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Psychosocial Status of Children with Auditory Processing Disorder


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1 PSYCHOSOCIAL STATUS OF CHILDREN WI TH AUDITORY PROCESSING DISORDER By NICOLE V. KREISMAN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007

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2 Copyright 2007 by Nicole V. Kreisman

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3 For Carlfaithful friend and inspiring mentorm ay your legacy live on in part through me and through this work. For my children, Anna Joy a nd Josiah Peterfor helping to teach me about the importance of Lifes everyday momentsMomm ys big paper is finally finished now. And mostly for BrianHow can I tell you that I love you, but I cant think of right words to say? FAYTCN To God be the glory.

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4 ACKNOWLEDGMENTS The completion of this dissertation has onl y been possible with the great support and assistance of so many people. First, Id like to acknowledge the critical ro le that my incredible husband, Dr. Brian Kreisman, played in encourag ing me to pursue this degree, providing me with strength, support and understanding throughout the entire process, around the world and back again, and loving me all the while. I thank Brian for being my best friend as well as my most respected colleague. I woul d like to acknowledge the inspir ation of Dr. Carl Crandell, who was a tremendous blessing as mentor and friend, a nd whose vital presence remains. I would also like to thank my beautiful children, Anna and Jo siah; as well as my parents, Nancy and Gary Van Cleave, along with the rest of my fam ily, for their constant love and support. I thank my dissertation committee chairman, Dr James Hall, for stepping into his role, encouraging and persistently guiding me through the process. I thank my committee members, Dr. Thomas Oakland, Dr. Mini Shrivastav, Dr. Scott Griffiths, and especially Dr. Joseph Smaldino, for their suggestions and encouragement toward the completion of this dissertation. I thank my great colleagues and students at the University of Florida, the University of Canterbury, and Towson University for their time, efforts and encouragement in support of my work. I thank my understanding, devoted, fabulous friends for cheering me on in the pursuit of this endeavor. I also would lik e to express my sincere apprec iation to the participants and parents involved in this research for giving th eir time and energy, and for opening and sharing of their lives with me so that ot hers may benefit. Most importa ntly, I thank Jesus for being my Lord and Savior.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........8 LIST OF FIGURES................................................................................................................ .........9 ABSTRACT....................................................................................................................... ............10 CHAPTER 1 INTRODUCTION..................................................................................................................12 2 REVIEW OF LITERATURE.................................................................................................19 Auditory Processing DisordersDefi nitions and Diagnostic Importance.............................19 Psychosocial Implications of Heari ng Loss in Children and Adolescents.............................20 Use of SSRS in Children with Communi cation and/or Sensory Impairments................24 Use of the BASC in Children with Language Impairment..............................................26 Use of COOP-A in Child ren with Hearing Loss.............................................................27 Use of COOP-A in Children with APD..........................................................................28 3 METHODS........................................................................................................................ .....35 Participants................................................................................................................... ..........35 Diagnosis of APD............................................................................................................... ....37 Psychosocial Measures.......................................................................................................... .39 The Social Skills Rating System (SSRS)........................................................................39 The Behavioral Assessment System for Children-Second Edition (BASC-2)................40 The Dartmouth Primary Care Cooperativ e Information Project Charts for Adolescents (COOP-A)...............................................................................................41 Procedures..................................................................................................................... ..........42 Audiological Assessment................................................................................................42 Intellectual Assessment...................................................................................................43 Language Assessment.....................................................................................................44 APD Assessment.............................................................................................................44 Psychosocial Assessment................................................................................................45 Statistical Analyses........................................................................................................... ......47 4 RESULTS........................................................................................................................ .......50 Child-Completed Dartmouth Primary Care C ooperative Information Project Charts for Adolescents (COOP-A).......................................................................................................51 Physical Fitness Subscale Chart......................................................................................52 Pain Subscale Chart.........................................................................................................52

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6 Stress Subscale Chart......................................................................................................52 School Work Subscale Chart...........................................................................................53 Emotional Feelings Subscale Chart.................................................................................53 Behavior Subscale Chart.................................................................................................54 Social Support Subscale Chart........................................................................................54 Self-Esteem Subscale Chart............................................................................................55 Family Subscale Chart.....................................................................................................55 Health Habits I................................................................................................................ .55 Overall Health Subscale Chart........................................................................................56 Energy Subscale Chart....................................................................................................56 Social Skills Rating System (SSRS), Student Forms.............................................................56 Cooperation Subscale......................................................................................................57 Assertion Subscale...........................................................................................................57 Empathy Subscale...........................................................................................................57 Self-Control Subscale......................................................................................................58 Behavioral Assessment System for Child ren-Second Edition (BASC-2), Self-Report Forms.......................................................................................................................... ........58 School Problems Composite Subscale............................................................................58 Internalizing Problems Composite Subscale...................................................................59 Inattention/Hyperactivity Composite Subscale...............................................................59 Emotional Symptoms Index Subscale.............................................................................60 Personal Adjustment Composite Subscale......................................................................60 Parent-Completed Dartmouth Primary Care Co operative Information Project Charts for Adolescents (COOP-A).......................................................................................................60 Physical Fitness Subscale Chart......................................................................................61 Pain Subscale Chart.........................................................................................................61 Stress Subscale Chart......................................................................................................62 School Work Subscale Chart...........................................................................................63 Emotional Feelings Subscale Chart.................................................................................63 Behavior Subscale Chart.................................................................................................63 Social Support Subscale Chart........................................................................................64 Self-Esteem Subscale Chart............................................................................................64 Family Subscale Chart.....................................................................................................65 Health Habits I................................................................................................................ .65 Overall Health Subscale Chart........................................................................................65 Energy Subscale Chart....................................................................................................65 Social Skills Rating System (SSRS), Parent Forms...............................................................66 Cooperation Subscale......................................................................................................66 Assertion Subscale...........................................................................................................67 Responsibility Subscale...................................................................................................67 Self-Control Subscale......................................................................................................67 Externalizing Problem Behavior Subscale......................................................................68 Internalizing Problem Behavior Subscale.......................................................................68 Behavioral Assessment System for Childre n-Second Edition (BASC-2), Parent Rating Scales......................................................................................................................... .........69 Externalizing Problems Composite Subscale..................................................................69

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7 Internalizing Problems Composite Subscale...................................................................69 Behavioral Symptoms Index Subscale............................................................................70 Adaptive Skills Composite Subscale...............................................................................70 Summary of Statistically Signifi cant Findings Across Instruments.......................................71 Post-Hoc Analyses.............................................................................................................. ....71 Reported Psychosocial Function and Age.......................................................................72 Reported Psychosocial Function and Gender..................................................................74 Comparisons Between Language-Normal and Language-Impaired Subgroups with APD............................................................................................................................ ..75 5 DISCUSSION..................................................................................................................... ....95 Childrens Self-Reported Psychosocial Status.......................................................................95 Parental Perceptions of Psychosocial Status...........................................................................98 Language Function Status of the APD Group......................................................................100 Limitations of this Study......................................................................................................100 Clinical Implications.......................................................................................................... ...102 Future Research................................................................................................................ ....103 APPENDIX A APD PARENT/PATIENT SURVEY...................................................................................105 B UNIVERSITY OF FLORIDA INFORMED CONSENT FORM........................................107 C TOWSON UNIVERSITY INFORMED CONSENT FORM...............................................110 D RESEARCH PARTICIPANT RECRUITMENT FLYER...................................................113 REFERENCES..................................................................................................................... .......114 BIOGRAPHICAL SKETCH.......................................................................................................121

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8 LIST OF TABLES Table page 4-1 Number of subjects in the APD a nd normal groups for various demographic characteristics................................................................................................................ .....77 4-2 Mean pure-tone airconduction thresholds ( M ) and standard deviations (s.d.) across frequencies for each ear (RE = right ear; LE = left ear) of both groups............................78 4-3 Mean tympanometric data for APD and normal groups....................................................79 4-4 Number of participants 2 standard devi ations or more below mean on assessments used in the APD test battery fo r both the APD and normal groups...................................80 4-5 Mean ranks ( m ) and sum of ranks ( U ) for the COOP-A and means ( M ) and standard deviations (s.d.) for the SSRS and BASC-2 for childrens psychosocial self-reports ratings for the APD group and the normal group..............................................................81 4-6 Statistical findings for child rens psychosocial self-reports..............................................82 4-7 Mean ranks (m) and sum of ranks (U) fo r the COOP-A and means (M) and standard deviations (s.d.) for the SSRS and BASC-2 for parental psychosocial ratings for the APD group and the normal group......................................................................................83 4-8 Statistical findings for pa rent psychosocial reports...........................................................84 4-9 Compiled statistically significant ( p < 0.05) findings across psychosocial scales for children and parents...........................................................................................................85 4-10 At-risk (3-5 ratings) fi ndings on COOP-A by childrens self-reports by subscale chart for both groups..........................................................................................................86 4-11 At-risk (3-5 ratings) find ings on COOP-A by parental reports by subscale chart for both groups.................................................................................................................... .....87 4-12 Summary of correlati on findings for age and statistically significant ( p < 0.05) psychosocial subscales for children and parents................................................................88 4-13 Summary of findings for gende r and statistically significant ( p < 0.05) psychosocial subscales for children and parents.....................................................................................89 4-14 Statistical findings across psychosocial sc ales for childrens se lf-ratings in languageimpaired versus language-normal APD subgroups............................................................90 4-15 Statistical findings across psychosocial sc ales for parent ratings of children in language-impaired versus la nguage-normal APD subgroups............................................91

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9 LIST OF FIGURES Figure page 2-1 Mean ratings across eight COOP subscal es by children with auditory processing disorders (APD), children with hearing lo ss (HL) and children with normal hearing (NH)........................................................................................................................... ........32 2-2 Percentage of children with auditory processing disorders (APD), children with hearing loss (HL) and children with normal hearing (NH) scoring 3, 4 or 5 on any COOP subscale, suggesting the child was at-risk for problems in that area......................33 2-3 Mean ratings across twelve COOP-A subs cales by children with auditory processing disorders and their parents.................................................................................................34 4-1 Mean audiometric results for right and left ears of participants in the APD and normal groups.................................................................................................................. ..92 4-2 Compiled Towson University APD group DPOA E data with mean group data line in bold........................................................................................................................... .........93 4-3 Compiled Towson University normal group DPOAE data with mean group data line in bold........................................................................................................................ ........94

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10 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PSYCHOSOCIAL STATUS OF CHILDREN WI TH AUDITORY PROCESSING DISORDER By Nicole V. Kreisman May 2007 Chair: James W. Hall, III Major Department: Communica tion Sciences and Disorders Children with hearing loss often exhibit reduc tions in psychosocial status compared to children with normal hearing stat us. It is reasonable to a ssume that children with other perceptual difficulties, such as Auditory Pr ocessing Disorder (APD) also may experience reduced psychosocial function. However, there remains a paucity of data examining the psychosocial health of children with APD. This investigation examined relationships between APD and psychosocial status, with an aim to add to the scholarship on non-auditory factors that may influence quality of life of children with APD. Participants consisted of nineteen chil dren (ages 9.5 17.8 years; M = 11.9 years) diagnosed with APD (APD group) and twenty ch ildren with no such diagnosis in a genderand age-matched (M = 12.8 years) group (normal gr oup). Extensive aud itory and auditory processing test batteries were admi nistered to confirm or rule out APD. Inclusion criteria for both groups included normal h earing status, non-verbal cogni tive function, and attention abilities. Normal group criteria also included no medical or academic disability, passing a language screening and no histor y of language impairment. The participants and their mothers completed appropriate versions of the Dartmout h Primary Care Cooperative Information Project Charts for Adolescents (COOP-A), the Behavi oral Assessment System for Children-Second Edition (BASC-2) and the Social Sk ills Rating System (SSRS).

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11 Group differences on questionnaire subscales m eans were analyzed by independent sample t -tests or the Mann Whitney U test for ordinal data. Statistical sign ificance was defined by p < 0.05 (two-tailed). The participants Emo tional Feeling and Over all Health COOP-A subscales and the BASC-2 Emotional Symptoms Index differed, with the APD group reporting increased reported psychosocial problems. Pare nt reports differed on the following: the COOPA Pain, School Work, and Emotional Feeli ng subscales; the BASC -2 Externalizing, Internalizing, Behavioral Symptoms Index a nd Adaptive Skills Index subscales; and the SSRS Responsibility, Externalizing Probl em Behaviors and Internalizing Problem Behaviors subscales. Parents reported increased problem s on these scales for children w ith APD. Eta-squared values for all significant findings indicated moderate to large effect sizes, s uggesting findings may be generalized to other children in this age group. Post-hoc analyses yi elded no significant gender or age between-groups differences, except for a moderately strong positive correlation (R = .53) between age and responsibility as measure by th e SSRS Parent Rating Form. No between-group differences were found on any subscale for APD ch ildren with (N = 9) or without (N = 10) a confirmed or suspected language disorder.

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12 CHAPTER 1 INTRODUCTION The major sequelae of sensorineural hearing loss (SNHL) are reductions in speech perception and communicative function. Because of these perceptual and communication difficulties, children with even minimal degrees of hearing loss often exhibit reductions in psychosocial health status compared to child ren with normal-hearing status. Specifically, children with SNHL often exhibit lower social and emotional health status. Social and emotional difficulties of children with hearing loss have been reported in areas such as increased depression, physical aggression, with drawal, loneliness, and decrea sed self-esteem and academic attainment (Bess, Dodd-Murphy & Parker, 1998 ; Hicks & Tharpe, 2002; Davis, Elfenbein, Schum & Bentler, 1986; Davis, Shepard, Stelma chowicz, & Gorga, 1981; Henggeler, Watson & Whelan, 1990; Knutson & Lans ing, 1990; Maxon, Brackett & va n den Berg, 1991). It is reasonable to assume that children with other speech-perceptual difficulties, such as Auditory Processing Disorder (APD), also may expe rience reduced psychosocial function. To support this assumption the Technical Report : (Central) Auditory Processing Disorders, by the Working Group on Auditory Processing Di sorders of the American Speech-LanguageHearing Association (ASHA, 2005) recently reported: In addition to the language and academic difficu lties often associated with (C)APD, some individuals with (C)APD have a higher like lihood of behavioral, emotional, and social difficulties. Communication deficits and a ssociated learning difficulties may adversely impact the development of self-esteem and feelings of self-worth. (p. 3) The authors of the technical repor t further advise that there is no evidence that (C)APD is the cause of severe psychological or sociopathic problems, nor are milder emotional or social difficulties necessarily diagnosti c of (C)APD, yet whenever si gnificant psychosocial concerns are present in an individual w ith (C)APD, the individual should be referred to the appropriate specialist for evaluation and follow-up (p. 3). However, as the lack of references in this area of

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13 the report suggests, there currently is a paucity of data regard ing the exact nature and extent of the psychosocial difficulties in children with APD. In order for audiologists and other professionals to obtain a more complete understa nding of the social and emotional health of children with APD, additional re search and study is needed. According to the Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children (J erger & Musiek, 2000), A PD may be broadly defined as a deficit in the proces sing of information that is specifi c to the auditory modality (p. 468). More specifically, according to the ASHA Wo rking Group (2005), (Central) Auditory Processing [(C)AP] refers to the efficiency and effectiveness by whic h the central nervous system (CNS) utilizes auditory information (p. 2). Auditory Processing Disorder (APD) refers to CNS processing difficulties of auditory info rmation as characterized by reduced performance in one or more of the following areas: s ound localization, sound la teralization, auditory discrimination, auditory pattern recognition, spee ch perception in the presence of competing and/or degraded acoustic signals, an d temporal auditory processes. The prevalence of APD among school-aged children in the United States is estimated to be approximately 2 to 3% (Chermak & Musiek, 1997) The identification, di agnosis, and treatment of APD in children is important for several reas ons, including co-morbidity and confusion with language impairment, dyslexia and other readi ng problems, behavioral problems, attention deficit disorders, and academic underachievement or failure. Again, according to the ASHA Working Group (2005), (C)APD can lead to or be associated with difficulties in learning, speech, language (including written language involv ing reading and spelling), social, and related functions (P. 3). Furthermore, other reports suggest untreated APD commonly leads to reduced communication (Smaldino & Crandell, 2004), which in turn can have psychosocial impacts such

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14 as loneliness, social anxiety, depression, a nger, and fear (Crande ll, 1998). Reduced communication also has been shown to lead to reductions in physical he alth and psychosocial health status as well as overall quality of life (Bess, Dodd-Murphy & Parker, 1998; Crandell, 1993). The use of self-report surveys is a well-accep ted procedure to examine psychosocial health (DeBruin, Diederiks, DeWitte, Stevens & Phil ipsen, 1994; Nelson, Wasson, Kirk, Keller, Clark, Dietrich, Stewart, & Zubkoff, 1987; Nelson, La ndgraf, Hays Wasson & Kirk, 1990). There is evidence that self-report surveys are effective in evaluating the h ealth status of people across a variety of cultures and chronic conditions (B ronfort & Bouter, 1999; Gilbertson & Langhorne, 2000; McFall, Arambula Solomon & Smith, 2000). Nu merous psychosocial health surveys have been designed for use with pediatric or adoles cent populations that examine specific dimensions of social and emotional functioning. Two such ex amples of these surveys are the Social Skills Rating System (SSRS) (Gresham and Elliot, 199 0), and the Behavioral Assessment System for Children, Second Edition (BASC-2) (Reynolds a nd Kamphaus, 2004). Both the SSRS and the BASC-2 utilize self-report questionnaires designed fo r use by teachers, parents, and/or students. The SSRS provides information on the positive and negative social skill behaviors of students. The SSRS has both parent and child versions, which may be used singly or in combination in order to provide a complete profile of a students social function. SSRS data can be utilized in order to inform parents, teacher s, and other support personnel of social skills behaviors in and out of the classroom as well as possible underlying causes. The BASC-2 provides a profile of adaptive a nd maladaptive behaviors and emotions of children and adolescents. BASC-2 data are often used by school and clini cal psychologists when making educational and psychological diagno ses and determining possible disability

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15 classifications in schools. The Parent Rating Sc ales (PRS) of the BASC-2 are used to measure both adaptive and problem behaviors in communi ty and home settings in 14 subcategories, which combine into composite scales. The Self-R eport of Personality (S RP) scale of the BASC2 measures 16 subcategories of at titudes and emotions of students as they rate themselves. Few brief self-report questionnaires that specif ically examine overall quality of life have been designed or adapted for use with a pe diatric or adolescent population (Elkayam and English, 2003). One exception is the Dartmout h Primary Care Cooperative Information Project Charts for Adolescents (COOP-A; Wasson, Kair ys, Nelson, Kalishman & Baribeau, 1994). The COOP-A was designed to be used by primary care physicians in their offices as a screening tool to evaluate the overall quality of life of adolesce nts. The COOP-A charts are designed to assess physical, emotional, and social dimensions of function (Nelson, et al 1987; Wasson, Kairys, Nelson, Kalishman & Baribeau, 1994). Recently, the COOP-A has been ut ilized in two research studie s to investigate the overall health status of children with varying degrees of hearing loss. Bess, Dodd-Murphy, and Parker (1998) reported on findings after the COOP-A was administered to 32 sixthand ninth-grade children with minimal SNHL, condu ctive hearing loss, and other (e.g., mixed) types of hearing loss, and to 591 children with normal hearing. Children with hearing loss reported a trend of greater dysfunction than those with normal hear ing on 9 of 10 COOP-A subscales in both the sixthand the ninth-grade leve ls. Using a Mantel-Haenszel Ch i-square test, statistically significant differences were found between groups of 6th-graders for the energy domain, and between groups of 9th-graders on the stress and behavior dom ains. Further stat istical analysis by examination of only high scores of 4 or 5 on the various subtests of the COOP-A, indicated that the children with hearing loss displayed lower self-esteem and energy than their sixth-grade

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16 peers and lower social support, hi gher stress and lower self-esteem than their ninth-grade peers. These higher self-ratings were chosen for furthe r investigation, as the authors of the COOP-A (Wasson, Kairys, Nelson, Kalishman & Baribeau, 1994) have suggested that scores of 3, 4 or 5 on each chart indicate that children may be at risk for greater dysfunction in that area. Similarly, Hicks and Tharpe (2002) examined the health status of ten children between the ages of 6 and 11 years with either mild-to-mode rate or high-frequency SNHL, and ten ageand grade-matched counterparts with normal heari ng. While no statistical significance between groups was found, the authors noted that the perc entage of the group of children with hearing loss that rated themselves as 3 or higher (more dysfunction) on the COOP-A charts was greater compared to their peers with nor mal hearing in seven of nine s ubscale questions administered. These trends suggest more self-reported social and emotional problems in the children with hearing loss than in their counterparts with nor mal hearing. However, the small sample size utilized in the study affected its statistical findings and and limited generalization to most children with hearing loss. The au thors also postulated, as the majority of the study participants with hearing loss utilized persona l amplification devices, that th e students stress and fatigue levels from energy expended on speech perception in adverse listening situ ations may have been reduced by remediation of their disability and handicap through their use of amplification. With the previous findings in mind, Kreism an, Crandell and Hall (2004) utilized the COOP-A in a preliminary study to determine if any psychosocial difficulties similar to those exhibited by children with heari ng loss also existed in children with APD. As the COOP-A is intended to be a screening instrument only, any si gnificant findings were c onsidered to be pilot data leading into future arenas of research. Te n children (6 male, 4 female) with APD and their parents participated in the study. Subjects in the APD Group ranged in age from 9;11 to 14;6

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17 with a mean age of 11 years 7 months. For comparative purposes, the data from the Hicks and Tharpe (2002) study groups were utilized: 1) the HL Group consisted of ten children (age range 6 to 11 years, M = 8;1) with either mild to moderate SNHL or high-frequenc y SNHL ; and 2) the Normal Hearing (NH) Group consisted of 10 children (age range 6 to 11 years, M = 7;11) with no hearing or auditory difficulties. Follo wing a thorough hearing and auditory processing evaluation, the charts of the COOP-A were admi nistered to the partic ipants in the APD Group and their parents. The children were aske d to answer the ratings on the instrument independently, and utilizing slightly modified instructions for th e purposes of the investigation, the parents of the participants were asked to complete the C OOP-A by responding to each chart via their perception of the most accurate answ er for their child. When mean ratings and percentage of ratings considered At-Risk (3, 4 or 5) were analyzed, results for the Kreisman, Crandell and Hall (2004) study suggested that children w ith APD experience greater psychosocial dysfunction than th eir peers without APD across a number social and emotional content areas relating to quality of life. Specifically, the APD Group exhibited significantly higher ratings on the COOP-A Emotional Feeling and Family subscale charts than did children in the comparison NH Group. In addition, the parents of the participants wi th APD reported greater psychosocial difficulties than did their children on all but one of the COOP-A subscale charts. With the exception of these preliminary fi ndings, there remains a paucity of data examining the psychosocial function of children w ith APD. The present investigation aimed at further exploring hypothesized emoti onal and/or social difficulties that may be present in this population. The results would add to the knowledge base of the audiology community working with children who have APD regarding possible non-auditory factors that may be influencing their quality of life.

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18 Data from two groups of students were comp ared. The experimental group of children consisted of nineteen pediatric participants between the ages of 9.5 and 17.8 years with a diagnosis of APD (APD group). A correspondin g genderand age-matched group consisted of twenty children had no such diagnosis, nor any other medical or academic disability (normal group). The study was conducted in two locati ons. Data for 17 APD subjects and 16 normal subjects were collected in the auditory laborat ory at Towson University in Maryland. Data for two children from the APD group and four children from the normal group were collected at the University of Florida in Gainesville. Followi ng a diagnostic audiometri c, cognitive, linguistic, and APD battery that placed the children into one of the two investigationa l groups, the pediatric participants and their accompa nying parents completed the COOP, the SSRS, and the BASC-2 questionnaires. Standard two-group compar ison procedures were conducted to explore differences between groups on psychosocial subs cale scores. Post-hoc analyses were also conducted to examine differences between gender and age of the pediatri c participants of both groups as well as linguistic function status of the APD group. Implications of findings and results are discussed.

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19 CHAPTER 2 REVIEW OF LITERATURE Auditory Processing DisordersDef initions and Diagnostic Importance While the management of auditory processing disorders has received mu ch attention in the audiology community within the last 30 years, th e concept of difficulties in the dispensation of auditory information beyond the level of the pe ripheral hearing system can be followed back much farther in the literature of the field of communication sciences and disorders (Wertz, Hall & Davis, 2002). Myklebust (1954) noted severa l disturbances of auditory function, including auditory agnosia, aphasia, and ot her lesions in the auditory cortex that appeared to arise from central nervous system pathways. He viewed receptive aphasia as a deficiency in the interpretation of auditory impulses, while wh at he referred to as central deafness was essentially a disturbance in the delivery of auditory impulses to higher cognitive centers of the brain (p.153). In another 1954 publication, Bocca, Calearo and Cassinari described a procedure they used to uncover hidden aud itory losses in the patients with temporal lobe tumors, by use of distorted speech. Kimura (1961) also described auditory per ceptual deficits witnessed in persons with unilateral te mporal-lobe damage by utilizing dic hotic speech stimuli and provided a model to explain the underlying phy siology of the central auditory ne rvous system as it related to dichotic speech perception. Much more work in the field of auditory neuroscience from then until now has also provided extensive eviden ce for the biological underpinnings of this somewhat elusive diagnostic area (Abbs & Sussman, 1971; Jerger Thibodeau, Martin, Mehta, Tillman, Greenwald, Britt, Scott & Overson, 200 2; Kraus & Disterhoff, 1982; Kraus, McGee, Carrell, King, Tremblay, & Nicol, 1 995; Musiek, Baran & Pinheiro, 1994). Katz (2002) defined auditory processing simply and eloquently as what we do with what we hear. In a more technical definition, Jerg er & Musiek (2000) stated that: APD may be

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20 broadly defined as a deficit in the processing of information that is specific to the auditory modality (p. 468). Even yet more specifically, accordi ng to the ASHA Working Group (2005), (Central) Auditory Processing [(C)AP] refers to the efficiency and effectiveness by which the central nervous system (CNS) utilizes auditory information (p. 2). Auditory processing disorder (APD) refers to CNS processing difficulties of a uditory information as characterized by reduced performance in one or more of the following areas: sound localiza tion, sound lateralization, auditory discrimination, auditory pattern rec ognition, speech perception in the presence of competing and/or degraded acoustic signals, a nd temporal auditory processes. (ASHA, 1996; ASHA, 2005). Further, Chermak, Bellis and Mu siek (2006; also Musiek, Bellis & Chermak, 2005) define APD as a primarily modality-sp ecific perceptual dysfunction that cannot be attributed to peripheral hearing loss or to higher-order, global cognitive, supramodal attention, or memory, language-based or rela ted disorders (p. 4). The identification, diagnosis, and treatment of APD in children is important for appropriate management. In the diagnostic process, APD must be differentiated from co-existing disorders including language impairment, dyslexia and ot her reading problems, behavioral problems, attention deficit disorders, and academic under achievement or failure (ASHA, 2005; Jerger & Musiek, 2000; Musiek & Cherma k, 1995). Indeed, reports su ggest untreated APD commonly leads to reduced communication function, which in turn can have psychosocial impacts such as loneliness, social anxiet y, depression, anger, and fear (Crandell, 1998). Psychosocial Implications of Hear ing Loss in Children and Adolescents While there is a paucity of research into the psychosocial implications of APD, the psychosocial implications of hearing loss of va rying degrees and confi gurations have been explored in children and adolescents (Davis et al.,1986; Culbertson & Gilbert,1986; Gilman, Easterbrooks, & Frey, 2004; Henggeler, Wa tson & Whelan,1990; Maxon, Brackett & van den

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21 Berg, 1991 Elkayam & English, 2003). The followi ng is a review of some of the experimental research conducted with an aim to describe em otional and social correlates for hard-of-hearing children. Davis et al. (1986) examined the psychosocial function of children with mild to moderate sensorineural hearing loss. Forty children with sensorineural hearing loss were studied. The forty children who served as part icipants were divide d into 3 experimental groups based on their three-frequency pure-tone averages (PTAs). Group A was comprised of those participants whose PTAs were 44 dBHL or less ( n = 16); Group B included those participants who PTAs were between 45 and 60 dBHL ( n = 15); and Group C was composed of the remaining participants, whose PTAs were 61 dBHL or greater The Missouri Childrens Picture Series, or MCPS (Sines, Pauker & Sines, 1974) and the Chil d Behavior Checklist, or CBC (Achenbach & Edelbrock, 1983) served as the instruments used to examine ps ychosocial function. The MCPS measured self-reported personality characterist ics of the participants. Results on the MCPS showed that scores across the 3 groups of child ren with hearing loss were statistically greater than test norms derived from data on children wi th normal hearing on the scales of aggression and somatization. These findings suggest that children with hearing lo ss are more likely to exhibit aggressive behaviors and to express corporeal complaints than their peers with normal hearing. On the CBC, a parental rating scale, pa rticipants with hearing loss produced patterns of greater impulsivity and aggressive behaviors, as well as more social isolation and academic difficulties, as compared to the instruments normative data set. Culbertson and Gilbert (1986) ex amined the self-concepts and classroom behaviors of a group of 25 children with unilatera l sensorineural hearing loss. Subjects in the experimental group ranged from 6 to 13 years of age and had pur e-tone averages no bette r than 45 dB HL for

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22 at least three years in their impaired ear. Th e participants were matched by age, gender, and socioeconomic status to the 25 children with normal hearing included in the control group. The Piers-Harris Childrens Self-Concept Scale (Piers & Harris, 1984) and the Behavior Rating Scale (BRS; Culbertson, 1986) were given to both gro ups following an evaluation that included cognitive and academic measures. The BRS, an unpublished scale at the time of the study, was comprised of positive and negative descriptors in the following five categories: attention to academic tasks, peer relations and social c onfidence, dependence-independence, emotional lability, and organization. While Culbertson ( 1986) found no significant differences in selfconcept between groups on the Piers-Harris measurem ent, trends of differences were revealed between the groups in four of the five behaviou ral categories of the BRS. For the categories of dependence-independence, attention to task, emo tional ability and peer relations, the children with unilateral hearing loss were rated by thei r teachers as having a greater percentage of negative behaviours than the chil dren with normal hearing. Lim itations of the Culbertson (1986) study include the lack of statistica l analysis of data, and the abse nce of data from a scale with published validity and reliability measures. Howeve r, the trends suggest th at teachers of children with only unilateral hearing loss rate them as displaying more negative behavioural characteristics in the classroom. Henggeler, Watson and Whelan (1990) compared the peer-relations of 35 adolescents with normal hearing to 35 adolescents with hearing lo ss who were enrolled in self-contained classes for the hearing-impaired that utilized a Tota l Communication approach. The parents of both groups of participants were given the Revise d Behavior Problem Checklist (RBPC; Quay & Peterson, 1987), the Social Competence Scal e of the CBC, or SBS-CBC (Achenbach & Edelbrock, 1983), and the Missouri Peer Rela tions Inventory (MPRI; Borduin, 1989). The

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23 adolescents in the normal hearing group and th e adolescents with hear ing loss with sufficient language skills also completed the MPRI. Results indicated that parents of the adolescents with hearing loss rated their children s peer relationships as higher in aggression and lower in emotional bonding than did the parents of the children with normal hearing. However, the adolescents with hearing loss themselves, in cont rast to their parents reports, rated their relationships as lower in aggressive tendencies th an their peer participan ts with normal hearing. Maxon, Brackett and van den Berg (1991) studied the self-perception of social skills in 41 students with hearing loss enrolled in mainstream educational settings as compared to 22 peers with normal hearing. Utilizing an instrument sp ecifically designed with the linguistic needs of students with hearing loss in mind, the Social Awareness Measure (Maxon, Brackett & van den Berg, 1983), students in bot h groups rated themselves on various measures of socialization. The 50 items on the Social Awareness Measure were de signed to be simple statements utilizing concrete vocabulary accompanied by pictorial re presentations. These 50 items were further divided into 14 sub-category variable s. The individual items were pr esented to the students in an interview format, and the students were asked to choose an alternative on a five point Likert scale for each item that best corresponded with how frequently the statement was true for them, from never to always. Results for the 14 variables on the Social Awareness Measure were analyzed according to heari ng status, gender, and age by analysis of variance (ANOVA) measures. Significant findings for children with hearing loss included increased reports of physical aggression and general ve rbal interactio ns than their peers with normal hearing, and fewer reports of verbal emotional expression and verbal aggression. Age and gender effects were also demonstrated.

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24 Elkayam and English (2003) modified the ad ult versions of the Self Assessment of Communication (SAC) and the Significant Ot her Assessment of Communication (SOAC) (Schow & Nerbonne, 1982) for use with an a dolescent population in or der to determine its potential for use by educational audiologists as a personal adjustment counseling tool. The significant others employed in this study were fr iends with normal hearing with whom the 15 participants with hearing loss identified as havi ng at least one class in common and as having interaction with outside school. Once both the SAC and the SOAC were completed, the first investigator met with the adolescent with hearing loss to discuss answers provided by both respondents in an informational and personal adjustment counselling session. The follow-up meetings with respondents were audio-taped and subsequently transcribed. A qualitative analysis of the recurring themes of the se ssions utilizing a file-card prot ocol was conducted independently by each of the investigators and then compared for consistency. Five themes identified in the investigation were: 1) The Inherent Isolation of Hearing Loss; 2) Ident ity and Self-Concept; 3) Cosmetics and Other Hearing Aid Issues; 4) Pr oblem Solving; and 5) Self-Acceptance. Use of SSRS in Children with Communi cation and/or Sensory Impairments Buhrow, Hartshorne and Bradley-Johnson (1998) examined both parent and teacher ratings of the social competence of children who were blind. Twenty mainstre amed elementary-school students who met the criteria for legal blindness were evaluated by both a parent and a teacher on the Parent Rating Scale and the Teacher Rating Scale of the SSRS, respectively. Parent and teacher ratings were compared via independent sample t-tests to the SSRS standardization norms acquired from 1021 teachers and 812 parents of ch ildren with sight. Results for the parents of the blind children indicated signi ficantly lower rating on the Asser tion Subscale as compared to the normative ratings. The teachers of the blind ch ildren also rated them significantly lower than

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25 the normative ratings from the sighted normativ e sample on the Cooperation subscale. Other overall and subscale ratings were not significantly diffe rent between groups. Koning and Magill-Evans (2001) utilized the SSRS parent-, teacherand self-rating forms to evaluate social skills in twenty-one boys ag ed 12-15 identified with Asperger Syndrome as compared to twenty-one boys matched on age who were recruited from local schools. Significant differences (at the p < .001 level) between the experi mental and the control groups were found via MANOVA analysis for all three ra ter sets for the Total Skill Ratings on the SSRS. Additionally, significant differences were found between groups for the Assertion, Cooperation, and Self-Control subscales of th e parent and teacher rating forms, and the Responsibility subscales of the parent form. As ide from the Overall Soci al Skill self-ratings, the only subscale rating for the children that reached statistical significance was Assertion. This study confirms the use of the SSRS in a group of children who commonly experience language and social skill interaction difficulties. It al so highlights the importance of obtaining ratings from the child with the suspected difficulties as well as observers such as their parents or teachers, as perceptions vary based on e xperience and environment of observation. Cartledge, Cochran and Paul (1996) utilized an early version of the SSRS Self-Report (SSRS-S; Gresham & Elliot, 1990) to evaluate social competence between three groups of adolescents (ages 12 to 21 years) with hearing loss enrolled in va rying educational settings. The first group of students attended a residential scho ol for the hearing impaired which utilized a Total Communication approach, the second group of adolescents with hearing loss were enrolled in a public school Total Communi cation program, and the third group of adolescents with hearing loss attended a public school program which utilized an Oral approach. Of the 72 adolescents who participated in the study, 35 participants were in the residential school group, 19

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26 participants were in the public school oral program group, and 18 of the participants were enrolled in the public school Total Communication program. It should be noted, however, that the two groups of students enrolled in the publ ic school programs spent the majority of their school days in self-contained cl assrooms for the hearing impaire d. Additionally, the majority of the female participants (70.2%) were in the public school groups, and the majority of the younger children (80.6%) attended the residential school. Findings on the SSRS-S varied by educational setting, gender, and ag e, with students in the two main streamed educational settings indicating significantly greater so cial competence ratings than th e group of participants in the residential program. Cartledge, Cochran and Paul (1996) suggested that either the students with public schools groups a greater chance to ev aluate themselves in a more challenging mainstream environment in light of their peers with hearing loss within their self-contained classroom, or that perhaps the students that were more socially competent to begin with were placed in the public schools. However, as olde r students and female students tended to rate themselves more highly than younger students and ma le students, the analysis must interpreted with caution as gender and age variable s were not uniform among the groups. Use of the BASC in Children with Language Impairment Redmond (2002) evaluated and discussed th e differences of five commonly used behavioral rating scales for us e with children with language imp airment. The Louisville Behavior ChecklistRevised, the Revised Behavi or Problem Checklist, the Achenbach System (Child Behavior Checklist and Teacher Report Fo rm), the Conners Rating ScalesRevised, and the BASC were compared and contrasted. Norma tive data for children with speech/language or other learning disorders were ei ther not presented or not inco rporated in the normative sets available for the Louisville Behavior Check listRevised, the Achenbach System (Child Behavior Checklist and Teacher Report Form) or the Conners Rating ScalesRevised. The

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27 Revised Behavior Problem Checklis t had separate clinical norms available as established on a sample of 158 children with lear ning disabilities, and the BASC reported that 1.9% of their total normative sample was comprised of children with speech and/or language disorders. While current prevalence data for speech and language diso rders is closer to 6 to 8% of the general population, the BASC was the only rating system of those evaluated to employ a measure to guard against excessively negative ratings. As students with speech/language disorders may be regularly suspected as having socio-emoti onal disorders, Redmond (2002) cautions that frequently the behavioral scales utilized may have inherent instru ment bias, thus invalidating the ratings. The use of multiple informants, the eval uation of differences across situations, and the collection of local norms was recommended. Use of COOP-A in Children with Hearing Loss In their 1998 study, Bess, Dodd-Murphy, and Park er also reported on findings for the COOP for 32 sixthand nint h-grade children with minimal S NHL, conductive hearing loss, and other (e.g., mixed) types of hearing loss, and for 591 children with normal hearing. Children with hearing loss reported a tre nd of greater dysfunction than t hose with normal hearing on 9 of 10 COOP subscales in both the si xthand the ninth-grade levels Using a Mantel-Haenszel Chisquare test, statistically significant differences were found between groups of 6th-graders for the energy domain, and between groups of 9th-graders on the stress and behavior domains of the COOP. Further statistical analysis by examina tion of only high scores of 4 or 5 on the various subtests of the COOP indicated that the childr en with hearing loss displayed lower self-esteem and energy than their sixth-grade peers and lower social support, higher stress and lower selfesteem than their ninth-grade peers. These higher self-ratings were chosen for further investigation, as the aut hors of the COOP (Wasson et al., 1994) have suggested that scores of 3, 4 or 5 on each chart indicate that children may be at risk for gr eater dysfunction in that area.

