Editorial: Auditory Processing Disorder

Multidisciplinary assessment and interventions for childhood auditory processing disorder (APD) and listening difficulties (LiD)

Purpose

Auditory processing disorder (APD) has been studied in both research and clinic settings, but the relation between the two has not been addressed. In a longitudinal research study (SICLiD), we found that children with clinically normal audiometry who had caregiver-reported listening difficulties (LiD), with or without clinically assessed APD, performed poorly on both listening and cognitive tests. Specific questions asked here were, for the children with LiD, what other neurodevelopmental clinical conditions were identified, what interventions were used by different clinical providers, and how clinical practice was predicted by research results.

Methods

Study setting was a large, research-led, tertiary pediatric hospital. Electronic medical records of 74 children aged 6-13 years, recruited into SICLiD and assigned to an LiD group based on a validated and reliable caregiver report (ECLiPS), were independently reviewed. Focus was on clinical assessments and interventions following appointments provided in the Hospital Divisions of Audiology, Occupational Therapy, Psychology (Developmental and Behavioral Pediatrics), and Speech-Language Pathology (SLP), prior to participation in SICLiD. Descriptive statistics on clinical encounters, identified conditions, and interventions were compared with quantitative, standardized performance on SICLiD assessments of listening and cognitive function. SICLiD z-scores were compared for participants with and without each clinical condition using univariate and logistic prediction analyses.

Results

Most (86%) of the children with LiD had been evaluated by at least one clinical service. Overall, 24 assessment categories related to LiD, including APD, were identified. Most common conditions were attention (32%), language (28%), hearing (18%), anxiety (16%), and autism spectrum (6%) disorders. Performance on SICLiD measures varied significantly between providers, conditions, and interventions. Significant relationships between SICLiD and clinical conditions were mostly caregiver-reported items from the ECLiPS or the Children's Communication Checklist (CCC-2). Other significant correlations were scarce, but included the SCAN composite score, which predicted clinical language and attention, but not other auditory abilities or APD. SICLiD data combined with caregiver reports provided reliable predictions of all clinical conditions except APD.

Conclusions

The variety of disciplines, assessments, conditions and interventions revealed here supports previous studies showing that LiD and APD are multifaceted problems of neurodevelopment. Comparisons between clinical- and research-based assessments suggest a diagnostic path that prioritizes caregiver reports and selected psychometric tests for screening and diagnostic purposes.

Relationship Between Cognitive Abilities and Basic Auditory Processing in Young Adults

PURPOSE

The diagnosis of auditory processing disorder (APD) is controversial particularly due to the influence of higher order factors of language and cognition on the diagnostic APD testing. As a result, there might be a need for testing for other domains (e.g., cognition) along with conducting the diagnostic APD testing to rule out the influence of other domains. In order to make recommendations on whether cognitive testing is needed along with the auditory processing testing, as a starting point, the current study was conducted to examine the relationship between cognitive abilities and basic auditory processing in young adults.

METHOD

A total of 38 young adults with normal audiometric thresholds between 250 and 8000 Hz participated in this study. They were tested on their executive function, language, processing speed, working memory, and episodic memory components of cognitive testing and tests for temporal fine structure and spectrotemporal sensitivity for auditory processing testing.

RESULTS

No significant correlation was found between the cognitive tests and the tests for basic auditory processing in young adults.

CONCLUSIONS

These findings present contrast to the existing findings in children and older adults where a stronger correlation between cognitive abilities and auditory processing has been found. The current findings suggest that testing for cognitive abilities may not be needed when testing for basic auditory processing in young adults.

Amplitude Modulation Perception and Cortical Evoked Potentials in Children With Listening Difficulties and Their Typically Developing Peers

PURPOSE

Amplitude modulations (AMs) are important for speech intelligibility, and deficits in speech intelligibility are a leading source of impairment in childhood listening difficulties (LiD). The present study aimed to explore the relationships between AM perception and speech-in-noise (SiN) comprehension in children and to determine whether deficits in AM processing contribute to childhood LiD. Evoked responses were used to parse the neural origins of AM processing.

METHOD

Forty-one children with LiD and 44 typically developing children, ages 8-16 years, participated in the study. Behavioral AM depth thresholds were measured at 4 and 40 Hz. SiN tasks included the Listening in Spatialized Noise-Sentences Test (LiSN-S) and a coordinate response measure (CRM)-based task. Evoked responses were obtained during an AM change detection task using alternations between 4 and 40 Hz, including the N1 of the acoustic change complex, auditory steady-state response (ASSR), P300, and a late positive response (late potential [LP]). Maturational effects were explored via age correlations.

RESULTS

Age correlated with 4-Hz AM thresholds, CRM separated talker scores, and N1 amplitude. Age-normed LiSN-S scores obtained without spatial or talker cues correlated with age-corrected 4-Hz AM thresholds and area under the LP curve. CRM separated talker scores correlated with AM thresholds and area under the LP curve. Most behavioral measures of AM perception correlated with the signal-to-noise ratio and phase coherence of the 40-Hz ASSR. AM change response time also correlated with area under the LP curve. Children with LiD exhibited deficits with respect to 4-Hz thresholds, AM change accuracy, and area under the LP curve.

CONCLUSIONS

The observed relationships between AM perception and SiN performance extend the evidence that modulation perception is important for understanding SiN in childhood. In line with this finding, children with LiD demonstrated poorer performance on some measures of AM perception, but their evoked responses implicated a primarily cognitive deficit.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25009103.

Early otitis media puts children at risk for later auditory and language deficits

BACKGROUND

Otitis media is a common disorder of early childhood suspected of hindering auditory and language development, but evidence regarding these effects has been contradictory. To examine potential sources of these contradictory past results and explore in more detail the effects of early otitis media on auditory and language development, three specific hypotheses were tested: (1) Variability in children's general attention could influence results, especially for measures of auditory functioning, leading to spurious findings of group differences; (2) Different language skills may be differentially affected, evoking different effects across studies depending on skills assessed; and (3) Different mechanisms might account for the effects of otitis media on acquisition of different language skills, a finding that would affect treatment choices.

METHOD

Children 5-10 years old participated: 49 with and 68 without significant histories of otitis media. The auditory function examined was temporal modulation detection, using games designed to maintain children's attention; two additional measures assessed that attention. Measures of lexical knowledge and phonological sensitivity served as the language measures.

