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International Journal of Pedi

jo ur n al ho m ep ag e: ww w.elSeveral researchers [16] have considered administration ofscreening for auditory processing disorders (APD) to be importantfor spreading awareness; early identication; planning manage-ment strategies; and making educational recommendations. Overthe last three decades, a number of screening checklists [712] andscreening tests [1317] have been proposed and used. In general, itis claimed that screening tests are better than checklists orquestionnaires for APD in terms of their sensitivity and specicity[18,19].

Jerger and Musiek [20], in a report of the consensus statementof the Conference on the Diagnosis of Auditory ProcessingDisorders in School-Aged Children, made recommendations fora screening procedure for APD. They advocated that a screeningtest for APD should consist of the following: tasks to tap processingof complex auditory stimuli such as temporal processing andspatial resolution; provide information on the sensitivity, and

specicity, inter-observer reliability, inter-test consistency, andvalidity. Further, it was emphasized that any new screening testshould have the optimum number of items for response,appropriate stimulus intensity and the expected response; beminimally inuenced by cognitive, attention, and linguisticdemands; and be brief (ideally 812 min). Similarly, Schow andSeikel [19] opined that a screening instrument should have a highsensitivity and specicity.

According to the American Speech-Language Hearing Associa-tion (ASHA) [21], the results of screening procedures should becompared to a gold standard to obtain their sensitivity andspecicity. Due to varying proles of APD, it has been reported thatit is difcult to dene the gold standard to measure the sensitivityand specicity of tests of central auditory dysfunction [2123]. Inthe past, several researchers [2,2426] and organizations [21,27]have recommended a test-battery approach to evaluate theefciency of screening tests.

Reports regarding the sensitivity and/or the specicity ofvarious screening tools for APD have not been very promising.Cherry [28] administered the Selective Auditory Attention Test, ascreening test, on 321 children in the age group of four to eightyears. It was found to detect 90% of children with learning

Accepted 17 December 2013

Available online 4 January 2014

Keywords:

Auditory processing disorders

Screening

Sensitivity

Specicity

Reliability

memory. The sensitivity and specicity were ascertained by comparing the results of the screening test

with that of diagnostic tests for auditory processing.

Methods: The STAP was administered on 500 school going children in the age range of 813 years. These

consisted of 141 children who were found at-risk on the Screening Checklist for Auditory Processing

(SCAP). Diagnostic APD tests (speech-in-noise, dichotic CV, gap detection and auditory memory) were

administered on 152 of the children referred and/or passed on the screening procedures.

Results: The results from the STAP indicated that the auditory memory subsection of the STAP was the

most affected followed by dichotic CV and speech-in-noise. Gap detection was the least affected among

the four subsections. A high and signicant correlation was noted between the subsections of the STAP

and the APD diagnostic tests. The sensitivity and specicity of the STAP on comparison with the

diagnostic tests was found to be 76.6% and 72%, respectively. It was found that when a combination of

SCAP and STAP was used for screening, the sensitivity and specicity were higher.

Conclusion: Based on the ndings of the study, it is recommended that both SCAP and STAP be

administered. Further, there was also a good testretest reliability of the SCAP, STAP and the APD

diagnostic tests.

2013 Elsevier Ireland Ltd. All rights reserved.

* Corresponding author. Laboratory for Language, Learning and The Brain, G36,

Leung kau Kui Building, The Chinese University of Hong Kong, Sha Tin, NT, Hong

Kong. Tel.: +852-39433779.

E-mail address: akshay@cuhk.edu.hk (A.R. Maggu).

0165-5876/$ see front matter 2013 Elsevier Ireland Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ijporl.2013.12.025Validation of the Screening Test for Auschool-aged children

Asha Yathiraj a, Akshay Raj Maggu b,*aDepartment of Audiology, All India Institute of Speech and Hearing, Manasagangotri,bDepartment of Linguistics and Modern Languages, The Chinese University of Hong Ko

A R T I C L E I N F O

Article history:

Received 13 September 2013

Received in revised form 21 October 2013

A B S T R A C T

Objectives: The present stu

that contains four subsectory Processing (STAP) on

ore 570006, India

Sha Tin, NT, Hong Kong

focussed on validating the Screening Test for Auditory Processing (STAP)

s: speech-in-noise, dichotic consonant vowel, gap detection and auditory

atric Otorhinolaryngology

s evier . c om / lo cat e/ i jp o r l

A. Yathiraj, A.R. Maggu / International Journal of Pediatric Otorhinolaryngology 78 (2014) 479488480disability. However, the number of children identied with APD,was not mentioned. Similarly, SCAN developed by Keith [14] wascriticized by Stach [29] for being uncertainly sensitive to APD. In2009, an improvised version of SCAN was developed by Keith.According to a technical report by Keith [30], SCAN 3A has asensitivity of 93% but a sensitivity of only 49%. On the other hand,Domitz and Schow [16] employed the Multiple Auditory Proces-sing Abilities (MAPA) and SCAN on 81 children studying in thirdgrade. MAPA was found to have a low sensitivity of 3040% whilethe specicity was 100%. They also reported that the SCAN had alow sensitivity of 45% with a specicity of 95%.

In order to increase the sensitivity and specicity of a screeningprocedure, Schow and Seikel [19], based on the ndings ofShiffman [31] recommended the use of a combination of ascreening questionnaire and a screening test. Shiffman [31] foundthe combination to result in a sensitivity of 83% and specicity of85%. In the view of this, Schow and Seikel [19] suggested that acombination of MAPA and Scales for Auditory Behaviors could helpstudy the comorbidity of APD with other disorders such asAttention Decit Hyperactivity Disorder (ADHD), learning disabil-ity (LD) and autism disorder.

