Over thirty years ago, a French physician and noted ear, nose and throat specialist, Dr. Guy Berard, began noticing that the hearing problems exhibited by many of his child patients were affecting their school work. He discovered that many times the learning and associated behavioral problems of the child were rooted in hypersensitivity, as well as below-normal sensitivity, to sounds at particular frequencies. It appeared to Dr. Berard that both of these auditory conditions were "clearly associated with many behavior and learning problems, including hyperactivity and dyslexia" (Berard, 1993). In response to these observations, Dr. Berard set about devising an auditory training program designed to normalize these hearing anomalies and ultimately cause the "amelioration of [the] behavior or learning problem" (Berard, 1993). This technology-based auditory training has since come to be known as the Berard Method of Auditory Integration Training (AIT).

In 1976, an American couple asked Dr. Berard to treat their institutionalized 12-year-old daughter who was diagnosed with autism. Although hesitant to do so, Dr. Berard agreed. It was the first time he had treated a patient with autism or, more specifically, the auditory hyperacusis associated with autism. Auditory hyperacusis is common among autistic children. In fact, it has been reported (Coleman, 1989) that many "autistic children cover their ears to shut out vacuum cleaner sounds, the sounds of crying infants, or sometimes the most ordinary of sounds." After two half-hour sessions a day, over a ten-day period, the child began to show signs of more normal behavior, especially in the presence of the kind of painful sounds from which she would previously withdraw (Stehli, 1991). Since that time, Dr. Berard has trained more than three hundred AIT trainers worldwide (G. Berard, personal communication, January 24, 1999).

The general purpose of this paper is to provide an overview of AIT and its applications in the auditory training of children with brain disorders including autism, pervasive developmental disorder and related conditions. Specific items to be discussed in this paper include: (a) a description of the auditory training protocol as prescribed by Guy Berard, (b) some of the theories currently being discussed to explain the effects of auditory training, (c) a description of the technology used to deliver this auditory training, (d) a synopsis of the auditory training of several male children observed by the author over a ten-day period, and (e) the results of three-month follow up questionnaires.

Typically, the auditory training begins with a listening assessment using an audiometer. This assessment is done primarily to determine above-normal, rather than below-normal regions of hearing sensitivity. The assessment generally includes measurement of the subject’s hearing acuity at assessment frequencies of 125 Hz, 250 Hz, 500 Hz, 750 Hz, 1 kHz, 1.5 kHz, 2 kHz, 3 kHz, 4 kHz, 6 kHz, and 8 kHz. The purpose of this assessment is, as mentioned earlier, to determine specific frequencies, or peaks, at which the subject exhibits particular sensitivity. Berard defines a peak as an assessment frequency that requires at least five decibels less volume than neighboring assessment frequencies to reach the subject's threshold of hearing. For instance, if a 1000-Hertz tone requires five decibels less volume to reach audibility as compared to a 750-Hertz tone and a 1500-Hertz tone, it is considered a peak. When the peaks are determined, up to a maximum of two notch filters are selected on Dr. Berard’s Audiokinetron audio processor. This device is used to electronically modulate the notch-filtered musical program material received from a cassette deck or a compact disc player by passing the music alternately through dynamically activated high and low pass filters. The modulated music is then routed to stereo headphones that are placed over the subject's ears for the administration of the auditory training sessions.

Trainees are required to meet with an auditory trainer twice a day for a total of twenty half-hour sessions distributed over ten consecutive days. During the first session, the subject listens to the modulated music at a very low volume. The volume is gradually raised over the course of the 20 sessions. After the tenth session, a second listening assessment is done. It is common for the listening assessment to have changed at this point. In this case it is necessary for new filters to be inserted. It is at this point that non-verbal trainees and those with delayed speech begin a speech stimulation protocol. Because the left hemisphere of the brain receives auditory impulses from the right ear, the left headphone volume is attenuated for the balance of the sessions. This is done in order to allow the higher volume of the modulated music presented at the right ear to stimulate the speech center located in the brain’s left hemisphere. A third listening assessment is conducted after the twenty sessions are completed. The parents, guardians, or adult trainees are asked to submit a post-auditory training questionnaire three months after the final session and again in six months. Follow-up sessions are sometimes required.

