Auditory processing screening and behavioral evaluation in students: establishing relations

Abstracts

Purpose

to characterize the auditory processing of students who failed in the simplified evaluation of the auditory processing and compare these found results with the results in the behavioral auditory processing evaluation.

Methods

it was performed the basic audiological evaluation (vocal and tonal audiometry and acoustic immitance measurements), the behavioral battery of the auditory processing, composed by the PSI (Pediatric Speech Intelligibility) portuguese version, PPS (Pitch Pattern Sequence), MLD (Masking Level Difference), SSW (Stagged Spondaic Words) portuguese version and GIN (Gap in Noise), and the retest of the simplified evaluation of the auditory processing with students from nine to fourteen years old registered between 4^th to 8^th grade of a public school in Porto Alegre.

Results

ten (90,9%) out of the eleven evaluated students that failed in the simplified evaluation showed alterations in the behavioral battery of auditory processing tests. The subprofiles which had the major number of alterations were the ones of decoding and integration, the most impaired auditory abilities were binaural interaction and separation and binaural integration concomitantly. There was no relevant association between the tasks of the simplified evaluation and the tests of the behavioral battery when comparing the same neuralphisiological report or similar task.

Conclusion

it was possible to characterize the auditory processing of the analyzed students. From the comparison between the simplified evaluation and the behavioral battery it was noted that the simplified evaluation can be a sensible predictor to the alterations of the auditory processing, in spite of not identifying the specific association between the compared abilities.

Auditory Perception; Child; Hearing Disorders

Objetivo

caracterizar o processamento auditivo de escolares que falharam na avaliação simplificada do processamento auditivo e comparar esses achados com os resultados na avaliação comportamental do processamento auditivo.

Métodos

realizou-se a avaliação audiológica básica (audiometria tonal e vocal e medidas de imitância acústica), bateria comportamental do processamento auditivo composta pelos testes PSI (Pediatric Speech Intelligibility) versão em português, PPS (Pitch Pattern Sequence), MLD (Masking Level Difference), SSW (Stagged Spondaic Words) versão em português e GIN (Gap in Noise) e reteste da avaliação simplificada do processamento auditivo com escolares de 9 a 14 anos, matriculados entre o 4º ano e a 8ª série do ensino fundamental de uma escola de ensino público de Porto Alegre.

Resultados

dos 11 escolares avaliados que falharam na avaliação simplificada, 10 (90,9%) apresentaram alterações na bateria comportamental do processamento auditivo. Os subperfis com maior número de alterações foram os de decodificação e integração, as habilidades auditivas mais prejudicadas foram de interação binaural e separação e integração binaural concomitantemente. Não houve associação significante entre as tarefas da avaliação simplificada e os testes da bateria comportamental ao comparar o mesmo correlato neurofisiológico ou tarefa semelhante.

Conclusão

foi possível caracterizar o processamento auditivo dos escolares avaliados. A partir da comparação entre a avaliação simplificada e a bateria comportamental verificou-se que a avaliação simplificada pode ser um preditor sensível às alterações de processamento auditivo, apesar de não se identificar associação específica entre as habilidades comparadas.

Percepção Auditiva; Criança; Transtornos da Audição

INTRODUCTION

The hearing is an essential sense, which allows us to interact with the world, reacting before the sounds. However, listening is not enough to understand the sound message. It is necessary the development of different auditory abilities that depend on both, the integrity of the auditory system at birth and the acoustic experience in the environment ¹, enabling the processing and the understanding of the content heard.

The auditory processing involves the skills of listening, recognizing and answering the information heard through the ear canals, by the detection of the sound by the external ear and its transmission through the auditory pathways until the brain², i.e. refers to the set of specific skills on which the individual depends to interpret what is heard³. Thus, what is done with what is heard is the result of the skills necessary for acoustic analysis and its interpretation. For this reason, it is not enough to have normal hearing thresholds. It is necessary to develop such skills from the first auditory experiences in the first years of life ⁴.

The auditory skills impairments manifest themselves through the auditory processing disorder (APD), which is characterized b’y difficulties in processing auditory information by the central nervous system, and by a deficit of one or more skills: sound localization, discrimination, sound recognition, auditory binaural interaction, temporal aspects of hearing (temporal sequence and resolution), auditory performance with acoustic signals in competition, auditory performance in unfavorable acoustic situations. The auditory abilities assessed by means of behavioral tests are: binaural interaction, auditory figure-ground, temporal resolution, binaural separation and integration, and temporal ordering⁵.

