The incidence of a disorder or condition refers to the number of new cases identified in a specified time period. Prevalence refers to the number of individuals who are living with the disorder or condition in a given time period.

The true incidence and prevalence of central auditory processing disorder (CAPD) is difficult to calculate due to the lack of gold standard assessment tools (Barry et al., 2015; Hind et al., 2011), the lack of universal and standardized diagnostic criteria (Wilson & Arnott, 2013), and other organizational barriers (e.g., regulations, time, test availability; Emanuel et al., 2011). Diagnostic guidance from professional organizations, payers, policymakers, and researchers varies (Neijenhuis et al., 2019; Wilson & Arnott, 2013). CAPD diagnosis rates differ widely depending on the criteria and the assessment instruments used (Barry et al., 2015; Wilson & Arnott, 2013), clinician experience and interpretation (Moore et al., 2018), and the presence of co-occurring disorders (Gokula et al., 2019; Maggu & Overath, 2021; Stavrinos et al., 2018). As such, reported prevalence estimates demonstrate significant variability across studies.

In school-age children, reported CAPD prevalence rates range from 0.2% (Nagao et al., 2016) to 2.5% (Schow et al., 2020) to 6.2% (Esplin & Wright, 2014). One study comparing different CAPD diagnostic criteria found that, depending on the testing protocol and criteria used, 7.3%–96% of school-age children who had been referred for auditory processing evaluation met the qualifications for diagnosis (Wilson & Arnott, 2013).

Some pediatric populations demonstrate higher rates of CAPD. Children with attention, cognition, or language disability diagnoses (e.g., attention-deficit/hyperactivity disorder, learning disability) are more likely to have a coexisting CAPD diagnosis or have auditory processing differences (Gokula et al., 2019; Maggu & Overath, 2021).

Individuals who experience auditory processing difficulties in childhood may continue to experience language and communication difficulties into adulthood (Del Zoppo et al., 2015).

The following list is illustrative, not exhaustive. It includes signs and symptoms that may be indicative of other disorders (e.g., language disorders) as well as central auditory processing disorder (CAPD). As such, this list must be considered carefully and in relation to comprehensive assessment and differential diagnosis. Signs and symptoms of CAPD may include the following:

• difficulty localizing sound
• difficulty understanding spoken language in competing messages, in noisy backgrounds, in reverberant environments, or when presented rapidly
• longer response time during oral communication
• frequent requests for repetitions
• inconsistent or inappropriate responses during oral communication
• difficulty comprehending rapid speech
• difficulty following complex auditory directions
• difficulty learning songs or nursery rhymes
• misunderstanding messages (e.g., difficulty detecting prosody changes that help to interpret sarcasm or jokes)
• poor musical and singing skills
• difficulty paying attention or avoiding distractions
• reading, spelling, and/or learning problems

Of note, variations in social communication norms or the use of multiple languages may influence the perception of a communication partner’s auditory processing but do not indicate CAPD.

The etiology of central auditory processing disorder may be linked to a specific lesion or disorder or may be unknown. Causes and risk factors for central auditory processing disorder may include the following (Bamiou et al., 2001; Baran & Musiek, 1999; Chermak & Musiek, 2011):

• genetic determinants
• neurological disorder, disease, or damage
• otologic disorder, disease, or injury (e.g., auditory deprivation secondary to recurrent otitis media)
• prenatal/neonatal factors, such as
• anoxia/hypoxia;
• cytomegalovirus;
• hyperbilirubinemia (i.e., buildup of bilirubin in the blood);
• low birth weight;
• prematurity; and
• prenatal drug exposure

Roles and Responsibilities of Audiologists

Audiologists play a primary role in the identification, screening, assessment, diagnosis, and treatment of individuals with central auditory processing disorder (CAPD). Professional roles and activities in audiology include clinical and educational services; prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).

The following roles and responsibilities are appropriate for audiologists:

• Maintain knowledge of the anatomy, physiology, and pathophysiology of the auditory and balance systems.
• Remain informed of research and varying professional perspectives in the area of CAPD.
• Educate other professionals about the needs of individuals with CAPD and the role of audiologists in CAPD treatment.
• Serve as an integral member of an interprofessional collaborative team for the assessment and treatment of CAPD.
• Conduct a comprehensive, culturally and linguistically responsive, audiologic evaluation.
• Obtain a CAPD-specific case history.
• Select an individualized and person-centered CAPD test battery.
• Administer CAPD-specific assessments and interpret the results.
• Diagnose CAPD.
• Communicate results and recommendations to the patient, their family, and other relevant parties (e.g., interprofessional team members) in a health-literate and person- and family-centered manner.
• Develop and implement a comprehensive and person-centered intervention plan as part of an interdisciplinary team.
• Proceed with evaluation and fitting for hearing assistive technology systems to address central auditory deficits.
• Provide education and counseling to the patient and their family.
• Refer the patient to other professionals, as needed, to facilitate access to comprehensive services (e.g., speech-language pathology, psychology, neuro-otology, neuropsychology).
• Advocate for individuals with CAPD in relation to the availability of and the funding for services and supports related to communication, social interaction, academic and occupational goals, and quality of life.

