Psychometric Properties of the Children's Auditory Perception Test: Reliability and Validity Analysis

Abstract

Purpose
This study aimed to revise and investigate the validity and reliability of the Children's Auditory Perception Test (CIAT), which was developed to evaluate auditory perception skills.

Methods
The study included 100 cochlear implant (CI) users between the ages of 2 and 15, and 80 individuals with normal hearing. In the first session, participants underwent the Turkish Early Language Development Test (TELD‐3) and audiometric assessments. The second session involved administering age‐appropriate subtests from the CIAT battery. Subtest reliability was evaluated using internal consistency and test–retest methods. We measured the construct validity by examining the relationships between subcategories. Also, we evaluated known‐group validity and predictive validity.

Results
The reliability analysis of the CIAT indicated high internal consistency, with a Cronbach's alpha coefficient of 0.913 for all 17 tests. Subcategories demonstrated reliability ranging from acceptable to excellent (α = 0.741–0.973). Significant differences were observed in auditory perception scores between children with CI and those with normal hearing (p < 0.005), demonstrating the known‐group validity of the test across different age groups. Multiple linear regression analysis revealed that factors such as age group, gender, special education duration, receptive and expressive language ages, CI duration, and usage status accounted for 78% of the variability in auditory perception scores (R² = 0.78), thus testing the predictive reliability of the model.

Conclusion
A valid and reliable test battery that evaluates auditory perception skills at different difficulty levels across a wide age range (2–15 years) has been introduced to the literature. However, a notable limitation is that this battery does not include auditory processing assessments, such as speech‐in‐competition (noise/babble) tests, which could enhance the comprehensiveness of the evaluation.

Full text

Brain and Behavior
ORIGINAL ARTICLE
Psychometric Properties of the Children’s Auditory
Perception Test: Reliability and Validity Analysis
Ozlem Icoz1Selen Yilmaz Isikhan2,3Esra Yucel1
1Department of Audiology, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey 2Department of Biostatistics, Faculty of Medicine, Hacettepe
University, Ankara, Turkey 3Vocational Higher School of Social Sciences, Hacettepe University, Ankara, Turkey
Correspondence: Ozlem Icoz (ozlmicoz@gmail.com)
Received: 1 November 2024 Revised: 8 January 2025 Accepted: 8 January 2025
Funding: Türkiye Bilimsel v e Teknolojik Araştırma Kurumu TUB1.
Keywords: auditory perception | auditory rehabilitation | cochlear implant | reliability | validity
ABSTRACT
Purpose: This study aimed to revise and investigate the validity and reliability of the Children’s Auditory Perception Test (CIAT),
which was developed to evaluate auditory perception skills.
Methods: The study included 100 cochlear implant (CI) users between the ages of 2 and 15, and 80 individuals with normal
hearing. In the first session, participants underwent the Turkish Early Language Development Test (TELD-3) and audiometric
assessments. The second session involved administering age-appropriate subtests from the CIAT battery. Subtest reliability was
evaluated using internal consistency and test–retest methods. We measured the construct validity by examining the relationships
between subcategories. Also, we evaluated known-group validity and predictive validity.
Results: The reliability analysis of the CIAT indicated high internal consistency, with a Cronbach’s alpha coefficient of 0.913 for
all 17 tests. Subcategories demonstrated reliability ranging from acceptable to excellent (α=0.741–0.973). Significant differences
were observed in auditory perception scores between children with CI and those with normal hearing (p<0.005), demonstrating
the known-group validity of the test across different age groups. Multiple linear regression analysis revealed that factors such as
age group, gender, special education duration, receptive and expressive language ages, CI duration, and usage status accounted
for 78% of the variability in auditory perception scores (R2=0.78), thus testing the predictive reliability of the model.
Conclusion: A valid and reliable test battery that evaluates auditory perception skills at different difficulty levels across a wide age
range (2–15 years) has been introduced to the literature. However, a notable limitation is that this battery does not include auditory
processing assessments, such as speech-in-competition (noise/babble) tests, which could enhance the comprehensiveness of the
evaluation.
1 Introduction
With the widespread implementation of newborn hearing screen-
ing, hearing loss is diagnosed at an early stage. Early intervention,
coupled with the use of suitable amplification systems, has
led to significant improvements in the language and auditory
perception skills of children with hearing impairment. It is crucial
for rehabilitative audiologists to regularly assess the progress of
auditory perception skills to gauge the effectiveness of the therapy
program. Auditory perception tests can be utilized alongside
other measurements to assess, guide habilitation, and reveal
rehabilitation needs of children with hearing loss by identifying
developed, emerging, and lost auditory and speech perception
areas (Kirk, Pisoni, and Osberger 1995).
