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Executive Functioning Skills of Children with Listening Difficulties

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Title: Executive Functioning Skills of Children with Listening Difficulties
Language: English
Authors: McGrath, Melissa A., Fletcher, Kathryn L., Bielski, Lynn M.
Source: Psychology in the Schools. Sep 2023 60(9):3520-3541.
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 22
Publication Date: 2023
Document Type: Journal Articles
Reports - Research
Descriptors: Children, Adolescents, Listening, Listening Skills, Executive Function, Skills, Auditory Tests, Referral, Attention Deficit Hyperactivity Disorder, Control Groups
DOI: 10.1002/pits.22940
ISSN: 0033-3085
1520-6807
Abstract: Children with normal hearing who present with listening difficulties (LiD) are frequently referred for assessment of auditory processing disorder (APD). Complicating diagnosis is the similarities of APD to other neurodevelopmental disorders, especially attention-deficit hyperactivity disorder (ADHD). Due to well-documented deficits in executive functioning (EF) in children with ADHD, we hypothesized that a possible root cause of observed listening deficits may be EF deficits, rather than auditory processing alone. For preliminary investigation into this hypothesis, the current study compared EF skills of children with LiD who were referred for APD assessment, with and without a diagnosis of ADHD. EF skills of 24 children between the ages of 7-16 were assessed utilizing the Behavioral Assessment of Dysexecutive Syndrome in Children, and the Behavior Rating Inventory of Executive Function, 2nd edition. Compelling differences were found between groups of children with LiD. Children without ADHD scored lower on measures of inhibitory control compared to children with a diagnosis of ADHD. Decreased EF skills exhibited in children with LiD, even those without a diagnosis of ADHD, support the need for transdisciplinary identification and management of children with LiD.
Abstractor: As Provided
Entry Date: 2023
Accession Number: EJ1387122
Database: ERIC
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  Value: <anid>AN0169726517;pis01sep.23;2023Aug04.05:06;v2.2.500</anid> <title id="AN0169726517-1">Executive functioning skills of children with listening difficulties </title> <p>Children with normal hearing who present with listening difficulties (LiD) are frequently referred for assessment of auditory processing disorder (APD). Complicating diagnosis is the similarities of APD to other neurodevelopmental disorders, especially attention‐deficit hyperactivity disorder (ADHD). Due to well‐documented deficits in executive functioning (EF) in children with ADHD, we hypothesized that a possible root cause of observed listening deficits may be EF deficits, rather than auditory processing alone. For preliminary investigation into this hypothesis, the current study compared EF skills of children with LiD who were referred for APD assessment, with and without a diagnosis of ADHD. EF skills of 24 children between the ages of 7–16 were assessed utilizing the Behavioral Assessment of Dysexecutive Syndrome in Children, and the Behavior Rating Inventory of Executive Function, 2nd edition. Compelling differences were found between groups of children with LiD. Children without ADHD scored lower on measures of inhibitory control compared to children with a diagnosis of ADHD. Decreased EF skills exhibited in children with LiD, even those without a diagnosis of ADHD, support the need for transdisciplinary identification and management of children with LiD.</p> <p>Practitioner points: Children with listening difficulties are often referred for assessment of auditory processing disorder (APD).Regardless of attention‐deficit hyperactivity disorder diagnosis, children referred for APD assessment display executive functioning deficits.Children with reported listening difficulties may benefit from classroom intervention to address executive functioning.</p> <p>Keywords: ADHD; auditory processing disorder; executive functions; inhibitory control; listening difficulty</p> <hd id="AN0169726517-2">INTRODUCTION</hd> <p>Effective listening skills in the classroom are crucial for academic achievement (DeWit et al., [<reflink idref="bib32" id="ref1">32</reflink>]; Eggenberger, [<reflink idref="bib36" id="ref2">36</reflink>]); and academic achievement lays the groundwork for economic and employment success later in life. Adults with higher academic achievement consistently demonstrate higher earnings compared to those adults with a high school diploma or less (National Center for Education Statistics, [<reflink idref="bib71" id="ref3">71</reflink>]). Higher grade point averages (GPAs) in high school predict higher earnings into adulthood (French et al., [<reflink idref="bib40" id="ref4">40</reflink>]). Moreover, the foundation for academic achievement begins in the early school years. Achievement scores in mathematics and reading at age seven are significantly associated with higher income levels in adulthood (Ritchie & Bates, [<reflink idref="bib75" id="ref5">75</reflink>]), and reading skills at third grade are predictive of achievement outcomes in high school and beyond (Lesnick et al., [<reflink idref="bib55" id="ref6">55</reflink>]). In summary, academic performance as early as the elementary school sets the path toward long‐term outcomes such as attending college, occupational success, and lifetime earnings.</p> <p>Particularly vulnerable to decreased academic achievement are students with high‐incidence disabilities, such as speech/language impairments, specific learning disabilities (LDs), and/or other health impairments (Sabornie et al., [<reflink idref="bib77" id="ref7">77</reflink>]). Compared to students without disabilities, students with speech/language impairments, specific LDs, and other health impairments are less likely to complete high school (National Center for Education Statistics, [<reflink idref="bib71" id="ref8">71</reflink>]). Students with LDs have lower employment rates and decreased enrollment and completion in postsecondary school (Murray, [<reflink idref="bib67" id="ref9">67</reflink>]). Students with other high‐incidence disorders, such as children with attention‐deficit hyperactivity disorder (ADHD), are also at greater risk for academic difficulties and failure (Chermak & Musiek, [<reflink idref="bib25" id="ref10">25</reflink>]; Loe & Feldman, [<reflink idref="bib56" id="ref11">56</reflink>]). Students with and without a diagnosis of ADHD may present as children with listening difficulties. Children with listening difficulties are often referred for assessment of auditory processing disorder (APD). Children with ADHD and children with listening difficulties display similar problematic classroom behaviors, with children in both groups showing behaviors such as inattentiveness, distractibility, and poor performance in academic work including difficulty reading and writing (Barkley, [<reflink idref="bib9" id="ref12">9</reflink>]; Geffner, [<reflink idref="bib41" id="ref13">41</reflink>]; Molitor et al., [<reflink idref="bib62" id="ref14">62</reflink>]). Given the similarities of behaviors in classroom settings, children with ADHD are frequently referred for assessment of APD.</p> <p>While is it unknown specifically why children with ADHD are also referred for assessment of APD, this may be in part due to parental concerns about integrating medication into treatment (Tarver et al., [<reflink idref="bib82" id="ref15">82</reflink>]), the perceived stigma associated with a diagnosis of ADHD (Barkley, [<reflink idref="bib9" id="ref16">9</reflink>]), and reported difficulty of consistent application of classroom interventions by teachers (Havey et al., [<reflink idref="bib44" id="ref17">44</reflink>]). Yet school‐aged children who demonstrate listening difficulties, both with and without ADHD, are continually being referred for evaluation of APD (Chermak & Musiek, [<reflink idref="bib25" id="ref18">25</reflink>]; Moore et al., [<reflink idref="bib66" id="ref19">66</reflink>]; Yathiraj & Vanaja, [<reflink idref="bib87" id="ref20">87</reflink>]). Most children who are referred for APD assessment are referred for evaluation based upon academic and behavioral difficulties similar to those displayed in children diagnosed with ADHD. However, of those children referred, very few are receiving a true diagnosis of APD. Low APD diagnosis rates are based upon numerous reasons, such as varied diagnostic guidelines, controversary surrounding APD, and questionable diagnostic validity of modality specificity (Moore et al., [<reflink idref="bib66" id="ref21">66</reflink>]). Furthermore, children with listening difficulties without a diagnosis of APD continue to display academic difficulties well into adolescence and report continued academic and achievement difficulties into adulthood (Heine & Slone, [<reflink idref="bib45" id="ref22">45</reflink>]; Moore et al., [<reflink idref="bib66" id="ref23">66</reflink>]; Del Zoppo et al., [<reflink idref="bib89" id="ref24">89</reflink>]). Emerging opinions suggest that many children who are referred for assessment of APD, even if not diagnosed, would benefit from the management of identified listening difficulties that may be contributing to decreased academic success (DeWit et al., [<reflink idref="bib31" id="ref25">31</reflink>], [<reflink idref="bib32" id="ref26">32</reflink>]; Fillippini et al., [<reflink idref="bib39" id="ref27">39</reflink>]). Furthermore, calls to label these children as those with listening difficulties rather than APD or suspected APD, have increased in the literature (Dillon & Cameron, [<reflink idref="bib34" id="ref28">34</reflink>]). Regardless of the label: Children with ADHD, APD, suspected APD, or listening difficulties (LiD) are at higher risk for academic failure. Children with LiD often return to school following APD assessment without an APD or ADHD diagnosis and continue to struggle with their academic work. To make proper accommodations for students, regardless of their label, more understanding of underlying cognitive deficits in children with LiD is necessary to provide appropriate intervention.</p> <p>Although researchers have examined academic achievement and numerous cognitive skill outcomes in children with ADHD and LiD, to our knowledge, researchers have not examined executive functions in children with LiD with and without ADHD. According to Barkley ([<reflink idref="bib8" id="ref29">8</reflink>]), executive functioning (EF) are important skills necessary for self‐regulation, and children's self‐regulation abilities (i.e., any self‐directed action that may serve to modify a subsequent behavior) are extremely important in monitoring their learning and classroom behaviors (Binns et al., [<reflink idref="bib14" id="ref30">14</reflink>]; Graham, [<reflink idref="bib43" id="ref31">43</reflink>]). Children with ADHD have documented deficits in self‐regulation skills and EF (Graham, [<reflink idref="bib43" id="ref32">43</reflink>]; Sabornie et al., [<reflink idref="bib77" id="ref33">77</reflink>]). Children and adolescents with ADHD reportedly struggle with academic tasks requiring the self‐regulation skills such as inhibition control, self‐monitoring, and metacognitive abilities (Barkley, [<reflink idref="bib8" id="ref34">8</reflink>]).