As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists who work in this capacity should be specifically educated and appropriately trained to do so.

Roles and Responsibilities of Speech-Language Pathologists

Speech-language pathologists (SLPs) play a role in the identification, screening, assessment, and treatment of individuals with CAPD as part of an interdisciplinary team. Professional roles and activities in speech-language pathology include clinical and educational services; prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

The following roles and responsibilities are appropriate for SLPs:

• Remain informed of research and varying professional perspectives in the area of CAPD.
• Educate other professionals about the needs of individuals with CAPD and the role of SLPs in CAPD treatment.
• Serve as a member of an interprofessional collaborative team for the treatment of CAPD.
• Screen auditory processing skills in individuals identified as at risk for CAPD and determine if a referral for a diagnostic CAPD evaluation is warranted.
• Conduct a comprehensive and culturally and linguistically responsive evaluation of speech, language, cognitive, social, and communication skills.
• Obtain a CAPD-specific case history.
• Identify the cognitive-communicative and/or speech and language factors that may be associated with CAPD.
• Identify or differentiate disorders in phonology or language processing that may co-occur with CAPD.
• Identify functional implications associated with CAPD.
• Communicate results and recommendations to the patient, their family, and other relevant parties (e.g., interprofessional team members) in a health-literate and person- and family-centered manner.
• Develop and implement a comprehensive and person-centered intervention plan as part of an interdisciplinary team.
• Provide education and counseling to the patient and their family.
• Refer the patient to other professionals, as needed, to facilitate access to comprehensive services (e.g., audiology, psychology, neuropsychology).
• Advocate for individuals with CAPD in relation to the availability of and the funding for services and supports related to communication, social interaction, academic and occupational goals, and quality of life.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who work in this capacity should be specifically educated and appropriately trained to do so.

Screening

The goal of screening for central auditory processing disorder (CAPD) is to identify individuals who are potential candidates for a comprehensive central auditory test battery. Abbreviated test protocols can be used for screening. Screening protocols may include CAPD screening test batteries, single screening tests, various combinations of tests of auditory processing skills, observational tools, or a combination of these options. Questionnaires and checklists are available to probe auditory behaviors related to academic achievement, listening skills, and communication and to allow for systematic observation of listening behavior. Communication checklists, language tests, and cognitive tests may identify younger children who have or may likely develop auditory difficulties.

There is no universally accepted method for screening for CAPD. There remains a need for valid and efficient screening tools.

Comprehensive Assessment

CAPD is an auditory deficit diagnosed by an audiologist based on clinical presentation and assessment findings (ASHA, 2005). However, there is currently no reference standard for diagnosing CAPD (American Academy of Audiology, 2010; Vermiglio, 2016).

Some difficulties associated with diagnosing CAPD are due to its heterogeneous presentation and the frequent overlap in symptoms with language and other disorders (de Wit et al., 2018). “Many disorders present behavioral characteristics similar to CAPD that can cause the listener to perform poorly on behavioral central auditory function tests and/or exhibit similar functional listening difficulties” (Ferre, 2014, p. 589).

Varying perspectives among interdisciplinary team members involved in the evaluation process may result in different diagnoses (e.g., CAPD, phonological awareness disorder, language processing disorder; McNamara et al., 2008; Richard, 2012). Therefore, a collaborative team including both audiologists and speech-language pathologists (SLPs) is valuable in the evaluation of CAPD, the identification of any language disorders that may occur together with CAPD, the differentiation between language and phonological processing disorders and CAPD, and the development of appropriate intervention strategies (Sharma et al., 2009). Audiologists and SLPs may share responsibilities in the following ways:

• Audiologists are responsible for evaluating and diagnosing problems in the reception and/or transference of auditory signals in the peripheral auditory system and the central auditory nervous system.
• SLPs are responsible for evaluating and diagnosing problems in the linguistic processing of the auditory signal.
• Audiologists and SLPs share responsibility for diagnosing problems in the phonemic processing of the auditory signal (Richard, 2013).

Assessment data may be gathered by the audiologist, the SLP, and other members of the interdisciplinary team (e.g., psychologist, special educator). Assessment data may identify the presence of disorders with symptoms similar to CAPD (e.g., peripheral hearing loss, attention-deficit/hyperactivity disorder, speech-language disorder, cognitive deficits, auditory neuropathy spectrum disorder). For example, a comprehensive speech and language evaluation includes spoken and written language, phonemic awareness, phonological working memory and phonological retrieval, and social communication. Psychoeducational assessments often performed by an educational psychologist may include tests of memory, executive functioning, and attention.

The order in which interdisciplinary assessments are completed may vary depending on the referral source and the needs of the individual (e.g., particular symptoms, case history information). Identification of other global and/or related disorders (e.g., speech, language, attention, executive function) by the appropriate professional (e.g., SLP, psychologist) may preclude additional CAPD testing and may lead to an intervention plan specific to those diagnoses.

All assessments are conducted in the language(s) used by the individual, and materials are chosen with linguistic relevance in mind. Delays in auditory processing resulting from multilanguage learning are not considered disorders if the delay does not exist in all language(s) used.

