The Effects of Auditory Stimulation on Auditory Processing Disorder

The Tomatis Method of auditory stimulation is a therapeutic intervention used to improve characteristics and behaviors in children and adults with disorders of communication, learning and autism and autism spectrum disorders (ASD).

1. Assessment: Each child received a complete battery of standardized measures prior to beginning the Tomatis Method protocol. Testing consisted of administration of the following batteries:

a. The Wide Range Achievement Test (WRAT)
b. The Lindamood Auditory Conceptualization Test (LACT)
c. The Phonemic Awareness Test
d. The Token Test for Children
e. The Test of Auditory Perceptual Skills

2. Treatment Procedures: Each child underwent a traditional Tomatis Method Protocol. The protocol consisted of 90 hours of auditory stimulation. The protocol is divided into four blocks of time. The auditory stimulation is administered by passing high quality, specifically prepared auditory stimulation through equipment designed to modulate the acoustic signal. The acoustic signal modulation equipment attenuates low frequency sounds and amplifies higher frequencies that fall within the language area allowing the child to gradually focus listening on the language frequencies. During all blocks of the listening protocol the child listen through headphones with an attached bone conduction oscillator permitting the sounds to be perceived through bone conduction as well as the usual air conduction. The following describes the different blocks of listening:

Block I: The Passive Phase.
Fifteen days of passive listening for two hours a day. The auditory stimulation consisted of non-filtered sound (music) with gating up to 8000 Hz.

Block II: The Active Phase.
Ten days of active listening for two hours a day. The child begins to tone, sing, read, and/or repeat words and phrases into a microphone. They listen to modulated voices. This phase ends with reading aloud thus completing the model of language acquisition and expression. Auditory stimuli is filtered up to 9000 Hz is used during this phase.

Block III: Stabilization Phase.
Ten days of mixed active and passive listening for two hours daily. Children participate in both passive work as well as microphone work.

Block IV: Maintenance Phase.
Ten days of mixed active and passive listening for two hours daily. Various levels of filtering are used from 2000 Hz to 9000 Hz.

Breaks between blocks:
Each child takes a three- week break between each block

Post Treatment Testing
Eight to twelve weeks following treatment each child underwent the same testing battery that was administered prior to their participation in the Tomatis Method.

Summary of Findings:

Auditory Discrimination

Auditory discrimination is the process used to discriminate among sounds or different frequency, duration or intensity (e.g. high/low, long/short, loud/soft). It is the ability to automatically notice, think about or manipulate the sounds in language (Torgesen, 1997). It refers generally to the awareness of words, syllables or phonemes. A problem with auditory discrimination can affect following directions, listening understanding, reading, spelling and writing skills. It can result in poor auditory memory and auditory fatigue. The following graph demonstrates improvement with auditory discrimination skills as a result of auditory stimulation using the Tomatis Method,

These results indicate that prior to treatment overall auditory discrimination skills of the 41 children were placed at the 14.33 precentile.followint treatment auditory discrimination skills improved to the 68.07th percentile, reflecting an average improvement of 53.74%.

Immediate Auditory Memory

Immediate auditory memory refers to the recall of the acoustic signal after it has been labeled, stored and recalled. This skill also requires that one be able to remember and recall various acoustic stimuli of different length and/or number. Auditory sequential memory is the ability to recall the order of a series of details. The following graphs demonstrate improvement with auditory memory skills for digits forward and reversed, as well as repetition of sentences and words as a result of auditory stimulation using the Tomatis Method.

These results indicated that prior to treatment overall immediate memory skills for digits forward of the 41 children were placed at the 9.68th percentile. Following the treatment these skills improved to the 46th percentile reflecting an average improvement of 36.32 %.

These results indicate that prior to treatment overall immediate memory skills for digits reversed of the 41 children were placed at the 19.10th percentile. Following the treatment these skills improved to the 37.37th percentile, reflecting an average improvement of 18.27%.

These results indicate that prior to treatment, overall immediate memory skills for auditory sequencing of the 41 children were placed at the 16.44th percentile. Following the treatment these skills improved to the 53.41st percentile, reflecting an average of 36.97%.