</p> <p>Despite the many similarities of children with LiD and children with ADHD, to date, there have been no published studies directly examining specific EF skills of children with reported LiD. For those children displaying LiD, deficits in EF may be an underlying cause of academic concerns with subsequent negative consequences on academic achievement. Given that children with LiD and children with ADHD demonstrate many of the same symptoms, the purpose of this study is to determine if children with LiD also show deficits in EF, similar to children with ADHD.</p> <hd id="AN0169726517-3">Auditory processing disorder</hd> <p>Prevalence estimates of APD are difficult to determine based upon the fact that there is no universal agreement on diagnostic criteria. Prevalence ranges include anywhere from 2%–3% (Chermak & Musiek, [<reflink idref="bib24" id="ref35">24</reflink>]; Palfery & Duff, [<reflink idref="bib72" id="ref36">72</reflink>]) to 12% (DiMaggio & Geffner, [<reflink idref="bib35" id="ref37">35</reflink>]) and as high as 20% (Katz, [<reflink idref="bib50" id="ref38">50</reflink>]). Research on APD has not been without controversy, with multiple arguments in topics ranging simply from the title of the disorder (ASHA, [<reflink idref="bib4" id="ref39">4</reflink>]; Jerger & Musiek, [<reflink idref="bib48" id="ref40">48</reflink>]), to specific diagnostic criteria (Riccio et al., [<reflink idref="bib73" id="ref41">73</reflink>]) and skepticism regarding the source of the disordered modalities in question (Cacace & McFarland, [<reflink idref="bib20" id="ref42">20</reflink>]; Maerlender & Heath, [<reflink idref="bib57" id="ref43">57</reflink>]). As such, it has recently been suggested that the term APD be replaced with a more encompassing umbrella term of "listening difficulty" (Dillon & Cameron, [<reflink idref="bib34" id="ref44">34</reflink>]). Much controversy surrounding APD has culminated to the point of multiple disciplines questioning the overall validity of APD as a diagnostic label (Dawes & Bishop, [<reflink idref="bib27" id="ref45">27</reflink>]; DeWit et al., [<reflink idref="bib32" id="ref46">32</reflink>]; Iliadou & Kiese‐Himmel, [<reflink idref="bib47" id="ref47">47</reflink>]). Regardless of the controversary, school‐aged children exhibiting not hearing, but "listening" difficulties must be managed and assessed by professionals from different fields, such as audiologists, speech‐language pathologists, and school psychologists.</p> <p>According to the American Speech‐Language and Hearing Association, a diagnosis of APD is confirmed if a child scores at or below two standard deviations below the mean on any two measures of auditory function (ASHA, [<reflink idref="bib4" id="ref48">4</reflink>]). The American Academy of Audiology (AAA) also stated that a child must score at or below two standard deviations below the mean on two or more measures, but added that if there is a difference noted between ears, or if one ear scores at or below two standard deviations below the mean, then the diagnosis of APD is warranted (American Academy of Audiology, [<reflink idref="bib1" id="ref49">1</reflink>]). Although the majority of children evaluated for APD display at least a mild right ear advantage (difference in performance between ears), there appears to be no systematic relationship between a reported ear advantage and a diagnosis of APD (Moore et al., [<reflink idref="bib66" id="ref50">66</reflink>]). In contrast to the diagnosis recommendations by AAA and American Speech‐Language Hearing Association (ASHA), the British Society of Audiology (BSA) reported that poor perception of speech and nonspeech stimuli must be present to make a diagnosis of APD. However, the BSA stated that a diagnosis of APD is only indicated if two tests of auditory function are failed, but that there must be at least one failure with speech stimuli and one with nonspeech stimuli.</p> <p>Because the central auditory nervous system (CANS) is not considered completely mature until at least the age of 12, some clinicians have advocated for a diagnosis of APD with a score of one standard deviation below the mean on a measure of auditory processing (Shaikh et al., [<reflink idref="bib78" id="ref51">78</reflink>]). Reasoning for the one standard deviation below as the cut‐off is reportedly due to concern that the current AAA and ASHA standards may miss children both at risk and with APD. To emphasize the impact of the variety of diagnostic criteria on the assessment of APD, Wilson and Arnott ([<reflink idref="bib86" id="ref52">86</reflink>]) completed a retrospective analysis of 150 children who were evaluated for APD between the ages of 7–15.5 years using each of the criteria (AAA, ASHA, BSA) for a positive diagnosis. Results yielded an APD diagnosis rate for anywhere from 7% to 96% dependent upon which criteria and assessment tools were used. These findings led Wilson and Arnott ([<reflink idref="bib86" id="ref53">86</reflink>]) to conclude that use of APD as a global diagnosis should be abandoned. Further confusion remains regarding differential diagnosis of closely related APD and language processing disorders or ADHD. Due to the ambiguity in achieving an APD diagnosis, the term LiD is utilized in the current and many other recent studies on the topic (Barry et al., [<reflink idref="bib11" id="ref54">11</reflink>]; Dillon & Cameron, [<reflink idref="bib34" id="ref55">34</reflink>]; Moore, [<reflink idref="bib63" id="ref56">63</reflink>], [<reflink idref="bib64" id="ref57">64</reflink>]; Sharma et al., [<reflink idref="bib79" id="ref58">79</reflink>]) to refer to children with reported deficits in listening with normal hearing, who may or may not have a formal diagnosis of APD.</p> <hd id="AN0169726517-4">Attention‐deficit hyperactivity disorder</hd> <p>ADHD is one of the most prevalent childhood neurodevelopmental disorders facing students today. According to the Centers for Disease Control and Prevention ([<reflink idref="bib22" id="ref59">22</reflink>]) the percentage of children in the United States, aged 4–17 years, with a diagnosis of ADHD by a health care provider as reported by parents, continues to increase, from 7.8% in 2003 to 11% in 2012. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (American Psychiatric Association, [<reflink idref="bib2" id="ref60">2</reflink>]) criteria for diagnosing ADHD indicate symptoms of "a persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development across more than one setting." Diagnosis of ADHD is usually completed by a pediatrician or psychologist. Criteria for ADHD diagnosis include that symptoms of ADHD be present before age 12 and contribute to deficits across settings (American Psychiatric Association, [<reflink idref="bib2" id="ref61">2</reflink>]). ADHD is most frequently diagnosed in the early school years, with symptoms becoming more apparent in the later school years when school‐age children are expected to attend to structured tasks for longer periods of time (Weyandt & Gudmundsdottir, [<reflink idref="bib85" id="ref62">85</reflink>]). Developmentally, children with ADHD also display deficits in adaptive functioning, motor coordination, language ability, self‐perception, and learning difficulties (Barkley, [<reflink idref="bib7" id="ref63">7</reflink>]).</p> <p>Perhaps contributing to developmental deficits in language ability and learning difficulty in children with ADHD are underlying deficits in auditory processing. One of the classroom behaviors observed in children with ADHD is difficulty listening. Children with ADHD display deficits in specific auditory skills such as auditory closure, binaural integration, and temporal ordering (Lanzetta‐Valdo et al., [<reflink idref="bib54" id="ref64">54</reflink>]). When assessing attention skills in school‐age children, auditory perception is a known contributing factor to the assessment of cognition (Iliadou & Kiese‐Himmel, [<reflink idref="bib47" id="ref65">47</reflink>]). Conversely, when children perform poorly on tasks of auditory perception, research has indicated that they also tend to perform poor on a range of cognitive measures (Moore, [<reflink idref="bib64" id="ref66">64</reflink>]).</p> <hd id="AN0169726517-5">Conceptual overlap of LiD and ADHD</hd> <p>Behavioral and cognitive characteristics of APD/LiD are strikingly similar to those of children with ADHD. Whereas research on the academic achievement of children with ADHD has been plentiful, a smaller body of research on LiD has indicated similar patterns in reduced achievement for both groups. For instance, overall GPA was found to be notedly lower in children with ADHD when compared with children without ADHD (Barkley et al., [<reflink idref="bib10" id="ref67">10</reflink>]; Molina et al., [<reflink idref="bib61" id="ref68">61</reflink>]). Similarly, adolescents labeled with LiD have demonstrated decreased GPA compared to their peers (Heine & Slone, [<reflink idref="bib45" id="ref69">45</reflink>]). Students with ADHD score lower on standardized achievement tests compared with their peers (Langberg et al., [<reflink idref="bib53" id="ref70">53</reflink>]). Similarly, both students diagnosed with APD and those with LiD, but not diagnosed, score lower on standardized tests such as the weschler individual achievement test compared with peers (Ferguson et al., [<reflink idref="bib38" id="ref71">38</reflink>]; Moore et al., [<reflink idref="bib65" id="ref72">65</reflink>], [<reflink idref="bib66" id="ref73">66</reflink>]). A summary of similar diagnostic symptomology in ADHD and LiD is summarized in Table 1.</p> <p>1 Table Overlapping diagnostic symptomology of ADHD and LiD.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th align="left">ADHD symptom</th><th align="left">LiD symptom</th></tr></thead><tbody valign="top"><tr><td align="left">Overall GPA is lower compared to children without ADHD (Barkley et al., <xref ref-type="bibr" rid="bibr10">2006</xref>; Molina et al., <xref ref-type="bibr" rid="bibr61">2009</xref>).</td><td align="left">Decreased GPA compared to peers (Heine & Slone, <xref ref-type="bibr" rid="bibr45">2008</xref>).</td></tr><tr><td align="left">Lower standardized achievement tests compared with peers (Langberg et al., <xref ref-type="bibr" rid="bibr53">2011</xref>).</td><td align="left">Score lower on standardized achievement tests compared to peers (Ferguson et al., <xref ref-type="bibr" rid="bibr38">2011</xref>; Moore et al., <xref ref-type="bibr" rid="bibr65">2010</xref>, <xref ref-type="bibr" rid="bibr66">2018</xref>).</td></tr><tr><td align="left">Classroom behaviors observed include difficulty listening. Children with ADHD exhibit deficits in specific auditory skills such as auditory closure, binaural integration, and temporal ordering (Lanzetta‐Valdo et al., <xref ref-type="bibr" rid="bibr54">2016</xref>).Poor performance in academic work including difficulty reading and writing (Barkley, <xref ref-type="bibr" rid="bibr8">2012</xref>; Molitor et al., <xref ref-type="bibr" rid="bibr62">2016</xref>).