For additional and complementary information, see the ASHA Practice Portal pages on Hearing Loss in Children, Spoken Language Disorders, Written Language Disorders, Speech Sound Disorders: Articulation and Phonology, Multilingual Service Delivery in Audiology and Speech-Language Pathology, Cultural Responsiveness, and Social Communication Disorder.

Case History

Accurate diagnosis relies on the interpretation of a test battery within the context of an individual’s medical and/or developmental history. A thorough case history for CAPD may include the following items:

• age, including chronological and mental age
• prenatal and birth history
• medical history, including medication history
• otologic history (e.g., ear infections, surgeries)
• neurologic history (e.g., head trauma)
• psychological history
• genetic testing results
• hearing health history and status, including previous hearing screening and testing results
• family health and hearing history
• coexisting disabilities
• cognitive status
• communication status, including language(s) used as well as identified needs and goals
• status of speech, language, reading, and social skills
• educational and/or occupational status, including any accommodations, supports, and/or services being received
• auditory and/or behavioral complaints (e.g., difficulty understanding speech in noisy environments, difficulty following rapid speech, inability to detect humor or sarcasm, distractibility)

See the ASHA Practice Portal page on Cultural Responsiveness for information on gathering a case history and ethnographic interviewing.

Audiologic Assessment Components

Audiologic Evaluation of the Peripheral Auditory System

It is essential to conduct an audiologic evaluation to diagnose or rule out hearing loss and other hearing-related disorders. Peripheral hearing loss can present with similar listening difficulties to CAPD. The presence of peripheral hearing loss may affect CAPD testing (Baran & Musiek, 1999). In some cases, the severity and/or configuration of the hearing loss will prohibit the completion of a CAPD evaluation.

Peripheral auditory disorders include conductive, sensorineural, and mixed hearing loss, as well as auditory neuropathy spectrum disorder (Norrix & Velenovsky, 2014) and cochlear synaptopathy (i.e., hidden hearing loss; Liberman et al., 2016). These disorders can affect an individual’s ability to hear and understand speech in background noise to varying degrees. See the Assessment sections of the ASHA Practice Portal pages on Hearing Loss in Adults and Hearing Loss in Children for information on assessing the peripheral auditory system.

Audiologic Evaluation of the Central Auditory System

The audiologist selects an individualized, person-centered central auditory processing test battery based on age, findings from the case history, interdisciplinary assessment results (e.g., language and cognitive evaluations), and results from the peripheral audiologic evaluation (Emanuel et al., 2011). Considerations include the strengths and weaknesses of the individual tests (e.g., sensitivity and specificity), the population on which they were normed, required response mode, and areas of the central auditory nervous system (CANS) to which each test is most sensitive (Chermak et al., 2017).

There are several behavioral audiologic measures that can be used to assess auditory processing skills:

• Auditory discrimination tests may be used to assess differentiation of similar acoustic stimuli that differ in frequency, intensity, and/or temporal parameters.
• Auditory temporal processing and patterning tests may be used to assess analyzation of acoustic events over time.
• Dichotic speech tests may be used to assess separation (i.e., binaural separation) or integration (i.e., binaural integration) of different auditory stimuli presented to each ear simultaneously.
• Monaural low-redundancy speech tests may be used to assess the recognition of degraded speech stimuli presented to one ear at a time, including speech in noise, speech in competition, low-pass filtered speech, or compressed (rapid) speech.
• Binaural interaction tests may be used to assess the combination of complementary inputs distributed between both ears, synthesizing intensity, time, or spectral differences of otherwise identical stimuli presented simultaneously or sequentially.

For a discussion of behavioral tests, see McNamara and Hurley (2019).

Several principles may influence the composition of a central auditory test battery:

• Refer to the appropriate professional(s) regarding suspected related disorders (e.g., speech, language, cognitive), preferably before central auditory processing testing is completed, as co-occurring diagnoses may preclude central auditory processing testing or interfere with accurate interpretation of results.
• Center the test battery process around the referring complaint(s) and the relevant information available to the audiologist rather than using a test-driven approach.
• Include measures that are sensitive to the integrity of the CANS.
• Examine different central processes, tasks, and the integrity of multiple levels and regions of the CANS.
• Choose testing materials and stimuli with linguistic and cultural relevance in mind.
• Consider an individual’s age and/or developmental status when choosing behavioral tests of central auditory function as well as potential variability in performance in young children due to factors such as response demands and task complexity (Smart et al., 2012).
• Select tests that were developed for (and have normative data on) a specific age group.
• Include both verbal and nonverbal stimuli to examine various aspects of auditory processing and various levels of the auditory nervous system.
• Test individuals who are successfully medicated for attention, anxiety, or other disorders while they are medicated to avoid confounding variables.
• Monitor an individual’s attention, motivation, and energy level for potential impact on optimum testing session length.
• Corroborate test results with an individual’s primary symptoms or concerns.

