www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Procedures
for
central
auditory
processing
screening
in
schoolchildren
夽
Nádia
Giulian
de
Carvalho
a,∗,
Thalita
Ubiali
a,
Maria
Isabel
Ramos
do
Amaral
b,
Maria
Francisca
Colella-Santos
baUniversidadeEstadualdeCampinas(UNICAMP),FaculdadedeCiênciasMédicas,CentrodeInvestigac¸ãoemPediatria(CIPED),
Campinas,SP,Brazil
bUniversidadeEstadualdeCampinas(UNICAMP),FaculdadedeCiênciasMédicas,CentrodeInvestigac¸ãoemPediatria(CIPED),
DepartamentodeDesenvolvimentoHumanoeReabilitac¸ão,Campinas,SP,Brazil
Received15January2018;accepted19February2018 Availableonline22March2018
KEYWORDS Hearing; Hearingtests; Auditoryperception; Child; Schoolchildren Abstract
Introduction:Centralauditoryprocessingscreeninginschoolchildrenhasledtodebatesin liter-ature,bothregardingtheprotocoltobeusedandtheimportanceofactionsaimedatprevention andpromotionofauditoryhealth.Definingeffectivescreeningproceduresforcentralauditory processingisachallengeinAudiology.
Objective: Thisstudyaimedtoanalyzethescientificresearchoncentralauditoryprocessing screeninganddiscusstheeffectivenessoftheproceduresutilized.
Methods:A searchwasperformedintheSciELOandPUBMeddatabasesby tworesearchers. ThedescriptorsusedinPortugueseandEnglishwere:auditoryprocessing,screening,hearing, auditoryperception,children,auditorytestsandtheirrespectivetermsinPortuguese. Inclu-sioncriteria:originalarticlesinvolvingschoolchildren,auditoryscreeningofcentralauditory skillsandarticlesinPortugueseorEnglish.Exclusioncriteria:studieswithadultand/or neona-talpopulations,peripheralauditoryscreeningonly,andduplicatearticles.Afterapplyingthe describedcriteria,11articleswereincluded.
Results:Attheinternationallevel,centralauditoryprocessingscreeningmethodsusedwere: screeningtestforauditoryprocessingdisorderanditsrevisedversion,screeningtestfor audi-toryprocessing,scaleofauditorybehaviors,children’sauditoryperformancescaleandFeather Squadron.IntheBrazilianscenario,theproceduresusedwerethesimplifiedauditoryprocessing assessmentandZaidan’sbatteryoftests.
夽 Pleasecitethisarticleas:CarvalhoNG,UbialiT,AmaralMI,Colella-SantosMF.Proceduresforcentralauditoryprocessingscreeningin schoolchildren.BrazJOtorhinolaryngol.2019;85:319---28.
∗Correspondingauthor.
E-mail:[email protected](N.G.Carvalho).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2018.02.004
1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusion:Attheinternationallevel,thescreeningtestforauditoryprocessingandFeather Squadronbatteries standoutasthemostcomprehensiveevaluationofhearingskills. Atthe nationallevel,thereisapaucityofstudiesthatusemethodsevaluatingmorethanfourskills, andarenormalizedby agegroup.Theuseofsimplifiedauditory processing assessmentand questionnairescanbecomplementaryinthesearchforaneasyaccessandlow-costalternative intheauditoryscreeningofBrazilianschoolchildren.Interactivetoolsshouldbeproposed,that allow theselection ofasmany hearing skillsaspossible, validated bycomparison withthe batteryoftestsusedinthediagnosis.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Audic¸ão; Testesauditivos; Percepc¸ãoauditiva; Crianc¸a;
Estudantes
Procedimentosdetriagemdoprocessamentoauditivocentralemescolares
Resumo
Introduc¸ão: Atriagemdoprocessamentoauditivocentralemescolarestemsuscitadodiscussões naliteratura,tantoemrelac¸ãoaoprotocoloaserusadoquantoàimportânciadeac¸õesvoltadas paraaprevenc¸ãoepromoc¸ãodasaúdeauditiva.Umdesafionaaudiologiaédefinir procedi-mentoseficazesnatriagemdoprocessamentoauditivocentral.
Objetivo:Analisaraspesquisascientíficasqueaplicaramtriagemdoprocessamentoauditivo centralediscutiraeficáciadosprocedimentosusados.
Método: Foi feita busca nas bases de dados SciELO e PUBMedpor duas pesquisadoras. Os descritoresusadosem portuguêseinglêsforam: processamentoauditivo,triagem,audic¸ão, percepc¸ão auditiva, crianc¸as, testes auditivos. Critérios de inclusão: artigos originais que envolveramescolares, triagemauditivadas habilidadesauditivas centraiseartigosem por-tuguêsouinglês.Critériosdeexclusão:pesquisascomapopulac¸ãoadultae/ouneonatal,apenas triagemauditivaperiféricaeartigosduplicados.Apósaplicac¸ãodoscritériosdescritosforam incluídos11artigos.
Resultados: Noâmbitointernacional,osmétodosdetriagemdoprocessamentoauditivocentral foramousodoScreeningTestforAuditoryProcessingDisorderesuaversãorevisada,Screening TestforAuditoryProcessing,oschecklistsScaleofAuditoryBehaviorseChildren’sAuditory Performance Scaleeo FeatherSquadron.No cenário brasileiro, osprocedimentos forama avaliac¸ãosimplificadadoprocessamentoauditivoeabateriadeZaidan.
