Central Auditory Processing Disorder

See the Treatment section of the Central Auditory Processing Disorder Evidence Map for pertinent scientific evidence, expert opinion, and client/patient perspective.

CAPD may affect listening, communication, academic success, and psychosocial wellness. The overall goal of intervention is to provide the individual with the ability to communicate more effectively in everyday contexts (e.g., home, classroom, work, community). Efforts to improve acoustic access and communication for individuals of any age requires an analysis of functional deficits and specific recommendations for change across settings.

A team approach to treatment is often utilized. Depending on the needs of the individual, team members may include an audiologist, an SLP, a teacher, parents, and a counselor. The approach, frequency, and intensity of treatment should be individualized based on communication strengths and needs, cultural background and values, preferred language, severity of the disorder, and available research evidence. See ASHA'S Practice Portal pages on Bilingual Service Delivery and Cultural Competence.

Treatment goals are based on

  • needs identified during the assessment process;
  • the individual's case history;
  • related speech-language and psychoeducational assessment data;
  • remediation of deficit skills; and
  • management of the disorder's impact on the individual.

Treatment approaches should

  • be 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—home, classroom, workplace, and community.

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

  1. Direct skills remediation (auditory training, "bottom-up")
  2. Compensatory strategies (recruiting higher-order skills to help compensate for the disorder "top-down")
  3. Environmental modifications (changing the learning or communication environment).

It is essential to consider the comorbidity of CAPD with other spoken and written language disorders (Sharma, Purdy, & Kelly, 2009) and the heterogeneity of CAPD when providing treatment (Fey et al., 2011; Richard, 2012). The focus of treatment is guided by the findings of a comprehensive assessment. 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 ASHA's Practice Portal pages on Spoken Language Disorders and Written Language Disorders.

This list of treatment approaches is not exhaustive, and the inclusion of any specific treatment does not imply endorsement by ASHA.

Direct Skills Remediation

Direct skills remediation (e.g., auditory training; sometimes referred to as "bottom-up" or "traditional listening treatments") includes procedures to target multiple skills associated with auditory processing (Bellis, 2002, 2003; Chermak & Musiek, 2002; cf. British Society of Audiology [BSA], 2011).

Direct skills remediation may address the following:

  • Auditory discrimination—training to distinguish the intensity, frequency, and duration of one sound from another
  • Phoneme discrimination—training to distinguish between speech sounds that make a difference in meaning in a particular language (e.g., /p/ vs. /b/ in English) and phoneme–grapheme skills (written representation of phonemes)
  • Temporal aspects of audition—training to perceive acoustic signals over time, including
    • temporal integration;
    • temporal gap discrimination; and
    • temporal ordering or sequencing.
  • Auditory pattern recognition—training to distinguish similarities and differences in sound patterns
  • Sound localization and lateralization—training to identify the location, origin, direction, and distance of a sound reaching each ear
  • Recognition of auditory information presented within a background of noise or competition (i.e., binaural separation)—dichotic listening training or speech-in-noise training
  • Recognition of disparate auditory stimuli presented to each ear simultaneously (i.e., binaural integration)—binaural interaction training (Bamiou, Campbell, & Sirimanna, 2006; Bellis, 2003; Bellis & Anzalone, 2008)

Computer-Based Training

Direct skills remediation includes computer-based training programs that may address both auditory and language components.  Consequently, 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). As with all other treatments, it is important that computer-based training be individualized and carefully monitored by an audiologist or SLP. More research is needed in the area of direct skills computer-based treatment approaches (Musiek, Shinn, & Hare, 2002; Phillips, 2002).

Available programs focus on

  • temporal processing;
  • linguistic and nonlinguistic auditory memory;
  • linguistic and non-linguistic dichotic ability,
  • speech-in-noise;
  • binaural integration and separation skills;
  • phonological awareness; and
  • reading 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, 2003; Musiek, Baran, & Schochat, 1999). Interhemispheric transfer of information underlies binaural hearing and binaural processing. Efficacy data in this area are still emerging (Weihing, Chermak, & Musiek, 2015).

