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Hearing is a complex ability that extends beyond the peripheral auditory system. A speech in noise/competition test is a valuable measure to include in the test battery when attempting to assess an individual's "hearing". The present study compared syllable vs. word scoring of the Greek Speech-in-Babble (SinB) test with 22 native Greek speaking children (6-12-year-olds) diagnosed with auditory processing disorder (APD) and 33 native Greek speaking typically developing children (6-12-year-olds). A three-factor analysis of variance revealed greater discriminative ability for syllable scoring than word scoring, with significant interactions between group and scoring. Two-way analysis of variance revealed SinB word-based measures (SNR50%) were larger (poorer performance) than syllable-based measures for both groups of children. Cohen's d values were larger for syllable-based mean scores compared to word-based mean scores between groups for both ears. These findings indicate that the type of scoring affects the SinB's resolution capacity and that syllable scoring might better differentiate typically developing children and children with APD.

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The opinion article "An Evidence-based Perspective on Misconceptions Regarding Pediatric Auditory Processing Disorder" by Neijenhuis et al. (1) presents a distorted view of the evidence-based approach used in medicine. The authors focus on the amorphous non-diagnostic entity "listening difficulties" not auditory processing disorder (APD) and create confusion that could jeopardize clinical services to individuals with APD. In our perspective article, we rebut Neijenhuis et al. (1), and more importantly, we present a rationale for evidence-based practice founded on the premise that research on APD is only clinically applicable when conducted on clinical populations diagnosed with APD.

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Objective: The purpose of this review was to describe and differentiate clinical syndromes caused by lesions of the central auditory nervous system (CANS). Design: Relevant literature was identified through Pubmed and Google Scholar searches using the key terms: central deafness, auditory agnosia, word deafness and cortical deafness. Given the authors' intent to review past and current perspectives on central deafness, no publication date range was imposed. Study sample: The review is organised around complete central deafness (CCD), central deafness (CD), word deafness and nonverbal agnosia (NVA), including anatomy and pathophysiology, symptom profile and audiological findings. Four case studies are presented to demonstrate the clinical correlates of CD. Conclusions: Central deafness is a rare condition typically resulting from bilateral compromise of the CANS. The closer to the auditory cortex bilateral lesions are located, the greater the probability of CD. A variety of symptoms present with or appear subsequent to CD, including tinnitus, hallucinations, voice changes and hypersensitivity to sounds (if heard by the patient), as well as diverse neurological symptoms depending on the non-auditory areas of the brain that may also be involved. Thorough and appropriate audiological testing is critical to accurately diagnose CD and its variants.

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OBJECTIVE: The present study was designed to test the hypothesis that medial olivocochlear system functionality is associated with speech recognition in babble performance in children diagnosed with central auditory processing disorder. METHOD: Children diagnosed with central auditory processing disorder who specifically demonstrated speech in noise deficits were compared to children diagnosed with central auditory processing disorder without these deficits. Suppression effects were examined across 15 time intervals to examine variability. Analysis of right and left ear suppression was performed separately to evaluate laterality. STUDY SAMPLE: 52 children diagnosed with central auditory processing disorder, aged 6-14 years were divided into normal or abnormal groups based on SinB performance in each ear. Cut-off value was set at SNR = 1.33 dB. Transient otoacoustic emissions suppression was measured. RESULTS: The abnormal Speech in Babble Right Ear group showed significant negative correlations with suppression levels for 7 of the 15 time intervals measured. No significant correlations with SinBR performance were observed for the remaining time intervals, as was the case for the typically evaluated R8-18 time interval and the Speech in Babble Left Ear. CONCLUSIONS: Results indicate that suppression is influenced by the time window analysed, and ear tested, and is associated with speech recognition in babble performance in children with central auditory processing disorder.