Conclusão:No âmbito internacional, as baterias Screening Test for Auditory Processing e Feather Squadronse destacampela avaliac¸ãomais completa dashabilidadesauditivas. Em âmbito nacional, há escassez de estudos que usem métodos que avaliem mais de quatro habilidades,comnormatizac¸ãoparaafaixaetária.A aplicac¸ãodaavaliac¸ãosimplificadado processamentoauditivoequestionáriospodesecomplementarnabuscadeumaopc¸ãodefácil acessoebaixocustonatriagemauditivaescolarbrasileira.Devemserpropostasferramentas interativas,quepossibilitetriaromaiornúmeropossíveldehabilidadesauditivas,validadapor meiodacomparac¸ãocomabateriadetestesusadosnodiagnóstico.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http://
creativecommons.org/licenses/by/4.0/).
Introduction
Auditoryscreeninginschool-agedchildrenhasbeen exten-sivelystudiedintheliterature,bothregardingtheprotocol tobeusedandtheimportanceofactionsaimedat preven-tionandpromotionofauditoryhealth,sincethisagegroup isundergoing oral andwritten languagedevelopmentand auditorychangesmayinterferewiththelearningprocess. Recent studies indicate that the incidence of peripheral auditoryalterationsvariesfrom14%to63.4%,dependingon theevaluationprocedureused.1,2
Itisknownthatperipheralauditorydysfunctionand/or a history of secretory otitis media in the first five years
of life can result in immaturity in the development of auditory pathways and central auditory abilities.3,4
Audi-tory screening procedures are often used in the school environment to evaluate the function of the peripheral auditory system. Among the most frequently used meth-ods,immittancescreeningisusedtoassessthemiddleear functions2,5,6andotoacousticemissionmeasuresareusedto
assesscochlearfunctionalintegrity.7,8
Listening to and understanding auditory information involvesgreatercomplexitycentraltotheauditory periph-ery,sinceitinvolvestheappropriatetransmissionofnerve impulses to the cochlear nuclei the, thalamus and audi-tory cortex. These auditory stations are responsible for
sound localizationand lateralization, auditory discrimina-tion, auditory recognition, temporal aspects of hearing, auditoryperformancewithcompetingacousticsignals,and auditory performance in unfavorableacoustic situations.9
Poorperformanceinoneormoreoftheseareasresultsin difficultyinprocessingauditory informationin thecentral auditory system and is called Central Auditory Processing Disorder(CAPD).
The literature contains relevant discussions about the nature of the CAPD and its direct or indirect association with higher cognitive functions, such as attention, mem-oryandlanguage.10---12ManyinvestigatorsconsiderCAPDas
a diagnostic entityidentified in ICD-10 asdiseases of the ear(H93.25),confirmingthephysiologicalnature(acquired or congenital) of this disorder. When children are diag-nosedearlyenough,theycanreceiveadequate supportat school and therapy by qualified professionals, facilitating theirdevelopment.12
ThesimilarityofsignsandbehaviorsinCAPDwithother conditionssuchasAttentionDeficit HyperactivityDisorder (ADHD)andAttentionDeficitDisorder(ADD)areconfounding factors for the diagnosis and generate questions. How-ever, although some symptoms are common in different clinical pictures, CAPD has signs and symptoms that are specificallyrelatedtoauditorydeficit,suchasdifficultyin understandinglanguagespokeninnoisyenvironments,when speechisquicklypresented;difficultywithwordsofsimilar soundsanddifficultyfollowingcomplexauditorycommands. Although these characteristic signs can be detected from theclinical historyand symptom assessmentthrough vali-datedquestionnaires,13itistheconsensusthatthediagnosis
ofCAPDcannotbemadebasedonlyonsuchquestionnaire data,but moreappropriately froman efficient batteryof tests.12
Withschoolchildren,carealwaysmustbetakentoobtain aglobalspeech-languageassessmentofthechildand, when-everpossible,amultiprofessionalone,sinceCAPDmightbe an associated comorbidity withother clinical alterations, increasingdiagnosticdifficultiesespeciallywithrespectto reading and writing performance.14,15 Understanding the
neuralmechanismsthroughwhichsoundstraveltothebrain isnecessaryforaidingspeechtherapyandfacilitatingearly diagnosisandeffectiveintervention.13
Definingeffectivescreeningprocedurestoassesscentral auditoryprocessingisachallengeforthefieldofAudiology. Since1986,researchershave beensearchingforscreening techniques,either throughbatteriesof testsand/or ques-tionnaires; however, there is no consensus regarding the most efficient protocol to be used for central auditory processingscreening.Auditoryscreeningshouldbeasimple and rapid procedure that can be applied to many indi-viduals,aiming at theearly identification of thosewith a high probability of having a specific problem and, based onthat identification, mandate a full evaluation.16,17 The
consequencesofthelackofaneffectivestandardizedtool aimed at screening hearing skills vary from the lack of dissemination of knowledge regarding CAPD in the school environment,totheinabilitytoobtainanepidemiological surveyregardingCAPDdiagnosis,especiallyinchildrenwith academicdifficulties.18
Studieshaveshownthatchildrenwithacademic difficul-tieshadworsespeechperceptioninsilenceandinnoise19,20;
therefore, rapid and effective screening procedures are requiredforchildrenwhomaybeatriskforCAPD.Theaim ofthepresentinvestigationwastoanalyzethestudiesthat appliedcentralauditoryprocessingscreeningin schoolchil-dren, and to discuss the effectiveness of the procedures used.
Methods
A review of the literature independently was performed by two researchers through an electronic search in the SciELO and PUBMed databases in the month of May of 2017.Theresearchwascarriedoutbycrossingthe follow-ing descriptors and their corresponding terms in English:
processamento auditivo (auditory processing), triagem
(screening),audic¸ão(hearing),percepc¸ãoauditiva(auditory perception),crianc¸as(children)andtestesauditivos (hear-ingtests).All identifiedarticleswere included, according to the inclusion and exclusion criteria, regardless of the yearofpublication.Thetitlesofthearticlesfoundinboth databasesweretransportedintoan Excelspreadsheet for the exclusion of articles in duplicateduring the matches madeduringthesearch.
