Volume 7 Number 2, 2000

News and Notes
SAIT’s Board of Directors recently elected the following officers: Stephen M. Edelson, Ph.D., President, Salem, OR; Sally Brockett, Vice-President, North Haven, CT; Cherri Saltzman, Secretary, Minnetonka, MN; and Rose Marie Davis, Treasurer, Buena Park, CA. The officers will serve a one-year term.

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In a recent ‘Letter to the Editor,’ published in the Journal of Autism and Developmental Disorders (1999, Vol. 25, No. 5), Nicole Simon wrote a brief theoretical article on autism and auditory dysfunction. She suggested that auditory problems seen in autism are similar to those seen in individuals suffering from Wernicke’s encephalopathy, which involves damage to the brainstem nuclei. Dr. Simon points to the inability of autistic individuals to decode rapid speech stimuli and to recognize features in speech, such as stressed syllables. Interestingly, Wernicke’s encephalopathy often occurs in people suffering from alcohol intoxication and vitamin B1, thiamine, deficiency. Dr. Simon encourages more research on auditory dysfunction in autism.

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A revised version of the SCAN-C was recently released on compact disc, produced by Auditec and distributed by The Psychological Corporation. SCAN-C, developed by Robert W. Keith, Ph.D., is a popular assessment instrument that is used to evaluate auditory processing disorders in children ages 5 to 11 years.

The SCAN-C includes four subtests: Filtered Words, Auditory Figure-Ground, Competing Words, and Competing Sentences. The test is designed for children who do not suffer from hearing loss, but appear to have problems in attending, listening, and understanding speech in conditions with background noise.

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In the last issue of The Sound Connection, we listed several classical recordings on compact disc that were designed to stimulate the brains of babies, children, and adults. Philips Classics, a division of PolyGram records, has just released another “timely” compact disc, ‘Mozart for the Millennium.’ In light of this newest product on the market, we wish our readers a Happy New Year and a Very Merry Millennium.

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SAIT to Distribute Practitioner List
Since its formation in 1992, SAIT’s Board of Directors has often discussed the possibility of distributing to the public a list of practitioners. SAIT had planned to distribute a practitioner list in 1995; but because of the FDA’s decision to classify AIT devices as ‘medical’ devices, the list was placed ‘on hold.’ Since the FDA has changed its position on AIT devices, SAIT will begin to distribute a list of practitioners. SAIT receives many requests each day through the mail and e-mail from parents who are searching for a practitioner who offers various auditory interventions in their community. The list of practitioners will be distributed in the mail as well as on SAIT’s Internet web page, www.sait.org.

The practitioner list will consist of SAIT professional members; and the list will include the various auditory interventions offered by each individual, such as auditory integration training, SAMONAS, Fast Forword, etc. If you are a professional member of SAIT and would like to be included on our practitioner list, please complete the enclosed form and return it to SAIT. You can mail the form to our office in Oregon (P.O. Box 4538, Salem, OR 97302, USA); or fax it to us at 503-363-9110.

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U.K. AIT Study: Wrong Conclusion?
Our office has received numerous telephone calls, faxes, and letters regarding the auditory integration training (AIT) study conducted in England by Chris Cullen, Oliver Mudford, Lorna Wing and Richard Millis. A summary description of the study was published in the last issue of The Sound Connection (1999, Vol. 7, No. 1). The study has been accepted for publication and will appear in the American Journal of Mental Retardation later this year.

The AIT study involved a double-blind design involving 16 autistic individuals, and AIT was administered using the BGC device. Many people were surprised with the reported findings of the study–there were no changes for those in the AIT condition, but there were significant improvements on two outcome measures for those in the placebo condition (i.e., a decrease in hyperactivity and a decrease in ear-occlusion). Interestingly, common reports from parents following AIT often include a general calmness in their children (i.e., a decrease in hyperactivity) and a decrease in ear-occlusion (i.e., covering one’s ears).

The improvements observed in the placebo condition could actually have been due to AIT. That is, in phase 1, half of the subjects received AIT, and half received a placebo (i.e., unprocessed music). In phase 2, those who received AIT in the first phase were given a placebo; and those who received the placebo in the first phase were given AIT. The beginning of each phase was staggered across time, and there was a 4-month time interval between the beginning of the two phases. It is quite possible that the significant improvements observed in the placebo group were due to having received AIT in the first phase–eight months earlier. This would be consistent with the findings obtained by Rimland and Edelson in 1994. The behavior of 445 individuals was assessed monthly, for nine consecutive months. For many in the study, the benefits from AIT lasted the entire nine months.

