The action of listening involves a complex interaction between the peripheral and central auditory systems. In Brazil, since the 1990s, studies have been carried out focusing on Central Auditory Processing (CAP)1 – defined by the American Speech-Language Hearing Association (ASHA) as the efficiency and effectiveness by which the central nervous systems uses auditory information. To do so, a set of skills is required, which aims to meet, discriminate, recognize, store and understand sound information.2

Central Auditory Processing Disorder (CAPD) can be described as any alteration in one or more auditory abilities, namely: sound localization and lateralization, auditory discrimination, recognition of auditory patterns, temporal aspects of hearing (temporal resolution, masking, integration and ordering), figure-ground and auditory closure.3

Individuals with CAPD have difficulty hearing and/or understanding auditory information, even when their auditory thresholds are quantitatively normal. They may have several difficulties, such as understanding speech in noisy environments, following instructions, discriminating similar speech sounds, and often request the repetition of verbal information. Overall, morbidities can also be observed regarding spelling, reading, and writing.4

There is a significant association between CAPD and language disorders and school learning difficulties.5–10 Therefore, the manifestations indicative of possible alterations are frequently observed in this period – corroborating the fact that the language and learning processes are complex and that there is an association between them and the integrity of the peripheral and central auditory pathways. Thus, it is understood that parents’ and teachers’ perceptions regarding the child's auditory behavior in different situations of daily life are extremely important to detect those children at potential risk for CAPD.

The American Academy of Audiology (AAA)2 and ASHA11 indicate that screening scales can be used to identify individuals at risk for CAPD, since family-based questionnaires and checklists are tools that can assist in providing information about individual's communication deficits and the impact on the daily life. Several questionnaires and behavioral checklists that assess hearing skills have been created and mentioned in the international literature, such as Children's Auditory Performance Scale (CHAPS),12 Screening Instrument for Targeting Educational Risk (SIFTER),13,14 Test of Auditory Processing Skills – Revised (TAPS-R),15 Children's Home Inventory of Listening Difficulties (CHILD),16,17 Fisher's Auditory Problems Checklist (FAPC),18 Auditory Processing Domains Questionnaire (APDQ),19 Listening Inventory for Education (LIFE),20 Listening Inventory for Education – Revised (LIFE-R),21 Scale of Auditory Behaviors (SAB),22 The Listening Inventory (TLI)23 and Evaluation of Children's Listening and Processing Skills (ECLIPS).24

The use of such tools has been discussed in the international literature for many years, and there have been divergences regarding their relevance and clinical applicability.11,25–27 However, in the Brazilian literature, there is no published evidence on which tools are available for the Portuguese language and have been used in research,1,28–39 nor is there information regarding the degrees of sensitivity, specificity and the auditory abilities focused by each one.

Therefore, the objective of this systematic review was to identify and analyze in the national literature the questionnaires and checklists for CAP screening available in Brazil for the Portuguese language.

The research question that guided the present study was: “Which questionnaires and checklists for CAP screening are available in Brazil for the Portuguese language?”.

Aiming to identify the studies in CAP screening through a questionnaire or checklist, scientific articles were searched in the following electronic databases: National Library of Medicine (PubMed), Scopus, Scientific Electronic Library Online (SciELO) and the Latin-American and Caribbean System on Health Sciences Information (LILACS).

As an alternative search source, we also used the “gray literature” – defined as any non-conventional print or electronic publication produced at all governmental, academic, and corporate levels.40 Thus, unpublished studies in scientific databases were also considered for the present study, such as monographs, theses and dissertations. The searches were performed in the Brazilian Digital Library of Theses and Dissertations (BDTD) and informally, including searches on the electronic search portals and the bibliographic references cited in the articles and in the “gray literature”, directly or indirectly related to the theme of this systematic review.

The descriptors used were selected from the exact descriptors and terms obtained through the Health Sciences Descriptors (DeCs), organized by the Virtual Health Library – Bireme – and the research strategy was as follows: Questionnaires OR Surveys and questionnaires AND Auditory OR Hearing tests OR Auditory Perception AND Brazil.

The studies were independently analyzed and selected by two examiners and, in case of divergence, consensus was sought. The following inclusion criteria were used: Brazilian studies, with no date or design restriction, that were created, translated, adapted and/or validated for Brazilian or European Portuguese, using questionnaires and checklists as tools for CAP screening. International studies not adapted to the Portuguese language were excluded, as well as those not available as full-text.

The collected data were analyzed and qualitatively compared regarding the following variables: general characteristics, target audience, age range of application, translation, adaptation and/or validation to Portuguese, focused listening skills, number of questions, correlation with the CAP tests, national studies published in full that used the tool and the degrees of sensitivity and specificity – in cases where validation occurred.

