LSHSS
Clinical Focus
Working Memory and Auditory Processing
in School-Age Children
Beula M. Magimairaja and Naveen K. Nagarajb
Purpose: Our goal is to present the relationships between
working memory (WM) and auditory processing abilities
in school-age children.
Review and Discussion: We begin with an overview of
auditory processing, the conceptualization of auditory
processing disorder, and the assessment of auditory
processing abilities in children. Next, we describe a model
of WM and a model of auditory processing followed by their
comparison. Evidence for the relationships between WM and
A
uditory processing is defined as the decoding
of auditory stimuli along the auditory pathway
in the central nervous system (CNS; Abrams &
Kraus, 2015). Behavioral performance typically ascribed
to auditory processing includes sound localization, sound
lateralization, auditory discrimination, auditory pattern
recognition, temporal processing, and speech perception
in competing or degraded listening conditions (American
Speech-Language-Hearing Association [ASHA], 2005).
Clinical assessment of these abilities, as defined here, is
within the scope of practice of an audiologist. Adequate
auditory processing abilities are integral to listening in a
variety of functional situations and are therefore associated
with receptive and expressive language (both spoken and
written) and overall learning abilities (ASHA, 2005).
Acoustic input received by the peripheral auditory system
is encoded and conveyed through the central auditory path-
way to the cortex. For spoken language stimuli, phonemic
a
Cognition and Language Lab, Communication Sciences and
Disorders, University of Central Arkansas, Conway
b acterized as a distinct clinical entity based on tests of
Cognitive Hearing Science Lab, Audiology and Speech Pathology,
University of Arkansas for Medical Sciences/University of Arkansas
at Little Rock
Correspondence to Beula M. Magimairaj: bmagimairaj@uca.edu
Editor-in-Chief: Shelley Gray
Editor: Ron Gillam
Received September 19, 2017
Revision received February 22, 2018
Accepted March 28, 2018
https://doi.org/10.1044/2018_LSHSS-17-0099
Publisher Note: This article is part of the Clinical Forum: Working
Memory in School-Age Children.
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auditory processing abilities in school-age children follows.
Specifically, we present evidence for the association (or lack
thereof) between WM/attention and auditory processing test
performance.
Clinical Implications: In conclusion, we describe a new
framework for understanding auditory processing abilities in
children based on integrated evidence from cognitive science,
hearing science, and language science. We also discuss
clinical implications in children that could inform future research.
processing is fundamental, and this involves auditory areas
in the temporal lobe among other brain regions. Sound
reception and acoustic or phonemic analysis are therefore
included as components of auditory processing (Richard,
2013). Phonemic processing is part of linguistic processing,
which is a complex cognitive function that additionally in-
volves assigning meaning to stimuli, comprehending syntax
and discourse. Based on current knowledge about the devel-
opment, organization, and functioning of the CNS, it is
evident that auditory processing engages bottom-up (ascend-
ing central auditory system), top-down (descending/efferent
system and cortical centers), and association and commis-
sural neural pathways (Moore, 2012; Schmithorst, Farah,
& Keith, 2013). A list of auditory processes and their descrip-
tions are presented in Table 1.
(Central) Auditory Processing Disorder
The concept of central auditory processing disorder
(APD) has its origins in descriptions of children who
had listening difficulties despite normal peripheral hear-
ing thresholds (Myklebust, 1954). APD came to be char-
auditory processing in individuals with known neurological
lesions of the central auditory pathway (Kimura, 1961).
Several tests have since been developed to assess the func-
tioning of the central auditory pathway when significant
listening difficulties are reported even in the absence of
identified neurological abnormalities (Dawes & Bishop,
2009; Jerger, 1998). In the following sections, we restrict
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
409
 Table 1. Auditory processes (ASHA, 2005) and their descriptions.

Auditory processes Descriptions

Sound localization and lateralization “Localization” is the term used to identify the spatial location of the external sound source,
whereas “lateralization” is reserved for the identification of sound location within the head
when heard through earphones.
Auditory discrimination The ability to determine if two sounds are different.
Auditory pattern recognition The ability to recognize the changing pattern in sound dimensions such as pitch/frequency
and duration.
Temporal processing: Temporal processing in general refers to perception of time variation of acoustic events.
• Temporal integration • Temporal integration is the ability of the auditory system to integrate acoustic energy over
• Temporal resolution time in brief sounds.
• Temporal masking • Temporal resolution is the ability of the auditory system to follow rapid amplitude changes
• Temporal ordering in sound over time.
• Temporal masking refers to the reduced perception of softer sounds that are preceding or
following louder sounds.
• Temporal ordering refers to the ability to recognize the durational sequence of the sound
pattern.
Binaural integration and separation The ability to integrate or separate auditory information presented to each ear.
Auditory closure The ability to reconstruct and fill in the missing or degraded acoustic signals such as speech
mixed with noise, compressed speech, and filtered speech.

our reference of auditory processing and APD to the de-
velopmental context of school-age children’s listening
abilities.
As per the position statement of the working group
on APD established by ASHA (2005), APD is a diagnos-
tic entity that requires demonstration of “a deficit in the
neural processing of auditory stimuli that is not due to
higher-order language, cognitive, or related factors.” It is
also stated that, “the deficit in neural processing of auditory
stimuli may coexist with, but is not the result of dysfunction
in other modalities. APD can also lead to or be associated
with difficulties in learning (e.g., spelling, reading), speech,
language, attention, social, and related functions” (ASHA,
2005). In the American Academy of Audiology (AAA, 2010)
clinical practice guidelines, APD is defined as a disorder
that may result from a variety of deficits in the function-
ing of the central auditory pathway that may be caused
by neurological diseases or neurotoxic substances. AAA
(2010) also specifies that age-related changes, communica-
tion or developmental disorders, and peripheral hearing
loss can also affect the functioning of the auditory path-
way. In addition to their auditory processing deficits, indi-
viduals diagnosed with APD often report difficulties
in learning, language, and reading abilities. The AAA
(2010) definition does not specify exclusion of other diag-
noses for the use of the term APD, whereas ASHA recog-
nizes the use of APD as a diagnostic term only if it is
established that other conditions such as language or cogni-
tive impairment are not causing the auditory processing
deficits. The AAA definition considers auditory processing
deficits as being associated with a range of different condi-
tions (e.g., individuals with hearing loss and language or
reading difficulties) and not strictly always as a distinct en-
tity. The AAA (2010) definition, therefore, is broad and
includes developmental APD as a subgroup. AAA (2010)
guidelines recommend that APD testing be done only for
children who are developmentally 7 years or older. This is
because of the time course of neural maturation and high
variability in performance on behavioral APD tests seen in
younger children.