RESULTS

Sustained attention was demonstrated equally across groups of children with and without histories of otitis media. Children with histories of otitis media performed more poorly than peers without those histories on the auditory measure and on both sets of language measures, but effects were stronger for phonological sensitivity than lexical knowledge. Deficits in temporal modulation detection accounted for variability in phonological sensitivity, but not in lexical knowledge.

CONCLUSION

When experimental factors are tightly controlled, evidence emerges showing effects of otitis media early in life on both auditory and language development. Mechanism of effects on language acquisition appear to involve both delayed auditory development and diminished access to the ambient language.

Amplitude modulation perception and cortical evoked potentials in children with listening difficulties and their typically-developing peers

Purpose

Amplitude modulations (AM) are important for speech intelligibility, and deficits in speech intelligibility are a leading source of impairment in childhood listening difficulties (LiD). The present study aimed to explore the relationships between AM perception and speech-in-noise (SiN) comprehension in children and to determine whether deficits in AM processing contribute to childhood LiD. Evoked responses were used to parse the neural origin of AM processing.

Method

Forty-one children with LiD and forty-four typically-developing children, ages 8-16 y.o., participated in the study. Behavioral AM depth thresholds were measured at 4 and 40 Hz. SiN tasks included the LiSN-S and a Coordinate Response Measure (CRM)-based task. Evoked responses were obtained during an AM Change detection task using alternations between 4 and 40 Hz, including the N1 of the acoustic change complex, auditory steady-state response (ASSR), P300, and a late positive response (LP). Maturational effects were explored via age correlations.

Results

Age correlated with 4 Hz AM thresholds, CRM Separated Talker scores, and N1 amplitude. Age-normed LiSN-S scores obtained without spatial or talker cues correlated with age-corrected 4 Hz AM thresholds and area under the LP curve. CRM Separated Talker scores correlated with AM thresholds and area under the LP curve. Most behavioral measures of AM perception correlated with the SNR and phase coherence of the 40 Hz ASSR. AM Change RT also correlated with area under the LP curve. Children with LiD exhibited deficits with respect to 4 Hz thresholds, AM Change accuracy, and area under the LP curve.

Conclusions

The observed relationships between AM perception and SiN performance extend the evidence that modulation perception is important for understanding SiN in childhood. In line with this finding, children with LiD demonstrated poorer performance on some measures of AM perception, but their evoked responses implicated a primarily cognitive deficit.

Detecting Central Auditory Processing Disorders in Awake Mice

Mice are increasingly used as models of human-acquired neurological or neurodevelopmental conditions, such as autism, schizophrenia, and Alzheimer's disease. All these conditions involve central auditory processing disorders, which have been little investigated despite their potential for providing interesting insights into the mechanisms behind such disorders. Alterations of the auditory steady-state response to 40 Hz click trains are associated with an imbalance between neuronal excitation and inhibition, a mechanism thought to be common to many neurological disorders. Here, we demonstrate the value of presenting click trains at various rates to mice with chronically implanted pins above the inferior colliculus and the auditory cortex for obtaining easy, reliable, and long-lasting access to subcortical and cortical complex auditory processing in awake mice. Using this protocol on a mutant mouse model of autism with a defect of the Shank3 gene, we show that the neural response is impaired at high click rates (above 60 Hz) and that this impairment is visible subcortically-two results that cannot be obtained with classical protocols for cortical EEG recordings in response to stimulation at 40 Hz. These results demonstrate the value and necessity of a more complete investigation of central auditory processing disorders in mouse models of neurological or neurodevelopmental disorders.

The interface of paediatric ENT and autism spectrum disorder: a complex conundrum for otolaryngologists

OBJECTIVE

Autism spectrum disorder is a lifelong neurodevelopmental condition encompassing complex physical and neurological symptoms, including complex sensory symptoms. This review explores the interface between autism spectrum disorder and paediatric ENT.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ('PRISMA') guideline, a robust literature search and review was conducted by two researchers. Thirty-four papers were filtered into the final review.

RESULTS

Published literature clearly demonstrates potential for autism spectrum disorder to present in the form of auditory and other sensory symptoms to ENT surgeons and audiologists who may not fully appreciate this complex condition. Despite this well-documented link, auditory symptoms, auditory processing disorders and hearing loss within autism spectrum disorder remain poorly understood.

CONCLUSION

Improved recognition and understanding of autism spectrum disorder by otolaryngologists could enable more effective diagnostic and management strategies for autistic children who present with auditory and other sensory symptoms. In light of the current 'autism epidemic,' there is an urgent need for further research on this theme.

Auditory Processing Disorder: Protocols and Controversy

PURPOSE

This study examined current auditory processing disorder (APD) protocols and audiologists' perspectives on the active debate seen in the literature regarding the status of APD as a unique disorder.

METHOD

This study used a cross-sectional, nonexperimental survey design. The participants were 134 U.S. audiologists, representing diversity across experience level and work setting.

RESULTS

Popular APD tests from prior surveys remain popular, and a few new tests have emerged. Most audiologists use diverse strategies to identify potential comorbid disorders as part of their APD protocol, including multidisciplinary assessment and referral to other specialists. Most participants disagreed with the assertion that APD is not a unique disorder; however, many also pointed out that patients' struggles with listening need to be the primary focus of APD assessment and management, regardless of the label of the disorder. Qualitative analysis of participant comments on the controversy yielded six themes: Clinical Experience, Comorbidity, Listening Skills, Literature Support, Overdiagnosis, and More Information Needed.

CONCLUSION

Most participants consider APD to be a unique disorder, citing clinical experience and the literature for support; however, many also indicated APD is complicated by comorbidity and APD may be overdiagnosed.