Norm-based interpretation of test results involves comparing the individual’s performance to normative group data (e.g., based on age). Patient-based interpretation involves comparing the individual’s performance to their own baseline performance. Comparison of results observed across disciplines or between tests can also be helpful with interpretation. For example, administering and comparing results for several tests that measure the same auditory process can be used to look for patterns in auditory processing abilities. Inconsistencies across tests may signal the presence of a nonauditory confound, and pervasive deficits on all tests may signal a cognitive deficit or other nonauditory confound.

Examples of current diagnostic criteria and interpretations of test results include the following:

• Performance deficits are noted in one or both ears of at least 2 SDs below the mean on two or more tests in the battery (Chermak & Musiek, 1997).
• If poor performance is observed on only one test,
• diagnosis may be withheld unless performance falls at least 3 SDs below the mean or the finding is accompanied by significant functional difficulty in auditory behaviors that rely on the process being assessed, and
• the failed test—and other tests that assess the same process—should be readministered to confirm initial findings.

Central auditory processing disorder (CAPD) may affect listening, communication, academic success, and psychosocial wellness. Priorities and specific goals for intervention aim to be person-centered, culturally and linguistically relevant, and jointly agreed upon with the individual seeking services at the center of the decision-making process. Effective communication in everyday contexts important to the individual (e.g., home, classroom, work, community) is an overarching consideration. Efforts to improve acoustic access and communication abilities for individuals of any age require an analysis of specific auditory processing weaknesses, functional deficits, and specific recommendations for change across settings.

A team approach to treatment is often used. The composition of the team may vary (e.g., audiologist, speech-language pathologist [SLP], teacher, interpreter, parents, counselor) depending on the needs and goals of the individual seeking treatment. See the ASHA resources on interprofessional education/interprofessional practice (IPE/IPP) and focusing care on individuals and their care partners as well as the ASHA Practice Portal pages on Cultural Responsiveness and Multilingual Service Delivery in Audiology and Speech-Language Pathology.

Treatment goals are based on the following considerations:

• patient and family input and goals
• auditory processing deficits
• needs identified during the assessment process
• case history information
• related assessment data (e.g., speech-language and psychoeducational)

Treatment approaches

• are based on the best available evidence;
• follow learning principles;
• strive to reduce functional deficits;
• strive to maximize generalization; and
• occur in multiple settings as appropriate (e.g., home, classroom, workplace, community).

Three treatment approaches for individuals diagnosed with CAPD, often used concurrently, include the following (ASHA, 2005):

1. Environmental modifications involve changing the learning or communication environment.
2. Direct skills remediation includes various auditory training techniques.
3. Compensatory strategies include strategies and/or adaptive techniques designed to minimize the impact of CAPD by strengthening higher order skills to compensate for and/or obtain missed auditory information.

It is essential to consider the co-occurrence of CAPD with other spoken and written language disorders (Sharma et al., 2009) and the heterogeneity of CAPD when providing treatment (Fey et al., 2011; Richard, 2012). Some treatment approaches and tasks may be the same as those used for spoken or written language disorders (Kamhi, 2011; Richard, 2013) given the overlap in functional symptoms of CAPD and language disorders. See the Treatment sections of the ASHA Practice Portal pages on Spoken Language Disorders and Written Language Disorders.

A comprehensive and person-centered treatment plan for CAPD may include, but not be limited to, the following interventions.

Environmental Modifications

Environmental modifications improve access to auditorily presented information. They include enhancement of the auditory signal and modifications to the listening environment to improve clarity and/or audibility of the signal itself (Crandell & Smaldino, 1999, 2000; Friederichs & Friederichs, 2005; Johnston et al., 2009; Smart et al., 2018). Various associated strategies and accommodations may be used to improve an individual’s access to information in various settings (Bellis, 2002, 2011; Chermak & Musiek, 1997; Hétu et al., 1990).

Enhancement of the auditory signal includes the use of hearing assistive technology. Examples include individual and group assistive listening devices such as frequency modulation/digital modulation (i.e., FM/DM), classroom audio distribution systems, and infrared technology. This type of auditory signal enhancement may be considered for school-age children who are having difficulties understanding auditory messages in the classroom to improve classroom listening behaviors and function (Reynolds et al., 2016; Rosenberg, 2002; Smart et al., 2018). Appropriate use of hearing assistive technology includes validation of benefits in typical listening conditions experienced by the individual using a variety of outcomes tools after fitting (American Academy of Audiology, 2008).

Modifications to the listening environment can be used to improve acoustics affecting speech intelligibility. The following changes may be helpful:

• Cover reflective surfaces (e.g., black/white boards not in use, linoleum or wood floors, untreated ceilings) to decrease reverberation.
• Use properly placed acoustic dividers.
• Use various absorption materials throughout open or empty spaces.
• Reduce competing signals by eliminating or moving external noise sources (e.g., aquariums, fluorescent lights that hum) from the learning space.

For more information, see the ASHA Practice Portal page on Classroom Acoustics and the Educational Audiology Association’s Classroom Acoustics and Hearing: Essentials to Learning [PDF].

