“1622, 13331 Cental Austory Processing Disorder ® ASHA Central Auditory Processing Disorder Collapse All Overview The scope of this page is central auditory processing disorder (CAPD) in children and adults. Content is relevant to both developmental and acquired CAPD. See the Central Auditory Processing Disorder Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective. Central Auditory Processing (CAP) 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 -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 skils: + Auditory discrimination + Temporal processing © Auditory pattem recognition ‘© Temporal aspects of audition, including = temporal integration; = temporal resolution (e.g., temporal gap detection); = temporal ordering; and = temporal masking. + Binaural processing ‘© Sound localization and lateralization © Auditory performance with competing or degraded acoustic signals (including dichotic listening; ASHA, 2005) Central Auditory Processing Disorder (CAPD) ‘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, processing disorder," and “auditory information processing disorder (central) auditory processing disorder,” anguage 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, 2008). Although sometimes difficult, careful differential diagnosis is important to the process of treatment planning, hitps:twwn.asha orgipractice-portalctinica/4opiesicetral-auditoryprocessing-disordertcoliapse_ 6 ane‘822, 13:31 Central Auditory Processing Disorder ‘+ CAPD may lead to or be associated with difficulties in higher order language, learning, and communication functions. ‘+ CAPD may coexist with other disorders (e.g, altention-deficivhyperactvity disorder [ADHD], language impairment, and learning disability) ‘+ CAPD is not due to peripheral hearing loss, which includes conductive hearing loss (.e., outer or middle ear), sensorineural hearing loss at the level of the cochlea or auditory nerve, including auditory neuropathy and synaptopathy (e., hidden hearing loss). Professionals have adopted varying perspectives on the interpretation of CAPD (Cacace & McFarland, 2008; DeBonis & Moncrieff, 2008; De Wit etal, 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 skils involved in auditory processing, some suggest that CAPD should be diagnosed by the specific deficit (e.g, dificulty 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). Central Auditory Processing and Language Processing There is general agreement that auditory perceptual abilities influence language development—particularly the pre-titeracy 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 speeci 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: + Central auditory processing, which begins when the neural representation of acoustic signals are processed after they leave the cochlea and travel through the auditory nerve to the primary auditory cortices of the left and right hemispheres (Hesch!'s gyri) + Phonemic processing, during which acoustic features of the signal are discriminated utilizing phonemic skills such as sound discrimination, blending, and segmenting + Linguistic processing, during which meaning is attached to the signal (begins at the level of HeschI's gyrus, expands to Wernicke's area, to the angular gyrus, and finally to the prefrontal and frontal cortex, where a response is planned, organized, and mediated). Incidence and Prevalence Data to calculate the incidence and pravalence 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: = Children: © 2%-3% (Chermak & Musick, 1997; Patfory & Duff, 2007). 2 7.3%-86% (Wilson & Amott, 2013). ‘+ Male to female ratio of 2:1 (Chermak & Musiek, 1997; Palfery & Duff, 2007), ‘+ Adults 55 and older: 23%-76% (Cooper & Gages, 1991; Golding, Carter, Mitchell, & Hood, 2004; Stach, Spretnjak, & Jerger, 1990}, hitpstwwn.asha orgipractice-portalctnica/4opicsicentral-auditoryprocessing-disordercoliapse_ 6 ane‘822, 13:31 Central Auditory Processing Disorder 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 wil provide data on patients receiving care for CAPD. Signs and Symptoms Signs and symptoms of CAPD may include one or more of the following behavioral characteristics: + Difficulty localizing sound + Difficulty understanding spoken language in competing messages, in noisy backgrounds, in reverberant environments, or when presented rapidly “+ Taking longer to respond in oral communication situations ‘+ Frequent requests for repetitions, saying “what” and “huh’ frequently + Inconsistent or inappropriate responding + Difficulty comprehending and following rapid speech ‘+ Difficulty following complex auditory directions or commands + Difficulty learning songs or nursery rhymes + Misunderstanding messages, such as detecting prosody changes that help to interpret sarcasm or jokes + Poor musical and singing skills ‘+ Difficulty paying attention + Being easily distracted + Poor performance on speech and language or psychoeducational tests in the areas of auditory-related skills ‘+ Associated reading, spelling, and leaning problems + Difficulty leaning a new language This listis illustrative, not exhaustive, and these behavioral characteristics