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Auditory Integration Training is an
Educational
intervention.
Berard AIT is an auditory intervention that
consists of
10 hours (20 sessions) over 10 or 12 consecutive days, under the supervision of
professionally trained
AIT Practitioners
who follow the
Berard AIT protocol.
The minimum
recommended age for AIT is 3 years of age.
AIT is a sound therapy
with many
scientific studies.
All information
provided here is for
educational purposes.
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Reviews of 28 Clinical Studies on
AIT - Auditory Integration Training (Berard
AIT)
"Conclusion: Auditory Integration Training does, in fact, appear to be a worthwhile, frequently
beneficial intervention which confers improvement in a number of symptoms,
in a significant proportion of disorders on the
autism
spectrum."
by Stephen M. Edelson, Ph.D. and
Bernard
Rimland, Ph.D. , Autism Research Institute, 4182 Adams Avenue, San Diego,
CA 92116
Auditory Integration Training: Historical Background
Auditory
Integration Training, as developed by French otolaryngologist Dr.
Guy Berard and based on the work of his predecessor, Alfred Tomatis,
typically consists of 20 half-hour sessions of listening to specially
modulated music over a 10 to 20-day period. AIT. has been reported to be beneficial in several
conditions, including ADD/ADHD, autism,
dyslexia, and hypersensitive hearing at certain frequencies.
The present
review covers 28 reports on AIT. Twenty-three reports
concluded that AIT benefits various population subgroups, three
studies claim to show no benefit (or no benefit over that seen in a control
group), and two studies reported rather ambiguous or contradictory results.
Considering the great difficulties in both providing a credible
placebo treatment and assessing improvement in the subject populations,
these results are quite encouraging. The balance of the evidence clearly
favors AIT as a useful intervention, especially in
autism.
Following
are summaries of all research studies known to us that have investigated
the efficacy of AIT. These studies were published
between January, 1993 and May, 2001 and have appeared in peer-reviewed
journals, professional newsletters, and/or were presented at professional
conferences. Twenty-six of the studies utilized subjects
with autism, attention
deficit/hyper-activity disorder, central auditory processing disorder,
and/or mental retardation. Two of the studies evaluated
the physiological effects of
Berard AIT on animals.
-
Section
A of the paper summarizes those studies supporting the efficacy
of
AIT;
-
Section
B summaries those studies that claim to have found no support for
its efficacy; and
-
Section
C summarizes the results of two studies which we have classified
‘ambiguous, contradictory, or controversial.
-
Following these three sections,
Section
D,
we discuss two additional reports in a Discussion section,
-
followed
by our Conclusions
The summaries
are listed chronologically within each disorder. All
used Berard-type equipment and procedures.
(We are not aware of any relevant research using the Tomatis approach
during the time period covered.)
The
following abbreviations are used for the tests/checklists utilized most
often in the studies:
- Aberrant
Behavior Checklist (ABC-1),
- Autism
Behavior Checklist (ABC-2),
- Behavior
Summarized Evaluation (BSE),
- Childhood
Autism Rating Scale (CARS),
- Clinical
Evaluation of Language Fundamentals--Revised (CELF-R),
- Conner’s
Parent Rating Scales (CPRS),
- Fisher’s
Auditory Problems Checklist (FAPC),
- Screening
Test for Auditory Processing Disorders (SCAN),
- Self-Injurious
Behavior Questionnaire (SIBQ),
- Staggered
Spondaic Word (SSW), and the
- Test
of Nonverbal Intelligence (TONI).
AIT AND AUTISM
STUDIES
(1)
Ocular Movements Among Individuals with Autism Pre- and Post-Auditory
Integration Training
Margaret
P. Creedon in collaboration with Stephen M. Edelson and Janice E. Scharre
Easter Seals
Therapeutic Day School, Autism Research Institute, and Illinois
College of Optometry
Paper
presented at the Annual Conference of the Association for the Advancement
of Behavioral Therapy, New York, 1993.
In an open-clinical
study, visual tracking movements and optokinetic nystagmus (a visual reflex)
were assessed in 22 autistic
individuals, ages 6 to 13 years, prior to, immediately following, and
three months after AIT. Significant improvements
were seen in horizontal tracking immediately following AIT and in both horizontal and vertical tracking
three months post-AIT
. No changes were seen in optokinetic nystagmus.
Parents
completed the FAPC and the ABC-1. The FAPC indicated significant improvement
at 3 months post-AIT, and the ABC-1
indicated significant improvement both immediately following and 3 months
post-AIT.
(2) Study of the Effects of
Auditory Integration Training in Autism
Dawn Cortez-McKee
and Jaak Panksepp
Bowling
Green State University, Ohio
Paper presented
at the Annual NW Ohio Autism Society Conference, 1993.
This open-trial clinical study utilized
33 autistic individuals. Participants were assessed
using multiple measures prior to (two baseline measures), and at 1-week,
1-month, and 3 months following AIT. The measures included: ABC-1, BSE, CARS, CPRS,
FAPC, and SIBQ. Significant improvement was seen on
all of the measures, except the FAPC, at the one- and three-month follow-up
assessment periods.
- AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
This
study was also an open-clinical trial with no control group for comparison.
(3 & 4) Two Studies of the Effects of Auditory Integration
Training in Autism
Tina K.