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly
cited.
© 2025 The Author(s). Brain and Behavior published by Wiley Periodicals LLC.
Brain and Behavior,2025;15:e70301
https://doi.org/10.1002/brb3.70301
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Various assessments have been developed to evaluate auditory
perception skills and overall auditory skills in children with
hearing loss. Auditory perception tests commonly used in the
literature include the Northwestern University-Children’s Per-
ception of Speech (NU-CHIPS) (Elliott and Katz 1980), Early
Speech Perception (ESP) (Moog et al. 1990), Pediatric Speech
Intelligibility (PSI) (Jerger et al. 1980), Word Intelligibility by
Picture Identification (WIPI) (Ross, Lerman, and Cienkowski
2004), and Evaluation of Auditory Responses to Speech (EARS)
(Allum-Mecklenburg 1996). However, except for the EARS, these
tests have not been adapted into Turkish. The EARS has been
adapted into more than 20 languages, including Turkish. How-
ever, it is crucial to develop language-specific test batteries
and conduct validity studies to ensure accurate assessment in
different linguistic contexts.
To the best of the author’s knowledge, several tools are available in
Turkish for assessing auditory perception in children, including
questionnaires like the Meaningful Auditory Integration Scale
(MAIS) (Robbins, Renshaw, and Berry 1991), the Infant-Toddler
Meaningful Auditory Integration Scale (IT-MAIS) (Zimmerman-
Phillips, Robbins, and Osberger 2000), the Auditory Behavior
in Everyday Life Questionnaire (ABEL) (Özses et al., 2022), the
Parents’ Evaluation of the Aural/Oral Performance of Children
(PEACH) (Ching and Hill 2007), and the Children’s Auditory
Performance Scale (CHAPS) (Baydan et al. 2020), as well as
speech-in-noise tests such as HINT-C (Kartal Özcan et al. 2023).
However, the Children’s Auditory Perception Test (CIAT) remains
the only test battery specifically designed to assess fundamental
auditory abilities in a hierarchical manner, focusing on detection,
identification, and recognition skills (Yucel and Sennaroglu 2011).
CIAT was developed in Turkish to evaluate the auditory percep-
tion skills of children aged 2–15. CIAT has been widely used in
many studies (Yücel et al. 2015; Ozkan et al. 2021, 2022; Yucel,
Sennaroglu, and Belgin 2009; Aslan et al. 2020). However, several
disadvantages have been identified in clinical use, highlighting
the need for revisions and the addition of supplementary tests
to the test battery. It has been observed that a number of the
pictures in the test are outdated, and several test items have been
reported to be unrecognizable by children today. Some examples
of outdated items include pictures of a stamp and a gas cylinder.
Also, the validity and reliability studies were conducted on a
small sample size, and there is a lack of normative data for
normally hearing children. The Open-Set Sentence Identification
Test, consisting of 2–3-word sentences, is too easy for older
children, and the recognition test only includes single-command
phrases, which do not adequately evaluate memory skills. These
limitations underscore the need to revise the existing test and
update the stimuli to better reflect cultural changes, as well as to
incorporate additional tests to enhance the overall assessment.
While updating this test battery that evaluates auditory percep-
tion abilities, our aim is to use a language appropriate to the
native language and to choose words and sentence structures
that children learn to use in daily language. This allows for more
accurate and effective assessment of children. In addition, using
the native language can help obtain more reliable results by better
reflecting the language patterns that children encounter in daily
life.
The aim of our study is to revise the CIAT and investigate its
validity and reliability. Through this, we aim to provide a test
battery for evaluating auditory perception skills that can be used
in clinical and research settings.
2Materials and Methods
This study was approved by the ethical committee of Hacettepe
University (GO 17/991 2018/03-20). Before beginning the study, all
parents and children were given verbal and written information
about the purpose of the study, and their written informed
consent was obtained.
