A Retrospective Study Distinguishing between Hyperacusis and Misophonia in children with Auditory Processing Disorder (APD).

OBJECTIVES: Decreased sound tolerance (DST) is common in children with auditory processing disorder (APD). This study aimed to differentiate between hyperacusis and misophonia in children with APD. DESIGN: A retrospective study evaluating outcomes of structured history and co-morbidity following Research Domain Criteria (RDoC) frame-work. Misophonia was considered as oversensitivity to eating/chewing sounds and hyperacusis as oversensitivity to other sounds. STUDY SAMPLE: Two hundred and seventy-nine children (160 males; 119 females), 6-16 year-olds with NVIQ ≥80, diagnosed with APD between January 2021 and December 2022. RESULTS: One hundred and forty-three out of 279 children with APD had DST, of which 107 had hyperacusis (without misophonia) and 36 had misophonia. Misophonia co-existed with hyperacusis in 35 children (97 %), and in one child misophonia occurred without hyperacusis. Misophonia was prevalent in older children, in females, and those with tinnitus. Fear and being upset were predominant emotional responses in hyperacusis (without misophonia) while disgust and verbal abuse were prevalent in misophonia (with or without hyperacusis). Compared to children without DST, the hyperacusis (without misophonia) and misophonia (with or without hyperacusis) groups had significant higher prevalence of ADHD, anxiety, and language impairment. Educational difficulties were similar in APD irrespective of the presence or absence of DST. Despite higher tinnitus prevalence in misophonia (with or without hyperacusis) along with similar co-morbidities and educational difficulties in both hyperacusis (without misophonia) and misophonia (with or without hyperacusis), the misophonia (with or without hyperacusis) group surprisingly had less support at school which was reflected in fewer Education, Health and Care Plan (EHCP). CONCLUSIONS: In APD misophonia mostly co-exists with hyperacusis, with differences in emotional responses, tinnitus prevalence, and gender distribution when compared to hyperacusis (without misophonia). Increase in awareness about misophonia is needed, as children with misophonia may have unidentified needs. Larger scale prospective study is required to clarify if misophonia evolves from hyperacusis, and to explore the factors underlying 'misophonia with hyperacusis' and 'misophonia without hyperacusis'. For clarity, DST studies need to specify if hyperacusis or misophonia co-existed when referring to hyperacusis or misophonia.

Visual Processing Impairment in Children With Suspected Auditory Processing Disorder: A Transdisciplinary Dimensional Approach to Diagnosis.

PURPOSE: The purpose of this study is to explore the utility of impairment(s) in language (LI), manual dexterity (IMD), and visual perceptual skills (IVPS) as a reference standard for diagnosing auditory processing disorder (APD). METHOD: Data from 104 participants with suspected APD (males = 57, females = 47; 6-16 years) were retrospectively analyzed. Index auditory processing (AP) tests included Auditory Figure Ground 0 dB, Competing Words-Directed Ear (CW-DE), and Time-Compressed Sentences (TCS). General Communication Composite (GCC) of the Children's Communication Checklist-2, manual dexterity (MD) component of the Movement Assessment Battery for Children-Second Edition, and Test for Visual Perceptual Skills-Third Edition (TVPS-3) were used to identify LI, IMD, and IVPS, respectively. RESULTS: Eighty-one (77.8%), 58 (55.8%), and 37 (35.6%) participants had LI, IVPS, and IMD, respectively. Four factors explaining 67.69% of the variance were extracted. TVPS-3 (except visual closure [VClo]) represented the first; AFG 0, VClo, and MD the second; CW-DE and GCC the third; and TCS the fourth. APD diagnosed by combining AP tests and comorbidities had better accuracy compared to AP tests alone. The combined approach had overall diagnostic accuracy of 92.2%, 88.4%, and 81.7% for the 9th, 5th, and 2nd percentile AP test cutoffs, respectively. CONCLUSIONS: First-order AP tests in this study were related to language, MD, and visual perceptual skills. Given the overlap of LI, IMD, and IVPS with impaired AP, these comorbidities are an effective reference standard for APD. APD can be diagnosed following failing one AP test if one or more comorbidities exist. Ninth percentile AP test cutoff had better diagnostic accuracy compared to the currently used 2nd percentile cutoff.

