Monday, February 20, 2006

A Critical Appraisal of Therapeutic Listening

History:

According to Frick (2002, p. 358), auditory training has been used in Europe since the mid-1900s to address sensory processing disorders and these techniques have been recently popularized in the United States. Frick has based her Therapeutic Listening program on the work of Dr. Alfred Tomatis and Dr. Guy Berard, both of whom are French physicians. Both the Tomatis and Berard programs are delivered by specific machines using earphones but these devices do not have FDA approval and have been banned in the United States (Barrett, 2003). Frick (2001) states “With the advent of new technology, similar altered music has become available on compact disc. The discs do not replace either the Tomatis Method or the Berard Method. The compact discs do provide a less intense way to access both the auditory and vestibular systems to impact neural function and integration and are easily available to clinicians in a variety of practice arenas.” The CDs referenced on Frick’s webpages are associated with Ingo Steinbach, a German engineer who also studied Tomatis’ and Berard’s methods.

Description:

As defined by the principle founder of this intervention technique, Therapeutic Listening “is a highly individualized method of auditory intervention utilizing electronically altered compact discs in protocols specifically tailored by sensory integrative professionals to match client need” (Frick, 2003). Presumably, the intervention includes a combination of listening to specially enhanced CDs and participation in a sensory-based occupational therapy program. There are very few references to Frick’s program in the literature, so practitioners need to attend her workshops in order to receive specific information about this intervention.

Goals of Treatment:

The goals of Therapeutic Listening are to improve the following functions: sensory modulation, balance, movement perception, exploration, sense of physical competence, praxis, sequencing, social competence, and language (Frick, 2002, p. 360).

Theory-base:

Frick (2003) states that “listening is a function of the entire brain; when we listen, we listen with the whole body.” This statement is not specifically explained or qualified, however, reference is made on the Vital Links website to accompanying interventions including postural training, respiratory intervention, and sensory diet. Tomatis (1993) believed that spectral enhancement of high frequency sound ranges would help listeners improve attention and awareness to sound. Because of the intricate linkages between auditory and vestibular systems, he also hypothesized that posture, laterality, and language development would improve when children listened to filtered music.

Appropriate clients for this method:

According to Frick (2002, p.360), clients of all ages can benefit from this technique but younger children (less than two years old) need a modified program that can be monitored by an experienced clinician.


Efficacy research:

The American Academy of Pediatrics (1998) and the American Academy of Audiology (1993) stated that there are no well-designed scientific studies demonstrating the usefulness of AIT. AIT devices, typically associated with the Tomatis and Berard intervention programs, do not have FDA approval and in 1997 the FDA banned the importation of the Electric Ear or any other AIT device made by Tomatis International, of Paris, France (Barrett, 2003).

Gilmor (1999) completed a meta-analysis of Tomatis-styled interventions and found that there was “compelling” evidence of improvement in the children who received intervention. However, all studies included in the meta-analysis had very small sample sizes and design problems with randomization and lack of control groups.

Edelson and Rimland are strong proponents of auditory integration interventions who have published supportive articles on AIT in the literature (1994, 1995). They published a literature review (undated) of auditory integration intervention studies that was widely distributed on the Internet and is frequently cited by parents and professionals as proof that AIT is effective. Many of the supporting studies that they cited in their review were published in newsletters, newspapers, and other forums where there is no rigorous peer-review. Also, they summarily dismissed any study that did not support auditory intervention techniques.

According to the National Research Council (2001, p. 100) “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.

Critical appraisal:

There have been many negative opinions of auditory interventions published by respected organizations such as the American Academy of Pediatrics, the American Academy of Audiology, and the National Research Council. It is concerning to me that these techniques continue to be so readily embraced by occupational therapy clinicians who are seeking therapeutic answers for the children on their caseloads. This is a very clear example of how our profession needs to consider evidence-based practice. The profession is collectively concerned about the acceptance of occupational therapy in general and sensory integration/processing interventions in particular. We all need to be as educated as possible on what constitutes appropriate levels of evidence that will be broadly accepted, and subsequently respected, valued, and reimbursed.

