Volume 9, Number 3, 2002

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Auditory Interventions and Seizures
One question often raised by practitioners is whether a person who has seizures should participate in an auditory-based intervention. Seizures are not uncommon in the developmental disability population. In most cases, but not all, seizures first appear in the first few years of life or at puberty.

Some seizures can be induced by auditory stimulation. For example, most children with Landau-Kleffner Syndrome (LKS) have epilepsy; and there is some indication that their seizure activity may be triggered by an auditory stimulus.

Many seizures can be triggered by a stressful situation. An auditory program may be perceived as stressful to a child as well as the travel to and from the clinic.

If a child has a history of seizure activity, the practitioner should ask the parents what may trigger a seizure in their child. If auditory stimulation may trigger a seizure, it is recommended that the auditory program not be given to the individual until we learn much more about the possible relationship between a specific auditory intervention and seizure activity.

If the child’s seizure activity sometimes occurs during a stressful situation, parents and practitioners should do their best to reduce the child’s level of stress before, during and after the auditory session. For example, it may be a good idea to sit down and watch television or look at a picture book before and/or after the session.

The practitioner should also ask the parents how often the seizures occur. Is it once a month? Every other week? Weekly? Daily? etc. Throughout the auditory program, the child should be watched carefully to see if his/her seizure activity occurs more often. Parents should also be instructed to watch for any signs of increased seizure activity at home, i.e., before and after the auditory session.

Note: The Autism Research Institute in San Diego has received many parent reports stating that Vitamin B6 with magnesium and Di-methyl-glycine (DMG) reduced or eliminated seizure activity in their children. Vitamin B6 and DMG are much safer than the commonly prescribed anti-seizure drugs.

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What’s Before AIT, What’s After AIT?
With such a vast array of interventions now available, parents and professionals are sometimes uncertain as to an appropriate sequence to follow. Due to individual differences and unique needs, it is not possible to set any hard and firm sequence that would be appropriate for all people. However, there are some factors that should be given consideration.

If one considers the hierarchy of development as a guide, it is logical to pursue biological interventions first in order to build a strong foundation for the other developmental areas. When the body is free of toxins and is nutritionally well- balanced, it is likely to respond better to other types of interventions. If the individual has sound sensitivity that is caused by a deficiency in magnesium, yeast overgrowth, mercury toxicity, or use of aspartame (i.e., NutraSweet), the biological treatments may correct the hypersensitive hearing.

Biological treatments vary in the length of time needed to see improvement. While many treatment results may be evident within weeks, some require much more time (i.e., mercury and yeast detoxification may take several months to a year or more). If the child is experiencing sound sensitivity to such a degree that it interferes with daily life activities and/or the child is quite delayed in language development, parents should consider proceeding with AIT in order to improve this situation as quickly as possible. In a case such as this, it is often best to plan another session of AIT after the biological treatments have been completed in order to “fine tune” and stabilize the system. AIT is usually more consistently maintained when the biological dysfunctions have been corrected.

The minimum age for auditory integration training (AIT) is 3 years; and if the child is an appropriate candidate, the only behavioral requirement is that the child accepts headphones. Since AIT may provide such fundamental and comprehensive benefits and sets the stage for further development in many other areas, it is often the first choice by professionals and parents in regard to sound-based interventions.

Some children respond well to AIT following craniosacral or chiropractic treatments since these address some structural problems and may help the sensory defensive child accept the headphones. These treatments may also help reduce problems with chronic ear infections/fluid that can interfere with getting AIT done. Thus, there may be cases where it is best to pursue some of the biological interventions before providing AIT; whereas in other cases, AIT may give the child some immediate benefit that will outweigh reasons for delaying it.

Activities can be done during and after the 10 days of AIT to help the individual integrate and adjust to the changes derived from AIT. Many practitioners recommend participation in sensory integration activities even during the 10-day period of AIT and in the following weeks. This can help reduce any irritability and hyperactivity that may occur and may help reorganize the system more quickly.

A variety of interventions can be provided after AIT to facilitate the development of skills that failed to develop appropriately due to the inefficient auditory system. Computer software programs such as Earobics (www.earobics.com) and SoundSmart by BrainTrain (www.braintrain.com) can be used to help children develop auditory attention and processing skills. Listening to well-structured music such as Mozart and Gregorian Chants (without headphones) can also help reorganize the system. Hemi-Sync (www.hemi-sync.com) music can also be used and does not require listening with headphones.