are not exclusive to CAPD. They may be present with other disorders (e.g. learning disabilty, language impairment, ADHD, and autism spectrum disorder). The variability in specific auditory processing skill deficits may contribute to the variabilty in observed behaviors. Causes ‘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) + Age-related changes in CANS function + Genetic determinants + Neurological disorder, disease, or damage © Brain injury (e.g., head trauma, meningitis) © Cerebrovascular disorder (e.g,, stroke) © Degenerative diseases (e.g., multiple sclerosis) © Exposure to neurotoxins (e.g., heavy metals, organic solvents) © Lesions of the central nervous system (CNS) © Seizure disorders + Nouromaturational delay secondary to deafness/auditory deprivation + Otologic disorder, disease, or injury (e.g., auditory deprivation secondary to recurrent otitis media) Prenatalineonatal factors, © Anoxialhypoxia © Cytomegalovirus (CMV) © Hyperbiliubinemia © Low birth weight © Prematurity © Prenatal drug exposure hitps:twwn.asha orgipractice-portalctnica/4opics/central-auditoryprocessing-disordercoliapse_ 6 ane‘822, 13:31 Central Auditory Processing Disorder Roles and Responsibilities Roles and Responsibilities of Audiologists Audiologists play a central role in the screening, assessment, diagnosis, and management of persons with CAPD as part of an interdisciptinary 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 Proferred Practice Patterns for the Profession of Audiology (ASHA, 2008), Appropriate roles for audiologists involved in the assessment, diagnos's, and management of CAPD include the following: ‘+ Remaining informed of research in the area of CAPD as related to the audiologist’s contribution to patient management + Educating other professionals about the needs of individuals with CAPD and the role of audiologists in CAPD management ‘+ Participating in interdisciplinary team consultation (see ASHA's resource on Intetprofessional EducationiInterprofessional Practice [IPE/IPP]) for the assessment and management of CAPD. ‘+ Conducting comprehensive audiologic evaluations ‘+ Obtaining a CAPD-specific case history “+ Selecting an appropriate and inaividualized CAPD test battery ‘+ Administering CAPD-specific assessments and interpreting the results + Diagnosing CAPD + Communicating results and recommendations to the patient/family and other appropriate parties ‘+ Developing and implementing culturally and linguistically appropriate assessment and intervention plans as part of an interdisciplinary team “+ Proceeding with assessment and fiting for hearing assistive technology systems (HATS), as appropriate + Providing education and counsel to the patient and family ‘+ Referring the patient to other professionals, as needed, to facilitate access to comprehensive services (e.g., speech- language pathology, psychology, neuro-otology, and neuropsychology) {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. Roles and Responsibilities of Speech-Language Pathologists Speechanguage pathologists (SLPs) play a role in the screening, assessment, and management of persons with CAPO as part of an interdiscipinary team, Professional roles and activities in speech-language pathology include clinica/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 responsiblties for SLPs involved in the assessment and management of CAPD and language processing disorders include the following: ‘+ Remaining informed of research in the area of CAPD as related to the SLP's contribution to patient management ‘= Educating other professionals about the needs of individuals with CAPD and the role of SLPs in CAPD management ‘+ Participating in interdisciplinary team consultation (see ASHA's resource on Interprofessional Educationi/Interprofessional Practice [IPE/IPP]) for the assessment and management of CAPD. + Collecting information about skills related to auditory processing (e.g., auditory working memory, auditory comprehension) Using a variety of screening and assessment instruments ‘+ Conducting comprehensive cognitive-communication and speech and language assessments. ‘+ Obtaining a CAPD-specific case history ‘+ Identifying the cognitive-communicative andior speech and language factors that may be associated with CAPD + Providing a clinical description of the patient's speech perception Helping to identify or differentiate disorders in phonology or language processing that may be comorbid to CAPD hitps:twwn.asha orgipractice-portalctinica/4opies/central-auditory-processing-disordercolapse_ 6 ane‘822, 13:31 Central Auditory Processing Disorder ‘+ Helping to determine the precise nature of the diagnosed disorders) and the functional implications associated with the disorder(s) + Communicating results and recommendations to the patient/family and other appropriate parties + Developing and implementing culturally and linguistically appropriate assessment and intervention plans as part of an interdisciplinary team + Providing education and counsel to the patient and family “+ Referring the patient to other professionals, as needed, to facilitate access to comprehensive services (0.g., audiology, psychology, and neuropsychology) {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. ‘Assessment See the Assessment section of the Central Auditory Processing Disorder Evidence Map for pertinent scientific evidence, ‘expert opinion, and clientipatient perspective. Team Approach Diverse perspectives among interdscipinary team members involvd in the evaluation process may result in affront diagnoses (e.9., CAPD, phonological awareness disorder, language processing disorder; McNamara, Bailey, & Harbers, 2008; Richard, 2012). Therefore, a team including both audiologists and SLPs is valuable inthe diagnosis of CAPD and the identification of language disorders that occur in association with CAPO. ‘+ Audiologists are responsible for evaluating and diagnosing problems in the reception and/or transference af aucltory signals in the peripheral auditory system and the CANS, ‘+ SLPs are responsible for evaluating and diagnosing problems in the linguistic processing of the auditory signal + Audiologists and SLPs share responsibilty for diagnosing problems in the phonemic processing of the auditory signal (Richard, 2013), Screening ‘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 tots Comprehensive Assessment ‘There is currently no reference standard for diagnosing CAPD (American Academy of Audiology [AAA], 2010; ASHA, 2005; Vermigiio, 2016). The audiologist, on the basis of clinical presentation and the findings of assessment measures, makes the diagnosis of CAPD. There may be dificulties 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 (0.g., psychologist, special educator). These assessment data may identiy 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 ‘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 Case history information is obtained by one or more professionals involved in the comprehensive assessment process and may Include the following hitps:twwn.asha orgipractice-portalctinica/topics/central-auditoryprocessing-disordercoliapse_ 6 518‘822, 13:31 Central Auditory Processing Disorder ‘+ Ago, including chronological and mental age in early childhood and age-related dectine in older adults + Auditory/behavioral complaints (e.g. difficulty understanding speech in noisy or reverberant environments, difficulty localizing sound, difficulty hearing on the phone, difficulty following rapid speech, dificulty following airections, inability to detect humor or sarcasm [prosody], distractibility, inattention) + Cognitive status and psychological factors (¢.g., attention, memory, motivation) + Cultural and linguistic background (e.g., native language) ‘+ Educational achievement (e.g., academic, leaming, reading dficulties) + Familyigenetic history + Health status (e.g., medical history and medications, previous illness or injury) + Hearing status (e.g., peripheral auditory system) + Pre-, per-, and postnatal course (e.g., congenital and early infancy events) + Prior and current related therapies ‘Risk factors and comorbidities (e.g,, learning disabilities, traumatic brain injury [TBI], epilepsy) + Social development + Speech, language, and literacy concerns Audiologic Assessment Components Audiologic Evaluation of Peripheral Auditory System ‘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 & Musick, 1998). 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 (¢.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.., hidden hearing loss; Liberman, Epstein, Cleveland, Wang, & Maison, 2016), These disorders can affect an individuals 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 in Adults and Permanent Childhood Hearing Loss for information on assessing the peripheral auditory system. Audlologic Evaluation of Central Auditory System The audiologist selects the appropriate CAP test battery, on the basis of findings from the case history, interdisciplinary assessment (0., 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 testis most sensitive (Chermak, Bamiou, liadou, & 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 audiolagic evaluation measures that can be used to assess auditory processing skills + Behavioral—assesses the functional capabiliies of the auditory system © Auditory discrimination tests to assess the abily to differentiate similar acoustic stimuli that differ in frequency, intensity, andlor temporal parameters. ‘© Auditory temporal processing and patterning tests to assess the ability to analyze acoustic events over time. © Dichotic speech tests to assess the abilly to separate (ie., binaural separation) or integrate (.e., binaural integration) disparate auditory stimull presented to each ear simultaneously ‘© Monaural low-redundancy speech tests to assess the recognition of degraded speech stimuli presented to one ear ata time, including speech-in-noise, speech-in-competition, low-pass fiered speech, or compressed (rapid) speech. © Binaural interaction tests t assess the ability to combine complementary inputs distributed between the ears, synthesizing intensity, time, or spectral differences of otherwise identical stimuli presented simultaneously or sequentially. For a discussion of behavioral tests, see McNamara