We are pleased to welcome David Gross Au.D., CCC/SLP/A, FAAA, as
our guest host for the tonight's chat on Monday, March 1, 2004.
He will be addressing the controversial topic of Auditory Integration
Therapy (AIT).
In 1994, the American Speech-Language-Hearing Association Subcommittee
on Auditory Integration Therapy (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. ASHA recommended that this position be re-examined
should scientific, controlled studies supporting AIT's effectiveness
and safety become available.
Dr. David I. Gross received his Doctor of Audiology Degree from
the Arizona School of Health Sciences/KirksvilleCollege of Medicine.
He is dual certified/licenced in both speech pathology/audiology
and has been serving the Long Island, NY community for over twenty
years.
Dr. Gross has served as director of several speech and hearing
departments and has served as an adjunct professor at Touro college.
He has given numerous professional presentations and has been published
in a professional journal. He has served as a consultant to several
hospitals and agencies.
<Robin> Tonight we are chatting with David Gross Au.D., CCC/SLP/A, FAAA about the controversial
topic of Auditory Integration Therapy (AIT).
<David_Gross> Good evening! Alfred Tomatis a French ENT/Psychologist developed AIT while trying
to retrain the ears of dysphonic singers. Today it is used to adress autism, learning
disabilities and psychological disorders. I hope to adress both sides of the AIT debate
during the chat.
<greenehornet> Thanks, I just received a report today as a matter of fact from our district
audiologist about a student who has APD in the area of integration.
<Robin> Dr. Gross, please define AIT for those of us who are unfamiliar with it.
<David_Gross> AIT is auditory integration therapy.
<David_Gross> It is said to be a system of retraing the way the ear hears.
<David_Gross> The purpose is to adjust the way we percieve sound.
<CHINA> Can it be used with children who have CAPD?
<David_Gross> CHINA, that is one of its main uses
<AdrienneFSU> Why/how would this help autism?
<greenehornet> I have never heard of AIT being used for Autism.
<David_Gross> The proponents claim autism is caused by sound hyper sensitivity.
<KarenK_ABA> I actually took a course online about Tomatis, and there were some good responses
to his methods with some autistic children.
<David_Gross> By decreasing hyperacusis(an extreme sensitivity to noise) they claim the ear
becomes more receptive to language.
<greenehornet> So it only helps those who have hyperacusis?
<KathyE> Does it help hyperacoustic children?
<KathyE> Like a child who screams when the music comes on in church?
<David_Gross> No-the supporters claim individuals may be sensitive to specific frquencies in
close contact with each other.
<David_Gross> It is not only for HYPERACUSIS as we traditionally define it.
<David_Gross> Tomatis claimed you want to FLATEN the audiogram making sensitivity at all
frequencies within 5db of each other.
<AdrienneFSU> Why?
<David_Gross> Tomatis claimed that many autistic/learning disabled/psychotic/dyslexic patients,
have supersensitive hearing at certain frequencies. He felt this sensitivity causes
patients to tune out sound. He further claims this tuning out is the cause of their
disability. Based on this hypothesis, he feels flatening out a patient's audiogram
will make them less sensitive to sound. This he explains will result in patients being
more receptive to auditory/language input, eventually resulting in remediation of their
problem.
<David_Gross> He described this phenomenon as SAW TOOTH AUDIOGRAMS and its correction as the
cure to a host of problems.
<David_Gross> THAT IS neighboring frequencies varied by 5db or more.
<KathyE> Not a dip in the middle like sensorineural hearing loss, then?
<David_Gross> No-we are talking neighboring frequencies.
<David_Gross> and hearing may be TOO GOOD
<greenehornet> So a saw tooth audiogram is usually an indicator for AIT?
<David_Gross> An audiogram is always the first step in the Tomatis procedure and the presence
of a saw tooth audiogram is the primary indicator for the need for AIT.
<AdrienneFSU> I'm still not sure I understand the theory of AIT-- how is a saw tooth
audiogram related to language?
<David_Gross> O.K. Lets take a step back for a moment. A saw tooth audiogram is said to
indicate that a person's hearing is hypersensitive at specific frequencies. As a
result of this they begin to tune out sound. By blocking out sound we block out our
primary source of linguistic input. If I can decrease this hypersensitivity and make
the listener more receptive to sound, I can make them more receptive to language input.
AIT is claimed to be the method needed to correct auditory hypersensitivity resulting
in an individual who can now acquire language.
<Robin> Please tell us about how you evaluate and determine if someone would benefit from AIT.
<David_Gross> A pre-therapy audiogram is taken.
<David_Gross> We look for the saw tooth pattern described before.