2.1 Participants
Overall, 180 participants aged 2–15 were included in the study,
comprising 100 cochlear implant (CI) users and 80 normally
hearing children. When determining the sample size, the rules of
thumb were applied, which suggest that the ratio of participants
(N) to measured variables (p) should be considered. According to
this guideline, the sample size must be greater than the number
of variables (N>p) (Dimitrov 2014). A widely accepted standard
recommends including 5–10 times the number of variables in
most studies (Wang and Wang 2019; Nunnally, Bernstein, and
Berge 1967). In this study, considering the subtest with the highest
number of items, the ratio is calculated as 7 participants per item,
resulting in a total of 175 participants (25 items ×7 participants
per item), exceeding the recommended minimum threshold.
Participants with CIs had undergone surgery at the Department
of ENT at Hacettepe University Hospital and were regularly
followed up in the Department of Audiology. Children who
visited the audiology department for a hearing test and were
found to have normal hearing were included in the control group.
Inclusion criteria for the study group were: (a) prelingual children
with bilateral severe to profound sensorineural hearing loss who
had unilateral or bilateral CIs, (b) no neurological or physiological
disorders in their medical records, (c) no history of meningitis,
auditory neuropathy spectrum disorder, or inner ear malfor-
mation, (d) received speech, language, and auditory training
postcochlear implantation, (e) activated speech processor for at
least 1 month, (f) exposed only to the native language (Turkish),
and (g) hearing thresholds with CIs within the speech range.
Inclusion criteria for the control group were: (a) bilateral normal
hearing, (b) no neurological or physiological problems in their
medical records, and (c) exposure only to the native language
(Turkish).
There was no significant difference between the gender (p=
0.283) and chronological age (p=0.756) between the study and
control groups. Demographic characteristics of the study and
control groups are presented in Table 1.
2.2 Study Design
This study was conducted in two phases:
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TABLE 1 Demographic characteristics of the study and control groups.
Study group
Number (%) or mean (SD)
Control group
Number (%) or mean (SD)
Gender Female 52 (52) 48 (60)
Male 48 (48) 32 (40)
Age group (month) 24–35 10 (10) 5 (6.3)
36–47 10(10) 10(12.5)
48–59 13 (13) 14 (17.5)
60–71 15 (15) 11 (13.8)
72–83 11 (11) 12 (15)
84+41 (41) 28 (35)
The average age 81.90 ±38.57 77.43 ±33.87
Receptive language 57.59 ±31.4 73.78 ±24.8
Expressive language 56.55 ±32.5 75.81 ±23.1
Duration of CI usage
(month)
1–12 21 (21%)
12–24 8 (8%)
24–36 16 (16%)
36+25 (25%)
CI types Unilateral 35 (35%)
Bimodal 17 (17%)
Bilateral 48 (48%)
Age at CI (month) 12–18 21 (21%)
18–24 8 (8%)
24–36 16 (16%)
36+25 (25%)
CI brand Nucleus 51 (52%)
Medel 38 (38%)
Advanced bionics 10 (10%)
Age at diagnosis (month) 5.38 ±7.8
Age at hearing aid fitting (month) 9.50 ±7.8
Average age at CI (month) 32.44 ±21.69
Duration of special education attendance (year) 4.11 ±3.1
In the first phase, the CIAT battery developed by Yücel et al.
2011 was revised to address current cultural needs and lifestyle
changes in its content and imagery. During the preparation phase,
various test batteries designed to evaluate auditory perception
skills were reviewed to determine the content for the new
test battery. The categories to be evaluated were identified and
ranked according to difficulty. For each category, the neces-
sary syllables, words, sentences, picture cards, and toys were
selected, considering the words and toys familiar to children
in their daily lives. In addition, feedback was gathered from
three experts in rehabilitative audiology, and a pilot study
was conducted with 20 native Turkish-speaking children aged
3–5 with normal hearing to review the materials for accept-
ability and suitability as an assessment tool for the Turkish
population.
In the second phase, the developed test battery was administered
to CI users and normally hearing participants, starting with the
first category and progressing through the levels according to
their developmental stages.
The test battery, consisting of a total of 17 different tests across 6
categories ranging from easy to difficult, was designed to evaluate
auditory perception skills in a hierarchical manner.
2.3 Material
The tests conducted as part of this study were carried out in two
sessions. In the first session, a pure tone audiometry test was
administered to the control group to exclude possible hearing
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losses and to determine if the hearing thresholds of the study
group were within the speech range. In addition, the Turkish
version of the Test of Early Language Development (TELD-3) was
used to evaluate language development in both groups.
