Central auditory testing in young Tanzanian children: feasibility and relationship to cognition.

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Published in final edited form as: Int J Audiol. 2025 Aug 21;65(4):464–475. doi: 10.1080/14992027.2025.2545441 Search in PMC Search in PubMed View in NLM Catalog Add to search Central Auditory Testing in Young Tanzanian Children: Feasibility and Relationship to Cognition Christin Ealer Christin Ealer , BA 1. Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Find articles by Christin Ealer 1 , Christopher E Niemczak Christopher E Niemczak , AuD, PhD 1. Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire 2. Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Find articles by Christopher E Niemczak 1, 2 , Jonathan Lichtenstein Jonathan Lichtenstein , PsyD, MBA 3. Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire 4. The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Find articles by Jonathan Lichtenstein 3, 4 , Samantha Leigh Samantha Leigh , BS 1. Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Find articles by Samantha Leigh 1 , Abigail Fellows Abigail Fellows , MA 1. Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Find articles by Abigail Fellows 1 , Ziyin Zhang Ziyin Zhang , MS 1. Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Find articles by Ziyin Zhang 1 , Catherine Rieke Catherine Rieke , AuD 1. Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Find articles by Catherine Rieke 1 , Anastasiya Kobrina Anastasiya Kobrina , PhD 1. Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire Find articles by Anastasiya Kobrina 1 , Albert Magohe Albert Magohe , MD 5. Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania Find articles by Albert Magohe 5 , Enica R Massawe Enica R Massawe , MD 5. Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania Find articles by Enica R Massawe 5 , Jay C Buckey Jay C Buckey , MD 1. Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire 2. Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Find articles by Jay C Buckey 1, 2 Author information Article notes Copyright and License information 1. Space Medicine Innovations Laboratory, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire 2. Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 3. Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire 4. The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire 5. Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania Contributors Statement Page Christin Ealer performed all data analysis, drafted the initial manuscript, and critically reviewed and revised the manuscript. Christopher E. Niemczak verified data integrity and critically reviewed and revised the manuscript. Jonathan Lichtenstein conceptualized and designed the study, verified data integrity, and critically reviewed and revised the manuscript. Samantha Leigh, Ziyin Zhang, Catherine Rieke and Anastasiya Kobrina verified data integrity and critically reviewed the manuscript for important intellectual content. Abigail Fellows and Albert Magohe conceptualized and designed the study, coordinated and supervised data collection, verified data integrity, and critically reviewed the manuscript for important intellectual content. Enica Massawe conceptualized and designed the study, coordinated and supervised data collection and critically reviewed the manuscript for important intellectual content. Jay C. Buckey conceptualized and designed the study and critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. ✉ Corresponding Author: Christopher E. Niemczak, AuD., PhD., Scientist, Assistant Professor of Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH 03756, [email protected] Issue date 2026 Apr. PMC Copyright notice PMCID: PMC13070252  NIHMSID: NIHMS2161759  PMID: 40839536 The publisher's version of this article is available at Int J Audiol Abstract Objective: Central auditory tests (CATs) typically target children aged six and older and are not included in pediatric cognitive assessment. CATs have shown significant correlations with neurocognitive processing ability in adults. Whether children under six can reliably complete CATs or if CAT performance correlates with cognitive ability in children with normal hearing is unclear. This study aimed to determine the feasibility of conducting CATs in young children and investigate whether performance on CATs could predict neurocognitive function in a cohort of young Tanzanian children. If young children can complete CATs and their results correlate with neurocognitive function, CATs could supplement cognitive screening in young children. Design: Data are from the first visit of an ongoing longitudinal study in Dar es Salaam, Tanzania. Each child was administered four CATs (the Hearing in Noise Test-HINT, Triple Digit Test-TDT, Staggered Spondaic Words test-SSW, and Gap Detection test-Gap) and one non-verbal cognitive test (Leiter-3). Performance on the CAT battery (HINT, TDT, SSW) was compared to performance on the Leiter-3, a non-verbal neurocognitive assessment. Study Sample: Cross-sectional study in an infectious disease center in Dar es Salaam, Tanzania. Participants included 486 Tanzanian children (50.6% female) aged 3–9 years with 46.7% living with HIV. Results: Over 70% of children completed at least one CAT during their first visit (average age 6.29 years) with 61% able to complete three (HINT, TDT, and SSW), minus Gap. By age five, 62.5% of children could complete the CAT battery. Completing the CAT battery predicted higher IQ, and performance on the battery was associated with stronger cognitive abilities. Conclusions: The studied CAT battery, minus Gap detection, could be completed reliably by age five. CATs and cognitive domains (IQ, processing speed, memory) were significantly associated. Administering CATs is feasible in children younger than six, potentially providing a valuable supplementary tool to assess auditory and cognitive function. Article Summary: This study measured the age children completed central auditory tests reliably and determined whether performance on those tests correlated with cognitive ability. Introduction: Central auditory tests (CATs) assess how the brain processes complex sounds and engage cognitive abilities such as attention, processing speed, and working memory ( Watson, 1991 ; Niemczak et al., 2021 ; Joseph et al., 2024 ). Research has shown a correlation between central auditory tests and cognitive function in adults ( Niemczak et al., 2021 ). Compared to traditional measures of neurocognitive function, like the Wechsler Intelligence Scale for Children (WISC), CATs can be quicker, more affordable, easier to administer and monitor, and less biased by gender or education ( Jalaei et al., 2019 ). To complete a central auditory test, children do not need to be able to read, do calculations, or have attended school. CATs could be particularly useful in resource-limited settings, such as sub-Saharan Africa, where traditional measures of cognitive function may not always be feasible. In children, significant associations have been found between central auditory abilities and executive function, intelligence, and emotional control ( Back et al., 2022 ). In older adults, central auditory ability, particularly frequency-pattern discrimination, has been associated with working memory and visuospatial abilities ( Sheft et al., 2015 ). This association has been further supported by the finding that central auditory processing disorders could be a marker of subtle cognitive dysfunction in the elderly ( Ghannoum et al., 2018 ). Previous research shows CATs are effective in assessing cognitive function in adults and children living with HIV ( Niemczak et al., 2021 ; Niemczak, Lichtenstein et al., 2021 ; Joseph, Niemczak et al., 2024 ), mild cognitive impairment ( Gates et al., 2011 ), or traumatic brain injury ( Gallun et al., 2017 ). Research exploring the connection between CATs and cognitive function in children, outside of those with Auditory Processing Disorder (APD), is limited. While children with APD typically score lower on cognitive tests than non-impaired peers ( Moore et al., 2010 ; Rosen et al., 2010 ; Tomlin et al., 2015 ), whether this relationship exists in children without documented auditory processing deficits is unclear. Literature suggests children under age six have unreliable CAT results ( (ASHA), 2005 ; Bellis, 2014 ; Lucker, 2015 ). At young ages, the brain may be insufficiently mature to support the neural processes tested by these tasks or sustain attention for the required length of time, leading to variable performance in young children ( Beck, 2002 ; (ASHA), 2005 ; Bellis, 2014 ; Lucker, 2015 ). But the ability to evaluate central auditory processing in young children could offer advantages such as identifying the need for timely interventions, therapeutic measures, and appropriate accommodations ( Lucker, 2015 ). CATs may provide useful information about a child’s hearing ability, the likelihood of having disorders like dyslexia, and the ability to process complex auditory signals ( Skarzynski et al., 2015 ). Since processing complex auditory signals requires a healthy central nervous system (CNS), CATs may indicate the overall health of the CNS ( Musiek & Baran, 2020 ; Musiek et al., 2021 ; Niemczak, Lichtenstein et al., 2021 ; Niemczak et al., 2024 ). CATs may be a useful supplement in screening for cognitive deficits in older adults, particularly those resulting from diffuse damage to the CNS ( Gates et al., 2008 ; Joseph, Niemczak et al., 2024 ). If CAT performance can unmask subtle cognitive decline in elderly patients, it stands to reason that analogous auditory-cognitive challenges might reveal emerging or subclinical vulnerabilities in children as they acquire and consolidate these very skills. This study evaluated the feasibility of administering CATs to young children and explored the relationship between CATs and cognitive performance at the child’s first visit. We administered four CATs that measured various aspects of central auditory processing. Two tests assessed speech-in-noise processing, one measured dichotic listening ability, and the fourth measured temporal resolution. CAT results were compared to validated cognitive outcomes from the Leiter-3. If young children can complete CATs reliably and the results correlate with neurocognitive function, CATs could be used to supplement cognitive assessments. This would be particularly useful in low- to middle-income countries because deployable, easy-to-administer assessments could be developed. Methods: The Committee for Protection of Human Subjects of Dartmouth College and the Research Ethics Committee of Muhimbili University of Health and Allied Sciences (MUHAS) approved the research protocol (Ethical Clearance Reference Number: STUDY00031305). Recruitment involved presenting the study to potential subjects, with both assent from the child and a consent form for the parent/guardian. Inclusion and exclusion criteria were reviewed to determine eligibility. Subjects meeting inclusion criteria could enroll, and both the parent/guardian and child had the opportunity to ask questions before signing the consent and assent forms. The study involved age-appropriate discussions with children, and assent was judged by verbal agreement or the absence of a negative response in very young children. Consent and assent forms were translated into Kiswahili, ensuring comprehension, and underwent review