Inclusion criteria: original articles involving schoolchil-dren, auditory screening with procedures focused on the evaluation of central auditory skills and articles in Por-tugueseand/orEnglishlanguages.
Exclusioncriteria:studiescarriedoutwithadultand/or neonatal populations, peripheral auditory screening only andduplicatedarticles.
Atotalof197articleswereidentified,50intheSciELO databaseand147in thePUBMeddatabase. Afterapplying theexclusioncriteria,11articlesmetthecriteriaandwere includedinthereview.Fig.1illustratestheselection pro-cess.
Results
The articles found in the SciELO and PUBMed databases, accordingtothecriteriadescribedinthisreview,were pub-lishedbetween1998and2016,asshowninTable1.
Table 2 shows the details of the analyzed studies regarding the sample characterization; screening method usedandthemainnotesontheresultsandconclusions.
Discussion
ThebasisofthediscussionofthestudycarriedoutbyAmos andHumes21 in 1998 is the use of the Screening Test for
AuditoryProcessingDisorder (SCAN),whichcontains three subtests: Filtered Speech, Speech in Noise and Compet-ingWords, asa screening method. The SCAN battery was standardizedforages3---11yearstobewidelyusedby audi-ologistsintheUnitedStates,aimingtodetectthepossible causesofpoorschoolperformanceinchildrenrapidly, uni-formly,andinastandardizedmanner.22However,according
toAmosandHumes,whenthebatterywasappliedbetween sixandsevenweeks afterthefirstevaluation in6---9 year old schoolchildren, an improvement was observed in the performanceof children in the FilteredSpeechand Com-petingWords tests,but not for the Speech in Noise test.
Studies excluded in languages other than Portuguese and English SciELO (0) and PUBMed (1)
N= 1
Studies found through performed search
SciELO (50) and PUBMed (147) N= 197
Studies in duplicate SciELO and PUBMed (2)
N= 2
Studies excluded by the title SciELO (30) and PUBMed (116)
N= 146
Studies excluded by the abstract SciELO (13) and PUBMed (24)
N= 37
Studies selected for the study SciELO (6) and PUBMed (5)
N= 11 Studies excluded after full-text
reading SciELO(0) and PUBMed (2) N= 2
Figure1 Explanatorydiagramonthearticleselectionprocess.
Table1 Overalldataofselectedarticles,consideringyearofpublication,authors,titlesanddatabases.
N. Year Authors Title Database
1 1998 AmosandHumes SCANTest-RetestReliabilityforFirst-and Third-GradeChildren
PubMed 2 2006 SimonandRossi Auditoryprocessingscreeninginschool
childrenfrom8to10yearsold
Scielo 3 2007 Lucasetal. Scan:performanceprofileofchildrenwith
seventoeightyears
Scielo/Pubmed 4 2008 Rodriguesetal. Auditoryprocessingscreeningtest(SCAN)
performanceprofileinsevenandeight year-oldchildrenlivinginCuiabá
Scielo
5 2009 Colella-Santosetal. Auditoryassessmentintheschool-age children
Scielo 6 2012 Etgesetal. Acousticimmitanceandauditoryprocessing
screeningfindingsinschoolchildren
Scielo 7 2012 ToscanoandAnastasio Auditoryabilitiesandacousticimmittance
measuresinchildrenfrom4to6yearsold
Scielo 8 2013 Nunesetal. ScaleofAuditoryBehaviorsandauditory
behaviortestsforauditoryprocessing assessmentinPortuguesechildren
Scielo/Pubmed
9 2013 YathirajandMaggu ScreeningTestforAuditoryProcessing (STAP):APreliminaryReport
PubMed 10 2016 AhmmedandAhmmed Settingappropriatepassorfailcut-off
criteriaforteststoreflectreallifelistening difficultiesinchildrenwithsuspected auditoryprocessingdisorder
PubMed
11 2016 BarkerandPurdy Aninitialinvestigationintothevalidityofa computer-basedauditoryprocessing assessment(FeatherSquadron)
Table2 Detailsofthereviewedstudies.
N◦ Sample Screening Results Conclusion
1 Age:6---9years;G1:25 childreninFirstGrade; G2:22childreninThird Grade;Nativelanguage: English.
SCAN(Keith,1986): FilteredSpeech,Speech inNoise,Competing (Dichotic)Words.
TheretestwithSCAN between6and7weeks showedsignificant improvementinthe FilteredSpeechand CompetingWordstests. OnlytheSpeechinNoise testshowedno
difference.
ThesecondSCAN administrationmay provideabetter estimateofthebest performanceofan individualchild. Thelackof
standardizationofthe secondscore(retest) confoundsasimple interpretationofsuch scores.
2 Age:8---10years;n=106 studentsinthe2ndand 3rdGrades.After audiometryandthe inclusionandexclusion criteriawereapplied,57 individualswithtypical developmentwere evaluated,33females and24males;Native language:Brazilian Portuguese.
Zaidan’sAuditory ProcessingScreening Battery(2001):Filtered Speech,SpeechinNoise, CompetingWords.
Filteredspeech: statisticallysignificant differenceinthe performanceof
individualsaged8,9and 10years.
SpeechinNoiseand CompetingWords: differenceswerenot statisticallysignificant. Therewasastatistically significantdifferencein theTotalBattery,which isthesumofthecorrect answersineachofthe subtests(Filtered Speech,SpeechinNoise andCompetingWords).
