A Multi-Sample Comparison and Rasch Analysis of the Evaluation of Children's Listening and Processing Skills Questionnaire.

OBJECTIVES: Assessing listening difficulties and associated complaints can be challenging. Often, measures of peripheral auditory functions are within normal ranges, making clinicians feel unsure about proper management strategies. The range and nature of observed or experienced difficulties might be better captured using a qualitative measure. The Evaluation of Children's Listening and Processing Skills (ECLiPS) questionnaire was designed to broadly profile the auditory and cognitive problems often present in children with listening difficulties. This 38-item questionnaire was initially standardized in British children aged 6 to 11 years, was subsequently modified for use with North-American children, and was recently translated into Flemish-Dutch. This study aimed to compare typical scores of the Flemish version with the UK and US versions, and to evaluate and compare its psychometric quality based on Rasch analysis. DESIGN: We selected 112 Flemish children aged 6 to 11 years with verified normal hearing and typical development, and asked two caregivers of every child to fill out the ECLiPS. Data from two comparator samples were analyzed, including responses for 71 North-American children and 650 British children. Typical values for ECLiPS factors and aggregates were determined as a function of age and gender, and meaningful differences across samples were analyzed. Rasch analyses were performed to evaluate whether ECLiPS response categories work as intended, and whether item scores fit a linear equal interval measurement scale that works the same way for everyone. Item and person metrics were derived, including separation and reliability indices. We investigated whether items function similarly across linguistically and culturally different samples. RESULTS: ECLiPS scores were relatively invariant to age. Girls obtained higher scores compared with boys, mainly for items related to memory and attention, and pragmatic and social skills. Across ECLiPS versions, the most pronounced differences were found for items probing social skills. With respect to its psychometric quality, ECLiPS response categories work as intended, and ECLiPS items were found to fit the Rasch measurement scale. Cultural differences in responses were noted for some items, belonging to different factors. Item separation and reliability indices generally pointed toward sufficient variation in item difficulty. In general, person separation (and reliability) metrics, quantifying the instrument's ability to distinguish between poor and strong performers (in a reproducible manner), were low. This is expected from samples of typically developing children with homogeneous and high levels of listening ability. CONCLUSIONS: Across the languages assessed here, the ECLiPS caregiver questionnaire was verified to be a psychometrically valid qualitative measure to assess listening and processing skills, which can be used to support the assessment and management of elementary school children referred with LiD.

Multitasking across the lifespan in different task contexts.

We assessed lifespan development of multitasking in a sample of 187 individuals aged 8-82 years. Participants performed a visuo-spatial working memory (VSWM) task together with either postural control or reaction time (RT) tasks. Using criterion-referenced testing we individually adjusted difficulty levels for the VSWM task to control for single-task differences. Age-differences in single-task performances followed U-shaped patterns with young adults outperforming children and older adults. Multitasking manipulations yielded robust performance decrements in VSWM, postural control and RT tasks. Presumably due to our adjustment of VSWM challenges, costs in this task were small and similar across age groups suggesting that age-differential costs found in earlier studies largely reflected differences already present during single-task performance. Age-differences in multitasking costs for concurrent tasks depended on specific combinations. For VSWM and RT task combinations increases in RT were the smallest for children but pronounced in adults highlighting the role of cognitive control processes. Stabilogram diffusion analysis of postural control demonstrated that long-term control mechanisms were affected by concurrent VSWM demands. This interference was pronounced in older adults supporting concepts of compensation or increased cognitive involvement in sensorimotor processes at older age. Our study demonstrates how a lifespan approach can delineate the explanatory scope of models of human multitasking.

A language-independent hearing screening self-test at school-entry.

The usage of a tablet-based language-independent self-test involving the recognition of ecological sounds in background noise, the Sound Ear Check, was investigated. The results of 692 children, aged between 5 and 9 years and 4 months, recruited in seven different countries, were used to analyze the validity and the cultural independence of test. Three different test procedures, namely a monaural adaptive procedure, a procedure presenting the sounds dichotically in diotic noise, and a procedure presenting all the sounds with a fixed signal-to-noise ratio and a stopping rule were studied. Results showed high sensitivity and specificity of all three procedures to detect conductive, sensorineural and mixed hearing loss > 30 dB HL. Additionally, the data collected from different countries were consistent, and there were no clinically relevant differences observed between countries. Therefore, the Sound Ear Check can offer an international hearing screening test for young children at school entry, solving the current lack of hearing screening services on a global scale.

