Central auditory processing (CAP)—also seen in the literature as (central) auditory processing or auditory processing—is the perceptual processing of auditory information in the central auditory nervous system (CANS) and the neurobiological activity that underlies that processing and gives rise to electrophysiologic auditory potentials (American Speech-Language-Hearing Association [ASHA], 2005).
Knowledge of the neuroanatomy and physiology of the central auditory nervous system is essential for understanding and interpreting underlying processes and deficits. Medwetsky (2011) provides in-depth information on this topic.
CAP consists of mechanisms that preserve, refine, analyze, modify, organize, and interpret information from the auditory periphery. These mechanisms underlie the following skills:
Terms used to describe a processing disorder may vary based on the perspective of the professional describing the problem. Terms include, but are not limited to, "auditory processing disorder," "(central) auditory processing disorder," "language processing disorder," and "auditory information processing disorder."
ASHA uses the term Central Auditory Processing Disorder (CAPD) to refer to deficits in the neural processing of auditory information in the CANS not due to higher order language or cognition, as demonstrated by poor performance in one or more of the skills listed above (ASHA, 2005). Although sometimes difficult, careful differential diagnosis is important to the process of treatment planning.
Professionals have adopted varying perspectives on the interpretation of CAPD (Cacace & McFarland, 2008; DeBonis & Moncrieff, 2008; De Wit et al., 2016; Friberg & McNamara, 2010; Jerger, 1998; McFarland & Cacace, 2006; Rees, 1973, 1981). Divergent perspectives among professionals reflect ongoing debate regarding how to define, assess, and treat auditory processing disorder.
Different viewpoints exist for a number of reasons, including the heterogeneity of symptoms, variations in the definition, the lack of a reference standard for diagnosis, the relationship between auditory perceptual deficits and language disorders, and the particular treatment approach(es) that follow from the diagnosis of CAPD (Kamhi, 2011; Moore, Rosen, Bamiou, Campbell, & Sirimanna, 2013; Vermiglio, 2014). Additional information providing an historical perspective on auditory processing disorder is available (DeBonis & Moncrieff, 2008; Richard, 2011).
Because of the heterogeneity of skills involved in auditory processing, some suggest that CAPD should be diagnosed by the specific deficit (e.g., difficulty processing signals in noise; difficulties with auditory discrimination, temporal processing, or binaural processing), rather than broadly as a CAPD (Vermiglio, 2016). Not all diagnoses of a CAPD represent a limitation for the individual (Dillon, Cameron, Glyde, Wilson, & Tomlin, 2012) or a condition that must be treated (Vermiglio, 2016).
There is general agreement that auditory perceptual abilities influence language development—particularly the pre-literacy skills—and that it can be difficult to separate the influence of auditory and language skills with regard to academic demands (Richard, 2012, 2013; Watson & Kidd, 2008). The act of processing speech is very complex and involves the engagement of auditory, cognitive, and language mechanisms, often simultaneously (Medwetsky, 2011).
Richard's (2013) continuum of processing includes both auditory processing and language processing. This continuum involves the following types of processing:
Data to calculate the incidence and prevalence of CAPD are not available due to the lack of universal, standardized diagnostic criteria. Guidance from national organizations varies. CAPD diagnosis varies widely depending on the criteria and the assessment instruments used. Some studies have estimated prevalence (the number of cases at a given point in time) as the following:
With the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM; American Medical Association, 2017), audiologists and physicians are able to assign a diagnostic code for CAPD in the medical record and for health insurance claims. Although coding does not address confounding factors of diagnostic criteria or assessment instrument variations, use of the new code will provide data on patients receiving care for CAPD.
Signs and symptoms of CAPD may include one or more of the following behavioral characteristics:
This list is illustrative, not exhaustive, and these behavioral characteristics are not exclusive to CAPD. They may be present with other disorders (e.g., learning disability, language impairment, ADHD, and autism spectrum disorder). The variability in specific auditory processing skill deficits may contribute to the variability in observed behaviors.
The etiology of CAPD may be linked to a specific lesion or disorder, or may be unknown. Causes and risk factors for CAPD may include the following (Bamiou, Musiek, & Luxon, 2001; Baran & Musiek, 1999; Chermak & Musiek, 2011):
Audiologists play a central role in the screening, assessment, diagnosis, and management of persons with CAPD as part of an interdisciplinary team. Professional roles and activities in audiology include clinical/educational services (diagnosis, assessment, planning, and management); prevention and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Audiology (ASHA, 2018) and ASHA's Preferred Practice Patterns for the Profession of Audiology (ASHA, 2006).
Appropriate roles for audiologists involved in the assessment, diagnosis, and management of CAPD include the following:
As indicated in the Code of Ethics (ASHA, 2016a), audiologists who work in this capacity should be specifically educated and appropriately trained to do so.
Speech-language pathologists (SLPs) play a role in the screening, assessment, and management of persons with CAPD as part of an interdisciplinary team. Professional roles and activities in speech-language pathology include clinical/educational services, prevention and advocacy, education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b) and ASHA's Preferred Practice Patterns for the Profession of Speech-Language Pathology (ASHA, 2004).
Appropriate roles and responsibilities for SLPs involved in the assessment and management of CAPD and language processing disorders include the following:
As indicated in the Code of Ethics (ASHA, 2016a), SLPs who work in this capacity should be specifically educated and appropriately trained to do so.