Another important factor in determining the efciency of ascreening procedure is the duration taken by a screeningprocedure. According to the consensus statement [20], a screeningprocedure should be between 8 and 12 min. However, the timetaken to administer SCAN is 20 min [32] while the time taken byMAPA is 30 min [16]. Recently, the Screening Test for AuditoryProcessing (STAP), developed by Yathiraj and Maggu [4] wasreported to take approximately 12 min for administration andscoring [46]. This screening test that has 4 subsections (speech-in-noise, dichotic CV, gap detection, auditory memory) was testedfor its relationship with the Screening Checklist for AuditoryProcessing (SCAP) [7,8] by Yathiraj and Maggu [5]. Only 7.8%among the total children studied were at-risk on both thescreening procedures and 20.5% were considered at-risk on eitherone of the screening procedures. However, data based ondiagnostic testing were not mentioned.

Keeping these issues in mind, the present study was carried outwith two aims. The rst aim was to test the sensitivity andspecicity of STAP. The second was to test the efcacy of STAP incombination with SCAP as both the screening procedures focus ondifferent aspects of auditory processing.

1. Method

The study was carried out in two stages. The rst stage involvedadministering the SCAP [7,8] and STAP [46] on school-goingchildren aged 813 years. In the second stage, three groups ofchildren, categorized based on the ndings of the screeningchecklist and/or screening test, were tested on a diagnostic testbattery.

1.1. Participants

For stage one of the study, children studying in regular schoolsin the age range of 813 years were recruited for the study. All thechildren studied in grades IIIVIII. None of the 2400 childrenselected for the study had complaints or history of hearing loss, eardischarge, communication problems or any psychological pro-blems, based on their school screening reports. It had beenestablished by psychologists visiting the schools that the child hadaverage to above average intelligent quotients. The SCAP wasadministered by 35 school teachers who had taught the childrenfor at least one year. All the teachers taught curricular subjectsother than second language. These teachers were selected so thatthey had a good idea about the pedagogic performance of thechildren that was not compromised by a lack of exposure to aregional language. In addition to being evaluated by the SCAP, 500children were also evaluated using the STAP. These 500 childrenconsisted of those who were suspected to have APD as well asthose children without symptoms of APD.

For the second stage of the study, 152 children were evaluatedon diagnostic tests. These children were semi-randomly selectedchildren from among the 500 children tested on both the SCAP andthe STAP. The 152 children represented three groups based on theirperformance on only SCAP (Group 1), only STAP (Group 2) and onSCAP as well as STAP (Group 3). Thus, Group 1 included those whowere referred (N = 30) and passed (N = 15) the SCAP but were notreferred on the STAP; Group 2 included those who were referred(N = 30) or passed (N = 25) on the STAP but were not referred on theSCAP; and Group 3 included those who were referred (N = 31) andpassed (N = 21) on both SCAP and STAP.

1.2. Instrumentation and environment

The four subsections of STAP screened for auditory processes/higher cognitive functions that were reported in the literature to befrequently affected in children with APD [46]. The stimuli wereplayed through a laptop loaded with Adobe Audition version 3.0and were routed to a TDH-39 headphone. The volume controls ofthe audio software as well as the laptop were manipulated toensure that the output from the TDH-39 headphones was 65 dBSPL. This was measured using an SLM (Larson Davis systems 824)with a in. 2540 microphone connected to a NBS 9A 6cc coupler.

The screening tools were administered in a quiet room, withinthe school premises. The room was free from audio and visualdistractions. It was ensured that with the TDH-39 headphone on,the audibility of the noise in the environment was much lowerthan the signal. The diagnostic tests were carried out in a sound-treated audiometric test suite. A calibrated dual channel diagnosticaudiometer (Madsen OB 922 version 2) with air conduction(TDH-39) and bone conduction (B-71) transducers was used tocarry out pure-tone audiometry, speech audiometry and the APDtests. A calibrated immittance meter (GSI Tympstar) was used toensure the presence of normal middle ear function. Compact disk(CD) versions of the diagnostic tests were played through a CDplayer of a laptop connected to the audiometer.

1.3. Stage 1: administration of screening tools

In stage 1 of the study, the two screening tools wereadministered on the children. The SCAP was chosen as it hadbeen found to have a high sensitivity and specicity of 71% and68%, respectively, as evaluated by Muthuselvi and Yathiraj [33].The screening checklist that consisted of 12 questions, tappedauditory memory and speech perception in noise difculties of thechildren. A cut-off score of 6 (one per positive symptom) had beenfound to differentiate children at-risk for APD and with no APD[33].

While the SCAP was administered on all 2400 children who metthe subject selection criteria, the STAP was administered on 500 ofthem. These 500 children were randomly selected from the 2400children. Half of these 500 children were initially tested with theSCAP and the other half with the STAP. The SCAP was administeredby the school teachers who met the requirements to administer thechecklist. On the other hand, the children were evaluated on theSTAP by an audiologist. A double blind approach was used whereinneither the teachers nor the audiologist knew the results of thetests. The teachers were instructed to refer all the children theysuspected to have APD as per the scores of the SCAP, besidesreferring those without symptoms of APD. The teachers were alsotold not to reveal the SCAP scores when referring the children.

Normal middle ear functioning was established from the immit-tance evaluation, wherein the participants obtained A-typetympanograms and acoustic reexes present at 500 Hz, 1 kHz,2 kHz. All the children had speech reception thresholds (SRT) of lessthan 25 dB HL, as measured on the modied PAL material [34].Further, their speech identication score in quiet, determined usingthe Monosyllable Speech Identication test in English for Indianchildren [35], was greater than 90%.