An individual’s access to auditory information may also be improved with the use of the following strategies and/or accommodations:

• requesting the presenter to speak more slowly, pause more often, emphasize key words, and “chunk” instructions
• asking the speaker to check that the listener has understood and to use repetition and rephrasing when communication breakdowns occur
• making strategic seating choices
• pairing verbal presentations or instructions with visuals
• recording verbal presentations
• using written supports such as email
• providing support for focused/attentive listening (e.g., use notetakers, preview information prior to instruction, use organizers)

Direct Skills Remediation

Direct skills remediation includes targeted auditory training techniques aimed at remediating auditory processing deficits (Bellis, 2002, 2011; British Society of Audiology, 2011; Chermak & Musiek, 2002). Although some clinicians support direct skills remediation in this population, others have provided scrutiny (Fey et al., 2011; Rees, 1973). See the Treatment section of the Central Auditory Processing Disorder (CAPD) Evidence Map for pertinent scientific evidence and clinical expertise on the use of direct auditory skills interventions in the treatment of CAPD.

Direct skills remediation may address the following skills (Bamiou et al., 2006; Bellis, 2011; Bellis & Anzalone, 2008):

• auditory discrimination—distinguishing the intensity, frequency, and duration of one sound from another
• phoneme discrimination—distinguishing between speech sounds that make a difference in meaning in a particular language (e.g., /p/ vs. /b/ in English) and phoneme–grapheme skills (i.e., written representation of phonemes)
• temporal aspects of audition—perceiving acoustic signals over time, including
• temporal integration—the ability to consolidate auditory information presented to both ears over time,
• temporal masking—the ability to separate one sound from another sound that immediately precedes or follows it,
• temporal resolution—the ability to detect a gap or small timing differences between two sounds, and
• temporal ordering or sequencing—the ability to sequence chronological signal occurrences over time
• auditory pattern recognition—distinguishing similarities and differences in sound patterns
• sound localization and lateralization—identifying the location, origin, direction, and distance of a sound reaching each ear
• binaural separation—recognizing auditory information presented within a background of noise or competition (e.g., dichotic listening, speech in noise)
• binaural integration—recognizing disparate auditory stimuli presented to each ear simultaneously

Computer-Based Training

Direct skills remediation includes computer-based training programs that may address auditory and/or language targets. Because of the continuum from the cochlea to the language areas, it may be difficult to isolate the specific factors contributing to treatment outcomes (Gillam et al., 2008; Richard, 2012). Some programs “are designed to capitalize on the plasticity of the [auditory] system” (Tremblay & Kraus, 2002, p. 97). As with all other treatments, it is important that computer-based training be evidence-based, individualized, and carefully monitored by an audiologist or SLP. Although more research is warranted, early evidence is supportive of these direct skills computer-based treatment approaches (Barker & Bellis, 2018; Barker & Hicks, 2020; Loo et al., 2010; Musiek et al., 2002; Phillips, 2002).

Available programs focus on the following skills:

• temporal processing
• linguistic and nonlinguistic auditory memory
• linguistic and nonlinguistic dichotic ability
• binaural integration and separation skills
• phonological awareness
• language decoding and comprehension

Computerized delivery may provide

• multisensory stimulation,
• engaging formats,
• feedback and reinforcement, and
• facilitation of intensive training.

Interhemispheric Transfer Training

Direct skills remediation also includes exercises to train interhemispheric transfer (Bellis, 2002; Musiek et al., 1999). Interhemispheric transfer of information underlies binaural hearing and binaural processing.

Exercises to train interhemispheric transfer include the following tasks:

• tasks that address interaural timing and intensity differences
• unimodal tasks (e.g., linking prosodic and linguistic acoustic features)
• multimodal tasks (e.g., writing to dictation, verbally describing a picture while drawing)

Compensatory Strategies

Compensatory strategies (e.g., metalinguistic and metacognitive) are designed to minimize the impact of CAPD on language, cognition, and academics. They focus on strengthening higher order central resources (e.g., language, memory, attention) to enhance listening skills, communication, social skills, and learning outcomes.

Metalinguistic strategies include the following examples:

• schema induction (i.e., predicting elements in a message) and discourse cohesion devices (i.e., grammatical means to link and establish relationships between sentences and paragraphs)
• use of graphic organizers (e.g., problem–solution map, story map, semantic network tree)
• use of context to understand and build vocabulary
• phonological awareness (see British Society of Audiology, 2011, Appendix K)
• semantic network expansion
• active listening (see British Society of Audiology, 2011, Appendix N)

Metacognitive strategies include the following examples:

• self-instruction
• organization skills
• metamemory techniques (e.g., mnemonics, mind mapping)
• problem solving
• assertiveness training

Language/Curricular-Based Treatment Approaches

Some school-age students may benefit from carefully targeted and individualized language interventions.

This applied curricular approach falls within the area of metacognitive or compensatory strategies. It “places CAPD symptoms within a broader framework and takes into account the complex interaction among the language knowledge, skills, and strategies needed for academic success” (Wallach, 2011, p. 273).

This broader-based information and linguistic processing framework (Cowan et al., 2009; Gillam et al., 2002; Kamhi, 2004; Nittrouer, 1999, 2002) focuses on the linguistic aspects of auditory processing deficits and includes linguistic goals.

