Teacher of the 21st century: Quality Education for ...

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weeks (Rimland & Edelson, 1995). Berard believes that optimum hearing occurs when a person hears all frequencies equally well (i.e. when the audiogram is ...

Teacher of the 21st century: Quality Education for Quality Teaching ATEE Spring University Riga 2006 ISBN 9984-617-95-5 The Hearing Ear and the Listening Brain – an Evaluation of Auditory Integration Training in Children/Students with Concentration Problems and Learning Difficulties Dzirdošas ausis un sadzirdoša uztvere – skolēnu ar koncentrēšanās problēmām un dzirdes traucējumiem integrēšanās novērtēšana.

Britta Alin Åkerman 1, 2 Lars Borazanci Persson 3, Sweden

Abstract It is obvious that people who cannot hear well will experience difficulties in many aspects of life, and particularly, children who cannot hear clearly what the teacher is saying, will be at great disadvantage in school. It is evident that there are variations in hearing dysfunction and that either abnormal sensitivity or abnormal insensitivity to certain sound frequencies, rates of vibration of sound waves, apart from the overall hearing ability, are associated with behaviour and learning problems, including hyperactivity and dyslexia. Hearing is the perception of sound, including both physical reception of the sound and its encoding and transmittal as information to the brain. Doctor Guy Berard developed an auditory integration training method (AIT) in the 1960s with the aim of normalizing the hearing in children with concentration difficulties. The training program entails 10 hours of listening to electronically modulated music through headphones in a 20-day period (four weeks). Initially the students´ hearing is evaluated audiometrically, identifying hearing thresholds, auditory laterality, auditory selectivity and sound sensitivity using the Frequency Discomfort Test (FDT). Identifying auditory peaks at specific sound levels indicates that the students may hear hyper-acutely on specific sound frequencies. The purpose of this study was to evaluate the effectiveness of AIT on the adaptive behaviour including concentration and learning difficulties. All 60 students at different schools for students in need of specific support, including a group of children with autism, in a district in Stockholm, Sweden, between 6 and 15 years of age were invited to this 9-month project. Subjects were matched in pairs with respect to age, gender and school. 27 students in the intervention group received AIT-training and 29 students in the control group did not receive AIT. Four assessments were conducted using questionnaires, pre-AIT, 3, 6 and 9 months post- AIT. This report presents the results from data in the group of children with autism. The results from the parents’ ratings show a difference between the intervention and control groups ranging from slight difference to considerable difference. Parents in the intervention group rate their children more concentrated, listening better and paying better attention, with improvements increasing over time. The data from the teachers did not show a difference between the two groups of the same range, however, according to the teachers students’ concentration mostly increased over time. KEY WORDS: Berard AIT-program, evaluation, autism, concentration, sound sensitivity



Stockholm Institute of Education, Department of Special Education Correspondence should be addressed to the Department of Special Education, Box 34103, SE-100 26 Stockholm, Sweden; e-mail: [email protected] 3 Berard’s Method Centers, Stockholm, Sweden; e-mail: [email protected]; [email protected] 2