</td><td align="left">Decreased listening in the classroom is a primary reason for referral of APD assessment. Assessment of children with Lid indicate deficits in specific auditory processes (Moore, <xref ref-type="bibr" rid="bibr64">2015</xref>, Geffner, <xref ref-type="bibr" rid="bibr41">2019</xref>).Difficulty with reading and/or writing (Geffner, <xref ref-type="bibr" rid="bibr41">2019</xref>).</td></tr></tbody></table> </ephtml> </p> <p>1 Abbreviations: ADHD, attention‐deficit hyperactivity disorder; APD, auditory processing disorder; GPA, grade point average; LiD, listening difficulties.</p> <p>In addition, the comorbidity of children diagnosed with both APD and ADHD is staggering. In a review of 425 children diagnosed with APD between the ages of 4–14 years, DiMaggio and Geffner ([<reflink idref="bib35" id="ref74">35</reflink>]) noted that 84% of children evaluated for APD have confirmed or suspected ADHD. Riccio et al. ([<reflink idref="bib74" id="ref75">74</reflink>]) reported that at least 50% of children diagnosed with APD would also fit the diagnostic criteria of ADHD. Consequently, a body of research has surfaced in recent years to delineate the distinction between ADHD and APD (Bellis et al., [<reflink idref="bib12" id="ref76">12</reflink>]; Chermak et al., [<reflink idref="bib23" id="ref77">23</reflink>]; Dawes & Bishop, [<reflink idref="bib27" id="ref78">27</reflink>]). APD is diagnosed by audiologists, and management of the disorder is usually completed by speech‐language pathologists (American Academy of Audiology, [<reflink idref="bib1" id="ref79">1</reflink>]; ASHA, [<reflink idref="bib4" id="ref80">4</reflink>]; DeBonis & Moncrieff, [<reflink idref="bib30" id="ref81">30</reflink>]). However, given the commonalities between ADHD and APD, psychologists are often faced with students with symptoms of auditory processing‐related deficits (Maerlender & Heath, [<reflink idref="bib57" id="ref82">57</reflink>]). Studies attempting to bridge the gap between audiology, speech pathology, and psychology have been limited, thus making it "difficult for psychologists to incorporate the putative APD construct into their own theoretical frameworks" (Maerlender & Heath, [<reflink idref="bib57" id="ref83">57</reflink>]; pp. 543–544). The gap in understanding LiD and APD across disciplines is further complicated by two distinct arguments regarding if APD and ADHD are indeed separate entities, or if they are just varying manifestations of similar neurodevelopmental disorders, such as language processing, ADHD, or reading disorders (DeBonis, [<reflink idref="bib29" id="ref84">29</reflink>]).</p> <p>In further consideration of APD as a separate diagnosis than other LDs, Magimairaj and Nagaraj ([<reflink idref="bib58" id="ref85">58</reflink>]) argued for a new framework of understanding LiD in children, indicating that the framework must include cognitive factors as a potential source of deficits along with auditory factors. Similarly, through a systematic review of 13 studies which were deemed to have "moderate" methodological quality, DeWit et al. ([<reflink idref="bib32" id="ref86">32</reflink>]) investigated characteristics of LiD that overlap with characteristics of children with specific language impairments (SLI), dyslexia, ADHD, LDs, or autism spectrum disorders. Children with LiD demonstrated similar presentations compared with children diagnosed with SLI, dyslexia, ADHD, and LD on tests of intelligence, memory, attention, and language. Only small differences were noted between all groups in auditory and visual skills. Children with LiD share overlapping deficits in skills in intelligence, attention, memory, and language with children diagnosed with other neurodevelopmental disorders such as SLI, dyslexia, ADHD, and LD. It has been reported that EF could be a potentially useful construct to further differentiate symptoms observed in various disorders, such as APD and ADHD (Chermak et al., [<reflink idref="bib23" id="ref87">23</reflink>]; Moore et al., [<reflink idref="bib65" id="ref88">65</reflink>]). However, none of the 13 studies described in DeWit et al.'s ([<reflink idref="bib32" id="ref89">32</reflink>]) review utilized measures that directly assess skills of EF.</p> <hd id="AN0169726517-6">Executive functions</hd> <p>Although researchers have examined academic achievement and numerous cognitive skill outcomes in children with ADHD and children with APD or LiD, to our knowledge, researchers have not compared examined executive functions in children with ADHD and LiD. The American Psychology Association ([<reflink idref="bib3" id="ref90">3</reflink>]) defines executive function (EF) as "higher level cognitive processes of planning, decision making, problem‐solving, action sequencing, task assignment and organization, effortful and persistent goal pursuit, inhibition of competing impulses, flexibility in goal selection, and goal conflict resolution." Although EF can be defined as an umbrella term of many specific skillsets, there exists a general consensus (Blair & Raver, [<reflink idref="bib15" id="ref91">15</reflink>]; Hughes, [<reflink idref="bib46" id="ref92">46</reflink>]; Miyake and Friedman, [<reflink idref="bib60" id="ref93">60</reflink>]) of three major subdomains within the EF construct: inhibitory control (IC), working memory (WM), and attention/set shifting. IC consists of three interrelated responses: suppressing prepotent responses; stopping ongoing responses; and resisting distracting stimuli. Working memory is a limited storage system where information is managed for ongoing mental processes (Baddeley, [<reflink idref="bib5" id="ref94">5</reflink>]). Lastly, attention/set shifting, also known as cognitive flexibility (CF), is the ability to switch flexibly between tasks or mental sets (Miyake & Friedman, [<reflink idref="bib60" id="ref95">60</reflink>]).</p> <p>Children with ADHD, as well as children with specific LDs and language impairments, have documented deficits in self‐regulation skills and EF (Graham, [<reflink idref="bib43" id="ref96">43</reflink>]; Sabornie et al., [<reflink idref="bib77" id="ref97">77</reflink>]). Children with ADHD demonstrate significant deficits in EF skills (Barkley, [<reflink idref="bib10" id="ref98">10</reflink>], [<reflink idref="bib8" id="ref99">8</reflink>]; Dawson & Guare, [<reflink idref="bib28" id="ref100">28</reflink>]). Biederman et al. ([<reflink idref="bib13" id="ref101">13</reflink>]) found that significantly more children and adolescents with ADHD had EF deficits compared to children without ADHD. A diagnosis of ADHD along with EF deficits is associated with an increased risk for grade retention and a decrease in academic achievement (Biederman et al., [<reflink idref="bib13" id="ref102">13</reflink>]). Children and adolescents with ADHD reportedly struggle with academic tasks requiring the executive control systems such as inhibition control, self‐monitoring, and metacognitive abilities (Barkley, [<reflink idref="bib8" id="ref103">8</reflink>]).</p> <p>Given the many similarities of LiD and ADHD, is it possible that decreased EF skills are contributing to the academic difficulties of children being referred for assessment of APD?</p> <p>Although LiD and ADHD share many of the same risk factors for decreased academic achievement, there have been no published studies to date directly examining the EF skills of students with LiD. For children referred for assessment due to LiD, deficits in EF may be an underlying cause of academic concerns with subsequent consequences on academic achievement. Identifying underlying impairments such as EF dysfunction is crucial to appropriate management, as it has been demonstrated that EF skills are malleable, and foundational to academic success.</p> <hd id="AN0169726517-7">Objectives of the current study</hd> <p>The current study investigated the EF skills of children with LiD referred for assessment of APDs, with and without ADHD, taking into consideration any underlying comorbidities such as specific LDs or language impairment. For the current study, we addressed the following questions: Do children with LiD and ADHD differ on EF compared to children with LiD without ADHD? Do children with LiD and ADHD differ on IC, WM, and CF compared to children with LiD without ADHD? It was hypothesized that child‐centered and parent‐report assessments of EF will confirm deficits in children with LiD, regardless of ADHD diagnosis.</p> <hd id="AN0169726517-8">METHODS</hd> <p></p> <hd id="AN0169726517-9">Participants</hd> <p>Children aged 7–16 years of age referred for assessment of APD to the university speech and hearing clinic were included in the study (<emph>N</emph> = 24). A total of 34 successful contacts were made, via phone call, to invite children to participate in the study. A total of 30 children were scheduled, however, only 24 evaluations were completed due to clinic closure and changes to in‐person assessment protocols, which began in March 2020. Four parents declined to participate: Two refused due to the lengthy drive time/distance from their home to the university clinic; one moved out of state; and one was not interested but did not indicate a reason. For inclusion, participants must have demonstrated hearing thresholds for conversational speech levels at 3 feet. Therefore, participants were only included if (a) hearing was deemed to be within the conversation speech threshold by the evaluating audiologist at the time of the APD assessment, and (b) hearing was screened and passed on the day of the EF assessment (criteria for passing a hearing screening on day of assessment was 25 dB at 500 Hz, 20 dB at 1000, 2000, and 4000 Hz). All of the children included in the study passed the hearing screening. One child did not respond to 500 Hz at 25 dB and was excluded from the study. Demographics were collected on child age, gender, socioeconomic status (if child is eligible for free or reduced lunch), level of parent education, and diagnosed disabilities as reported by the parent (ADHD; specific LDs in reading, writing, or math; speech/language delay or disorder; sensory processing disorder; and/or anxiety or depression). Due to the high incidence of concomitant disabilities, children with other diagnoses in addition to ADHD were included in the study.</p> <p>Descriptive data for the sample is presented in Table 2. The total number of participants was 24 children (15 male and 9 females) between the ages of 7‐ and 16‐years‐old (<emph>M</emph> = 9.62, SD = 2.08). Of the 24 children, 62.5% (<emph>n</emph> = 15) had a prior diagnosis of ADHD. Chart reviews and parent interviews confirmed the ADHD diagnosis either by pediatrician or psychoeducational testing. Instruments completed before the APD evaluation included the Children's Auditory Performance Scale (CHAPS) and the NICHQ Vanderbilt Scale. The CHAPS was completed by school personnel and rated the student's listening ability in specific conditions as compared to students of the same age. The NICHQ Vanderbilt Scale was used as a screener for attention deficits. ADHD group status was confirmed only if totals on the parent assessment scale indicated a diagnosis of ADHD (predominantly inattentive subtype, predominately hyperactive/impulsive subtype, or ADHD combined). For the group without ADHD, teacher and parent reports were void of inattentiveness or other ADHD behaviors. A total of 11 of the 15 children with ADHD were reportedly medicated; and each of the 11 children had reportedly received that medication on the day of the assessment. Eight of the eleven children receiving pharmacological treatment were also enrolled in some form of nonpharmacological treatment such as speech therapy or resource support. However, it should be noted that many of these children had concomitant factors such as specific LDs in reading or writing, which may have dictated enrollment in special services.