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28 Hicks and Tharpe (2002) also examined the heal th status of ten children between the ages of 6 and 11 years with either mild-to-moderate or high-frequency SNHL, and ten ageand gradematched counterparts with normal hearing. While no statistical significance between groups was found, the authors noted that the pe rcentage of the group of childre n with hearing loss that rated themselves as 3 or higher (more dysfunction) on the COOP charts was greater compared to their peers with normal hearing in seven of nine s ubscale questions administered. These trends suggest more self-reported social and emotional problems forchildren with hearing loss than their counterparts with normal hearing. The author s also postulated, as th e majority of the study participants with hearing loss util ized personal amplification devices that the student s stress and fatigue levels from energy expended on speech pe rception in adverse listening situations may have been reduced by remediation of their di sability and handicap through their use of amplification. However, the small sample size utilized in the Hicks and Tharpe (2002) study affected statistical findings and limited the conclusions. Use of COOP-A in Children with APD Kreisman, Crandell and Hall (2004) utilized the COOP-A in a preliminary study to determine if any psychosocial difficulties similar to those exhibited by chil dren with hearing loss also existed in children with APD. As the CO OP-A is intended to be a screening instrument only, the primary purpose of the pilot was to expl ore possible future arenas of research. Ten participants were included in the pilot study. Pa rticipants consisted of children between 9 years, 11 months and 14 years, 6 months old ( M = 11;7). Standard periphe ral auditory testing was conducted, including pure-tone air conduction th resholds from 250 to 8000 Hz in octave intervals, tympanometry, and distortion product ot oacoustic emissions. Also, each participant had a history of English as a first language, nor mal growth and development, and was free from significant medical problems. The diagnosis of APD was made with a diagnostic evaluation

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29 battery protocol based on guidelines delineate d by the Report of the Consensus Conference on the Diagnosis of Auditory Processing Disord ers in School-Aged Children (Jerger & Musiek, 2000). An APD was defined by scores two standard deviations below the mean for at least one ear on at least two different APD test battery procedures. Following completion of the audiometric testi ng, children included in the study completed a speech perception task, and subsequently were assessed with the COOP-A questionnaire. In accordance with the COOP-A protocol (Wasson et al., 1994), the examiners instructed each child to select the category (1 through 5) that most closely matched th e childs own perception of how they functioned on each subscale chart (e.g. Emoti onal Feelings, School Work, Pain). Whenever possible, all questionnaires were administered verbally to the subjects in a face-to-face interaction with the investigators. The stude nts either responded ve rbally, by circling the corresponding number, or simply by pointing to the desired categor y on the chart. When it was not possible to complete the COOP-A in a faceto-face manner due to time constraints, parents were given the questionnaire with instructions for their child to complete it at home, and return the instrument by mail to the investigators. Us ing a slightly modified instruction set for the purposes of the present i nvestigation, the parents of the child ren with APD were also asked to complete the COOP-A. Their instructions we re to complete the ratings independently, by responding to each chart via their perception of the most accurate answer for their child. Results from the Kreisman, Cr andell and Hall (2004) pilot study are shown in Figures 2-1, 2-2, and 2-3. Specifically, Figure 2-1 presents the mean ratings for each COOP-A question for the experimental group (children with APD) compared to the me an ratings of children with hearing loss (HL) and the mean ratings of children with normal hearing without APD (NH). The results for the HL and NH control groups were derived from nationally-reported data (Hicks &

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30 Tharpe, 2002). The mean age for the HL group was 8 years, 1 month, and the mean age for the NH group was 7 years, 11 months. Of the twel ve COOP-A charts administered, only eight corresponded to those reported in Hicks and Thar pe (2002), due to the utilization of slightly differing versions of the instrume nt. The eight COOP-A questions evaluated for the HL versus NH groups were: Physical Fitness, School Wo rk, Family, Emotional/Feelings, Self-Esteem, Overall Health, Energy, and Pain. Mean ratings for the APD group were greater than those for the NH group on six of eight subscales (Sc hool Work, Emotional/Feelings, Family Communication, Self-Esteem, Overall Health, an d Pain), suggesting greater psychosocial dysfunction for the experimental group than the control group. A dditionally, the APD group mean ratings were greater than or equal to thos e of the group of children with hearing loss on six of eight subscales, specifically: Physical Fitness, Emotional/Feelings, Family, Self-Esteem, Energy and Pain. Figure 2-2 displays the percentage of child ren in each group responding to a given COOPA question with a score of 3 or greater. A self-reported score of 3, 4 or 5 on any COOP-A question indicates that a child may be at-risk fo r difficulties in that ar ea (Wasson, et al, 1994). The APD group percentages for 3 to 5 ratings were greater than or equal to their NH counterparts on seven of eight subscale questions, speci fically: Physical Fitness, School Work, Emotional/Feelings, Family, Self-Esteem, Overall Health, and Pain. These pilot data again suggest more psychosocial dysfunction by screening the data categorically for the experimental group with APD than the NH controls. Figure 23 displays the mean ratings for each COOP-A question for the experimental group (children with APD) compared to the mean ratings of their parents for the various content areas.

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31 In summary, preliminary findings suggested a trend for children with APD to exhibit greater difficulties than their counterparts with normal hearing for a number of psychosocial dimensions (e.g., self-esteem, family communi cation, school work, emotional/feelings and overall health). The outcomes of the pilot study al so suggested that the parents of children with APD rate their children as having greater psychosocial di fficulties than the children rate themselves across a wide variety of psychosoc ial domains. The findings were limited, however, as the experimental APD group was small ( n = 10), and the compared hearing-impaired and normal-hearing peer groups wit hout APD were derived from nati onally published, non-local data with largely different mean ages. This resear ch was a direct precursor to the present study.

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32 0 1 2 3 4 5Mean Rating P hys ical F it n e ss School Work E mo t io n a l F e eli n g s Family Self-E s teem Overall He a lt h Ener g y P a i nCOOP Questions APD HL NH Figure 2-1: Mean ratings across eight COOP subscales by children with auditory processing disorders (APD), children with hearing lo ss (HL) and children with normal hearing (NH). Data for the HL and NH groups were derived from Hicks & Tharpe (2002). Self-ratings offered were from 1 to 5, w ith 1 representing the best function and 5 representing the most dysfunction for each question area.

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33 0 10 20 30 40 50 60 70 80Percent 3-5 Ratings P hysic a l Fitness Scho o l Work Emotional Feel i ngs Fa m i l y Se lf -Est e em O v era l l H ea l t h Energy PainCOOP Questions APD HL NH Figure 2-2: Percentage of child ren with auditory processing disorders (APD), children with hearing loss (HL) and children with normal hearing (NH) scoring 3, 4 or 5 on any COOP subscale, suggesting the child was at-r isk for problems in that area. Data for the HL and NH groups were derived from Hicks & Tharpe (2002).

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34 0 1 2 3 4 5 M ean R a ti ng Physical Fitness School W or k Emotional F ee l ings Soc ia l S u pp or t Stress Fa mi ly Se l f Es t e e m Hea lth Ha bi t s Behavior Energy Pain O verall Healt hCOOP Questions Parent Child w/APD Figure 2-3: Mean ratings across twelve COOP-A subscal es by children with auditory processing disorders and their parents. Ratings offere d were from 1 to 5, with 1 representing the best function and 5 representing the most dysfunction for each question content domain.

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35 CHAPTER 3 METHODS Participants Thirty-nine children served as participants in this study. They were divided into two groups. The group of interest cons isted of nineteen volunteer pediat ric participants between ages 9.5 and 17.8 years with a diagnosis of APD (A PD group). A corres ponding genderand agematched volunteer group (normal group) consisted of twenty children with no evidence of APD nor any other medical or academic disability. Criteria for diagnosis of APD are described below. All participants met the following criteria: Age between 10 and 18 years, +/6 months; Pure-tone air conduction hearing threshold levels equal to or better than 15 dB hearing level (HL) at all frequencies tested (250, 500, 1000, 2000, 3000, 4000, 6000 and 8000 Hz), bilaterally; A score of 90 to100% on monosyllabic word re cognition testing in quiet at an intensity level of 40 dB sensation level (SL) re: 3frequency pure-tone average (PTA) of air conduction thresholds at 500, 1000 and 2000 Hz; Normal middle ear function as indicated by tympanometry; Average or above intellectual function for age as measured by the Ravens Standard Progressive Matrices (Rave n, 1976), the Matrices Sub-Te st of the Kaufman Brief Intelligence Test-Second Edition (K-BIT 2; Kaufman & Kaufman, 2004), or documented by another full-scale intelligence assessment completed by a licensed psychologist within a time period of 2 years; Negative history of attention de ficit disorder or attention de ficit hyperactivity disorder as determined by parental report and normal performance on the Auditory Continuous Performance Task (ACPT; Keith, 1994a), or attention skills within normal limits as documented per previous evaluation by a licen sed psychologist within a time period of two years (the reader is di rected to Chermak, Hall & Mu siek, 1999; Chermak, Somers & Seikel, 1998; and Chermak & Musiek, 1997 for further discussion of the differential diagnosis of APD and ADD); English as a primary language as re ported by the participants parent;

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36 Normal growth and development and no hi story of significant medical problems via parental report on the APD Parent/Patient Su rvey. A copy of this form can be found in Appendix A. In addition, all participan ts in the normal group had a history normal language development as indicated by parent report and ve rified by the Clinical Evaluation of Language FundamentalsFourth Edition (CELF-4) Screening Te st. The CELF-4 Screening Test also was administered to the participants of the APD group if they did not in itially present with a diagnosis of language disorder via parent or clinical re port in order to id entify a comprehensive profile of these participants. The participants evaluated for in clusion in the APD group and the normal group that did not pass the CELF-4 Screen ing Test were referred for a comprehensive diagnostic language evaluation by a speech-languag e pathologist. The study was conducted in two locations. Two participants from the APD group and four children in the normal group were tested at the University of Fl orida in Gainesville, whereas the remaining participants (17 APD, 16 Normal) were tested at Towson University in Towson, Maryland. Prior to participating in the study, each child s accompanying parent was required to sign an Informed Consent Form (ICF) approved by th e University of Florida Institutional Review Board (IRB) if the participant was enrolled in the study in Ga inesville, FL, and/or an ICF approved by the Towson University IRB if the pa rticipant was enrolled in the study in Towson, Maryland. Additionally, each pediat ric participant was required to indicate a willingness to participate in the study via a Child Assent Script approved by the respective IRBs. A copy of the University of Florida Informed Consent Form a nd Child Assent Script is found in Appendix B, and a copy of the Towson University Informed Consent Form is found in Appendix C. The study was not blind in that all participants a nd their parents knew which study group (APD or normal) they were being included during their completion of the questionnaires. All participants received free hearing and auditory processing evaluations as well as a comprehensive written

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37 report, trial use of a suitable FM system wh en appropriate, and a $20 Target Gift Card upon completion of the research protocol. Diagnosis of APD An APD for a child was defined by scores two standard deviations below the mean for at least one ear on at least two diffe rent procedures of the APD test battery. Following is a brief summary of test administration and analysis for each of the assessments included in the APD battery. Further details on test procedures ar e available from the sources cited for each assessment. The Synthetic Sentence Index with Ipsilate ral Competing Message (SSI-ICM; Wilson & Strouse, 1998; Noffsinger, Wilson & Musiek, 199 4; Feeney & Hallowell, 2000) is comprised of a closed set of ten nonsense sentences that ha ve been constructed to approximate English syntactic sentence structure. The nonsense sent ences are presented against a background of an ipsilateral noise competition comprised of a narrative discourse. Participants are required to identify the nonsense sentences presented, given a num bered reference list from which to choose. The Staggered Spondaic Word (SSW) Test (Kat z, 1963; Katz, 1986) presents a series of two spondees to the listener, first to one ear and then to the other, with the second part of the first spondee and the first part of the second spondee presented simultaneously to opposite ears. The listener is asked to repeat both spondees in the order in which they are presented. The Dichotic Digits, Double Pairs Test (Audiology Illustrated, 1994; Musiek, 1983) involves the presentation of a tw o numbers between 1-9 (except se ven) to both ears at the same time. The listener is asked to repeat the words from both ears in each set, in whatever order they choose (free recall). The Frequency Pattern Sequence test (Audiol ogy Illustrated, 1994; Musiek, 1994) involves the presentation of a series of groups of three different pitches. The listener is first asked to

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38 report the patterns verbal ly (e.g., HIGH-LOW-HIGH), and then to report the pr esented patterns by humming in repetition. The Duration Pattern Sequence test (Audiology Illustrated, 1994; Mu siek, 1994) presents of a series of groups of three different length to nes. The listener is asked to report the patterns verbally (e.g., LONG-SHORT-LONG). The Auditory Random Gap Detection Test (R GDT; Keith, 2000b) is a test in which two tones are presented at varying time intervals. The lis tener is asked to report if they hear one tone or two beeps in order to determine how close together the two sounds can be heard and still differentiated. If a participant scored two standard deviat ions below normal limits on one of the six diagnostic auditory processing measures desc ribed above, the SCAN-C or SCAN-A Competing Words, Auditory Figure Ground and Filtered Words subtests would also be administered. The SCAN-C: Test for Auditory Processing Disord ers in ChildrenRevised (Keith, 2000a) or SCAN-A: Test for Auditory Processing Disord ers in Adolescents a nd Adults (Keith, 1994b) Competing Words Subtest involves the presenta tion of an open set of different monosyllabic words to both ears at the same time. The listener is asked to repeat the words coming first into the right ear, then into the left The Filtered Words Subtest of the SCAN-C: Test for Auditory Processing Disorders in ChildrenRevised (Keith, 2000a),or SCAN-A: Te st for Auditory Processing Disorders in Adolescents and Adu lts (Keith, 1994b) is a task in which speech is filtered above 500 Hz so that certain frequencies are absent. The listener is asked to repeat the words presented from an open set.

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39 The Auditory Figure-Ground Subtest of the SCAN-C: Test for Auditory Processing Disorders in ChildrenRevise d (Keith, 2000a) or SCAN-A: Te st for Auditory Processing Disorders in Adolescents and Adu lts (Keith, 1994b) requi res the listener to repeat words against a background of competing multi-talker babble. Psychosocial Measures The Social Skills Rating System (SSRS; Gresham and Elliot, 1990), the Behavioral Assessment System for Children-Second Edition (BASC-2; Reynolds and Kamphaus, 2004), and The Dartmouth Primary Care Cooperative Char ts for Adolescents (COOP-A; Wasson et al., 1994) were utilized to assess ps ychosocial status. These questi onnaires were utilized because previous investigations have shown them to be valid for these purposes in children with hearing loss or other communication disorders (Koning & Magill-Evans, 2001; Cartledge, Cochran & Paul, 1996; Redmond, 2002; Bess, Dodd-Murp hy & Parker, 1998; Hicks & Tharpe, 2002; Kreisman, Crandell & Hall, 2004). The COOP-A pilot study (Kreisman, Crandell & Hall, 2004) provided preliminary findings suggesting the use of the charts to be appropriate for use with children with APD and their parents. Thus it was used in the presen t investigation. The selection of the other two inst ruments investigation was based on the desire for more robust, standardized comprehensive asse ssments of emotional and social function in children which matched with the normative ages of the COOP-A (10-18 years), had both se lf-report and parent rating forms, and yielded subscale measurements that would lend themselves to comparable analysis across instruments. The Social Skills Ra ting System (SSRS) The SSRS provides information on the positiv e and negative social skill behaviors exhibited by students in and out of the classr oom (Gresham and Elliot, 1990). The SSRS was standardized on a sample of 4170 children in the United States. The SSRS items are rated

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40 according to both perceived frequency (Never, Sometimes, or Very Often) and importance (Not Important, Important, or Critical). The Social Sk ills Scale of the SSRS contains five subscales that measure positive social behaviors. The five subscales incorporated into the Social Skills Scale of the SSRS are Cooperation, Empathy, Asse rtion, Self-Control, and Responsibility. The Problem Behaviors Scale of the SSRS measures behaviors that can interfere with the development of positive social skills. The th ree subscales incorporated into the Problem Behaviors Scale of the SSRS are Externalizing Problems, Internalizing Problems, and Hyperactivity. Internal consistency is high for SSRS roms and levels, with median coefficient alpha reliability scores of .90 and .84 for the Social Skills and Problem Behaviors Scales, respectively. Test-retest reliability coefficien ts ranged from .77 to .84 for parents and .52 to .66 for students on the Social Skills subscales, s uggesting adequate to good stability on repeated measurements with the SSRS over time. The info rmation that the SSRS provides can be utilized in order to suggest possible inte rventions for students with pr oblems learning or demonstrating appropriate social skills behavior s by examination of their causes. The Behavioral Assessment System for Children-Second Edition (BASC-2) The BASC-2 provides a profile of adaptive a nd maladaptive behaviors and emotions of children and adolescents ages 2 through 21 year s (Reynolds and Kamphaus, 2004). The BASC-2 has forms designed specifically for use by parents with a different section designed for use by the students themselves. The General norm sample of the BASC-2 was conducted on 4800 parents and 3400 children. 2.1% of the standardization population of the BASC-2 was comprised of children with language impairment. The Parent Ra ting Scales (PRS) of th e BASC-2 are used to measure both adaptive and problem behaviors in both the community and home settings in 14 subcategories utilizing a four-c hoice response format. Examples of subcategories of the PRS include Adaptability, Anxiety, Leadershi p, Depression, Functional Communication, and

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41 Withdrawal. Internal consistency of the PRS co mposite scores as measured by coefficient alpha are between .90 and .95. PRS test-re-t est reliability is also high, with estimates for the composite scores from .78 to .92. The Self-Report of Pers onality (SRP) scale of the BASC-2 has been reported to provide insight into a childs own th oughts and feelings. The SRP is a self-report questionnaire that measures 16 subcategories of attitudes and emotions including Attitude to School, Locus of Control, Interpersonal Relations Social Stress, and Self-Esteem. Internal consistency of the SRP composite scores as meas ured by coefficient alpha are also high, ranging between .83 and .96. SRP test-re-test reliability is also high, with estimates in the upper .70s to low .80s. The BASC-2 is widely used by school and clinical psychologists in determining Individuals with Disabilities Education Act (IDEA) and Diagnos tic and Statistical Manual of Mental Disorders-Fourth Editi on (DSM-IV) classifications. The Dartmouth Primary Care Cooperative Information Project Charts for Adolescents (COOP-A) The COOP-A is a quality of life screening in strument designed for use with individuals between ages 10 and 20 years (Wasson et al., 1994). The COOP-A charts are designed to screen across physical, emotional, and social dimensions of functioning in an individual. The COOP-A consists of a series of pictographic self-rating ch arts that are designed to represent function of one of 12 content areas. The twelve subscale ch arts included in the COOP-A are: Physical Fitness, Energy, Pain, School Work, Behavior, St ress and Emotional Feelings, Social Support, Family, Self Esteem, Health Habits I, and Overal l Health. Each individua l chart consists of a question and five illustrative alternatives from which an individual may choose an answer most appropriate for him or herself base d on a five-point Likert scale wh erein 5 represents the greatest dysfunction and 1 represents the least dysfunction. An example que stion on the Family chart of the COOP-A is: During the past month, how often did you talk about your problems, feeling or

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42 opinions with someone in your family? Corresp onding alternatives from which to choose are as follows: 1 = All of the time, 2 = Most of the time, 3 = Some of the time, 4 = A little of the time, and 5 = None of the time. Wasson, Kairys, Nels on and colleagues (1994) indicated that average test-retest correlations ranged from .71 to .80 fo r the Physical Fitness, Emotional Feelings, School Work, Social Support, Family Communica tion and Health Habits, and Cronbachs alpha test for internal consistency -reliability was between .60 and .94 for those six dimensions. Procedures Audiological Assessment The first thirty-nine children who met the inclus ion criteria as stated above and agreed to serve as subjects were included as participants. Participants were recruited from the Department of Communication Sciences and Disorders/Univer sity of Florida Speech and Hearing Clinic (UFSHC), the University of Florida Departme nt Of Communicative Disorders Speech and Hearing Center at Shands Hospital, the Sp eech-Language-Hearing Clinic (TUSLHC) and the Center for Amplification, Rehabilitation a nd Listening (CARL) at Towson University. Participants also were recruited from self-refe rrals following advertisements in local parent magazines and educational newsletters, as well as flyers distributed at informational events for parents, educators and other pr ofessionals seeking more info rmation on speech, language, and auditory disorders in children. A copy of the recruitment flyer is found in Appendix D. The 39 children who met the other inclusion criteria to be participants firs t underwent pure-tone audiometry. The pure-tone air conduction test consisted of oc tave intervals from 250 through 8000 Hz, as well as the interoctaves 3000 and 6000 Hz Hearing sensitivity was tested in soundtreated booths using a calibrated Grason-Stadler, Inc. Version 61 (GSI-61) two-ch annel clinical audiometer and either Etymotic Research vers ion 3A EAR-Tone Insert Earphones (ER-3A) or TDH-50 supra-aural audiometric earp hones. Participants were be required to have pure-tone air

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43 conduction thresholds better than or equal to 15 dB HL at all frequencies (250 through 8000 Hz) tested in both ears in order to participate in the study. Word recognition performance was assessed utilizing the NU-6 Ordere d by Difficulty Version II lists presented via compact disc presentation (Auditec of St. Louis, 1980; Hurley & Sells, 2003). In order to be included in the study, participants were required to have a percent correct score of 90 to100% on these monosyllabic word tasks in quiet at 40 dB SL re: the average of their pure-tone air conduction thresholds at 500, 1000 and 2000 Hz (PTA). Tympanograms and acoustic reflex threshol ds were obtained via a GSI-33 or GSI Tympstar Middle Ear Analyzer. Both groups of participants were requ ired to have normal middle ear function, as defined by middle ear pe ak pressure values between -150 to +100 decaPascals (daPa), static compliance of 0.3 to 1.4 milliliters (ml), and ear canal volume of 0.6 to 1.5 cubic centimeters (cm3) in both ears. Distortion product otoacoustic emissions (DPOAE) measurement was conducted using either an Otodynamics ILO 92 v.6 DPOAE System or a Grason Stadler Audera DPOAE system. The ILO v.6 device was configured using the Diagnostic 65/55 stimulus and the Diagnostic configuration. Intellectual Assessment All participants (except four who had prev ious documentation of average or aboveaverage intelligence as tested by a licensed psychol ogist within a two-year time period) were given either the Ravens Sta ndard Progressive Matrices ( n = 1) (SPM; Raven, 1976) or the Matrices sub-section assessment of the Kaufman Brief Intelligence Test-2nd Edition ( n = 34) (KBIT 2; Kaufman & Kaufman, 2004) in order to screen for normal non-verbal intellectual functioning. The scores on the Ravens SPM an d the K-BIT 2 are high ly correlated with nonverbal intelligence measures on more comprehensiv e measures of intelligence as well as with each other. The Ravens SPM was initially chosen for use in the present research study, but was

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44 abandoned for the K-BIT 2 due to improved time and ease administration and scoring. Participants were tested individually in a quiet room in the UFSHC, the TUSLHC or the CARL, utilizing the Ravens SPM test ing booklets or the K-BIT 2 test kit, and following the administration procedures as outlined in the resp ective test manuals. Answers were recorded by the test administrator on the corresponding answ ering sheets, and scored accordingly. The results on the Ravens SPM were compared to Table SPM9, Smoothed Summary Norms for Children and Young People in th e United States of America. Scores at or above the 25th percentile were considered to be average or a bove average intellectual function for the Ravens SPM. The results on the K-BIT 2 were compared to the Nonverbal portion of Table B.1: Verbal and Nonverbal Standard Scores, Confidence Interval s and Percentile Ranks. Standard scores at or above 85 for the corresponding age group were c onsidered to be average or above average intellectual functioning for the K-BIT 2. Language Assessment Language screening of all participants wa s conducted via the CELF-4 Screening Test (Semel, Wiig & Secord, 2003). Participants were tested individually in a quiet room, using the CELF-4 Screening Test booklet, an d following the administration procedures as outlined in the CELF-4 Manual. All participants who did not pa ss the CELF-4 Screening Test were referred for a comprehensive language evaluation by a speechlanguage pathologist. Prospective normal participants who did not pass the CELF-4 Screen ing Test were not included in the study. APD Assessment APD assessment was conducted in a singl e-walled sound-treated booth (Industrial Acoustics Company) using a calibrated GSI-61 clin ical audiometer and ER -3A insert earphones. The following APD procedures, as described above, were admini stered to all of the study participants:

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45 Synthetic Sentence Index with Ipsilate ral Competing Message (SSI-ICM); Staggered Spondaic Word (SSW) test; Dichotic Digits, Double Pairs test; Frequency Pattern Sequence test, both verbal and hummed response modes; Duration Pattern Sequence test; Auditory Random Gap Detection Test (RGDT). Any participant who did not have previous clinical documentation of attention within normal limits underwent assessment with the Auditory Continuous Performance Task (ACPT). In addition to the above procedures, any participan t who was considered for inclusion in the APD group for the study due to results two standard deviations below the mean on any of the six diagnostic APD procedures previously mentione d also completed the SCAN-C or SCAN-A: Test for Auditory Processing Disorders in Childre nRevised, Competing Words Subtest, Filtered Words Subtest and Auditory Figure-Ground Subtest. Standard administrative and scoring procedur es, as outlined in the manuals for each APD test, were followed. As previously detailed, an APD diagnosis was made if a child scored two standard deviations below the mean on at least tw o different APD test procedures for at least one ear, with at least one of the failed procedures from the diagnostic assessments other than the SCAN-A or SCAN-C subtes ts (ASHA, 2005). Psychosocial Assessment Psychosocial assessment of all thirty-nine pa rticipants incl uded in the study was conducted via the SSRS, the BASC-2, and the COOP-A ques tionnaires. All participants were tested individually in quiet rooms of the UFSHC, the TUSLHC or the CA RL. Administration procedures as outlined in the respective test manuals were followed. The accompanying parents of the participants were asked to complete their appropriate questi onnaires independently, utilizing a pencil and paper ve rsion of the assessments. For the SSRS and the BASC-2 questionnaires, parents were asked to comple te the questionnaires according to the printed

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46 instructions. For the COOP-A, the parents were asked to respond to each chart according to their perception of their participating childs function in each given area. They were instructed to ask questions of the investigator if any item was unclear. The same examiner administered the questionnai res to all pediatric participants in both sites. When written or verbal language disorder s were previously diagnosed or were suspected due to parental report or belo w-criterion performance on the CELF -4 Screening Test, pediatric participants were given the psyc hosocial test assessments in an interview format. In order to minimize any possible effects of the interviewer on the response pattern of the participant, the examiner sat beside the participant at a table, utilizing the questionnaire as a mutual reference point. Pediatric participants were instructed to respond to each individual item on the questionnaires either by verbal or pointed res ponses, and the examiner recorded the childs responses accordingly on the questionnaires corre sponding answer sheet. When no language disorders were suspected, the participant was gi ven a choice as to whether they would like the examiner to read the questions, or if they would like to complete the quest ionnaires on their own. When independent completion was chosen, test instructions we re given for standard selfadministration procedures, with the examiner ava ilable in the room to answer questions. All participants were encouraged to answer as openl y as possible, according to what they believed to be true for themselves, and only the subjects fi nal response to any given item was recorded. Additionally, all participants were reassured that the confidentiality of thei r responses would be maintained, and that their parents would not know of their responses to the questionnaires unless discussed with them first. In order to discour age any conscious or uncons cious influence in the pediatric participants responses, parents were discouraged from being present in the room during psychosocial assessm ent of their children.

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47 Statistical Analyses Statistical analyses were conducted to expl ore differences between groups on psychosocial subscale scores. Multivariate analysis of variance (MANOVA) proced ures were initially explored as a means of examining the differe nces between the two groups across the three different psychosocial assessment subscales. Ho wever, upon preliminary review the data were found to violate the assumptions of multivariate normality and linearit y, and thus were not appropriate for the MANOVA analys is procedure. Standard twogroup analysis procedures were utilized instead, comparing each group on each subscale of the three instruments. T-tests were completed on the continuous scales (SSRS and BASC-2) while a nonparametric equivalent (Mann-Whitney U test) was completed for comparison of the COOP-A ordinal data. Statistical significance was defined by p < 0.05 (two-tailed) for all tests. Due to the relatively small group sizes, eta-squared and r-squa re values were calculated for the continuous and ordinal data, respectively, to assess effect sizes and magnit udes of the differences between groups as a measure of generalizab ility of the findings. Pallant ( 2005) indicated that eta-squared represents the proportion of variance in the dependent variable that is explained by the independent variable (p. 208). Et a-squared was calculated by the following formula: 2 2 12 2 N N t t For the COOP-A subscale charts, r-square valu es (Z-value of Mann-Whitney U divided by the square root of N) were calcula ted (Rosenthal, 1991). Effect si zes were interpreted based on the following classification guidelines (Cohen, 1988) : .010 to .059= small effect, .060 to .139 = moderate effect, .140 and above = large effect. The creators of the COOP-A s uggested the utilization of a di chotomous categorization into Average (ratings of 1 or 2) or At-Risk (ratings of 3, 4 or 5) assemblages by practitioners in

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48 order to determine possible need for further fo llow-up on the particular content area represented by each subscale chart (Wasson et al, 1994). Thus chi-square tests for independence were conducted between groups on the proportion of Av erage or At-Risk classifications for each subscale chart. Again, statistic al significance was defined by p < 0.05 (two-tailed) for the Pearson chi-square values. As Rosenthal and Rosnow (1991, p. 51) assert that very usable 2 values can be obtained even with expected freque ncies as low as 1, so lo ng as the total number of independent observations (N) is not too small and corrections for continuity may do more harm than good, no corrections were employed when analyzing this data. Post-hoc analyses were also conducted to examine any possible differences between gender and age of the pediatric pa rticipants of both groups as well as linguistic func tion status of the APD group. The Spearman Rank Order Correlati on (rho) test for non-parametric data and Pearson product-moment correlation coefficients (r) for continuous variables were utilized in order to evaluate possible correl ations between subscale scores and age. To assess differences between genders and mean ratings on the comp osite subscales of the BASC-2 and the SSRS, independent-samples t -tests were conducted. The non-parame tric equivalent, the Mann-Whitney U, was utilized in order to assess differences between gender and mean rank of the COOP-A subscales. Post-hoc analyses also were conducted on all subscales of each of the three psychosocial questionnaires (COOP-A, SSRS, and BASC-2), comparing the results for the pediatric participants in the APD group with confirmed or suspected language impairment (languageimpaired APD subgroup, n = 9) to those of th e pediatric participants in the APD group with normal language function (language-normal APD subgroup, n = 10). The parent responses on the three psychosocial instruments for the two APD subgroups were al so compared. As with the

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49 normal v. APD group comparisons, statistical analys es for all composite subscales of the BASC2 and subscales of the SSRS were c onducted utilizing independent-samples t -test measures, and the Mann-Whitney U test for non-parametric data was utilized for analysis of the COOP-A subscale charts. Statistica l significance was defined by p < 0.05 (two-tailed).

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50 CHAPTER 4 RESULTS Descriptive data were compiled for gender, age, linguistic function stat us, grade level, and type of school (public, private, and home) be tween the normal and APD groups. A summary of descriptive statistics can be found in Table 4-1. Preliminary analyses were completed to determine if any differences existed between the normal and APD groups on age or gender. Results indicated that there was no ag e difference between the normal group ( M = 12.79, SD = 2.347) and the APD group [ M = 11.93, SD = 2.093; t (37) = -1.199, p = .238]. A chi-square test for independence was conducted be tween groups on the proportion of males and females, with statistical significance defined by p < 0.05 (two-tailed) for the Pear son chi-square values. No difference on gender was found ( 2 = .265, n = 39). As two parents in the normal group did not complete their questionnaires by the time of this publication, their data could not be included. All parent raters ( n = 37) were female (i.e. mothers). Initial descriptive findings were evaluated in order to ensure comparable peripheral hearing status between groups. Audiomet ric results were within normal limits (pure-tone thresholds 15 dB HL) for all participants in bot h groups at 250, 500, 1000, 2000, 3000, 4000, 6000 and 8000 Hz per inclusion criteria. Mean audiometric fi ndings for both groups are displayed in Figure 4-1, and means and standard deviations for both grou ps by frequency are detailed in Table 4-2. Tympanometric results were also within normal limits for all participants in both groups per inclusion criteria. Mean tympanometric data ar e detailed for right and left ears of both the groups in Table 4-3. Mean diagnostic distorti on product otoacoustic emissions (DPOAEs) were within normal limits for both groups. However, a small and equivalent proportion of participants in each group had DPOAE amplitudes below normal limits for one or more test frequencies. Graphs of compiled DPOAE findings with mean s for the participants tested at Towson

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51 University for the APD group are shown in Fi gure 4-2 and for the normal group are shown in Figure 4-3. Using the diagnostic auditory pro cessing test battery cr iterion, a student was diagnosed with an auditory processing disorder if findings for at least one ear were two standard deviations below the mean on at least two diffe rent procedures. A summary of results on the APD test battery for those students who were included in each group is shown in Table 4-4. Statistical analyses were conducted on each of the three instruments (COOP-A, BASC-2, and SSRS), as determined a priori, comparing the results for the pediatric participants in the APD group to those of the pediat ric participants in the normal group, and comparing the results of the parents of the participants in the APD group to those of the parents of the participants in the normal group. Statistical analyses were completed using SPSS 13.0 for Windows (Chicago, IL: SPSS Inc.). See Table 4-5. for a summary of findings and Table 4-6 for details of statistical results between pediatric participant groups. Se e Table 4-7 for a summary of findings and Table 4-8 for details of statistical re sults between parent groups, as de scribed below. In addition, a summary of statistically significan t findings for both children and adults can be found in Table 49. Child-Completed Dartmouth Primary Care Coop erative Information Project Charts for Adolescents (COOP-A) Recall that each individual ch art of the COOP-A is its own subscale screener and consists of a question and five illustrativ e alternatives from which an individual may choose the most appropriate answer. Ratings for each chart are based on a five-point Li kert scale wherein 1 represents the least dysf unction and 5 represents the greatest dysfunction in any given domain. The Mann-Whitney U test for non-parametric data was utilized in order to compare Sum of Ranks for all subscale charts on the COOP-A due to the ordinal nature of the data, and r-square values were caluculated to assess effect sizes. Additionally, as the creators of the COOP-A

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52 suggested the utilization of a dichotomous categorization into Average (ratings of 1 or 2) or At-Risk (ratings of 3, 4 or 5) assemblages by practitioners in or der to determine possible need for further follow-up (Wasson et al, 1994), chi-s quare tests for independence were conducted between groups on the proportion of Average or At -Risk classifications for each subscale chart. See Table 4-10 for a summary of findings for pro portions of students cons idered At-Risk from both groups for each subscale chart. Physical Fitness Subscale Chart The Physical Fitness subscale chart for the COOP-A asks the question, During the past month, what was the hardest physical activ ity you could do for at least 10 minutes ? Results indicated no difference between the two groups ( p = .417). The effect size was small (r2 = .017). The mean ranks were 21.25 and 18.68 for the nor mal and APD groups, respectively. The Pearson chi-square value was .136, suggesting no difference for the propor tion of participants classified as Average or At-Risk between the APD and normal groups. Pain Subscale Chart The Pain subscale chart of th e COOP-A poses the question, During the past month, how often were you bothered by pains such as; back aches, headaches, cramps or stomachaches? Results indicated no difference between the APD group and the normal group ( p = .319). The effect size was small (r2 = .025). The mean ranks were 18.33 and 21.76 for the normal and APD groups, respectively. The Pears on chi-square value was .648, sugge sting no difference exists for the proportion of participants classified as A verage or At-Risk between the APD and normal groups. Stress Subscale Chart The Stress subscale chart of the COOP-A poses its question this way: During the past month, how much stress or pressu re do you feel from other peopl e? (family, friends, teachers,

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53 other grown-ups or other kids) Results suggest ed no difference between the two groups for this subscale ( p = .145). However, the effect size was moderate (r2 =.055). The mean ranks were 17.55 and 22.58 for the normal and APD groups, respectively, suggesting a trend for the APD group to report more problems with stress. Fu rther, in contrast to the results of the MannWhitney U analysis, the Pearson chi-square valu e was .034, suggesting a difference exists for the proportion of participants classified as Ave rage or At-Risk betw een the APD and normal groups. Further review indicates there to be 80% of the normal group ratings falling in the Average category versus 47.4% of the AP D group, and 20% of the normal group ratings falling in the At-Risk category versus 52.6% of the APD group. These findings also indicate a greater proportion of students within the APD group rate themselves as At-Risk for problems with stress than do students in the normal group. School Work Subscale Chart The School Work subscale chart of the COOP-A asks, During the last month you were in school, how did you do? Results suggested no difference between the APD group and the normal group ( p = .131). The effect size was moderate (r2 = .058). The mean ranks were 17.55 and 22.58 for the normal and APD groups, respectiv ely. The Pearson chi-square value was .134, suggesting no difference exists fo r the proportion of par ticipants classified as Average or AtRisk between the APD and normal groups. Emotional Feelings Subscale Chart The Emotional Feelings subscale chart of the COOP-A asks the question, During the past month, how often did you feel anxious, depressed, irritable, sad or downhearted and blue? Results indicated a difference betwee n the APD group and the normal group ( p = .011) with a large effect size (r2 = .165). Recall that with the MannWhitney U for the COOP-A, the group with the greater mean rank represents the gr oup with greater reported psychosocial difficulties

