Treatments For Autism - Auditory Integration Therapy

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Aetna Insurance

Clinical Policy Bulletin: Sensory and Auditory Integration Therapy

Policy

Aetna considers sensory and auditory integration therapies experimental and investigational for the management of persons with various communication, behavioral, emotional, and learning disorders and for all other indications. The effectiveness of these therapies is unproven.

Background

Sensory integration refers to the process by which the brain organizes and interprets external stimuli such as touch, movement, body awareness, sight, sound and gravity. It has been postulated that certain behavioral and emotional problems result from the malfunctioning of this process. Sensory integration therapy (SIT) is a type of treatment usually performed by occupational therapists or physical therapists who provide various sensory stimulation to the patient, often in combination with and within the context of purposeful muscle activities, to improve how the brain processes and organizes sensory information. This type of therapy requires activities that consist of full body movements employing different kinds of equipment such as textured mitts, carpet squares, scooter boards, ramps, swings, and bounce pads. It is believed that SIT does not teach higher-level skills, but enhances the sensory processing abilities of the subject to acquire them.

Although the use of SIT as a treatment for children with learning disabilities and other behavioral disorders (e.g., autism, attention-deficit disorder, fragile X syndrome, and developmental delay) has been quite popular, there is widespread skepticism regarding its effectiveness. Kaplan et al (1993) stated that SIT is not more effective than other, more conventional methods of treatment for children with learning disabilities. Hoehn and Baumeister (1994) reported that SIT is not only an unproven, but also an ineffective, primary or adjunctive remedial treatment for children with learning disabilities and other disorders.

Tharpe (1996) stated that “Although anecdotal reports and testimonials of positive treatment outcomes abound, there remains a dearth of empirical studies designed to scrutinize the claims made by proponents of auditory integration therapy. Until such time that auditory integration therapy technology meets the standards of scientific efficacy, it is best considered to be an experimental treatment....” Furthermore, the American Speech-Language-Hearing Association declared that auditory integration training is an experimental procedure because it has not yet satisfied standards for effectiveness that would justify the inclusion of this method as a mainstream treatment for a variety of communication, behavioral, emotional, and learning disorders.

An assessment of auditory integration therapy (AIT) for autism by the Wessex Institute concluded that trials have produced conflicting results, and it is uncertain whether auditory integration therapy is any more effective than placebo (Best & Milne, 1997). A systematic evidence review by Cullen, et al. (1999) concluded:
"Previous claims for the benefits of AIT in reduction of problem behaviors and increases in IQ and adaptive/social skills were not supported by the results. AIT may divert parents' and service providers' resources from better-validated interventions".

An assessment conducted by the National Initiative for Autism (UK) (2003) concluded:
"Auditory integration therapy has also recently been subject to careful analysis, and again the results indicate that the effects are no greater than for placebo conditions [citing Mudford et al, 2000; Dawson and Watling, 2000]."

A meta-analysis of research on sensory integration treatment (Vargas and Camilli, 1999) concluded that more recent studies do not show overall positive effects from sensory or auditory integration therapies.

An assessment conducted by the National Initiative for Autism (UK) (2003) stated:
"Experimental data in support of a variety of other treatments, such as Facilitated Communication, auditory or sensory integration programmes, psychoanalytically based interventions or teaching methods such as the Son Rise programme (Option), Walden or Daily Life Therapy (Higashi) did not exist".

An assessment conducted by Hender (2001) for the Centre for Clinical Effectiveness (Monash University) identified no randomized controlled clinical studies of sensory integration therapy for attention-deficit hyperactivity disorder, and identified only one study (by Werry, et al., 1990), a comparative study with concurrent controls. Hender (2001) noted the sources of bias that limit reaching definitive conclusions about the effectiveness of sensory integration therapy for attention-deficit hyperactivity disorder from this single study.

An assessment conducted by the National Academy of Sciences (NAS) (2001) concluded that there is insufficient evidence of the effectiveness of sensory integration therapy for autism. The NAS report states that “[t]here is a paucity of research concerning sensory integration treatments in autism…. These interventions have also not yet been supported by empirical studies.” In addition, the AAP (2001) stated that research data supporting the effectiveness of sensory integration therapy in managing autistic children is scant.