</p> <p>2 Table Demographics of the participants.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th align="left">Characteristic</th><th align="left">%</th><th align="left"><italic>N</italic></th></tr></thead><tbody valign="top"><tr><td align="left">Gender</td><td /><td /></tr><tr><td align="left">Male</td><td align="char" char=".">62.5</td><td align="char" char=".">5</td></tr><tr><td align="left">Female</td><td align="char" char=".">37.5</td><td align="char" char=".">9</td></tr><tr><td align="left">Race/ethnicity</td><td /><td /></tr><tr><td align="left">White</td><td align="char" char=".">87.5</td><td align="char" char=".">21</td></tr><tr><td align="left">Black</td><td align="char" char=".">4.2</td><td align="char" char=".">1</td></tr><tr><td align="left">Other</td><td align="char" char=".">4.2</td><td align="char" char=".">1</td></tr><tr><td align="left">Prefer not to answer</td><td align="char" char=".">4.2</td><td align="char" char=".">1</td></tr><tr><td align="left">Eligible for free/reduced lunch</td><td /><td /></tr><tr><td align="left">Yes</td><td align="char" char=".">25</td><td align="char" char=".">6</td></tr><tr><td align="left">No</td><td align="char" char=".">62.5</td><td align="char" char=".">15</td></tr><tr><td align="left">Missing</td><td align="char" char=".">12.5</td><td align="char" char=".">3</td></tr><tr><td align="left">Parent education level</td><td /><td /></tr><tr><td align="left">High school or equivalent</td><td align="char" char=".">4.2</td><td align="char" char=".">1</td></tr><tr><td align="left">Some college</td><td align="char" char=".">4.2</td><td align="char" char=".">1</td></tr><tr><td align="left">Associate degree</td><td align="char" char=".">16.7</td><td align="char" char=".">4</td></tr><tr><td align="left">Bachelor's degree</td><td align="char" char=".">33.3</td><td align="char" char=".">8</td></tr><tr><td align="left">Masters</td><td align="char" char=".">33.3</td><td align="char" char=".">8</td></tr><tr><td align="left">Doctorate</td><td align="char" char=".">8.3</td><td align="char" char=".">2</td></tr></tbody></table> </ephtml> </p> <p>Confirming the low diagnosis rate of APD in children that are typically referred for APD assessment, only 1 of the 24 children had received a diagnosis of APD following the audiology evaluation. Criteria for a positive diagnosis of APD was based upon the ASHA ([<reflink idref="bib4" id="ref104">4</reflink>]) guidelines, which state that performance deficits in one or both ears of at least two standard deviations below the mean, on two or more tests in the assessment battery, should yield a diagnosis of APD. Multiple assessments are utilized during an APD assessment and are catered to each individual child. Direct performance tests completed by audiologists at the time of the APD assessment included the SCAN‐3‐C tests for APDs (Keith, [<reflink idref="bib51" id="ref105">51</reflink>]); Dichotic Digits Test (Musiek, [<reflink idref="bib68" id="ref106">68</reflink>]); Gaps in Noise Test (Musiek et al., [<reflink idref="bib70" id="ref107">70</reflink>]); Test of Auditory Processing Skills (Martin & Brownell, [<reflink idref="bib59" id="ref108">59</reflink>]); and Listening in Spatialized Noise Test (LiSN‐S; Cameron & Dillon, [<reflink idref="bib21" id="ref109">21</reflink>]). Refer to the appendix for a complete list with descriptions of assessments completed by audiologists during the APD assessment session.</p> <p>An overwhelming majority of the sample had indicated other diagnoses; only 2 of the 24 participants had no other reported diagnoses. The majority of the children were White (<emph>n</emph> = 21) and 18 of the caregivers reported an education level of bachelor's degree or higher. Caregivers also reported that 25% of the sample (<emph>n</emph> = 6) were eligible for free or reduced school lunches (see Table 2).</p> <hd id="AN0169726517-10">Recruitment procedures</hd> <p>Recruitment of participants were completed in one of two methods. Ten children were recruited on the day of the APD evaluation and 14 children were recruited retroactively. A descriptive breakdown of participants from each method is featured in Table 3.</p> <p>3 Table Demographics by recruitment method.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th align="left">Demographic variable</th><th align="left">APD assessment session</th><th align="left">Research session</th></tr></thead><tbody valign="top"><tr><td align="left">Mean age (SD)</td><td align="left">9.0 (1.67)</td><td align="left">10.1 (2.30)</td></tr><tr><td align="left">Gender</td><td /><td /></tr><tr><td align="left">Male</td><td align="left">6</td><td align="left">9</td></tr><tr><td align="left">Female</td><td align="left">4</td><td align="left">5</td></tr><tr><td align="left">Race/ethnicity</td><td /><td /></tr><tr><td align="left">White</td><td align="left">9</td><td align="left">12</td></tr><tr><td align="left">Black</td><td align="left">1</td><td align="left">0</td></tr><tr><td align="left">Other</td><td align="left">0</td><td align="left">1</td></tr><tr><td align="left">Prefer not to answer</td><td align="left">0</td><td align="left">1</td></tr><tr><td align="left">Eligible for free/reduced lunch</td><td /><td /></tr><tr><td align="left">Yes</td><td align="left">2</td><td align="left">4</td></tr><tr><td align="left">No</td><td align="left">8</td><td align="left">7</td></tr><tr><td align="left">Missing</td><td align="left">0</td><td align="left">3</td></tr><tr><td align="left">Parent education level</td><td /><td /></tr><tr><td align="left">High school or equivalent</td><td align="left">0</td><td align="left">1</td></tr><tr><td align="left">Some college</td><td align="left">0</td><td align="left">1</td></tr><tr><td align="left">Associate degree</td><td align="left">1</td><td align="left">3</td></tr><tr><td align="left">Bachelor's degree</td><td align="left">5</td><td align="left">3</td></tr><tr><td align="left">Masters</td><td align="left">3</td><td align="left">5</td></tr><tr><td align="left">Doctorate</td><td align="left">1</td><td align="left">1</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 <emph>Note</emph> : Values in columns represent n for each group, except for age.</item> <item>3 Abbreviation: APD, auditory processing disorder.</item> </ulist> <hd id="AN0169726517-11">APD assessment session</hd> <p>Between 1 and 2 APD evaluations tend to be scheduled weekly at the university speech and hearing clinic. Children were referred by pediatricians, school speech pathologists, classroom teachers, neuropsychologists, or parents. Information regarding the study was provided in a "preappointment" packet routinely mailed to caregivers before the APD evaluations. If the child met eligibility for the study based upon age and hearing status, the audiologist completing the evaluation notified the principal investigator, who then discussed the study and answered any caregiver questions as needed. If the parent or caregiver agreed for their child to undergo EF assessment, then a signed consent was completed, and the evaluation was scheduled the same day. Because APD evaluations routinely took 1–2 h, a few caregivers opted to schedule the EF evaluation during a subsequent visit. However, the majority of participants from this recruitment method (8 out of the 10) were seen on the same day as the APD evaluation, following a brief lunch break.</p> <hd id="AN0169726517-12">Research session</hd> <p>Children who were evaluated at the same outpatient clinic no more than 6 months previously were contacted via phone call by a trained graduate assistant. Rationale and procedures for the study were discussed with the parent or caregiver, and if they verbalized an interest in participating, an appointment was scheduled for assessment. Before the visit, caregivers were mailed a consent to participate form, confirmation letter, and directions to the assessment location.</p> <p>Since there were two recruitment methods (i.e., EF testing with children the same day of their APD assessment [APD assessment session] and EF testing with children who completed an APD assessment within the previous 6 months [research session]), demographics were compared between these two groups, which appeared similar in all variables (see Table 3). All the children in the parent‐reported ADHD group and all but two of the children in the non‐ADHD group (see Table 4) had at least one reported other diagnosis (specific LD, speech/language delay, sensory processing disorder, and anxiety/depression). Of the 24 participants, 1 had 4 additional diagnoses, 1 had 3 additional diagnoses, 10 had 2 additional diagnoses, and 5 had 1 diagnosis, the remaining 2 had no additional diagnoses.</p> <p>4 Table Frequencies of other disability diagnoses by ADHD and Non‐ADHD Group.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th align="left">Reported diagnosis</th><th align="left">ADHD group</th><th align="left">Non‐ADHD group</th></tr><tr valign="bottom"><th align="left">%</th><th align="left"><italic>n</italic></th><th align="left">%</th><th align="left"><italic>n</italic></th></tr></thead><tbody valign="top"><tr><td>SLI‐Reading</td><td>40</td><td>6</td><td>11.1</td><td>1</td></tr><tr><td>SLI‐Writing</td><td>33.3</td><td>5</td><td>0</td><td>0</td></tr><tr><td>SLI‐Math</td><td>6.7</td><td>1</td><td>0</td><td>0</td></tr><tr><td>Speech/language delay/disorder</td><td>40</td><td>6</td><td>55.6</td><td>5</td></tr><tr><td>Sensory processing disorder</td><td>40</td><td>6</td><td>22.2</td><td>2</td></tr><tr><td>Anxiety or depression</td><td>53.3</td><td>8</td><td>0</td><td>0</td></tr></tbody></table> </ephtml> </p> <p>4 Abbreviations: ADHD, attention‐deficit hyperactivity disorder; SLI, specific learning impairment.</p> <p>Because poor EF skills have been demonstrated not only in ADHD but also speech/language disorders, LDs, and anxiety/depression (Bailey et al., [<reflink idref="bib6" id="ref110">6</reflink>]; Brenneman et al., [<reflink idref="bib16" id="ref111">16</reflink>]; Bruce et al., [<reflink idref="bib18" id="ref112">18</reflink>]; Sabornie et al., [<reflink idref="bib77" id="ref113">77</reflink>]), the number of other reported diagnoses except ADHD was used as a continuous covariate in all of the data analyses.</p> <hd id="AN0169726517-13">Procedures and measures</hd> <p>Participants enrolled in the study completed two EF measures. Parents completed a rating inventory assessing their child's EF, and the children were administered a five‐subtest standardized measure of EF. Because parents or primary caregivers accompanied the children to the APD assessment session or the research session, they completed the rating inventory in an observation suite while the child was undergoing EF testing. The consideration of both parent questionnaires and performance‐based measures have been recommended to obtain a comprehensive view of children's EF skills (Bunger et al., [<reflink idref="bib19" id="ref114">19</reflink>]).