Fitting a Hearing Aid on the Better Ear, Worse Ear, or Both: Associations of Hearing-aid Fitting Laterality with Outcomes in a Large Sample of US Veterans.

Longitudinal electronic health records from a large sample of new hearing-aid (HA) recipients in the US Veterans Affairs healthcare system were used to evaluate associations of fitting laterality with long-term HA use persistence as measured by battery order records, as well as with short-term HA use and satisfaction as assessed using the International Outcome Inventory for Hearing Aids (IOI-HA), completed within 180 days of HA fitting. The large size of our dataset allowed us to address two aspects of fitting laterality that have not received much attention, namely the degree of hearing asymmetry and the question of which ear to fit if fitting unilaterally. The key findings were that long-term HA use persistence was considerably lower for unilateral fittings for symmetric hearing loss (HL) and for unilateral worse-ear fittings for asymmetric HL, as compared to bilateral and unilateral better-ear fittings. In contrast, no differences across laterality categories were observed for short-term self-reported HA usage. Total IOI-HA score was poorer for unilateral fittings of symmetric HL and for unilateral better-ear fittings compared to bilateral for asymmetric HL. We thus conclude that bilateral fittings yield the best short- and long-term outcomes, and while unilateral and bilateral fittings can result in similar outcomes on some measures, we did not identify any HL configuration for which a bilateral fitting would lead to poorer outcomes. However, if a single HA is to be fitted, then our results indicate that a better-ear fitting has a higher probability of long-term HA use persistence than a worse-ear fitting.

Dementia and hearing-aid use: a two-way street.

OBJECTIVES: Hearing-aid use may reduce risk of dementia, but cognitive impairment makes use more challenging. An observed association between reduced hearing-aid use and incident dementia could reflect either or both of these causal paths. The objective was to examine the effects of each path while minimising contamination between paths. METHODS: Health records data from 380,794 Veterans who obtained hearing aids from the US Veterans Affairs healthcare system were analysed. Analysis 1 (n = 72,180) used multivariable logistic regression to model the likelihood of incident dementia 3.5-5 years post hearing-aid fitting for patients free of dementia and mild cognitive impairment (MCI). Analysis 2 (n = 272,748) modelled the likelihood of being a persistent hearing-aid user at 3 years 2 months after fitting, contrasting subgroups by level of cognitive function at the time of fitting. Analysis time windows were optimized relative to dataset constraints. Models were controlled for available relevant predictors. RESULTS: The adjusted OR for incident dementia was 0.73 (95% CI 0.66-0.81) for persistent (versus non-persistent) hearing-aid users. The adjusted OR for hearing-aid use persistence was 0.46 (95% CI 0.43-0.48) in those with pre-existing dementia (versus those remaining free of MCI and dementia). CONCLUSION: Substantial independent associations are observed in both directions, suggesting that hearing-aid use decreases risk of dementia and that better cognitive function predisposes towards persistent use. Research studying protective effects of hearing-aid use against dementia needs to account for cognitive status. Clinically, hearing devices and hearing care processes must be accessible and usable for all, regardless of their cognitive status.

The large numbers of minicolumns in the primary visual cortex of humans, chimpanzees and gorillas are related to high visual acuity.

Minicolumns are thought to be a fundamental neural unit in the neocortex and their replication may have formed the basis of the rapid cortical expansion that occurred during primate evolution. We sought evidence of minicolumns in the primary visual cortex (V-1) of three great apes, three rodents and representatives from three other mammalian orders: Eulipotyphla (European hedgehog), Artiodactyla (domestic pig) and Carnivora (ferret). Minicolumns, identified by the presence of a long bundle of radial, myelinated fibers stretching from layer III to the white matter of silver-stained sections, were found in the human, chimpanzee, gorilla and guinea pig V-1. Shorter bundles confined to one or two layers were found in the other species but represent modules rather than minicolumns. The inter-bundle distance, and hence density of minicolumns, varied systematically both within a local area that might represent a hypercolumn but also across the whole visual field. The distance between all bundles had a similar range for human, chimpanzee, gorilla, ferret and guinea pig: most bundles were 20-45 µm apart. By contrast, the space between bundles was greater for the hedgehog and pig (20-140 µm). The mean density of minicolumns was greater in tangential sections of the gorilla and chimpanzee (1,243-1,287 bundles/mm2) than in human (314-422 bundles/mm2) or guinea pig (643 bundles/mm2). The minicolumnar bundles did not form a hexagonal lattice but were arranged in thin curving and branched bands separated by thicker bands of neuropil/somata. Estimates of the total number of modules/minicolumns within V-1 were strongly correlated with visual acuity.