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BACKGROUND: Pediatric central auditory processing disorder (CAPD) is frequently comorbid with other childhood disorders. However, few studies have examined the relationship between commonly used CAPD, language, and cognition tests within the same sample. PURPOSE: The present study examined the relationship between diagnostic CAPD tests and "gold standard" measures of language and cognitive ability, the Clinical Evaluation of Language Fundamentals (CELF) and the Wechsler Intelligence Scale for Children (WISC). RESEARCH DESIGN: A retrospective study. STUDY SAMPLE: Twenty-seven patients referred for CAPD testing who scored average or better on the CELF and low average or better on the WISC were initially included. Seven children who scored below the CELF and/or WISC inclusion criteria were then added to the dataset for a second analysis, yielding a sample size of 34. DATA COLLECTION AND ANALYSIS: Participants were administered a CAPD battery that included at least the following three CAPD tests: Frequency Patterns (FP), Dichotic Digits (DD), and Competing Sentences (CS). In addition, they were administered the CELF and WISC. Relationships between scores on CAPD, language (CELF), and cognition (WISC) tests were examined using correlation analysis. RESULTS: DD and FP showed significant correlations with Full Scale Intelligence Quotient, and the DD left ear and the DD interaural difference measures both showed significant correlations with working memory. However, ∼80% or more of the variance in these CAPD tests was unexplained by language and cognition measures. Language and cognition measures were more strongly correlated with each other than were the CAPD tests with any CELF or WISC scale. Additional correlations with the CAPD tests were revealed when patients who scored in the mild-moderate deficit range on the CELF and/or in the borderline low intellectual functioning range on the WISC were included in the analysis. CONCLUSIONS: While both the DD and FP tests showed significant correlations with one or more cognition measures, the majority of the variance in these CAPD measures went unexplained by cognition. Unlike DD and FP, the CS test was not correlated with cognition. Additionally, language measures were not significantly correlated with any of the CAPD tests. Our findings emphasize that the outcomes and interpretation of results vary as a function of the subject inclusion criteria that are applied for the CELF and WISC. Including participants with poorer cognition and/or language scores increased the number of significant correlations observed. For this reason, it is important that studies investigating the relationship between CAPD and other domains or disorders report the specific inclusion criteria used for all tests.

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BACKGROUND: The pure-tone audiogram, though fundamental to audiology, presents limitations, especially in the case of central auditory involvement. Advances in auditory neuroscience underscore the considerably larger role of the central auditory nervous system (CANS) in hearing and related disorders. Given the availability of behavioral audiological tests and electrophysiological procedures that can provide better insights as to the function of the various components of the auditory system, this perspective piece reviews the limitations of the pure-tone audiogram and notes some of the advantages of other tests and procedures used in tandem with the pure-tone threshold measurement. PURPOSE: To review and synthesize the literature regarding the utility and limitations of the pure-tone audiogram in determining dysfunction of peripheral sensory and neural systems, as well as the CANS, and to identify other tests and procedures that can supplement pure-tone thresholds and provide enhanced diagnostic insight, especially regarding problems of the central auditory system. RESEARCH DESIGN: A systematic review and synthesis of the literature. DATA COLLECTION AND ANALYSIS: The authors independently searched and reviewed literature (journal articles, book chapters) pertaining to the limitations of the pure-tone audiogram. RESULTS: The pure-tone audiogram provides information as to hearing sensitivity across a selected frequency range. Normal or near-normal pure-tone thresholds sometimes are observed despite cochlear damage. There are a surprising number of patients with acoustic neuromas who have essentially normal pure-tone thresholds. In cases of central deafness, depressed pure-tone thresholds may not accurately reflect the status of the peripheral auditory system. Listening difficulties are seen in the presence of normal pure-tone thresholds. Suprathreshold procedures and a variety of other tests can provide information regarding other and often more central functions of the auditory system. CONCLUSIONS: The audiogram is a primary tool for determining type, degree, and configuration of hearing loss; however, it provides the clinician with information regarding only hearing sensitivity, and no information about central auditory processing or the auditory processing of real-world signals (i.e., speech, music). The pure-tone audiogram offers limited insight into functional hearing and should be viewed only as a test of hearing sensitivity. Given the limitations of the pure-tone audiogram, a brief overview is provided of available behavioral tests and electrophysiological procedures that are sensitive to the function and integrity of the central auditory system, which provide better diagnostic and rehabilitative information to the clinician and patient.

