LSHSS

Clinical Forum
Treatment for Central Auditory Processing Disorders

Clinical Issues in Central Auditory

Processing Disorders
Robert W. Keith
University of Cincinnati, OH

ver the years, a substantial amount of

research has been published indicating that
certain children, adolescents, and adults with
normal hearing have difficulty understanding speech and
language through the auditory modality. These individuals
have difficulties with all types of acoustic distortions of
auditory information including, for example, reverberation,
background noise, acoustic filtering, rapid speech, and
competing speech. In fact, the basic difficulty with an
auditory processing disorder is that any speech signal
presented under less than optimal conditions is difficult to
understand. The type of distortion is irrelevant to the main
ABSTRACT: Speech-language pathologists are often faced
with the need to assess and treat the suspected auditory
processing problems of children with language and
learning difficulties. This article discusses central auditory
processing disorders (CAPDs). Included are a discussion of
background information, a current definition of CAPDs, a
general discussion of test battery approaches following
suggestions made by the American Speech-LanguageHearing Association (ASHA) Task Force on Central
Auditory Processing Consensus Development (1996), and
various approaches to intervention with persons identified
as having a CAPD. Finally, there is brief discussion of
remaining questions to be answered. The article attempts
to examine various controversies related to all aspects of
CAPDs and increase the readers awareness of current
issues concerning this disorder.
KEY WORDS: central auditory processing disorders,
central auditory processes, sensitized speech tests,
remediation, language disorders

LANGUAGE, S PEECH,

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problem of a disturbance in auditory processing. These

individuals have become known as persons with central
auditory processing disorders (CAPDs).
The term central emerged years ago, and was originally
meant to differentiate between the diagnosis of auditory
processing disorders that occurred at brain stem and cortical
levels (i.e., the central auditory nervous system) from those
originating in the cochlea or auditory nerve (i.e., the
peripheral auditory system). An example of distortion
occurring in the cochlea is auditory recruitment resulting
from endolymphatic hydrops. An example of distortion
occurring in the auditory nerve is auditory fatigue associated
with an acoustic tumor. Both result in reduced speech
discrimination. Other terms used in the past to describe
CAPDs include central deafness, auditory agnosia, dysacusis,
central auditory imperception, auditory processing disorders,
central hearing loss, non-sensory hearing loss, and obscure
auditory dysfunction. Whatever the label, what is common to
this population is that they have normal or near-normal
hearing but have difficulty understanding speech under less
than optimal listening conditions. It may be unfortunate that
the word central became associated with auditory processing disorders because that term does not appear to clarify the
problem and is a continuing source of controversy and
misunderstanding.
Professionals interested in communication disorders have
worked to understand CAPD and its possible relationship to
language, reading, and learning problems. The problem of
understanding this disorder becomes more complex when
other difficulties, such as attention deficit disorder (ADD),
low intelligence levels, language delays, learning disabilities, and reading disorders, are present. When auditory,
language, and learning problems coexist, it is difficult to

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determine which condition is primary and which is secondary, or which causes the other to occur. For example, does
a CAPD cause a language/learning disorder? Are ADD
and CAPD really the same thing?
Some professionals question the existence of CAPD as a
distinct entity. However, most professionals in the field of
communication disorders have encountered individuals who
have normal hearing, normal receptive and expressive
language, and normal attention, but have difficulty processing acoustically distorted speech, competing speech, or
speech in the presence of background noise. What is clear,
therefore, from a clinical (some would say anecdotal)
perspective, is that CAPDs do exist, independent of all
other factors. Unfortunately, anecdotal evidence is not good
science, and it is necessary to be more rigorous in developing an understanding of this particular auditory disorder.

DEFINITION OF A CAPD
Various committees of the American Speech-LanguageHearing Association (ASHA) have attempted to develop
coherent statements of understanding concerning CAPDs.
The most recent attempt was the ASHA Task Force on
Central Auditory Processing Consensus Development (1996)
(referred to as the Task Force). This report is necessary
reading for anyone who is seriously interested in this
disorder. The Task Force included speech scientists, speechlanguage pathologists, and audiologists.
The definition of a CAPD advanced by the Task Force is
based on the principle that central auditory processes are the
auditory system mechanisms and processes responsible for the
following behavioral phenomena. These processes include:

assessment and remediation that professionals would take.

Therefore, although general agreement exists that CAPDs
exist, there is not consensus on where to draw the line for
specifics of the definition. This lack of consensus is still a
long way from the position taken by Rees (1973) many
years ago, who found evidence for CAPDs so limited that
she gave up the search as being futile.

