Volume 2 Number 4, 1995
for ’95 ASA Conference
On Thursday, July 13th, several members of the Board of Directors and Professional Advisory Board will present a panel discussion titled “Auditory Integration Training: An Interactive Presentation Among Practitioners, Families, & Listeners.” The presentation will be moderated by Dr. Margaret Creedon. The participants will also include, in alphabetical order: Lois Blackwell, Sally Brockett, Carol Cloud, Monica Doben-Stevens, Dr. Jon Kaunitz, Dr. Bernard Rimland, and Deborah Woodward. The presentation time is from 1:30 to 3:00 p.m.
Also on July 13th, SAIT will hold its fourth annual membership meeting. Both SAIT members and non-members are invited to attend the meeting. There will be a discussion on some of the current issues involving AIT, including age and volume level. New officers will also be announced. The meeting time is from 5:00 to 7:00 p.m. The location of the meeting will be listed in the conference brochure.
SAIT will also be sponsoring a booth in the exhibit area to share information about AIT and SAIT to families and professionals who are attending the conference. If you are willing to help at the booth to distribute information and to discuss issues please write or fax the SAIT office right away.
The prevalence of hyperacusis in the population is not known. Although there may be as many as 1% of the population who are “sound sensitive,” hyperacusis sufferers go well beyond the definition of sound sensitive and often cannot tolerate their surroundings. Hyperacusis is defined as an auditory phenomenon characterized by a collapsed tolerance to normal environmental sounds. The cause is theorized to involve a breakdown or dysfunction in the efferent portion of the auditory nerve. Perhaps the efferent fibers of the auditory nerve are selectively damaged even though the hair cells that allow one to hear pure tones in an audiometric evaluation remain intact. For this reason, there are no known tests which confirm hyperacusis.
Many E.N.T. doctors subject individuals with hyperacusis to hearing tests which make their condition deteriorate even more. All of these elements make it difficult to apply and obtain disability for those who can no longer tolerate the sound of their work environment.
Recruitment refers to sound sensitivity associated with degrees of sensorineural hearing loss. This problem seems to involve the cochlea or inner ear. People with recruitment are unable to hear certain sounds of various frequencies and/or volumes. Once the sound reaches the certain point to where the recruitment sufferer can hear it, they are often overwhelmed by sound; and it is perceived as far too loud. Individuals with hyperacusis have no hearing loss so all sounds seem too loud. Recruitment sufferers, for example, often have high frequency hearing loss (above 10 KHz). Hyperacusis sufferers, on the other hand, are often most distressed at high frequency sounds. Their sensitivities, however, often involve the full spectrum of sounds. Those with hyperacusis also have a very difficult time with quick shifts in sound level. Their dynamic range and ability to handle sudden shifts (outbursts) of sound is severely impaired. Although many in the field of hearing believe that the ear is unable to sense pain, hyperacusis and recruitment sufferers often experience pain and discomfort to the ears.
Hyperacusis and recruitment are usually caused by noise or a head trauma. The noise trauma may be cumulative in nature or may be related to one specific incident like a rock concert. Almost all individuals with hyperacusis and recruitment eventually develop tinnitus (i.e., ringing in the ears). Those who suffer from hyperacusis and recruitment experience similar sound sensitivities to those with hyperacute hearing (for example, autistic children). Understanding that many autistic children are nonverbal, parents of sound sensitive autistic children can learn much from hyperacusis sufferers in understanding why their children react to noise the way they do. At this point in time, almost everyone with hyperacute hearing seems to be born with the condition. There is also a clear difference in the cause, treatment, and methods of intervention for children and adults with hyperacute hearing. For example, much success has been experienced in alleviating some of the problems of autistic children with auditory integration training (AIT). Hyperacusis and recruitment sufferers, however, see no improvement from AIT. In my experience, their condition worsens, particular their tinnitus. I caution practitioners, therefore, from prescribing AIT for hyperacusis or recruitment patients who were not born with a collapsed tolerance to sound or experience tinnitus. In the zeal to help, much damage can be done.