Based on the published literature, there is currently very little evidence that Therapeutic Listening or any auditory integration therapy has proven to be an effective intervention. However, that does not mean it is not potentially useful. Rather, we need to conduct appropriate, well-designed studies and publish them in peer-reviewed journals. In the meantime, we need to be very cautious at how we present these interventions to the public.

References:

American Academy of Pediatrics Committee on Children with Disabilities (1998). Auditory integration training and facilitated communication for autism. Pediatrics, 102, 431-433.

Barrett, S. (2003, July). Mental Help: Procedures to Avoid. Retrieved November 22, 2003, from http://www.quackwatch.org/01QuackeryRelatedTopics/mentserv.html

Committee on Educational Inverventions for Children with Autism, National Research Council (2001). Educating Children with Autism. Washington, D.C.: National Academies Press.

Edelson, S.M., & Rimland, B. (n.d.). The Efficacy of Auditory Integration Training: Summaries and Critiques of 28 Reports (January, 1993 - May, 2001). Retrieved November 22, 2003, from http://www.up-to-date.com/saitwebsite/aitsummary.html

Executive Committee, American Academy of Audiology. (1993). Position statement: Auditory integration training. Audiology Today, 5, 21.

Frick, Sheila (2001, March). An Overview of Auditory Interventions. Retrieved November 22, 2003, from http://www.vitallinks.net/auditory.shtml

Frick, Sheila (2002). Therapeutic Listening: An Overview. In Bundy, A.C., Lane, S.J., & Murray, E.A. (Eds.). Sensory Integration Theory and Practice, 2nd ed. Philadelphia: F.A. Davis.

Frick, Sheila (2003, Spring). What is Therapeutic Listening? Vital Links. Retrieved November 22, 2003, from http://www.vitallinks.net/PDF/spring2003.pdf

Gilmor, T.M. (1999). The Efficacy of the Tomatis method for Children with Learning and Communication Disorders, International Journal of Listening, 13, 12-23.

Rimland, B. & Edelson, S. (1994). The effects of auditory integration training on autism. American Journal of Speech and Language Pathology, 3, 16 - 24.

Rimland, B. & Edelson, S. (1995). Auditory integration training in autism: A pilot study. Journal of Autism and Developmental Disorders, 25, 61 - 70

Tomatis, A. (1993). The Ear and Language. Ontario: Moulin.

31 comments:

Anonymous said...

Chris, i am a senior OTA student. I was very excited to come across your blog. I think i can really learn a lot from it. Keep up the good work.
CE

Labyrinth Journeys said...

Check out the latest article "The Effect of Sound-Based Intervention on Children with Sensory Processing Disorders and Visual-Motor Delays" by Leah Hall and Jane Case-Smith in AJOT March/April 2007!

ncm4Kids said...

Just a comment on your posting relating to the research into Berard AIT - in commenting on the 20-plus research documents on AIT, Rimland and Edleson did not 'summarily discount' papers opposed to AIT, but took the time to carefully discuss the reasons for the lack of validity of these papers.

Chris said...

I'm not sure what the original web article said as it is now link dead - but recall that they discounted any study that did not agree with AIT. This entry was written 3 years ago (in 2006). There are now Cochrane reviews that dispute the effectiveness of this intervention.

http://www.cochrane.org/reviews/en/ab003681.html

FDA ban, American Academy of Audiology criticism, American Academy of Pediatrics criticism, and now the Cochrane review. This goes to show how no matter how much evidence and expert opinion there is against something - it will never dissuade the zealots.

Anonymous said...

Thanks from an OT who is sick and tired of OTs out there who recommend anything that is out there, regardless of empiric research to support its use. Everyone gets brushed and put on a listening therapy program....and stay on them for years. I am glad to find something from the "other side".

Anonymous said...

Thanks for the opposing view. From an OT who is sick of non-judicious use of any fad modality, without research to support it. Everyone gets brushed, everyone gets a listening program... for years! ugh. Thanks again for the sharing the critical review.

portlandapd said...