Diverse 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, Bailey, & Harbers, 2008; Richard, 2012). Therefore, a team including both audiologists and SLPs is valuable in the diagnosis of CAPD and the identification of language disorders that occur in association with CAPD.
The goal of screening for a CAPD is to identify individuals who are potential candidates for a more comprehensive central auditory testing battery. Screening can be accomplished using abbreviated test protocols. A number of 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.
There is no universally accepted method for screening for CAPD. There remains a need for valid and efficient screening tools.
There is currently no reference standard for diagnosing CAPD (American Academy of Audiology [AAA], 2010; ASHA, 2005; Vermiglio, 2016). The audiologist, on the basis of clinical presentation and the findings of assessment measures, makes the diagnosis of CAPD. There may be difficulties associated with diagnosing CAPD due to its heterogeneous presentation and the frequent overlap in symptoms with language disorders.
Assessment data may be gathered by the audiologist, the SLP, and other members of the interdisciplinary team (e.g., psychologist, special educator). These assessment data may identify the presence of disorders with symptoms similar to CAPD (e.g., peripheral hearing loss, ADHD, speech-language disorder, cognitive deficits) and help determine if further CAPD testing is warranted. The order in which assessments are completed may vary depending on the referral source and the needs of the individual (e.g., symptoms, case history information).
Case history information is obtained by one or more professionals involved in the comprehensive assessment process and may include the following:
An undiagnosed hearing loss may contribute to behavioral complaints. The presence of a peripheral hearing loss does not necessarily preclude the assessment of CAPD; however, it may differentially affect testing (Baran & Musiek, 1999). When evaluating an individual with hearing loss, tests that use stimuli minimally affected by peripheral impairment should be used whenever possible (Musiek, Baran, & Pinheiro, 1990). In some cases (e.g., profound hearing loss), testing cannot be completed.
Peripheral auditory disorders include conductive, sensorineural, and mixed hearing loss, as well as auditory neuropathy (Norris & Velenovsky, 2014) and cochlear synaptopathy (i.e., hidden hearing loss; Liberman, Epstein, Cleveland, Wang, & Maison, 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 ASHA's Practice Portal pages on Hearing Loss—Beyond Early Childhood and Permanent Childhood Hearing Loss for information on assessing the peripheral auditory system.
The audiologist selects the appropriate CAP test battery, on the basis of findings from the case history, interdisciplinary assessment (e.g., results of language and cognitive assessments), and peripheral audiologic evaluation. Audiologists should have knowledge of the strengths and weaknesses of the individual tests, required response mode, and areas of the CANS to which each test is most sensitive (Chermak, Bamiou, Iliadou, & Musiek, 2017).
The test battery may be used to diagnose impairment in one or more neurophysiologic processes that occur as auditory signals travel through the CANS. The identification of specific deficits in the CANS can lead to targeted recommendations and treatment plans.
There are two types of audiologic evaluation measures that can be used to assess auditory processing skills.
For a discussion of behavioral tests, see McNamara and Hurley (2017).
Electrophysiologic measures may be useful in cases where behavioral procedures are not feasible (e.g., infants and very young children, non-English speakers), when there is suspicion of frank neurologic disorder, when a confirmation of behavioral findings is needed, or when behavioral findings are inconclusive.
Principles applied when determining the composition of a central auditory test battery include the following:
Norm-based interpretation of test results involves comparing the individual's performance to normative group data. Patient-based interpretation involves comparing the individual's performance to his or her own baseline performance. Comparison of results observed across disciplines can also be helpful with interpretation.
Examples of suggested diagnostic criteria and interpretations of test results include the following:
Various professionals may be involved in providing essential information during the assessment period.
A comprehensive speech and language assessment includes assessment of spoken and written language; phonemic awareness (e.g., ability to segment and blend sounds in syllables and words); phonological working memory and phonological retrieval; and social communication. See ASHA's Practice Portal pages on Spoken Language Disorders, Written Language Disorders, Speech Sound Disorders: Articulation and Phonology, and Social Communication Disorders.
These assessments include tests of memory, executive functioning, and attention. An educational psychologist or cognitive psychologist may perform these assessments.
CAPD is an auditory deficit; therefore, the audiologist is the professional who makes the diagnosis (ASHA, 2005). "However, 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). Interdisciplinary assessment and differential diagnosis of CAPD and related/comorbid disorders is important in the development of appropriate intervention strategies. See also De Wit et al. (2017).
SLPs diagnose cognitive-communication and language-related disorders (including language processing disorders) that may co-occur with CAPD. Differentiating between language and phonological processing disorders and CAPD requires collaboration between audiologists and SLPs.
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
Treatment approaches should
Three treatment approaches for individuals diagnosed with CAPD, often used concurrently, include the following (ASHA, 2005):
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 (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:
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
Computerized delivery may provide
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
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.
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:
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).
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).
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).
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.
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:
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 refers to the frequency, intensity, and duration of service and the culmination of those three variables (Warren, Fey, & Yoder, 2007).
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 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 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 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.
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.
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.
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).
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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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.
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.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Central Auditory Processing Disorder. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Central-Auditory-Processing-Disorder/.