Considerations for a strategic-based language/curriculum-relevant approach (based on Wallach, 2011) include the following:

• Focus on enhancing language comprehension and production skills to help students with auditory weaknesses access curricular content (Kaderavek, 2011). For example, help students learn concepts and skills such as paraphrasing, explaining differences, knowing word meanings, and using complex syntax.
• Address language knowledge, skills, and strategies that underlie academic tasks (Ehren, 2000; Ehren et al., 2004).
• Select goals for contextualized (e.g., language accompanied by gesture, facial, and other supports) and decontextualized (e.g., language within testing contexts, many written materials) aspects of language (Wallach, 2008).
• Recognize that metalinguistic aspects are involved in auditory tasks. For example, sentence memory tasks involve metalinguistic knowledge of sentence structure, and auditory discrimination tasks involve phonemic judgments and the metalinguistic ability to analyze the sound structure of language (Schuele & Boudreau, 2008; van Kleeck, 1994).
• Identify curricular and instructional demands across grades and determine the impact on language use. Recognize the need for disciplinary literacy, the concept that each academic subject has its own language (Ehren et al., 2004; Heller & Greenleaf, 2007; VanSledright, 2002, 2004).
• Develop language interventions that focus on content-area subjects. Connect with school-based colleagues and consider curriculum demands placed on students (Brozo, 2009; Wallach et al., 2009).
• Teach strategies to help students derive meaning from spoken and written language and organize incoming information (Blachowicz & Fisher, 2004; Ehren, 2009; McKeown et al., 2009; Nippold, 2010). For example, create expectations for what they are likely to hear in the classroom as they will influence what is attended to, perceived, and remembered.
• Understand the reciprocal nature of spoken and written language. Written language skills can facilitate auditory processing by improving metalinguistic awareness and by introducing various language forms and new vocabulary (Schuele & Boudreau, 2008; Scott, 2009; van Kleeck, 2004; Zucker et al., 2009).

Assessing Treatment Progress

The provision of standardized measures as well as academic/learning measures prior to treatment as well as posttreatment may be used to assess treatment progress. Measures may include indices of auditory performance (e.g., pattern tests, dichotic digits, speech recognition for time-compressed speech); functional indices of metalanguage (e.g., phonemic analysis, phonemic synthesis); and/or global measures of listening, communication, and academic performance (e.g., self-assessment or informant communication, questionnaires, and/or education scales).

As listening and learning demands change over time, alterations to the treatment plan may be indicated. It is important that the relative efficacy of each treatment approach implemented be monitored on an ongoing basis and that changes be made as needed.

Special Considerations: Adolescents and Adults

Children with auditory processing deficits may have more difficulty as they enter noisy auditory-based learning environments with high demands on their listening skills. Adolescents and adults may experience more difficulties with understanding and listening as educational and vocational communication demands change or increase.

The following suggestions may be applicable for adolescents and adults with CAPD:

• Make adjustments based on different contextual demands at home, at school, at work, and in the community (e.g., moving from an open cubicle to a closed office, using strategic seating or hearing assistive technology in large conference rooms or lecture halls).
• Use multiple treatment options and approaches, as well as academic and vocational training, career counseling, and transition planning.
• Focus on self-advocacy.

Regulations

A court decision by the United States Ninth Circuit Court of Appeals (2012) determined that an auditory processing disorder constitutes an “other health impairment” under the Individuals with Disabilities Education Improvement Act (IDEA, 2004). See E. M. . . . v. Pajaro Valley Unified School District [PDF]. This court case helped define CAPD under the IDEA for school administrators and educators, parents, the judiciary, and administrative bodies and legal representatives in the western states.

Court filings related to the case described CAPD (also referred to as “auditory processing disorder”) as a deficiency in neurological processing that adversely affects an individual’s ability to identify and distinguish similar sounds and understand oral communication. In addition, evidence introduced in court established that CAPD requires a diagnosis by an audiologist.

In addition to helping define CAPD, this court case could also improve access to services under the IDEA in public school settings. Court documents revealed that, given the similarity of symptoms caused by CAPD and attention-deficit/hyperactivity disorder, CAPD clearly falls within the scope of identified illnesses that could be covered by “other health impairment.” CAPD can satisfy the three elements of an “other health impairment” in that it is (a) a chronic medical condition (b) that impacts a child’s alertness in a classroom and (c) adversely affects the child’s ability to learn.

Some state education departments may review eligibility for CAPD under the IDEA disability categories of “speech or language impairment” or “specific learning disability.” However, establishing CAPD in the category of “other health impairment” provides a specific and recognized category with which to argue for service eligibility.

Coding and Payment

Payment and coverage of audiology and speech-language pathology services related to the evaluation and treatment of CAPD varies based on factors such as the patient’s diagnosis(es), the payer (e.g., Medicare, Medicaid, or commercial insurance), and the patient’s specific health insurance plan. It is important for audiologists and SLPs to understand coverage policies for the payers they commonly bill, to verify coverage for each patient prior to initiating services, and to be familiar with correct diagnosis and procedure coding for accurate claims submission.

