When the hearing test is normal but listening is still difficult. 

Most of us think we know what it means to have good hearing. You sit in a quiet room, put on headphones and press a button when you hear a series of increasingly faint tones. If the audiogram comes back within the normal range, the obvious conclusion is that hearing is fine.

For many people, however, that is not the end of the story. They can hear the tones perfectly well and still struggle to follow a conversation in a restaurant. They lose parts of what someone is saying when several people are speaking. They find meetings exhausting, have difficulty separating one voice from another or discover that listening becomes much harder as soon as noise, distraction or competing information enters the environment.

This distinction between hearing and listening has interested me for years and became central to my doctoral research, which examined auditory processing and spatial listening in adults with ADHD using electrophysiological, behavioural and subjective measures.

A new scoping review in Acta Psychologica illustrates just how much remains unresolved when adults report listening difficulties despite normal peripheral hearing. The researchers set out to examine how developmental auditory processing disorder, or APD, is assessed in adults. They searched ten databases and initially identified 1,787 records. After screening, only six studies met the criteria for inclusion. Of those, just two were experimental studies involving adults, with a combined sample of only 59 participants. The remaining four were surveys of clinicians.

For an area concerned with difficulties that can affect communication, work, relationships and everyday functioning, that is an extraordinarily small evidence base.

The review also found substantial variation in the tests clinicians use, the people referred for assessment and the criteria applied. The authors concluded that there is currently no consensus about which diagnostic tests or criteria should be used for developmental APD in adults.

That uncertainty raises a much broader problem in auditory science. Hearing is not a single process. The ability to detect a quiet tone is important, but everyday listening asks much more of the nervous system. The brain has to organise rapidly changing acoustic information, separate relevant from irrelevant sounds, use spatial cues, follow speech over time and combine incoming auditory information with attention, memory and prediction.

Real life adds another complication: these processes rarely occur in isolation. A conversation in a busy café is simultaneously an auditory task, an attentional task and often a working-memory task. You have to identify the voice you want to follow, suppress competing speech, retain what was said a few seconds earlier and prepare your own response while the conversation continues.

That is one reason the boundary between auditory and cognitive difficulty can become so interesting.

It was also one of the questions underlying my own research in adults with ADHD. People with ADHD can report substantial listening difficulties, particularly in complex environments, even when conventional hearing measures are normal. The scientific challenge is determining where those difficulties arise. Is the auditory system processing information differently? Are attentional demands making it harder to select relevant signals? Is working memory contributing? Does the difficulty emerge only when several systems are placed under demand simultaneously?

The answer may not be the same for every person. It is important not to stretch the new APD review beyond what it actually studied. The authors specifically excluded participants with co-occurring cognitive, developmental, congenital or neurological conditions. It therefore does not tell us how APD should be diagnosed in adults with ADHD, nor does it establish that listening difficulties in ADHD are APD.

In some ways, that limitation makes the research gap even more interesting. The adults who arrive in clinics do not always fit neatly into isolated diagnostic categories. Attention, language, memory, sensory processing, anxiety, fatigue and hearing can interact. Yet research often has to separate these systems in order to study them.

That creates a familiar tension between scientific control and real-world experience.

The audiogram remains an essential measure of peripheral hearing sensitivity. But when someone says, “I can hear, but I struggle to listen,” a normal audiogram should not automatically end the conversation. It may simply mean we need to ask a different question.

Reference

Redi, C. R., Dechsling, A., Marentakis, G., & Nordahl-Hansen, A. (2026). Mapping the landscape of tests employed in diagnosing developmental auditory processing disorder in adults: A scoping review. Acta Psychologica, 269, 107637.

https://doi.org/10.1016/j.actpsy.2026.107637

Related reading

Explore my ADHD research & neuroscience FAQ for more information about auditory processing, attention, sensory experiences and the challenges of understanding ADHD through different research methods.

You may also be interested in my ADHD in the workplace FAQ, where I discuss how background noise, interruptions and demanding listening environments can affect everyday functioning.

For a practical perspective on the workplace environment, read Maybe the ADHD employee is not the problem. Maybe the office is.

For a closer look at the relationship between ADHD and auditory processing, explore ADHD and auditory processing: where does the difference actually begin?, which examines how electrophysiological, behavioural and subjective measures can contribute different perspectives on listening difficulties.