<David_Gross> You are not looking for a loss but rather an up down pattern.
<David_Gross> EVEN IF HEARING FALLS WITHIN NORMAL LIMITS.
<KarenK_ABA> Should this be done regularly with children with autism?
<David_Gross> Karen again this is Tomatis's view.
<KathyE> At what age can this be done/tested?
<David_Gross> The younger the better.
<KarenK_ABA> We've tried so many other ideas in our program, this seems like it might have some
value also.
<greenehornet> I was told you can't test below age 7.
<David_Gross> As soon as an audiogram can be obtained.
<greenehornet> The premise is the tests start at age 7.
<David_Gross> Age 7 is the landmark for CAPD testing.
<David_Gross> This is because the neurological development involved in auditory processing is
still developing.
<greenehornet> Ah ok
<David_Gross> Tomatis DID NOT USE THIS LANDMARK.
<David_Gross> For the purpose of TOMATIS testing-you must be able to get FREQUENCY SPECIFIC
THRESHOLDS IN BOTH EARS.
<AdrienneFSU> I can imagine giving a hypersensitive child this test would not be fun. Any
tips for keeping the child on task and calm?
<David_Gross> Hard to test populations are always a challenge. I frequently rely on visual
reinforcement audio., play activities (put block in box), and try to have 2 clinicians
present. Using warbeled tones instead of pure tones at times also helps. Frequently
I use A.B.A. (Applied Behavior Analysis) techniques if the child has been exposed to
such programs (earning rewards does wonders). When all else fails DPOAEs (Distortion
Product Otoacoustic Emissions) and ABR (Auditory Brainstem Response) are great backups.
<Robin> Tell us more about the evaluation..you start with an audiogram...
<Robin> Once the results of the audiogram indicate this up-down or saw tooth pattern, are
there any other factors to consider before starting AIT?
<KarenK_ABA> Does the child need any specific abilities in order to be able to proceed with AIT?
<Robin> Please tell us what other factors to consider, specific abilities, etc.
<David_Gross> Robin, I'm not sure exactly what you are asking. If you mean to obtain an accurate
audiogram, audiologists have a range of new tests that can be used to obtain thresholds
even with non-responsive populations (OAE,ABR and others). Which leads to another issue-
providers of Tomatis therapy are mostly not audiologists, yet most perform their own
audiological testing. If you are addressing AIT in particular, as long as an individual
will wear the headphones for the length of the treatment session, there are no
restrictions as to who can go through the treatment. It is said to be basically one
size fits all.
<David_Gross> We haven't looked at the other side of the coin.
<David_Gross> DETRACTORS TO AIT-including ASHA- feel AIT may actually cause damage.
<KarenK_ABA> Damage to the ears (hearing system), to the thought processes, or other damage?
<David_Gross> Since the equipment cannot be coupled to standardized equipment we have no way of
measuring output
<KarenK_ABA> That's a bit scary!
<David_Gross> It may result in noise induced hearing loss
<Robin> oh boy
<greenehornet> Oh
<AdrienneFSU> holy cow
<David_Gross> Also - there is a great increase in violent behavior.
<David_Gross> It usualy vanishes within several weeks of therapy.
<Robin> Its understandable why this is controversial!
<David_Gross> KAREN-thats the problem
<KarenK_ABA> With my students, I would be very concerned in the increase in violent behavior
since they can already be quite aggressive.
<David_Gross> Karen ABA- the violence is said to be a temporary side affect.
<KarenK_ABA> So can you give some idea of who really should be targeted for AIT?
<David_Gross> Proponents claim it helps autism,learning disabilities, schizophrenia, dyslexia,
etc.
<Aubrey> How would it help with language disorders?
<David_Gross> Again, you need to accept Tomatis' premise that hyperacoustic patients learn to
block out sounds. This results in language input being blocked. If we reduce sound
sensitivity we increase the ability to tolerate sound. This results in the patient
opening up to previously blocked language input.
<AdrienneFSU> Good question Aubrey, I am not seeing a connection either.
<greenehornet> Did they specify as to what degree of Autism AIT helps? (the severity)
<David_Gross> Not really. It is supposed to be a cure all.
<David_Gross> AIT includes counseling for both patient and family.
<KathyE> Say, a three year old already diagnosed with phonological processing disorder and
sensory integration dysfunction, who reacts with a meltdown to music might be a
candidate?
<David_Gross> Tomatis supporters would say yes.
<David_Gross> REmember the PRIMARY FUNCTION OF THE EAR IS BALANCE.
<David_Gross> NOT HEARING
<KathyE> Yes, and vestibular problems are part of the sensory stuff.