</p> <hd id="AN0169726517-14">Behavior Rating Inventory of Executive Function, 2nd edition</hd> <p>The Behavior Rating Inventory of Executive Function, 2nd edition (BRIEF‐2) (Gioia et al., [<reflink idref="bib42" id="ref115">42</reflink>]) is a widely used EF scale that has been standardized and validated for use with boys and girls ages 5–18 years old. The BRIEF‐2 parent form includes a list of behaviors that the caregiver was instructed to rate (never, sometimes, or often) based upon the child's behaviors in the previous 6 months. Responses were summed to provide scales in the areas of inhibition, self‐monitoring, emotional control, initiation, WM, planning/organization, task monitoring, and organization of materials. Each subset was then translated to <emph>t</emph>‐scores and overall composites were scored into a total global executive composite (GEC) which consists of three indexes: Behavior Regulation Index, Emotion Regulation Index, and Cognitive Regulation Index. On the BRIEF‐2, <emph>T</emph> scores are used to interpret the level of EF as reported by parents on the instrument's rating forms. These scores are linear transformations of the raw scale scores (<emph>M</emph> = 50, SD = 10). T scores provide information about an individual's scores relative to the scores of respondents in the standardization sample. For all BRIEF‐2 clinical scales and indexes, <emph>T</emph> scores from 60 to 64 are considered mildly elevated, and <emph>T</emph> scores from 65 to 69 are considered potentially clinically elevated. <emph>T</emph> scores at or above 70 are considered clinically elevated. For examining specific subscales, children's scores on the WM, shift (CF), and inhibit (IC) were used.</p> <p>The normative sample for the BRIEF‐2 included children from a range of racial, ethnic, and socioeconomic backgrounds from a variety of geographic regions and residential areas. Internal consistency (Cronbach's <emph>α</emph>) of the BRIEF‐2 parent rating scales is above 90 (Gioia et al., [<reflink idref="bib42" id="ref116">42</reflink>]). The BRIEF‐2 is a valid assessment of EF based upon parent report, with high reported correlations with other similar scales such as the Child Behavior Checklist, Behavior Assessment System for Children, 2nd edition, and Conners 3rd Edition—Parent. In this study, the Cohen's <emph>κ</emph> was 864 for the GEC.</p> <hd id="AN0169726517-15">The Behavioral Assessment of Dysexecutive Syndrome in Children</hd> <p>The Behavioral Assessment of Dysexecutive Syndrome in Children (BADS‐C) may be administered to children between the ages of 7–16 years of age, with comparison to normative data (updated in 2007) based upon a representative sample.</p> <p>The BADS‐C (Emslie et al., [<reflink idref="bib37" id="ref117">37</reflink>]) is a reliable and valid assessment of executive functions for ages 7–16. The BADS‐C battery consists of five subtests: the Playing Cards Test, the Water Test, the Key Search Test, Zoo Map Tests 1 and 2, and the Six Part Test. Emslie et al. ([<reflink idref="bib37" id="ref118">37</reflink>]) reported that the battery has excellent inter‐rater reliability for most measures (0.91–1.0), with lower reliability (0.53) for only one measure, the number of perseverative errors on the Water test. The test authors indicated that test–retest reliability was assessed after 3–4 weeks, and significant improvements in performance were found for the Playing Cards and Six Parts tests.</p> <p>On the BADS‐C, raw scores for each of the component subtests can be converted to age‐scaled scores, which are adjusted for the child's age and estimated IQ. Age‐scaled scores range from 1 to 19, with a mean of 10 and a standard deviation of 3. The range of the total age‐scaled scores of all subtests is 35–85. The total age‐scaled score is converted to an "overall scaled score," ranging from 49 to 146 with a mean of 100 and standard deviation of 15. According to the overall scaled score, the results are classified functionally as follows: Impaired performance (overall scaled score range 49–68); borderline performance (overall scaled score range 70–78); low average performance (overall scaled score range 80–88); average performance (overall scaled score range 90–109); high average performance (overall scaled score range 111–119); and superior performance (overall scaled score range 121–146).</p> <p>Each of the five subtests (Playing Card Test, Water Test, Key Search Test, Zoo Map Test, and Six‐Part Test) were administered to each participant. The current study examines the Playing Cards subtest as a measure of IC, the Zoo Maps subtest as a measure of WM and the Six‐Part Test as a measure of CF. The EF composite was used to assess the overall measure of EF for subjects. Interrater reliability in this study was assessed for the BADS‐C with Cohen's <emph>κ</emph> (<emph>κ</emph> = .778).</p> <hd id="AN0169726517-16">Data scoring</hd> <p>Following each assessment, the first author scored all tests (BRIEF‐2 and BADS‐C). To ensure interrater reliability, the scoring of each assessment was then rescored via observing the recording of the assessment by a trained graduate student. If there was a discrepancy between scores on any items or subtest scores for either assessment, the first author rescored the assessment to ensure correct scoring procedures were completed. Cohen's <emph>κ</emph> was run to determine if there was agreement between the first author and trained graduate student of each of the subtests/composite scores on the BADS‐C and the BRIEF‐2. There was good agreement between the two raters on overall scores for the BADS‐C, κ = 778, 95% confidence interval (CI) [0.489, 1.07], <emph>p</emph> = .001; and good agreement between the two raters on overall composite scores for the BRIEF‐2, <emph>κ</emph> = 864, 95% CI [0.605, 1.12], <emph>p</emph> = .000.</p> <hd id="AN0169726517-17">RESULTS</hd> <p>To ensure that there were no differences between the two recruitment methods, two independent samples <emph>t</emph>‐tests were conducted to compare the BADS‐C and BRIEF‐2 overall scores for the APD assessment session participants and research session participants. There were no significant differences in overall EF scores on the BADS‐C for the APD assessment session participants (<emph>M</emph> = 74.18, SD = 24.24) and the research session participants (<emph>M</emph> = 76.61, SD = 20.59), <emph>t</emph> (<reflink idref="bib22" id="ref119">22</reflink>) = 0.266, <emph>p</emph> = .79. There were also no significant differences on the overall EF scores for the BRIEF‐2 for the APD assessment session participants (<emph>M</emph> = 70.72, SD = 13.16) and the research session participants (<emph>M</emph> = 69.00, SD = 9.40), <emph>t</emph> (<reflink idref="bib22" id="ref120">22</reflink>) = 0.374, <emph>p</emph> = .71.</p> <p>To investigate if there were group differences in EF, overall scores from the BADS‐C and BRIEF‐2 were compared between groups of children with LiD, with and without ADHD. A strong correlation was found between the number of other diagnoses and the BRIEF‐2 overall scores (<emph>r</emph> = .538; <emph>p</emph> < .05). Correlation between the BADS‐C overall scores and the number of other diagnoses was small and not significant (<emph>r</emph> = −0.158; <emph>p</emph> = .538). Due to the high number of reported "other" diagnoses throughout the sample, a continuous variable of number of other diagnoses was included as a covariate in each multivariate analysis of covariance (MANCOVA).</p> <p>The first one‐way MANCOVA was run to determine if there were differences on EF as measured by the overall scores on the BADS‐C and BRIEF‐2 (see Table 5). It should be noted that standard and <emph>t</emph>‐score interpretations for each assessment are converse in values. For the BADS‐C, an average score is considered 100 with a standard deviation of 15, therefore, lower scores on the BADS‐C corresponds with decreased performance or decreased EF skills. On the contrary, average <emph>t</emph>‐scores for the BRIEF‐2 is 50, with scores above 65 having potential clinical significance, therefore higher scores on the BRIEF correspond to higher reported deficits in EF.</p> <p>5 Table Overall EF means, standard deviations for BADS and BRIEF scores for each group.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th align="left">Group</th><th align="left">BADS‐C</th><th align="left">BRIEF‐2</th></tr><tr valign="bottom"><th align="left"><italic>M</italic></th><th align="left">SD</th><th align="left"><italic>M</italic></th><th align="left">SD</th></tr></thead><tbody valign="top"><tr><td>ADHD</td><td align="char" char=".">75.2</td><td align="char" char=".">10.3</td><td align="char" char=".">79.7</td><td align="char" char=".">24.0</td></tr><tr><td>Non‐ADHD</td><td align="char" char=".">65.2</td><td align="char" char=".">11.3</td><td align="char" char=".">68.6</td><td align="char" char=".">16.6</td></tr></tbody></table> </ephtml> </p> <ulist> <item>5 <emph>Note</emph> : BRIEF‐2 <emph>T</emph> scores have a <emph>M</emph>  = 50, SD = 10 and BADS‐C standard scores have a <emph>M</emph>  = 100 and SD = 15.</item> <item>6 Abbreviations: ADHD, attention‐deficit hyperactivity disorder; BADS‐C, Behavioral Assessment of Dysexecutive Syndrome in Children; BRIEF‐2, Behavior Rating Inventory of Executive Function, 2nd edition; EF, executive functioning.</item> </ulist> <p>There was homogeneity of regression slopes, as assessed by the interaction term between the number of other diagnoses and ADHD status, <emph>F</emph> (<reflink idref="bib2" id="ref121">2</reflink>,<reflink idref="bib19" id="ref122">19</reflink>) = 0.396, <emph>p</emph> = .665. There was homogeneity of variances and covariances, as assessed by Box's <emph>M</emph> test, <emph>p</emph> > .001. There were no multivariate outliers in the data as assessed by Mahalanobis distance values greater than a specific cut‐off point (<emph>p</emph> > .001). Residuals were normally distributed, as assessed by Shapiro–Wilk's test (<emph>p</emph> > .05). However, there was a somewhat nonlinear relationship between overall scores of EF for each group, as assessed by visual inspection of scatterplots. The one‐way MANCOVA indicated that there were no statistically significant differences between the ADHD and non‐ADHD groups on the combined dependent variables after controlling for the number of other diagnoses, <emph>F</emph> (<reflink idref="bib2" id="ref123">2</reflink>,<reflink idref="bib20" id="ref124">20</reflink>) = 1.689, <emph>p</emph> = .210, Wilks' <emph>Λ</emph> = 856, partial <emph>η</emph><sups>2</sups> = .144.</p> <p>Although there were no significant differences between groups on combined overall EF scores for each measure, additional analysis was completed to investigate if the groups differed on specific EF skills, using either BADS‐C or BRIEF‐2 measures. Two separate MANCOVAs were completed to test for potential group differences on either the BADS‐C or BRIEF‐2 subscales for IC, WM, and CF while controlling for the number of other diagnoses.