Brainstem auditory physiology in children with listening difficulties. Hear Res 2023;429:108705. [PMID: 36709582 PMCID: PMC10152893 DOI: 10.1016/j.heares.2023.108705]

Children who have listening difficulties (LiD) despite having normal audiometry are often diagnosed as having an auditory processing disorder. A lack of evidence regarding involvement of specific auditory mechanisms has limited development of effective treatments for these children. Here, we examined electrophysiologic evidence for brainstem pathway mechanisms in children with and without defined LiD. We undertook a prospective controlled study of 132 children aged 6-14 years with normal pure tone audiometry, grouped into LiD (n = 63) or Typically Developing (TD; n = 69) based on scores on the Evaluation of Children's Listening and Processing Skills (ECLiPS), a validated caregiver report. The groups were matched on age at test, sex, race, and ethnicity. Neither group had diagnoses of major neurologic disorder, intellectual disability, or brain injuries. Both groups received a test battery including a measure of receptive speech perception against distractor speech, Listening in Spatialized Noise - Sentences (LiSN-S), along with multiple neurophysiologic measures that tap afferent and efferent auditory subcortical pathways. Group analysis showed that participants with LiD performed significantly poorer on all subtests of the LiSN-S. The LiD group had significantly greater wideband middle ear muscle reflex (MEMR) growth functions in the left ear, and shorter Wave III and Wave V latencies in auditory brainstem responses (ABR). Across individual participants, shorter latency ABR Wave V correlated significantly with poorer parent report of LiD (ECLiPS composite). Greater MEMR growth functions also correlated with poorer ECLiPS scores and reduced LiSN-S talker advantage. The LiD and TD groups had equivalent summating potentials, compound action potentials, envelope-following responses, and binaurally activated medial olivocochlear reflexes. In conclusion, there was no evidence for auditory synaptopathy for LiD. Evidence for brainstem differences in the LiD group was interpreted as increased central gain, with shorter ABR Wave III and V latencies and steeper MEMR growth curves. These differences were related to poorer parent report and speech perception in competing speech ability.

Functional Hearing Difficulties in Veterans: Retrospective Chart Review of Auditory Processing Assessments in the VA Health Care System

PURPOSE

Approximately 23 million Americans might have functional hearing difficulties (FHDs) that are not well explained by their audiometric thresholds. Clinical management of patients with FHDs is the subject of considerable debate, with few evidence-based guidelines to direct patient care. A better understanding of the characteristics of patients who seek help for FHDs, as well as current audiological management practices, is needed to direct research efforts to the areas greatest opportunity for advancement of clinical care.

METHOD

A retrospective chart review was conducted examining the medical records of a random sample of 100 Veterans who underwent auditory processing assessments across the VA Health Care System between 2008 and 2020.

RESULTS

Patients were young to middle-age, often with previous traumatic brain injury or blast exposure. Mental health, sleep, and pain disorders were common. No consistent relationships emerged between specific patient factors and domains of auditory processing deficits. Low-gain hearing aids were provided to 35 patients, 69% of whom continued wearing their hearing aids for at least 2 years.

CONCLUSION

Future research should address the potential overlap in symptoms and treatment for comorbid health conditions and FHDs, as well as the conditions underlying successful hearing aid use in this patient population.

Speech-in-noise testing: Innovative applications for pediatric patients, underrepresented populations, fitness for duty, clinical trials, and remote services

Speech perception testing, defined as providing standardized speech stimuli and requiring a listener to provide a behavioral and scored response, has been an integral part of the audiologic test battery since the beginning of the audiology profession. Over the past several decades, limitations in the diagnostic and prognostic validity of standard speech perception testing as routinely administered in the clinic have been noted, and the promotion of speech-in-noise testing has been highlighted. This review will summarize emerging and innovative approaches to speech-in-noise testing with a focus on five applications: (1) pediatric considerations promoting the measurement of sensory and cognitive components separately; (2) appropriately serving underrepresented populations with special attention to racial, ethnic, and linguistic minorities, as well as considering biological sex and/or gender differences as variables of interest; (3) binaural fitness for duty assessments of functional hearing for occupational settings that demand the ability to detect, recognize, and localize sounds; (4) utilization of speech-in-noise tests in pharmacotherapeutic clinical trials with considerations to the drug mechanistic action, the patient populations, and the study design; and (5) online and mobile applications of hearing assessment that increase accessibility and the direct-to-consumer market.

Speech cortical activation and connectivity in typically developing children and those with listening difficulties

Listening difficulties (LiD) in people who have normal audiometry are a widespread but poorly understood form of hearing impairment. Recent research suggests that childhood LiD are cognitive rather than auditory in origin. We examined decoding of sentences using a novel combination of behavioral testing and fMRI with 43 typically developing children and 42 age matched (6-13 years old) children with LiD, categorized by caregiver report (ECLiPS). Both groups had clinically normal hearing. For sentence listening tasks, we found no group differences in fMRI brain cortical activation by increasingly complex speech stimuli that progressed in emphasis from phonology to intelligibility to semantics. Using resting state fMRI, we examined the temporal connectivity of cortical auditory and related speech perception networks. We found significant group differences only in cortical connections engaged when processing more complex speech stimuli. The strength of the affected connections was related to the children's performance on tests of dichotic listening, speech-in-noise, attention, memory and verbal vocabulary. Together, these results support the novel hypothesis that childhood LiD reflects difficulties in language rather than in auditory or phonological processing.

Visual Processing Impairment in Children With Suspected Auditory Processing Disorder: A Transdisciplinary Dimensional Approach to Diagnosis

PURPOSE

The purpose of this study is to explore the utility of impairment(s) in language (LI), manual dexterity (IMD), and visual perceptual skills (IVPS) as a reference standard for diagnosing auditory processing disorder (APD).

METHOD

Data from 104 participants with suspected APD (males = 57, females = 47; 6-16 years) were retrospectively analyzed. Index auditory processing (AP) tests included Auditory Figure Ground 0 dB, Competing Words-Directed Ear (CW-DE), and Time-Compressed Sentences (TCS). General Communication Composite (GCC) of the Children's Communication Checklist-2, manual dexterity (MD) component of the Movement Assessment Battery for Children-Second Edition, and Test for Visual Perceptual Skills-Third Edition (TVPS-3) were used to identify LI, IMD, and IVPS, respectively.

RESULTS

Eighty-one (77.8%), 58 (55.8%), and 37 (35.6%) participants had LI, IVPS, and IMD, respectively. Four factors explaining 67.69% of the variance were extracted. TVPS-3 (except visual closure [VClo]) represented the first; AFG 0, VClo, and MD the second; CW-DE and GCC the third; and TCS the fourth. APD diagnosed by combining AP tests and comorbidities had better accuracy compared to AP tests alone. The combined approach had overall diagnostic accuracy of 92.2%, 88.4%, and 81.7% for the 9th, 5th, and 2nd percentile AP test cutoffs, respectively.