There is a problem with the way the data were analyzed. In the analysis of their data, Cullen et al. collapsed the data together for each condition. The data for the AIT condition, from both phase 1 and 2, were collapsed together; and the data for the placebo condition from both phases were collapsed together. A request was made to Dr. Mudford, one of the authors of the study, to analyze the AIT and placebo data for each phase separately, in order to see if the significant improvement in the placebo condition may have occurred in the second phase of the study. Dr. Mudford replied that he will not separate the data because it will increase the likelihood of a Type I error. That is, when too many statistical analyses are conducted on a set of data, there is an increased likelihood that there will be a finding which is deemed significant when, in fact, it is due to chance. However, by failing to analyze the data in this manner, Mudford risks making a Type II error: failing to find a real effect of treatment.

Since improvement in the placebo condition could have actually been due to receiving AIT earlier, one cannot unequivocally state that the participants in the Cullen et al. study received no benefits from AIT. Further the findings present an unexplained paradox in that those in the placebo condition were said to have shown significant improvements. This requires explanation.

Three previous studies which have documented improvement following AIT have relied primarily on children and adults who had some form of auditory problem, such as sound sensitivity (i.e., painful hearing), hyperacusis (i.e., hearing too well), and/or central auditory processing problems (Rimland & Edelson, 1994, 1995; Edelson et al., 1999). Rimland and Edelson have reported that individuals who were not considered sound sensitive improved from AIT, but most of these individuals had some other form of auditory dysfunction. In contrast, there is no indication that the subjects in the Cullen et al. study suffered from any of these auditory problems. One would not expect an auditory intervention to help individuals who do not have any auditory problems.

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ASHA Journal Publishes Two Articles on AIT
Two articles on AIT–one pro and one con–were published in the October, 1999 issue of Language, Speech, and Hearing Services in Schools.

The article in support of AIT was written by Jane R. Madell of Long Island College Hospital in Brooklyn, New York. In her article entitled, ‘Auditory Integration Training: One Clinician’s View,’ Dr. Madell discussed several issues about AIT, including its theoretical basis, auditory attention and processing, and candidacy criteria.

Dr. Madell reported her preliminary findings on word recognition and uncomfortable loudness thresholds. Dr. Madell studied several populations including children with autism, learning disabilities, AD/HD, and central auditory processing disorder. Overall, Dr. Madell reported improvements in all of these populations following AIT. Although Dr. Madell conducted pre-treatment and post-treatment measures, there were no control subjects with whom to compare these results.

The second article, written by Anne Marie Tharpe, raised several criticisms about AIT, such as the small number of published research findings supporting AIT in the past 10 years and the lack of a theoretical basis for AIT. In general, Dr. Tharpe’s article highlighted important issues such as the need for more research and objective measurement tools. However, Dr. Tharpe cited some inaccurate information regarding AIT. For example, she describes the FDA’s old policy on AIT; she stated “… the practice of AIT should be considered investigational and conducted only with the approval of an institutional review board and with informed consent from the subject or legal guardian” (page 381). Unfortunately, Dr. Tharpe is not aware of the FDA’s decision made a year earlier regarding AIT devices. Such out-of-date information provides the reader with inaccurate and rather negative information about AIT.

Dr. Tharpe also cited two studies, Zollweg et al. (1997) and Yencer (1998), as evidence that there are no treatment effects with AIT. Both of these studies have severe limitations which were not mentioned in her paper. The majority of subjects in the Zollweg et al. (1997) study were mentally retarded, 27% of the narrow-band filter settings were set incorrectly, and the output levels of the AIT device were much higher than the maximum level recommended for AIT—output levels were measured as high as 120 dBA. In her study, Yencer (1998) evaluated children with Central Auditory Processing Disorder (CAPD) and measured change after only one month post-AIT. Huskey et al. (1994) from the University of North Carolina also investigated children with CAPD and found no changes at one month post-AIT, but they did find improvement two to three months post AIT.