Several explanations for the apparent normalizing effects of AIT upon the hearing response curve of recipients have been posited. The Society for Auditory Intervention Techniques (previously known as the Society for Auditory Integration Training) has published a pamphlet containing synopses of some of the prevalent theories put forth by researchers and other professionals (Society for Auditory Intervention Techniques [SAIT], 1997). One theory attributed to Guy Berard (SAIT, 1997) is that, because the fixed filters have filtered hypersensitive frequencies, less sensitive areas of the cochlea can better be stimulated by the modulated sound source. Stephen Edelson (SAIT, 1997) suggests that lateral inhibition of less sensitive neurons by more sensitive neighboring neurons may contribute to the below-normal sensitivity at certain frequencies. He suggests that by filtering out the frequencies associated with the most sensitive neurons, the neighboring neurons of below-normal sensitivity can then be stimulated by the modulated signal. This stimulation process may actually cause a lateral inhibition of the previously hypersensitive neurons, thereby flattening the hearing response.

Another explanation suggested by Berard (SAIT, 1997) is that AIT strengthens the tensor tympani muscle (attached to the malleus) and the stapedius muscle (attached to the stapes) of the middle ear. Ordinarily, these muscles prohibit traumatic pressure to the delicate inner ear in the presence of high intensity sound stimuli. However, if these muscles chronically malfunction and the muscle tension is not normal, hearing can become impaired. If the muscles are chronically tightened, then diminished sound sensitivity can result. However, if the middle ear muscles fail to contract in the presence of loud sounds, painfully intense sounds can be transmitted to the inner ear and the rest of the auditory system. It is thought that AIT strengthens these muscles, therefore normalizing middle ear function.

Jaak Panksepp (SAIT, 1997) has suggested that biochemical changes induced by AIT may also explain the effects of this auditory training. It may be that this auditory training may attenuate the elevated levels of brain opioid activities commonly exhibited by autistic subjects. It is possible that AIT normalizes those areas of the brain responsible for releasing endogenous opioids. Opioids are naturally produced chemical substances that alter sensory perception and reaction. Perhaps AIT reduces the production of these opioids by the autistic patient, thereby ameliorating their sometimes detached and unresponsive behavior.

In addition to Dr. Berard’s personal clinical work and research conducted over the past thirty years, a number of studies investigating the efficacy of AIT have been conducted over the past fifteen years in North America. One of the first studies (Cortez-McKee & Panksepp 1993) was an open trial clinical study of 33 autistic children. The children were assessed before and after auditory training using standardized instruments, including the Fisher’s Auditory Problems Checklist, the Aberrant Behavior Checklist, the Conner’s Parent Rating Checklist, the Childhood Autism Rating Scale, the Behavior Summarized Evaluation Test, and the Self-Injurious Behavior Questionnaire. Varying levels of improvement were indicated by all measures except the Fisher’s Auditory Problems Checklist.

In a double-blind placebo study (Veale, 1993), five autistic subjects receiving auditory training were compared to five receiving a placebo treatment. The ABC, CPRC and FAPC questionnaires completed three months after auditory training indicated some improvement in subjects of the experimental group. In a related clinical study by Veale (1993), 46 autistic subjects who received auditory training were rated by their parents using the ABC, CPRC, FAPC, and the Autistic Behavior Composite Checklist and Profile (ABCCP). After one month and six months, the subjects exhibited improvements in behavior including reductions in hyperactivity, greater socialization, reduced auditory difficulties, and lessened anxiety.

Bernard Rimland, Director of the Autism Research Institute in San Diego, and Stephen Edelson, of the Society for Auditory Intervention Techniques in Salem, Oregon, collaborated on several studies investigating the effects of auditory training on autism. In 1994, they conducted an open-clinical research study on 445 subjects. In it, they utilized three devices used to filter and modulate recorded sound, including Guy Berard’s Audiokinetron. The ABC, CPRS and FAPC questionnaires were submitted by caregivers on a monthly basis for nine months following the administration of AIT. The responses indicated a pronounced reduction in problem behaviors, which remained stable during the nine-month post-auditory training period.