WHO SHOULD BE TESTED FOR A CAPD?

There are least two approaches for identifying children
who should be tested for the possible presence of a CAPD.
They include: (a) identifying children who fall in certain
categories on various checklists of auditory performance
(e.g., Sanger, Freed, & Decker, 1985; Smoski, Brunt, &
Tannahill, 1992), and (b) referral on the basis of certain
observed behaviors. Children with a CAPD may exhibit
some of the following 10 characteristics (Keith, 1999):
Normal pure-tone hearing thresholds: Some have a
significant history of chronic otitis media that has
been treated or resolved.
Inconsistent responses to auditory stimuli: Children
often respond inappropriately, but, at other times, they
seem unable to follow auditory instructions.
Difficulty with auditory localization skills: This may
include problems with telling how close or far away
the source of the sound is and differentiating soft and
loud sounds. Also, there are frequent clinical reports
that these children become frightened and upset when
they are exposed to loud noise, and often hold their
hands over their ears to stop the sound.

sound localization and lateralization;

Difficulty with auditory discrimination.

auditory discrimination;

Deficiencies in remembering phonemes and manipulating them: These difficulties may be evident on tasks
such as reading, spelling, and phonics, as well as
phonemic synthesis or analysis (Katz, 1992, p. 84).

auditory pattern recognition;

temporal aspects of audition, including:

temporal resolution,

temporal masking,

temporal integration, and

temporal ordering;

Difficulty understanding speech in the presence of

background noise.

auditory performance decrements with competing

acoustic signals; and
auditory performance decrements with degraded
acoustic signals.
The definition of a CAPD proposed by the Task Force is
an observed deficiency in one or more of a group of
mechanisms and processes related to a variety of auditory
behaviors (ASHA Task Force on Central Auditory Processing Consensus Development, 1996, p. 43). This definition of
a CAPD is inclusive, recognizing the contribution of
neurocognitive, attentional, and auditory factors. The
definition applies to nonverbal, as well as verbal, signals and
is broader than the construct of CAPDs proposed by Cacace
and McFarland (1998), which includes only non-linguistic
factors. Their exclusive definition limits the approach to

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Difficulty with auditory memory, either span or

sequence, and poor ability to remember auditory
information or follow multiple instructions.
Poor listening skills: This problem may be characterized by decreased attention to auditory information,
distractibility, or restlessness in listening situations.
Difficulty understanding rapid speech or persons with
an unfamiliar dialect.
Frequent requests for information to be repeated. For
example, one teacher described these children as
saying huh and what frequently.
The profiles of these children often include significant
reading problems, poor spelling, and poor handwriting.
They may have articulation or language disorders. In the
classroom, they may act out frustrations that result from
their perceptual deficits, or they may be shy and withdrawn
because of the poor self-concept that results from multiple

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failures. Children who exhibit these behaviors are candidates for central auditory testing (Keith, 1999).

The Test Battery Approach

A number of test procedures have been suggested to
assess children, adolescents, and adults who have complaints of difficulty understanding speech in non-optimal
acoustic conditions. In fact, specific tests have not changed
much over the years since the early investigation of
sensitized speech (Calearo & Antonelli, 1973). At that time,
sophisticated radiologic imaging procedures were unavailable, and the purpose of central auditory testing was to
identify brain lesions in adult subjects. That purpose is
very different from todays purpose, where central auditory
testing is used to identify auditory processing disorders in
children and adults with language and learning problems.
Bergman, Hirsch, Solzi, and Mankowitz (1987) called the
purpose of CAPD testing the identification of functional
disorders of auditory communication (p. 147).
The test battery that follows from the Task Force
definition of CAPD attempts to examine the mechanisms
and processes thought to be responsible for certain auditory
behaviors. The components of the assessment recommended
by the Task Force include:
history;
observation of auditory behaviors;
audiologic test procedures;
pure tones, speech recognition, immittance;
temporal processes;
localization and lateralization;
low redundancy monaural speech;
dichotic stimuli;

stimuli simultaneously to the two ears, with interaction

between the stimuli resulting in comprehension of a
complete message (e.g., binaural fusion tests), or comprehension depending on changes in masking conditions (e.g.,
Masking Level Difference Test). Readers will note the Task
Force suggestion that a speech-language evaluation be
conducted in concert with the inclusive definition of
CAPDs. The Task Force was not specific in recommending
specific auditory or speech and language tests.
There are many excellent sources of information on tests
of central auditory function including, but not limited to,
textbooks by Pinheiro and Musiek (1985), Katz, Stecker, and
Henderson (1992), Katz (1994), Roeser and Downs (1995),
Bellis (1996), and Hall and Mueller (1997). Readers
interested in details of the administration and interpretation
of central auditory tests are directed to these resources.