Early cochlear implantation supports narrative skills of children with prelingual single-sided deafness.

Prelingual single-sided deafness (SSD) not only affects children's hearing skills, but can also lead to speech-language delays and academic underachievement. Early cochlear implantation leads to improved spatial hearing, but the impact on language development is less studied. In our longitudinal study, we assessed the language skills of young children with SSD and a cochlear implant (CI). In particular, we investigated their narrative skills in comparison to two control groups: children with SSD without a CI, and children with bilateral normal hearing. We found that children with SSD and a CI performed in line with their normal-hearing peers with regard to narrative and verbal short-term memory skills. Children with SSD without a CI had worse narrative (group difference = - 0.67, p = 0.02) and verbal short-term memory (group difference = - 0.68, p = 0.03) scores than the implanted group. Verbal short-term memory scores and grammar scores each correlated positively with narrative scores across all groups. Early grammar scores (at 2-3 years of age) could partially predict later narrative scores (at 4-6 years of age). These results show that young children with prelingual SSD can benefit from early cochlear implantation to achieve age-appropriate language skills. They support the provision of a CI to children with prelingual SSD.

Effectiveness of Auditory Training in Experienced Hearing-Aid Users, and an Exploration of Their Health-Related Quality of Life and Coping Strategies.

Hearing aids (HA) are a fundamental component in restoring auditory function; however, they cannot completely alleviate all problems encountered by adults with hearing impairment. The aim of this study is twofold. Firstly, we assess the health-related quality of life and coping strategies of experienced HA users. Secondly, we assess whether HA users can benefit from auditory training. To this end, 40 participants who had worn HAs for more than 6 months participated in this study. Half of the participants received auditory training, while the other half served as a passive control. The training consisted of a personalized training scheme, with outcome measures including speech in noise perception in free-field and via direct streaming to the HA, phoneme identification, cognitive control, and health-related quality of life. Results showed that experienced HA users reported a relatively good quality of life. Health-related quality of life was correlated with aided speech perception in noise, but not with aided pure tone audiometry. Coping strategies were adaptive, leading to improved communication. Participants showed improvements in trained tasks, consonant identification, and speech in noise perception. While both groups yielded improved speech in noise perception at the end, post hoc analysis following a three-way interaction showed a significantly larger pre-post difference for the trained group in the streaming condition. Although training showed some improvements, the study suggests that the training paradigm was not sufficiently challenging for HA users. To optimize daily life listening, we recommend that future training should incorporate more exercises in noise and focus on cognitive control.

Speech perception in noise, working memory, and attention in children: A scoping review.

PURPOSE: Speech perception in noise is an everyday occurrence for adults and children alike. The factors that influence how well individuals cope with noise during spoken communication are not well understood, particularly in the case of children. This article aims to review the available evidence on how working memory and attention play a role in children's speech perception in noise, how characteristics of measures affect results, and how this relationship differs in non-typical populations. METHOD: This article is a scoping review of the literature available on PubMed. Forty articles were included for meeting the inclusion criteria of including children as participants, some measure of speech perception in noise, some measure of attention and/or working memory, and some attempt to establish relationships between the measures. Findings were charted and presented keeping in mind how they relate to the research questions. RESULTS: The majority of studies report that attention and especially working memory are involved in speech perception in noise by children. We provide an overview of the impact of certain task characteristics on findings across the literature, as well as how these affect non-typical populations. CONCLUSION: While most of the work reviewed here provides evidence suggesting that working memory and attention are important abilities employed by children in overcoming the difficulties imposed by noise during spoken communication, methodological variability still prevents a clearer picture from emerging.

Measures of Speech Understanding in Noise for Young Children with a Cochlear Implant in Mainstream and Special Education.