<David_Gross> So Tomatis followers believe we are not only changing hearing.
<AdrienneFSU> Then I shall rephrase my question- What does BALANCE have to do with language
disorders?
<David_Gross> Adriene-Think SI (Sensory Integration) - Tomatis felt a lot of language learning
is done by VIBRO TACTILE STIMULATION.
<AdrienneFSU> I am not familiar with vibro tactile stimulation....
<KarenK_ABA> Me either.
<David_Gross> A lot of it in Utero.
<KathyE> Aha! So uterine constraint history might also be releveant?
<David_Gross> Kathy-now you have his reasoning.
<David_Gross> Vibro tactile means VIA TOUCH.
<David_Gross> If you place a BONE VIBRATOR ON THE KNEE YOU HEAR IT IN THE EAR BECAUSE BONES
TRANSMIT VIBRATION.
<listener> But knees don't have auditory nerves.
<David_Gross> True, but they are bone, a great place to transmit sound/vibration to places
that do have auditory receptors.
<David_Gross> He claims AUTISM is seen in greater numbers in cross cultural populations since
we are disturbing preprogrammed language patterns.
<KarenK_ABA> I can't say I see that specifically in the group I've been working with (cross
cultural population).
<listener> So, does Tomatis help vertigo?
<listener> Adult
<David_Gross> Listener-probably, at least according to Tomatis. He does claim it helps balance
problems. Again, vertigo has many causes. Results would vary by sight of lesion, at
least in my opinion.
<Robin> It appears that AIT is quite controversial.......how often is it being used, who is
administering it, and what is the success rate?
<David_Gross><Robin>-AIT is VERY controversial-thats why I focused my doctoral research on it.
<David_Gross> ASHA still feels it is EXPERIMENTAL.
<listener> ASHA doesn't feel it is experimental, they have a position paper against it's use
because it doesn't demonstrate effectiveness.
<David_Gross> Listener, actually in its 2004 osition paper under Summary and Recommendations,
ASHA specifically states the AAA and ASHA and others still feel AIT is experimental, and
AIT should be reexamined if and when new research indicates another look is warranted.
You are quoting only a small portion of the report. I believe listed under concerns, of
which I am the first to say there are many.
<KarenK_ABA> What are your personal feelings?
<David_Gross> Mixed
<KarenK_ABA> How you ever experienced/known any successes?
<David_Gross> Several of the students I followed made great progress.
<David_Gross> Others have made minor changes.
<KarenK_ABA> Were they autistic? How severe?
<David_Gross> ALL were autistic ranging in ages from 6 to 13.
<David_Gross> Several were very severe.
<David_Gross> So I wonder how Audiograms were obtained.
<David_Gross> The ABR shows hearing changes.
<KathyE> ABR under sedation?
<David_Gross> The research does not say
<David_Gross> but ABR and OAE don't REQUIRE sedation.
<David_Gross> Ive done ABR on high level autistic children without sedation.
<KarenK_ABA> How long does the entire treatment take? Or is this something that is ongoing?
<David_Gross> There are several versions
<David_Gross> TRADITIONAL TOMATIS THERAPY is 2-1 hour sessions over 10 days.
<David_Gross> Better success is reported if treated twice-
<KarenK_ABA> Do you see immediate results?
<David_Gross> Most parents claim to see almost immediate progress.
<David_Gross> EVEN GREATER if its the second round.
<David_Gross> BUT-sometimes you must wonder if a PLACEBO affect exists.
<KathyE> My grandchild is a hyperactive 3 year old, with sound sensitivity who did require
sedation for ABR after 3 attempts at different places).
<Robin> Kathy, has your grandchild had AIT?
<KathyE> No, but I think he might benefit. Fits the profile so far, from what I am hearing.
<KathyE> He shows extreme sound sensitivity, vestibular problems, phonological processing
disorder, etc. We are using ST, OT, fish oils, etc.
<David_Gross> Kathy E-the problem is-at least in MY HUMBLE OPINION -AIT has become a cure all.
<David_Gross> For some it works great
<David_Gross> BUT SO DO OTHER PROGRAMS.
<David_Gross> Such as Fast Forword or Easy Listening, etc.
<KarenK_ABA> Really? I didn't think it was that popular. It's only done in certain centers--is
that correct?
<Robin> What is involved in the actual therapy?
<AdrienneFSU> perhaps you could explain "the equipment"? What exactly do you do?
<David_Gross> The equipment used for AIT has been dubbed "The Kinetron". This system allows
numerous sound sources (tapes, disks, records, etc.) to be fed through a series of
filters. The unit presents sounds at varied intensities via airphones. Initially the
sensitive frequencies are filtered out (as determined by pretreatment audiogram) .