Yes, evidence-based practice demands evidence. The Tomatis method (Auditory Integration Therapy) has also been carefully tested by Karen Yencer in her doctoral dissertation (See her chapter "Is Auditory Integration Training an Effective Treatment for Children with Central Auditory Processing Disorders?" pp. 151-173 in the volume, Central Auditory Processing Disorders: Mostly Management, edited by Masters, Stecker and Katz (1998). She found no treatment effect for a carefully controlled comparison of AIT treatment to a non-treatment group. The American Speech-Language and Hearing Association (ASHA) has ruled that any audiologist or SLP providing AIT therapy for compensation is in violation of the Code of Ethics because there is no demonstrated evidence that AIT has any therapeutic effect.

I have looked carefully at the Edelman study you mentioned. It is a simple pre-treatment vs. post-treatment questionnaire filled out by parents who were paying a considerable amount of money for their children to receive the therapy. No control group. Not surprising that the parents saw a difference. Who would want to spend a bundle and then say that they didn't notice any difference? It is not a well planned study, so it cannot argue that AIT is useful.

I am very glad to see you pointing out the need for carefully set up studies, rather than simple anecdotal evidence. Hear, hear.

Rosalie said...

Chris, I would like to speak for practitioners of Berard AIT and say that while we need to hear well-reasoned and informed argument to balance our positive views on AIT, it is disturbing to read this kind of comment, which contains so many flaws. You don't highlight what measure Yencer used, and whether it was deemed an appropriate instrument. And, it was Edelson, not Edelman - AND it was Edelson and RImland. And they tested over 400 people with autism, so that's not anecdotal any more - AND there was indeed a control group. This kind of uninformed opinion is why we cannot take such comments seriously. The bottom line is - if you're a parent paying a lot of money for a treatment, YOU BET you'd want a result or you'd have something to say. Seems to me some professionals should respect their clients a bit more?

Chris said...

Thanks for your comments, Rosalie, but wouldn't it be correct to tell us why your name links to a company that sells these products so we could understand your potential bias?

Let's not focus on whether or not a commenter mistypes the name of a researcher and instead focus on more salient and meaningful issues.

For one, the American Speech-Language Hearing Association disagrees with your assessment. I encourage everyone to read their position statement at http://www.asha.org/docs/html/TR2004-00260.html

So who should the public listen to - the professional association that says this intervention has no research support?? - or the company trying to hawk their product??

www.filteredsoundtraining.net said...

Chris, as you saw I did not hide my bias in favour of AIT . In fact lack of bias is not a reality, but the goal of academics who have so little commitment to clients' difficulties that they find it easier to poke holes in what helps rather than get involved in what helps clients. Let's start with seeing the advantages of an intervention that has had such good press, and work to build up a more 'acceptable' research foundation since that matters so much to you. Here's a question most academics don't concern themselves with:- Since there are many hundreds of satisfied users of AIT, whose lives have been improved by this intervention, what 'compelling evidence' can you offer to warrant denying them access? What have you on offer that is better? I see you ignored my other questions, so perhaps shouldn't expect an answer to this one.

Chris said...

Bias is something that all honest people should acknowledge so that we can try to remove factors that can cause us to make incorrect decisions or imprecise recommendations. It is unfortunate if you think that people want to control for bias simply so they can restrict interventions for families or perhaps from your perspective restrict your sales. I don't believe that the world is populated by mean-spirited academics who are trying to poke holes in your belief system or business specifically.

In any event, in case you haven't read into this blog deeply, I am not an academic - but rather a full time clinician. I teach on the side, sometimes.

The compelling evidence you ask for was provided in the independent assessment of the American Speech-Language Hearing Association's position paper. It seems to be rather compelling that a professional organization does not support an intervention. It is equally compelling that this opinion is shared by a great many professionals.

Compelling does not equate to conclusive - but you asked for compelling.

As I have discussed in this blog and elsewhere frequently - we have a responsibility as professionals to consider evidence when we are making clinical decisions. We also have to consider the impact that our decisions have on the people who we are providing a service to. That impact is measured in time, money, emotional expense, and many other factors.

Many clinicians want to have something more than anecdote before they recommend an expensive and controversial intervention to a family. That doesn't seem to be an unreasonable position. I understand that you are equating multiple anecdotal stories as adequate evidence for you - but we have accepted research protocols and 'levels of evidence' for a reason.