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54 for that subscale chart. The mean rank for the normal group was 17.55 and the mean rank for the APD group was 22.58, indicating greater reported difficulties on the Emotional Feelings subscale for the APD group. However, the Pearson chi-s quare value was .095, suggesting no statistically significant difference exists for the proportion of participants classified as Average or AtRisk between the APD and normal groups. Behavior Subscale Chart The Behavior subscale chart of the COOP-A poses the question, During the past month, compared to other kids your age, has your beha vior caused problems for you or other persons? Results suggested no difference between the two groups for this subscale ( p = .261) with a small effect size (r2 = .032). The mean ranks were 18.20 and 21.89 for the normal and APD groups, respectively. There was no difference betw een the APD and normal groups for the proportion of participants classified as Average or At-Risk (Pears on chi-square value of .267). Social Support Subscale Chart The Social Support subscale chart of the C OOP-A asks, During the past month, if you needed someone to listen or to help you, wa s someone there for you? Results suggested no difference between the APD group and the normal group ( p = .106). In contrast to this nonsignificant finding, the eff ect size was moderate (r2 = .067), with the mean rank for the normal group at 17.40 and the mean rank for the APD gr oup at 22.74. The effect size indications suggest a trend for the particip ants in the APD group to rate themselves as having more difficulties with social support than their coun terparts in the normal group. The Pearson chisquare value was .267, suggesting no difference for the proportion of partic ipants classified as Average or At-Risk between the APD and no rmal groups. This is possible as though the proportions of participants that fall into the 2 categories may not be related, the effect size

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55 calculation (r2) is based on the ranks of the ratings for each group, and so may differ from the nominal analysis that the Pears on chi-square value provides. Self-Esteem Subscale Chart The Self-Esteem subscale chart of the COOP -A poses the questi on, During the past month, how often have you felt badly about yourself? There wa s no difference between the two groups for this subscale ( p = .189). The effect size was small (r2 = .044). The mean ranks were 18.38 and 21.71 for the normal and APD groups, resp ectively. The Pearson chi-square value was .184, suggesting no difference for the proportion of participants classified as Average or At-Risk between the APD and Normal groups. Family Subscale Chart The Family subscale chart of the COOP-A as ks, During the past month, how often did you talk about your problems, feelings or opinions with someone in your family? For this subscale, there was no difference between the APD group and the normal group ( p = .336). The effect size was small (r2 = .024). The mean rank for the normal group was 18.38 and the mean rank for the APD group was 21.71. The Pearson chi-square value was .421, confirming no difference for the proportion of participants classified as Average or At-Risk between the APD and normal groups. Health Habits I The Health Habits I subscale chart of the COOP -A poses its question this way: During the past month, how often did you do things that are harmful to your health such as: smoke cigarettes or chew tobacco have unprotected sex use alcohol including beer or wine? There was no difference between the APD group and the normal group ( p = .330). The effect size was small (r2 = .024). The mean ranks were 20.48 and 19.50 for the normal and APD

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56 groups, respectively. The Pearson chi-square value could not be determined as all ratings for both groups were constant within the Average classification. Overall Health Subscale Chart The Overall Health subscale chart of the C OOP-A asks the question, During the past month, how would you rate your health? Ther e was a difference between the APD group and the normal group ( p = .037) with a moderate effect size (r2 = .111). Recall that with the MannWhitney U for the COOP-A, if there is a statisti cally significant difference, the group with the greater mean rank represents the group with gr eater reported psychosocia l difficulties for that subscale chart. The mean rank for the norma l group was 16.53 and the mean rank for the APD group was 23.66, indicating lower reported overall he alth on this subscale chart for the APD group. Despite the findings on the Mann-Whitney U, the Pearson chi-square value was .060, suggesting no statistically si gnificant difference exists for the proportion of participants classified as Average or At-Risk between the APD and normal groups. Energy Subscale Chart The Energy subscale chart of the COOP-A as ks, During the past month, how often did you feel tired? There was no stat istically significant difference be tween the two groups for this subscale ( p = .220), and the effect size was small (r2 = .039). The mean ranks were 21.98 and 17.92 for the normal and APD groups, respectively. There was also no stat istically significant difference for the proportion of participants classified as Average or At-Risk between the APD and normal groups (Pearson chi-square value of .060). Social Skills Rating Syst em (SSRS), Student Forms The items on the Student Forms of the SSRS are rated on a three-point Likert scale according to perceived frequency, where Never = 0, Sometimes = 1, and Very Often = 2. The four subscales incorporated into the Social Skills Scale for the Student Forms (Elementary

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57 and Secondary Level) of the SSRS measure positive social be haviors, with higher ratings indicating greater self-perceived skill. The f our Student Form Social Skills subscales are Cooperation, Assertion, Empathy and Self-Control. To assess differences between group mean ratings on the subscales of the SSRS, independent-samples t -tests were conducted and etasquared values were calculated to assess effect sizes. Cooperation Subscale The Cooperation subscale of the SSRS asks students to rate how often they complete social behaviors that are presen ted, such as: I finish classroom work on time. For the Cooperation subscale for the SSRS Student Forms (combined El ementary and Secondary ratings), there was no difference between scores for the normal group ( M = 15.53, SD = 2.695) and the APD group [ M = 14.68, SD = 2.451; t (36) = 1.008, p = .320]. The magnitude of the differences in the means was small (eta squared = .026). Assertion Subscale The Assertion subscale of the SSRS asks student s to rate how frequently they complete associated social behaviors, for example: I st art talks with class memb ers. For the Assertion subscale for the SSRS Student Forms, there was no difference between scores for the normal group ( M = 13.95, SD = 3.677) and the APD group [ M = 14.84, SD = 2.035; t (37) = -.943, p = .353]. The effect size of the differences in the means was small (eta squared = .023). Empathy Subscale The Empathy subscale of the SSRS asks students to rate how often they complete social behaviors that are presented, such as: I feel sorry for others when bad things happen to them and I listen to my friends when they talk a bout problems they are havi ng. For the Empathy subscale for the SSRS Student Forms (combined El ementary and Secondary ratings), there was no significant difference between scores for the normal group ( M = 16.45, SD = 2.743) and the

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58 APD group [ M = 16.47, SD = 2.435; t (37) = -.028, p = .977]. The magnitude of the differences in the means was very small (eta squared = .00002). Self-Control Subscale The Self-Control subscale of the SSRS asks stude nts to rate how frequently they complete associated social behaviors, for instance: I c ontrol my temper when people are angry at me. For the Self-Control subscale for the SSRS Stude nt Forms, there was no difference between scores for the normal group ( M = 12.80, SD = 3.270) and the APD group [ M = 12.80, SD = 3.270; t (37) = .917, p = .365]. The effect size of the differe nces in the means was small (eta squared = .022). Behavioral Assessment System for Children-S econd Edition (BASC-2), Self-Report Forms The items on the Self-Report Forms of the BASC-2 are rated according to either a true/false forced choice paradigm, or a fourpoint Likert scale according to self-reported frequency of Never, Sometimes, Often, or Almost Always. The five composite subscales of the BASC-2 that are incorporated in to the Self-Report Forms utilized (both the SelfReportChild and the Self-ReportAdolescent) are School Problems, Internalizing Problems, Inattention/Hyperactivity, Emo tional Symptoms Index, and Personal Adjustment. To assess differences between group mean ratings on the composite subscales of the BASC-2, independent-samples t -tests were conducted and eta-square d values were calculated to assess effect sizes. School Problems Composite Subscale The School Problems composite subscale asks stude nts to rate their thoughts, feelings and behaviors for such content areas as attitude to sc hool, attitude to teachers, and the structure of the educational process. High scores on the School Problems composite subs cale are indicative of a pattern of overall dissatisfacti on with the schooling process. For the School Problems composite

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59 subscale, there was no difference be tween scores for the normal group ( M = 121.55, SD = 30.490) and the APD group [ M = 121.26, SD = 27.974; t (37) = .031, p = .976]. The magnitude of the differences in the means was extremely small (eta squared = .00003). Internalizing Problems Composite Subscale The Internalizing Problems co mposite subscale of the BASC-2 asks students to rate themselves for such content areas as locus of c ontrol, social stress, sense of inadequacy and depression. High self-reported scores on the In ternalizing Problems composite subscale are indicative of a pattern of overall emotional diffi culties and inwardly directed distress (Reynolds & Kamphaus, 2004). For the Internalizing Probl ems composite subscale Self-Report Forms, there was no significant difference be tween scores for the normal group ( M = 297.45, SD = 36.523) and the APD group [ M = 309.16, SD = 36.090; t (37) = -1.006, p = .321]. The effect sizes of the differences in the means was small (eta squared = .027). Inattention/Hyperactivity Composite Subscale The Inattention/Hyperactivity composite subscale of the BASC-2 asks students to rate their behaviors for such difficulties as being too noisy and difficulty standing still. High self-reported scores on this composite subscale are indicative of a pattern of overall impulsivity and attention difficulties, and may warrant further evaluation considering the possibility of an Attention Deficit Disorder or Attention Deficit/H yperactivity Disorder diagnosis. For the Inattention/Hyperactivity composite subscale Self-Report Forms, there was no difference between scores for the normal group ( M = 97.50, SD = 14.870) and the APD group [ M = 102.11, SD = 17.355; t (37) = -.891, p = .378]. The magnitude of the differences in the means was small (eta squared = .021).

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60 Emotional Symptoms Index Subscale The Emotional Symptoms Index subscale of the BASC-2 combines content items from both the Internalizing Problems a nd Personal Adjustment composite subscales and is specific to the Self-Report forms of the BASC -2. Content areas include sense of inadequacy, social stress, anxiety, depression, self-relian ce and self-esteem. High self-re ported scores on the Emotional Symptoms Index composite subscale can be indica tive of a global pattern of serious broad-based emotional disorders (Reynolds & Kamphaus, 2004). There was a significant difference between the normal group ( M = 274.10, SD = 25.805) and the APD group [ M = 294.47, SD = 32.404; t (37) = -2.071, p = .045]. The magnitude of the differences in the means was moderate (eta squared = .158). As the mean for the APD gr oup exceeded that of the normal group, statistical analysis indicates greater reported em otional problems for the APD group. Personal Adjustment Composite Subscale The Personal Adjustment composite subscale of the BASC-2 includes content areas that assess behaviors which may lead to positive outco mes, such as self-acceptance and social support. Low self-reported scores on the Person al Adjustment subscale may suggest poor peer or parental relati onships, and poor coping strategies. For this subscale, there was no difference between scores for the normal group ( M = 211.60, SD = 23.270) and the APD group [ M = 202.00, SD = 31.050; t (37) = 1.006, p = .280]. The effect sizes of the differences in the means was small (eta squared = .031). Parent-Completed Dartmouth Primary Care C ooperative Information Project Charts for Adolescents (COOP-A) For the COOP-A, the parents were asked to respond to each chart according to their perception of their participating childs function in each given area. Each individual chart of the COOP-A given to the parents was identical to thos e given to their children, and acts as its own

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61 subscale screener. Parents were asked to comp lete their ratings on th e COOP-A independently via paper and pencil format, but were encouraged to ask questions of the investigator if any item was unclear. Ratings for each chart are based on a five-point Likert scal e wherein 1 represents the least dysfunction and 5 repres ents the greatest dysfunction in any given area. The MannWhitney U test for non-parametric data was utili zed in order to compare Sum of Ranks for all subscale charts on the COOP-A due to the ordinal nature of the data, and r-square values were calculated to assess effect sizes (Rosenthal 1991). Additionally, chi-square tests for independence were conducted between groups on the proportion of Average or At-Risk classifications for each subscale chart, with statistical significance defined by p < 0.05 (twotailed) for the Pearson chi-square values. See Table 4-11 for a summary table of findings for proportions of students that parent s consider to be At-Risk fr om both groups for each subscale chart. Physical Fitness Subscale Chart Results for the Physical Fitness subscale ch art for the COOP-A s uggested that parents perceived no statistically significan t difference between the two groups ( p = .986). The effect size was very small (r2 < .0005). The mean ranks were 19.03 and 18.97 for the normal and APD groups, respectively. The Pear son chi-square value was .677, confirming no statistically significant difference for the proportion of particip ants classified as Average or At-Risk between the APD and normal groups. Pain Subscale Chart Results for the Pain subscale chart suggested a significant difference between the parental ratings for the APD group and the normal group ( p = .032), with a moderate effect size (r2 = .125). Recall that with the Mann-Whitney U for th e COOP-A if there is a significant difference in results, the group with the greater mean rank represents the group with greater parental reports

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62 of psychosocial difficulties in their children for that subscale. The mean rank for the normal group was 15.28 and the mean rank for the APD group was 22.53, indicating greater parental reports of pain for the children in the APD group. The Pearson chisquare value was .004, indicating the parents reported a significant difference for the proportion of participants classified as Average or At-Risk between the APD and normal groups. Additional review indicates there to be 94.4% of th e normal group parent ratings in the Average category versus 52.6% of the APD group, and 5.6% of the normal gr oup ratings falling in the At-Risk category versus 47.4% of the APD group parent ratings. Based on these findings, more parents of children within the APD group rate their childre n as At-Risk for problems with pain than parents of students in the normal group. Stress Subscale Chart Results of the parent-completed Stress subsca le chart of the COOP-A suggested that no difference exists between the two groups ( p = .151). In contrast to this non-significant finding, the effect size was moderate (r2 = .056), and the mean ranks were 16.61 and 21.26 for the normal and APD groups, respectively. The effect size in dications suggest a tren d for the parents of participants in the APD group to rate their children as having mo re difficulties with stress than their counterparts in the normal group. The Pearson chi-square value was .219, however, suggesting no difference for the proportion of par ticipants classified as Average or At-Risk between the APD and normal groups. Recall that this apparent discrepancy between the chisquare statistic and the effect size is possible because the r-squar ed calculation is based on the ranks of the ratings for each group, and so may di ffer from the nominal analysis that the Pearson chi-square value provides.

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63 School Work Subscale Chart Findings for the School Work subscale chart su ggested a significant difference between the parental reports for the APD group and the normal group ( p = .033), with a moderate effect size (r2 = .122). The mean rank for the normal group was 15.39 and the mean rank for the APD group was 22.42, indicating greater parental reported difficulties for the APD group on the School Work subscale. However, the Pearson chi-squa re value was .238, suggesting no difference exists for the proportion of participan ts classified as Average or At-Risk for the School Work subscale chart between groups. Again, the discrepanc ies between the categorical analysis and the ordinal analyses may be explained by the nature of the data that is being analyzed here. Emotional Feelings Subscale Chart The Emotional Feelings subscale chart of the COOP-A asks the question, During the past month, how often did you feel anxious, depressed, irritable, sad or downhearted and blue? There was a difference between parental ra tings of the APD group and the normal group ( p = .023), with a large effect size (r2 = .140). The mean rank for the normal group was 15.56 and the mean rank for the APD group was 22.26, indicating greater parent-reported difficulties on the Emotional Feelings subscale fo r the children in the APD group. In contrast to these MannWhitney U findings, the Pearson chi-square valu e was .087, suggesting no difference exists for the proportion of participants classified as A verage or At-Risk between the APD and normal groups. Behavior Subscale Chart Results for the Behavior subscale chart of the COOP-A suggested no difference between the two groups for this subscale ( p = .159). In contrast to this non-significant finding, the effect size was moderate (r2 = .054), and the mean ranks were 16.89 and 21.00 for the normal and APD groups, respectively. The effect si ze indications suggest a trend for the parents of participants in

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64 the APD group to rate their child ren as having more difficultie s with behavior than their counterparts in the normal group. The Pearson chi-square value was .157, however, suggesting no difference for the proportion of participants pa rent ratings classified as Average or AtRisk for the Behavior subscale char t between the APD and normal groups. Social Support Subscale Chart For the Social Support subscale chart, there wa s no difference between parental ratings of the APD group and the normal group ( p = .325), with a small effect size (r2 = .026). The mean rank for the normal group was 17.50 and the mean rank for the APD group was 20.42. The Pearson chi-square value was .324, suggesting no difference for the propor tion of participants classified as Average or At-Risk per pa rent ratings between the APD and normal groups. Self-Esteem Subscale Chart Results of the parent-completed Self-Esteem subscale chart of the COOP-A suggested no difference between the two groups for this subscale ( p = .054) though a trend was evident. The mean rank for the normal group was 15.75 and the mean rank for the APD group was 22.08, suggesting a non-statistically signi ficant trend toward greater pare nt-reported difficulties on the Self-Esteem subscale chart for th e children in the APD group. The magnitude of the differences between mean ranks was moderate (r2 = .100). Lending additional support to the weight of this trend, the Pearson chi-square value was .009, indi cating a significant difference exists for the proportion of participants classified as Average or At-Risk per parent al ratings between the APD and normal groups. Further review indicates there to be 100% of the normal group ratings falling in the Average category versus 68.4% of the APD Group, and 0% of the normal group ratings falling in the At-Ri sk category versus 31.6% of the APD group. These findings indicate that a higher proportion of parents of students in the APD group rate their children as At-Risk for problems with self esteem than do parents of students in the normal group.

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65 Family Subscale Chart For the Family subscale chart, there was no difference between the parent ratings of the APD group and the parent ra tings of the normal group ( p = .694), with a very small effect size (r2 = .004). The mean rank for the normal group was 18.33 and the mean rank for the APD group was 19.63. The Pearson chi-square value was .331, suggesting no difference for the proportion of participants classified as Average or At-Risk per pare nt ratings between the APD and normal groups on the Family subscale chart. Health Habits I Results for the Health Habits I subscale ch art suggested no difference between parental ratings of the APD group and the normal group ( p = 1.000). The mean rank was 19.00 for both the normal and APD groups. The Pearson chi-sq uare value could not be determined as all ratings for both groups were constant within the Average classification. Overall Health Subscale Chart For the Overall Health subscale, there was no difference between the pa rent ratings of the APD group and the parent ra tings of the normal group ( p = .122). In cont rast to this nonsignificant finding, the eff ect size was moderate (r2 = .065), and the mean ranks were 16.47 and 21.39 for the normal and APD groups, respectively. The effect size indications suggest a trend for the parents of participants in the APD group to rate their children as having poorer overall health than their counterparts in the norma l group. The Pearson chi-square value was .316, however, suggesting no significant difference for the proportion of partic ipants that parent ratings classified as Average or A t-Risk between the APD and normal groups. Energy Subscale Chart For the Energy subscale chart of the COOP -A, there was no difference between the parental ratings of the two groups for this subscale ( p = .585), with a very small effect size (r2 =

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66 .008). The mean ranks were 19.86 and 18.18 for the normal and APD groups, respectively. The Pearson chi-square value was .316, suggesting no difference for the propor tion of participants that parent ratings classified as Average or At-Risk between the APD and normal groups. Social Skills Rating Syst em (SSRS), Parent Forms The items on the Parent Forms of the SSRS are rated on a three-point Likert scale according to parent observed frequency of soci al behavior occurrence, where Never = 0, Sometimes = 1, and Very Often = 2. The four subscales incorporated into the Social Skills domain for the Parent Forms (Elementary and Secondary Level) of the SSRS measure positive social behaviors, with higher rati ngs indicating greater pa rent-perceived social skill. The four Parent Form Social Skills subscales are Coopera tion, Assertion, Responsibili ty and Self-Control. The Problem Behaviors domain includes three subscales that measure behaviors which may negatively impact social skill development and function. Both the Elementary and Secondary Level Parent Forms of the SSRS include Extern alizing and Internalizing Problem Behavior subscales. Additionally, the Elementary Le vel Parent Form of the SSRS includes the Hyperactivity subscale in the Problem Behavior do main. Due to slight group differences in age, the Hyperactivity subscale of the Problem Behavior domain was not statistically examined in the present study. To assess differences between group mean ratings on the included Parent Form subscales of the Social Skill and Problem Behavior domains of the SSRS, independent-samples t -tests were conducted and eta-sq uared values were calculated. Cooperation Subscale The Cooperation subscale of the SSRS asks pare nts to rate how ofte n they believe their children complete social behaviors that are pr esented, such as: Keeps room clean and neat without being reminded. For the Cooperation subscale for the SSRS Parent Forms (combined Elementary and Secondary ratings), there was no difference between scores for the normal group

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67 ( M = 13.33, SD = 2.449) and the APD group [ M = 12.44, SD = 2.555; t (32) = 1.043, p = .305]. The magnitude of the differences in th e means was small (eta squared = .033). Assertion Subscale The Assertion subscale of the SSRS asks parents to rate how frequently they believe their children complete associated social behaviors, fo r example: Makes friends easily. Results for the Assertion subscale for the SSRS Parent Forms indicated no difference between scores for the normal group ( M = 16.00, SD = 2.574) and the APD group [ M = 16.00, SD = 2.82; t (32) < .0005, p = 1.000]. The effect size of the differences in the means was extremely small (eta squared < .0005). Responsibility Subscale The Responsibility subscale of the SSRS asks pa rents to rate how fre quently their children complete social behaviors that are presented, such as: Reports accidents to appropriate persons and Asks permission before using another family members property. There was a significant difference between the normal group ( M = 16.94, SD = 1.924) and the APD group [ M = 14.78, SD = 3.173; t (28.016) = 2.477, p = .020]. The magnitude of the differences in the means was large (eta squared = .158). Recall that within the Social Skills do main of the SSRS, if there is a significant difference, the group with the lowe r mean rank represents the group with fewer parentally-reported social skills for the associated subscale. As the mean for the normal group exceeded that of the APD group, statistical analysis indicates greater reported social skills on the Responsibility subscale for the normal group. Self-Control Subscale The Self-Control subscale of the SSRS asks pa rents to rate how frequently they believe their children complete associated social behavi ors, for instance: Respon ds appropriately when hit or pushed by other children. For the Self-Cont rol subscale of the SSRS Student Forms, there

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68 was no difference between scores for the normal group ( M = 16.11, SD = 2.494) and the APD group [ M = 14.67, SD = 2.590; t (34) = 1.704, p = .097]. However, the effect size of the differences in the means was moderate (eta squa red = .079), suggesting a tr end in the data that parents reported the children in the APD group to have fewer self-control social skills than the children in the normal group. Externalizing Problem Behavior Subscale The Externalizing Problem Behavior subscale of the SSRS asks parents to rate how frequently their children complete behaviors that may interfere with social skills performance, such as: Gets angry easily and Fights with others. There was a difference between the normal group ( M = 2.00, SD = 1.749) and the APD group [ M = 3.22, SD = 1.768; t (34) = -2.085, p = .045]. The magnitude of the differences in th e means indicated a moderate effect size (eta squared = .113). Recall that within the Problem Behaviors domain of the SSRS, if there is a significant difference, the group with the lowe r mean rank represents the group with fewer parentally-reported negative behaviors for the as sociated subscale. The mean for the APD group exceeded that of the normal gr oup, with statistical analysis indicating greater reported externalizing problem behaviors on this subscale for the APD group. Internalizing Problem Behavior Subscale The Internalizing Problem Behavior subscale of the SSRS asks parents to rate how frequently their children exhibi t behaviors such as anxiety, sa dness and poor self-esteem that may interfere with social skills performance. Example items included in Parent Forms for this subscale are: Appears lonely and Acts sad or depressed. There wa s a significant difference between the normal group ( M = 2.50, SD = 1.790) and the APD group [ M = 4.33, SD = 2.425; t (34) = -2.580, p = .014]. The magnitude of the differences in the means indicated a large effect size (eta squared = .164). As the mean for the APD group exceeded that of the normal group,

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69 statistical analysis indicates th at parents reported increased in ternalizing problem behaviors on this subscale for the APD group. Behavioral Assessment System for Children -Second Edition (BASC-2), Parent Rating Scales The items on the Parent Rating Composite Scales of the BASC-2 are rated on a four-point Likert scale according to self-reported frequency of Never, Sometimes, Often, or Almost Always. The four composite subscales of the BASC-2 that are incorporated into the Parent Rating Scales utilized (both th e PRS-Child and the PRS-Adolescen t) are Externalizing Problems, Internalizing Problems, Behavioral Symptoms Index, and Adaptive Sk ills. To assess differences between group mean parental ratings on the co mposite subscales of the BASC-2, independentsamples t -tests were conducted and eta-squa red values were calculated. Externalizing Problems Composite Subscale The Externalizing Problems com posite subscale of the BASC-2 asks parents to rate their childs behaviors for the following content areas: hyperactivity, aggression, and conduct problems. High scores on the Externalizing Prob lems composite subscale are indicative of parental perceptions of obvious disruptive behavi ors in their children. For the Externalizing Problems composite subscale, there was a signifi cant difference between scores for the normal group ( M = 134.22, SD = 13.524) and the APD Group [ M = 151.50, SD = 19.518; t (34) = -3.087, p = .004]. The magnitude of the differences was large (eta squared = .219 ). The mean of the APD group exceeded that of the normal group, indicating greater parental reports of externalizing problem behaviors fo r the children in the APD group. Internalizing Problems Composite Subscale The Internalizing Problems co mposite subscale of the BASC-2 Parent Rating Scales asks parents to rate their children fo r such content areas as anxiety, depression and somatization. As

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70 with the Self-Report forms, high scores for th e Internalizing Problems composite subscale are indicative of a pattern of inwardly directed di stress. For the Interna lizing Problems composite subscale Parent Rating Scales, scores for the normal group ( M = 136.83, SD = 12.491) and the APD group [ M = 167.22, SD = 31.454; t (34) = -3.810, p = .001] differed. The magnitude of the differences was large (eta squared = .299). As the mean for the APD group exceeded that of the normal group, statistical analysis indicates that parents reported increased internalizing problem behaviors on this subscale for the APD group. Behavioral Symptoms Index Subscale The Behavioral Symptoms Index subscale of the BASC-2 is specific to the Teacher and Parent Rating Scales of the BASC-2. Cont ent areas include: Hype ractivity, Aggression, Depression, Atypicality, Withdrawal and Attention Problems. Hi gh ratings on this subscale may be indicative of a global pattern of psychosocia l problem behaviors. There was a significant difference between the normal group ( M = 270.78, SD = 25.316) and the APD group [ M = 320.33, SD = 40.359; t (28.584) = -4.413, p < .0005]. The magnitude of the differences was very large (eta squared = .364). The mean for the APD group exceeded that of the normal group, and statistical analysis confirmed gr eater parental reports of psychos ocial problem behaviors for the APD group. Adaptive Skills Composite Subscale The Adaptive Skills composite subscale of th e BASC-2 includes content areas that assess behaviors which may lead to positive outcomes, such as leadership, communication skills and emotional expression. Low parent al ratings on this subscale ma y suggest poor adaptability and coping strategies, inappropriate so cial interactions, or difficulty with activities of daily living. For the Adaptive Skills composite subscale, there was a significant difference between scores for the normal group ( M = 260.94, SD = 22.784) and the APD group [ M = 237.06, SD = 32.809;

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71 t (34) = 2.537, p = .016]. The magnitude of the differen ces was large (eta squared = .159). Examination of the means reveals that the mean of the APD group was lower than that of the normal group, indicating parental reports of lowe r adaptive skills for th e children in the APD group. Summary of Statistically Signif icant Findings Across Instruments In summary, three of twenty-one subscales were found to have statistically significant different results upon comparison of the partic ipants in the APD group to those of the participants in the normal group, with the pa rticipants in the AP D group reporting greater psychosocial problems than thei r counterparts in the normal gr oup. The subscales that were found to be different were the Emotional Feelings and Overall Health subscales of the COOP-A, and the Emotional Symptoms Index of the BASC-2. Twelve of twenty-two subscales were found to have significantly different results for parental ratings between groups. Statistical comparison indicat ed differences for the Pain, School Work, Emotional Feelings and Self-Estee m subscale charts of the COOP-A, all four composite subscales of the BASC-2 (Externalizi ng Problems, Internalizing Problems, Behavioral Symptoms Index, and Adaptive Skills), and the Re sponsibility, Externalizing Problem Behaviors and Internalizing Problem Behavior s of the SSRS. Again, for all significant findings, parents of participants in the APD group reported more ps ychosocial problems for their children than did the parents of children in the normal group. A su mmary of significant findings for parent and participant ratings can be found in Table 4-9. Post-Hoc Analyses Post-hoc analyses were conduc ted in order to determine th e possible effects of age and gender on any statistically significan t findings or trends. Post-hoc analyses were also conducted between the language-impaired and language-nor mal subgroups of the APD group parental and

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72 self-ratings for all subscales on all three psychosocial question naires utilized, employing the same methods of statistical analysis repor ted for the between group (APD vs. Normal) examinations as previously detailed. Reported Psychosocial Function and Age COOP-A and age correlation results The analysis of age on the self-completed St ress subscale chart of the COOP-A yielded a Spearman rho value of .046, ( n = 39, p = .782), indicating no correlati on. The analysis of age on child-completed COOP-A Emotional Feeling su bscale yielded a Spearman rho value of -.003 ( n = 39, p = .986), indicating no correlation. The analys is of age on the ratings for the childcompleted COOP-A Overall H ealth subscale chart yielded a Spearman rho value of .299 ( n = 39, p = .064), indicating a small to medium pos itive correlation between increasing age and increasing self-reports of poor overa ll health. Statistical analysis of age on the parent-completed COOP-A Pain subscale chart Pain subscal e yielded a Spearman rho value of -.032, ( n = 37, p = .850), indicating no significant correlation. The an alysis of age on the parent-completed School Work subscale chart of the COOP-A yi elded a Spearman rho value of -.076, ( n = 37, p = .654), indicating no correlation. The analysis of age on parent-compl eted COOP-A Emotional Feeling subscale yielded a Spearman rho value of -.007 ( n = 37, p = .969), indicating no correlation. The analysis of age on the ratings for the parent -completed COOP-A Self-Esteem subscale chart yielded a Spearman rho value of -.240 ( n = 37, p = .153), indicating a sma ll correlation between increasing age and decreasing parental reports of self-esteem problems in their children. SSRS and age correlation results The analysis of age on the ratings for the pa rent-completed SSRS Responsibility subscale yielded a Pearsons r value of .534 ( n = 36, p = .001), indicating a strong correlation between increasing participant age and pare ntal reports of higher responsi bility skill levels in their

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73 children. The analysis of age on the parental ra tings for the Externalizing Problem Behaviors subscale of the SSRS yielded a Pearsons r value of -.294 ( n = 36, p = .082), indicating a small to medium correlation between increasing partic ipant age and parental reports of higher responsibility skill levels in th eir children. The analysis of age on the Internalizing Problem Behaviors subscale of the SSRS Parent Form indi cated a small negative correlation between the two variables ( r = -.098, n = 36, p = .569). These findings suggest a tr end for parents to rate their children as displaying fewer internalizing problem be haviors, such as anxiety or sadness, as they grow older. BASC-2 and age correlation results The analysis of age on the BASC-2 Self-R eport Emotional Symptoms Index composite subscale indicated no significant corr elation between the two variables ( r = -.021, n = 39, p = .899). The analysis of age on the Externalizi ng Problems composite subscale of the BASC-2 Parent Rating Scales indicated no statistically significant correlation between the two variables ( r = -.086, n = 36, p = .616). The analysis of age on the Internalizing Problems composite subscale of the BASC-2 Parent Rating Scal es indicated no statistically significant correlation between the two variables ( r = -.014, n = 36, p = .934). The analysis of age on the BASC-2 Parent Rating Scales Behavioral Symptoms Index composite subscale indicated a sma ll correlation between the two variables ( r = -.123, n = 36, p = .473). These findings suggest a trend for parents to rate their children as having fewer nega tive behavioral symptoms as they grow older. The analysis of age on the BASC-2 Parent Rating Scales Adapti ve Skills composite subscale indicated a small positive correlation between the two variables ( r = -.148, n = 36, p = .387). These findings suggest a trend for parents to ra te their children as having more positive adaptive skills, such as coping or communication skills, as they grow older.

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74 Summary of age correlation results across instruments In summary, there were a few correlations associated with age across the various significant findings of the psyc hosocial subscales. On the CO OP-A, there was a moderate correlation for children to report lower overall he alth as they advanced in age, and a small correlation between increasing age of the child an d decreasing parental reports of self-esteem problems in their children. On the BASC-2, th ere were small correlations associated with parents reporting fewer negative behavioral symptoms and increas ed adaptive skills as their children grew older. And on the SSRS, there was a small negative correlation for parental reports of internalizing problems, a small to moderate negative corr elation for parental reports of externalizing problems, and a strong positive correlation for parental reports of greater responsibility skills for older ch ildren. A summary of all correlation findings for the various psychosocial subscales assessed may be found in Table 4-12. Reported Psychosocial Function and Gender COOP-A and gender comparison of mean rank results No statistically significant findings for gender differences were observed for any of the examined COOP-A subscales. Results on the child-completed Stress subscale chart yielded p = .866, the Emotional Feelings subscale chart yielded p = .647, and the Overall Health subscale chart yielded p = .424. Results on the parent-compl eted Pain subscale chart yielded p = .545, the School Work subscale chart yielded p = .803, the Emotional Feelings subscale chart yielded p = .562, and the Self Esteem subscale chart yielded p = .960. SSRS and gender comparison of means results Results on the Responsibility subscale of the SSRS Parent Forms yielded p = .548, the Externalizing Problem Be haviors subscale yielded p = .873, and the Internalizing Problems

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75 Behaviors subscale yielded p = .540. No significant findings for gender differences were observed for any of the examined SSRS subscales. BASC-2 and gender comparison of means results No significant gender differences were obs erved for any of the BASC-2 composite subscales of interest. Results on the self-report Emotional Sy mptoms Index composite subscale yielded p = .632. The BASC-2 Parent Report forms Externalizing Prob lems, Internalizing Problems, Behavioral Symptoms Index and Ad aptive Skills composite subscales yielded p = .210, p = .783, p = .460, and p = .110, respectively. Summary of gender analyses results across instruments To summarize, no gender differences were obser ved for any of the subscales of interest. A summary of all p -values on gender for the various psychos ocial subscales assessed is found in Table 4-13. Comparisons Between Language-Normal a nd Language-Impaired Subgroups with APD Preliminary analyses were completed to determine if any statistically significant differences existed between the language-imp aired and language-normal APD subgroups on age or gender. Results indicated that there was no significant difference between age for the language-normal subgroup ( M = 12.20, SD = 1.865) and the language-impaired APD group [ M = 11.69, SD = 2.352; t (17) = .517, p = .612]. A chi-square test for independence was conducted between the two APD subgroups on the proportion of males and females, with statistical significance defined by p < 0.05 (two-tailed) for the Pearson ch i-square values. No significant difference on gender was found ( 2 = .498, n = 19). Statistical significance levels were not reache d for any of the parentor child-completed instrument subscales, suggesting comparable psychosocial functi on across content areas for the children with and without language impairment w ho have APD. See Tables 4-14 and 4-15 for a

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76 summary of statistical results between APD linguistic subgroups for participants and their parents, respectively.