Filtering is slowly diminished as the patient becomes desensitized. The major concern
with this device is there is no way to couple a device to determine output levels.
Therefore we may be exposing patients to unsafe noise levels.
<greenehornet> What happens during therapy? Procedures?
<David_Gross> PROCEDURES-thats a lengthy discussion-but basically the patient is exposed to
several types of sounds(A LONG DISCUSSION TO ITSELF). Some of these include the
mother's voice (when available) to recreate the in utero environment. Gregorian chants
and Mozart music are also used.
<David_Gross> The patient is presented these sounds while wearing headphones. At first the
hypersensitive sounds are filtered out then slowly introduced. It is suggested that
this progressively desensitizes the patient to sound, making them more receptive to
auditory input.
<Robin> Which profession provides AIT?
<David_Gross> Thats another problem-ALMOST ANYONE CAN BECOME AIT CERTIFIED.
<Robin> Thats a problem.
<David_Gross> So you have psychologists, social workers, OTs, PTs, SLPs, etc., all involved.
<KathyE> Anybody who thinks it might work and gets training can become certified.
<David_Gross> Since ANYONE can treat you wonder about the accuracy of audiograms.
<David_Gross> WHICH IS ASHA's concern.
<David_Gross> WHO DOES THE AUDIO?
<David_Gross> HOW DO WE JUDGE PROGRESS?
<David_Gross> HOW SAFE IS THE PROCEDURE?
<Robin> I can certainly see why ASHA is concerned.
<KarenK_ABA> How certified are these AIT instructors? What does the training involve?
<David_Gross> Karen-you cover theory-and how to use the TOMATIS AUDIOKINETRON therapy device.
<David_Gross> Its a VERY short course.
<KarenK_ABA> It seems that there should be a bit more expertise since this could be somewhat
dangerous.
<Robin> And how, Karen!
<KarenK_ABA> I wouldn't want to put my child's welfare in the hands of just anyone with a few
hours of training.
<David_Gross> Karen-again-it depends who you believe.
<David_Gross> TOMATIS FOLKS CLAIM THE DEVICE IS SAFE-AND THE SUCCESS STORIES TALK FOR THEMSELVES.
<KarenK_ABA> Do you have the success rate as reported by an independent?
<David_Gross> In my study of 10 post therapy students all showed between 1yr to 4yr gains in
language skills (receptive).
<KarenK_ABA> Impressive!
<David_Gross> AGAIN THIS WAS AN ARCHIVLIE STUDY
<David_Gross> NO CONTROL GROUP
<David_Gross> DEPENDING ON OTHER PEOPLES TESTING
<David_Gross> UNFORTUNATELY most of the research is published by supporters with almost no
individual research.
<David_Gross> THATS WHY I PICKED THE AREA TO LOOK AT.
<KathyE> I'd like to know more about benefits and risks...
<David_Gross> Kathy, reported benefits: increased language skills, improved articulation skills,
enhanced voice quality, improved reading skills, reduced psychiatric problems.
Numerous other risks: noise induced hearing loss, increase in violent behavior in
autisic population (reported to be temporary), waste of time/money/emotional investment
in a questionable treatment.
<KathyE> What hearing loss damage if any has been documented?
<David_Gross> YOU HAVE TO REMEMBER A LOT OF THESE KIDS HAVE -5dB thresholds at many frequencies.
<David_Gross> AND ALL FREQUENCIES AT NORMAL LIMITS
<David_Gross> SO post flattening
<David_Gross> do we see a loss or RETUNING OF THE EAR?
<KathyE> Depends on your interpretation?
<David_Gross> SO what comes first, the chicken or the egg?
<David_Gross> Are the documented changes a hearing loss or an improved ear?
<David_Gross> Also, since each program is individualized, the changes vary.
<Robin> We have been chatting for close to an hour...any more questions for Dr. Gross?
<AdrienneFSU> Dr. Gross- Thanks for presenting the AIT controversy with both sides of the
arguments. It's always good to evaluate both before implementing any treatment.
Personally, I don't see the evidence yet but I'm glad I know more about it now.
Thanks.
<KathyE> Thanks very much
<KarenK_ABA> I've enjoyed the information. Thanks.
<Robin> Dr. Gross, thank you for being here tonight.
<David_Gross> Hope I addressed your questions and concerns.
<KathyE> Very good overall presentation, for someone like me who needed an overview! Thank you!
<David_Gross> You are welcome!
<Robin> Thanks to everyone for participating and asking such good questions.
<KarenK_ABA> Good night!
<greenehornet> Good night and thank you for presenting both sides.