Common safeguards used by individuals suffering from hyperacusis and recruitment are ear plugs and/or ear muffs. Reducing sound in this manner is effective and may be useful in the short-term. Ear plugs and muffs, however, tend to make tinnitus more noticeable. Prolonged use of these protective devices may be necessary with the initial onset of hyperacusis, however prolonged use can collapse their tolerance to sound even more. This becomes a delicate line to learn.
Currently, a treatment proposed for hyperacusis employs the gentle introduction of pink noise at volumes which are barely audible to the individual. This can be accomplished by listening to pink noise tapes or by using a hearing masking appliance called the viennatone AM/ti. The AM/ti device is worn like a hearing aid and emits a sound similar to the static noise one hears between channels on an FM radio station. The individual uses these devices for a disciplined period of time each day at sound levels which are barely audible and will not worsen their tinnitus. Ultimately, the goal is six hours a day for a period of at least one year. By doing this, the auditory system will experience improvement in its collapsed tolerance to normal environmental sounds. Rarely do any individuals recover completely; however, many individuals who continue with therapy may improve their tolerances 10-50%. Most average about 15% improvement. Other aids to hyperacusis are reducing stress levels by using biofeedback or specific drugs to help one deal with the stress of living a life where the volume control seems to be stuck on high.
Aside from being founder and editor of The Hyperacusis Network, I have, like many, walked a long, hard road, desperately seeking solutions to my sound sensitivity. Like some in the network, I have tried AIT and know of no one with hyperacusis who has experienced improvement. I do not believe that AIT works for hyperacusis or recruitment patients. It has been the networks experience, for those who have tried it, that AIT often worsens hyperacusis by further collapsing one’s tolerance to sound and increasing one’s level of tinnitus. This may be temporary or permanent depending on the individual sufferer. I am not angry that AIT did not help me. How can I expect practitioners of AIT to know the difference between hyperacusis and hyperacute hearing when most E.N.T.’s cannot explain either auditory phenomena. I know that AIT helps many autistic children and young adults. I have seen it with my own eyes. Although the levels of improvement can vary dramatically from one child to another, it is clear that AIT is part of an answer for hyperacute hearing. I have fully recovered from my setback from AIT, but there are many examples in the world of those who have not. Even Dr. Berard and The Georgiana Organization do not understand the differences between hyperacusis and hyperacute hearing or the damage that can and has been done. This concerns me a great deal.
I have had the pleasure of communicating with many parents of autistic children who do everything they can to care for the precious children. They have asked me so many questions, “What is it like for my child when they cover their ears and run away?” I have had the pleasure of communicating with Drs. Berard Rimland and Stephen Edelson. These are very compassionate, knowledgeable, and caring professionals. The autistic community is very fortunate to have these wonderful individuals to help care for them.
I established The Hyperacusis Network to address the needs of those who are sound sensitive. The network has a membership of nearly 500 individuals throughout the world who are sound sensitive or who are members of the medical community who seek to understand our problems and learn ways to help us. Realizing our condition at this time, is incurable, we know our strengths lie in ourselves. We share ways to cope, educate our families and the medical community, and openly discuss current therapies proposed. The network publishes a free quarterly newsletter, written by individuals who have hyperacusis, recruitment, or hyperacute hearing. The American Tinnitus Association, the National Institute for Hearing Disorders, and organizations throughout the world constantly refer people to our free network. For those who would like more information about The Hyperacusis Network, please send a self-addressed envelope to The Hyperacusis Network, 444 Edgewood Drive, Green Bay, WI 54302.
Sound sensitivity is very common in autism. Bernard Rimland reports sound sensitivity to be a significant feature in 40% of the many thousands of E-2 Diagnostic Checklists he has received from parents of autistic children since 1965. Carl Delacato (1974) devoted several pages to the problem of sensitive hearing in his book on autism, The Ultimate Stranger; and Philip Ney, a Canadian psychiatrist, proposed over a decade ago that sensitive hearing may be a cause, rather than just a symptom of many cases of autism.