The British Society of Audiology addressed differ-
ences between their interpretation of the concept of APD
and the AAA (2010) definition in a “white paper” (Moore,
Rosen, Bamiou, Campbell, & Sirimanna, 2013). In this
article, the authors focused on developmental APD (i.e.,
APD not linked to peripheral hearing loss or known neu-
rological lesions). The authors highlighted that poor per-
formance on nonspeech psychoacoustic measures did not
correlate consistently or strongly with the listening diffi-
culties faced by children diagnosed with APD. Instead,
speech-based measures such as listening in noise and cog-
nitive measures were stronger indicators of children’s re-
ported functional listening difficulties. The authors concluded
that APD might be indicative of a broader neurodevelop-
mental disorder rather than a unique clinical entity because
it often co-occurred with language and learning disorders
(Moore et al., 2013).
Assessment of APD
In addition to electrophysiological measures, ASHA
(2005) specifies five auditory areas in behavioral assess-
ment as a guide for assessing and diagnosing APD. These
areas are (a) auditory discrimination of differences in fre-
quency, intensity, or temporal parameters; (b) temporal
processing and patterning (e.g., sequencing, patterning,
gap detection, backward/forward masking); (c) dichotic lis-
tening (speech); (d) monaural low-redundancy speech per-
ception (e.g., degraded speech, speech in noise, competing
speech); and (e) binaural interaction (e.g., masking level
difference, localization, lateralization). No currently rec-
ommended APD test battery contains a test from all of the
above areas (Dawes & Bishop, 2009). There is no widely
accepted consensus on which deficits are necessary for
diagnosis, which measures have high sensitivity and speci-
ficity, or which skill(s) corresponds to weakness in a specific

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 functional auditory-language ability or learning outcome.
Many tests for auditory processing are criticized for having
poor psychometrics (Dawes & Bishop, 2009). Assessment
for APD has included parent/teacher questionnaires, behav-
ioral screening tests, test batteries (Barry, Tomlin, Moore,
& Dillon, 2015; Bellis, 2002; Bellis & Ferre, 1999; Domitz
& Schow, 2000; Ferre, 2002; Geffner & Goldman, 2010,
2009; Jerger & Musiek, 2000; Katz, 1992, 2001; Keith, 2000,
2009; Medwetsky, 2011; Musiek, 1983; Musiek & Chermak,
1994; Richard & Ferre, 2006), and electrophysiological
measures (Jerger & Musiek, 2000; Kraus & Hornickel,
2013a). A multidisciplinary team approach including the
parent, educator, audiologist, speech-language pathologist,
and psychologist is recommended for assessment and inter-
vention. Surveys of audiologists indicate that the majority
of audiologists do not administer any one recommended
auditory processing test battery (Emanuel, Ficca, & Korczak,
2011). Instead, clinicians administer tests based on their
experience and based on the child’s history. Emanuel et al.
(2011) reported that only 54% of audiologists refer for an
evaluation by a speech-language pathologist, 37% by an edu-
cational specialist, and 36% by a psychologist. Although
national guidelines recommended it, audiologists are not
mandated to consult other professionals when diagnosing
APD (AAA, 2010; ASHA, 2005).
As a response to the need for a unified framework,
Moore and colleagues in the United Kingdom–based
multicenter study of auditory processing (IHR Multicentre
Study of Auditory Processing [IMAP]; Moore, Ferguson,
Edmondson-Jones, Ratib, & Riley, 2010) created a research
test battery that included cognitive and language measures.
IMAP included experimental auditory tasks (backward and
simultaneous masking, frequency discrimination, vowel–
consonant–vowel speech in noise), sustained attention audi-
tory and visual tasks, and standardized cognitive tests
(forward and backward digit span, nonword repetition,
nonverbal IQ, reading). Language performance was not
measured. However, rating scales such as the Children’s
Communication Checklist–2 (CCC-2; Bishop, 2003) and Chil-
dren’s Auditory Processing Performance Scale (CHAPPS;
Smoski, Brunt, & Tannahill, 1998) were used as indicators
of language abilities. Results indicated that cognitive factors
were the best predictors of children’s listening difficulties in
realistic listening environments.
Traditional APD test batteries require failure (i.e., per-
formance < 2 SDs from the mean) in more than one type
of behavioral APD test or significant failure in one area
(i.e., performance < 3 SDs). Given performance heterogene-
ity and problems with interpreting test scores using the
traditional approach, a hierarchical adaptive approach to
testing has been proposed (Cameron, Glyde, Dillon, King,
& Gillies, 2015; Dillon, Cameron, Glyde, Wilson, & Tomlin,
2012). In this approach, an initial assessment indicates if
and what further assessments are needed. The goal is to
keep the test battery short to avoid fatigue and only admin-
ister additional tests when scores fall below some cutoff
point in a given test. For example, after administering
questionnaires and hearing screening, the Listening in
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Spatialized Noise–Sentences Test (LiSN-S; Cameron &
Dillon, 2007) is recommended. If children perform poorly
on the LiSN-S, a verbal memory test is given. The recom-
mendation is to administer the dichotic digits test last and
only if verbal memory scores are good, because poor ver-
bal memory is known to affect the dichotic digits test. In
summary, a hierarchical testing model includes master
assessments that first determine the nature of the listen-
ing difficulty as manifested in daily listening situations
(e.g., competing signals, rapid speech, reverberation, spatial/
pitch cues, demands on auditory working memory [WM]).
This is followed by detailed tests that are selected based
on failures in the master assessment (Dillon et al., 2012).
Selecting tests for hierarchical APD assessment is based on
the availability of deficit-specific treatment and can include
cognitive and language measures, although which specific
measures is not yet delineated.
Clinicians and researchers continue to lack a consen-
sual theoretical and clinical framework for conceptualiz-
ing APD because professionals from different disciplines
characterize it differently (Jerger, 1998). Under the Individ-
uals With Disabilities Education Act, APD is not a quali-
fying diagnosis for special education services in U.S. public
schools. It also does not fit under existing categories of dis-
ability given the diversity of its symptoms. Policy makers
are perplexed about the nature of APD and how to best
serve children with the diagnosis. These controversies have
left clinicians who administer APD tests without a standard
protocol. A multidisciplinary team evaluation is ideal but
often not implemented. The result is weak diagnostic cri-
teria and poor educational support for the children. Chil-
dren diagnosed with APD often have comorbid deficits in
attention, language, and memory (Chermak, Hall, & Musiek,
1999; Ferguson, Hall, Riley, & Moore, 2011; Riccio, Hynd,
Cohen, Hall, & Molt, 1994). Auditory processing is part of a
complex cognitive system (Banai & Kraus, 2014). Given the
heterogeneous cognitive profiles of children suspected to have
APD, it is suggested that auditory processing deficits are
best characterized as a subcomponent that may be affected
rather than categorizing the deficits as a unique clinical dis-
order (Banai & Kraus, 2014; Pennington & Bishop, 2009).