CONCLUSIONS

First-order AP tests in this study were related to language, MD, and visual perceptual skills. Given the overlap of LI, IMD, and IVPS with impaired AP, these comorbidities are an effective reference standard for APD. APD can be diagnosed following failing one AP test if one or more comorbidities exist. Ninth percentile AP test cutoff had better diagnostic accuracy compared to the currently used 2nd percentile cutoff.

Frequency-Following Response and Auditory Middle Latency Response: an analysis of central auditory processing in young adults

ABSTRACT Purpose: to compare the latency and amplitude of the Frequency-Following Response and the Auditory Middle Latency Response in typical individuals and those with altered auditory abilities, as well as to investigate the sensitivity and specificity of both assessments in relation to central auditory processing. Methods: 32 individuals of both sexes were distributed into Group 1 (without altered auditory abilities) and Group 2 (with altered auditory abilities). The groups were divided according to behavioral tests of central auditory processing. Individuals in both groups underwent auditory evoked potentials. Student’s t-test was used for analysis, considering a 5% significance. Results: in Group 2, V and A had higher latency and lower amplitude and slope. Group 2 also had lower Na and Pa amplitudes in waves A1C3 and A2C3. The Frequency-Following Response showed 93% sensitivity and specificity, while the Auditory Middle Latency Response showed 87% sensitivity and 93% specificity. Conclusion: the individuals presented with altered hearing abilities showed higher latency and lower response amplitude in the Frequency Following Response and Auditory Middle Latency Response compared to typical individuals. The Frequency- Following Response showed a better balance of sensitivity and specificity.

Frequency-Following Response e Potencial Evocado Auditivo de Média Latência: uma análise frente ao processamento auditivo central de jovens adultos

RESUMO Objetivo: comparar a latência e a amplitude do Frequency-Following Response e do Potencial Evocado Auditivo de Média Latência em indivíduos típicos e com alterações das habilidades auditivas, assim como investigar a sensibilidade e especificidade de ambas as avaliações frente ao processamento auditivo central. Métodos: 32 indivíduos de ambos os sexos foram distribuídos em Grupo 1 (sem alterações de habilidades auditivas) e Grupo 2 (com alteração em habilidades auditivas). Os grupos foram divididos de acordo com testes comportamentais do processamento auditivo central. Os indivíduos de ambos os grupos foram submetidos aos potenciais evocados auditivos. O teste T de Student foi utilizado para a análise, considerando 5% de significância. Resultados: no Grupo 2, V e A apresentaram maior latência e menor amplitude e slope. O Grupo 2 também apresentou menores amplitudes de Na e Pa nas ondas A1C3 e A2C3. O Frequency-Following Response apresentou 93% de sensibilidade e especificidade, enquanto o Potencial Evocado Auditivo de Média Latência apresentou 87% de sensibilidade e 93% de especificidade. Conclusão: os indivíduos com alteração das habilidades auditivas apresentaram maior latência e menor amplitude de resposta no Frequency Following Response e Potencial Evocado Auditivo de Média Latência em relação aos indivíduos típicos. O Frequency-Following Response apresentou melhor equilíbrio de sensibilidade e especificidade.

Central Auditory Processing and Cognitive Functions in Children

Introduction  Nowadays, there is no consensus on whether central auditory processing disorder is a primary or a secondary deficit to other cognitive deficits. A better understanding of the association between cognitive functions and central auditory skills may help elucidate this dilemma. Objective  To investigate possible associations between auditory abilities and cognitive functions in schoolchildren. Methods  Fifty-eight schoolchildren, aged between 8 years and 0 months old and 11 years and 11 months old, who underwent the following tests: masking level difference, gaps in noise, pitch pattern sequence test, dichotic digits test, sustained auditory attention ability test, Wechsler intelligence scale for children - IV, junior Hayling test, five digits test, and behavior rating inventory of executive function. Results  Significant correlations were found between the hearing ability of temporal resolution and executive functions, temporal ordering/sequencing, binaural integration and separation, and sustained auditory attention, operational memory, inhibitory control, and cognitive flexibility; binaural integration was also associated with intelligence. The statistically significant positive correlation found between the ability of binaural interaction and the components of emotional control and behavior regulation of the behavior rating inventory of executive function was unexpected. Conclusion  The associations identified reinforce the complexity of the tasks involved in the evaluation of central auditory processing and the need for multidisciplinary evaluation for the differential diagnosis of auditory processing disorder. Confirmation of the presence or absence of comorbidities between different disorders allows directing the therapeutic behaviors and reducing the impact of possible auditory and/or cognitive deficits in the different daily life situations of children.

The Auditory Processing Domains Questionnaire (APDQ): Brazilian–Portuguese version

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Questionnaires can be useful tools for obtaining information on auditory behavior.

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APDQ demonstrates separating the three clinical groups studied.

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The translated version of the questionnaire showed good reliability parameters.

Objective

The present study aimed to determine the fidelity, reliability, and internal validity of the APDQ when translated from English to Brazilian–Portuguese language.

Methods

The first phase included the APDQ translation into Brazilian–Portuguese including forward translation, translation assessment and back-translation in a group of 10 students. The second phase involved establishing the internal consistency and reliability of the APDQ Brazilian–Portuguese version. Data was collected from 66 students without any risk factor for auditory processing disorder. Subjects were divided into a younger group (7–10 yrs) and an older group (11–17 yrs).

Results

All items showed appropriate quality in terms of translation. In determining internal consistency, Cronbach's alpha in subscales of auditory processing, attention and language was found to be 0.93, 0.85 and 0.74, respectively. Intraclass Correlation Coefficient for total score was 0.95, ensuring a strong test-retest reliability.

Conclusion

The Brazilian–Portuguese version of the APDQ has favorable translation quality, internal validity and reliability. It is now ready for continued study as a differential screening tool for 7- to 17-year-old Brazilian children with listening difficulties who are at risk for auditory processing disorder, attention deficits and language learning challenges.

