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Original Paper
Folia Phoniatr Logop 2012;64:217226
DOI: 10.1159/000342139
Efficacy of Auditory Training Using the Auditory
Brainstem Response to Complex Sounds: Auditory
Processing Disorder and Specific Language
Impairment
R. Filippini D.M. Befi-Lopes E. Schochat
Department of Physiotherapy, Speech-Language and Hearing Sciences and Occupational Therapy, School of
Medicine, University of Sao Paulo, Brazil
havioral performance and decreased latencies to c-ABR in
background noise at final assessment. Conclusions: These
data suggest that efficacy of formal AT can be demonstrated
by c-ABR with background noise.
Copyright 2012 S. Karger AG, Basel
Introduction
Auditory training (AT), signal enhancement and lin-
guistic and cognitive strategies have been recommended
for the management of (central) auditory processing dis-
orders (APD) [1] . Children with APDs usually have nor-
mal hearing thresholds, but they experience difficulties
in understanding sounds, especially speech sounds, in
challenging situations [2] . AT improves speech sound de-
coding through modifications in the neural bases that
underlie auditory processing in APD children [3, 4] , and
its efficacy is demonstrated through improvements in be-
havioral and electrophysiological responses [58] .
Relationships between APD and language disorders,
such as specific language impairment (SLI), are associ-
ated with disorders in the neural decoding of rapid and
acoustically complex sounds like speech [911] . SLI chil-
dren exhibit significantly delayed language development
without vision, hearing, cognitive, psychiatric or neuro-
Key Words
Auditory evoked potentials Auditory perceptual
disorders Language development disorders Acoustic
stimulation
Abstract
Objectives: This study verified the efficacy of a formal audi-
tory training (AT) program in children with hearing and lan-
guage disorders using the auditory brainstem response to
complex sounds (c-ABR) with and without background noise.
Patients and Methods: Thirty children (713 years) were dis-
tributed into four groups: typical development (TD: n = 7),
auditory processing disorder (APD: n = 9) and specific lan-
guage disorder (SLIa: n = 6, and SLIb: n = 8). All children un-
derwent behavioral assessment of auditory processing and
c-ABR with and without background noise. The APD and SLIa
groups underwent 8 weeks of formal AT, but all children
were reevaluated 12 weeks after the initial assessment. Re-
sults: The TD group presented better behavioral perfor-
mance than the other groups. For c-ABR in silence, no sig-
nificant differences were observed among groups or assess-
ments, except regarding VA complex measures, which were
altered in the APD group. For c-ABR with background noise,
however, the APD, SLIa and SLIb groups presented delayed
latencies. Groups that underwent formal AT improved be-
Published online: September 22, 2012
Renata Filippini
Rua Diana
183 ap 21 Perdizes
05019-000 So Paulo (Brazil)
E-Mail refilippini.rf @ gmail.com
2012 S. Karger AG, Basel
10217762/12/06450217$38.00/0
Accessible online at:
www.karger.com/fpl
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Folia Phoniatr Logop 2012;64:217226 218
logical deficits [12, 13] . These children have inferior per-
formance on assessments of auditory discrimination
tasks at behavioral and electrophysiological levels. Their
auditory-evoked potentials from the cortex (e.g., mis-
match negativity responses) to complex sounds reveal al-
terations in peak latency and/or morphology compared
to children with typical development (TD) [1417] .
Cortical influence over the subcortical acoustic analy-
ses of complex sounds has been demonstrated in recent
studies, which compared cortical and subcortical audi-
tory evoked potential responses to complex sounds in
learning-impaired children [1820] . The results of these
studies suggest the existence of a sensory-cognitive inter-
action in which bottom-up processes extract the acoustic
features of signal while attenuating irrelevant features,
and top-down processes, such as attention and memory,
modulate subcortical activity and tune the brainstem re-
sponses to complex sounds [21] .
Subcortical auditory processing can be objectively
evaluated using the auditory brainstem response to com-
plex sounds (c-ABR). The c-ABR provides direct infor-
mation on the decoding of speech sound structure by the
auditory nervous system because the brainstem response
reflects the acoustic features of the stimulus (frequency
and duration) with exceptional precision [22, 23] . Nu-
merous studies have demonstrated deficits in the c-ABR,
especially during background noise in children with
APD, learning impairment, and autism, and also im-
provements after AT in these populations [20, 2428] .