This approach emphasizes functional outcomes related to
listening difficulties, in addition to identifying the source(s)
of difficulty, which are typically multifactorial during
development (Moore, 2015; Pennington, 2006). Unlike con-
ditions such as autism or intellectual disability, the develop-
mental course of APD is not well defined. Thus, current
limitations in the assessment of APD primarily relate to
(a) an incomplete understanding of the underlying source(s)
of a child’s behavioral auditory symptoms and (b) the
potential influence of nonauditory or higher-order cogni-
tive influences on auditory processing measurement.
In this article, our aim is to describe the links between
WM and auditory processing abilities in school-age chil-
dren. The first rationale for this stems from similarities
observed between WM and APD models. We first describe
a prominent model of WM and compare it to a model of
APD. Next, based on developmental studies, we present
411
 the literature on the influence (or lack thereof ) of WM
mechanisms on auditory processing test performance. An
influence of cognitive processes (e.g., attention, WM) on
auditory processing measurement challenges the notion of
assessing auditory processing as a bottom-up linear mech-
anism and categorizing the deficits as a unique disorder.
Alternatively, identification of auditory processes that are
least influenced by cognitive factors may support their in-
clusion in clinical protocols used by audiologists, especially
if supported by large-scale studies that have been repli-
cated. We then elaborate on a novel framework for con-
ceptualizing APD, which is motivated by integrated
evidence from across disciplines on children’s auditory pro-
cessing abilities, developmental models of memory and at-
tention, and the association of auditory processing abilities
to cognitive and language performance. The rationale for
this also lies in cumulative evidence on the comorbidity
between APD and language, attention, and learning dis-
orders. An integrated framework has the potential to advance
our understanding of developmental listening difficulties in
children and improve assessment and treatment procedures.
Importantly, misdiagnoses can be reduced and sources
of deficits can be better identified. We end by discussing
clinical implications that arise from studying the above
links.
A Model of WM
Miller, Galanter, and Pribram introduced the term
WM in 1960 in their publication “Plans and the Structure
of Behavior.” They defined WM as the ability to access
quickly one of many plans stored in memory toward its ex-
ecution. Atkinson and Shiffrin (1968) used the term WM
to refer to the short-term memory (STM) component of
their model of memory. In addition, their model included
sensory memory and a long-term memory (LTM) store.
According to the Atkinson and Shiffrin model, STM/WM
contained sensory information, which was attended to and
brought into conscious awareness. Baddeley and Hitch in
1974 provided a more elaborate and functional description
of WM through a multicomponent model (Baddeley, 2000;
see Figure 1). They corroborated evidence for and proposed
verbal and visuospatial STM as components of a larger
WM system. The system also involved a central executive,
which was a supervisory attentional system. Norman and
Shallice in 1980 defined the distinction between automatic
processing versus controlled processing, with the latter
needing greater recruitment of the supervisory attentional
system. The central executive in the Baddeley and Hitch
model is responsible for the control of information in WM.
According to this model, WM capacity is essential for ac-
tively maintaining serial order of information and is par-
ticularly crucial for units that are difficult to encode
semantically. Alternatively, LTM systems are associated
with efficient functions such as linguistic proficiency in a
primary or well-practiced spoken language or ease of lan-
guage comprehension (Baddeley, 2012). This is because
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information in LTM is organized based on meaning and
associative learning.
Baddeley and colleagues proposed WM as an active
memory system that individuals use to hold and manipu-
late information in conscious awareness. Central executive
processes such as sustained attention, attention allocation,
inhibition, updating, and shifting provide the attention
focus and control needed for encoding input, planning
action, problem solving, and recalling information from
LTM (Baddeley, 2012). Domain-specific components are
dedicated to process verbal information (i.e., phonologi-
cal loop/phonological STM) and visuospatial information
(i.e., visuospatial sketchpad/visuospatial STM), respec-
tively. Subsequently, an episodic buffer component was
proposed. The buffer provides for integration of multiple
sources of information (e.g., audiovisual integration), includ-
ing information from LTM (Baddeley, 2003). Since the
multicomponent model of WM was proposed, several models
of WM have evolved (Baddeley, 2012; Barrouillet, Gavens,
Vergauwe, Gaillard, & Camos, 2009; Cowan et al., 2005;
Unsworth & Engle, 2007). Discussion of the various models
is beyond the scope of this article. Whereas each model
differs in structural and functional details, most converge
on evidence that the WM system has both domain-general
and domain-specific components, which interact during
cognitive processing (Baddeley, 2012; Barrouillet et al., 2009;
Camos & Barrouillet, 2014; Jarrold & Towse, 2006). Impor-
tantly, many studies suggest significant improvements in
children’s WM capacity between 7 and 12 years of age
(Camos & Barrouillet, 2011; Gathercole, 1999; Magimairaj
& Montgomery, 2012). In this article, we use the WM
model by Baddeley and colleagues to guide our review of
the association between WM and auditory processing in
children. We chose this model because there is a cumulative
body of literature that supports it and because most studies
related to WM assessment or intervention in children with
language and related learning impairments are based on
this model (Gathercole, 1999).
A Model of Auditory Processing
One prominent model of auditory processing is the
Buffalo model (Katz, 1992). In this model of auditory pro-
cessing, four categories are defined based on audiological
APD assessment results. These are decoding, tolerance-
fading memory, integration, and organization problems
(see Figure 2). This categorization resulted from performance
patterns on three tests: a phonemic synthesis test, a speech-
in-noise test, and the dichotic Staggered Spondaic Word
(SSW)1 Test (Katz, 1962, 1963, 1968, 1973), which is central
to the battery. In addition, children’s behavioral symptoms
1
SSW is a dichotic listening task used to assess binaural integration. In
this task, two overlapping spondee words (two-syllable words such as
lap-top, air-plane) are presented to the ears simultaneously. The second
syllable of the first spondee overlaps with the first syllable of the
second spondee. The listener is asked to repeat both the spondee
words.
 Figure 1. The multicomponent model of working memory.

and academic profiles are considered. Decoding relates to
identification, manipulation, and recall of phonemes.
Tolerance-fading memory involves verbal (auditory)
STM recall in the presence of noise. Integration relates
to interhemispheric information transfer (indexed by
binaural integration or separation tasks) and integration
of auditory–visual information. The fourth category re-
flects organization, including planning and sequencing.
For each category, corresponding neuroanatomical sites
and systems in the CNS are proposed (Tillery, 2015).
