Introduction
The term (central) auditory processing disorder [(C)APD] refers to difficulties in the processing of auditory information in the central nervous system [1]. Individuals with (C)APD demonstrate poor performance in sound localization, sound lateralization, discrimination, pattern recognition, temporal processing, and speech-in-noise processing [1]. Although it is primarily caused by disruptions in auditory processing, (C)APD is known to be associated with broader cognitive deficits [2-4]. A recent retrospective study conducted in India reported the prevalence to be 0.7% among individuals aged 6 to 18 years [5].
Early identification and rehabilitation of (C)APD necessitate a multidisciplinary approach because of its probable effects on listening, communication, and academic performance, as well as its common co-occurrence with language and learning difficulties [6,7]. Intervention planning for (C)APD is based on documented auditory processing deficits and related functional performance issues, necessitating a multidisciplinary team that includes audiologists, speech-language pathologists, educators, psychologists, and parents [7]. Team composition depends on auditory processes affected and individual complaints [6-8]. It is essential for the team to communicate and collaborate regularly to ensure that the interventions are aligned with specific needs. This approach ensures better outcomes and improves quality of life. Team members need to have adequate awareness and knowledge of the condition for early identification and to ensure appropriate referral to the audiologist.
Audiologists and speech-language pathologists are involved in the diagnosis and intervention planning of all individuals with (C)APD [6,8]. They improve auditory comprehension, language skills, and overall communication effectiveness. Teachers and special educators are usually the first professionals to identify the symptoms [1,9,10]. They support children with (C)APD by referring them to audiologists and speech language pathologists, help implement strategies to improve learning and academic performance in classrooms, and modify teaching methods [1,9,10]. Psychologists address the emotional and behavioral challenges that may arise from (C)APD by providing coping strategies and support for both the individual and their family [11]. In India, pediatricians are the primary care providers and the first point of contact for parents [12]. They can recognize early signs of (C)APD among children and recommend them for identification and intervention [12]. It is crucial to assess the awareness and knowledge of the team members involved in the assessment and intervention of (C)APD. Various studies conducted in different countries with different populations have revealed that awareness of (C)APD among professionals is limited [10,13].
In a study among primary school teachers, awareness and knowledge of (C)APD were assessed using a questionnaire distributed to 53 primary schools in the Republic of Ireland [10]. The findings revealed that the majority of participants reported poor or very poor awareness (89.1%) and knowledge (92%) of (C)APD [10]. The authors recommended the establishment of training programs for teachers to improve awareness and support services for children with (C)APD [10]. The study emphasizes the importance of teachers’ understanding of (C)APD for early recognition and appropriate referral of children suspected of having the disorder [10].
In another study, the awareness and attitudes of UK general practitioners (GPs) and ear, nose, and throat consultants (ENTCs) regarding (C)APD were assessed [13]. The study revealed a general lack of knowledge and awareness about (C)APD among both GPs and ENT-Cs [13]. GPs (69.5%) demonstrated a lower awareness level of (C)APD than ENT-Cs; and the majority of respondents (36.8%) rated themselves as not well informed about (C)APD, with only a small percentage feeling adequately informed (GPs: 6.1%, ENT-Cs: 19.6%) [13]. There was a significant but positive correlation (rs=0.203) between awareness levels and likelihood of referral for assessment. Additionally, the study highlighted a potential shortfall in services for (C)APD at the primary care level due to the reported lack of awareness among GPs [13].
In India, pediatricians play a crucial role in identifying children at risk for developmental disorders and referring them to access early intervention services in their communities [12]. Sensitizing pediatricians to the signs and symptoms of (C)APD can facilitate timely and appropriate referrals to audiologists, speech-language pathologists, and psychologists. However, the symptoms of (C)APD are often subtle and may be missed [14]. Early identification and intervention of (C)APD is the need of the hour and can be facilitated by increased awareness and knowledge of the condition among healthcare professionals and teachers, thereby resulting in appropriate referrals [7]. Limited awareness and understanding of (C)APD can lead to underdiagnosis, delayed intervention, and poor academic and social outcomes [7]. Understanding the current level of awareness of (C)APD among pediatricians is crucial for bridging the gap between early identification and intervention.