The NAS (2001) concluded that there is insufficient evidence of the effectiveness of auditory integration therapy in autism. The NAS concluded that “auditory integration therapy has received more balanced investigation than has any other sensory approach to intervention, but in general studies have not supported either its theoretical basis or the specificity of its effectiveness.”
Tochel (2003) performed a structured evidence review of SIT and AIT for the Wessex Institute. Regarding SIT, the assessment concluded that “[w]e have found insufficient evidence about the clinical effects of sensory integration therapy in children with autistic spectrum disorders.” Regarding AIT, the report found “[w]eak evidence from limited research suggests that AIT is unlikely to be more effective than unprocessed music in children with autistic spectrum disorders, although both AIT and unprocessed music may be associated with similar improvement in some scores from baseline. However, the clinical importance of these changes is unclear.”

Sinha, et al. (2004) reported on the results of a structured evidence review for the Cochrane Collaboration of AIT for autism. The investigators reported that there is “[n]o clear evidence yet for auditory integration therapy's effect on autism.” The investigators explained that “[s]ix relatively small studies met the inclusion criteria for AIT. These largely measured different outcomes and reported mixed results. Suggestion of benefit in two outcomes requires corroboration by further research using well-designed trials with long-term follow-up.” The review also concluded that more research is needed to inform parents', carers' and practitioners' decision making about this therapy for individuals with autism spectrum disorders.

In a systematic review, Sinha and colleagues (2006) evaluated the effectiveness of AIT and other sound therapies in people (adults or children) with autism spectrum disorders (ASD).  A total of 6 randomized controlled trials of AIT, including 1 cross-over study, were identified, with a total of 171 participants aged 3 to 39 years. 17 different outcome measures were used, with only two outcome measures used by three or more studies.  Meta-analysis was not possible owing to very high heterogeneity or presentation of data in unusable forms.  Three studies did not show any benefit of AIT over control conditions.  Three studies reported improvements at 3 months in the AIT group for total mean scores of the Aberrant Behavior Checklist (ABC), which is of questionable validity.  Of these, one study also reported improvements at 3 months in the AIT group for ABC subgroup scores.  No significant adverse effects of AIT were reported.  The authors concluded that currently there is insufficient evidence to support the use of AIT for individuals with ASD.

AIT Institute

Auditory Integration Training and The Brain

Overview

Auditory Integration Training is a foundational therapy that trains and coordinates the efforts of the ear and the audio-recipient structures in the brain.  This approach was developed by Dr. Guy Berard who was inspired by the work of Dr. Alfred Tomatis.

The Human Auditory System

This is a highly specialized system, which is capable of a wide range of functional plasticity and a great deal of potential to acquire different phonetic systems.  (Prof. Dr. rer. nat. Lutz Jäncke (Project Leader) at the University of Zurich. In a study using functional MRI, the researchers at University of Zurich are exploring the degree to which short term influences can alter the functional neuroanatomy of the auditory system.  They are investigating the activation of the auditory cortex and its adjacent cortical regions during auditory stimulation.  The scientists are studying the auditory cortices of musicians and non-musicians.  They hypothesize that the human auditory cortex is highly plastic and capable of adapting to long-term auditory stimulation.  This is important research since with Auditory Integration Training, our goal is to change how the brain processes sounds.  We use randomized music to present the brain with unpredictable and novel sounds to process. Our clinical evidence indicates that Auditory Integration Training has a profound effect on the brain’s rate of processing  sounds. 

Description Of Auditory Integration Training
Auditory Integration Training like many other therapies helps to bring new dimension to the brain functioning.  It makes the brain more efficient.  Auditory Integration Training is structured listening program.

It takes 10 days to re-train the ears and re-train the brain to function more efficiently.

Auditory Integration Training, using the Berard method is a 10-day program designed to improve language comprehension, clarify hearing and reduce hearing sensitivities.

