Int. Adv. Otol.

2009; 5:(1) 104-115

REVIEW

Auditory Processing Disorder in Children: Definition, Assessment and Management

Sanem Sahli

Department of Otorhinolaryngology, Head and Neck Surgery, Section of Audiology and Speech Pathology, Hacettepe University Faculty of Medicine,
Ankara, Turkey

Hearing is a complex process that is often taken for granted. As sounds strike the eardrum, the sounds (acoustic
signals) begin to undergo a series of transformations through which the acoustic signals are changed into neural
signals. These neural signals are then passed from the ear through complicated neural networks to various parts
of the brain for additional analysis, and ultimately, recognition or comprehension. Auditory Processing Disorder
(APD) previously known as “Central Auditory Processing Disorder” (CAPD) is a such disorder that auditory
information is incorrectly processed in the brain. It is not a sensory hearing impairment; individuals with APD
usually have normal peripheral hearing ability. APD is an umbrella term that describes a variety of problems with
the brain that can interfere with processing auditory information. APD is assessed through the use of special tests
designed to assess the various auditory functions of the brain. In APD, the approaches to remediation or
management fall into three main categories: (1) enhancing the individual’s auditory perceptual skills, (2)
enhancing the individual’s language and cognitive resources, and (3) improving the quality of the auditory signal

Submitted : 22 August 2008 Revised : 11 December 2008 Accepted : 14 December 2008

Auditory processing disorder (APD), also known as may be reliant on or associated with intact central
central auditory processing disorder (CAPD) is a term auditory function, they are considered higher order
used to describe individuals with normal hearing who cognitive-communicative and/or language related
have auditory-based receptive communication or functions and, thus, are not included in the definition
language problems. While some individuals are more of CAP [1].
difficult to assess because of distorsions from the Auditory processing disorders (APDs) have received
central auditory nervous system. considerable attention over the past few decades. APD
Auditory processing disorder refers to difficulties in is not a new entity in audiology. For many years,
the perceptual processing of auditory information in professionals have been aware that some individuals
the CNS (Central Nervous System) as demonstrated by with normal results on tests of peripheral function
poor performance in one or more of the auditory and report difficulty in speech understanding. Since APD
temporal skills (sound localization and lateralization, involves processing of auditory signal, audiologists are
auditory discrimination, auditory pattern recognition, called on to make this diagnosis of APD based upon a
temporal aspects of audition) [1]. battery of tests.
Although abilities such as phonological awareness, Much of the recent attention has focused on the
attention to and memory for auditory information, controversy surrounding the operational definition of
auditory synthesis, comprehension and interpretation APD, the heterogeneous nature of APD, and an
of auditorily presented information and similar skills appropriate test battery for APD assessment [2].

Corresponding address:
Sanem Sahli
Department of Otorhinolaryngology, Head and Neck Surgery, Section of Audiology and Speech Pathology,
Hacettepe University Faculty of Medicine, Ankara 06100, Turkey
Phone : +90 312 305 42 00; Fax: +90 312 310 27 30; E-mail:ssahli@[Link]
Copyright 2005 © The Mediterranean Society of Otology and Audiology

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 Auditory Processing Disorder in Children: Definition, Assessment and Management