Therewasastatistically significantdifferencein thecombinedanalysisof theperformanceofthe individualsinthethree agegroups,considering thetotalauditory processingscreening battery,thatis,the resultsimprovedasthe ageincreased. 3 n=40students,withno auditoryorphonological complaints;Group1 (n=20;age:7years), Group2(n=20;age:8 years).Nativelanguage: BrazilianPortuguese.
Zaidan’sAuditory ProcessingScreening Battery(2001):Filtered Speech,SpeechinNoise, CompetingWords.
Themeanscorefor childrenaged7yearsin theFilteredSpeech, SpeechinNoiseand CompetitiveWordstests was33.35;32.5and 71.8,respectively;Inthe 8-year-oldchildrenit was:33.5;34.5and79.9. Differencesinfindings comparedtoother studiesdemonstratethe needtoevaluatealarger numberofchildrenfrom differentgeographic regions.
4 n=215children,withno auditoryorphonological complaints;G1:109 childrenaged7years; G2:106childrenaged8 years;Nativelanguage: BrazilianPortuguese.
Zaidan’sAuditory ProcessingScreening Battery(2001):Filtered Speech,SpeechinNoise, CompetingWords.
Themeanscoresand standarddeviationinthe FilteredSpeech,Speech inNoiseandCompeting Wordstestsinchildren aged7yearswere, respectively,24.4±5.1; 33.4±3.4and76.5±9.7 points,andinchildren aged8years,theywere, respectively,24.0±4.8; 34.0±3.0and
77.5±10.8points.
Thescoresofthisstudy cannotbegeneralizedto normalvaluesforall Brazilianchildrendueto regionalvariability.
Table2 (Continued)
N◦ Sample Screening Results Conclusion
5 Age:5---10years;n=287 children;G1:children aged5---6years;G2: childrenaged7---8years; G3:childrenaged9---10 years;Nativelanguage: BrazilianPortuguese.
SimplifiedAuditory processingassessment (ASPA):SoundLocalization (SL),memoryforverbal sounds(MSSV)and nonverbalsoundsin sequence(MSSNV).
Theschoolchildrenof thisstudyhadmore difficultyinmemorizing sequencesofsoundsor temporalorderthan locatingthesound source.
Atotalof56%ofthe studentspassedthe screening.Regardingthe groupsstudied,GroupsI andIIhadalargernumber ofchildrenwhofailedthe auditoryscreening, consideringbothimmitance andauditoryprocessing tests.
6 Age:7---10years;n=130 studentsfrom1stto4th grades;Nativelanguage: BrazilianPortuguese.
SimplifiedAuditory processingassessment (ASPA):soundlocalization tests,memoryforverbal sounds(MSSV)and nonverbalsoundsin sequence(MSSNV).
Atotalof76.15%ofthe childrenpassedthe ASPA.Moreover,itwas observedthatthetestin whichthestudents showedtheworst performancewasthe memoryforverbal soundsinsequence. 12.3%ofthestudents failedtheimmittance screeningandASPAtest.
Mostofthesubjectspassed theASPAtest,withahigher frequencyofcorrect answersinthesound localizationtest.Therewas nostatisticalassociation betweentheimmittance screeningresultandthe ASPAresult. 7 Age:4---6years;n=61 children;Native language:Brazilian Portuguese. SimplifiedAuditory ProcessingAssessment (ASPA):soundlocalization tests,memoryforverbal sounds(MSSV)and nonverbalsoundsin sequence(MSSNV).
Therewasanalteration inatleastoneofthe auditoryskills
investigatedin24.6%of thechildren.
Youngerchildrenshoweda greateroccurrenceof alterationsinauditoryskill testsandacoustic
immitancemeasures.
8 Age:10---13years;n=51 Portuguesechildrenwith normalperipheral hearing;Native language:European Portuguese.
ScaleofAuditoryBehaviors (SAB)questionnaireadapted toEuropeanPortuguesewas appliedtotheparents.The childrenweresubmittedto theSoundLocalization, Memoryforverbalsounds andNonverbalSoundsin Sequence,SpeechinNoise, DichoticDigitstest, HarmonicPatternDichotic DigitsTest,Standard durationtestand Gaps-In-Noisetest.
Asignificantcorrelation wasobservedbetween thequestionnairescore andthebehavioraltest results,withhighestof thembeingobservedin thetestsrelatedto temporalprocessing.
Therewasacorrelation betweentheSABscoreand theresultsobtainedinthe behavioralauditorytestsin Portuguesechildren, suggestingthatthis questionnairecanbeused inauditoryprocessing screening.
9 Age:8---13years;n=400 childrenwithnohearing orlanguagecomplaints; G1(8---9years,n=82), G2(9---10years,n=77), G3(10---11years,n=78), G4(11---12years,n=82), G5(12---13years,n=81); Englishspeakers.
ScreeningTestforAuditory Processing(STAP)divided intofoursubtests:(1) Speechperceptioninnoise; (2)Dichotic
consonant-vowel;(3)Gap detection;(4)Auditory Memory.
Itwasdeterminedthat 16%ofthechildrenwere atriskforCAPDatone ormoreSTAPsubtests. Amongthese16%,the auditorymemorytest wasmostoftenaffected (73.4%),followedby binauralintegration (65.6%),auditory separation/closure (59.4%)andtemporal resolution(53.1%).
TheSTAPisabletodetect threedifferentmechanisms relatedtoauditory
processing(binaural integration,temporal resolutionandspeech perceptioninnoisewith auditorymemory).The studyalsoindicatesthatthe numberofchildrenatrisk foreachofthedifferent auditoryprocessesvaries.
