Volume 2 Number 1, 1994

Issues Discussed at SAIT’s Second Annual Meeting
The Society for Auditory Integration Training (SAIT) held its second annual meeting on July 6, 1994 at Bally’s Resort Casino Hotel in Las Vegas. A discussion forum enabled the members in attendance to participate and voice their ideas, concerns, and opinions. Following are highlights of the discussion.

Procedural deviations: The impor­tance of informing parents of any deviation from standard procedure was emphasized. Some AIT practitioners are using their own method to provide AIT without any evidence to indicate whether the outcome is equivalent to procedures that have already received empirical support. There was also concern about instructors who are using their own methods yet instructing future practitioners on how to conduct AIT. SAIT strongly recommends that deviations from standard procedure should only be done for research purposes, with explicit parent permission.

Minimum age: minimum age of 4 years continues to be recommended since some research on young children indicates the threshold for possible hearing damage is lower than that of adults.

P.E. tubes: If AIT is given to a child who has PE tubes, parents should be informed that it may not be as effective. Additionally, Dr. Guy Berard states that AIT may lead to an ear infection if given to a child with PE tubes.

Negative behaviors after AIT: Numerous possible causes of problem behaviors after AIT were discussed, including: the listener may not have adjusted to the way he/she perceives his/her environ­ment; the listener may be making progress for which appropriate adjustments are not being made in the environment, thus leading to frustration; the listener may not be able to ‘tune-out’ sounds in his/her surroundings any more and does not yet know how to deal with certain sounds; changes in and/or reactions to medications; changes in school or group home; etc.

In addition, there was a discussion of the possibility of losing the benefits from AIT after ear infections, excessive fluid in the middle ear, and exposure to loud sounds.

What is the Best Way to Set the Volume Level of the AIT Device?
First, there are two important points that must be clearly understood by the practitioner.

1. The digital readout on neither the Audiokinetron nor the Audio Tone Enhancer/Trainer (ATET; BGC) gives measurements of decibel level. The readings represent relative ‘degrees’ of volume. Volume level on the ATET device varies depending upon the music being played, and whether filters are set. On the Audiokinetron, these variables plus the number of bars lit on the ‘Level Control, Gain’ display affect the volume level. For these reasons, it is necessary to use a sound level meter to determine the actual output of the AIT device and to be sure it does not exceed 80 dB.

2. The volume level is always adjusted according to the comfort level of the listener. This means that some listeners may have a very low setting, especially during the first few sessions. Volume may be increased as the listener becomes able to tolerate more without discomfort. It is not necessary to use high output if this is uncomfortable to the listener. AIT can be effective even at lower volumes.

The following procedure should be used for setting the volume level:

1. At the beginning of the first training session, the volume level should be moderately low and gradually increased until the listener reports discomfort. Then the volume is reduced slightly so the music is perceived as loud but not painful. It most cases, the maximum volume level is reached during the first or second listening session. Basically, it is important to reach the highest easily tolerable volume level as soon as possible so that the listener receives the greatest benefit from AIT.

If a person cannot communicate whether the sound level is uncomfortable, then the listener should be watched very closely to determine whether he/she looks like he/she is experiencing any discomfort. In most cases, the listener will not experience any discomfort during AIT as long as the volume level does not exceed 70 to 80 decibels.

Occasionally, the listener may experience slight discomfort for a brief moment; for example, a listener may have a grimace on his/her face. This is often a result of certain frequency combinations in the music, such as harmonics. This type of reaction is not a concern as long as it occurs only a few times in a half-hour listening session.

Some listeners who experience pain from noise in their surroundings are afraid that AIT will hurt. It may be necessary, in these cases, to increase the volume very gradually during the first session or two. This can be done by increasing the volume slightly every five or ten minutes, depending on the listener’s comfort.

2. The listener should hear the music equally well in both ears. If the person does not hear as well in one ear, then the volume level should be increased until the listener hears the sounds equally well in both ears. If a person is unable to communicate equal hearing in his/her ears but the audiogram indicates a hearing deficit in one ear relative to the other, then the volume should be decreased by 30% for the ear without the deficit.

