Wit, 2016 Auditory Processing Disorders

JSLHR
Review Article
Characteristics of Auditory Processing

Disorders: A Systematic Review
Ellen de Wit,a Margot I. Visser-Bochane,a Bert Steenbergen,b,c Pim van Dijk,d
Cees P. van der Schans,a,e and Margreet R. Luingea
Purpose: The purpose of this review article is to describe In total, 48 studies were included, of which only 1 was
characteristics of auditory processing disorders (APD) by classified as having strong methodological quality.
evaluating the literature in which children with suspected or Significant dissimilarities were found between children
diagnosed APD were compared with typically developing referred with listening difficulties and controls. These
children and to determine whether APD must be regarded as differences relate to auditory and visual functioning,
a deficit specific to the auditory modality or as a multimodal cognition, language, reading, and physiological and
deficit. neuroimaging measures.
Method: Six electronic databases were searched for peer- Conclusions: Methodological quality of most of the
reviewed studies investigating children with (suspected) APD in incorporated studies was rated moderate due to the
comparison with typically developing peers. Relevant studies heterogeneous groups of participants, inadequate
were independently reviewed and appraised by 2 reviewers. descriptions of participants, and the omission of valid and
Methodological quality was quantified using the American reliable measurements. The listening difficulties of children
Speech-Language-Hearing Association’s levels of evidence. with APD may be a consequence of cognitive, language,
Results: Fifty-three relevant studies were identified. Five and attention issues rather than bottom-up auditory
studies were excluded because of weak internal validity. processing.
C
hildren with auditory processing disorders (APD) definition of developmental APD and whether the disorder
encounter listening difficulties despite displaying can be considered a distinct clinical disorder (Bellis, 2003;
normal or near-normal hearing acuity. Depending Cacace & McFarland, 2009; Dawes & Bishop, 2009; Kamhi,
on the definition used, the prevalence of APD among chil- 2011; Rosen, 2005; W. J. Wilson & Arnott, 2013; W. J.
dren and adults varies between 0.5% and 7.0% (Bamiou, Wilson, Heine, & Harvey, 2004). One of the main questions
Musiek, & Luxon, 2001; Chermak & Musiek, 1997; Hind among professionals working with children with APD is
et al., 2011), with a 2:1 ratio between boys and girls (Chermak whether the listening difficulties in children with APD are due
& Musiek, 1997). After more than 40 years of research, to a specific auditory sensory processing deficit (bottom-up
there is still no consensus among speech-language patholo- problem) or to a cognitive deficit (top-down problem). In
gists, audiologists, and researchers regarding the nature and other words, can we speak about modality specificity in
children with APD, or do we need to speak about a multi-
modal deficit (e.g., Cacace & McFarland, 2014; Dillon,
a
Research Group Healthy Ageing, Allied Health Care and Nursing, Cameron, Tomlin, & Glyde, 2014; McFarland & Cacace,
Hanze University of Applied Sciences, Groningen, the Netherlands 2014; Moore, 2012, 2015; Moore & Ferguson, 2014; Moore
b
Behavioural Science Institute, Radboud University Nijmegen,
& Hunter, 2013)?
the Netherlands
c
Australian Catholic University, Melbourne, Australia
During the past 15 years, special interest groups and
d
Department of Otorhinolaryngology, Head & Neck Surgery, task forces from various countries around the world intro-
University Medical Center Groningen, University of Groningen, duced several position statements in an attempt to achieve
the Netherlands more uniformity for the diagnosis and diagnostic criteria of
e
Department of Rehabilitation Medicine, University Medical Center APD. The American Speech-Language-Hearing Associa-
Groningen, University of Groningen, the Netherlands tion (ASHA, 2005), the American Academy of Audiology
Correspondence to Ellen de Wit: e.de.wit@pl.hanze.nl (AAA, 2010), and the British Society of Audiology (BSA,
Editor: Nancy Tye-Murray 2011a) stated that APD arises from deficiencies in the central
Associate Editor: Suzanne Purdy nervous system, which can lead to impaired performance
Received March 26, 2015 on behavioral psychoacoustic tasks (Moore, Rosen, Bamiou,
Revision received July 15, 2015
Accepted August 7, 2015 Disclosure: The authors have declared that no competing interests existed at the time
DOI: 10.1044/2015_JSLHR-H-15-0118 of publication.
384 Journal of Speech, Language, and Hearing Research • Vol. 59 • 384–413 • April 2016 • Copyright © 2016 American Speech-Language-Hearing Association
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Campbell, & Sirimanna, 2013). There is debate on how for an APD assessment. They reported diagnosis rates rang-
to differentiate between the processing of auditory in- ing from 7.3% to 96.0% when using the different criteria
formation and higher order functions, such as cognition (W. J. Wilson & Arnott, 2013).
and/or language, and whether the processing of both speech As a consequence of the ongoing debate about APD,
and nonspeech sounds is impaired in children with APD speech-language pathologists and audiologists find it dif-
(Cacace & McFarland, 2009). According to the BSA (2011a), ficult to identify and subsequently treat children with possi-
“APD is characterized by poor perception of both speech ble APD (Friel-Patti, 1999; Richard, 2011). A prerequisite
and nonspeech sounds, and is a collection of symptoms that for suitable treatment of APD is recognition of APD.
usually co-occurs with other neurodevelopmental disorders” One of the most frequently reported characteristics of APD
(p. 3). In their position statement, they also indicated that is an obvious impairment of auditory perception, especially
“attention is a key element of auditory processing and that in the presence of background noise (ASHA, 2005; Jerger
attention may make a major contribution to APD” (BSA, & Musiek, 2000). Other frequently reported symptoms are
2011a; Moore, 2011). The working groups of ASHA (2005) difficulties with comprehending and complying with verbal
and AAA (2010) make no distinction between the processing instructions, misinterpreting oral messages, requesting
of speech and nonspeech information and did not include repetition, problems with maintaining focus, and having
higher order cognitive and/or language-related functions in difficulties with the localization of sounds (AAA, 2010;
their definition. According to these working groups, abili- ASHA, 2005; DeBonis & Moncrieff, 2008; Moore et al.,
ties such as phonological awareness, attention, and memory 2013). In this systematic review, we describe studies com-
may be associated with central auditory processing diffi- paring the performance of children with listening difficulties
culties. However, they did not include these skills in their (suspected APD [susAPD] or APD) with that of their typi-
definition because these are considered higher order cog- cally developing (TD) peers. The aim of this systematic
nitive, communicative, and/or language-related func- review is to describe the characteristics of APD and sus-
tions (ASHA, 2005). Cacace and McFarland (Cacace & APD and to provide a summary of the differences in perfor-
McFarland, 2005, 2013; McFarland & Cacace, 1995) de- mance on behavioral, physiological, and neuroimaging
fined APD as “a modality specific perceptual dysfunction measurements. The central question of this systematic re-
that is not due to peripheral hearing loss” and claimed view is whether the listening difficulties of children with
that there is no basis for diagnosing APD when modality susAPD are due to a specific auditory deficit or to a multi-
specificity cannot be demonstrated with any degree of cer- modal deficit.
tainty in patients concerning listening problems (Cacace
& McFarland, 2013, p. 573).
The diagnosis of APD is currently achieved by using Method
a variety of criteria such as the presence of a minimal set
of specific symptoms (e.g., listening difficulties in the pres- Identification of Studies
ence of background noise) and/or poor performance on Between January 2012 and March 2012, the following
auditory processing tests (Ahmmed et al., 2014; Cacace & six electronic databases were searched: PubMed, CINAHL,
McFarland, 2009). The diagnostic criteria provided by Eric, PsychINFO, Communication & Mass Media Com-
ASHA (2005) are poor performance (at least 2 SD below plete, and EMBASE. In May 2015, a second search was
the mean) on two or more tests of the APD test battery conducted in five of the six electronic databases (Pubmed,
or a performance of 3 SD below the mean on one compo- CINAHL, Eric, PsychINFO, and Communication & Mass
nent of the test battery. ASHA did not specify whether the Media Complete) to locate studies that were published be-
poor performance must be present in one or both ears. In tween March 2012 and May 2015. The results of EMBASE
contrast, AAA (2010) did specify ear performance in their were not included in the second search because of significant
diagnostic criteria. The diagnostic criterion of AAA is differences in use and outcome of the database in compari-
a score of 2 SD or more below the mean for at least one son with the first search.
ear on at least two different tests of the APD test battery. In PubMed, the following search terms were utilized
BSA (2011a) did not mention specific diagnostic criteria in to identify studies: (“Auditory Diseases, Central”[Mesh]
their most current position statement, although they did note OR auditory processing[tiab] OR auditory perceptual[tiab])
that APD should be assessed with the utilization of stan- AND (child[tiab] OR children[tiab] OR adolescent*[tiab]).
dardized tests of auditory perception and that both direct In CINAHL, Eric, PsychINFO, and Communication &
and indirect measures (e.g., questionnaires) should be used. Mass Media Complete, the following search terms were
A key issue is that there is currently no gold standard used to identify studies: (TI “auditory processing” OR TI
available for assessing APD, and none of the available “auditory perception” OR TI “auditory perceptual”) OR
tests meet the criteria of good validity and reliability (BSA, (AB “auditory processing” OR AB “auditory perception”
2011a; Katz et al., 2002; Keith, 2009; Moore et al., 2013). OR AB “auditory perceptual”) AND (AB child OR AB
W. J. Wilson and Arnott (2013) used nine diagnostic criteria adolescent). In EMBASE, the search terms included “audi-
from international literature (AAA, 2010; ASHA, 2005; tory processing,” “auditory perception,” “auditory per-
Bellis, 2003; BSA, 2011a; Dawes & Bishop, 2009; McArthur, ceptual” child:ab OR children:ab OR adolescent:ab OR
2009) for diagnosing APD in 150 children who were referred adolescents:ab.
de Wit et al.: Characteristics of Auditory Processing Disorders 385