All the children were evaluated individually on four differentdiagnostic APD tests. The tests were selected to evaluate monauralauditory separation/closure, binaural auditory integration, tempo-ral resolution, and auditory memory. The children were evaluatedon these auditory processes/higher cognitive factors as it has beenreported in the literature that they were often affected in childrenwith APD. Auditory separation/closure was found to be deviant inindividuals with APD by Welsh et al. [36], Katz et al. [37], andMuthuselvi and Yathiraj [33]. Likewise, binaural auditory integra-tion was reported to be deviant by Musiek et al. [38], Katz et al. [37]and Muthuselvi and Yathiraj [33]; temporal resolution by Musieket al. [38] and Muthuselvi and Yathiraj [33] found that auditorymemory was affected in a high percentage of children (82.3%)studied by them.

To evaluate the above auditory processes/higher cognitivefactors, the tests used included Speech-in-noise test in Indian-English (SPIN-IE) [39], Dichotic CV test [40], Gap detection test(GDT) [41] and the Revised Auditory Memory and Sequencing Testin Indian-English (RAMST-IE) [42]. The order in which theparticipants were tested on these four tests was randomized toavoid any test order effect. For the two monaural tests (SPIN-IE andGDT) half the participants were tested in right ear rst and theother half in the left ear rst, to eliminate any ear-order effect.

A. Yathiraj, A.R. Maggu / International Journal of Pediatric Otorhinolaryngology 78 (2014) 479488 4811.3.1. Procedure for administration of SCAP

The school teachers who administered the SCAP wereinstructed to mark on the checklist provided as to whether eachchild had any of the symptoms listed. Each child was evaluatedonly by one teacher who was informed not to reveal the scoresobtained. Among the 2400 children, 250 were randomly evaluatedon the STAP prior to being evaluated by the teachers on the SCAP.This was done to avoid any test order effect.

1.3.2. Procedure for administration of STAP

The STAP was administered on each child independently whoheard the stimuli played using Adobe Audition version 3.0 throughheadphones. Prior to placing the headphone on a child who wasseated in front of the audiologist, he/she was instructed to listen tothe recorded instructions and respond verbally. Their responses tothe test items were noted by the audiologist who administered thetest. It was observed that despite the DCV subsection having anextra practice item, approximately 40% of the children requiredadditional instructions from the audiologist to carry out this task.For these children, the screening test was paused and verbalinstruction, similar to what was provided in the recording, wasgiven again by the audiologist. The children were then made tocarry out the practice items of the DCV once again beforeproceeding with the test.

The time taken by each child for the administration of the STAPwas also noted. The duration taken was noted from the time childentered the test room and settled down till the completeadministration of the test. For thirty randomly selected partici-pants, the time for the administration of the test as well the timefor scoring the responses just after the completion of the screeningtest was also noted. It was found that it took approximately 12 minfor the administration of the test and scoring of the responses ofeach child. Without the time taken for scoring, the test tookapproximately 10 min.

For all four subsections, each correct response was assigned ascore of one while an incorrect response a score of zero. Using therecommended cut-off criteria [46] the children were categorizedas having passed or referred for each of the four subsections.

It was found that among the 500 children who were tested onthe STAP, 141 children obtained scores of six or more on the SCAP,based on which they were referred. The remaining 359 childrenscored less than six on the SCAP and hence were passed. Further, itwas found that on the STAP, 91 of them were referred on one ormore of the subsections and 409 of them passed all the foursubsections. The number of children who were referred on bothSCAP and STAP was 77. The information on participants issummarized in Table 1.

1.4. Testretest reliability

The testretest reliability of the SCAP and STAP was done afteran interval of 2 month on approximately 10% of the children whowere tested on both screening procedures. For the checklist it wasdone on 63 children and on the screening test it was done on 50children. It was ensured that none of these children had undergoneany form of rehabilitation for auditory processing problems duringthis period.

1.5. Stage 2: administration of the diagnostic tests

Among the 500 children who were tested on both the screeningprocedures, 152 children were selected in a semi-random mannerfor complete diagnostic testing, such that it consisted of a proportionof individuals who were referred on SCAP, STAP and a combination ofthe both. These children underwent routine audiological evaluationin addition to being tested on a battery of APD tests. The routineaudiological evaluation included pure-tone audiometry, immittanceevaluation and speech audiometry. From the pure-tone test results itwas conrmed that they had AC and BC thresholds within 15 dB HLin the frequencies 250 Hz to 8 kHz and 250 Hz to 4 kHz, respectively.

Table 1Depicting the owchart of recruitment of participants and their responses on

screening procedures.

diagnostic tests. None of these 14 children had undergone any formof rehabilitation following the earlier evaluation. The childrenwere retested to establish the testretest reliability of thediagnostic APD tests.

1.6. Analyses

The scores of the screening procedures and diagnostic testswere processed using SPSS 16.0 software and the R software(version 2.14.2). Descriptive and inferential analyses were carriedout and are reported in the results section. The inferential statisticsincluded Spearmans correlation coefcient, Pearsons product

A. Yathiraj, A.R. Maggu / International Journal of Pediatric Otorhinolaryngology 78 (2014) 479488482The CD versions of all the diagnostic tests were played on acomputer, the output of which was routed to the transducer via thediagnostic audiometer (Madsen OB 922). The 1 kHz calibrationtone, recorded in the CD of each test, was used to calibrate the VUmeter deection, prior to the appraisal of each child. Thiscalibration was done for each of the four diagnostic APD tests.