and Hurley (2017). hitps:twwn.asha orgipractice-portalctinica/4opics/central-auditoryprocessing-disordercoliapse_ 6 ane‘822, 13:31 Central Auditory Processing Disorder + Electrophysiologic—assosses noural processes in the central auditory pathway and provides information about the integrity of the CANS from the vestibulocochlear nerve (also known as the “auditory vestibular nerve” or “eighth cranial nerve") to the auditory cortex. These measures include auditory brainstem response (ABR), middle latency response (MLR), late cortical response, P300, and mismatch negativity Electrophysiologic measures may be useful in cases where behavioral procedures are not feasible (e.9., 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. Tost Prncpls ofan Audologc Evaluation ofthe Central Auditory System Principles applied when determining the composition of a central auditory test battery include the following: + The test battery process should not be test-driven; rather, it should be motivated by the referring complaint(s) and the relevant information available to the audiologist. + Acentral auditory test battery should include measures that are sensitive to the integrity of the CANS. ‘+ Tesis should examine different central processes, tasks, and the integrity of multiple levels and regions of the CANS. ‘+ Most available behavioral central auditory tests are more appropriate for administration to children 7 years of age and older due to the challenging nature of the tasks and considerable performance variability, + Communication checklists, language tests, and cognitive tests can be used to identify younger children that may be "at Tisk" for aualtory difficulties (Moore et al., 2013). A diagnosis should be withheld until formal testing can be completed, «= Tests should generally include both nonverbal and verbal stimuli to examine different aspects of auditory processing and different levels of the auditory nervous system, ‘+ Individuals who are medicated successfully for attention, anxiety, or other disorders that may confound test performance should be tested under the influence of their medication. + Neuromaturation, subject state, and cognitive factors may affect the outcomes of many electrophysiolagic procedures when used with children younger than 10 years of age. These measures need to be administered and interpreted accordingly ‘+ The duration of the test session should be appropriate to the individuat's attention, motivation, and energy level. As with all behavioral tests, its important to monitor the individual's level of attention and effort and to take steps to maintain motivation throughout testing, ‘+ Referral to the appropriate professional(s) should be made when there is a suspected speech or language impairment or intellectual, psychological, or other deficit. In some cases, this referral should precede CAP testing to ensure accurate interpretation of test results. Comorbid diagnoses may preclude CAP testing (e.., significant intellectual deficit, severe hearing loss). + Test findings should be corroborated by relating them to the individual's primary symptoms or complaints (e.g., difficulty hearing withthe left ear vs. the right ear, dffculty understanding rapid speakers, difficulty hearing in the presence of compating noise). Intrprtation of Corral Auditory Diagnostic Test Battory 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: + Performance deficits are noted in one or both ears of at least two standard deviations below the mean on two or more tests in the battery (Chermak & Musiek, 1997) + If poor performance is observed on only one test: 2 Diagnosis may be withheld unless performance falls at least three standard deviations below the mean or the finding is accompanied by significant functional diffculty in auditory behaviors that rely on the process being assessed. © The failed test—and other tests that assess the same process—should be re-administered to confirm initial findings. ‘+ Administering and comparing results for several tests that measure the same auitory process can be used (0 look for patterns in auditory processing abilities and to support the findings of the evaluation, + Inconsistencies across tests might signal the presence of a non-auditory confound, even when CAPD criterion is met Likewise, pervasive deficits on all tests may signal a cognitive deficit or other non-auditory confound. hitps:twwn.asha orgipractice-portalctinica/topics/central-auditoryprocessing-disordercoliapse_ 6 78‘822, 13:31 Central Auditory Processing Disorder Interdisci inary Contributions to Assessment Various professionals may be involved in providing essential information during the assessment period. ‘Speech and Language Assessment ‘A comprehensive speech and language assessment includes assessment of spoken and written language; phonemic awareness (¢.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. Psychoeducational or Cognitive Assessment These assessments include tests of memory, executive functioning, and attention. An educational psychologist or cognitive psychologist may perform these assessments. Differential Diagnosis 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. 