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Earobics: Melissa Adle of Cognitive Concepts, Inc
The ability to read is the most critical skill a child will learn in school. However, many students continue to struggle with the task of reading throughout their school careers and into adulthood. Years of research have been dedicated to the fields of identifying specific deficits of students with reading difficulties and devising effective techniques for prevention and remediation of reading disabilities.

The resulting discoveries abound with documentation of the importance of listening skills, specifically auditory processing and phonemic awareness, to the development of literacy. In order for children to read, they need to understand how printed letters reflect our spoken language. Therefore we must be certain that children are first perceiving the sounds in our language accurately (auditory processing); and second, they must be able to identify the individual speech sounds, or phonemes, that make up words and understand how phonemes can be manipulated to create and change words (phonemic awareness). The current research findings reveal that without these two foundational listening skills, students cannot easily link spoken language to print, and consequently struggle with reading. [Editor’s note: In addition to the critical listening skills, the visual system must also be able to process visual information quickly and accurately.]

In addition to discovering the role of phonemic awareness and auditory processing in reading, research has also identified specific instructional practices and techniques that are clinically proven to improve these essential listening skills. Findings reveal that in order to be most effective, instruction must be explicit, systematic, and follow a developmentally appropriate hierarchy where linguistic complexity of tasks increases gradually throughout instruction. Important learning variables must be carefully controlled in order to thoroughly and gradually develop skills. Students must have adequate practice to develop mastery of certain skills before more complex tasks are addressed. When instruction is carried out carefully in this manner, deficits in phonological awareness, which represent the core deficits of reading disabilities, can be remediated.

In order to provide students with skill development, many therapists, teachers, and parents are using a software program called Earobics. Earobics is an interactive CD- ROM program that provides this type of scientifically based, systematic instruction for children in auditory processing and phonemic awareness.

Research has identified specific auditory processing and phonemic awareness skills that underlie the reading process. The Earobics program targets and trains students in these important skills. Specifically, students develop auditory processing skills such as auditory discrimination, figure-ground discrimination, auditory pattern recognition and temporal resolution while playing the Earobics games. Phonemic awareness skills developed include phoneme identification, identification of position of a sound in a word, rhyming, blending, segmentation and manipulation of phonemes. In addition, the Earobics program trains students in relevant cognitive skills that also play a role in the reading process such as auditory attention and memory. The adaptive training format of the program offers a “built-in intelligence” that allows the program to automatically adjust to the skill level of the player. In this way, the student receives individualized instruction and attention to facilitate the development of skills. This is a comprehensive and individualized training program.

Research with Earobics is currently underway in numerous settings, and many independent studies have been completed that examine the effectiveness of the programs. These studies have documented significant gains in children who participate in the Earobics program. A California school district found statistically significant improvement in phonological awareness skills to improve decoding, reading fluency and weekly spelling scores. In another study, the University of Cincinnati Children’s Hospital Center compared two groups of children with Down Syndrome and concluded that the phonological awareness and language skills of students improved when using Earobics.

To date, Cognitive Concepts, Inc. has produced two Earobics programs, one for students ages four to seven, and a more advanced version for students ages seven to ten. The company also offers an Educational Development Program that, in addition to software, includes staff development services, teacher’s resource materials, print-based literature, audio and video tapes.

New products for Cognitive Concepts include a third version of the program: Earobics One for Adolescents and Adults. This product provides very basic and essential auditory processing and phonemic awareness skill training to students who are ages ten and above, yet still struggle with reading.

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Autism and Hearing Loss
The Journal of Autism and Developmental Disorders (Vol. 29, No. 5, 1999) published a study by Rosenhall, Nordin, Sandstrom, Ahlsen, and Gillberg, conducted at the Child Neuropsychiatry Clinic in Goteborg, Sweden, to determine whether the prevalence of hearing loss or deafness was higher than that in the general population. A group of 199 children and adolescents with autistic disorder was audiologically evaluated from 1979 to 1991. The group consisted of 153 boys, age 1.2 to 21.3 (7.0 mean) and 46 girls, age 1.3 to 20 (8.4 mean). IQ evaluations were performed; and 28% of the group had average intelligence (IQ>70), 28% were mildly mentally retarded (IQ 50 – 70), and 44% were severely mentally retarded (IQ <50).