A study into the comparative effects of AIT-processed music, unprocessed music, and silence on newborn chickens (Waldhoer et al., 1995) indicated an increase in growth among the chicks exposed to AIT-modulated music. Changes in brain serotonin levels were detected in the post-mortem brain tissue examinations of all chicks exposed to both modulated and unmodulated music. Serotonin, which is an amine, is important to mental activity. Further study may reveal similar chemical responses to auditory stimuli in humans that may prove beneficial in normalizing human brain function.

In a pilot research project investigating the effects of AIT on dementia, Natalie Trem (1995) conducted a double blind, placebo-controlled study of eleven subjects who met the criteria for dementia. These female subjects ranged in age from 70 to 96. Five of the subjects were assigned to the auditory training group. The author stated that, although the auditory training did "not significantly affect the cognitive status of individuals with dementia," as indicated by the Mini-Mental State Exam (MMSE), the nursing facility staff provided anecdotal evidence of positive change in the auditory training group. The author concluded that perhaps a future investigation that implements "a more behaviorally oriented instrument used with a less impaired population may yield significant results."

In July of 1998, I observed the administration of auditory training to several children over a ten-day period. About half of the subjects were non-verbal and unable to respond to the listening assessments. The following is a synopsis of my observations of these children. I have included listening assessment graphs (Calliham, 1998) of one of the children able to respond to the assessment stimuli. Several other children to be discussed (pseudonyms have been used to maintain confidentiality) were non-verbal and therefore unable to undergo listening assessments. I have also included the results of three-month follow up questionnaires provided by the children’s parents (Calliham, 1998).

Andrew, age five, had previously received auditory training when he was three years old. His parents originally sought auditory training principally to ameliorate hyperacusis in the presence of specific auditory stimuli such as "airbrakes on semitrucks [sic], loud crying of babies, chainsaw, motorcycles, [and] loud music." In the follow up session I observed, Andrew was reported by his parents to have developed a stammering problem in addition to a re-emergence of hypersensitivity to certain sounds. His pre-auditory training listening assessment indicated a peak in his hearing curve at 4 kHz in both ears. The Berard protocol does not allow for filtering at either 4 kHz or 6 kHz (G. Berard, personal communication, January 10, 1999). Therefore, no filters were set for the first ten sessions. Preceding commencement of the final ten sessions, a second listening assessment was conducted. The resulting listening assessment indicated a ten-decibel peak in the response of the right ear at 8 kHz. In addition, while technically not a peak as defined by Berard, the listening assessment showed increased sensitivity, relative to the lower frequencies, in both ears at 1.5 kHz and above. It was determined that both the 1.5 kHz and 8 kHz filters would be set. In order to address the stammering problem, anti-stammering settings were introduced; the volume of the left ear was adjusted to a setting that equaled one-half of the right ear volume. Ordinarily, these anti-stammering volume settings are recommended for all twenty sessions. In this case the auditory trainer decided that the trainee’s stammering was not of sufficient severity to warrant this particular protocol until the final ten sessions. Prior to the sessions on the ninth day, the auditory trainer's daily report indicates that Andrew exhibited "less stuttering and is calmer." The tenth day pre-session comments indicated that Andrew had been "overall—less anxious—less stuttering." Following the twentieth and last session, a final listening assessment was conducted. The resulting listening assessment indicated more consistent hearing sensitivity across the audible spectrum in both ears. Andrew’s three-month post-auditory training questions were answered during a telephone conversation between the AIT trainer and Andrew’s mother. The results, as reported by the auditory trainer, included some of the following comments. Andrew’s "stuttering is gone—except when he tries to talk too fast." His sound sensitivity was reported to be "not noticeable as much-- [it] does not upset him as much."