Inclusion and Exclusion Criteria reviewers, blinded to each other’s results, appraised each
study on the basis of the quality indicators: study design,
Studies published from 1954 to May 31, 2015, were
blinding, sampling/allocation, group/participant compara-
considered eligible if they met the following criteria: (a) They
bility, outcomes, significance, and precision. The quality
were published in a peer-reviewed journal and were written
indicator “intention to treat” of ASHA’s LOE scheme was
in English, (b) the focus of the study was to investigate
removed because there were no treatment studies included
whether the characteristics or performance of children with
in the review. One point was assigned for each marker that
susAPD or clinically diagnosed APD in the presence of
satisfied the highest level of quality. In the cases of indi-
normal peripheral hearing differ from those of TD children
cators with multiple possible levels, only the highest level of
or normative data from TD children, (c) the study contained
quality received 1 point (for a description, see Supplemental
data regarding participants primarily under age 18 years,
Table 1). A final score was derived from the total number
(d) participants in the experimental group had either sus-
of indicators that conformed to the highest level of quality.
APD or a diagnosis of APD (for details see Supplemental
The highest possible quality score was 7 points. All dis-
Digital Content 1), (e) participants in the control group
crepancies were resolved by consensus among the three re-
were TD children or a norm group that was described in
viewers in a consensus meeting.
detail, and (f) the study contained a description of the re-
On the basis of the quality score, we classified studies
search method and tests used for the identification of dif-
into three categories. Studies assigned 5 to 7 points were
ferences between children with susAPD or APD and their
classified as strong, studies awarded 2 to 4 points were clas-
TD peers.
sified as moderate, and studies awarded 1 or 0 points were
Studies were excluded when (a) the focus was to in-
classified as weak (adapted to the quality assessment tool
vestigate auditory processing skills in children with a main
developed by Gyorkos et al., 1994). The quality score refers
diagnosis of learning difficulties, speech-language impairment
to the internal validity of a study (i.e., how well the study
(SLI) or language impairment, dyslexia, attention-deficit/
was carried out). Strong studies had no major weaknesses in
hyperactivity disorder (ADHD), or autism; (b) participants
the design that threatened the internal validity of the study
were neonates or individuals with peripheral hearing loss,
and the likelihood of the results (minor threats of informa-
chronic otitis media, brain damage, neuropathy, cochlear
tion bias, selection bias, and confounders).
implants, or Down syndrome; and (c) the study contained
Variables were compiled in order to extract relevant
nonreviewed books or book chapters, narrative reviews,
data from the studies. The list of variables was established
dissertations, or case studies or case series. RefWorks was used
with discussion between the first two authors. The list
to remove duplicates. A review protocol (see Supplemental
contained the following components:
Digital Content 1) was created to ensure that each reviewer
applied the same criteria during the process of selection, 1. Study characteristics: sample size, definition of APD
screening, and data extraction. used, norm used to diagnose APD, aim of the study,
and research question
Search Outcome 2. Participant characteristics: description, age, gender,
diagnosis and comorbidity (inclusion and exclusion
First, two reviewers (the first and second authors)
criteria), and education
independently screened the titles of the remaining studies
against the inclusion and exclusion criteria. Second, two re- 3. Measures: auditory processing tests, hearing tests,
viewers (the first and second or first and last authors), speech and language tests, intelligence and attention
blinded to each other’s results, screened the remaining stud- tests, and other measurements
ies according to the abstracts. The selections of both re- 4. Study results: main outcome, main findings, and
viewers were compared. Because it was not always obvious significant symptoms reported for APD
from the abstract whether the study satisfied the inclusion
criteria, remaining studies were read more extensively for All information and aggregated data were extracted
eligibility by one of the three reviewers (the first, second, from the selected studies, and methodological assessment
and last authors). They individually read and reviewed the was based on information provided in the studies. Missing
study against the formulated criteria for inclusion. In the information is indicated as not reported.
event of uncertainty, a second author reviewed the study.
In a final consensus meeting, all selections were discussed, Results
and any discrepancies between reviewers’ evaluations were
resolved by consensus. In total, 3,317 references were screened by title, and
548 studies were screened by abstracts. Of the remain-
ing 194 studies, eligibility was assessed by one of the
Quality Assessment and Data Extraction three authors (the first, second, or last authors). A total of
Each included study was independently reviewed and 141 full-text studies were excluded for various reasons.
evaluated for methodological quality by two reviewers Most excluded studies in Stage 3 (full-text articles
(the first and second or first and last authors) with ASHA’s assessed for eligibility) reported no group differences between
levels of evidence (LOE) scheme (Mullen, 2007). The two children with susAPD and TD controls or investigated
386 Journal of Speech, Language, and Hearing Research • Vol. 59 • 384–413 • April 2016

auditory processing skills in children with a primary diag- APD and central APD refer to children with a diagnosis of
nosis of learning difficulties, dyslexia, language impairment, APD. In Tables 1, 2, 3, 4, and 5, the column that refers to
or ADHD. One study was excluded because it was not clear the number of APD participants included in the study uses
whether the study contained data regarding participants lettered footnotes to denote cases where the authors utilized
under age 18 years (the study mentioned only that the the term susAPD.
40 children in the study groups were between 7 and 24 years In 18 of the 48 included studies, the experimental
of age). Six studies were excluded because children in the groups were children with susAPD (including the studies of
control group were initially referred to a clinic because of Dhamani et al. [2013] and Sharma et al. [2014], in which
APD concerns but subsequently were classified as non– they used the term listening difficulties). Children with sus-
APD after elaborate testing. Last, 54 studies were included APD were included on the basis of (a) a presumption of the
for assessing the methodological quality. Supplemental Fig- parents, teacher, and/or speech-language therapist (n = 5);
ure 1 illustrates the identification, selection, and reasons (b) a reference for an APD assessment to an audiology
for exclusion of the studies in this review (Prisma Flow clinic due to abnormal auditory behavior (n = 7); or (c) low
Diagram, Moher, Liberati, Tetzlaff, Altman, & The results on an APD screening test (e.g., the SCAN or SCAN-A
PRISMA Group, 2009). The two experiments described in test; Keith, 1986, 1994; n = 5). Moore et al. (2010) used a
the study by Schmithorst, Farah, and Keith (2013) were population approach. Their study included 1,469 randomly
both utilized in this systematic review and were catego- selected 6- to 11-year-old children with normal hearing
rized into Experiment A and Experiment B in the tables. who were divided into groups: children with poorer auditory
processing (lower 5%, n ≈ 73) and children with typical
auditory processing (upper 95%, n ≈ 1,396).
Methodological Quality In 30 of the 48 studies, the experimental group con-
Five studies (Gopal & Kowalski, 1999; Meister, von sisted of children with diagnosed APD, including the study
Wedel, & Walger, 2004; Phillips, Comeau, & Andrus, 2010; by Yalçinkaya et al. (2010), which used the term auditory
Tobey, Cullen, & Rampp, 1979; Zwissler et al., 2014) were listening problems. The diagnosis was made on the basis
classified as weak on the basis of the total quality score and of various criteria. Seventeen studies used the criterion of
are excluded from this systematic review (see Supplemental a low result on two or more of the behavioral diagnostic
Table 2); 47 studies were classified as moderate, and only auditory processing tests. Nine of the 17 studies specified a
one study had strong internal validity. In total, 48 studies low result at 2 SD below the mean. Six studies utilized low
were included in this systematic review (see Supplemental results (1 or 2 SD below the mean) on one or more of the
Table 3). auditory processing tests, and two studies used low results
All studies were based on cross-sectional data, and on three or more of the behavioral diagnostic auditory pro-
most studies used a case-control design (n = 35). In all of cessing tests as a diagnostic criterion. Three studies used
the studies, p values were reported. The researchers were typical symptoms reported by parents or teachers (e.g., diffi-
blinded in only two studies (Gopal, Daily, & Kao, 2002; culty hearing with background noise, difficulty understanding
Jirsa, 2001), and only one study used a randomly selected or following directions in the classroom, difficulty remaining
sample (Moore, Ferguson, Edmondson-Jones, Ratib, & focused and easily distracted) as diagnostic criteria. In this
Riley, 2010). In 16 studies, it was not clear whether the systematic review, we refer to the group of children with
authors used a valid outcome measure. Information regard- susAPD or diagnosed APD as children with APD.
ing validity and/or reliability was missing in these studies. Sanches and Carvallo (2006) included two APD
In only four studies (Dhamani, Leung, Carlile, & Sharma, groups (I and II). Children in Group I exhibited low scores
2013; James, Van Steenbrugge, & Chiveralls, 1994; Moore (<68% in one or both ears) on the speech-in-noise test
et al., 2010; Olakunbi, Bamiou, Stewart, & Luxon, 2010) the and < 85% on the Staggered Spondaic Word (SSW)1 test,
participants within groups were well described (with partici- and children in Group II demonstrated normal scores
pant information in a table) and the children in the different (>68% in both ears) on the speech-in-noise test and < 85%
groups were comparable in hearing; language, intelligence, on the SSW test. Both groups are included in this system-
and reading abilities; and the absence of comorbid disorders. atic review. Five studies (Barry, Tomlin, Moore, & Dillon,
2015; Gyldenkærne, Dillon, Sharma, & Purdy, 2014;
Iliadou & Bamiou, 2012; Ludwig et al., 2014; Tomlin,
APD or susAPD Dillon, Sharma, & Rance, 2015) included a clinical group
The included studies used dissimilar terminology to of children with listening difficulties and a referral for
describe the experimental group. A number of studies used an APD assessment in their study. On the basis of per-
the term susAPD (instead of APD or central APD) to de- formance on APD assessment and diagnostic criteria of
scribe children with listening difficulties. Three studies used APD, they divided the clinical group into a subgroup
a different term—auditory listening problems (Yalçinkaya,
Yilmaz, & Muluk, 2010) or listening difficulties (Dhamani
et al., 2013; Sharma, Dhamani, Leung, & Carlile, 2014)— 1
Sanches and Carvallo (2006) used the Portuguese version of the SSW.
instead of APD. In cases of susAPD, either there was suspi- No reference was included in their article. The original test (English
cion of APD or children were at risk for APD. The terms version) was developed by Katz (1962).