Mild to moderate hearing loss (20 to 40 dB HL), in all cases sensorineural, was observed in 7.9% (10/126) of those who could be tested appropriately; and 1.6% (2/126) were found to have unilateral hearing loss. Difficulty was experienced in testing some individuals in the group, and this problem is felt to have contributed to the wide range of results quoted from a number of referenced studies conducted with much smaller study groups. Of the total group, 63% (126/199) were judged to be reliably tested for auditory thresholds.

Bilateral hearing loss or deafness, ranging from pronounced to profound, was observed in 3.5% (7/199) of all cases, representing a prevalence over 10 times greater than found in the general population, and comparable to the prevalence found in populations with mental retardation. However, hearing deficits in this study group (all with autism) occurred at similar rates at all levels of intellectual functioning. It does not appear that the covariation with intellectual impairment per se can account for all of the variance of hearing deficit in autism.

Hyperacusis (“hyper acute hearing”) was determined through auditory brainstem response (ABR) testing for both the autism group and a control group. Hyperacusis was observed in 18.0% (20/111) of the autism group with normal hearing, compared to 0% in an age matched comparison group. No hyperacusis was observed in an age matched non-autism comparison group.

Serous otitis media (“ear infections”) was observed in 23.5% (38/162) of those tested in the autism group, compared with 5 to 7% in the general population. Related hearing loss (temporary) was found in 18.3% (23/126) of those that could be reliably tested.

The study emphasizes the need for auditory evaluation of individuals with autism in order to refer those with pronounced to profound hearing loss to habilitation and to follow those with mild to moderate hearing loss because of the risk of deterioration.

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Announcing the Autism Treatment Evaluation Checklist (ATEC)
A major obstacle in autism research has been the lack of a valid means of measuring the effectiveness of various treatments. Over the years, researchers have published hundreds of studies attempting to evaluate different biomedical and psycho-educational interventions intended to benefit autistic children. Much of this research has produced inconclusive or, worse, misleading results, because there are no useful tests or scales designed to measure treatment effectiveness. Lacking such a scale, researchers have resorted to using scales such as the Childhood Autism Rating Scale (CARS), the Gilliam Autism Rating Scale (GARS), or the Autism Behavior Checklist (ABC), all of which were designed to diagnose autism—to tell whether or not a child is autistic–and not to measure treatment effectiveness.

Two recent reviews have commented on the problem: “Often, investigators have to use diagnostic instruments to measure changes in response to treatment . . . this approach has not been very successful . . .because most diagnostic instruments . . .are not sufficiently sensitive to changes within an individual”1 ” . . . [M]easures of clinical improvement to validate treatment outcomes are even more seriously deficient.”2

The Autism Treatment Evaluation Checklist (ATEC) was developed by Bernard Rimland and Stephen M. Edelson, of the Autism Research Institute, to fill this need, which is especially urgent right now because of the 20 or more studies starting soon to evaluate secretin.

The ATEC is a one-page form designed to be completed by parents, teachers, or caretakers. It consists of 4 subtests: I. Speech/Language Communication (14 items); II. Sociability (20 items); III. Sensory/Cognitive Awareness (18 items); and IV. Health/Physical/Behavior (25 items).

Unlike most of the scales, it is not copyrighted and may be used free of charge by any researcher. Copies are available on request from the Autism Research Institute or at the ARI web site, www.autism.com/atec.

Users of the ATEC may have it scored free (4 subscores and a total score) by entering the responses via computer to the ATEC form on the website for immediate and free-of-cost scoring.

Results of research using the ATEC will appear in future issues of the Autism Research Review International (only with the express permission of the researchers who use ATEC, of course).

References

1. Lord, Catherine, in: Handbook of Autism and Pervasive Developmental Disorders (1997). Ed. by D.J. Dohen and F.R. Volkmar, Wiley, New York City (p. 477).

2. Accordo, P., and Bostwick, H., “Zebras in the living room: The changing faces of autism,” Journal of Pediatrics, Vol. 135, No. 5, November 1999, p. 533.

[Reprinted from the Autism Research Review International, 1999, Vol. 13, No. 4]

Editor’s Note: One way practitioners can track improvements in their clients is to encourage parents as well as teachers to complete the ATEC prior to the intervention and then following the intervention at regular intervals. For example, a parent can complete the form monthly for six consecutive months. Parents and caretakers can simply complete the ATEC on the Internet and then email, fax, or mail the summary scores to the practitioner. However, the practitioner may need to send a friendly note via postal mail or e-mail to remind their clients to complete the ATEC on schedule.