy to reclaim. As Teri Bellis aptly pointed out at the conference, neuroscience and cognitive science are continually
changing the way we think so what we believe is true today may not be what we believe tomorrow.
My Take on the Auditory Memory Question
Part of the processing of auditory memory is pan-sensory (e.g., processing in the hippocampus) but it surely begins as auditory signals.
So I would not discard auditory memory simply because beyond the auditory part it may be processed in many other ways. There are
other important considerations, as well, why we should consider auditory memory as part of auditory processing and part of the scope
of practice of audiology. The audiologist can test for auditory memory problems and then, most importantly, the audiologist can do
therapy for auditory memory and thereby improve this vital function. Following therapy; test scores improve and we see carryover into
the child’s education and communication.
As mentioned in my recently published book (Katz, 2009); I got into auditory memory work unhappily. I could find no one in my community
who was doing this work. And when I recommended memory training invariably the parents did not follow my directions and the SLPs, to whom
I referred the children, did not do it either (although some taught useful strategies). So despite my own major auditory memory limitations I began
to give the therapy myself. Not only have the children improved their auditory memory skills, but miracle of miracles, my own auditory memory has
improved at age 75. I presume that this improvement is from simply notating the children’s responses. Why did I not try it out before?
From my point of view, if we can improve auditory memory by basic auditory training (without resorting to strategies or compensations)
that is most critical. It’s the bottom line for me and, I think, for audiology as a helping profession. I don’t know if you can improve auditory
memory by purely visual or other means, but I do know that auditory training works very well. If some audiologists care to ignore auditory
memory it would be unfortunate because this is one of the most important auditory functions that we have and this problem can be ameliorated
by auditory training. When memory is improved it makes a difference in the lives of our clients.
My Take on the Auditory Organization Question
What are the audiologists referring to when they discount organization? For example, in the Buffalo Model the most important aspect of the Organization
category is auditory sequencing; in the form of word or sound reversals. If auditory sequencing is being written off because it is an output or efferent function
this is also an overgeneralization that will unnecessarily limit our scope of practice. Here is my background with auditory sequencing.
I was not aware of the work of Alexander Luria or Robert Efron when I started studying auditory reversals on the SSW test in the early 60s.
However, when those investigators used their techniques and I used the SSW test it turned out that there was considerable overlap in where the
lesions were located in our brain damaged patients (see Katz and Pack, 1975, p.99). Using the SSW the greatest number of reversals were in the
Rolandic region of the brain and commonly, but to a lesser extent, the anterior temporal lobe (Katz and Pack, 1975, pp. 102-3). This is in agreement
with the sequencing regions noted by both Luria (1970) and Efron (as cited by National Advisory Neurological Diseases and Stroke, 1969). Importantly
Efron also located a visual reversal region more posteriorly in the brain. Clearly if reversals behaved as if they were completely pan-sensory then auditory
and visual sequencing would involve the same regions of the brain. Obviously, there are important elements that are not pan-sensory, but rather are unique to
each modality.
Marilyn Pinheiro (Pinheiro and Andrews, 1974) presented a paper that sheds further light on reversals. The study employed AEPs while the subjects responded to
three tones per item that represented either loud or soft signals (a precursor to her pitch pattern test). They found an AEP variation when subjects made reversals
versus when they gave correct responses. The marker for reversals appeared at the beginning of the first tone. Because it was before the second and third tones were
even presented it surely was not an output error. In fact, when the subjects were told that the pattern was “loud, loud, soft” and not “soft, soft, loud” they maintained
that they heard “soft, soft, loud”. This suggests that it was recorded incorrectly in the brain. This is not to say that there are no output reversals, just that the majority
that we see appear to be input reversals and some may be both input and output reversals.
In 1981 Jay Lucker wrote that those who had lots of reversals on the SSW test “…were disorganized,
unable to follow directions sequentially…” and that “SSW reversals appear to correlate highly with organization
problems.” For many years following that excellent observation we found his observations to be insightful and to be invaluable.
Thus, when the Buffalo Model was developed, reversals were used as the indicator of the Organization category and it has served
many of us very well for more than 20 years. Of course, each audiologist is free to exclude professional aspects with which they disagree or
are not comfortable, but we cannot write it out of the profession without exhaustive discussion and a true consensus. Recall that vestibular work
was in jeopardy in our profession some years ago and APD itself was in jeopardy for a number of years and was practically on the verge of extinction
from both outside and inside pressures. Fortunately reason and caution won out so we still have both.
Summary and Conclusions
To exclude auditory memory from our scope of practice because it is pan-sensory and auditory organization (i.e., auditory sequencing) because it is an
output/efferent function would be serious mistakes. As I see it, both rationales for exclusion are gross overgeneralizations that would hurt patients who
have these problems and unnecessarily limit audiologists who serve those with memory and organizational issues. While some aspects of auditory
memory are pan-sensory other aspects are auditory. It is for this reason that auditory training works in correcting auditory memory disorders. Because
auditory memory is such a vital processing function in communication, education and in daily life and because audiologists are capable of testing and
improving such difficulties, these are powerful reasons for elevating auditory memory work by audiologists, but at a minimum we need to keep it in our
scope of practice.
With regard to organization or sequencing being excluded from the auditory processing domain because it is an output function; this would ignore that
there are separate auditory and visual sequencing areas in the brain and that most of the problems that we see clinically appear to be input and not output
reversals. As in the case with auditory memory, auditory sequencing can be improved with auditory training. Therefore from my standpoint, it would be
both unwise and inappropriate to cut out of the body of auditory processing and audiology either auditory memory or auditory sequencing.
While we cannot deny that processing of auditory information is not strictly an auditory event; that does not mean that it should be removed from our area
of expertise. If we take that narrow path we will find that we will lose much more than these two aspects of our profession. Auditory memory and sequencing
have a special relationship to audiology which is important to preserve.
References
Katz, J. (2009). Therapy for APD: Simple, Effective Procedures. Denver, CO: Educational Audiology Association, p. 79.
Katz, J. and Pack, G. (1975). New developments in differential diagnosis using the SSW test, M.D. Sullivan (Ed.) in Central Auditory Processing Disorders, University of Nebraska Press, 97-103.
Lucker, J. (1981). Interpreting SSW Test Results of LD Children. SSW Reports, 3: 7.
Luria, A.R. (1970). Traumatic Aphasias: Its Syndrome, Psychology and Treatment. The Hague, Mouton, pp. 176-177; 267-268.
National Advisory Neurological Diseases and Stroke (1969). Human Communication and its Disorders – An Overview. Bethesda, MD: US Department of Health, Education and Welfare, p. 108.