Therefore, this study is essential to assess the awareness, knowledge, and referral practices of pediatricians regarding (C)APD. The findings of this study will be useful in informing the need for targeted training, resource development, and interdisciplinary collaboration for improved management of the disorder. This study aimed to assess the awareness and knowledge of symptoms, causes, distinguishing features, assessment, and management of (C)APD among pediatricians in India.
Subjects and Methods
This study used a questionnaire-based cross-sectional survey design conducted between September 2023 and May 2024. Ethical approval was obtained from the Institutional Ethics Committee of Sri Ramachandra Institute of Higher Education and Research (DU) (Ref. No. CSP-III/24/JAN/01/07). In addition, permission was obtained from the respective department heads to conduct the study at various hospitals. The Checklist for Reporting Survey Studies (CROSS) was used to report the methods of the current study [15].
Selection of participants
Pediatricians practicing in different settings in India were recruited to participate in the current study using a convenience sampling method. A total of 143 pediatricians were contacted (120 in person and 23 via online mode) to participate in the study. Pediatricians practicing in India with at least 1 year of experience were included in the study. Pediatricians with less than 1 year of experience working in countries other than India were excluded.
Study procedure
The current study was conducted in two phases: 1) development and content validation of the questionnaire and 2) administration of the developed questionnaire.
Phase I. Development and content validation of the questionnaire
The questionnaire was developed based on a review of the literature and expert opinions. The questions were framed to assess awareness and knowledge regarding the causes, symptoms, assessment, treatment, and management of (C)APD. Content validation was performed by calculating the content validity index (CVI). CVI was calculated using the following steps (Table 1):
• Step 1. Preparation of a content validation form: A content validation form was prepared, and the raters were expected to rate the items using a 5-point relevance scale: 1, highly irrelevant; 2, irrelevant; 3, relevant with modification; 4, relevant; and 5, highly relevant.
• Step 2. Panel of reviewers: The panel of reviewers included one audiologist, one speech-language pathologist, and one pediatrician with over 10 years of work experience. The content validation form was provided to all three reviewers separately. They were requested to critically evaluate all questions and were provided with instructions on scoring and the relevance scale. The reviewers were asked to comment on the questions and provide suggestions for modifications.
• Step 3. Recoding of relevance scale: The relevance scale was further recoded to calculate the item-level content validity index (I-CVI). Relevance scales 5 and 4 were coded as 1, and relevance scales 3, 2, and 1 were coded as 0.
• Step 4. Calculating CVI: The “experts’ agreement” score was calculated by adding the coded scores provided by all experts. The I-CVI for each item was calculated by dividing the “experts in agreement” score by the “number of experts.” The average I-CVI scores across all items were calculated to obtain the scale-CVI/average (S-CVI/Ave) score to determine the CVI. The S-CVI/Ave score was 0.80 for the three validators. Items with an I-CVI score of 1 were retained, whereas items with a score of less than 1 were modified. The reviewers have suggested rephrasing and modifying the six questions to improve coherence. The questions have been revised in accordance with the reviewers’ comments and suggestions.
The final questionnaire comprised 14 items (Supplementary Material 1 in the online-only Data Supplement) and a brief description of the study, including information regarding ethical clearance, confidentiality, risks associated with participation, and contact information of the principal investigator. The questionnaire was structured to assess the awareness and knowledge of (C)APD among pediatricians regarding the following aspects:
• General awareness of (C)APD: four questions (Q1–Q4). This domain assessed whether pediatricians were aware of (C)APD, whether they had suspected it in children, and their ability to distinguish (C)APD from hearing loss (e.g., item in the questionnaire: Are you aware of the term (C)APD?).
• Causes of (C)APD: two questions (Q5 and Q6). This domain explored pediatricians’ understanding of whether the condition is developmental, acquired, or genetic, and its cooccurrence with developmental disorders (e.g., item in the questionnaire: Can (C)APD co-occur with other developmental disorders such as learning disability and autism spectrum disorder?).