Combination of Comorbidities as a Reference Standard for Evaluating Auditory Processing Disorder: Response to the Letter to the Editor From Schow et al. (2021)

PURPOSE

Concerns expressed by Schow et al. (2021) around the evidence-based diagnostic criteria suggested by Ahmmed (2021a) are addressed here. The use of combination of comorbidities as a reference standard for evaluating auditory processing tests is a valid strategy, consistent with the Research Domain Criteria framework from the National Institute of Mental Health as well as the Standards for Reporting of Diagnostic Accuracy Studies. The correlations between auditory processing tests and some comorbidities in Ahmmed (2021a) were significant at p < .01. The low sensitivity and specificity reported was not related to the principle of using comorbidities as a reference standard but due to the choice of comorbidities combined in the reference standard. Ahmmed (2021a) suggested the option of inclusion of other comorbidities in addition to language impairment and impaired manual dexterity in the reference standard. Visual processing impairment could be considered as the additional comorbidity to improve sensitivity and specificity of the approach suggested by Ahmmed (2021a).

Speech Perception in Noise Predicts Oral Narrative Comprehension in Children With Developmental Language Disorder

We examined the relative contribution of auditory processing abilities (tone perception and speech perception in noise) after controlling for short-term memory capacity and vocabulary, to narrative language comprehension in children with developmental language disorder. Two hundred and sixteen children with developmental language disorder, ages 6 to 9 years (Mean = 7; 6), were administered multiple measures. The dependent variable was children's score on the narrative comprehension scale of the Test of Narrative Language. Predictors were auditory processing abilities, phonological short-term memory capacity, and language (vocabulary) factors, with age, speech perception in quiet, and non-verbal IQ as covariates. Results showed that narrative comprehension was positively correlated with the majority of the predictors. Regression analysis suggested that speech perception in noise contributed uniquely to narrative comprehension in children with developmental language disorder, over and above all other predictors; however, tone perception tasks failed to explain unique variance. The relative importance of speech perception in noise over tone-perception measures for language comprehension reinforces the need for the assessment and management of listening in noise deficits and makes a compelling case for the functional implications of complex listening situations for children with developmental language disorder.

Listening Difficulties in Children With Normal Audiograms: Relation to Hearing and Cognition

OBJECTIVES

Children presenting at audiology services with caregiver-reported listening difficulties often have normal audiograms. The appropriate approach for the further assessment and clinical management of these children is currently unclear. In this Sensitive Indicators of Childhood Listening Difficulties (SICLiD) study, we assessed listening ability using a reliable and validated caregiver questionnaire (the Evaluation of Children's Listening and Processing Skills [ECLiPS]) in a large (n = 146) and heterogeneous sample of 6- to 13-year-old children with normal audiograms. Scores on the ECLiPS were related to a multifaceted laboratory assessment of the children's audiological, psycho- and physiological-acoustic, and cognitive abilities. This report is an overview of the SICLiD study and focuses on the children's behavioral performance. The overall goals of SICLiD were to understand the auditory and other neural mechanisms underlying childhood listening difficulties and translate that understanding into clinical assessment and, ultimately, intervention.

DESIGN

Cross-sectional behavioral assessment of children with "listening difficulties" and an age-matched "typically developing" control group. Caregivers completed the ECLiPS, and the resulting total standardized composite score formed the basis of further descriptive statistics, univariate, and multivariate modeling of experimental data.

RESULTS

All scores of the ECLiPS, the SCAN-3:C, a standardized clinical test suite for auditory processing, and the National Institutes of Health (NIH) Cognition Toolbox were significantly lower for children with listening difficulties than for their typically developing peers using group comparisons via t-tests and Wilcoxon Rank-Sum tests. A similar effect was observed on the Listening in Spatialized Noise-Sentences (LiSN-S) test for speech sentence-in-noise intelligibility but only reached significance for the Low Cue and High Cue conditions and the Talker Advantage derived score. Stepwise regression to examine the factors contributing to the ECLiPS Total scaled score (pooled across groups) yielded a model that explained 42% of its variance based on the SCAN-3:C composite, LiSN-S Talker Advantage, and the NIH Toolbox Picture Vocabulary, and Dimensional Change Card Sorting scores (F[4, 95] = 17.35, p < 0.001). High correlations were observed between many test scores including the ECLiPS, SCAN-3:C, and NIH Toolbox composite measures. LiSN-S Advantage measures generally correlated weakly and nonsignificantly with non-LiSN-S measures. However, a significant interaction was found between extended high-frequency threshold and LiSN-S Talker Advantage.

CONCLUSIONS

Children with listening difficulties but normal audiograms have problems with the cognitive processing of auditory and nonauditory stimuli that include both fluid and crystallized reasoning. Analysis of poor performance on the LiSN-S Talker Advantage measure identified subclinical hearing loss as a minor contributing factor to talker segregation. Beyond auditory tests, evaluations of children with complaints of listening difficulties should include standardized caregiver observations and consideration of broad cognitive abilities.

Executive Function and Sensory Processing in Dichotic Listening of Young Adults with Listening Difficulties

Previous studies have suggested that varying attention demands in dichotic listening (DL) tasks might be a clinically feasible method to distinguish ‘bottom-up’ from ‘top-down’ deficits in listening. This study aims to investigate DL processing in adults with listening difficulties (LD). We assessed the performance of a listening difficulties group (LDG) (n = 24, mean age = 24, backward digit span = 4.0) and a control group (CG) (n = 25, mean age = 29.2, backward digit span = 6.4) in DL tests involving non-forced and both right and left-forced attention. The results indicated an overall significantly worse performance of LDG compared to the CG, which was greater for forced-left condition. This same result was observed when controlling for working memory (WM) variance. Both groups presented an overall right ear advantage with no difference in terms of the magnitude of advantage. These results indicate that LD presented by the LDG might be due to a combination of sensory and cognitive deficits, with emphasis on the cognitive component. However, the WM, although impaired in the LDG group, was not the main factor in segregating both groups. The role of the additional cognitive processes such as inhibitory control in LD is discussed.