Electronic Health Records As a Platform for Audiological Research: Data Validity, Patient Characteristics, and Hearing-Aid Use Persistence Among 731,213 U.S. Veterans.

OBJECTIVES: This article presents a summary of audiological, general health, and hearing aid (HA) outcome data in a large sample of U.S. Veterans receiving HAs. The current article also provides the foundation for a series of papers that will explore relationships between a wide range of factors and HA outcomes. DESIGN: The patient sample is all (n = 731,213) patients for whom HAs were ordered between April 2012 and October 2014 through the U.S. Veterans Health Administration Remote Order Entry System. For these patients, Veterans Affairs electronic health records (EHRs) stored in various databases provided data on demographics, received diagnostic and procedure codes (2007 to 2017), audiometry, self-reported outcomes up to 6 months postfitting, and HA battery orders (to 2017). Data cleaning and preparation was carried out and is discussed with reference to insights that provide potential value to other researchers pursuing similar studies. HA battery order data over time was used to derive a measure of long-term HA use persistence. Descriptive statistics were used to characterize the sample, comparative analyses against other data supported basic validity assessment, and bivariate analyses probed novel associations between patient characteristics and HA use persistence at 2 years postfitting. RESULTS: Following extensive cleaning and data preparation, the data show plausible characteristics on diverse metrics and exhibit adequate validity based on comparisons with other published data. Further, rates of HA use persistence are favorable when compared against therapy persistence data for other major chronic conditions. The data also show that the presence of certain comorbid conditions (Parkinson's disease, diabetes, arthritis, and visual impairment) are associated with significantly lower HA use persistence, as are prior inpatient admissions (especially among new HA recipients), and that increasing levels of multimorbidity, in general, are associated with decreasing HA use persistence. This is all despite the fact that deriving relevant audiological care-process variables from the available records was not straightforward, especially concerning the definition of the date of HA fitting, and the use of battery ordering data to determine long-term HA use persistence. CONCLUSIONS: We have shown that utilizing EHRs in audiology has the potential to provide novel insights into clinical practice patterns, audiologic outcomes, and relations between factors pertaining to hearing and to other health conditions in clinical populations, despite the potential pitfalls regarding the lack of control over the variables available and limitations on how the data are entered. We thus conclude that research using EHRs has the potential to be an integral supplement to population-based and epidemiologic research in the field of audiology.

A Measure of Long-Term Hearing Aid Use Persistence Based on Battery Reordering Data.

OBJECTIVE: We describe the construction of a hearing aid long-term use persistence measure based on battery reorder data. The measure is derived from the notion that hearing aid users keep using their devices for some time after placing a battery order. DESIGN: A hearing aid user is defined as persistent at time T if they placed a battery order within a time span W preceding T. We characterize and validate this measure using electronic health records from a large sample of US Veterans. RESULTS: We describe how to choose parameters T and W for calculating persistence rates in the patient sample. For validation, the associations of persistence with: (1) the duration over which users received outpatient hearing aid care; (2) self-reported hearing aid use shortly after fitting; and (3) patient age and hearing loss are investigated. In all cases, plausible dependencies are observed. CONCLUSIONS: We conclude that our persistence measure is viable and hope this will motivate its use in similar studies.

Insights Into Conducting Audiological Research With Clinical Databases.

Purpose The clinical data stored in electronic health records (EHRs) provide unique opportunities for audiological clinical research. In this article, we share insights from our experience of working with a large clinical database of over 730,000 cases. Method Under a framework outlining the process from patient care to researcher data use, we describe issues that can arise in each step of this process and how we overcame specific issues in our data set. Results Correct interpretation of findings depends on an understanding of the data source and structure, and efforts to establish confidence in the data through the processes are discussed under the framework. Conclusion We conclude that EHRs have considerable utility in audiological research, though researchers must exhibit caution and consideration when working with EHRs.

Concurrent evaluation of independently cued features during perceptual decisions and saccadic targeting in visual search.