3. At the beginning of every listening session, the volume should be set lower than the established level for that individual. After a few seconds of listening, the volume level should be increased gradually until the established output level for that person is reached. At the end of the 30-minutes listening session, the volume should be reduced again prior to removing the headphones.

A Letter from Bill Clark
My warmest greetings to those of you using AIT. In 1989.Dr. Bernard Rimland phoned me about a device that had been sent to him from France by Dr. Guy Berard. The device, an earlier version of the Audiokinetron, had been damaged in transit; and Dr. Rimland, knowing that I was both an electronics engineer and the father of an autistic child, asked if I might help him by repairing it. He explained that Dr. Berard had brought about some very notable improvement in a number of autistic children through the use of this auditory training device. He said that Dr. Berard was about to retire, that the machine we were working with was the only one in the United States, and that it was important to try to see if we could reproduce Dr. Berard’s results in autistic children, since after he retired his work might be lost.

Upon dismantling the device, I saw that the design and construction were several decades old; and that by using state of the art integrated circuits, I could build a much simpler, much more reliable and adaptable device. With the encouragement of Dr. Rimland and Dr. Edelson, I proceeded to do so. The device I designed is known as the Audio Tone Enhancer/Trainer, or BGC machine, and is available from the BGC Company here in San Diego. (Although the “C” in BGC stands for Clark, I personally derive no income from the manufacture or sale of the BGC machine.)

As you know from research published by Drs. Rimland and Edelson, comparisons of the BGC device to the original and later models of the Audiokinetron device designed by Dr. Berard, show the machines to be very similar in their efficacy.

I have seen a great deal of concern recently with respect to FDA action taken against importation of the Berard device. I believe that most of the concern is unfounded. The Berard device was being imported into the United States as a “Medical Device”, presumably to avoid import duties. The FDA has as its primary concern the protection of the public. When a device is represented as a ‘Medical Device,’ it basically must be shown to be of no harm and it cannot be misrepresented. ‘Me FDA further regulates manufacturers to assure that a device cannot become harmful by improper manufacturing techniques. As long as the users of AIT equipment and their manufacturers do not make unfounded claims, I do not believe that the FDA will bother them.

AIT should be thought of in the same manner as music therapy. It is an aid that better allows an autistic individual to cope with the environment. There have been other “side benefits” that have been reported by many people who have used AIT. These “side benefits” should be viewed as individual comments on AIT and not claims of efficacy. Those people using AIT who have observed significant and beneficial effects should treat them as such, observations, not proof. As most of you know, for any procedure to be formally accepted by the FDA, a tremendous number of controlled tests must be performed. These tests require a great deal of money and time. It is for this reason that no formal claim can be made for AIT.

I believe that AIT is very helpful with autistic individuals and that given time, it will be formally accepted. There are many formal studies being made of AIT; and in due time, I am convinced that it will be demonstrated to be a useful tool in working with autistic individuals. I further believe that if those people working with AIT can properly organize and attract the attention of researchers, then studies can be formally completed and, as a result, accepted. There are many of you who are working with AIT to bring about a positive result, as opposed to those who are simply working with AIT as a business. The smallest positive difference that can be made in the life of an autistic is well worth the effort. It is my hope that you all enjoy success in your efforts.

William A. Clark

ASA Presentations on AIT (1994)
There were several presentations during the Autism Society of America National Conference in Las Vegas that focused on AIT. Melanie Highfill and Jacqueline Cimorelli of North Carolina presented results of their study using a Positron Emission Tomography (PET) to measure physiological changes in one child who received a ‘modified’ version of AIT. They reported that PET scans conducted after a second set of modified AIT listening sessions showed more normal levels of glucose utilization than prior to the listening sessions. (A PET scan was not given prior to the first set of listening sessions.) These changes were still present six months following AIT.