Also described are functional behaviors associated with
each category, for example, phonemic processing (for
decoding), verbal STM recall in noise (for tolerance-fading
memory), integrating audiovisual information during
reading and spelling (for integration), and performance on
executive function tasks (for organization).2
that both include the WM components of verbal STM
(auditory decoding, tolerance-fading memory), the episodic
buffer (integrating audiovisual and LTM information), and
the central executive (organization). The WM model pro-
posed by Baddeley and colleagues has been highly influ-
ential and is supported by a cumulative body of literature
from clinical as well as neurotypical populations and
across behavioral and neuroimaging studies in both children
and adults. Categories in the Buffalo model of auditory
Figure 2. The Buffalo model of auditory processing disorder.

Comparison Between Models of Auditory

Processing and WM
When examining a prominent model of auditory
processing, we observed parallels to the multicomponent
model of Baddeley and colleagues. For example, the Buffalo
model parallels Baddeley’s multicomponent WM model in

2
Similarly, in the Bellis–Ferre model of auditory processing (Bellis,
2002; Ferre, 2002), auditory decoding, prosody, and integration are
recognized. Auditory decoding corresponds to phonemic analysis. The
prosodic category relates to perception of tonal patterns and includes
binaural integration and separation abilities. Integration includes
interhemispheric skills (e.g., multimodal task performance), including
binaural integration and separation. Secondary profiles include
auditory association and output organization.

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 processing may be interpreted to reflect deficits in one
or more components of the WM system as defined by
Baddeley (2003). Auditory decoding, audiovisual integra-
tion, and organization abilities can also be associated with
language processing at various levels of complexity. For ex-
ample, poor phonological processing abilities, such as those
seen in some children with specific language impairment or
dyslexia, could potentially lead to auditory processing pro-
files that correspond to APD models (Dawes & Bishop,
2009). Similarly, auditory memory and auditory sequencing
of spoken material that are often challenging for children
diagnosed with APD are integral functions attributed
to the phonological loop component of WM. Whether
processing of nonlinguistic auditory sounds also uses the
same subcomponent of the WM system has not been
well explored (Baddeley, 2012). Nevertheless, reported
listening problems in children are typically manifested as
difficulties in listening to speech in daily environments
and especially when the target speech signal is degraded
due to factors such as noise and reverberation. In addi-
tion, deficits in attention and executive functioning that
often coexist in children diagnosed with APD are key
functions attributed to the central executive component
of WM. Importantly, another challenge to traditional
APD models is their description of neural substrates. As
seen in Figure 2, all neural substrates described in the
Buffalo model categories are at the cortical level (Tillery,
2015). These same areas underlie attention, WM, LTM,
and language functioning (including reading), thus posing
a challenge for the diagnostic categorization as being
unique to APD.
In summary, WM components, such as the phono-
logical loop, episodic buffer, and central executive, corre-
spond to key components defined in prominent auditory
processing models (Bellis, 2002; Ferre, 2002; Katz, 1992;
Medwetsky, 2011). The comorbidity of auditory process-
ing, attention, language, and reading disorders supports
this notion (Sharma, Purdy, & Kelly, 2009). Remarkably
similar cognitive behavioral profiles have been reported in
children diagnosed with APD and children diagnosed as
having specific language impairment (Ferguson et al., 2011).
Medwetsky (2011) proposed a spoken language processing
model to broaden the concept of auditory processing to
include auditory, language, and cognitive mechanisms.
Measures of verbal STM, WM, and attention (all of which
are key components of Baddeley’s multicomponent model)
were included in this model in addition to auditory pro-
cessing measures. However, the Medwetsky model itself
has not been tested systematically. Other studies have re-
ported that cognitive factors such as “WM and executive
attention” and “processing speed and alerting attention”
underlie listening difficulties in children suspected to have
APD, in addition to a “general auditory factor” (Ahmmed
et al., 2014). These studies will be elaborated in the next
section. According to current evidence, both domain-general
attention and domain-specific (auditory–verbal) compo-
nents of WM show relationships to children’s auditory
processing abilities.
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Relationships Between WM and Auditory
Processing Abilities in School-Age Children
Age-Related Links
In assessing auditory processing abilities, it is recom-
mended that behavioral testing be conducted for children
who are developmentally 7 years or older (AAA, 2010;
ASHA, 2005). This is because of the difficulty in test inter-
pretation in younger children. The age of 7 years is also
mentioned in studies of WM as the developmental period
that marks the beginning of significant improvements in
WM functioning (Camos & Barrouillet, 2011; Cowan, 2017;
Gaillard, Barrouillet, Jarrold, & Camos, 2011). For exam-
ple, a significant developmental shift is noted in children’s
verbal rehearsal and attention allocation ability at 7 years
with continued improvement through 11 years (Camos &
Barrouillet, 2011). Similarly, variability on tests of auditory
processing and electrophysiological measures, such as the
middle latency response, reduces from 7 years onward
(Weihing, Schochat, & Musiek, 2012). Processing of degraded
speech improves in children markedly between 5 and 12 years
of age (Eggermont, 2014). This developmental overlap be-
tween auditory processing abilities and WM abilities is im-
portant to reconcile.
Relationships Between Attention, WM, and Auditory
Processing Test Performance
There is substantial clinical and research evidence
that supports the comorbidity between attention and audi-
tory processing. Attention, an integral component of WM,
is suggested to be primarily responsible for the strong
association between WM and complex cognitive task per-
formance (Barrouillet et al., 2009; Cowan et al., 2005; Engle,
2002; Lépine, Barrouillet, & Camos, 2005). Both caregivers
and professionals describe children suspected to have APD
or diagnosed with APD as having behavioral deficits such
as inattention, distractibility, and poor organization, in
addition to their listening difficulties. The direction of cau-
sality of whether APD causes attention deficits or an atten-
tion deficit leads to auditory processing deficits remains
elusive. Some auditory processing task performances (e.g.,
dichotic SSW, phonemic synthesis, and speech in noise)
have proven to be not influenced by medications used to
treat attention disorders such as attention deficit disorder
(ADD) or attention-deficit/hyperactivity disorder (ADHD;
Tillery, Katz, & Keller, 2000). This finding implied that
variation in attention did not influence these behavioral
measures. Other studies have shown some auditory pro-
cessing abilities (e.g., frequency discrimination) to be more
susceptible than others (e.g., frequency modulation detec-
tion)3 to attention variation (Sutcliffe, Bishop, Houghton,
& Taylor, 2006). Overall, the influence of attention poten-
tially varies depending on the nature and demands of an au-
ditory processing task.
3
Frequency modulation detection is the ability to detect the fluctuation
in frequency or pitch in a sound.
 Researchers have suggested that behavioral symp-
toms of APD primarily reflect cognitive processing abili-
ties such as attention (Ahmmed et al., 2014; Moore, 2012;
Moore et al., 2010, 2013; Tomlin, Dillon, Sharma, &
Rance, 2015). For example, in a large population-based
study (N = 1,469) by Moore et al. (2010), children with
poor auditory processing also scored low on cognitive
and communication measures, albeit the strength of the
correlation between auditory perception and cognitive
scores (attention, STM, WM, nonverbal IQ) was low. Cog-
nitive performance and attention variations that led to
response variability in auditory processing best predicted
listening abilities, including speech perception in noise
(SPIN). Auditory processing measures used by Moore et al.