APDs are wide-spectrum disorders. Investigators have learning impaired children may result from a basic
attempted to document the heterogeneous nature of deficit in processing rapidly changing sensory inputs”
[9]
APDs by sub-grouping APD or describing the . These investigators hypothesize that impaired
characteristics in terms of commonalities [3-5]. temporal processing disrupts the normal development
Although this may be beneficial in management, no of an efficient phonological system and these
sub-grouping system or model is universally accepted. phonological difficulties result in language and
In addition, APD may exist with other learning, reading disorders [2].
language, or reading disorders. This comorbidity has Poor temporal processing is one of the characteristics
created controversial debate on differential diagnosis of APD and is a key component of auditory function [10].
of APD or if the diagnosis of APD should only be Temporal processes are critical in a number of
made when it is a single entity. auditory functions “including auditory discrimination,
Most investigations of APD have not described the binaural interaction, pattern recognition, localization/
specific auditory deficits or characteristics of their lateralization, monaural low-redundancy speech
subjects. This may have led to some of the conflicting recognition, and binaural integration” [11].
results in both behavioral and electrophysiological The underlying physiological neural mechanisms for
measures in children with APD. The research reported temporal processing may be assessed by behavioral
in this dissertation represents is a first-step in and electrophysiological means. Behavioral tests
addressing some of the confounding issues “stress” the auditory system by degrading the acoustic
surrounding APD. Specifically, this investigation will environment or signal by introducing background or
address a subgroup of children with APD who have speech noise or by filtering the signal. Behavioral tests
specific temporal processing deficits [2]. may require multiple auditory processes such as
Temporal processing refers to the processing of attention, memory, and perception [12]. Further,
acoustic stimuli over time. Temporal processing is behavioral tests may be confounded by learning,
very important for us to be able to understand speech attention, fatigue, hearing sensitivity, intelligence,
in quiet and in background noise, since speech stimuli developmental age, motivation, motor skills, language
and other background sounds vary over time. experience, and language impairments [13].
Speech and hearing professionals need to be familiar Terminology
with the various aspects of temporal processing for
Auditory Processing Disorder (APD) refers to how the
two reasons. Some children with auditory processing
problems have difficulty in temporal processing of brain recognizes and interprets auditory information.
auditory stimuli. Such difficulties can hinder the When a child’s auditory processing ability is
acquisition of speech, language and reading. Older disordered, he is unable to properly analyze the words
individuals can also have temporal processing deficits or sounds he hears. Auditory processing disorders are
which can affect their ability to understand speech and unrelated to hearing impairment and children with
to benefit from amplification in the presence of auditory processing disorders typically present with
hearing loss [6]. normal hearing [Link] is also referred to as
Temporal processing deficits have also been central auditory processing disorder [14].
associated with learning disabilities. Tallal’s works [7-9] It was not until the late 1960s and 1970s that the term
demonstrate that impaired temporal processing may ‘central auditory processing disorder’ was used to
result in language disorders, speech processing describe children with similar symptoms as adults with
disorders and reading disorders. Tallal reports, “The a central auditory nervous system lesion [15-20]. Since
phonological and language difficulties of language- then, interest has continued to grow as numerous

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articles, conferences, books and special committees • Auditory performance decrements with degraded
have been devoted to this topic. acoustic signals.
One of the controversies surrounding APD has been ‘A central auditory processing disorder’ is an observed
the terminology used to describe the disorder. deficiency in one or more of the above-listed behaviors [22].
“Central” has been used to distinguish the VIII nerve, The ASHA published their first definitive Technical
brainstem and cortical areas as the anatomical site of Report “(Central) Auditory Processing Disorders” in
dysfunction in contrast to the cochlea as a”peripheral” January 2005 as an update to the “Central Auditory
site of lesion. Central auditory processing is used Processing: Current Status of Research and
interchangeably with central auditory function, central Implications for Clinical Practice”[22] and complements
auditory perception, auditory language processing, and the UK’s “Medical Research Council’s Institute of
auditory language learning. This has caused many Hearing Research’s” Auditory Processing Disorder
investigators to adopt APD which relates to no specific (APD) pamphlet, 2004 [24].
anatomical site of dysfunction [13].
The 2000 Bruton Consensus Conference on the
However, other investigators continue to use “central” “Diagnosis of Auditory Processing Disorders in
to emphasize the disorder occurs central to the School Aged Children” defined an auditory processing
peripheral hearing mechanism [21]. Other terminology
disorder as “a deficit in the processing of information
used to describe auditory processing disorders include
that is specific to the auditory modality [2].
central hearing loss, auditory perception disorder,
central deafness, word deafness, auditory agnosia, The problem may be exacerbated in unfavorable
auditory memory deficit, auditory sequencing problem acoustic environments. It may be associated with
and auditory dysfunction [2]. difficulties in listening, speech understanding,
language development, and learning. In its pure form,
One of the problems in defining auditory processing
however, it is conceptualized as a deficit in the
disorders is that it is a description of symptoms of
processing of auditory input” [13].
functional deficits [22]. Auditory processing, as stated
simply is “what we do with what we hear” [4]. Butler Subgroups of APD
(1983) defined auditory processing as the abstraction There are many models that attempt to describe APD.
of meaning from an acoustic signal and the retrieval of Investigators have attempted to document the
that meaning [23]. heterogeneous nature of APDs by sub-grouping APD
The American Speech-Language-Hearing Association or describing the characteristics in terms of
(ASHA) 1996 Task Force defines central auditory commonalities [3,5]. Based on the functions and test
processing as “the mechanisms and processes signs that are associated with various sites of lesion,
responsible for the following behavioral phenomena: APD categories were developed [4,25]. As in most fields,
• Sound localization and lateralization, categories enable us to break down complex problems
into smaller understandable units. Although this may
• Auditory discrimination,
be beneficial in management, no sub-grouping system
• Auditory pattern recognition, or model is universally accepted [2].
• Temporal aspects of audition including temporal One such model designed at the University at Buffalo
resolution, temporal masking, temporal integration, is “The Buffalo Model”. The Buffalo Model focuses
temporal ordering, on the relationship between patterns of performance
• Auditory performance decrements with competing on one particular test of auditory processing and
acoustic signals and learning difficulties in children. This model contains