Table2 (Continued)
N◦ Sample Screening Results Conclusion
10 Age:6---11years;n=109 childrenwithhearing complaintsdespite normalperipheral hearing;English speakers.
SCAN-C(Keith,2000); IMAP(Mooreetal., 2010);CHAPS questionnairefor teachers(Smoskietal., 1998).
Therewasacorrelation betweenthetestsand theCHAPS
questionnaire.
OfthedifferentCHAPS domains,onlytheIdeal CHAPS,Auditory Memory,andAttention werecorrelatedwiththe TPAC.
11 G1=847childrenaged 5---13years,withnormal peripheralhearingand nolanguageorlearning complaints;G2=46 childrenaged5---14 years,whowere reevaluatedafter7days (FeatherSquadronand conventional evaluation);English speakers. FeatherSquadron: Lateralizationand detection,Auditory memory,Temporal resolution,Dichotic listening,Figure-Ground andSpeechinNoise.
Asignificantcorrelation wasobservedbetween theresultsofmost auditoryskillsassessed withtheFeather Squadronandthe traditionalauditory processingevaluation test.
TheFeatherSquadron testbatteryisa time-efficient,feasible, andreliableapproach forauditoryprocessing screeninginschool-aged children.
Therefore, theinterpretation of the screening findings at asecondtestapplicationwasquestioned.Theseandother factorssuggestedaneedforreviewandnormalizationofthe SCAN.22
The battery wasrevised andexpanded byadding com-peting sentences and modifying instructions to make it moreunderstandable toyounger children.The Competing Wordstestwasreviewedandrevisedforchildrenaged5---11 years.22 Sincethen, thesearchfornewstrategiesand
sci-entificevidencebasedonSCANhasbeenongoing.22---24 The
advantagesof theSCAN,includerapidity, sinceitrequires only 20min, and its utility, since it can be administered in the school environment,initially using aportable tape player.However,theSCANonly screenstheauditoryskills of Closure, Figure-Ground and Binaural Integration. The literaturepointsoutthatschool-aged childrenwith learn-ing impairment also may have difficulties with Temporal Processing.25,26Therefore,childrenwithalterationsinthese
skillswouldnotbeadequatelyscreenedwiththeSCAN. In2012,YathirajandMaggudevelopedtheScreeningTest forAuditoryProcessing(STAP)andin2013,theyappliedthis screeningbatteryto400schoolchildrenaged8---13years.27
TheSTAPinitiallyconsistedoffoursubtests:SpeechinNoise Perception,Consonant-VowelDichotic,GapDetection,and AuditoryMemorytests.Theauthorsdemonstratedthatthe SpeechPerceptionin Noise andAuditory Memorysubtests couldbegroupedintoasinglesubtestbecauseofthe asso-ciationbetweenAuditoryMemoryandSpeechPerceptionin Noise; thereafter, the STAP consisted of threesubtests.27
STAP has the advantages of being quick, lasting approxi-mately 12min, beingeasy toadminister usinga notebook andheadset,anditcanbegiveninaquietroomatschool. However,it isstillnot possibletodetermine whether the STAPperformancewillbeconfirmedbythediagnostictests. Accordingtotheresearchers,thenextstepinthediagnosis ofchildrenscreenedwithSTAPistoconfirmtheidentified
risks.27Afterthatoccurs,thebatterycanberecommended
forauditoryscreening.16,17
Thequestionnaires,ortheso-called‘‘checklists’’,have beenimportantinternationallyasameansofscreening cen-tralauditoryprocessing.13,28 In2013,theScaleofAuditory
Behaviors (SAB) questionnaire, adapted to European Por-tuguese, was applied to the parents of 51 children aged 10---13 years.There wasa significant correlation between the questionnaire score and that of the behavioral tests, withthehighest correlation observed inthe testsrelated totemporal processing.Ofthechildren withscoreslower than46points,94.4%hadalterationsinoneormorecentral auditoryprocessingtests,suggestingthatSABcanbeused asascreeningtoolforauditoryprocessing.13
In 2016, Ahmmed and Ahmmed28 used the
Chil-dren’sAuditory PerformanceScale (CHAPS)andSCAN-Cas screeningmethodsandobservedacorrelationofthe ques-tionnairewithsevenCAPtests.TheCHAPShassixdomains oflistening conditions:(1) listeningin noise(environment withother competing stimuli, e.g., television andpeople talking);(2) situation of listening in silence; (3)situation ofideallistening(nodistractionsandcommunicativeaction occurswithvisualcontact),(4)multipleinputs(inaddition tolisteningthereareotherformsofinput,suchasvisualand tactile);(5) auditorymemory; and(6)auditory attention. OfthedifferentCHAPSdomains,onlyCHAPSwiththeideal listeningsituation,auditorymemoryandattentionwere cor-relatedwiththeCAPtest.
Theuseofquestionnairesisasimpleandinexpensive pro-cedurethatcanaddinformationtothescreeningofat-risk children. Studies suggest that when the checklist proce-duresand auditory testsare applied in a complementary way,thereisacorrelationwiththediagnostictests.29
Theuseofinteractiveandeasy-accesstoolshasgained importanceasascreeningmethod.24,30 BarkerandPurdy24
thatevaluates fiveauditoryprocessingmechanisms:sound localization,auditorypatternrecognition,temporalaspects ofhearing,dichoticlisteningwithcompetingacousticsignals and auditory performance with degraded acoustic signal. The screening was applied to 945 students aged 5---14 yearsusingIPadtablets.Asignificantcorrelationwasfound betweentheFeatherSquadronscoresandtheresultsof tra-ditionalauditory processingassessment in most CAP skills assessedbythebattery.Thestudystandsoutinthe interna-tionalscenarioasitcoversfiveofthesixauditoryprocessing skills recommended by the American Speech-Language-HearingAssociation(ASHA).9Thetestcanbecompletedin
30min, can be used for schoolchildren screening and the studyconfirmsthefindingsinthediagnosticbattery.