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77 Table 4-1: Number of subject s in the APD and normal gr oups for various demographic characteristics. APD Group ( n = 19) Normal Group ( n = 20) Gender Male 9 6 Female 10 14 Age (in years) Mean 11.93 12.79 Range 9.6.8 9.6-16.9 Grade Level 4 3 2 5 7 4 6 4 2 7 2 2 8 1 4 9 0 2 10 0 1 11 2 2 12 0 1 Language Disorder Normal 10 20 Impaired 9 0 Type of School Public 9 7 Private 8 8 Home 2 5

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78 Table 4-2: Mean pure-tone air-conduction thresholds ( M ) and standard deviations (s.d.) acros s frequencies for each ear (RE = right ear; LE = left ear) of both groups. Frequency (Hz) 250 500 1000 2000 3000 4000 6000 8000 Ear RE LE RE LE RE LE RE LE RE LE RE LE RE LE RE LE APD group M 7.8 6.6 7.5 6.3 6.6 7.5 4.4 4.1 2.2 2.8 4.1 4.4 4.6 5.0 4.1 2.8 s.d. 5.0 4.7 4.0 6.1 4.9 4.0 6.4 5.2 5.8 6.3 5.5 6.4 6.0 6.5 8.4 9.9 Normal group M 6.9 7.2 5.6 5.3 5.0 6.4 4.4 5.8 2.2 1.9 2.8 3.9 4.1 2.6 4.2 3.3 s.d. 5.6 3.5 5.8 4.9 4.6 4.1 4.4 5.0 4.2 5.1 6.1 4.3 6.6 5.8 6.8 6.7

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79 Table 4-3: Mean tympanometric data for APD and normal groups. APD Group ( n = 19) Normal Group ( n = 20) Right Ear Left Ear Right Ear Left Ear Ear Canal Volume (cm3) 1.10 1.10 1.24 1.22 Peak Pressure (daPa) 3.55 1.32 14.50 5.75 Static Compliance (ml) 0.65 0.66 0.80 0.78

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80 Table 4-4: Number of participan ts 2 standard deviations or more below mean on assessments used in the APD test battery for both the APD and normal groups. APD Group ( n = 19) Normal Group ( n = 20) Staggered Spondaic Word test 17 3 Dichotic Digits, Double Pairs 8 0 Frequency Pattern Sequence test 14 1 Duration Pattern Sequence test 16 1 Random Gap Detection test 7 0 Synthetic Sentence I ndex: Ipsilateral Competing Message 6 0 SCAN: Auditory Figure-Ground Subtest 5 0 SCAN: Competing Words Subtest 5 0 SCAN: Filtered Words Subtest 0 0 Auditory Continuous Performance Test 0 0

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81 Table 4-5: Mean ranks ( m ) and sum of ranks ( U ) for the COOP-A and means ( M ) and standard deviations (s.d.) for the SSRS and BASC-2 for childrens psychosocial self-reports ratings for the APD group and the normal group. ______________________________________________________________________________ Children's Self-Reports Scale Subscale APD group Normal group COOP-A m U m U Physical Fitness 18.68 355.00 21.25 425.00 Pain 21.76 413.50 18.33 366.50 Stress 22.58 429.00 17.55 351.00 School Work 22.58 429.00 17.55 351.00 Emotional Feelings 24.34 462.50 15.88 317.50 Behavior 21.89 416.00 18.20 364.00 Social Support 22.74 432.00 17.40 348.00 Self-Esteem 22.26 423.00 17.85 357.00 Family 21.71 412.50 18.38 367.50 Health Habits I 19.50 370.50 20.48 409.50 Overall Health 23.66 449.50 16.53 330.50 Energy 17.92 340.50 21.98 439.50 BASC-2 M s.d. M s.d. School Problems 121.26 27.974 121.55 30.490 Internalizing Problems 309.16 36.090 297.45 36.523 Emotional Symptoms Index 293.47 32.404 274.10 25.805 Inattention/Hyperactivity 102.11 17.355 97.50 14.870 Personal Adjustment 202.00 31.050 211.60 23.270 SSRS M s.d. M s.d. Cooperation 14.68 2.451 15.53 2.695 Assertion 14.84 2.035 13.95 3.677 Empathy 16.47 2.435 16.45 2.743 Self-Control 11.89 2.865 12.80 3.270 ______________________________________________________________________________

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82 Table 4-6: Statistical findings for childrens psychosocial self-reports. ______________________________________________________________________________ Children's Self-Reports Scale Subscale t -value df Z -value p Effect Size COOP-A r -sq Physical Fitness n/a n/a -0.812 0.417 0.017 Pain n/a n/a -0.996 0.319 0.025 Stress n/a n/a -1.458 0.145 0.055 School Work n/a n/a -1.509 0.131 0.058 Emotional Feelings n/a n/a -2.533 0.011* 0.165 Behavior n/a n/a -1.125 0.261 0.032 Social Support n/a n/a -1.615 0.106 0.067 Self-Esteem n/a n/a -1.315 0.189 0.044 Family n/a n/a -0.961 0.336 0.024 Health Habits I n/a n/a -0.975 0.330 0.024 Overall Health n/a n/a -2.082 0.037* 0.111 Energy n/a n/a -1.227 0.220 0.039 BASC-2 eta-sq School Problems 0.031 37 n/a 0.976 0.00003 Internalizing Problems -1.006 37 n/a 0.321 0.027 Emotional Symptoms Index -2.071 37 n/a 0.045* 0.104 Inattention/Hyperactivity -0.888 37 n/a 0.378 0.378 Personal Adjustment 1.096 37 n/a 0.280 0.280 SSRS eta-sq Cooperation 1.008 36 n/a 0.320 0.026 Assertion -0.943 29.94 n/a 0.353 0.023 Empathy -0.028 37 n/a 0.977 0.00002 Self-Control 0.917 37 n/a 0.367 0.022 ______________________________________________________________________________ *= p < 0.05

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83 Table 4-7: Mean ranks (m) and sum of ranks (U) for the COOP-A and means (M) and standard deviations (s.d.) for the SSRS and BASC-2 for parental psychosocial ratings for the APD group and the normal group. ______________________________________________________________________________ Parental Reports Scale Subscale APD group Normal group COOP-A m U m U Physical Fitness 18.97 360.50 19.03 342.50 Pain 22.53 428.00 15.83 275.00 Stress 21.26 404.00 16.61 299.00 School Work 22.42 426.00 15.39 277.00 Emotional Feelings 22.26 423.00 15.56 280.00 Behavior 21.00 399.00 16.89 304.00 Social Support 20.42 388.00 17.50 315.00 Self-Esteem 22.08 419.50 15.75 283.50 Family 19.63 373.00 18.33 330.00 Health Habits I 19.00 361.00 19.00 342.00 Overall Health 21.39 406.50 16.47 296.50 Energy 18.18 345.50 19.86 357.50 BASC-2 M s.d. M s.d. Externalizing Problems 151.50 19.518 134.22 13.524 Internalizing Problems 167.22 31.454 136.83 12.491 Behavioral Symptoms Index 320.33 40.359 270.78 25.316 Adaptive Skills 237.06 32.809 260.94 22.784 SSRS M s.d. M s.d. Cooperation 12.44 2.555 13.33 2.449 Assertion 16.00 2.828 16.00 2.574 Responsibility 14.78 3.173 16.94 1.924 Self-Control 14.67 2.590 16.11 2.494 Externalizing Problem Behaviors 3.22 1.768 2.00 1.749 Internalizing Problem Behaviors 4.33 2.425 2.50 1.790 ______________________________________________________________________________

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84 Table 4-8: Statistical findings for parent psychosocial reports. ______________________________________________________________________________ Parental Reports Scale Subscale t -value df Z -value p Effect Size COOP-A r-sq Physical Fitness n/a n/a -0.017 0.976 0.000 Pain n/a n/a -2.151 0.032* 0.125 Stress n/a n/a -1.437 0.151 0.056 School Work n/a n/a -2.126 0.033* 0.122 Emotional Feelings n/a n/a -2.279 0.023* 0.140 Behavior n/a n/a -1.408 0.159 0.054 Social Support n/a n/a -0.985 0.325 0.026 Self-Esteem n/a n/a -1.927 0.054 0.100 Family n/a n/a -0.393 0.694 0.004 Health Habits I n/a n/a 0.000 1.000 0.000 Overall Health n/a n/a -1.548 0.122 0.065 Energy n/a n/a -0.546 0.585 0.008 BASC-2 eta-sq Externalizing Problems -3.087 34 n/a 0.004* 0.219 Internalizing Problems -3.810 22.23 n/a 0.001* 0.299 Behavioral Symptoms Index -4.413 28.58 n/a 0.000* 0.364 Adaptive Skills 2.537 34 n/a 0.017* 0.159 SSRS eta-sq Cooperation 1.043 32 n/a 0.305 0.033 Assertion 0.000 32 n/a 1.000 0.000 Responsibility 2.477 28.01 n/a 0.020* 0.158 Self-Control 1.704 34 n/a 0.097 0.079 Externalizing Problem Behaviors -2.085 34 n/a 0.045* 0.113 Internalizing Problem Behaviors -2.580 34 n/a 0.014* 0.164 ______________________________________________________________________________ = p < 0.05

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85 Table 4-9: Compiled statistically significant ( p < 0.05) findings across psychosocial scales for children and parents. Children's Self-Reports Scale Subscale t -value df Z -value p Effect Size COOP-A r-sq Emotional Feelings n/a n/a -2.533 0.011 0.165 Overall Health n/a n/a -2.082 0.037 0.111 BASC-2 eta-sq Emotional Symptoms Index -2.071 37 n/a 0.045 0.104 Parental Reports Scale Subscale t -value df Z -value p Effect Size COOP-A r-sq Pain n/a n/a -2.151 0.032 0.125 School Work n/a n/a -2.126 0.033 0.122 Emotional Feelings n/a n/a -2.279 0.023 0.140 BASC-2 eta-sq Externalizing Problems -3.087 34 n/a 0.004 0.219 Internalizing Problems -3.810 22.23 n/a 0.001 0.299 Behavioral Symptoms Index -4.413 28.58 n/a 0.000 0.364 Adaptive Skills 2.537 34 n/a 0.017 0.159 SSRS eta-sq Responsibility 2.477 28.02 n/a 0.020 0.158 Externalizing Problem Behaviors -2.085 34 n/a 0.045 0.113 Internalizing Problem Behaviors -2.580 34 n/a 0.014 0.164 ______________________________________________________________________________

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86 Table 4-10: At-risk (3-5 ratings ) findings on COOP-A by childrens self-reports by subscale chart for both groups. ______________________________________________________________________________ Subscale APD Normal Difference Significance % At Risk % At Risk % At Risk (Chi-Square) Physical Fitness 10.53 0.00 10.53 0.136 Pain 42.11 35.00 7.11 0.648 Stress 52.63 20.00 32.63 0.034* School Work 21.05 5.00 16.05 0.134 Emotional Feelings 31.58 10.00 21.58 0.095 Behavior 15.79 5.00 10.79 0.267 Social Support 15.79 5.00 10.79 0.267 Self-Esteem 26.32 10.00 16.32 0.184 Family 57.89 45.00 12.89 0.421 Health Habits I 0.00 0.00 0.00 constant Overall Health 42.11 15.00 27.11 0.060 Energy 47.37 70.00 -22.63 0.151 ______________________________________________________________________________ = p < 0.05

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87 Table 4-11: At-risk (3-5 ratings ) findings on COOP-A by parental reports by subscale chart for both groups. ______________________________________________________________________________ Subscale APD Normal Difference Significance % At Risk % At Risk % At Risk (Chi-Square) Physical Fitness 15.79 10.00 5.79 0.677 Pain 47.37 5.00 42.37 0.004* Stress 47.37 25.00 22.37 0.219 School Work 26.32 10.00 16.32 0.238 Emotional Feelings 26.32 5.00 21.32 0.087 Behavior 10.53 0.00 10.53 0.157 Social Support 5.26 0.00 5.26 0.324 Self-Esteem 31.58 0.00 31.58 0.009* Family 36.84 20.00 16.84 0.331 Health Habits I 0.00 0.00 0.00 constant Overall Health 15.79 5.00 10.79 0.316 Energy 26.32 35.00 -8.68 0.414 ______________________________________________________________________________ = p < 0.05

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88 Table 4-12: Summary of corre lation findings for age and st atistically significant ( p < 0.05) psychosocial subscales for children and parents. ______________________________________________________________________________ Children's Self-Reports Scale Subscale Correlation Statistic COOP-A Spearmans rho Emotional Feelings -0.003 Overall Health 0.299 ** BASC-2 Pearsons R Emotional Symptoms Index -0.021 Parental Reports Scale Subscale Correlation Statistic COOP-A Spearmans rho Pain -0.032 School Work -0.076 Emotional Feelings 0.007 Self-Esteem -0.240 BASC-2 Pearsons R Externalizing Problems -0.086 Internalizing Problems -0.014 Behavioral Symptoms Index -0.123 Adaptive Skills 0.148 SSRS Pearsons R Responsibility 0.534 *** Externalizing Problem Behaviors -0.294 ** Internalizing Problem Behaviors -0.098 Note: = small correlation, ** = modera te correlation, *** = strong correlation

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89 Table 4-13: Summary of findings for gender and statistically significant ( p < 0.05) psychosocial subscales for children and parents. ______________________________________________________________________________ Children's Self-Reports Scale Subscale p -value COOP-A Mann-Whitney U Emotional Feelings 0.647 Overall Health 0.424 BASC-2 t -test Emotional Symptoms Index 0.632 Parental Reports Scale Subscale p -value COOP-A Mann-Whitney U Pain 0.545 School Work 0.803 Emotional Feelings 0.562 Self-Esteem 0.960 BASC-2 t -test Externalizing Problems 0.210 Internalizing Problems 0.783 Behavioral Symptoms Index 0.460 Adaptive Skills 0.110 SSRS t -test Responsibility 0.548 Externalizing Problem Behaviors 0.873 Internalizing Problem Behaviors 0.540

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90 Table 4-14: Statistical findi ngs across psychosocial scales for childrens self-ratings in language-impaired versus la nguage-normal APD subgroups. ______________________________________________________________________________ Childrens Reports Scale Subscale t -value df Z -value p COOP-A Physical Fitness n/a n/a -0.698 0.485 Pain n/a n/a -1.462 0.144 Stress n/a n/a -0.723 0.470 School Work n/a n/a -1.232 0.218 Emotional Feelings n/a n/a -0.552 0.581 Behavior n/a n/a -0.315 0.753 Social Support n/a n/a -1.125 0.261 Self-Esteem n/a n/a -0.482 0.630 Family n/a n/a 0.000 1.000 Health Habits I n/a n/a 0.000 1.000 Overall Health n/a n/a -0.305 0.760 Energy n/a n/a -0.218 0.827 BASC-2 School Problems 1.525 17 n/a 0.146 Internalizing Problems 0.672 17 n/a 0.511 Emotional Symptoms Index 1.093 17 n/a 0.291 Inattention/Hyperactivity -1.113 17 n/a 0.281 Personal Adjustment -0.187 17 n/a 0.854 SSRS Cooperation -0.771 17 n/a 0.451 Assertion 0.536 17 n/a 0.599 Empathy 0.911 15.21 n/a 0.377 Self-Control 0.270 17 n/a 0.270

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91 Table 4-15: Statistical findings across psychosocial scales for pa rent ratings of children in language-impaired versus la nguage-normal APD subgroups. ______________________________________________________________________________ Parental Reports Scale Subscale t -value df Z -value p COOP-A Physical Fitness n/a n/a -0.414 0.679 Pain n/a n/a -0.588 0.556 Stress n/a n/a -0.611 0.541 School Work n/a n/a -0.087 0.930 Emotional Feelings n/a n/a -0.478 0.633 Behavior n/a n/a -0.185 0.853 Social Support n/a n/a -1.219 0.223 Self-Esteem n/a n/a -0.387 0.699 Family n/a n/a -0.256 0.798 Health Habits I n/a n/a 0.000 1.000 Overall Health n/a n/a -0.576 0.565 Energy n/a n/a -0.149 0.882 BASC-2 Externalizing Problems 1.399 16 n/a 0.181 Internalizing Problems 0.106 16 n/a 0.917 Behavioral Symptoms Index 0.734 16 n/a 0.473 Adaptive Skills 0.854 16 n/a 0.406 SSRS Cooperation -1.082 14 n/a 0.297 Assertion -0.334 15 n/a 0.743 Responsibility 0.405 16 n/a 0.691 Self-Control 1.449 16 n/a 0.167 Externalizing Problems Behaviors -0.466 16 n/a 0.648 Internalizing Problem Behaviors -0.127 16 n/a 0.901

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92 Figure 4-1: Mean audiometric re sults for right and left ears of participants in the APD and normal groups. 0 5 10 15 20 25 2505001000 20003000 40006000 8000 Frequency (Hz) dB HL Right ear APD Right ear Normal Left ear APD Left ear Normal

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93 Figure 4-2: Compiled Towson Univ ersity APD group DPOAE data with mean group data line in bold. Each line represents the DPOAE findings for each ear (RE or LE accordingly in legend label) for each participant (first tw o digits of legend la bel represent subject identification number) in the APD group.

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94 Figure 4-3: Compiled Towson University normal group DPOAE data with mean group data line in bold. Each line represents the DPOAE findings for each ear (RE or LE accordingly in legend label) fo r each participant (first two digits of legend label represent subject identificati on number) in the normal group.

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95 CHAPTER 5 DISCUSSION The purpose of this study was to examine the psychosocial status of children with APD, with an aim to increase the knowledge base of the community of professionals working with these children regarding possible non-auditory factors that ma y be influencing their quality of life. The investigation was desi gned to compare the selfand pa rent reports of children with APD to those of a genderand age-matched pe er group without APD on three psychosocial questionnaires (COOP-A, SSRS, and BASC-2). Thirty-nine children served as participants for this research study. APD was confirmed for nineteen participants enrolled in the experimental group, while twenty participants with no evidence of APD by formal assessment were enro lled in the normal group. Thirty-seven mothers of the participants served as parental raters (19 in the APD group and 18 in the normal group). Following a comprehensive diagnosti c evaluation of peripheral and central auditory function, as well as screening assessments of auditory atte ntion, language and intellectual function, the participants and their parent s were asked to complete th e COOP-A, BASC-2, and SSRS questionnaires. Statistical analyses were conducted via two-group comparison methods for ratings on the three instruments. Overall, the ma jor finding from this study is that children with APD exhibit psychosocial difficulties similar to or greater than childre n without APD. For several subscales of the psychos ocial instruments, findings for both the APD child and parent groups differed from those for the normal group. Childrens Self-Reported Psychosocial Status There were significant differences between gr oups on the participants self-completed Emotional Feeling ( p = .011) and Overall Health ( p = .037) subscales of the COOP-A, and the Emotional Symptoms Index for the BASC-2 ( p = .045), with the APD group reporting more

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96 difficulties than the normal group. Recall that the COOP-A is a sc reener, and each chart is its own subscale. In other words, the Emotional Feeling subscale is a single chart, and as such, received a single rating between 1 and 5. The COOP-A is very quick and its validity as a screener has been demonstrated. However, the COOP-A is only a screener, and does not hold the weight of more rigorous and t horough comprehensive assessments, such as the BASC-2 or the SSRS. Though the data from screeners should not be used to represent im portant qualities, the COOP-A was utilized in this study because previously published had suggested its appropriateness for use with children who had aud itory deficits, and because it was going to be used in combination with two other psychomet rically sound psychosocial assessments. Since there are only two subject groups one can simply examine and compare the mean ratings to determine the direction and inte rpretation of the findings. The mean ratings for the APD group were higher than the normal group for all significant subscales, indicating the children in the APD group reported more problems than the children without APD. The Emotional Symptoms index of the BASC-2 is specific to the childrens self-report version, that is, this index is not included in the parents version. It combines content items from both the Internalizing Problems and Personal Adjustment compos ite subscales, including areas such social stress, anxiety, de pression, and self-esteem. Hi gh self-reported scores on the Emotional Symptoms Index composite subscale can reflect a global patte rn of serious broadbased emotional disorders (Reynolds & Kampha us, 2004). Children who display APD are more likely to display negative emotional symptoms than normal children. This finding draws a parallel with the significant COOP-A finding on the Emotional Fe eling subscale chart, providing further evidence that the APD group reported more emotional symptoms than the normal group.

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97 For the three statistically significant subscal es based on childrens psychosocial reports, there was a large effect size (r2 = .165) for the Emotional Feelings subscale of the COOP-A. The Overall Health subscale chart of the COOP-A (r2 = .111) and the Emotional Symptoms Index of the BASC-2 (eta squared = .104) were characterize d by moderate effects. The strength of these effect sizes enhances the ability for their interpretation to be gene ralized to a larg er population of children in this age group with APD. An additional analysis of Average (ratings of 1 or 2) versus At-Risk (ratings of 3, 4 or 5) on the COOP-A responses was completed in order to determine th e proportion of children who would be identified as needing further foll ow-up on the particular content area represented by each subscale chart (Wasson et al., 1994). The reader is again directed to Table 4.7 and Figure 4.6 for summaries of findings for proportions of students considered At-Risk from both groups for each subscale chart. The only sta tistically significant difference was found in the Stress domain ( 2 = .034). The differences between the significant subscales found when utilizing the Mann-Whitney U procedures versus the chi-square analysis may be resolved by analyzing the inherent distinc tions between the two statistica l methods. The Mann-Whitney U test is evaluating mean rankings of the 1-5 ratin gs on the subscale charts, while the chi-square procedure works only with the nominal categories of Average or At-Risk. Therefore, on the Stress subscale chart, for example, the mean ranks were 17.55 and 22.58 for the normal and APD groups, respectively, and the Mann-Whitney U analysis suggested that no st atistically significant difference exists between the two groups for this subscale ( p = .145); however when broken down into the dichotomous nominal categories the chi-square analysis was significant ( 2 = .034) for a greater proportion of children w ith APD to be considered at-risk for problems in this area.

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98 Parental Perceptions of Psychosocial Status Statistically significant differences by parent report were found on subscales of all three psychosocial instruments utilized in the pres ent investigation: the Pain, School Work, and Emotional Feeling subscale charts of the COOP-A; the Externalizing Problems, Internalizing Problems, Behavioral Symptoms Index and Adaptiv e Skills Index subscales of the BASC-2; and the Responsibility, Externalizing Problem Beha viors and Internalizing Problem Behaviors subscales of the SSRS. The COOP-A was designed as a self-rating sc ale for use by pre-teens and adolescents when working with primary care physicians in th eir practices. Parents of subjects in this investigation, however, were asked to complete the COOP-A according to their perceptions of their childs psychosocial status for the various charts. These directions were also given to parents completing the COOP-A dur ing a pilot investigation of ps ychosocial characteristics of children with APD (Kreisman, Crandell & Hall, 2004), and they proved to be a useful modification. In the pilot study, parents tended to co rroborate their childrens self-perceptions. In the present investigation, findings suggest th at parents report more social and emotional difficulties for their children with APD than parents of the children with normal auditory abilities. Statistically significan t differences were found between groups with moderate to large effect sizes for the Pain ( p = .032, r2 = .125), School Work ( p = .032, r2 = .122), and Emotional Feeling subscale charts ( p = .032, r2 = .140 Pearson chi-square tests for independence on the proportion of Average (ratings of 1 or 2) versus At-Risk (ratings of 3, 4 or 5) responses on the COOP-A were again completed in order to determine the proporti on of children who would be id entified by their parents as potentially needing further follow-up in a par ticular content area. Statistically significant differences were found in the Pain ( 2 = .004) and Self-Esteem ( 2 = .009) domains. These

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99 findings once again indicate a great er tendency for parents of child ren with APD to report at-risk function for their children in these areas. On the comprehensive behavioral questionnaire the BASC-2, parents of children with APD reported significantly more problems for all four composite subscales. There were large effect sizes for all findings: Externalizing Problems ( p = .004), Internalizing Problems ( p = .001), Behavioral Symptoms Index ( p < .0005) and Adaptive Skills Index ( p = .017). Additionally, parents of children with APD re ported significantly more social skills difficulties for their children on the SSRS forms than parents of th e children in the normal group on 3 of the 6 subscales measured, with moderate to larg e effect sizes: Responsibility Skills ( p = .020), Externalizing Problem Behaviors ( p = .045), and Internalizin g Problem Behaviors ( p = .014). Taken in combination, these findings from pa rental reports on the three psychosocial instruments utilized in the study in dicate an overall pattern of pa rental concern regarding reduced emotional health status, poor or inappropriate be haviors, and difficult adaptations to school that their children may be experiencing. Interesti ngly, parents reported over three times as many significantly differing subscales as their children. Ther e may be several possible explanations for this difference in perceptions for children vers us parents. Could it be that the children with APD are underreporting their emotional and social problems? Or, are pare nts overly-sensitive to the difficulties of their children, and perh aps over-reporting difficulties? Educational audiologists and others who interact on a regul ar basis with children diagnosed with APD can attest to the frequent subjectiv e challenges, difficulties and de licacies involved with working with their parents, often much more so than the children themselves. Parents of children with APD can appear at times to be: demanding, judg mental, insensitive, overly-sensitive, anxious, depressed, overwhelmed, guilt-ridden, beleaguered, and fatigued. Could it be that part of the

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100 reason these parents may come across to professiona ls with any or all of the above traits is because they are reflecting some of the psychosoc ial problems they perceive their children to be experiencing? Language Function Status of the APD Group A somewhat unexpected findi ng uncovered on post-hoc anal ysis was the lack of statistically significant differen ces on any subscale between children in the APD group who had a confirmed or suspected language disorder ( n = 9) versus those with no evidence of language disorder ( n = 10). While interpretation of this negative finding s hould be guarded due to the small size of the subject sample, it suggests th at APD may impact psyc hosocial function of children more than other communication disorder s. In many ways, and to many professionals who work with children with communication disord ers, auditory processing would appear to be invariably linked with language function, and language function intr insically linked with psychosocial status. It is reasonable to assume that poor speech perception inevitably leads to disordered language reception or expression, poor reading or writing abilit ies, and a poor ability to effectively communicate and, therefore, that ps ychosocial function is similarly impacted by all of these disorders. However, the recent wo rk of Wible, Nicol and Kraus (2005), based on research with auditory evoked potentials, challenges the presumed correlation of brainstem and cortical auditory processing disorders with language-impair ment. That is, the connection between auditory processing and language function may not be as clear-cut or unambiguous as one might suspect. Limitations of this Study This study has several limitations. First a nd foremost, it cannot be overstated that the COOP-A, while an effective screening instrument for quality of life concerns in adolescents when used in primary care physicians offices, is not a psychometrically appropriate tool for

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101 research. Further, as the study pa rticipants and their parents were not blinded to the categories in which they were included, it is very possible that their answers to the items on the psychosocial questionnaires were influenced by their feelings regarding th eir group status. As the study participants were recruited in a voluntary fashion, with contact initiated by most of the parents of the children with APD due to their concerns about their childs comm unication status, their group type was typically known from the outset a nd a halo effect may have impacted their responses. The study may have stronger implicati ons if the parents and children participating could be blinded to their group status. Additi onally, all subscales were analyzed by two-tailed statistical analysis procedures. While the use of the two-tailed procedures helped in guarding against Type I errors and inflation of results, additionally significant findings on psychosocial may have been observed by utilizing a one-tailed statistical design for t hose psychosocial areas that were hypothesized to be poorer in children with APD. In additional to the design limitations, there were limitations regarding participants involved in the study as well. Da ta were collected and analyzed for a relatively small number of participants meeting the inclusi on criterion and available to the investigator when the study was conducted. While moderate to strong effect size s suggest that findings ca n be generalized to a larger population, statistical power would be greatly enhanced by a larger number of subjects. Also, due to the normative standards for the C OOP-A, no participant belo w the age of 10 years could be included in the study. As many ch ildren are referred for comprehensive APD evaluations in first, second or third grades, th e study would have more implications for school age children with APD if the age criterion coul d be stretched down as young as 7 years or even younger.

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102 In addition to these limitations, the present re search findings are rest ricted geographically to two essentially suburban college-town areas w ithin the eastern United States. Further, while socio-economic status (SES) was indirectly m onitored for consistency between groups, it was not overtly controlled, nor was ra cial or ethnic bac kground. Finally, the ab sence of father and teacher ratings limits the findings to those of the mothers and the participants themselves, leaving out two important observers who may ha ve remarkable viewpoints on the psychosocial status of these children. Clinical Implications The findings of this investig ation confirm that children with APD experience emotional and social difficulties of signifi cance when compared with thei r non-APD peers. Audiologists who provide diagnostic auditory processing evaluati ons need to be aware of, and to be able to provide informational counseling regarding, not only the communicative disorders associated with the diagnosis of APD, but also the psychos ocial difficulties that these children may be harboring. Additionally, audiologists should be ready and willing to provide appropriate nonprofessional personal adjustment counseling within their scope of practice for these children with APD and their families, or to refer patients and their parent s to appropriate professions for counseling. Just as English (2002) asserts that audiologists can and should be key professionals that may be able to help provide a safety net for children with hearing loss as they (and their parents) face challenges in their psychosocial an d emotional development (p. 15), so too should audiologists be able to provide similar support for comparable difficulties faced by children with APD. Indeed, as Sanders (1993) pointedly pronounces, audiology programs should be held accountable regarding thei r ability to provide services fo r the whole child with auditory difficulties, as It is the impact of the communica tion/learning handicap on the childs sense of self-worth and well-being that most severe ly limits the quality of his life (p. 373).

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103 Although the findings of the pres ent investigation suggest th at the COOP-A may provide for audiologists a clinically valuable and f easible measure of how a child with APD views his/her functional health across a broa d range of content area s, it should be reiterated that it is not suitable for use as a research tool on its own. The COOP-A may also be utilized by parents to report their perceptions of the same issues regard ing their childs quality of life. The COOP-A chart method is a quick, easy-to-u se screening tool that appear s to have validity for a brief indication of quality of life concerns in children aged 10 to 18 years with APD. In addition to a screening measure such as the COOP-A, audiolog ists should also consider the use of more rigorous psychosocial assessments such as the BA SC-2 or the SSRS with their patients, from which they may find outcomes in children with APD that may also warrant nonprofessional counseling follow-up by audiologists, or even su ggest referral for further evaluation and/or intervention by medical or psyc hological professionals. Future Research This study provides a springboard for much future research on the relation between psychosocial function and auditory processing disorders. Indee d, research is already underway by the author and colleagues to examine possible improvement in psychosocial function with the utilization of frequency modulati on (FM) assistive listening technol ogies. Determination of the impact of age of identification and/or age of intervention or re mediation on psychosocial status of children with APD is also needed. As the great majority (17 of 19) of experimental participants in the present inve stigation were formally diagnosed with APD within 6 months of their completion of this study, and none of th em were younger than 9.5 years at their time of participation, it is highly probable that the ps ychosocial difficulties they and their mothers reported had changed over time. Inter-reporter di fferences (especially parent versus child) could

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104 also be explored in future investigations to de termine effective strategies for accurately defining psychosocial status for children with APD. Possible differences in the psychosocial char acteristics of children with APD versus language impairment also require further investigation due to conflicting research findings, hypotheses and subjective reports concerning the link between aud itory processing and language. Futher elucidation of this relationship might be gained by evaluating the psychosocial status of children with a primary diagnosis of language impairment, as well as investigation of the various APD sub-categorizations (e.g. orga nizational deficits, integration deficits, auditory figure-ground deficits, temporal processing defi cits and decoding deficits).

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105 APPENDIX A APD PARENT/PATIENT SURVEY APD Parent/Patient Survey Patient Name: _____________________________________________________________ Date of Birth: _________________ Age: ________ Gender: ________ Parent Name: ______________________________________________________________ Address: _________________________________________________________________ Contact #: ____________________________ Referred by: _________________________ Please answer the following questions. We w ill review the responses on the date of the hearing evaluation. Yes No Maybe handedness? right or left (circle correct answer) easily distracted? ___ ___ ___ inattentiveness to sounds? ___ ___ ___ problems paying attention to sounds? ___ ___ ___ problem localizing where sound is coming from? ___ ___ ___ problems hearing in noise or when others are talking? ___ ___ ___ complains about loud sounds in the environment? ___ ___ ___ confuses directions or cant follow demands? ___ ___ ___ reverses words, numbers, letters, etc? ___ ___ ___ asks speakers to repeat (e.g. Says What? or Huh?)? ___ ___ ___ coordination problems? ___ ___ ___ Please continue on reverse side of sheet

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106 Yes No Maybe musically inclined? ___ ___ ___ ear infections as a child? ___ ___ ___ ventilation tubes inserted for ear infections? ___ ___ ___ noises in ear (e.g. seashore sound, ringing)? ___ ___ ___ If yes, examples: ___________________________ intensive care nursery after birth? ___ ___ ___ learning disability? ___ ___ ___ speech and/or language disorder? ___ ___ ___ attention deficit (hyperactivity) disorder (ADD/ADHD)? ___ ___ ___ If yes, treated with medication? ___ ___ ___ others in family with language/hearing problems? ___ ___ ___ How many hearing tests has your child had? (circle) 1 2 3 4 5 >5 Comments: __________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

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107 APPENDIX B UNIVERSITY OF FLORIDA INFORMED CONSENT FORM Date: Dear _______________________________: At present, various research projects are being conducted in the Department of Communication Sciences and Disorders at the University of Florida to help us better understand the communicative difficulties experi enced by individuals. I am a Clinical Professor at the University of Florida and would like to ask your cooperation in one such project: a study of how Frequency Modulation (FM) system s affect speech perception and emotional health in children with auditory processing difficulties. FM de vices consist of a microphone and a small speaker (s). The speakers voice, for example the teacher is sent via radio si gnal from the microphone to the speaker that is placed near the listener (the student). FM devices are commonly used in noisy environments to ensure optimal speech understanding. If you (and your child) consent to have your child be a participant in this investigation, your child will first be seen for a complete heari ng evaluation (listening to tones and words, and measurements of how the ear is functioning) either at the Depart ment of Communicative Disorders at Shands Hospital or the De partment of Communication Sciences and Disorder/University of Florida Speech and Heari ng Clinic at Dauer Hall. And you will be asked to complete a case history form. Such tests are routinely done at both facilities to help us determine if an individual has a hearing loss. Your child will then receive one or more auditory tests to determine how the brain is processing or using special t ypes of sounds, including words, sentences, and sequences of high and low pitch t ones. These tests are typically given to children to assess their abilities to process, or listen to, auditory information. Each of these tests will require your child to listen to tones or words presented in one or both ears. After the hearing and auditory proc essing tests, your child will then be seen at the Department of Communication Sciences and Disord ers at the University of Flor ida and asked to listen to sentences (Hearing in Noise Test-HINT) with a nd without use of a Frequency Modulation (FM) system. The words and sentences will be pres ented in quiet and in a background of noise. The noise will be as loud as no rmal conversational speech. Following these tests, you and your child will be given questionnaires [The Dartmouth Primary Care Cooperative Information Project Charts for Adolescents (COOP), The Behavioral Assessment System for Children, Second Edition (BASC-2), The Social Skills Rating System (SSRS), The Listening Inventory for Educati on (LIFE), and The Screener Instrument for Targeting Educational Risk (SIFTER)] that will help the investigators to understand how each child learns best and give us more information relating to thei r emotional and social health. The questionnaires will be presented in a face-to-face interview format whenever possible. Your child may either respond to the questions verbal ly, by marking their desire d response, or simply by pointing to their desired response. Auditory evoked cortical responses, such as th e Auditory Late Response and the P300, will be measured in participants who are fit with an FM system. Th is is necessary to document

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108 electrophysiological changes in au ditory processing of speech stim uli. These are completely non-invasive procedures in which brain activity is recorded in response to auditory stimuli. These measures are obtained routinely for diagnostic purposes in both of the participating speech and hearing centers. Your child will be at no risk during this experiment. All of the above procedures and instrumentation for this research are routinely used in clinical and/or rese arch procedures at the Department of Communication Sciences and Disorders and Department of Communicative Disorders. All procedures are c onsidered non-invasive in nature, in that there will be no sort of shots or other instruments used that will break or puncture th e skin. There should be minimal discomfort during this investigati on. All loudness levels used in this investigation are below the Occupational Safety & Health Administrati on (OSHA) allowable levels. OSHA is a governmental institution that re gulates loudness levels and prot ects individuals from suffering from noise induced hearing loss. Their allowabl e levels are 85 decibels and below for an 8 hour time period. Our noise testing level is conducte d at 65 decibels and ta kes less than 1 hour. In addition to the information obtained from th ese evaluations, whenever feasible and approved by the School Board of Alachua County the part icipants results on the Florida Comprehensive Assessment Test (FCAT) will be included in anal ysis of your childs academic performance. The FCAT is administered to students in Grad es 3-11. It consists of two basic components: criterion-referenced tests in mathematics, r eading, science, and writi ng, and norm-referenced tests in reading and mathematics. Performan ce of individual students is measured against national norms. Permission will be obtained from the Alachua County School Board prior to use of these test results. All test results and information obt ained from this investigation w ill be kept confidential to the extent provided by law. All forms and information pertaining to participants will be coded by an identification number. Names of participants will appear in a master roster to be kept only by myself. Upon completion of this investigation, the master rost er will be destroyed. In all probability, there will be publications and presentations of the results of this study. Most scientific reports and publications present results such as this in statistical form, and in some instances, case studies are presented. In either case, your childs identity will be kept confidential to the extent provided by law. You are free to withdraw your childs consent and discontinue participation at any time prior to completion of this investigation. Your childs participation or non-partic ipation will not affect any treatment or services you are receiving at Communicative Disord ers or Communication Sciences and Disorders. None of the records obtained from th is study will go into your childs record. In addition, there will be no direct benefit to your child from this study. However, your child will receive the above-m entioned hearing evaluations and compensation of $10.00 for parking and travel fees. Throughout the study, the researchers will notif y you of new informa tion that may become available and might affect your decision to remain in the study. If you wish to discuss the

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109 information above or any discomforts you may expe rience, you may ask ques tions now or call the Principal Investigator listed at the bottom of this form. If you agree to have your child participate in this investigatio n, please fill out the bottom of this form. I have read the information contained in this form and give my consent to have my child participate in the research project outlined there. Signature of Participant: ____ ________________ _________________ _______________ Name (please print): __________ _________________ ________________ ____________ Address: _________ ____________________ ____________________ ________________ Birthdate: _______________ _______ Telephone: ______________ _________________ Signature of Investigator: ___ ________________ _________________ ________________ Signature of Witness: ______ ________________ _________________ _______________ If you have any questions regarding this study, please feel free to cont act me at the telephone number and address below. Questions or concerns about the research participants rights can be directed to the UFIRB, PO Bo x 112250, University of Florida, Gainesville, FL 32611-2250 Phone: (352) 392-0433. James Wilbur Hall III, Ph.D. Associate Chair and Clinical Professor Chief, Division of Audiology Department of Communicative Disorders University of Florida 1600 SW Archer Rd P.O. Box 100174 Gainesville, FL 32610-0174 (352) 273-6181 jhall@phhp.ufl.edu

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110 APPENDIX C TOWSON UNIVERSITY INFORMED CONSENT FORM TOWSON UNIVERSITY INFORMED CONSENT FORM Title of Study : Speech Perception and Psychosocial Functi on in Children with Auditory Processing Disorders Principal Investigator : Nicole V. Kreisman, M.A., CCC-A 109F Van Bokkelen Hall Towson University Dept. of Audiology, Speech-La nguage Pathology and Deaf Studies 8000 York Road Towson, MD 21252-0001 (410) 704-2652 Purpose of the Study : The purpose of this study is to examine the so cial and emotional health in children who have auditory processing disorders and the effects of fr equency modulated (FM) systems on their speech understanding and quality of life. Frequency modulat ed systems are a type of technology used to improve speech understanding in difficult or noisy liste ning environments such as within a classroom. An auditory processing disorder is a weakness in the abi lity to understand speech and other sounds, such as tones, in different listening conditions. Assessme nt of auditory processing deficits goes beyond the simple hearing test to evaluate how quickl y and accurately sounds are processed. Participants: Young adults (ages 10 to18) who are native Englis h speakers, have normal hearing, and are free from significant medical problems, including attention defic it disorder, may qualify for these study groups: Group 1: Young adults who have auditory processing disorder. Group 2: Young adults who have language disorder. Group 3: Young adults with normal auditory processing and language abilities. Procedures : Participants who qualify for the study will first be seen for a complete hearing evaluation (listening to tones and words, and measurements of how the ears are functioning) at the Towson University Speech-Language-Hearing Clinic. Such tests are routinely done at the Speech-Language-Hearing Clinic to help us determine if an individual has a hearing lo ss. Participants will al so undergo a screening evaluation for language disorders, and a standardized nonverbal intelligence task. Participants will then receive one or more auditory tests to determine how the brain is processing or using special types of sounds, including words, sentences, and sequences of high and low pitch tones. These tests are typically given to children to assess their abilit ies to process, or listen to, auditor y information. Each of these tests will require the participant to listen to tones or word s presented in one or both ears. The parents of the participants will be asked to complete a case history form.