• Symptoms of (C)APD: two questions (Q7 and Q8). Q8 comprises nine subdivisions. This domain focused on recognition of symptoms of (C)APD, such as speech-in-noise difficulties, attention deficits, and challenges with auditory memory (e.g., item in the questionnaire: Which of the following symptoms are not associated with (C)APD?).
• Diagnosis and treatment of (C)APD: six questions (Q9– Q14). This domain explored pediatricians’ knowledge of the age for reliable testing, referral practices, and multidisciplinary team involvement in diagnosis and intervention of (C)APD (e.g., item in the questionnaire: A pediatrician is considering a referral for a 9-year-old child with suspected APD. Which of the following professionals would be most appropriate for comprehensively evaluating the child’s auditory processing skills?).
The questionnaire was sent back to the reviewers for verification, and upon their approval, the questionnaire was converted to a Google Form.
Phase II. Administration of the developed questionnaire
The minimum required sample size was calculated using the following formula:
where z=1.96 at the 95% confidence level (p=0.5 assumed prevalence of awareness to maximize sample size), q=1–p=0.5, and L=0.086 (allowable error of 8.6%). By substituting these values, the estimated sample size was 118. A total of 143 pediatricians were approached, of whom 118 provided complete responses.
The principal investigator approached pediatricians practicing at research institutions, hospitals, and private clinics. They were approached through e-mail and in-person meetings. The study was briefly described, and informed consent was obtained from the participants prior to data collection. The questionnaire was shared with the participants when they provided their consent. Two formats (Google Forms and hard copies) of the questionnaire were used for the data collection. This was done to ensure that the participants used the format that was convenient for them. Only complete responses were considered for data entry, and responses with incomplete or missing data were excluded. In addition, responses from pediatricians who did not meet the inclusion criteria were excluded.
Statistical analysis
Correct responses were scored as 1; incorrect responses and “don’t know” responses were scored as 0. Descriptive statistics were used to analyze the data obtained from the questionnaire. The analysis was performed using Microsoft Excel. The item-wise and total scores for each participant were calculated. Composite scores were calculated by summing the correct responses to assess symptom knowledge since the questions had subdivisions.
Fisher’s exact tests and subgroup analysis were conducted to explore associations between participant characteristics and the domains of awareness, knowledge, and referral practices. Fisher’s exact test was performed since expected cell counts were below 20%. Cramer’s V values were calculated to indicate the strength of association. Holm’s adjustments for multiple comparisons were performed. All statistical tests were conducted at a significance level of α=0.05. Internal consistency of the questionnaire and its subscales was assessed using Cronbach’s alpha. The alpha coefficient was computed for the symptoms, referral/management, and overall scales, with interpretation according to standard guidelines (α≥0.70 considered acceptable reliability) [16].
Results
A total of 118 pediatricians (61 males, 57 females; mean age=35.72±8.34 years) with a minimum of one year of clinical experience participated in the study. The participants’ work experience varied, with the majority having 1–5 years of experience (62.71%), followed by 6–10 years (14.40%), 11–15 years (5.93%), 16–20 years (7.62%), and over 21 years (9.32%). Most participants had completed a Doctor of Medicine in Pediatrics (67.7%), while others had completed Bachelor of Medicine and Bachelor of Surgery (16.1%), Diploma in Child Health (12.7%), or Diplomate of National Board (3.3%). Participants were predominantly from Karnataka (55.1%) and Tamil Nadu (37.3%), and practiced in private hospitals (55.1%), private clinics (16.1%), government hospitals (15.0%), research institutions (11.3%), and pediatric intensive care units (2.5%). Their areas of specialization included general pediat-rics (81.35%), developmental pediatrics (5.08%), pediatric neurology (0.84%), pediatric medicine (11.86%), and neonatology (0.84%). The overall questionnaire demonstrated acceptable internal consistency (Cronbach’s α=0.554).