The evaluation of the auditory processing allows you to sort out the auditory processing disorders in sub-profiles, three of them primary and two secondary. The primary sub-profiles are: auditory decodification, prosody and integration; and the secondary ones are: auditory association and output organization⁶.

In the auditory processing evaluation it is crucial to consider the age range of individuals, since the performance in tests increases with the advancement of age until the pre-adolescence, having little variation in adult age. The students participating in the present study, may take the following tests: verbal and non-verbal sequential memory, , sound localization, PSI (Pediatric Speech Intelligibility), dichotic digits, SSW (Staggered Spondaic Words), filtered speech, binaural fusion, PPS (Pitch Pattern Sequence), DPS (Duration Pattern Sequence), RGDT (Random Gap Detection Test) and GIN (Gap in Noise) ⁷.

Children with APD often present a wide variety of school and communicative complaints, including inability to follow complex verbal instructions, poor verbal cognitive performance if compared with the non-verbal performance, reading and writing difficulties, language delay, difficulty of coping with competitive sounds and of sustaining the attention to the information aurally/verbally presented⁶.

These manifestations, among others, when generated by alterations in auditory abilities, may be confirmed by electrophysiological measures that verify the integrity of the auditory pathway, and by behavioral tests that evaluate the auditory function. The main objective of the evaluation of the children auditory processing is to check the integrity and the neuromaturation status of the auditory pathway⁸ in order to be able to characterize the disorder and to direct the hearing rehabilitation.

Evaluate the auditory processing in children at school age contributes to early diagnosis of APD and enables the appropriate therapeutic orientation⁹.

Several studies^10-13 utilized the screening for auditory processing disorders (APD) as an instrument for the detection of possible disorders of the auditory processing^1,13-15 . It is known the importance of the use of screening for APD within the school ambit¹ since auditory processing disorders may be related to learning alterations^13,16,17, language¹⁵ and phonological awareness¹⁰ problems , reading and writing difficulties¹⁸ among other difficulties that can negatively interfere in the school performance.

Some studies^11-13,17 used the screening for APD as an instrument of auditory processing screening, because besides being an easy and quick application tool, it may indicate, based on a low resulting performance, a possible impairment of the hearing function, which will require a more complete assessment ¹⁷. Thus, the objective of this work was to characterize the auditory processing of schoolchildren who failed in the screening for auditory processing disorders and compare the findings of the screening with the results obtained in the behavioral evaluation of the auditory processing.

METHODS

The research was approved by the Research Ethics Committee of the Federal University of Health Sciences, Porto Alegre (CEP/UFCSPA), according to the 870/11 Opinion. In accordance with the ethical principles of research involving human beings, the participants were evaluated voluntarily, subject to the prior consent of their legal guardians, by means of the signature of the Free and Informed Consent Term (FICT). In addition, the subject himself authorized, formally, his participation in the research by means of his signature of the Assent/Consent Term for children, which is required by the CEP/UFCSPA for researches involving children.

This is a descriptive field research, with a quantitative prospective and cross-sectional data collection.

The population of the study included students from a public network school of Porto Alegre (RS) who attended classes from the 4^th to the 8^th grade of elementary school. The schoolchildren, male and female, ranged between nine and 14 years old.

In 2011, these students performed the screening for auditory processing disorders^19,20, in a school environment. The screening for APD was performed individually in a quiet room. The following replies were considered normal for the different skills tested: non-verbal sequential memory (to understand the request and reply with at least two sequences of four sounds in three presentations), verbal sequential memory (to reply with at least two sequences of four syllables in three presentations), sound localization (to answer at least four of the five directions presented, inclusive the lateral localization which must be present). The subjects who presented these answers received the result “passed” to their tests. The others, with lower results, received the answer “failed”.

Telephone contact was made with the legal responsibles for the students who had failed in this screening and they were invited to participate in the additional audiological assessment and in the auditory processing evaluation by means of behavioral battery. Out of the 157 students screened, 43 (27.3%) failed and were invited for this search. Of these, 20 agreed to participate, but only 13 came for the proposed procedures.