388
Journal of Speech, Language, and Hearing Research • Vol. 59 • 384–413 • April 2016
Table 1. Summary of participant characteristics, reported measurements, and characteristics of children in the auditory processing disorders (APD) group for studies that made use of
questionnaires and checklists.
n Age range (M) Gender

Study TD APD TD APD TD APD Measurement Characteristics of APD group
Barry et al. (2015) 14 12 7.1–12.8 7.1–12.8 M = 4, F = 10 M = 7, F = 5 LIFE: short version On all questionnaires, children with APD
(9.62) (8.35) TEAP were rated as having more difficulties
ECLiPS: parental report (greater listening difficulty).
FAPC: parental report
Ferguson et al. 47 19 6.0–11.9 6.2–13.9 M = 26, F = 21 M = 13, F = 6 CPRS-R:S ns
(2011) (8.7) (9.07) CCC-2 Poorer General Communication Composite
scores and all individual CCC-2 scale
scores
CHAPPS Poorer performance scores for the Noise,
Multiple Inputs, Auditory Memory, and
Auditory Attention scales
Moore et al. NRc,d NRa,c,d 6–12 6–12 NR NR CCC-2 (General Poorer General Communication Composite
(2010) Communication scores
Composite score)
CHAPPS (total score) Poorer auditory processing is not related to
everyday listening (no association between
CHAPPS results and separate auditory
processing test results).
Poorer total scores on the CHAPPS in children
with lower performance on the derived
Frequency Resolution test and composite
auditory procecssing measure
Iliadou & Bamiou 39 38 11;4–12;7b,e 11;4–12;7e M = 24,b F = 15 M = 25, F = 13 CHAPPS–Greek Poorer performance scores on all six scales
(2012) (12.14) (12.21) version (Ideal, Quiet, Noise, Multiple Inputs,
Auditory Attention, Auditory Memory)
Sharma, Dhamani, 15 21a 10–15 10–15 NR NR Self-developed Lower scores for attention and memory,
et al. (2014) (12.5) (12.3) questionnaire listening ability in quiet, and listening-
in-noise ability
(table continues)

Table 1. (Continued).

b b
Kreisman et al. 20 19 9.6–16.9 9.5–17.8 M = 6, F = 14 M = 9, F = 10 SSRS Greater psychosocial problems reported
(2012) (12.79) (11.93) by parents on the Responsibility,
Externalizing Problem Behaviors, and
Internalizing Problem Behaviors subscales
BASC-2 Greater psychosocial problems reported by
parents on the Externalizing Problems,
Internalizing Problems, Behavioral
Symptoms Index, and Adaptive Skills
Index subscales
Greater psychosocial problems reported by
the children on the Emotional Symptoms
Index subscale
COOP-A Greater psychosocial problems reported
by parents on the Pain, School Work,
Emotional Feelings, and Self-Esteem
subscales
Greater psychosocial problems reported
de Wit et al.: Characteristics of Auditory Processing Disorders
by the children on the Emotional

Feeling and Overall Health subscales
Olakunbi et al. 8 8 7.3–14.8b 7.3–14.8 M = 4,b F = 4 M = 5, F = 3 GMAP (reduced form: Poorer in judging metre
(2010) (10.3) (11.5) Melody and Metre
subtests)
Yalçinkaya et al. 41 26a 7–8 7–8 M = 25, F = 16 M = 21, F = 5 ORS from the CELF-4 Poorer listening skills
(2009) (7.58) (7.66) Better speaking, reading, and writing skills
Note. Studies are arranged in order of the measurements used. Age is presented in years, except where indicated format is in years;months. TD = typically developing children; M =
male; F = female; LIFE = Listening Inventory for Education–Revised (Anderson et al., 2011; shortened version: Purdy et al., 2009); TEAP = Teacher Evaluation of Auditory Performance
(Purdy et al., 2002); ECLiPS = Evaluation of Children’s Listening and Processing Skills (Barry & Moore, 2014); FAPC = Fisher’s Auditory Problems Checklist (Fisher, 1976); CPRS-R:S =
Conners’ Parent Rating Scale–Revised: Short Form (Conners, 1996); CCC-2 = Children’s Communication Checklist–Second Edition (Bishop, 2003); CHAPPS = Children’s Auditory
Processing Performance Scale (Smoski et al., 1998); ns = no significant differences between groups; NR = not reported; SSRS = Social Skills Rating System (Gresham & Elliot, 1990);
BASC-2 = Behavioral Assessment System for Children–Second Edition (Reynolds & Kamphaus, 2004); COOP-A = Dartmouth Primary Care Cooperative Information Project Charts
for Adolescents (Wasson et al., 1994); GMAP = Gordon’s Musical Aptitude Profile (Gordon, 2001); ORS from the CELF-4 = Observational Rating Scale from the Clinical Evaluation of
Language Fundamentals–Fourth Edition (Semel, Wiig, & Secord, 2003).
a
Suspected APD. bAge or gender matched. cThe two questionnaires used in the study (CCC-2 and CHAPPS) were sent in a follow-up letter to caregivers; only 60% (n = 856) completed
both questionnaires. dMoore et al. (2010) used the population approach in their study. In the study, 1,469 randomly chosen 6- to 11-year-olds with normal hearing were included. For
the analyses, Moore et al. divided the group into children with poorer auditory processing (suspected APD) and children with typical auditory processing. The children with poorer
auditory processing were defined as the lower 5% of the included children (5% of 1,469 children ≈ 73 children), and the children with typical auditory processing were defined as
the upper 95% of the included children (95% of 1,469 children ≈ 1,396 children). eAge is presented in years;months.
389

390
auditory and/or visual behavioral measurements.

Ferguson et al. 47 19 6.0–11.9 6.2–13.9 M = 26, F = 21 M = 13, F = 6 Speech intelligibility: ns

(2011) (8.7) (9.07) ASL derived from
the BKB sentences
and VCV nonwords
(in quiet and in
speech-modulated
noise)
Moore et al. 1,396c 73a,c 6–12 6–12 NR NR Speech-in-noise test Poorer speech-in-noise (VCV) perception
(2010) (VCV nonwords in
speech-modulated
noise)
Lagacé et al. 10 10 8;11–12;5b 9;4–12;10 M = 5,b F = 5 M = 5, F = 5 Speech perception Poorer overall sentence key word recognition
(2011) (10;3)e (10;6)e in noise: TPB scores for both high- and low-predictable
sentences and at all four SNRs (−3, 0, +3, +4)
Poorer average key word recognition score
at SNRs of 0 and +3 dB
Same benefit from linguistic contextual
information when listening to speech in the
presence of background noise
Balen et al. 12 12 7.1–10.10 7.01–10.06 NR NR RGDT Higher mean values of the silence interval
(2009) (9.05) (7.59) thresholds in all frequencies
Cameron et al. nd (48) 10a b
7;0–9;11 M = 7, F = 3 LiSN–prototype Poorer performance on all LiSN SNR and
(2006) (8;6)e advantage measures (low-cue SNR, high-cue
SNR, tonal advantage, and spatial advantage)
Poorest performance (outside normal limits) on
condition in which the maskers were spatially
separated from the target (spatial advantage
measure)
Cameron & nd (70) 9a b
6;6–11;2 NR M = 8, F = 1 LiSN-S Poorer performance on conditions in which
Dillon (2008) (9;1)e the maskers were spatially separated from
the target
(table continues)


Barry et al. 14 12 7.1–12.8 7.1–12.8 M = 4, F = 10 M = 7, F = 5 DDT Poorer performance
(2015) (9.62) (8.35) FPT Poorer performance
MLD ns
GIN Poorer performance
LiSN-S:
High cue Poorer performance
Low cue Poorer performance
Tonal advantage ns
Spatial advantage ns
Total advantage ns
Sharma, 15 21a 10–15 10–15 NR NR DDT ns
Dhamani, (12.5) (12.3) FPT Poorer performance (lower mean scores)
et al. (2014) MLD Poorer performance (higher mean scores)
GIN ns
LiSN-S: ns
High cue
Low cue
Talker advantage
Spatial advantage
Total advantage
Modulation detection: Poorer performance (lower mean scores)
sinusoidal amplitude
modulation
TFS1 and TSF-LF tests ns
Speech localization ns
Stream segregation: ns
ABA paradigm
Brief-tone frequency Poorer performance (higher thresholds)
discrimination
a
Gyldenkærne 18 101 6.8–12.8 6.8–12.8 NR NR DDT Poorer performance (lower mean percentage
et al. (2014) (NR) (NR) correct scores for left and right ears)
FPT Poorer performance (lower mean percentage
correct scores binaurally)
MLD ns
GIN ns
(table continues)
391

392

Rocha-Muniz 25 25 6–12 6–12 NR NR Speech-in-noise test Poorer performance (lower mean scores for
et al. (2014) (8.80) (8.72) (monosyllabic left and right ears)
words)
DDT Poorer performance (lower mean scores for
left and right ears)
PFT Poorer performance (lower mean scores
binaurally)
Rosen et al. 28 20a 6–14b 6–14 M = 15, F = 13 M = 13, F = 7 DDT Poorer performance (lower mean scores for
(2010) (10.3) (10.1) left and right ears)
PFT Poorer performance (lower mean scores
binaurally)
Vanniasegaram 33 32a 6–14b 6–14 M = 18, F = 15 M = 20, F = 12 Pure-tone Poorer mean auditory thresholds across all
et al. (2004) (10.2) (10.1) audiometry frequencies (average threshold hearing
levels within normal limits)
Tympanometry ns
CS: dichotic listening Poorer performance (lower scores on average in
task both ears)
TDT Poorer performance at all interstimulus intervals
and at short and long interstimulus intervals
separately (14/32 children)
CCMP Poorer performance (11/32 children)
SM/BM ns
b b
Olakunbi et al. 8 8 7.3–14.8 7.3–14.8 M = 4, F = 4 M = 5, F = 3 DDT ns
(2010) (10.3) (11.5) FPT Poorer performance (lower mean scores for
left and right ears)
DPT Poorer performance (lower mean scores for
right ear only)
Bellis et al. 10 7 NR NR M = 6, F = 4 NR DDT Poorer overall performance
(2008) (12.6) (10.86) Poorer left-ear performance
Larger right-ear advantage on auditory task
Visual analog of Poorer overall performance.
the DDT (self- Poorer left visual field performance
developed) Right visual field advantage (reversed pattern of
asymmetry)
(table continues)


Bellis et al. 10 7 NR NR NR NR DDT, FPT, and DPT Poorer overall performance
(2011) (12.6) (10.9) Poorest performance on the auditory patterns
tests (FPT, DPT)
Better performance in the humming response
condition than labeling performance for the
auditory FPT and DPT
Larger right-ear advantage for the auditory DDT
Visual analogs: Poorer overall performance
Dichoptic Digits, Poorest performance on the visual patterns tests
Visual High/Low, Better performance in the humming response
Visual Duration condition than labeling performance for the
Patterns (self- visual high/low task
developed) Reversed laterality for the Dichoptic Digits task
(right visual field advantage instead of left
visual field advantage)
Dawes et al. 98 22 6–11 6–13 NRd M = 14, F = 8 Auditory: 2-Hz FM ns
(2009) (NR) (10.1) Auditory: 40-Hz FM Poorer performance
Auditory: 240-Hz FM Poorer performance
Auditory: iterated Poorer performance
rippled noise
detection
Visual: coherent form ns
detection
Visual: coherent ns
motion detection
b b
Dagenais et al. 10 10 8–10 8–10 M = 7, F = 3 M = 7, F = 3 VRT paradigm: visually Slower performance: longer VRTs in the
(1997) (8;9)e (8;7)e presented one- and one-syllable words in the immediate-response
two-syllable words condition
More errors for both (one- and two-syllable)
long-delay conditions
Putter-Katz et al. 9 10 5.5–15 5.5–15 NR NR The Hebrew speech ns
(2002) discrimination test:
word recognition
scores
The Hebrew speech Slower performance: longer mean VRTs
discrimination test:
VRT
(table continues)
393