Electrophysiological Screening for Children With Suspected Auditory Processing Disorder: A Systematic Review

Objective: This research aimed to provide evidence for the early identification and intervention of children at risk for auditory processing disorder (APD). Electrophysiological studies on children with suspected APDs were systematically reviewed to understand the different electrophysiological characteristics of children with suspected APDs. Methods: Computerized databases such as PubMed, Cochrane, MEDLINE, Web of Science, and EMBASE were searched for retrieval of articles since the establishment of the database through May 18, 2020. Cohort, case-control, and cross-sectional studies that evaluated the literature for the electrophysiological assessment of children with suspected APD were independently reviewed by two researchers for literature screening, literature quality assessment, and data extraction. The Newcastle-Ottawa Scale and 11 entries recommended by the Agency for Healthcare Research and Quality were used to evaluate the quality of the literature. Results: In accordance with the inclusion criteria, 14 articles were included. These articles involved 7 electrophysiological testing techniques: click-evoked auditory brainstem responses, frequency-following responses, the binaural interaction component of the auditory brainstem responses, the middle-latency response, cortical auditory evoked potential, mismatch negativity, and P300. The literature quality was considered moderate. Conclusions: Auditory electrophysiological testing can be used for the characteristic identification of children with suspected APD; however, the value of various electrophysiological testing methods for screening children with suspected APD requires further study.

An Objective Approach Toward Understanding Auditory Processing Disorder

Purpose In the field of audiology, auditory processing disorder (APD) continues to be a topic of ongoing debate for clinicians and scientists alike, both in terms of theory and clinical practice. In the current viewpoint, we first lay out the main issues that are central to the controversy surrounding APD, and then suggest a framework toward their resolution. Method The current viewpoint is informed by reviewing existing studies in the field of APD to better understand the issues contributing to the controversies in APD. Results We found that, within the current definition of APD, the two main issues that make the APD diagnosis controversial are (a) comorbidity with other disorders and (b) the lack of domain specificity. These issues remain unresolved, especially with the use of the existing behavioral APD test batteries. In this viewpoint, we shed light on how they can be mitigated by implementing the administration of an objective, physiological test battery. Conclusions By administering an objective test battery, as proposed in this viewpoint, we believe that it will be possible to achieve a higher degree of specificity to the auditory domain that will not only contribute towards clinical practice but also contribute towards strengthening APD as a theoretical construct.

Auditory Processing Disorder and Its Comorbidities: A Need for Consistency in Test Cutoff Scores

Purpose No gold standard criteria exist for diagnosing developmental auditory processing disorder (APD). This study aimed to identify APD criteria, which are consistent with that used for comorbidities, and how comorbidities predicted APD. Method A retrospective study of 167 participants (males = 105, females = 62; age: 6-16 years; nonverbal IQ > 80) with suspected APD is presented. Five SCAN-3 tests evaluated auditory processing (AP). Comorbidities included attention-deficit/hyperactivity disorder, language impairment, and impaired manual dexterity, which were identified using percentile ≤ 5 in the Swanson, Nolan and Pelham parental rating scale; Children's Communication Checklist-2; and Movement Assessment Battery for Children-2, respectively. Results Percentiles ≤ 9, ≤ 5, and < 2 in two or more AP tests had sensitivities (specificities) of 76% (70.6%), 59.3% (76.5%), and 26% (82.4%), respectively, in predicting comorbidities, which were present in 150 of the 167 participants. The criterion of "≤ 9 percentile in two or more AP tests" (Approach I) diagnosed APD in 119 participants, and criterion "≤ 5 percentile in two or more AP tests or ≤ 5 percentile in one AP plus one or more measures of comorbidities" (Approach II) diagnosed 123. The combination of approaches diagnosed 128 participants (76.6%) with APD, of which 114 were diagnosed by each approach (89%). Language impairment and impaired manual dexterity, but not attention-deficit/hyperactivity disorder, predicted APD. Conclusions "Percentile ≤ 9 in two or more AP tests" or "percentile ≤ 5 in one AP plus one or more measures of comorbidities" are evidence-based APD diagnostic criteria. Holistic and interprofessional practice evaluating comorbidities including motor skills is important for APD.

Basic Measures of Auditory Perception in Children: No Evidence for Mediation by Auditory Working Memory Capacity

Immature auditory perception in children has generally been ascribed to deficiencies in cognitive factors, such as working memory and inattention. This notion appears to be commonly accepted for all children despite limited empirical evidence. In the present work, we examined whether working memory capacity would predict basic aspects of hearing, pure-tone frequency discrimination and temporal gap detection, in typically-developing, normal-hearing children (7–12 years). Contrary to our expectation, working memory capacity, as measured by digit spans, or intrinsic auditory attention (on- and off-task response variability) did not consistently predict the individual variability in auditory perception. Present results provide no evidence for a role of working memory capacity in basic measures of auditory perception in children. This lack of a relationship may partly explain why some children with perceptual deficits despite normal audiograms (commonly referred to as auditory processing disorders) may have typical cognitive abilities.

Portable Automated Rapid Testing (PART) for auditory assessment: Validation in a young adult normal-hearing population

This study aims to determine the degree to which Portable Automated Rapid Testing (PART), a freely available program running on a tablet computer, is capable of reproducing standard laboratory results. Undergraduate students were assigned to one of three within-subject conditions that examined repeatability of performance on a battery of psychoacoustical tests of temporal fine structure processing, spectro-temporal amplitude modulation, and targets in competition. The repeatability condition examined test/retest with the same system, the headphones condition examined the effects of varying headphones (passive and active noise-attenuating), and the noise condition examined repeatability in the presence of recorded cafeteria noise. In general, performance on the test battery showed high repeatability, even across manipulated conditions, and was similar to that reported in the literature. These data serve as validation that suprathreshold psychoacoustical tests can be made accessible to run on consumer-grade hardware and perform in less controlled settings. This dataset also provides a distribution of thresholds that can be used as a normative baseline against which auditory dysfunction can be identified in future work.