In the second session, which occurred within the same week,
CIAT was administered to participants who met the inclusion
criteria for the study. All tests were conducted by an audiologist
in a quiet environment. Each participant completed all relevant
subtests of the CIAT battery appropriate to their chronological
age and auditory perception level. After two weeks, the test was
repeated for 72 randomly selected participants to assess test–retest
reliability.
2.3.1 Test of Early Language Development
Language development was assessed using the TELD-3, which
includes two subtests: receptive language and expressive lan-
guage. The test was administered in mixed auditory-verbal
settings and measures language skills in children aged 2–7 years
and 11 months (Güven and Topbaş 2014). Due to the lack of other
standardized language tests for older children, the final items
of the TELD-3 were also given to children aged 8 and older. In
addition, the age-equivalent scores and standard scores of the
subtests were recorded.
2.3.2 Children’s Auditory Perception Test
CIAT was developed in Turkish to evaluate the auditory percep-
tion skills of children aged 2–15. It consists of 17 tests divided into
6 different categories. The categories are:
1. Category: Phoneme Detection Test
(i) Subtest 1a: Phoneme Detection Test
1. Category: Pattern Identification Test
(i) Subtest 2a: Differentiating Synthetic Syllable Structures Test
(ii) Subtest 2b: Identification Synthetic Syllable Structures Test
(iii) Subtest 2c: Pattern Perception Test (this test consists of both
standard and subversions)
1. Category: Speech Identification Test (closed-set)
(i) Subtest 3a: Word Identification Test (these tests consist of
both standard and subversions)
a. Subtest 3a.1. Trisyllable Word Identification Test
b. Subtest 3a.2. Monosyllabic Word Identification Test
(ii) Subtest 3b: Sentence Identification Test
(iii) Subtest 3c: Mrs. Potato Head Test
1. Category: Auditory and Visual Integration Test (it consists of
two lists: List A and List B)
2. Category: Modified Open-Set Speech Identification Test (it
consists of two lists: List A and List B)
3. Category: Open-Set Speech identification and Recognition
Tes t
(i) Subtest 6a: Turkish Sentence Test (this test consists of both
standard and subversions, with each version containing six
lists: List A to List F)
(ii) Subtest 6b: Listen and Do Test (this test consists of both
standard and subversions, with each version containing six
lists: List A to List F)
In the test battery, the maximum scores for each test category
varied. To calculate the total auditory perception score and
to enable accurate comparison between categories, raw scores
were normalized to a range of 0–100. This normalization pro-
cess ensures that variables measured by different tests are in
the same range, preventing any single variable from becoming
disproportionately influential (Han et al. 2013).
Since the maximum total score that can be obtained from each
test differs, participant scores were adjusted to fall within a 0–100
range across all tests. The following formula was applied to all
tests for this purpose:
𝑧𝑖 =(𝑥𝑖 −−min(𝑥))∕(max(𝑥) −−min(𝑥)) ×100
where zi is the ith normalized value in the data set, xi is the ith
value in the data set, min(x) is the smallest value in the data set,
and max(x) is the largest value in the data set.
2.4 Statistical Analysis
The Pearson chi-square test was used for categorical variables,
and Student’s t-tests were used for continuous variables to
investigate differences in demographic and clinical variables
between the control and study groups, as well as differences
in auditory perception test scores across demographic groups.
Descriptive statistics of clinical and demographic characteristics
are presented as frequency, percentage, mean, and standard devi-
ation, depending on the distribution. For comparisons between
control and study groups that did not show a normal distribution,
the Mann–Whitney Utest was applied. In tests that fall under
the same basic category and share the same minimum and
maximum scores, equivalences between categories were checked
to represent a large number of test items with fewer tests. Equiv-
alence analyses were performed using RStudio programming. All
other statistical tests and graphs were implemented by BM SPSS
Statistics (Version 23).
To determine the stability of the results obtained from the
auditory perception test over time, the reliability coefficient was
calculated using the test–retest method. For this purpose, data
were collected from the same group after a two-week interval, and
the consistency between the measurement results was examined
using the intraclass correlation coefficient (ICC). Cronbach’s
alpha reliability analysis was performed to assess the internal
consistency of the items in the total score and subcategories of
the auditory perception test.
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To evaluate known-group validity, a type of construct validity, the
Mann–Whitney Utest was employed by comparing the auditory
perception scores of normal-hearing children and CI users across
age groups. In addition, predictive validity was assessed through
multiple linear regression analysis, exploring the relationship
between clinical features and auditory perception scores.