1.5.1. Procedure for administration of the Speech-in-noise test in

Indian English (SPIN-IE)

The SPIN-IE test, developed by Yathiraj et al. [39] wasadministered using the two lists of 25 monosyllabic Englishwords. These stimuli were presented monaurally at 0 dB SNR at40 dB SL (ref. SRT) via headphones. The noise used was an eight-talker speech babble which was interrupted to avoid auditoryfatigue. It was ensured that the interruption was not presentduring the presentation of a stimulus. The duration of the noisesegments was semi-random and varied for from 310 ms to620 ms. The children were instructed that they would hear a ladytalking in a crowd and they should listen to the words spoken bythe lady while ignoring other sounds. The verbal responses of theparticipants were noted. A correct response was given a score of1 and an incorrect response a score of 0. The scores obtainedwere compared with the age appropriate norms [43].

1.5.2. Procedure for administration of the Dichotic CV test (DCV)

The Dichotic CV test was evaluated using the CD version of thetest, recorded by Yathiraj [40] at 40 dB SL (ref. SRT). The listcontaining a 0 ms lag was utilized. The children were informedthat they would hear two syllables simultaneously, one in eachear. They were asked to repeat both the syllables they heardthrough headphones. The verbal responses of the participantswere noted. A score of 1 was given if the child repeated both thesyllables presented in the two ears correctly. These double correctresponses were noted and compared with age appropriate norms[43].

1.5.3. Procedure for administration of the Gap detection test (GDT)

The Gap detection test (GDT) was carried out using the testdeveloped by Shivaprakash [41]. The signals were presentedmonaurally to each ear at 40 dB SL (ref. PTA) through head phones.The participants were required to indicate as to which set of noisebursts in a triad contained a gap. The minimum gap duration thatthe participants were able to detect was compared with normativegiven by Shinn et al. [44].

1.5.4. Procedure for administration of the Revised Auditory Memory

and Sequencing Test in Indian English (RAMST-IE)

The CD version of Revised-Auditory Memory and SequencingTest (RAMST-IE) developed by Yathiraj et al. [42] was presented at40 SL (ref. SRT) through two sound-eld loudspeakers. Theloudspeakers were placed at a distance of one meter at 458azimuth on either side of the head of a participant. The participantswere instructed to listen to each word sequence before repeatingthe stimuli. They were also informed that the number of stimuli inthe word-sequences would gradually increase. A score of 1 wasgiven for each correctly repeated word to calculate the auditorymemory score. The responses were compared with the ageappropriate norms developed by Yathiraj et al. [43].

The criteria to diagnose a child as having APD or not was doneusing the recommendations of Yathiraj et al. [43]. According tothem, for children who failed on only one diagnostic test, a 2 SDcriteria was recommended and for those who failed more than onediagnostic test, a 1 SD criteria was advocated.

Fourteen of the children were administered the diagnostic testsafter a period of two months. These children were selectedrandomly from those who had been evaluated earlier on themoment correlation coefcient and Kappas measure of agree-ment.

2. Results

To check the sensitivity and specicity of the STAP, the datacollected using the same were compared with that of the fourdiagnostic tests that were administered. Similarly, a comparison ofthe SCAP with the diagnostic tests was also carried out. This wasdone with SCAP in isolation as well as in combination with theSTAP. The results obtained are provided under the following sub-headings: results of the APD screening procedures; results of theAPD diagnostic tests; relation between the STAP and diagnostictests; sensitivity and specicity of the screening procedures; cut-off criteria for referral with STAP; and testretest reliability ofSCAP, STAP and the diagnostic APD tests.

2.1. Results of the APD screening procedures

From the data of the STAP obtained from the 500 children whowere tested with it, 18.2% (91) were found to be affected in one ormore of its subsections. Further, 77 children were found to be at-risk on both STAP and SCAP. Details of those who were referred oneach subsection of the STAP are given in Table 2.

Fig. 1 depicts the number of participants who were affected ineach subsection as well as combination of subsections of the STAP.Participants who obtained low scores on more than one subsectionwere represented multiple times. The number of times aparticipant is represented in the gure depended on the numberof subsections he/she obtained low scores. For example, childrenwho obtained low scores on SPIN, DCV and GD were representedunder each of the headings in isolation as well as in thecombination of SPIN + DCV and SPIN + DCV + GD subsections. Itcan be observed from Fig. 1 and Table 2 that among the 91 childrenwith scores below the recommended cut-off values [46], theauditory memory subsection had the maximum number ofchildren (N = 56). When pairs of subsections were considered,the combination of SPIN and AM had a larger number (N = 38) ofchildren at-risk for APD, compared to the other combinations.Further, when a combination of three subsections was considered,

Table 2Percentage (number in parenthesis) of children referred on the subsections of the

STAP.

STAP subsections % of children referred on each subsection of STAP

All children tested

on STAP (N = 500)

Children found to be

at-risk for APD on

STAP (N = 91)

SPIN 9.6% (48) 52.7% (48)

DCV 9.6% (48) 52.7% (48)

GD 8% (40) 43.9% (40)

AM 12% (56) 61.5% (56)

subs

A. Yathiraj, A.R. Maggu / International Journal of Pediatric Otorhinolaryngology 78 (2014) 479488 483Fig. 1. Number of children among the 91 with scores below the cut-off values on eachlow scores on more than one subsection were represented multiple times).the combination of SPIN, DCV and AM had the maximum number(N = 13) of children at-risk.

