Auditory integration training

1. Introduction

Version followed: classic Bérard Auditory Integration Training (AIT) as set out in Guy Bérard's Hearing Equals Behavior (1993; updated with Sally Brockett, 2011) and described in detail by the ASHA Working Group technical report (2004): 20 half-hour listening sessions over 10 working days on the Ears Education and Retraining System (EERS, "Audiokinetron"), with audiogram-guided filtering. CD-based derivatives (Digital Auditory Aerobics, The Listening Program, Samonas) are different products and are not followed here. [source: ASHA 2004; Northshire listing of Bérard & Brockett 2011]

What it is. AIT is a headphone-based sound-exposure programme, not a psychotherapy and not music therapy. Guy Bérard, a French ear, nose and throat physician, developed it in France; sources differ on the date (Sinha et al. 2006 give 1982; Raising Children Network says it was developed in the 1960s and first used with autistic people in 1975) [uncertain]. It became widely known in English after Annabel Stehli's 1991 book about her autistic daughter. Most US practitioners have been speech-language pathologists or audiologists. [source: Wikipedia; Sinha et al. 2006; Raising Children Network; ASHA 2004]

Proposed mechanism (proponents' theory, not established). Proponents hold that distorted or hypersensitive hearing (hyperacusis) disrupts attention, behaviour and learning. On this view, listening to music with a wide frequency range that is randomly modulated, with the person's "hypersensitive" frequencies filtered out, retrains the auditory system. Bérard claimed that audiogram "peaks and valleys" (threshold differences of 5 dB or more between adjacent frequencies) flatten after training. The validity of these peaks as abnormalities has been questioned, and reviewers state that the neurological mechanism is unknown. [source: ASHA 2004; Devine 2007; Sinha et al. 2006]

Evidence status, as the sources give it. The Cochrane review (Sinha, Silove, Hayen & Williams, CD003681) concludes there is no evidence that AIT or other sound therapies are effective for autism and no evidence to support its use at this time. The Cochrane summary page is dated 2022, Issue 3; the review is often cited as 2011 or 2012 [uncertain about the original date]. Several bodies class AIT as experimental or investigational: the American Academy of Pediatrics (1998), ASHA (1994; the 2004 technical report says it "has not met scientific standards for efficacy and safety"), the American Academy of Audiology (2010) and the Educational Audiology Association. The New York State Department of Health (1999) recommended against it for young children with autism. Raising Children Network (Australia) rates it "ineffective". No AIT device is FDA-approved as a medical device. [source: Cochrane summary; ASHA 2004; AAA 2010; Raising Children Network]

Implication for the psychotherapist. Treat AIT as an experimental adjunct within audiological, medical or rehabilitation care. It never replaces assessment or evidence-based treatment of hearing, developmental, attentional or mental-health conditions. Your usual role is informed-consent support, coordination with the audiologist or ENT, and helping the family manage the course; you are not the person running the device. [synthesis]

2. Framework

Professional frame. There is no regulated profession and no internationally registered qualification for AIT. Bérard practitioners are trained and listed by Bérard-method trainers. In the US most have been speech-language pathologists or audiologists, with some psychologists, physicians, social workers and teachers. AIT is not music therapy, so HCPC, AMTA/CBMT or other music-therapy registration does not cover or imply competence in it. Do not run AIT equipment without Bérard practitioner training and audiological support. ASHA warned its members that providing AIT could breach its Code of Ethics. The American Academy of Audiology's code requires that the experimental status be clearly explained to consumers before treatment begins or fees are charged. [source: ASHA 2004; Wikipedia; AAA 2010; Raising Children Network]

Format. The programme is individual and clinic-based, though some practitioners deliver it in the home. The person listens through circumaural headphones to music processed by the EERS, which has a reported frequency response of 30–15,000 Hz. [source: ASHA 2004; ISRCTN12514406]

Phases (Bérard protocol as reported by ASHA 2004):