Let us be honest about statements though - on your website it states "Everybody gets some benefit—only sometimes it’s not necessarily the benefit they were looking for. For example:- A stubborn difficult child with dyslexia is brought by his parents for training to help his behaviour … his behaviour doesn’t change but his dyslexia does! He received a benefit, but not the one his parents were hoping for the most." With this kind of generic criteria for improvement perhaps we should not be surprised that people come back to you and are able to say that "something improved!"

I quite honestly don't know why you are only hearing the stories of the people who are satisfied. Perhaps confirmation bias may be a factor. If you listen broadly you will also hear the reasonable hesitancy that is expressed by professional organizations like ASHA. You may also begin to hear the voices of people who were not helped at all by the interventions.

I also encourage you to consider the commitment bias that is engendered in your customer base after they have incurred significant cost for these kinds of programs.

Your question about alternatives is a little broad - there are many intervention programs that are more accepted and have a better research base than auditory interventions.

Finally, I am not trying to deny anyone access to anything. I think that families should be free to pursue whatever interventions they want. The problems arise when we are using public monies to fund these investigational interventions or when families are not being properly informed that the interventions are not broadly accepted as mainstream practice.

Anonymous said...

I am a parent of my 9 yr old daughter that started the Therapeutic Listening through an OT at our children's hospital in the city. Unfortunately the 3rd day in my daughter started having negative effects. They changed her CD and still continued negative effects. Changed the CD for the 3rd time, by this time she was so deregulated she couldn't tolerate even the headphones on much less the music for 30 minutes. We were not the only ones who noticed a big set back in our daughter but the school, her assistant, respite worker, neighbors and friends...even the OT herself noticed her negative effects. She became more emotional, irrational, very defiant, more clumsy, very messy, sloppier, louder and her attention span was always low but now is next to nil. This is very frustrating to us as parents. She is now stopped the listening and seems "stuck" at this "deregulated" state. It is now 6 weeks since we started the program and we are 3 weeks finished. Throughout my research and from other parents I spoke to about this program, there were no negative effects reported ...NONE. I guess I did not not research well enough. I never would have started if I thought there were any risk.
I am desperately trying to find ANYONE, parents or professionals, who has experienced negative side effects with the therapeutic listening program. I am struggling to know what to do. Our Pediatrician is suggesting medication, which is a last resort for me. It's something we have been able to avoid until now.

Chris said...

I have never heard any other parent report these kinds of effects either.

'Proving' a negative impact would probably be just as difficult as 'proving' a positive impact. With so many other potentially confounding variables I imagine it would be very difficult to definitively state it was DUE TO the program.

I am sorry that you are having these difficulties. Maybe someone else will chime in with anecdotes of negative responses. Aside from your own situation, the largest negative response I hear seems to be that it is ineffective and just a waste of time and money.

ncm4kids said...

About the adverse reaction to Therapeutic Listening - with Berard AIT we find that on day 3 or 4 the biggest change can happen. It occurs about once every 1000 clients in my experience. Such clients need to continue and complete the course, but with mega-support though sensory calming, e.g. water-play, even swimming. In addition metabolic support for this period of huge change, through mega-doses of magnesium citrate, with vit B6 nourishes the nervous system

ncm4kids said...

It is rare to find such powerful reactions to the sensory re-organisation that (despite Chris's insistence to the contrary) happens during AIT, and seemingly during TLP as well. It is just a good idea to support this process of change neurologically (sensory calming activities) and metabolically (magnesium intake, rescue remedy, etc). And complete the course. This why I tend to favour Berard AIt which starts and completes a set programme.

Chris said...

How do you suppose that you can assign significance to something that you report occurs 1/1000 times? Have you indeed seen that many children that you can have a large enough sample where you have controlled for other variables and determined that indeed the problem is associated with some intervention? Just wondering.

Megadosing/overdosing with magnesium or B6 can lead to cardiac and central nervous system dysfunction, up to and including death. Please don't anyone follow these kinds of suggestions and please make sure you always consult your physician about these matters.