Suggested Parameters for Evaluating Central

Auditory Tests
When selecting a central auditory test battery, the
examiner should consider a number of factors. These
include the purposes of the test, its modality, normative
data, efficiency, validity, and reliability. Important factors
to consider are: (a) whether the test is single modality
(auditory) or cross-modality (auditory to visual), (b) the
content of the signal (non-linguistic, low-linguistic, or high
linguistic content), and (c) the childs age, intelligence, and
ability to respond appropriately to the test. The test chosen
should meet criteria for the following psychometric factors:
validity (including content, construct, and criterion related)
and reliability (including test-retest, inter-examiner, interitem, and inter-form). Also, the examiner should evaluate
whether complete normative data are available and how
they were collected (Fallis & Keith, 1997).

binaural interaction procedures; and

administration of speech-language measures.
The Task Force recognized that middle, late, and eventrelated evoked potentials are still being developed but can
also be used in the assessment of CAPDs. Use of eventrelated evoked potentials seems warranted based on some
evidence that electrophysiologic findings are abnormal in
children with receptive and expressive language disorders
and CAPDs (Diniz, Albernaz, Munhoz, & Fukuda, 1997;
Jirsa & Clontz, 1990; Kraus et al., 1993).

Specific Test Procedures

In regard to audiologic test procedures, low redundancy
speech refers to such tests as filtered words and auditory
figure-ground (speech-in-noise) testing. Monaural testing is
conducted using earphones, with the signal heard in one ear
at a time. Dichotic testing is conducted by presenting
different acoustic stimuli with simultaneous onset and offset
times by earphone to the two ears. Dichotic stimuli include
consonant-vowel syllables, digits, monosyllable words, two
syllable words (spondees), and sentences. Binaural interaction procedures are conducted by presenting different

TREATMENT APPROACHES TO PERSONS

WITH A CAPD
There is little agreement concerning treatment approaches
that follow from the identification of a CAPD and even less
documentation of treatment outcomes. Two treatment terms
(sometimes used interchangeably) are remediation and
management. However, these two terms have distinct
meanings. To remediate is to alter central auditory nervous
system function. Management, on the other hand, involves
modifying behavior, performance, or environment with
compensatory or cognitive techniques (Keith & Fallis, 1998).
Briefly, basic management strategies include: (a) modification of the environment, (b) perceptual training, (c) compensatory training, and (d) cognitive training.
Recommendations for environmental modification may
include the use of a personal assistive listening device
(ALD) or FM (frequency modulated) unit, preferential
seating, and classroom amplification (sound field) devices.
The identified child may also be assigned a listening
buddy to provide peer support for checking verbal
directions and assignments. Several authors (ASHA, 1991;

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341

DiSogra, 1995; Flexer, 1989, 1990; Scharff, Ray, &

Bagwell, 1981) describe management strategies for the
classroom or home that are related to alterations of the
physical (or psychological) environment.
Recent studies on the benefits of perceptual training
were published by Merzenich et al. (1996) and Tallal et al.
(1996). These authors described the positive effects of
computer-based games (known as Fast ForWord) that train
or modify temporal processing deficits in these children.
Merzenich et al. claimed that these studies strongly
indicate that the fundamental temporal processing deficits
of LLI children can be overcome by training (p. 80). (For
further discussion of Fast ForWord, see the companion
articles by Veale and Gillam, this issue.)
Compensatory training, or auditory skills development,
has been used to strengthen perceptual processes and teach
specific academic skills. There are many different approaches to teaching auditory skills that presume to assist
the child with a CAPD. Some of these techniques include:
speech sound discrimination (auditory discrimination)
(Sloan, 1986),
auditory analysis (Rosner, 1993),
phonemic synthesis (auditory synthesis) (Katz, 1983),
auditory memory strategies (Butler, 1983),
auditory figure-ground training (Gillet, 1993),
prosody training (Chermak & Musiek, 1997; Hargrove
& McGarr, 1994; Hargrove, Roetzer, & Hoodin,
1989), and
temporal processing strategies (McCroskey, 1984;
Tallal et al., 1996).
Cognitive training involves teaching the child to actively
monitor and self-regulate message comprehension skills and
develop new problem-solving skills. Cognitive therapy may
include language training (linguistic or metalinguistic),
vocabulary development, and the teaching of organizational
skills. In a discussion of metalinguistic strategies, Chermak
and Musiek (1997) included discourse cohesion, schema
induction, context-derived vocabulary building, segmentation, prosody, and metamemory (p. 192). Butler (1983)
reported on the teaching of mnemonic strategies to assist
the child with a CAPD. She suggested using rehearsal,
paragraphing, imagery, networking (building bridges to
store new concepts), analysis of new ideas, and key ideas
to think systematically. Finally, cognitive therapy may also
include the teaching of organizational skills, including
teaching the child how to:
follow directions,
use written notes,
develop self-monitoring strategies,
know what they know,
listen and anticipate,
ask relevant questions, and
answer questions.
A number of texts and articles provide suggestions for
the management and remediation of children with CAPDs.