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 Auditory Processing Disorder in Children: Definition, Assessment and Management

four subtypes: Decoding, Tolerance-Fading Memory, represent higher-level language, attention, and/or
Integration and Organization [4,26]. executive function and, therefore, some may argue
Decoding describes individuals who “have difficulty against their inclusion under the umbrella of APD [21].
in keeping up with the flow of communication, have Auditory decoding refers to persons with “poor
poor phonemic skills, are slow responders, often have auditory closure abilities, characterized by poor
articulation errors, have difficulty in following performance on tests of monaural low redundancy
directions, and have weak oral reading and spelling speech and speech-in-noise” [29]. Integration Deficit
skills” [27]. refers to difficulties in interhemispheric transfer.
Persons with tolerance-fading memory have difficulty Associative Deficit refers to “an underlying inability
in speech understanding with competing background to apply the rules of language to incoming acoustic
noise and have short-term memory problems. These information” [29]. Output-Organization Deficit is a
individuals are often described as impatient and are deficit in organizing, planning, and sequencing
easily over-stimulated. They tend to have poor reading responses. Again, it is possible that a person may have
comprehension and may have handwriting difficulty. more than one sub-type [2].
Integration refers to how auditory information is
Except these models, Musiek & Gollegly report three
integrated with other factors in one’s environment
types of APD in children with learning disabilities.
Integrating what you hear with what you see, or
These three types are based on an underlying
recognizing two sounds in one’s environment, but
neurophysiological deficit or neuromaturational delay:
focusing on the most salient of the two are examples of
neuromorphological disorder, maturational delay of
the integration process [28].
the CNS and finally neurologic diseases and insults.
Organization, the last model, describes persons who These types are theoretical and have not been directly
have difficulty in sequencing events and have investigated due to the invasive nature of necessary
sequencing errors. These individuals are often research procedures [5].
disorganized at home or school. Often a person will Etiology
exhibit characteristics of more than one sub-type [26].
The cause of APD is often unknown. In children,
The Bellis/Ferre model describes a method of auditory processing difficulty may be associated with
subprofiling APD. Each subprofile is related to its conditions such as dyslexia, attention deficit disorder,
underlying neurophysiologic region of dysfunction in autism, autism spectrum disorder, specific language
the brain as well as to its higher-level language and impairment, pervasive developmental disorder or
learning implications and sequelae. This model developmental delay. Sometimes this term has been
includes three primary profiles and two secondary misapplied to children who have no hearing or
profiles. The three primary profiles (Auditory language disorder but have challenges in learning [30].
Decoding Deficit, Prosodic Deficit, Integration There are many possible causes of APD. Causes of
Deficit) represent auditory and related dysfunction in APD in children are not completely understood. Often,
the primary auditory cortex (usually left hemisphere), these children do not show any neurological disease or
nonprimary auditory cortex (usually right hemisphere) any neurological abnormality.
and corpus callosum (interhemispheric dysfunction).
Not all cases of APD have an underlying structural
Secondary profiles (Associative Deficit and Output deficit, therefore, APD may be difficult to diagnose
Organization Deficit) represent dysfunction and with computerized tomography or magnetic resonance
associated sequelae that may be considered to imaging scans of the brain. Researchers have