Simultaneous search for one of two targets is slower and less accurate than search for a single target. Within the Signal Detection Theoretic (SDT) framework, this can be attributed to the division of resources during the comparison of visual input against independently cued targets. The current study used one or two cues to elicit single- and dual-target searches for orientation targets among similar and dissimilar distractors. In Experiment 1, the accuracy of target discrimination in brief displays was compared at setsizes of 1, 2 and 4. Results revealed a reduction in accuracy that scaled with the product of set size and the number of cued targets. In Experiment 2, the accuracy and latency of observers' saccadic targeting were compared. Fixations on single-target searches were highly selective towards the target. On dual-target searches, the requirement to detect one of two targets produced a significant reduction in target fixations and equivalent rates of fixations to distractors with opposite orientations. For most observers, the dual-target cost was predicted by an SDT model that simulated increases in decision-noise and the distribution of capacity-limited resources during the comparison of selected input against independently cued targets. For others, search accuracy was consistent with a single-item limit on perceptual decisions and saccadic targeting during search. These findings support a flexible account of the dual-target cost based on different strategies to resolve competition between independently cued targets.

Minimal and Mild Hearing Loss in Children: Association with Auditory Perception, Cognition, and Communication Problems.

OBJECTIVES: "Minimal" and "mild" hearing loss are the most common but least understood forms of hearing loss in children. Children with better ear hearing level as low as 30 dB HL have a global language impairment and, according to the World Health Organization, a "disabling level of hearing loss." We examined in a population of 6- to 11-year-olds how hearing level ≤40.0 dB HL (1 and 4 kHz pure-tone average, PTA, threshold) is related to auditory perception, cognition, and communication. DESIGN: School children (n = 1638) were recruited in 4 centers across the United Kingdom. They completed a battery of hearing (audiometry, filter width, temporal envelope, speech-in-noise) and cognitive (IQ, attention, verbal memory, receptive language, reading) tests. Caregivers assessed their children's communication and listening skills. Children included in this study (702 male; 752 female) had 4 reliable tone thresholds (1, 4 kHz each ear), and no caregiver reported medical or intellectual disorder. Normal-hearing children (n = 1124, 77.1%) had all 4 thresholds and PTA <15 dB HL. Children with ≥15 dB HL for at least 1 threshold, and PTA <20 dB (n = 245, 16.8%) had minimal hearing loss. Children with 20 ≤PTA <40 dB HL (n = 88, 6.0%) had mild hearing loss. Interaural asymmetric hearing loss ( left PTA - right PTA ≥10 dB) was found in 28.9% of those with minimal and 39.8% of those with mild hearing loss. RESULTS: Speech perception in noise, indexed by vowel-consonant-vowel pseudoword repetition in speech-modulated noise, was impaired in children with minimal and mild hearing loss, relative to normal-hearing children. Effect size was largest (d = 0.63) in asymmetric mild hearing loss and smallest (d = 0.21) in symmetric minimal hearing loss. Spectral (filter width) and temporal (backward masking) perceptions were impaired in children with both forms of hearing loss, but suprathreshold perception generally related only weakly to PTA. Speech-in-noise (nonsense syllables) and language (pseudoword repetition) were also impaired in both forms of hearing loss and correlated more strongly with PTA. Children with mild hearing loss were additionally impaired in working memory (digit span) and reading, and generally performed more poorly than those with minimal loss. Asymmetric hearing loss produced as much impairment overall on both auditory and cognitive tasks as symmetric hearing loss. Nonverbal IQ, attention, and caregiver-rated listening and communication were not significantly impaired in children with hearing loss. Modeling suggested that 15 dB HL is objectively an appropriate lower audibility limit for diagnosis of hearing loss. CONCLUSIONS: Hearing loss between 15 and 30 dB PTA is, at ~20%, much more prevalent in 6- to 11-year-old children than most current estimates. Key aspects of auditory and cognitive skills are impaired in both symmetric and asymmetric minimal and mild hearing loss. Hearing loss <30 dB HL is most closely related to speech perception in noise, and to cognitive abilities underpinning language and reading. The results suggest wider use of speech-in-noise measures to diagnose and assess management of hearing loss and reduction of the clinical hearing loss threshold for children to 15 dB HL.

Communication calls produced by electrical stimulation of four structures in the guinea pig brain.

