[Development of Auditory Processing and Perception Skills with and without APD in Primary School Age]. / Entwicklung auditiver Verarbeitungs- und Wahrnehmungsleistungen mit und ohne AVWS im Grundschulalter.

BACKGROUND: We examined two student age groups (1st and 4th class) in a control-group comparison whether the maturation processes of the central hearing system in typically developing children are also present in children with Central Auditory Processing Disorders (CAPD) at primary-school age. MATERIALS AND METHODS: The analyses included results of a behavioral test battery from 82 first graders (40 with CAPD; 42 healthy controls) and 65 fourth graders (35 with CAPD; 30 healthy controls). An ANOVA with the total value of the following 7 standardized examinations, and subsequently a MANOVA with the detailed test results were carried out: Speech (words) in Noise Recognition (Göttinger Sprachaudiometrie II); Dichotic Word Pair Understanding (Uttenweiler-Test); Heidelberger Phoneme Discrimination Subtests: Phoneme Discrimination, Phoneme Identification, Phoneme Analysis; the Subtest Auditory Sequential Memory for Digits of the Illinois Test of Psycholinguistic Abilities (German version); Mottier's Nonword Repetition Test. RESULTS: The ANOVA showed significant main effects of "class" (1st versus 4th; p < 0.001, η²â€Š= 0.418) and "group" (CAPD versus healthy controls; p < 0.001; η²â€Š= 0.690), but no interaction effects between both. The result of the MANOVA was similar. Main effects, but only for two tests (phoneme identification; phoneme analysis) as well as the interaction of "class" and "group" were statistically significant, with statistically small effect sizes of 3 and 6 %. DISCUSSION: Based on this cross-sectional study, the difference between the two study groups appears to be independent of the school class level. CONCLUSION: At primary-school age, there is evidence of maturation of the central hearing system for both children with CAPD and healthy children.

[Test Diagnosis of Processing Disorders (APD) in Primary School - a factor analytical study]. / Testdiagnostik von AVWS im Grundschulalter ­ eine faktorenanalytische Untersuchung.

OBJECTIVE: Our eclectic test battery for diagnosing Auditory Processing Disorders (APD) was applied in some pre-studies. Now, its underlying content structure should be examined by a factor analytic study. MATERIAL AND METHODS: Test results from 143 children with APD with an average age of 8.3 (SD 1.1) yrs. went into several Exploratory Factor Analyses (EFA; principal component analysis). Considering the underlying correlations of the test variables, and in consideration of the results of discriminant analysis pre-studies, an EFA with 12 (of a total of 16) diagnostic test variables seemed appropriate. RESULTS: The Kaiser-Meyer-Olkin-measure of sampling adequacy was moderate middling to good (0.739). The determination of the optimal number of factors was based on the Kaiser criterion (eigenvalue > 1) and spoke in favour of four factors accounting for a cumulative variance of 63.7 %. A Scree-Test confirmed the four-component-solution. The component matrix showed that the loadings of the unrotated factors was mostly large on the first factor and therefore hardly to interpret. To obtain a better representation of the components, a Promax rotation was conducted. A clearly interpretable pattern of the rotated loadings resulted, forming these four components: phonematic processing; verbal-auditory memory; fundamental hearing processing, and a processing component of low redundance speech. CONCLUSION: Based on these findings, a preliminary model of the central auditory processes of our APD-test battery was drafted as well as a contribution to construct validity made.

[APD in First Graders. Which tests discriminate between normal and impaired children?] / Diagnostik von AVWS bei Erstklässlern: Welche Tests trennen auffällige von unauffälligen Kindern?

OBJECTIVE: In a controlled group comparison it was shown for 2nd, 3th and 4th graders that children with auditory processing disorders (APD) could be distinguished from those without (Non-APD) by three to four diagnostic tools. The hit rate was 93.6 % resp. 97.5 % 1, 2. The current study investigated whether such a separation is also possible in first graders. MATERIAL AND METHODS: Performance of 77 first graders in two clinically and diagnostically confirmed groups (n = 40 with APD, mean age: 6.93, SD 0.53 yrs; n = 37 Non APD, mean age: 6.90, SD 0.52 yrs) in 8 auditory processing tests of an eclectic test battery were compared (Dichotic Words Test; Phoneme Discrimination and Phoneme Identification; Word-Understanding in Background Noise; Binaural Summation Word Test; Sound Blending; Auditory Sequential Memory of Digits; Nonword Repetition). RESULTS: A differentiation of each clinical group with a multivariate statistical tool (discriminant analysis) functioned successfully. Children with APD were significantly distinguished from unimpaired children with an accuracy of 94.8 % (cross-validated in 92.2 %) via four test variables: (1) Auditory Sequential Memory of digits; (2) Phoneme Discrimination; (3) Nonword Repetition; (4) Word Understanding in Background Noise. CONCLUSIONS: The quality of the diagnostic a-priori-grouping using a multivariate statistics (discriminant analysis) could be confirmed for first graders too.