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suggested that the problem underlying APD “may be AD/HD. Co-occurrence between AD/HD and APD is
invisible to many neurologic and radiologic studies” [31]. 41% for children with confirmed diagnosis of AD/HD,
Other prenatal or perinatal factors that may be and 43% for children suspected of having AD/HD [36].
indicated in APD are: hyperbilirubinemia, ototoxic Children with dyslexia are often “wrongly diagnosed”
drugs, anoxia, low birth weight, RH incompatibility, because symptoms that characterize dyslexia appear to
prematurity, abnormal secretion that affects brain cell be indistinguishable from APD. Dyslexia is defined by
development prior to birth, and unspecified birth the International Dyslexia Association (2000) as a
problems. Maternal factors which may adversely language-based disability in which a person has
affect development of the central nervous system trouble with understanding words, sentences or
include diabetes, rubella, syphilis cytomegaloviruses paragraphs where both oral and written language are
and toxemia [32]. affected. An APD can influence a child’s ability to
read since specific auditory performance deficits will
Hereditary factors may also play an important
prevent a child from developing good reading skills. In
role[32,33]. Future brain imaging studies such as
one sample of 94 children with learning disabilities,
functional magnetic resonance imaging may prove of
only one child was free from central auditory
value in further understanding the mechanisms
processing dysfunction [4,37].
involved in brain function and auditory processing in
normal children and children with APD [2]. All of these groups are heterogeneous in nature.
However, it is important to note that not all children
Comorbidity of APD
with a language, learning or attention disorder will
APD has been observed in diverse clinical populations, have an auditory processing disorder. APDs have also
including those where central nervous system (CNS) been linked to children with chronic otitis media [38-41]
pathology or neuromorphological disorder is suspected and also the elderly and aging population [42]. This has
(e.g. developmental language disorder, dyslexia, led some investigators to question if auditory
learning disabilities, attention deficit disorder) and processing deficits underlie language disorders, or if
those where evidence of CNS pathology is clear auditory processing disorders are one type of language
([Link], multiple sclerosis, epilepsy, traumatic disorder [22,43-46].
brain injury, tumor and Alzheimer’s disease).
Controversy exists about the label of APD in children
Moreover, these conditions are not mutually exclusive with multi-sensory deficits. Some investigators argue
and may be characterized as co-morbid: an individual that if multi-sensory deficits are present, then the
may suffer from APD, attention deficits and learning diagnosis of APD is inappropriate, and the diagnosis is
difficulties. Whether these disorders are causal to one only appropriate where there is a single auditory
another remains unclear [10]. deficit [34]. However, given the interconnections of the
There is an intimate relationship between language, nervous system and the influence of higher-level
attention and auditory skills. Auditory processing functions such as language, cognition and attention,
disorders often coexist with learning disabilities, the single modality-specific definition for APD is not
logical [21].
language disorders, attention deficit disorders and
dyslexia[10,34]. Children with Attention Oral language acquisition depends upon the efficient
Deficit/Hyperactivity Disorder manifest behaviors processing of acoustic stimuli [22]. Some children with
strikingly similar to children with Auditory Processing specific language impairments have difficulties in
Disorder [35]. DiMaggio and Geffner (2003) showed that perceiving rapid acoustic events and have difficulty in
84% of children with APD had confirmed or suspected processing auditory information of brief duration