The use of two types of speech-in-noise (SPIN) assessment, namely digits-in-noise self-tests and open-set, monosyllabic word tests, to assess the SPIN understanding performance of children with cochlear implants (CI) in mainstream and special education, was investigated. The tests' feasibility and reliability and the influence of specific cognitive abilities on their results were studied. The results of 30 children with CIs in mainstream and special education were compared to those of 60 normal-hearing children in elementary school. Results indicate that the digit triplet test (DTT) was feasible for all children tested in this study, as seen by the familiarity of all the digits, the high stability of the test results (<3 dB SNR), and a small measurement error (≤2 dB SNR). Remembering full triplets did not form a problem and results did not show systematic attention loss. For children with CIs, the performance on the DTT was strongly related to the performance on the open-set monosyllabic word-in-noise task. However, small but significant differences were observed in the performance of children with CIs in mainstream and special education on the monosyllabic word test. Both tests showed little influence of cognitive abilities, making them both useful in situations where the bottom-up auditory aspect of SPIN performance needs to be investigated or in situations where sentence-in-noise tests are too challenging.

Toward a Listening Training Paradigm: Evaluation in Normal-Hearing Young and Middle-Aged Adults.

OBJECTIVES: Adults' most common complaint relates to understanding speech in noisy environments. Hearing aids can compensate for sensory loss but do not restore hearing to normal. Listening training has the potential to partially remediate these problems. In this study, we propose and evaluate a Flemish version of a listening training paradigm, which involves the use of cognitive control as well as auditory perception. The paradigm entails a discrimination task where participants are cued to attend to one of two concurrent talkers with target speakers randomly varying between a female and a male voice. We evaluate learning effects, different scenarios, and masking types. DESIGN: In total, 70 young and 54 middle-aged adults participated in this study. Each adult performed one or more conditions. Participants' hearing was screened before participation, all middle-aged adults passed a cognitive screening task. RESULTS: Analyses indicated learning effects across scenarios that were similar in terms of speech intelligibility. Our results indicated better speech intelligibility when the female speaker was the target, but speech intelligibility did not differ when the target was the male speaker. An unintelligible masker noise results in worse speech intelligibility than a competing talker masker. Our results suggest that listeners could use an intensity cue to identify and/or select the target speaker when presented at a lower signal to noise ratio (SNR). Error analysis suggested higher cognitive control demands when the target and masker were presented at similar levels (i.e., around 0 dB SNR). The addition of independent trials with the intensity of target and masker reversed improved speech intelligibility. Inhibitory control, but not task switching, was reliably correlated with listening performance. CONCLUSIONS: The proposed paradigm turned out to be feasible and practicable, demonstrating its potential for training speech intelligibility in noise. We believe that this training paradigm can generate real-life benefits including for persons with hearing loss. This latter application awaits future evaluation.

Lilliput: speech perception in speech-weighted noise and in quiet in young children.

OBJECTIVE: The aim of this study was to develop an open-set word recognition task in speech-weighted noise and in quiet for young children and examine age effects for open versus closed response formats. DESIGN: Dutch monosyllabic words were presented in quiet and in stationary speech-weighted noise to 4- and 5-year-old children as well as to young adults in an open-set response format. Additionally, performance in open and closed context was assessed, as well as in a picture-pointing paradigm. STUDY SAMPLE: More than 200 children and 50 adults with normal hearing participated in the various validation phases. RESULTS: Average fitted speech reception thresholds (50%) yielded an age effect between 4-year and 5-year olds (and adults), both in speech-weighted noise and in quiet. The closed-set format yielded lower (better) SNRs than the open-set format, and children benefitted to the same extent as adults from phonetically similar words in speech-weighted noise. Additionally, the 4 AFC picture-pointing paradigm can be used to assess word recognition in quiet from 3 years of age. CONCLUSIONS: The same materials reveal performance differences between 4 and 5 years of age (and adults), both in quiet and speech-weighted noise using an open-set response format. This relatively small yet significant difference in SRT for a gap of only 1 year shows a developmental change for word recognition in speech-weighted noise and in quiet in the first decade of life.The study is part of the protocol registered on ClinicalTrials.gov (ID = NCT04063748).

Comparing the Outcomes of a Personalized Versus Nonpersonalized Home-Based Auditory Training Program for Cochlear Implant Users.