This study investigated c-ABR responses in children
with APD and SLI in silence and background noise prior
to and after a formal AT program. We hypothesized that
children with SLI would respond similarly to c-ABR and
AT as a child with APD.
Material and Methods
Thirty children aged 713 years (mean age = 9.09 8 1.54 years)
participated in this study. All subjects exhibited normal otoscop-
ic examinations and normal middle ear function. All subjects
demonstrated normal hearing sensitivity (pure tone thresholds
! 20 dB hearing level at octaves from 250 to 8,000 Hz), and normal
responses to click-evoked ABR. None of the children demonstrat-
ed evident or diagnosed neurological, cognitive, or psychiatric
disorders.
Nine children had no language or learning problems but dem-
onstrated deficits in two of three behavioral tests of (central) audi-
tory processing [(C)AP] assessment performed in this study (APD
group), and underwent a formal AT program. Fourteen children
previously diagnosed with SLI by a specialized speech pathologist
and exhibiting a normal overall IQ measured by the Coloured
Progressive Matrices of Raven et al. [29] presented deficits in at
least one of the three behavioral tests of (C)AP performed in this
study. All 14 SLI children were offered to undergo formal AT, but
only 6 of them took the opportunity. Thus, in order to ensure that
any improvements observed in these children were due to AT and
not to speech therapy, the SLI group was divided into two sub-
groups: the SLIa group (n = 6) that underwent formal AT and
concurrent speech therapy, and the SLIb group (n = 8) that under-
went speech therapy only.
To guarantee the stability of the electrophysiological evalua-
tion, and to make sure that changes in responses between assess-
ments were due to AT and not to typical neural maturation, 7
children with typical hearing, language and learning develop-
ment and normal assessment of (C)AP were also included in this
study (TD group, control), but they received no stimulation.
Three central auditory tests were administered to each group
during the initial assessment to evaluate differences in the follow-
ing auditory abilities: auditory closure (Speech-in-Noise test), fig-
ure-ground (Staggered Spondaic Word test, or the Dichotic Digits
test), and temporal sequencing and interhemispheric transference
(Pitch Pattern Sequencing test). The SLI groups were adminis-
tered tests that did not involve complex verbal response due to the
deficits in language development and to avoid the influence of
these deficits on test performance and analysis. These tests were
not applied to the TD and APD groups because they are too easy
for these populations.
The c-ABR was conducted after the behavioral assessment in
an electrically and acoustically treated room in which the chil-
dren remained comfortably seated and watched a movie of their
choice that was presented at 40 dB SPL. ABR recordings were col-
lected from an Fz electrode on the forehead; the right mastoid was
used as a reference, and the left mastoid was used as the ground
(1020 electrode system) [30] .
The complex stimulus was the 40-ms synthesized stimulus,
/da/, which was selected because stop consonants provide consid-
erable phonetic information, and their perception is particularly
vulnerable to background noise. The stimulus consisted of the
syllable initial burst and formant transitions. Greater details on
stimulus production and features have been described previously
by Russo et al. [26] and King et al. [31] .
The /da/ stimulus was delivered using BioMARK (Biological
Marker of Auditory Processing, Bio-logic Systems Corp., Munde-
lein, Ill., USA) through earplugs monaurally to the right ear at
alternating polarities and intensity of 80 dB nHL. The stimulation
rate was 10.9 stimuli per second. The response was band-filtered
between 100 and 2,000 Hz, and the recording window was 74.67
ms. Three blocks of 1,000 stimuli per block were collected in si-
lence and ipsilateral white noise (+5 dB SNR), which were com-
bined for each condition.
The positive peak V, which is analogous to the click-evoked
peak V, was identified on the resulting wave response followed by
six negative peaks (labeled A, C, D, E, F and O). Peaks V and A
likely represent the onset of the response at the rostral brainstem,
and peaks D, E and F are locked to the fundamental frequency.
Peak C reflects the voicing of the /da/ stimulus, and peak O re-
flects the stimulus offset [32] . The peak latency and amplitude
were analyzed. The VA complex measures of latency, amplitude
and slope were also analyzed.