Validity of the Multiple Auditory Processing Assessment-2: A Test of Auditory Processing Disorder

Purpose A normative study using the Multiple Auditory Processing Assessment-2 (MAPA-2; Schow et al., 2018) was recently completed. With access to these data, the authors extend that work and support a definite construct for auditory processing disorder (APD). The goal here is to examine MAPA-2 reliability and validity (construct, content, and concurrent). Evidence for the APD construct is further buttressed by measures of sensitivity and specificity. Results of MAPA-2 testing on children diagnosed with learning disability (LD), attention-deficit/hyperactivity disorder (ADHD), and specific language impairment (SLI) are included. Method Normative data (previously published as the MAPA-2) allowing derivation of these findings included a representative sample of 748 children (53% girls) ages 7-14 years tested by 54 speech-language pathologists and audiologists in 27 U.S. states. The authors examined diagnostic accuracy based on the American Speech-Language-Hearing Association (2005) criteria (index test) for confirmed cases of APD. The index was also used to identify listening problems for three other diagnostic categories (LD, ADHD, and SLI). Validated questionnaire responses from parents and school personnel allowed incorporation of functional measures widely supported in APD diagnosis but unavailable with other normative and sensitivity/specificity studies. Results Reliability and validity were both satisfactory, and diagnostic accuracy for an APD group of 18 (28% female) compared to the remaining typical group of 625 yielded 89% sensitivity and 82% specificity. The remaining three groups (LD, ADHD, and SLI), where comorbidity was expected to be about 50%, had APD-type listening problems with a prevalence ranging from 52% to 65%. Conclusions Current results provide important evidence for the construct of APD. The MAPA-2 can be administered by an audiologist or speech-language pathologist. A similar diagnostic protocol in Australia yielded positive therapeutic gains. Further study is encouraged to determine if the present positive findings will be found in future research.

Peripheral Auditory Involvement in Childhood Listening Difficulty

OBJECTIVES

This study tested the hypothesis that undetected peripheral hearing impairment occurs in children with idiopathic listening difficulties (LiDs), as reported by caregivers using the Evaluation of Children"s Listening and Processing Skills (ECLiPS) validated questionnaire, compared with children with typically developed (TD) listening abilities.

DESIGN

Children with LiD aged 6-14 years old (n = 60, mean age = 9.9 yr) and 54 typical age matched children were recruited from audiology clinical records and from IRB-approved advertisements at hospital locations and in the local and regional areas. Both groups completed standard and extended high-frequency (EHF) pure-tone audiometry, wideband absorbance tympanometry and middle ear muscle reflexes, distortion product and chirp transient evoked otoacoustic emissions. Univariate and multivariate mixed models and multiple regression analysis were used to examine group differences and continuous performance, as well as the influence of demographic factors and pressure equalization (PE) tube history.

RESULTS

There were no significant group differences between the LiD and TD groups for any of the auditory measures tested. However, analyses across all children showed that EHF hearing thresholds, wideband tympanometry, contralateral middle ear muscle reflexes, distortion product, and transient-evoked otoacoustic emissions were related to a history of PE tube surgery. The physiologic measures were also associated with EHF hearing loss, secondary to PE tube history.

CONCLUSIONS

Overall, the results of this study in a sample of children with validated LiD compared with a TD group matched for age and sex showed no significant differences in peripheral function using highly sensitive auditory measures. Histories of PE tube surgery were significantly related to EHF hearing and to a range of physiologic measures in the combined sample.

Impact of hearing loss on the performance of auditory processing measured by questionnaires in Korean adolescents

Increasing use of personal listening devices has been accompanied by increase in the prevalence of hearing loss (HL) among youth in Korea, as in other countries. Auditory processing disorder (APD) is one of the main factors affecting academic achievement at school. This study aimed to investigate the prevalence of HL in students attending general middle- and high schools and compare the findings with the APD survey results. From June 1 to December 31, 2016, Korean adolescents (n = 2,791) in the first years of middle- and high school underwent audiometric testing and otologic examination and completed questionnaires on APD. The survey was sponsored by the Korean Society of Otolaryngology-Head and Neck Surgery and the Korean Otology Society. The prevalence of speech-frequency hearing loss (SFHL) and high-frequency hearing loss (HFHL) in the poorer ear was 11.6% and 10.3%, respectively, among Korean adolescents. We analysed data from the Scale of Auditory Behaviors, Fisher’s Auditory Problems Checklist, and KNISE-Auditory Behavioral Checklist and compared these with the results of hearing tests. We observed positive correlations among the APD questionnaire results and mean hearing levels. This study suggested that hearing loss, especially bilateral high-frequency hearing loss, may affect central auditory processing.

Listening Difficulties in Children: Behavior and Brain Activation Produced by Dichotic Listening of CV Syllables

Listening difficulties (LiD) are common in children with and without hearing loss. Impaired interactions between the two ears have been proposed as an important component of LiD when there is no hearing loss, also known as auditory processing disorder (APD). We examined the ability of 6-13 year old (y.o.) children with normal audiometric thresholds to identify and selectively attend to dichotically presented CV syllables using the Bergen Dichotic Listening Test (BDLT; www.dichoticlistening.com). Children were recruited as typically developing (TD; n = 39) or having LiD (n = 35) based primarily on composite score of the ECLiPS caregiver report. Different single syllables (ba, da, ga, pa, ta, ka) were presented simultaneously to each ear (6 × 36 trials). Children reported the syllable heard most clearly (non-forced, NF) or the syllable presented to the right [forced right (FR)] or left [forced left (FL)] ear. Interaural level differences (ILDs) manipulated bottom-up perceptual salience. Dichotic listening (DL) data [correct responses, laterality index (LI)] were analyzed initially by group (LiD, TD), age, report method (NF, FR, FL), and ILD (0, ± 15 dB) and compared with speech-in-noise thresholds (LiSN-S) and cognitive performance (NIH Toolbox). fMRI measured brain activation produced by a receptive speech task that segregated speech, phonetic, and intelligibility components. Some activated areas [planum temporale (PT), inferior frontal gyrus (IFG), and orbitofrontal cortex (OFC)] were correlated with dichotic results in TD children only. Neither group, age, nor report method affected the LI of right/left recall. However, a significant interaction was found between ear, group, and ILD. Laterality indices were small and tended to increase with age, as previously reported. Children with LiD had significantly larger mean LIs than TD children for stimuli with ILDs, especially those favoring the left ear. Neural activity associated with Speech, Phonetic, and Intelligibility sentence cues did not differ significantly between groups. Significant correlations between brain activity level and BDLT were found in several frontal and temporal locations for the TD but not for the LiD group. Overall, the children with LiD had only subtle differences from TD children in the BDLT, and correspondingly minor changes in brain activation.

Development of auditory perception in preschool children

OBJECTIVE

The aim of this study was to determine whether the auditory skills presented by five-year-old children can predict their performance in auditory processing (AP) tests at seven years old.