Screening and baseline (before day 1). Goals: rule out contraindications, get an audiogram and a hearing-sensitivity profile, and record baseline behaviour. Trials required normal peripheral hearing and middle-ear function confirmed by ENT or audiological evaluation, including immittance testing. Move on when medical and audiological clearance has been given, filters have been chosen and consent is documented. [source: ASHA 2004; ISRCTN12514406; Devine 2007 citing Bettison 1996]
Listening days 1–5 (sessions 1–10). Two 30-minute sessions a day at least 3 hours apart (one trial used 4 hours), on consecutive working days; a 2-day weekend break is acceptable. [source: ASHA 2004; Devine 2007]
Midpoint audiogram (after about session 10). Goal: decide whether to change the filter settings. [source: ASHA 2004]
Listening days 6–10 (sessions 11–20). Same schedule, with filters updated if the midpoint test indicated it. [source: ASHA 2004]
Post-training audiogram (after session 20) and follow-up. Research protocols reassessed at 1 day, 1 month, 3 months, and in one study up to 12 months. Bérard did not recommend follow-up or repeat sessions, but US practice differs, and some programmes add a second 10-day course. [source: ASHA 2004; ISRCTN12514406; Devine 2007]

Dose. About 10 hours of listening in total, usually over 10 consecutive days (10–20 days in some protocols). [source: Sinha et al. 2006; AAA 2010; ISRCTN12514406]

3. Guiding principles

Experimental status is disclosed first. In practice, the family hears plainly, before any fee, that AIT is classed as experimental and that the Cochrane review found no evidence of effectiveness. [source: AAA 2010; ASHA 2004; Cochrane summary]
Adjunct, not replacement. In practice, evidence-based speech, language, behavioural, educational and mental-health care continues unchanged during and after AIT. [source: ASHA 2004 on delayed effective treatment; synthesis]
Hearing safety outranks protocol. In practice, use the lowest effective output and stop for pain or distress. Measured eardrum levels reached 118 dB SPL at the device's maximum setting and 110 dB SPL at the highest setting a trained practitioner used. Children's smaller ear canals probably receive more than coupler measurements show. A review judged hearing loss unlikely if practitioners use lower rather than maximal settings. [source: ASHA 2004; Sinha et al. 2006]
Audiology before, during and after. In practice, an audiologist or ENT checks the ears at baseline, at midpoint and at the end, covering wax, fluid, middle-ear function and hearing level. [source: Raising Children Network; ASHA 2004; Sinha et al. 2006 as cited in Devine 2007]
Individualised filtering within strict limits. In practice, filter at most two frequency bands, chosen from the audiogram. [source: ASHA 2004]
Fixed, predictable schedule. In practice, keep to two sessions a day at least 3 hours apart on consecutive working days. Bérard's view is that the unpredictability belongs in the sound, not in the routine. [source: ASHA 2004; synthesis]
Systematic monitoring of side effects. In practice, carers complete a daily checklist of any changes during the course. [source: Devine 2007 citing Bettison 1996]
Child assent and comfort. In practice, accustom the child to the headphones before treatment, and treat refusal as information, not as something to override. [source: ISRCTN12514406; synthesis]
Do not over-read audiograms or checklists. In practice, audiogram "peaks" and non-validated sound-sensitivity questionnaires do not diagnose any disorder. [source: ASHA 2004; Devine 2007]

4. Intervention inventory

The Bérard protocol has few named components. The items below are the procedural steps the sources describe, plus the psychotherapist's adjunct tasks, which are marked [synthesis]. Device operation (Bérard's filter-setting rules, modulation parameters and volume curves) is taught in practitioner training; Bérard's book is not drawn on, so finer detail is not given here [uncertain].