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OBJECTIVE: To provide audiologists with strategies to minimise confounding cognitive and language processing variables and accurately diagnose central auditory processing disorder (CAPD). DESIGN: Tutorial. STUDY SAMPLE: None. RESULTS: Strategies are reviewed to minimise confounding cognitive and language processing variables and accurately diagnose CAPD. CONCLUSIONS: Differential diagnosis is exceedingly important and can be quite challenging. Distinguishing between two or more conditions presenting with similar symptoms or attributes requires multidisciplinary, comprehensive assessment. To ensure appropriate interventions, the audiologist is a member of the multidisciplinary team responsible for determining whether there is an auditory component to other presenting deficits or whether one condition is responsible for the symptoms seen in another. Choice of tests should be guided both by the symptoms of the affected individual, as established in an in-depth interview and case history, the individual's age and primary language, and by the specific deficits reported to be associated with specific clinical presentations. Knowing which tests are available, their strengths and limitations, the processes assessed, task and response requirements, and the areas of the central auditory nervous system (CANS) to which each test is most sensitive provides the audiologist with critical information to assist in the differential diagnostic process.

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BACKGROUND: The known link between auditory perception and cognition is often overlooked when testing for cognition. PURPOSE: To evaluate auditory perception in a group of older adults diagnosed with mild cognitive impairment (MCI). RESEARCH DESIGN: A cross-sectional study of auditory perception. STUDY SAMPLE: Adults with MCI and adults with no documented cognitive issues and matched hearing sensitivity and age. DATA COLLECTION: Auditory perception was evaluated in both groups, assessing for hearing sensitivity, speech in babble (SinB), and temporal resolution. RESULTS: Mann-Whitney test revealed significantly poorer scores for SinB and temporal resolution abilities of MCIs versus normal controls for both ears. The right-ear gap detection thresholds on the Gaps-In-Noise (GIN) Test clearly differentiated between the two groups (p < 0.001), with no overlap of values. The left ear results also differentiated the two groups (p < 0.01); however, there was a small degree of overlap ∼8-msec threshold values. With the exception of the left-ear inattentiveness index, which showed a similar distribution between groups, both impulsivity and inattentiveness indexes were higher for the MCIs compared to the control group. CONCLUSIONS: The results support central auditory processing evaluation in the elderly population as a promising tool to achieve earlier diagnosis of dementia, while identifying central auditory processing deficits that can contribute to communication deficits in the MCI patient population. A measure of temporal resolution (GIN) may offer an early, albeit indirect, measure reflecting left temporal cortical thinning associated with the transition between MCI and Alzheimer's disease.

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BACKGROUND: Including speech recognition in noise testing in audiological evaluations may reveal functional hearing deficits that may otherwise remain undetected. PURPOSE: The current study explored the potential utility of the Speech-in-Babble (SinB) test in the assessment of central auditory processing disorder (CAPD) in young children for whom diagnosis is challenging. RESEARCH DESIGN: A cross-sectional analysis. STUDY SAMPLE: Forty-one Greek children 4-13 yr of age diagnosed with CAPD and exhibiting listening and academic problems (clinical group) and 20 age-matched controls with no listening or academic problems participated in the study. DATA COLLECTION AND ANALYSIS: All participants' auditory processing was assessed using the same tests and instrumentation in a sound-treated room. Two equivalent lists of the SinB test, developed at the Psychoacoustic Laboratory of the Aristotle University of Thessaloniki, were administered monaurally in a counterbalanced order. SinB consists of lists of 50 phonetically balanced disyllabic words presented in background multitalker babble. Five signal-to-noise ratios (SNRs) were used in a fixed order. The children were instructed to repeat the word after each presentation. The SNR at which the child achieved 50% correct word identification served as the dependent variable or outcome measure, with higher SinB scores (measured in SNR dB) corresponding to poorer performance. RESULTS: SinB performance was better (lower SNR) for the normal control group versus the clinical group [F(1,35) = 43.03, p < 0.0001]. SinB inversely correlated with age for both CAPD and control groups (r = -0.648, p << 0.001 and r = -0.658, p < 0.005, respectively). Regression analysis revealed that linear models better explained the variance in the data than a quadratic model for both the control and CAPD groups. The slope (beta value of the linear model) was steeper for the clinical group compared to the control group (beta = -0.306 versus beta = -0.130, respectively). An analysis of covariance run with age as the covariate to assess the potential effect of comorbidity on SinB performance in children with CAPD with and without comorbid conditions revealed no significant differences between groups [F(1,38) = 0.149, p > 0.05]. CONCLUSIONS: This study offers the first detailed presentation of the performance of Greek children on a Greek language SinB test. The main finding is that SinB scores improved as a function of age in a constant manner as represented by the slope of the linear regression line for both CAPD and control groups. Results suggest that this speech recognition in competition test holds promise for differentiating typically developing Greek children from those children with CAPD across the age range studied here (4-13 yr). The SinB seemed rather immune to the presence of comorbid conditions presented by some of the children in this study, suggesting its potential utility as a valid measure of central auditory processing. While there are many speech-in-noise or competition tests in English, there are fewer in other languages. Tests like the SinB should be developed in other languages to ensure that children demonstrating "listening" problems can be properly evaluated.