3Results
The control group performed statistically higher in the recep-
tive language skill (p<0.001) and expressive language skill
(p<0.001).
3.1 Equivalence Analysis Results
The equivalences between categories were examined, and the
results are presented in Appendix 1.
The equivalence analysis of Lists A and B in the Auditory and
Visual Integration Test showed that the equivalence test was not
significant, with t(358) =−0.0134 and p=0.989. Therefore, the
difference between Lists A and B was not significant at the 5%
level. Similarly, the equivalence analysis for Lists A and B in the
Modified Open-Set Speech Identification Test was not significant.
In the Open-Set Speech Identification Test category, the Turkish
Sentence Test (both subversion Lists A–F and standard version
Lists A–F) showed insignificant p-values. Similarly, for the Listen
and Do Test, both the subversion Lists A and B and the standard
version Lists A and B also had insignificant p-values.
Based on these findings, as the lists showed similar scores, only
the first lists from each category of tests were used in the analysis.
3.2 Reliability Analysis
Reliability analysis of the total test battery and its subtests, includ-
ing test–retest reliability and item-total correlation results, are
presented in Table 2. The Cronbach’s alpha reliability coefficient
for all 17 tests was 0.913. The Cronbach’s αcoefficients in the
subcategories ranged from 0.741 to 0.973, indicating that the
internal consistency of all categories ranged from acceptable to
excellent reliability (α=0.913 >0.90).
3.3 Test–Retest Reliability
Test–retest reliability was assessed in 72 randomly selected sub-
jects with a 2-week interval between tests. This interval was
deemed appropriate, as significant changes in speech perception
skills are unlikely within such a short period. The reliabil-
ity values varied between 0.228 and 0.962. For the Phoneme
Detection, Differentiating Synthetic Syllable Structure, Pattern
Perception, Pattern Perception Subversion, and Trisyllable Word
Recognition Subversion tests, the scores obtained in the retest
were identical to the original test, resulting in zero variance and
an inability to calculate a test value. However, approximately
98% of the observations received the same total score in the
Phoneme Detection Test. Similarly, 100% of the observations in
the Differentiating Synthetic Syllable Structure Test and 98% in
the Pattern Perception Test achieved the same highest score. In
the Pattern Perception Subversion and Trisyllable Word Recog-
nition Subversion tests, 98% of the observations matched their
previous test scores. Likewise, 96% of the observations received
the highest score in the Turkish Sentence Test (subversion). All
calculated item-total correlations for the tests were greater than
0.50, indicating that all 17 tests significantly contributed to the
overall scale. Therefore, all items in the scale effectively measure
thesameconstruct.
3.4 Validity Analysis
3.4.1 Known-Group Validity
To evaluate the known-group validity, a type of construct validity,
the score differences between the control group and the study
group were tested across different age groups. The results of this
analysis are presented in Figure 1a–g. According to the findings,
in the 24–35-month age group, the total scores of the control group
were significantly higher than those of the study group in the
first three categories (p<0.05). For the 36–47-month age group,
significant differences were observed between the two groups in
all categories except for the fifth category (p<0.05). In older
age groups (48 months and above), no significant differences
were found between the two groups in the first two categories,
while the control group achieved significantly higher mean scores
than the study group in the subsequent categories (p<0.05).
These differences in mean scores provide evidence of the test’s
discriminative ability.
3.5 Predictive Validity
In predicting auditory perception scores, a multiple linear
regression analysis was conducted including factors such as
chronological age group, gender, special education period, recep-
tive language equivalent age, expressive language equivalent age,
duration of CI, and CI usage status. The results of this analysis are
presented in Table 3.
The model identified that the variables significantly affecting the
total auditory perception score were chronological age, duration
of CI, CI usage status, and expressive language age (p<0.05).
Variables were selected using the stepwise regression analysis
method. The significant variables in the model accounted for 78%
of the explanatory success for the total auditory perception score
(R2=0.78). This model was found to be statistically significant
in explaining the dependent variable (F=84.93, p<0.001).
According to the estimated regression coefficients:
∙A 1-year increase in the chronological age led to an average
increase of 5.02 points in the auditory perception score.
∙A 1-year increase in the duration of CI use resulted in an
average increase of 8.29 points in the total score.
∙Each change in CI usage status (from unilateral CI to bilateral
CI) was associated with an average increase of 5.68 points in
the total score.
