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.

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).

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.

Setting appropriate pass or fail cut-off criteria for tests to reflect real life listening difficulties in children with suspected auditory processing disorder.

OBJECTIVE: This paper explores the pass or fail cut-off criteria, the number of test fails, and the nature of tests that are most appropriate in predicting listening difficulties (LiD) in children with suspected APD (SusAPD). METHODS: One hundred and nine English-speaking children (67 males, 42 females) aged between 6 and 11 years with SusAPD were assessed. The Children's Auditory Performance Scale (CHAPS) scores 2 SD below the mean were taken as markers of LiD in different listening conditions. Binary logistic regression analyses were carried out to evaluate the cut-off criterion (2 SD or 1.5 SD or 1 SD below the mean) of failing at least two tests, from the SCAN-C and IMAP test batteries, which significantly predicted LiD. Analyses were also carried out to assess if the group of auditory processing (AP) or cognitive or combination of AP plus cognitive tests were significant in predicting LiD. Receiver Operative Characteristic (ROC) curves were also explored to evaluate how the sensitivity and specificity in confirming LiD varied with the number of test fails. RESULTS: Filtered Words, Competing Words, Competing Sentences, VCV in ICRA noise, Digit Span, Sight Word Reading and the Cued Auditory Attention tests correlated with one or more of the CHAPS domains. Failing at least two of these tests 1.5 SD below the mean significantly predicted (p<.05) CHAPS Ideal scores 2 SD below the mean, and failing at least two of the tests 1 SD below the mean significantly predicted (p<.05) CHAPS Memory and CHAPS Attention scores 2 SD below the mean. The combination of AP plus cognitive tests had significantly higher ability to predict CHAPS Ideal, Memory and Attention scores, compared to the group of AP or cognitive tests separately. ROC curves showed that failing at least two of the tests was associated with the best sensitivity and specificity in predicting LiD. CONCLUSION: Of the different CHAPS domains only the CHAPS Ideal, Memory and Attention correlated with the APD tests. Failing at least two APD tests from a combination of AP and cognitive tests 1 SD and 1.5 SD below the mean, but not 2 SD, is more appropriate in confirming LiD.

Assessment of children with suspected auditory processing disorder: a factor analysis study.

OBJECTIVES: To identify the factors that may underlie the deficits in children with listening difficulties, despite normal pure-tone audiograms. These children may have auditory processing disorder (APD), but there is no universally agreed consensus as to what constitutes APD. The authors therefore refer to these children as children with suspected APD (susAPD) and aim to clarify the role of attention, cognition, memory, sensorimotor processing speed, speech, and nonspeech auditory processing in susAPD. It was expected that a factor analysis would show how nonauditory and supramodal factors relate to auditory behavioral measures in such children with susAPD. This would facilitate greater understanding of the nature of listening difficulties, thus further helping with characterizing APD and designing multimodal test batteries to diagnose APD. DESIGN: Factor analysis of outcomes from 110 children (68 male, 42 female; aged 6 to 11 years) with susAPD on a widely used clinical test battery (SCAN-C) and a research test battery (MRC Institute of Hearing Research Multi-center Auditory Processing "IMAP"), that have age-based normative data. The IMAP included backward masking, simultaneous masking, frequency discrimination, nonverbal intelligence, working memory, reading, alerting attention and motor reaction times to auditory and visual stimuli. SCAN-C included monaural low-redundancy speech (auditory closure and speech in noise) and dichotic listening tests (competing words and competing sentences) that assess divided auditory attention and hence executive attention. RESULTS: Three factors were extracted: "general auditory processing," "working memory and executive attention," and "processing speed and alerting attention." Frequency discrimination, backward masking, simultaneous masking, and monaural low-redundancy speech tests represented the "general auditory processing" factor. Dichotic listening and the IMAP cognitive tests (apart from nonverbal intelligence) were represented in the "working memory and executive attention" factor. Motor response times to cued and noncued auditory and visual stimuli were grouped in the "processing speed and alerting attention" factor. Individuals varied in their outcomes in different tests. Poor performance was noted in different combinations of tests from the three factors. Impairments solely related to the "general auditory processing" factor were not common. CONCLUSIONS: The study identifies a general auditory processing factor in addition to two other cognitive factors, "working memory and executive attention" and "processing speed and alerting attention," to underlie the deficits in children with susAPD. Impaired attention, memory, and processing speed are known to be associated with poor literacy and numeracy skills as well as a number of neurodevelopmental disorders. Individuals with impairments in the "general auditory processing" tests along with tests from the other two cognitive factors may explain the co-occurrence of APD and other disorders. The variation in performance by individuals in the different tests noted was probably due to a number of reasons including heterogeneity in susAPD and less-than ideal test-retest reliabilities of the tests used to assess APD. Further research is indicated to explore additional factors, and consensus is needed to improve the reliability of tests or find alternative approaches to diagnose APD, based on the underlying factors.

Mismatch negativity and frequency representational width in children with specific language impairment.

The aim of this study was to compare the degree of frequency separation that is required between tones to generate mismatch negativity (MMN) in a group of children with specific language impairment (SLI) and a comparison group, who had their temporal processing abilities assessed in a previous experiment. Using a 1000Hz standard (85%) and 1020, 1050, and 1100Hz deviant tones presented at inter-stimulus intervals (ISIs) of 200 and 400ms, MMN was compared in 19 children with SLI (13 males, six females, age range 7y 4mo-11y 10mo, mean age 9y 7mo [SD 1y 2mo]), and 19 comparison children (13 males, six females, age range 7y 3mo-11y 4mo, mean age 9y 5mo [SD 1y 3mo]). Temporal processing ability was assessed by the Auditory Fusion Test-Revised. Children with SLI who had poor temporal processing abilities generated a positive mismatch response (P-MMR) for 2% tone contrasts at 400ms ISI but MMN with larger contrasts. These children also generated stronger MMN than the comparison group at 200ms ISI for 2% contrasts. Children with SLI who had good temporal processing abilities generated only P-MMR in response to contrasts up to 10% for both ISIs. Some children with SLI show an inverse relationship between frequency discrimination and temporal processing. Furthermore, certain stimulus-related and biological criteria may need to be met for P-MMR to switch to MMN.