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The impact of mild Central Auditory Processing Disorder on school performance during adolescence.

Central Auditory Processing (CAP) difficulties have attained increasing recognition leading to escalating rates of referrals for evaluation. (1) Recognition of the association between (Central) Auditory Processing Disorder ((C)APD) and language, learning, and literacy difficulties has resulted in increased referrals and detection in school-aged children. However, attention to (C)APD as a cause of academic difficulties in adolescence is still overlooked. The present clinical observation report is based on the supposition that even mild (C)APD could result in significant impact on different academic and life domains during adolescence. The aim of presenting this report is to alert school staff to the association between C(APD) and academic performance deficits in order to prompt its consideration as a possible etiological factor in underperformance.

(C)APD is a deficit in the ability to process and channel information through the auditory system, reflected in difficulty in some or all of the following auditory tasks: sound localization and lateralization, dichotic listening, temporal processing, and sound discrimination in competing or degraded listening conditions. (2) Behavioral characteristics associated with the suspected disorder include difficulty comprehending speech in competing or reverberant environments, requests for repetition of information often using nonspecific clarification requests, misunderstanding messages, inconsistent or inappropriate responses, delays in responding to oral communication, difficulty following complex auditory directions, difficulty with sound localization, inattentiveness and distractibility, and literacy difficulties. (2,3) The heterogeneous nature of this extensive list of associated behavioral features has evoked criticism since it defies definition and specification on the basis of a unique cluster of diagnostic signs that reflect some underlying mechanism. (3) However, (C)APD is not a unitary disorder but rather a combination of functional deficits that has been observed in various population groups attributed to various causes, such as central nervous system pathology or neurodevelopmental disorders. (4)

Diagnosis of (C)APD is based on performance on a specialized battery of tests assessing the integrity of the central auditory pathway and identifying the nature of the auditory deficit, particularly in auditory closure, auditory figure-ground, binaural separation, binaural integration, and temporal processing.

There are several plausible reasons for adolescents presenting at a CAP evaluation, such as escaped early diagnosis in childhood or positive diagnosis made in childhood, but insufficient intervention by means of instructive strategies only. Inadequate diagnosis or management may be attributable to limited availability of the current more sophisticated intervention strategies or to prevailing professional perspectives at time of diagnosis of limited advantage to intensive treatment for (C)APD. In addition, increased academic demands at adolescent school levels could magnify the burden of (C)APD leading to greater awareness of deficits.

The present paper aims to increase awareness of the need for evaluation referral for C(APD) by school staff in appropriate cases of underperformance by presenting the following case studies.


The present report is based on a compilation of 3 case studies of adolescents, coincidently all aged 14 years, presenting at an audiological clinic for CAP evaluation over a 3-month period in the same year. All were referred by school staff with concerns about unexplained academic underperformance and a variety of other difficulties as presented in Table 1.

After giving informed written consent, all 3 clients were evaluated by a dually qualified audiologist-speech pathologist on a battery including audiological (low redundancy, dichotic listening, and temporal processing) and nonaudiological (short-term auditory memory, language, and literacy screening) tests. Comparison between test performance and normative data led to a diagnosis of C(APD). Following diagnosis, the 3 clients participated in 4 individualized 30-minute intervention sessions focusing on speech discrimination, auditory closure, dichotic listening, and short-term auditory memory. Diagnostic criteria, therapy strategy, and outcome are presented in Table 2.

Clients showed cooperation and motivation during participation in the intervention programs. In addition to one-on-one sessions with an audiologist-speech pathologist, parents and teachers were provided with guidance materials suggesting home and classroom strategies for promoting effective listening and communication, organization, noise acoustics, and short-term auditory memory. (5) All 3 clients exhibited marked improvement in deficit areas on audiological and nonaudiological retesting at termination of therapy, strongly confirmed by self-perception reports and parent and teacher reports. Case A obtained the lead role in the school play, demonstrated greater structure, and greatly improved organizational skills and academic performance; Case B exhibited increased self-esteem manifested in improved social confidence and interactions; and Case C joined the school debating team and participated with confidence. All 3 clients exhibited better organizational skills, improved academic performance, more dedicated and structured work attitudes, and enhanced social confidence. Together with this marked improvement, clinicians' recommendations were for continued monitoring and review.


The present case observations emphasize that even mild (C)APD can result in significant impairment in adolescence. Theoretical explanations for the phenomenon could be attributable to the relatively sudden increased physiological, psychological, intellectual, and emotional challenges negotiated during adolescence that would impact on academic burden. The significant challenges of adolescence, defined by intrapsychic energy expended predominantly at establishing personal identity, self-autonomy, and social role consolidation, have been well established. (6) With entry into this adolescence crisis, developmental difficulties would be magnified with auditory processing deficits. In addition to general challenges of adolescence, academic demands magnify during this period. (7) The coincidence of breakdown around age 14 during middle school years, reinforced by the therapists' impressions of increased referrals at this age, may be due to more intense aural-oral instructive modes, multiple task learning, and directives toward school-qualifying achievements and examinations.

Rapid positive response of the clients to intervention suggests neural plasticity of the CAP system even in adolescence. However, the present clinical observations can make no claims about possible ceiling effects of plasticity and corrective response in (C)APD.