A parent panel discussion, led by Sally Brockett, presented experiences of two families whose children received AIT. These parents reported the specific changes they observed in their children following AIT, including: improved toileting skills, independence, no longer delayed auditory response time, increased social and environmental curiosity, increased verbalizations and clarity of speech, and decreased hyperactivity and irritability.

Drs. Charles Amenta and Stephen Edelson discussed AIT and the need for more objective research to document the effects of the procedure. Dr. Amenta questioned Dr. Berard’s theory on how AIT may work, but admitted there have been other significant developments in science that were not able to be easily and clearly explained. And, as he put it, sometimes the theory is wrong, but the treatment works. In addition, Dr. Amenta voiced his concerns about the integrity of some previous research studies.

Drs. Bernard Rimland and Stephen Edelson discussed their results on AIT as part of a presentation on a variety of research studies (birth month in autism, candida albicans, facilitated communication). The AIT portion included a summary of their first two research studies as well as some new results from their third study.

Dr. C. A. Kotsanis presented his results of a multi-treatment approach to autism, which combined nutritional and allergy treatment with AIT. Pre-testing on 12 autistic children identified many nutritional and allergy problems as well as sound sensitivity, language, and attention deficits. During the following one-year period, these children were treated nutritionally with rotation and elimination diets, therapeutic multivitamin and amino acid supplementation as needed and maximized nutrient intake. Allergy intervention included food dye elimination (100% had tested positive), filtered water, environmental clean-up, phenol free antigens as needed, and treatment for positive inhalants. AIT was given for a 10-day period. At the conclusion of the study, parent evaluations and clinical observations revealed group profiles which exhibited increases in verbal and communication skills, appropriate social behaviors, attention span, eye contact, and memory. Dr. Kotsanis also reported a decrease m sound sensitivity, impulsivity and sensitivity to touch in most of his clients.

Input from Dr. Guy Berard
We are pleased to introduce a column written by Dr. Guy Berard beginning with this issue of The Sound Connection. Dr. Berard will share information and stories from his personal experiences with AIT

The aim of AIT is to strengthen the auditory system’s ability to bring sound information from the surrounding environment to the individual’s brain as precisely as possible.

Does this mean that individuals receive auditory information differently from one another?

YES–it does. I have experienced a significant event which illustrated this fact to me, and many of my trainees already know the story.

Many years ago, I was training a 50-year-old man suffering from increasing hearing loss. At that time, I was using commercial records for my music source for the device.

During the first session, I was surprised to hear my patient singing at the top of his voice, eyes closed, beating time conscientiously.

His song didn’t sound like anything known; it was a sort of “TRA-LA LA, TRA-LA LERE ……”

At the end of the session, I asked the man, “What were you singing during the session?”

Answer: “Well, Carmen, by Bizet.”

Truly, the record was Carmen, but the song that I heard was as far from Carmen as Reggae is different from Gregorian chants.

The mid audiotest showed an important improvement in his hearing- A vanishing of the distortions and a raising of the graphic on the acute frequencies.

The last day of the treatment, without any special reason, I again, put on the record of Carmen. After 10 minutes, hearing nothing from my patient, I asked him, “Is it okay?”

He answered, “Yes, good.”
I asked, “Do you know this music?’
He answered, ‘No, not at all.”
I responded, ‘Well, it’s Carmen.’
He said, ‘No, it’s absolutely not Carmen!’
I said, “YES!”
He said, “NO!
I declared, ‘Yes, it is written on the record!”
He stated, ‘NO, it is not the same record!”
I replied, “Yes, I have only ONE CARMEN!!

Then, I had to carefully explain what had happened to HIS Carmen … (but I still wonder if he was really convinced!)

In this case, it was the same individual, hearing the same information, but receiving it differently due to the modifications in his hearing.

This typical example is similar to the remarks of children saying: “My father doesn’t talk like before.”

FDA Visits BGC Office
Representatives of the Food and Drug Administration (FDA) met with D.A. George of BGC Enterprises, Inc. to discuss the nature and purpose of the Audio Tone Enhancer/Trainer (ATET) device. This visit follows the FDA’s recent classification of the Audiokinetron as a ‘medical device.’ BGC Enterprises was asked to submit a letter to the FDA explaining why the ATET machine is not a medical device and how the ATET is different from the Audiokinetron. The FDA has not yet made any decisions concerning the ATET.

