Understanding speech in noisy and reverberant environments, such as classrooms, requires the integration of auditory, language, and cognitive abilities. Many children struggle to listen in such settings. The vast majority of children with listening difficulties (LiD) are diagnosed with peripheral hearing loss. However, at least 5% of children referred to audiology services present with normal peripheral hearing. In these cases, the diagnosis can be challenging because the role of hearing, auditory processing, language, and cognitive deficits can differ between children. It is imperative to develop more sensitive and more consistent diagnostic tools for children with LiD because correct diagnosis is the first step to successful treatment. If LiD remains untreated, it can negatively affect long-term academic outcomes.

As a first step toward better diagnosis, we explored the relationships among auditory processing, phoneme identification, sentence understanding in noise, language, cognitive abilities, and reading performance in a representative sample of 221 school-aged children. Using a structural equation model enabled us to simultaneously consider how bottom-up auditory processing and top-down language and cognitive processing contribute to speech-in-noise outcomes.

Our structural equation model showed that bottom-up auditory resolution of nonspeech sounds supports phoneme identification in noise, which in turn facilitates sentence understanding in noisy and reverberant conditions. Sentence understanding in noise was strongly supported by top-down language abilities, while memory and intelligence contributed indirectly by enhancing language abilities. Reading performance in this cohort was primarily influenced by cognitive factors, particularly nonverbal intelligence. Notably, cognitive abilities had minimal direct impact on nonspeech auditory processing measures, supporting a conceptual separation between auditory processing and cognitive abilities.

This study is the first to simultaneously quantify the direct and indirect contributions of auditory, language, and cognitive abilities to children’s speech-in-noise perception and reading performance. Our findings underscore the multifactorial nature of LiD and the clinical need for a multidisciplinary diagnostic approach for accurate diagnosis as a first step to effective remediation.