by both the Dartmouth and MUHAS IRB. Participants: 486 children (age 3–9 years at first visit, 50.6% female, 46.7% children living with HIV (CLWH)) performed central auditory and neurocognitive tests as part of a larger longitudinal study in Dar es Salaam, Tanzania (Niemczak, Fellows et al., 2021; Niemczak, Lichtenstein et al., 2021; Lichtenstein et al., 2022 ; Joseph, Niemczak et al., 2024 ). All data were from the children’s first study visit. Hearing sensitivity measures peripheral hearing ability, or the quietest sound that can be heard. Hearing sensitivity was measured by trained administrators using either Békésy audiometry, modified Hughson-Westlake, or Conditioned Play Audiometry procedure if the child could not perform Békésy audiometry, at 0.5, 1.0, 2.0, 4.0, 6.0, 8.0 kHz ( Jerger, 1960 ). If the child had trouble with the modified Hughson-Westlake procedure, Conditioned Play Audiometry was conducted at all frequencies. The pure tone average (PTA) was calculated across 0.5 – 4 kHz. PTAs less than or equal to 25 dB HL were considered consistent with normal hearing. All peripheral and central auditory test were completed using the WAHTS system ( Meinke et al., 2017 ). The cohort was socioeconomically diverse and included children from low socioeconomic backgrounds. Our method of calculating socioeconomic status (SES) has been extensively detailed elsewhere ( Lichtenstein et al., 2022 ). Briefly, a medical history and demographic questionnaire were completed for each child. These forms covered child education, early life experiences, health problems, developmental milestones, caregiver/parent education and employment, income, quality of the home environment, and material possessions. For the SES measure, selected variables from the demographic data fell within three main categories: household assets and access to resources, measures of income and occupation, and measures of parental education. We focused on variables that were not expected to change over the course of the study, so that an individual’s SES score would remain as constant as possible. The first principal component, representing 32.7% of the variance in the data, was used to calculate a single value estimating socioeconomic status for each participant. This value is the one used in our analyses. To account for potential confounding variables, we included HIV status, socioeconomic status, PTA, and age as predictors in our models. This approach enabled us to determine if CATs could predict neurocognitive function independently of these other factors. The relationships between HIV status, socioeconomic status, and cognitive domains were also examined, but the focus of this work was to establish the feasibility of CATs at a young age and to assess any relationship to cognitive function. Central Auditory Testing: Four CATs were administered to each child: the Triple Digit Test (TDT), the Hearing in Noise Test (HINT), the Gap Detection Test (Gap), and the Staggered Spondaic Words test (SSW). Each child attempted all four CATs. All CATs were conducted in Kiswahili, the native language of all participating children. Staff were trained on conducting central auditory testing and their performance was routinely monitored for consistency. The entire CAT battery took approximately 40 minutes. The TDT and HINT both assess speech-in-noise abilities. The methodology has been described previously in Niemczak, Lichtenstein et al. (2021), and is briefly summarized here. In the TDT, three-digit triplets (e.g., 2-8-1 = mbili-nane-moja) were presented binaurally. Digit triplet recognition was tested in the presence of competing Schroeder-phase masking noise and used an adaptive paradigm. The test started at a 0-dB initial signal-to-noise ratio (SNR) with the masker fixed at 65 dB sound pressure level (SPL); SNRs were adaptively adjusted after each presentation (+2 dB for each incorrect response and −0.5 dB for each correct response). The speech reception threshold was calculated as the SNR of the last six presentations. The HINT uses sentence stimuli instead of digit triplets. We used an adaptive paradigm in three test conditions: Noise Front, Noise Right, and Noise Left. In each condition, a different list of sentences was presented in the presence of speech-shaped masking noise. The noise level was fixed at 65 dB SPL. The level of each sentence changed adaptively depending on whether the test administer indicated that the previous sentence was repeated correctly (2 dB up for incorrect answers and 2 dB down for correct answers). The sentence level was decreased adaptively to find the lowest level where the sentences could be repeated reliably. This level was expressed as a SNR. The average SNR of the last six sentences was used as the outcome. The composite SNR of all three noise conditions was calculated as Composite Score = [2×Noise Front + (Noise Right + Noise Left)]/4 . The Gap test measures auditory temporal resolution and has been described previously ( Maro et al., 2014 ; Niemczak et al., 2023 ). Participants listen to a block of white noise containing a short gap (i.e., break in the white noise) and push a button as soon as they identify this gap ( Buss et al., 2017 ). We used an adaptive gap detection algorithm which converged to the subject’s Gap threshold (i.e., the shortest gap that can be detected reliably). The test started with a 20 msec gap length and continued lower (gaps at 20, 16, 13, 10, 7, 4, 2, 1 ms) until the subject reliably identified their Gap threshold using the average of their five lowest responses. From these Gap tests, the percentage of the time a gap was correctly detected vs. gap length was plotted. The resulting curve can be fit by the Hill equation, allowing for the calculation