394

Moossavi et al. 20 17 9–11 9–11 M = 13, F = 7 M = 12, F = 5 Lateralization test Poorer performance on all lateralization tests
(2014) (9.4) (9.1) (ITD-LPN/ITD-HPN (higher mean errors)
and IID-LPN/IID-HPN)
Ferguson & 47 19 6–13 6–13 M = 26, F = 21 M = 13, F = 6 IHR-STAR software:
Moore (2014) (8.6) (9.7) Tone detection in quiet
1k200 Poorer (higher) thresholds
1k20 Poorer (higher) thresholds
Derived auditory ns
processing:
temporal integration
BM Poorer (higher) thresholds
SM
SM0 ns
SMN Poorer (higher) thresholds
Derived auditory ns
processing:
frequency resolution
Frequency Poorer (higher) thresholds
discrimination
Ludwig et al. 313 39 6–19 6–17 M = 156, F = 157 M = 31, F = 8 Interaural test: Poorer performance on all tests (elevated
(2014) (11.7) (9.1) Frequency discrimination thresholds)
Level
Duration
Dichotic test: Poorer performance on all tests
Frequency (elevated thresholds)
Level
Duration
Sinusoidal amplitude
modulation
Elliot et al. 22 11 Age match: 87–166 Age match: M = 4, F = 7 Serial recall with Best performance in quiet and equally disrupted
(2007) 85–156 monthsb months M = 3, F = 8; irrelevant-sounds by both speech and tones (e.g., controls
(129.45)f; (130.64)f span match: task (tones and more disrupted by speech than by tones)
span match: M = 6, F = 5 speech)
74–127 months
(101.64)f
(table continues)


James et al. 12 6 Age match: 8;6–10;8 M = 12 M=6 Auditory phoneme Poorer performance (lower mean performance
(1994) 8;2–10;7b (9;8)e; (9;9)e discrimination task in the word and nonword phonological
language match: processing subtest; poorest in discriminating
7;3–9;6 (7;9)e nonwords)
Auditory Lexical Poorer performance (lower average score)
Decision Test–
Imageability and
Frequency (PALPA)
Auditory word Poorer performance (lower mean
comprehension: test performance score)
for Spoken Word to
Picture Matching
(PALPA)
Rickard et al. 10 15 8.3–11.3b 7.11–12.11 M = 9,b F = 1 M = 12, F = 3 UCAST-FW Poorer in understanding speech when high-
(2013) (9.4) (9.2) frequency information is removed from the
speech signal (higher mean UCAST-FW score)
Note. Studies are arranged in order of the measurements used. Age is presented in years, except where indicated format is in years;months or in months. TD = typically developing
children; M = male; F = female; ASL = Adaptive Sentence List (MacLeod & Summerfield, 1990); BKB = Bamford-Kowal-Bench (Bench et al., 1979); VCV = vowel–consonant–vowel; ns = no
significant differences between groups; NR = not reported; TPB = Test de Phrases dans le Bruit (a Canadian–French speech-in-noise test; Lagacé et al., 2010); SNR = signal-to-noise
ratio; RGDT = Random Gap Detection Test (Keith, 2002; McCroskey & Keith, 1996); nd = normative data; LiSN = Listening in Spatialized Noise Test (Cameron & Dillon, 2007); LiSN-S =
Listening in Spatialized Noise Test-Sentences (Cameron & Dillon, 2007, 2008); DDT = Dichotic Digits Test (Musiek, 1983); FPT = Frequency Patterns Test (Musiek, 1994, 2002; Pinheiro
& Ptacek, 1971); MLD = masking level difference (R. H. Wilson et al., 2003); GIN = Gaps in Noise (Baker et al., 2008; Musiek et al., 2005); TFS1 = Temporal Fine Structure-1 test (Sek &
Moore, 2012); TFS-LF = Temporal Fine Structure–Low Frequency test (Sek & Moore, 2012); PFT = Pattern of Frequency Test; CS = Competing Sentences (based on Bergman et al.,
1987); TDT = Tallal Discrimination Task (Tallal & Piercy, 1973); CCMP = Consonant Cluster Minimal Pairs (Adlard & Hazan, 1998); SM/BM = Simultaneous and Backward Masking
tasks (Wright et al., 1997); DPT = Duration Patterns Test (Musiek et al., 1990; Pinheiro & Musiek, 1985); FM = frequency modulation; VRT = vocal reaction time; ITD = interaural time
differences; LPN = low-pass noise; HPN = high-pass noise; IID = interaural intensity differences; IHR-STAR = Institute of Hearing Research STAR software (Barry et al., 2010); SM0 =
simultaneous-masking noise task—bandpass noise; SMN = simultaneous-masking noise task—spectrally notched noise; PALPA = Psycholinguistic Assessments of Language
Processing of Aphasia (Kay et al., 1992); UCAST-FW = University of Canterbury Adaptive Speech Test–Filtered Words (O’Beirne et al., 2012).
a
Suspected APD. bAge or gender matched. cMoore et al. (2010) used the population approach in their study. In the study, 1,469 randomly chosen 6- to 11-year-olds with normal
hearing were included. For the analyses, Moore et al. divided the group into children with poorer auditory processing (suspected APD) and children with typical auditory processing. The
children with poorer auditory processing were defined as the lower 5% of the included children (5% of 1,469 children ≈ 73 children), and the children with typical auditory processing
were defined as the upper 95% of the included children (95% of 1,469 children ≈ 1,396 children). dThe authors reported that there were approximately equal numbers of boys and girls
in each year-normative group (Dawes et al., 2009). eAge is presented in years;months. fAge is presented in months.
395

396
cognitive, language, and reading behavioral measurements.

Barry et al. 14 12 7.1–12.8 7.1–12.8 M = 4, F = 10 M = 7, F = 5 TONI: NV-IQ Poorer performance

(2015) (9.62) (8.35) Serial short-term memory: Poorer performance
digit span (forward)
Working memory: Poorer performance
digit span (backward)
Attention quotient: Poorer performance (poorer mean scores)

IVA+Plus, Sustained
Attention (auditory
and visual)
WARP Poorer performance

Gyldenkærne 18 101a 6.8–12.8 6.8–12.8 NR NR TONI-3: NV-IQ Poorer performance (lower mean
et al. (2014) (NR) (NR) standard scores)
WARP Poorer performance (fewer mean
words/minute)
IVA+Plus, Sustained Poorer performance (lower mean scores
Attention: for auditory and visual sustained
Auditory attention)
Visual
Tomlin et al. 50 36 7.0–12.2 7.0–12.9 M = 19, F = 31 NR Digit Span subset (forward Poorer performance (poorer cognitive
(2015) (9.3) (NR) and backward; ability)
CELF-4)
TONI-4: NV-IQ Poorer performance (poorer cognitive
ability)
IVA+Plus, Sustained Poorer performance (poorer cognitive
Attention: ability)
Auditory
Visual
Dhamani et al. 12 12a 10–15b 10–15 NR NR Selective attention and Poorer (slower) attention switching
(2013) (12.5) (11.38) attention-switching Poorer inhibitory control
task: modified Higher overall false-alarm rates
multiprobe signal
method
Sharma, 15 21a 10–15 10–15 NR NR Digit Span test (CELF-4) Poorer performance (lower mean scores)
Dhamani, (12.5) (12.3) Selective attention and Poorer (slower) attention switching
et al. (2014) attention-switching task Poorer inhibitory control
Higher false-alarm rate at the expected
epoch and higher overall false-alarm
rates
Sustained auditory ns
attention: auditory
continuous
performance test
(table continues)


Moore et al. 1,396c 73a,c 6–12 6–12 NR NR IHR Cued Attention Test: Auditory phasic alertness is not related
(2010) Novel Extrinsic Test to any individual auditory processing
(auditory and visual) task threshold
Reduced visual alertness: Visual
alertness is related generally to
auditory processing threshold and
specifically to backward masking and
frequency discrimination.
Intrinsic Attention More variable response profiles
Matrix Reasoning of Poorer performance on individual tests
the WASI achieved lower mean standard scores.
Poorer performance on the derived
auditory processing tests achieved
no lower mean standard scores.
Digit Span subtest of Poorer performance on individual tests

the WISC-III achieved lower mean standard scores.
Repetition of Nonsense Poorer performance on individual tests
Words subset of achieved lower mean standard scores.
the NEPSY Poorer performance on the derived
Word and Nonword test Poorer performance on individual tests
of the TOWRE achieved lower mean standard scores.
(table continues)
397

398

Ferguson et al. 47 19 6.0–11.9 6.2–13.9 M = 26, F = 21 M = 13, F = 6 Matrix Reasoning and Poorer performance on test of IQ
(2011) (8.7) (9.07) Vocabulary subtest (lower mean age-equivalent scores
of the WASI for overall IQ, NV-IQ, and verbal IQ)
Repetition of Nonsense Poorer performance on test of language
Words subset of (lower mean age-equivalent score for
the NEPSY repetition of nonsense words)
Spoonerisms subset of Poorer performance on test of language
the Phonological (lower mean age-equivalent scores
Assessment Batteryd for phonology)
TOWRE Poorer performance on test of reading
(lower mean age-equivalent scores)
TROG-E Poorer performance on test of language
(lower mean age-equivalent scores
for receptive grammar)
Digit Span (subtest of ns
WISC-III)
a b
Rosen et al. 28 20 6–14 6–14 M = 15, F = 13 M = 13, F = 7 BPVS Poorer performance, but within normal
(2010) (10.3) (10.1) limits on average (BPVS: 98.1)
TROG Poorer performance, but within normal
limits on average (TROG: 93.5)
Four NV-IQ measures from Poorer performance, but within
WISC (picture normal limits on average (NV-IQ: 96.4)
completion, coding, Lower standard scores on three of the
block design, and four NV-IQ subtests (picture
object assembly) completion, coding, and block design)
b b
Maerlender nd 22 7–14 M = 14, F = 8 DSF (subtest of WISC-IV) Poorer performance (lower mean value)
(2010) (22) Lower mean scores than the other
short-term memory scores
within participants
DSB (subtest of WISC-IV) Poorer performance (lower mean value)
LSR (subtest of WISC-IV) ns
LSNR (subtest of WISC-IV) Poorer performance (lower mean value)
(table continues)