Veale
Comprehensive
Concepts in Speech and Hearing, Cincinnati, Ohio
Paper Presented
at the International ASA Conference on Autism, Toronto, Canada,
1993.
Study
I. In a double-blind placebo
pilot study, five autistic subjects participated in the experimental
group and five in the control group. Parents completed
three different evaluation forms--the ABC-1, the CPRC, and the FAPC.
These instruments were completed prior to, one month following,
and three months following AIT. There were no initial differences between
the experimental and control groups, but positive trends indicating improvement
in the experimental group were seen at three months following AIT for all three evaluation forms.
Study
II. This was an open clinical
study involving 46 autistic participants. Parents
completed the ABC-1, CPRS, FAPC as well as the Autistic Behavior
Composite Checklist and Profile. Significant improvements
were observed at one month and six months following AIT. Some of the behavioral changes
included: reductions in hyperactivity, social withdrawal, auditory problems,
restlessness, and anxiety.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
Study I included a control-placebo
group, but there were only five subjects in each group.
Given this small number, it is not surprising that, despite
the benefits seen, there were no significant differences between the
two groups. Study II which did find significant
pre- and post-treatment differences was an open-clinical trial and
did not include a placebo-group.
(5)
The Effects of Auditory Integration Training in Autism
Bernard Rimland and Stephen M. Edelson
Autism Research Institute, San
Diego, California
American Journal of Speech-Language Pathology, 1994, 5,
16-24.
This study involved an open-clinical research
design which included several experimental control measures. There
were 445 autistic subjects in the study, with ages ranging from 4 to 41
years. A significant reduction in sound sensitivity was found, based
on the presentation of pure tones prior to and immediately following the
AIT sessions.
Analyses of the hearing tests conducted prior to, after 5 hours of listening,
and after 10 hours of listening, showed hearing acuity to have improved
slightly while the amount of variability within the audiogram decreased.
Subjects were also assigned at random to one of several filtering conditions
(e.g., filter auditory peaks, no filters, filter painful frequencies).
No differences in the efficacy of the AITwere found among the filtering conditions.Parents
completed several different questionnaires on a monthly basis for 9 months.
These included the ABC-1, CPRS, and the FAPC. The responses to these behavioral
measures indicated a sharp reduction in problem behaviors, starting one
month following the AIT listening sessions. These changes remained stable throughout
the entire 9 months of post-AIT evaluations. Participants
were assigned at random to one of three different
AIT
devices. No differences were found in the efficacy of the devices.Correlational
analyses were employed to attempt to develop a profile of those individuals
who may benefit from AIT. Lower functioning individuals displayed significantly greater
improvement, as indicated by the ABC-1 and the CPRS.No
significant relationships were found between behavioral improvement and
age, degree of sound sensitivity, and the amount of variability in the
pre-AIT audiogram.
- AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
Although
a placebo group was not employed in this research project, the study
did include several experimental controls, such as videotape raters
who were ‘blind’ to before/after conditions, and random assignment
to filter conditions and to Auditory
Integration Training
devices.
(6)
Positron Emission Tomography Measure of Modified Auditory Integration
Therapy: A Case Study
Jacqueline M. Cimorelli and Melanie K. Highfill
University of North Carolina at Greensboro & Center
for the Dev. of Comm. and Learning, Winston-Salem, NC
Presented at the ASA National Conference, Las Vegas, 1994.
Reported in ADVANCE for Speech-Language
Pathologists and Audiologists, June 26, 1995.A single-subject
research design investigated changes in brain functioning following
AIT using Positron Emissions Test (PET) Scan technology.
The research subject was an 8-year old male with mental retardation and
autism. PET
scans were conducted prior to a second set of AIT listening sessions (baseline), one day
after the listening sessions, and six months later. The results at both
the one-day and six-month follow-up evaluations indicated a normalization
of brain wave activity, including a decrease in hyper-metabolism in the
frontal lobe and an increase in activity in the occipital lobe.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
Although these results are encouraging,
this study involved only one subject; and there was no control subject
for comparison. Additionally, a PET scan had not been given
prior to the first set of Auditory
Integration Training sessions;
thus, the baseline information used in the research study may not
be an appropriate measure for comparison.
(7)
Changes in Unilateral and Bilateral Sound Sensitivity as a Result of
Auditory Integration Training
Deborah
Woodward
Woodward
Audiology, McLeansville, NC
The
Sound Connection, 1994, 2, p.4.
Loudness
tolerance was investigated in 60 children with autism and related
disorders. Uncomfortable loudness level (UCL) measurements were performed
prior to and immediately following AIT.
Prior to AIT, the results from the
left and right monaural presentations (to each ear independently) as well
as the binaural presentation (to both ears simultaneously) were much lower
than 90 dBHTL, where 90 dBHTL is considered a normal lower limit of UCL.
Furthermore, the binaural tolerance to the speech noise was 9 to 11 dBHTL
less than the monaural tolerance level, where 3 to 6 dBHTL is considered
normal. Following AIT, the monaural
tolerance level to each ear increased 13 to 15 dBHTL, but overall, the
monaural and binaural tolerance levels were lower than normal. This increased
tolerance to speech noise was statistically significant. In addition,
the binaural tolerance level was only 5 dBHTL lower than the monaural
sound presentations, indicating a more normal response.
(8)
Parental Perceptions of Change Following Auditory Integration Training
for Autism
Dana Monville
and Nickola Nelson
Western
Michigan University
Paper presented
at the American Speech-Language-Hearing Conference, New Orleans, 1994.