One of the main central processes affecting the cortical representation of conspecific vocalizations is the collateral output from the extended motor system for call generation. Before starting to study this interaction we sought to compare the characteristics of calls produced by stimulating four different parts of the brain in guinea pigs (Cavia porcellus). By using anaesthetised animals we were able to reposition electrodes without distressing the animals. Trains of 100 electrical pulses were used to stimulate the midbrain periaqueductal grey (PAG), hypothalamus, amygdala, and anterior cingulate cortex (ACC). Each structure produced a similar range of calls, but in significantly different proportions. Two of the spontaneous calls (chirrup and purr) were never produced by electrical stimulation and although we identified versions of chutter, durr and tooth chatter, they differed significantly from our natural call templates. However, we were routinely able to elicit seven other identifiable calls. All seven calls were produced both during the 1.6 s period of stimulation and subsequently in a period which could last for more than a minute. A single stimulation site could produce four or five different calls, but the amygdala was much less likely to produce a scream, whistle or rising whistle than any of the other structures. These three high-frequency calls were more likely to be produced by females than males. There were also differences in the timing of the call production with the amygdala primarily producing calls during the electrical stimulation and the hypothalamus mainly producing calls after the electrical stimulation. For all four structures a significantly higher stimulation current was required in males than females. We conclude that all four structures can be stimulated to produce fictive vocalizations that should be useful in studying the relationship between the vocal motor system and cortical sensory representation.

Lifetime leisure music exposure associated with increased frequency of tinnitus.

Tinnitus has been linked to noise exposure, a common form of which is listening to music as a leisure activity. The relationship between tinnitus and type and duration of music exposure is not well understood. We conducted an internet-based population study that asked participants questions about lifetime music exposure and hearing, and included a hearing test involving speech intelligibility in noise, the High Frequency Digit Triplets Test. 4950 people aged 17-75 years completed all questions and the hearing test. Results were analyzed using multinomial regression models. High exposure to leisure music, hearing difficulty, increasing age and workplace noise exposure were independently associated with increased tinnitus. Three forms of music exposure (pubs/clubs, concerts, personal music players) did not differ in their relationship to tinnitus. More males than females reported tinnitus. The objective measure of speech reception threshold had only a minimal relationship with tinnitus. Self-reported hearing difficulty was more strongly associated with tinnitus, but 76% of people reporting usual or constant tinnitus also reported little or no hearing difficulty. Overall, around 40% of participants of all ages reported never experiencing tinnitus, while 29% reported sometimes, usually or constantly experiencing tinnitus that lasted more than 5 min. Together, the results suggest that tinnitus is much more common than hearing loss, but that there is little association between the two, especially among the younger adults disproportionately sampled in this study.

Visuospatial working memory mediates inhibitory and facilitatory guidance in preview search.

Visual search is faster and more accurate when a subset of distractors is presented before the display containing the target. This "preview benefit" has been attributed to separate inhibitory and facilitatory guidance mechanisms during search. In the preview task the temporal cues thought to elicit inhibition and facilitation provide complementary sources of information about the likely location of the target. In this study, we use a Bayesian observer model to compare sensitivity when the temporal cues eliciting inhibition and facilitation produce complementary, and competing, sources of information. Observers searched for T-shaped targets among L-shaped distractors in 2 standard and 2 preview conditions. In the standard conditions, all the objects in the display appeared at the same time. In the preview conditions, the initial subset of distractors either stayed on the screen or disappeared before the onset of the search display, which contained the target when present. In the latter, the synchronous onset of old and new objects negates the predictive utility of stimulus-driven capture during search. The results indicate observers combine memory-driven inhibition and sensory-driven capture to reduce spatial uncertainty about the target's likely location during search. In the absence of spatially predictive onsets, memory-driven inhibition at old locations persists despite irrelevant sensory change at previewed locations. This result is consistent with a bias toward unattended objects during search via the active suppression of irrelevant capture at previously attended locations. (PsycINFO Database Record

Heritability of non-speech auditory processing skills.

Recent insight into the genetic bases for autism spectrum disorder, dyslexia, stuttering, and language disorders suggest that neurogenetic approaches may also reveal at least one etiology of auditory processing disorder (APD). A person with an APD typically has difficulty understanding speech in background noise despite having normal pure-tone hearing sensitivity. The estimated prevalence of APD may be as high as 10% in the pediatric population, yet the causes are unknown and have not been explored by molecular or genetic approaches. The aim of our study was to determine the heritability of frequency and temporal resolution for auditory signals and speech recognition in noise in 96 identical or fraternal twin pairs, aged 6-11 years. Measures of auditory processing (AP) of non-speech sounds included backward masking (temporal resolution), notched noise masking (spectral resolution), pure-tone frequency discrimination (temporal fine structure sensitivity), and nonsense syllable recognition in noise. We provide evidence of significant heritability, ranging from 0.32 to 0.74, for individual measures of these non-speech-based AP skills that are crucial for understanding spoken language. Identification of specific heritable AP traits such as these serve as a basis to pursue the genetic underpinnings of APD by identifying genetic variants associated with common AP disorders in children and adults.