Intuitively, the most common remedy to help someone suffering from sound sensitive hearing is the use of ear plugs, ear muffs, and/or a sound chamber. Reducing sound in this manner is effective and may be a useful consideration for short-term use, such as when a child sleeps, goes to a cafeteria, a loud auditorium, or the dentist. Should hearing protection be considered as a means of helping sensitive hearing, it is important to consider the size of the ear canal and the noise reduction characteristics of the earplug or earmuff being used. Keep in mind also that a small earplug may be a hazard to a young child who may swallow it.
In general, there are three categories of hearing protectors: a custom-made molded earplug, a factory-manufactured earplug, and an earmuff. A good molded earplug is the Killion “musicians earplug” (Filtered Ear Attenuator ER-15 or ER- 25) because it reduces noise uniformly across the frequency bandwidth. This type of hearing protector must be obtained from an audiologist or hearing aid dealer because a mold of the ears must be made for the earplugs. Manufactured earplugs and earmuffs, on the other hand, are primarily made for the reduction of industrial noise or targetshooting; and noise reduction is not uniform across the frequency bandwidth, somewhat distorting auditory input. Manufactured hearing protectors are easily purchased from drug, hardware, sporting goods, and safety supply stores. Aside from making sure that a plug fits the ear canal comfortably and that all involved know how to use the hearing protector correctly, it is important to make sure that the intended earplug or muff is not designated only for targetshooting. Certain hearing protectors designed for target shooting have no noise reduction properties except when the blast from the gun causes a ball-bearing valve in a chamber to close temporarily.
The use of hearing protectors, in general, reduces the person’s ability to hear speech and receive other important auditory information, so that any potential benefit gained from the short-term use of hearing protection must be weighed against the potential harm from the artificially created hearing loss and auditory deprivation. More importantly, the continual reduction of external sounds has been observed to cause the person’s auditory system to adapt to the artificially created quiet so that sounds soon become as painful with the hearing protector as they were without.
Another way to treat sensitive hearing in some cases is through supplementation of the mineral, magnesium. A deficiency of magnesium is known to cause sensitive hearing and increased irritability. According to the Autism Research Review International (1990, Vol. 4, No. 4), an appropriate amount of magnesium would be approximately 20 milligrams for each 10 pounds of body weight, per day (i.e., 100 mg for a 50 pound child). If magnesium deficiency is the cause of the sound sensitivity, improvement will likely be seen in a few days.
Auditory Integration Training (AIT) is a procedure that may also reduce sound sensitivity. Individuals listen to music which is processed through an AIT device. The program, administered by a trained practitioner, involves listening to the music through headphones for twenty 30-minute listening sessions.
Other treatments for sensitive hearing may include various sensory integration techniques used by occupational and physical therapists, such as intensive brushing therapy, joint compression, and deep pressure. These types of therapy would especially be indicated if there were signs of sensory defensiveness from touch, smell, visual, or vestibular over-reactivity in addition to sound sensitivity. Integration techniques serve to reorganize sensory input, since there are many areas in the brainstem, vestibular system, and higher cortex areas where the various sensory cells are adjacent and engage in simultaneous processing. As the overall neurological irritability is reduced, sensitive hearing may also be reduced. It is important to note that these techniques should be done under the supervision of an occupational or physical therapist with a sensory integration background, since the exact techniques needed may vary from child to child. An additional benefit of sensory integration is that this type of therapy may be begun with an infant exhibiting sound sensitivity long before age 4, when AIT would be considered. (Editor’s note: See discussion on age, this issue.)
Parents may want to consider some of the interventions described above prior to trying AIT. Furthermore, if AIT does not decrease the child’s sensitivity to sounds, it is recommended that there be at least a three-month wait following AIT before trying another strategy in order to evaluate the effectiveness of each. As with some forms of intensive sensory integration therapy, employing several interventions simultaneously may be stressful for the child.
This article was written by Deborah Woodward who is an audiologist and a member of SAIT’s Board of Directors. Her address is: Woodward Audiology, 7151 Friendship Church Road, McLeansville, NC 27301. Special thanks to Dr. Stephen Edelson, Dr. Bernard Rimland, Dan Malcore, and Sally Brockett for their suggestions on an earlier draft of this paper.