A survey
was mailed to 150 parents of children diagnosed with either autism
or pervasive developmental disorder whose children had received AIT between 1991 and 1993. Forty parents (27%) responded
to the survey. Of those who responded, 25 (63%) reported an increase in
attention span; 25 (63%) reported a decrease in sound sensitivity; and
12 (30%) reported an increase in language. Four parents (10%) reported
an increase in tantrums and aggression.
(9) Auditory
Integration Training
Jane R.
Madell and Darrell E. Rose
Long Island
College Hospital, Brooklyn, NY; and Mayo Clinic, Jacksonville, F
American
Journal of Audiology, March, 1994, 14-18.
This study
involved an open clinical trial of AIT on
four children. Their diagnoses included: autism,
PDD, and learning disabilities. Audiograms of all four children showed
improvement following AIT (i.e., a decrease in variability). Behavioral
improvement was observed in three of the four children. The benefits reported
were: increased calmness, decreased sound sensitivity, and improvements
in speech/language and word recognition in noise.
(10)
Auditory Integration Training: A Pilot Study
Bernard Rimland and Stephen M. Edelson
Autism Research Institute, San Diego, California
Journal of Autism and Developmental
Disorders, 1995, 25, 61-70.
The study utilized a blind-placebo controlled
experimental design. Eight subjects were assigned at random to the experimental
AIT group,
and 9 were assigned to the placebo group. The placebo group listened to
the same, but unprocessed, music. Three months following AIT, significant improvements were observed on the
ABC-1 and the FAPC. Although there were no changes in sound sensitivity
nor changes in the audiogram, the majority of subjects had not been reported
to be sound sensitive, nor were they able to be tested audiometrically.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY: Although the subjects were assigned at random
to the
AIT and
placebo groups, there were initial differences between the two groups.
Regression analysis suggested the effects observed were not artifacts
of the initial differences.
(11) Epileptic
Activity in Autism and Acquired Aphasia: A Study Using Magneto-Encephalography
Jeffrey
D. Lewine, Sherri L. Provencal, John T. Davis, and William W. Orrison,
Jr.Department of Radiology, School of Medicine,
University of Utah Medical School
Paper presented
at the Autism Society of America National Conference, Orlando,
Florida, 1997
Magnetoencephalography
and EEG recordings were used to measure electrical activity in the brain
in one child with dyslexia and one high-functioning autistic adult.
Baseline recordings demonstrated larger than normal responses in the areas
associated with hyperacusis. Following AIT,
a more normalized balance or symmetry in electrical activity was observed.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY: These findings document physiological changes
due to AIT; however,
there were only two subjects in the study and no control group.
(12) Auditory Integration Training: A Double-Blind Study
of Behavioral, Electro-Physciological, and Audiometic Effects in Autistic
Subjects
Stephen M. Edelson, Deborah Arin, Margaret Bauman,
Scott E. Lukas, Jane H. Rudy, Michelle Sholar, and Bernard Rimland
Autism
Research Institute, San Diego, CA; Massachusetts General Hospital, Boston,
MA; McLean Hospital, Belmont, MA; and Upper Valley Medical Centers, Troy,
OH
Focus
on Autism and Other Developmental Disabilities, 1999, 14,
73-81.
Nineteen
autistic subjects were assigned at random to either the experimental
group (n=9), which listened to AIT-processed
music, or a placebo group (n=10), which listened to the same, but unprocessed,
music. All evaluations were ‘blind’ to group assignment. Behavioral, electro-physiological,
and audiometric measures were assessed prior to and following AIT Behavioral: A significant improvement was observed
in behavioral problems (using the ABC-1) in the experimental group at
the 3-month follow-up assessment. Electrophysiological: Of the 19 subjects,
three experimental group and two placebo group subjects were able to cooperate
with the auditory P300 Event Related Potential (ERP) task. All five subjects
showed abnormal P300 ERPs prior to the AIT
listening sessions. Three months following AIT, all three subjects showed a dramatic improvement
in their auditory P300 ERP. No improvement was seen in the placebo group.
Audiometric: The subjects' poor communication and attention skills precluded
formal statistical evaluation of the data from a battery of audiometric
tests; however, an audiologist was able to assign correctly 10 of the
15 subjects for whom partial data were available to the treated and non-treated
groups, on a ‘blind’ basis.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
AIT was
reported to produce both behavioral improvement and normalization
of brain wave activity. The behavioral changes on the ABC-1 are consistent
with those obtained in a previous study (Rimland & Edelson, 1995,
Section A, #10). Although the electrophysiological findings are encouraging,
they are based on a total of only five subjects.
(13) Auditory Integration Training and Autism: Two
Case Studies
Mark Morgan Brown
Private
Practitioner, Republic of Ireland
British
Journal of Occupational Therapy, 1999, 62,
13-18.
This is
a clinical study of two autistic siblings, a 5-year old male and
a 3 1/2-year old female. Observations were made at three and six months
following AIT.
Improvements were reported in attention, arousal and sensory modulation,
balance and movement perception, praxis and sequencing, speech and language,
social and emotional maturity, and eye control.