Fig. 2 depicts the number of children (N = 91) affected on one,two, three or all four subsections of the STAP. Each participant isrepresented only once in the gure. For example, if a child obtainedlow scores on all the three subsections i.e. SPIN, DCV and GD, he/she would be represented under the heading SPIN + DCV + GDonly. Among the 91 children referred based on the scores of theSTAP, one subsection of the screening test was affected in 24children (26.4%), two subsections were affected in 43 children(47.3%), three subsections in 14 children (15.4%) and 10 children(10.9%) had all four subsections affected. As can be seen in Fig. 2,among those affected only in one subsection, AM (N = 9) and DCV(N = 8), were affected more when compared to SPIN (N = 3) and GD(N = 4). Additionally, the combination of SPIN and AM had themaximum number (N = 13) of children who were at-risk, whencompared to the other combination of subsections.

2.2. Results of the APD diagnostic tests

On analysing the scores of the 152 children who were tested onthe four diagnostic tests (SPIN, DCV, GDT, and AMT), it was found

Fig. 2. Distribution of the 91 participants with scores below the cut-off values on indiviobtained low scores is represented only once).

Table 3Number (%) of participants who failed each diagnostic APD test and were diagnosed to

SPIN DCV GDT

Rt ear Lt ear Rt ear

39 (25.6%) 37 (24.3%) 25 (16.4%) 29 (19.1%)

Note. N = 152.ection as well as combination of subsections of the STAP (participants who obtainedthat 92 (60.5%) of them were found to have APD. The diagnosis wasbased on the criteria recommended by Yathiraj et al. [43]. Thenumber of children who failed each of the four diagnostic APD testsas well as the total number of those diagnosed to have APD isprovided in Table 3.

Among the diagnostic tests, the test with the maximum failureswas AMT (32.2%) followed by DCV (28.9%), SPIN (average of left andright ears = 24.9%) and the GDT (average of left and rightears = 17.7%). Using the criteria recommended by Yathiraj et al.[43], out of the 152 children evaluated on the diagnostic tests,60.5% (92) were found to have APD (Table 3 and Fig. 3).

2.3. Relationship between STAP and the diagnostic tests

The relation between the STAP and the diagnostic tests wasdetermined using Spearmans rank relation coefcient. A highcorrelation (r = 0.82) between the STAP and the diagnostic teststhat was signicant at the 0.001 level was obtained. Further, therelation between each subsection of the STAP and their diagnosticcounterparts was tested using Pearsons product moment correla-tion coefcient. The results of this correlation (Fig. 4) indicated apositive correlation between STAP and each of the diagnostic tests

dual subsection or combinations of subsections of the STAP (each participant who

have APD.

AMT Number diagnosed to have APD

Lt ear

44 (28.9%) 49 (32.2%) 92 (60.5%)

except for the GDT. The GDT was the only test where there was anegative correlation, indicating that as the scores of the GDsubsection of the STAP improved, gap detection thresholdsdecreased and thus, smaller gaps could be detected on thediagnostic GDT.

2.4. Sensitivity and specicity of STAP and SCAP

To determine the sensitivity and specicity of the SCAP andSTAP, the pass/refer details of each of the screening procedures as

well as their combination (SCAP + STAP) were compared with thediagnosis of the children. This was done using the data of the threegroups (Group 1: refer/pass on SCAP; Group 2: refer/pass on STAP;and Group 3: refer/pass on SCAP + STAP) of children formed fromthose who were referred/passed on SCAP, STAP and SCAP + STAP.The information regarding the diagnosis was based on the naldiagnosis made from the ndings of the four diagnostic tests usingthe criteria given by Yathiraj et al. [43]. A 2 2 decision matrix wasused to obtain information about the true positives and truenegatives of the SCAP (Table 4a), the STAP (Table 4b) and thecombination of SCAP + STAP (Table 4c).

Using Eqs. (1) and (2), given below, the sensitivity andspecicity respectively, were calculated. The outcomes of thesecalculations are provided in Table 5.

Sensitivity True positiveTure positive False negative 100 (1)

Spesificity True negativeTure negative False positive 100 (2)

2.5. Cut-off criterion for referral

Analysis was done to decide the number of subsections of STAPa child needed to get scores below the recommended cut-offcriterion, in order to be referred for diagnostic APD evaluation. To

Fig. 3. Percentage of children found to have APD on the various tests and diagnosedto have the condition.

A. Yathiraj, A.R. Maggu / International Journal of Pediatric Otorhinolaryngology 78 (2014) 479488484Fig. 4. Scatter plots reecting the distribution of scores across the subsections of the STAP (X axis) and their diagnostic counterparts (Y axis).

Table 4True positives, false positives, false negative and true negatives of: (a) SCAP Group 1; (b) STAP Group 2; and (c) SCAP + STAP combined Group 3.

(a) Group 1

SCAP Diagnostic APD tests results Total

Present Absent

Refer 23 (74.1%) 7 (50%) 30Pass 8 (25.8%) 7 (50%) 15

Total 31 14 45

(b) Group 2

STAP Diagnostic APD tests results Total

Present Absent

Refer 23 (76.6%) 7 (28%) 30Pass 7 (23.3%) 18 (72%) 25

Total 30 25 55

(c) Group 3

SCAP + STAP Diagnostic AP

A. Yathiraj, A.R. Maggu / International Journal of Pediatric Otorhinolaryngology 78 (2014) 479488 485establish this, the sensitivity and specicity of the STAP with thenumber of affected subsections was determined (Table 6).

The sensitivity was the highest when one affected subsection ofthe STAP was considered as a cut-off for deciding whether to passor refer a child for diagnostic evaluation to conrm the presence ofAPD (Fig. 5). However, the specicity of the STAP was the lowestwhen one affected subsection was considered as a cut-off to make apass/refer criteria. It was the highest when all four subsectionswere considered. With increase in the number of affectedsubsections to make a pass/refer criteria, the sensitivity droppedconsiderably. In contrast, the increase in the specicity was moregradual (Fig. 5).