Audiologists and SLPs use the National Center for Health Statistics International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes to describe the patient’s diagnosis and Current Procedural Terminology codes to describe CAPD-related evaluation and treatment. The term “central auditory processing disorder” is specifically used to classify this diagnosis within the ICD-10-CM. Payer policies often outline specific coverage guidelines and list relevant ICD-10-CM and Current Procedural Terminology codes.

Coding options are different for each discipline. For more information about coding, see the following ASHA resources:

• Coding for Reimbursement Frequently Asked Questions: Audiology—What code/s should I use for auditory processing (AP) evaluation and treatment?
• Coding for Reimbursement Frequently Asked Questions: Speech-Language Pathology—What code/s should I use for auditory processing (AP) evaluation and treatment?
• ICD-10-CM Coding FAQs for Audiologists and SLPs: What code should an audiologist use for CAPD?
• ICD-10-CM Coding FAQs for Audiologists and SLPs: What ICD-10-CM code should I use for auditory processing (AP)?

ASHA Resources

• ASHA Blog: Dig Deeper if Treating a Child With Suspected APD
• ASHA Blog: Does Auditory Processing Disorder Meet the Criteria for a Legitimate Clinical Entity?
• ASHA Leader: Don’t Wait to Diagnose Auditory Processing Disorder
• ASHA Position Statement: (Central) Auditory Processing Disorders—The Role of the Audiologist
• Central Auditory Processing and the Common Core
• Coding for Reimbursement Frequently Asked Questions: Audiology—What code/s should I use for auditory processing (AP) evaluation and treatment?
• Coding for Reimbursement Frequently Asked Questions: Speech-Language Pathology—What code/s should I use for auditory processing (AP) evaluation and treatment?
• Focusing Care on Individuals and Their Care Partners
• Hearing-Related Topics: Terminology Guidance
• ICD-10-CM Coding FAQs for Audiologists and SLPs: What code should an audiologist use for CAPD?
• ICD-10-CM Coding FAQs for Audiologists and SLPs: What ICD-10-CM code should I use for auditory processing (AP)?
• Infection Control Resources for Audiologists and Speech-Language Pathologists
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• Tips for the Differential Diagnosis of Central Auditory Processing Disorder (CAPD) [ASHA Case Study Video; Ferre, 2016]
• Understanding Auditory Processing Disorders in Children
• Understanding the Differences Between Auditory Processing, Speech and Language Disorders, and Reading Disorders [PDF]

Other Resources

This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.

• American Academy of Audiology Clinical Practice Guidelines—Diagnosis, Treatment and Management of Children and Adults with Central Auditory Processing Disorder [PDF]
• British Society of Audiology Practice Guidance: An Overview of Current Management of Auditory Processing Disorder (APD) [PDF]
• Court Decision: E.M. . . . v. Pajaro Valley Unified School District [PDF]
• Educational Audiology Association: Classroom Acoustics and Hearing: Essentials to Learning [PDF]
• The Importance of Good Classroom Acoustics [PDF]

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American Academy of Audiology. (2010). Diagnosis, treatment and management of children and adults with central auditory processing disorder [Clinical practice guidelines]. https://audiology-web.s3.amazonaws.com/migrated/CAPD%20Guidelines%208-2010.pdf_539952af956c79.73897613.pdf [PDF]

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American Speech-Language-Hearing Association. (2005). (Central) auditory processing disorders—The role of the audiologist [Position statement]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2016). Scope of practice in speech-language pathology [Scope of practice]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. https://www.asha.org/policy/

American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://www.asha.org/policy/

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Bamiou, D.-E., Musiek, F. E., & Luxon, L. M. (2001). Aetiology and clinical presentations of auditory processing disorders—A review. Archives of Disease in Childhood, 85(5), 361–365. https://doi.org/10.1136/adc.85.5.361

Baran, J. A., & Musiek, F. E. (1999). Behavioral assessment of the central auditory nervous system. In F. E. Musiek & W. F. Rintelmann (Eds.), Contemporary perspectives in hearing assessment (pp. 375–415). Allyn & Bacon.

Barker, M. D., & Bellis, T. J. (2018). Effectiveness of a novel computer/tablet-based auditory training program in improving dichotic listening skills in children. Journal of Speech Pathology & Therapy, 3(1), 129. https://doi.org/10.4172/2472-5005.1000129

Barker, M. D., & Hicks, C. B. (2020). Treating deficits in auditory processing abilities. Language, Speech, and Hearing Services in Schools, 51(2), 416–427. https://doi.org/10.1044/2019_LSHSS-19-00001

Barry, J. G., Tomlin, D., Moore, D. R., & Dillon, H. (2015). Use of questionnaire-based measures in the assessment of listening difficulties in school-aged children. Ear and Hearing, 36(6), e300–e313. https://doi.org/10.1097/AUD.0000000000000180

Bellis, T. J. (2002). Developing deficit-specific intervention plans for individuals with auditory processing disorders. Seminars in Hearing, 23(4), 287–296. https://doi.org/10.1055/s-2002-35877

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Bellis, T. J., & Ferre, J. M. (1999). Multidimensional approach to the differential diagnosis of central auditory processing disorders in children. Journal of the American Academy of Audiology, 10(06), 319–328. https://doi.org/10.1055/s-0042-1748503

Blachowicz, C. L. Z., & Fisher, P. (2004). Building vocabulary in remedial settings: Focus on word relatedness. Perspectives, 30(1), 24–31.