OBJECTIVES: Audiological rehabilitation includes sensory management, auditory training (AT), and counseling and can alleviate the negative consequences associated with (untreated) hearing impairment. AT aims at improving auditory skills through structured analytical (bottom-up) or synthetic (top-down) listening exercises. The evidence for AT to improve auditory outcomes of postlingually deafened adults with a cochlear implant (CI) remains a point of debate due to the relatively limited number of studies and methodological shortcomings. There is a general agreement that more rigorous scientific study designs are needed to determine the effectiveness, generalization, and consolidation of AT for CI users. The present study aimed to investigate the effectiveness of a personalized AT program compared to a nonpersonalized Active Control program with adult CI users in a stratified randomized controlled clinical trial. DESIGN: Off-task outcomes were sentence understanding in noise, executive functioning, and health-related quality of life. Participants were tested before and after 16 weeks of training and after a further 8 months without training. Participant expectations of the training program were assessed before the start of training. RESULTS: The personalized and nonpersonalized AT programs yielded similar results. Significant on-task improvements were observed. Moreover, AT generalized to improved speech understanding in noise for both programs. Half of the CI users reached a clinically relevant improvement in speech understanding in noise of at least 2 dB SNR post-training. These improvements were maintained 8 months after completion of the training. In addition, a significant improvement in quality of life was observed for participants in both treatment groups. Adherence to the training programs was high, and both programs were considered user-friendly. CONCLUSIONS: Training in both treatments yielded similar results. For half of the CI users, AT transferred to better performance with generalization of learning for speech understanding in noise and quality of life. Our study supports the previous findings that AT can be beneficial for some CI users.

Coupling of sensorimotor and cognitive functions in middle- and late adulthood.

Introduction: The present study explored age effects and the coupling of sensorimotor and cognitive functions in a stratified sample of 96 middle-aged and older adults (age 45-86 years) with no indication of mild cognitive decline. In our sensorimotor tasks, we had an emphasis on listening in noise and postural control, but we also assessed functional mobility and tactile sensitivity. Methods: Our cognitive measures comprised processing speed and assessments of core cognitive control processes (executive functions), notably inhibition, task switching, and working memory updating. We explored whether our measures of sensorimotor functioning mediated age differences in cognitive variables and compared their effect to processing speed. Subsequently, we examined whether individuals who had poorer (or better) than median cognitive performance for their age group also performed relatively poorer (or better) on sensorimotor tasks. Moreover, we examined whether the link between cognitive and sensorimotor functions becomes more pronounced in older age groups. Results: Except for tactile sensitivity, we observed substantial age-related differences in all sensorimotor and cognitive variables from middle age onward. Processing speed and functional mobility were reliable mediators of age in task switching and inhibitory control. Regarding coupling between sensorimotor and cognition, we observed that individuals with poor cognitive control do not necessarily have poor listening in noise skills or poor postural control. Discussion: As most conditions do not show an interdependency between sensorimotor and cognitive performance, other domain-specific factors that were not accounted for must also play a role. These need to be researched in order to gain a better understanding of how rehabilitation may impact cognitive functioning in aging persons.

Language-Independent Hearing Screening - Increasing the Feasibility of a Hearing Screening Self-Test at School-Entry.

A tablet-based language-independent self-test involving the recognition of ecological sounds in background noise, the Sound Ear Check (SEC), was adapted to make it feasible for young children. Two experiments were conducted. The first experiment investigated the SEC's feasibility, as well as its sensitivity and specificity for detecting childhood hearing loss with a monaural adaptive test procedure. In the second experiment, the SEC sounds, noise, and test format were adapted based on the findings of the first experiment. The adaptations were combined with three test procedures, one similar to the one used in Experiment 1, one presenting the sounds dichotically in diotic noise, and one presenting all the sounds with a fixed signal-to-noise ratio and a stopping rule. Results in young children show high sensitivity and specificity to detect different grades of conductive and sensorineural hearing loss (70-90%). When using an adaptive, monaural procedure, the test duration was approximately 6 min, and 17% of the results obtained were unreliable. Adaptive staircase analyses showed that the unreliable results probably occur due to attention/motivation loss. The test duration could be reduced to 3-4 min with adapted test formats without decreasing the test-retest reliability. The unreliable test results could be reduced from 17% to as low as 5%. However, dichotic presentation requires longer training, reducing the dichotic test format's feasibility.

Age-related hearing loss is associated with alterations in temporal envelope processing in different neural generators along the auditory pathway.