Present

Refer 26 (83.8%) Pass 5 (16.1%)

Total 31

The numbers in bold indicate the true positives and true negatives.Additionally, a Kappa measure of agreement was carried outbetween the number of individuals identied at different cut-offcriteria of the STAP and the number of individuals identied on thediagnostic tests. It revealed a moderate (k = 0.52) and signicantagreement (p < 0.001) with the cut-off criteria of greater than orequal to one (Table 6). No such signicant agreement was obtainedwith higher cut-off criteria.

Table 5Sensitivity and specicity of SCAP, STAP and SCAP + STAP.

Tests Sensitivity Specicity

SCAP 74.1% 50%

STAP 76.6% 72%

SCAP + STAP 83.8% 76.2%

Table 6Agreement between STAP and the diagnostic tests with different affected

subsections of STAP.

No. of affected

subsections of STAP

Kappa measure

of agreement (k)

Signicance

level

I 1 0.52 p < 0.001 2 0.13 p > 0.05 3 0.25 p > 0.054 0.13 p > 0.05

The numbers in bold indicate the cut-off criterion with the highest agreement that

was signicant.2.6. Testretest reliability of the screening procedures and diagnostic

APD tests

The testretest reliability was established for each of thescreening procedures (SCAP and STAP) as well as the fourdiagnostic tests. This reliability was done on approximately 10%of the children who were tested on each of the above procedures.

2.6.1. Testretest reliability of SCAP

The testretest reliability for the SCAP was determined on 63(12.6%) of the 500 children who were tested on both screeningprocedures. The teachers responses that were obtained after a gap

D tests results Total

Absent

5 (23.8%) 31

16 (76.2%) 21

21 52of 2 months were compared with their earlier responses usingPearsons product moment correlation coefcient. A high correla-tion (r = 0.91) that was signicant at the 0.001 was obtainedbetween the two evaluations.

2.6.2. Testretest reliability of STAP

In order to determine the reliability of the STAP, the screeningtest was administered again on 50 children (10%) after an interval

Fig. 5. Sensitivity and specicity of the STAP with different number of affectedsubsections of the screening tests where the scores were below the recommended

cut-off point.

A. Yathiraj, A.R. Maggu / International Journal of Pediatric Otorhinolaryngology 78 (2014) 479488486of 2 months. The correlation between the scores obtained on the1st and 2nd evaluation of STAP was checked using Pearsonsproduct moment correlation coefcient. These correlation coef-cients ranged from 0.82 to 0.93 and were signicant at the 0.01level. This indicates that the subsections of STAP had good testretest reliability.

2.6.3. Testretest reliability of diagnostic APD tests

For the diagnostic APD tests, the testretest reliability was alsochecked for approximately 10% (14) of the 152 children on whomthe test had been done earlier. The diagnostic APD testing wasagain carried out after a gap of 2 months after the rst evaluation.The relation between the scores obtained in the rst and secondevaluation was tested with Pearsons product moment correlation.The scores of the two evaluations of the diagnostic APD tests werehighly correlated with the coefcient ranging from 0.81 to 0.97(p < 0.01) across the various diagnostic APD tests. These ndingsestablished that a good testretest reliability existed for these APDdiagnostic tests.

3. Discussion

3.1. Outcome of the SCAP

The sensitivity of the SCAP obtained in the current study, andobtained by Muthuselvi and Yathiraj [33], were comparable. In thecurrent study, the SCAP had a sensitivity of 74.1% that was similarto the value of 71% obtained by Muthuselvi and Yathiraj [33]. Thisindicates the stability of the SCAP across different testers andparticipants.

When the specicity of the SCAP was examined, it was found thatin the current study, a large over-referral occurred (50% of the 14children). This indicates that the teachers tended to unnecessarilyrefer children for diagnostic evaluation, despite them not having aproblem. In contrast, in the study by Muthuselvi and Yathiraj [33],this over-referral rate was much lesser. The earlier study reportedof a specicity of 68%, which is considerably higher than what wasobtained in the current study (50%). However, in both the studies,the testretest reliability of the SCAP was high. This reects thatwhen the questionnaire is administered by the same set ofteachers, even after a gap of 2 months, reliable results are obtained.On the other hand, considerable variability occurs in the specicityof the test when a different set of teachers administer the checklist.Thus, it can be concluded that the variation in the under-referralrate when different sets of teachers are used is considerably lesswhen compared to the variation in the over-referral rate.

The subjective nature of questionnaires has been reported inseveral studies [19,4548]. Schow and Seikel [19] recommendedthat questionnaires to detect the presence of any condition shouldbe used only in the absence of tests that are less subjective.

Despite, checklists being considered as being subjective, it wasobserved in the current study, that the testretest reliability of theSCAP was high (r = 0.91). This conrms that when the same set ofteachers is used to administer the checklist even after a gap of twomonths, there are minimal variations in their responses. They areconsistent in their ability to pass and refer children in a similarmanner.

Based on the ndings of the present study and that ofMuthuselvi and Yathiraj [33], it can be inferred that when usingchecklists like the SCAP, teachers are likely to correctly identifychildren suspected to have APD with fairly high accuracy.However, depending on the caution used by the teachers, theyare likely to over refer them. Additionally, close to 30% of thechildren with APD are likely to be missed if only checklists areused. Hence, if these drawbacks of checklists are to be overcome,either modication of the same should be done or the use of analternate mode of screening, such as the use of a screening testshould be utilized.