The same audiologist performed the formal AT of all trained
children participating in this study. The AT program of both
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Efficacy of Auditory Training Using
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Folia Phoniatr Logop 2012;64:217226 219
groups followed the same principles, although several adaptive
solutions were performed due to the linguistic development of
some SLI children. The training program consisted of an 8-week
program of one 50-min session per week. Children were placed in
a sound booth and asked to perform tasks related to competitive
speech perception, speech-in-noise, dichotic speech perception,
and frequency and duration patterns of discrimination and se-
quencing. All stimuli and competition intensity were controlled
from an audiometer. No training activity involved the same tests
used during assessment, and the activities were changed weekly
to avoid a lack of motivation. The difficulty level was increased
each time the child reached 70% correct answers, and the materi-
als were adapted to the childs language development level. To
learn more about the AT applied in this study refer to Musiek and
Schochat [5] .
The children from the APD and SLIa groups were submitted
to behavioral and electrophysiological reevaluation 12 weeks after
the first assessment, that is, 1 month after the 8-week AT. The
children in the TD and SLIb groups, who were not enrolled in AT,
were also submitted to reevaluation 12 weeks after the first assess-
ment.
Statistical analysis of behavioral assessment involved repeated
measures ANOVA with two factors (assessment and group) for
auditory closure, figure-ground and temporal sequencing abili-
ties. For electrophysiological assessment, a repeated measures
ANOVA technique was applied to evaluate the interaction effects
of group, assessment and stimulus presentation condition (i.e.,
silence or background noise) for all peak latencies and VA com-
plex measures. The Tukey method was used to locate the differ-
ences suggested by ANOVA, and the significance level was set at
0.05 for all comparisons.
Ethics
The Institutional Review Board of the Hospital das Clinicas,
School of Medicine, So Paulo University approved this study
(protocol No. 0117/08). The parents of the participating children
signed a written informed consent prior to the evaluations.
Results
Although all responses had been compared between
and within groups, in both the assessment and stimulus
presentation conditions, only the statistically significant
differences obtained are fully detailed in this section.
Behavioral Assessment
ANOVA repeated measures demonstrated the exis-
tence of interactions between group and assessment for
the three auditory abilities assessed in this study. In gen-
eral, the TD group presented better behavioral perfor-
mance; this can be verified in table1 , which illustrates the
mean and standard deviation for each ability, group and
assessment.
The auditory closure ability assessment revealed that
APD and SLIa groups presented a smaller percentage of
correct answers, even though only the APD group pre-
sented a statistically significant difference when com-
pared to the TD group in both evaluations (initial: p =
0.041; final: p = 0.019). No statistically significant differ-
ences were observed between evaluations within the
groups.
Initially, in the figure-ground assessment, the APD
and SLIa groups presented worse performance compared
to the TD group (p ! 0.001 and p = 0.017, respectively)
and to the SLIb group (but the latter without a statisti-
cally significant difference). Both the APD and SLIa
groups demonstrated a statistically significant improve-
ment after formal AT (APD: p = 0.026; SLIa: p = 0.005) to
figure-ground ability; there was no effect for groups that
did not receive training (TD: p = 0.448; SLIb: p = 0.612).
Table 1. Mean and standard deviation (SD) of all groups according to evaluated abilities and to both assessments
TD APD SLIa SLIb
mean SD mean SD mean SD mea n SD
AC RE initial 84.57 8.77 75.11 8.67 85.00 18.71 91.25 9.91
final 90.86 5.98 78.67 10.20 96.67 5.16 92.50 10.35
LE initial 92.00 7.30 77.78 9.62 71.67 17.22 91.25 9.91
final 92.00 4.62 81.33 9.38 88.33 7.53 95.00 5.35
FG RE initial 93.93 4.30 53.61 18.29 67.50 14.14 85.00 17.73
final 94.29 4.73 68.89 20.62 84.17 8.90 84.06 17.11
LE initial 92.50 6.12 55.83 23.12 70.00 10.95 80.31 17.19
final 93.21 5.35 66.67 25.92 84.58 8.43 82.19 17.85
TS initial 94.29 4.50 47.22 15.64 53.33 28.75 60.00 17.32
final 95.36 4.19 65.00 18.03 71.25 25.39 60.94 17.21
AC = Auditory closure ability; FG = figure-ground ability; TS = temporal sequencing ability; RE = right ear; LE = left ear.