In Brazil, the CAP screening procedure most com-monly usedwith schoolchildren is the Simplified Auditory ProcessingAssessment(ASPA),31 consisting ofdichotic
pro-cedures(freefieldandwithsoundinstruments)andincludes theskillsofsoundlocalizationandtemporalorder(memory forverbalandnonverbalsoundsinsequence).Inthepresent studysurvey,threeofthe11identifiedstudies(27.27%)used thismethod,asshowninTable2.
Colella-Santos and collaborators6 screened 287
schoolchildren aged 5---10 years using the ASPA. In this study,44%ofschoolchildrenfailedtheauditoryprocessing screening; memorizing sound sequences and performing temporal ordering were the skills most often impaired. Childrenaged5---8yearsshowedhigherfailurerates.
ToscanoandAnastasioevaluatedschoolchildrenaged4---6 yearsusingASPAand24.6%showedatleastonealteredskill. Theauthorsalsofound thatyoungerchildrenhadahigher rate of abnormalities in auditory skill tests and acoustic immittancemeasures.32
The prevalence of hearing skill alterations found in anotherstudy33 usingtheASPA,weresimilartothatofthe
previousstudy.Ofthe130studentsbetween7and10years, 23.85%failedthescreening,exhibitingworseperformance in the memory for verbal sounds in sequence and better performanceinsoundlocalization.
Foryoungerchildren,theASPAhaswidespread applica-bilitybecauseit requires only abrief administrationtime and requires readily accessible materials,. However, per-formance on the test improves with advancing age until pre-adolescence.Sincethebatterydoesnotevaluate audi-torymechanisms,itisunabletoidentifyschoolchildrenwith otherauditorymechanismimpairments.However,theASPA canbe a sensitive predictor of CAPDs, becausewhen the assessedauditorymechanismshavematured,andwhenthe skillsarealtered,thebehavioraltestsareverylikelytobe altered,sincetheyincludemorecomplextasks.34
AnotherCAPscreeningmethodusedinBrazilistheZaidan battery,whichconsistsintheSCANadaptedtoPortuguese.35
Thebattery wasappliedtochildren aged6---11 yearswho hadnormalhearinglevelsandnospeech,languageorCAPD alterations;subsequently,itwasevaluatedinchildrenwith aclinicaldiagnosisofCAPD.Theresultswerenotconclusive due tothe small number of children in the experimental group(n=11)andthegreatvariationinageinthegroup.35
However,theZaidanscreeningbatterywasutilizedinmore recentstudiesin2006,2007and2008,thatwereincludedin thisarticle,representingthreeofthe11identifiedstudies (27.27%).
In 2006, researchers applied the SCAN to 57 children aged 8---10 years using a portable stereo disk-player and two headphones.18 They observed an improvement in the
screeningtest performanceasageincreased,whenscores wereconsideredinthetotalauditoryprocessingscreening battery,whichisthesumofthecorrectanswersineachof thesubtests(FilteredSpeech,SpeechinNoiseand Compet-ingWords). Therewasa statisticallysignificantdifference in the combined analysis of the individuals’ performance for thethreeage groups,demonstratingtheability ofthe testtoevaluatematurationofthecentralauditorynervous system.18
In2007,the batterywasappliedto40children aged7 and8yearsinthemunicipalityofBauru,stateofSãoPaulo, using an audiometer coupled tothe Compact Disc Player (CD) to establish a standard of normal for the SCAN test in central auditory processingevaluation, and to be able tocomparethefindingswiththoseinZaidan’sstudy. How-ever,differencesinscoreswereobserved.Accordingtothe researchers,itisnecessary toexecuteastudy withlarger numbersofchildrenandchildrenfromdifferentgeographic regions.23
In 2008, the Zaidan battery was again applied to schoolchildren aged7 and8 yearsold in themunicipality ofCuiabá,stateofMatoGrosso.36Theresearchersanalyzed
theperformanceprofileinanauditoryprocessingscreening testin215students,usingaportablestereoCDplayer. How-ever,accordingtotheresearchers,thescoreresultsofthis batteryshowedstatisticallysignificantdifferencesinthe Fil-teredSpeechandCompetingWordssubtests,comparedto the previous study by Zaidan (2001). The authors believe thatsuchdifferencesrequiremulticenterstudiesthat con-siderthesocial,culturalandethnicdifferencesofthetested individuals.
Thesestudies18,23,36indicatethatitisdifficultto
general-izeaboutthestandardofnormalfromtheresultsobtained usingthe battery standardized by Zaidan. Another signifi-cantaspectoftheZaidanbatteryisthatitdoesnotevaluate temporalprocessingassessmentmechanisms,asmentioned anddiscussedinrelationtotheuseoftheSCANinits Amer-icanversion.SotheuseoftheZaidanbatteryasascreening methoddoes notallowtheearly identificationof children withtemporalprocessingdifficulties.