Combination of Comorbidities as a Reference Standard for Evaluating Auditory Processing Disorder: Response to the Letter to the Editor From Schow et al. (2021).

PURPOSE: Concerns expressed by Schow et al. (2021) around the evidence-based diagnostic criteria suggested by Ahmmed (2021a) are addressed here. The use of combination of comorbidities as a reference standard for evaluating auditory processing tests is a valid strategy, consistent with the Research Domain Criteria framework from the National Institute of Mental Health as well as the Standards for Reporting of Diagnostic Accuracy Studies. The correlations between auditory processing tests and some comorbidities in Ahmmed (2021a) were significant at p < .01. The low sensitivity and specificity reported was not related to the principle of using comorbidities as a reference standard but due to the choice of comorbidities combined in the reference standard. Ahmmed (2021a) suggested the option of inclusion of other comorbidities in addition to language impairment and impaired manual dexterity in the reference standard. Visual processing impairment could be considered as the additional comorbidity to improve sensitivity and specificity of the approach suggested by Ahmmed (2021a).

Auditory Processing Disorder and Its Comorbidities: A Need for Consistency in Test Cutoff Scores.

Purpose No gold standard criteria exist for diagnosing developmental auditory processing disorder (APD). This study aimed to identify APD criteria, which are consistent with that used for comorbidities, and how comorbidities predicted APD. Method A retrospective study of 167 participants (males = 105, females = 62; age: 6-16 years; nonverbal IQ > 80) with suspected APD is presented. Five SCAN-3 tests evaluated auditory processing (AP). Comorbidities included attention-deficit/hyperactivity disorder, language impairment, and impaired manual dexterity, which were identified using percentile ≤ 5 in the Swanson, Nolan and Pelham parental rating scale; Children's Communication Checklist-2; and Movement Assessment Battery for Children-2, respectively. Results Percentiles ≤ 9, ≤ 5, and < 2 in two or more AP tests had sensitivities (specificities) of 76% (70.6%), 59.3% (76.5%), and 26% (82.4%), respectively, in predicting comorbidities, which were present in 150 of the 167 participants. The criterion of "≤ 9 percentile in two or more AP tests" (Approach I) diagnosed APD in 119 participants, and criterion "≤ 5 percentile in two or more AP tests or ≤ 5 percentile in one AP plus one or more measures of comorbidities" (Approach II) diagnosed 123. The combination of approaches diagnosed 128 participants (76.6%) with APD, of which 114 were diagnosed by each approach (89%). Language impairment and impaired manual dexterity, but not attention-deficit/hyperactivity disorder, predicted APD. Conclusions "Percentile ≤ 9 in two or more AP tests" or "percentile ≤ 5 in one AP plus one or more measures of comorbidities" are evidence-based APD diagnostic criteria. Holistic and interprofessional practice evaluating comorbidities including motor skills is important for APD.

Auditory processing, co-morbidities, and parental report of sleep disturbance in children with auditory processing disorder (APD).