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111 After the hearing and auditory processing tests, t he participant will be asked to listen to sentences and words with and without a Frequency Modulation (FM) system on. FM devices consist of a microphone and a small speaker(s). The speakers voice, for exampl e the teacher, is sent via radio signal from the microphone to the speaker that is placed near the li stener (the student). FM devices are commonly used in noisy environments to ensure optimal speech u nderstanding. The words and sentences will be presented in quiet and in a background of noise. T he noise will be as loud as normal conversational speech. Following these tests, the participants and th eir parents will be given questionnaires that will help the investigators to understand how each child learns best and give us more information relating to their emotional and social health. All audiological and speech perception testing will either be completed by an Audiologist who holds a Certificate of Clinical Competence from the Am erican Speech-Language-Hearing Association (ASHA) and holds a valid License in the State of Maryland, or by a Towson University Doct or of Audiology (Au.D.) student under the direct supervision of a Certified and Licensed Audiologist. All audiological and speech perception testing will take place inside a sound treated booth. The evaluations will be conducted over two sessions on one day (morning and afternoon) with each session lasting about 2-3 hours. A one-hour lunch break will be provided, and if participants appear tired at any other stage during testing, they will also be offered breaks Benefits : It is hoped that the results of this study will have beneficial effects in identifying the social and emotional health of young adults with auditory proc essing disorders, and provide valuable insight into potential improvements in speech percepti on that may be obtained by an FM system. Risks : There are no known risks associated with parti cipation in this study. Standard audiological testing and questionnaire techniques will be employ ed. The sound intensity levels will be carefully monitored, and will be no louder than the level of nor mal conversational speech. Should the assessment become distressing to the participant, it will be terminated immediately. Cost Compensation : 1. Each participant will receive a free hearing and auditory processing assessment with comprehensive written report. 2. When appropriate, a recommendation for a fitting and trial use of a suitable FM system will be made. 3. Each participant will be paid $20.00 for their completion of the study. Rights as a Participant : 1. Subjects participation in this study will remain st rictly confidential. Only the principal investigator will have access to the identities of the subjects and information associated with their identities. Any data collected through the computer system will be labeled using a code number which will be randomly assigned to the subject. This computer will be password protected and all other information related to the study will be held in a locked cabinet in the Principal investigators office. Although the information gathered may be published or presented, at no time will identifying information regarding subjects be used. 2. Participation in this study is voluntary. At any time prior to or during the study, the participant or his/her parent/guardian are free to discontinue partic ipation. A decision not to participate or to withdraw from the study will have no effect on the individuals status or any current or future services he/she may be receiving at the Towson University Speech-Language-Hearing Clinic or any other clinic or school. 3. The participant or their parent/guardian are fr ee to ask questions regar ding the study and/or the test procedures. These questions will be answer ed by the investigator. 4. If any questions should arise regarding this stud y, please contact the principal investigator, Ms. Nicole Kreisman, Instructor in Audiology, at phone (410) 704-3617 or the Institutional Review Board Chairperson, Dr. Patricia Alt, Office of University Research Services, at phone (410) 7042236.

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112 Informed Consent : 1. I agree to my childs participation in a scientific study entitled Speech Perception and Psychosocial Function in Children with Auditory Processing Disorders. 2. I understand the information given to me. I have received answers to all questions regarding this study. 3. To the best of my knowledge, there are no phy sical or mental issues present that would pose a risk while participating in this study. 4. I understand that participation is voluntary and that I may discontinue participation in this study at any time by informing the principal investigator. 5. I understand that I will receive a signed copy of this consent form. __________________________________________________ ___________________ Parent/Guardian Signature Date ____Affirmative agreement/assess of subject, ________________________________________ I certify that the informed consent form procedure was followed and all questions regarding this study were answered. __________________________________________________ ___________________ Principal Investigator Date IRB Approval Number 06-A038 on 31-Jan-2006

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113 APPENDIX D RESEARCH PARTICIPANT RECRUITMENT FLYER Young Adults (ages 10-18) Needed for a Study of Sound Processing Title of Study : Speech Perception and Psychosocial Func tion in Children with Auditory Processing Disorders Principal Investigator : Nicole V. Kreisman, M.A., CCC-A Purpose of the Study : To examine the social and emotional health in children who have auditory processing and language disorders and the effects of frequency modulated (FM) systems on their speech understanding and quality of life. Participants Needed : Young adults (ages 10 to18) who are native English speakers, have normal hearing, and are free from significant medical problem s, including attention deficit disorder, may qualify for these study groups: Group 1: Young adults who have auditory processing disorder. Group 2: Young adults who have language disorder. Group 3: Young adults with normal auditory processing and language abilities. Procedures : The evaluations will be conducted over two sessions on one day (morning and afternoon) with each session lasting about 2-3 hours, by a Certified and Licensed Audiologist or a Doctor of Audiology (Au.D.) student under direct supervision of the Audiologis t. Participants who qualify for the study will first be seen for a complete hearing a nd auditory processing evaluation at the Towson University Speech-Lang uage-Hearing Clinic. Next, participants will be asked to listen to sentences and words with and without a Frequency Modulation (FM) system on. FM devices consist of a microphone and a small sp eaker(s). FM devices are commonly used in noisy environments to ensure op timal speech understanding. Following these tests, participants and their parents will be given questionnaires that will help the investigator to understand how each child learns best. Risks : There are no known risks associated with participat ion in this study. Testing is painless and standard audiological testing and questionnaire techniques will be employed. All sounds presented will be carefully monitored, and will only be as loud as conversational speech. Compensation : 4. Each participant will receive a free hearing and auditory processing assessment with a comprehensive written report. 5. When appropriate, a recommendation for the fitting and trial use of a suitable FM system will be made. 6. Each participant will be paid $20.00 for their completion of the study. If interested please contact: Nicole V. Kreisman, M.A., CCC-A Instructor in Audiology at Towson University Approved by the Institutional Review Boar d (IRB) of Towson University on 31-Jan-2006

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116 Feeney, P., & Hallowell, B. (2000). Pract ice and list effects on the Synthetic SentenceIdentification test in young and elderly listeners. Journal of Speech, LanguageHearing Research, 43, 1160-1168. Gilbertson, L., & Langhorne, P. (2000). Home -based occupational therapy: stroke patients satisfaction with occupational performance and service provision. British Journal of Occupational Therapy, 63 (10), 464-468. Gilman, R., Easterbrooks, S. & Frey M. (2004). A preliminary study of multidimensional life satisfaction among deaf/hard of hearing youth across environmental settings. Social Indicators Research, 66, 143-164. Gresham, F., & Elliot, S. (1990). Social Skills Rating System Bloomington, MN: Pearson Assessments. Hathaway, S., & McKinley, J. (1943). Minnesota Multiphasic Personality Inventory. Minneapolis, MN: The University of Minnesota. Henggeler, S., Watson, S., & and Whelan, J. (1 990). Peer relations of hearing-impaired adolescents. Journal of Pediatric Psychology, 15 (6), 721-731. Hicks, C. B., & Tharpe, A. (1992) Listening effort and fatigue in school-age children with and without hearing loss. Journal of Speech, Language, and Hearing Research 45, 573-584. Hurley, R.M., & Sells, J.P. (2003). An abbreviated word recognition protocol based on item difficulty. Ear and Hearing, 24 111-118. Jerger, J., & Jerger, S. (1974). Audito ry findings in brainstem disorders. Archives of Otolaryngology, 99, 342-349. Jerger, J., & Musiek, F. (2000). Report of th e consensus conference on the diagnosis of auditory processing disorder s in school-aged children. Journal of the American Academy of Audiology, 11, 467-474. Jerger, J., Thibodeau, L., Martin, J., Mehta, J., Tillman, G., Greenwald, R., Britt, L., Scott, J., & Overson, G. (2002). Behavioral and elctrophysiologic eviden ce of auditory processing disorder: A twin study. Journal of the American Ac ademy of Audiology, 13, 438-460. Katz, J. (1963). The use of staggered spondaic words for assessing the integrity of the central auditory nervous system. Journal of Auditory Research, 2 327-337. Katz, J. (1986). SSW Test Users Manual. Vancouver, WA: Precision Acoustics. Katz, J. (1992). Classification of auditory proc essing disorders. In J. Katz, N. Stecker, & D. Henderson (Eds.), Central auditory processing : A transdisciplinary view St. Louis: Mosby.

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117 Kaufman, A.S., & Kaufman, N.L. (2004). Kaufman Brief Intelligence Test: Second edition Circle Pines, MN: American Guidance Service. Keith, R. (1994a). ACPT: Auditory Continuous Performance Test. San Antonio, TX: The Psychological Corporation. Keith, R. (1994b). SCAN-A: Test for auditory processing disorders in adolescents and adults. San Antonio, TX: The Ps ychological Corporation. Keith, R. (1995). Development and standard ization of SCAN-A: Test of auditory processing disorders in adolescents and adults. Journal of the American Academy of Audiology, 6 286-292. Keith, R. (2000a). SCAN-C: Test for auditory processing disorders in children-revised. San Antonio, TX: The Psyc hological Corporation. Keith R. (2000b). Auditory Random Gap Detection Test. St. Louis, MO: Auditec. Kimura, D. (1961). Some effects of tempor al lobe damage on auditory perception. Canadian Journal of Psychology 15 156-165. Knutson, J. & Lansing, C. (1990). The re lationship between communication problems and psychological difficulties in persons with profound acquired hearing loss. Journal of Speech and Hearing Disorders, 55, 656-664. Koning, C. & Magill-Evans, J. (2001). Social and language skills in adolescent boys with Asperger syndrome. Autism, 5 23-36. Kraus, N., & Disterhoff, J. (1982). Response plas ticity of single neuron s in rabbit auditory association cortex during tone-signalled learning. Brain Research, 246 205-215. Kraus, N., McGee, T., Carrell, T., King, C., Trem blay, K., & Nicol, T. (1995). Central auditory system plasticity associated w ith speech discrimination training. Journal of Cognitive Neuroscience, 7 25-32. Kreisman, N. V., Crandell, C., & Hall, J. (2004). Ch ildren with APD: Emotional and social health status. Paper presented at the American Speech-Language-Hearing Association 2004 Annual Convention, Philadelphia, Pennsylvania. Maxon, A. B., Brackett, D., & van den Berg, S. (1983). The Social Awareness Scale: An analysis of the hearing-impaired childs perc eptions. Paper presented at the American Speech-Language-Hearing Association, Cincinnati, OH. Maxon, A. B., Brackett, D., & van den Berg, S. (1991). Self perception of socialization: The effects of hearing status, age and gender. The Volta Review, 7-18.

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119 Raven, J., Raven, J.C., & Court, J.H. (2004). Manual for Ravens progressive matrices and vocabulary scalesSection 3: Standard progressive matrices Oxford, England: Oxford Psychologists Press. Raven, J., Raven, J.C., & Court, J.H. (2003 ). Manual for Ravens progressive matrices and vocabulary scalesSection 1: general overview Oxford, England: Oxford Psychologists Press. Raven, J.C. (1976). Standard progressive matrices: Sets A, B, C, D, & E Oxford, England: Oxford Psychologists Press. Reynolds, C., & Kamphaus, R. (2004). BASC-2, Behavior Assessment System for Children, Second edition: Manual. Circle Pines, MN: AGS Publishing. Redmond, S. (2002). The use of rating scales with children who have language impairments. American Journal of Speech -Language Pathology, 11 124-138. Rosenthal (1991). Meta-analytic proce dures for social research (Revised). Thousand Oaks, CA: Sage Publications, Ltd. Rosenthal, R., & Rosnow, R. (1991). Essentials of behavioral research: Methods and data analysis (Second edition). New York: McGraw-Hill, Inc. Sanders, D.A. (1993). Management of hearing handic ap: Infants to elderly (3rd edition). Englewood Cliffs, NJ: Prentice Hall. Schow, R., & Nerbonne, M. (1982). Communication screening profile: use with elderly clients. Ear and Hearing, 3 135-147. Semel, E., Wiig, E., & Secord, W. (2003). Clinical Evaluation of Language Fundamentals Screening Test Fourth edition San Antonio, TX: Psychological Corporation. Sines, J., Pauker, J., & Sines, L. (1974). The Missouri Childrens Picture Series manual. Iowa City, IA: Psychological A ssessment and Services, Inc. Smaldino, J., & Crandell, C. (2004). Speech percep tion in the classroom. In C. Crandell, J. Smaldino, and C. Flexer (Eds.), Sound Field amplification: Applications to speech perception and classroom acoustics (Second Edition), (p.49-56). Clifton Park, NY: Thompson Delmar Learning. Wasson, J., Kairys, S., Nelson, E., Kalishman, N ., & Baribeau, P. (1994). A short survey for assessing health and social problems of adolescents. Journal of Family Practice, 38 489-494. Wertz, D., Hall, J., & Davis, W. (2002). Auditory processing disorders: Management approaches past to present. Seminars in Hearing, 23 277-285

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120 Wible, B., Nicol, T., & Kraus, N. (2005). Corre lation between brainstem and cortical auditory processes in normal and language-impaired children. Brain, 128 417-423. Wilson, R.H., & Strouse, A. (1998). Tonal & speech materials for auditory perceptual assessment disc 2.0 [CD] Mountain Home, TN: VA Medical Centers.

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121 BIOGRAPHICAL SKETCH Nicole VanCleave Kreisman was born and raised in Des Moines, Iowa. She received her Bachelor of Arts in Communicative Disorders fro m the University of Northern Iowa, and her Master of Arts in Audiology and Speech-Language Pathology from the University of Memphis. She has worked as a clinical and educational audiologist for over 10 years. She began her doctoral work at the University of Florida in 2002. She has been privileged to work in the classroom and the clinic with Doctor of A udiology (Au.D.), Master of Audiology (M.Aud.), and undergraduate students at the University of Fl orida (Gainesville, FL), the University of Canterbury (Christchurch, New Z ealand), and Towson University (Towson, MD). She has a son (Josiah), a daughter (Anna), and an incredible husband (Brian).


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PSYCHOSOCIAL STATUS OF CHILDREN WITH AUDITORY PROCESSING DISORDER


By

NICOLE V. KREISMAN

















A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2007

































Copyright 2007

by

Nicole V. Kreisman




















For Carl-faithful friend and inspiring mentor-may your legacy live on in part through me and
through this work. For my children, Anna Joy and Josiah Peter-for helping to teach me about
the importance of Life's everyday moments-Mommy's big paper is finally finished now. And
mostly for Brian-"How can I tell you that I love you, but I can't think of right words to say?"
FAYTC-N





To God be the glory.









ACKNOWLEDGMENTS

The completion of this dissertation has only been possible with the great support and

assistance of so many people. First, I'd like to acknowledge the critical role that my incredible

husband, Dr. Brian Kreisman, played in encouraging me to pursue this degree, providing me

with strength, support and understanding throughout the entire process, around the world and

back again, and loving me all the while. I thank Brian for being my best friend as well as my

most respected colleague. I would like to acknowledge the inspiration of Dr. Carl Crandell, who

was a tremendous blessing as mentor and friend, and whose vital presence remains. I would also

like to thank my beautiful children, Anna and Josiah; as well as my parents, Nancy and Gary

Van Cleave, along with the rest of my family, for their constant love and support.

I thank my dissertation committee chairman, Dr. James Hall, for stepping into his role,

encouraging and persistently guiding me through the process. I thank my committee members,

Dr. Thomas Oakland, Dr. Mini Shrivastav, Dr. Scott Griffiths, and especially Dr. Joseph

Smaldino, for their suggestions and encouragement toward the completion of this dissertation. I

thank my great colleagues and students at the University of Florida, the University of

Canterbury, and Towson University for their time, efforts and encouragement in support of my

work. I thank my understanding, devoted, fabulous friends for cheering me on in the pursuit of

this endeavor. I also would like to express my sincere appreciation to the participants and

parents involved in this research for giving their time and energy, and for opening and sharing of

their lives with me so that others may benefit. Most importantly, I thank Jesus for being my

Lord and Savior.









TABLE OF CONTENTS

page
pM.ge

A C K N O W L E D G M E N T S ............................................................................................... ......... ...... 4

LIST OF TABLES.............................................................8

LIST OF FIGURES .............................................................9

A B ST R A C T ...... .... .... .............................................. ....................... ....... ... .. .. ................. 10

CHAPTER

1 IN TRODU CTION ............... .............................................. ...............12

2 REV IEW OF LITERA TU RE ...............................................................................................19

Auditory Processing Disorders-Definitions and Diagnostic Importance.............................19
Psychosocial Implications of Hearing Loss in Children and Adolescents.............................20
Use of SSRS in Children with Communication and/or Sensory Impairments................24
Use of the BASC in Children with Language Impairment............................. ...............26
Use of COOP-A in Children with Hearing Loss...................................................27
U se of CO OP-A in Children w ith APD ...................... ..................................................28

3 M E TH O D S .......................................................................................... ......................... 35

P participants .......................................................................................... ....................... .3 5
D diagnosis of A PD ................................................................. ................... ...............37
Psychosocial M measures .............................................................................. ............ .........39
The Social Skills R eating System (SSR S) ........................................................................39
The Behavioral Assessment System for Children-Second Edition (BASC-2)................40
The Dartmouth Primary Care Cooperative Information Project Charts for
A adolescents (C O O P -A ) .......................................................................... ...............4 1
P rocedures......................................................................................... .......... ............... 42
A udiological A ssessm ent ..............................................................................................42
Intellectual A ssessm ent .................. ...................................... ...............43
Language Assessment ............................ ................ ...............44
A PD A ssessm ent .................................. ... ... .................................. ...............44
P sychosocial A ssessm ent ..............................................................................................45
Statistical Analyses ............................................................ .... ....... ................................47

4 R E S U L T S .............. ......... ................................................ .......................................... . 5 0

Child-Completed Dartmouth Primary Care Cooperative Information Project Charts for
A adolescents (COOP-A)............ .. .. ....................................... ...............51
Physical Fitness Subscale Chart ................................................................................52
Pain Subscale Chart .............. ...................................................... .. .............. ..52









Stress Subscale Chart .......................... .. .. ............... ...............52
School W ork Subscale Chart......................................................................................53
E m otional Feelings Subscale C hart...............................................................................53
B behavior Sub scale C hart ............................................................................. ...............54
Social Support Subscale C hart .................................................................... ...............54
Self-E steem Sub scale C hart ........................................................................ ...............55
Fam ily Subscale Chart ............ .... .. .................................. ........ ........55
Health Habits I...................................................................................... ....................55
O overall H health Subscale C hart .................................................................... ...............56
Energy Subscale Chart ..............................................56
Social Skills Rating System (SSRS), Student Forms ...........................................................56
Cooperation Subscale .............. ...... ..... .............................. ...........57
Assertion Subscale..................... .......................................57
Empathy Subscale ................. ............... ... .... ....... 57
Self-C control Subscale...... ...... ............................... .. .. ............ .... ... ...... ...............58
Behavioral Assessment System for Children-Second Edition (BASC-2), Self-Report
Form s ............................................................. ....... .. ............................. ...............................58
School Problem s C om posite Subscale ...................... ....................................................58
Internalizing Problem s Composite Subscale.................................................................59
Inattention/Hyperactivity Composite Subscale................. ...................................59
Em otional Sym ptom s Index Subscale....................... ....................................................60
Personal Adjustment Composite Subscale ....................................................................60
Parent-Completed Dartmouth Primary Care Cooperative Information Project Charts for
A adolescents (COOP-A)............ .. .. ......................................... ................60
Physical Fitness Subscale Chart .................................................................................61
Pain Subscale Chart................ ......... ................. .....................61
Stress Subscale Chart .............. ...................................... ...........62
School W ork Subscale Chart.........................................................................................63
Em otional Feelings Subscale Chart...............................................................................63
B behavior Sub scale C hart ............................................................................. ...............63
Social Support Subscale C hart .................................................................... ...............64
Self-E steem Sub scale C hart ........................................................................ ...............64
Fam ily Subscale Chart ............ .... .. .................................. ........ ........65
Health Habits I...................................................................................... ....................65
O overall H health Subscale C hart .................................................................... ...............65
Energy Subscale Chart .................................................................. ...................65
Social Skills Rating System (SSRS), Parent Forms ................. ...................................66
Cooperation Subscale 6.............. .................... ..... 66
A assertion Subscale............... ...... .. ..... ............................... ...............67
Responsibility Subscale............ .. .. .................................. .. ................67
Self-Control Subscale..................................... ........... ........... ................67
Externalizing Problem Behavior Subscale.................... ...................................68
Internalizing Problem B behavior Subscale ................................ ..... ..... .........................68
Behavioral Assessment System for Children-Second Edition (BASC-2), Parent Rating
Scales .............. ....................................... .. .. ... ....................... . ...... ....................... ......... 69
Externalizing Problems Composite Subscale................................................................69



6









Internalizing Problem s Composite Subscale.................................................................69
Behavioral Sym ptom s Index Subscale..........................................................................70
Adaptive Skills Composite Subscale................. ...... ... ................70
Summary of Statistically Significant Findings Across Instruments.....................................71
Post-H oc A nalyses.......................................... .. ... ... ..........................................................71
Reported Psychosocial Function and Age.....................................................................72
Reported Psychosocial Function and Gender................................................................74
Comparisons Between Language-Normal and Language-Impaired Subgroups with
APD ........................................................... .......... .........................................................75

5 DISCU SSION ................................................................ .......... ........................................................95

Children's Self-Reported Psychosocial Status .....................................................................95
Parental Perceptions of Psychosocial Status.........................................................................98
Language Function Status of the APD Group...................................100
Limitations of this Study ............................ .................. ...............100
Clinical Implications............... ... .... .... .... ...... ......... ... ...............102
Future R research ................................................................. ................... ...............103

APPENDIX

A APD PA REN T/PA TIEN T SU RV EY ...................................................................................105

B UNIVERSITY OF FLORIDA INFORMED CONSENT FORM .............. ...............107

C TOWSON UNIVERSITY INFORMED CONSENT FORM.............................................110

D RESEARCH PARTICIPANT RECRUITMENT FLYER..........................................113

R E F E R E N C E S .............. ................................................................................. ................... 1 14

B IO G R A P H IC A L SK E T C H .......................................................................................................12 1









LIST OF TABLES


Table page

4-1 Number of subjects in the APD and normal groups for various demographic
characteristics.................................... . ..................................................... ...............77

4-2 Mean pure-tone air-conduction thresholds (M) and standard deviations (s.d.) across
frequencies for each ear (RE = right ear; LE = left ear) of both groups............................78

4-3 Mean tympanometric data for APD and normal groups.................................. ...............79

4-4 Number of participants 2 standard deviations or more below mean on assessments
used in the APD test battery for both the APD and normal groups..............................80

4-5 Mean ranks (m) and sum of ranks (U) for the COOP-A and means (MAl) and standard
deviations (s.d.) for the SSRS and BASC-2 for children's psychosocial self-reports
ratings for the APD group and the normal group. ..........................................................81

4-6 Statistical findings for children's psychosocial self-reports. ........................... ...............82

4-7 Mean ranks (m) and sum of ranks (U) for the COOP-A and means (M) and standard
deviations (s.d.) for the SSRS and BASC-2 for parental psychosocial ratings for the
APD group and the norm al group ...............................................................................83

4-8 Statistical findings for parent psychosocial reports. .......................................................84

4-9 Compiled statistically significant (p < 0.05) findings across psychosocial scales for
children and parents. ............................... ... ................................... ...............85

4-10 At-risk (3-5 ratings) findings on COOP-A by children's self-reports by subscale
chart for both groups............... ... ..... .... ..... ... ............. ...............86

4-11 At-risk (3-5 ratings) findings on COOP-A by parental reports by subscale chart for
both groups......................................... ............. .............................................................. 87

4-12 Summary of correlation findings for age and statistically significant (p < 0.05)
psychosocial subscales for children and parents.............................................................88

4-13 Summary of findings for gender and statistically significant (p < 0.05) psychosocial
subscales for children and parents. .................................................................................89

4-14 Statistical findings across psychosocial scales for children's self-ratings in language-
impaired versus language-normal APD subgroups.........................................................90

4-15 Statistical findings across psychosocial scales for parent ratings of children in
language-impaired versus language-normal APD subgroups.........................................91









LIST OF FIGURES


Figure page

2-1 Mean ratings across eight COOP subscales by children with auditory processing
disorders (APD), children with hearing loss (HL) and children with normal hearing
(N H ). ............. ............ ................................................ ......................................... . 3 2

2-2 Percentage of children with auditory processing disorders (APD), children with
hearing loss (HL) and children with normal hearing (NH) scoring 3, 4 or 5 on any
COOP subscale, suggesting the child was at-risk for problems in that area......................33

2-3 Mean ratings across twelve COOP-A subscales by children with auditory processing
disorders and their parents. ........................................................................... ...............34

4-1 Mean audiometric results for right and left ears of participants in the APD and
norm al groups. ............................................................... .................... ...............92

4-2 Compiled Towson University APD group DPOAE data with mean group data line in
b o ld ............. ............. ................................................ .......................................... . 9 3

4-3 Compiled Towson University normal group DPOAE data with mean group data line
in bold. .................................................. . ................................... ......................... 94









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

PSYCHOSOCIAL STATUS OF CHILDREN WITH AUDITORY PROCESSING DISORDER
By

Nicole V. Kreisman

May 2007

Chair: James W. Hall, III
Major Department: Communication Sciences and Disorders

Children with hearing loss often exhibit reductions in psychosocial status compared to

children with normal hearing status. It is reasonable to assume that children with other

perceptual difficulties, such as Auditory Processing Disorder (APD) also may experience

reduced psychosocial function. However, there remains a paucity of data examining the

psychosocial health of children with APD. This investigation examined relationships between

APD and psychosocial status, with an aim to add to the scholarship on non-auditory factors that

may influence quality of life of children with APD.

Participants consisted of nineteen children (ages 9.5 17.8 years; M = 11.9 years)

diagnosed with APD (APD group) and twenty children with no such diagnosis in a gender- and

age-matched (M = 12.8 years) group (normal group). Extensive auditory and auditory

processing test batteries were administered to confirm or rule out APD. Inclusion criteria for

both groups included normal hearing status, non-verbal cognitive function, and attention

abilities. Normal group criteria also included no medical or academic disability, passing a

language screening and no history of language impairment. The participants and their mothers

completed appropriate versions of the Dartmouth Primary Care Cooperative Information Project

Charts for Adolescents (COOP-A), the Behavioral Assessment System for Children-Second

Edition (BASC-2) and the Social Skills Rating System (SSRS).









Group differences on questionnaire subscales means were analyzed by independent sample

t-tests or the Mann Whitney U test for ordinal data. Statistical significance was defined by

p < 0.05 (two-tailed). The participant's Emotional Feeling and Overall Health COOP-A

subscales and the BASC-2 Emotional Symptoms Index differed, with the APD group reporting

increased reported psychosocial problems. Parent reports differed on the following: the COOP-

A Pain, School Work, and Emotional Feeling subscales; the BASC-2 Externalizing,

Internalizing, Behavioral Symptoms Index and Adaptive Skills Index subscales; and the SSRS

Responsibility, Externalizing Problem Behaviors and Internalizing Problem Behaviors subscales.

Parents reported increased problems on these scales for children with APD. Eta-squared values

for all significant findings indicated moderate to large effect sizes, suggesting findings may be

generalized to other children in this age group. Post-hoc analyses yielded no significant gender

or age between-groups differences, except for a moderately strong positive correlation (R = .53)

between age and responsibility as measure by the SSRS Parent Rating Form. No between-group

differences were found on any subscale for APD children with (N= 9) or without (N= 10) a

confirmed or suspected language disorder.









CHAPTER 1
INTRODUCTION

The major sequelae of sensorineural hearing loss (SNHL) are reductions in speech

perception and communicative function. Because of these perceptual and communication

difficulties, children with even minimal degrees of hearing loss often exhibit reductions in

psychosocial health status compared to children with normal-hearing status. Specifically,

children with SNHL often exhibit lower social and emotional health status. Social and emotional

difficulties of children with hearing loss have been reported in areas such as increased

depression, physical aggression, withdrawal, loneliness, and decreased self-esteem and academic

attainment (Bess, Dodd-Murphy & Parker, 1998; Hicks & Tharpe, 2002; Davis, Elfenbein,

Schum & Bentler, 1986; Davis, Shepard, Stelmachowicz, & Gorga, 1981; Henggeler, Watson &

Whelan, 1990; Knutson & Lansing, 1990; Maxon, Brackett & van den Berg, 1991). It is

reasonable to assume that children with other speech-perceptual difficulties, such as Auditory

Processing Disorder (APD), also may experience reduced psychosocial function.

To support this assumption the Technical Report: (Central) Auditory Processing Disorders,

by the Working Group on Auditory Processing Disorders of the American Speech-Language-

Hearing Association (ASHA, 2005) recently reported:

In addition to the language and academic difficulties often associated with (C)APD, some
individuals with (C)APD have a higher likelihood of behavioral, emotional, and social
difficulties. Communication deficits and associated learning difficulties may adversely
impact the development of self-esteem and feelings of self-worth. (p. 3)

The authors of the technical report further advise that there is no evidence that (C)APD is the

cause of severe psychological or sociopathic problems, nor are milder emotional or social

difficulties necessarily diagnostic of (C)APD, yet "whenever significant psychosocial concerns

are present in an individual with (C)APD, the individual should be referred to the appropriate

specialist for evaluation and follow-up" (p. 3). However, as the lack of references in this area of









the report suggests, there currently is a paucity of data regarding the exact nature and extent of

the psychosocial difficulties in children with APD. In order for audiologists and other

professionals to obtain a more complete understanding of the social and emotional health of

children with APD, additional research and study is needed.

According to the Report of the Consensus Conference on the Diagnosis of Auditory

Processing Disorders in School-Aged Children (Jerger & Musiek, 2000), "APD may be broadly

defined as a deficit in the processing of information that is specific to the auditory modality" (p.

468). More specifically, according to the ASHA Working Group (2005), "(Central) Auditory

Processing [(C)AP] refers to the efficiency and effectiveness by which the central nervous

system (CNS) utilizes auditory information" (p. 2). Auditory Processing Disorder (APD) refers

to CNS processing difficulties of auditory information as characterized by reduced performance

in one or more of the following areas: sound localization, sound lateralization, auditory

discrimination, auditory pattern recognition, speech perception in the presence of competing

and/or degraded acoustic signals, and temporal auditory processes.

The prevalence of APD among school-aged children in the United States is estimated to be

approximately 2 to 3% (Chermak & Musiek, 1997). The identification, diagnosis, and treatment

of APD in children is important for several reasons, including co-morbidity and confusion with

language impairment, dyslexia and other reading problems, behavioral problems, attention

deficit disorders, and academic underachievement or failure. Again, according to the ASHA

Working Group (2005), "(C)APD can lead to or be associated with difficulties in learning,

speech, language (including written language involving reading and spelling), social, and related

functions" (P. 3). Furthermore, other reports suggest untreated APD commonly leads to reduced

communication (Smaldino & Crandell, 2004), which in turn can have psychosocial impacts such









as loneliness, social anxiety, depression, anger, and fear (Crandell, 1998). Reduced

communication also has been shown to lead to reductions in physical health and psychosocial

health status as well as overall quality of life (Bess, Dodd-Murphy & Parker, 1998; Crandell,

1993).

The use of self-report surveys is a well-accepted procedure to examine psychosocial health

(DeBruin, Diederiks, DeWitte, Stevens & Philipsen, 1994; Nelson, Wasson, Kirk, Keller, Clark,

Dietrich, Stewart, & Zubkoff, 1987; Nelson, Landgraf, Hays Wasson & Kirk, 1990). There is

evidence that self-report surveys are effective in evaluating the health status of people across a

variety of cultures and chronic conditions (Bronfort & Bouter, 1999; Gilbertson & Langhorne,

2000; McFall, Arambula Solomon & Smith, 2000). Numerous psychosocial health surveys have

been designed for use with pediatric or adolescent populations that examine specific dimensions

of social and emotional functioning. Two such examples of these surveys are the Social Skills

Rating System (SSRS) (Gresham and Elliot, 1990), and the Behavioral Assessment System for

Children, Second Edition (BASC-2) (Reynolds and Kamphaus, 2004). Both the SSRS and the

BASC-2 utilize self-report questionnaires designed for use by teachers, parents, and/or students.

The SSRS provides information on the positive and negative social skill behaviors of

students. The SSRS has both parent and child versions, which may be used singly or in

combination in order to provide a complete profile of a student's social function. SSRS data can

be utilized in order to inform parents, teachers, and other support personnel of social skills

behaviors in and out of the classroom as well as possible underlying causes.

The BASC-2 provides a profile of adaptive and maladaptive behaviors and emotions of

children and adolescents. BASC-2 data are often used by school and clinical psychologists when

making educational and psychological diagnoses and determining possible disability









classifications in schools. The Parent Rating Scales (PRS) of the BASC-2 are used to measure

both adaptive and problem behaviors in community and home settings in 14 subcategories,

which combine into composite scales. The Self-Report of Personality (SRP) scale of the BASC-

2 measures 16 subcategories of attitudes and emotions of students as they rate themselves.

Few brief self-report questionnaires that specifically examine overall quality of life have

been designed or adapted for use with a pediatric or adolescent population (Elkayam and

English, 2003). One exception is the Dartmouth Primary Care Cooperative Information Project

Charts for Adolescents (COOP-A; Wasson, Kairys, Nelson, Kalishman & Baribeau, 1994). The

COOP-A was designed to be used by primary care physicians in their offices as a screening tool

to evaluate the overall quality of life of adolescents. The COOP-A charts are designed to assess

physical, emotional, and social dimensions of function (Nelson, et al, 1987; Wasson, Kairys,

Nelson, Kalishman & Baribeau, 1994).

Recently, the COOP-A has been utilized in two research studies to investigate the overall

health status of children with varying degrees of hearing loss. Bess, Dodd-Murphy, and Parker

(1998) reported on findings after the COOP-A was administered to 32 sixth- and ninth-grade

children with minimal SNHL, conductive hearing loss, and other (e.g., mixed) types of hearing

loss, and to 591 children with normal hearing. Children with hearing loss reported a trend of

greater dysfunction than those with normal hearing on 9 of 10 COOP-A subscales in both the

sixth- and the ninth-grade levels. Using a Mantel-Haenszel Chi-square test, statistically

significant differences were found between groups of 6th-graders for the energy domain, and

between groups of 9th-graders on the stress and behavior domains. Further statistical analysis by

examination of only high scores of 4 or 5 on the various subtests of the COOP-A, indicated that

the children with hearing loss displayed lower self-esteem and energy than their sixth-grade









peers and lower social support, higher stress and lower self-esteem than their ninth-grade peers.

These higher self-ratings were chosen for further investigation, as the authors of the COOP-A

(Wasson, Kairys, Nelson, Kalishman & Baribeau, 1994) have suggested that scores of 3, 4 or 5

on each chart indicate that children may be at risk for greater dysfunction in that area.

Similarly, Hicks and Tharpe (2002) examined the health status often children between the

ages of 6 and 11 years with either mild-to-moderate or high-frequency SNHL, and ten age- and

grade-matched counterparts with normal hearing. While no statistical significance between

groups was found, the authors noted that the percentage of the group of children with hearing

loss that rated themselves as 3 or higher (more dysfunction) on the COOP-A charts was greater

compared to their peers with normal hearing in seven of nine subscale questions administered.

These trends suggest more self-reported social and emotional problems in the children with

hearing loss than in their counterparts with normal hearing. However, the small sample size

utilized in the study affected its statistical findings and and limited generalization to most

children with hearing loss. The authors also postulated, as the majority of the study participants

with hearing loss utilized personal amplification devices, that the students' stress and fatigue

levels from energy expended on speech perception in adverse listening situations may have been

reduced by remediation of their disability and handicap through their use of amplification.

With the previous findings in mind, Kreisman, Crandell and Hall (2004) utilized the

COOP-A in a preliminary study to determine if any psychosocial difficulties similar to those

exhibited by children with hearing loss also existed in children with APD. As the COOP-A is

intended to be a screening instrument only, any significant findings were considered to be pilot

data leading into future arenas of research. Ten children (6 male, 4 female) with APD and their

parents participated in the study. Subjects in the APD Group ranged in age from 9;11 to 14;6









with a mean age of 11 years 7 months. For comparative purposes, the data from the Hicks and

Tharpe (2002) study groups were utilized: 1) the HL Group consisted often children (age range

6 to 11 years, M= 8;1) with either mild to moderate SNHL or high-frequency SNHL; and 2) the

Normal Hearing (NH) Group consisted of 10 children (age range 6 to 11 years, M= 7;11) with

no hearing or auditory difficulties. Following a thorough hearing and auditory processing

evaluation, the charts of the COOP-A were administered to the participants in the APD Group

and their parents. The children were asked to answer the ratings on the instrument

independently, and utilizing slightly modified instructions for the purposes of the investigation,

the parents of the participants were asked to complete the COOP-A by responding to each chart

via their perception of the most accurate answer for their child. When mean ratings and

percentage of ratings considered "At-Risk" (3, 4 or 5) were analyzed, results for the Kreisman,

Crandell and Hall (2004) study suggested that children with APD experience greater

psychosocial dysfunction than their peers without APD across a number social and emotional

content areas relating to quality of life. Specifically, the APD Group exhibited significantly

higher ratings on the COOP-A Emotional Feeling and Family subscale charts than did children in

the comparison NH Group. In addition, the parents of the participants with APD reported greater

psychosocial difficulties than did their children on all but one of the COOP-A subscale charts.

With the exception of these preliminary findings, there remains a paucity of data

examining the psychosocial function of children with APD. The present investigation aimed at

further exploring hypothesized emotional and/or social difficulties that may be present in this

population. The results would add to the knowledge base of the audiology community working

with children who have APD regarding possible non-auditory factors that may be influencing

their quality of life.









Data from two groups of students were compared. The experimental group of children

consisted of nineteen pediatric participants between the ages of 9.5 and 17.8 years with a

diagnosis of APD (APD group). A corresponding gender- and age-matched group consisted of

twenty children had no such diagnosis, nor any other medical or academic disability (normal

group). The study was conducted in two locations. Data for 17 APD subjects and 16 normal

subjects were collected in the auditory laboratory at Towson University in Maryland. Data for

two children from the APD group and four children from the normal group were collected at the

University of Florida in Gainesville. Following a diagnostic audiometric, cognitive, linguistic,

and APD battery that placed the children into one of the two investigational groups, the pediatric

participants and their accompanying parents completed the COOP, the SSRS, and the BASC-2

questionnaires. Standard two-group comparison procedures were conducted to explore

differences between groups on psychosocial subscale scores. Post-hoc analyses were also

conducted to examine differences between gender and age of the pediatric participants of both

groups as well as linguistic function status of the APD group. Implications of findings and

results are discussed.