[Auditory Processing Disorder: Is The Diagnosis Already Possible In First Graders?] / Auditive Verarbeitungs- und Wahrnehmungsstörung: Ist die Diagnose schon bei Erstklässlern möglich?

OBJECTIVE: Significant differences in performance on an eclectic German test battery for Auditory Processing Disorders (APD) was found in the most diagnostic tools between children with APD and controls in the 2nd, 3rd and 4th school year of primary education. Aim of the present study was to examine whether it is also the case for first graders. MATERIAL AND METHODS: The performance in the behavioral test battery (including 14 specific auditory tests) was compared in two subject groups (aged 6-8 yrs): 41 first graders with APD of a clinical database, 37 typically developing first graders without APD (controls). RESULTS: Significant mean group differences were detected in the performance on 12 of 14 tests, because children with APD showed lower scores (excepted from two PaTsy-subtests: sound frequencies; sound intensities). The significance concerning the monaural threshold values narrowly retained statistical significance with Bonferroni correction. The controls mastered the PaTsy-subtests only in 86-89 % of all cases, children with APD in 73-83 %. The test scores of both boys and girls with APD were lower than those of their peers without APD. CONCLUSIONS: First graders with versus without APD could be significantly distinguished. Generally, there was seen a trend that in first graders the same performance was reduced as in elementary school pupils of higher grade level. For use in clinical diagnosis of APD, nonverbal auditory tests for the investigated specific age segment appears debatable.

A European Perspective on Auditory Processing Disorder-Current Knowledge and Future Research Focus.

Current notions of "hearing impairment," as reflected in clinical audiological practice, do not acknowledge the needs of individuals who have normal hearing pure tone sensitivity but who experience auditory processing difficulties in everyday life that are indexed by reduced performance in other more sophisticated audiometric tests such as speech audiometry in noise or complex non-speech sound perception. This disorder, defined as "Auditory Processing Disorder" (APD) or "Central Auditory Processing Disorder" is classified in the current tenth version of the International Classification of diseases as H93.25 and in the forthcoming beta eleventh version. APDs may have detrimental effects on the affected individual, with low esteem, anxiety, and depression, and symptoms may remain into adulthood. These disorders may interfere with learning per se and with communication, social, emotional, and academic-work aspects of life. The objective of the present paper is to define a baseline European APD consensus formulated by experienced clinicians and researchers in this specific field of human auditory science. A secondary aim is to identify issues that future research needs to address in order to further clarify the nature of APD and thus assist in optimum diagnosis and evidence-based management. This European consensus presents the main symptoms, conditions, and specific medical history elements that should lead to auditory processing evaluation. Consensus on definition of the disorder, optimum diagnostic pathway, and appropriate management are highlighted alongside a perspective on future research focus.

Mental health problems in adolescents with cochlear implants: peer problems persist after controlling for additional handicaps.

The aims of the present multi-center study were to investigate the extent of mental health problems in adolescents with a hearing loss and cochlear implants (CIs) in comparison to normal hearing (NH) peers and to investigate possible relations between the extent of mental health problems of young CI users and hearing variables, such as age at implantation, or functional gain of CI. The survey included 140 adolescents with CI (mean age = 14.7, SD = 1.5 years) and 140 NH adolescents (mean age = 14.8, SD = 1.4 years), their parents and teachers. Participants were matched by age, gender and social background. Within the CI group, 35 adolescents were identified as "risk cases" due to possible and manifest additional handicaps, and 11 adolescents were non-classifiable. Mental health problems were assessed with the Strengths and Difficulties Questionnaire (SDQ) in the versions "Self," "Parent," and "Teacher." The CI group showed significantly more "Peer Problems" than the NH group. When the CI group was split into a "risk-group" (35 "risk cases" and 11 non-classifiable persons) and a "non-risk group" (n = 94), increased peer problems were perceived in both CI subgroups by adolescents themselves. However, no further differences between the CI non-risk group and the NH group were observed in any rater. The CI risk-group showed significantly more hyperactivity compared to the NH group and more hyperactivity and conduct problems compared to the CI non-risk group. Cluster analyses confirmed that there were significantly more adolescents with high problems in the CI risk-group compared to the CI non-risk group and the NH group. Adolescents with CI, who were able to understand speech in noise had significantly less difficulties compared to constricted CI users. Parents, teachers, and clinicians should be aware that CI users with additionally special needs may have mental health problems. However, peer problems were also experienced by CI adolescents without additional handicaps.