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They include texts referenced previously, and a recent text

by Masters, Stecker, and Katz (1998). Another resource for
the management or remediation of auditory skills may be
found in Kelly (1995). There is a great need for outcome
studies that document the effectiveness of all of the
treatment suggestions listed here. While awaiting these
studies, however, clinical experience indicates that children
with CAPDs are substantially helped using some of the
techniques discussed.

REMAINING QUESTIONS TO BE
ANSWERED
Speech-language pathologists will recognize that it takes
years to resolve questions regarding any clinical and
research area. When this author entered the field of
communication disorders, stuttering was little understood
and the subject of intense investigation. There were honest
philosophical differences and stirring debates between
approaches taken, for example, by Wendall Johnson at the
University of Iowa and Bryng Bryngelson at the University
of Minnesota. Treatment modalities actually used in the
clinic included forcing left-handed people to attempt to
change dominance by immobilizing their left hand and
doing such exercises as practicing table tennis with the
right hand. Clearly the problem of stuttering is much better
understood and treated in 1999.
Further, as an audiologist, this author understands that
disagreement exists among speech-language pathologists
concerning the optimal method of obtaining language
samples. Some individuals have the opinion that to obtain a
true picture of a childs language development, it is
necessary to observe that child in a natural context and
obtain language samples with different communication
partners. Other individuals feel that standardized language
testing, using a broad spectrum of diagnostic assessments,
obtains an adequate picture of the childs language abilities.
These examples are given only to point out, by analogy,
that similar controversy exists in the area of CAPDs. There
is general consensus that CAPDs exist, but consensus on
the approach to the assessment and remediation of children
with these disorders has not been reached. I suspect that
there will never be a unitary approach either to assessment
or remediation because CAPD is a complex multifactorial
disorder. Just as with language disorders, each child
requires a slightly different approach to assessment and
remediation because each child is different. There will
probably be better models of remediation developed in the
future, and techniques for computer-assisted remediation,
still in their infancy, will improve. Until we have better
models for remediation, many of the guidelines suggested
here, and others not discussed, have helped some children
with CAPDs.
Many needs exist for the future. One need is to clarify
definitions of CAPD and criteria used to diagnose persons
with that disorder. In her companion article, Friel-Patti (this
issue) notes that CAPD is not one of the diagnostic
categories contained in the Diagnostic and Statistical

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Manual of Mental Disorders (American Psychiatric Association, 1994). In a recent book (Keith, 1999), this author
addressed the need for mutually exclusive and exhaustive
diagnostic criteria that would allow clinicians to diagnose,
treat, and communicate about individuals with CAPD. There
needs to be clearer understanding of CAPDs and their
relationship to language, learning, and ADD. Additional
normative data for available tests of central auditory function
are necessary, as is the development of new tests. We need
to better understand how to relate central auditory test
results to specific treatment plans, and, most importantly,
there needs to be a better understanding of treatments that
work best for children and outcome studies to verify their
effectiveness. We have traveled a long distance, but we have
a way to go before CAPD is completely understood.

Fallis, R., & Keith, R. W. (1997, April). Reliability and validity

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Flexer, C. (1989). Turn on sound: An odyssey of sound field
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Flexer, C. (1990). Children with developmental disabilities: The
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Gillam, R. B. (1999). Computer-assisted language intervention
using Fast ForWord: Theoretical and empirical considerations
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Gillet, P. (1993). Auditory processes. Novato, CA: Academic
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Received February 9, 1999

Accepted June 30, 1999

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Contact author: Robert W. Keith, Mail Location 670528,

University of Cincinnati Medical Center, Cincinnati, OH 45267.
Email: Robert.Keith@uc.edu

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