I am interested in science and evidence - not anecdotal statements about things that supposedly occur 1/1000 times and then 'cures' for those ill effects that actually are quite dangerous.

Thanks for posting your comments. These are the kinds of things that people need to see so that they can be informed of exactly how questionable these interventions are.

Liz Ditz said...

ncm4kids recommends "rescue remedy" which essentially is homeopathy with a side of brandy (27%).

Homeopathy is the "one quackery to rule them all".

In my personal view, anyone endorsing homeopathy has lost all credibility.

Anonymous said...

I am the mom to my 9 yr old daughter... thank you everyone for your comments. I am interested in any input that is based on experience.
I do agree that we could never be certain that this adverse reaction is solely due to TLP. We do however keep her very routine based and with the aid of a developmental/behavioral practitioner every week for the past year and a half as well as her regular OT and rehab clinics, my daughter was at a "manageable" level. We felt the TLP would simply be an added and relaxing intervention that would help her further...a non-invasive addition so to speak. I was so optimistic and was eager to start. We were actually on a list to receive the TLP for over a year! The TLP was the only change introduced to her at this time.
My daughter has multiple diagnoses and it is her behavior, impulsivity and sensory issues that is in high gear right now which all started to change on that 3rd day of TLP. Everyone noticed the difference. I would not be able to get my daughter to continue with the program now even if I wanted to. She would kick, scream, cry, hiss even, with any attempt. For the last few days towards the end, I was playing the CD's on a stereo in the room instead of the headphones but it just irritated her to the point of whaling herself to the floor and crying. It was not a battle we were willing to continue.
I do like the idea of sensory calming techniques which has never been mentioned to me before. She may very well be open to that idea :)...but I do understand it's not the answer to end all.

One thing that I would like to state to any other parents researching and considering this type of intervention (something that I wish realized prior to starting)...If there is room for "positive" impact there has to be room for "negative" impact as well. Just because you don't find or hear of many (or ANY) negative effects, don't mean there are none.
I am thrilled that this works for many and I wish all the best to those that are about to start but for our daughter it did not have the positive outcome we were expecting. Hoping we (she) will regain some control again soon...without the use of medication.

Thanks again for everyone's input :)

Anonymous said...

We are doing ILS for my son and having very negative side effects - acute sound sensitivity, light defensive, oral defensive. He is so dis regulated he can not function normally anymore. Any one have this experience with ILS? Thanks.

Christopher Alterio said...

As previously posted, the largest negative response I hear seems to be that it is ineffective and just a waste of time and money. I wouldn't be surprised if various 'listening therapy' hucksters weren't just flooding public comment areas with negative comments so they can bolster their own products to whoever attends their 'continuing education conferences.' Based on the outrageous things that people seem willing to post this seems to be a reasonable explanation for the 'side effect' comments - most of which I just trashcan.

Anonymous said...

We are on cd 4 of tlp. My son has been in more trouble the last week & a hOt than ever before at school. His therapist is saying go back to cd2... That she is tryin to tweek it.but after reading some comments on Herr I'm extremely worried I have messed him up forever, Idk if I want him to continue.

Christopher Alterio said...

I would not worry too much - it is very difficult to understand how this intervention could really have a negative impact either, other than being a waste of time and money. There is no convincing evidence of these therapies having a positive or negative effect. Talk to the folks at school, find out if there are other/new factors that might be contributing to behavioral difficulties, and talk to your therapists and MDs to help you make informed choices.

Anonymous said...

Thank you for this review. I realize this blog was from 2006, but nothing has changed with regards to efficacy of AIT or TL. We will always have dubious and invalidated treatments in the field of developmental disabilities. This field is a breeding ground for such treatments because of the desperate nature and ignorance of professionals. Parents will always be consumers of such dubious treatments including AIT, TL, sensory integration therapy, facilitated communication, PROMT, NDT, etc. I feel bad for the parents and their children in need of help. Professional and therapists mislead parents with large unsubstantiated claims with poor assumptions. Although, I do not feel bad for therapists promoting these treatments. They will be exposed for their ignorance. I will do my part and be proud of scientific-based treatments.