Moossavi et al. 20 17 9–11 9–11 M = 13, F = 7 M = 12, F = 5 DSF (subtest of WISC-IV) Poorer performance (lower mean scores)
(2014) (9.4) (9.1) DSB (subtest of WISC-IV) Poorer performance (lower mean scores)
Persian nonword Poorer performance (lower mean scores)
repetition testf
James et al. 12 6 Age match: 8;6–10;8 M = 12 M=6 Repetition tasks/ Poorer performance on the repetition of
(1994) 8;2–10;7b (9;8)e; (9;9)e immediate phonological nonwords (three- and four-syllable
language match: memory: nonword words)
7;3–9;6 (7;9)e repetition task
Phonological similarity Poorer performance on serial word recall
effect and effect of (overall recall became poorer with an
word length on serial increase of list length)
recall task
Articulation rates task ns
Bench & Maule 18 18 8.3–12.7 8.2–12.8 M = 14b, F = 4 M = 14, F = 4 ISMT Higher mean percentage errors
(1997) (10.8) (10.7) Less use of internal speech
Note. Studies are arranged in order of the measurements used. Age is presented in years, except where indicated format is in years;months. TD = typically developing children; M = male;
F = female; TONI-3 = Test of Nonverbal Intelligence–Third Edition (Brown et al., 1997); NV-IQ = nonverbal intelligence quotient; IVA+Plus = Integrated Visual and Auditory Continuous
Performance Test–BrainTrain (Sandford & Turner, 1995, 2014); WARP = Wheldall Assessment of Reading Passages (Madelaine & Wheldall, 2002); NR = not reported; CELF-4 = Clinical
Evaluation of Language Fundamentals–Fourth Edition (Semel et al., 2003); TONI-4 = Test of Nonverbal Intelligence–Fourth Edition (Brown et al., 2010); ns = no significant differences
between groups; IHR Cued Attention Test = Institute of Hearing Research Cued Attention Test (Riley et al., 2009); WASI = Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999);
WISC-III = Wechsler Intelligence Scale for Children–Third Edition (Wechsler, 1991); NEPSY = Neuropsychological Test Battery (Korkman et al., 1998); TOWRE = Test of Word Reading
Efficiency (Torgesen et al., 1999); TROG-E = Test for Reception of Grammar, Version 2–Electronic (Bishop, 2005); BPVS = British Picture Vocabulary Scale (Dunn & Dunn, 2009);
nd = normative data; DSF = Digit Span Forward; WISC-IV = Wechsler Intelligence Scale for Children–Fourth Edition (Wechsler et al., 2004); DSB = Digit Span Backward; LSR = Letter
Span Rhyming; LSNR = Letter Span Nonrhyming; ISMT = Internal Speech Memory Test (Conrad, 1979).
a
Suspected APD. bAge or gender matched. cMoore et al. (2010) used the population approach in their study. In the study, 1,469 randomly chosen 6- to 11-year-olds with normal
hearing were included. For the analyses, Moore et al. divided the group into children with poorer auditory processing (suspected APD) and children with typical auditory processing. The
children with poorer auditory processing were defined as the lower 5% of the included children (5% of 1,469 children ≈ 73 children), and children with typical auditory processing were
defined as the upper 95% of the included children (95% of 1,469 children ≈ 1,396 children). dSpoonerisms subset (Walton & Brooks, 1995) of the Phonological Assessment Battery
(Frederickson et al., 1997). eAge is presented in years;months. fMoossavi et al. (2014).
399

400
electroacoustic and electrophysiological measures of the auditory system.

Butler et al. 8 8 8–13 8–13 M = 5,b F = 3 M = 5, F = 3 DPOAE ns

(2011) (10.8) (11.3) contralateral suppression
Burguetti & 38 50 9–10 9–10 M = 18, F = 20 M = 26, F = 24 TOAE ns
Carvallo (2008) contralateral suppression
Acoustic reflex sensitization ns
Muchnik et al. 15 15 8–13b 8–13 M = 11,b F = 4 M = 11, F = 4 TEOAE levels Higher TEOAE levels with and without
(2004) (9.13) (9.47) CAS in both ears (only in the
standard window)
TEOAE Reduced suppression effect (lower
contralateral suppression mean suppression values)
Sanches & 15 I:20 7–11 7–11 M = 7, F = 8 I: M = 10, F = 10; TEOAE Higher proportional lack of suppression
Carvallo (2006) II:16 II: M = 8, F = 8 contralateral suppression in both APD groups
Yalçinkaya et al. 12 12 5–10b 5–10 M = 8,b F = 4 M = 8, F = 4 TEOAE Right ear:
(2010) (6.58) (6.58) contralateral suppression Lower TEOAE amplitudes at 1.0 and
3.0 kHz
Reduced suppression effect (lower
suppression values at 1.0 and
2.0 kHz)
Left ear:
Reduced suppression effect (lower
suppression values at 2.0 kHz)
Gopal & Pierel 9 9a 7–13 7–13 NR NR ABR BIC Smaller BIC amplitude occurring in
(1999) (10.7) (9.2) (binaural and monaural the latency domain of ABR peak V
stimuli)
Gopal et al. 10 10a 9.2–15.7 9.2–15.7 M = 6, F = 4 M = 7, F = 3 ABR Longer latencies of waves III and V
(2002) (11.8) (12.5) (monaural stimuli) Smaller mean amplitudes of waves III
and V
Left ear: smaller wave I descending
and wave III and V ascending
slopes at the low repetition rate
condition
Right ear: smaller wave V ascending
slope at the high repetition rate
condition
(table continues)


b b
Jirsa (2001) 30 37 9.2–13.6 M = 17, F = 13 M = 20, F = 17 ABR (MLS) Longer wave V latency for both the
(binaural stimuli— left and right ears
monaural responses) Larger variance for wave V latency
Kumar & Singh 15 15a 8–12b 8–12 M = 8, F = 7 M = 8, F = 7 Speech-evoked ABR Longer latencies of wave V and A
(2015) (9.33) (9.87) (BioMARK; speech Higher overall scores on BioMark
syllable /da/ )
Rocha-Muniz 18 18 6–12 months 6–12 months M = 10, F = 8 M = 14, F = 4 Speech-evoked ABR Increased latency only for initial
et al. (2012) (109.83)c (110.00)c (speech syllable /da/ ) negative peak
a
Liasis et al. 9 9 8–12b 8–12 M = 5, F = 4 M = 4, F = 5 Speech-evoked ERP Longer N1 peak latency
(2003) (10) (9.5) (speech syllable /ba/ Larger peak-to-peak amplitude of the
vs. /da/ ) P85-120-N1 and P2-N2
Smaller peak-to-peak amplitude of
the N1-P2
Mismatch negativity (difference in
onset, duration, or peak latency)
ns
Roggia & 8 8 9–14b 9–14 M = 4,b F = 4 M = 4, F = 4 AEP: mismatch negativity ns
Colares (2008)
Sharma, Purdy, 22 55 7–12 9–12 M = 10, F = 12 M = 36, F = 19 Speech-evoked cortical Smaller P1 amplitude
et al. (2014) (10.7) (9.7) AEP (speech syllable Smaller N250 amplitude in quiet only
/da/ per stimulus
condition, with noise
and quiet blocks
randomized)
Jirsa & Clontz 18 18a b
9.2–11.6 NRb NR Auditory ERP Delayed mean latency for the N1, P2,
(1990) (binaural clicks) and P3 components
Longer interpeak latency interval P2-P3
Lower P3 amplitude
Note. Studies are arranged in order of the measurements used. Age is presented in years, except where indicated format is in months. TD = typically developing children; M = male;
F = female; DPOAE = distortion product otoacoustic emission; ns = no significant differences between groups; TOAE = transient otoacoustic emissions; TEOAE = transient evoked
otoacoustic emissions; CAS = contralateral acoustic stimulation; NR = not reported; ABR = auditory brainstem response; BIC = binaural interaction component; MLS = maximum-
length sequences; ERP = event-related potential; AEP = auditory evoked potentials.
a
Suspected APD. bAge or gender matched. cAge presented in months.
401

402
neuroimaging measurements.

Farah et al. (2014) 12 12a 7–14b 7–14 M = 10,b F = 2 M = 10, F = 2 DTI (during dichotic listening White matter microstructure differences:
(10.9) (10.9) task with speech-related Decreased fractional anisotropy in frontal
stimuli) multifocal white matter regions centered
in the prefrontal cortex bilaterally and
left anterior cingulate. Increased radial
diffusivity and decreased axial diffusivity
accounted for the decreased fractional
anisotropy, suggesting delayed myelination
in frontal white matter tracts and disrupted
fiber organization.
Increased mean diffusivity in temporal white
matter in the left sublenticular part of the
internal capsule
Pluta et al. (2014) 15 13 7.0–16.0 7.3–16.0 M = 8, F = 7 M = 6, F = 7 Resting state fMRI: regional Differences in resting-state brain activity in
(11.7) (12.2) homogeneity the APD group: decreased coactivation
of the superior frontal gyrus and the
posterior cingulate cortex/the precuneus
Resting state fMRI: independent Inconsistent results; drawing conclusions is
component analysis not possible.
a
Schmithorst 12 12 7–14 months 7–14 months M = 10, F = 2 M = 10, F = 2 fMRI (during dichotic listening Lesser functional activation in the left frontal
et al. (2013), (133.6)c (129.9)c task with speech-related eye fields during dichotic speech-
Experiment Ad stimuli) related presentations relative to dichotic
presentations
Schmithorst 14 10a 7–14 months 7–14 months M = 12, F = 2 M = 8, F = 2 DTI (during dichotic listening task Greater axial diffusivity in the sublenticular
et al. (2013), (131.1)c (131.3)c with speech-related stimuli) part of the left internal capsule
Experiment Bd
Note. Age is presented in years, except where indicated format is in months. TD = typically developing children; M = male; F = female; DTI = diffusion tensor imaging; fMRI = functional
magnetic resonance imaging.
a
Suspected APD. bAge or gender matched. cAge presented in months. dThe study by Schmithorst et al., 2013, contains two experiments, which we have termed Experiment A and
Experiment B.