British Society of Audiology. (2011). An overview of current management of auditory processing disorder (APD) [Practice guidance]. http://www.thebsa.org.uk/wp-content/uploads/2014/04/BSA_APD_Management_1Aug11_FINAL_amended17Oct11.pdf [PDF]

Brozo, W. G. (2009). Response to intervention or responsive instruction? Challenges and possibilities of response to intervention for adolescent literacy. Journal of Adolescent & Adult Literacy, 53(4), 277–281. https://www.jstor.org/stable/30250068

Buehler, V. (2012). Treatment of (central) auditory processing disorder: Bridging the gap between the audiologist and the speech-language pathologist. SIG 9 Perspectives on Hearing and Hearing Disorders in Childhood, 22(2), 46–56. https://doi.org/10.1044/hhdc22.2.46

Cacace, A. T., & McFarland, D. J. (2009). Controversies in central auditory processing disorder. Plural.

Chermak, G. D., Bamiou, D.-E., Iliadou, V., & Musiek, F. E. (2017). Practical guidelines to minimise language and cognitive confounds in the diagnosis of CAPD: A brief tutorial. International Journal of Audiology, 56(7), 499–506. https://doi.org/10.1080/14992027.2017.1284351

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Chermak, G. D., & Musiek, F. E. (2011). Neurological substrate of central auditory processing deficits in children. Current Pediatric Reviews, 7(3), 241–251.

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de Wit, E., van Dijk, P., Hanekamp, S., Visser-Bochane, M. I., Steenbergen, B., van der Schans, C. P., & Luinge, M. R. (2018). Same or different: The overlap between children with auditory processing disorders and children with other developmental disorders: A systematic review. Ear and Hearing, 39(1), 1–19. https://doi.org/10.1097/AUD.0000000000000479

de Wit, E., Visser-Bochane, M. I., Steenbergen, B., van Dijk, P., van der Schans, C. P., & Luinge, M. R. (2016). Characteristics of auditory processing disorders: A systematic review. Journal of Speech, Language, and Hearing Research, 59(2), 384–413. https://doi.org/10.1044/2015_JSLHR-H-15-0118

Dillon, H., Cameron, S., Glyde, H., Wilson, W., & Tomlin, D. (2012). An opinion on the assessment of people who may have an auditory processing disorder. Journal of the American Academy of Audiology, 23(02), 097–105. https://doi.org/10.3766/jaaa.23.2.4

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Ferre, J. M. (2014). Differential intervention for central auditory processing disorder, attention deficit hyperactivity disorder, and learning disability. In G. D. Chermak & F. E. Musiek (Eds.), Handbook of central auditory processing disorder, Volume II: Comprehensive intervention (2nd ed., pp. 589–616). Plural.

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Friberg, J. C., & McNamara, T. L. (2010). Evaluating the reliability and validity of (central) auditory processing tests: A preliminary investigation. Journal of Educational Audiology, 16(1), 4–16.

Friederichs, E., & Friederichs, P. (2005). Electrophysiologic and psycho-acoustic findings following one-year application of a personal ear-level FM device in children with attention deficit and suspected central auditory processing disorder. Journal of Educational Audiology, 12, 31–36.

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Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert review. ASHA extends its gratitude to the following subject matter experts who reviewed content and provided feedback during the development of this page.

• Jane Baran, PhD, CCC-A/SLP
• Gail Chermak, PhD, CCC-A
• David DeBonis, PhD, CCC-A
• Ellen de Wit, MSc
• Tatyana Elleseff, MA, CCC-SLP
• Jeanane Ferre, PhD, CCC-A
• Alan Kamhi, PhD, CCC-SLP
• Georgina Lynch, PhD, CCC-SLP
• Tena McNamara, AuD, CCC-A/SLP
• Cynthia McCormick Richburg, PhD, CCC-A
• Gail Richard, PhD, CCC-SLP
• Deborah Ross-Swain, EdD, MS, CCC-SLP
• Jennifer Smart, PhD, CCC-A
• Andrew Vermiglio, AuD, CCC-A
• Geraldine Wallach, PhD, CCC-SLP

In addition, ASHA thanks the members of the American Speech-Language-Hearing Association (ASHA) Working Group on Auditory Processing Disorders whose work was foundational to the development of this content. Members of the working group (2002–2004) were Teri James Bellis (chair), Gail D. Chermak, Jeanane M. Ferre, Frank E. Musiek, Gail G. Rosenberg, and Evelyn J. Williams (ex officio). Members of the Working Group (2002–2003) included Jillian A. Armour, Jodell Newman Ryan, and Michael K. Wynne. Susan J. Brannen, member (2004) and vice president for professional practices in audiology (2001–2003), and Roberta B. Aungst, vice president for professional practices in audiology (2004–2006), served as monitoring vice presidents.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Central auditory processing disorder [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Central-Auditory-Processing-Disorder/