The criteria for the inclusion of individuals in the sample were: airway hearing thresholds equal to or less than 15dB at frequencies of 500, 1000, 2000 and 4000Hz in both ears; tympanometric curves type A²¹ in both ears; the retest of the screening for APD failure on the evaluation; presence of cochleo-palpebral reflex, and absence of proven record of developmental disorders. The use of this last inclusion criterion is due to the fact that the performance of the auditory processing tests depends on the integrity of the central auditory pathways as well as of the integrative areas. Thus, children with noticeable alterations in their motor, linguistic and cognitive development were not included in the study.

Of the 13 students coming for the proposed procedures, one was excluded due to altered tympanometric curve and history of atypical development evidenced during anamnesis, and one was excluded for having passed the retesting of the screening for APD. Thus, the sample was reduced to 11 students.

The complementary audiological evaluation included: inspection of the external acoustic meatus; pure tone audiometry through bone and air conduction at 500, 1000, 2000 and 4000Hz; speech recognition threshold²²; percentual index of speech recognition²³ performed at 40dB above the tritonal average of 500, 1000 and 2000Hz; acoustic immittance measures, including tympanometric curve and the ipsilateral and contralateral acoustic reflexes at 500, 1000, 2000 and 4000Hz.

The auditory processing evaluation was composed of the following procedures: retest of the screening for APD ^19,20 to check if the initial results were maintained; PSI (Pediatric Speech Intelligibility) Portuguese version²³ with ipsilateral competitive message; PPS (Pitch Pattern Sequence)²⁴; MLD (Masking Level Difference) ²⁵; SSW (Staggered Spondaic Words)Portuguese version²³; GIN (Gaps in Noise) ²⁶.

The selection of tests for the auditory processing evaluation was based on the American Speech-Language Hearing Association (ASHA) recommendations⁵ which recommends that this battery includes tests of temporal processing (GIN, PPS), dichotic with speech stimuli (SSW, PSI) and recognition of low redundancy (PSI), binaural interaction (MLD). Each test was performed according to its manual, and a specific pattern of normality in accordance with the age was used^19,23,24,26.. Children whose tests resulted altered were forwarded to speech rehabilitation with emphasis on auditory processing.

The assessments took place from July to August 2012 at Clinicas Integradas of Centro Universitário Metodista - IPA. On the evaluation day, the responsible for the schoolchildren responded to an anamnesis geared towards children with auditory processing alterations²³.

For the pure tone audiometry and for the behavioral assessment of auditory processing the AC33 Interacoustics audiometer was used, duly calibrated and coupled to a Panasonic DVD player for accomplishing the behavioral tests of auditory processing. But the acoustic immittance measures (tympanometry and acoustic reflex test) were carried out with the AT 22t Interacoustics equipment, also properly calibrated.

After the procedures completion, the results were analyzed using the Fisher’s Exact Test, an association test. This test aims to verify if two variables are significantly associated. It is an alternative for the Chi-square Test, for studies based on small samples. For the test, the maximum level of significance was 5% (p£0,05) and the software used for the statistical analysis was the Statistical Package for Social Science (SPSS) version 13.0.

RESULTS

Figure 1 shows the distribution of the sample in relation to age, sex and grade. The average age was 11.1 years with a variation of 2.1 years. Out of the 11 individuals of the sample, eight were male (72.7%). There was a greater number of participants attending the 4^th grade at school (45.5%), being nine the predominant age-group (36.4%).

The altered sub-profiles and skills of the sampled individuals can be observed in Table 1. Binaural interaction, and separation and binaural integration occurring concomitantly were the skills that showed the highest prevalence of changes, occurring in eight students (72.7 % ), and the decoding and integration sub-profile was the most altered, occurring in seven individuals in the sample (63.6 % ).

Table 2 shows the number of schoolchildren who failed in more than one skill, in only one (binaural interaction), or who did not fail in any of them. The majority of individuals in the sample (81.8 %) presented failure in more than one skill of the auditory processing.

Table 3 presents the results of the screening for APD and of each test of the auditory processing behavioral battery. The tests with the highest number of alterations were the SSW and the PPS, in which nine (81.8 %) of the individuals presented alterations.

Table 4 presents the relationship between the students who failed the screening for APD and those who showed alteration in the battery of tests of auditory processing. The sensitivity test showed 90% as the sensitivity value for the screening for APD in which the schoolchildren had failed.

