Auditory Integration

Auditory Integration Training began in the 1960s, in France, with an ear, nose, and throat physician named Dr. Alfred Tomatis. Using the Tomatis Method, clinicians treat patients with "filtered" sounds of music, Gregorian chants, and voices, through an electronic device, in hopes of retraining the ear. Dr. Guy Berard, also a physician, trained under Dr. Tomatis in France but decided that the Tomatis Method was too lengthy and expensive, since it sometimes lasted 100-150 hours or more, extending over weeks, months, or years. So Dr. Berard developed his own electronic device where patients could listen to filtered music for a total of ten hours over a ten-day period.

Dr. Berard's technique is different from Dr. Tomatis's as it is refined to hyper-cute auditory sensitivity. Dr. Berard's focus in practice was to assist children who had difficulty learning in school. According to Dr. Berard, processing problems may occur if one hears some sound frequencies much better than other frequencies. For example, a person may be hypersensitive to the frequencies 2,000 and 8,000 Hertz, but hear all the other frequencies in the spectrum at a normal level. Auditory Integration Training addresses the hearing distortions, hyperacute hearing and sensory processing anomalies which cause discomfort and confusion in learning disabled and developmentally delayed children. AIT seeks to retrain the auditory system for those having an impairment of auditory discrimination or abnormal auditory perception.

Auditory Integration Training (AIT) has been presented as a hearing enhancement process. Research on autism suggests that individuals with the disorder have sensory dysfunctions, making them hypersensitive or hyposensitive to certain sensory stimulation. If their perception of the environment is distorted, then behavior is likely to be impacted by these sensory differences. There are reports of individuals with autism having keenly acute hearing, resulting in the world being an overwhelming and intimidating auditory environment. This can lead to withdrawal, screaming to block out sound, or other extreme behavioral reactions in an attempt to cope with hypersensitive hearing.

Treatment

During audiometric testing individuals will show peaks or hypersensitive responses to certain frequencies. This means that their sensory systems perceive certain sounds as painful or aversive. AIT relies on specially designed equipment that randomizes and filters high and low frequency sounds and intensity levels. It enables individuals to listen to music with these frequencies filtered out, allowing their hearing to adjust and normalize, flattening out the hypersensitive peaks. Basically, the individual listens to filtered electronically modulated music for ten hours over a period of ten days.

Dr. Berard's system, the Ear Education and Retraining System (EERS), uses a machine to electronically select high and low frequency sounds from music. The individual undergoing the treatment then hears these sounds through headphones. If the individual has auditory peaks of sensitivity, those frequencies are filtered out completely or partially. Filters are set on the AIT device to dampen frequencies to which the individual is sensitive. Dr. Berard believes that the auditory system can be retrained, resulting in a flattened audiogram with the peaks and valleys in hearing evened out.

Individuals undergo an audiometric evaluation prior to enrollment, in Auditory Integration Training . The purpose of the audiometric testing is to determine if hyperacute hearing is present. This would be reflected on the graphed hearing thresholds by peaks in certain frequency levels.

The child would then begin AIT. The training is delivered under headset conditions,so the child needs to tolerate wearing headphones in a contained space (minimal movement) for 30 minutes at a time. Modifications can be made, but they aren't encouraged or endorsed. Prior to the training, parents are encouraged to help their child become comfortable wearing headphones to listen to music. For best results, participants should refrain from work, school, camp, or participation in mentally or physically taxing activities while undergoing AIT:

Dr. Jane Madell, an audiologist, described what the individual hears as music that sounds a bit "drunk" (Madell & Rose 1994). Because the high and low frequencies are modified randomly, the result is an uneven balance in tones that is constantly changing. This prevents the individual from anticipating the sounds/music. It also results in some rather bizarre sounding music. For the first five hours of treatment, sound levels for both the right and left ears are equal. For individuals with language or communication deficits, the sound level is reduced in the left ear during the final five hours of training. The reason for this is to enhance sound going to the left hemisphere. The goal is to stimulate better left hemisphere development since it is responsible for processing speech and language.

At the conclusion of the treatment, another audiometric evaluation is completed. Some programs also complete an audiogram at the halfway point, after five hours of treatment. The purpose of the hearing evaluations is to determine if auditory peaks continue to be present and if any new peaks have developed. When AIT is completed, the peaks should have disappeared, indicating that the individual perceives all sound frequencies equally.

Individuals who exhibit indications of hypersensitive hearing appear to be the best candidates for Auditory Integration Training (AIT). Obvious evidence of this would be the behavior of constantly covering or holding one's ears. The presence of peaks on an audiogram is also a good indicator for benefits from AIT.

Dr. Cecile Wuarin, the psychologist who worked with Dr. Berard, feels that parents/caretakers should receive pre- and after-care consultation so they will be made aware of and be able to deal constructively with possible changes they may see in their son/daughter. For example, one possible change is an increase in attention span. If a person has a short attention span, it may be easy to redirect him/her away from a toy or task. However, if the person's attention span increases, he/she may become more stubborn and more difficult to redirect because his/her attention span is much longer.

Other behavioral changes may include an increase in emotional behavior (e.g., anger, crying, reacting to other people crying), independence (e.g., leaving an area without permission), and social growth (e.g., increased interaction). Dr. Wuarin states that if the trainee changes, the family must also change in how they perceive and interact with their son/daughter. This failure to change is evident when a parent reports that their son/daughter is "on their nerves" because they are not acting the way they used to act. One goal of AIT is to get them "to act" more adaptively and age-appropriately. Recognition of this is essential (e.g., an 18-year-old who wants to go to bed at 11 P.M. instead of her current bedtime of 8 P.M.). In general, we believe that since understanding and working effectively with autistic people is much different than understanding and working with people with other disorders (e.g., mental retardation), pre- and after-care consultation should be handled by professionals who have experience working with autistic individuals.