This report alerts school health professionals to the importance of early diagnosis and intervention for (C)APD to avoid later implications during adolescence. Lack of professional consensus regarding standards and criteria for diagnosis and intervention contributes to inadequate diagnosis and implementation of appropriate therapy in childhood. (8) However, it is of vital importance that school staff be apprised of the relevance of C(APD) in general and the possibility and relevance of late diagnosis and intervention even during early adolescence. Adolescent school health concerns would benefit from greater attention directed toward diagnosed (C)APD previously considered too mild to warrant intervention.


(1.) Heine C. Central auditory processing in children: a theoretical and clinical perspective. Acquiring Knowledge Speech, Lang Hear. 2003; 5(3):131-133.

(2.) American Speech-Language-Hearing Association. 2005. (Central) auditory processing disorders: working group on auditory processing disorders [online]. Available at: members/deskref-journals/deskref/default.html. Accessed July 1, 2006.

(3.) DeBonis DA, Moncrieff D. Auditory processing disorders: an update for speech-language pathologists. Am J Speech Lang Pathol. 2008;17:4-18.

(4.) Musiek FE, Chermak GD. Handbook of (Central) Auditory Processing Disorder: Auditory Neuroscience and Diagnosis, Vol. I. San Diego, Calif: Plural Publishing; 2006.

(5.) Bellis TJ. Assessment and Management of Central Auditory Processing Disorders in the Educational Setting: From Science to Practice. Delmar, NY: Thompson Learning; 2003.

(6.) Marcia JE. Development and validation of ego identity status. J Pers Soc Psychol. 1996;3:551-558.

(7.) Barber BK, Olsen JA. Assessing the transitions to middle and high school. J Adolesc Res. 2004; 19:3-30.

(8.) Heine C, Joffe B, Greaves E. The dilemma of APD: clinical decision-making. In: Williams C, Leitao S, eds. Nature Nurture Knowledge: Proceedings of the 2003 Speech Pathology Australia National Conference. Melbourne, Australia: Speech Pathology Australia; 2003:105-108.



(a) Lecturer, (, School of Human Communication Sciences, La Trobe University, Bundoora, Victoria 3084, Australia.

(b) Lecturer, (, Department of Psychology, Tel Aviv University, Tel Aviv 69978, Israel.

Address correspondence to: Chyrisse Heine, Lecturer, (, School of Human Communication Sciences, La Trobe University, Bundoora, Victoria 3084, Australia.
Table 1. Case History Information

Demographic       Referral Agency and         Family and Medical
Information       Concerns                    History; Milestones

Case A, female,   School counselor            Recurrent ear infections
eighth grade      Language, literacy            as a toddler
                  Classroom behavior and      Ventilation tubes
                    social concerns:            inserted bilaterally
                    forgetfulness,              twice
                    difficulty with           Myringotomy, left ear at
                    organization,               age 13 years
                    listening, and            Age-appropriate
                    following directions        milestones

Case B, female,   Specialist teacher          Maternal chicken pox
ninth grade       Literacy, numeracy            during pregnancy,
                  Classroom behavior: lack      induced birth
                    of focus,                 Migraines
                    forgetfulness,            Age-appropriate
                    inattention                 milestones

Case C, male,     Specialist teacher          Upper respiratory tract
eighth grade      Language, literacy            allergies
                  Classroom behavior:         Age-appropriate
                    difficulty with             milestones
                    organization, following
                    listening in noise

Demographic       Parental Behavioral
Information       Observations                Previous Assessments

Case A, female,   Difficulty remembering      Audiologist at age
eighth grade        information, following      5 (1998)
                    directions; easily

Case B, female,   Daydreaming;                Nil
ninth grade         distractible;
                    forgetful; difficulty

Case C, male,     Often appears confused;     Audiologist at age
eighth grade        distractible; lacks         9 (2002)
                    motivation and            Educational Psychologist
                    confidence; difficulty      age 11 (2004),
                    following directions        reviewed 1 month ago

Table 2. Diagnostic Criteria, Therapy Strategy, and Posttest Outcomes

         Audiological Deficit            Nonaudiological Deficit

Case A   Mild auditory closure deficit   Short-term auditory
           bilaterally                     memory (STAM) deficit
         Mild dichotic listening
         Mild binaural interaction

Case B   Mild auditory figure-ground     Auditory closure deficit
           deficit, right ear            Language and literacy
         Dichotic listening difficulty     deficit
           bilaterally                   STAM deficit

Case C   Mild auditory figure-ground     STAM deficit
           deficit, left ear
         Mild dichotic listening
           difficulty, right ear

         Therapy Targets            Posttest Outcomes

Case A   Speech discrimination      Improvement in all areas of
         Dichotic listening           auditory processing,
         Auditory closure             organizational skills, and
         STAM                         STAM
         Organizational skills

Case B   Speech discrimination      Improvement in all areas of
         Auditory figure-ground       auditory processing and STAM
           training                 Language and literacy not
         Dichotic listening           reassessed
         Auditory closure
         Vocabulary, reading, and

Case C   Speech discrimination      Improvement in all areas of
         Auditory figure-ground       auditory processing,
           training                   organizational skills, and
         Dichotic listening           STAM
         Auditory closure
         Organizational skills
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Article Details
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Title Annotation:Health Services Applications
Author:Heine, Chyrisse; Slone, Michelle
Publication:Journal of School Health
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2008
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