CHAPTER 2
REVIEW OF LITERATURE

Auditory Processing Disorders-Definitions and Diagnostic Importance

While the management of auditory processing disorders has received much attention in the

audiology community within the last 30 years, the concept of difficulties in the dispensation of

auditory information beyond the level of the peripheral hearing system can be followed back

much farther in the literature of the field of communication sciences and disorders (Wertz, Hall

& Davis, 2002). Myklebust (1954) noted several disturbances of auditory function, including

auditory agnosia, aphasia, and other lesions in the auditory cortex that appeared to arise from

central nervous system pathways. He viewed receptive aphasia as a deficiency in the

interpretation of auditory impulses, while what he referred to as "central deafness" was

essentially a disturbance in the delivery of auditory impulses to higher cognitive centers of the

brain (p.153). In another 1954 publication, Bocca, Calearo and Cassinari described a procedure

they used to uncover "hidden auditory" losses in the patients with temporal lobe tumors, by use

of distorted speech. Kimura (1961) also described auditory perceptual deficits witnessed in

persons with unilateral temporal-lobe damage by utilizing dichotic speech stimuli and provided a

model to explain the underlying physiology of the central auditory nervous system as it related to

dichotic speech perception. Much more work in the field of auditory neuroscience from then

until now has also provided extensive evidence for the biological underpinnings of this

somewhat elusive diagnostic area (Abbs & Sussman, 1971; Jerger, Thibodeau, Martin, Mehta,

Tillman, Greenwald, Britt, Scott & Overson, 2002; Kraus & Disterhoff, 1982; Kraus, McGee,

Carrell, King, Tremblay, & Nicol, 1995; Musiek, Baran & Pinheiro, 1994).

Katz (2002) defined auditory processing simply and eloquently as "what we do with what

we hear." In a more technical definition, Jerger & Musiek (2000) stated that: "APD may be









broadly defined as a deficit in the processing of information that is specific to the auditory

modality" (p. 468). Even yet more specifically, according to the ASHA Working Group (2005),

"(Central) Auditory Processing [(C)AP] refers to the efficiency and effectiveness by which the

central nervous system (CNS) utilizes auditory information" (p. 2). Auditory processing disorder

(APD) refers to CNS processing difficulties of auditory information as characterized by reduced

performance in one or more of the following areas: sound localization, sound lateralization,

auditory discrimination, auditory pattern recognition, speech perception in the presence of

competing and/or degraded acoustic signals, and temporal auditory processes. (ASHA, 1996;

ASHA, 2005). Further, Chermak, Bellis and Musiek (2006; also Musiek, Bellis & Chermak,

2005) define APD as a "primarily modality-specific perceptual dysfunction that cannot be

attributed to peripheral hearing loss or to higher-order, global cognitive, supramodal attention, or

memory, language-based or related disorders" (p. 4).

The identification, diagnosis, and treatment of APD in children is important for appropriate

management. In the diagnostic process, APD must be differentiated from co-existing disorders

including language impairment, dyslexia and other reading problems, behavioral problems,

attention deficit disorders, and academic underachievement or failure (ASHA, 2005; Jerger &

Musiek, 2000; Musiek & Chermak, 1995). Indeed, reports suggest untreated APD commonly

leads to reduced communication function, which in turn can have psychosocial impacts such as

loneliness, social anxiety, depression, anger, and fear (Crandell, 1998).

Psychosocial Implications of Hearing Loss in Children and Adolescents

While there is a paucity of research into the psychosocial implications of APD, the

psychosocial implications of hearing loss of varying degrees and configurations have been

explored in children and adolescents (Davis et al.,1986; Culbertson & Gilbert,1986; Gilman,

Easterbrooks, & Frey, 2004; Henggeler, Watson & Whelan,1990; Maxon, Brackett & van den









Berg, 1991 Elkayam & English, 2003). The following is a review of some of the experimental

research conducted with an aim to describe emotional and social correlates for hard-of-hearing

children.

Davis et al. (1986) examined the psychosocial function of children with mild to moderate

sensorineural hearing loss. Forty children with sensorineural hearing loss were studied. The

forty children who served as participants were divided into 3 experimental groups based on their

three-frequency pure-tone averages (PTAs). Group A was comprised of those participants

whose PTAs were 44 dBHL or less (n = 16); Group B included those participants who PTA's

were between 45 and 60 dBHL (n = 15); and Group C was composed of the remaining

participants, whose PTAs were 61 dBHL or greater. The Missouri Children's Picture Series, or

MCPS (Sines, Pauker & Sines, 1974) and the Child Behavior Checklist, or CBC (Achenbach &

Edelbrock, 1983) served as the instruments used to examine psychosocial function. The MCPS

measured self-reported personality characteristics of the participants. Results on the MCPS

showed that scores across the 3 groups of children with hearing loss were statistically greater

than test norms derived from data on children with normal hearing on the scales of aggression

and somatization. These findings suggest that children with hearing loss are more likely to

exhibit aggressive behaviors and to express corporeal complaints than their peers with normal

hearing. On the CBC, a parental rating scale, participants with hearing loss produced patterns of

greater impulsivity and aggressive behaviors, as well as more social isolation and academic

difficulties, as compared to the instrument's normative data set.

Culbertson and Gilbert (1986) examined the self-concepts and classroom behaviors of a

group of 25 children with unilateral sensorineural hearing loss. Subjects in the experimental

group ranged from 6 to 13 years of age and had pure-tone averages no better than 45 dB HL for









at least three years in their impaired ear. The participants were matched by age, gender, and

socioeconomic status to the 25 children with normal hearing included in the control group. The

Piers-Harris Children's Self-Concept Scale (Piers & Harris, 1984) and the Behavior Rating Scale

(BRS; Culbertson, 1986) were given to both groups following an evaluation that included

cognitive and academic measures. The BRS, an unpublished scale at the time of the study, was

comprised of positive and negative descriptors in the following five categories: attention to

academic tasks, peer relations and social confidence, dependence-independence, emotional

liability, and organization. While Culbertson (1986) found no significant differences in self-

concept between groups on the Piers-Harris measurement, trends of differences were revealed

between the groups in four of the five behavioral categories of the BRS. For the categories of

dependence-independence, attention to task, emotional ability and peer relations, the children

with unilateral hearing loss were rated by their teachers as having a greater percentage of

negative behaviours than the children with normal hearing. Limitations of the Culbertson (1986)

study include the lack of statistical analysis of data, and the absence of data from a scale with

published validity and reliability measures. However, the trends suggest that teachers of children

with only unilateral hearing loss rate them as displaying more negative behavioral

characteristics in the classroom.

Henggeler, Watson and Whelan (1990) compared the peer-relations of 35 adolescents with

normal hearing to 35 adolescents with hearing loss who were enrolled in self-contained classes

for the hearing-impaired that utilized a Total Communication approach. The parents of both

groups of participants were given the Revised Behavior Problem Checklist (RBPC; Quay &

Peterson, 1987), the Social Competence Scale of the CBC, or SBS-CBC (Achenbach &

Edelbrock, 1983), and the Missouri Peer Relations Inventory (MPRI; Borduin, 1989). The









adolescents in the normal hearing group and the adolescents with hearing loss with sufficient

language skills also completed the MPRI. Results indicated that parents of the adolescents with

hearing loss rated their children's peer relationships as higher in aggression and lower in

emotional bonding than did the parents of the children with normal hearing. However, the

adolescents with hearing loss themselves, in contrast to their parents' reports, rated their

relationships as lower in aggressive tendencies than their peer participants with normal hearing.

Maxon, Brackett and van den Berg (1991) studied the self-perception of social skills in 41

students with hearing loss enrolled in mainstream educational settings as compared to 22 peers

with normal hearing. Utilizing an instrument specifically designed with the linguistic needs of

students with hearing loss in mind, the Social Awareness Measure (Maxon, Brackett & van den

Berg, 1983), students in both groups rated themselves on various measures of socialization. The

50 items on the Social Awareness Measure were designed to be simple statements utilizing

concrete vocabulary accompanied by pictorial representations. These 50 items were further

divided into 14 sub-category variables. The individual items were presented to the students in an

interview format, and the students were asked to choose an alternative on a five point Likert

scale for each item that best corresponded with how frequently the statement was true for them,

from "never" to "always". Results for the 14 variables on the Social Awareness Measure were

analyzed according to hearing status, gender, and age by analysis of variance (ANOVA)

measures. Significant findings for children with hearing loss included increased reports of

physical aggression and general verbal interactions than their peers with normal hearing, and

fewer reports of verbal emotional expression and verbal aggression. Age and gender effects

were also demonstrated.









Elkayam and English (2003) modified the adult versions of the Self Assessment of

Communication (SAC) and the Significant Other Assessment of Communication (SOAC)

(Schow & Nerbonne, 1982) for use with an adolescent population in order to determine its

potential for use by educational audiologists as a personal adjustment counseling tool. The

significant others employed in this study were friends with normal hearing with whom the 15

participants with hearing loss identified as having at least one class in common and as having

interaction with outside school. Once both the SAC and the SOAC were completed, the first

investigator met with the adolescent with hearing loss to discuss answers provided by both

respondents in an informational and personal adjustment counselling session. The follow-up

meetings with respondents were audio-taped and subsequently transcribed. A qualitative analysis

of the recurring themes of the sessions utilizing a file-card protocol was conducted independently

by each of the investigators and then compared for consistency. Five themes identified in the

investigation were: 1) The Inherent Isolation of Hearing Loss; 2) Identity and Self-Concept; 3)

Cosmetics and Other Hearing Aid Issues; 4) Problem Solving; and 5) Self-Acceptance.

Use of SSRS in Children with Communication and/or Sensory Impairments

Buhrow, Hartshorne and Bradley-Johnson (1998) examined both parent and teacher ratings

of the social competence of children who were blind. Twenty mainstreamed elementary-school

students who met the criteria for "legal" blindness were evaluated by both a parent and a teacher

on the Parent Rating Scale and the Teacher Rating Scale of the SSRS, respectively. Parent and

teacher ratings were compared via independent sample t-tests to the SSRS standardization norms

acquired from 1021 teachers and 812 parents of children with sight. Results for the parents of

the blind children indicated significantly lower rating on the Assertion Subscale as compared to

the normative ratings. The teachers of the blind children also rated them significantly lower than









the normative ratings from the sighted normative sample on the Cooperation subscale. Other

overall and subscale ratings were not significantly different between groups.

Koning and Magill-Evans (2001) utilized the SSRS parent-, teacher- and self-rating forms

to evaluate social skills in twenty-one boys aged 12-15 identified with Asperger Syndrome as

compared to twenty-one boys matched on age who were recruited from local schools.

Significant differences (at the p < .001 level) between the experimental and the control groups

were found via MANOVA analysis for all three rater sets for the Total Skill Ratings on the

SSRS. Additionally, significant differences were found between groups for the Assertion,

Cooperation, and Self-Control subscales of the parent and teacher rating forms, and the

Responsibility subscales of the parent form. Aside from the Overall Social Skill self-ratings, the

only subscale rating for the children that reached statistical significance was Assertion. This

study confirms the use of the SSRS in a group of children who commonly experience language

and social skill interaction difficulties. It also highlights the importance of obtaining ratings

from the child with the suspected difficulties as well as observers such as their parents or

teachers, as perceptions vary based on experience and environment of observation.

Cartledge, Cochran and Paul (1996) utilized an early version of the SSRS Self-Report

(SSRS-S; Gresham & Elliot, 1990) to evaluate social competence between three groups of

adolescents (ages 12 to 21 years) with hearing loss enrolled in varying educational settings. The

first group of students attended a residential school for the hearing impaired which utilized a

Total Communication approach, the second group of adolescents with hearing loss were enrolled

in a public school Total Communication program, and the third group of adolescents with

hearing loss attended a public school program which utilized an Oral approach. Of the 72

adolescents who participated in the study, 35 participants were in the residential school group, 19









participants were in the public school oral program group, and 18 of the participants were

enrolled in the public school Total Communication program. It should be noted, however, that

the two groups of students enrolled in the public school programs spent the majority of their

school days in self-contained classrooms for the hearing impaired. Additionally, the majority of

the female participants (70.2%) were in the public school groups, and the majority of the

younger children (80.6%) attended the residential school. Findings on the SSRS-S varied by

educational setting, gender, and age, with students in the two mainstreamed educational settings

indicating significantly greater social competence ratings than the group of participants in the

residential program. Cartledge, Cochran and Paul (1996) suggested that either the students with

public schools groups a greater chance to evaluate themselves in a more challenging

"mainstream" environment in light of their peers with hearing loss within their self-contained

classroom, or that perhaps the students that were more socially competent to begin with were

placed in the public schools. However, as older students and female students tended to rate

themselves more highly than younger students and male students, the analysis must interpreted

with caution as gender and age variables were not uniform among the groups.

Use of the BASC in Children with Language Impairment

Redmond (2002) evaluated and discussed the differences of five commonly used

behavioral rating scales for use with children with language impairment. The Louisville

Behavior Checklist-Revised, the Revised Behavior Problem Checklist, the Achenbach System

(Child Behavior Checklist and Teacher Report Form), the Conners Rating Scales-Revised, and

the BASC were compared and contrasted. Normative data for children with speech/language or

other learning disorders were either not presented or not incorporated in the normative sets

available for the Louisville Behavior Checklist-Revised, the Achenbach System (Child

Behavior Checklist and Teacher Report Form) or the Conners Rating Scales-Revised. The









Revised Behavior Problem Checklist had separate clinical norms available as established on a

sample of 158 children with learning disabilities, and the BASC reported that 1.9% of their total

normative sample was comprised of children with speech and/or language disorders. While

current prevalence data for speech and language disorders is closer to 6 to 8% of the general

population, the BASC was the only rating system of those evaluated to employ a measure to

guard against excessively negative ratings. As students with speech/language disorders may be

regularly suspected as having socio-emotional disorders, Redmond (2002) cautions that

frequently the behavioral scales utilized may have inherent instrument bias, thus invalidating the

ratings. The use of multiple informants, the evaluation of differences across situations, and the

collection of local norms was recommended.

Use of COOP-A in Children with Hearing Loss

In their 1998 study, Bess, Dodd-Murphy, and Parker also reported on findings for the

COOP for 32 sixth- and ninth-grade children with minimal SNHL, conductive hearing loss, and

other (e.g., mixed) types of hearing loss, and for 591 children with normal hearing. Children

with hearing loss reported a trend of greater dysfunction than those with normal hearing on 9 of

10 COOP subscales in both the sixth- and the ninth-grade levels. Using a Mantel-Haenszel Chi-

square test, statistically significant differences were found between groups of 6th-graders for the

energy domain, and between groups of 9th-graders on the stress and behavior domains of the

COOP. Further statistical analysis by examination of only high scores of 4 or 5 on the various

subtests of the COOP indicated that the children with hearing loss displayed lower self-esteem

and energy than their sixth-grade peers and lower social support, higher stress and lower self-

esteem than their ninth-grade peers. These higher self-ratings were chosen for further

investigation, as the authors of the COOP (Wasson et al., 1994) have suggested that scores of 3,

4 or 5 on each chart indicate that children may be at risk for greater dysfunction in that area.









Hicks and Tharpe (2002) also examined the health status of ten children between the ages

of 6 and 11 years with either mild-to-moderate or high-frequency SNHL, and ten age- and grade-

matched counterparts with normal hearing. While no statistical significance between groups was

found, the authors noted that the percentage of the group of children with hearing loss that rated

themselves as 3 or higher (more dysfunction) on the COOP charts was greater compared to their

peers with normal hearing in seven of nine subscale questions administered. These trends

suggest more self-reported social and emotional problems forchildren with hearing loss than their

counterparts with normal hearing. The authors also postulated, as the majority of the study

participants with hearing loss utilized personal amplification devices, that the students' stress and

fatigue levels from energy expended on speech perception in adverse listening situations may

have been reduced by remediation of their disability and handicap through their use of

amplification. However, the small sample size utilized in the Hicks and Tharpe (2002) study

affected statistical findings and limited the conclusions.

Use of COOP-A in Children with APD

Kreisman, Crandell and Hall (2004) utilized the COOP-A in a preliminary study to

determine if any psychosocial difficulties similar to those exhibited by children with hearing loss

also existed in children with APD. As the COOP-A is intended to be a screening instrument

only, the primary purpose of the pilot was to explore possible future arenas of research. Ten

participants were included in the pilot study. Participants consisted of children between 9 years,

11 months and 14 years, 6 months old (M= 11;7). Standard peripheral auditory testing was

conducted, including pure-tone air conduction thresholds from 250 to 8000 Hz in octave

intervals, tympanometry, and distortion product otoacoustic emissions. Also, each participant

had a history of English as a first language, normal growth and development, and was free from

significant medical problems. The diagnosis of APD was made with a diagnostic evaluation









battery protocol based on guidelines delineated by the Report of the Consensus Conference on

the Diagnosis of Auditory Processing Disorders in School-Aged Children (Jerger & Musiek,

2000). An APD was defined by scores two standard deviations below the mean for at least one

ear on at least two different APD test battery procedures.

Following completion of the audiometric testing, children included in the study completed

a speech perception task, and subsequently were assessed with the COOP-A questionnaire. In

accordance with the COOP-A protocol (Wasson et al., 1994), the examiners instructed each child

to select the category (1 through 5) that most closely matched the child's own perception of how

they functioned on each subscale chart (e.g. Emotional Feelings, School Work, Pain). Whenever

possible, all questionnaires were administered verbally to the subjects in a face-to-face

interaction with the investigators. The students either responded verbally, by circling the

corresponding number, or simply by pointing to the desired category on the chart. When it was

not possible to complete the COOP-A in a face-to-face manner due to time constraints, parents

were given the questionnaire with instructions for their child to complete it at home, and return

the instrument by mail to the investigators. Using a slightly modified instruction set for the

purposes of the present investigation, the parents of the children with APD were also asked to

complete the COOP-A. Their instructions were to complete the ratings independently, by

responding to each chart via their perception of the most accurate answer for their child.

Results from the Kreisman, Crandell and Hall (2004) pilot study are shown in Figures 2-1,

2-2, and 2-3. Specifically, Figure 2-1 presents the mean ratings for each COOP-A question for

the experimental group (children with APD) compared to the mean ratings of children with

hearing loss (HL) and the mean ratings of children with normal hearing without APD (NH). The

results for the HL and NH control groups were derived from nationally-reported data (Hicks &









Tharpe, 2002). The mean age for the HL group was 8 years, 1 month, and the mean age for the

NH group was 7 years, 11 months. Of the twelve COOP-A charts administered, only eight

corresponded to those reported in Hicks and Tharpe (2002), due to the utilization of slightly

differing versions of the instrument. The eight COOP-A questions evaluated for the HL versus

NH groups were: Physical Fitness, School Work, Family, Emotional/Feelings, Self-Esteem,

Overall Health, Energy, and Pain. Mean ratings for the APD group were greater than those for

the NH group on six of eight subscales (School Work, Emotional/Feelings, Family

Communication, Self-Esteem, Overall Health, and Pain), suggesting greater psychosocial

dysfunction for the experimental group than the control group. Additionally, the APD group

mean ratings were greater than or equal to those of the group of children with hearing loss on six

of eight subscales, specifically: Physical Fitness, Emotional/Feelings, Family, Self-Esteem,

Energy and Pain.

Figure 2-2 displays the percentage of children in each group responding to a given COOP-

A question with a score of 3 or greater. A self-reported score of 3, 4 or 5 on any COOP-A

question indicates that a child may be at-risk for difficulties in that area (Wasson, et al, 1994).

The APD group percentages for 3 to 5 ratings were greater than or equal to their NH counterparts

on seven of eight subscale questions, specifically: Physical Fitness, School Work,

Emotional/Feelings, Family, Self-Esteem, Overall Health, and Pain. These pilot data again

suggest more psychosocial dysfunction by screening the data categorically for the experimental

group with APD than the NH controls. Figure 2-3 displays the mean ratings for each COOP-A

question for the experimental group (children with APD) compared to the mean ratings of their

parents for the various content areas.









In summary, preliminary findings suggested a trend for children with APD to exhibit

greater difficulties than their counterparts with normal hearing for a number of psychosocial

dimensions (e.g., self-esteem, family communication, school work, emotional/feelings and

overall health). The outcomes of the pilot study also suggested that the parents of children with

APD rate their children as having greater psychosocial difficulties than the children rate

themselves across a wide variety of psychosocial domains. The findings were limited, however,

as the experimental APD group was small (n = 10), and the compared hearing-impaired and

normal-hearing peer groups without APD were derived from nationally published, non-local data

with largely different mean ages. This research was a direct precursor to the present study.












O APD
23- HL

s52-- L Ln 0 m NH
1





4' 0 kv I 6\ 1

0

4 0

COOP Questions
Figure 2-1: Mean ratings across eight COOP subscales by children with auditory processing
disorders (APD), children with hearing loss (HL) and children with normal hearing
(NH). Data for the HL and NH groups were derived from Hicks & Tharpe (2002).
Self-ratings offered were from 1 to 5, with 1 representing the best function and 5
representing the most dysfunction for each question area.











0 IU
.- 60 0 APD
S50 OHL
S40-- NH
S30
20
10


00




COOP Questions

Figure 2-2: Percentage of children with auditory processing disorders (APD), children with
hearing loss (HL) and children with normal hearing (NH) scoring 3, 4 or 5 on any
COOP subscale, suggesting the child was at-risk for problems in that area. Data for
the HL and NH groups were derived from Hicks & Tharpe (2002).




















a)2-


*Parent
EDChildw/APD


& 0, 11 A e V1 1" 4

4
COOP Questions


Figure 2-3: Mean ratings across twelve COOP-A subscales by children with auditory processing
disorders and their parents. Ratings offered were from 1 to 5, with 1 representing the
best function and 5 representing the most dysfunction for each question content
domain.









CHAPTER 3
METHODS

Participants

Thirty-nine children served as participants in this study. They were divided into two

groups. The group of interest consisted of nineteen volunteer pediatric participants between ages

9.5 and 17.8 years with a diagnosis of APD (APD group). A corresponding gender- and age-

matched volunteer group (normal group) consisted of twenty children with no evidence of APD

nor any other medical or academic disability. Criteria for diagnosis of APD are described

below.

All participants met the following criteria:

Age between 10 and 18 years, +/- 6 months;

Pure-tone air conduction hearing threshold levels equal to or better than 15 dB hearing
level (HL) at all frequencies tested (250, 500, 1000, 2000, 3000, 4000, 6000 and 8000
Hz), bilaterally;

A score of 90 tol00% on monosyllabic word recognition testing in quiet at an intensity
level of 40 dB sensation level (SL) re: 3-frequency pure-tone average (PTA) of air
conduction thresholds at 500, 1000 and 2000 Hz;

Normal middle ear function as indicated by tympanometry;

Average or above intellectual function for age as measured by the Raven's Standard
Progressive Matrices (Raven, 1976), the Matrices Sub-Test of the Kaufman Brief
Intelligence Test-Second Edition (K-BIT 2; Kaufman & Kaufman, 2004), or documented
by another full-scale intelligence assessment completed by a licensed psychologist within
a time period of 2 years;

Negative history of attention deficit disorder or attention deficit hyperactivity disorder as
determined by parental report and normal performance on the Auditory Continuous
Performance Task (ACPT; Keith, 1994a), or attention skills within normal limits as
documented per previous evaluation by a licensed psychologist within a time period of
two years (the reader is directed to Chermak, Hall & Musiek, 1999; Chermak, Somers &
Seikel, 1998; and Chermak & Musiek, 1997 for further discussion of the differential
diagnosis of APD and ADD);

English as a primary language as reported by the participant's parent;









Normal growth and development and no history of significant medical problems via
parental report on the APD Parent/Patient Survey. A copy of this form can be found in
Appendix A.

In addition, all participants in the normal group had a history normal language

development as indicated by parent report and verified by the Clinical Evaluation of Language

Fundamentals-Fourth Edition (CELF-4) Screening Test. The CELF-4 Screening Test also was

administered to the participants of the APD group if they did not initially present with a

diagnosis of language disorder via parent or clinical report in order to identify a comprehensive

profile of these participants. The participants evaluated for inclusion in the APD group and the

normal group that did not pass the CELF-4 Screening Test were referred for a comprehensive

diagnostic language evaluation by a speech-language pathologist. The study was conducted in

two locations. Two participants from the APD group and four children in the normal group were

tested at the University of Florida in Gainesville, whereas the remaining participants (17 APD,

16 Normal) were tested at Towson University in Towson, Maryland.

Prior to participating in the study, each child's accompanying parent was required to sign

an Informed Consent Form (ICF) approved by the University of Florida Institutional Review

Board (IRB) if the participant was enrolled in the study in Gainesville, FL, and/or an ICF

approved by the Towson University IRB if the participant was enrolled in the study in Towson,

Maryland. Additionally, each pediatric participant was required to indicate a willingness to

participate in the study via a Child Assent Script approved by the respective IRBs. A copy of the

University of Florida Informed Consent Form and Child Assent Script is found in Appendix B,

and a copy of the Towson University Informed Consent Form is found in Appendix C. The

study was not blind in that all participants and their parents knew which study group (APD or

normal) they were being included during their completion of the questionnaires. All participants

received free hearing and auditory processing evaluations as well as a comprehensive written









report, trial use of a suitable FM system when appropriate, and a $20 Target Gift Card upon

completion of the research protocol.

Diagnosis of APD

An APD for a child was defined by scores two standard deviations below the mean for at

least one ear on at least two different procedures of the APD test battery. Following is a brief

summary of test administration and analysis for each of the assessments included in the APD

battery. Further details on test procedures are available from the sources cited for each

assessment.

The Synthetic Sentence Index with Ipsilateral Competing Message (SSI-ICM; Wilson &

Strouse, 1998; Noffsinger, Wilson & Musiek, 1994; Feeney & Hallowell, 2000) is comprised of

a closed set often nonsense sentences that have been constructed to approximate English

syntactic sentence structure. The nonsense sentences are presented against a background of an

ipsilateral noise competition comprised of a narrative discourse. Participants are required to

identify the nonsense sentences presented, given a numbered reference list from which to choose.

The Staggered Spondaic Word (SSW) Test (Katz, 1963; Katz, 1986) presents a series of

two spondees to the listener, first to one ear and then to the other, with the second part of the first

spondee and the first part of the second spondee presented simultaneously to opposite ears. The

listener is asked to repeat both spondees in the order in which they are presented.

The Dichotic Digits, Double Pairs Test (Audiology Illustrated, 1994; Musiek, 1983)

involves the presentation of a two numbers between 1-9 (except seven) to both ears at the same

time. The listener is asked to repeat the words from both ears in each set, in whatever order they

choose (free recall).

The Frequency Pattern Sequence test (Audiology Illustrated, 1994; Musiek, 1994) involves

the presentation of a series of groups of three different pitches. The listener is first asked to









report the patterns verbally (e.g., HIGH-LOW-HIGH), and then to report the presented patterns

by humming in repetition.

The Duration Pattern Sequence test (Audiology Illustrated, 1994; Musiek, 1994) presents

of a series of groups of three different length tones. The listener is asked to report the patterns

verbally (e.g., LONG-SHORT-LONG).

The Auditory Random Gap Detection Test (RGDT; Keith, 2000b) is a test in which two

tones are presented at varying time intervals. The listener is asked to report if they hear one tone

or two beeps in order to determine how close together the two sounds can be heard and still

differentiated.

If a participant scored two standard deviations below normal limits on one of the six

diagnostic auditory processing measures described above, the SCAN-C or SCAN-A Competing

Words, Auditory Figure Ground and Filtered Words subtests would also be administered. The

SCAN-C: Test for Auditory Processing Disorders in Children-Revised (Keith, 2000a) or

SCAN-A: Test for Auditory Processing Disorders in Adolescents and Adults (Keith, 1994b)

Competing Words Subtest involves the presentation of an open set of different monosyllabic

words to both ears at the same time. The listener is asked to repeat the words coming first into

the right ear, then into the left

The Filtered Words Subtest of the SCAN-C: Test for Auditory Processing Disorders in

Children-Revised (Keith, 2000a),or SCAN-A: Test for Auditory Processing Disorders in

Adolescents and Adults (Keith, 1994b) is a task in which speech is filtered above 500 Hz so that

certain frequencies are absent. The listener is asked to repeat the words presented from an open

set.









The Auditory Figure-Ground Subtest of the SCAN-C: Test for Auditory Processing

Disorders in Children-Revised (Keith, 2000a) or SCAN-A: Test for Auditory Processing

Disorders in Adolescents and Adults (Keith, 1994b) requires the listener to repeat words against

a background of competing multi-talker babble.

Psychosocial Measures

The Social Skills Rating System (SSRS; Gresham and Elliot, 1990), the Behavioral

Assessment System for Children-Second Edition (BASC-2; Reynolds and Kamphaus, 2004), and

The Dartmouth Primary Care Cooperative Charts for Adolescents (COOP-A; Wasson et al.,

1994) were utilized to assess psychosocial status. These questionnaires were utilized because

previous investigations have shown them to be valid for these purposes in children with hearing

loss or other communication disorders (Koning & Magill-Evans, 2001; Cartledge, Cochran &

Paul, 1996; Redmond, 2002; Bess, Dodd-Murphy & Parker, 1998; Hicks & Tharpe, 2002;

Kreisman, Crandell & Hall, 2004). The COOP-A pilot study (Kreisman, Crandell & Hall, 2004)

provided preliminary findings suggesting the use of the charts to be appropriate for use with

children with APD and their parents. Thus it was used in the present investigation. The

selection of the other two instruments investigation was based on the desire for more robust,

standardized comprehensive assessments of emotional and social function in children which

matched with the normative ages of the COOP-A (10-18 years), had both self-report and parent

rating forms, and yielded subscale measurements that would lend themselves to comparable

analysis across instruments.

The Social Skills Rating System (SSRS)

The SSRS provides information on the positive and negative social skill behaviors

exhibited by students in and out of the classroom (Gresham and Elliot, 1990). The SSRS was

standardized on a sample of 4170 children in the United States. The SSRS items are rated









according to both perceived frequency (Never, Sometimes, or Very Often) and importance (Not

Important, Important, or Critical). The Social Skills Scale of the SSRS contains five subscales

that measure positive social behaviors. The five subscales incorporated into the Social Skills

Scale of the SSRS are Cooperation, Empathy, Assertion, Self-Control, and Responsibility. The

Problem Behaviors Scale of the SSRS measures behaviors that can interfere with the

development of positive social skills. The three subscales incorporated into the Problem

Behaviors Scale of the SSRS are Externalizing Problems, Internalizing Problems, and

Hyperactivity. Internal consistency is high for SSRS roms and levels, with median coefficient

alpha reliability scores of .90 and .84 for the Social Skills and Problem Behaviors Scales,

respectively. Test-retest reliability coefficients ranged from .77 to .84 for parents and .52 to .66

for students on the Social Skills subscales, suggesting adequate to good stability on repeated

measurements with the SSRS over time. The information that the SSRS provides can be utilized

in order to suggest possible interventions for students with problems learning or demonstrating

appropriate social skills behaviors by examination of their causes.

The Behavioral Assessment System for Children-Second Edition (BASC-2)

The BASC-2 provides a profile of adaptive and maladaptive behaviors and emotions of

children and adolescents ages 2 through 21 years (Reynolds and Kamphaus, 2004). The BASC-2

has forms designed specifically for use by parents with a different section designed for use by the

students themselves. The General norm sample of the BASC-2 was conducted on 4800 parents

and 3400 children. 2.1% of the standardization population of the BASC-2 was comprised of

children with language impairment. The Parent Rating Scales (PRS) of the BASC-2 are used to

measure both adaptive and problem behaviors in both the community and home settings in 14

subcategories utilizing a four-choice response format. Examples of subcategories of the PRS

include Adaptability, Anxiety, Leadership, Depression, Functional Communication, and









Withdrawal. Internal consistency of the PRS composite scores as measured by coefficient alpha

are between .90 and .95. PRS test-re-test reliability is also high, with estimates for the composite

scores from .78 to .92. The Self-Report of Personality (SRP) scale of the BASC-2 has been

reported to provide insight into a child's own thoughts and feelings. The SRP is a self-report

questionnaire that measures 16 subcategories of attitudes and emotions including Attitude to

School, Locus of Control, Interpersonal Relations, Social Stress, and Self-Esteem. Internal

consistency of the SRP composite scores as measured by coefficient alpha are also high, ranging

between .83 and .96. SRP test-re-test reliability is also high, with estimates in the upper .70s to

low .80s. The BASC-2 is widely used by school and clinical psychologists in determining

Individuals with Disabilities Education Act (IDEA) and Diagnostic and Statistical Manual of

Mental Disorders-Fourth Edition (DSM-IV) classifications.

The Dartmouth Primary Care Cooperative Information Project Charts for Adolescents
(COOP-A)

The COOP-A is a quality of life screening instrument designed for use with individuals

between ages 10 and 20 years (Wasson et al., 1994). The COOP-A charts are designed to screen

across physical, emotional, and social dimensions of functioning in an individual. The COOP-A

consists of a series of pictographic self-rating charts that are designed to represent function of

one of 12 content areas. The twelve subscale charts included in the COOP-A are: Physical

Fitness, Energy, Pain, School Work, Behavior, Stress and Emotional Feelings, Social Support,

Family, Self Esteem, Health Habits I, and Overall Health. Each individual chart consists of a

question and five illustrative alternatives from which an individual may choose an answer most

appropriate for him or herself based on a five-point Likert scale wherein 5 represents the greatest

dysfunction and 1 represents the least dysfunction. An example question on the Family chart of

the COOP-A is: "During the past month, how often did you talk about your problems, feeling or









opinions with someone in your family?" Corresponding alternatives from which to choose are as

follows: 1 = All of the time, 2 = Most of the time, 3 = Some of the time, 4 = A little of the time,

and 5 = None of the time. Wasson, Kairys, Nelson and colleagues (1994) indicated that average

test-retest correlations ranged from .71 to .80 for the Physical Fitness, Emotional Feelings,

School Work, Social Support, Family Communication and Health Habits, and Cronbach's alpha

test for internal consistency-reliability was between .60 and .94 for those six dimensions.

Procedures

Audiological Assessment

The first thirty-nine children who met the inclusion criteria as stated above and agreed to

serve as subjects were included as participants. Participants were recruited from the Department

of Communication Sciences and Disorders/University of Florida Speech and Hearing Clinic

(UFSHC), the University of Florida Department Of Communicative Disorders Speech and

Hearing Center at Shands Hospital, the Speech-Language-Hearing Clinic (TUSLHC) and the

Center for Amplification, Rehabilitation and Listening (CARL) at Towson University.

Participants also were recruited from self-referrals following advertisements in local parent

magazines and educational newsletters, as well as flyers distributed at informational events for

parents, educators and other professionals seeking more information on speech, language, and

auditory disorders in children. A copy of the recruitment flyer is found in Appendix D. The 39

children who met the other inclusion criteria to be participants first underwent pure-tone

audiometry. The pure-tone air conduction test consisted of octave intervals from 250 through

8000 Hz, as well as the interoctaves 3000 and 6000 Hz. Hearing sensitivity was tested in sound-

treated booths using a calibrated Grason-Stadler, Inc. Version 61 (GSI-61) two-channel clinical

audiometer and either Etymotic Research version 3A EAR-Tone Insert Earphones (ER-3A) or

TDH-50 supra-aural audiometric earphones. Participants were be required to have pure-tone air









conduction thresholds better than or equal to 15 dB HL at all frequencies (250 through 8000 Hz)

tested in both ears in order to participate in the study. Word recognition performance was

assessed utilizing the NU-6 Ordered by Difficulty Version II lists presented via compact disc

presentation (Auditec of St. Louis, 1980; Hurley & Sells, 2003). In order to be included in the

study, participants were required to have a percent correct score of 90 to 100% on these

monosyllabic word tasks in quiet at 40 dB SL re: the average of their pure-tone air conduction

thresholds at 500, 1000 and 2000 Hz (PTA).

Tympanograms and acoustic reflex thresholds were obtained via a GSI-33 or GSI

Tympstar Middle Ear Analyzer. Both groups of participants were required to have normal

middle ear function, as defined by middle ear peak pressure values between -150 to +100

decaPascals (daPa), static compliance of 0.3 to 1.4 milliliters (ml), and ear canal volume of 0.6 to

1.5 cubic centimeters (cm3) in both ears. Distortion product otoacoustic emissions (DPOAE)

measurement was conducted using either an Otodynamics ILO 92 v.6 DPOAE System or a

Grason Stadler Audera DPOAE system. The ILO v.6 device was configured using the

Diagnostic 65/55 stimulus and the Diagnostic configuration.

Intellectual Assessment

All participants (except four who had previous documentation of average or above-

average intelligence as tested by a licensed psychologist within a two-year time period) were

given either the Raven's Standard Progressive Matrices (n = 1) (SPM; Raven, 1976) or the

Matrices sub-section assessment of the Kaufman Brief Intelligence Test-2nd Edition (n = 34) (K-

BIT 2; Kaufman & Kaufman, 2004) in order to screen for normal non-verbal intellectual

functioning. The scores on the Raven's SPM and the K-BIT 2 are highly correlated with non-

verbal intelligence measures on more comprehensive measures of intelligence as well as with

each other. The Raven's SPM was initially chosen for use in the present research study, but was









abandoned for the K-BIT 2 due to improved time and ease administration and scoring.

Participants were tested individually in a quiet room in the UFSHC, the TUSLHC or the CARL,

utilizing the Raven's SPM testing booklets or the K-BIT 2 test kit, and following the

administration procedures as outlined in the respective test manuals. Answers were recorded by

the test administrator on the corresponding answering sheets, and scored accordingly. The

results on the Raven's SPM were compared to Table SPM9, Smoothed Summary Norms for

Children and Young People in the United States of America. Scores at or above the 25th

percentile were considered to be average or above average intellectual function for the Raven's

SPM. The results on the K-BIT 2 were compared to the Nonverbal portion of Table B. 1: Verbal

and Nonverbal Standard Scores, Confidence Intervals and Percentile Ranks. Standard scores at

or above 85 for the corresponding age group were considered to be average or above average

intellectual functioning for the K-BIT 2.