of the gap length where 50% of the gaps were detected correctly ( Hill, 1910 ; Niemczak, Cox et al., 2023 ). These values were used in the analysis. The SSW tests dichotic auditory processing. Two spondaic words (e.g., vuna-ngano, pata-pesa, which roughly translate to: harvest-wheat, earn-money) were presented where the first syllable of one word and the second syllable of the other word were presented to both ears simultaneously ( Katz & Smith, 1991 ). The participant was asked to repeat all four words, in order. Each syllable was scored as either correct or incorrect. Nonverbal Intelligence Testing: Participants completed a test of nonverbal intelligence and overall cognitive function (the Leiter International Performance Scale—3rd Edition; Leiter-3). The Leiter-3 assesses cognitive functioning in individuals from 3 to 75+ years of age. Details of how this testing was conducted within our cohort has been described in Lichtenstein, Bowers et al. (2022). The test is nonverbal, meaning that examiners communicate to the examinees with gestures and body language, not verbal instructions or cues. Three composite scores are generated, which measure nonverbal memory, processing speed, and nonverbal IQ. The nonverbal memory composite measures attention, working memory, and retrieval. The processing speed composite measures attention and speed of processing. The nonverbal IQ composite reflects problem solving, categorical and logical reasoning, pattern recognition, mental sequencing, and appreciation for visual-spatial relationships. Statistical Analysis: Feasibility of Central Auditory Testing in Children: To test the feasibility of CATs in young children, we calculated completion percentages for each CAT. The completion percentage was the number of children who could complete a given test divided by the total number of children. Children could generally complete three CATs (the HINT, TDT, and SSW), but could not complete the Gap (0.6% completion rate). Due to limited data on Gap performance, we chose to focus on the other three tests for the analysis on how central auditory test performance relates to cognitive function. This limitation is addressed in the discussion. To explore how CAT completion changes with age, we stratified age into six brackets (3–4 years, 4–5 years, 5–6 years, 6–7 years, 7–8 years, and 8–9 years) and calculated the battery completion rate within each bracket. Each age bracket included individuals from the lower bound, inclusive, up to but not including the upper bound (e.g., the 3–4-year group includes those aged 3.00 to 3.99 years). The HINT, TDT, and SSW constituted the Central Auditory Test (CAT) battery in this analysis. The battery completion rate was the number of children who could complete all three tests in the CAT battery divided by the number of children in that age bracket. Whether a child completed the test was ultimately left to the discretion of trained administrators, who used their judgment to assess comprehension and attention based on prior experience with CATs. Consistency was monitored by local and Dartmouth-based teams. Factors Associated with Completion of the CAT Battery at a Very Young Age (3–5 Years Old): We divided the 3–5-year-olds into groups that could and could not complete the CAT battery. We then compared descriptive statistics (i.e., mean, standard deviation) on various factors between the groups using t-tests and chi-square tests as appropriate. Factors examined included age, gender, HIV status, socioeconomic status, years of education, pure tone audiometric thresholds, and the three Leiter-3 composite scores (Nonverbal IQ, Nonverbal Memory, and Processing Speed). We also examined the relationship between CAT battery completion and cognitive performance in very young children using odds ratios. We examined if the odds of a 3–5-year-old’s cognitive testing falling above the median was different between children who could complete the CAT battery compared to those who could not. 95% confidence intervals (CI) were calculated to estimate the precision of the odds ratio estimates. CAT Completion and Performance to Predict Neurocognitive Function: To provide a single measure of performance on the CAT battery, we created a Global CAT Score . Each child’s result on the TDT, HINT, and SSW was converted to a z-score based on the mean and standard deviation of the full sample of children who were able to complete the respective tasks. The child’s three z-scores were then averaged to produce the Global CAT Score, yielding a composite measure in which each task was equally weighted. Although the Global CAT Score reflects performance relative to all other completers in the sample, all analyses using this variable included age as a covariate in regression models to appropriate control for age-related effects. Additionally, all Leiter-3 composite scores (Nonverbal IQ, Processing Speed, and Nonverbal Memory) used in the analysis were age-standardized. To explore how the CAT battery related to cognitive domains, we conducted two sets of three linear regressions (total of six regressions). To account for multiple comparisons, a Bonferroni-corrected p-value of 0.008 (0.05/6 comparisons) was used to assess significance. Each model included all predictors and a given outcome. The first set of regressions included all 486 children and examined whether completion of the CAT battery predicted the three Leiter-3 composites. Predictors included age, socioeconomic status, HIV status, pure tone average in the right ear, pure tone average in the left ear, and CAT completion; the response variable was either Nonverbal IQ, Nonverbal Memory, or Processing Speed. The second set of regressions included only the 297 children who completed the