Auditory integration training (AIT) has received a great of deal media coverage since the publication of the book The Sound of a Miracle (Stehli, 1991). In her book, Annabel Stehli wrote about the dramatic cognitive and emotional improvements seen in her autistic daughter after only 10 hours of AIT, administered in the clinic of the otorhinolaryngologist Guy Berard in Annecy, France. Dr Guy Berard, a French ear, nose, and throat specialist developed in the1960s an auditory training method to normalize the hearing in children with various auditory anomalies, particularly hypersensitive hearing which blocks learning. He found that there is a direct connection between poor hearing and disruptive classroom behaviour, i.e. a child who cannot hear well becomes frustrated and bored, and because of this boredom and frustration «acts up» (1993). From the early 1960s until his retirement in 1991, Berard treated over 8.000 patients, children included. His method of AIT had effects not only on the ability to catch the sound but also on the cognitive development – how we listen, interpret and use information and knowledge, how we think and reason and its influence on our behaviour. The intention with the AIT-program was to rehabilitate children with hearing problems, including perception of sound, both physical reception and its encoding and transmittal as information to the brain. Our ears have different functions depending on which side of the head they are on. It is well known that the right-brain and leftbrain react to stimuli in different ways. The right ear reacts more to stimuli connected to speech and language and is associated with the left-brain. According to the findings of two American researchers (Sininger & ConeWesson, 2004) the left ear is more responsive to music and is associated with the right brain. The hearing was examined in small children by using otoacoustic emission (OAE). A small transducer is fitted into the ear canal providing sound to activate OAE. Energy generated in the cochlea is transmitted back into the middle ear and ear canal and is then measured by a microphone in the transducer-probe assembly. With this method Sininger and Cone-Wesson discovered that the specializing of hearing already starts in the ears. For example, hearing difficulties in the right ear will have negative effects on the learning in maths and on the speech and language development, which was concluded in a study by Jensen et al (1989). AIT, as developed and practiced by Berard, entails 10 hours of listening to electronically modulated music through headphones. The patient’s hearing is first evaluated audio- metrically using an air conduction test to identify hearing thresholds including specific sound frequencies («peaks»), which he or she may hear hyperacutely. The AIT device is then adjusted by setting filters to dampen the peak frequencies to which the individual is hypersensitive. The filtered music is then modulated by a brief dampening of high and low frequencies on a near-random basis for periods ranging from 250 milliseconds to 2 seconds, at a pace determined by the music played. The loudness is adjusted to each participant’s comfort level, usually at 60–80 dBA. The individual listens to the filtered, electronically modulated music for one 30-minute session per day, five days a week during four weeks (Rimland & Edelson, 1995). Berard believes that optimum hearing occurs when a person hears all frequencies equally well (i.e. when the audiogram is nearly a straight line) (Berard, 1993). Berard (1993) has summarized his clinical experience with over 8.000 patients with hearing problems that he had treated with AIT over several decades of which 48 patients were autistic. While auditory problems are clearly and important symptom of autism, there is a surprising paucity of research on the subject (Rimland & Edelson, 1994). Although it has received little professional attention, sound sensitivity, especially at certain frequencies, has been widely recognized as affecting a substantial proportion of autistic children and adults. In 1964, Rimland began collecting data on many aspects of autism, including sound sensitivity, through the use of a parent questionnaire (Rimland, 1994). In a large-scale study on the effects of AIT in children and adults with autism (n = 445) Rimland and Edelson (1994) observed a significant decrease in sound sensitivity following AIT. Raters were blind to the assessments performed before and after the AIT listening sessions. Positive effects were described, both according to changes in the audiogram before and after the training period, and from the parents’ ratings in questionnaires regarding changes in their children’s behaviour and concentration. Geffner et al (1996) studied long-term effects of the Berard Auditory Integration Program on eight children between 6 and 14 years of age with the diagnosis of ADD. The children underwent a battery of tests to examine hearing, auditory processing and language skills before the program. An evaluation was made immediately after, six months later and one year subsequent to the completion of the AIT. A comparison of hearing thresholds and tolerance data, auditory processing, and language skills were made to determine whether any changes were observed after the AIT-program. After following these eight children over a one-year period, the authors summarized that hearing, auditory processing, and language skills could and did improve after these children with ADD received AIT. Additionally, these improvements were generally maintained over time and, in many cases, continued improving after AIT. Edelson et al (1999) have studied 19 autistic subjects, assigned at random to either the experimental group (9), which listened to AIT-processed music, or a placebo group (n = 10), which listened to the same, but unprocessed, music. All evaluations were «blind» to group assignment. The authors found that AIT produced both behavioural improvement and normalization of brain wave activity. One study from Sweden has reported that AIT brings about little or no improvement in behaviour and sound sensitivity (Gillberg et al, 1997). The effects of AIT in individuals with autism were studied over a 9-month period. There were several inherent problems in this study, including: no control group, assessments based on

diagnostic checklists rather than treatment outcome measures, and a misinterpretation of statistical analyses (Edelson et al, 1999).