of APD+ (those who met diagnostic criteria for APD) and less adequate performances in children with APD (see
a subgroup of APD– (those without an APD diagnosis). Table 1 for details). Children with APD were rated as
From these five studies, only the data of the APD+ group having more listening difficulties and poorer listening skills
in comparison with their TD peers were used in this system- compared with their TD peers. Furthermore, they had
atic review. lower attention and memory skills, poorer communication
Three of the included studies had no control group abilities, and greater psychosocial problems and were
with TD peers but used normative data as a control group poorer at judging metre, which is a specific part of musical
(Cameron & Dillon, 2008; Cameron, Dillon, & Newall, skills.
2006; Maerlender, 2010). Two studies used more than one Questionnaires are a relatively cheap and quick as-
control group. Elliot, Bhagat, and Lynn (2007) included sessment tool that can be deployed easily in health care. Ac-
11 age-matched controls and 11 span-matched controls, cording to Moore et al. (2013), well-designed and validated
and James et al. (1994) included six age-matched controls questionnaires are a good and useful instrument for cap-
and six language age-matched controls. Both control groups turing and characterizing the problems of children with
were included in this systematic review. listening complaints. However, no well-validated or stan-
dardized questionnaires or checklists are available for asses-
General Study Characteristics sing listening difficulties in children (Moore, 2012; Moore
et al., 2013).
The total number of participants experiencing APD A questionnaire that is commonly used in APD test-
in the 48 included studies was 1,033, compared with ing, although without known validity, is the Children’s Au-
2,714 participants in the control groups. The sample size of ditory Processing Performance Scale (CHAPPS; Smoski,
the experimental groups varied from six (James et al., 1994) Brunt, & Tannahill, 1998). The CHAPPS is a questionnaire
to 101 (Gyldenkærne et al., 2014), and the sample size of designed for teachers of children with listening difficulties
the controls varied from six (James et al., 1994) to 1,396 to rate the listening abilities of a child against his or her
(Moore et al., 2010). All of the included studies except the classmates on six scales (Noise, Quiet, Ideal, Multiple Inputs,
study by Maerlender (2010) mentioned that children in the Auditory Memory/Sequencing, and Auditory Attention).
experimental and control groups exhibited normal peripheral In this systematic review, three studies used the CHAPPS.
hearing. Ten studies reported no gender information. In Two of the studies reported poorer scores in children with
studies that gave information about gender, 64.0% of the APD on four (Ferguson, Hall, Riley, & Moore, 2011) to
participants with APD were boys (n = 424) and 36.0% of the six (Iliadou & Bamiou, 2012) subscales of the CHAPPS.
participants with APD were girls (n = 239), whereas 54.9% The Noise, Memory, and Attention subscales showed the
of the controls were boys (n = 600) and 45.1% of the controls poorest scores.
were girls (n = 492). Fifteen studies matched the control and Barry et al. (2015) compared three other currently
experimental groups by gender, and 20 studies matched the available questionnaires for assessing listening difficulties in
control and experimental groups by age. The mean age of children (Fisher’s Auditory Problems Checklist: Fisher,
the participants in the APD group was 9 years 10 months 1976; Listening Inventory for Education–Revised: Anderson,
(range: 5 years–17 years 6 months), and the mean age of the Smaldino, & Spangler, 2011; Teacher Evaluation of Audi-
controls was 10 years 1 month (range: 5–19 years). tory Performance: Purdy, Kelly, & Davies, 2002) with a new
developed and well-designed questionnaire (Evaluation of
Characteristics of Children With APD Children’s Listening and Processing Skills: Barry & Moore,
Studies were grouped on the basis of the type of mea- 2014) to assess whether the new questionnaire can contribute
surements used: (a) questionnaires and checklists; (b) audi- to the clinical assessment of children with APD. All ques-
tory and visual behavioral tests; (c) cognitive, language, tionnaires used in the study by Barry et al. (2015) were sen-
and reading behavioral tests; (d) electroacoustic and electro- sitive to the presence of listening difficulties. However,
physiological tests; and (e) neuroimaging measurements. the four questionnaires also correlated with the cognitive
Tables 1–5 illustrate the participant characteristics, mea- measures of the study. This raises the question of which
surements used, and the characteristics associated with construct is measured with questionnaires designed for asses-
APD. Only significant group differences between children sing listening difficulties.
with APD and TD children are reported. A number of A well-designed and validated questionnaire for screen-
studies are mentioned more than once because they utilized ing a child’s communication abilities (DeBonis, 2015;
different types of measurements within the study. Only the Ferguson et al., 2011; Moore et al., 2013) is the Children’s
primary outcome measurements of the studies are included Communication Checklist–Second Edition (CCC-2;
in this systematic review (i.e., performance on tests used Bishop, 2003). The only study with strong internal validity
for inclusion is not reported). included in this systematic review (Moore et al., 2010)
discovered that poorer-for-age performance on the individ-
ual auditory processing tests was significantly related to
Questionnaires and Checklists poor communication (measured with the CCC-2). Also,
All eight studies that used parental or teacher- Ferguson et al. (2011) reported significantly lower perfor-
based questionnaires or checklists determined significantly mance on the CCC-2 in children with APD.

Auditory and/or Visual Behavioral Measurements children in the condition in which the mask was spatially
separated from the target. The one study with the highest
Of the 24 studies that used auditory and/or visual be-
quality rating of 5 points reported that poor performance
havioral tests, 23 demonstrated significantly lower scores
of children on individual auditory processing tests was re-
in children with APD (see Table 2 for details). In contrast,
lated to poor speech-in-noise performance and that more
the study by Ferguson et al. (2011) determined no differ-
deficient speech-in-noise was also associated with lower
ences between groups.
cognitive scores (Moore et al., 2010).
There were between-studies variations in participant
Three studies (Bellis et al., 2008, 2011; Dagenais, Cox,
performance on auditory tests. This could be explained
Southwood, & Smith, 1997) reported that children with
by the use of various tests to measure auditory processing
APD, in addition to the lower scores on auditory tests, had
and the application of different norms and cutoff points
lower scores for visual measurements. In the study by Dawes
for the tests. Some of the studies showed that children
et al. (2009), significant group differences were reported
with APD have poorer performance on tests of temporal
for three of the auditory tasks but not for the visual tasks.
processing (Balen et al., 2009; Barry et al., 2015; Bellis,
However, the proportion of children who performed more
Billiet, & Ross, 2011; Gyldenkærne et al., 2014; Olakunbi
poorly on visual tasks was higher in the APD group than in
et al., 2010; Rocha-Muniz et al., 2014; Rosen, Cohen, &
the control group. Dagenais et al. (1997) reported that chil-
Vanniasegaram, 2010; Sharma, Purdy, & Kelly, 2014).
dren with APD demonstrated longer vocal reaction times
All children included in the APD groups had poorer perfor-
and produced more errors than the controls on a visual
mance on auditory pattern tests (e.g., Frequency Pattern
vocal reaction time paradigm. Putter-Katz et al. (2002) also
Test, Musiek, 1994, 2002; Noffsinger, Wilson, & Musiek,
found slower performance in children with APD but found
1994; Pinheiro & Ptacek, 1971; see also Duration Pattern
no differences between groups in performance accuracy
Test, Musiek, Baran, & Pinheiro, 1990; Pinheiro & Musiek,
on an auditory vocal reaction time paradigm.
1985). However, the performance on tests of temporal reso-
lution (e.g., Random Gap Detection Test, Keith, 2002; see
Cognitive, Language, and Reading
also Gaps-In-Noise Test, Musiek et al., 2005) differed be-
tween studies. Behavioral Measurements
The ability of children to separate or integrate stimuli All 12 studies that used cognitive, language, and/or
presented binaurally can be tested with the Masking Level reading behavioral tests found lower scores in children
Differences Test (Aithal, Yonovitz, & Aithal, 2006; Wilson, with APD (see Table 3). The results show that children with
Moncrieff, Townsend, & Pillion, 2003), the Competing Sen- APD had poorer nonverbal intelligence (NV-IQ), poorer
tence Test (Bergman, Hirsch, Solzi, & Mankowitz, 1987; memory and attention skills, and lower scores on tests
Willeford & Burleigh, 1994), or the Dichotic Digits Test for language (grammar, phonology, and vocabulary) and
(Musiek, 1983). The performance of children with APD on reading.
tests of binaural processing differed among studies (Barry Cognitive measurements include several aspects of
et al., 2015; Bellis, Billiet, & Ross, 2008; Bellis et al., 2011; cognition. In this systematic review, cognitive abilities were
Gyldenkærne et al., 2014; Olakunbi et al., 2010; Rocha- divided into intelligence, memory, and attention skills
Muniz et al., 2014; Rosen et al., 2010; Sharma et al., 2014; (Ferguson et al., 2011; Moore, 2015; Moore & Hunter,
Vanniasegaram, Cohen, & Rosen, 2004). Although all stud- 2013). All studies that included an NV-IQ test (Barry et al.,
ies used the same Dichotic Digit Test (Musiek, 1983), not 2015; Ferguson et al., 2011; Gyldenkærne et al., 2014;
all studies found significant differences in binaural integra- Moore et al., 2010; Rosen et al., 2010; Tomlin et al., 2015)
tion skills between children with APD and their TD peers. found lower mean standard scores in children with APD
A speech-in-noise test or low-pass filter test can be compared with their TD peers. However, Rosen et al. (2010)
used to assess the ability of a child to listen in a noisy envi- mentioned that the IQ scores of children with APD were
ronment (e.g., Speech Perception in Noise Test, Kalikow, lower than those of the controls but were within normal
Stevens, & Elliott, 1977; Bamford-Kowal-Bench Speech- limits on average. Similar results were found in studies that
in-Noise Test, Bench, Kowal, & Bamford, 1979; Nyquette, included an attention test (Barry et al., 2015; Dhamani
2005; see also Listening in Spatialized Noise-Sentences et al., 2013; Gyldenkærne et al., 2014; Moore et al., 2010;
Test, Cameron & Dillon, 2007, 2008; Dillon, Cameron, Sharma et al., 2014; Tomlin et al., 2015).
Glyde, Wilson, & Tomlin, 2012), one of the main com- Auditory memory span can be divided into short-term
plaints of children with listening difficulties. Cameron et al. memory and working memory. In almost all studies (Barry
(2006) and Cameron and Dillon (2008) reported that chil- et al., 2015; Bench & Maule, 1997; Ferguson et al., 2011;
dren with APD were within normal limits on a task in James et al., 1994; Maerlender, 2010; Moore et al., 2010;
which the distraction voice and the speaker were the same Moossavi, Mehrkian, Lotfi, Faghihzadeh, & Sajedi,
voice originating from the same location. Instead, APD 2014; Sharma et al., 2014; Tomlin et al., 2015), children
children exhibited diminished performance in the condition with APD turned out to have weaker performance on tests
in which the masker and target were spatially separated. of memory. Bench and Maule (1997) also reported memory
However, Barry et al. (2015) and Sharma et al. (2014) recall problems with visually presented words in children
found no differences between children with APD and TD with APD. Ferguson et al. (2011) did not report significant