Withtheadvancesintechnology,theutilizationof Tele-health in audiology has become prominent as a means toimprove accessto auditory health servicesand quality of care.37 Currently, the use of teleaudiology in
periph-eral auditory screening in children is gaining traction.30
Concerns withperipheral hearing were described in most of the studies analyzed in this review, with emphasis on the study of tonal thresholds in the articles identi-fied in Tables 1 and 2 from 1 to 4; study of middle ear conditions through Immittance measures in Studies 5 and 6, or the combined use of tonal threshold and Immittancemeasures inStudies 7and8. Whenperipheral auditoryscreening wasnotperformed immediatelybefore CAP screening, thecriterion of performing theprocedure within 72h after CAP screening was considered, mainly to ensuremiddle earfunction conditions (Study 11). It is known that mild to moderate hearing loss is common in schoolchildren andchronic otitis media is itsmain cause, affectingapproximately80%ofchildrenandresultinginat
leastoneoccurrenceof temporaryhearingloss duringthe year.38
The central auditory processing screening initiatives reviewed in this study are satisfactory with respect to beingeasytoapplyandshortduration.However,itis nec-essary to consider the reality of each geographic region withrespect tofeasibility; the use of audiometers,IPADs and/or computers may not be possible in some school environments.
TheuseofonlyonetoolsuchastheASPAorthe question-nairealsodoesnotaddressthecomplexityofCAPscreening, sincenoneofthemethodscanaddress,inasinglebattery, all the auditory mechanisms underlying the hearing skills recommended by ASHA.9 The use of ASPA and the
ques-tionnaires can complement each other in the search for aneasy-accessandlow-costalternative.Anotherchallenge is to adapt adequate auditory screening to different age groups.Inthisreview,theassessedagerangevariedfrom4 to14yearsof age,throughsixcombinedornotcombined screeningpossibilities.
Basedontheanalyzedstudies,thereisaneedfor tech-nologicalresourcesthatidentifyevaluationproceduresthat includetheauditoryskillsintheaudiologicalevaluation.The STAPandFeatherSquadronhaveamorecompletebattery forCAPscreening.TheFeatherSquadronwasappliedinthe agegroupof5---14years,anddividedthebatteryintwo ver-sions, for childrenaged 5---7years andthoseolder than 8 years.TheSTAPbatterywasappliedonlyinschoolchildren olderthan8years,reflectingthematurationofCAPskillsby thatage.Consideringtheanalyzedstudies,itisclear that centralauditory processingscreening isan areayet tobe explored.
Newstudiesshouldbecarriedoutthataimtoidentifya batteryofproceduresthatscreenasmanyauditoryskillsas possible,thatcanevaluatedifferentagegroups, andthen bevalidatedbycomparisonwiththebatteryoftestsusedin theCAPDdiagnosis.
Conclusion
At theinternational level,twoscreening batteriescan be highlighted for their most comprehensive assessment of hearingskills---STAPandFeatherSquadron.Atthenational level,thereisashortageofstudies thatusecentral audi-toryprocessingscreeningmethodsthatevaluatemorethan four central auditory processing skills. The association of questionnairesinschoolchildrenscreeningpractices,theuse of ASPA for pre-school children and thedevelopment and studyofnewauditoryscreeningproposalsforolderchildren aresuggested,includingproceduresaimedattheevaluation ofcentralauditoryskillsthatcanbeappliedintheschool environment. Such procedures should be validated based onstudiesthatconfirmtheschoolchildren’sperformancein centralauditoryprocessingscreeningbycomparingitwith theperformanceintheCAPbehavioralassessmentbattery tests.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Dadalto EV, Nielsen CSCB, Oliveira EAM, Taborda A. Preva-lenceofcommunicationdisordersinscholarsofthemunicipal elementary school network of Vila Velha/ES. Rev CEFAC. 2012;14:1115---21.
2.LindauTA,DelecrodeCR,CardosoACV.Achados timpanométri-cosemumgrupodeescolares.RevCEFAC.2013;15:1453---60. 3.BorgesLR, PaschoalJR,Colella-SantosMF.(Central)Auditory
Processing:theimpactofotitismedia.Clinics.2013;68:959---68. 4.Bayat A, Farhadi M, EmamdjomehH, Saki N, Mirmomeni G, RahimF.Effectofconductivehearinglossoncentralauditory function.BrazJOtorhinolaryngol.2017;83:137---41.
5.AraújoSA,MouraJR,CamargoLA,AlvesW.Avaliac¸ãoauditiva emescolares.RevBrasOtorrinolaringol.2002;68:263---6. 6.Colella-Santos MF, Bragato GR, Martins PMF, Dias AB.
Triagem auditiva em escolares de 5 a 10 anos. Rev CEFAC. 2009;11:644---53.
7.Farias VV, Camboim ED, Azevedo MF, Marques LR. Ocorrên-cia de falhasna triagemauditiva em escolares.Rev CEFAC. 2012;14:1090---5.
8.Tamanin D, Ramos N, Dutra LV, Bassanesi HJC. Triagem auditiva escolar: identificac¸ão de alterac¸ões auditivas em crianc¸asdoprimeiroano doensinofundamental.RevCEFAC. 2015;17:1403---14.
9.American Speech-Language-Hearing Association [Internet]. (Central) auditory processing disorders --- the role of the audiologist [Position Statement]; 2005. Available from www.asha.org/policy[cited14.11.17].
10.MooreDR,FergusonMA,Edmondson-JonesAM,RatibS,RileyA. Natureofauditoryprocessingdisorderinchildren.Pediatrics. 2010;126:382---90.
11.Ahmmed AU, Ahmmed AA, Bath JR, Ferguson MA, Plack CJ, Moore DR. Assessment of children withsuspected audi-tory processing disorder: a factor analysis study. Ear Hear. 2014;35:295---305.
12.ChermakGD,MusiekFE,WeihingJ.Beyondcontroversies:the sciencebehindcentralauditoryprocessingdisorder.HearRev. 2017;24:20---4.
13.NunesCL,PereiraLD,CarvalhoGS.ScaleofAuditoryBehaviors etestesauditivoscomportamentaisparaavaliac¸ãodo proces-samentoauditivoemcrianc¸asfalantesdoportuguêseuropeu. CoDAS.2013;25:209---15.