Method Aim The purpose of this report is to evaluate the effectiveness of AIT in autistic individuals regarding symptoms as indicated in four questionnaires to parents and teachers that were used pre-AIT, 3, 6 and 9 months post-AIT. The overall aim is to investigate whether concentration and learning in this group have changed after the AITprogram. Subjects All children and adolescents between 6 and 16 years of age, registered in special classes for students in need of special education in a district in Stockholm were offered the opportunity to participate in this study. Of the total of 60 students available for this study 56 were accepted. In this paper the results from a group of 21 students with autism will be reported. These students attend a special school for children with autism and have received a primary diagnosis of autism from an independent hospital. To measure the effects of AIT the group of 56 students were divided into one intervention-group and one control-group. Before the students were assigned to their groups, parents and teachers were asked to fill in questionnaires. Subjects were matched in pairs with respect to age, gender and school. Subjects from these pairs were then assigned, at random, either to the intervention- or the control-group. Procedure Parents and teachers in the intervention group were asked to complete questionnaires prior to the AIT listening sessions. The students’ parents in the control group were also asked to complete the same questionnaires, motivated to participate in the study by their children being offered AIT after the project. The teachers in both groups also received the same questionnaires. In order to assist in keeping the AIT-program schedule, the teachers accompanied their students to the listening sessions. Audiometric tests were administered to all the students in the intervention and the control groups prior to AIT, after the 20 sessions and 3, 6 and 9 months post-AIT. The parents and teachers filled in the same questionnaires 3, 6 and 9 months post-AIT. The number of questions in the questionnaires for parents and teachers differed due to additional questions for parents, regarding sleeping routines. Listening sessions took place in a quiet, comfortable room at Berard´s Method Center in Stockholm, supervised by Lars Persson, certified AIT practitioner and trainer. Lars Persson was educated by doctor Berard and has practised the method more than seven years, both in Sweden and Turkey, and reports a number of positive effects among both children and adults with different problems like dyslexia, autism, stress and depression.

Results Since the number of students in the group of students with autism is very limited, it is not possible to do any statistical analysis. The questionnaires consist of a total of 31 questions for teachers and 33 for parents. Summing the responses to questions in the questionnaires referring to variations in concentration (six questions) is presented below. The responses regarding the rest of the students will be presented in a forthcoming report. The histograms show mean values of the sums of the raw data based on 10 questionnaires for the intervention group and 11 for the control group on the 1st and 4th assessments. The parents’ and the teachers’ assessments regarding the students’ concentration with respect to tasks they like performing are presented in figure 1. For teachers the questions concern school subjects and for parents household duties. Teachers and parents were asked to rate concentration on a 5-grade scale where 1 = severe concentration difficulties and 5 = good concentration ability for the child. High rating implies that the students are more concentrated. (Figures 1– 4 present score are based on a 5-grade scale). P – I = parents in intervention group. P – C = parents in control group T – I = teachers in interventions group. T – C = teachers in control groups The results of the estimated increase/decrease in concentration – comparing the pre AIT and nine months post-AIT assessments are presented below with percentage in brackets.

P – I: 4.3, 4.7 (increase 9.3%); P – C: 4.2, 4.8 (increase 14.2%); T – I: 3.9. 4.4 (increase 12.8%); T – C: 4.6, 4.5 (decrease 2.2%). According to the parents in both groups (intervention and control) the children are more concentrated after nine months compared to the first assessment. The teachers estimate their students to have slightly better concentration at the last assessment in the intervention group. Parents’ and teachers’ assessments about their students’ concentration in respect to performing tasks they don’t like to do are presented in figure 2. High rating implies that the students are more concentrated according to their parents and teachers.