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BACKGROUND: According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis of speech sound disorder (SSD) requires a determination that it is not the result of other congenital or acquired conditions, including hearing loss or neurological conditions that may present with similar symptomatology. PURPOSE: To examine peripheral and central auditory function for the purpose of determining whether a peripheral or central auditory disorder was an underlying factor or contributed to the child's SSD. RESEARCH DESIGN: Central auditory processing disorder clinic pediatric case reports. STUDY SAMPLE: Three clinical cases are reviewed of children with diagnosed SSD who were referred for audiological evaluation by their speech-language pathologists as a result of slower than expected progress in therapy. RESULTS: Audiological testing revealed auditory deficits involving peripheral auditory function or the central auditory nervous system. These cases demonstrate the importance of increasing awareness among professionals of the need to fully evaluate the auditory system to identify auditory deficits that could contribute to a patient's speech sound (phonological) disorder. CONCLUSIONS: Audiological assessment in cases of suspected SSD should not be limited to pure-tone audiometry given its limitations in revealing the full range of peripheral and central auditory deficits, deficits which can compromise treatment of SSD.

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Diagnostic batteries to assess the integrity of the central auditory nervous system (CANS) include behavioral (i.e., psychophysical) tests, electrophysiologic procedures, and to some degree, electroacoustic procedures. In this chapter, we focus on behavioral tests used to identify lesions (including diffuse lesions), abnormalities, or dysfunction of the CANS, as well as identify associated functional deficits (e.g., listening in noise deficits). Following a brief review of several tests considered more peripheral in their application (e.g., pure-tone thresholds, otoacoustic emissions, acoustic reflex), we provide some historic context and a review of tests currently in use which are sensitized by design to measure central auditory function, as well as others which have not been adopted clinically and new tests and procedures which hold promise for clinical diagnosis. Tests reviewed include those of dichotic listening, temporal processing (e.g., temporal resolution and temporal patterning), binaural interaction (e.g., masking level differences), monaural low-redundancy measures (e.g., speech in noise or competition, filtered speech, time-compressed speech), and new paradigms which measure auditory evoked potentials in response to test stimuli typically used in behavioral tests.

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Auditory training (AT) is an important component of rehabilitation for patients with central auditory processing disorder (CAPD). The present article identifies and describes aspects of AT as they relate to applications in this population. A description of the types of auditory processes along with information on relevant AT protocols that can be used to address these specific deficits is included. Characteristics and principles of effective AT procedures also are detailed in light of research that reflects on their value. Finally, research investigating AT in populations who show CAPD or present with auditory complaints is reported. Although efficacy data in this area are still emerging, current findings support the use of AT for treatment of auditory difficulties.