Schooling Relates to Mental Health Problems in Adolescents with Cochlear Implants-Mediation by Hearing and Family Variables.

Aim of this multicenter study was to investigate whether schooling relates to mental health problems of adolescents with cochlear implants (CI) and how this relationship is mediated by hearing and family variables. One hundred and forty secondary school students with CI (mean age = 14.7 years, SD = 1.5), their hearing parents and teachers completed the Strengths and Difficulties Questionnaire (SDQ). Additional audiological tests (speech comprehension tests in quiet and noise) were performed. Students of special schools for hearing impaired persons (SSHIs) showed significantly more conduct problems (p < 0.05) and a significantly higher total difficulty score (TDS) (p < 0.05) compared to students of mainstream schools. Mental health problems did not differ between SSHI students with sign language education and SSHI students with oral education. Late implanted students and those with indication for additional handicaps were equally distributed among mainstream schools and SSHIs. However, students in SSHIs were more restricted to understand speech in noise, had a lower social background and were more likely to come from single-parent families. These factors were found to be partial mediators of the differences in mental health problems between the two school types. However, no variable could explain comprehensively, why students of SSHIs have more mental health problems than mainstream pupils.

Auditory processing in children with specific language impairments: are there deficits in frequency discrimination, temporal auditory processing or general auditory processing?

BACKGROUND/AIMS: Specific language impairment (SLI) is believed to be associated with nonverbal auditory (NVA) deficits. It remains unclear, however, whether children with SLI show deficits in auditory time processing, time processing in general, frequency discrimination (FD), or NVA processing in general. PATIENTS AND METHODS: Twenty-seven children (aged 8-11) with SLI and 27 control children (CG), matched for age and gender, were retrospectively compared with regard to their performance on five NVA skills in terms of just noticeable differences (JND) and time order judgments (TOJ). JND was used for FD, intensity discrimination, and gap detection, while TOJ was used for FD and clicks. RESULTS: Children with SLI performed significantly worse than the CG only on the FD tasks (JND and TOJ). The other nonverbal tasks showed no significant intergroup differences. Additionally, moderate associations were found between the FD tasks and phonological skills, as well as between FD tasks and language scores. CONCLUSION: Children with SLI appear to have restricted FD skills compared to controls, but there was no evidence for a common NVA deficit or reduced temporal auditory abilities.

Short-term memory (STM) constraints in children with specific language impairment (SLI): are there differences between receptive and expressive SLI?

PURPOSE: Specific language impairment (SLI) is assumed to be causally related to deficits in auditory short-term memory (STM). Although verbal STM deficits have been consistently found in SLI, the results of visual STM tests are inconsistent. Do these inconsistencies reflect different study populations of expressive SLI (ELI) and receptive-expressive SLI (R/ELI)? METHOD: Twenty-one children (ages 6-11) with ELI, 21 with R/ELI, and 21 controls (CG) matched on age and nonverbal intelligence were retrospectively compared with regard to their visual and auditory STM. RESULTS: ELI children and R/ELI children performed significantly poorer than the CG in auditory-verbal STM tests. On tests for visual STM (symbol sequences), the R/ELI children performed significantly poorer than the CG. For hand movements, children with R/ELI scored slightly poorer compared to both other groups but without reaching statistical significance. Correlation analyses showed significant associations between symbol sequences and receptive language measures. Regression analysis found that the scores of symbol sequences and digit sequences together accounted for 39% of the variance of the receptive language measures, whereas the scores for nonsense syllables accounted for 24% of the variance of the expressive language measures. CONCLUSION: R/ELI children appear to have more complex STM deficits, as they showed visual STM constraints in addition to auditory STM constraints.

Pedaudiologic findings after severe neonatal hyperbilirubinemia.