P – I: 1.6; 2.0 (increase 25%); P – C: 1.9, 2.2 (15.8%): T – I: 1.5, 1.4 (decrease 6.7%); T – C: 1.5, 1.8 (increase 20%). According to the more tedious tasks at home, the children in both groups are slightly better at concentration at the end of the study, and slightly better in the intervention group compared to the control group. For the teachers there is a difference between the first and the last assessments and also between the intervention and control groups. In the control group the teachers estimate the students‘ concentration to have increased while in the intervention group the concentration ability has decreased. Figure 3 shows the childrens’/students’ ability to start a task (a higher value means a better ability).

P – I: 2.5, 3.1 (increase 24%); P – C: 2.4, 2.9 (increase 20.8%); T – I: 2.4, 2.7 (increase 12.5.%); T – C: 2.8, 3.0 (increase 7.1%). In this question there is a considerable congruence between parents and teachers in the intervention group and a higher rating of the students’ ability in all groups. Figure 4 displays the childrens’/students’ self-confidence according to the opinion of their parents and teachers. They have been rated on a 5-grade scale where 1= low self-confidence and 5 = high self-confidence.

P – I: 3.2, 3.7 (increase 15.6%); P – C: 3.2, 3.8 (increase 18.8%); T – I: 3.3, 3.2 (decrease 3%); T – C: 3.0, 3.7 (increase 23.3%). According to the parents of the children in both groups the self-confidence has increased; according to the teachers, self-confidence has decreased in the intervention group but increased in the control group. Figure 5 shows how parents and teachers estimate their childrens’/students’ ability to react and pay attention when talking to them. They had three alternatives: a) listen immediately, b) listen only after repeating the question and c) listen only after repeating the question several times. The figure shows the mean values of the ratings; a low score indicates good attention, (listen immediately is coded 1, listen after repeating the question is coded 2 and listen after being prompted several times is coded 3).

P – I: 2.6, 1.6 (increase 38.5%); P – C: 1.9, 2.1 (decrease 10.5%); T – I: 2.3, 2.1 (increase 8.7%); T – C: 2.6, 2.0 (increase 23%). The results show that the parents in the intervention group estimate their childrens’ attention to be more focused at the last assessment compared to the control group where the rating scores of the attention have decreased. Teachers in both groups estimate the students´ concentration and focusing to be better the last assessment. Figure 6 shows how parents and teacher estimate the students’ focus ability when they are asked to perform tasks at school or doing homework. A lower value means that the students are doing what they are asked to immediately or after being prompted. Rating alternatives are the same as in figure 5, i.e. 1 = task performed when told once, 3 = task performed after being prompted several times.

P – I: 2.7, 1.9 (increase 29.6%); P – C: 2.4, 2.6 (decrease 8.3%); T – I: 2.3, 2.2 (increase 4.3%); T – C: 2.6, 2.0 (increase 23.1%). In figure 6 the parents’ estimations in the intervention group and the teachers’ estimations in the control group are nearly the same. The comparison between parents in the intervention and control groups shows that the parents in the intervention group estimate their children to be more directly focused on a task, which is manifested by faster reactions. To give a more extensive view of improvements following AIT in children with autism we would like to present two case studies. Parents and teachers were asked to rate problems on a 0–10 scale before and after AIT

in order to identify improvements. (0 = severe problem, 10 = no problem). The real names of the children in these case studies have been changed. Jenny was a 14-year-old girl with Asperger syndrome. Before AIT her mother stated that her daughter had problems with concentration in school which she rated 2. Her mother rated auditory uptake (3), toleration of background noises (2), memorizing and recollection ability/academic performance (2), comprehension of language (3). Jenny was also undergoing treatment at the Child- and Adolescence Psychiatry Department and was on medication for depression. At the nine months control after AIT, Jenny’s mother rated the following improvements: concentration in school, rate 5, auditory uptake, rate 9, toleration of background noises, rate 6, memorizing and recollection ability/academic performance, rate 7, comprehension of language, rate 5. Her sleeping pattern was also improved. Jenny was taken off medication for depression and the treatment at the hospital was terminated. Total score before AIT was 12 and the total score nine months after AIT was 32. Sune, a four-year old hyperactive boy with aggressive behaviour and frequent tantrums, almost no language, underwent considerable improvements rated by his mother. Before AIT his language was rated 3, impulsive control rated 1, concentration rated 2, tactile tolerance rated 2, ability to experience physical pain rated 2. After AIT his hyperactivity, aggressive behaviour and tantrums ceased, language and vocalising improved dramatically. Total score before AIT was 10 and after nine months the total score had increased to 41.

