Auditory integration training/therapy (AIT)

Janzen20 reports that many parents in the USA now wish procedures or treatments such as auditory integration training to be carried out on their children but it is something schools feel is outside their responsibility. The authors and practitioners of this procedure claim it will desensitise children with autistic spectrum disorders and other pervasive developmental disabilities to the sounds that they find distracting, painful, and distressing, but much controversy surrounds this procedure. It has been introduced to New Zealand and promoted among parents of autistic children.

Auditory integration training (AIT) has been widely promoted as a treatment for pervasive development disabilities including autistic spectrum disorders (ASD), attention-deficit disorders (ADD, ADHD), and individuals with auditory sensory problems. It was initiated by Berard43 in France, and further developed by Tomatis and

alternative treatment for the last decade in many countries including the USA. It has not been approved as a treatment or medical device by the United States Food and Drug Administration (USFDA)42 or the New Zealand Ministry of Health.41 Since that time it has become one of the most controversial topics in the field of communicative disorders and at times elicits highly charged and heated discussions between advocates and detractors of the process.42,44

Tharpe42 suggests that part of the friction seems to lie in the weak basis of AIT’s theoretical framework and the targeting of children whose parents are considered vulnerable. This is probably due to the limited help that established mainstream medicine can provide.

The theoretical basis of auditory integration is not well understood and some of the suggested theories are well outside the current knowledge and understanding of the audiological processes and function.44 Berard, the founder of the procedure, claimed in his book ‘Hearing Equals Behavior’,43 that auditory processing problems can lead to different distortions in the auditory system (shown in peaks and valleys) that arise when people perceive sounds in an atypical manner and this could result in problems in behaviour and cognition.43,44 Berard considered threshold differences in hearing of 5-10 dB to be significant. However this is contradicted by current knowledge of the audiological system, where variations of 5-10 dB are well within the normal range of variability.44 Berard claimed that AIT strengthened the middle ear muscles (ossicles), which improved the ability to respond to loud sounds.43,44 He compared his form of auditory training to physiotherapy given on an elbow stating that he made it a rule to follow to the best of his ability, this kind of purely mechanical orientation in auditory retraining. Maddell states that current knowledge of the auditory system makes this theory implausible.44 It appears from Berard's writing, that he used very loud sounds on people he tested, as he describes in detail, patient reactions when sound intensities of the range 100-140 dB were used. There were no details given as to the doses that were administered during treatments but if sound exposures were excessive, there is the strong possibility of hearing loss and in such cases, there would certainly be a reduction in hearing sensitivity. The effects of temporary and permanent threshold shifts, which occur when the ear is subjected to certain sound level doses, are well known.

Typical AIT treatment consists of 18-20 listening sessions of 30-minute intervals over 10 consecutive days. A specially designed sound processor deletes low and high frequencies from music at random and this modulated music is transmitted to the patient’s ear via headphones. Audiograms are taken before, at mid-point of the treatment period, and at the conclusion of the course of treatment.

Major concerns raised by several authors include the insufficient number of high quality peer reviewed published articles on this topic and the calibre of some practitioners who have little or no professional training in audition.44 Much research and information is anecdotal as there are major problems in reporting AIT data. The ideal double blind studies are extremely difficult to report in children with autistic spectrum disorders and other pervasive developmental disabilities. Unless there is a large number of subjects, the matching of subjects remains a major obstacle. This is further compounded with the huge variety or spectrum of symptoms found in children with autistic spectrum disorders and other pervasive developmental disabilities. Due to the complexity of carrying out double blind studies, other forms of effectively evaluating AIT data will probably be needed.44

Tharpe42 and Madell44 draw attention to the placebo effect, which cannot be discounted. When significant amounts of money are paid for a service, parents, carers or clients usually have considerable expectation that it will work to justify the expense. This can introduce bias, as those making the investment perceive it to work irrespective of whether it does or not. If the practitioner or clinician, as well as the client have high expectations, an even stronger placebo effect can occur.42,45 Studies by Yancer46 and Zollweg47 incorporated placebo control groups in evaluating the effectiveness of AIT with children diagnosed with auditory processing disorders and multiple handicaps. Zollweg’s47 findings indicated that AIT did not appear to give any more benefits than listening to ‘unmodulated’ music. Yancer46did not find significantly increased benefits from those receiving no form of auditory treatment.

Madell suggests some criteria which should be mandatory as part of this procedure. As current practitioners deliver music at sound pressure levels reaching 85 dB, equipment should be regularly calibrated to ensure that permanent hearing loss doesn’t occur.

patient should be fully evaluated by a clinician who is competent in the fields of audition, speech language development and developmental psychology.44

Preliminary data reported by Madell indicate that this procedure may be effective for some children.44 Janzen20 has also reported that AIT appears to have helped individuals with autism that have highly sensitive hearing but, as yet, the efficacy of AIT appears inconclusive.42 There have been some questions raised as to whether AIT should be considered an educational aid or tool rather than a form of treatment. If AIT is promoted solely as an educational aid rather than a medical device, it probably would not fall under the jurisdiction of the US FDA or the New Zealand Ministry of Health for approved medical devices and treatments. However if promoted solely on this basis, it could not be promoted as a device for treating or curing any condition associated with autistic spectrum disorder, attention-deficit/hyperactivity disorder or any physical or mental condition.