</p> <p>Using scores from the BADS‐C subsets of IC, WM, and CF, a MANCOVA was run to determine if there were differences between the ADHD and non‐ADHD groups. Means for both groups on all measures were somewhat similar (see Table 6). There was a linear relationship between the IC, WM, and CF scores for each group, as assessed by visual inspection of a scatterplot. There was homogeneity of regression slopes, as assessed by the interaction term between number of other diagnoses and the ADHD group, <emph>F</emph> (<reflink idref="bib3" id="ref125">3</reflink>,<reflink idref="bib18" id="ref126">18</reflink>) = 21.95, <emph>p</emph> = .124. There was homogeneity of covariances, as assessed by Box's <emph>M</emph> test, <emph>p</emph> > .001. There were no univariate or multivariate outliers as indicated by no standardized residuals greater than ±3, or Mahalanobis distance values greater than a specific cut‐off point (<emph>p</emph> > .001), respectively. Residuals were normally distributed, as assessed by Shaprio–Wilk's test (<emph>p</emph> > .05).</p> <p>6 Table Means and standard deviations on BADS‐C for ADHD and non‐ADHD groups.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th align="left">Group</th><th align="left">Cognitive flexibility</th><th align="left">Working memory</th><th align="left">Inhibitory control</th></tr><tr valign="bottom"><th align="left"><italic>M</italic> (SD)</th><th align="left"><italic>M</italic> (SD)</th><th align="left"><italic>M</italic> (SD)</th></tr></thead><tbody valign="top"><tr><td>ADHD</td><td align="char" char="(">6.47 (1.68)</td><td align="char" char="(">8.73 (2.28)</td><td align="char" char="(">7.96 (4.65)</td></tr><tr><td>Non‐ADHD</td><td align="char" char="(">7.44 (1.13)</td><td align="char" char="(">7.78 (2.39)</td><td align="char" char="(">5.67 (4.48)</td></tr></tbody></table> </ephtml> </p> <ulist> <item>7 <emph>Note</emph> : BADS‐C scaled scores have a <emph>M</emph>  = 10 and SD = 3.</item> <item>8 Abbreviations: ADHD, attention‐deficit hyperactivity disorder; BADS‐C, Behavioral Assessment of Dysexecutive Syndrome in Children.</item> </ulist> <p>Results indicated marginally significant differences with a moderate effect size between the ADHD and non‐ADHD groups on the specific subscales after controlling for the number of other diagnoses, <emph>F</emph> (<reflink idref="bib3" id="ref127">3</reflink>,<reflink idref="bib19" id="ref128">19</reflink>) = 3.80, <emph>p</emph> = .052, Wilks' <emph>Λ</emph> = 673, partial <emph>η</emph><sups>2</sups> = .327. There were statistically significant differences for measures of IC (<emph>F</emph> (<reflink idref="bib1" id="ref129">1</reflink>,<reflink idref="bib21" id="ref130">21</reflink>) = 4.52, <emph>p</emph> = .046) as well as a marginally significant effect for CF (<emph>F</emph> (<reflink idref="bib1" id="ref131">1</reflink>,<reflink idref="bib21" id="ref132">21</reflink>) = 4.04, <emph>p</emph> = .057). For IC, children without ADHD performed significantly lower (<emph>M</emph> = 5.67, SD = 4.48) than children with ADHD (<emph>M</emph> = 7.96, SD = 4.65). Although marginally significant, there was a trend for CF, with children with ADHD scoring lower (<emph>M</emph> = 6.47, SD = 1.68) compared with children without ADHD (<emph>M</emph> = 7.44, SD = 1.13). There were no significant differences between groups on WM.</p> <p>Lastly, a MANCOVA was run to examine group differences for IC, CF, and WM on subset scores from the BRIEF‐2 parent rating scale, while again controlling for the number of other diagnoses. Means for parent ratings of all three EF skills were rated higher (greater levels of observed impairments) for children with ADHD (see Table 7). All assumptions were met as indicated linear relationships between the IC, WM, and CF scores for each group, as assessed by visual inspection of a scatterplot. There was homogeneity of regression slopes, as assessed by the interaction term between number of other diagnoses and ADHD group, <emph>F</emph> (<reflink idref="bib3" id="ref133">3</reflink>,<reflink idref="bib18" id="ref134">18</reflink>) = 21.95, <emph>p</emph> = .124. There was homogeneity of variances and covariances, as assessed by Box's <emph>M</emph> test, <emph>p</emph> > .001. There were no univariate or multivariate outliers as indicated by no standardized residuals greater than ±3, or Mahalanobis distance values greater than a specific cut‐off point (<emph>p</emph> > .001), respectively. Results indicated that there was no statistically significant difference between the ADHD and non‐ADHD groups on IC, WM, and CF, after controlling for the number of other diagnoses, <emph>F</emph> (<reflink idref="bib3" id="ref135">3</reflink>,<reflink idref="bib19" id="ref136">19</reflink>) = 218, <emph>p</emph> = .883, Wilks' <emph>Λ</emph> = 967, partial <emph>η</emph><sups>2</sups> = .033, when using parent report of EF deficits, via scores from the BRIEF‐2.</p> <p>7 Table Means and standard deviations for each subscale for the ADHD and non‐ADHD groups on BRIEF‐2.</p> <p> <ephtml> <table><thead valign="bottom"><tr valign="bottom"><th align="left">Group</th><th align="left">Cognitive flexibility</th><th align="left">Working memory</th><th align="left">Inhibitory control</th></tr><tr valign="bottom"><th align="left"><italic>M</italic> (SD)</th><th align="left"><italic>M</italic> (SD)</th><th align="left"><italic>M</italic> (SD)</th></tr></thead><tbody valign="top"><tr><td align="left">ADHD</td><td align="char" char="(">69.9 (13.2)</td><td align="char" char="(">70.2 (9.71)</td><td align="char" char="(">68.3 (14.0)</td></tr><tr><td align="left">Non‐ADHD</td><td align="char" char="(">62.8 (9.44)</td><td align="char" char="(">64.2 (11.5)</td><td align="char" char="(">60.2 (9.53)</td></tr></tbody></table> </ephtml> </p> <ulist> <item>9 <emph>Note</emph> : BRIEF‐2 <emph>T</emph> ‐scores have a <emph>M</emph>  = 50, SD = 10.</item> <item>10 Abbreviations: ADHD, attention‐deficit hyperactivity disorder; BRIEF‐2, Behavior Rating Inventory of Executive Function, 2nd edition.</item> </ulist> <hd id="AN0169726517-18">DISCUSSION</hd> <p>While previous studies have established that children with LiD demonstrate decreased cognitive skills as measured by nonverbal intelligence, sustained attention, and auditory WM when compared to age‐matched controls (Barry et al., [<reflink idref="bib11" id="ref137">11</reflink>]; Moore et al., [<reflink idref="bib65" id="ref138">65</reflink>]), the current study adds to this literature with the preliminary findings that executive functions may also be deficit in children with LiD. Results confirmed that, although overall EF deficits are expected in children with ADHD, both groups of children performed below average on the BADS‐C and the BRIEF‐2. IC measured by the BADS‐C highlighted significant differences, with children without ADHD scoring even lower on IC measures than children with ADHD even controlling for other diagnoses. Marginally significant differences in CF as measured by the BADS‐C were found but with reverse findings: Children with LiD and ADHD scored lower on measures of CF compared to children with LiD and without ADHD. Taken together, these findings indicated that decreased EF in children with LiD, regardless of ADHD diagnosis, support the notion that top‐down processing, which asserts the necessary contribution of EF for successful listening and learning, plays a foundational role in the receiving and comprehension of auditory information.</p> <p>Similar concentrations of comorbidities, similar academic difficulties, and below average scores on EFs between children with ADHD and LiD support the notion that the large numbers of children being referred for assessment of APD may constitute part of a larger, less defined neurodevelopmental disorder that includes decreased auditory attention as well as decreased EF skills. Findings from Rosen et al. ([<reflink idref="bib76" id="ref139">76</reflink>]) support that there may indeed be at least two subgroups of children with LiD. They reported that the majority of children referred for assessment of APD scored lower than controls on verbal and nonverbal cognitive measures, however, of those with LiD, the children that scored better on auditory measures also did not differ on cognitive scores from controls. Cunha et al. ([<reflink idref="bib26" id="ref140">26</reflink>]) had similar findings with children with suspected APD diagnosed with SLD. Those children that demonstrated decreased auditory processing co‐occurring with SLD demonstrated a specific cognitive profile, which included distractibility, decreased attention, and decreased verbal and spatial reasoning. Auditory processing abilities have been demonstrated to be highly correlated with IC in adults (Johns et al., [<reflink idref="bib49" id="ref141">49</reflink>]; Yoon et al., [<reflink idref="bib88" id="ref142">88</reflink>]), and decreased IC on nonspeech measures such as frequency and spatial pattern tasks have been documented in children with suspected APD (Dhamani et al., [<reflink idref="bib33" id="ref143">33</reflink>]; Sharma et al., [<reflink idref="bib79" id="ref144">79</reflink>]). The current study illuminated IC as a concern for children with LiD, as compared to children with ADHD.</p> <p>School aged children with reported LiD are frequently referred for evaluation of APDs (Chermak & Musiek, [<reflink idref="bib25" id="ref145">25</reflink>]; Moore et al., [<reflink idref="bib66" id="ref146">66</reflink>]; Yathiraj & Vanaja, [<reflink idref="bib87" id="ref147">87</reflink>]). However, of those children referred, very few are receiving a diagnosis of APD. As a result, many children are returning to school with continued LiD and unanswered questions regarding the true premise of their academic difficulties. The findings from this study may assist school psychologists when they encounter children with behaviors consistent with ADHD or LiD. Even without a formal diagnosis, decreased EF could be an important factor to consider when making recommendations. Core considerations for the management of poor listening skills, and resultant academic difficulty, center on different perspectives regarding bottom–up and top–down processing. Those that support the contribution of bottom‐up processing advocate that disruptions in auditory processing may originate due to decreased auditory sensory processing and/or neural dysfunction at the level of the CANS. In contrast, advocates for top–down processing argue that, to integrate incoming auditory information, children's attention, memory, and other cognitive skills, such as EF, are necessary and crucial skills for successful listening and learning.</p> <p>The current study endorses the position that, while effective listening ultimately requires both the integration of bottom–up processing and top–down control, top–down control must be intact to achieve the accurate processing of auditory information. It is argued that decreases in cognitive skills required for top–down processing, and not auditory sensory dysfunction, is what may drive many referrals for assessment of APD. The complex interaction between cognition and auditory processing abilities has been demonstrated in the literature (Sharma et al., [<reflink idref="bib80" id="ref148">80</reflink>]; Tomlin et al., [<reflink idref="bib83" id="ref149">83</reflink>]), and the current study contributes to this body of research.