Discussion Auditory integration training is a form of direct sensory stimulation and we wanted to investigate whether the training could give effective results on individuals’ concentration and ability to pay quick attention in a group of students with autism. The most important issue in this study has therefore been to investigate the possibilities of establishing something about the effectiveness of the AIT-program by using parents’ and teachers’ questionnaires. It is, however, important to bear in mind that, when interpreting data, the intervention- and control- groups are very small. Histograms can only show tendencies. When discussing the design of this study we considered the issue of introducing processed music to the intervention group and unprocessed music to the control group under identical conditions. Since the students were classmates, we realised that there would be a high risk of contaminating any «blind-situation» through students exchanging information. Had the students attended different schools, the situation would have offered more alternatives in this sense. We also discussed the issue of how to motivate the children in the control group to participate in this study and we decided on offering them the AIT-program after the project as a reward. Autism involves especially difficult and troublesome problems, including difficulties in communicating with and eliciting cooperation from the participants during the auditory assessment. Approximately half of all children with autism generally have severe to moderate learning problems. Most of the children are also mentally retarded which influences their learning and also to a high degree their concentration ability. Thus, due to a delay in most areas of the cognitive development and also to their lack of normal social behaviour, communication and emotional development will in general be on a par with their abilities to participate in the AIT-program. Would they be able to understand what was expected of them and could they endure the auditory training with their headphones on for 30 minutes? Some of the students had problems with this, which may have influenced the results. Another fact that we didn’t take into consideration, and that may have influenced the results, is that parents and teachers have different capacities in filling in the questionnaires. The parents especially, who also may have communication problems, could have misunderstood the questions. There could also have been the risk of being influenced not to see or understand improvements by remembering responses from previous assessments. One important aspect to investigate would have been the auditory processing problems in children with autism, i.e. selecting the children on the basis of sound sensitivity and/or auditory processing problems and studying the children in separate groups, to compare students with sound sensitivity problems with those not having these problems. The limited number of participants in the group of children with autism prevented us from doing this comparison. When analyzing the material, we could see that the mean values of the ratings in the intervention and control groups were not the same in the different assessments from the beginning even though we had randomised them in different groups with respect to age and gender. Therefore we have chosen to analyze the difference between the first and the last questionnaires only, as we could see that the tendencies were increasing over time. Despite the limitations, including the limited number of participants, it is important to notice that there are small positive tendencies in the intervention group with respect to concentration after the AIT-program, especially with regard to the parents´ estimation. By comparing the parents’ responses in both groups, scores differ more in the intervention group compared to the control group. This is especially apparent when parents ask their children to perform a task at home. In the analyzed results of the responses to all questions, the parents in the intervention