AIT involves several components including some audiological work, behavior analysis and management, educational issues, and after-care counseling for the client and family. The most satisfactory results can be obtained when a multi-disciplinary team approach is used for the administration of the AIT program. The Society for Auditory Integration Techniques (SAIT) recommends a multi-disciplinary team which could include (but is not limited to) specialists in the fields of audiology, psychology, special education, and speech/language.

Therapy Outcome

Parents of children who have received AIT have noted a variety of improvements. Some feel it has made little difference in their child's behavior, while others have noted significant changes after their child received AIT. While individual benefits will vary, behavioral aspects listed in literature and promotional materials include the following:

• improved attention to auditory stimuli and better comprehension
• improved memory for routine information
• improved organizational skills
• improved social behavior, interaction, and eye contact
• improved awareness of the environment
• increased communication; less echolalia and longer sentence structures
• decreased sensitivity to sounds
• decreased perseverative behaviors, impulsivity, and distractibility
• decreased irritability, yelling, and tantrums
• decreased lethargy and sitting around

Additional benefits have been suggested in limited studies utilizing positron emission tomography (PET) procedures to document physiological changes in cortical activity (Zarella 1995). For example, following completion of AIT; one boy showed decreased hypermetabolism in the frontal lobes of the brain paired with heightened activity in the occipital lobe. Behavioral observation indicated improved focus and sustained attention on academic seatwork.

Drs. Bernard Rimland and Stephen M. Edelson have conducted four studies on AIT: the first being a blind, placebo-controlled pilot study of AIT: using seventeen children. Eight in the experimental group received AIT: and nine in the control group listened to the same music but without the electronic modification. The children were tested before treatment, after the ten days of listening, and regularly for three months afterward. They discovered the experimental group tested significantly better on the Fisher's Auditory Problems checklist as well as the Aberrand Behavior Checklist. Some individuals show improvement during the treatment period or immediately afterward. Others report changes days, weeks, or even months later.

Advantages/Disadvantages

Though AlT may benefit some children with autism, the cost of treatment or lack of available practitioners can make it inaccessible.

Children younger than four years of age should not receive AIT: Since some of the muscles and structures in the middle ear and brain are still maturing and making basic connections, AIT could cause more harm than good.

The actual sessions require headphones that fit around the ears. Children with autism may need to be introduced gradually to this sensation prior to the actual training to overcome tactile defensiveness or sensitivity.

The child needs to sit relatively quiet for the 3D-minute session. It's recommended that her hands not be engaged in any tasks that require thought and attention. If a child can't sit still for an extended period of time, she may have something to eat or drink rather than books or puzzles to play with to keep her focused on the music rather than on other cognitive tasks.

Otitis media and ventilating tubes are fairly common in young children. Children who have tubes or ear infections shouldn't receive AIT since it could be painful or ineffective. Sound could be further distorted or displaced by traveling through the tube or fluid rather than directly impacting the eardrum.

Improvements from AIT shouldn't be expected immediately, but over time. It's also difficult to determine if changes are due to maturation, AI1; or a combination of factors or intervention that may be ongoing. A regression in behavior is also possible during the training, b ut it should resolve quickly after completing AIT.

Some parents were told the treatment effect could wear off and would have to be periodically repeated; however, the benefits of retraining are unknown at this time. Retraining shouldn't be necessary in the majority of cases. If indications suggest retraining, the parents should wait at least nine months before redoing AIT with their child.

The treatment is geared toward people who experience hypersensitive hearing and want to desensitize over-responsive reactions to auditory stimuli. However, the methodology is also being used with autistic individuals who don't present with hyper-acute hearing difficulties. The benefits of conducting AIT on individuals in the absence of hearing sensitivity issues are extremely questionable from an ethical standpoint. A global hope of "curing" autism through AIT hasn't been substantiated, even anecdotally. It's irresponsible to recommend or conduct treatment on a person who doesn't evidence the symptoms to prompt consideration of the treatment.

Individuals providing AIT are often minimally trained and unqualified to conduct or interpret audiometric measures of hearing. Requirements to be a practitioner amount basically to having the financial means to purchase the equipment and attend seminars in how to run the machine. Not only is the science of hearing (i.e., audiology) not a prerequisite, but sometimes it isn't addressed at all!

In the decade since AIT was introduced, several modifications have been made to the equipment. However, calibration information for the devices is usually not specific in regard to tolerance levels, filtering, and output levels. Without careful calibration specifics on the machines used, the possibility of damage to a normal hearing mechanism is very real. A child could suffer irreparable harm to hearing acuity if she's exposed to intense auditory stimuli without careful instrumentation control.

Further research is needed in what AIT actually does. There's a lack of sufficient study to determine its risks, benefits, and outcomes. Parents are participating in AIT treatment for their child at tremendous personal expense and effort. Efficacy studies haven't been conducted to determine if that expense and time are merited.

References

• Facing Autism, Lynn M. Hamilton Waterbrook Press 2000
• The Source for Treatment Methodologies in Autism Linguisystems Inc., 2000
• Stephen M. Edelson, Ph.D. Center for the Study of Autism, Salem, Oregon