General awareness of (C)APD
Questions 1–4 focused on the general aspects and awareness of (C)APD (Fig. 1). Most pediatricians (94.07%) reported being aware of (C)APD. However, only 32.20% had previously suspected a child to have this condition, while most (65.25%) stated that they had not suspected children to have (C)APD, and a small proportion of participants (2.55%) expressed uncertainty.
While 58.70% correctly recognized that (C)APD is not the same as hearing loss, 32% believed that the two were similar, and 9.3% were uncertain. Approximately 62.71% of the participants recognized that (C)APD is a distinct condition that can occur in the presence of normal peripheral hearing. However, 27.12% of pediatricians believed otherwise, while a few participants (10.17%) were not sure.
Fisher’s exact tests (Table 2) indicated no significant associations between the awareness domain and demographic variables, including state, years of experience, qualification, or work setting (p>0.05).
Causes of (C)APD
Most pediatricians (63.5%) believed (C)APD to be developmental in origin, whereas 25.42% identified it as acquired, and 11.01% attributed it to genetic causes. A majority (76.27%) reported that (C)APD can co-occur with other developmental disorders, although 11.86% were either unaware or uncertain.
Awareness of symptoms
Questions 7 and 8 focused on the symptoms of (C)APD. There was considerable variability in the identification of (C)APD symptoms (Fig. 2). The questions in this domain demonstrated acceptable internal consistency (Cronbach’s α=0.791). While some pediatricians recognized difficulties in social communication (33.83%), academics and learning (35.05%), and speechin-noise perception (21.80%), only 9.32% associated the disorder with difficulty in following instructions.
Question 8 was divided into nine sub-questions to assess awareness of (C)APD symptoms (Table 3), which revealed mixed understanding. When asked if children with (C)APD could locate the direction of a sound, only a few (35.59%) indicated “yes,” whereas most pediatricians (61.86%) indicated “no,” and a few (2.54%) were uncertain. Most pediatricians (67.80%) believed that children with (C)APD could differentiate similar sounds, while a few (28.81%) disagreed or were unsure (3.39%). Over three-quarters (78.81%) of the pediatricians felt that slow, clear speech could be understood by these children, while 17.80% disagreed and 3.39% were uncertain. The majority (72.03%) agreed that they had difficulty listening in noisy environments, 22.88% disagreed, and 5.08% were unsure.
Nearly three-quarters of the participants (73.73%) reported that children with (C)APD required multiple repetitions, whereas the remaining participants either disagreed (19.49%) or were uncertain (6.78%). When asked if children with (C) APD gradually developed the ability to respond to verbal cues, 72.88% of pediatricians agreed, 16.95% disagreed, and 10.17% were unsure.
Pediatricians were also asked if children with (C)APD could remember the order of spoken instructions, and 38.14% of pediatricians answered “yes,” 38.14% indicated “no,” and 23.73% were uncertain. When questioned about maintaining focus and attention, 53.39% of pediatricians responded positively, 27.97% disagreed, and 18.64% were unsure. Pediatricians were asked if children with (C)APD found it easy to maintain friendships, and the responses were nearly equal: 33.05% indicated “yes,” 33.90% indicated “no,” and 33.05% were uncertain. Recognition of deficits in auditory attention, need for repetition, and social interaction challenges was inconsistent, reflecting limited clinical familiarity with the disorder’s broader functional manifestations.
Subgroup analyses of the symptom knowledge domain using Fisher’s exact tests (Table 4) revealed that pediatricians with ≥11 years of experience (p=0.043) and those with postgraduate or super-specialty qualifications demonstrated sig-nificantly better recognition of (C)APD symptoms (p=0.009). These findings suggest that clinical experience and postgraduate qualifications are associated with a greater understanding of (C)APD symptomatology.