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The TD group presented significantly better initial
performance in temporal sequencing ability compared to
the other groups (APD: p ! 0.001; SLIa: p = 0.002; SLIb:
p = 0.005); the latter groups did not differ significantly on
this measure. The groups who received formal AT dem-
onstrated significantly better performance after training
compared to the initial assessment (APD: p = 0.001;
SLI a: p = 0.036). The SLIb and TD groups exhibited no
changes in their performance on temporal sequencing
ability between evaluations.
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Peak A
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Peak C
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Peak E
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Initial Final Initial Final
Silence Noise
Peak F
TD group
APD group trained
SLIa group trained
SLIb group
Fig. 1. Latencies (in milliseconds) for the c-ABR peaks, plotted by listening condition and group. Gray symbols
refer to the silence condition, black symbols to the noise condition.
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Electrophysiological Assessment
ANOVA repeated measures demonstrated interac-
tions between groups, assessments and conditions of
stimulus presentation for the transient portion of c-ABR
response (peaks V, A, C) and peak D. For the VA complex
measures no interactions were observed. The relation-
ship of average responses of peaks V, A, C and D, between
groups, assessments and stimulus presentation condi-
tions are illustrated in figures 1 and 2 .
For c-ABR in silence ( table2 ), no significant differences
in latency were observed among the groups at the initial
and final assessments or between the assessments for all
peaks, except for peak E. For this peak the APD group dem-
onstrated significantly delayed latencies only when com-
pared to the SLIb group (p = 0.042). The SLIa group, how-
ever, exhibited significantly delayed latencies for peak E at
the initial assessment compared to both TD (p = 0.012) and
SLIb (p = 0.004) groups. After training no differences were
observed between the four groups for peak E, and only the
SLIa group presented a significantly earlier latency for this
peak compared to the initial assessment (p = 0.04).
The APD group presented a longer latency of the VA
complex when compared to the TD (p = 0.002), SLIa (p =
0.001) and SLIb (p = 0.011) groups, as well as a shallower
slope than the TD (p = 0.005) and SLIb (p = 0.039) groups.
No statistically significant differences in VA complex
amplitude of c-ABR in silence were observed among the
groups. No changes in group responses were observed
after the training period, as demonstrated by the absence
of statistically significant differences between the initial
and final assessments.
The introduction of ipsilateral background noise to c-
ABR assessment altered all measures of c-ABR in varying
degrees. Statistically significant increases of transient re-
sponse latencies compared to c-ABR in silence were ob-
served for all groups, to a greater extent in the SLIa group
( fig.1 ).
Regarding initial assessment of c-ABR in background
noise ( table3 ), the latency of all peaks presented statisti-
cally significant differences between groups, except for
peak F (p = 0.075). In general, TD presented better (short-
er) responses for all peaks than the other groups. The
Table 2. Mean and standard deviation (SD) to latency and complex VA measures of c-ABR in silence, accordingly to studied groups
for both assessments
TD APD SLIa SLIb
mean SD mean SD mean SD mea n SD
V
initial 6.53 0.33 6.66 0.40 6.64 0.31 6.59 0.31
final 6.63 0.24 6.63 0.36 6.67 0.44 6.59 0.26
A
initial 7.45 0.30 7.83 0.54 7.51 0.27 7.63 0.19
final 7.60 0.37 7.71 0.43 7.58 0.44 7.48 0.28
C
initial 18.43 0.73 18.46 0.56 18.74 0.79 18.89 0.58
final 18.21 0.43 18.36 0.26 18.56 0.77 18.58 0.59
Latency
ms
D
initial 22.22 0.44 22.77 0.69 22.51 0.57 22.39 0.24
final 22.45 0.37 22.49 0.22 22.22 0.45 22.14 0.46
E
initial 31.04 0.48 31.42 0.71 31.45 0.88 30.80 0.35
final 31.16 0.44 31.19 0.26 30.72 0.57 31.02 0.27
F
initial 39.41 0.55 39.75 0.54 39.59 0.97 39.27 0.39
final 39.33 0.64 39.61 0.55 39.23 0.34 39.37 0.53
O
initial 48.10 0.38 48.21 0.39 47.88 0.46 48.13 0.34
final 47.94 0.29 48.01 0.62 47.93 0.31 47.95 0.59
LAT
initial 0.92 0.14 1.17 0.18 0.88 0.13 1.02 0.21
final 0.92 0.14 1.10 0.18 0.91 0.16 0.90 0.09
VA
AMP
initial 0.41 0.15 0.26 0.09 0.29 0.07 0.35 0.11
final 0.34 0.07 0.27 0.09 0.29 0.06 0.35 0.14
Slope
initial 0.45 0.17 0.22 0.10 0.33 0.04 0.35 0.11
final 0.37 0.09 0.25 0.08 0.32 0.07 0.38 0.13
LAT = Latency; AMP = amplitude.