OBJECTIVES: To evaluate the prevalence of sleep disturbance and its relationship with auditory processing (AP) and co-morbidities in children diagnosed with auditory processing disorder (APD). METHODS: Data from 109 children (Males = 59, Females = 50) with mean non-verbal intelligence quotient (NVIQ) of 89.44 (SD:18.16), aged between 6 and 16 years (mean: 10 years 7 months; SD: 2 years 9 months) with a diagnosis of APD were analysed. Participants performed ≤1.33 SD below the mean in two or more out of five SCAN-3 diagnostic APD tests that included 'Filtered Words' (FW), 'Auditory Figure Ground 0 dB' (AFG0), 'Competing Words-Directed Ear' (CW-DE), 'Competing Sentences' (CS) and 'Time Compressed Sentences' (TCS). Concern about sleep in addition to other symptoms and medical history were documented from structured parental history sheet which forms part of the routine APD assessment. Language impairment (LI), attention-deficit-hyperactivity-disorder (ADHD) and oppositional defiant disorder (ODD), and anxiety were evaluated using the 'Children's Communication Checklist-2' (CCC-2), 'Swanson Nolan and Pelham rating scale' (SNAP-IV) and 'Anxiety Scale for Children-Autism Spectrum Disorder' (ASC-ASD) respectively. RESULTS: Sixty children had sleep disturbance, a prevalence of 55% (95% CI 45.2%-64.6%). The two groups of APD children, with (n = 49) and without sleep (n = 60) disturbance, did not vary in their auditory processing abilities. The sleep disturbed group had significant issues with pragmatic language impairment, hyperactivity/impulsivity, oppositional defiant symptoms and anxiety compared to the group without sleep disturbance when they were analysed separately. After the variables were considered in step wise fashion in binary logistic regression analyses, only pragmatic language impairment and anxiety predicted sleep disturbance (p < .01). CONCLUSION: In APD the prevalence of sleep disturbance is high, justifying screening within a transdisciplinary APD assessment protocol. Sleep disturbance in APD is predicted by pragmatic language impairment and anxiety, but not by ADHD symptoms or ODD.

Auditory processing and neuropsychological profiles of children with functional hearing loss.

OBJECTIVES: This paper compares structured history, auditory processing abilities and neuropsychological findings of children with functional hearing loss (FHL) to those with suspected auditory processing disorder without FHL (control). The main aim was to evaluate the value of a holistic assessment protocol for FHL used in a routine pediatric audiology clinic. The protocol incorporated a commercially available test battery for auditory processing disorder (APD), non-verbal intelligence (NVIQ) and tools to screen for common co-existing neurodevelopmental conditions such as attention deficit hyperactivity disorder (ADHD), language impairment (LI) and developmental coordination disorder (DCD). The outcome of such holistic assessment was expected to help in understanding the nature of FHL and to provide individualized support to mitigate their difficulties. METHODS: This retrospective study compared two groups, 40 children (M = 17, F = 23) in each group between seven and sixteen years of age, one group with a history of FHL and the other with suspected APD without FHL (control). The groups were matched against age, gender, hand use, diagnosis of APD or non-APD (31 with APD and 9 without APD in each group) and non-verbal intelligence. All the children were healthy English speaking children attending mainstream schools with no middle or inner ear abnormalities. Structured history was obtained from parents regarding different nonacademic and academic concerns. The SCAN-3:C and SCAN-3:A test batteries were used to assess auditory processing abilities; Lucid Ability test for NVIQ; Children's Communication Checklist-2 (CCC-2) for language ability; Swanson Nolan and Pelham-IV Rating Scale (SNAP-IV) for ADHD; and the manual dexterity components of the Movement Assessment Battery for Children-2 (MABC-2) as a screening tool for DCD. RESULTS: About 60% of children in both the groups had concerns regarding listening in noisy background. In the history, poor attention was reported in 45% of children in the FHL group compared to 82.5% in the control group (p < 0.01). Hyperacusis was present in 35% of children in the FHL group and in 62% of children in the control group (p < 0.05). Concerns about overall academic abilities were present in 59% of children in the FHL group and 75% of the controls (p > 0.05). Only 15% of children in the FHL group had concerns with numeracy skills in contrast to 41% of the controls (p < 0.05). Significantly fewer (p < 0.01) children in the FHL group (41%) received additional support at school than the controls (75%). Fewer children performed poorly in Filtered Words (FW) test of the SCAN-3 batteries, 30% in the FHL group and 17.5% in the control group, in contrast to Auditory Figure Ground 0 (AFG0), 85% in FHL and 80% in the control group. The number of children performing poorly in AFG0 was significantly higher compared to all the other SCAN-3 tests in FHL (P < 0.05), in contrast to FW and Competing Sentences (CS) only in the control group (p < 0.05). The control group had higher prevalence of atypical ear advantage (AEA) in left directed Competing Words (CW) (32.5%) and Time Compressed Sentences (TCS) (32.5%) compared to FW (7.5%). In contrast, FHL group had higher prevalence of AEA in AFG0 (48.7%) compared to CS (21%). High proportions of children in both the groups had LI (80% in FHL and 82.5% in the control group), with significantly lower (p < 0.05) levels of ADHD symptoms in the FHL group (39.5%) compared to the control group (72.5%). Impaired manual dexterity was present in 30.7% of children in FHL group and 47.5% in the controls. CONCLUSIONS: The prevalences of APD and language impairment are high compared to ADHD symptoms in children with FHL, and holistic assessment is recommended. Despite some similarities in the auditory and neuropsychological profiles between children with FHL and those with suspected APD without FHL some differences were noted. The results suggest that children with FHL have genuine difficulties that need to be identified and addressed. Future research is required to identify the neural pathways which could explain the similarities and dissimilarities between the two groups.