Diagnosis and treatment of (C)APD
This section of the questionnaire (questions 9–14) focused on the diagnosis and treatment of (C)APD. The questions in this domain demonstrated acceptable internal consistency (Cronbach’s α=0.702). Most participants (75.42%) agreed that early diagnosis could improve, whereas 24.58% disagreed. Pediatricians had varying opinions regarding the minimum age for assessing (C)APD (Table 5). Among the participants, 32.20% indicated 3–4 years was the appropriate age, 28.81% indicated 4–5 years, 26.27% indicated 5–6 years, and 12.71% suggested 6–7 years.
In response to a hypothetical scenario-based question asking whether they would recommend (C)APD testing for a child with normal hearing but difficulty understanding speech in noisy environments, the majority (91.52%) answered “yes.” Regarding referral practices, 90.67% indicated that they would refer such cases to an audiologist and speech-language pathologist (ASLP), whereas others preferred referring the child to a neurologist (8.47%) or a radiologist (0.84%) (Fig. 3). Fisher’s exact tests indicated no significant associations between referral practices in the management domain and demographic variables, such as state, years of experience, qualification, or work setting (p>0.05). Regarding effective management of (C)APD, 68.64% of pediatricians responded “yes,” 14.40% responded “no,” and 16.94% were uncertain.
Pediatricians were asked to provide their opinions on the team members required for the diagnosis and management of (C)APD (Fig. 4). The majority (86.44%) identified ASLPs as key members of the management team, while 6.77% recommended including a neurologist. A few pediatricians suggested including a special educator (3.38%) and an occupational therapist (3.38%) as part of the team.
Discussion
The current study explored the awareness and knowledge of symptoms and challenges associated with (C)APD among pediatricians in India. A total of 118 pediatricians participated in the survey, with most responses from Southern Indian states and a few from the Northern states. All pediatricians were experienced professionals, with the majority having at least 1–5 years of clinical experience. The participants specialized in various areas within the field of pediatrics and worked in diverse healthcare settings. Thus, the survey attempted to obtain the responses of pediatricians from different backgrounds to provide a broad perspective. Notably, 92% of the respondents were from Karnataka and Tamil Nadu.
While most pediatricians (94.07%) were aware of (C)APD, they did not always suspect the condition in children. The majority of the participants (62.71%) recognized (C)APD as a separate clinical condition, distinct from hearing loss. However, a few pediatricians either believed that hearing loss and (C)APD were similar or were uncertain of the difference between the two conditions. These findings highlight that the pediatricians in the current study had differing opinions on (C)APD.
The majority of participants were uncertain about the causes of (C)APD. Many pediatricians have indicated that (C)APD was developmental, while others indicated that it is either acquired or genetic. While a majority of the pediatricians acknowledged that (C)APD could co-occur with a developmental disorder, some of them indicated otherwise. It is crucial to obtain a comprehensive medical history, including birth history, developmental history, and family history, of the child to identify the etiological factor of (C)APD, as the disorder is multifactorial [17].
Pediatricians had varied opinions regarding the symptoms of (C)APD. Many pediatricians have reported that children with (C)APD can differentiate between similar sounds, understand speech in a noisy environment, remember the sequence of verbal instructions, and find it easy to maintain focus and attention. However, it has been well established that children with (C)APD find it difficult to differentiate between similar sounds, understand speech in reverberant and competing environments, remember the sequence of verbal instructions, and maintain focus and attention [1,13,18]. This finding indicates that pediatricians had limited knowledge of the symptoms of (C)APD. Lack of knowledge to identify the symptoms of (C)APD has significant consequences, as it can lead to delayed identification and management of the condition [13,19,20]. Thus, it is crucial for pediatricians to be aware of the symptoms of (C)APD, as they are usually the primary healthcare providers for children.
A notable finding of the current study was the higher level of symptom knowledge observed in pediatricians with more years of experience and postgraduate qualifications, indicating that clinical exposure may have contributed to their general knowledge of (C)APD symptoms. These findings are similar to those reported by Almusawi and Hamadah [21]. The authors reported a higher level of awareness of (C)APD in teachers with more years of experience, indicating the influence of teaching hours in classrooms [21].