DESIGN

Thirty-five children were evaluated for AP at two different times. At evaluation 1, the children were between 5 years 2 months and 6 years 1 month of age, and at evaluation 2, they were between 7 years 1 month and 7 years 8 months of age. The interval between the evaluations ranged from 18 to 23 months. After evaluation 2, the 7-year-olds were classified according to their performance on central AP tests. The children were divided into three groups: GI included nine children with at least two AP tests that scored two standard deviations below the mean and the presence of a speech complaint; GII included 18 children with at least two AP tests that scored two standard deviations below the mean and no speech complaints; and GIII included eight children with no more than one test scored two standard deviations below the mean and no speech disorders complaint. The analysis was performed considering each test individually and as a battery of applied tests. From the results obtained, a discriminant analysis was performed to assess the differences in test performance between the groups when the children were 5 years old.

RESULTS

The discriminant analysis showed that with the results obtained during evaluation 1, it was possible to predict which group 74.3% of the children would be classified into after evaluation 2. The percentage of correct classifications for each group was 77.8% for GI, 66.7% for GII and 87.5% for GIII. That is, 87.5% of the children who were classified as GIII after evaluation 2 had already demonstrated good auditory performance in the tests applied at 5 years of age.

CONCLUSIONS

Children who exhibited lower scores on AP tests at 7 years of age had demonstrated poor auditory perception at 5 years of age. This finding is relevant because it offers the possibility of stimulating or training these auditory skills in preschoolers to foster their development.

On differentiating auditory processing disorder (APD) from attention deficit disorder (ADD): an illustrative example using the Cattell-Horn-Carroll (CHC) model of cognitive abilities

Objective: To clarify the distinction between Auditory Processing Disorder (APD) and Attention Deficit Disorder (ADD) using the CHC Model.Design: A cross-sectional study compared responses of caregivers about their children's behaviour to identify characteristics of APD (CHC Model) and ADD (DSM-5).Study Sample: Caregivers, mostly mothers (92%), of 149 children (M 61%; F 39%) aged from 6 to 16 years, referred for "Auditory Processing Assessment" of their child, were shown an A4 card displaying the characteristics of AP from the CHC Model on one side, and of ADD from DSM-5 on the other. Both sides were untitled. For each side, caregivers were asked if the characteristics were true of their child using a Conners-type four-point scale.Results: The majority of children were rated by caregivers as displaying characteristics of ADD, rather than an APD problem. Comparing problems with AP vs. problems with ADD gave: Wilcoxon T = 9.71; z = 4.86, p < 0.001.Conclusion: The finding that most children referred for an AP Assessment showed characteristics of ADD was surprising. Given the continuing audiological controversies about the nature of AP and about differentiating AP disorders from ADD, the CHC Model offers a different and informative perspective.

British children's performance on the listening in spatialised noise-sentences test (LISN-S)

Objective: To investigate whether British children's performance is equivalent to North American norms on the listening in spatialised noise-sentences test (LiSN-S). Design: Prospective study comparing the performance of a single British group of children to North-American norms on the LiSN-S (North American version). Study sample: The British group was composed of 46 typically developing children, aged 6-11 years 11 months, from a mainstream primary school in London. Results: No significant difference was observed between the British's group performance and the North-American norms for Low-cue, High-cue, Spatial Advantage and Total Advantage measure. The British group presented a significantly lower performance only for Talker Advantage measure (z-score: 0.35, 95% confidence interval -0.12 to -0.59). Age was significantly correlated with all unstandardised measures. Conclusion: Our results indicate that, when assessing British children, it would be appropriate to add a corrective factor of 0.35 to the z-score value obtained for the Talker Advantage in order to compare it to the North-American norms. This strategy would enable the use of LiSN-S in the UK to assess auditory stream segregation based on spatial cues.

Listening Difficulties in Children With Fetal Alcohol Spectrum Disorders: More Than a Problem of Audibility

Purpose Data from standardized caregiver questionnaires indicate that children with fetal alcohol spectrum disorders (FASDs) frequently exhibit atypical auditory behaviors, including reduced responsivity to spoken stimuli. Another body of evidence suggests that prenatal alcohol exposure may result in auditory dysfunction involving loss of audibility (i.e., hearing loss) and/or impaired processing of clearly audible, "suprathreshold" sounds necessary for sound-in-noise listening. Yet, the nexus between atypical auditory behavior and underlying auditory dysfunction in children with FASDs remains largely unexplored. Method To investigate atypical auditory behaviors in FASDs and explore their potential physiological bases, we examined clinical data from 325 children diagnosed with FASDs at the University of Washington using the FASD 4-Digit Diagnostic Code. Atypical behaviors reported on the "auditory filtering" domain of the Short Sensory Profile were assessed to document their prevalence across FASD diagnoses and explore their relationship to reported hearing loss and/or central nervous system measures of cognition, attention, and language function that may indicate suprathreshold processing deficits. Results Atypical auditory behavior was reported among 80% of children with FASDs, a prevalence that did not vary by FASD diagnostic severity or hearing status but was positively correlated with attention-deficit/hyperactivity disorder. In contrast, hearing loss was documented in the clinical records of 40% of children with fetal alcohol syndrome (FAS; a diagnosis on the fetal alcohol spectrum characterized by central nervous system dysfunction, facial dysmorphia, and growth deficiency), 16-fold more prevalent than for those with less severe FASDs (2.4%). Reported hearing loss was significantly associated with physical features characteristic of FAS. Conclusion Children with FAS but not other FASDs may be at a particular risk for hearing loss. However, listening difficulties in the absence of hearing loss-presumably related to suprathreshold processing deficits-are prevalent across the entire fetal alcohol spectrum. The nature and impact of both listening difficulties and hearing loss in FASDs warrant further investigation.

Comment on Yathiraj & Vanaja (2018), "Criteria to Classify Children as Having Auditory Processing Disorders"

Purpose The purpose of this letter is to comment on an article by Yathiraj and Vanaja (2018) titled "Criteria to Classify Children as Having Auditory Processing Disorders." Conclusions Although there is a need to diagnose auditory processing disorders in school-age children, the criteria recommended by Yathiraj and Vanaja (2018) are not empirically derived. Continued research is needed to clearly define an auditory processing disorder in this population and develop highly sensitive and specific tests to diagnose the disorder.