Exercises to train interhemispheric transfer include

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

Compensatory Strategies

Compensatory strategies (e.g., metalinguistic and metacognitive; sometimes referred to as "top-down") 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, and attention) to enhance listening skills, communication, social skills, and learning outcomes.

  • Metalinguistic strategies include
    • 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 BSA, 2011, Appendix K);
    • semantic network expansion; and
    • active listening (see BSA, 2011, Appendix N).
  • Metacognitive strategies include
    • self-instruction;
    • organization skills;
    • metamemory techniques (e.g., mnemonics, mind mapping);
    • problem solving; and
    • assertiveness training.

Language/Curricular-Based Treatment Approaches

Some students may benefit from carefully targeted individualized language interventions.

This applied curricular approach falls within the area of "top-down" 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, Rosen, & Moore, 2008; Gillam, Hoffman, Marler, & Wynn-Dancy, 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, Lenz, & Deshler, 2006).
  • 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 (e.g., sentence memory tasks involve metalinguistic knowledge of sentence structure; 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—each academic subject has its own language (Ehren et al., 2006; 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, 2010; Wallach, Charlton, & Christie, 2009).
  • Teach strategies to help students derive meaning from spoken and written language and organize incoming information (Blachowicz & Fisher, 2004; Ehren, 2009; McKeown, Beck, & Blake, 2009; Nippold, 2009). For example, create expectancies for what they are likely to hear in the classroom; expectancies 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, 2006; Zucker, Justice, & Piasta, 2009).

Environmental Modifications

Environmental modifications improve access to auditorily presented information (ASHA, 2005). They include enhancement of the auditory signal and the listening environment ("bottom-up") to improve clarity and/or audibility of the signal itself (Crandell & Smaldino, 2000, 2001) and management approaches ("top-down") to improve access to information in various settings (Bellis, 2002, 2003; Chermak & Musiek, 1997; Hedu, Gagnon-Tuchon, & Bilideau, 1990).

Enhancement of the Auditory Signal and Listening Environment (Bottom-Up)

  • Enhancement of the auditory signal—using remote microphone hearing assistive technology, including individual and group assistive listening devices such as FM/DM or infrared technology—
    • may be indicated for some individuals with CAPD when deficits are found on monaural low redundancy speech and dichotic speech tests (Bellis, 2003; Rosenberg, 2002), both of which involve degraded signals, figure ground, or competing speech—factors similar to the effects of noise and reverberation in various settings; and
    • may be considered initially for individuals with CAPD as an accommodation strategy due to their signal-to-noise (S/N) enhancement capabilities (Crandell, Charlton, Kinder, & Kreisman, 2001).
    • Prior to fitting, performance should be verified using electroacoustic, real-ear, and behavioral measures, including norm-referenced speech recognition in noise testing (AAA, 2008).
    • Subsequent to fitting, benefits should be validated in typical listening conditions experienced by the individual using a variety of outcomes tools (AAA, 2008).

    More research is needed regarding the use of personal HATS as a management strategy for CAPD (Lemos et al., 2009; Rosenberg et al., 1999; Stach, Loiselle, Jerger, Mintz, & Taylor, 1987).

  • Modifications to the listening environment—improving acoustics that can affect speech intelligibility—can include
    • covering reflective surfaces (e.g., black/white boards not in use, linoleum or wood floors, untreated ceilings) to decrease reverberation;
    • using properly placed acoustic dividers;
    • using various absorption materials throughout open or empty spaces; and
    • reducing competing signals by eliminating or moving external noise sources (e.g., aquariums, fluorescent lights that hum) from the learning space.

See ASHA's technical report on school facilities (2002), ASHA's Practice Portal page on Classroom Acoustics, and The Stationery Office's bulletin on the acoustic design of schools (The Stationery Office Department for Education and Skills, 2003).

Management Approaches (Top-Down)

  • Top-down management approaches—compensatory strategies designed to strengthen higher order resources (i.e., language, memory, attention) and buttress deficient auditory processing skills and enhance listening, including
    • advising the speaker to speak more slowly, pause more often, emphasize key words, and "chunk" his or her instructions;
    • asking the speaker to check that the listener has understood and knows to use repetition and rephrasing when communication breakdowns occur;
    • pairing verbal presentations or instructions with visuals;
    • using written supports such as e-mail or mind maps; and
    • providing support for focused/attentive listening (e.g., use notetakers, preview information prior to instruction, and use organizers).