HINT, SSW, and TDT and examined whether performance on the CAT battery predicted each Leiter-3 composite. Predictors were age, socioeconomic status, HIV status, pure tone average in the right ear, pure tone average in the left ear, and the Global CAT Score; the response variables were Nonverbal IQ, Nonverbal Memory, or Processing Speed. Supplemental analyses were conducted to assess the relationship between CATs and cognitive function amongst the 8–9-year-olds, who are the oldest children in this cohort. As was done with the 3–5-year-olds, 8–9-year-olds were divided into those who could and could not complete the CAT battery. We calculated descriptive statistics between groups (i.e., mean, standard deviation) on various factors using t-tests and chi-square tests as appropriate. Factors examined included age, gender, socioeconomic status, years of education, pure tone audiometric thresholds, and the three Leiter-3 composite scores (Nonverbal IQ, Nonverbal Memory, and Processing Speed). The relationship between completion of the CAT battery and cognitive performance in 8–9-year-olds was examined using odds ratios. We examined if the odds of an 8–9-year-old’s cognitive testing falling at or below the median was different between children who could complete the CAT battery compared to those who could not. 95% confidence intervals (CI) were calculated to estimate the precision of the odds ratio estimates. A final supplemental analysis calculated the percentage of children within each age bracket who successfully completed each CAT. These data were visualized as stacked bar charts to illustrate the relative proportions of test completion and non-completion across age groups. Results: The overall cohort included 486 children with a mean age of 6.00 years (SD = 1.65); 49.4% were male, and 46.1% were HIV-positive. Mean pure tone averages were 10.29 dB HL (SD = 5.89) in the right ear and 9.73 dB HL (SD = 6.47) in the left ear. Additional demographic details by age group can be found in Table 1 . Table 1: Demographics Overall Cohort (n = 486) 3–4 years (n = 66) 4–5 years (n = 86) 5–6 years (n = 88) 6–7 years (n = 78) 7–8 years (n = 91) 8–9 years (n = 77) Age in Years (SD) 6.00 (1.65) 3.42 (0.28) 4.50 (0.32) 5.46 (0.27) 6.49 (0.30) 7.39 (0.29) 8.35 (0.29) Male (%) 240 (49.38) 34 (51.52) 41 (47.67) 41 (46.59) 38 (48.72) 48 (52.75) 38 (49.35) HIV-Positive (%) 224 (46.09) 28 (42.42) 37 (43.02) 40 (45.45) 38 (48.72) 44 (48.35) 37 (48.05) Education in Years (SD) 2.30 (1.45) 0.70 (0.46) 1.02 (0.56) 1.60 (0.94) 2.19 (1.11) 3.04 (1.27) 3.73 (1.24) Socioeconomic Status (SD) 0.00 (1.01) 0.44 (1.04) −0.18 (0.91) −0.09 (1.03) 0.07 (1.04) −0.10 (1.02) −0.02 (0.96) Pure Tone Average (dB HL): Right Ear (SD) 10.29 (5.89) 12.29 (2.43) 10.60 (5.43) 11.23 (6.43) 10.59 (5.48) 9.65 (5.96) 9.67 (6.06) Pure Tone Average (dB HL): Left Ear (SD) 9.73 (6.47) 10.63 (2.47) 9.49 (4.86) 11.33 (7.35) 10.43 (7.48) 9.43 (6.80) 8.20 (4.81) Nonverbal IQ Percentile (SD) 75.72 (16.36) 56.63 (20.50) 73.33 (15.15) 76.71 (14.65) 82.97 (14.18) 79.60 (10.15) 79.96 (12.19) Processing Speed Percentile (SD) 68.47 (13.66) 67.84 (11.15) 68.22 (13.11) 65.77 (12.83) 64.99 (11.13) 69.70 (15.44) 74.26 (15.17) Nonverbal Memory Percentile (SD) 76.37 (13.43) 82.58 (11.76) 85.63 (11.29) 76.33 (9.41) 70.82 (12.46) 71.96 (13.53) 73.32 (14.97) Completion of CAT battery (%) 297 (61.11) 11 (16.67) 36 (41.86) 55 (62.50) 58 (74.36) 72 (79.12) 65 (84.42) Open in a new tab CAT completion rates were generally high, except for the Gap test. On their first visit, 362 children (74.5%) completed the TDT, 345 (71.0%) completed the HINT, and 348 (71.6%) completed the SSW. Gap completion rates were much lower—only three children (0.6%) completed the Gap at their first visit. See Figure 1 for the completion rates on each CAT. Figure 1: Central Auditory Test Completion Rates. Open in a new tab Figure 1 . – Central Auditory Test Completion Rates . Left Panel -- Percentages of children that could complete each test (blue) and couldn’t complete each test (orange) are displayed for all tested CATs. Because of low completion rates on the Gap (lighter bars, dashed lines), the Gap was not included in the CAT battery and thus not included in the right panel . Right Panel-- Percentages of children that could complete the entire CAT battery (blue) and couldn’t complete the battery (orange) are displayed for age brackets from 3–9 years old . Completion rates increased with age. 11/66 (16.7%) of 3–4-years-old could complete all three central auditory tests (HINT, TDT, and SSW), compared to 65/77 (84.4%) of 8–9-year-olds. By age five, a majority (55/88 = 62.5%) of children could complete the CAT battery. Children younger than seven could generally complete the CATs, except for the Gap: 60% could complete the HINT, 51.2% could complete the SSW, 55.8% could complete the TDT, and 0.4% could complete the Gap. See Figure 1 for completion rates within a given age bracket. Table 2 compares demographic, peripheral hearing, and cognitive variables between 3–5-year-olds who could complete the CAT battery (TDT, HINT, and SSW) at their first visit versus 3–5-year-olds who could not. The composition of CLWH did not significantly differ between the group able to complete the CAT battery and the group that could not ( Table 2 ). On average, those who could complete the battery were older (4.37 versus 3.88 years, p<.001), with higher Nonverbal IQs (78.79 versus 59.76, p<.001), faster processing speeds (74.57 versus 64.91, p<.001), and better nonverbal memories (89.05 versus 81.98, p<.001). Gender distribution, years of education, HIV status, socioeconomic status, and right and left ear pure tone averages did not differ statistically between the two groups. The average PTA across the