Interactive Metronome (IM) (www.interactivemetronome.com) is another sound-based intervention that may be used by some individuals after AIT. Since it may take as long as six to nine months for the changes from AIT to be integrated into the system, it is generally recommended that other sound-based interventions not be considered prior to this period. This will allow parents and professionals time to see how the individual has responded to AIT and if there are continuing concerns. Interactive Metronome is designed to help improve motor planning, sequencing and timing capabilities. While these abilities may improve with AIT, some individuals may need more “fine tuning” in these areas; and IM may serve this function. In order to participate in IM, children must be able to participate in a series of coordinated, repetitive movement activities. Although headphones are required for listening to the metronome beats, these soft tones are much less likely to be disruptive to the benefits of AIT than the hours of listening to music and/or speech sounds that are basic to other sound-based interventions.

Currently, there is no data available on the impact of using headphones to listen to the music/speech sounds used in a variety of sound-based interventions. Parents and professionals need to be cautious about this since it is known that listening to music with headphones can have a negative impact on AIT results.

As one can see, many issues must be considered when determining the sequence of interventions. The individual’s needs and differences are a priority and options must take these into account.

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Guy Berard Selects Stephen M. Edelson to be His Successor
Dr. Guy Berard, the pioneer of auditory integration training (AIT), recently selected Dr. Stephen M. Edelson of Salem, Oregon to be his successor. This responsibility involves setting procedural standards and guidelines as well as protocol for AIT. This succession will not begin immediately – Dr. Edelson will gradually take on the responsibilities of Dr. Berard.

Dr. Edelson was the first person in the U.S. to conduct AIT. He co-authored three research papers on the efficacy of AIT. Over the years, he has been closely tracking the research on AIT; and he, along with Dr. Bernard Rimland, wrote the first comprehensive review of the literature. Dr. Edelson has been active in the Society for Auditory Intervention Techniques (formerly the Society for Auditory Integration Training). He was one of the founding members, served as President for eight years and Vice President for two years, and is co-editor of The Sound Connection. He also maintains SAIT’s Internet website (www.sait.org) as well as the Autism Research Institute’s AIT practitioner list.

Over the past 10 years, Drs. Berard and Edelson have corresponded on a regular basis to discuss and to make decisions on many pressing issues on AIT. This has included the determination of appropriate filter setting, modifications of the overall AIT procedure, the minimum age issue, and dealing with the Food and Drug Administration.

Dr. Edelson also works with Dr. Bernard Rimland, Director of the Autism Research Institute in San Diego and is on the Professional Advisory Board of the Autism Society of America. He is the past President and currently on the Board of Directors for the Autism Society of Oregon. Dr. Edelson was named ‘Volunteer of the Year’ in 2000 by the Autism Society of America.

Dr. Edelson will do his very best to continue the high professional standards of AIT which were established by Dr. Berard. Since auditory-based interventions are becoming more and more popular, he is ready to take on the many challenges that lay ahead. Your feedback and support will be appreciated.

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Letter from Dr. Guy Berard

Last Considerations Concerning AIT and Minimum Age of Children
Since the beginning of my work, I have placed a great deal of thought into these issues, in order to avoid wrong ways.

I first used:

  • my understanding of AIT
  • my own experience with AIT

Then gradually I had to add:

  • the reports sent to me by practitioners and parents,
  • my correspondences with other professionals in Audiology and Autism

These contacts with professionals taught me that there could be some underlying conditions, different than the usual ENT area, such as mercury toxicity, magnesium deficiency, the possible need for secretin, which could lead to sound sensitivity found in autism or other behaviour anomalies.

Being aware of this information, practitioners should discuss these possibilities with parents before applying AIT with my method. The parents will realize that the practitioner is informed of different sound sensitivity issues.

AIT can be appropriate for sound sensitivity, particularly when other underlying conditions have been ruled out or treated. AIT may also be appropriate for enhancing skills and abilities such as attention, language, socialization, etc. depending upon the individual.

Now, as for the minimum age for applying AIT, all my trainees are aware of the different rules that I have successfully taught, according to my own past experience. The first paragraph of this article explains that, little by little, I have had to take into consideration all of the advices which were provided to me by these numerous correspondents.

I shall now conclude that:

  • in the interest of children,
  • for eliminating any possibilities of damage of the ears, even if very very rare,
  • for suppressing the criticism of audiologists or other ENTs,

the minimum will be imperatively 3 years old, never less, even if parents are insisting for obtaining a younger age.