AIT and Attention Deficit (ADD) and Attention Deficit Hyperactivity Disorder
(ADHD) Reports
(14)
Non-Pharmacological Techniques in the Treatment of Brain Dysfunction
Jeffrey
M. Gerth, Steve A. Barton, Harold F. Engler, Alyne C. Heller, David Freides,
and
Jane Blalock
Georgia Institute of Technology, Emory University,
and the Atlanta Speech School
Technical
Report prepared for the GTRI Fellows Council, Georgie Tech Research Institute,
Georgia Institute of Technology, June, 1994.
This study
evaluated the effectiveness of AIT on 10 children with auditory-based learning deficits.
Eight of the ten had also been diagnosed as having Attention Deficit
Disorder. Subjects were given a series of diagnostic
tests, and parents were requested to complete several questionnaires.
Two subscales from the Woodcock-Johnson Psycho-Educational Battery test
were used to evaluate changes in auditory processing. These
subscales, the Sound Blending scale and the Incomplete Words scale, indicated
an improvement of one standard deviation or more in 4 of the 10 subjects,
and moderate improvement in two other subjects. Performance
on other criteria (e.g., CPRS and the FAPC) “could not be meaningfully
evaluated, given the amount of missing data.”
(15)
Auditory Processing Skills and Auditory
Integration Training in Children with ADD
Donna Geffner,
Jay R. Lucker, Ann Gordon and Dolores A. DiStasio
St. John's
University, Jamaica, NY and Ann Gordon Associates, Stony Brook, NY
Paper Presented
at the Annual Convention of the American-Speech-Language Hearing Association,
New Orleans, 1994
This study
investigated changes in audition and language in 16 children with AD/HD.
A large number of tests were employed to evaluate possible changes
as a result of AIT.
The measures included: standard audiometric
threshold testing, tolerance for tones and speech, speech recognition
in quiet and noise conditions, and the Goldman-Fristoe-Woodcock (GFW)
Test of Auditory Selective Attention. Post-assessments
were conducted within 3 months following AIT. Significant improvement was
observed in the subjects' tolerance to tones and speech, speech recognition
in the noise condition, and in listening skills as measured by the GFW
Auditory Selective Attention Test and several subscales from the Detroit
Test of Learning Aptitude (oral commissions, attention span for unrelated
words, and attention span for related words.)
- AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
No control group was utilized in this study.
(16)
Long-Term Effects of Auditory Integration
Training Comparing Treated and Non-Treated Children
Donna Geffner,
Jay R. Lucker, and Ann Gordon
St. John's
University, Jamaica, NY; and Ann Gordon Associates, Commack, NY
Paper Presented
at the Annual Convention of the American Speech-Language-Hearing Association,
Seattle, 1996.
The study
involved a one-year follow-up evaluation of children with Attention Deficit
Disorder. Those receiving AIT (n=10) were compared to a control group (n=10)
which did not receive AIT. Using a tolerance testing procedure
for 'uncomfortable' listening levels, improvement of 6 dB in the left
ear was observed for the AIT group, but no change was observed in those in the control
group. No differences were found between the two groups with respect to
listening to 'comfortable' speech. Additionally, tests
evaluating speech recognition in noise and auditory-language processing
showed improvement for those in the AIT group but not for those in the control group.
(17)
The Effects of Auditory
Integration Training on Children Diagnosed
with Attention Deficit/Hyperactivity Disorder: A Pilot Study
Wayne J.
Kirby
University
of North Carolina at Asheville
Paper presented
at the First Annual Congress of International Association of Berard AIT Practitioners,
Antwerp, Belgium, 2000.
The Sound
Connection, 2000, Vol. 7, pp. 4 &
5.
This study
employed a placebo-control design in which five children listened to AIT-processed
music and five children listened to the same, but unprocessed, music.
Subjects were assessed using the Auditory Continuous Performance
Test (ACPT) prior to and three months following the experimental/placebo
listening sessions. The ACPT provides measures for impulsivity and inattention
and also includes a 'total number of errors' score. Comparison
of the two groups at three months post-AIT indicated
a statistically significant reduction in the total number of errors for
those in the AIT group. Improvement was also observed on the impulsivity
and inattention scores for the AIT group, but these results were not significantly
different from the results obtained from the placebo group.
AIT and Central
Auditory Processing Disorder (CAPD) Reports
(18)
The Effects of Auditory Integration Therapy on Central Auditory
Processing
Brenda Huskey,
Kathryn Barnett, and Jacqueline M. Cimorelli
University
of North Carolina at Greensboro
Paper presented
at the American Speech-Language-Hearing Conference, New Orleans, 1994.
In an experimental
study, two auditory processing tasks were administered to six subjects
in the AIT treatment group and six subjects in a control group. These
tasks included the SSW test and the Phonemic Synthesis Test (PST).
Pre- and post-tests were given prior to, and at 4 to 6 weeks, and
at 8 to 12 weeks following AIT. For the SSW test, there were no improvements
in the subjects 4 to 6 weeks following AIT, but there were improvements on the total score
and on the left competing condition at 8 to 12 weeks following AIT. There were no changes in
the results from the PST.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
Although a control group
was employed, there were only six subjects in each group.
Additionally, the control group did not receive a placebo treatment
to permit evaluation of the possibility of a ‘placebo-effect.’
(19) Clinical Outcome Evaluation:
Auditory Integration Training
Jane H.
Rudy, Sharon S. Morgan, and Marianne Shepard
Upper Valley
Medical Centers, Troy, Ohio
Paper presented
at the Ohio Speech-Language-Hearing Conference, 1994.