Pressure toward dropping the age limit to 3 years has been mounting from both parents and practitioners, who point to the potential advantages of early intervention. Some have used AIT with children as young as 2 years of age. As he has learned of apparent positive results with some 3 year olds and in the absence of known negative or adverse results, Dr. Berard has reconsidered; and he now feels that 3 years may be a suitable age (personal communication, 5/4/95).
Whatever the trainees age, extreme care should be taken to ensure that the volume is well below the EPA and OSHA noise exposure limits-in all cases-and that AIT devices be checked frequently to prevent excessive loudness-never above 85 dB. This caution is especially important for young children since EPA and OSHA limits have been determined for adults and not for children.
Until a safe age limit and volume level are established, practitioners who give AIT to young children should proceed cautiously. The next issue of The Sound Connection will contain a discussion of the age issue. SAIT would appreciate your thoughts on this issue.
Introductory comments by Dr. James Jerger, Professor and Head, Division of Audiology and Speech Pathology, Baylor College of Medicine, focused on two main issues; one, scientific, (double-blind trials may never be able to identify and prove all of nature’s secrets); and two, clinical observations and anecdotal reports may lead to false hopes. He stated that many procedures exist today that have never undergone double-blind studies but are accepted without criticism. However, he also reminded the audience that the mind, untrained in the rigors of scientific research, is easily deceived.
Following Dr. Jerger’s comments, the report on AIT that was prepared by an Ad Hoc ASHA committee was presented to provide background on AIT. This report was featured in The Sound Connection (Vol. 2, No. 2) and is available by calling ASHA (301) 897-5700, ext. 320 or 135.
Dr. Jane Madell then presented information on how she conducts AIT at her treatment center. She stated that she views AIT as a treatment for sound sensitivity, hypersensitive hearing and certain auditory processing disorders, but not as a cure for any disorder. Candidacy for the training is based on criteria she has developed to help screen out those who might not have an auditory disorder. Dr. Madell stated that she believes the audiogram reflects auditory attention and listening ability, and not so much the actual hearing ability. Dr. Madell explained that she has developed some of her own modifications of the AIT procedure based on her opinions and experiences, and therefore does not practice AIT exactly as Dr. Berard teaches.
Dr. Judith Gravel discussed her concerns about AIT, stating that AIT concepts are inconsistent with present knowledge of anatomy and audiology; and there is no evidence that such a short intervention technique could produce significant, long-term benefits. She commented that some AIT centers have loose candidacy requirements and that the procedure is basically the same regardless of age and diagnosis. Dr. Gravel stressed the need for research that could document efficacy, then lead to funding and the development of standard protocols. She questioned whether it is the AIT procedure or simply a systematic treatment approach that actually produces the benefits.
A question and answer period concluded the teleseminar.
The audiotape is available through Ann Parks at ASHA, (301) 897-5700, ext. 236.
1. Illnesses that affect the auditory system, such as ear infections, may interfere with the AIT results, causing the child to revert to old behaviors and problems. Sometimes ear infections clear up with no apparent ill effect,; however, some parents have reported that the ear infection was the beginning of the child’s regression and apparent loss of AIT improvements. Fluid, with no infection, can also interfere with the AIT results; however, this is usually temporary; and once the fluid drains, the negative behaviors subside. As Dr. Berard’s book reminds us, Hearing Equals Behavior, so when fluid distorts hearing, behavior is affected.
2. Exposure to loud sounds can also cause the benefits of AIT to be lost. This would include listening to very loud music, exposure to loud noise from power equipment (e.g., chain saws, lawn mowers, etc.) and sudden, very loud noise such as gunfire and fireworks. Hearing should be protected from this type of noise pollution by use of ear plugs or hearing protector earmuffs. These devices can prevent loss of hearing and loss of AIT benefits due to noise exposure.
3. Medications that have ototoxic side effects can also have a negative impact on the results of AIT. Ototoxic means that the medication produces side effects that damage the auditory system. This can occur with any type of medication, not just those used for treating ear infections. Medications that are applied to the skin, such as an ointment, or eye drops and eye ointments, can be absorbed into the blood stream and affect the auditory system. Many medications, such as aspirin, Motrin, Advil, and Benedryl, may cause tinnitus or ringing in the ears.