cohort was 11.91 dB HL in the right ear and 11.31 dB HL in the left ear. Table 2: Characteristics of 3–5 Year Olds Who Could Complete CAT Battery versus 3–5 Year Olds Who Could Not Complete (n = 47) Incomplete (n = 105) t-statistic or Chi-squared value P-value Age in Years (SD) 4.37 (0.50) 3.88 (0.60) 5.24 <.001 % Male 21/47 (44.68%) 54/105 (51.43%) 0.59 0.44 % HIV-Positive 18/47 (38.30%) 47/105 (44.76%) 0.55 0.46 Education in Years (SD) 0.95 (0.53) 0.89 (0.57) 0.63 0.63 Socioeconomic Status (SD) 0.13 (1.09) 0.07 (0.97) 0.32 0.75 Pure Tone Average (dB HL): Right Ear (SD) 10.23 (5.36) 12.63 (3.93) 2.76 0.21 Pure Tone Average (dB HL): Left Ear (SD) 8.99 (4.53) 12.32 (3.57) −4.46 0.08 Nonverbal IQ Percentile (SD) 78.79 (15.80) 59.76 (18.11) 6.55 <.001 Processing Speed Percentile (SD) 74.57 (15.09) 64.91 (9.14) 4.07 <.001 Nonverbal Memory Percentile (SD) 89.05 (12.05) 81.98 (10.62) 3.47 <.001 Open in a new tab Figure 2 displays the odds of being above the median Leiter-3 composite score based on whether a 3–5-year-old could or could not complete the CAT battery. 3–5-year-olds who could complete the battery were significantly more likely to be above the median IQ (Odds Ratio: 8.33; 95% CI: [3.33, 20.00]. p<.0001), above the median processing speed (Odds Ratio: 4.76; 95% CI: [2.13, 11.11]. p = .0001) and above the median nonverbal memory (Odds Ratio: 2.70; 95% CI: [1.27, 5.88]. p = 0.01) than 3–5-year-olds who could not complete the battery. Figure 2: Completing the CAT Battery at ages 3–5 increases the likelihood of scoring above the median Leiter-3 composite scores compared to non-completers. Open in a new tab Figure 2 . – Odds Ratios with 95% Confidence Intervals. An odds ratio greater than 1 indicates that 3–5-year-olds who could complete the CAT battery were significantly more likely to be above the Leiter-3 Composite median score. Asterisks next to the Leiter-3 Composite indicate significance: * < 0.01, *** < .001. We ran two sets of linear regressions. The first ( Table 3 ) assessed whether completion of the CAT battery (binary variable, 0 or 1) predicted Nonverbal IQ, Nonverbal Memory, and Processing Speed. The second ( Table 4 ) assessed whether performance (continuous variable, Global CAT Score a ) on the CAT battery predicted those same three cognitive domains. Completion of the CAT battery significantly predicted Nonverbal IQ (p = 0.001) but did not predict Nonverbal Memory (p = 0.12) or Processing Speed (p = 0.80). Performance on the CAT battery significantly predicted Nonverbal IQ (p = 0.005), Nonverbal Memory (p = 0.001) and Processing Speed (p <.001). Table 3: Results of Linear Regression: Completing CATs Predicts Neurocognitive Function. Nonverbal IQ Nonverbal Memory Processing Speed β p β p β p Age 0.46 0.44 −2.95 < .001 1.08 0.10 HIV-Negative Status 3.92 0.013 3.27 0.043 8.43 < .001 Socioeconomic Status 1.95 0.013 0.15 0.86 1.55 0.079 Pure Tone Average (Right) 0.00 1.00 −0.072 0.64 0.080 0.63 Pure Tone Average (Left) −0.29 0.039 −0.27 0.061 −0.42 0.008 CAT Completion 7.61 0.002 2.72 0.27 0.30 0.91 Open in a new tab Grey-scaled boxes highlight CAT Completion results. Significant p-values are bolded for emphasis. For each regression the cognitive composite was the outcome variable. Age, HIV status, SES, Pure Tone Average (Right), Pure Tone Average (Left) and CAT completion were predictors. CAT completion indicated that the child completed the HINT, TDT, and SSW. Table 4: Results of Linear Regression: Performance on CAT Battery Predicts Neurocognitive Function. Nonverbal IQ Nonverbal Memory Processing Speed β p β p β P Age −0.74 0.27 −3.81 < .001 −0.77 0.33 HIV-Negative Status 2.97 0.071 1.47 0.42 5.44 0.005 Socioeconomic Status 2.29 0.004 0.46 0.60 1.74 0.062 Pure Tone Average (Right) 0.040 0.79 0.055 0.74 0.12 0.49 Pure Tone Average (Left) −0.24 0.10 −0.39 0.016 −0.44 0.011 Global CAT Score 3.05 0.0027 3.49 0.002 5.20 < .001 Open in a new tab Grey-scaled boxes highlight Global CAT Score results. Significant p-values are bolded for emphasis. For each regression the cognitive composite score was the outcome variable, and HIV status, SES, Pure Tone Average (Right), Pure Tone Average (Left), and global CAT score were predictors. Of note, the mean Global CAT Score was −2.62 with a standard deviation of 7.80. Supplemental analyses are displayed in Supplemental Figure 1 , Supplemental Table 1 , and Supplemental Figure 2 . Supplemental Table 1 compares demographic, peripheral hearing, and cognitive variables between 8–9-year-olds who could complete the CAT battery (TDT, HINT, and SSW) at their first visit versus 8–9-year-olds who could not. On average, those who could complete the battery had higher Nonverbal IQs (81.42 versus 70.90, p<.01). Age, gender distribution, years of education, socioeconomic status, and right and left ear pure tone averages did not statistically differ between the two groups. Supplemental Figure 1 displays the odds of being at or below the median Leiter-3 composite score based on whether an 8–9-year-old could or could not complete the CAT battery. 