In an open-clinical
study, 13 subjects diagnosed with attention deficit/hyperactivity disorder
(ADHD) and/or central auditory processing dysfunction (CAPD) were given
a variety of assessments prior to, immediately following, and three months
post-AIT. These
tests examined hearing acuity, central auditory processing (SSW, SCAN),
auditory evoked potentials (i.e., brain waveforms--P200 and P300), language
function (CELF-R), and intelligence (TONI). Immediately
following AIT,
there were significant improvements in the SSW, SCAN, and CELF-R, and
no change in the TONI. Three-months post-AIT,
there was additional improvements in the SSW and CELF-R, but no further
change in the SCAN. There was also a significant improvement
in the TONI. An analysis of the P200 waveform indicated
a significant change in amplitude but no change in the P300 waveform latency.
No significant changes in hearing acuity were detected during any of the
assessments.
- AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
This was an open-clinical study, and there was no control group.
Studies
Investigating Mixed Populations
(20)
Auditory Integration Training: One Clinician's View
Jane R.
Madell
Long Island
College Hospital and State University of New York, Brooklyn
Language,
Speech, and Hearing Services in Schools, 1999,
30, 371-377.
Changes
in speech perception were evaluated in several disorders prior to and
following AIT. The populations included:
autism, pervasive developmental
disorder (PDD), multisystem developmental disorder (n=46), attention deficit
disorder or attention deficit/hyperactivity disorder (n=26), and central
auditory processing disorder with leaning disabilities
(CAPD/LD, n=46). Subjects' speech perception
was assessed by asking them to recognize words in both
quiet and competing noise environments. Improvement
in speech perception was documented in both the quiet
and noise conditions following AIT. In a second part of this
study, uncomfortable loudness thresholds (UCLS) were evaluated
in individuals diagnosed with autism
(n=24, PDD (n=26), and CAPD (n=10). UCLs also improved
in these children following AIT.
- AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
This is an excellent clinical study with many subjects and multiple
measures of change. However, a control group was
not used for comparison.
(21)
A Comparative Study of the Earducator and the AudioKinetron
Sally Brockett, M.S, Berard AIT Practitioner
and Berard AIT Professional Instructor
IDEA Training
Center, North Haven, Connecticut
The Sound
Connection, 2001, 8, 1 & 6.
This study
compared the effects of two Berard AIT devices --the
Earducator and the
AudioKinetron. A total of 19 children diagnosed with
autism,
learning disabilities and attention deficit disorder participated in this
study. The children were assigned at random to either the
Earducator or
the AudioKinetron; and the evaluators, the parents, were ‘blind’ to group
assignment. The ABC-1 and the Attention Deficit Disorders Evaluation Scale
were used to assess changes. The results showed improvement
in both groups of children and no differences between the two
AIT devices.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
Although the aim of this study was to
compare two
Berard AIT
devices, a placebo group would have also provided additional information
regarding the effectiveness of the two
AIT devices.
Reports
of AIT and Animal Studies
(22)
An Animal Model of Auditory
Integration Training
M. Waldhoer,
J. Panksepp, D. Pruitt, M. Vaningan, D. McKee, J. Rossi III, and J. Lindsey
Bowling
Green State University & Toxicology, Wright-Patterson Air Force Base
Paper presented
at the Annual Society for Neuroscience Convention, San Diego, 1995.
This study
was undertaken to follow up the positive findings seen in an earlier study
on autistic children conducted by these authors (see
Section A,
#2). AIT was administered to newborn domestic chicks, selected as
the species of choice because of their responsivity to sounds.
Starting at two days of age, subjects were included in one of three
groups--AIT (experimental), music
(control 1, same music as the AIT group but not processed), and silence (control
2). Following AIT, those in the experimental group exhibited an
increase in growth and a reduced inhibition to separation-induced vocalizations
in response to music. Post-mortem analysis of the brain
tissue indicated a reduction in serotonin and 5-HIAA levels in the two
music groups (experimental and control 1). In addition,
an analysis of the behavioral effect of cyproheptadine,
a general serotonin antagonist, yielded comparable behavioral effects.
The data suggest that AIT may modify serotonergic tone in the brain
(23)
Biochemical Changes As a Result of Auditory
Integration Training-type Modulated and Unmodulated Music
Jaak Panksepp,
John Ross III, and T.K. Narayanan
Bowling
Green State University, Ohio
Lost
& Found: Perspectives on Brain, Emotion, and Culture,
1996/7, Vol. 2, p. 1 & 4.
This experiment
involved four conditions in which groups of chicks were exposed to either
AIT-type modulated music (using the
EASe Disc 1, produced by Vision Audio, Inc., Joppa, MD); unmodulated music
(the same music source but not processed); human voices (male and female);
or no sound. For both the modulated and unmodulated
conditions, neurochemical assays indicated a dramatic increase in norepinephrine
and its principle metabolite, MHPG. The researchers
also found increases in brain dopamine and its metabolite (HVA), but these
changes were not as large. No clear changes were observed
in brain serotonin and epinephrine. Very little change
was observed for those included in the 'human voice' and 'no sound' conditions.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
Changes were not observed
in the human voice condition (placebo group) and
no sound conditions, but neurochemical changes were found in the modulated
condition (AIT group)
and the unmodulated condition (placebo group). These
findings indicate that listening to music produced neurochemical changes.