(2010) were experimental (i.e., not standardized). They
were backward and simultaneous masking, frequency dis-
crimination, and vowel–consonant–vowel words in noise.
Ahmmed et al. (2014) used a factor analytic approach to
identify auditory and nonauditory factors related to chil-
dren’s listening difficulties (N = 110). They administered
a widely used clinical APD test battery (SCAN-C com-
prising of dichotic speech, speech-in-noise, and auditory
closure tests; Keith, 2009), along with a research test bat-
tery that included backward and simultaneous masking,
frequency discrimination, motor speed tasks with auditory/
visual stimuli, attention, WM, nonverbal intelligence, and
reading, to 6- to 11-year-old children. All children were
previously referred for APD assessment due to reported
listening difficulties.
Results revealed (a) a “general auditory processing”
factor, (b) a “WM and executive attention” factor, and (c)
a “processing speed and alerting attention” factor. Despite
a separable auditory processing factor, the authors found
that cognitive factors best predicted functional listening
outcomes. Next, we present studies specific to two auditory
processing tests (dichotic listening and SPIN) and their
relationship with WM and attention. These tests are hall-
mark APD measures that have been consistently used.
Dichotic Listening
The dichotic listening paradigm is one measure that
is consistently included in all auditory processing test
batteries as a measure of interhemispheric communication
(corpus callosum) and brainstem or cortical integrity
(depending on the type of stimuli used and the required
response). Originally, this paradigm was used to demon-
strate auditory deficits resulting from well-defined unilateral
temporal lobe lesions (Kimura, 1961). The paradigm in-
volves presenting auditory stimuli to both ears simulta-
neously and requiring the participant to report from both
ears (assessing binaural integration) or only from one ran-
domly selected ear while ignoring the other ear (dichotic
competing words/competing sentences assessing binaural
separation). Importantly, the dichotic listening paradigm
is also included in cognitive test batteries as a measure of
auditory attention. For example, the Woodcock–Johnson
III Tests of Cognitive Abilities (Woodcock, McGrew, &
Mather, 2001) includes a Dichotic Listening subtest as a
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measure of selective auditory attention where participants
are required to selectively ignore one ear and attend to the
other. Furthermore, using behavioral and neuroimaging
procedures, studies have now established that attention,
which is an integral component of WM, plays a robust role
during dichotic listening tasks (Hugdahl et al., 2009; Jones,
Moore, & Amitay, 2015; Schmithorst et al., 2013).
Tomlin et al. (2015) reported significant associations
between cognitive measures (i.e., STM, WM, attention,
nonverbal IQ), functional outcomes, and a subset of audi-
tory processing tests that included dichotic digits. Dichotic
digits showed the highest correlation (moderate effect size)
with auditory WM and attention, in accordance with
results reported by Sharma et al. (2009). Similarly, Ahmmed
et al. (2014) reported significant positive correlations be-
tween dichotic tests (competing words and sentences) and
STM. Gyldenkærne, Dillon, Sharma, and Purdy (2014)
investigated the links between attention and auditory pro-
cessing in 101 children with listening difficulties and a con-
trol sample of 18 children who had no reported listening
difficulties (age range was 7–12 years). Positive correlations
(small effect size) were reported between dichotic digits per-
formance and both auditory and visual sustained attention
ability. However, their data also indicated that poor APD
test performance occurred in some children in the presence
of normal-range sustained attention scores. The authors
concluded that, although APD test performance can be in-
fluenced by attention, there was a possibility that deficits
in attention and poor auditory processing test performance
were affected by a third underlying factor that was common
to both. Given the small effect size of the correlations, it
was suggested that poor auditory performance was not
completely explained by attention deficits, thereby suggest-
ing the need for differential treatment when indicated. As
an attempt to isolate the influence of cognitive factors on
dichotic listening testing, Cameron et al. (Cameron, Glyde,
Dillon, & Whitfield, 2016; Cameron, Glyde, Dillon, Whitfield,
& Seymour, 2016) developed the Dichotic Digits Difference
Test, which is based on difference scores obtained from
Diotic (same stimuli presented to both ears simultaneously)
and Dichotic subtests (different stimuli to each ear presented
simultaneously). Because both tasks are assumed to share
the same response demands and the diotic condition serves
as a control condition, any difference in performance was
attributed to binaural integration abilities. Results suggested
that factors other than dichotic listening ability, such as
attention and memory, still accounted for significant vari-
ance in children’s performance.
SPIN
Several developmental studies have explored the asso-
ciation between children’s WM capacity and SPIN using
different types of speech stimuli (Cameron & Dillon, 2008;
Eisenberg, Shannon, Martinez, Wygonski, & Boothroyd,
2000; Magimairaj, Nagaraj, & Benafield, 2018; McCreery,
Spratford, Kirby, & Brennan, 2017; Osman & Sullivan, 2014;
Sullivan, Osman, & Schafer, 2015; Tomlin et al., 2015).
Some of these studies were motivated in part by studies in
415
 older adults with hearing impairment that suggested an as-
sociation between SPIN and WM capacity (Akeroyd, 2008;
Holt & Lotto, 2008; McCoy et al., 2005; Rönnberg et al.,
2013; Rönnberg, Rudner, Foo, & Lunner, 2008). McCreery
et al. (2017) examined the association between WM capac-
ity, language, and SPIN in 96 typically developing school-
age children between 5 and 12 years of age. WM capacity
was indexed using subtests of the Automated Working Mem-
ory Assessment (Alloway, 2007). Speech perception was
measured in steady-state speech-shaped noise. Monosyllabic
words, syntactically correct but semantically anomalous
sentences (e.g., The jaws giggle at the frosty tractor) and
sentences with anomalous semantics and syntax (e.g., Ghost
four smart tooth) were used as speech stimuli in an immedi-
ate recall paradigm. Standardized receptive vocabulary
and syntactic knowledge measures were also administered.
Across all three stimulus categories, WM capacity signifi-
cantly predicted SPIN. In addition, better vocabulary was
associated with better SPIN for both sentence types (but not
for monosyllabic words).
According to Sullivan and colleagues, listening com-
prehension in noise places greater demands on children’s
WM because cognitive resources are shared between the
primary task of listening and the secondary requirement
of filtering out noise. Osman and Sullivan (2014) evaluated
the influence of noise on auditory WM performance in 20
typically developing 8- to 10-year-old children. Children’s
WM performance was significantly poorer in noise relative
to quiet, and this was attributed to increased recruitment
of cognitive resources in noise. To the same sample of chil-
dren, a listening comprehension task was administered
in quiet and noise (Sullivan et al., 2015). Comprehension
involved listening to two- to seven-sentence-long passages
and answering questions about the main idea, vocabulary,
reasoning, details, and comprehension. Stronger correla-
tions between listening comprehension and WM in noise
relative to quiet were interpreted as reflecting increased
WM demands in noise.