4.1 Pre-training medical and audiological screening

Purpose / when: Before any listening, to exclude people for whom loud headphone sound is unsafe and to get a baseline hearing profile.
Steps: (1) Refer to an audiologist or ENT for otoscopy (wax, infection, eardrum), pure-tone audiometry and middle-ear (immittance) testing. (2) Check the exclusions used in trials and parent guidance: history of seizures; under 3 years; ear wax problems; ear infection or middle-ear fluid; inner-ear damage or hearing loss; abnormal middle-ear function; associated neurological or metabolic disease (one trial excluded these). (3) Record baseline behaviour and sound-sensitivity measures; one trial used the Sensory Profile, CARS and SRS, and Cochrane-included trials often used the Aberrant Behavior Checklist and Fisher's Auditory Problems Checklist. These are licensed instruments: use them under their own terms and do not reproduce items. (4) Document informed consent that names the experimental status. [source: Raising Children Network; ISRCTN12514406; Devine 2007; Cochrane summary; AAA 2010]
Example language (illustrative): "Before anyone puts headphones on, we need a hearing specialist to check the ears and confirm there's no infection, fluid or hearing loss. If there is, this programme isn't safe right now."
Watch for: Screening done only by the AIT provider, without an audiologist (AAA notes this is common). Any seizure history. Recent ear surgery or grommets: ask the ENT, because sensitivity may change after adenoid surgery (single anecdotal report) [uncertain].

4.2 Identifying sound sensitivity and audiogram "peaks"

Purpose / when: At baseline, to decide whether to filter and which frequencies, as Bérard's method assumes that hypersensitive frequencies show as peaks.
Steps: (1) Take the audiogram across the standard frequencies. (2) Mark "peaks": frequencies whose threshold differs by about 5–10 dB from the adjacent frequencies. (3) Add carer and teacher reports of everyday sound intolerance. Bettison's trial used two non-validated questionnaires. [source: ASHA 2004; Devine 2007]
Example language (illustrative): "Which everyday sounds bother him most: hand dryers, vacuum cleaners, crowds, sirens? How does he show it?"
Watch for: ASHA notes that the validity of peaks as abnormalities has been questioned. Do not present them to the family as a diagnosis. A child with severe sound intolerance needs proper audiological assessment of hyperacusis whatever happens with AIT. [source: ASHA 2004; synthesis]

4.3 Filter selection

Purpose / when: Before session 1 and again after the midpoint audiogram, to attenuate the suspected hypersensitive bands.
Steps: (1) The EERS has eight one-octave band-reject filters, at 0.75, 1, 1.5, 2, 3, 4, 6 and 8 kHz, each giving up to 40 dB attenuation. (2) Set no more than two filters, matched to the identified peaks. (3) Filters apply to both ears together; only the volume can be set separately for each ear. [source: ASHA 2004]
Example language (illustrative, to the family): "The machine turns down one or two pitch ranges that his hearing test suggests may be uncomfortable for him."
Watch for: Requests to use more than two filters, or to choose filters without an audiogram; both fall outside the protocol as reported. [source: ASHA 2004]

4.4 Volume setting and hearing-level safety

Purpose / when: At every session.
Steps: (1) Set the volume separately for each ear. Secondary sources say proponents set it as loud as is comfortable [source: Wikipedia]; reviewers advise lower rather than maximal settings [source: Sinha et al. 2006]. (2) Never use the maximum: 118 dB SPL was measured at the eardrum at maximum and 110 dB SPL at a trained practitioner's highest setting, and occupational limits allow only 30 minutes at 110 dBA for adults. (3) Remember that children need stricter limits than adults, and their smaller ear canals mean the true level at the eardrum is probably higher than measured. (4) Calibration equipment for independent checks has not been available, so ask the provider how output is checked. [source: ASHA 2004]
Example language (illustrative): "If the sound ever hurts, or your ears ring or feel full afterwards, tell us straight away and we'll stop."
Watch for: Covering the ears, grimacing, crying or pulling at the headphones; tinnitus or muffled hearing after a session (stop and refer to audiology). Any setting near the device maximum. [source: ASHA 2004; synthesis]

4.5 Headphone familiarisation

Purpose / when: Before session 1, especially with young or autistic children.
Steps: In one trial, a Bérard practitioner trained each child to wear the headphones before treatment and also trained the parents. A graded approach is a reasonable way to do this [synthesis]: let the child handle the headphones, wear them briefly without sound, then with soft familiar music, and reward tolerance. [source: ISRCTN12514406]
Example language (illustrative): "Let's just try them on for a count of ten, with no sound. You can take them off whenever you like."
Watch for: Persistent refusal. Forcing headphones on a distressed child is not acceptable (see section 5).

