Auditory processing disorder

Also called APD, Central auditory processing disorder

Normal hearing test, real difficulty understanding speech. Often mistaken for inattention, and it responds well to changing the room rather than the person.

What it is

Difficulty making sense of sound, despite the ears working normally. The problem is in how the brain processes what it hears, particularly speech in noise.

The hearing test is normal, which is precisely why it gets missed. A child who cannot follow instructions in a classroom, or an adult who cannot follow a conversation in a pub, is told their hearing is fine, and the difficulty gets attributed to not listening, not concentrating, or not trying.

It overlaps heavily with ADHD, autism, dyslexia and developmental language disorder, and distinguishing them can be genuinely difficult. It can also follow brain injury, stroke or a history of repeated glue ear in early childhood.

Diagnosis is by specialist audiology, and services are patchy across the UK. That is frustrating, and it matters less than it sounds, because almost all the useful intervention is environmental and can be started without a formal diagnosis.

Most of what helps is changing the listening conditions: reducing background noise, improving acoustics, using remote microphone systems, and changing how people speak.

Signs you might notice

Difficulty understanding speech when there is background noise, while managing fine in a quiet room.

Frequently asking for repetition, or saying what.

Mishearing similar-sounding words, and difficulty following multi-step instructions.

Being slow to respond, appearing to daydream, or seeming not to listen.

Difficulty telling where a sound is coming from.

Getting very tired by listening, and withdrawing from noisy places.

Trouble with phone calls, and with learning to read and spell.

First step for anybody with these difficulties: a standard hearing test, to rule out ordinary hearing loss and glue ear.

How it can affect day-to-day life

The characteristic experience is exhaustion. Following speech takes deliberate effort all day, and the fatigue that produces looks like poor behaviour by the afternoon.

Being disbelieved is a running theme, because the hearing test result is used as proof that nothing is wrong.

Classrooms are almost purpose-built to make it worse: hard surfaces, background chatter, a teacher facing a whiteboard. Small changes to seating, acoustics and instruction style transform the day.

Open-plan offices do the same to adults, and reasonable adjustments under the Equality Act apply.

Video calls with poor audio, several speakers and no captions are particularly hard, and captions help enormously.

Supporting someone well

Get a full hearing test first.

Reduce the noise rather than raising the voice. Turn off the radio, close the door, choose the quiet corner.

Get the person's attention first, face them, and let them see your face. Speak clearly at a normal pace rather than loudly.

Give one instruction at a time, and back it up in writing or pictures.

Ask for a remote microphone system at school, where a teacher's microphone transmits straight to the child. It is often the single most effective adjustment.

Ask school for acoustic changes, seating near the teacher, written instructions, and extra processing time; ask an employer for the equivalent.

Use captions and transcripts routinely.

Build in listening breaks, and expect fatigue rather than treating it as behaviour.

Where to get help

A GP practice or school for a hearing test first, then referral to audiology.

A specialist audiology service for assessment, and speech and language therapy for the language side.

RNID for information on hearing and communication support.

Speech and Language UK for classroom strategies.