Neonatal hyperbilirubinemia (NHB) above 20 mg/dl (NHB20) has been shown to increase the risk of hearing impairments. Up to now, audiological findings based on behavioural audiometry (BA), otoacoustic emissions (TEOAE) and auditory brainstem responses (ABR) from children after being diagnosed with NHB20 have not been thoroughly compared to those with lower NHB-levels. We, therefore, aimed to assess the presence and characteristics of auditory dysfunction in children with NHB20. The audiological data of 15 children aged 11 months to 9 years with a NHB level between 22.6 and 45.6 mg/dl and/or MRI-confirmed bilirubin encephalopathy (NHBG) were compared retrospectively to 15 children with NHB levels between 12.5 and 19.4 mg/dl (CG). After matching by weeks of gestation at birth, BA, TEOAE and ABR were performed in all the children. Subsequently the groups were compared. Only two children of the NHBG had consistently normal audiologic findings. Hearing function disorders were detected in 87% (13/15) of the NHBG-children, ranging from total deafness to normal BA, including unilateral and bilateral deafness as well as cochlear hearing loss. Auditory neuropathy/dys-synchrony (AN) was found in a total of eight children (53%) of the NHBG. In addition, it was found that after the occurrence of NHB20, initially detected TEOAE can disappear in some cases. In the comparison group (CG) only two children demonstrated a hearing dysfunction, both of which were cochlear hearing impairments, whereas no child had AN. A bias towards hearing impairments has to be taken into account for both groups. Detailed pedaudiologic testing should be mandatory for all children after the occurrence of NHB20 including follow-up during the first 12 months. Audiological diagnostic work-up in the affected children requires objective investigations of hearing functions, while BA is recommended to evaluate the adequate therapeutic procedure.

Screening of the hearing of newborns - Update.

INTRODUCTION: Permanent congenital bilateral hearing loss (CHL) of moderate or greater degree (≥40 dB HL) is a rare disease, with a prevalence of about 1 to 3 per 1000 births. However, it is one of the most frequent congenital diseases. Reliance on physician observation and parental recognition has not been successful in the past in detecting significant hearing loss in the first year of life. With this strategy significant hearing losses have been detected in the second year of life. With two objective technologies based on physiologic response to sound, otoacoustic emissions (OAE) and auditory brainstem response (ABR) hearing screening in the first days of life is made possible. OBJECTIVES: The objective of this health technology assessment report is to update the evaluation on clinical effectiveness and cost-effectiveness of newborn hearing screening programs. Universal newborn hearing screening (UHNS) (i), selective screening of high risk newborns (ii), and the absence of a systematic screening program are compared for age at identification and age at hearing aid fitting of children with hearing loss. Secondly the potential benefits of early intervention are analysed. Costs and cost-effectiveness of newborn hearing screening programs are determined. This report is intended to make a contribution to the decision making whether and under which conditions a newborn hearing screening program should be reimbursed by the statutory sickness funds in Germany. METHODS: This health technology assessment report updates a former health technology assessment (Kunze et al. 2004 [1]). A systematic review of the literature was conducted, based on a documented search and selection of the literature using predefined inclusion and exclusion criteria and a documented extraction and appraisal of the included studies. To assess the cost-effectiveness of the different screening strategies in Germany the decision analytic Markov state model which had been developed in our former health technology assessment report was updated. RESULTS: Universal newborn hearing screening programs are able to substantially reduce the age at identification and the age at intervention of children with CHL to six months of age in the German health care setting. High coverage rates, low fail rates and - if tracking systems are implemented - high follow-up-rates to diagnostic evaluation for test positives were achieved. New publications on potential benefits of early intervention could not be retrieved. For a final assessment of cost-effectiveness of newborn hearing screening evidence based long-term data are lacking. Decision analytic models with lifelong time horizon assuming that early detection results in improved language abilities and lower educational costs and higher life time productivity showed a potential of UNHS for long term cost savings compared to selective screening and no screening. For the short-term cost-effectiveness with a time horizon up to diagnostic evaluation more evidence based data are available. The average costs per case diagnosed range from 16,000 EURO to 33,600 EURO in Germany and hence are comparable to the cost of other implemented newborn screening programs. Empirical data for cost of selective screening in the German health care setting are lacking. Our decision analytic model shows that selective screening is more cost-effective but detects only 50% of all cases of congenital hearing loss. DISCUSSION: There is good evidence that UNHS-Programs with appropriate quality management can reduce the age at start of intervention below six months. Up to now there is no indication of considerable negative consequences of screening for children with false positive test results and their parents. However, it is more difficult to prove the efficacy of early intervention to improve long-term outcomes. Randomized clinical trials of the efficacy of early intervention for children with CHL hearing losses are inappropriate because of ethical reasons. Prospective cohort studies with long-term outcomes of rare diseases are costly, take a long time and simultaneously substantial benefits of early intervention for language development seem likely. CONCLUSIONS: A UNHS-Program should be implemented in Germany and be reimbursed by the statutory sickness funds. To achieve high coverage and because of better conditions for obtaining low false positive rates UNHS should be performed in hospital after birth. For outpatient deliveries additionally screening measures in an outpatient setting must be provided.

