Auditory Integration Therapy
Auditory integration training (AIT) is an intervention technique which is currently considered experimental. It was created to attempt to improve the way individuals with autism spectrum disorders (ASD) recognize and respond to sound and to reduce other behaviors associated with ASD. AIT has also been referred to as auditory enhancement training (AET) and audio-psycho-phonology (APP).
Auditory integration training (AIT) was first written about in 1982 in a book by the otolaryngologist Guy Berard, which was translated in 1993 from French to the English title Hearing Equals Behavior. In his writing, Berard suggests that various disorders (“autism,” hyperactivity, depression, learning difficulties) are associated with atypical sensitivity to sound.
The AIT technique became widely popular after the 1991 publication of Annabel Stehli’s The Sound of a Miracle: A Child’s Triumph over Autism. In this book, Stehli described the full recovery of her daughter, who was diagnosed with autism and schizophrenia, after 10 h of AIT at Berard’s clinic. In 1994, the American Speech-Language-Hearing Association (ASHA) published a review of the existing data on AIT in response to such accounts linking AIT to increased eye contact, social awareness, verbalizations, auditory comprehension, and articulation and reduced tantrums and hyperacusis (i.e., oversensitivity to certain frequency ranges of sound) in children with autism spectrum disorders, learning difficulties, attention deficit disorder, and dyslexia. Currently, several professional organizations (including the American Speech-Language-Hearing Association, the American Academy of Audiology, the Educational Audiology Association, and the American Academy of Pediatrics) indicate that AIT should be considered an experimental rather than an evidence-based treatment due to the lack of scientific data supporting its benefits.
While in the United States the majority of AIT practitioners use the original Berard or a modified methodology, there are other methods of AIT in existence (including the Tomatis and Clark methods).
Rationale or Underlying Theory
Dr. Guy Berard, an ear, nose, and throat (ENT) physician, first introduced auditory integration training (AIT) suggesting that many learning and behavioral disorders, “including autism,” are associated with hypersensitivity to sound at particular frequencies possibly resulting in disturbances in learning and discomfort. He suggested that although many children with autism spectrum disorders (ASD) can hear sound, the way in which they process sounds is different and can result in reduced emotional responsiveness and repetitive behaviors even if hypersensitivity to sound does not exist.
Goals and Objectives
In 1982, Dr. Berard suggested that auditory integration training (AIT) would involve a “reeducation” of the hearing process for individuals with autism spectrum disorders (ASD) targeting the atypical sound perception theorized to be present in a variety of behavioral and learning disorders. Specifically, he suggests the training of the middle ear muscles, and the auditory nervous system is targeted through listening exercises.
Auditory integration training (AIT) has been promoted by Dr. Berard as a useful intervention for a variety of disorders (e.g., learning disabilities, behavior disorders, autism, pervasive developmental disorder, attention deficit disorder, attention deficit hyperactivity disorder, tinnitus, progressive deafness, hyperacusis, allergic disorders, depression, suicidal tendencies, poor organizational skills) and has also been recommended for reducing foreign accents and writer’s block.
Auditory integration training (AIT) begins with an audiogram (i.e., a graph showing the results of a pure-tone hearing test) to determine whether auditory “abnormalities” exist. The treatment involves ten consecutive days of therapy centered upon listening to music (that has been modified to dampen certain sound frequencies and intensities to correspond to those found abnormal on the audiogram) for 30 min twice a day. It is recommended that sessions occurring on the same day be separated by at least 3 h, while a 2-day interruption of therapy on weekends is allowed.
Audiograms are also used to determine if filter settings need to be adjusted mid-intervention and to monitor response to treatment post-intervention. Berard asserts that following AIT, audiograms show that auditory distortions are eliminated, as they become “flattened.” He explains that the “peaks and valleys” in the original audiograms reflect areas of hyper- and hyposensitivity, but there is debate as to whether these patterns truly indicate auditory “abnormalities.”
Following the recommended 20 auditory integration therapy (AIT) sessions in Dr. Berard’s method, an audiogram is obtained and reviewed, while changes in behavior patterns are examined to measure outcome. In efficacy studies of AIT, outcome measures have included post-intervention assessments in the following areas: cognitive ability, core features of autism (i.e., social interaction, communication, and behavioral problems), hyperacusis, auditory processing, behavioral problems, attention and concentration, activity level, quality of life in school and at home, and adverse events.
The US Food and Drug Administration (FDA) banned the import of the Berard’s original equipment (Audiokinetron or Ears Education and Retraining System) used for AIT as a medical device based on finding that there was no sufficient evidence to support that it benefited individuals medically. The FDA regards the Audiokinetron as an educational aid but not appropriate for the treatment or curing of any medical conditions, such as autism spectrum disorders. The Digital Auditory Aerobics (DAA) device was introduced as a result of this limited access to the Audiokinetron in the United States. The 20 compact disks (CDs) (each containing 30 min of modulated music) available with this device are believed to match the output of the Audiokinetron device. Other AIT programs are available (e.g., Samonas Sound Therapy, The Listening Program) which provide music on CDs and promise similar results to Berard’s AIT programs.