4.6 Listening sessions

Purpose / when: The core of the programme: 20 sessions.
Steps: (1) Two 30-minute sessions a day, at least 3 hours apart, on 10 consecutive working days (a weekend break is acceptable). (2) Play music with a wide frequency range ("dynamic" music) through the EERS. The device modulates the amplitude randomly at 0.5–4 Hz and switches between low- and high-pass filtering every 250 ms to 2 seconds, so the listener cannot predict the sound. (3) The person sits through the session wearing the headphones; a staff member stays present. Sources do not specify what activities the listener may do [uncertain]. One parent guide mentions that some versions add physical activity, but that refers to other sound programmes. [source: ASHA 2004; Sinha et al. 2006; Kemp thesis abstract; Raising Children Network]
Example language (illustrative): "Today's music is the second half-hour; we'll take the headphones off when the timer ends."
Watch for: Distress during sessions; tiredness, irritability or changes in sleep or behaviour across the course, which carers record daily. In one trial, two participants with co-occurring psychiatric disorders had adverse effects. [source: Devine 2007 citing Bettison 1996]

4.7 Midpoint audiogram and re-setting

Purpose / when: After about 10 sessions, to decide whether the filters should change.
Steps: Repeat the audiogram, compare it with baseline, and change filter settings only if the comparison indicates it. Raising Children Network also advises an ear check (wax, fluid, eardrum) at midpoint. [source: ASHA 2004; Raising Children Network]
Watch for: New fluid, wax or threshold shifts. These are reasons to pause and refer, not to re-filter. [synthesis]

4.8 Daily carer side-effect and behaviour log

Purpose / when: Every day of the course, to pick up unwanted effects early.
Steps: Give carers a simple daily form covering sleep, appetite, irritability, tantrums, ear complaints, headaches, sound reactions and anything new. Review it before each day's first session. This follows Bettison's (1996) use of a parent daily checklist; the form's content is my own [synthesis]. [source: Devine 2007 citing Bettison 1996]
Example language (illustrative): "Anything at all that seems different, good or bad, write it down. We'd rather hear about it than miss it."
Watch for: Parents in both treatment and control groups reported minor physical complaints, with no difference between groups. Interpret changes cautiously in both directions. [source: Sinha et al. 2006]

4.9 Post-training audiogram and follow-up

Purpose / when: After session 20 and at agreed follow-up points.
Steps: (1) Repeat the audiogram and ear check at the end. (2) Repeat behaviour and sensitivity measures at fixed points. Research used 1 day, 1 month, 3 months, and up to 6 and 12 months. In Bettison's study, gains seen at 1 month in both groups had largely reverted by 12 months. (3) Bérard did not recommend follow-up courses; some US programmes add a second 10-day course or "boosters". [source: ASHA 2004; ISRCTN12514406; Devine 2007; Kemp thesis abstract]
Example language (illustrative): "We'll look again in one and three months, using the same questions as before, so we can see honestly whether anything has changed."
Watch for: Pressure to buy repeat courses without measured change. [synthesis]

4.10 Psychotherapist adjunct tasks [synthesis]

Purpose / when: When a client or family in your care is considering or undergoing AIT.
Steps: (1) Explore what the family hopes AIT will do, and share the evidence status (section 1) neutrally. (2) Make sure an audiologist or ENT is involved and that the experimental status was disclosed before fees were paid. (3) Keep current evidence-based treatment running; agree with the family that AIT does not pause it. (4) Plan for the child's predictability needs during the 10 days: visual schedule, transport, the 3-hour gap. (5) After the course, review the carer log and follow-up measures with the family and help them decide about any further spending. (6) For children: get the child's assent at each session in a form suited to their age and communication, keep parents and carers involved, and follow local safeguarding and mandatory-reporting duties as usual.
Example language (illustrative): "It's your decision. My job is to make sure you have the facts, that his ears are protected, and that the work we're already doing carries on."
Watch for: Family guilt or blame if AIT "doesn't work"; financial strain; hope being invested in one intervention.