People with age-related hearing loss suffer from speech understanding difficulties, even after correcting for differences in hearing audibility. These problems are not only attributed to deficits in audibility but are also associated with changes in central temporal processing. The goal of this study is to obtain an understanding of potential alterations in temporal envelope processing for middle-aged and older persons with and without hearing impairment. The time series of activity of subcortical and cortical neural generators was reconstructed using a minimum-norm imaging technique. This novel technique allows for reconstructing a wide range of neural generators with minimal prior assumptions regarding the number and location of the generators. The results indicated that the response strength and phase coherence of middle-aged participants with hearing impairment (HI) were larger than for normal-hearing (NH) ones. In contrast, for the older participants, a significantly smaller response strength and phase coherence were observed in the participants with HI than the NH ones for most modulation frequencies. Hemispheric asymmetry in the response strength was also altered in middle-aged and older participants with hearing impairment and showed asymmetry toward the right hemisphere. Our brain source analyses show that age-related hearing loss is accompanied by changes in the temporal envelope processing, although the nature of these changes varies with age.

Intracochlear pressure as an objective measure for perceived loudness with bone conduction implants.

BACKGROUND: The generally accepted method to assess the functionality of novel bone conduction implants in a preclinical stage is to experimentally measure the vibratory response of the cochlear promontory. Yet, bone conduction of sound is a complex propagation phenomenon, depending on both frequency and amplitude, involving different conduction pathways. OBJECTIVES: The aim of this study is to validate the use of intracochlear sound pressure (ICP) as an objective indicator for perceived loudness for bone conduction stimulation. It is investigated whether a correlation exists between intracochlear sound pressure measurements in cadaveric temporal bones and clinically obtained results using the outcome of a loudness balancing experiment. METHODS: Ten normal hearing subjects were asked to balance the perceived loudness between air conducted (AC) sound and bone conducted (BC) sound by changing the AC stimulus. Mean balanced thresholds were calculated and used as stimulation levels in a cadaver trial (N = 4) where intracochlear sound pressure was measured during AC and BC stimulation to assess the correlation with the measured clinical data. The intracochlear pressure was measured at the relatively low stimulation amplitude of 80 dBHL using a lock-in amplification technique. RESULTS: Applying AC and BC stimulation at equal perceived loudness on cadaveric heads yield a similar differential intracochlear pressure, with differences between AC and BC falling within the range of variability of normal hearing test subjects. CONCLUSION: Comparing the perceived loudness at 80 dB HL for both AC and BC validates intracochlear pressure as an objective indicator of the cochlear drive. The measurement setup is more time-intensive than measuring the vibratory response of the cochlear promontory, yet it provides direct information on the level of the cochlear scalae.

Longitudinal auditory data of children with prelingual single-sided deafness managed with early cochlear implantation.

Individuals with single-sided deafness (SSD) have no access to binaural hearing, which limits their ability to localize sounds and understand speech in noisy environments. In addition, children with prelingual SSD are at risk for neurocognitive and academic difficulties. Early cochlear implantation may lead to improved hearing outcomes by restoring bilateral hearing. However, its longitudinal impact on the development of children with SSD remains unclear. In the current study, a group of young children with prelingual SSD received a cochlear implant at an early age. From the age of four, the children's spatial hearing skills could be assessed using a spatial speech perception in noise test and a sound localization test. The results are compared to those of two control groups: children with SSD without a cochlear implant and children with bilateral normal hearing. Overall, the implanted group exhibited improved speech perception in noise abilities and better sound localization skills, compared to their non-implanted peers. On average, the children wore their device approximately nine hours a day. Given the large contribution of maturation to the development of spatial hearing skills, further follow-up is important to understand the long-term benefit of a cochlear implant for children with prelingual SSD.

The Impact of Location and Device Coupling on the Performance of the Osia System Actuator.

Active transcutaneous bone conduction (BC) devices offer the benefit of improved power output compared to passive transcutaneous devices and remove the risk of skin infections that are more common in traditional percutaneous BC devices. Despite these advantages, more research is needed on implant location, device coupling, and their influence on device performance. This study is aimed at quantifying the extent to which certain parameters affect device output when using the Osia® system actuator. Parameters under study are (1) implant location, (2) comparison with the actuator of a state-of-the-art BC device, (3) bone undergrowth simulation, and (4) skull fixation. Five human cadaveric heads were implanted with the actuator at three different implant locations: (1) recommended, (2) posterior Osia® positions, and (3) standard Baha® position. At each location, the cochlear promontory velocity and the intracochlear pressure difference were measured. A percutaneous bone conduction actuator was used as a reference for the obtained measurements. Stimulation levels corresponded to a hearing level of 60 dB HL for frequencies between 250 and 6000 Hz. In addition, bone cement was used as a simulation for reactive bone growth. Results obtained in four heads indicate an improved power transmission of the transcutaneous actuator when implanted at the recommended position compared to the actuator of the percutaneous device on its respective recommended location when stimulating at an identical force level. A correlation was found between the promontory vibration and the actuator position, indicating that the same level of stimulation leads to higher promontory vibrations when the device is implanted closer to the ear canal. This is mainly reflected at frequencies higher than 1 kHz, where an increase was observed in both measurement modalities. At lower frequencies (<1 kHz), the power transmission is less influenced by the implant position and differences between the acquired responses are limited. In addition, when no rigid coupling to the skull is provided, power transfer losses of up to 30 dB can be expected.