14.CarvalhoNG,NovelliCVL,Colella-SantosMF.Fatoresnainfância eadolescênciaquepodeminfluenciaro processamento audi-tivo:revisãosistemática.RevCEFAC.2015;17:1590---603. 15.SouzaMA,PassaglioNJS,LemosSMA.Alterac¸õesdelinguagem
eprocessamento auditivo: revisãode literatura.Rev CEFAC. 2016;18:513---9.
16.EngelmanL,FerreiraMIDC.Avaliac¸ãodoprocessamento audi-tivo emcrianc¸ascomdificuldadesde aprendizagem.RevSoc BrasFonoaudiol.2009;14:69---74.
17.NorthernJL,DownsMP.Theauditorysystem.In:NorthernJL, Downs MP, editors. Hearing in children. 5th ed. Lippincott: WilliamseWilkens;2002.p.29---54.
18.SimonLF,RossiAG.Triagemdoprocessamentoauditivoem esco-laresde8a10anos.PsicolEscEduc.2006;10:293---304. 19.AndersonS,ChandrasekaranB,YiHG,KrausN.Cortical-evoked
potentialsreflectspeech-in-noiseperceptioninchildren.EurJ Neurosci.2010;32:13---407.
20.CarvalhoNG,NovelliCL,Colella-SantosMF.Evaluationofspeech innoiseabilitiesinschoolchildren.IntJPediatr Otorhinolaryn-gol.2017;99:66---72.
21.AmosNE,HumesLE.SCANtest---retestreliabilityforfirst-and third-gradechildren.JSpeechLangHearRes.1998;41:834---45. 22.KeithRW.DevelopmentandstandardizationofSCAN-Ctestfor auditoryprocessingdisordersin children.JAm AcadAudiol. 2000;11:438---45.
23.LucasPA,ZacareCC,AlvesFOC,AmantiniRCB,BevilacquaMC, ZaidanE.Scan:perfildedesempenhoemcrianc¸asdeseteeoito anos.Pró-FonoRAtualCient.2007;19:370---3.
24.BarkerMD,PurdySC.Aninitialinvestigationintothevalidity ofacomputer-basedauditoryprocessingassessment(Feather Squadron).IntJAudiol.2016;55:173---83.
25.OliveiraJC,MurphyCFB,SchochatE.Processamentoauditivo (central)emcrianc¸ascomdislexia:avaliac¸ãocomportamental eeletrofisiológica.CoDAS.2013;25:39---44.
26.SantosTS,ManciniPC,SancioLP,CastroAR,LabancaL,Resende LM.Achadosdaavaliac¸ãocomportamentaleeletrofisiológicado processamentoauditivo.AudiolCommunRes.2015;20:225---32. 27.Yathiraj A, Maggu AR. Screening test for auditory processing (STAP): a preliminary report. J Am Acad Audiol. 2013;24:867---78.
28.AhmmedAU,AhmmedAA.Settingappropriatepassorfail cut-off criteria for tests to reflectreal life listening difficulties inchildrenwithsuspectedauditoryprocessingdisorder.IntJ PediatrOtorhinolaryngol.2016;84:166---73.
29.WilsonWJ,JacksonA,PenderA,RoseC,WilsonJ,HeineC,etal. TheCHAPSSIFTER,andTAPS-Raspredictorsof(C)APskillsand (C)APD.JSpeechLangHearRes.2011;54:278---91.
30.Skarzy´nskiPH, ´SwierniakW, PiłkaA, SkarzynskaMB, Wlodar-czykAW,KholmatovD,etal.Ahearingscreeningprogramfor childreninprimaryschoolsinTajikistan:atelemedicinemodel. MedSciMonit.2016;22:2424---30.
31.PereiraLD,SchochatE.Processamentoauditivocentral: abor-dagem passo a passo. In: Pereira LD, Schochat E, editors.
Processamento auditivo central: manual de avaliac¸ão. São Paulo:Lovise;1997.p.49---60.
32.ToscanoRDGP,AnastasioART.Habilidadesauditivasemedidas daimitânciaacústicaemcrianc¸asde4a6anosdeidade.Rev CEFAC.2012;14:650---8.
33.EtgesCL,ReisMCP,MenegottoIH,SleiferP,SolderaCLC. Acha-dosnatriagemimitanciométricaedeprocessamentoauditivo emescolares.RevCEFAC.2012;14:1098---107.
34.Vargas GC, Ferreira MIDC, Vidor DCGM, Machado MS. Avaliac¸ão simplificada e comportamental do processamento auditivo em escolares: estabelecendo relac¸ões. Rev CEFAC. 2014;16:1069---77.
35.Zaidan E [dissertac¸ão] Desenvolvimento de uma bateria de testesdetriagemdafuncãoauditivacentralempré-escolarese escolaresnafaixade6a11anos.SãoPaulo(SP):Universidade deSãoPaulo;2001.
36.RodriguesPAL,SameshimaK,ZaidanE.Perfildedesempenhoem testedetriagemdeprocessamentoauditivo(SCAN)emcrianc¸as deseteeoitoanosresidentesemCuiabá.RevSocBras Fonoau-diol.2008;13:173---8.
37.Molini-Avejonas DR, Rondon-Melo S, Amato CA, Samelli AG. Asystematicreviewoftheuse oftelehealthinspeech, lan-guage and hearing sciences. J Telemed Telecare. 2015;21: 367---76.
38.Klausen O, Moller P, Holmefjord A, Reisaeter S, Asbjornsen A. Lasting effects of otitis media with effusion on lan-guageskillsandlisteningperformance.ActaOtolaryngolSuppl. 2000;543:73---6.