</p> <hd id="AN0169726517-19">IMPLICATIONS</hd> <p>Although further research is necessary, the results that children with LiD have IC deficits may inform treatment. The provision of efficacious treatment is the paramount end goal when determining the true nature of deficits contributing to decreased academic performance and referrals for APD assessment. Historically, specific bottom–up treatment approaches such as auditory skills training have been recommended for children that are referred for assessment of APD with identified auditory weaknesses (Musiek et al., [<reflink idref="bib69" id="ref150">69</reflink>]). However, while targeted auditory training may result in improvements on the specific targeted auditory task, such as the identification of spatial or temporal patterning in sound sequences, this bottom–up approach does not result in improvements in cognitive functioning (Tomlin & Vandali, [<reflink idref="bib84" id="ref151">84</reflink>]). This could be founded on the fact that auditory sensory processing at the level of the CANS has little demonstrated relationship to listening in noise or understanding verbal directions (Moore, [<reflink idref="bib63" id="ref152">63</reflink>]).</p> <p>The International Classification of Functioning for Disability and Health recommends a more global approach to improving an individuals' functioning across contexts. In other words, the most efficacious and impactful intervention programs should consider children's personal and environmental factors in concert with physiological deficits (Stucki et al., [<reflink idref="bib81" id="ref153">81</reflink>]). The results of this study indicated that all children referred for assessment of APD demonstrate deficits in EF based upon scores from the BADS‐C (average scores for non‐ADHD and ADHD groups were 68.56 and 79.67, respectively, with an average score on the BADS‐C ranging 85–115) and the BRIEF‐2 (both groups' averages scored in at least the mildly elevated range, since scores 60 and above indicate clinical significance, and non‐ADHD and ADHD groups average scores were 65.22 and 72.53, respectively). A top–down approach for intervention is warranted given the below average EF scores across groups and identified deficits in IC for children without diagnoses of ADHD. Direct, nonpharmacological interventions have been successful in decreasing ADHD symptoms across environments and has resulted in large effect sizes for inhibition training (Lambez et al., [<reflink idref="bib52" id="ref154">52</reflink>]). Furthermore, training in self‐regulatory skills has been effective treatment in improving the academic skills in classrooms for children with and without ADHD (Briesch & Chafouleas, [<reflink idref="bib17" id="ref155">17</reflink>]).</p> <p>In addition to the suggested recommendations for treatment, more research is needed on children with LiD to design more specific treatment models. There are several weaknesses of the current study that should be addressed in future research. First and foremost, the power of the findings would have been increased by a larger sample. Despite the small sample size, a moderate effect size (<emph>η</emph><sups>2</sups> = .327) was found between groups on overall measures from the BADS‐C, however, these findings should be interpreted with caution.</p> <p>The sample in the current study also highlighted some notable areas to change in future studies. Although the information was gathered on ADHD status from parent report, specific information regarding ADHD subtypes was not collected. Differences in presentations for either predominately inattentive, predominately hyperactive and impulsive, or combined presentations may have impacted performances on the behavioral assessments as well as parent report of executive function deficits in the home environment. An increased understanding of the various presentations of ADHD and how this might have impacted performance on EF assessments would provide further insight into potential group differences, both within the ADHD group as well as compared to children without ADHD. Eleven children from the ADHD group were reportedly receiving pharmacological intervention, and 8 of the 11 children were also enrolled in some form of nonpharmacological treatment such as speech therapy or resource support. However, it should be noted that many of these children had concomitant factors such as specific LDs in reading or writing, which may have dictated the enrollment in special services. The reported and observed EF deficits in the ADHD group may have been diminished given enrollment in current interventions. The impact that medication and behavioral interventions have on EF in children with ADHD should be considered in future studies. However, notable deficits in children in the non‐ADHD group as well indicate that specific interventions should be considered even without a diagnosis of ADHD. Furthermore, there may have been a self‐selection bias of participants in the study, as the children that were evaluated were done so based primarily upon parental concerns of academic skills. This, along with the homogenous nature of the sample (primarily White, educated parents) highlights the need for additional studies of this kind in children from more diverse backgrounds, especially given the increased incidence of EF deficits in children from less advantaged SES backgrounds (Blair & Raver, [<reflink idref="bib15" id="ref156">15</reflink>]).</p> <p>While these results must be interpreted conservatively, they do justify additional research to further confirm if children with LiD demonstrate EF deficits, especially IC. Continued research indicating an overall trend of EF deficits in this group of children will guide the creation of more concrete and focused intervention techniques, focusing on breakdowns in top–down processing, to increase the academic achievement of this significantly at‐risk group of students. The need for evidence‐based, transdisciplinary intervention can be further highlighted by the fact that children with LiD continue to display academic difficulties well into adolescence, with continued academic and achievement difficulties into adulthood (Heine & Slone, [<reflink idref="bib45" id="ref157">45</reflink>]; Moore et al., [<reflink idref="bib66" id="ref158">66</reflink>]; Del Zoppo et al., [<reflink idref="bib89" id="ref159">89</reflink>]).</p> <hd id="AN0169726517-20">ACKNOWLEDGMENTS</hd> <p>Materials for this study were funded in part by Lions‐McKinney Foundation of Indiana.</p> <hd id="AN0169726517-21">CONFLICT OF INTEREST STATEMENT</hd> <p>The authors declare no conflict of interest.</p> <hd id="AN0169726517-22">DATA AVAILABILITY STATEMENT</hd> <p>The data that support the findings of this study are available from the corresponding author upon reasonable request.</p> <hd id="AN0169726517-23">APPENDIX</hd> <hd1 id="AN0169726517-24">AUDITORY PROCESSING EVALUATION TEST DESCRIPTIONS</hd1> <p>The evaluation of Auditory Processing (AP) abilities relies on results from many different tests. Below are descriptions of tests that may be administered as part of the Auditory Processing Evaluation. <emph>The specific battery of tests administered completed is based on many factors, therefore not all tests may be given during an evaluation</emph>.</p> <p></p> <ulist> <item> 1. Preappointment assessment instruments (items a–d: children only)</item> <p></p> <item> a. <emph>The CHAPS</emph>: Completed by school personnel, this questionnaire rates the student's listening ability in specific conditions as compared to students of the same age.</item> <p></p> <item> b. <emph>Fisher's Auditory Problems Checklist</emph> (Fishers): Completed by school personnel or a caregiver, this checklist is designed to provide information about listening behaviors. This screening tool compares the child's ability with other children of similar age.</item> <p></p> <item> c. <emph>NICHQ Vanderbilt Assessment Scales</emph> are used by healthcare professionals to help diagnose attention deficits in children between the ages of 6 and 12. Parents and Teachers complete the assessment. We use this questionnaire primarily as a screening for attention‐deficit, which should be addressed before an AP evaluation is completed. To get accurate results on AP tests, children must have sufficient attention to complete the tests. Other conditions that are screened on this instrument include hyperactivity/impulsive subtype, oppositional‐defiant disorder, conduct disorder, and anxiety/depression.</item> <p></p> <item> d. Hearing, medical, and family medical history questionnaires</item> <p></p> <item> 2. Hearing evaluation: The hearing evaluation is a test of peripheral auditory function, which means a test of the outer ear, middle ear, and hearing organ of the inner ear. People with AP deficits often have completely normal peripheral auditory function, that is, they can hear quiet tones and understand speech in quiet. We always confirm whether peripheral hearing is normal before doing an AP evaluation.</item> <p></p> <item> a. Otoscopy—visual inspection of the ear canal and eardrum</item> <p></p> <item> b. Tympanometry—tests eardrum and middle ear function</item> <p></p> <item> c. Acoustic reflex threshold—tests middle ear reflex and associated neural pathways</item> <p></p> <item> d. Pure tone audiometry, air and bone conduction—tests tonal hearing</item> <p></p> <item> e. Speech discrimination testing—tests speech understanding</item> <p></p> <item> f. Otoacoustic emissions with or without contralateral noise—tests inner ear function, and/or efferent neural pathway function</item> <p></p> <item> g. Quick SIN (adult), BKB‐SIN (child) with or without contralateral noise—tests speech understanding in noise</item> <p></p> <item> 3. The Auditory Continuous Performance Test screens for auditory attention deficits. It can aid in the diagnosis of attention‐deficit disorder or ADHD in children 6–11. The child listens to a list of words and raises a thumb every time he or she hears the target word (dog).</item> <p></p> <item> 4. SCAN‐3: Refers to a large test battery. The individual subtests commonly used are described below.</item> <p></p> <item> a. The <emph>filtered words</emph> subtest asks the listener to repeat words that have been low‐pass filtered to remove high frequencies (high pitches), giving the speech a muffled quality. This subtest assesses how well the listener can evaluate distorted speech, or speech that is compromised by a poor acoustic environment. This subtest represents functional auditory abilities in everyday situations (e.g., when speech is distorted by poor articulation, or an accent, or listening to poor recordings of speech through media devices).</item> <p></p> <item> b. <emph>The gap detection (GD)</emph> subtest requires the listener to detect silent gaps in background noise. GD ability is necessary to understand running speech, particularly to separate words, and identify certain consonant sounds.</item> <p></p> <item> c. <emph>Auditory figure ground 0 dB (AFG 0)</emph> subtest asks the listener to discriminate words embedded in background noise, when both the speech and noise are the same volume (0 dB signal to noise ratio). This assesses how well the listener can detect speech in a difficult situation where the noise and speech are equally loud. This subtest represents functional auditory abilities in everyday situations when speech is taking place in the presence of background noise (e.g., in a restaurant or classroom).