5. Handling problems

The sources say little about clinical difficulties beyond safety and evidence. Everything below is my own [synthesis] unless a source is tagged.

Pain, ringing or muffled hearing during or after a session. Stop the session and do not resume until an audiologist has checked hearing. Report the output setting used. Risk is higher at high settings and in children. [source: ASHA 2004; Sinha et al. 2006]
Overwhelm or panic in a sound-sensitive or autistic child. Remove the headphones and move to a quiet space. Do not "push through" in the name of desensitisation. Restart only with lower volume, after more familiarisation, and with the child's assent. If distress recurs across sessions, stop the course; the child's wellbeing outweighs completing all 20 sessions.
Refusing headphones / resistance. Go back to graded familiarisation (4.5). Offer choice and control: when to put them on, a visual timer, a comfort object. Forced restraint to complete sessions is not acceptable.
Missed sessions / non-adherence to the schedule. The protocol assumes consecutive working days, with only a 2-day weekend break allowed [source: ASHA 2004]. Agree with the practitioner in advance how a missed day will be handled. Do not compress the schedule by shortening the 3-hour gap. Help the family plan transport and school around the 10 days.
Behavioural or emotional deterioration during the course. Check the daily log. Rule out ear infection, pain, sleep loss and disrupted routine. Adverse effects were reported in two participants with co-occurring psychiatric disorders [source: Devine 2007 citing Bettison 1996]. Be cautious with clients who have active psychiatric conditions, and pause if mental state worsens.
Seizure history or onset. A seizure history is an exclusion criterion [source: ISRCTN12514406; Raising Children Network]. If a seizure occurs, stop the course and refer for urgent medical review.
Musical trauma triggers. The music is chosen by the practitioner and electronically altered. For adolescents and adults with trauma histories, a particular piece, genre or distortion can act as a reminder. Ask beforehand about music to avoid. Allow the client to stop. Use grounding afterwards if needed.
Unrealistic hope, cost and delayed effective treatment. ASHA notes that families may lose money and time and be less able to pursue effective options [source: ASHA 2004]. Name this openly. Keep evidence-based care running. Agree before starting what change would count, and measure it.
Requests for repeat courses or boosters. Bérard did not recommend follow-up sessions [source: ASHA 2004]. Review the measured outcomes with the family before any further course, and frame the decision as theirs.
Rupture with a family over your view of AIT. Separate respect for their choice from your duty to inform. Avoid ridicule. Restate your shared goal, which is the child's wellbeing, and stay available whatever they decide.
CD or home-based "AIT" products. Digital Auditory Aerobics needs no training, and no detailed calibration data are available for it; other products, such as The Listening Program and Samonas, use different protocols [source: ASHA 2004]. Do not treat them as equivalent to Bérard AIT, and apply the same hearing-safety cautions.
Claims for adult depression, suicidality and similar conditions. Bérard promoted AIT for depression and suicidal tendencies [source: Wikipedia; ASHA 2004 candidacy list]. There is no supporting evidence. Never let AIT delay standard risk assessment and treatment.

Sources

Sources:

Further reading (not drawn on) [uncertain beyond what the sources above report]:

Bérard, G. (1993). Hearing Equals Behavior. Keats.
Bérard, G., & Brockett, S. (2011). Hearing Equals Behavior: Updated and Expanded. Shirespress.
Stehli, A. (1991). The Sound of a Miracle. Doubleday.
American Academy of Pediatrics, Committee on Children With Disabilities (1998). Auditory integration training and facilitated communication for autism. Pediatrics, 102(2), 431–433.
Bettison, S. (1996), as reported in Devine (2007).

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