Language Assessment

Language screening of all participants was conducted via the CELF-4 Screening Test

(Semel, Wiig & Secord, 2003). Participants were tested individually in a quiet room, using the

CELF-4 Screening Test booklet, and following the administration procedures as outlined in the

CELF-4 Manual. All participants who did not pass the CELF-4 Screening Test were referred for

a comprehensive language evaluation by a speech-language pathologist. Prospective normal

participants who did not pass the CELF-4 Screening Test were not included in the study.

APD Assessment

APD assessment was conducted in a single-walled sound-treated booth (Industrial

Acoustics Company) using a calibrated GSI-61 clinical audiometer and ER-3A insert earphones.

The following APD procedures, as described above, were administered to all of the study

participants:









Synthetic Sentence Index with Ipsilateral Competing Message (SSI-ICM);
Staggered Spondaic Word (SSW) test;
Dichotic Digits, Double Pairs test;
Frequency Pattern Sequence test, both verbal and hummed response modes;
Duration Pattern Sequence test;
Auditory Random Gap Detection Test (RGDT).

Any participant who did not have previous clinical documentation of attention within normal

limits underwent assessment with the Auditory Continuous Performance Task (ACPT). In

addition to the above procedures, any participant who was considered for inclusion in the APD

group for the study due to results two standard deviations below the mean on any of the six

diagnostic APD procedures previously mentioned also completed the SCAN-C or SCAN-A: Test

for Auditory Processing Disorders in Children-Revised, Competing Words Subtest, Filtered

Words Subtest and Auditory Figure-Ground Subtest.

Standard administrative and scoring procedures, as outlined in the manuals for each APD

test, were followed. As previously detailed, an APD diagnosis was made if a child scored two

standard deviations below the mean on at least two different APD test procedures for at least one

ear, with at least one of the failed procedures from the diagnostic assessments other than the

SCAN-A or SCAN-C subtests (ASHA, 2005).

Psychosocial Assessment

Psychosocial assessment of all thirty-nine participants included in the study was conducted

via the SSRS, the BASC-2, and the COOP-A questionnaires. All participants were tested

individually in quiet rooms of the UFSHC, the TUSLHC or the CARL. Administration

procedures as outlined in the respective test manuals were followed. The accompanying parents

of the participants were asked to complete their appropriate questionnaires independently,

utilizing a pencil and paper version of the assessments. For the SSRS and the BASC-2

questionnaires, parents were asked to complete the questionnaires according to the printed









instructions. For the COOP-A, the parents were asked to respond to each chart according to their

perception of their participating child's function in each given area. They were instructed to ask

questions of the investigator if any item was unclear.

The same examiner administered the questionnaires to all pediatric participants in both

sites. When written or verbal language disorders were previously diagnosed or were suspected

due to parental report or below-criterion performance on the CELF-4 Screening Test, pediatric

participants were given the psychosocial test assessments in an interview format. In order to

minimize any possible effects of the interviewer on the response pattern of the participant, the

examiner sat beside the participant at a table, utilizing the questionnaire as a mutual reference

point. Pediatric participants were instructed to respond to each individual item on the

questionnaires either by verbal or pointed responses, and the examiner recorded the child's

responses accordingly on the questionnaire's corresponding answer sheet. When no language

disorders were suspected, the participant was given a choice as to whether they would like the

examiner to read the questions, or if they would like to complete the questionnaires on their own.

When independent completion was chosen, test instructions were given for standard self-

administration procedures, with the examiner available in the room to answer questions. All

participants were encouraged to answer as openly as possible, according to what they believed to

be true for themselves, and only the subject's final response to any given item was recorded.

Additionally, all participants were reassured that the confidentiality of their responses would be

maintained, and that their parents would not know of their responses to the questionnaires unless

discussed with them first. In order to discourage any conscious or unconscious influence in the

pediatric participants' responses, parents were discouraged from being present in the room

during psychosocial assessment of their children.









Statistical Analyses

Statistical analyses were conducted to explore differences between groups on psychosocial

subscale scores. Multivariate analysis of variance (MANOVA) procedures were initially

explored as a means of examining the differences between the two groups across the three

different psychosocial assessment subscales. However, upon preliminary review the data were

found to violate the assumptions of multivariate normality and linearity, and thus were not

appropriate for the MANOVA analysis procedure. Standard two-group analysis procedures were

utilized instead, comparing each group on each subscale of the three instruments.

T-tests were completed on the continuous scales (SSRS and BASC-2) while a non-

parametric equivalent (Mann-Whitney U test) was completed for comparison of the COOP-A

ordinal data. Statistical significance was defined byp < 0.05 (two-tailed) for all tests. Due to the

relatively small group sizes, eta-squared and r-square values were calculated for the continuous

and ordinal data, respectively, to assess effect sizes and magnitudes of the differences between

groups as a measure of generalizability of the findings. Pallant (2005) indicated that eta-squared

"represents the proportion of variance in the dependent variable that is explained by the

independent variable" (p. 208). Eta-squared was calculated by the following formula:

t2
t 2+(N+N2-2)

For the COOP-A subscale charts, r-square values (Z-value of Mann-Whitney U divided by the

square root of N) were calculated (Rosenthal, 1991). Effect sizes were interpreted based on the

following classification guidelines (Cohen, 1988): .010 to .059= small effect, .060 to .139 =

moderate effect, .140 and above = large effect.

The creators of the COOP-A suggested the utilization of a dichotomous categorization into

"Average" (ratings of 1 or 2) or "At-Risk" (ratings of 3, 4 or 5) assemblages by practitioners in









order to determine possible need for further follow-up on the particular content area represented

by each subscale chart (Wasson et al, 1994). Thus, chi-square tests for independence were

conducted between groups on the proportion of Average or At-Risk classifications for each

subscale chart. Again, statistical significance was defined by p < 0.05 (two-tailed) for the

Pearson chi-square values. As Rosenthal and Rosnow (1991, p. 51) assert that "very usable x2

values can be obtained even with expected frequencies as low as 1, so long as the total number of

independent observations (N) is not too small" and "corrections for continuity may do more

harm than good," no corrections were employed when analyzing this data.

Post-hoc analyses were also conducted to examine any possible differences between

gender and age of the pediatric participants of both groups as well as linguistic function status of

the APD group. The Spearman Rank Order Correlation (rho) test for non-parametric data and

Pearson product-moment correlation coefficients (r) for continuous variables were utilized in

order to evaluate possible correlations between subscale scores and age. To assess differences

between genders and mean ratings on the composite subscales of the BASC-2 and the SSRS,

independent-samples t-tests were conducted. The non-parametric equivalent, the Mann-Whitney

U, was utilized in order to assess differences between gender and mean rank of the COOP-A

subscales.

Post-hoc analyses also were conducted on all subscales of each of the three psychosocial

questionnaires (COOP-A, SSRS, and BASC-2), comparing the results for the pediatric

participants in the APD group with confirmed or suspected language impairment (language-

impaired APD subgroup, n = 9) to those of the pediatric participants in the APD group with

normal language function (language-normal APD subgroup, n = 10). The parent responses on

the three psychosocial instruments for the two APD subgroups were also compared. As with the









normal v. APD group comparisons, statistical analyses for all composite subscales of the BASC-

2 and subscales of the SSRS were conducted utilizing independent-samples t-test measures, and

the Mann-Whitney U test for non-parametric data was utilized for analysis of the COOP-A

subscale charts. Statistical significance was defined by p < 0.05 (two-tailed).









CHAPTER 4
RESULTS

Descriptive data were compiled for gender, age, linguistic function status, grade level, and

type of school (public, private, and home) between the normal and APD groups. A summary of

descriptive statistics can be found in Table 4-1. Preliminary analyses were completed to

determine if any differences existed between the normal and APD groups on age or gender.

Results indicated that there was no age difference between the normal group (M= 12.79, SD =

2.347) and the APD group [M= 11.93, SD= 2.093; t(37) = -1.199,p =.238]. A chi-square test

for independence was conducted between groups on the proportion of males and females, with

statistical significance defined by p < 0.05 (two-tailed) for the Pearson chi-square values. No

difference on gender was found (x2 = .265, n = 39). As two parents in the normal group did not

complete their questionnaires by the time of this publication, their data could not be included.

All parent raters (n = 37) were female (i.e. mothers).

Initial descriptive findings were evaluated in order to ensure comparable peripheral hearing

status between groups. Audiometric results were within normal limits (pure-tone thresholds <15

dB HL) for all participants in both groups at 250, 500, 1000, 2000, 3000, 4000, 6000 and 8000

Hz per inclusion criteria. Mean audiometric findings for both groups are displayed in Figure 4-1,

and means and standard deviations for both groups by frequency are detailed in Table 4-2.

Tympanometric results were also within normal limits for all participants in both groups per

inclusion criteria. Mean tympanometric data are detailed for right and left ears of both the

groups in Table 4-3. Mean diagnostic distortion product otoacoustic emissions (DPOAEs) were

within normal limits for both groups. However, a small and equivalent proportion of participants

in each group had DPOAE amplitudes below normal limits for one or more test frequencies.

Graphs of compiled DPOAE findings with means for the participants tested at Towson









University for the APD group are shown in Figure 4-2 and for the normal group are shown in

Figure 4-3. Using the diagnostic auditory processing test battery criterion, a student was

diagnosed with an auditory processing disorder if findings for at least one ear were two standard

deviations below the mean on at least two different procedures. A summary of results on the

APD test battery for those students who were included in each group is shown in Table 4-4.

Statistical analyses were conducted on each of the three instruments (COOP-A, BASC-2,

and SSRS), as determined a priori, comparing the results for the pediatric participants in the

APD group to those of the pediatric participants in the normal group, and comparing the results

of the parents of the participants in the APD group to those of the parents of the participants in

the normal group. Statistical analyses were completed using SPSS 13.0 for Windows (Chicago,

IL: SPSS Inc.). See Table 4-5. for a summary of findings and Table 4-6 for details of statistical

results between pediatric participant groups. See Table 4-7 for a summary of findings and Table

4-8 for details of statistical results between parent groups, as described below. In addition, a

summary of statistically significant findings for both children and adults can be found in Table 4-

9.

Child-Completed Dartmouth Primary Care Cooperative Information Project Charts for
Adolescents (COOP-A)

Recall that each individual chart of the COOP-A is its own subscale screener and consists

of a question and five illustrative alternatives from which an individual may choose the most

appropriate answer. Ratings for each chart are based on a five-point Likert scale wherein 1

represents the least dysfunction and 5 represents the greatest dysfunction in any given domain.

The Mann-Whitney U test for non-parametric data was utilized in order to compare Sum of

Ranks for all subscale charts on the COOP-A due to the ordinal nature of the data, and r-square

values were calculated to assess effect sizes. Additionally, as the creators of the COOP-A









suggested the utilization of a dichotomous categorization into "Average" (ratings of 1 or 2) or

"At-Risk" (ratings of 3, 4 or 5) assemblages by practitioners in order to determine possible need

for further follow-up (Wasson et al, 1994), chi-square tests for independence were conducted

between groups on the proportion of Average or At-Risk classifications for each subscale chart.

See Table 4-10 for a summary of findings for proportions of students considered "At-Risk" from

both groups for each subscale chart.

Physical Fitness Subscale Chart

The Physical Fitness subscale chart for the COOP-A asks the question, "During the past

month, what was the hardest physical activity you could do for at least 10 minutes?" Results

indicated no difference between the two groups (p = .417). The effect size was small (r2 = .017).

The mean ranks were 21.25 and 18.68 for the normal and APD groups, respectively. The

Pearson chi-square value was .136, suggesting no difference for the proportion of participants

classified as "Average" or "At-Risk" between the APD and normal groups.

Pain Subscale Chart

The Pain subscale chart of the COOP-A poses the question, "During the past month, how

often were you bothered by pains such as; backaches, headaches, cramps or stomachaches?"

Results indicated no difference between the APD group and the normal group (p =.319). The

effect size was small (r2 = .025). The mean ranks were 18.33 and 21.76 for the normal and APD

groups, respectively. The Pearson chi-square value was .648, suggesting no difference exists for

the proportion of participants classified as "Average" or "At-Risk" between the APD and normal

groups.

Stress Subscale Chart

The Stress subscale chart of the COOP-A poses its question this way: "During the past

month, how much stress or pressure do you feel from other people? (family, friends, teachers,









other grown-ups or other kids)" Results suggested no difference between the two groups for this

subscale (p = .145). However, the effect size was moderate (r2 =.055). The mean ranks were

17.55 and 22.58 for the normal and APD groups, respectively, suggesting a trend for the APD

group to report more problems with stress. Further, in contrast to the results of the Mann-

Whitney U analysis, the Pearson chi-square value was .034, suggesting a difference exists for the

proportion of participants classified as "Average" or "At-Risk" between the APD and normal

groups. Further review indicates there to be 80% of the normal group ratings falling in the

"Average" category versus 47.4% of the APD group, and 20% of the normal group ratings

falling in the "At-Risk" category versus 52.6% of the APD group. These findings also indicate a

greater proportion of students within the APD group rate themselves as "At-Risk" for problems

with stress than do students in the normal group.

School Work Subscale Chart

The School Work subscale chart of the COOP-A asks, "During the last month you were in

school, how did you do?" Results suggested no difference between the APD group and the

normal group (p = .131). The effect size was moderate (r2 = .058). The mean ranks were 17.55

and 22.58 for the normal and APD groups, respectively. The Pearson chi-square value was .134,

suggesting no difference exists for the proportion of participants classified as "Average" or "At-

Risk" between the APD and normal groups.

Emotional Feelings Subscale Chart

The Emotional Feelings subscale chart of the COOP-A asks the question, "During the past

month, how often did you feel anxious, depressed, irritable, sad or downhearted and blue?"

Results indicated a difference between the APD group and the normal group (p = .011) with a

large effect size (r2 = .165). Recall that with the Mann-Whitney U for the COOP-A, the group

with the greater mean rank represents the group with greater reported psychosocial difficulties









for that subscale chart. The mean rank for the normal group was 17.55 and the mean rank for the

APD group was 22.58, indicating greater reported difficulties on the Emotional Feelings subscale

for the APD group. However, the Pearson chi-square value was .095, suggesting no statistically

significant difference exists for the proportion of participants classified as "Average" or "At-

Risk" between the APD and normal groups.

Behavior Subscale Chart

The Behavior subscale chart of the COOP-A poses the question, "During the past month,

compared to other kids your age, has your behavior caused problems for you or other persons?"

Results suggested no difference between the two groups for this subscale (p = .261) with a small

2
effect size (r2= .032). The mean ranks were 18.20 and 21.89 for the normal and APD groups,

respectively. There was no difference between the APD and normal groups for the proportion

of participants classified as "Average" or "At-Risk" (Pearson chi-square value of .267).

Social Support Subscale Chart

The Social Support subscale chart of the COOP-A asks, "During the past month, if you

needed someone to listen or to help you, was someone there for you?" Results suggested no

difference between the APD group and the normal group (p = .106). In contrast to this non-

significant finding, the effect size was moderate (r2 = .067), with the mean rank for the normal

group at 17.40 and the mean rank for the APD group at 22.74. The effect size indications

suggest a trend for the participants in the APD group to rate themselves as having more

difficulties with social support than their counterparts in the normal group. The Pearson chi-

square value was .267, suggesting no difference for the proportion of participants classified as

"Average" or "At-Risk" between the APD and normal groups. This is possible as though the

proportions of participants that fall into the 2 categories may not be related, the effect size









calculation (r2) is based on the ranks of the ratings for each group, and so may differ from the

nominal analysis that the Pearson chi-square value provides.

Self-Esteem Subscale Chart

The Self-Esteem subscale chart of the COOP-A poses the question, "During the past

month, how often have you felt badly about yourself?" There was no difference between the two

groups for this subscale (p= .189). The effect size was small (r2 = .044). The mean ranks were

18.38 and 21.71 for the normal and APD groups, respectively. The Pearson chi-square value

was .184, suggesting no difference for the proportion of participants classified as "Average" or

"At-Risk" between the APD and Normal groups.

Family Subscale Chart

The Family subscale chart of the COOP-A asks, "During the past month, how often did

you talk about your problems, feelings or opinions with someone in your family?" For this

subscale, there was no difference between the APD group and the normal group (p = .336). The

effect size was small (r2 = .024). The mean rank for the normal group was 18.38 and the mean

rank for the APD group was 21.71. The Pearson chi-square value was .421, confirming no

difference for the proportion of participants classified as "Average" or "At-Risk" between the

APD and normal groups.

Health Habits I

The Health Habits I subscale chart of the COOP-A poses its question this way: "During the

past month, how often did you do things that are harmful to your health such as:

smoke cigarettes or chew tobacco
have unprotected sex
use alcohol including beer or wine?"
There was no difference between the APD group and the normal group (p =.330). The effect

size was small (r2 = .024). The mean ranks were 20.48 and 19.50 for the normal and APD









groups, respectively. The Pearson chi-square value could not be determined as all ratings for

both groups were constant within the "Average" classification.

Overall Health Subscale Chart

The Overall Health subscale chart of the COOP-A asks the question, "During the past

month, how would you rate your health?" There was a difference between the APD group and

the normal group (p= .037) with a moderate effect size (r2 .111). Recall that with the Mann-

Whitney U for the COOP-A, if there is a statistically significant difference, the group with the

greater mean rank represents the group with greater reported psychosocial difficulties for that

subscale chart. The mean rank for the normal group was 16.53 and the mean rank for the APD

group was 23.66, indicating lower reported overall health on this subscale chart for the APD

group. Despite the findings on the Mann-Whitney U, the Pearson chi-square value was .060,

suggesting no statistically significant difference exists for the proportion of participants

classified as "Average" or "At-Risk" between the APD and normal groups.

Energy Subscale Chart

The Energy subscale chart of the COOP-A asks, "During the past month, how often did

you feel tired?" There was no statistically significant difference between the two groups for this

subscale (p= .220), and the effect size was small (r2= .039). The mean ranks were 21.98 and

17.92 for the normal and APD groups, respectively. There was also no statistically significant

difference for the proportion of participants classified as "Average" or "At-Risk" between the

APD and normal groups (Pearson chi-square value of .060).

Social Skills Rating System (SSRS), Student Forms

The items on the Student Forms of the SSRS are rated on a three-point Likert scale

according to perceived frequency, where "Never" = 0, "Sometimes" = 1, and "Very Often" = 2.

The four subscales incorporated into the Social Skills Scale for the Student Forms (Elementary









and Secondary Level) of the SSRS measure positive social behaviors, with higher ratings

indicating greater self-perceived skill. The four Student Form Social Skills subscales are

Cooperation, Assertion, Empathy and Self-Control. To assess differences between group mean

ratings on the subscales of the SSRS, independent-samples t-tests were conducted and eta-

squared values were calculated to assess effect sizes.

Cooperation Subscale

The Cooperation subscale of the SSRS asks students to rate how often they complete social

behaviors that are presented, such as: "I finish classroom work on time." For the Cooperation

subscale for the SSRS Student Forms (combined Elementary and Secondary ratings), there was

no difference between scores for the normal group (M= 15.53, SD = 2.695) and the APD group

[M= 14.68, SD = 2.451; t(36) = 1.008,p =.320]. The magnitude of the differences in the means

was small (eta squared = .026).

Assertion Subscale

The Assertion subscale of the SSRS asks students to rate how frequently they complete

associated social behaviors, for example: "I start talks with class members." For the Assertion

subscale for the SSRS Student Forms, there was no difference between scores for the normal

group (M= 13.95, SD = 3.677) and the APD group [M= 14.84, SD = 2.035; t(37) = -.943, p =

.353]. The effect size of the differences in the means was small (eta squared =.023).

Empathy Subscale

The Empathy subscale of the SSRS asks students to rate how often they complete social

behaviors that are presented, such as: "I feel sorry for others when bad things happen to them"

and "I listen to my friends when they talk about problems they are having." For the Empathy

subscale for the SSRS Student Forms (combined Elementary and Secondary ratings), there was

no significant difference between scores for the normal group (M= 16.45, SD= 2.743) and the









APD group [M= 16.47, SD = 2.435; t(37) = -.028,p =.977]. The magnitude of the differences

in the means was very small (eta squared = .00002).

Self-Control Subscale

The Self-Control subscale of the SSRS asks students to rate how frequently they complete

associated social behaviors, for instance: "I control my temper when people are angry at me."

For the Self-Control subscale for the SSRS Student Forms, there was no difference between

scores for the normal group (M= 12.80, SD = 3.270) and the APD group [M= 12.80, SD =

3.270; t(37) = .917, p = .365]. The effect size of the differences in the means was small (eta

squared = .022).

Behavioral Assessment System for Children-Second Edition (BASC-2), Self-Report Forms

The items on the Self-Report Forms of the BASC-2 are rated according to either a

true/false forced choice paradigm, or a four-point Likert scale according to self-reported

frequency of "Never," "Sometimes," "Often," or "Almost Always." The five composite

subscales of the BASC-2 that are incorporated into the Self-Report Forms utilized (both the Self-

Report-Child and the Self-Report-Adolescent) are School Problems, Internalizing Problems,

Inattention/Hyperactivity, Emotional Symptoms Index, and Personal Adjustment. To assess

differences between group mean ratings on the composite subscales of the BASC-2,

independent-samples t-tests were conducted and eta-squared values were calculated to assess

effect sizes.

School Problems Composite Subscale

The School Problems composite subscale asks students to rate their thoughts, feelings and

behaviors for such content areas as attitude to school, attitude to teachers, and the structure of the

educational process. High scores on the School Problems composite subscale are indicative of a

pattern of overall dissatisfaction with the schooling process. For the School Problems composite









subscale, there was no difference between scores for the normal group (M= 121.55, SD =

30.490) and the APD group [M= 121.26, SD = 27.974; t(37) = .031, p = .976]. The magnitude

of the differences in the means was extremely small (eta squared = .00003).

Internalizing Problems Composite Subscale

The Internalizing Problems composite subscale of the BASC-2 asks students to rate

themselves for such content areas as locus of control, social stress, sense of inadequacy and

depression. High self-reported scores on the Internalizing Problems composite subscale are

indicative of a pattern of overall emotional difficulties and inwardly directed distress (Reynolds

& Kamphaus, 2004). For the Internalizing Problems composite subscale Self-Report Forms,

there was no significant difference between scores for the normal group (M= 297.45, SD =

36.523) and the APD group [M= 309.16,SD = 36.090;t(37) = -1.006,p= .321]. Theeffect

sizes of the differences in the means was small (eta squared = .027).

Inattention/Hyperactivity Composite Subscale

The Inattention/Hyperactivity composite subscale of the BASC-2 asks students to rate their

behaviors for such difficulties as being too noisy and difficulty standing still. High self-reported

scores on this composite subscale are indicative of a pattern of overall impulsivity and attention

difficulties, and may warrant further evaluation considering the possibility of an Attention

Deficit Disorder or Attention Deficit/Hyperactivity Disorder diagnosis. For the

Inattention/Hyperactivity composite subscale Self-Report Forms, there was no difference

between scores for the normal group (M= 97.50, SD = 14.870) and the APD group [M= 102.11,

SD = 17.355; t(37) = -.891, p =.378]. The magnitude of the differences in the means was small

(eta squared = .021).









Emotional Symptoms Index Subscale

The Emotional Symptoms Index subscale of the BASC-2 combines content items from

both the Internalizing Problems and Personal Adjustment composite subscales and is specific to

the Self-Report forms of the BASC-2. Content areas include sense of inadequacy, social stress,

anxiety, depression, self-reliance and self-esteem. High self-reported scores on the Emotional

Symptoms Index composite subscale can be indicative of a global pattern of serious broad-based

emotional disorders (Reynolds & Kamphaus, 2004). There was a significant difference between

the normal group (M= 274.10, SD = 25.805) and the APD group [M= 294.47, SD = 32.404;

t(37) = -2.071, p= .045]. The magnitude of the differences in the means was moderate (eta

squared = .158). As the mean for the APD group exceeded that of the normal group, statistical

analysis indicates greater reported emotional problems for the APD group.

Personal Adjustment Composite Subscale

The Personal Adjustment composite subscale of the BASC-2 includes content areas that

assess behaviors which may lead to positive outcomes, such as self-acceptance and social

support. Low self-reported scores on the Personal Adjustment subscale may suggest poor peer

or parental relationships, and poor coping strategies. For this subscale, there was no difference

between scores for the normal group (M= 211.60, SD = 23.270) and the APD group [M=

202.00, SD =31.050; t(37) = 1.006, p = .280]. The effect sizes of the differences in the means

was small (eta squared = .031).

Parent-Completed Dartmouth Primary Care Cooperative Information Project Charts for
Adolescents (COOP-A)

For the COOP-A, the parents were asked to respond to each chart according to their

perception of their participating child's function in each given area. Each individual chart of the

COOP-A given to the parents was identical to those given to their children, and acts as its own









sub scale screener. Parents were asked to complete their ratings on the COOP-A independently

via paper and pencil format, but were encouraged to ask questions of the investigator if any item

was unclear. Ratings for each chart are based on a five-point Likert scale wherein 1 represents

the least dysfunction and 5 represents the greatest dysfunction in any given area. The Mann-

Whitney U test for non-parametric data was utilized in order to compare Sum of Ranks for all

subscale charts on the COOP-A due to the ordinal nature of the data, and r-square values were

calculated to assess effect sizes (Rosenthal, 1991). Additionally, chi-square tests for

independence were conducted between groups on the proportion of Average or At-Risk

classifications for each subscale chart, with statistical significance defined byp < 0.05 (two-

tailed) for the Pearson chi-square values. See Table 4-11 for a summary table of findings for

proportions of students that parents consider to be "At-Risk" from both groups for each subscale

chart.

Physical Fitness Subscale Chart

Results for the Physical Fitness subscale chart for the COOP-A suggested that parents

perceived no statistically significant difference between the two groups (p = .986). The effect

size was very small (r2 < .0005). The mean ranks were 19.03 and 18.97 for the normal and APD

groups, respectively. The Pearson chi-square value was .677, confirming no statistically

significant difference for the proportion of participants classified as "Average" or "At-Risk"

between the APD and normal groups.

Pain Subscale Chart

Results for the Pain subscale chart suggested a significant difference between the parental
2
ratings for the APD group and the normal group (p = .032), with a moderate effect size (r

.125). Recall that with the Mann-Whitney U for the COOP-A if there is a significant difference

in results, the group with the greater mean rank represents the group with greater parental reports









of psychosocial difficulties in their children for that subscale. The mean rank for the normal

group was 15.28 and the mean rank for the APD group was 22.53, indicating greater parental

reports of pain for the children in the APD group. The Pearson chi-square value was .004,

indicating the parents reported a significant difference for the proportion of participants

classified as "Average" or "At-Risk" between the APD and normal groups. Additional review

indicates there to be 94.4% of the normal group parent ratings in the "Average" category versus

52.6% of the APD group, and 5.6% of the normal group ratings falling in the "At-Risk" category

versus 47.4% of the APD group parent ratings. Based on these findings, more parents of

children within the APD group rate their children as "At-Risk" for problems with pain than

parents of students in the normal group.

Stress Subscale Chart

Results of the parent-completed Stress subscale chart of the COOP-A suggested that no

difference exists between the two groups (p = .151). In contrast to this non-significant finding,

the effect size was moderate (r2 = .056), and the mean ranks were 16.61 and 21.26 for the normal

and APD groups, respectively. The effect size indications suggest a trend for the parents of

participants in the APD group to rate their children as having more difficulties with stress than

their counterparts in the normal group. The Pearson chi-square value was .219, however,

suggesting no difference for the proportion of participants classified as "Average" or "At-Risk"

between the APD and normal groups. Recall that this apparent discrepancy between the chi-

square statistic and the effect size is possible because the r-squared calculation is based on the

ranks of the ratings for each group, and so may differ from the nominal analysis that the Pearson

chi-square value provides.









School Work Subscale Chart

Findings for the School Work subscale chart suggested a significant difference between the

parental reports for the APD group and the normal group (p = .033), with a moderate effect size

(r = .122). The mean rank for the normal group was 15.39 and the mean rank for the APD group

was 22.42, indicating greater parental reported difficulties for the APD group on the School

Work subscale. However, the Pearson chi-square value was .238, suggesting no difference exists

for the proportion of participants classified as "Average" or "At-Risk" for the School Work

subscale chart between groups. Again, the discrepancies between the categorical analysis and the

ordinal analyses may be explained by the nature of the data that is being analyzed here.

Emotional Feelings Subscale Chart

The Emotional Feelings subscale chart of the COOP-A asks the question, "During the past

month, how often did you feel anxious, depressed, irritable, sad or downhearted and blue?"

There was a difference between parental ratings of the APD group and the normal group (p =

.023), with a large effect size (r2 = .140). The mean rank for the normal group was 15.56 and the

mean rank for the APD group was 22.26, indicating greater parent-reported difficulties on the

Emotional Feelings subscale for the children in the APD group. In contrast to these Mann-

Whitney U findings, the Pearson chi-square value was .087, suggesting no difference exists for

the proportion of participants classified as "Average" or "At-Risk" between the APD and normal

groups.

Behavior Subscale Chart

Results for the Behavior subscale chart of the COOP-A suggested no difference between

the two groups for this subscale (p = .159). In contrast to this non-significant finding, the effect

size was moderate (r2 = .054), and the mean ranks were 16.89 and 21.00 for the normal and APD

groups, respectively. The effect size indications suggest a trend for the parents of participants in









the APD group to rate their children as having more difficulties with behavior than their

counterparts in the normal group. The Pearson chi-square value was .157, however, suggesting

no difference for the proportion of participants parent ratings classified as "Average" or "At-

Risk" for the Behavior subscale chart between the APD and normal groups.

Social Support Subscale Chart

For the Social Support subscale chart, there was no difference between parental ratings of
2
the APD group and the normal group (p= .325), with a small effect size (r= .026). The mean

rank for the normal group was 17.50 and the mean rank for the APD group was 20.42. The

Pearson chi-square value was .324, suggesting no difference for the proportion of participants

classified as "Average" or "At-Risk" per parent ratings between the APD and normal groups.

Self-Esteem Subscale Chart

Results of the parent-completed Self-Esteem subscale chart of the COOP-A suggested no

difference between the two groups for this subscale (p = .054) though a trend was evident. The

mean rank for the normal group was 15.75 and the mean rank for the APD group was 22.08,

suggesting a non-statistically significant trend toward greater parent-reported difficulties on the

Self-Esteem subscale chart for the children in the APD group. The magnitude of the differences

between mean ranks was moderate (r2 = .100). Lending additional support to the weight of this

trend, the Pearson chi-square value was .009, indicating a significant difference exists for the

proportion of participants classified as "Average" or "At-Risk" per parental ratings between the

APD and normal groups. Further review indicates there to be 100% of the normal group ratings

falling in the "Average" category versus 68.4% of the APD Group, and 0% of the normal group

ratings falling in the "At-Risk" category versus 31.6% of the APD group. These findings

indicate that a higher proportion of parents of students in the APD group rate their children as

"At-Risk" for problems with self esteem than do parents of students in the normal group.









Family Subscale Chart

For the Family subscale chart, there was no difference between the parent ratings of the

APD group and the parent ratings of the normal group (p = .694), with a very small effect size (r2

= .004). The mean rank for the normal group was 18.33 and the mean rank for the APD group

was 19.63. The Pearson chi-square value was .331, suggesting no difference for the proportion

of participants classified as "Average" or "At-Risk" per parent ratings between the APD and

normal groups on the Family subscale chart.

Health Habits I

Results for the Health Habits I subscale chart suggested no difference between parental

ratings of the APD group and the normal group (p = 1.000). The mean rank was 19.00 for both

the normal and APD groups. The Pearson chi-square value could not be determined as all

ratings for both groups were constant within the "Average" classification.

Overall Health Subscale Chart

For the Overall Health subscale, there was no difference between the parent ratings of the

APD group and the parent ratings of the normal group (p = .122). In contrast to this non-

significant finding, the effect size was moderate (r2= .065), and the mean ranks were 16.47 and

21.39 for the normal and APD groups, respectively. The effect size indications suggest a trend

for the parents of participants in the APD group to rate their children as having poorer overall

health than their counterparts in the normal group. The Pearson chi-square value was .316,

however, suggesting no significant difference for the proportion of participants that parent

ratings classified as "Average" or "At-Risk" between the APD and normal groups.

Energy Subscale Chart

For the Energy subscale chart of the COOP-A, there was no difference between the

parental ratings of the two groups for this subscale (p = .585), with a very small effect size (r2
parental ratings of the two groups for this subscale (p =.5 85), with a very small effect size (r









.008). The mean ranks were 19.86 and 18.18 for the normal and APD groups, respectively. The

Pearson chi-square value was .316, suggesting no difference for the proportion of participants

that parent ratings classified as "Average" or "At-Risk" between the APD and normal groups.

Social Skills Rating System (SSRS), Parent Forms

The items on the Parent Forms of the SSRS are rated on a three-point Likert scale

according to parent observed frequency of social behavior occurrence, where "Never" = 0,

"Sometimes" = 1, and "Very Often" = 2. The four subscales incorporated into the Social Skills

domain for the Parent Forms (Elementary and Secondary Level) of the SSRS measure positive

social behaviors, with higher ratings indicating greater parent-perceived social skill. The four

Parent Form Social Skills subscales are Cooperation, Assertion, Responsibility and Self-Control.

The Problem Behaviors domain includes three subscales that measure behaviors which may

negatively impact social skill development and function. Both the Elementary and Secondary

Level Parent Forms of the SSRS include Externalizing and Internalizing Problem Behavior

subscales. Additionally, the Elementary Level Parent Form of the SSRS includes the

Hyperactivity subscale in the Problem Behavior domain. Due to slight group differences in age,

the Hyperactivity subscale of the Problem Behavior domain was not statistically examined in the

present study. To assess differences between group mean ratings on the included Parent Form

subscales of the Social Skill and Problem Behavior domains of the SSRS, independent-samples

t-tests were conducted and eta-squared values were calculated.

Cooperation Subscale

The Cooperation subscale of the SSRS asks parents to rate how often they believe their

children complete social behaviors that are presented, such as: "Keeps room clean and neat

without being reminded." For the Cooperation subscale for the SSRS Parent Forms (combined

Elementary and Secondary ratings), there was no difference between scores for the normal group









(M= 13.33, SD = 2.449) and the APD group [M= 12.44, SD = 2.555; t(32) = 1.043,p =.305].

The magnitude of the differences in the means was small (eta squared = .033).

Assertion Subscale

The Assertion subscale of the SSRS asks parents to rate how frequently they believe their

children complete associated social behaviors, for example: "Makes friends easily." Results for

the Assertion subscale for the SSRS Parent Forms indicated no difference between scores for the

normal group (M= 16.00, SD = 2.574) and the APD group [M= 16.00, SD = 2.82; t(32) < .0005,

p = 1.000]. The effect size of the differences in the means was extremely small (eta squared <

.0005).

Responsibility Subscale

The Responsibility subscale of the SSRS asks parents to rate how frequently their children

complete social behaviors that are presented, such as: "Reports accidents to appropriate persons"

and "Asks permission before using another family member's property." There was a significant

difference between the normal group (M= 16.94, SD = 1.924) and the APD group [M= 14.78,

SD = 3.173; t(28.016) = 2.477, p = .020]. The magnitude of the differences in the means was

large (eta squared = .158). Recall that within the Social Skills domain of the SSRS, if there is a

significant difference, the group with the lower mean rank represents the group with fewer

parentally-reported social skills for the associated subscale. As the mean for the normal group

exceeded that of the APD group, statistical analysis indicates greater reported social skills on the

Responsibility subscale for the normal group.

Self-Control Subscale

The Self-Control subscale of the SSRS asks parents to rate how frequently they believe

their children complete associated social behaviors, for instance: "Responds appropriately when

hit or pushed by other children." For the Self-Control subscale of the SSRS Student Forms, there









was no difference between scores for the normal group (M= 16.11, SD = 2.494) and the APD

group [M= 14.67, SD = 2.590; t(34) = 1.704, p = .097]. However, the effect size of the

differences in the means was moderate (eta squared = .079), suggesting a trend in the data that

parents reported the children in the APD group to have fewer self-control social skills than the

children in the normal group.

Externalizing Problem Behavior Subscale

The Externalizing Problem Behavior subscale of the SSRS asks parents to rate how

frequently their children complete behaviors that may interfere with social skills performance,

such as: "Gets angry easily" and "Fights with others." There was a difference between the

normal group (M= 2.00, SD = 1.749) and the APD group [M= 3.22, SD = 1.768; t(34) = -2.085,

p =.045]. The magnitude of the differences in the means indicated a moderate effect size (eta

squared = .113). Recall that within the Problem Behaviors domain of the SSRS, if there is a

significant difference, the group with the lower mean rank represents the group with fewer

parentally-reported negative behaviors for the associated subscale. The mean for the APD group

exceeded that of the normal group, with statistical analysis indicating greater reported

externalizing problem behaviors on this subscale for the APD group.

Internalizing Problem Behavior Subscale

The Internalizing Problem Behavior subscale of the SSRS asks parents to rate how

frequently their children exhibit behaviors such as anxiety, sadness and poor self-esteem that

may interfere with social skills performance. Example items included in Parent Forms for this

subscale are: "Appears lonely" and "Acts sad or depressed." There was a significant difference

between the normal group (M= 2.50, SD = 1.790) and the APD group [M= 4.33, SD = 2.425;

t(34) = -2.580,p =.014]. The magnitude of the differences in the means indicated a large effect

size (eta squared = .164). As the mean for the APD group exceeded that of the normal group,









statistical analysis indicates that parents reported increased internalizing problem behaviors on

this subscale for the APD group.