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OBJECTIVE: Evaluate auditory temporal resolution threshold outcomes across three different populations. DESIGN: Two commercially available tests of auditory gap detection (Random gap detection (RGDT) test, and Gaps-in-noise (GIN) test) were administered to all participants. STUDY SAMPLE: Adult professional musicians (APM) (N = 11, age range 28-61 years); children with central auditory processing disorder (CAPD) (N = 22, age range 7.5-17 years); and first episode psychosis patients (FEP) (N = 17, age range 18-48 years). RESULTS: It was not possible to calculate a threshold for the RGDT for 13 of 22 children with CAPD and for 7 of 17 adults with FEP due to response inconsistency. Analysis of variance (ANOVA) excluding cases that produced inconsistent RGDT results showed that only RGDT thresholds differed across groups (F = 8.73, p = 0.001). Three t-tests comparing test means within group revealed statistically significant differences between the gap detection thresholds obtained with the RGDT vs. the GIN for each group. No significant correlations were seen between RGDT and GIN. CONCLUSION: Lower/better gap detection thresholds and smaller standard deviations were obtained using the GIN in all three groups. Lack of correlation between the two tests suggests that they may measure different processes.

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PURPOSE: To provide a commentary on "Auditory Processing Disorder and Auditory/Language Interventions: An Evidence-Based Systematic Review" by Fey et al. (2011). METHOD: Examination of the conclusions drawn by Fey et al. (2011) in the context of the American Academy of Audiology (2010a, 2010b) and American Speech-Language-Hearing Association (2005a, 2005b, 2005c) guidelines for the diagnosis and treatment of auditory processing disorder, the evidence cited therein, and other pertinent published reports. RESULTS: The review provided by Fey et al. (2011) is limited due to the exclusion of pertinent efficacy studies from their analysis, inclusion of studies that did not employ strictly auditory-based therapies, and lack of well-defined experimental groups in many of the studies cited. Further, the questions posed by their literature review may not have addressed the efficacy of true auditory interventions in the remediation of auditory difficulties in children who have primary deficits in central auditory processing. CONCLUSION: A more comprehensive review than that done by Fey et al. (2011) would have better addressed the fundamental question of the efficacy of direct remediation activities for children with central auditory processing disorder.

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PURPOSE: The sensitivity, specificity, and efficiency of commonly used behavioral central auditory processing tests and test batteries were determined for 20 individuals with known lesions of the central auditory nervous system (CANS) and related auditory symptoms. RESEARCH DESIGN: Twenty-nine individuals with no known neurological involvement served as the control group. Both groups were administered dichotic digits (DD), competing sentences (CS), frequency patterns (FP), and low-pass filtered speech (FS) tests. DATA ANALYSIS: Diagnostic indices for individual tests and test batteries comprised of two, three, or four tests were calculated both using a lax criterion in which failure on only one test in a battery led to a positive diagnosis and using a strict criterion in which failure on all tests in the battery was necessary to trigger a positive diagnosis. RESULTS: The test battery providing the best balance between sensitivity and specificity varied as a function of criterion. The two-test DD-FP battery using a strict criterion demonstrated the best balance. CONCLUSIONS: Limitations of particular tests, the advantages of larger test batteries to more broadly examine multiple auditory processes, the degree to which the present results can be generalized clinically to populations without known brain lesions, and other clinical considerations are discussed.

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BACKGROUND: The recently developed Gaps-In-Noise (GIN) test has provided a new diagnostic tool for the detection of temporal resolution deficits. Previous reports indicate that the GIN is a relatively sensitive tool for the diagnosis of central auditory processing disorder ([C]APD) in adult populations. PURPOSE: The purpose of the present study was to determine the feasibility of the GIN test in the pediatric population. RESEARCH DESIGN: This was a prospective pseudorandomized investigation. STUDY SAMPLE: This investigation involved administration of the GIN to 72 participants divided into six groups of normal children ranging from 7 through 18 years of age. DATA COLLECTION AND ANALYSIS: The approximate GIN threshold (the shortest gap duration for which at least four of six gaps were correctly identified) served as the dependent variable. Results were analyzed using an ANOVA to examine between- and within-group differences. RESULTS: No statistically significant differences were seen in GIN thresholds among age groups. In addition, within group analysis yielded no statistically significant differences between ears within each age group. No developmental effect was seen in GIN thresholds between the ages of 7 and 18 years. Children as young as age 7 are able to complete the GIN with no significant difficulty and perform at levels commensurate with normal adults. The absence of ear differences suggests that temporal resolution as measured by the GIN is an auditory process that develops relatively early and symmetrically (i.e., no laterality or ear dominance effects). CONCLUSIONS: The GIN procedure appears to be a feasible measure of temporal resolution in both pediatric and adult populations.