In the literature, the sensitivity for a screening APD checklisthas been reported to be similar to that obtained using the SCAP.Extrapolating the information provided by Drake et al. [49], thesensitivity and specicity of CHAPPS were found to be 75% and 25%respectively. While the sensitivity of CHAPPS was found to besimilar to that of the STAP, the specicity was much lower thanthat observed in the present study as well as by Muthuselvi andYathiraj [33]. This substantiates that screening checklists for APDdo have fairly high sensitivity, but have questionable specicity.

Schow and Seikel [19] opined that when considering thesensitivity and specicity of screening procedures, . . . highsensitivity is good even if specicity suffers a bit because if oneuses a diagnostic test follow-up, the false positives will be detectedand not passed on (p. 139). Although Schow and Seikel haveremarked that the specicity could be low, having a very lowspecicity, such as that established with the CHAPPS by Drake et al.[49] would defeat the purpose of a screening procedure due to thevery high over-referral rate. In comparison, the SCAP can beconsidered a more useful checklist to screen for the presence ofAPD.

3.2. Outcome of the STAP

The number of children found to be affected on the STAP was18.2%. The percentage of children suspected to have APD washigher than that obtained with the SCAP. This occurred since the500 children on whom the STAP was measured included those whowere suspected to have APD on the SCAP. However, the group onwhom the SCAP was administered included the general popula-tion. The variation in the number of individuals suspected to haveAPD in the two screening procedures can be partly ascribed to thedifference in population on whom the percentage of affectedpersons was calculated.

Among the four subsections of the STAP, it was observed thatAM was the most affected and GD the least. SPIN and DCV wereequally affected. This was seen when all 91 participants who werereferred on the STAP were considered (Fig. 1). However, when thedata of the 24 participants who obtained low scores on only one ofthe subsections of STAP were considered, the order of subsectionsin which more difculty occurred differed. Within these 24participants, it was seen that the AM and DCV subsections wereaffected in more children (9 and 8 respectively). In contrast on theGD and SPIN it was 4 and 3 respectively (Fig. 2). This differenceexisted as poor performance in SPIN mainly occurred along withlow scores in other subsections and not in isolation. It largelyoccurred along with AM. However, DCV and AM tended to beaffected in isolation and along with other subsections of the STAP,as can be seen in Fig. 2.

Report of AM and DCV being more adversely affected comparedto other diagnostic APD tests, has also been noted by Muthuselviand Yathiraj [33]. They reported this nding on children suspectedto have APD, who were evaluated on a battery of ve diagnostictests (DCV, SPIN, GDT, AMST, and MLD). Thus, the trend that wasobserved on the diagnostic APD tests by Muthuselvi and Yathirajwas also reected in the subsections of the STAP. Thus, it can beconstrued that the STAP did provide a representation of theauditory processing difculties that are found when children aretested on diagnostic APD tests.

In the current study, when combinations of affected subsectionswere considered, the grouping of SPIN and AM cropped up mostoften followed by DCV and AM (Fig. 2). The number of childrenhaving problems with both SPIN and AM was the highest (N = 13).These children exceeded the number having low scores in anyisolated subsection or any other combination of the subsections of

A. Yathiraj, A.R. Maggu / International Journal of Pediatric Otorhinolaryngology 78 (2014) 479488 487the STAP. Additionally, from the ndings of the STAP, it can be seenthat if AM was removed as a subsection, 9 (9.9%) of the childrenwould have been missed. However, if SPIN subsection wasremoved, only 3 (3.3%) of the children would have been missed.

The nding that SPIN and AM are closely linked has beensubstantiated in recent studies by Yathiraj and Maggu [4,6]. From aprinciple component analysis carried out on the data of 267children aged 813 years, they found that the third component wasshared by the SPIN and AM subsections of the STAP [4]. This wasconrmed using a conrmatory factor analysis in 400 children [6].The link between speech perception in noise and auditory memoryhas been emphasized by Katz [50] while describing the tolerancefading memory decit, mentioned in the Buffalo model. Therelation between speech perception in noise and auditory workingmemory has also been observed by Brannstrom et al. [51]. Theyobserved this association on 21 normal hearing adults, who wereevaluated using auditory evoked potentials.

3.3. Outcome of the diagnostic tests

Among the children diagnosed to have APD (N = 92), the teststhat the children failed more frequently was the AMT followed bythe DCV and SPIN. Relatively lesser children failed the GDTdiagnostic tests (Table 3 and Fig. 3). This pattern is in consonancewith that found with the subsections of the STAP with reference tothe former two tests. It also is in line with the ndings ofMuthuselvi and Yathiraj [33]. The fact that repeatedly it isestablished that auditory memory is affected predominately inchildren with APD, corroborates the need to include it in an APDtest battery.

In the literature, the use of auditory memory has not beenconsidered as an important component of any gold standard testbattery. The tests that have been used as gold standard includedichotic tests [20,33,37,38], tests for gap detection [33,38], tests forspeech perception in noise [33,36,38], and temporal patterning[2,20,52].

3.4. Relation between STAP and diagnostic tests

The high correlation between each subsection of the STAP and thediagnostic APD tests that evaluated similar auditory processesindicates the utility of the screening test. This high correlationreveals that the screening test provides a good indication of theperformance of children on different auditory processes. Thus, itcan be inferred that high or low scores on each of the subsections ofthe STAP would result with a corresponding increase or decrease inperformance on related diagnostic APD tests.

