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Auditory Processing

Auditory Processing Disorder Defined

Dr. Marsh looking in a patient's earAuditory Processing Disorder (formerly called Central Auditory Processing Disorder or CAPD) is really an umbrella term that describes various sub-types of disordered auditory processing in a child or an adult. A person with disordered processing has normal (or near-normal) hearing, as measured on a hearing test, but does not seem to “hear well” or understand what is heard. Hearing and understanding may be inconsistent. Processing of sound is disordered in the pathways from the auditory (hearing) nerve through the brainstem and higher auditory pathways in the brain.

Auditory processing skills include listening to the information (auditory attention), analyzing the sound or word (auditory decoding or discrimination), attaching meaning according to the rules of language (auditory association), pulling everything into a whole that can be used (integration), and organizing and producing a response (auditory output-organization).

No two persons with APD are alike. A person with APD may have a combination of different auditory processing problems or just one type of processing problem.


• Academic performance is generally poor despite normal hearing, normal non-verbal intelligence (performance IQ), and normal visual processing skills

• Difficulty following directions

• Distractibility in background noise

• Inattentiveness or short attention span

• Poor or inconsistent memory for auditory information

• Problems in spelling words that are dictated

• Need for repetition

• Says “what” or “huh” a lot

• Inconsistent response to sound or “selective listening”

• Hears but doesn’t understand

• Delayed or inappropriate response to verbal questions

• Functions as if there is mild hearing loss despite normal hearing

• Bothered by loudness

• Reading or spelling problems

• Language disorder

• Presence of Attention Deficit Disorder (the two disorders often co-exist)

• History of chronic otitis media (middle ear fluid)

• History of infancy risk factors for central nervous system dysfunction such as asphyxia, hyperbilirubinemia, meningitis, head injury, severe brain insult (such as intraventricular hemorrhage or hydrocephalus) or seizure disorder

Who is a Candidate for an APD Evaluation?

Auditory Processing Evaluation is most often performed on school-age children although many adults are also tested. Testing below school age is done less frequently because fewer materials are available for this age range, however, these cases are considered on a case-by-case basis. We look at the needs and problem areas reported by the parents and/or referral source, and determine what tests would be appropriate for each child and what benefits might be gained using the tests available for that child’s age.

In order to be a candidate for Auditory Processing Evaluation, three factors must be present, regardless of age:

1. Normal (or near-normal) hearing test results

2. Clear speech articulation so that tests can be scored accurately

3. Normal range intelligence (IQ score)-this is an important factor because the tests are developed and studied on groups of people with normal-range IQ’s and valid score interpretation is problematic when a person’s IQ is not in this range

When a prospective evaluation candidate has IQ scores falling below normal range, we consider these referrals on a case-by-case basis. We look carefully at what benefits could be gained from the evaluation for each patient, considering individual circumstances, needs and abilities.

The Intake Process for APD Evaluation

Our APD Evaluation Program requires that parents (or the patient, in the case of an adult) answer some initial questions over the phone. Then an intake packet is sent with instructions for completing the enclosed forms.

At their convenience, parents are asked to provide the following:

• Completed Case History Form

• Copies of diagnostic evaluations that have been done by other professionals prior to scheduling the evaluation; these may include school psychoeducational evaluations, IEPs (Individualized Education Plan), Psychological Testing, physicians’ notes, Speech Language Evaluation and other related records

• A checklist of symptoms completed by the parents or by the patient in the case of an adult

• For child evaluations, rating forms completed by all teachers who see the child in a group setting

The evaluation is scheduled once the audiologist has reviewed these items. The hearing test must precede the rest of the evaluation in order to confirm the presence of normal hearing and rule out any medical issues such as middle ear fluid. Generally, the hearing test and the Auditory Processing Evaluation are scheduled for separate dates. The hearing test is often scheduled for late afternoon to minimize time missed from work or school. Auditory Processing Disorder Evaluations are generally scheduled for early in the morning as many people (especially children) can give their best, most focused performance in the morning.

Note: Much of the information in the following sections is borrowed heavily with permission, from Jeanane M. Ferre’s excellent book, Processing Power: “A Guide to CAPD Assessment and Management.” Another excellent resource for parents is “When the Brain Can’t Hear” by Teri Bellis. We highly recommend this book. It is written very plainly and is very helpful for anyone struggling with auditory processing difficulties in themselves or a loved one.

Auditory Processing Disorder Subtypes or Specific Problem Areas

As noted above, no two persons with APD are alike. A person with an APD may have more than one subtype, or problem area. Following is a list of APD subtypes and some of the problems that are sometimes seen with each subtype.