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TABLE 2 Internal consistency and test–retest reliability of the CIAT.
Test–retest reliability
Item-total
correlation Internal consistency
Intraclass correlation
(pvalue)
Cronbach α
coefficient
Phoneme Detection PD —0.914 —
Pattern Identification DSSS —0.834 0.90
ISSS 0.514 (<0.001) 0.854
PP —0.944
PP-S —0.871
Speech Identification TWI 0.496 (<0.001) 0.952 0.965
MWI 0.747 (<0.001) 0.951
SI 0.585 (<0.001) 0.952
PHT 0.938 (<0.001) 0.968
TSWI-S — 0.965
SSWI-S 0.712 (<0.001) 0.960
Auditory and Visual
Integration
AVI 0.863 (<0.001) 0.903 —
Modified Open-Set Speech
Identification
SI-MO 0.228 (0.054) 0.917 —
Open-Set Speech Identification
and Recognition
TST —0.900 0.741
TST-S 0.962 (<0.001) 0.923
LD 0.914 (<0.001) 0.907
LD-S 0.874 (<0.001) 0.907
General 0.913
Abbreviations: AVI, auditory visual integration test; DSSS, Differentiating Synthetic Syllable Structure test; ISSS, Identification Synthetic Syllable Structure test; LD-
A, Listen and Do Test standard version; LD-S, Listen and Do Test subversion; MWI, Monosyllabic Word Identification test standard version; MWI-S, Monosyllabic
Word Identification test subversion; PD, Phoneme Detection test; PHT, Mrs. Potato Head test; PP, Pattern Perception standard version; PP-S, Pattern Perception
test subversion; SI, Sentence Identification test; SI-MO, Modified Open-Set Sentence Identification test; TST, Turkish Sentence Test; TST-S, Turkish Sentence Test
standard version; TWI, Trisyllable Word Identification test standard version; TWI-S, Trisyllable Word Identification test subversion.
∙A 1-month increase in expressive language age led to an
increase of 0.29 points in the total score.
4 Discussion
In our study, the aim was to validate and ensure the reliability of
an updated auditory perception test tailored to the characteristics
of the Turkish language, incorporating current cultural needs and
lifestyle changes in its content and imagery. This study stands
out as the first to revisit and enhance an existing test while thor-
oughly evaluating its validity and reliability in Turkish-speaking
children.
The literature emphasizes the importance of developing tests
tailored to specific languages and cultures for evaluating speech
perception skills. El-Dessouky et al. (2019) developed an Arabic
assessment chart of auditory skills for children with CI aged 3–6
years. Likewise, Bhimte and Rangasayee (2018) created a speech
perception test in Hindi for children aged 3–7 years with normal
hearing. Dawson et al. (2022) adapted the English version of
the ESP test for children with normal hearing aged 3–6 years,
modifying it to meet the linguistic requirements of the Tamil
language.
In the present study, both the wide age range of children evaluated
and the inclusion of scores from both CI users and normal-
hearing children make it unique. This design allows for a more
comprehensive comparison of auditory perception skills across
different populations, providing valuable insights into the perfor-
mance of children with varying hearing abilities. By incorporating
both groups, the study can offer a clearer understanding of how
CIs impact auditory perception in comparison to typical hearing
development.
The Auditory Visual Integration Test, Modified Open- Set Speech
Identification Test, and Listen and Do Test, as part of the CIAT
battery, include two equivalent subtests each. In the Open-Set
Speech Identification Test category, the Turkish Sentence Test’s
subversion and standard versions offer six equivalent subtests.
Statistical analysis showed no significant differences between
Lists A and F across all categories, confirming they are equivalent
and interchangeable. The availability of equivalent tests within
CIAT is a key strength, as it enables assessment of a child’s actual
6of11 Brain and Behavior,2025

FIGURE 1 (a–g) Error plots (mean ±standard deviation) of auditory perception test score by chronological age. *pvalue <0.05.
performance using different lists, reducing score inflation due to
test familiarity within the same session.
In our study, similar to findings in the literature, it was observed
that children using CIs lag behind their normal-hearing peers
in receptive and expressive language skills. This outcome is
not unexpected, as the auditory input provided by CIs is sig-
nificantly limited compared to typical acoustic hearing. It has
been well documented that, even after years of experience with
CIs, children often lag behind their normal-hearing peers in
spoken language proficiency. This variability in spoken language
outcomes following cochlear implantation is widely recognized
(Niparko et al. 2010), with children with CIs, on average, showing
delayed language development even after more than ten years of
implant use (Geers and Sedey 2011).