Associations between the results of the assessments and the students age, sex and school grade were made, but they were not statistically significant (p> 0.05)

Table 5 presents comparative data between the battery tests of auditory processing and the screening for APD tasks by neurophysiological correlate.

Table 5 shows the comparison between the sound localization (SL) task and the MLD and the PSI tests. From this comparison, no significant association (p>0.05) between the variables presented in Table 5 was found.

DISCUSSION

To interpret acoustic information, the integrity of the whole set of the auditory processing skills is required¹⁴. In the present study, the skills in which the individuals presented more failure were binaural interaction (72.7 %) and binaural separation and integration (72.7 %), and most of the sample demonstrated deficits in more than one ability (81.8 %). The binaural separation and integration is revealed²⁷ to be one of the most altered skills in children, corroborated by the study¹⁸ conducted with 15 schoolchildren, from eight to 12 years old, which showed that all the participants presented alterations in at least one hearing skill, and the binaural interaction showed the greatest number of failures.

The sub-profiles with more alterations were the decoding and the integration, when concomitant (63.3 % ). Such findings are consistent with similar study involving children aged 7 to 11, in which the same sub-profiles were the most altered, occurring in 19 (90.4 %) of the 21 participants of the sample¹⁷. Another study²⁸ carried out with 15 children that were assessed by means of the SSW test showed that 8 (53.3 %) of them presented the decoding sub-profile altered.

The screening for APD assesses the skills of sound localization, verbal and non-verbal sequential memory¹⁹, which may be considered simple tasks. Thus, when these skills are altered, there is a strong probability that the auditory processing behavioral tests result altered, since they have more complex tasks than the screening for APD. In the present study, only one child (9.1 % ), among the 11 who failed the screening for APD, presented normal results in the behavioral tests, demonstrating that the screening for APD should be used as a screening instrument integrating other protocols as demonstrated in other studies^1,10,12.

In screening for APD, the most altered skill was the SL (54.5 %), and the verbal and non-verbal sequential memory were altered in 27.3% of the sample. Such results did not corroborate the studies that had used the same evaluation instrument^14,15 and that had found more alterations in verbal sequential memory. This divergence between the results may be attributed to the fact that the sample of the present study is small.

Among the behavioral tests of auditory processing, the SSW and the PPS showed a larger number of failures, having nine of the 11 children presented alterations. The large number of alterations in the SSW test can be attributed to the fact that it evaluates various auditory abilities, especially if used with other tests of the behavioral battery. For this reason, studies^29,30. use the SSW as an important instrument for the detection of auditory processing disorders.

The PSI test showed alteration in only two children. Perhaps because the test seems to be easy for children from the fourth to the eighth grade, as demonstrated another study¹³, which also used the PSI with children from nine to 11 years old, and found failure in only two of the 28 participants. It is worth mentioning that the children’s version was performed by all participants with the purpose of having their results compared under the same modality. That is, some children would not be able to perform a version in which the reading was required. Thus, it was agreed to use the children’s version so that the children could be assessed under the same modality (visual identification of figures). If some individuals performed the test by means of recognizing pictures and others by recognizing sentences, the comparison between the versions could present discrepancies.

The SL task and the MLD and PSI testes were compared in order to find a correlation between them because they are mediated by the same neurophysiological structure, namely, the brainstem⁶. With regard to MLD, the ability to detect the signal in background noise depends on the temporal and the spectral characteristics of pure tone and masking noise, as well as on the interaural difference between them. In this way, the lower brainstem is activated to facilitate the perception when the pure tone and the masking noise are out of phase (when they occur at different times), whereas when they are in phase (when they occur at the same time), such facilitation does not happen³¹. The PSI test evaluates the auditory figure-ground because it is a test in which the competitive message has the role to reduce the extrinsic redundancy of the message, so that the brainstem can lead the perceptually more important acoustic characteristics to the primary auditory cortex, delaying the other ones⁶. Another study showed that the version used for adults aimed to identify some brainstem subtle alterations³¹.

No studies that compared the tasks of the screening for APD and the behavioral tests of auditory processing were found in literature. Likewise, the fact that the comparisons between the tasks of the screening for APD and the battery tests of behavioral auditory processing do not indicate any statistically significant relationship, demonstrates the possible absence of direct relationship between the screening for APD and the battery of tests, since they do not assess the auditory processing in the same way. Therefore, it is suggested the use of the screening for APD as an indicator of the need to carry out the assessment of the auditory processing through the behavioral battery.