The sensitivity and specicity of the STAP (Table 4b) indicatedthat both aspects were high. The sensitivity was similar to thatobtained on the SCAP, but the specicity was higher. However, onaddition of the SCAP and STAP performance (Table 4c), thesensitivity and the specicity of the screening proceduresincreased and the false positives and false negatives decreased.This indicates that the two screening procedures do not tapidentical aspects of APD. This increase in sensitivity and specicitycan be ascribed to the additional associated information related toAPD that are obtained from the SCAP. The SCAP provides additionalinformation regarding speech, language and academic perfor-mance. As the sensitivity and specicity were higher when bothscreening procedures were used, it is recommended that thecombination should be used in an APD screening program.

The cut-off criterion of the STAP for referring the children fordiagnostic evaluation was found to be similar with both thestatistical techniques that were used. It was found that thesensitivity of the STAP was the highest with a cut-off criterion ofone (i.e. poor scores in one and more subsections of STAP). Thesensitivity reduced by 52.4% when the cut-off criteria wasincreased from one to four (i.e. poor scores on one subsection topoor scores on all four subsections of STAP). The specicity of theSTAP was lowered by 25.4% when the cut-off criterion was changedfrom four to one. Further, the Kappa measure of agreement alsoindicated that the maximum agreement with the diagnostic testswas observed with the cut-off criteria of one. In view of the drasticreduction of the sensitivity yet marginal increase in specicitywith higher cut-off criteria (Table 5), as well as the ndings of theKappa measure of agreement, it is recommended that a cut-offcriterion of one be used. Thus, if a child obtains lower than therecommended cut-off scores on any one of the subsections of theSTAP, they should be referred for evaluation on a diagnostic APDtest battery.

According to Chermak and Musiek [53] an APD battery shouldcontain at least one test of temporal processing, one of dichoticlistening and one monaural redundancy test. Similarly, ASHA [27]advocated the used of both speech and non-verbal tests in an APDbattery that should assess sound localization and lateralization,auditory discrimination, auditory temporal processing, auditorypattern processing, dichotic listening auditory performance incompeting acoustic signals, and auditory performance withdegraded acoustic signals. In the current study, the diagnostictests used to determine the sensitivity, specicity and the cut-offcriterion for referral of the STAP, met the requirements of Chermakand Musiek as well as most of the requirements of ASHA. Hence,the diagnostic tests used to validate the STAP can be considered asa representation of what an APD test battery typically shouldcontain. It can be concluded that since the STAP has been validatedwith a representation of a typical gold standard test-battery, itssensitivity, specicity and referral criterion are also valid. Further,the fact the SCAP, STAP and the four diagnostic tests had a goodtestretest reliability, indicate that all the measures used in thestudy provide stable information.

4. Conclusion

From the ndings of the present study, it can be inferred thatteachers are able to use the SCAP to correctly identify children withsuspected APD. However, they tend to over-refer children, despitethem not having adequate number of symptoms of the condition inorder to refer them. Approximately 30% of the children with APDare likely to be missed if only the SCAP is used. The STAP wasdeveloped to tap four different auditory processes/higher cognitivefunctions (monaural auditory separation/closure, binaural audito-ry integration, temporal resolution, and auditory memory). Thesewere evaluated using four subsections (SPIN, DCV, GD, and AM)containing a limited number of test items. The time taken toadminister the screening test along with the scoring tookapproximately 12 min.

Among the four subsections of the STAP, it was observed thatAM was the most affected and GD the least. SPIN and DCV wereequally affected. Low scores in the SPIN subsection mainlyoccurred along with low scores in other the subsections and notisolation. It largely occurred along with AM. However, DCV and AMtended to be affected in isolation and along with other subsectionsof the STAP. The sensitivity and specicity of the STAP were foundto be 76.6% and 72% respectively. These values increased when theSTAP was used along with the SCAP to 83.8% and 76.2%respectively. As the sensitivity and specicity were higher whenthe combination of SCAP and STAP were used, it is recommendedthat an APD screening program should include both procedures.The sensitivity of the STAP and its agreement with the diagnostictests was the highest when a cut-off criterion of one was used.Hence, it is recommended that if a child obtained low scores on

even one of the subsections of the STAP, they should be referred fordetailed APD evaluation.

Processing: A Transdisciplinary View, Mosby Yearbook Inc., St. Louis, 1992, pp.129140.

[29] B.A. Stach, Controversies in the screening of central auditory processing disorder,in: F.H. Bess, J.W. Hall (Eds.), Screening Children for Auditory Function, Bill

A. Yathiraj, A.R. Maggu / International Journal of Pediatric Otorhinolaryngology 78 (2014) 479488488Acknowledgement

We thank the All India Institute of Speech and Hearing forhaving funded the project of which the current paper is a part.

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Validation of the Screening Test for Auditory Processing (STAP) on school-aged childrenMethodParticipantsInstrumentation and environmentStage 1: administration of screening toolsProcedure for administration of SCAPProcedure for administration of STAP

Test-retest reliabilityStage 2: administration of the diagnostic testsProcedure for administration of the Speech-in-noise test in Indian English (SPIN-IE)Procedure for administration of the Dichotic CV test (DCV)Procedure for administration of the Gap detection test (GDT)Procedure for administration of the Revised Auditory Memory and Sequencing Test in Indian English (RAMST-IE)

Analyses

ResultsResults of the APD screening proceduresResults of the APD diagnostic testsRelationship between STAP and the diagnostic testsSensitivity and specificity of STAP and SCAPCut-off criterion for referralTest-retest reliability of the screening procedures and diagnostic APD testsTest-retest reliability of SCAPTest-retest reliability of STAPTest-retest reliability of diagnostic APD tests

DiscussionOutcome of the SCAPOutcome of the STAPOutcome of the diagnostic testsRelation between STAP and diagnostic tests

ConclusionAcknowledgementReferences