4.1 Examination of Reliability
Reliability is an estimate of the instrument’s ability to repro-
duce consistent results (Koo and Li 2016). Reliability tests were
conducted to examine whether the questionnaire items were
consistent with each other. Cronbach’s alpha values, a measure
of internal consistency, were calculated. The Cronbach’s alpha
for the entire battery was 0.913, indicating excellent internal
consistency. For the subtests, Cronbach’s alpha ranged from 0.741
to 0.973, showing that all tests have good to excellent internal
consistency. Test–retest reliability was assessed with a 2-week
interval between tests. It is assumed that any changes in par-
ticipants’ performance during this period could be attributed to
variations in their auditory perception abilities or other external
factors that might influence the results (DeVon et al. 2007).
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TABLE 3 Multiple linear regression analysis of auditory perception score.
95% confidence interval
BSDStd.Bt-value p-value Lower Higher
Age 5.02 1.46 0.303 3.42 0.001 2.108 7.940
Duration of CI 8.29 1.58 0.346 5.24 0.000 5.163 11.459
CI usage status 5.68 1.71 0.183 3.47 0.001 2.541 9.341
Age of expressive language 0.29 0.07 0.320 3.85 0.000 0.140 0.439
F statistic 84.93 p<0.001
R(Elliott and Katz, 1980)0.78
Abbreviations: B, estimation of coefficient, R2, coefficient of determination, SD, standard deviation.
The reliability coefficients ranged from 0.228 to 0.962. Lower
values were due to very low variance in some tests. Specifically,
for Phoneme Detection, Pattern Identification, and Trisyllable
Word Identification Subversion tests, valid correlation values
could not be calculated because the scores from the retests
were the same and the variance of the retest values was zero.
However, the fact that 96%–100% of participants obtained the
same scores in these tests supports the consistency of the tests.
Item-total correlations were all above 0.50, confirming that each
test significantly contributes to the overall scale. For an item
to be considered acceptable, its item-total correlation coefficient
should not be negative, and the acceptable item-total correlation
value should be greater than 0.30 (Cláudia de Souza, Neusa
Maria, and Guirardello 2017). These results show that CIAT is
a stable and reliable tool for measuring auditory perception.
Overall, the test battery demonstrates strong reliability in both
internal consistency and temporal stability, making it suitable for
clinical and research use.
4.2 Examination of Validity
Validity is the degree to which a measurement tool can accurately
measure what it is intended to measure (Alpar 2016). In this con-
text, known-group validity and predictive validity were evaluated
in our study.
The known-group validity analysis demonstrated that the CIAT
is effective in distinguishing between children who use CI and
those with normal hearing. In this context, the primary purpose of
using the known-group validity analysis is not to predict hearing
loss or measure diagnostic accuracy, but rather to emphasize how
useful the CIAT is as a tool for differentiating known groups
based on auditory perception abilities. Moreover, no study in the
literature comprehensively evaluates auditory perception skills
across a wide age range for both normal-hearing children and
children using CI, according to age groups.
In the Phoneme Detection Test and the Pattern Identification
Test, no statistically significant differences were observed in
children older than 48 months. Although children with CI have
caught up to their normal-hearing peers in the initial stages of
auditory perception skills, they lag behind in word identification
and recognition stages. In the Auditory Visual Integration Test
and the Open-Set Speech Identification and Recognition Test,
no statistically significant differences were found between CI
users and normal-hearing children in the 24–35-month group.
Similarly, in the Modified Open-Set Speech Identification Test, no
significant differences were observed between the 24–35-month
and 36–47-month groups. These findings are thought to be due
to the difficulty level of these tests, considering the language
development levels of children in this age group.
It is well known that several factors influence the success of CIs.
Some of these factors include the onset of hearing loss, residual
hearing, duration of hearing loss, age at implantation, duration of
CI use, preoperative auditory performance, as well as educational
and environmental factors (Demir et al. 2019; Geers 2006). The
measurement of speech perception provides direct evidence of
the assistance offered to the individual by the CI (Dowell et al.
2002). In our study, the predictive success of chronological age,
8of11 Brain and Behavior,2025

APPENDIX 1 Equivalence analysis results.