Sam was six years old when he arrived for his AIT sessions. He was reported by his parents to be speech delayed. He was also reported to have a high threshold to pain. His pre-auditory training questionnaire did not indicate a problem with hypersensitivity to sound. However, the pre-auditory training listening assessment showed auditory hyperacusis measured at -10 dB in the right ear at 750 Hz, 1 kHz, 4 kHz, and 6 kHz. Peaks were evident at 500 Hz and 1 kHz in addition to acute sensitivity of -10 dB in the left ear at 6 kHz and 8 kHz (see Figure 1). Sam began the auditory training with filters inserted at 1 kHz and 8 kHz. The mid-auditory training listening assessment indicated peaks at 750 Hz and 8 kHz. The second half of the auditory training began with filters set at these two frequencies and the speech stimulation volume set at a higher level for the right ear than the left. At the beginning of the last day, the parents reported that they felt his articulation was improving and that he was calming down and paying better attention. The final listening assessment indicated that Sam’s sensitivity to sound at all frequencies between 125 Hz and 8 kHz had risen to a level at, or above, 0 dB (see Figure 2). The graph indicated virtually no peaks as defined by Berard. The three-month post-auditory training questionnaire indicated several behavioral changes since auditory training. His parents reported that he had begun "making friends" and "interacting with more than one-on-one." They indicated that his play and language skills were improving. His writing skills had also improved. They stated that their son was "doing great since AIT."

Figure 1. Sam’s Pre-Auditory Training Listening Assessment

Figure 2. Sam’s Post-Auditory Training Listening Assessment

Carl, a nine-year-old boy, was diagnosed with severe autism. His mother reported his language skills to be limited to saying "Mum-Mum" and "no." His "receptive language" was reported as "good." He was currently attending an autistic classroom. His mother further indicated that Carl seemed "to have painful hearing at times" that seemed to be caused by a variety of sources that were not specifically identified in the pre-auditory training questionnaire. Because of his non-verbal, severely autistic status, listening assessments could not be obtained. At the first session, Carl twice tried to remove the headphones. For the next two sessions he remained fairly calm. During the third session he moved all over the room, laughing hysterically. He remained calm during the fifth through tenth sessions. A mid-auditory training listening assessment was not attempted. Speech stimulation volume settings were implemented for the remaining five days. Carl’s mother informed the auditory trainer at the beginning of the first speech stimulation session that he had been indicating headaches the previous evening by hitting himself in the head. He had purposely urinated on the coffee table and had bowel movements on his bed and in the pool. During the first speech stimulation session, Carl was very active throughout, jumping in and out of his chair. During the second session that day, he cried and whined. The auditory trainer inserted filters at 750 Hz and 8 kHz in a successful attempt to maintain volume levels while, at the same time, reducing auditory discomfort. The filters were removed for subsequent sessions. No listening assessment was attempted at the end of the auditory training. The three-month post-auditory training questionnaire indicated that he seemed to be less acutely sensitive to sound.

According to the pre-auditory training questionnaire completed by his mother, Norman, an autistic, non-verbal six-year-old, exhibited hypersensitivity specifically to the sounds of vacuum cleaners, blenders, and microwave ovens. He also exhibited negative reactions generally to sounds in various sections of shopping malls and grocery stores. His language ability was reported as two or three words at a time. His speech was further described as "difficult for most people to understand." On the morning of the first day of AIT, Norman would not sit still; after placing the headphones on his head he began to move around the room. With his mother’s permission, he was placed in a large car seat. He did not resist. In fact, he seemed to be very comfortable in the seat. He allowed the headphones to be placed on his head and secured with an athletic sweatband. Norman’s mother reported behavioral developments such as playing with his brothers more than usual and talking more than usual using single words and short phrases. The trainer's comments during this period included: "counted to ten a couple of times," "said ‘new music’ between tracks," and "said ‘song’ and ‘music.’ " Speech stimulation settings were introduced at the eleventh session. Over the course of the final five days of auditory training, Norman’s mother said that he "continued to talk more," and that he "ran to answer the phone [on the third night] and spontaneously said ‘Hi, Daddy' for the first time." At the beginning of the tenth day, Norman’s mother indicated that "he has made tremendous progress in his language." The post-auditory training questionnaire was submitted three months after the auditory training. In it, Norman’s mother indicated that he was sleeping "more soundly," seemed to "understand more," and had become more social; he had begun playing with his brothers and other children. His vocabulary had expanded, his speech was easier to understand, and he was "less sensitive to noises." Although his mother reported "improvement in all areas—more responsiveness," no improvement was reported in his schoolwork; he was "still in a special Ed classroom." Finally, Norman’s mother commented that "we think AIT was a turning point" in his life.