The Intelligibility of Time-Compressed Speech Is Correlated with the Ability to Listen in Modulated Noise.

Speech perception in difficult listening conditions depends highly on the temporal processing ability of the auditory pathway. In the present study, we investigate the inter-subject variability of young normal-hearing listeners in the identification of time-compressed speech and how the ability to identify time-compressed speech, as assessed by the speech reception threshold (SRTrate: the speech rate at which 50% of the speech is perceived correctly) is associated with the ability to identify speech in unmodulated (SRTunmod) and modulated noise (SRTmod). These tasks are highly dependent on the temporal processing abilities of the auditory pathway. We observed a large inter-subject variability in the SRTrate and found that it is significantly correlated with the SRT when listening to unmodulated and modulated noise. Furthermore, we found that listeners who are better at perceiving speech at high rates are better in listening to speech in modulated noise. This effect persisted even when controlling for their ability to perceive speech in unmodulated noise. In addition, we also found that an increase in speech rate from 2.7 to 6.6 syllables per second resulted in a reduction in glimpsing of 5.3 dB when listening to speech in a 4-Hz amplitude-modulated masker, even though speech in quiet was 100% intelligible at both rates. These results indicate that the ability of young normal-hearing individuals to efficiently process temporal features of speech is an imperative factor when listening to speech in difficult listening situations.

Instant improvement in monaural spatial hearing abilities through cognitive feedback.

Several studies report that sound localization performance of acute and chronic monauralized normal-hearing listeners can improve through training. Typically, training sessions are administered daily for several days or weeks. While this intensive training is effective, it may also be that monaural localization abilities improve instantly after providing explicit top-down information about the direction dependent change in timbre and level. The aim of the present study was to investigate whether cognitive feedback (i.e., top-down information) could instantly improve sound localization in naive acutely monauralized listeners. Forty-three normal-hearing listeners (experimental group), divided over five different centers, were tested. Two control groups, consisting of, respectively, nine and eleven normal-hearing listeners, were tested in one center. Broadband sounds (0.5-20 kHz) were presented from visible loudspeakers, positioned in azimuth (- 90° to 90°). Participants in the experimental group received explicit information about the noticeable difference in timbre and the poor localization in the monauralized listening condition, resulting in an instant improvement in sound localization abilities. With subsequent roving of stimulus level (20 dB), sound localization performance deteriorated immediately. The reported improvement is related to the context of the localization test. The results provide important implications for studies investigating sound localization in a clinical setting, especially during closed-set testing, and indicate the importance of top-down information.

The digit triplet test as a self-test for hearing screening at the age of school-entry.

OBJECTIVE: The current study aimed to investigate the feasibility of the digit triplet test (DTT) as a self-test in normal-hearing children at school-entry age (5-6 years) compared to an administrator-controlled test. DESIGN AND STUDY SAMPLE: Thirty-seven first grade elementary school children took part in this study. Next to a pure-tone screening, the test battery consisted of a DTT speech-in-noise screening (self-test and administrator-controlled assessment), and cognitive tests related to auditory/working memory and attention skills. RESULTS: The reference-SRT ± 2SD, obtained with the administrator-controlled DTT, was -9.8 ± 1.6 dB SNR, and could be estimated with a precision of 0.7 dB. The test duration for one ear was about 4.5 min. Self-tests resulted in higher (poorer) SRTs. Only a small proportion of children performed stably across repeated self-test administrations. With about 6 min for one ear, the test duration was rather long. The influence of auditory/working memory and attentional abilities appeared to be limited. CONCLUSION: Our data suggest that a self-administered DTT is not suitable for a large proportion of children at school-entry.