Autism
Reports
(1)
Auditory Integration Training for Children with Autism: No Behavioral
Effects Detected
Oliver C.
Mudford, Barbara A. Cross, S. Breen, Chris Cullen, David Reeves, Judith
Gould,
and Jo Douglas
Keele University,
University of Manchester, and UK National Autistic Society
American
Journal of Mental Retardation, 2000, 105, 118-129.
In a double-blind
crossover design, 16 autistic children were evaluated for a 4-month
period. Several measures were used in this study including:
parent and teacher rating scales (ABC-1, Nisonger Child Behavior Rating
Form), direct observations (stereotypy, object obsessive, disruptive behaviors,
stigmatising behaviors, vocal stereotypy), intelligence/cognitive testing
(Leiter International Performance Scale), speech-language evaluation (Reynell
Developmental Language Scales III), social/adaptive behavior (Vineland
Adaptive Behavior Composite), standard audiometric testing, and parent
reports. Improvements were observed in both the
AIT group and the placebo group on adaptive/social
behavior and expressive language. Statistically significant
improvements in hyperactivity and ear occlusion were observed in the
subjects who participated in the placebo condition.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
Although
the significant improvements seen in those in the placebo condition
were dismissed by the authors, it is quite possible that these improvements
may have been due to the subjects having received
AIT
eight months earlier (i.e., they may have participated in the
AIT group prior to
the crossover). This is a real possibility given:
(a) the two areas of improvement in the placebo group are consistent
with findings associated with
AIT; and
(b) Rimland and Edelson (1994, see
Section A, #5) and Gillberg et
al. (1997, see Section C, #2) documented improvement up to 9 months
following
AIT.
The present authors called this possibility to Mudford’s attention
and suggested that the data be reanalyzed to test it.
Mudford refused, claiming that additional analyses of the data
would increase the likelihood of error. On the contrary, reanalysis
of the data would have decreased the likelihood of error.
Here we see an eagerness to declare
AIT ineffective
when the data do not necessarily support such a conclusion.
AIT and Central
Auditory Processing Problems (CAPD) Reports
(2)
The Effects of Auditory Integration Training
for Children with Central Auditory Processing Disorder (CAPD)
Karen A.
Yencer
State University
of New York at Buffalo
Doctoral
Dissertation, 1996; American Journal of Audiology, 1998, 7,
32-44.
Thirty-six
children diagnosed with central auditory processing disorder participated
in an experimental condition (i.e., listened to AIT music), a placebo condition (i.e., listened to
unmodulated music), or a control condition (i.e., did not listen to music).
Children with autism,
pervasive developmental disorder (PDD), and multiple-handicaps were excluded
from the study. A battery of tests were administered
to the subjects prior to and one month following the listening sessions.
These included: standard audiometric testing, the SSW test, the
Phonemic Synthesis test, the Standard Progressive Matrices test, FAPC,
auditory brainstem response (ABR), event-related potential (P300), and
a speech-in-noise test. The P300 analyses indicated
some improvement in the AIT
condition (mean latency from 366.2 msec. to 348.5 msec.) versus a slight
worsening in the placebo condition (mean latency from 400.8 msec. to 402.2
msec.). Significant improvements were found for the
three conditions on all measures except the speech-in-noise test.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
Yencer examined changes
following
AIT
after only four weeks following the
AIT
sessions. Stephen M. Edelson, who consulted on
this study, noting that Berard
and others had stated a need for at least 3 months of follow-up, insisted
that she examine changes for at least three months following the
AIT
sessions.
However, Yencer chose to conduct follow-up measures for only
one-month because of her dissertation schedule. Cutting
corners may be acceptable in meeting academic requirements, but not
acceptable where decisions affecting the welfare of handicapped children
are concerned. Note that Huskey, Barnett, and Cimorelli
(1994) investigated AITon a similar population (i.e., CAPD) and found no improvement at 4
to 6 weeks following AIT,
but did observe improvement at 6 to 8 weeks post-AIT
(see
Section A, #18).
AIT Studies
Investigating Mixed Populations
(3)
The Efficacy of Auditory Integration Training: A Double Blind
Study
William
Zollweg, Vere Vance, and David Palm
University
of Wisconsin at La Crosse; Research Associates, Inc.; and Gundersen Lutheran
Hospital
American Journal of Audiology,
1997, 6, 39-47
The
study involved a double-blind research design involving 30 participants
who were assigned at random to either an experimental
AIT group or a placebo-control group. The participants
were 7 to 24 years old, and the majority carried diagnoses of mild to
profound mental retardation. Some of the participants were diagnosed as
having autism.
Evaluations were conducted using audiometric tests, a Loudness Discomfort
Level test, and the ABC-1 at 3, 6, and 9 months following
AIT. Although no differences
were found between the
AIT and control groups with respect to hearing and
behavioral changes, both groups showed improvements. The results from
the Loudness Discomfort Level test indicated that the control group had
a higher tolerance for the frequency 250 Hertz than the
AIT group at the 9-month post-assessment measure.
-
AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
There are several severe problems with this study. First,
the title should have stated “… in a Mixed Population” since fewer
than a third of the subjects were autistic; thus one cannot
generalize these findings to the autism
population. Neither
Berard, nor any other responsible investigator, has proposed AIT
as a treatment for mental retardation. Second,
the volume level was much higher than recommended. The
recommended volume level is 80 dB SPL or lower. The
decibel level in the Zollweg et al. study was measured as high as
122 dB SPL. Finally, an analysis of the audiograms
indicated that 27% were given the wrong narrow band filters.