Cameron and Dillon (2008) developed the LiSN-S to
assess children suspected to have APD. LiSN-S is a speech
repetition task in which children’s speech perception abil-
ity is measured in the presence of competing speech noise.
However, the spatial location of the target speech is fixed
directly in front while changing the perceived spatial loca-
tion of competing speech noise to either come from the front
(0° azimuth) or from the sides (±90° azimuth). Along with
the spatial location, the vocal characteristic (pitch) of the
competing speech noise was also varied to be the same or
different from the target speaker. This resulted in two condi-
tions, one in which pitch and the spatial location of the tar-
get and competing speech matched (“low cue” condition)
and the other called “high cue” condition, where both the
pitch and the spatial locations were different. Importantly,
LiSN-S was shown to be distinct from other auditory pro-
cesses (Cameron & Dillon, 2008) and also appeared to be
less influenced by high-order cognitive abilities such as WM
and language (Tomlin et al., 2015). Whereas no positive
correlation was observed for LiSN-S in the high-cue condition
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with STM, WM, or attention, in the LiSN-S low-cue condi-
tion, weak correlations (small effect size) were reported with
STM and auditory WM (r = .18–.27), but no significant
correlations with attention (Tomlin et al., 2015). In addition,
any difference in scores between the high- and low-cue con-
ditions is indicative of auditory processing deficits because
both subtests have the same task requirements. The test
design minimizes the influence of attention, language knowl-
edge, and auditory memory. However, even if cognitive
and language factors played a role, they would affect both
conditions similarly and therefore allow differentiation of
an auditory processing deficit (Dillon et al., 2012).
Given the need for more large-scale studies to
study the association between WM and SPIN in children,
we examined the relation between children’s SPIN, lan-
guage abilities, and WM capacity in 83 school-age children
who represented a continuum of individual differences in
cognitive abilities (Magimairaj et al., 2018). Children’s SPIN
was assessed using the Bamford–Kowal–Bench Speech-in-
Noise Test (BKB-SIN; Etymotic Research, 2005) and used
as the dependent variable. BKB-SIN was selected because
it is widely used clinically and is standardized for school-
age children. Multiple standardized measures of language
and WM measures were used to predict SPIN. As ex-
pected, significant positive correlations were observed
between attention, memory, and language measures (con-
trolling for age). However, none of the predictors correlated
significantly with BKB-SIN performance. On principal
component analysis, distinct factors were revealed for WM,
language, SPIN, and nonverbal IQ, respectively. The load-
ing of BKB-SIN as a unique factor was robust (with mini-
mal secondary loading from sentence recall and STM).
These findings did not support an association between
WM capacity and SPIN in children as measured using the
BKB-SIN. Findings corroborated the utility of the BKB-
SIN in audiological assessment given its dissociation from
cognitive–linguistic factors.
Differences between Magimairaj et al. (2018) and
studies that have shown an association between SPIN
and WM (i.e., McCreery et al., 2017; Sullivan et al., 2015)
may be due to the nature of the speech stimuli used. In
Magimairaj et al., meaningful sentences were used with
three to four keywords to be scored. Listening to meaning-
ful spoken stimuli represents every communication
and hence is ecologically valid. McCreery et al. (2017) used
sentences with four keywords. However, their sentences
were void of meaning and ungrammatical or had correct
grammar without meaning. Repeating unrelated words
is comparable to the word span task, which is typically
used as a measure of phonological STM. Grammatically
correct but meaningless sentences potentially tap on syn-
tactic knowledge in addition to STM. The association ob-
served between WM and SPIN in McCreery et al. (2017)
may have been mediated by STM. Sullivan et al. (2015) used
a listening comprehension task in noise in contrast to a sen-
tence repetition in noise paradigm as used in Magimairaj
et al. However, an absence of partial correlations (control-
ling for age) and the small sample size in Sullivan et al.
 (2015) may also explain the differences between study re-
sults. Overall, existing evidence suggests either weak or no
associations between cognitive–linguistic factors and SPIN
tasks that use meaningful words/sentences in a repetition
paradigm (Caldwell & Nittrouer, 2013; Cameron & Dillon,
2008; Eisenberg et al., 2000; Magimairaj et al., 2018;
Moore et al., 2010; Nittrouer et al., 2013; Tomlin et al., 2015).
These results in children align with studies that report no
significant association between WM capacity and speech
identification and comprehension in noise in older adults with
hearing impairment (Nagaraj, 2017; Sheft, Shafiro, Wang,
Barnes, & Shah, 2015; Smith & Pichora-Fuller, 2015). Fur-
thermore, meta-analysis data on young adults with normal
hearing suggest that WM capacity was not reliably as-
sociated with individuals’ speech identification in noise
(Füllgrabe & Rosen, 2016). These data suggest that WM
predicts less than 2% variance in speech identification in
noise (Füllgrabe & Rosen, 2016). More studies in children
are warranted to replicate the proposed role of WM capac-
ity in SPIN using stimuli of varying length and linguistic
complexity.
Evidence for Dissociations Between Other Auditory
Processing and Cognitive Measures
Studies have reported data on auditory processing
tasks that appear distinct from cognitive measures and
explain unique variance in listening ability. For example,
Sharma et al. (2009) observed no significant correlation
between attention/memory and gap detection or masking
level difference in a sample of 68 children suspected to have
APD or diagnosed with APD. Riccio, Cohen, Garrison,
and Smith (2005) found no significant correlation between
subtests of the screening test for APDs (SCAN; Keith,
1986) and the SSW Test (Katz, 1962), with visual attention
skills, in a sample of 36 children who had a diagnosis of
APD or ADHD or both. However, this result was not repli-
cated. Gyldenkærne et al. (2014) reported a significant
positive relationship between sustained visual attention
ability and auditory processing test performance. All these
studies also reported that not all children diagnosed with
APD had auditory attention and memory deficits and vice
versa. In a study by Rosen, Cohen, and Vanniasegaram
(2010), weak or nonexistent correlations were reported be-
tween auditory processing (i.e., tone discrimination and con-
sonant cluster minimal pairs discrimination) and language
and nonverbal IQ in children diagnosed with APD as well
as in the control group.