Each day of Auditory Integration Training consists of 2-thirty minute sessions.  Clients wear studio quality headphones and listen to “music” that sounds like its been stirred up in the blender.  That’s called “randomization”.
The idea is to make the “music” move.  The brain learns through movement.  In order to understand the process, think of movement in terms of fluctuating frequencies and fluctuating volumes of sounds.  Auditory Integration Training influences changes in brain operation by presenting the ears with fluctuating sounds, which heightens the brain’s attention to flow along the auditory pathways of the brain.

When the brain hears these mixed up and novel sounds, it has to switch gears to a more attentive state.

Over and over again the brain has to sort and re-assemble the sound segments.  As this is happening inside the brain, many brain structures get practice in communicating with adjacent brain structures in a new series of circuitry and by making new connections.

This information flow is what the brain considers to be movement – in a synaptic sense.  This neuronal activity allows the individual to experience a heightened awareness of sound processing.  During the sessions, the brain is practicing a series of new levels of attentional states.

Four Elements That Pertain Directly To Human Nature And The Brain

As I have observed individuals throughout the 13 years of practice in the field of Auditory Integration Training, four categories of brain functioning have come to mind:

• Neuroplasticity this is the recognition that change happens in the brain according to experiences that therapies and learning provide to it.  Plasticity isn’t possible without sufficient attention.  Neuroplasticity is the ability of the brain to shape or mold itself by expansion or contraction of neuronal processes due to injury, electrical activities or chemical stimulation.  It is dependent upon a structural change of the neuron.
• Attention This is the brain’s response to the world around it and also its attempt to encounter the world and its elements.
• Motivation  This is the emotional side of attention.  E-motion is motion outward – it is interactional.  It’s the brain attempt to initiate action or movement.  This is a purposeful  emotional state which often leads to interaction with another person or thing.

• And Movement The means by which the brain learns more about its world.  Movement provides the brain and the individual with an opportunity to adjust to input.  It is one of the outcomes of motivation and emotional curiosity.  Many times movement attempts to find stasis. Think of movement as information flow along neuronal pathways.

History Of Auditory Integration Training
It was developed by Dr. Berard in France nearly 35 years ago.  Berard's method is based upon the work of Alfred Tomatis.  The Tomatis style of Auditory Training is a long, not as intense experience as the Berard method.  The Berard method was introduced to the US in the very late 1980’s, it was initially embraced by the autism support groups through the work of Annabel Stehli, who wrote “Sound of a Miracle” and later authored a series of anecdotal accounts, called “Dancing in the Rain”.  Berard AIT was initially developed for those who had sensitive or painful hearing and then became an alternative method of helping people with major depression and suicidal tendencies.

The Current Criteria For Uses Of Auditory Integration Training
We look at test results and then compare that to a health and behavior history. 

Many people benefit from Auditory Integration Training, so diagnosis is not a necessary criterion. Auditory Integration Training has benefited people with:

• Closed-head injury,
• People with learning disabilities,
• People on the autism spectrum,
• People on the ADD spectrum,
• People with Down Syndrome,
• People with Rett Syndrome,
• People with Angelman Syndrome,
• People with Williams Syndrome,
• People with episodic or major depression and many people in between. 

Neuro-Functional Deficits In Autism - Autism Spectrum Disorder (ASD)
There are 4 neuro-functional deficits in autism, according to Lyn Waterhouse at Trenton State College:

• The first is a problem with the hippocampus (memory center), too much cell-packing.  It’s inefficient and this means that there’s too much fragmentation.
• The second is that the center of the limbic system, the amygdala is not assigning significance to events as they happen.
• The third the oxytocin system is faulty and does not allow sufficient bonding and affiliative behavior.
• The fourth is too much attention.  Over-processing of meaningless data.  There is a problem with the temporal & parietal lobes. 

Remember the importance of the spectrum factor, these deficits and symptoms will array themselves along a range of degree of intensity.  Therefore, there is a range of effectiveness of therapies for different people, different degrees of effectiveness.

How Long Does Auditory Integration Training Last?
For many people one time through Auditory Integration Training is sufficient.  For people on the autism spectrum or those with severe forms of sensory integration disorder, they may find themselves repeating sessions.  Most of the people with mood disorder find one time through to be sufficient; however, Berard found that those with severe depression, especially with suicidal tendencies, should go through multiple times.  