The efficacy of auditory integration training (AIT) continues to be debated. A review of the available existing research indicates that three studies suggest improvements with AIT at 3 months post-intervention based on reported improved performance scores on the Aberrant Behavior Checklist. It should be noted that investigators in these studies were associated with organizations that promote or directly provide AIT. Similar results have not yet been replicated by any independent studies. The review highlights the fact that the studies examining AIT were not randomized controlled trials (used to minimize bias), did not contain control or alternative treatment group, and involved single or very few participants or used surveys or animals.
The American Speech-Language-Hearing Association (ASHA) issued a report on AIT, in which it states that further research in AIT is discouraged given the lack of evidence that it is an effective treatment for individuals with autism spectrum disorder (ASD) but indicates that a “high level of evidence” of its efficacy should be provided if future AIT trials are conducted. ASHA also cautioned parents to take precautions to avoid hearing loss while also being aware of the costs involved in receiving AIT. In studies where children or adults with ASD (ages 3–39 years) were selected and randomly assigned to study treatment groups, though no adverse effects were reported, no noteworthy changes were found in the participants’ ability to process sound, their quality of life, or their core and associated features of ASD following AIT. ASHA expressed concerns that clear criteria (based on evidence-based research) are not available, indicating which individuals will be most appropriate for AIT, and families could find both their financial resources and hope strained or depleted by investing in interventions that lack empirical support. In addition, the professional organization had reservations regarding the variability in AIT treatment protocols and the possible noise-induced hearing loss that might be associated with AIT devices, as sufficient data on the risk to participants regarding intensity of sound and length of presentation is not currently available for the devices. In more recent studies (2013–2016), electrophysiological changes and behavioral changes via caregiver report were observed in children with ASD following a series of AIT sessions. Authors of these studies suggested further research to explain the neural mechanisms of how AIT may affect such changes. Still, studies during this same time period suggested the lack of efficacy of AIT, some suggesting increased occurrence of stereotypy post-AIT.
Considering that ASD behaviors can often resemble auditory processing disorders (APD), ASHA has also ruled out the diagnosis of APD, for which AIT is often suggested, in children with ASD unless reliable testing reveals deficits on multiple assessments. In the case that a child with ASD does meet this guideline, the benefit of receiving intervention involving listening tasks with limited social interaction can also be questioned.
Qualifications of Treatment Providers
The majority of auditory integration training (AIT) practitioners are speech-language pathologists or audiologists but have also included psychologists, physicians, social workers, and teachers. No training is required to operate the Digital Auditory Aerobics (DAA) device that is currently used within the United States to provide AIT based on Berard’s method. Other AIT programs do provide trainings to practitioners (e.g., The Listening Program [2½ days], Samonas Sound Therapy [offers a credentialing process following pre-workshop training, initial and advanced workshop training, and a year of practice]). The American Speech-Language-Hearing Association, the American Academy of Audiology, the Educational Audiology Association, and the American Academy of Pediatrics nonetheless all state that AIT should be considered an experimental rather than an evidence-based treatment due to the limited amount of scientific research studies supporting its benefits.
References and Readings
- American Academy of Audiology. (1993). Position statement: Auditory integration training. Audiology Today, 5(4), 21.Google Scholar
- American Speech-Language-Hearing Association Working Group on Auditory Integration Training. (2003). Auditory integration training. (Technical Report). Rockville: Author.. Retrieved from www.asha.org/docs/html/TR2004-00260.html
- Berard, G. (1993). Hearing equals behaviour. New Canaan: Keats Publishing. (Original work published 1982).Google Scholar
- Berard, G. (1995). Concerning length, frequency, number, and follow-up AIT sessions. The Sound Connection Newsletter, 2(3), 5–6. Available from The Society for Auditory Intervention Techniques.Google Scholar
- Educational Audiology Association. (1997). Auditory integration training: Educational Audiology Association position statement. Educational Audiology Newsletter, 14(3), 16.Google Scholar
- Gillberg, C., & Coleman, M. (2000). The biology of autistic syndromes (3rd ed.). London: MacKeith Press.Google Scholar
- Gilmore, T., Madaule, P., & Thompson, B. (1989). About the Tomatis method. Toronto: Listening Center Press.Google Scholar
- Mudford, O. C., & Cullen, C. (2005). Auditory integration training: A critical review. In J. W. Jacobson, R. M. Foxx, & J. A. Mulick (Eds.), Controversial therapies for developmental disabilities: Fad, fashion, and science in professional practice (pp. 351–362). Mahwah: Lawrence Erlbaum Associates.Google Scholar
- Sinha, Y., Silove, N., Wheeler, D. M., & Williams, K. J. (2009). Auditory integration training and other sound therapies for autism spectrum disorders (Review). Hoboken: Wiley.Google Scholar
- Stehli, A. (1991). The sound of a miracle. A child's triumph over autism. New York: Doubleday.Google Scholar
- Tharpe, A. M. (1998). Treatment fads versus evidence-based practice. In F. H. Bess (Ed.), Children with hearing impairment: Contemporary trends (pp. 179–188). Nashville: Vanderbilt Bill Wilkerson Center Press.Google Scholar
- Tochel, C. (2003). Sensory or auditory integration therapy for children with autistic spectrum disorders. London: Bazian Ltd (Eds.), Wessex Institute for Health Research and Development, University of Southampton.Google Scholar
- Veale, T. (1993). Effectiveness of AIT Using the BCG Device (Clark Method): A Controlled Study. Paper Presented at the World of Options International Autism Conference. Toronto.Google Scholar