Auditory Decoding Deficit

• Difficulty analyzing the differences between speech sounds

• Difficulty on tasks that require discriminating or analyzing sounds (such as understanding new vocabulary words or spelling words that are read aloud)

• Seems not to hear even though hearing is normal

• Mis-hearing things frequently and not even realizing it until someone else points out the mistake

• Says “huh” and “what” a lot or asks for repetition even when the person seems to be listening and paying attention to what is said

• May have difficulty with the following areas because of not “hearing” correctly:

• Vocabulary development

• Grammar skills (use of plurals, verb tenses, etc.)

• Using multiple-meaning words

• Understanding who, what, where, when and why questions

• Learning the differences between have been, has been, and had been

• Reading, spelling and note-taking

• Marked difficulty hearing when listening situations are less than ideal such as in background noise, rooms with reverberation, or large open areas such as the gym or playground

Auditory Integration Deficit

• “Hears” better with the right ear compared to the left ear

• May have poor phonics, spelling and writing skills

• May have difficulty getting the “big picture” that is necessary to do well in word recognition and spelling

• May have trouble using symbols, space or visual imagery

• May have poor visual-motor integration

• May be poor with the rhythm aspects (pauses, beats) of songs or nursery rhymes

• May have difficulty with fine motor skills

• As the child grows older and tasks at school and at home become more complex, it takes more work to figure out how to do a task

• May, in time, start to give up when tasks get hard and exhibit poor listening skills as frustration levels increase

• May exhibit, over time, less and less ability to tolerate distractions

Auditory Associative Deficit

• Difficulty applying the rules of language to sounds that are heard

• Poor receptive language skills

• Low vocabulary for age

• May have poor understanding of complex sentences

• May have a variety of language difficulties such as any of the following:

• Difficulty with categories and labels

• Words that have multiple meanings such as “bark” (could be a dog’s bark or the bark of a tree)

• Antonyms, synonyms and homonyms

• Negative questions such as “Why didn’t she do that?”

• May say “I don’t understand” or “I don’t know what that means” a lot

• May have trouble understanding jokes or riddles with humor based on associations among words

• May have trouble understanding common expressions

• Phonics may be good but understanding of what is read is usually very poor

• May have trouble understanding word problems in math

• May have tremendous difficulty learning a foreign language

Auditory Output-Organization Deficit

• Trouble organizing, sequencing, recalling and/or expressing an answer

• Poor hearing in background noise (auditory figure-ground problems)

• May show signs of poor recall such as omitting words on tests, using words that were given on a previous test item, or having more trouble with the words depending upon the order in which they were presented (for example, trouble remembering words at the beginning of a list but not at the end)

• Difficulty when answers must be recalled in a specific order

• Trouble following directions that are long or have several parts

• Difficulty with motor-planning skills

• Trouble starting assignments

• Trouble remembering homework

• Trouble taking notes

• Trouble organizing papers and work

• Speech-language problems may be seen, such as sound blending, expressive language or articulation problems

The following ideas also come from Jeanane M. Ferre’s excellent book, Processing Power: “A Guide to CAPD Assessment and Management”.

Management of Auditory Processing Disorders

To optimally perform at school, home or work, three management areas must be addressed:

1. Environmental Modification-the environment must be adapted to minimize noise and maximize auditory processing capabilities as much as possible. This might include, for instance, preferential classroom seating, reducing extraneous noise and repeating or rephrasing information.

2. Direct Intervention-this involves remediation efforts to improve auditory discrimination, integration skills, associative skills and teaching specific language or academic skills. Examples include teaching the person to hear differences in sounds or words, teaching the person to pick out words in the presence of background noise, and teaching the child to use rhythm and tempo cues in speech.

3. Compensatory Strategies-the person with APD must be taught and encouraged to use strategies to cope with and compensate for deficit areas. For example, lectures could be taped, the person could be taught how to ask for repetition of things not heard or understood, and the use of visual cues to complement what is heard can be taught.

If you or your child is diagnosed with an auditory processing disorder or weak area, your ACENTA audiologist will help identify management strategies falling into all three of the above categories for each disordered or weak area of auditory processing. Managing these weak areas requires a team approach involving the person with the processing difficulty, family members (i.e. parents), and other professionals working with the person. This may include teachers, speech-language pathologists, psychologists, learning disabilities specialists, social workers, neurologists, pediatricians or other physicians, in addition to the audiologist.