Most pediatricians acknowledge that early diagnosis of (C)APD is necessary for effective management. However, they were uncertain of the appropriate age at which (C)APD could be reliably tested and identified. Emich-Widera, et al. [18] reported that (C)APD could be accurately diagnosed when children are between 6 and 7 years of age. This provides general guidance regarding the age range for (C)APD testing.
Several pediatricians have reported that they would recommend (C)APD testing for children with difficulties in understanding speech in noisy situations, even if they have normal hearing. In contrast, in the study by Baldry and Hind [13], many ENT specialists reported that they typically do not refer patients for CAPD testing if they have normal hearing, even when auditory symptoms persist, highlighting a gap in referral practices.
In the current study, most pediatricians identified ASLPs as essential team members required for diagnosing (C)APD. Additionally, most of them (86.44%) reported that ASLPs were involved in the management of (C)APD. Only a few (13.56%) believed that other professionals, such as neurologists, special educators, and occupational therapists, were involved. This similarity could be seen in another study [13], where ENT consultants and general physicians mostly referred patients to an ASLP whenever they suspected a child with (C)APD. Future studies can consider exploring the awareness and knowledge of other professionals who may also be involved in the identification of (C)APD.
Thus, the findings of the current study indicate high general awareness of (C)APD and limited knowledge regarding symptoms, differentiation from other conditions, and management of the condition. This gap may be due to several training-related factors. Pediatric training in India typically provides limited structured and in-depth exposure to (C)APD, with most curricula prioritizing general developmental and neurological disorders [22,23]. Consequently, pediatricians may be unfamiliar with symptomatology, age for reliable testing, and appropriate referral pathways. This aligns with international reports that medical professionals often lack sufficient training in (C)APD [19,20,24].
Furthermore, this limited training and knowledge result in the absence of standardized referral pathways. In many clinical settings, referrals for suspected (C)APD are not clearly defined due to a lack of structured guidelines, leading to under-referral or mis-referral [25]. Additionally, gaps in interdisciplinary collaboration exacerbate this issue, as ASLPs may not be well integrated into paediatric practice [25]. Without established collaborative models, pediatricians may not consistently involve ASLPs, leading to missed opportunities for early identification and management of (C)APD [25].
Agrawal, et al. [19] indicated that it is crucial to increase awareness of (C)APD in education and health. Continuing education programs, workshops, and training modules may be developed based on study findings [20]. Effective referral pathways involving audiologists and pediatricians could be established to streamline care. This can facilitate the early detection of (C)APD and enhance its differentiation from other developmental disorders [20]. The study findings can be used to develop counselling and educational materials for parents of children with (C)APD and simple screening tools or checklists for use by pediatricians to help with the early detection of (C)APD.
Some limitations of this study should be considered when interpreting the results. While content validity was established with an S-CVI/Ave score of 0.80, formal reliability testing was not conducted during questionnaire development. While the survey was disseminated to pediatricians across the country, responses were obtained from pediatricians from certain geographical regions, which may limit generalizability. Another limitation of this study is the reliance on self-report questionnaires, which may have been influenced by social desirability bias. Future studies should ensure that awareness of pediatricians across different geographical locations is assessed and consider incorporating objective assessments to reduce reporting bias.
In conclusion, this study highlights that while pediatricians in India are broadly aware of (C)APD, their depth of knowledge regarding its clinical characteristics, diagnosis, and management remains limited. Many participants were unfamiliar with key symptoms, were uncertain about the appropriate age for assessment, and demonstrated inconsistent understanding of its overlap with other developmental disorders. Clinical experience and postgraduate qualifications were associated with a greater understanding of (C)APD symptomatology. These findings highlight the need for enhanced training and structured awareness programs to improve the practical application of (C)APD knowledge in clinical settings. Future recommendations include the incorporation of (C)APD-related training into medical education and the organization of continuing medical education workshops. The development of context-specific screening checklists can enable pediatricians to make timely referrals and facilitate early interventions. Establishing clear interdisciplinary referral pathways and integrating audiologists into paediatric care teams may further optimize outcomes for children with (C)APD.
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