Given the methodological flaws, these findings are not applicable
even to the mentally retarded population.
(1)
The Long-Term Effects of Auditory Training on Children with Autism
Sue Bettison
Autism
Research Institute, Sydney, Australia
Journal
of Autism and Developmental Disorders,
1996, 26, 361-374.
“Eighty
children, 3-17 years of age, with autism
or Asperger syndrome and mild to severe distress in the presence of some
sounds, were randomly allocated to two groups. The
experimental group received auditory training and the control group listened
to the same unmodified music under the same conditions. Significant
improvements in behavior and severity of autism
were maintained for 12 months by both groups. Informal
data suggested that a range of abnormal responses to sound and other sensory
abnormalities may also have improved. Verbal and performance
IQ increased significantly 3 to 12 months after interventions.
Findings suggest that some aspect of both auditory training and
listening to selected unmodified music may have a beneficial effect on
children with autism
and sound sensitivity, …” [Author Abstract]
- AUTISM
RESEARCH INSTITUTE COMMENT ON THIS AIT STUDY:
The results indicated significant
improvement in both the experimental
AIT and
placebo groups, but there were no differences between the two groups.
Bettison attributed these improvements to listening to music
in a structured environment. However, critics have
interpreted these findings as evidence of ‘no benefits’ associated
with
AIT, which
is a debatable point.
While
this is an exemplary study in many respects, the instruments used to assess
changes associated with AIT had severe shortcomings. One
of the primary measures used to investigate changes in sound sensitivity
was a modified version of the Hearing Sensitivity Questionnaire (HSQ)
designed by Rimland and Edelson (1991). The HSQ was designed only
as a survey of sound sensitivity in the autism
population and not an instrument to evaluate treatment effectiveness.
Rimland and Edelson did not use it as an assessment measure in
any of their three studies on AIT. Additionally, Bettison employed
a scoring method for the HSQ that was said to provide a measure of the
person’s degree of sound sensitivity. This scoring method lacks even face
validity (i.e., the appearance that the checklist is valid).
For example, if a parent agreed with the item: ‘Have there been
certain sounds which the person does not seem to hear?,’ this response
was considered an indication of hypersensitivity to sounds rather
than hyposensitivity to sounds.
Another
measure used in the study, the Developmental Behavior Checklist, had been
used previously in clinical settings, but it was also not designed to
measure treatment effectiveness. When evaluating the
efficacy of an intervention, it is crucial that the appropriate measurement
tools be used.
(2)
Auditory Integration Training in Children with Autism: Brief
Report of an Open Pilot Study
Christopher
Gillberg, Maria Johansson, Suzanne Steffenberg, and Orjan Berlin
Autism,
1997, 1, 97-100
Nine children
with "an autistic disorder" were given
AIT for 10 days, in accordance with the procedure
recommended by Guy Berard.
No control group nor control procedure was used. At
the end of the 9-month follow-up period, 8 of the 9 children showed improvement
on the Autism Behavior Checklist (ABC) total score, and 7 of 9
children showed improvement on the ABC sensory subscale. Rimland
and Edelson.
Table 1: Tabulation of Studies
(Number of Studies)
|
Disorders |
Positive Findings |
Ambiguous, Controversial, &/or Contradictory |
Results Unclear or Questionable
|
No Effectsa |
| Autism |
13 |
1 (Bettison)
1 (Gillberg) |
1 (Mudford et al.) |
0 |
| ADHD |
4 |
|
0 |
0 |
| CAPD |
2 |
0 |
1 (Yencer) |
0 |
| Several
Populations |
|
0 |
1 (Zollweg et al.) |
0 |
| Animals
(chicks) |
2 |
0 |
0 |
0 |
a
Note that none of the studies failed to show discernible
benefits.
Of the 28
research studies that evaluated physiological, behavioral, and cognitive
changes in the subjects, the authors of 23 (82%) studies concluded that
their data supported the efficacy of AIT three (11%) claimed to have found no evidence
of efficacy, and two (7%) report ambiguous, contradictory results.
Discussion
Negative
Bias
We recognize
at the outset that no research study is perfect--all have flaws and shortcomings
of various kinds. However, the 23 studies with
positive outcomes, by and large, exhibited fewer and less serious shortcomings
than the subset of three supposedly negative studies.
All three of these studies demonstrated an alarming bias favoring
negative results [Mudford et al. (Section B, #1), Yencer (Section B, #2);
and Zollweg et al. (Section B, #3)].
Two additional
published reports clearly show a negative bias regarding
AIT by some researchers.
In a ‘Letter to the Editor’ entitled “When is a significant change
not significant?,” Patricia Howlin criticized
a controlled-placebo AIT study (Rimland and Edelson, 1995,
Section
A, #10) by stating that the statistically significant differences on two
measures were clinically not important (Journal
of Autism and Developmental Disorders, 1997,
27, 347-348). Howlin’s criticisms
were based on her misunderstandings. She stated “Thus, the mean fall in
the ABC score was less than 0.4 points; hardly a dramatic change in a
scale of 58 items” (page 348). Howlin assumed
that the maximum possible score on the ABC-1 was 58; however, the maximum
possible score was only 3. Thus, the difference
of almost 0.4 points is a meaningful proportion of the 0 to 3 range and
is clinically significant. Regarding another
measure, Howlin stated that a 12-point difference on the 93-item FAPC
was also not clinically important. Howlin was
wrong again. The FAPC contains 25 items, not
93 items; thus, an average change on 12 of 25 items is quite dramatic
and clinically significant. Again, the results
were positive, not negative.