The search strategy occurred from June to August 2017. First, the search was carried out in the usual scientific electronic databases, resulting in 3378 published articles. Of these, 66 articles were excluded as they were duplicates in and among the databases themselves. Of the 3312 remaining studies for the initial analysis, 3311 studies were excluded because they did not address the object of this study and/or because they were international studies not adapted to the Portuguese language. Only one article,1 which adequately met the selection criteria for this systematic review, was included.

Using the same search strategy, a search was carried out in the “gray literature” through the Brazilian Digital Library of Theses and Dissertations (BDTD), resulting in 279 studies (169 dissertations and 110 theses), which were excluded as they did not assess the study theme.

Finally, informal searches were carried out in Google Scholar and the bibliographic references of the studies collected for this review. Therefore, four articles35–38 and three abstracts34,41,42 were found, which had been published in Congress Annals that assessed the present theme. It was necessary to contact the authors to have access to the studies not available as full-texts. With the exception of one abstract,34 it was possible to obtain all studies in their original full-text versions. These search and selection strategies are shown diagrammatically in Fig. 1.

Figure 1.

Diagram of study search and selection strategy.

(0.57MB).

In total, seven articles were selected for this systematic review, as shown in Table 1. Of these, three questionnaires were informally created by the studies’ authors36–38; two were translated and adapted from the international literature1,43 (SAB and CHAPS); one was translated only35; (QFISHER); and, finally, the other was translated, adapted and validated44 (APDQ). No original Brazilian studies that proposed to elaborate, adapt and validate tools to screen for CAP were identified.

Table 2 shows the population groups that have been previously studied and the respective questionnaires that have been used.

Table 3 demonstrates the auditory skills assessed by each tool.

Table 4 compares and synthesizes the tools regarding the analyzed variables.

Questionnaires are important tools in clinical practice and in several fields of knowledge, and currently there are few tools available in Brazilian Portuguese for audiology.43 Regarding the tools for CAP screening, the interest in the creation, translation, adaptation and/or validation of these tools in Brazil is quite recent, compared to the international scientific productions, all emerging in the last decade.

Regarding the translation, adaptation and/or validation studies, it is important to highlight the difficulty of locating them in the scientific databases. With the exception of the Scale of Auditory Behaviors (SAB),1 published in article format, the remaining articles were found only by searching the “gray literature”. It is believed that this fact influences the small number of studies found at the national level that have used questionnaires and checklists as CAP function screening methods28–33,39 and, consequently, the possible lack of knowledge by professionals regarding the use of such tools in clinical practice.

The population assessed by the tools found in the present systematic review comprises children and adolescents, with a predominance of preschoolers and school-aged children. This was also observed in seven other studies28,39 that used these diagnostic tools in their methodologies for CAP assessment, and it was observed that CHAPS and SAB were the most often used questionnaires in the national literature.28,39

The difficulty in identifying and/or the absence of screening tools in questionnaire or checklist format aimed at adult and elderly individuals is emphasized. This is believed to be due to the fact that the signs and symptoms of CAPD manifest mainly during the school period, making the study focus aim at the pediatric population for early detection and intervention.5–10 A positive association between CAPD and reading/writing learning difficulties/disorders has been well established in the literature. Therefore, it is emphasized that losses in such processes can jeopardize an adequate overall child development.

Regarding the number of questions, this variable was very heterogeneous. For purposes of classification, in this systematic review, a “short tool” was defined as that having 15 items and a “long tool” as having more than 15 items. With the exception of two questionnaires,1,36 the rest of the assessed tools are long, containing an average of 38 questions. In clinical practice, the application time of the tool is also a variable to be considered and, in the identified studies, this factor was not explained.

Not all studies sought to associate performance in the questionnaire and CAP tests. Therefore, the auditory abilities focused on each one were studied also considering the subjective analysis of the items of each tool, according to Table 3. It can be observed that the tools that cover all CAP auditory abilities are the APDQ and CHAPS. However, more studies are needed for objective verification.

Questionnaires such as the one by Lima-Gregio et al.,36 “Audiological and Cognitive Aspects in Preschoolers”37 and the “Auditory/Attention Questionnaire”,38 were created as methodological tools of their respective studies.