689). Interdisciplinary assessment and differential diagnosis of CAPD and relatedicomorbid 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. Treatment ‘See the Treatment section of the Central Auaitory Processing Disorder Evidence Map for pertinent scientific evidence, expert opinion, and cliontipatiant perspective. CAPD may affect listening, communication, academic success, and psychosocial wellness, The overall goal of intervention is to provide the individual withthe abilty 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. hitps:twwn.asha orgipractice-portalctnical4opics/central-auditoryprocessing-disordercoliapse_ 6 ane‘822, 13:31 Central Auditory Processing Disorder Three treatment approaches for individuals diagnosed with CAPD, often used concurrently, include the following (ASHA, 2008): 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 leaming or communication environment), Itis 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 {uided 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 overtap 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" of includes procedures to target multiple skils associated with auditory processing (Bellis, 2002, 2003; Chermak & Musick, 2002; cf. British Society of Audiology [BSA], 2011). traditional Iistening treatments") 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.9.,/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 2 temporal ordering or sequencing. + Auditory pattern recognition—training to distinguish similarities and differences in sound pattems + 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 (1 ‘separation)—dichotc listening training or speech-in-noise training . binaural + Recognition of disparate auditory stimuli presented to each ear simultaneously (ie., 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 ofthe fauaitory] system” (Tremblay & Kraus, 2002). As with all other treatments, itis 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; Philips, 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 skils; ‘= phonological awareness; and ‘+ reading decoding and comprehension, Computerized delivery may provide hitps:twwn.asha orgipractice-portalctnica/4opics/central-auditoryprocessing-disordercoliapse_ 6 ane‘822, 13:31 Central Auditory Processing Disorder ‘+ multisensory stimulation; ‘+ engaging formats; + feedback and reinforcement; and + facilitation of intensive training, Interhemispheric Transfer Training Direct skills remediation also includes exercises to train interhemispherie transfer (Bellis, 2002, 2003; Musiek, Baran, & ‘Schochat, 1999). Interhemispheric transfer of information underlies binaural hearing and binaural processing. Etficacy data in this area are still emerging (Wining, Chermak, & Musick, 2015). Exercises to train intechemispheric transfer include + tasks that address interaural temporal offsets and intensity diferences; ‘+ unimodal tasks (e.g, linking prosodic and linguistic acoustic features); and ‘+ multimodal tasks (e.9., writing to dictation, verbally describing a picture while drawing). Compensatory Strategies Compensatory strategies (e.9., 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 Ink 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 © selfinstruction: © 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 leam concepts and skills such as paraphrasing, explaining differences, knowing word meanings, and using complex syntax. + Address language knowledge, skills, and stratagies that underlie academic tasks (Ehren, 2000; Ehren, Lenz, & Deshler, 2006). + Select goals for contextualized (e.9., language accompanied by gesture, facial, and other supports) and decontextualized (eg., language within testing contexts, many written materials) aspects of language (Wallach, 2008). hitps:twwn.asha orgipractice-portalctinica/topics/central-auditoryprocessing-disordercoliapse_ 6 sone‘822, 13:31 Central Auditory Processing Disorder ‘+ 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, Charkton, & Christie, 2009), + Teach strategies to help students derive meaning from spoken and written language and organize incoming information (Blachowiez & 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 wil influence what is attended to, perceived, and remembered. ‘+ Understand the reciprocal nature of spoken and written language, Written language skils can facilitate auditory processing by improving metalinguistic awareness and by introducing various language forms and new vocabulary (Schuele & Boudreau, 2008; Scott, 2009; van Kleeck, 2008; Zucker, Justice, & Piasta, 2009). Environmental Modifications Environmental modifications improve access to auditorily presented information (ASHA, 2008). They include enhancement of the auditory signal and the listening environment (“bottom-up”) to improve clarity andior audibly ofthe signal itself (Crandell & Smaidino, 2000, 2001) and management approaches ("top-down") to improve access to information in various settings (Bellis, 2002, 2003; Chermak & Musiek, 1997; Hedu, Gagnon-Tuchon, & Blideau, 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— ‘2 