The scope of this page is central auditory processing disorder (CAPD) in children and adults. Content is relevant to both developmental and acquired CAPD; however, this page does not specifically address adult acquired CAPD from causes such as brain injury, disease, or factors of aging.
See the Central Auditory Processing Disorder (CAPD) Evidence Map for summaries of the available research on this topic.
Hearing-related terminology may vary depending upon context and a range of factors. See ASHA’s resource on hearing-related topics: terminology guidance for more information.
The ASHA Practice Portal aims to provide access to the best available evidence, expertise, and resources to support the individual clinical decision making of professionally educated clinicians. Long-standing variation in perspectives within the professions of audiology and speech-language pathology regarding the diagnosis, assessment, and treatment of CAPD makes the need for informed clinical decision making of paramount importance.
Central auditory processing—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.
Knowledge of the neuroanatomy and physiology of the CANS is essential for understanding and interpreting underlying processes and deficits. Medwetsky (2011) provides in-depth information on this topic.
Central auditory processing consists of mechanisms that preserve, refine, analyze, modify, organize, and interpret information from the auditory peripheral system. These mechanisms underlie skills such as auditory discrimination, temporal aspects of audition, and binaural processing (ASHA, 1996; Bellis, 2011; Chermak & Musiek, 1997).
There is general agreement that auditory perceptual abilities and language development are interrelated—as are auditory processing skills and pre-literacy skills (Corriveau et al., 2010)—and that it can be difficult to separate the influence of auditory and language skills with regard to academic demands (Richard, 2012, 2013). The act of processing speech is complex and involves the engagement of auditory, cognitive, and language mechanisms, often simultaneously (Medwetsky, 2011).
Richard’s (2013, 2017) continuum of processing includes both auditory processing and language processing. This continuum involves the following types of processing:
Terms used to describe a disorder in the processing of auditory information 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 (2005) 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 cognitive factors) demonstrated by poor performance in one or more of the following skills:
This terminology aligns with the National Center for Health Statistics classification of the diagnosis within the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).
Although sometimes difficult, careful differential diagnosis is important to the process of treatment planning:
Professionals have adopted varying perspectives on the interpretation of CAPD (Buehler, 2012; Cacace & McFarland, 2009; DeBonis, 2015; de Wit et al., 2016; Friberg & McNamara, 2010; Jerger, 1998; Jutras et al., 2007; McDermott et al., 2016; McFarland & Cacace, 2006; Moore et al., 2010; Rees, 1973, 1981; Richard, 2011; Sharma et al., 2019). These different perspectives reflect ongoing debate regarding how to define, assess, and treat CAPD.
Different viewpoints on CAPD exist for several 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 (Bellis & Ferre, 1999; Kamhi, 2011; Katz et al., 1992; Moore, 2018; Moore et al., 2013; Vermiglio, 2014). For example, some professionals propose that a CAPD diagnosis may indicate a broader language-based disorder necessitating language treatment targets (DeBonis, 2015; de Wit et al., 2016; Kamhi, 2011). Some suggest that CAPD be diagnosed by specific deficit (e.g., difficulty processing signals in noise; difficulties with auditory discrimination, temporal processing, or binaural processing) rather than broadly as CAPD because of the diverse skills involved in auditory processing (Vermiglio, 2016).
Of note, not all diagnoses of CAPD represent a limitation for the individual (Dillon et al., 2012) or a condition that must be treated (Vermiglio, 2016).
A person- and family-centered plan of care for CAPD ideally involves a team of professionals. The composition of an interprofessional team varies based on the needs of the individual, who (along with their support system) is integral to the process (e.g., planning, decision making, service delivery). See the ASHA resources on interprofessional education/interprofessional practice (IPE/IPP) and person-centered care in audiology as well as the ASHA Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology and Cultural Responsiveness.
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:
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):
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:
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.
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:
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.
See the Assessment section of the Central Auditory Processing Disorder (CAPD) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
For guidance and considerations on infection control practices during the assessment process, see the ASHA’s page on infection control resources for audiologists and speech-language pathologists.
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.
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:
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.
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:
See the ASHA Practice Portal page on Cultural Responsiveness for information on gathering a case history and ethnographic interviewing.
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:
For a discussion of behavioral tests, see McNamara and Hurley (2019).
Several principles may influence the composition of a central auditory test battery:
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:
See the Treatment section of the Central Auditory Processing Disorder (CAPD) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
See the Service Delivery section of the Central Auditory Processing Disorder (CAPD) Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
For guidance and considerations on infection control practices during the treatment process, see ASHA’s page on infection control resources for audiologists and speech-language pathologists.
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 person-centered care in audiology 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:
Treatment approaches
Three treatment approaches for individuals diagnosed with CAPD, often used concurrently, include the following (ASHA, 2005):
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 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:
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:
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):
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:
Computerized delivery may provide
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:
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:
Metacognitive strategies include the following examples:
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:
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.
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:
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.
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:
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]. https://www.asha.org/Practice-Portal/Clinical-Topics/Central-Auditory-Processing-Disorder/
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