Testing And Candidacy For Auditory Integration Training
When we began our practice in 1991, we used an audiometer to do our intake, midpoint and exit testing. But when people are very young or when they are non-verbal or have motor timing problems, this may not be a satisfactory way of finding out how people hear.  So we found out about some equipment that was manufactured in the UK and was used to test babies.  This equipment is called Otoacoustic Emissions Testing.  It sends signals into the ear canal and then registers the feedback or echo of the cochlea.  The signals have to transit the canal, pass through the ear drum and then hit the cochlea.  That journey is recorded electronically and is sent to the computer as a graph.  So while there really isn’t a direct comparison to audiometry, it gives a more reliable view of the hearing profile.  It can be made more reliable when behaviors are quiet, the body is relaxed and ambient noise is reduced. 

When we have a test of the hearing profile in hand, we look to find out which ear needs the most work. One of the elements we’ve noticed over the years is that usually there is some asymmetry in hearing potential ear to ear.  So we look at the ear that needs the most work & pick out the frequencies that are most easily registered.  Then we take that frequency or frequencies out of the music presentation that will follow over the next 10 days. 

This approach is much like “Constraint-Induced Movement Therapy” devised for stroke patients.  This type of therapy helps to remap the motor strip of the brain.  The therapy is used to restore functions to limbs of stroke patients who have lost function as much as 45 years before!  Schwartz & Begley 192     Edward Taub did landmark work in this area. 

The reason I have compared Auditory Integration Training to Constraint Induced Movement therapy is because the protocol calls for restricting the easily heard frequencies and increasing stimulation of the frequencies registering as troughs on the hearing profile.  Furthermore, added this mix is the randomization of the sounds.  The remaining sounds cut in and out rapidly and unpredictably.

Outcomes Of Auditory Integration Training
Some of the outcomes of Auditory Integration Training are better attention, better listening, more motivation to engage in social communication,fewer overt symptoms of depression, better eye contact, better sensory integration, and better balance and coordination. 

No brain really WANTS to change, so while a person is undergoing Auditory Integration Training, some adverse reactions may show up in terms of behaviors and visceral responses.  There may be some over-activity, some fatigue, and increase or decrease in appetite, more irritability, some nausea, as a result of possible vestibular disturbance. 

The unfamiliar, unpredictable stimulus of randomized “music” leads itself to brain disturbance, which leads to a reorganization of neurons and re-routing of information across many structures of the brain.  Twenty half hour practice sessions, give plenty of practice in moving around the new routes and leads to new attentional levels in the brain.  Attention in the brain gains new vistas.

Routing Auditory Input

The brain breaks incoming data into tiny bits.  It distributes these pieces to different departments and then reassembles them, collecting other useful pieces of information along the way that relate to our past experiences and even what we WANT to hear.

The sounds signals are actually registered as pressure changes, like vibrations, that hit the ear drum & move the little bones in the ear.  They travel further into the ear to the cochlea – shaped like a seashell – a spiral container filled with hair cells that bend as they are vibrated.  Each of the 15,000 hair cells responds to particular frequencies at particular loudness. 

• The hair cell motion is converted into electrical signals that fire neurons. 
• Each hair cell is sensitive to a limited frequency range

Our brains actually SHAPE what we hear.

There are more neural networks extending FROM the brain TO the ears than are coming from the ears to the brain. 

Layer upon layer of sound units pile up and beg to be registered by a whole array of brain departments.  The brain develops “models” of what it expects to hear – phonemes, words, or music.

Those who are dyslexic or who have a condition called Central Auditory Processing Disorder, CAPD, must be continually surprised at what they hear.  Their phonemic models continually break down.  This leads to a sort of communication traffic jam. 

The Ear

First the ear processes the sounds.  Then the information is broken down & channeled to the brainstem, through the auditory nerve.  This nerve has 25,000 nerve fibers – which are not many compared to the nerve bundles for vision and touch.  The nerves are always fired up, ready to take information to the right spots in the brain. 

The Brainstem

The brainstem sorts its pieces of information by tone and timbre or quality of the piece of sound.  The brainstem preserves the sound and starts to distinguish the sets of sounds as phonemes, that don’t carry any meaning in themselves.  Ratey 94  The medulla examines the vibrations for spatial characteristics.  Ratey 94  We maintain mental maps in our cortex to estimate WHERE the sound comes from – per research that has come out from Michael Graziano at Princeton University.   