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 sit to the effects of noise and reverberation in various settings; and 2 may be considered initially for individuals with CAPD as an accommodation strategy due to their signal-to-noise {SIN) enhancement capabilties (Crandell, Charlton, Kinder, & Kreisman, 2001), © Prior to fiting, performance should be verified using electroacoustic, real-ear, and behavioral measures, including normsreferenced speech recognition in noise testing (AAA, 2008). ‘© Subsequent to fitting, benefits should be validated in typical listening conditions experienced by the individual using a vatiety 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). + Modif ions to the listening environment—improving acoustics that can affect speech intelligblity—can include © covering reflective surfaces (e.9., 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 extemal noise sources (e.9., aquariums, fluorescent lights that hum) from the learning space. ‘See ASHA’s technical report on schoo! 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.2., language, memory, attention) and buttress deficient auditory processing skils and enhance listening, including © advising the speaker to speak more slowly, pause more often, emphasize key words, and “chunk” his or her instructions; hitps:twwn.asha orgipractice-portalctinica/4opies/central-auditory-processing-disordercolapse_ 6 ane‘822, 13:31 Central Auditory Processing Disorder °° 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 suppor for focused/attentive listening (e.g., use notetakers, preview information prior to instruction, and use organizers). Assessing Treatment Progress Test-etest of standardized measures as well as academiclearring measures may be used to assess treatment progress. Measures may include indices of auditory performance (o.g., patter tests, dichotic cgi, speech recognition for ine- 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 overtime, alterations tothe treatment and management plan willbe indicated. tis 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 leaming 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 clienticaregiver 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 ofa group), The appropriateness of treatment format (individual vs. group vs. both) depends on the primary goal for the individual ata particular point inthe treatment process. Provider Provider refers to the person providing the treatment (e9., audiologist, SLP, trained volunteer, caregiver). Itis important for audiologists and SLPs to collaborate with each other and with other professionals regarding treatment allematives, including opportunities for co-reatment. Ti hitps:twwn.asha orgipractice-portalctinica/4opies/central-auditory-processing-disordercolapse_ 6 vane‘822, 13:31 Central Auditory Processing Disorder 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 skils, 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 EM... . 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 flings relates 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 ral 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 salisfy 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 abilty to learn. ‘Some state education departments may review elighility 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 (|CD-9) described CAPD as part of "Developmental Speech-Language Deficits'—specifcally, "Mixed Receptive-Expressive Language Disorder; Central Auditory Processing Disorder.” In the new code, CAPD is no longer described as a developmental speech-language disorder. 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: + Coding for Reimbursement Frequently Asked Questions: Audiology—What codels should | use for auditory processing (AP) evaluation and treatment? ‘+ Coding for Reimbursement Frequently Asked Questions: Speech-Language Pathology—What code/s should I use for auditory processing (AP) evaluation and treatment? hitps:twwn.asha orgipractice-portalctnica/4opies/central-auditoryprocessing-disordercoliapse_ 6 ane‘822, 13:31 ‘Cental Austory Processing Disorder 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) Resources References About This Content Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in al settings; however, members ‘must consider al applicable local, state and federal requirements when applying th information in thor specific work soltng (© 1997-2022 American Speech-Languags-Hearing Assocation hitps:twwn.asha orgipractice-portalctinica/4opies/central-auditory-processing-disordercolapse_ 6 148‘822, 13:31 Central Auditory Processing Disorder hitps:twwn.asha orgipractice-portalctinica/4opies/central-auditory-processing-disordercolapse_ 6 ssn.‘822, 13:31 Central Auditory Processing Disorder hitps:twwn.asha orgipractice-portalctnica/4opics/central-auditoryprocessing-disordercoliapse_ 6 sens‘822, 13:31 Central Auditory Processing Disorder hitps:twwn.asha orgipractice-portalctinica/topics/central-auditoryprocessing-disordercoliapse_ 6 ame‘822, 13:31 Central Auditory Processing Disorder hitps:twwn.asha orgipractice-portalctinica/4opies/central-auditory-processing-disordercolapse_ 6 rene