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APD group presented significantly delayed latencies for
peaks D (TD and SLIb: p = 0.001) and E (SLIb: p = 0.042);
the SLIa group also presented significantly delayed laten-
cies compared to the TD and SLIb groups for peaks V
(TD: p = 0.001; SLIb: p = 0.049), A (TD: p = 0.001), C (TD:
p = 0.010; SLIb: p = 0.049), D (TD and SLIb: p ! 0.001), E
(TD: p = 0.012; SLIb 0.004), and O (TD: p = 0.006; SLIb:
p = 0.023).
The APD group demonstrated significant improve-
ments in the latencies of peaks V and D (p = 0.027 and
p = 0.023, respectively) at final assessment compared to
the initial assessment. The SLIa group also exhibited sig-
nificant improvements of peaks V (p = 0.039), C (p =
0.003), D (p = 0.003) and E (p = 0.049) at the final assess-
ment.
No differences in VA complex measures were observed
among groups at initial assessments. No changes in either
the latencies or amplitudes of the VA complex were ob-
served. However, a tendency towards statistical signifi-
cance in slope of the VA complex (p = 0.093) was ob-
served.
Discussion
Behavioral Assessment
In general, the APD and SLIa groups exhibited worse
initial performance than the TD and SLIb groups for the
evaluated auditory abilities. However, after formal AT,
the APD and SLIa groups demonstrated significant be-
havioral improvements, as demonstrated in previous
studies [5, 6, 3335] . These improvements may be due to
a learning-induced neural cell reorganization, which
strengthened or created new connections after the in-
tense stimulation of formal AT [4] .
It is important to note that SLIa children presented
worse initial performance not only when compared to
TD children but also when compared to the SLIb children
(i.e. auditory closure and figure-ground abilities). This
difference was probably influenced by the heterogeneity
and the wide range of clinical manifestations of children
in the SLI population [13] . Also, even though we tried to
randomly divide the SLI children into two groups, per-
haps children whose parents agreed to participate in the
1.6
1.4
1.2
1.0
0.8
0.6
Initial Final Initial Final
Silence Noise
VA latency
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VA slope
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VA amplitude
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Silence Noise
TD group
APD group trained
SLIa group trained
SLIb group
Fig. 2. VA latency (milliseconds), slope
(microvolts/millisecond) and amplitude
(microvolts). For details see legend to fig-
ure 1.
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Efficacy of Auditory Training Using
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Folia Phoniatr Logop 2012;64:217226 223
formal AT program (SLIa group) were those with the
poorest language development.
One may argue that because the SLI groups were not
homogeneous, results may have been influenced by the
pretraining differences noted above. But, even though the
SLIb children presented better behavioral performance,
they still demonstrated (C)AP deficits, especially in tem-
poral sequencing ability in which both groups presented
very similar performance, which was not improved in the
SLIb group after the 12-week interval between assess-
ments. This is a strong indication that AT influenced im-
provements observed in the SLIa group, at least regarding
temporal sequencing ability.
Thus, even though we cannot discuss the influence of
AT on linguistic development, because no language eval-
uations were performed prior to and after formal AT, this
study showed that some SLI children demonstrated the
same behavioral improvements obtained by APD chil-
dren after AT, supporting the important role of this in-
tervention in SLI children who present (C)APD, as is al-
ready well established for children who present only (C)
APD [58] .
Electrophysiological Assessment
Previous studies about c-ABR in silence in children
with learning and language impairment disorders, (C)
APD, and autism have shown delayed latencies of onset
peaks and shallower VA slopes [25, 26, 36] for these pop-
ulations, which indicate that these children have syn-
chrony deficits in brainstem neural responses to complex
sounds. However, the current study did not point out sig-
nificant differences in c-ABR in silence among groups,
except for the APD group, which presented shallower VA
slopes than the other groups.