In this study, it was possible to identify alterations in the auditory processing skills in 90.9% of individuals who failed in the screening for APD, which demonstrates that the screening for APD is a useful tool, together with other instruments, for screenings in the school environment^10,11. It is worth observing that, if used in isolation, the screening may offer misinterpretations, causing damage to the treatment. In addition, among the consulted studies, none of them used it as a single diagnosis tool.

It is known that the auditory abilities impairment may be found in comorbidity with language, speech and writing problems as well as with low school performance³⁰. Therefore, it must be emphasized the importance of the speech pathologist action in schools, in order to provide an appropriate treatment for the APD cases.

Thus, it is important to highlight the need of further researches with substancial samples, in order to add greater credibility to the hypotheses presented.

CONCLUSION

It was possible to characterize the auditory processing of the schoolchildren of the sample, who presented more difficulties in the binaural interaction and in the binaural separation and integration, and in sub-profiles of decoding and integration when occurring concomitantly.

There was no statistically significant association between the tasks of the screening for APD and the behavioral tests of the auditory processing. However, from the comparison between them it was realized that the screening for APD may be a sensitive predictor of impairments in the auditory processing, although no specific associations between the abilities compared were identified. Thus, it is suggested to carry out a behavioral evaluation of the auditory processing with those individuals who fail in the screening for APD. Besides, the importance of the auditory processing screenings among the school population deserves special attention due to the close relationship between auditory skills and learning acquisition.

Figure 1
–Distribution of the sample by age, sex and school grade

Table 1
– Altered skills and sub-profiles

Variable	Category	N cases	%
Altered skills	Binaural Interaction	8	72,7
	Binaural Separation and integration	8	72,7
	Temporal resolution	3	27,3
	Temporal pattern	3	27,3
	Figure-ground	1	9,1
Altered sub-profiles	Integration	1	9,1
	Association	1	9,1
	Prosody	-	-
	Decodiing	-	-
	Output Organization	-	-
	None	1	9,1
	Decoding+ integration	7	63,6
	Decoding+ integration+ Output organization	1	9,1

Table 2
– Altered skills

Variable	Category	N cases	%
Altered Skills	None	1	9,1
	One	1	9,1
	More than one	9	81,8

Table 3
Results of the screening and of the behavioral auditory processing evaluations

Test		Normal		Alterad
		n	%	n	%
ASPA	VSM	8	72,7	3	27,3
	NVSM	8	72,7	3	27,3
	SL	5	45,5	6	54,5
SSW		2	18,2	9	81,8
PSI		9	81,8	2	18,2
PPS		2	18,2	9	81,8
GIN		8	72,7	3	27,3
MLD		5	45,5	6	54,5

• Screening: Screening for auditory processing disorders
  VSM: Verbal sequential memory
  NVSM: Non-verbal sequential memory
  SL: Sound Localization
  SSW: Staggered Spondaic Words
  PSI: Pediatric Speech Intelligibility
  PPS: Pitch Pattern Sequence
  GIN: Gap in Noise
  MLD: Masking Level Difference

Table 4
Results of the auditory processing tests battery x Screening for APD

Tests Battery	Screening for APD		Total
	Altered *
	N	%	N	%
Normal	1	9,1	1	9,1
Normal	10	90,9	10	90,9
Total	11	100	11	100

• ^*
  The sensibility value of 90% obtained with students who failed in the Screening for auditory processing disorders. Sensibility is the proportion of individuals with altered results who are precisely identified by the test. It indicates how good the test is at identifying the impairment in question. For this research data the sensibility value is 90,0%.

Table 5
Comparison between the sound localization task (SL) and the testes MLD e PSI

Variable	Category	SL				p*
		Normal		Altered
		N	%	n	%
MLD	Altered	4	80,0	1	16,7	0,080 ns**
	Normal	1	20,0	5	83,3
PSI	Altered	3	60,0	6	100,0	0,182 ns**
	Normal	2	40,0	-	-

• ^*
  Value of p ref to Fisher Exact Test, the maximum significance level assumed was 5% (p≤0,05).
• ^**
  non-significant
• MLD: Masking Level Difference
  PSI: Pediatric Speech Intelligibility
  SL: Sound Localization

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Publication Dates

• Publication in this collection
  Jul-Aug 2014

History

• Received
  27 Jan 2013
• Accepted
  09 July 2013