Theories of Auditory Integration Training
In this section of The Sound Connection, we describe various theories on why auditory integration training works for some individuals. The theories can be classified in different ways, such as those explaining a reduction in auditory peaks, a reduction in sound sensitivity, and an increase in attention as well as postulating change in the middle ear, inner ear, and mid-brain.

The Middle Ear

Although the structure and movement within the middle ear is relatively simple, Drs. Alfred Tomatis and Guy Berard have stressed its importance in understanding auditory integration training (AIT).

Brief overview of the middle ear. The middle ear contains the body’s three smallest bones (malleus, incus, and stapes; together they are termed the ossicles), and two of the body’s smallest muscles (tensor tympani muscle and stapedius muscle). When sound enters the outer ear and strikes the tympanic membrane (i.e., the ear drum), the vibration of the ear drum causes the malleus to move, which in turn, moves the incus, which moves the stapes. The vibrating stapes then strikes the oval window of the inner ear (cochlea), which then causes fluid in the cochlea to bend the tiny hair cells which the auditory nerve then interprets as various sounds.

The tensor tympani muscle and the stapedius muscle are responsible for providing the proper tension to the ossicles. Additionally, when exposed to a loud sound, the two muscles react together, which in turn, restricts the movement of the ossicles. As a result, the stapes strikes against the inner ear with limited force. This is known as the acoustic reflex. This is important in protecting the person from loud and harmful sounds.

AIT theories. Two theories focus on the role of the middle ear in explaining how individuals may benefit from receiving AIT. One explanation is that muscle tension is not adequate for proper functioning of the middle ear. AIT listening sessions exercise and strengthen the muscles in the middle ear, which then leads to the correct amount of muscle tension and efficient sound transmission.

A second explanation is that the tensor tympani muscle and the stapedius muscle are no longer working together to form the acoustic reflex. This may result from a trauma to the middle ear, such as a middle ear infection. By listening to very stimulating, modulated music, the two muscles are given a ‘good work- out,’ and as a result, they start to work together to form the acoustic reflex.

Sound Sensitivity and a Possible Cause are Documented
In a recent article, Collett, Roge, Descouens, Moron, Duverdy, and Urgell (The Lancet, 1993, 342, pages 923-924) examined the medial olivocochlear (MOC) bundle, located in the brainstem, in 11 autistic individuals, ranging in age from 6 to 30 years, with a mean of 13.5 years. A previous study reported that sound sensitivity in the non-autistic population may be associated with a dysfunctional MOC bundle.

Subjects were presented with a stimulus (click sound) in the outer ear canal at a peak sound pressure level of 63 +/- 3 dB sound pressure level (SPL). Half of the presentations included stimulation to the other ear (contralateral stimulation) using white noise, and half of the presentations did not include contralateral stimulation. The researchers measured the evoked otoacoustic emissions of the MOC bundle.

There was no difference between the autistic subjects and the control group when contralateral stimulation was not presented. However, there was less contra- lateral suppression of the evoked otoacoustic emissions in the autistic subjects as compared to a non-autistic control group. Collett and his colleagues suggest that this finding may indicate an alteration in the functioning of the MOC bundle and may quite possibly explain sound sensitivity in autistic individuals. That is, sounds may be perceived as louder because they are not adequately suppressed in the brainstem.

Mystery of Hearing Nearer Solution
Although a good deal is now known about the physiology of hearing, there is still much to be discovered. According to the July/August, 1994 NCRR Reporter, researchers at Boys Town National Research Hospital, working with researchers at the Woods Hole Biological Laboratory, have discovered that a tiny strip of cells in the inner ear, the stria vascularis, plays an important role in converting the mechanical energy from sound waves to the electrical energy carried by nerve cells, by manipulating potassium ions to create an electrical charge.

Bernard Rimland, Ph.D.