8–9-year-olds who could not complete the battery were significantly more likely to be at or below the median IQ (Odds Ratio: 11.11; 95% CI: [1.39, 100.00]. p<.01) than 8–9-year-olds who could complete the battery. Supplemental Figure 2 illustrates the percentage of children in each age bracket who successfully completed each test. As anticipated, completion rates generally increased with age, except for the gap test, which only a small number of children were able to complete. Discussion: Results show that administering CATs to young children in this Tanzanian cohort is feasible and that CAT performance relates to simultaneously measured to cognitive measures. Many children younger than seven years of age could complete CATs. During the first visit, a significant number of children were able to complete the TDT (74.5%), HINT (71.0%), and SSW (71.6%). The Gap completion rates were much lower, with only three children (0.6%) completing it during their first visit. Our study also found that completion of the TDT, HINT, and SSW tests predicted Leiter-3 Nonverbal IQ performance, and performance on CATs predicted performance on all three Leiter-3 composites. For the success of our longitudinal study, determining the feasibility of administering CATs to young children was essential. Completion rates improved with age, with only 16.7% of 3–4-year-olds completing the CAT battery (HINT, TDT, and SSW) compared to 84.4% of 8–9-year-olds. By age five, most children (62.5%) could complete the CAT battery, suggesting that many CATs can be completed earlier than previously shown in Skarzynski, Wlodarczyk et al. (2015) and Back et al. (2022) . A 62% full-battery completion rate among typically developing five-year-olds may appear low from a clinical perspective. However, attempting these assessments in young children still yields critical and actionable insights. First, even partial data from the majority of participants provide valuable normative benchmarks, enabling the mapping of age-related trajectories in auditory processing development. Understanding when and how children begin to succeed or struggle on specific CAT subtests offers concrete milestones for developmental readiness, informing appropriate age cutoffs or task adaptations. Second, difficulty completing or performing poorly on CAT tasks may serve as an early marker of vulnerability. Children within a healthy cohort who struggle may represent the lower end of typical performance, suggesting that these same tasks could be even more sensitive to impairment in clinical populations. Third, identifying which tasks are most challenging (e.g., the Gap test, which fewer than 1% could complete) highlights specific task demands, such as complex instructions, auditory memory load, or rapid response requirements, that may be particularly challenging for young children. Without data from younger cohorts, such feasibility insights would remain unknown. Thus, this study highlights the potential for younger children to complete CATs, which could have significant implications for the early detection of central auditory impairment. The finding that very few children could complete the Gap also adds value to the literature. The Gap test may be less intuitive than the TDT, HINT, and SSW tests, which only require the child to repeat what they hear. Children may require more maturity before being able to complete the Gap test. Our cohort may be more likely to complete CATs at younger ages than clinical populations. Cultural differences between Tanzanian and Western children may affect the feasibility of central auditory testing in these two groups ( Jukes et al., 2021 ). While data on the general temperament of young Tanzanian children is limited, in this study their performance on the Leiter-3 suggested they are highly focused, not easily distracted, and receptive to instruction, which may contribute to increased completion rates and better CAT performance. This finding warrants further investigation into the feasibility of CATs in young Western children. Moreover, our cohort was part of a research study. Children were incentivized and motivated to complete CATs, which may not be the case in clinical populations. This study suggests that the CAT battery has potential as a supplement to traditional cognitive screen measures in children. In young children, the CAT battery could potentially serve as a quick check of normal function. Those who could complete the battery at a younger age than most might be less likely to experience cognitive difficulties than their peers who could not complete the battery. Indeed, 3–5-year-olds who successfully completed the battery demonstrated significantly better performance across all three Leiter composites than those who could not. Odds ratios further established the CAT battery’s potential as a cognitive screener. Children 3–5-years old who completed the CAT battery were significantly more likely to have Leiter-3 composites above the median than their peers who could not complete the battery. Although completion of the CAT battery was associated with higher Leiter scores across the 3–5 age group, we acknowledge that most 3-year-olds (83.3%) are unable to complete the CAT battery. Therefore, while the completion of the CAT battery is likely indicative of at least average cognitive function for both 3–5-year-olds, its clinical utility as a screener may be most pronounced in children aged 4 and older who are more likely to complete the test. Furthermore, inability to complete the CAT battery at an older age may indicate cognitive dysfunction (see Supplemental Table 1 and Supplemental Figure 1 ). Although we did not apply a Bonferroni correction for multiple comparisons, only one result—Nonverbal IQ in the 8–9-year-olds (p = 0.01)—exceeded the corrected threshold of 0.005. Future research could delve into the potential of abnormal CAT performance relative to age norms as a robust predictor of neurocognitive function. Another aim of our study was to assess the predictive relationship of the CAT battery to neurocognitive function across the entire cohort. Children who completed the CAT battery tended to have stronger core cognitive abilities, even when controlling for age, socioeconomic status, HIV status, and peripheral hearing ability. This builds on previous work showing that HIV status, socioeconomic status, and neurocognitive function are related in children. HIV status and socioeconomic status