In another
report, Rankovic, Rabinowitz, and Lof (1996) measured the sound output
levels of a single AudioKinetron, as reportedly used by a local
AIT Practitioner (American Journal
of Speech-Language Pathology, 5, 68-72).
The highest output level used by the practitioner was measured
at 110 dB SPL, and the maximum output level of the
AIT device was measured at 118 dB SPL.
The authors concluded that these output levels can be harmful to
hearing, and warned that AIT is potentially dangerous. However,
an
AIT device, like
any radio, compact disc or audiocassette player, can be set to play too
loudly. Should all be banned as potentially dangerous? Every
practitioner is aware of his/her responsibility to make sure that the
device is played at an appropriate level. Basing conclusions on a single,
very probably atypical case, is a poor practice—the authors’ conclusions
are not justified.
A good deal
of what has been written about AIT is excessively skeptical, negative or
derogatory, permeated with the assumption that AIT is ineffective. Our
review of all the research on the efficacy of AIT that we have been able to find refutes this negative
view.
Probably
because AIT lacks a plausible rationale and is counter-intuitive, it
has become the target of skepticism and of negatively biased research.
One’s opinion about an intervention, like one’s opinion about
an individual, should be based on evidence rather than prejudice.
The present authors were themselves skeptical when first learning
about AIT. Their interest was stimulated,
despite their initial skepticism, by a number of almost-too-good-to-be-true
clinical reports from parents of autistic children who had been treated
at Dr. Guy Berard’s clinic in Annecy,
France. There is a place for skepticism, but
there is also a place for safe, non-intrusive, short-term and relatively
inexpensive therapies with reasonably good track records.
Physiological
Findings
It is of
interest that all seven studies that sought evidence of physiological
change (e.g., electrophysiological, biochemical) as a result of AIT, including the two animal studies, reported positive
findings (Section A, #s 6, 11, 12, 19, 22, 23;
Section B, #2).
This is an area where further research is indicated, in our opinion.
‘Placebo’
Music -- Less Inert Than We Think?
Five studies
described in this paper utilized a placebo group and found significant
improvements in both the AIT group and the placebo group (Bettison, 1996,
Section C, #1; Panksepp et al., 1996/7,
Section A, #23; Waldhoer et al.,
1995,
Section A, #22; Yencer, 1998,
Section B, #2; Zollweg et al., 1997,
Section B, #3). While such findings are typically
construed to indicate ‘no benefits’ from AIT, we believe there may be more to the story than
that.
Jaak Panksepp
has raised the intriguing possibility (personal communication) that the
presumably inert ‘placebo’ music may have had, contrary to expectation,
a significant beneficial effect. Guy
Berard specified that the music used in his version of AIT must have (1) a good tempo/beat, (2)
a large variation in frequency within short intervals, and (3) a strong
unpredictability component. Bill Clark, an audio
engineer and developer of a popular AIT device, after analyzing the output of over one
thousand compact discs, identified about 70 discs that best meet Berard’s
specifications. Most
AIT Practitioners use the music from Clark’s list
As Panksepp points out, this small subset of carefully selected,
attention-arousing music is not a random sample of available music and
may, in fact, confer benefits that disqualify it from placebo status.
Panksepp suggests such music arouses and activates attentional
circuits in the brain (Panksepp, 1996/7, See
Section A, #23).
Future
Research on Auditory Integration Training
Based
on our monitoring of Auditory
Integration Training research, we offer the following suggestions
for consideration in future research studies.
-
Diagnostic
instruments are inappropriate for evaluating treatment efficacy.
Assessment instruments designed specifically for evaluating
treatment efficacy should be utilized.
-
An
assessment follow-up period of at least three months is necessary.
-
In
a mixed population, separate statistical analyses should be conducted
to assess specific populations (e.g., AD/HD, autism,
CAPD, dyslexia).
-
When
describing the AIT procedure, specify the filter settings, loudness
levels, etc. topermit assessment and replication
of the research.
-
The consistent findings of better
than expected outcomes for the placebo groups in a number of studies,
as well as evidence from other sources, suggests that certain kinds
of music may stimulate significant improvement in attention and learning
in some individuals, even without filtering and/or modulation of the
music. Additional research in this area is
clearly needed.
-
All seven of the studies in this
review that have measured electrophysiological or biochemical responses
have reported such changes in the subjects given AIT. Further study of physiological
responses to AIT is indicated.
Our review of the available literature
on Auditory
Integration Training has produced 23 studies with positive results
and only 3 claiming no benefits from
AIT. While none of the research
done thus far on AIT is of Nobel Prize quality, the positive studies
are far more credible than those with negative results.
As we point out in our comments, the 3 studies that claim no benefits
are deeply flawed, with conclusions that are not supported by the research
procedures nor the research data.
AIT does, in fact, appear to be a worthwhile, frequently
beneficial intervention which confers improvement in a number of symptoms,
in a significant proportion of disorders on the autism
spectrum.
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