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 Auditory Processing Disorder in Children: Definition, Assessment and Management

relative to surrounding segments. This difficulty will * The child has difficulty in auditory discrimination
not only affect phoneme recognition, but also affect and has diminished ability to discriminate among
the listener’s ability to segment speech. A degraded speech sounds (phonemes).
acoustic environment may hinder speech processing. * The child has difficulty in remembering phonemes
This degraded environment has also been theorized to and manipulating them (e.g. on tasks such as
be one of the etiologies of specific language reading, spelling and phonics as well as phonemic
impairments in that the amount and type of linguistic synthesis or analysis)
input necessary for optimal language acquisition is not
* The child has difficulty in understanding speech in
present [2,47,48].
the presence of background noise.
However, it is important to note that not all children
* The child has difficulty in auditory memory (either
with specific temporal processing deficits show
span or sequence). Unable to remember auditory
language or speech disorders. There are two
information or follow multiple instructions.
contrasting models regarding the influence of lower
order perceptual processing and higher order cognitive * The child demonstrates scatter across subtests with
processing on language and learning disabilities [43,44]. domains assessed by speech-language and
Models describe how listeners perceive the acoustic psychoeducational tests, with weaknesses in
signal, conduct auditory analysis involving complex auditory-dependent areas.
pattern recognition, match acoustic patterns to some * The child has poor listening skills characterized by
internal representation(s), extract meaning from strings decreased attention for auditory information,
of lexical representations, and construct a message distractible or restless in listening situations.
level interpretation [2,49].
* The child responds inconsistently to auditory
Assessment
information (some times responds appropriately,
An auditory processing assessment must accomplish sometimes not) or has inconsistent auditory
three things: first, it must be determined if auditory awareness (one-to-one conversation is better than in
processing is affected; second, if auditory processing is a group setting) The child has a receptive and
deficient, then the severity of the APD must be expressive language disorder; there may be a
assessed; third, the clinician must determine if the discrepancy between expressive and receptive
APD can account for the person’s communication and language skills.
learning difficulties. These three goals of an APD
assessment are not without controversy. * The child has a receptive and expressive language
disorders; there may be a discrepancy between
A. Dependant variable measures
expressive and receptive language skills.
Presenting symptoms were based on parental report
* The child has difficulty in understanding rapid
during the initial case history interview. Additionally,
speech or persons with an unfamiliar dialect.
listening difficulties were quantified using the
following two questionnaires * The child has poor musical abilities and does not
recognize sound pattems or rhythms; has poor vocal
1. Symptoms
prosody in speech production.
A child with APD typically exhibits the following
These examples are only a few of the behaviors that
behaviors;
are associated with APD. Not every child with
* The child behaves as if a peripheral hearing loss was auditory processing problem will exhibit all of the
present, despite normal hearing behaviors mentioned. The number of problems

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experienced by a given child will be an expression of completed by parents or teachers. It is comprised of

the severity of their auditory processing problems [50]. the list of 25 statements, such as “Says “Huh?” and
Recognizing children who have Auditory Processing “What?” at least five or more times per day” and
Disorder “Experiences problems with sound discrimination”.
However, many of these statements are not specific for
In children with APD, general characteristics, physical
APD, such as “Has a short attention span”, “Has a
features and emotional-social difficulties described in
language problem (morphology, syntax, vocabulary,
Table 1 [51].
phonology)” and “Has an articulation (phonology)
2. Children’s Auditory Performance Scale (CHAPS) problem”. The number of items checked is scored as a
and Fisher’s Auditory Checklist percentage, which can be compared against norms for
The CHAPS[52] is a screening questionnaire for 5-11 years old. The authors recommend referral to an
listening difficulties. Parents or teachers are asked to audiologist for APD examination if a child’s score is
compare the child’s listening in a range of conditions poorer than 72%, close to one standard deviation
such as ‘Multiple Inputs’, ‘Ideal’ or ‘Noise’. The below the mean.
CHAPS provides average scores for each condition as
B. Assessment tests used for diagnosis of APD
well as a total score. The CHAPS recommends referral
for APD evaluation if the average total score or any of 1. SCAN
the average scores for each condition are lower than The SCAN is a US-produced standardised test of
< 0.05. auditory processing, and is the most commonly used
Fisher’s auditory checklist[53] is a screening instrument for diagnosis of APD [54]. It is composed of
questionnaire for listening difficulties that can be four subtests including (a) discrimination of

Table 1. General characteristics, physical features and emotional-social difficulties in children with APD.