group have noticed a better concentration and attention over time, as for the control group but in some questions not to the same extent. There is only a small difference between the intervention and control groups when the children were asked to perform tasks they liked (for example practical homework, cooking, painting, performing other tasks they enjoyed). The same applies to tasks the children don’t like to do, for example their homework, getting dressed, house cleaning etc. The greatest difference between the intervention and control groups is childrens’ ability to pay attention, responding to instructions to perform a task and getting started with a task, which we suggest has been influenced by the AIT-program. Ratings from the teachers in both groups mostly show increased ability in the students to concentrate and pay attention at school, but did not differentiate much in the two groups. It is also important to take childrens’ general development over time into consideration, which of course influences the results in both groups. The questionnaires did not contain questions related to specific symptoms of autism; however a number of improvements in this sense in the children in the intervention group were particularly pointed out by personnel/teachers. One teacher observed that the children were generally more relaxed yet more «with it» when coming back from the listening sessions. Further reports 9 months post- AIT tell of improvements in vocalising and speech and language development/comprehension in four cases. One boy baffled the personnel by speaking full sentences from using «telegram language» like «food soon», «water now», etc. to «we’re out of bread in our department, could you please lend us some?» The same boy stopped his echolalia completely, and increased his presence and awareness to extent that the personnel started speaking of an «awakening». He also had a dramatic identity improvement and started using «I» and «me» instead of referring to himself in third person. Another boy baffled his teacher with his sudden comprehension of time perspectives. He started telling about past events, his present doings and sharing his future plans with the personnel, and by this showing his understanding of the difference between the past, the present and the future. Better mood regulation with fewer temper tantrums was reported in four cases. Improvements in social behaviour and increased interest in interacting with others were reported in three cases. Regarding eye contact, observations tell of improvements in four cases of which one boy, who always used to look away and avoid eye contact, started looking straight into the eyes post-AIT. Improved cognitive comprehension, understanding more advanced instructions, more alert reactions, higher arousal level and increased contingency was reported in four cases. Other reported observations told of more endurance, patience and contentment, reduced sound sensitivity, improved motor skills and reduced restlessness. The children also seemed happier and more «easy going». Another factor that may have influenced the results is that especially in schools for children with autism, the teachers from time to time change their pedagogical models, their teaching and structuring. For children with autism it is important to use individual schemes for every student. Many factors can therefore contribute to changes in the students, which could be one explanation for unexpected results. A lot of letters from parents and teachers sent to us after the project that underlined their opinions about a positive effect of the AIT-program, including concentration and attention. One mother wrote that all conflicts that used to happen between her and her autistic daughter nearly disappeared. Before the AIT her daughter often had headaches, which also decreased. These letters also tell us that the children generally seem to be more satisfied with life. They are also more emotionally open and taking more interest in what is going on around them. They are calmer and less hyperactive. Nobody has expressed any negative opinion about the training in their letters, nor have they observed any changes to less concentration or attention in their children. We cannot generalize the results to other groups, but we believe that hearing problems have a negative influence on the students’ schoolwork. The small changes in the intervention group may have influenced their hearing problems in a positive way, as some of the children seem to be more concentrated and pay more attention both at home and in school. As we know several additional control studies of AIT with autistic populations are currently underway in USA and Australia that will contribute significant information on the effectiveness of AIT according to Rimland and Edelson (1998), We will present the results of the data concerning the rest of the students in a forthcoming report, in which we also intend to present the results of the auditory assessments. Acknowledgments The authors would like to thank all parents, students and children for participating in this study. Thanks also to Maria Gamla Stan Special School’s administration for handling of and assisting in the distribution of the questionnaires. Our thanks also go to the City of Stockholm Competence Development Fund, which provided the funding for the Project Berard.

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3. Geffner, D., Lucker, J.R., Gordon, A. & DiStasio, D. (1996) Long-Term Effects of Auditory Integration Training on Auditory Processing Skills in Children with ADD. St. John´s University, Jamaica, NY. 4. Gillberg, C., Johansson, M., Steffenberg, S., & Berlin, O. (1997) Auditory integration training in children with autism: Brief report of an open pilot study. Autism. I: 97–100. 5. Jensen, J. H., Borre, S. & Johansen, P. A. (1989) Unilateral Sensorineural hearing loss in children: cognitive abilities with respect to right/left ear differences Brit Journal of Audiology. No 23: 215–220. 6. Sininger, Y. & Cone-Wesson, B (/2004). Asymmetric cochlear mimics hemispheric specialization. Science. September, 13. 7. Stehli, A (1995). Sound of a Miracle. The Inspiring True Story of a Mother’s Fight to Free Her Child from Autism, Beauford Books, N.Y. USA. 8. Rimland, B. Edelson, S. M. (1994) The Effects of Auditory Integration Training on Autism. American Journal of SpeechLanguage Pathology. No 5: 16–24. 9. Rimland, B. & Edelson; S (1995) Brief Report: A Pilot Study of Auditory Integration Training in Autism. Journal of Autism and Developmental Disorders. Vol 25 (1): 61–70.