Assessing Treatment Progress

Test–retest of standardized measures as well as academic/learning measures 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 and communication (e.g., self-assessment or informant communication and education scales).

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

Special Considerations: Adolescents and Adults

Children with processing deficits may have more difficulty as they enter noisy auditory-based learning environments with high demands on their listening skills. As educational and vocational communication demands change or increase, adolescents and adults may experience more difficulties with understanding and listening. In addition, an acquired deficit, such as TBI or a stroke, may lead to spoken language disorders, which may have an auditory component.

The following considerations may be applicable for adolescents and adults with a CAPD diagnosis:

  • Make adjustments based on different contextual demands at home, school, work, and in the community (e.g., focusing in an open cubicle at work; processing information in challenging listening environments, such as large classrooms or lecture halls)
  • Provide multiple treatment options, such as academic and vocational training, career counseling, and transition planning
  • Assist with self-advocacy

Service Delivery

See the Service Delivery section of the Auditory Processing Disorder Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

In addition to determining the type of treatment that is optimal for individuals diagnosed with CAPD, audiologists and SLPs should consider other service delivery variables that may have an impact on treatment outcomes.

Dosage

Dosage refers to the frequency, intensity, and duration of service and the culmination of those three variables (Warren, Fey, & Yoder, 2007).

Format

Format refers to the structure of the treatment session (e.g., individual or part of a group). The appropriateness of treatment format (individual vs. group vs. both) depends on the primary goal for the individual at a particular point in the treatment process.

Provider

Provider refers to the person providing the treatment (e.g., audiologist, SLP, trained volunteer, caregiver). It is important for audiologists and SLPs to collaborate with each other and with other professionals regarding treatment alternatives, including opportunities for co-treatment.

Timing

Timing refers to timing of intervention relative to diagnosis. When an individual is diagnosed with CAPD, he or she may present with speech, language, and communication disorders that warrant immediate intervention.

Setting

Setting refers to the location of treatment (e.g., home, school, work, community-based,). A naturalistic treatment environment is important for facilitating generalization and carryover of skills, and home practice is essential for helping an individual make optimal progress.

Regulations

A recent 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 IDEA in public school settings. Court documents revealed that, given the similarity of symptoms caused by CAPD and ADHD, 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:" (1) a chronic medical condition (2) that impacts a child's alertness in a classroom and 3) 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.

Reimbursement

CAPD Coding

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is a set of diagnostic codes used by physicians, hospitals, and health care professionals, including audiologists and SLPs, to indicate diagnoses for all patient encounters.

In October 2015, the ICD-10-CM diagnostic category for CAPD changed (World Health Organization, 2015). Previously, the International Classification of Diseases, Ninth Revision (ICD-9) described CAPD as part of "Developmental Speech-Language Deficits"—specifically, "Mixed Receptive-Expressive Language Disorder; Central Auditory Processing Disorder." In the new code, CAPD is no longer described as a developmental speech-language disorder. It is listed in the chapter, "Diseases of the Ear and Mastoid Process," indicating the medical nature of the deficit. This could help with coverage by public and private payers because developmental conditions are often denied coverage. As a medical condition, CAPD may better meet medical necessity criteria.

Billing for Services

Providing appropriate procedure codes for evaluation and treatment is an important aspect of successfully billing for services. Payer policies often outline specific coverage guidelines and list relevant ICD-10-CM and Current Procedural Terminology (CPT) codes (American Medical Association, 2017).

Diagnostic and procedure codes that audiologists and SLPs use to describe CAPD-related evaluation and treatment include CPT codes and ICD-10-CM diagnostic codes. Coding options are different for each discipline. For more information about coding, see the following ASHA resources:

Payer policies regarding coverage of CAPD vary.  SLPs working with private insurance should verify coverage based on each individual.

Medicaid may provide for CAPD services. For example, in North Carolina, services are covered—but only in the school setting. See Medicaid and Health Choice Clinical Coverage Policy No. 10C [PDF] (North Carolina Division of Medical Assistance, 2015).

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.