The other day (er, week) I promised to post some thoughts on AIT, so here they are.
There are plenty of treatments offered to cure or improve Auditory Processing Disorder (APD). Auditory processing is not just about hearing. Hearing is the sensory business that the ears do, and the auditory processing is what the brain then does with the signals from the auditory nerves. The ears also have the semicircular canals, which provide us with information about balance — that sense of balance, along with the proprioception of our joints, ligaments, muscles, tendons and bones, give us the sensory information we need for coördination. In auditory processing disorder, the sensory part of hearing often works just fine; it is not a hearing problem, it is an understanding problem. The ears are getting the information and are sending suitable signals; but there are some “tangles” or “speed-bumps” in the interpretation of the signal.
One treatment popularly lauded on Web advertisements is Auditory Integration Training (AIT), which is supposed to also help problems related to tinnitus, hyperacussis (oversensitivity to high-pitched and/or sudden noises, or sound in general), autism, ADD or ADHD. Depending upon the practitioner, AIT may also be sold as effective treatment for dyslexia, stuttering, depression, speech delay, and even head-banging or echolalia. That’s quite a list of highly diverse issues, which immediately sends off mental warning bells.
AIT was developed by Dr Guy Berard, who is also the author of the (out-of-print) book, Hearing Equals Behavior,
“Everything happens as if human behavior were largely conditioned by the manner in which one hears.”
(Hmn, I bet a lot of Deaf people would beg to differ with Dr Berard’s assertion!)
So how is this method supposed to work? From the various Web sites describing it, AIT uses pre-recorded music, which the client then listens to in modified form through headphones. Difference frequencies of sound are filtered or adjusted through a device such as an “Audiokinetron”.
The process of listening to such treated music is supposed to “re-train” the brain to better understand what is being heard. Usually treatment involves 10 to 20 such half-hour sessions of sitting and listening (in addition to before, during and after consultation sessions). After the client has listened to these recordings (the sum of the active part of the treatment; as measurements before or after are peripheral), they are never supposed to use headphones for listening. I have yet to find out why using headphones ever again could somehow undo the treatment, as opposed to listening to music without headphones.
I find the concepts behind AIT to be curious at best; how can listening to pitch-modulated music help a person better understand speech, such as distinguishing phenomes, identifying word-breaks, or following one person’s voice when there is background noise? These are the sorts of issues that frequently appear in APD. So am I missing some vital behavioural or audiological details here in these descriptions?
Of course, it would be foolish to dismiss something merely because I do not understand how it is supposed to work, just from the descriptions given. Not being a “SpLaT” (Speech Language therapist /pathologist) myself, I sought the opinions of professionals, and went to the American Speech-Hearing-Language Association’s Web page to see their Position Statement on Auditory Integration Training (C)2004:
In 1994, the American Speech-Hearing-Language Association (ASHA) Subcommittee on Auditory Integration Training (AIT) concluded that AIT, a method proposed for treating a variety of auditory and nonauditory disorders, was experimental in nature and had not yet met scientific standards as a mainstream treatment. The subcommittee recommended that ASHA develop a position statement and guidelines regarding AIT as soon as more research findings became available. The 2002 ASHA Work Group on AIT, after reviewing empirical research in the area to date, concludes that AIT has not met scientific standards for efficacy that would justify its practice by audiologists and speech-language pathologists.*
Their Technical Report goes into much more detail as to why they reached that conclusion. Some of those reasons include serious problems with research methodology. For example:
- The 1994 Bernard Rimland & Stephen Edelson study examining AIT with autistics lacked a control group and showed no statistically significant difference in sound sensitivity.
- Their 1995 study did not have a well-matched control group, and no differences were seen regarding hearing between the control and test groups.
- The 1996 Bettison study and 1997 Zollweg, Palm, and Vance study also lacked control groups, and neither found differences between the different treatments given.
- The 1998 Yencer study also found no differences between the treatment, placebo and control groups.
And so on. The report also lists concerns about the safety of equipment sometimes used in AIT practice.
Likewise, the American Academy of Audiology also describes AIT is “entirely investigational”, and they state that: “The Academy believes that prospective, systematic research of this technique is needed to demonstrate its efficacy. “
This statement is also affirmed by the Educational Audiology Association (link is pdf file). The Policy Statement from the American Academy of Pediatrics states, “Although two investigations indicated AIT may help some children with autism, as yet there are no good controlled studies to support its use.”
A more recent 2006 study by Sinha, Silove, Wheeler & Williams looking at AIT for autism spectrum disorders concluded, “At present there is not sufficient evidence to support its use.”
But don’t a tiny percentage of audiologists and other service providers use AIT? As audiology professor Maurice H. Miller PhD noted, “In conclusion, and despite enthusiastic reports from some understandably well-meaning parents and practitioners, AIT has not met criteria for effectiveness and safety.” Unfortunately, good intentions, or biographies and glowing letters are not the same thing as good research data.
Doubtless there are some parents out there who will protest that their investment in such treatment has been well-rewarded. Once again, this is why we use double-blind studies, because people will unconsciously see improvements, and will also assign any improvements (regardless of the cause) as resulting from the latest treatment. If your child has improved in some manner or another, that’s fabulous! Children do make leaps and improvements as they mature. (One of the hallmarks of children with various disorders is that the maturation is slower or erratic compared to their peers.) Certainly, consciously focusing upon understanding what is heard results in better comprehension because the person is using more mental resources to process the sensory input. Getting lots of attention also frequently improves behaviour as children seek to please their parents and other adults, because children (like everyone else) like attention, especially positive attention.
Let me clarify: if I am seeking a treatment, whether it is considered to be a medical intervention or an educational intervention, then I want to know that it has been tested to ensure the actual efficacy, and that the “results” we are seeing are not merely from expectation effects, experimenter effects, “regression to the mean” (cause-and-effect issues that result from fluctuating severity levels), or placebo effects.
So what’s the big deal about control groups and all? Because we want evidence-based practice. We have to be able to sort out what changes happen over time in response to a treatment, and what changes simply happen because of maturity or whatever. In other words, we want to be able to prove that a treatment is doing something before we spend lots of time and money on it.
If your insurance company won’t pay for AIT, it might not be just because they are cheap (and there are certainly no lack of legitimate complaints about medical insurance companies in general). It is probably because they are cheap and will not pay for a treatment that has no proven benefit, one that has been dismissed by a number of professional organisations.
Sure, I would like a solution to this issue, but I don’t believe that AIT is part of it.