Evidence Supporting That WM Modulates Auditory
Processing Abilities and Their Development
Cognitive factors such as WM shape neural process-
ing of auditory stimuli (Kraus & Hornickel, 2013b; Kraus,
Strait, & Parbery-Clark, 2012; Strait, Parbery-Clark, Hittner,
& Kraus, 2012). Kraus and colleagues have demonstrated
changes in auditory brainstem function resulting from
long-term language and music experience as well as from
short-term auditory and musical training. Importantly,
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auditory attention and WM are identified among contribut-
ing factors that influence the neuroplasticity of subcortical
areas (e.g., Hornickel, Chandrasekaran, Zecker, & Kraus,
2011; Kraus & Chandrasekaran, 2010; Kraus & Hornickel,
2013b; Kraus & White-Schwoch, 2015; Strait et al., 2012).
The scope of interactions between cognitive, sensory, and
reward circuits is supported by the larger number of de-
scending projection fibers from the cortex in comparison to
ascending projection fibers (Kraus & Hornickel, 2013b).
Studies also suggest that development of auditory selective
attention mediates children’s listening in noise ability. For
example, Jones et al. (2015) demonstrated that children’s
listening in unpredictable noise became adultlike by 9–11
years of age and selective attention ability was a major fac-
tor that accounted for the children’s auditory judgments.
Clinical Implications
An Integrated Framework for Conceptualizing
Auditory Processing
From our review of the relationships between WM
and auditory processing abilities in children, what is known
about the integrated functioning of the nervous system
(Moore, 2012; Schmithorst et al., 2013), and evidence of
multifactorial risk factors in neurodevelopmental disorders
(Moore, 2015; Pennington, 2006), it is clear that we need
a novel framework for understanding auditory processing
abilities in children. The framework must include cogni-
tive and linguistic factors as potential sources of deficits
along with auditory factors. We provide a schematic for
such a framework (see Figure 3). The basis for this frame-
work is the cumulative evidence across the disciplines of
hearing, language, and cognitive science. This includes stud-
ies in typically developing children and those suspected to
have APD, the literature on children with specific language
impairment, and models of developmental attention and
memory. In addition, in-depth review of WM models and
methodological approaches to the assessment of WM were
considered toward this conceptualization. Interestingly,
traditional APD models have shown remarkable overlap
Figure 3. An integrated framework to conceptualize listening
difficulties in children.
417
 with WM models. Advances in the WM literature need to
be effectively integrated to studies in children suspected to
have APD. For example, one recommendation is to use
multiple tasks to measure WM capacity (Conway et al.,
2005). Another is to use time-controlled WM tasks (Barrouillet
et al., 2009) because cognitive performance is measured as
a function of cognitive load, which is governed by the time
allowed to perform a task (Barrouillet & Camos, 2010).
Such methodological details have not been incorporated in
studies of APD. Similarly, control of cognitive or language
load of auditory tasks has been a challenge for traditional
APD tests.
As indicated in our framework (see Figure 3), cognitive,
linguistic, and auditory factors may play a role individually
or jointly in any combination to cause listening difficulties
in children. This is because these systems are linked and
are not compartmentalized. For example, WM allows us
to bring information to conscious awareness during con-
trolled cognitive tasks, including auditory processing tasks.
Processing and retaining serial order of auditory stimuli
is a critical function of WM. Similarly, WM plays a role in
various aspects of language processing as is evidenced by
interactions between phonological STM, LTM, the episodic
buffer, and the central executive. Auditory processing and
language processing are often described to be on a contin-
uum but are in fact highly integrated and can be reciprocal
in their influence. The heterogeneous profiles of children
with listening difficulties reflect combinations of deficits
across these factors. Based on such a framework, one ap-
proach may be to develop and standardize a front-end uni-
fied assessment, which includes only the most sensitive
areas that are known to characterize difficulties in children
with reported listening problems (i.e., taking into account
overlapping conditions such as APD, specific language im-
pairment, ADD/ADHD, and learning disability) across areas
of language, attention, memory, and auditory processes. The
uniqueness of the measures would be important. Doing so
may be an efficient way to ensure that no major area goes
unrecognized up front. Based on failures or profiles noted,
comprehensive discipline-specific assessments may follow.
Another approach may be to develop combination tasks
that combine two sensitive areas, thereby increasing the
chances of early detection of a potential problem. Most
important, building a quick broad initial profile has signif-
icant clinical application in helping clinicians with “where
to start” when they are tasked with evaluating a child with
listening difficulties. Such an assessment must also adhere
to established standards to ensure high specificity and sensi-
tivity. For example, Standards for Psychological and Educa-
tional Testing (American Educational Research Association,
American Psychological Association, National Council on
Measurement in Education, & Joint Committee on Standards
for Educational and Psychological Testing, 2014) may be
used as a guide for establishing task validity and reliability.
Incorporating tasks that are engaging for children and
available on one integrated platform would be ideal. A mea-
sure for use as an initial tool must be made available for use
across professional disciplines so that key areas are profiled
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efficiently and parents get a better view of their child’s
difficulties.
Moore et al. (2010) in the IMAP project and Dillon
et al. (2012) have also proposed the assessment of cogni-
tion and language along with auditory processes, and both
these lines of research have made significant contribu-
tions toward better understanding children with listen-
ing difficulties. However, more work is needed. The most
sensitive language and cognitive tasks and the best ways to
measure them in children suspected to have APD are not
yet well established. For example, in the IMAP battery,
children’s language was not measured directly, but a parent
questionnaire was used as an indicator of language abilities
(CCC-2; Bishop, 2003). IMAP also included the CHAPPS
listening behavior checklist, which is reported to have poor
validity as a screening measure (Wilson et al., 2011). One
important auditory component not included in the IMAP
is binaural integration. The IMAP comprises a battery of
tests from various sources and includes both novel and
already available standardized tasks. The IMAP auditory
processing tests are language free, and inclusion of cogni-
tive measures in the protocol was an important addition.
The tasks have been designed to be engaging for children
and control for fatigue. However, the reliability of some
of the tasks is reported to be inadequate (Ahmmed et al.,
2014).
Dillon and colleagues have developed differential
testing procedures such as the use of difference scores
(difference between tests that differ in only one factor) to
help differentiate and isolate factors that contribute to
performance. For example, the LiSN-S test is based on dif-
ference scores and allows assessment of children’s spatial
processing ability. In addition, the test targets one of the
primary reported complaints, which is difficulty in listening
in noisy environments. A similar innovative paradigm was
reported in a study of children with specific language im-
pairment. Leonard, Deevy, Fey, and Bredin-Oja (2013)
developed a picture-pointing sentence comprehension task
to isolate cognitive capacity limitations from language-
based deficits in children’s sentence comprehension. Per-
formance difference in two sentence conditions that are
identical in linguistic structure but differ only in cognitive
demand due to difference in the nature of picture foils
helped isolate cognitive capacity limitations. More such
paradigms are needed for better differentiation of sources
of deficits. Decision tree and hierarchical approaches are
not new to clinical assessment. However, their applica-
tion to children with significant listening difficulties is just
beginning (Dillon et al., 2012). Continued work is needed
in this regard.