Olivary Study – Hearing Near & Far

The brainstem sends the sound vibrations to the superior olivary to figure out that louder sounds are closer.  Here is where it is interesting to bring in information from Scientific American Feb 2000 article on autism by Patricia Rodier.  She notes that in autopsy studies that people with autism have a “disappeared” superior olivary!!!!  She notes that there are other physical characteristics and brain measurement anolomalies with people with autism. 

The olivaries send messages to the midbrain and this coordinates the body’s reflexes and reactions.  The superior colliculus in the midbrain is crucial for integrating sensory information from the sensory information systems.  It tries to bring about a unified response to experiences.   Ratey 94  The Superior Olivary has a lot to do with timing.  It interprets information from both ears.

The Journey Continues

From the superior colliculus, the auditory impulses travel to the thalamus and then to the primary auditory cortex in the temporal lobe.  This links it to the secondary auditory cortex and that structure connects to other parts of the brain which coordinate hearing with memories and awareness.  As the signals travel to the medial geniculate bodies (in the thalamus), the signal is divided between 2 types of cells:  the parvocellular and the magnocellular cells.  The magnocellular process the rapidly incoming sounds & send them to the auditory cortex. 

Auditory Cortex

By the time the sound signals arrive in the cortex, the columns of neurons there are sensitive to specific differences in sound frequencies and changes in frequencies and cause different columns to fire.  Then the cortex must do a comparison between the patterns generated by the columns of neurons with the stored patterns with which it’s already familiar. 

Long Trip

As you can see there’s a very complicated route that these signals must travel.  Auditory impulses travel across a large neural landscape.  The left and the right sides of the brain must work together to discriminate complex sounds.  The right side examines the sounds for harmonies and relationships between close sounds.  The left side compares auditory information with the language centers. 

Broca’s Area

Broca’s Area is located in the left frontal lobe near the primary motor cortex.  Paula Tallal (FastForWord fame) has found that fast processing of speech takes place in Broca’s area of the Left Hemisphere.  Broca’s area is thought of as the controller of the motor cortex (controller of voice box and tongue).  Apparently speech has a great deal to do with the movement regions of the brain.  Ratey 97

In the 1990’s, researcher Michael Merzenich at the University of California (San Francisco) found in animal research that auditory inputs have the power to change the brain.  By altering sound input, they found changes happening in the auditory cortices of monkeys’ brains – this factor changed the rate at which the brain processes sounds.

When Merzenich and Tallal put their research together, they discovered that children with specific language impairment construct their auditory cortex from faulty inputs.  They found these children take as long as 1/3 to 1/5 of a second to decode mini sound segments, this is as long as it takes neruo-typs to process SYLLABLES.  One factor in the specific language impairments were the number & intensity of ear infections.  Schwartz & Begley
Auditory Integration Training, like many other therapies helps to bring new dimension to the brain and how the brain operates.  I like to think that it makes the brain more efficient.

Changes In Audition

In 1999 there was research performed by Rainer Klinke at the Physiologisches Institute of Frankfurt, Germany.  He tested the effects of cochlear implants on a group of 3 to 4 month old kittens who had been born deaf.  Brain imaging showed that the unstimulated auditory nervous system in the deaf kitties had not developed like normal cats.  After the implants, the kitties began to respond to sounds in the same way cats born with normal hearing did. 
Not surprisingly, their auditory ciritces change too.  Within a short time the size of the region of the auditory cortex that responded to sound had increased.  The strength of the electrical signals in the auditory cortex rose and measures of information processing in the cortex increased as well. 

When scientists remove the cochlea of lab animals in one ear soon after birth.  The number and size of auditory neurons in the brainstem are reduced.  But this effect can be reversed again by providing sensory input.  For instance, with congenitally deaf children given cochlear implants (which bypass the damaged sensory hair cells of the inner ear) and carry acoustic signals directly to the cortex of the brain, the sudden onset of sensory – in this case auditory – input leads to nearly perfect speaking and hearing as well as individuals with normal language development. 