Source-Space Cross-Frequency Amplitude-Amplitude Coupling in Tinnitus.

The thalamocortical dysrhythmia (TCD) model has been influential in the development of theoretical explanations for the neurological mechanisms of tinnitus. It asserts that thalamocortical oscillations lock a region in the auditory cortex into an ectopic slow-wave theta rhythm (4-8 Hz). The cortical area surrounding this region is hypothesized to generate abnormal gamma (>30 Hz) oscillations ("edge effect") giving rise to the tinnitus percept. Consequently, the model predicts enhanced cross-frequency coherence in a broad range between theta and gamma. In this magnetoencephalography study involving tinnitus and control cohorts, we investigated this prediction. Using beamforming, cross-frequency amplitude-amplitude coupling (AAC) was computed within the auditory cortices for frequencies (f1, f2) between 2 and 80 Hz. We find the AAC signal to decompose into two distinct components at low (f1, f2 < 30 Hz) and high (f1, f2 > 30 Hz) frequencies, respectively. Studying the correlation of AAC with several key covariates (age, hearing level (HL), tinnitus handicap and duration, and HL at tinnitus frequency), we observe a statistically significant association between age and low-frequency AAC. Contrary to the TCD predictions, however, we do not find any indication of statistical differences in AAC between tinnitus and controls and thus no evidence for the predicted enhancement of cross-frequency coupling in tinnitus.

Source space estimation of oscillatory power and brain connectivity in tinnitus.

Tinnitus is the perception of an internally generated sound that is postulated to emerge as a result of structural and functional changes in the brain. However, the precise pathophysiology of tinnitus remains unknown. Llinas' thalamocortical dysrhythmia model suggests that neural deafferentation due to hearing loss causes a dysregulation of coherent activity between thalamus and auditory cortex. This leads to a pathological coupling of theta and gamma oscillatory activity in the resting state, localised to the auditory cortex where normally alpha oscillations should occur. Numerous studies also suggest that tinnitus perception relies on the interplay between auditory and non-auditory brain areas. According to the Global Brain Model, a network of global fronto-parietal-cingulate areas is important in the generation and maintenance of the conscious perception of tinnitus. Thus, the distress experienced by many individuals with tinnitus is related to the top-down influence of this global network on auditory areas. In this magnetoencephalographic study, we compare resting-state oscillatory activity of tinnitus participants and normal-hearing controls to examine effects on spectral power as well as functional and effective connectivity. The analysis is based on beamformer source projection and an atlas-based region-of-interest approach. We find increased functional connectivity within the auditory cortices in the alpha band. A significant increase is also found for the effective connectivity from a global brain network to the auditory cortices in the alpha and beta bands. We do not find evidence of effects on spectral power. Overall, our results provide only limited support for the thalamocortical dysrhythmia and Global Brain models of tinnitus.

Attentional control via parallel target-templates in dual-target search.

Simultaneous search for two targets has been shown to be slower and less accurate than independent searches for the same two targets. Recent research suggests this 'dual-target cost' may be attributable to a limit in the number of target-templates than can guide search at any one time. The current study investigated this possibility by comparing behavioural responses during single- and dual-target searches for targets defined by their orientation. The results revealed an increase in reaction times for dual- compared to single-target searches that was largely independent of the number of items in the display. Response accuracy also decreased on dual- compared to single-target searches: dual-target accuracy was higher than predicted by a model restricting search guidance to a single target-template and lower than predicted by a model simulating two independent single-target searches. These results are consistent with a parallel model of dual-target search in which attentional control is exerted by more than one target-template at a time. The requirement to maintain two target-templates simultaneously, however, appears to impose a reduction in the specificity of the memory representation that guides search for each target.

Human decision making based on variations in internal noise: an EEG study.

Perceptual decision making is prone to errors, especially near threshold. Physiological, behavioural and modeling studies suggest this is due to the intrinsic or 'internal' noise in neural systems, which derives from a mixture of bottom-up and top-down sources. We show here that internal noise can form the basis of perceptual decision making when the external signal lacks the required information for the decision. We recorded electroencephalographic (EEG) activity in listeners attempting to discriminate between identical tones. Since the acoustic signal was constant, bottom-up and top-down influences were under experimental control. We found that early cortical responses to the identical stimuli varied in global field power and topography according to the perceptual decision made, and activity preceding stimulus presentation could predict both later activity and behavioural decision. Our results suggest that activity variations induced by internal noise of both sensory and cognitive origin are sufficient to drive discrimination judgments.