differences in memory span between children with APD no significant differences in the amplitude and latency of
and TD children. the mismatch negativity between children with APD and
Lower performance of children with APD was also controls.
found on tests of language and reading abilities. Still, some
studies mentioned that the significantly poorer performance
Neuroimaging Measurements
of children with APD compared with TD children was
within normal limits on average. Three neuroimaging studies reported differences in
The authors of the one study with the highest quality brain activity and white matter microstructure between
rating (Moore et al., 2010) reported that reduced general children with APD and controls (see Table 5). Two studies
cognitive ability and auditory inattention were predictors of (Farah, Schmithorst, Keith, & Holland, 2014; Schmithorst
listening difficulties. Moore et al. (2010) compared chil- et al., 2013) used children with susAPD and an atypical
dren’s cognitive abilities with their auditory processing skills. left-ear advantage in dichotic listening as the experimental
Children with low performance on the individual auditory group and TD children with a typical right-ear advantage
processing tests also exhibited weak cognitive, communica- as the controls. Sensory and attention deficits can be predic-
tion, and speech-in-noise performance and performed more tive factors for a left-ear advantage, and an altered white
poorly on a visual alertness task and on intrinsic auditory matter microstructure was associated with listening difficul-
attention measures. ties in children. The study by Pluta et al. (2014) reported
differences in resting-state brain activity between children
with APD and controls. Children with APD had decreased
Electroacoustic and Electrophysiological Measures coactivation of the superior frontal gyrus and the posterior
of the Auditory System cingulate cortex/the precuneus.
Nine of the 14 studies that used electroacoustic or
electrophysiological measures reported significantly abnor-
mal performance in children with APD. Three of the stud- Discussion
ies (Burguetti & Carvallo, 2008; Butler, Purcell, & Allen, The purpose of this systematic review was twofold:
2011; Roggia & Colares, 2008) found no differences be- (a) to describe the characteristics associated with APD
tween the groups (see Table 4). by evaluating the literature in which the performance of
Otoacoustic emissions (OAEs) were used as an out- children with suspected or diagnosed APD was compared
come measurement in five studies (Burguetti & Carvallo, with the performance of TD children, and (b) to deter-
2008; Butler et al., 2011; Muchnik et al., 2004; Sanches & mine whether APD must be regarded as a deficit specific
Carvallo, 2006; Yalçinkaya et al., 2010), four of which used to the auditory modality or as a multimodal deficit.
transient evoked OAEs and one of which used distortion The results of our review showed that several characteris-
product OAEs. Three of the five studies found reduced tics are significantly associated with children who were
transient evoked OAE suppression effects in children with referred for an APD assessment. Children with listening
APD (Muchnik et al., 2004; Sanches & Carvallo, 2006; difficulties scored considerably differently for auditory
Yalçinkaya et al., 2010), and two of the five studies reported measurements. However, notable dissimilarities between
no group differences (Burguetti & Carvallo, 2008; Butler groups were also found in visual functioning, communica-
et al., 2011). tion, cognition, language, and reading and in physiologi-
Auditory brainstem responses (ABRs) were used in cal measures such as auditory event-related potentials,
nine studies (Gopal et al., 2002; Gopal & Pierel, 1999; Jirsa, OAEs, and brain structure and activity. In other words,
2001; Jirsa & Clontz, 1990; Kumar & Singh, 2015; Liasis the characteristics of children with susAPD are not specific
et al., 2003; Rocha-Muniz, Befi-Lopes, & Schochat, 2012; or limited to the auditory modality.
Roggia & Colares, 2008; Sharma et al., 2014). Gopal and The between-groups results showed that the listening
Pierel (1999) analyzed the binaural interaction component difficulties that were observed in children who were referred
(BIC) and observed BIC waveforms in all children. They to an audiology or speech and hearing clinic for an APD
found no latency differences between groups, but they did assessment were not due to impaired peripheral hearing
determine a smaller BIC amplitude in children with APD. and were more common in boys than in girls. One study
Four of the eight studies analyzed response peaks, latencies, (Maerlender, 2010) did not explicitly state that the children
and/or amplitudes of ABR waves and found smaller mean in the study groups had good peripheral hearing sensitivity,
amplitudes and longer latencies of waves III and V in children but the author referred in the introduction to the definition
with APD (Gopal et al., 2002; Jirsa, 2001; Kumar & Singh, of APD from Jerger and Musiek (2000), in which it was
2015; Rocha-Muniz et al., 2012). Four of the ABR studies argued that impaired peripheral hearing does not cause the
used auditory event-related potentials (Jirsa & Clontz, deficits of children with APD. Not all studies reported gen-
1990; Liasis et al., 2003; Roggia & Colares, 2008; Sharma der information, but in the 35 studies that did provide this
et al., 2014) and found smaller amplitude and differences information it was shown that approximately twice as many
in long latency potentials between children with APD and boys were included in the APD groups. This is in accor-
TD children. Liasis et al. (2003) and Roggia and Colares dance with the 2:1 ratio between boys and girls mentioned
(2008) analyzed the mismatch negativity. Both found by Chermak and Musiek (1997).

Comparison between studies is difficult because of dif- Purdy et al., 2002). This could be an indication that the lis-
ferences in chronological age, definition used for APD, par- tening difficulties of children reflect a more global deficit
ticipant characteristics, and test methods. The mean age of rather than a specific auditory deficit.
the participants in the APD groups was 9 years 10 months. One of the more significant findings to emerge from
ASHA (2005) and AAA (2010) reported that the use and this study is that cognitive abilities (e.g., NV-IQ, memory,
interpretation of results of auditory behavioral measures is and attention) significantly influence the listening diffi-
complicated in children under age 7 years because of task culties of many children referred for auditory processing
complexity and maturational variability in the central audi- testing. All studies that used measures of NV-IQ, attention,
tory nervous system. It has been argued that maturational language, and reading reported lower scores (sometimes
effects can influence test scores until age 12 years (BSA, within normal limits) in children with APD. In addition,
2011b; Whitelaw & Yuskow, 2006). With respect to electro- two of the neuroimaging studies suggested that attention
physiological measures, it is known that results vary in chil- may play a role in the listening problems of children with
dren under age 10 years (AAA, 2010; ASHA, 2005; BSA, APD. The only study in this systematic review assessed
2011b). The maturational time course is a likely cause for as being methodologically strong (Moore et al., 2010)
the large between-studies variation. Indeed, all studies in reported that the difficulties of children who achieve low
this review that used electrophysiological measures included scores on auditory processing tests are caused by cognitive
children under the age of 10 years in the APD group. and attention problems, or top-down processing, rather
Another possible explanation for the variation in per- than by bottom-up, sensory processing problems. Ahmmed
formance between groups could be the fact that there was et al. (2014) did a factor analysis of outcomes from 110
significant variation between studies in recruitment proce- children with susAPD on an APD test battery (SCAN-C:
dure, diagnostic criteria used for APD, measurements used Test for Auditory Processing Disorders in Children, Keith,
to test auditory skills, and information available about the 2000) and the IMAP (IHR Multicentre Study of Auditory
included participants. Our finding that different terms were Processing) test battery (Moore et al., 2010) to investigate
used for the appointment of children in the study group the role of attention, cognition, memory, sensorimotor
(APD, central APD, susAPD, auditory listening problems, processing speech, speech, and nonspeech auditory pro-
listening difficulties) and the presence of even more diag- cessing in children experiencing listening problems. They
nostic criteria used for including children with APD is in reported three factors underlying the deficits in children
accordance with the findings of W. J. Wilson and Arnott with listening difficulties: (a) general auditory processing
(2013) and W. J. Wilson, Arnott, and Henning (2013), who (represented by frequency discrimination, backward mask-
mentioned that it is difficult to compare different popula- ing, simultaneous masking, and monaural low-redundancy
tions or individuals with APD using different criteria. The speech tests), (b) working memory and executive attention
included samples of children were very diverse, and there (represented by dichotic listening and the IMAP cognitive
was substantial variability in intragroup performance. It tests), and (c) processing speed and alerting attention
was difficult to detect whether groups were comparable (represented by motor response times to cued and non-
because of missing information regarding the recruitment cued auditory and visual stimuli). Children with susAPD
procedure and scarce information about language, reading, performed poorer on different combinations of tests assess-
and cognitive functions of the included children. ing these underlying factors. Poorer performance solely on
Although the included studies varied with respect to general auditory processing was not common. It is sur-
the participant characteristics, the definition of APD, the prising that NV-IQ was not an underlying dimension of
tests used for measuring auditory performance and cogni- susAPD in the study by Ahmmed et al. (2014). In addition,
tive skills, the stimuli used, and test protocols in electro- other studies reported that performance on auditory pro-
acoustic and electrophysiological measures, there were also cessing tests is associated with the cognitive abilities of a
similarities among the different studies. All studies that used child (e.g., Allen & Allan, 2014; DeBonis, 2015; Maerlender,
an auditory pattern test (Frequency Pattern Test or Duration Wallis, & Isquith, 2004).
Pattern Test) found significantly poorer performances in
children with listening difficulties. In addition, similar results
were found in children with language impairment (Stollman, Comorbidity
van Velzen, Simkens, Snik, & van den Broek, 2003). Fur- As already mentioned, the included samples of chil-
thermore, correlations were found between auditory pattern dren with APD were very heterogeneous. In addition to lis-
tests and tests of NV-IQ as well as between auditory pattern tening complaints, a number of the participants included
tests and tests of attention (e.g., Gyldenkærne et al., 2014; in the APD groups reported comorbid diagnoses such as
W. J. Wilson et al., 2011). SLI, dyslexia, ADHD, and/or autism. However, it was not
The results of the studies that used electrophysiologi- always evident whether participants experienced difficulties
cal measures, such as ABR, suggest that children with lis- in other skills in addition to listening problems. Much of
tening difficulties have abnormalities in auditory evoked the time, explicit information regarding language, reading,
potential latency and amplitude. Similar results were found and cognitive functions of the included children was missing.
in children with other developmental disorders, such as From previous studies, we are aware that there is an
learning disabilities, dyslexia, and SLI (e.g., Bishop, 2007; overlap in characteristics between children who have been