𝑿±𝑺𝑺 Median Minimum Maximum p-value
Auditory and
Visual Integration
Tes t
List A 16.59 ±7.07 20 0 20 0.989
List B 16.60 ±7.07 20 0 20
Modified Open-Set
Speech
Identification Test
List A 35.42 ±21.43 49 0 50 0.919
List B 35.19 ±21.36 49 0 50
Open-
Set
Speech
Identi-
fication
and
Recog-
nition
Tes t
Turkish Sentence
Tes t Standa rd
Version
List A 15.21 ±8.26 20 0 20 0.918
List B 15.30 ±8.28 20 0 20
List C 15.33 ±8.29 20 0 20
List D 15.28 ±8.27 20 0 20
List E 15.29 ±8.28 20 0 20
List F 15.28 ±8.28 20 0 20
Turkish Sentence
Tes t Standa rd
Version
List A 28.60 ±21.26 43 0 46 0.943
List B 28.76 ±21.26 44 0 46
List C 28.68 ±21.35 44 0 46
List D 28.73 ±21.37 44 0 46
List E 28.70 ±21.35 44 0 46
List F 28.67 ±21.35 44 0 46
Listen and Do Test
Subversion
List A 7.62 ±3.96 10 0 10 0.529
List B 7.36 ±3.87 9.50 0 10
Listen and Do Test
Standard Version
List A 6.79 ±4.15 9 0 10 0.891
List B 6.85 ±4.17 9 0 10
*p<0.05.
duration of CI use, CI usage status, and expressive language age
in explaining auditory perception scores was found to be 78%. The
most influential of these variables is the duration of CI usage.
This analysis demonstrates the strong predictive validity of these
factors for auditory perception scores.
The degree of hearing loss has been shown to negatively correlate
with auditory perception abilities, and the type of hearing tech-
nology used significantly influences these abilities (Blamey et al.
2001). To ensure group homogeneity, all participants in the study
group were selected from CI users. The main limitation of this
study is that the study group consisted solely of children using
CI. This decision was made to focus specifically on the auditory
perception abilities of CI users, as the test was designed primarily
to address the unique needs of this population. However, this
limitation means that the effect of the degree of hearing loss on
auditory perception performance, as well as potential differences
between CI users and hearing aid users, could not be effectively
evaluated. Future studies should include children using hearing
aids and those with varying degrees of hearing loss to provide
a more comprehensive understanding of auditory perception
across different groups. In addition, similar research should be
conducted with adult populations to further explore the impact
of varying degrees of hearing loss and expand the applicability of
these findings.
A more comprehensive evaluation of hearing capacity should
include a Speech-In-Competition (Noise/Babble) Test (Iliadou
et al. 2024). One limitation of this study is the absence of real-
life speech perception assessments, such as speech-in-babble
perception, dichotic digits, and temporal processing evaluation.
Future studies should incorporate these measures to better
address real-life auditory challenges.
The use of our test in measuring the effectiveness of auditory
interventions and long-term follow-up studies will provide sig-
nificant contributions to determining the prognostic value of the
test. In conclusion, this study demonstrates that the CIAT is a reli-
able and valid tool for assessing auditory perception in children,
establishing a foundation for applying its clinical and educational
use. Future research should expand the test’s application to
diverse populations and adapt it to various languages.
5 Conclusion
The CIAT has been established as a valid and reliable test battery
in the literature, designed to assess auditory perception skills such
as detection, pattern perception, identification, and recognition
at varying difficulty levels across a wide age range, from 2 to 15
years.
9of11

Author Contributions
Ozlem Icoz: conceptualization, methodology, data curation, investiga-
tion, validation, writing–original draft, resources, funding acquisition.
Selen Yilmaz Isikhan: formal analysis, funding acquisition, visualiza-
tion. Esra Yucel: writing–review and editing, project administration,
supervision, resources, funding acquisition.
Acknowledgments
This study was the thesis study of Özlem İçöz for PhD degree in Audiology
at Hacettepe University. Open access funding provided TUBITAK. The
authors are grateful to the children and their families who participated in
the research.
Ethics Statement
This study was approved by the ethical committee of Hacettepe University
(GO 17/991 2018/03-20).
Consent
Before beginning the study, all parents and children were given verbal
and written information about the purpose of the study, and their written
information consent was obtained.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
The data supporting the results reported in the manuscript are kept by
the first author. Where appropriate, data analyzed or generated during
the study may be shared.
Peer Review
The peer review history for this article is available at https://publons.com/
publon/10.1002/brb3.70301.
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