Bobby Nabeyama
1-9-13

Berenice said...

Hi Chris, I'm so glad I found your blog, I'm a mum of a 8 years old, diagnosed with a ASD, we live in Buenos Aires, Argentina, he had a lot of intervention since he was almost 4, and it definetely paid back. He's probably one of these called 'late bloomers'. The thing is, he's on medication because he has ADHD and I'm trying some other ways to help him, I'm affraid the consecuences of medication on him. We heard about iLs and Vital links, but I think the first base the therapy on the way the sound is transmitted an the last one claims that it is the music or sound itself wich is modified. Are both similar therapies? is Tomatis the origin of both and the critical appraisal discussed here includes both iLs and Vital and other brands? I apologize for my english

Christopher Alterio said...

Hi Berenice - thanks for writing. There are claims that the various listening therapies have substantive differences, but one commonality that they all have is that there is no evidence to support any of them. I think that is the most important fact to consider at this time.

I refer readers to the 2010 American Academy of Audiology Position Statement on AIT, which concludes that this is an experimental treatment. http://www.audiology.org/resources/documentlibrary/Documents/AIT_Position%20Statement.pdf

ncm4kids said...

Hi all, the polemic around Auditory Training continues, I see, despite this approach being medically validated by research done recently and published in 2013. Too bad for thebias of therapists and so called experts, who prefer to tout their own biases over the scientific evidence. I prefer to be with people , parents and professionals, who are not afraid to follow the evidence of their own eyes, and do What Works. Am in Jakarta just completing AIT for 18 people, most with ASD and sensory problems, And pre post assessment showed effectiveness, and pleased parent reports. So come on then, why the negativity?

Christopher Alterio said...

Can you kindly direct us to this research that validates these approaches and has overturned the previously published caution from the medical and audiology professional groups? Thanks!

Anonymous said...

September 2014

FYI:
AAA (American Academy of Audiology) Position on AIT (considered experimental):
http://audiology-web.s3.amazonaws.com/migrated/AIT_Position%20Statement.pdf_539978b2a238a5.97970694.pdf

ASHA (American Speech-Language-Hearing Association) Position on AIT (considered experimental):
http://www.asha.org/policy/TR2004-00260.htm

HOWEVER, Therapeutic Listening(R) is listed as an ASHA Approved CE Provider.
http://buyersguide.asha.org/Listing/Company/SLP_-_School_Related_Products/Expressive_Language/468768

Therefore, not all sound-based intervention is dubious or lack endorsement from hearing/listening related associations.

Christopher Alterio said...


Nice try anonymous, but being listed as a CE provider is not a clinical endorsement. There is nothing wrong with attempting to be educated about something, particularly if it is a modality that requires more scientific scrutiny.

That does not equate to a green light for use in therapy, at all.

Anonymous said...

Hi,

I wish I had gone through the comments section more deeply to understand the effects of listening therapy, an year ago. As anonymous said, if therez a positive, there will definelty be a negative.
I tried listening therapy for my son for a year with chips being "tried" ...No therapist is sure which chip/cd/music is the best for a child. Its trial and error based. During the first 6 months, my son was getting better. But after that he had issues that he never ever had before. Aggressiveness, biting, pinching, banging his head-just to name a few.But we completed the course in 10 months.

Since his issues were worsening,(he was not even able to walk on a street), We again re-started the whole therapy, as advised by our therapist. But had to stop in 2 months.
His sensory issues are worse, ever since. He had little issues before I started this music therapy. Now its as if a whole rack of sensory stimulus had fallen down.

I would suggest to parents to think twice before getting into these things.
1. There is no evidence on the cure.
2. Not even the most experienced therapist knows which music would be best for your child.
3. Lots and lots of negative effects, after completing the course (after spending huge sum of money, energy and forcing the child to vestibular and proprio activities).

Anonymous said...

This is heartbreaking to hear. I am glad I read this before subjecting my son to it. I tried listening to Mozart and was aggravated after 10 minutes. The changes in dynamics of the music is typical for classical music but it is extreme making it annoying and unpleast to listen to.