Behavioral Assessment System for Children-Second Edition (BASC-2), Parent Rating
Scales

The items on the Parent Rating Composite Scales of the BASC-2 are rated on a four-point

Likert scale according to self-reported frequency of "Never," "Sometimes," "Often," or "Almost

Always." The four composite subscales of the BASC-2 that are incorporated into the Parent

Rating Scales utilized (both the PRS-Child and the PRS-Adolescent) are Externalizing Problems,

Internalizing Problems, Behavioral Symptoms Index, and Adaptive Skills. To assess differences

between group mean parental ratings on the composite subscales of the BASC-2, independent-

samples t-tests were conducted and eta-squared values were calculated.

Externalizing Problems Composite Subscale

The Externalizing Problems composite subscale of the BASC-2 asks parents to rate their

child's behaviors for the following content areas: hyperactivity, aggression, and conduct

problems. High scores on the Externalizing Problems composite subscale are indicative of

parental perceptions of obvious disruptive behaviors in their children. For the Externalizing

Problems composite subscale, there was a significant difference between scores for the normal

group (M= 134.22, SD = 13.524) and the APD Group [M= 151.50, SD = 19.518; t(34) = -3.087,

p =.004]. The magnitude of the differences was large (eta squared =.219). The mean of the

APD group exceeded that of the normal group, indicating greater parental reports of

externalizing problem behaviors for the children in the APD group.

Internalizing Problems Composite Subscale

The Internalizing Problems composite subscale of the BASC-2 Parent Rating Scales asks

parents to rate their children for such content areas as anxiety, depression and somatization. As









with the Self-Report forms, high scores for the Internalizing Problems composite subscale are

indicative of a pattern of inwardly directed distress. For the Internalizing Problems composite

subscale Parent Rating Scales, scores for the normal group (M= 136.83, SD= 12.491) and the

APD group [M= 167.22, SD 31.454; t(34)= -3.810,p =.001] differed. The magnitude of the

differences was large (eta squared = .299). As the mean for the APD group exceeded that of the

normal group, statistical analysis indicates that parents reported increased internalizing problem

behaviors on this subscale for the APD group.

Behavioral Symptoms Index Subscale

The Behavioral Symptoms Index subscale of the BASC-2 is specific to the Teacher and

Parent Rating Scales of the BASC-2. Content areas include: Hyperactivity, Aggression,

Depression, Atypicality, Withdrawal and Attention Problems. High ratings on this subscale may

be indicative of a global pattern of psychosocial problem behaviors. There was a significant

difference between the normal group (M= 270.78, SD = 25.316) and the APD group [M=

320.33, SD = 40.359; t(28.584) = -4.413,p < .0005]. The magnitude of the differences was very

large (eta squared =.364). The mean for the APD group exceeded that of the normal group, and

statistical analysis confirmed greater parental reports of psychosocial problem behaviors for the

APD group.

Adaptive Skills Composite Subscale

The Adaptive Skills composite subscale of the BASC-2 includes content areas that assess

behaviors which may lead to positive outcomes, such as leadership, communication skills and

emotional expression. Low parental ratings on this subscale may suggest poor adaptability and

coping strategies, inappropriate social interactions, or difficulty with activities of daily living.

For the Adaptive Skills composite subscale, there was a significant difference between scores for

the normal group (M= 260.94, SD= 22.784) and the APD group [M= 237.06, SD= 32.809;









t(34) = 2.537,p =.016]. The magnitude of the differences was large (eta squared = .159).

Examination of the means reveals that the mean of the APD group was lower than that of the

normal group, indicating parental reports of lower adaptive skills for the children in the APD

group.

Summary of Statistically Significant Findings Across Instruments

In summary, three of twenty-one subscales were found to have statistically significant

different results upon comparison of the participants in the APD group to those of the

participants in the normal group, with the participants in the APD group reporting greater

psychosocial problems than their counterparts in the normal group. The subscales that were

found to be different were the Emotional Feelings and Overall Health subscales of the COOP-A,

and the Emotional Symptoms Index of the BASC-2.

Twelve of twenty-two subscales were found to have significantly different results for

parental ratings between groups. Statistical comparison indicated differences for the Pain,

School Work, Emotional Feelings and Self-Esteem subscale charts of the COOP-A, all four

composite subscales of the BASC-2 (Externalizing Problems, Internalizing Problems, Behavioral

Symptoms Index, and Adaptive Skills), and the Responsibility, Externalizing Problem Behaviors

and Internalizing Problem Behaviors of the SSRS. Again, for all significant findings, parents of

participants in the APD group reported more psychosocial problems for their children than did

the parents of children in the normal group. A summary of significant findings for parent and

participant ratings can be found in Table 4-9.

Post-Hoc Analyses

Post-hoc analyses were conducted in order to determine the possible effects of age and

gender on any statistically significant findings or trends. Post-hoc analyses were also conducted

between the language-impaired and language-normal subgroups of the APD group parental and









self-ratings for all subscales on all three psychosocial questionnaires utilized, employing the

same methods of statistical analysis reported for the between group (APD vs. Normal)

examinations as previously detailed.

Reported Psychosocial Function and Age

COOP-A and age correlation results

The analysis of age on the self-completed Stress subscale chart of the COOP-A yielded a

Spearman rho value of .046, (n = 39, p= .782), indicating no correlation. The analysis of age on

child-completed COOP-A Emotional Feeling subscale yielded a Spearman rho value of -.003 (n

= 39, p= .986), indicating no correlation. The analysis of age on the ratings for the child-

completed COOP-A Overall Health subscale chart yielded a Spearman rho value of .299 (n = 39,

p =.064), indicating a small to medium positive correlation between increasing age and

increasing self-reports of poor overall health. Statistical analysis of age on the parent-completed

COOP-A Pain subscale chart Pain subscale yielded a Spearman rho value of -.032, (n = 37,p =

.850), indicating no significant correlation. The analysis of age on the parent-completed School

Work subscale chart of the COOP-A yielded a Spearman rho value of -.076, (n = 37,p =.654),

indicating no correlation. The analysis of age on parent-completed COOP-A Emotional Feeling

subscale yielded a Spearman rho value of-.007 (n = 37,p = .969), indicating no correlation. The

analysis of age on the ratings for the parent-completed COOP-A Self-Esteem subscale chart

yielded a Spearman rho value of -.240 (n = 37, p = .153), indicating a small correlation between

increasing age and decreasing parental reports of self-esteem problems in their children.

SSRS and age correlation results

The analysis of age on the ratings for the parent-completed SSRS Responsibility subscale

yielded a Pearson's r value of .534 (n = 36, p = .001), indicating a strong correlation between

increasing participant age and parental reports of higher responsibility skill levels in their









children. The analysis of age on the parental ratings for the Externalizing Problem Behaviors

subscale of the SSRS yielded a Pearson's r value of -.294 (n =36, p = .082), indicating a small to

medium correlation between increasing participant age and parental reports of higher

responsibility skill levels in their children. The analysis of age on the Internalizing Problem

Behaviors subscale of the SSRS Parent Form indicated a small negative correlation between the

two variables (r = -.098, n= 36, p= .569). These findings suggest a trend for parents to rate their

children as displaying fewer internalizing problem behaviors, such as anxiety or sadness, as they

grow older.

BASC-2 and age correlation results

The analysis of age on the BASC-2 Self-Report Emotional Symptoms Index composite

subscale indicated no significant correlation between the two variables (r = -.021, n = 39, p =

.899). The analysis of age on the Externalizing Problems composite subscale of the BASC-2

Parent Rating Scales indicated no statistically significant correlation between the two variables (r

= -.086, n = 36, p = .616). The analysis of age on the Internalizing Problems composite subscale

of the BASC-2 Parent Rating Scales indicated no statistically significant correlation between the

two variables (r = -.014, n = 36,p =.934). The analysis of age on the BASC-2 Parent Rating

Scales' Behavioral Symptoms Index composite subscale indicated a small correlation between

the two variables (r = -.123, n = 36,p = .473). These findings suggest a trend for parents to rate

their children as having fewer negative behavioral symptoms as they grow older. The analysis of

age on the BASC-2 Parent Rating Scales' Adaptive Skills composite subscale indicated a small

positive correlation between the two variables (r = -.148, n = 36,p =.387). These findings

suggest a trend for parents to rate their children as having more positive adaptive skills, such as

coping or communication skills, as they grow older.









Summary of age correlation results across instruments

In summary, there were a few correlations associated with age across the various

significant findings of the psychosocial subscales. On the COOP-A, there was a moderate

correlation for children to report lower overall health as they advanced in age, and a small

correlation between increasing age of the child and decreasing parental reports of self-esteem

problems in their children. On the BASC-2, there were small correlations associated with

parents reporting fewer negative behavioral symptoms and increased adaptive skills as their

children grew older. And on the SSRS, there was a small negative correlation for parental

reports of internalizing problems, a small to moderate negative correlation for parental reports of

externalizing problems, and a strong positive correlation for parental reports of greater

responsibility skills for older children. A summary of all correlation findings for the various

psychosocial subscales assessed may be found in Table 4-12.

Reported Psychosocial Function and Gender

COOP-A and gender comparison of mean rank results

No statistically significant findings for gender differences were observed for any of the

examined COOP-A subscales. Results on the child-completed Stress subscale chart yielded p =

.866, the Emotional Feelings subscale chart yielded p = .647, and the Overall Health subscale

chart yielded = .424. Results on the parent-completed Pain subscale chart yielded = .545, the

School Work subscale chart yielded p = .803, the Emotional Feelings subscale chart yielded p =

.562, and the Self Esteem subscale chart yielded p = .960.

SSRS and gender comparison of means results

Results on the Responsibility subscale of the SSRS Parent Forms yielded p =.548, the

Externalizing Problem Behaviors subscale yielded =.873, and the Internalizing Problems









Behaviors subscale yielded p =.540. No significant findings for gender differences were

observed for any of the examined SSRS subscales.

BASC-2 and gender comparison of means results

No significant gender differences were observed for any of the BASC-2 composite

subscales of interest. Results on the self-report Emotional Symptoms Index composite subscale

yielded p =.632. The BASC-2 Parent Report forms' Externalizing Problems, Internalizing

Problems, Behavioral Symptoms Index and Adaptive Skills composite subscales yielded p =

.210, p .783, p = .460, and p = .110, respectively.

Summary of gender analyses results across instruments

To summarize, no gender differences were observed for any of the subscales of interest. A

summary of all p-values on gender for the various psychosocial subscales assessed is found in

Table 4-13.

Comparisons Between Language-Normal and Language-Impaired Subgroups with APD

Preliminary analyses were completed to determine if any statistically significant

differences existed between the language-impaired and language-normal APD subgroups on age

or gender. Results indicated that there was no significant difference between age for the

language-normal subgroup (M= 12.20, SD= 1.865) and the language-impaired APD group [M

11.69, SD= 2.352; t(17) .517,p= .612]. A chi-square test for independence was conducted

between the two APD subgroups on the proportion of males and females, with statistical

significance defined byp < 0.05 (two-tailed) for the Pearson chi-square values. No significant

difference on gender was found (x2 = .498, n = 19).

Statistical significance levels were not reached for any of the parent- or child-completed

instrument subscales, suggesting comparable psychosocial function across content areas for the

children with and without language impairment who have APD. See Tables 4-14 and 4-15 for a









summary of statistical results between APD linguistic subgroups for participants and their

parents, respectively.












Table 4-1: Number of subjects in the APD and normal groups for various demographic
characteristics.


APD Group (n


Normal Group (n = 20)


Gender


Age (in years)


Grade Level










Language Disorder


Type of School


Male
Female

Mean
Range


11.93
9.6-17.8


12.79
9.6-16.9


Normal
Impaired

Public
Private
Home











Table 4-2: Mean pure-tone air-conduction thresholds (MI) and standard deviations (s.d.) across frequencies for each ear (RE = right
ear; LE = left ear) of both groups.


Frequency (Hz)


250


500


1000


2000


3000


4000


6000


8000


Ear


APD group


RE LE RE LE RE LE RE LE RE LE RE LE RE LE RE LE

M 7.8 6.6 7.5 6.3 6.6 7.5 4.4 4.1 2.2 2.8 4.1 4.4 4.6 5.0 4.1 2.8


s.d. 5.0 4.7 4.0 6.1 4.9 4.0 6.4


5.2 5.8 6.3


5.5 6.4 6.0 6.5


Normal group


M 6.9 7.2 5.6 5.3


5.0 6.4 4.4


s.d. 5.6 3.5 5.8 4.9 4.6 4.1 4.4


5.8 2.2 1.9 2.8 3.9 4.1 2.6 4.2 3.3

5.0 4.2 5.1 6.1 4.3 6.6 5.8 6.8 6.7


8.4 9.9









Table 4-3: Mean tympanometric data for APD and normal groups.


Ear Canal Volume (cm )

Peak Pressure (daPa)

Static Compliance (ml)


APD Group (n= 19)

Right Ear Left Ear

1.10 1.10

3.55 1.32

0.65 0.66


Normal Group (n = 20)

Right Ear Left Ear

1.24 1.22

14.50 5.75

0.80 0.78










Table 4-4: Number of participants 2 standard deviations or more below mean on assessments
used in the APD test battery for both the APD and normal groups.


Staggered Spondaic Word test

Dichotic Digits, Double Pairs

Frequency Pattern Sequence test

Duration Pattern Sequence test

Random Gap Detection test
Synthetic Sentence Index: Ipsilateral
Competing Message
SCAN: Auditory Figure-Ground Subtest

SCAN: Competing Words Subtest

SCAN: Filtered Words Subtest

Auditory Continuous Performance Test


APD Group (n

17


Normal Group (n = 20)

3












Table 4-5: Mean ranks (m) and sum of ranks (U) for the COOP-A and means (MAl) and standard
deviations (s.d.) for the SSRS and BASC-2 for children's psychosocial self-reports
ratings for the APD group and the normal group.

Children's Self-Reports
Scale Subscale APD group Normal group

COOP-A m U m U
Physical Fitness 18.68 355.00 21.25 425.00
Pain 21.76 413.50 18.33 366.50
Stress 22.58 429.00 17.55 351.00
School Work 22.58 429.00 17.55 351.00
Emotional Feelings 24.34 462.50 15.88 317.50
Behavior 21.89 416.00 18.20 364.00
Social Support 22.74 432.00 17.40 348.00
Self-Esteem 22.26 423.00 17.85 357.00
Family 21.71 412.50 18.38 367.50
Health Habits I 19.50 370.50 20.48 409.50
Overall Health 23.66 449.50 16.53 330.50
Energy 17.92 340.50 21.98 439.50

BASC-2 AlM s.d. AlM s.d.
School Problems 121.26 27.974 121.55 30.490
Internalizing Problems 309.16 36.090 297.45 36.523
Emotional Symptoms Index 293.47 32.404 274.10 25.805
Inattention/Hyperactivity 102.11 17.355 97.50 14.870
Personal Adjustment 202.00 31.050 211.60 23.270

SSRS M s.d. M s.d.
Cooperation 14.68 2.451 15.53 2.695
Assertion 14.84 2.035 13.95 3.677
Empathy 16.47 2.435 16.45 2.743
Self-Control 11.89 2.865 12.80 3.270












Table 4-6: Statistical findings for children's psychosocial self-reports.


Children's Self-Reports
Scale Subscale t-value df Z-value p Effect Size

COOP-A r-sq
Physical Fitness n/a n/a -0.812 0.417 0.017
Pain n/a n/a -0.996 0.319 0.025
Stress n/a n/a -1.458 0.145 0.055
School Work n/a n/a -1.509 0.131 0.058
Emotional Feelings n/a n/a -2.533 0.011* 0.165
Behavior n/a n/a -1.125 0.261 0.032
Social Support n/a n/a -1.615 0.106 0.067
Self-Esteem n/a n/a -1.315 0.189 0.044
Family n/a n/a -0.961 0.336 0.024
Health Habits I n/a n/a -0.975 0.330 0.024
Overall Health n/a n/a -2.082 0.037* 0.111
Energy n/a n/a -1.227 0.220 0.039

BASC-2 eta-sq
School Problems 0.031 37 n/a 0.976 0.00003
Internalizing Problems -1.006 37 n/a 0.321 0.027
Emotional Symptoms Index -2.071 37 n/a 0.045* 0.104
Inattention/Hyperactivity -0.888 37 n/a 0.378 0.378
Personal Adjustment 1.096 37 n/a 0.280 0.280

SSRS eta-sq
Cooperation 1.008 36 n/a 0.320 0.026
Assertion -0.943 29.94 n/a 0.353 0.023
Empathy -0.028 37 n/a 0.977 0.00002
Self-Control 0.917 37 n/a 0.367 0.022

*= p < 0.05










Table 4-7: Mean ranks (m) and sum of ranks (U) for the COOP-A and means (M) and standard
deviations (s.d.) for the SSRS and BASC-2 for parental psychosocial ratings for the
APD group and the normal group.



Parental Reports
Scale Subscale APD group Normal group

COOP-A m U m U
Physical Fitness 18.97 360.50 19.03 342.50
Pain 22.53 428.00 15.83 275.00
Stress 21.26 404.00 16.61 299.00
School Work 22.42 426.00 15.39 277.00
Emotional Feelings 22.26 423.00 15.56 280.00
Behavior 21.00 399.00 16.89 304.00
Social Support 20.42 388.00 17.50 315.00
Self-Esteem 22.08 419.50 15.75 283.50
Family 19.63 373.00 18.33 330.00
Health Habits I 19.00 361.00 19.00 342.00
Overall Health 21.39 406.50 16.47 296.50
Energy 18.18 345.50 19.86 357.50

BASC-2 M s.d. M s.d.
Externalizing Problems 151.50 19.518 134.22 13.524
Internalizing Problems 167.22 31.454 136.83 12.491
Behavioral Symptoms Index 320.33 40.359 270.78 25.316
Adaptive Skills 237.06 32.809 260.94 22.784

SSRS M s.d. M s.d.
Cooperation 12.44 2.555 13.33 2.449
Assertion 16.00 2.828 16.00 2.574
Responsibility 14.78 3.173 16.94 1.924
Self-Control 14.67 2.590 16.11 2.494
Externalizing Problem Behaviors 3.22 1.768 2.00 1.749
Internalizing Problem Behaviors 4.33 2.425 2.50 1.790












Table 4-8: Statistical findings for parent psychosocial reports.


Parental Reports
Effect
Scale Subscale t-value df Z-value p Size

COOP-A r-sq
Physical Fitness n/a n/a -0.017 0.976 0.000
Pain n/a n/a -2.151 0.032* 0.125
Stress n/a n/a -1.437 0.151 0.056
School Work n/a n/a -2.126 0.033* 0.122
Emotional Feelings n/a n/a -2.279 0.023* 0.140
Behavior n/a n/a -1.408 0.159 0.054
Social Support n/a n/a -0.985 0.325 0.026
Self-Esteem n/a n/a -1.927 0.054 0.100
Family n/a n/a -0.393 0.694 0.004
Health Habits I n/a n/a 0.000 1.000 0.000
Overall Health n/a n/a -1.548 0.122 0.065
Energy n/a n/a -0.546 0.585 0.008

BASC-2 eta-sq
Externalizing Problems -3.087 34 n/a 0.004* 0.219
Internalizing Problems -3.810 22.23 n/a 0.001* 0.299
Behavioral Symptoms Index -4.413 28.58 n/a 0.000* 0.364
Adaptive Skills 2.537 34 n/a 0.017* 0.159

SSRS eta-sq
Cooperation 1.043 32 n/a 0.305 0.033
Assertion 0.000 32 n/a 1.000 0.000
Responsibility 2.477 28.01 n/a 0.020* 0.158
Self-Control 1.704 34 n/a 0.097 0.079
Externalizing Problem Behaviors -2.085 34 n/a 0.045* 0.113
Internalizing Problem Behaviors -2.580 34 n/a 0.014* 0.164

*=p <0.05











Table 4-9: Compiled statistically significant (p < 0.05) findings across psychosocial scales for
children and parents.

Children's Self-Reports
Effect
Scale Subscale t-value df Z-value p Size

COOP-A r-sq
Emotional Feelings n/a n/a -2.533 0.011 0.165
Overall Health n/a n/a -2.082 0.037 0.111

BASC-2 eta-sq
Emotional Symptoms Index -2.071 37 n/a 0.045 0.104

Parental Reports
Effect
Scale Subscale t-value df Z-value p Size


COOP-A


BASC-2


SSRS


Pain
School Work
Emotional Feelings



Externalizing Problems
Internalizing Problems
Behavioral Symptoms Index
Adaptive Skills



Responsibility
Externalizing Problem Behaviors
Internalizing Problem Behaviors


-2.151
-2.126
-2.279


-3.087
-3.810
-4.413
2.537



2.477
-2.085
-2580


34
22.23
28.58
34



28.02
34
34


0.032
0.033
0.023



0.004
0.001
0.000
0.017



0.020
0.045
0.014


r-sq
0.125
0.122
0.140

eta-sq
0.219
0.299
0.364
0.159

eta-sq
0.158
0.113
0.164









Table 4-10: At-risk (3-5 ratings) findings on
chart for both groups.


Subscale


APD
% At Risk


COOP-A by children's self-reports by subscale


Normal
% At Risk


Difference
% At Risk


Significance
(Chi-Square)


Physical Fitness
Pain
Stress
School Work
Emotional Feelings
Behavior
Social Support
Self-Esteem
Family
Health Habits I
Overall Health
Energy

*=p <0.05


10.53
42.11
52.63
21.05
31.58
15.79
15.79
26.32
57.89
0.00
42.11
47.37


0.00
35.00
20.00
5.00
10.00
5.00
5.00
10.00
45.00
0.00
15.00
70.00


10.53
7.11
32.63
16.05
21.58
10.79
10.79
16.32
12.89
0.00
27.11
-22.63


0.136
0.648
0.034*
0.134
0.095
0.267
0.267
0.184
0.421
constant
0.060
0.151









Table 4-11: At-risk (3-5 ratings) findings on
both groups.


Subscale


APD
% At Risk


COOP-A by parental reports by subscale chart for


Normal
% At Risk


Difference
% At Risk


Significance
(Chi-Square)


Physical Fitness
Pain
Stress
School Work
Emotional Feelings
Behavior
Social Support
Self-Esteem
Family
Health Habits I
Overall Health
Energy

*=p <0.05


15.79
47.37
47.37
26.32
26.32
10.53
5.26
31.58
36.84
0.00
15.79
26.32


10.00
5.00
25.00
10.00
5.00
0.00
0.00
0.00
20.00
0.00
5.00
35.00


5.79
42.37
22.37
16.32
21.32
10.53
5.26
31.58
16.84
0.00
10.79
-8.68


0.677
0.004*
0.219
0.238
0.087
0.157
0.324
0.009*
0.331
constant
0.316
0.414










Table 4-12: Summary of correlation findings for age and statistically significant (p < 0.05)
psychosocial subscales for children and parents.

Children's Self-Reports
Scale Subscale Correlation Statistic

COOP-A Spearman's rho
Emotional Feelings -0.003
Overall Health 0.299 **

BASC-2 Pearson's R
Emotional Symptoms Index -0.021

Parental Reports
Scale Subscale Correlation Statistic


COOP-A


Pain
School Work
Emotional Feelings
Self-Esteem


Spearman's rho
-0.032
-0.076
0.007
-0.240


Externalizing Problems
Internalizing Problems
Behavioral Symptoms Index
Adaptive Skills


Responsibility
Externalizing Problem Behaviors
Internalizing Problem Behaviors


Note: = small correlation, ** = moderate correlation, *** = strong correlation


BASC-2


SSRS


Pearson's R
-0.086
-0.014
-0.123
0.148

Pearson's R
0.534
-0.294
-0.098











Table 4-13: Summary of findings for gender and statistically significant (p < 0.05) psychosocial
subscales for children and parents.

Children's Self-Reports
Scale Subscale p-value

COOP-A Mann-Whitney U
Emotional Feelings 0.647
Overall Health 0.424

BASC-2 t-test
Emotional Symptoms Index 0.632

Parental Reports
Scale Subscale p-value


COOP-A


Pain
School Work
Emotional Feelings
Self-Esteem


Mann-Whitney U
0.545
0.803
0.562
0.960


Externalizing Problems
Internalizing Problems
Behavioral Symptoms Index
Adaptive Skills


Responsibility
Externalizing Problem Behaviors
Internalizing Problem Behaviors


BASC-2


SSRS


t-test
0.210
0.783
0.460
0.110

t-test
0.548
0.873
0.540










Table 4-14: Statistical findings across psychosocial scales for children's self-ratings in
language-impaired versus language-normal APD subgroups.

Children's Reports
Scale Subscale t-value df Z-value p

COOP-A
Physical Fitness n/a n/a -0.698 0.485
Pain n/a n/a -1.462 0.144
Stress n/a n/a -0.723 0.470
School Work n/a n/a -1.232 0.218
Emotional Feelings n/a n/a -0.552 0.581
Behavior n/a n/a -0.315 0.753
Social Support n/a n/a -1.125 0.261
Self-Esteem n/a n/a -0.482 0.630
Family n/a n/a 0.000 1.000
Health Habits I n/a n/a 0.000 1.000
Overall Health n/a n/a -0.305 0.760
Energy n/a n/a -0.218 0.827

BASC-2
School Problems 1.525 17 n/a 0.146
Internalizing Problems 0.672 17 n/a 0.511
Emotional Symptoms Index 1.093 17 n/a 0.291
Inattention/Hyperactivity -1.113 17 n/a 0.281
Personal Adjustment -0.187 17 n/a 0.854
SSRS
Cooperation -0.771 17 n/a 0.451
Assertion 0.536 17 n/a 0.599
Empathy 0.911 15.21 n/a 0.377
Self-Control 0.270 17 n/a 0.270










Table 4-15: Statistical findings across psychosocial scales for parent ratings of children in
language-impaired versus language-normal APD subgroups.

Parental Reports
Scale Subscale t-value df Z-value p

COOP-A
Physical Fitness n/a n/a -0.414 0.679
Pain n/a n/a -0.588 0.556
Stress n/a n/a -0.611 0.541
School Work n/a n/a -0.087 0.930
Emotional Feelings n/a n/a -0.478 0.633
Behavior n/a n/a -0.185 0.853
Social Support n/a n/a -1.219 0.223
Self-Esteem n/a n/a -0.387 0.699
Family n/a n/a -0.256 0.798
Health Habits I n/a n/a 0.000 1.000
Overall Health n/a n/a -0.576 0.565
Energy n/a n/a -0.149 0.882

BASC-2
Externalizing Problems 1.399 16 n/a 0.181
Internalizing Problems 0.106 16 n/a 0.917
Behavioral Symptoms Index 0.734 16 n/a 0.473
Adaptive Skills 0.854 16 n/a 0.406

SSRS
Cooperation -1.082 14 n/a 0.297
Assertion -0.334 15 n/a 0.743
Responsibility 0.405 16 n/a 0.691
Self-Control 1.449 16 n/a 0.167
Externalizing Problems Behaviors -0.466 16 n/a 0.648
Internalizing Problem Behaviors -0.127 16 n/a 0.901
















250 500 1000


Frequency (Hz)
2000 3000


4000 6000


10
-- -Right ear APD
dB HL --O- Right ear Normal
-0-Left ear APD
-X-Left ear Normal

15






20






25


Figure 4-1: Mean audiometric results for right and left ears of participants in the APD and

normal groups.


8000

















MD --19RE
19LE
25D- 13RE





23LE

i1 2 -. 1. R IDLE


-15J --7L
/\ '.- I D7EE
OILE

M1OE
Sa------___________--______ _________________-*_*_.-'__ Q7LE



0---16LE
-1* gf \ ______f________ \+
195IH iIC1Mz 1.0HZN IrmIMz Sr2hz ~IM z ~iIL rW EOL MZ 90$4. rz MI M 79BH 23F.E


b-o5 3 l r n t-23LE

-* \r 17.22L E
-22P,9 E
'" V ^ 122LE
-Bfl '. 39RE
\r -'t-39LE
-Mf J3 V' -t1RE
\1, -c-1EE
-M J3 -41LE
Fr~ u-ly p




Figure 4-2: Compiled Towson University APD group DPOAE data with mean group data line in

bold. Each line represents the DPOAE findings for each ear (RE or LE accordingly

in legend label) for each participant (first two digits of legend label represent subject

identification number) in the APD group.












-I*- 2J .E
2- 0 LE
ISRE
18LE
-1SRE
-- 15LE
--- 12 RE






-152 'X 15RE
M- 12 LE

15 -*- 21 LE

15fl- -* .^ S b- ^' ^ ^^ ^ "^ --*. .dEE~
77.
-u 511 -"-** 09 LE


I E l '-- j..** .j '" -. .. hi *.*5 '. !J I v ElE
j ~ .-- .- '2 -42'^IP


\D \ z \36LE



3-- 53LE
-M -Zf- tl--~I- H fl5 Z 3JP1- M 11 A 425 RE
5D-U-QSLE

Fr~ uI~ ~-*-38LE






Figure 4-3: Compiled Towson University normal group DPOAE data with mean group data line
in bold. Each line represents the DPOAE findings for each ear (RE or LE
accordingly in legend label) for each participant (first two digits of legend label
represent subject identification number) in the normal group.









CHAPTER 5
DISCUSSION

The purpose of this study was to examine the psychosocial status of children with APD,

with an aim to increase the knowledge base of the community of professionals working with

these children regarding possible non-auditory factors that may be influencing their quality of

life. The investigation was designed to compare the self- and parent reports of children with

APD to those of a gender- and age-matched peer group without APD on three psychosocial

questionnaires (COOP-A, SSRS, and BASC-2).

Thirty-nine children served as participants for this research study. APD was confirmed for

nineteen participants enrolled in the experimental group, while twenty participants with no

evidence of APD by formal assessment were enrolled in the normal group. Thirty-seven mothers

of the participants served as parental raters (19 in the APD group and 18 in the normal group).

Following a comprehensive diagnostic evaluation of peripheral and central auditory function, as

well as screening assessments of auditory attention, language and intellectual function, the

participants and their parents were asked to complete the COOP-A, BASC-2, and SSRS

questionnaires. Statistical analyses were conducted via two-group comparison methods for

ratings on the three instruments. Overall, the major finding from this study is that children with

APD exhibit psychosocial difficulties similar to or greater than children without APD. For

several subscales of the psychosocial instruments, findings for both the APD child and parent

groups differed from those for the normal group.

Children's Self-Reported Psychosocial Status

There were significant differences between groups on the participant's self-completed

Emotional Feeling (p =.011) and Overall Health (p =.037) subscales of the COOP-A, and the

Emotional Symptoms Index for the BASC-2 (p =.045), with the APD group reporting more









difficulties than the normal group. Recall that the COOP-A is a screener, and each chart is its

own subscale. In other words, the Emotional Feeling subscale is a single chart, and as such,

received a single rating between 1 and 5. The COOP-A is very quick and its validity as a

screener has been demonstrated. However, the COOP-A is only a screener, and does not hold the

weight of more rigorous and thorough comprehensive assessments, such as the BASC-2 or the

SSRS. Though the data from screeners should not be used to represent important qualities, the

COOP-A was utilized in this study because previously published had suggested its

appropriateness for use with children who had auditory deficits, and because it was going to be

used in combination with two other psychometrically sound psychosocial assessments. Since

there are only two subject groups, one can simply examine and compare the mean ratings to

determine the direction and interpretation of the findings. The mean ratings for the APD group

were higher than the normal group for all significant subscales, indicating the children in the

APD group reported more problems than the children without APD.

The Emotional Symptoms index of the BASC-2 is specific to the children's self-report

version, that is, this index is not included in the parent's version. It combines content items from

both the Internalizing Problems and Personal Adjustment composite subscales, including areas

such social stress, anxiety, depression, and self-esteem. High self-reported scores on the

Emotional Symptoms Index composite subscale can reflect a global pattern of serious broad-

based emotional disorders (Reynolds & Kamphaus, 2004). Children who display APD are more

likely to display negative emotional symptoms than normal children. This finding draws a

parallel with the significant COOP-A finding on the Emotional Feeling subscale chart, providing

further evidence that the APD group reported more emotional symptoms than the normal group.









For the three statistically significant subscales based on children's psychosocial reports,

there was a large effect size (r2 = .165) for the Emotional Feelings subscale of the COOP-A. The

Overall Health subscale chart of the COOP-A (r2 = .111) and the Emotional Symptoms Index of

the BASC-2 (eta squared = .104) were characterized by moderate effects. The strength of these

effect sizes enhances the ability for their interpretation to be generalized to a larger population of

children in this age group with APD.

An additional analysis of "Average" (ratings of 1 or 2) versus "At-Risk" (ratings of 3, 4 or

5) on the COOP-A responses was completed in order to determine the proportion of children

who would be identified as needing further follow-up on the particular content area represented

by each subscale chart (Wasson et al., 1994). The reader is again directed to Table 4.7 and

Figure 4.6 for summaries of findings for proportions of students considered "At-Risk" from both

groups for each subscale chart. The only statistically significant difference was found in the

Stress domain (x2 = .034). The differences between the significant subscales found when

utilizing the Mann-Whitney U procedures versus the chi-square analysis may be resolved by

analyzing the inherent distinctions between the two statistical methods. The Mann-Whitney U

test is evaluating mean rankings of the 1-5 ratings on the subscale charts, while the chi-square

procedure works only with the nominal categories of "Average" or "At-Risk." Therefore, on the

Stress subscale chart, for example, the mean ranks were 17.55 and 22.58 for the normal and APD

groups, respectively, and the Mann-Whitney U analysis suggested that no statistically significant

difference exists between the two groups for this subscale (p = .145); however when broken

down into the dichotomous nominal categories the chi-square analysis was significant (x2 = .034)

for a greater proportion of children with APD to be considered at-risk for problems in this area.









Parental Perceptions of Psychosocial Status

Statistically significant differences by parent report were found on subscales of all three

psychosocial instruments utilized in the present investigation: the Pain, School Work, and

Emotional Feeling subscale charts of the COOP-A; the Externalizing Problems, Internalizing

Problems, Behavioral Symptoms Index and Adaptive Skills Index subscales of the BASC-2; and

the Responsibility, Externalizing Problem Behaviors and Internalizing Problem Behaviors

subscales of the SSRS.

The COOP-A was designed as a self-rating scale for use by pre-teens and adolescents

when working with primary care physicians in their practices. Parents of subjects in this

investigation, however, were asked to complete the COOP-A according to their perceptions of

their child's psychosocial status for the various charts. These directions were also given to

parents completing the COOP-A during a pilot investigation of psychosocial characteristics of

children with APD (Kreisman, Crandell & Hall, 2004), and they proved to be a useful

modification. In the pilot study, parents tended to corroborate their children's self-perceptions.

In the present investigation, findings suggest that parents report more social and emotional

difficulties for their children with APD than parents of the children with normal auditory

abilities. Statistically significant differences were found between groups with moderate to large

effect sizes for the Pain (p = .032, r2 = .125), School Work (p =.032, r2 = .122), and Emotional
2
Feeling subscale charts (p = .032, r = .140

Pearson chi-square tests for independence on the proportion of "Average" (ratings of 1 or

2) versus "At-Risk" (ratings of 3, 4 or 5) responses on the COOP-A were again completed in

order to determine the proportion of children who would be identified by their parents as

potentially needing further follow-up in a particular content area. Statistically significant

differences were found in the Pain (x2 = .004) and Self-Esteem (x2 = .009) domains. These









findings once again indicate a greater tendency for parents of children with APD to report at-risk

function for their children in these areas.

On the comprehensive behavioral questionnaire the BASC-2, parents of children with APD

reported significantly more problems for all four composite subscales. There were large effect

sizes for all findings: Externalizing Problems (p =.004), Internalizing Problems (p =.001),

Behavioral Symptoms Index (p <.0005) and Adaptive Skills Index (p =.017). Additionally,

parents of children with APD reported significantly more social skills difficulties for their

children on the SSRS forms than parents of the children in the normal group on 3 of the 6

subscales measured, with moderate to large effect sizes: Responsibility Skills (p = .020),

Externalizing Problem Behaviors (p =.045), and Internalizing Problem Behaviors (p =.014).

Taken in combination, these findings from parental reports on the three psychosocial

instruments utilized in the study indicate an overall pattern of parental concern regarding reduced

emotional health status, poor or inappropriate behaviors, and difficult adaptations to school that

their children may be experiencing. Interestingly, parents reported over three times as many

significantly differing subscales as their children. There may be several possible explanations

for this difference in perceptions for children versus parents. Could it be that the children with

APD are underreporting their emotional and social problems? Or, are parents overly-sensitive to

the difficulties of their children, and perhaps over-reporting difficulties? Educational

audiologists and others who interact on a regular basis with children diagnosed with APD can

attest to the frequent subjective challenges, difficulties and delicacies involved with working

with their parents, often much more so than the children themselves. Parents of children with

APD can appear at times to be: demanding, judgmental, insensitive, overly-sensitive, anxious,

depressed, overwhelmed, guilt-ridden, beleaguered, and fatigued. Could it be that part of the









reason these parents may come across to professionals with any or all of the above traits is

because they are reflecting some of the psychosocial problems they perceive their children to be

experiencing?

Language Function Status of the APD Group

A somewhat unexpected finding uncovered on post-hoc analysis was the lack of

statistically significant differences on any subscale between children in the APD group who had

a confirmed or suspected language disorder (n = 9) versus those with no evidence of language

disorder (n = 10). While interpretation of this negative finding should be guarded due to the

small size of the subject sample, it suggests that APD may impact psychosocial function of

children more than other communication disorders. In many ways, and to many professionals

who work with children with communication disorders, auditory processing would appear to be

invariably linked with language function, and language function intrinsically linked with

psychosocial status. It is reasonable to assume that poor speech perception inevitably leads to

disordered language reception or expression, poor reading or writing abilities, and a poor ability

to effectively communicate and, therefore, that psychosocial function is similarly impacted by all

of these disorders. However, the recent work of Wible, Nicol and Kraus (2005), based on

research with auditory evoked potentials, challenges the presumed correlation of brainstem and

cortical auditory processing disorders with language-impairment. That is, the connection

between auditory processing and language function may not be as clear-cut or unambiguous as

one might suspect.

Limitations of this Study

This study has several limitations. First and foremost, it cannot be overstated that the

COOP-A, while an effective screening instrument for quality of life concerns in adolescents

when used in primary care physicians' offices, is not a psychometrically appropriate tool for