Instead of developing diagnostic APD categories/
labels (which has not proven to be the most effective in
getting services for children with listening difficulties),
the goal of assessment must be to delineate specific deficit
areas in a given child that have the potential for remediation.
Hierarchical assessments can be time and cost-effective
because they can lead to determination of target areas that
may benefit from intervention (Dillon et al., 2012). To avoid
 confusion to parents, the use of APD as a categorical di-
agnostic term in children with developmental listening
difficulties should be restricted unless cross-disciplinary
evaluations are complete. Finally, our framework reflects
the importance of a multidisciplinary team approach in
not only developing front-end or hierarchical assessments
but also in designing effective interventions. Importantly,
management of functional listening and learning difficulties
must be joint efforts of speech language pathologists and
audiologists, along with parents and relevant professionals.
Integrated treatment approaches need to undergo system-
atic testing to ensure they address the key areas that are
difficult for children. This is also important to demonstrate
that any novel treatments are distinct from conventional
language intervention approaches in terms of benefit. In
summary, proposing such a framework is important because
it is clear that there are children with significant auditory
symptoms that affect their ability to listen, learn, and
function as well as their peers. These children slip through
the cracks due to the heterogeneity of their symptoms.
Other Implications
Based on our review of the relationships between
WM and auditory processing, we note several other clini-
cal implications. First, given the overlap in developmental
trajectories of auditory processing abilities and WM abili-
ties, age at evaluation must be taken into account during
assessment and intervention for auditory processing dif-
ficulties. APD testing is not recommended for children
developmentally younger than 7 years (AAA, 2010). Cli-
nicians must adhere to this recommendation given the sub-
stantial evidence that supports this. Doing so may save
time and resources for parents and children and avoid mis-
diagnosis. However, any significant listening difficulties
noted in children at any age (including at younger ages)
must call for a speech-language evaluation, a peripheral
hearing assessment, and cognitive assessment as indicated.
This is because identification of breakdowns in any level
of language or cognitive processing triggers the consider-
ation of language enrichment opportunities for the children.
Enriching overall language knowledge and processing
abilities (e.g., phonological awareness, vocabulary) early
has the potential to improve children’s functional commu-
nication abilities or compensate for deficits. Enhancing
children’s language knowledge and processing may be im-
portant to listening in complex auditory environments.
Studies in adults have shown that listening in degraded con-
ditions is crucially constrained by an individuals’ lexical
knowledge (Benard, Mensink, & Baskent, 2014; Nagaraj
& Magimairaj, 2017). Systematic studies in children are
needed to model the contribution of specific linguistic fac-
tors to listening in complex environments.
Second, comorbidity of auditory processing deficits
or WM deficits with other developmental disorders (e.g.,
learning disability, ADD/ADHD, specific language impair-
ment) is often a rule and not an exception because of the
multifactorial nature of risk factors for developmental
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disorders (Pennington, 2006) and due to the organization
and integrated functioning of the CNS (Kraus & Hornickel,
2013a). In other words, a deficit in one area of processing
(e.g., WM or auditory processing) does not necessarily
mandate a stand-alone diagnostic category for that area
(Kamhi, 2011). Clinicians must therefore effectively collab-
orate with other professionals and flexibly incorporate
techniques that accommodate the child’s deficits. To assess
auditory processing, understanding stimulus characteris-
tics, their neural representation, and their psychological cor-
relates is important. To this end, cognitive systems such as
WM are integral to auditory processing abilities and their
development. Most important, as an alternative to diag-
nostic categorization, a decision tree approach can better
enable clinicians to reach specific goals (First, 2013). Dillon
et al. (2012) proposed a hierarchical approach to APD
assessment with master assessments followed by detailed
auditory assessments as indicated. Cameron et al. (2015)
evaluated the hierarchical assessment model and followed
it up with deficit-specific treatment for spatial processing
deficits or memory deficits or improved auditory access
(LiSN and Learn or Memory Booster or FM listening sys-
tem). Significant improvements were reported for all train-
ing options. Clinicians and researchers must move toward
a decision tree approach that integrates cognitive–linguistic
factors effectively in addition to auditory processing as-
sessment. One possibility is to use a broad but efficient
cross-disciplinary assessment up front that incorporates at-
tention, memory, language, and audition so that no area
is missed. Such a tool must be made available to multiple
professionals who can then refer children for discipline-
specific comprehensive evaluations. More research is needed
to add to our knowledge about those areas of auditory
processing that are clearly distinct or least influenced by
other cognitive measures. Also, auditory assessments must
be designed to minimize language or cognitive influences
as much as possible, and use of redundant measures across
disciplines must be minimized.
Third, improving auditory access using assistive lis-
tening devices (e.g., FM systems) has been shown to be
effective (Cameron et al., 2015). There are also studies that
support targeted auditory training (using nonspeech stimuli
or speech stimuli) for children with language and listening
difficulties (e.g., Kraus et al., 1995; Merzenich et al., 1996;
Tallal, 2004; Tallal & Gaab, 2006; Tallal et al., 1996). How-
ever, most of these studies lack high levels of evidence. For
example, it has been demonstrated that auditory training
programs such as FastForword are not significantly dif-
ferent from traditional language interventions (Fey et al.,
2011; Gillam et al., 2008; Kamhi, 2011). Another challenge
to decontextualized auditory or computerized cognitive
training programs has been a lack of consistent far-transfer
effects (Halliday, Taylor, Millward, & Moore, 2012; Murphy,
Moore, & Schochat, 2015; Shipstead, Hicks, & Engle, 2012).
Given the prominence of children’s difficulty listening in
complex auditory environments and emerging evidence
suggesting a distinction of SPIN and spatialized listening
from other auditory and cognitive factors (e.g., Cameron &
419
 Dillon, 2008; Magimairaj et al., 2018), listening training in
spatialized noise appears to hold promise for intervention.
This needs to be systematically replicated across indepen-
dent studies.
Finally, auditory-language stimulation and enrich-
ment must be emphasized during development (Kraus &
Chandrasekaran, 2010; Kraus & Hornickel, 2013b). This
concept is not new. However, the current research evidence
on neuroplasticity makes a compelling case to promote the
enhancement of children’s auditory experiences beginning
early in the critical period (Zhao & Kuhl, 2016). Emphasiz-
ing prevention should be at the forefront, not just assess-
ment and remediation. In addition, integrating auditory
enrichment with functional and contextualized activities (e.g.,
musical experience, play, language experience, and social
interaction) and optimizing attention and memory load
may allow the children to receive the most benefits.
Acknowledgments
A Hearing Health Foundation’s Emerging Research Grant
to the authors and a Medical Research Endowment Grant from
the University of Arkansas for Medical Sciences to the second
author funded the authors’ studies cited in this article.
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