Four-year-old Richard was diagnosed with Pervasive Developmental Disorder (PDD) when he was three. Because of his disorder, the listening assessment was unproductive. Though verbal, his language skill level was reported as six months behind his age level. His mother described him on the pre-auditory training questionnaire as having experienced "sensory defensiveness in the auditory area." She went on to indicate that when Richard is in an over-stimulating environment "he frequently covers his ears in an attempt to filter out noise which may cause him to further ‘overload.’ " Some of the auditory stimuli that were particularly bothersome included the sound of wind and loud machinery. When Richard indicated some auditory discomfort, 750 Hz and 8 kHz filters were inserted for the second session only. Speech stimulation protocol was begun on the sixth day of auditory training. He became slightly unbalanced on his feet following the twelfth session. Because of this development, and in light of the fact that Richard did have verbal skills, albeit at a lower level than normal, the auditory trainer made the decision to remove speech stimulation for the duration of the session. Before the first session on the ninth day, Richard’s mother said that the loud sound of an amusement park ride that would have previously been intolerable did not bother him the preceding day. On the last day of auditory training, his mother indicated that his sound sensitivities had decreased considerably. The three-month post-auditory training questionnaire submitted by Richard’s mother indicated several changes since his auditory training. He was described as "more settled—seems more mature" and "more socially aware—asking for friends." His play skills had also improved: he was "sharing toys [and] playing (interacting) better with friends." His speech was more "fine tuned" and he was communicating with "more connecting words—longer sentences." His auditory hyperacusis was "greatly diminished" and he was "more focused."

The results of available research, as well as the large body of anecdotal evidence, suggest that Auditory Integration Training is an effective complement to traditional healthcare. These results, in conjunction with my own personal observations, have convinced me that auditory training offers great potential benefit for many who suffer from auditory hyperacusis and related brain disorders. I am personally committed to an ongoing program of research that may lead to effective auditory training-based opportunities for these and other conditions. I encourage researchers and other professionals to work closely with parents in order to expand the knowledge about, and access to, this promising music technology.

References

Berard, Guy (1993). Hearing Equals Behavior (Trans). New Canaan, CT: Keats. (Original work published 1982).

Calliham, Susan (1998). [Listening assessments and three-month follow-up questionnaires]. Unpublished raw data.

Coleman, M. (1989). Young Children With Autism or Autistic-like Behavior. Infants and Young Children 1(4), 22-31.

Cortez-McKee, Dawn & Panksepp, J. (1993). Study of the Effects of AIT in Autism. Paper presented at the Annual NW Ohio Autism Society Conference. Bowling Green State University, OH. Summary in Stephen M. Edelson and Bernard Rimland, (Eds.), Summaries of Research on Auditory Integration Training (January, 1993 - July, 1997: 23 Reports). San Diego, CA: Autism Research Institute.

Rimland, Bernard & Edelson, S. M. (1994). The Effects of Auditory Integration Training in Autism. American Journal of Speech-Language Pathology, 5, 16-24.

Society for Auditory Intervention Techniques (1997). Some Theories of Auditory Integration Training. Salem, OR: Author.

Stehli, Annabel (1991). The Sound of a Miracle: A Child’s Triumph Over Autism. Westport, CT: The Georgianna Organization, Inc.

Trem, Natalie F. (1995) The Effects of Auditory Integration Training on Dementia: A Pilot Study. Unpublished master’s thesis, Old Dominion University, VA.

Veale, Tina K. (1993) Comprehensive Concepts in Speech and Hearing. Paper presented at the International ASA Conference on Autism. Toronto, Canada. Summary in Stephen M. Edelson and Bernard Rimland, (Eds.), Summaries of Research on Auditory Integration Training (January, 1993 - July, 1997: 23 Reports). San Diego, CA: Autism Research Institute.

Waldhoer, M., Panksepp, J., Pruitt, D., Vaningan, M., McKee, D., Rossi, III, J., & Lindsey, J. (1995). An Animal Model of Auditory Integration Training. Paper presented at the Annual Society for Neuroscience Convention, San Diego. Summary in Stephen M. Edelson and Bernard Rimland, (Eds.), Summaries of Research on Auditory Integration Training (January, 1993 - July, 1997: 23 Reports). San Diego, CA: Autism Research Institute.

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