Intelligibility of degraded speech and the relationship between symptoms of inattention, hyperactivity/impulsivity and language impairment in children with suspected auditory processing disorder.

OBJECTIVES: To compare the sensitivity and specificity of Auditory Figure Ground sub-tests of the SCAN-3 battery, using signal to noise ratio (SNR) of +8 dB (AFG+8) and 0 dB (AFG0), in identifying auditory processing disorder (APD). A secondary objective was to evaluate any difference in auditory processing (AP) between children with symptoms of inattention versus combined sub-types of Attention Deficit Hyperactivity Disorder (ADHD). METHODS: Data from 201 children, aged 6 to 16 years (mean: 10 years 6 months, SD: 2 years 8 months), who were assessed for suspected APD were reviewed retrospectively. The outcomes of the SCAN-3 APD test battery, Swanson Nolan and Pelham-IV parental rating (SNAP-IV) and Children's Communication Checklist-2 (CCC-2) were analysed. RESULTS: AFG0 had a sensitivity of 56.3% and specificity of 100% in identifying children performing poorly in at least two of six SCAN-3 sub-tests or one of the two questionnaires, in contrast to 42.1% and 80% respectively for AFG+8. Impaired AP was mostly associated with symptoms of ADHD and /or language impairment (LI). LI was present in 92.9% of children with ADHD symptoms. Children with symptoms of combined ADHD plus LI performed significantly poorly (p < 0.05) compared to inattention ADHD plus LI in Filtered Words (FW) sub-test, but not in the rest of the SCAN-3 sub-tests. CONCLUSION: Speech in noise tests using SNR of 0 dB is better than +8 dB in assessing APD. The better FW performance of the inattention ADHD plus LI group can be speculated to be related to known difference in activity in a neural network between different sub-types of ADHD. The findings of the study and existing literature suggest that neural networks connecting the cerebral hemispheres, basal ganglia and cerebellum are involved in APD, ADHD and LI.

Setting appropriate pass or fail cut-off criteria for tests to reflect real life listening difficulties in children with suspected auditory processing disorder.