April 13, 2002, Annecy, France

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WARNING: Use Correct Headphones for AIT Devices! Tim Hagen, Engineer and Designer of the EarducatorTM
When purchasing replacement or spare headphones to use with AIT devices (AudioKinetron, BGC Audio Tone Enhancer/Trainer, EarducatorTM, etc.), it is very important to observe the device manufacturer’s recommendations. Delivered Sound Pressure Level (SPL) is at the top of the list of concerns. Impedance, as well as frequency response and consistency of performance, are also high on the list. Leakage of sound or noise, and wearer comfort are other factors.

Leakage refers to intrusion (of unwanted ambient noises) upon the person listening to the program, or to disturbance of other occupants of the room by sounds emanating from the headphones. On the subject of comfort, the distance between the ear and shoulder of young children must be considered – the height adjustment rails for instance, should not press into the base of the neck.

SPL and impedance. Various headphones which may appear suitable in regard to build quality, frequency response/fidelity and lack of sound distortion, may differ considerably regarding the Sound Pressure Level (SPL) delivered to the ear. It is of course critical to set the required sound level range for the program listener with confidence in the system. To use headphones of unknown sensitivity (SPL v. input power) is like fitting to one’s motor-car a set of wheels with arbitrary diameter – larger than standard size would cause the vehicle to go faster than indicated by the speedometer, and vice-versa.

A recent examination of the specs of different headphones for the same quoted impedance have revealed a possible disparity in SPL output as great as 8dB at the same volume setting!

Impedance is the most commonly quoted specification. It is given in ohms, and the figure should never be lower than allowed by the AIT device manufacturer, otherwise damage or distortion may occur; and the sound pressure given to the ears may go beyond acceptable levels.

The safe procedure is to use the same make and model of headphones recommended by the manufacturer of the AIT device.

Technical aspects for those who wish to examine alternatives:

Comparisons of SPL must be made, with a detailed headphone specification and basic scientific calculator handy. Typical data sheet for a good headphone example would include these features:

Frequency response 20 Hz – 25,000 Hz
Nominal SPL 80 dB at 1mW (one milliwatt)
Nominal impedance 75 ohms at 1kHz
Ambient noise attenuation 14 dBA

The SPL is usually quoted at a power input of 1mW. However, the AIT device will not deliver the same power to different impedances even if the volume setting is unchanged! A (theoretical) steady test tone passed through the device at a given output volume setting – without modulation occurring – should appear as a constant electrical drive level at the headphone socket (measured in volts, AC). This voltage applied to the headphones is converted to electrical power in milliwatts, and then, according to the “sensitivity” of the phones, into sound pressure. To do the math:

Step 1 Calculate the voltage delivered to one earpiece of the original phone by multiplying its impedance in ohms by one milliwatt, then compute square root of result.
Step 2 Do the same for the alternative model of headphone.
Step 3 Divide the voltage obtained in Step 1 by that obtained in Step 2.
Step 4 Apply the calculator’s log10 function and multiply result by 20. This shows the difference in SPL to be expected, at a fixed volume setting, between the two headphone models.

Example: comparison of phone model X (75 ohm) with model Y (100 ohm). The dBs quoted below refer to the performance of 2 fictitious phones and do not necessarily refer to actual output potential of AIT devices.

Step 1 Voltage into model X for specified 80 dB @ 1mW is 0.15 volts.
Step 2 Voltage into model Y for specified 85 dB @ 1mW is 0.20 volts.
Step 3 0.15/0.20 = 0.75
Step 4 Log 0.75 = -0.12 and x20 yields -2.5 dB (A positive number would have appeared if voltage 1 had been larger than voltage 2.)

Interpretation: in this comparison assume a fixed volume control setting of an AIT device, giving (theoretical) test tone of 0.15 volts. This would deliver 80 dB output from the 75-ohm model X as per the data given, and 85 dB plus -2.5 dB = 82.5 dB from the 100-ohm model Y. The dBs are added together, keeping the plus or minus signs in place.

Note: the “steady test tone” is a simple convenience for comparison purposes; music program content is highly variable and would be measured by a more complex time-averaging meter.

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Pilot Study Documents Impact of AIT on Sensory System
Auditory Integration Training (AIT) was introduced into the United States in the early 1990’s as an intervention for sound sensitivity and problems with auditory processing. The majority of the children who received AIT during the early 1990’s were those with autism spectrum disorders and therefore, prior to this intervention, they experienced the variety of sensory integration difficulties often associated with the disorder. Parents and occupational therapists began reporting important changes in the area of sensory integration that they observed following AIT. It soon became apparent that many of these children not only showed a decrease in sound sensitivity and an improvement in auditory processing, but they also exhibited fewer difficulties with other sensory integration issues after completing AIT.