The questionnaire created by Lima-Gregio et al.36 aimed to compare the performance of children with and without a history of recurrent otitis media, in the Sound Localization test (SL), with parents’ answers to a questionnaire. With the exception of the question that investigated inattention, there was no significant difference between the two tested groups – the questionnaire and the SL Test were insufficient tools to differentiate the tested groups. The authors believe this fact is justified by socioeconomic factors of the assessed sample.36

On the other hand, the questionnaire called “Audiological and Cognitive Aspects in Preschoolers”37 aimed to identify the risk factors for CAPD in preschool children attending the public school system. The tool was effective in identifying statistically significant risk factors for CAPD in the assessed population regarding the variables: higher number of siblings, more requests to repeat instructions and difficulty in understanding in a competitive environment. Another important finding was the high number of children who had never been submitted to any type of audiological examination, with some of them often requesting repetition of instructions.37

The tool “Auditory/Attention Questionnaire”38 was used to assess children with cleft lip and palate (CLP) through the parents’ perception. The findings showed that most of the interviewed parents pointed out at least one of the behaviors related to attention contained in the questionnaire, suggesting that the presence of CLP may be related to difficulties in hearing care.38 Although that is the main focus of the tool, it can be observed that several questions include more skills, which suggests it can be used for other skills in addition the auditory attention and in other populations, as well as the fact that it can identify or screen individuals with Attention-Deficit and Hyperactivity Disorder (ADHD).

The SAB tool, originally proposed by Schow, Seikel, Brockett and Whitaker in 2007,22 was adapted and translated into European Portuguese.1 The important correlation between the tool and all the auditory abilities tested in the study is highlighted, but mainly with the ability of temporal ordering. In Brazil, some studies have been used to investigate auditory behavior and temporal resolution of children with obstructive sleep apnea syndrome (OSAS)28 and CAP function in students in the first years of schooling.29 It should be noted that there is a published version of SAB available for Brazilian Portuguese,45 which, however, does not show methodological data for the translation, adaptation and validation steps of the tool for use in this population.

The CHAPS tool12 has been translated and adapted into Brazilian Portuguese.43 During the process of translation and adaptation to Brazilian Portuguese, there was a correlation between the Auditory Memory module questions and the performance in the Dichotic Digits Test (DD) – binaural integration step. Brazilian studies used CHAPS prior to its translation and formal adaptation, aiming to assess the auditory behavior of children submitted to surgery due to CLP through the assessment of teachers30,31 and the parents’ own perception.39

CHAPS is the tool most often used in the assessment of children with CLP.

The FAPC tool (1976)18 does not have an adapted version, but has been informally translated in studies32,35 to be used as a screening tool for CAPD in children. The tool is a scale and consists of 24 questions that address the behavioral difficulties observed in the individual's daily life. If the scoring of the items is equal to or greater than seven, the individual is considered to be at risk for CAPD.

The use of the FAPC, called by the study authors35 as “QFISHER”, is highlighted as an effective tool for auditory training monitoring in children with CAPD. The study demonstrated an association between the improvement in the scores with the following tests: DD, Non-verbal Dichotic (NVD), Synthetic Sentence Identification with Competitive Message (PSI/SSI), Dichotic Consonant-Vowel (DCV) and List of Sentences in Portuguese with contralateral message (LSPMC).

It is noteworthy that the APDQ questionnaire19 was translated and validated into Brazilian Portuguese with 100% sensitivity and specificity, being therefore the most robust tool for use in clinical practice and research. One study44 used the questionnaire after it was translated, back-translated and culturally adapted in a group of school-age children without CAPD. The total score of the original questionnaire was 208 points and the translated version averaged 199.2 points – close to that of the original score. Another study33 used the translated and validated version in school-age individuals with CAPD, obtaining an average of 92.6 points. The authors state that there is a statistically significant difference between the CAPD and the non-CAPD groups assessed in the translation study, suggesting this questionnaire can be a potential tool to identify individuals at risk. Nevertheless, there was a positive correlation between the total score of the questionnaire and the SL Test.

The information obtained through well-structured questionnaires about the child's auditory behavior by third parties, such as parents, guardians and/or teachers, can be very useful for the early identification of changes in CAP function, which will lead to other evaluation, diagnostic and therapeutic processes that will ensue, according to each child's needs. However, more national studies should be developed to demonstrate their effectiveness, mainly by associating the screening tools to the CAP behavioral evaluation data.

This systematic review shows the need to develop screening tools for CAP function for the adult and elderly populations, as they are currently restricted to the pediatric population. Regarding the study translation, adaptation and/or validation processes, it is essential to clarify the analysis of the results and parameters of normality of each tool for the Brazilian population, since these limitations were found in most studies found in the “gray literature”.

New studies with greater methodological stringency should be carried out and published for the purpose of demonstrating reliability, supporting evidence-based practice and disseminating the use another auxiliary tool in the diagnosis of CAPD, which will allow the use of such tools in clinical practice.

There is a scarcity of national literature on CAP screening and the only tool validated to Brazilian Portuguese, published as a monograph, is the Auditory Processing Domains Questionnaire (APDQ). It is suggested that new studies with greater methodological stringency related to the processes of tool adaptation and validation be developed and published in the usual scientific databases, aiming at greater diffusion and clinical applicability.

The authors declare no conflicts of interest.