</item> <p></p> <item> d. Competing words‐directed ear subtest asks the listener to repeat a word that is presented to one ear, while a different word is presented simultaneously to the other ear. The listener is directed to either repeat the word heard in the right ear first, or to repeat the word heard in the left ear first. This allows assessment of ear‐specific ability to process competing messages. In some cases, the competing words‐free recall version of this test may be administered, which allows the listener to repeat back the words in any order.</item> <p></p> <item> e. <emph>Competing Sentences</emph> subtest asks the listener to repeat a sentence that is presented to one ear while a different sentence is presented to the other ear simultaneously. The listener is directed to either repeat the sentence heard in the right ear first, or to repeat the sentence heard in the left ear first. This allows assessment of ear‐specific ability to process competing messages.</item> <p></p> <item> f. <emph>Time compressed sentences (TCS)</emph> subtests asks the listener to repeat sentences that are played at an increased rate. The sentences are played in the right ear first and then they are played in the left ear.</item> <p></p> <item> 5. The <emph>dichotic digits test</emph> evaluates the listener's ability to repeat different numbers presented simultaneously to both ears, that is a different number is given to each ear. The test includes single number pairs and double number pairs. The listener is asked to repeat all numbers heard in each trial. This test assesses the listener's ability to identify and combine two different messages presented to both ears at the same time. This is an auditory skilled called <emph>binaural separation/integration</emph>. Because the test uses numeric digits, the linguistic load (amount of information that has to be deciphered) is considered light, meaning it does not require extensive language processing. Therefore, performance on this test is less influenced by deficits in language processing.</item> <p></p> <item> 6. The <emph>pitch pattern sequence</emph> test uses nonverbal stimuli. It consists of a series of three tones presented at either of two frequencies (high pitch or low pitch). The listener's task is to describe the pitch pattern (e.g., high, low, high). Ability to assess pitch patterns is essential for interpreting speech, intonation, and other sounds.</item> <p></p> <item> 7. The <emph>duration pattern sequence</emph> test uses nonverbal stimuli. It consists of a series of three tones of a single frequency (pitch) presented with different durations (long or short). The listener's task is to describe the duration pattern (e.g., long, short, short). Ability to assess duration patterns is essential for interpreting speech and other sounds.</item> <p></p> <item> 8. The <emph>masking level difference (MLD)</emph> test assesses the ability of the brain to perceive differences in the phase of a sound reaching the two ears. The phase of sound is a measure of the timing of a sound. The ability to perceive differences in phase is an ability that helps with locating sound sources in the environment. This ability also aids in distinguishing a desired speech signal from background noise. The test uses a tone and noise delivered to both ears under three different phase conditions. (<reflink idref="bib1" id="ref160">1</reflink>) Tone and noise are in same phase at both ears, (<reflink idref="bib2" id="ref161">2</reflink>) tones are out of phase and noise is in phase at the two ears, 3) tones are in phase and noise is out of phase at the two ears. The difference in performance between these conditions is called the MLD.</item> <p></p> <item> 9. The <emph>gaps in noise</emph> used for adults, nonverbal stimuli consisting of multiple six‐second bursts of noise are presented to one ear at a time. These bursts of noise contain up to three gaps that vary in duration. The listener is asked to indicate each time a gap is perceived. The ability to perceive short‐duration gaps is necessary to parse the speech signal into sentences, words and syllables, and to discriminate certain speech sounds (e.g., stop consonants).</item> <p></p> <item> 10. The <emph>test of auditory processing skills</emph> (TAPS) is a large test battery that may also be given by a speech‐language pathologist. We typically administer three subtests of the TAPS, which assess auditory memory, or how well a person can remember what they have heard. The three subtests are the numbers forward, numbers reversed, and sentence memory.</item> <p></p> <item> a. In the Numbers Forward subtest, the listener is asked to repeat a series of numbers in the order in which they were heard. The number of digits in the series grows until the listener can no longer do the task accurately.</item> <p></p> <item> b. In the Numbers Reversed subtest, the listener is asked to repeat a series of numbers in the reverse order in which they were heard. The number of digits in the series grows until the listener can no longer do the task accurately.</item> <p></p> <item> c. In the Sentence Memory subtest, the listener is asked to repeat sentences, word for word. The sentences are typically multiple part instructions. The sentences continue to grow in length until the listener can no longer do the task accurately.</item> <p></p> <item> 11. The listening in spatialized noise test—tests the ability of listeners to understand speech when there is noise coming from different directions.</item> <p></p> <item> 12. Electrophysiological tests—(example: auditory brainstem response test) a variety of different tests that involve measurements of the brain's activity in response to sound. These tests may be recommended to determine whether sound information is traveling through the brain properly.</item> </ulist> <ref id="AN0169726517-25"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref49" type="bt">1</bibl> <bibtext> American Academy of Audiology. (2010). Diagnosis, treatment, and management of children and adults with central auditory processing disorder. https://<ulink href="http://www.audiology.org/wp-content/uploads/2021/05/CAPD-Guidelines-8-2010-1.pdf%5f539952af956c79.73897613-1.pdf">www.audiology.org/wp-content/uploads/2021/05/CAPD-Guidelines-8-2010-1.pdf%5f539952af956c79.73897613-1.pdf</ulink></bibtext> </blist> <blist> <bibl id="bib2" idref="ref60" type="bt">2</bibl> <bibtext> American Psychiatric Association. (2022). 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Header DbId: eric
DbLabel: ERIC
An: EJ1387122
AccessLevel: 3
PubType: Academic Journal
PubTypeId: academicJournal
PreciseRelevancyScore: 0
IllustrationInfo
Items – Name: Title
  Label: Title
  Group: Ti
  Data: Executive Functioning Skills of Children with Listening Difficulties
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22McGrath%2C+Melissa+A%2E%22">McGrath, Melissa A.</searchLink><br /><searchLink fieldCode="AR" term="%22Fletcher%2C+Kathryn+L%2E%22">Fletcher, Kathryn L.</searchLink><br /><searchLink fieldCode="AR" term="%22Bielski%2C+Lynn+M%2E%22">Bielski, Lynn M.</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Psychology+in+the+Schools%22"><i>Psychology in the Schools</i></searchLink>. Sep 2023 60(9):3520-3541.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 22
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2023
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Listening%22">Listening</searchLink><br /><searchLink fieldCode="DE" term="%22Listening+Skills%22">Listening Skills</searchLink><br /><searchLink fieldCode="DE" term="%22Executive+Function%22">Executive Function</searchLink><br /><searchLink fieldCode="DE" term="%22Skills%22">Skills</searchLink><br /><searchLink fieldCode="DE" term="%22Auditory+Tests%22">Auditory Tests</searchLink><br /><searchLink fieldCode="DE" term="%22Referral%22">Referral</searchLink><br /><searchLink fieldCode="DE" term="%22Attention+Deficit+Hyperactivity+Disorder%22">Attention Deficit Hyperactivity Disorder</searchLink><br /><searchLink fieldCode="DE" term="%22Control+Groups%22">Control Groups</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1002/pits.22940
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0033-3085<br />1520-6807
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Children with normal hearing who present with listening difficulties (LiD) are frequently referred for assessment of auditory processing disorder (APD). Complicating diagnosis is the similarities of APD to other neurodevelopmental disorders, especially attention-deficit hyperactivity disorder (ADHD). Due to well-documented deficits in executive functioning (EF) in children with ADHD, we hypothesized that a possible root cause of observed listening deficits may be EF deficits, rather than auditory processing alone. For preliminary investigation into this hypothesis, the current study compared EF skills of children with LiD who were referred for APD assessment, with and without a diagnosis of ADHD. EF skills of 24 children between the ages of 7-16 were assessed utilizing the Behavioral Assessment of Dysexecutive Syndrome in Children, and the Behavior Rating Inventory of Executive Function, 2nd edition. Compelling differences were found between groups of children with LiD. Children without ADHD scored lower on measures of inhibitory control compared to children with a diagnosis of ADHD. Decreased EF skills exhibited in children with LiD, even those without a diagnosis of ADHD, support the need for transdisciplinary identification and management of children with LiD.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2023
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1387122
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1387122
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1002/pits.22940
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 22
        StartPage: 3520
    Subjects:
      – SubjectFull: Children
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Listening
        Type: general
      – SubjectFull: Listening Skills
        Type: general
      – SubjectFull: Executive Function
        Type: general
      – SubjectFull: Skills
        Type: general
      – SubjectFull: Auditory Tests
        Type: general
      – SubjectFull: Referral
        Type: general
      – SubjectFull: Attention Deficit Hyperactivity Disorder
        Type: general
      – SubjectFull: Control Groups
        Type: general
    Titles:
      – TitleFull: Executive Functioning Skills of Children with Listening Difficulties
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: McGrath, Melissa A.
      – PersonEntity:
          Name:
            NameFull: Fletcher, Kathryn L.
      – PersonEntity:
          Name:
            NameFull: Bielski, Lynn M.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 09
              Type: published
              Y: 2023
          Identifiers:
            – Type: issn-print
              Value: 0033-3085
            – Type: issn-electronic
              Value: 1520-6807
          Numbering:
            – Type: volume
              Value: 60
            – Type: issue
              Value: 9
          Titles:
            – TitleFull: Psychology in the Schools
              Type: main
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