During this period, there were a variety of theories presented to explain how the process of AIT may work (The Society for Auditory Integration Techniques [SAIT], 1994, 1995, 1996, 1997). However, most of these theories did not address why the changes in sensory integration would occur. Sally Brockett presented the Cerebellar-Vestibular System Theory which provides an explanation for the more global impact that AIT has on the individual (Brockett, 1994). A second article, “Auditory Integration Training from a Sensory Integration Perspective” by Sheila Frick and Nancy Lawton-Shirley, was published soon after and provided additional ideas on this concept (Frick & Lawton-Shirley, 1994). In January, 1999, the British Journal of Occupational Therapy published a report by Mark Morgan Brown on two case studies on AIT and autism (Brown, 1999) which further identified the effects of AIT on sensory processing. However, no data-based clinical reports have been done to measure the changes that are so often reported.

In 2001, Sally Brockett conducted a pilot study at IDEA Training Center with a group of 14 children with varied diagnoses, but all with identified sensory integration difficulties, to see if the anecdotal reports of sensory improvements could be quantified. The children participated in a standard program of AIT (two 30-minute sessions a day for 10 days). Parents were provided with The Sensory Checklist*, a list of sensory integration behaviors to rate prior to AIT, and then at one month, three months and six months post-AIT. The checklist contained items typically seen on sensory integration checklists and included areas such as vestibular hypersensitivity, vestibular hyposensitivity, tactile discrimination, self-regulation, play interactions, etc.

Analysis of the data indicates the following changes after AIT:

% Change (Median) Significance Levels
Vestibular Hypersensitivity 100% p<.005
Vestibular Hyposensitivity 67% not significant
Play Interactions 67% p<.005
Tactile Hyposensitivity 55% p<.005
Tactile Hypersensitivity 50% not significant
Self Regulation 42% p<.01
Poor Tactile Discrimination 33% not significant

Most of the areas measured showed a statistically significant improvement. Three areas did not achieve statistical significance, possibly due to small group size and the impact that individual differences can have when the group is relatively small.

The results of this pilot study are quite encouraging; however, the sample size is small and the checklist used was not standardized. The Sensory Profile provides a standard method for measuring children’s sensory processing abilities and may prove to be useful for further exploration of the relationship between AIT and sensory changes (Dunn, 1999). Brockett has started a larger study using The Sensory Profile as the measurement tool.

Brockett, S. (1994). The Cerebellar-Vestibular System Theory. The Sound Connection, 2.

Brown, M. M. (1999). Auditory Integration Training and Autism: Two Case Studies. British Journal of Occupational Therapy, 62, 13-18.

Dunn, W. (1999). The Sensory Profile. San Antonio, Texas: The Psychological Corporation.

Frick, S., & Lawton-Shirley, N. (1994, December). Auditory Integration Training from a Sensory Integration Perspective. Sensory Integration: Special Interest Section Newsletter, 17.

Various articles published in The Sound Connection (1994 to 1997).

*The Sensory Checklist was adapted from Emotional and Sensory Processing Problems, Appendix A, by Susan S. Poisson and Georgia A. DeGangi.

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MP3 Recordings Not Recommended for AIT
We have received several inquiries about using mp3 formatted music as a music source for AIT. MP3 formatted music is usually described as ‘near-cd quality.’

Background. MP3 formatted music is often played on computers and can be transferred over the Internet (e.g., Napster). MP3 music files are usually 10% of the size of a music file from a compact disc. Thus, if the size of a music file from a compact disc is 100 megs, the mp3 file size would be around 10 megs. This is a tremendous savings of space.

Using today’s technology, songs can be extracted from compact discs and converted into mp3 music files. As a result, music from 10 to 12 compact discs can be stored on one cd-rom. Thus, 10 or more hours of music from compact discs can be placed on just one cd-rom. Additionally, the latest stereo units, walkmans, and boom boxes can play mp3 files from cd-rom discs.

These mp3 recordings are not appropriate for AIT. In order to condense a normal music file from a compact disc to an mp3 music file, the upper and lower frequency ranges are deleted from the original music source. The loss of the upper and lower frequency ranges is usually not recognized by the normal hearing ear. However, since the listener must hear the full range of music in order for AIT to be most effective, mp3 formatted music is not recommended.