OBJECTIVE: This paper explores the pass or fail cut-off criteria, the number of test fails, and the nature of tests that are most appropriate in predicting listening difficulties (LiD) in children with suspected APD (SusAPD). METHODS: One hundred and nine English-speaking children (67 males, 42 females) aged between 6 and 11 years with SusAPD were assessed. The Children's Auditory Performance Scale (CHAPS) scores 2 SD below the mean were taken as markers of LiD in different listening conditions. Binary logistic regression analyses were carried out to evaluate the cut-off criterion (2 SD or 1.5 SD or 1 SD below the mean) of failing at least two tests, from the SCAN-C and IMAP test batteries, which significantly predicted LiD. Analyses were also carried out to assess if the group of auditory processing (AP) or cognitive or combination of AP plus cognitive tests were significant in predicting LiD. Receiver Operative Characteristic (ROC) curves were also explored to evaluate how the sensitivity and specificity in confirming LiD varied with the number of test fails. RESULTS: Filtered Words, Competing Words, Competing Sentences, VCV in ICRA noise, Digit Span, Sight Word Reading and the Cued Auditory Attention tests correlated with one or more of the CHAPS domains. Failing at least two of these tests 1.5 SD below the mean significantly predicted (p<.05) CHAPS Ideal scores 2 SD below the mean, and failing at least two of the tests 1 SD below the mean significantly predicted (p<.05) CHAPS Memory and CHAPS Attention scores 2 SD below the mean. The combination of AP plus cognitive tests had significantly higher ability to predict CHAPS Ideal, Memory and Attention scores, compared to the group of AP or cognitive tests separately. ROC curves showed that failing at least two of the tests was associated with the best sensitivity and specificity in predicting LiD. CONCLUSION: Of the different CHAPS domains only the CHAPS Ideal, Memory and Attention correlated with the APD tests. Failing at least two APD tests from a combination of AP and cognitive tests 1 SD and 1.5 SD below the mean, but not 2 SD, is more appropriate in confirming LiD.

Assessment of children with suspected auditory processing disorder: a factor analysis study.

OBJECTIVES: To identify the factors that may underlie the deficits in children with listening difficulties, despite normal pure-tone audiograms. These children may have auditory processing disorder (APD), but there is no universally agreed consensus as to what constitutes APD. The authors therefore refer to these children as children with suspected APD (susAPD) and aim to clarify the role of attention, cognition, memory, sensorimotor processing speed, speech, and nonspeech auditory processing in susAPD. It was expected that a factor analysis would show how nonauditory and supramodal factors relate to auditory behavioral measures in such children with susAPD. This would facilitate greater understanding of the nature of listening difficulties, thus further helping with characterizing APD and designing multimodal test batteries to diagnose APD. DESIGN: Factor analysis of outcomes from 110 children (68 male, 42 female; aged 6 to 11 years) with susAPD on a widely used clinical test battery (SCAN-C) and a research test battery (MRC Institute of Hearing Research Multi-center Auditory Processing "IMAP"), that have age-based normative data. The IMAP included backward masking, simultaneous masking, frequency discrimination, nonverbal intelligence, working memory, reading, alerting attention and motor reaction times to auditory and visual stimuli. SCAN-C included monaural low-redundancy speech (auditory closure and speech in noise) and dichotic listening tests (competing words and competing sentences) that assess divided auditory attention and hence executive attention. RESULTS: Three factors were extracted: "general auditory processing," "working memory and executive attention," and "processing speed and alerting attention." Frequency discrimination, backward masking, simultaneous masking, and monaural low-redundancy speech tests represented the "general auditory processing" factor. Dichotic listening and the IMAP cognitive tests (apart from nonverbal intelligence) were represented in the "working memory and executive attention" factor. Motor response times to cued and noncued auditory and visual stimuli were grouped in the "processing speed and alerting attention" factor. Individuals varied in their outcomes in different tests. Poor performance was noted in different combinations of tests from the three factors. Impairments solely related to the "general auditory processing" factor were not common. CONCLUSIONS: The study identifies a general auditory processing factor in addition to two other cognitive factors, "working memory and executive attention" and "processing speed and alerting attention," to underlie the deficits in children with susAPD. Impaired attention, memory, and processing speed are known to be associated with poor literacy and numeracy skills as well as a number of neurodevelopmental disorders. Individuals with impairments in the "general auditory processing" tests along with tests from the other two cognitive factors may explain the co-occurrence of APD and other disorders. The variation in performance by individuals in the different tests noted was probably due to a number of reasons including heterogeneity in susAPD and less-than ideal test-retest reliabilities of the tests used to assess APD. Further research is indicated to explore additional factors, and consensus is needed to improve the reliability of tests or find alternative approaches to diagnose APD, based on the underlying factors.