Comparing the clinical effectiveness of different new-born hearing screening strategies. A decision analysis.

BACKGROUND: Children with congenital hearing impairment benefit from early detection and treatment. At present, no model exists which explicitly quantifies the effectiveness of universal newborn hearing screening (UNHS) versus other programme alternatives in terms of early diagnosis. It has yet to be considered whether early diagnosis (within the first few months) of hearing impairment is of importance with regard to the further development of the child compared with effects resulting from a later diagnosis. The objective was to systematically compare two screening strategies for the early detection of new-born hearing disorders, UNHS and risk factor screening, with no systematic screening regarding their influence on early diagnosis. DESIGN: Clinical effectiveness analysis using a Markov Model. DATA SOURCES: Systematic literature review, empirical data survey, and expert opinion. TARGET POPULATION: All newborn babies. TIME SCALE: 6, 12 and 120 months. PERSPECTIVE: Health care system. COMPARED STRATEGIES: UNHS, Risk factor screening (RS), no systematic screening (NS). OUTCOME MEASURES: Quality weighted detected child months (QCM). RESULTS: UNHS detected 644 QCM up until the age of 6 months (72,2%). RS detected 393 child months (44,1%) and no systematic screening 152 child months (17,0%). UNHS detected 74,3% and 86,7% weighted child months at 12 and 120 months, RS 48,4% and 73,3%, NS 23,7% and 60,6%. At the age of 6 months UNHS identified approximately 75% of all children born with hearing impairment, RS 50% and NS 25%. At the time of screening UNHS marked 10% of screened healthy children for further testing (false positives), RS 2%. UNHS demonstrated higher effectiveness even under a wide range of relevant parameters. The model was insensitive to test parameters within the assumed range but results varied along the prevalence of hearing impairment. CONCLUSION: We have shown that UNHS is able to detect hearing impairment at an earlier age and more accurately than selective RS. Further research should be carried out to establish the effects of hearing loss on the quality of life of an individual, its influence on school performance and career achievement and the differences made by early fitting of a hearing aid on these factors.

Economic evaluation of newborn hearing screening: modelling costs and outcomes.

OBJECTIVES: The prevalence of newborn hearing disorders is 1-3 per 1,000. Crucial for later outcome are correct diagnosis and effective treatment as soon as possible. With BERA and TEOAE low-risk techniques for early detection are available. Universal screening is recommended but not realised in most European health care systems. Aim of the study was to examine the scientific evidence of newborn hearing screening and a comparison of medical outcome and costs of different programmes, differentiated by type of strategy (risk screening, universal screening, no systematical screening). METHODS: In an interdisciplinary health technology assessment project all studies on newborn hearing screening detected in a standardized comprehensive literature search were identified and data on medical outcome, costs, and cost-effectiveness extracted. A Markov model was designed to calculate cost-effectiveness ratios. RESULTS: Economic data were extracted from 20 relevant publications out of 39 publications found. In the model total costs for screening of 100,000 newborns with a time horizon of ten years were calculated: 2.0 Mio.euro for universal screening (U), 1.0 Mio.euro for risk screening (R), and 0.6 Mio.euro for no screening (N). The costs per child detected: 13,395 euro (U) respectively 6,715 euro (R), and 4,125 euro (N). At 6 months of life the following percentages of cases are detected: U 72%, R 43%, N 13%. CONCLUSIONS: A remarkable small number of economic publications mainly of low methodological quality was found. In our own model we found reasonable cost-effectiveness ratios also for universal screening. Considering the outcome advantages of higher numbers of detected cases a universal newborn hearing screening is recommended.