General Characteristics;

* Says “huh” or ‘what’ freguently * Has difficulty in phonics and speech-sound discrimination
* Gives inconsistent responses to auditory stimuli * Has poor auditory memory (span and sqeuence)
* Often misunderstands what is said * Has poor receptive and expressive language
* Constantly requests that information be repeated * Gives slow or delayed response to verbal stimuli
* Has poor auditory attention * Has reading, spelling and other academic problems
* Is easily distracted * Learns poorly through the auditory channel
* Has difficulty in following oral instructions * Exhibits behavior problems
* Has difficulty in listening in the presence of background noise

Physical Features Emotional and Social Difficulties

* Poor general health * Temper tantrum/explosive behaviour

* Enuresis/encopresis * Low self-esteem
* Increased incidence of otitis media * Low frustration tolerance
* Increased frequency of allergies/food sensitivities * Mood swings
* Greater frequency of disturbance in sleep/wake cycles * Hyperactivity
* Poor motor coordination * Poor peer relations
* Suspected underaroused central nervous system * Problem with taking turns
* Greater frequency of minor physical anomalies * Poor self control
* Poor general social skills
* Agressiveness
* Impulsiveness

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monaurally presented single words against background strategies are divided into parent, teacher and student
noise, (b) acoustically degraded single words and (c) approaches. The team may choose to utilize these
dichotically presented single words and (d) sentence strategies during an early intervening, assessment or
stimuli. The child version, the SCAN-C [50] is for use intervention stage.
with children aged 5-11 years and the SCAN-A [55] for A. Teacher Modification Strategies
those aged 11 years plus.
1. Classroom environment
2. Random Gap Detection (RGD) Test
* Reduction of noise/minimize distractions
[56]
The RGDT is a standardised test that assesses an * Preferential seating away from noise
individual’s gap detection threshold of tones and white * Use of classroom amplification system
noise. The test includes stimuli at four frequencies
(500, 1,000, 2,000, and 4,000 Hz) and white noise 2. Teaching techniques
clicks of 50 ms duration. This test provides an index of * Clear enunciation at a slow-moderate rate of speech
auditory temporal resolution. In children, an overall * Insert purposeful pauses between concept
gap detection threshold greater than 20 ms constitutes * Shortened verbal instructions; only pertinent content
failure 50. This point is slightly below <2 SD, based on
* Provide visual cues during lecture and/or oral
US population-based normative data for children aged
directions
5-11 years published with the RGDT.
* Provide repetition of oral information and steps of
3. Gaps in Noise (GIN) Test assignment
The GIN is another measure of auditory temporal * Give breaks between intense concepts taught for
resolution. The test assesses an individual’s gap comprehension
detection threshold in white noise. Comparative * Check for comprehension early and often
performance data exist for adult normal-hearing * Have student repeat directions to the teacher
listeners and adults with confirmed neurological
* Preview and review concepts for lecture
involvement of the auditory nervous system [57].
3. Peer assistance
4. Pitch Patterns Sequence (PPS) Test and Duration
Patterns Sequence (DPS)Test * Use of a positive peer partner for comprehension of
directions
The PPS and DPS are measures of auditory pattern
* Use of cooperative learning groups
identification [31,58-60]. The PPS consists of series of three
tones presented at either of two pitches, for example * Use of a note-taker
‘high high low’ or ‘low low high’. The DPS consists of 4. Assingment modifications
series of three tones that vary in duration rather than
* Allow extended time to complete assignments and/or tests
pitch, for example, ‘two short, one long’ or ‘one long,
* Provide visual instructions
one short, one long’. Individuals are asked to describe
the pattern of pitches presented. US population-based * Preview language of concept prior to assignment
normative data are provided for children aged 6 years * Frequent checks for comprehension at pre-
through 9 for the PPS, though only adult performance determined points
norms are available for the DPS. * Vary grading techniques

Strategies for Auditory Processing Disorder B. Student Modification Strategies

Several strategies exist which may positively impact a * Teach use of visual cues to supplement auditory
student in their educational environment. These information

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* Teach use of short and long term memory techniques 4. Katz, J., Classification of auditory processing
(i.e. rehearsal, chunking, mnemonics, visual disorders. In J. Katz, N. Stecker, &D. Henderson
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word Book.,1992, pp.81-91
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* Teach student to advocate for themselves by asking considerations in the neuroauditory evaluation of
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