Mismatch negativity and frequency representational width in children with specific language impairment.

The aim of this study was to compare the degree of frequency separation that is required between tones to generate mismatch negativity (MMN) in a group of children with specific language impairment (SLI) and a comparison group, who had their temporal processing abilities assessed in a previous experiment. Using a 1000Hz standard (85%) and 1020, 1050, and 1100Hz deviant tones presented at inter-stimulus intervals (ISIs) of 200 and 400ms, MMN was compared in 19 children with SLI (13 males, six females, age range 7y 4mo-11y 10mo, mean age 9y 7mo [SD 1y 2mo]), and 19 comparison children (13 males, six females, age range 7y 3mo-11y 4mo, mean age 9y 5mo [SD 1y 3mo]). Temporal processing ability was assessed by the Auditory Fusion Test-Revised. Children with SLI who had poor temporal processing abilities generated a positive mismatch response (P-MMR) for 2% tone contrasts at 400ms ISI but MMN with larger contrasts. These children also generated stronger MMN than the comparison group at 200ms ISI for 2% contrasts. Children with SLI who had good temporal processing abilities generated only P-MMR in response to contrasts up to 10% for both ISIs. Some children with SLI show an inverse relationship between frequency discrimination and temporal processing. Furthermore, certain stimulus-related and biological criteria may need to be met for P-MMR to switch to MMN.

Cochlear microphonics in sensorineural hearing loss: lesson from newborn hearing screening.

The diagnostic dilemma surrounding the presence of cochlear microphonics (CM) coupled with significantly elevated auditory brainstem response (ABR) thresholds in babies failing the newborn hearing screening is highlighted. A case report is presented where initial electo-diagnostic assessment could not help in differentiating between Auditory Neuropathy/Auditory Dys-synchrony (AN/AD) and sensorineural hearing loss (SNHL). In line with the protocol and guidelines provided by the national Newborn Hearing Screening Programme in the UK (NHSP) AN/AD was suspected in a baby due to the presence of CM at 85 dBnHL along with click evoked ABR thresholds of 95 dBnHL in one ear and 100 dBnHL in the other ear. Significantly elevated thresholds for 0.5 and 1kHz tone pip ABR fulfilled the audiological diagnostic criteria for AN/AD. However, the possibility of a SNHL could not be ruled out as the 85 dBnHL stimuli presented through inserts for the CM would have been significantly enhanced in the ear canals of the young baby to exceed the threshold level of the ABR that was carried out using headphones. SNHL was eventually diagnosed through clinical and family history, physical examination and imaging that showed enlarged vestibular aqueducts. Presence of CM in the presence of very high click ABR thresholds only suggests a pattern of test results and in such cases measuring thresholds for 0.5 and 1 kHz tone pip ABR may not be adequate to differentiate between SNHL and other conditions associated with AN/AD. There is a need for reviewing the existing AN/AD protocol from NHSP in the UK and new research to establish parameters for CM to assist in the differential diagnosis. A holistic audiological and medical approach is essential to manage babies who fail the newborn hearing screening.

Contralateral suppression of otoacoustic emissions in children with specific language impairment.

OBJECTIVE: The purpose of the investigation was to determine whether a group of children with specific language impairments (SLI) have reduced peripheral auditory processes thought to be associated with speech-in-noise intelligibility. DESIGN: Transient evoked otoacoustic emissions (TEOAE) and their suppression by the efferent activity of the medial olivocochlear system (MOCS) in response to contralateral acoustic stimulation were used to compare these processes in 18 children with SLI and 21 controls. RESULTS: The results revealed no group difference in TEOAE suppression effect or left/right asymmetry of TEOAE suppression effect. CONCLUSIONS: These results suggest that children with SLI do not have auditory processing problems at this peripheral level casting doubt on a hypothesized relationship between strength of MOCS activity and language impairment.