Perhaps the small number of subjects was insufficient
to reveal differences in the c-ABR in silence among
groups. Also, the aforementioned heterogeneity of the
SLI population, associated with the Banai et al. [37] state-
ment that not all children within the same disorder spec-
trum (i.e. learning problems) exhibit deficits in c-ABR in
silence, may explain the absence of differences among the
groups as well as the lack of concordance of this study
with previous studies.
No changes were observed in any peaks of c-ABR in
silence after training, which is consistent with previous
Table 3. Mean and standard deviation (SD) to latency and complex VA measures of c-ABR in background noise, according to studied
groups for both assessments
TD APD SLIa SLIb
mean SD mean SD mean SD mea n SD
V
initial 7.05 0.97 8.05 0.91 9.12 0.76 7.92 0.95
final 6.83 0.69 7.86 1.1 7.95 0.84 7.54 0.34
A
initial 8.29 0.94 9.3 0.94 10.09 0.83 9.07 0.77
final 8.13 0.79 8.75 1.03 9.07 0.87 8.72 0.31
C
initial 18.97 1.26 19.72 0.96 21.21 1.11 20.01 1.33
final 18.47 0.64 19.53 0.62 19.17 0.7 19.76 1.26
Latency
ms
D
initial 23.43 0.82 24.36 0.89 25.30 0.5 23.18 0.89
final 23.43 1.12 23.8 0.9 24.23 0.78 23.73 0.61
E
initial 32.35 1.41 32.70 0.77 33.08 1.12 31.84 0.94
final 32.41 1.05 32.18 0.92 32.47 1.84 32.1 1.24
F
initial 40.85 1.32 40.77 0.92 41.42 1.32 40.26 0.94
final 40.66 1.39 40.35 0.7 41.16 1.62 40.29 1.22
O
initial 48.54 0.74 49.10 1.25 49.69 0.77 48.66 0.72
final 48.46 0.65 49.26 1.04 49.58 1.35 48.86 1.35
LAT
initial 1.23 0.30 1.17 0.43 0.97 0.34 1.15 0.40
final 0.92 0.14 1.10 0.18 0.91 0.16 0.90 0.09
VA
AMP
initial 0.15 0.08 0.10 0.04 0.15 0.05 0.13 0.06
final 0.34 0.07 0.27 0.09 0.29 0.06 0.35 0.14
Slope
initial 0.12 0.05 0.10 0.06 0.16 0.05 0.12 0.05
final 0.34 0.07 0.27 0.09 0.29 0.06 0.35 0.14
LAT = Latency; AMP = amplitude.
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Folia Phoniatr Logop 2012;64:217226 224
training studies that demonstrated no changes in brain-
stem responses to complex sounds after AT [31, 38] .
We may hypothesize that the neural changes that re-
sult from AT do not occur in the inferior colliculus nuclei,
the generator of the transient brainstem response to the
/da/ stimulus [32, 37] . The second hypothesis is that la-
tency measures are not efficient to monitor improve-
ments in subcortical response and, perhaps, frequency
measurements, rather than timing, would have been a
better method to analyze the benefits of AT on c-ABR in
silence. Unfortunately, some technical limitations pre-
vented such analysis in the current study.
The addition of ipsilateral white noise to c-ABR evalu-
ation negatively influenced responses. This effect of back-
ground noise has been shown previously [26] ; responses
to the transient portion of the stimulus (waves V and A)
are more susceptible to background noise than responses
to the sustained portion of the /da/ stimulus. The former
are primarily the response to the acoustic information of
the consonant stimulus, increasing the difficulty of con-
sonant discrimination in background noise [27] .
The TD group presented better responses than the
other groups even with the addition of background noise,
especially regarding transient responses. As mentioned
before, it has been proposed that top-down processes are
responsible for correct speech perception in background
noise [21, 39] , therefore, we may suggest that children
with (C)APD and SLI are more susceptible to background
noise effects on sound processing, which may be a conse-
quence of deficits in top-down modulation.
On the other hand, the SLIa group exhibited worse re-
sponses, not only when compared to the TD group, but
also when compared to the APD group and even when
compared to the SLIb group. This may reinforce the no-
tion that the SLIa group consisted of children with poor-
er language development, and, since assessments in si-
lence revealed no differences between the two SLI groups,
we suggest, based on the heterogeneity of this population,
the existence of a subgroup of SLI children that exhibit
even more susceptibility to the deleterious effects of back-
ground noise on neural synchrony.