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Results of an online questionnaire probing audiologists' professional education and clinical practices in central auditory processing and its disorders are reported. Respondents demonstrated scant knowledge of the efficiency of central auditory tests and procedures; however, they were rather consistent in reporting more frequent use of tests and procedures they rated as more efficient. Many of the tests and procedures (including electrophysiologic measures) reported as most frequently used are among those cited in the literature as having good sensitivity and specificity. Respondents recognized the audiologist's treatment responsibilities in the areas of environmental accommodations and assistive listening devices; however, less than half of the respondents judged auditory training to fall within the audiologist's purview. Comparison with a similar study published in 1998 revealed an increase in respondents' academic preparation in (C)APD, with little change in clinical preparation, and use of a more efficient central auditory test battery.

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This paper presents a brief review of temporal processing, its relevance to audiologists, and methods for its clinical evaluation. Results are then summarized from the administration of four tests of auditory temporal resolution (Auditory Fusion Test-Revised [AFTR], Random Gap Detection Test [RGDT], Binaural Fusion Test [BFT], and Gaps-In-Noise Test [GIN]) to ten children with normal hearing (mean age = 8.7 years). Statistically significant differences in mean temporal resolution thresholds derived from the four tests resulted from differences in stimulus and task variables. From a clinical perspective, however, all tests yielded comparable results, indicating normal temporal resolution for all 10 children. Differences among the four tests with regard to ease of use, time required for administration and scoring, and face validity are discussed. Additional research is needed to determine the relative sensitivity and specificity, and, therefore, the clinical utility of these four temporal resolution tests in both pediatric and adult populations.

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This response to A. T. Cacace and D. J. McFarland (2005) identifies points of agreement and disagreement regarding the concept of modularity in the diagnosis of (central) auditory processing disorder [(C)APD]. We concur that the evaluation of (C)APD must take into consideration the influence of higher order global or pansensory issues on performance on tests of central auditory function. To accomplish this goal, multidisciplinary (e.g., multimodal) testing is an integral part of differential diagnosis of (C)APD. We also agree that the efficiency of diagnostic tests of (C)APD should not be evaluated by imprecise criteria [e.g., "presumed" or "suspected" (C)APD], which do not provide accurate measures of the true sensitivity and specificity of these tests. Our conceptualization and recommendations for clinical practice in this area diverge, however, from that of Cacace and McFarland in a number of pivotal ways. Based on the current limitations of multimodal assessment relative to issues related to scope of practice and test efficiency, as well as the accumulated basic science and clinical literature that demonstrates the nonmodularity and interactive organization of the brain, we recommend use of the sensitized test battery of the central auditory nervous system (CANS) in combination with multidisciplinary testing to differentially diagnose (C)APD and to guide treatment of the disorder. We assert that sensitivity and specificity measures derived from individuals with well-circumscribed lesions of the CANS provide an important guide to establishing the validity of central auditory diagnostic tests. We note that researchers in the area of auditory science and (C)APD must acknowledge the challenges of the clinical arena, and we encourage their continued help to develop diagnostic tools that are both efficient and practical for the differential diagnosis of (C)APD. We conclude that our approach, which combines multidisciplinary evaluation and specific tests of central auditory function that have demonstrated sensitivity and specificity for disorders of the CANS, allows us to identify (and thus rehabilitate) the auditory deficits present in individuals with (C)APD in its "purest" form. It also permits the identification and rehabilitation of auditory deficits in individuals who exhibit auditory perceptual problems that coexist with other processing problems, while ruling out those who perform poorly on auditory tests because of a global, supramodal problem involving cognition, attention, language, memory, or related skills.

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