Classification of frequency response areas in the inferior colliculus reveals continua not discrete classes.

A differential response to sound frequency is a fundamental property of auditory neurons. Frequency analysis in the cochlea gives rise to V-shaped tuning functions in auditory nerve fibres, but by the level of the inferior colliculus (IC), the midbrain nucleus of the auditory pathway, neuronal receptive fields display diverse shapes that reflect the interplay of excitation and inhibition. The origin and nature of these frequency receptive field types is still open to question. One proposed hypothesis is that the frequency response class of any given neuron in the IC is predominantly inherited from one of three major afferent pathways projecting to the IC, giving rise to three distinct receptive field classes. Here, we applied subjective classification, principal component analysis, cluster analysis, and other objective statistical measures, to a large population (2826) of frequency response areas from single neurons recorded in the IC of the anaesthetised guinea pig. Subjectively, we recognised seven frequency response classes (V-shaped, non-monotonic Vs, narrow, closed, tilt down, tilt up and double-peaked), that were represented at all frequencies. We could identify similar classes using our objective classification tools. Importantly, however, many neurons exhibited properties intermediate between these classes, and none of the objective methods used here showed evidence of discrete response classes. Thus receptive field shapes in the IC form continua rather than discrete classes, a finding consistent with the integration of afferent inputs in the generation of frequency response areas. The frequency disposition of inhibition in the response areas of some neurons suggests that across-frequency inputs originating at or below the level of the IC are involved in their generation.

Neuromagnetic indicators of tinnitus and tinnitus masking in patients with and without hearing loss.

Tinnitus is an auditory phenomenon characterised by the perception of a sound in the absence of an external auditory stimulus. Chronic subjective tinnitus is almost certainly maintained via central mechanisms, and this is consistent with observed measures of altered spontaneous brain activity. A number of putative central auditory mechanisms for tinnitus have been proposed. The influential thalamocortical dysrhythmia model suggests that tinnitus can be attributed to the disruption of coherent oscillatory activity between thalamus and cortex following hearing loss. However, the extent to which this disruption specifically contributes to tinnitus or is simply a consequence of the hearing loss is unclear because the necessary matched controls have not been tested. Here, we rigorously test several predictions made by this model in four groups of participants (tinnitus with hearing loss, tinnitus with clinically normal hearing, no tinnitus with hearing loss and no tinnitus with clinically normal hearing). Magnetoencephalography was used to measure oscillatory brain activity within different frequency bands in a 'resting' state and during presentation of a masking noise. Results revealed that low-frequency activity in the delta band (1-4 Hz) was significantly higher in the 'tinnitus with hearing loss' group compared to the 'no tinnitus with normal hearing' group. A planned comparison indicated that this effect was unlikely to be driven by the hearing loss alone, but could possibly be a consequence of tinnitus and hearing loss. A further interpretative linkage to tinnitus was given by the result that the delta activity tended to reduce when tinnitus was masked. High-frequency activity in the gamma band (25-80 Hz) was not correlated with tinnitus (or hearing loss). The findings partly support the thalamocortical dysrhythmia model and suggest that slow-wave (delta band) activity may be a more reliable correlate of tinnitus than high-frequency activity.

Sensitivity to lexical stress in dyslexia: a case of cognitive not perceptual stress.

Sensitivity to lexical stress in adult German-speaking students with reading difficulty was investigated using minimal pair prepositional verbs whose meaning and syntax depend on the location of the stressed syllable. Two tests of stress perception were used: (i) a stress location task, where listeners indicated the location of the perceptually most prominent syllable, and (ii) a stress pattern identification task, where listeners indicated if the stress pattern was appropriate for its semantic frame. The students with reading difficulties performed worse than the normally reading students on both tasks. Their poorer performance did not reflect the lack of a percept for lexical stress rather patterns of performance across the two tasks suggested that each loaded onto different underlying cognitive abilities. Deficits in these, rather than perceptual difficulties, explained observed group differences. Students with reading difficulties have a normal implicit knowledge of lexical stress usage but lack the necessary cognitive resources for developing an explicit metalinguistic awareness of it. Deficits in these skills not deficiencies in lexical stress perception are implicated in their reading difficulties.