were related to neurocognitive function, consistent with our previous work ( Lichtenstein et al., 2022 ). In the current study, children living with HIV performed significantly worse on all three Leiter-3 composites. Other studies have also documented worse performance on neurocognitive testing in CLWH compared to HIV-negative children ( Sherr et al., 2009 ; Ruel et al., 2012 ; Boivin et al., 2018 ). Multiple factors could contribute to impaired neurocognitive function in CLWH, including increased likelihood of intrauterine infections in the mother, poverty, toxic stress, slow brain development, and ART toxicity ( Wedderburn et al., 2019 ). Children of lower socioeconomic status also scored lower on all three Leiter-3 composites. Numerous studies have reported lower cognitive performance amongst those of lower socioeconomic status, perhaps due to differing parenting behavior, inadequate language exposure, nutritional deficiencies, or prenatal factors ( Hackman et al., 2010 ; Duncan & Magnuson, 2012 ; Lawson et al., 2018 ). Examiners should be aware of how HIV status and socioeconomic status might influence scores when administering central auditory and neurocognitive tests to diverse populations. In our study, we accounted for these demographic variables by including them as covariates, which enabled us to show that CAT performance relates to neurocognitive function independently of these factors. However, it is important to note that we controlled for peripheral hearing ability using only average pure-tone thresholds for the right and left ears (PTA Right and PTA Left), rather than thresholds at individual frequencies. This may have limited the precision with which we accounted for the influence of peripheral hearing on CAT performance and its relationship to cognitive outcomes. Completing the CAT battery required that the child understood instructions and paid sufficient attention to the tasks (Back, Crippa et al., 2022). Scoring highly on the CAT battery requires a child to process and integrate information rapidly, maintain sustained attention, and recruit working memory ( Katz & Smith, 1991 ; Ingvalson et al., 2015 ). Similar abilities support success on the Leiter-3 ( Roid et al., 2013 ), and thus could contribute to the relationship between performance on the CAT battery and on the Leiter-3. After controlling for age, socioeconomic status, HIV status, and peripheral hearing ability, better performance on the CAT battery predicted higher core cognitive ability, stronger attention/working memory, and faster processing speed. These relationships between CAT performance and cognitive domains are consistent with what has been reported in adults ( Anderson et al., 2013 ; Dryden et al., 2017 ). This study extends these relationships to children. While we are using the auditory system to evaluate cognition, CATs were not developed to assess cognition in children. Numerous factors may influence the relationship observed. For example, variability in the development and maturation of attentional capabilities could affect CAT results. Also, we defined lower cognitive performance relative to the sample median rather than normative percentile cutoffs, as most children scored substantially below standardized benchmarks. While this approach reflects the distribution of scores in our cohort, it may reduce comparability with other populations. In this context, however, CATs offer a valuable means to assess both auditory and cognitive functions in low- and middle-income countries (LMICs). CATs could supplement traditional measures of cognitive functioning, like the Wechsler Intelligence Scale for Children (WISC), as they are quicker, easier to administer, require less examiner training, and may be less biased towards gender, culture, or education. They can be particularly useful in LMICs where access to traditional measures of cognitive functioning is limited. Conclusion: Children can complete CATs reliably at an earlier age than shown in previous studies. By age five, most of the children in our cohort could complete the CAT battery. Completion of the CAT battery at a young age is strongly associated with better cognitive function at that age. Better performance on the battery predicted more robust cognitive abilities. CATs may offer clues into the cognitive functioning of young children, offering a valuable measure to deploy in LMICs. Further longitudinal studies are needed to determine if these early CAT results have predictive ability for later cognitive function. Supplementary Material Supplemental Figure 1 NIHMS2161759-supplement-Supplemental_Figure_1.docx (17KB, docx) Supplemental Figure 2 NIHMS2161759-supplement-Supplemental_Figure_2.docx (21.4KB, docx) Supplemental Table 1 NIHMS2161759-supplement-Supplemental_Table_1.docx (14.4KB, docx) Acknowledgements: We would like to thank the study team in Tanzania (Claudia Gasana, Filmon Samuel, Godfrey Njau, Joyce Kibasa, Joyce Machunda, Modestus Choka, Matilda Kabeho, and Pascal Maibe) for their substantial contributions towards data collection. Funding/Support: This study was funded by the National Institutes of Health (NIH), specifically the National Institute of Child Health and Human Development (NICHD) (R01HD095277). Role of Funder/Sponsor: The funder/sponsor did not participate in the work. 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Supplementary Materials Supplemental Figure 1 NIHMS2161759-supplement-Supplemental_Figure_1.docx (17KB, docx) Supplemental Figure 2 NIHMS2161759-supplement-Supplemental_Figure_2.docx (21.4KB, docx) Supplemental Table 1 NIHMS2161759-supplement-Supplemental_Table_1.docx (14.4KB, docx) ACTIONS View on publisher site PDF (597.6 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top