diagnosed with APD, SLI, dyslexia, ADHD, and/or autism Keith, 2009). As a result of missing information about va-
(e.g., Dawes & Bishop, 2009, 2010; Miller & Wagstaff, lidity and reliability in most studies, the studies included in
2011; Sharma, Purdy, & Kelly, 2009). In our systematic re- our systematic review scored no points on this item.
view, we found that children who were labeled as children Validation of auditory processing tests is also com-
with APD scored lower on language and communication plicated by the fact that there is no consensus regarding
scales; experienced attention and memory difficulties; and the construct to be measured. Most of the tests used linguis-
achieved lower scores on tests of NV-IQ, language, and tic information and required attention, concentration,
reading. Poor listening skills and inattentiveness are behav- and memory skills (Dawes & Bishop, 2009; Moore, 2012;
ioral characteristics that are also found in children diag- Moore & Hunter, 2013). The question of whether perfor-
nosed with ADHD (e.g., Dawes & Bishop, 2009; Levy & mance of children on auditory processing tests correlates
Parkin, 2003; Riccio & Hynd, 1996). Lower scores on tests with performance on cognitive, language, and reading
of cognition, language, and communication are also tests was examined in several studies. Correlations were
found in children with SLI and dyslexia (e.g., Dawes & shown between performances on auditory processing tests
Bishop, 2009; Levy & Parkin, 2003; Sharma et al., 2009). (Frequency Pattern Test, SSW, Dichotic Digit Test, Gaps-
Dawes and Bishop (2010) studied the characteristics of In-Noise Test) and tests of cognition, language, and reading
25 children with an APD diagnosis and 19 children with a (Allen & Allan, 2014; Maerlender et al., 2004; Murphy,
diagnosis of dyslexia. They found similar performance La Torre, & Schochat, 2013; Riccio, Cohen, Garrison, &
between the APD group and the dyslexia group on psy- Smith, 2005; Tomlin et al., 2015). Allen and Allan (2014)
chometric tests of IQ, auditory processing, language, and reported that the performance of children on behavioral
literacy. They also reported that approximately 50% of auditory processing tests using speech-based material might
the children diagnosed with APD fit a diagnosis of dys- be affected by the language abilities of a child.
lexia and/or SLI (Dawes & Bishop, 2010). The use of questionnaires to assess listening difficulties
On the basis of the corresponding symptoms between of children was proposed by several authors (e.g., DeBonis,
disorders, it is of extreme importance that cognitive, language, 2015; Moore et al., 2013). However, no questionnaires with
reading, and attention abilities of a child in an APD study satisfying psychometric properties currently are available
are reported. Fey et al. (2011) emphasized the difficulty for assessing listening difficulties. As a consequence, the
in unraveling the relationship between different test perfor- underlying concept being measured is not clear. In the study
mances of children with APD in different studies due to by Barry et al. (2015), the Evaluation of Children’s Listening
the use of various inclusion criteria and the absence of and Processing Skills questionnaire was particularly sensi-
hearing, cognitive, and objective test results for individual tive to cognitive difficulties.
participants.
Modality Specificity of APD
Methodological Quality Another key issue and topic of debate is whether APD
Methodological quality of most of the studies included can be considered as a unique and identifiable clinical entity.
in this systematic review unfortunately was rated moderate. According to Cacace and McFarland (e.g., 2009, 2013),
Five studies were excluded from the analyses as a result APD can be construed as a distinct disorder only if modality
of weak methodological quality, and only one study re- specificity can be demonstrated. They recently stated, “If
ceived more than 4 points in the quality appraisal system the modality specificity of the deficit cannot be demon-
and therefore qualified as having strong internal validity. strated with any degree of certainty in assessment of APD,
Heterogeneous groups of participants, inadequate de- then there seems to be no basis for concluding that the
scriptions of participants, and the absence of valid and re- patients had an auditory-perceptual disorder” (Cacace &
liable measurements explains the dubious quality of the McFarland, 2013, p. 586). This opinion has been discussed by
studies. On the other hand, the heterogeneity of the study other researchers (e.g., Dillon et al., 2014; Moore & Ferguson,
groups seems a logical consequence of the lack of consensus 2014). According to Moore and Hunter (2013), it is impos-
on the nature and definition of developmental APD (Bellis, sible to distinguish hearing or auditory processing from
2003; Cacace & McFarland, 2009; Dawes & Bishop, 2009; cognition, and, as a consequence, it is not plausible to speak
DeBonis, 2015; Kamhi, 2011; Rosen, 2005). about modality specificity in APD. Dillon et al. (2014) and
Moore and Ferguson (2014) believed it is not helpful clini-
cally to state that only children with specifically auditory
Validity of Measurements problems can “have” the diagnosis of APD. A way of test-
A major issue in the comparison of the studies is the ing modality specificity is the use of a test in a nonauditory
lack of validity and reliability of the behavioral tests and modality—for example, the use of a visual analog of an
questionnaires used for testing listening difficulties in chil- auditory processing test (Cacace & McFarland, 2013). Four
dren (BSA, 2011a; DeBonis, 2015). Many auditory pro- studies included in this systematic review used visual analogs
cessing tests are available for clinicians; however, most are to test modality specificity. The children with APD per-
without information about validity, reliability, and appro- formed more poorly on both visual and auditory tasks, in-
priate norm data (Dawes & Bishop, 2009; Katz et al., 2002; dicating that the listening difficulties were not specific to

the auditory modality. The overall results of our systematic results. Third, because of our strict inclusion criteria, studies
review also indicate that the listening difficulties of children that did not mention auditory processing or one of the
with susAPD and APD are not specific to the auditory used synonyms in the title were excluded from this review.
modality. These findings are consistent with those of other Fourth, for evaluating the methodological quality of the
researchers, who also suggested that the processing of audi- included studies, we used an adapted version of ASHA’s
tory stimuli of a child demands multiple skills, including LOE scheme (Mullen, 2007). The original version of ASHA’s
in particular those that are visual, auditory, and cognitive LOE also works with the system in which 1 point is assigned
in nature (e.g., BSA 2011a; Cacace & McFarland, 2009; when a criterion meets the highest quality but does not clas-
Dawes & Bishop, 2009; Kamhi, 2011; Levy & Parkin, 2003; sify studies into three categories. To qualify the evidence,
Richard, 2011). we decided to classify the studies on the basis of their total
quality score in weak, moderate, and high studies (adapted
from the quality tool developed by Gyorkos et al., 1994).
Clinical Implications In the event of changing the number of points for the three
In this study, we reported the differences between chil- categories, it is possible that studies will be assigned to a
dren with listening difficulties and TD children. The results different category and that other studies will be included
suggest that listening difficulties in children who are referred or excluded from the review as a consequence. Last, given
for an APD assessment do not occur only in the auditory the wide variation between studies in terms of participants
domain but rather are multimodal. It is also evident that and outcome measures, we were not able to conduct a
auditory processing tests are influenced by cognitive (NV-IQ, meta-analysis.
attention, memory), language, and reading skills. Given that
there is no consensus about APD as a valid diagnostic
construct and that there are serious doubts about the validity
Concluding Remarks
of the auditory processing tests, we recommend evaluating We found significant differences between children re-
listening difficulties from an interdisciplinary perspective in ferred with listening difficulties and TD children. These
order to obtain the broadest view possible of the child and differences relate to auditory and visual functioning, cogni-
his or her environment. Because of maturational effects in the tion (NV-IQ, attention, and memory), language, reading,
central auditory pathway, factors such as chronological age physiological measures (e.g., auditory event-related poten-
should be taken into account in the testing of children with tials and OAEs), and brain structure and activity. Our
listening difficulties. We agree with the recommended as- results suggest that the problems of children with listening
sessment process proposed by DeBonis (2015)—that assess- difficulties are multimodal and may be caused by cognitive,
ment of children with listening difficulties in the classroom memory, attention, and language deficits. Children who
has to start with assessing overall listening abilities and are referred with listening difficulties may fail the auditory
the use of comprehensive global testing, including speech tests that are involved in the typical diagnosis of APD. How-
and language tests and psychoeducational evaluation. Tra- ever, it is important to realize that the evidence for a spe-
ditional auditory processing tests rarely should be used cific auditory condition is inadequate. As a consequence,
because they may reflect some aspects of auditory, language, interventions that these children may require might be more
and/or cognitive ability (DeBonis, 2015). We also recom- successful when focused on cognitive or language skills
mend an evaluation of the performance and functioning of rather than only auditory functioning.
a child in the classroom and at home (rather than in a clini-
cal setting only) to investigate the real-life listening prob-
lems of a child. Acknowledgments
Although APD may not be a clinical entity, chil- This research was funded by Regional Attention and Action
dren may still benefit from adjustment of the environment for Knowledge circulation. The Regional Attention and Action
(e.g., classrooms with adapted acoustics) or compensa- for Knowledge circulation scheme is managed by the Foundation
tion strategies. It will be of interest to determine whether Innovation Alliance (Stichting Innovatie Alliantie) with funding
from the ministry of Education, Culture and Science, the Netherlands.
auditory intervention programs (e.g., compensation strate-
The first author received a doctoral studentship from the Hanze
gies, listening devices, training modules) can support the University of Applied Sciences Groningen and the University of
functioning of children with listening difficulties. Groningen, the Netherlands.
Limitations of the Current Review

References
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Characteristics of Auditory Processing

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n Age range (M) Gender

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by the children on the Emotional

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Ferguson et al. 47 19 6.0–11.9 6.2–13.9 M = 26, F = 21 M = 13, F = 6 Speech intelligibility: ns

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n Age range (M) Gender

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n Age range (M) Gender

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n Age range (M) Gender

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Barry et al. 14 12 7.1–12.8 7.1–12.8 M = 4, F = 10 M = 7, F = 5 TONI: NV-IQ Poorer performance

Attention quotient: Poorer performance (poorer mean scores)

WARP Poorer performance

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Digit Span subtest of Poorer performance on individual tests

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n Age range (M) Gender

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(1997) (10.8) (10.7) Less use of internal speech

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Butler et al. 8 8 8–13 8–13 M = 5,b F = 3 M = 5, F = 3 DPOAE ns

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n Age range (M) Gender

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n Age range (M) Gender

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Limitations of the Current Review

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