The Brain And Some Valuable Brain Statistics

Here are some interesting statistics about the brain:

• The brain is the greediest organ of the body.
• It burns oxygen & glucose at 10 times the rate of all other body tissues – at rest!
• The brain is only 2.5% of the total body weight, but is responsible for 20% of the energy consumed when the body is at rest.  Greenfield 27
• The brains of children between the ages of 3 and 10 consume two times as much of the blood nutrient glucose as those of adults.  Ratey 35
• The brains of children are less efficient and therefore need more fuel.
• Auditory neurons appear in the first 3 weeks after conception. 
• Auditory centers in the brainstem emerge by 13 weeks of gestation.

The brain is vital for processing and coordinating information that floods through the senses.  The outputs of the brain are expressed as movements (muscular and neural).  All human communication relies on movement whether its body language, how the lips, tongue and mouth move when speaking or in physical gestures, (like a hug).

Neurons actually anticipate signals – that is – they are primed to expect the same old kind of signal.  But when they get a new intensity of signal or a new nuance of signal, they perceive the input as new & quite disturbing.  This disturbance is good, since it leads to reorganization. 

• A baby’s brain contains something on the order of 100 billion nerve cells.
• Each neuron makes an average of 2,500 connections or synapses.
• The connectivity peak may be 15,000 synapses by the time the child is 2 or 3 & then the system goes through a period of “pruning”.
• The synapses that stay are more efficient and carry traffic more reliably. 

• The motto of neurons is survival of the busiest.  The adult brain boasts about 100 trillion synapses, some estimates go as high as 1,000 trillion. 

Movement And The Brain

Movement is a very important factor in brain development.  It’s important for most brain functions, like memory, emotion, language and learning, cognition and to behavior.  Ratey 148  You will hear about the cerebellum anytime you hear about movement and the brain.  The cerebellum coordinates physical movement, as well as the movement of thoughts. 

The brain circuits that control, sequence and time mental acts are the same circuits that are used to control or order, sequence & time physical acts.  Motor activity takes place in 3 stages:

• We analyze the incoming data (either external or internal)
• We formulate & monitor a response plan – this is the stage that involves thought-processing.  It is here at this sequencing stage that involves organizing the serial order of information & integrating this information with the previously learned data.
• We execute the plan

We can surmise that exercise can produce chemical changes that give us stronger, healthier & happier brains.  We must not forget to view PLAY as a motor activity – it helps learning & social relationships develop. PLAY is an activity that gives children a sense of mastery & is rewarding.  Play as a motor activity prepares us for later adult social interactions. 

Motion And Movement Of Information

The entire front half of the brain is devoted to organizing action – physical & mental.  The frontal cortex is the most interconnected part of the brain.  Ratey 148  The primary motor cortex & the premotor cortex are located here.  Ratey 156  This is where our “self-awareness” lies.  It is driven by motor neurons.  Another actor is the cerebellum as mentioned before.  The cerebellum heavily influences the cortex. 

The sensory cortex located just behind the primary motor area gathers additional data about our thoughts, past experiences, emotions and stored memories, which gives our movements & actions extra meaning, and complexity. 

Motor function happens under the influence of attention & emotion.  Our brains constantly use attention and emotion to determine what is important & what is not.  This ability determines whether we survive.  The feedback loop is extra tight between the motor system and the attentional and emotional circuits. 

Music Equated With Motion

Music makes both sides of the brain work interdependently.  The left side is better at targeting the succession of sounds – the rhythm.  The right side works on elements of timbre – sound quality.

Henri Platel (from the University of Caen, France) used PET scans to study non-musical men as they listened to classical music and the random sequences of musical notes.  He found that Broca’s area was activated then his subjects listened to classical (well-known) pieces of music. 

The brain is an organ that breaks sensory information apart and reassembles it to form the final “perception”.  There is not single “attention center.”  There are multiple distribution systems.

• The prefrontal cortex occupies itself with task related memory and planning. 
• The parietal cortex involved itself with bodily and environmental awareness 
• The anterior cingulate is concerned with motivation. 
• The cerebellum and the basal ganglia center their efforts with habit formation and coordination of movement.