4. Gradual diminishing of AIT results is sometimes seen with individuals who had very sensitive hearing prior to AIT. The hypersensitive hearing may slowly return for unknown reasons. In many cases, repeating AIT may reduce the sensitivity again. More research is needed to determine who may benefit from repeating AIT on a long term basis.
5. Dr. Berard reports that wearing headphones to listen to music following AIT can also cause loss of the benefits. This occurs because the music is being directly introduced through the ear canal rather than dissipated through the atmosphere as it would be normally. If there are any slight peaks or distortions in the individual’s hearing, they may gradually worsen due to the use of headphones. In a sense, it is a reverse AIT procedure because the therapeutic effect of the modulation is missing.
Adaptation to Loud Sounds. Dr. Guy Berard. If certain sounds bother an individual, exposure to stimulating sounds, such as through AIT, may allow a person to adapt auditorily to intense sounds. As a result, they may consciously or unconsciously learn to ignore stimulating sounds after AIT. Adaptation is a built-in mechanism which, after continued exposure to a stimulus, reduces the perception of that stimulus.
Reduction in Internal Noise. Dr. Stephen Edelson. Several researchers have suggested that some autistic individuals hear noise in their heads, such as a white noise or buzzing. In the book, The Ultimate Stranger (1974), Carl Delacato theorized that autistic children may have senses which are hypersensitive, hyposensitive, or experience high degrees of auditory noise. Several clinicians around the country have reported that some listeners state that a noise in their head disappeared after receiving AIT.
If some autistic individuals do suffer from an internal noise in their ears and/or head, this may suggest a theory of the development of autism. That is, if noise is present at birth or starts in the early childhood years, then it may be very difficult for the person to understand people talking, and the noise may be quite painful in some cases.
The sounds of high frequencies go to the cochlea through the upper part of the eardrum, the ossicles, and the oval window. The lower frequencies proceed directly from the lower part of the eardrum, through the air in the middle ear, to the round window of the inner ear. In France, we call this area the “tympanum box” or the “ossicle box.”
If we want AIT to affect the brain by alternating low and high frequency sounds, we need to have these two auditory circuits working correctly. If this system is not working properly, we need to determine which circuit is disturbed and then determine how to proceed.
There is a simple way to examine this. When the configuration of the audiogram shows some hearing loss in one ear or in both ears, then one should conduct a bone conduction test. If the results for both the bone and air conduction are close to one another for all of the frequencies, then the sounds are proceeding normally through the middle ear. That is, there are no obstacles in this part of the ear. AIT can then be conducted to treat auditory and behavioral anomalies.
If there is a distance between the results of the air and bone conduction tests, it is called a “Rinne.” This indicates that a part of the sound is blocked in the middle ear, and the sound cannot reach the cochlea or the inner ear. There are two possible problems when this occurs:
(1) The Rinne is “open” at 25 dBs or more for the low frequencies. This means that these sounds cannot reach the round window in a normal manner, and this may be due to the presence of liquid or infection. The patient should be referred to a general practitioner or an ENT for medical treatment before starting AIT.
(2) The Rinne is “open” at 25 dBs for ALL frequencies. This indicates that the middle ear is not working properly because of a blockage, fracture, or absence of the ossicles. This may also indicate “scleroadhesive otitis,” which is brought about by a gummy substance which blocks the middle ear. An ENT who specializes in copho-surgery can treat the problem. In either case, if the Rinne is open, it is best to seek the advice of an ENT.
This interesting and informative booklet was written by a researcher whose hearing had deteriorated badly and who began experiencing severe tinnitus while entering college for training to become an audiologist. His many books and articles are based on a trek of 20 years studying nutrition, pharmacology, neurology, Oriental medicine and many other fields. You can’t get much more eclectic than Yanick!
He has used his methods on many hundreds of patients with tinnitus and other problems, with, he reports, frequent good results.
I don’t agree with some of what he says, but who knows-he could easily be right. Considering how little is known about tinnitus, I would certainly try his methods if I had tinnitus. They are certainly safe. If you or your clients try Yanick’s ideas, please write to SAIT with the results-good or bad. We’ll keep our readers advised.