It is important to note that the c-ABR in background
noise prior to AT also revealed that the APD and SLIb
groups exhibited a balance in their responses to all peaks,
indicating that some SLI children respond to brief rapid
sounds in noise just like children with (C)APD.
Both the APD and SLIa groups demonstrated im-
provements in the latencies of c-ABR in background
noise peaks after AT, even though SLIa group modifica-
tions were more prominent. These findings are consistent
with previous studies that have demonstrated improve-
ments in c-ABR after AT programs, specifically for laten-
cies from the transient portion of the response with no
improvements in responses in silence [40, 41] . These re-
sults suggest that the auditory stimulation may strength-
en the neural decoding of the acoustic features of sound
at the brainstem level and decrease the susceptibility to
the negative effects of background noise in both popula-
tions.
C-ABR is stable and reliable even in the presence of
background noise [42] . Both groups in the current study
that did not have AT and received no other auditory stim-
ulation exhibited no modifications in their responses.
These results confirm the role of AT in improvements of
the c-ABR in background noise observed in the APD and
SLIa groups, and also suggest that induced plasticity in
auditory pathways strengthened connections in top-
down and bottom-up processing of sounds.
However, if AT promoted all of the improvements ob-
served in the SLIa group, then the APD group, which was
also submitted to AT, should have exhibited the same
clear and significant differences between the initial and
final assessments. Three hypotheses may be formulated
to explain this discrepancy.
The first explanation may be associated with the ini-
tial responses. The SLIa group initially exhibited more
delayed latencies than the APD group, even though no
statistically significant differences between them were
observed. It was stated that children with fewer deficits in
c-ABR do not obtain the same benefits from AT as chil-
dren with more deficits in the response [23, 32] ; thus,
maybe for that reason children with APD presented
smaller variations in their responses between assess-
ments. This may also suggests that c-ABR is an important
tool for the identification of individuals who would ben-
efit from this type of intervention.
The second explanation may be related to the inter-
vention. Even though the AT program for both groups
had the same principles, children with SLI had AT con-
comitant with speech therapy for their language deficits,
while children with APD had only AT. The speech ther-
apy may have contributed to the development of cognitive
abilities that favored top-down modulation of sound pro-
cessing. This hypothesis is corroborated by previously
cited studies that demonstrated improvements in c-ABR
responses after AT through computer games, which in-
clude stimulation of auditory, linguistic and cognitive
abilities.
The last hypothesis is related to auditory system matu-
ration. The APD group presented deficits especially for
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Efficacy of Auditory Training Using
c-ABR
Folia Phoniatr Logop 2012;64:217226 225
the transient portion of the response (peaks V and A), but
the SLIa group presented an overall deficit for all peak
latencies, which suggests a delay in maturation of these
individuals. Children with SLI present an overall deficit
in neural development maturation [43, 44] , thus we may
suggest that the delayed responses from SLIa children in
the c-ABR recorded with background noise may reflect
an immaturity in sound processing at the brainstem lev-
el as well as in cognitive processes, which affect the sub-
cortical analysis of sound and the cortical modulation of
sound processing. Therefore, auditory maturation in the
SLIa group may have been accelerated by formal AT and
speech therapy, through the process of learning and plas-
ticity, balancing their responses with the APD and SLIb
groups.
It is important to emphasize that these results for the
SLIa group cannot be accounted for by speech therapy
only, because the SLIb group did not show any improve-
ments on c-ABR responses. Therefore, we suggest that the
association between auditory and linguistic stimulation
is more effective for (C)APD intervention than AT only.
This study observed auditory processing deficits at be-
havioral and electrophysiological levels in SLI groups,
similar to those observed in APD. We also observed the
benefits of formal AT, and formal AT associated with
speech and language therapy on behavioral and electro-
physiological responses. c-ABR in background noise may
be an important tool for the monitoring of AT influences
on auditory processing at low levels of the auditory ner-
vous system, although the small number of subjects in
each group may have influenced these results.
We strongly recommend further studies to compare
auditory, linguistic and cognitive measures in SLI chil-
dren, as well as to compare cortical and subcortical audi-
tory potentials to simple and complex sounds relating au-
ditory and linguistic deficits to intervention benefits in
children with language and hearing disorders.
Acknowledgment
This work was supported by FAPESP (process No. 2010/
50416-0).

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