Interpretation and Following Directions

These skills are inherently dependent upon skills of auditory discrimination, auditory association and other auditory skills. Directions were presented according to the progression of the difficulty of the directions by chronological age and grade. These skills, while heavily loaded with auditory memory and sequencing skills, focus on one’s ability to comprehend and understand and interpret meaningful auditory information well enough to follow directions. The following graph demonstrates the improvement of the children to interpret and follow directions as a result of the Tomatis Method of auditory stimulation.

These results indicate that prior to the treatment, overall ability of the 41 children to interpret and follow directions was at the 31.29th percentile Following the treatment, these skills improved to the 66.54th percentile reflecting an average improvement of 35.25%.

Auditory Cohesion

Auditory cohesion is the ability to interpret, organize and synthesize auditory information on a higher-order level of functioning. These skills are necessary for listening comprehension, organization, semantic and linguistic organization, understanding ambiguous information and abstract reasoning and problem solving.

These results indicate that prior to the treatment, overall auditory cohesion ability of the 41 children was at the 23.15th percentile. Following the treatment, these skills improved to the 56.63rd percentile, reflecting an improvement of 33.48%.

Overall Auditory Processing

The following graph reflects the improvement of all auditory processing skills that include immediate auditory memory, auditory discrimination, interpretation following directions, and auditory cohesion.

These results indicate that prior to the treatment overall auditory processing skill ability of the 41 children was at the 8.41st percentile. Following the treatment these skills improved to the 58th percentile reflecting an improvement of 49.93%

Auditory Latency

Auditory latency refers to processing delays. This can be a lapse, hesitation, or frank delay in response time when presented with auditory stimuli requiring a response. The following graph reflects a reduction in auditory latency or processing delays as a result of auditory stimulation using the Tomatis Method.

These results indicate that prior to the treatment average delays in processing were present 63% of the time. Following treatment delays were reduced by 24.23%.

Discussion:

Overall auditory processing skills improved following participation in a 90 hour Tomatis Method auditory stimulation protocol. Comparison of pre and post treatment evaluations indicates improvement in the skills of immediate auditory memory, auditory sequencing, interpretation and following directions, auditory discrimination and auditory cohesion. Auditory processing skills are a cluster of skills that are basic to the listening, communication and learning processes. Although sequential in development, these skills overlap and are essentially inseparable. Auditory processing skill weaknesses result in difficulty in the ability to use auditory information to listen, communicate and learn.

The findings of this study indicate that measurable improvement was attained following the Tomatis Method. Skills of auditory discrimination demonstrated the area of greatest improvement with the average improvement being 53.74%. Problems with auditory discrimination can affect all other auditory processing skills. It is logical to suggest that as auditory discrimination skills improve other skills will improve. Problems with auditory discrimination can affect auditory memory, auditory comprehension, auditory cohesion and result in processing delays. Analysis of the information obtained from this study indicates that as a result of improved auditory discrimination, all other auditory processing skills improved.

Skills of immediate auditory memory as measured by digits forward and reversed sentences and single words demonstrated improvement following the Tomatis Method. Auditory memory skills are affected by skills of auditory discrimination, auditory latency, and familiarity with the language that is being processed and auditory endurance. When referring to the auditory processing skills hierarchy (Bellis, 1996), immediate memory skill acquisition requires prior acquisition of auditory discrimination, localization, auditory figure-ground, auditory association and auditory closure.

The ability to interpret and follow directions demonstrated improvement following the Tomatis Method of auditory stimulation. As with other auditory skills, this skill ability requires prior acquisition of auditory discrimination, auditory association, auditory closure and immediate auditory memory. For the most part, not one auditory skill functions independently of the others. However, when examining the pre-post treatment assessment results the findings strongly suggest that the ability to interpret and follow instructions is measurably improved.

Auditory cohesion skills demonstrated improvement. This higher order skill ability improvement is reflective of improvement of auditory skills that are further down on the auditory skills hierarchy.

The Tomatis Method of auditory stimulation is a controversial method of auditory skills training. This study seeks to provide an initial attempt to demonstrate the relationship between the Tomatis Method and improvement of auditory processing skills. The results of these findings do suggest that the Tomatis Method can be an effective auditory stimulation intervention in improving auditory processing skills in some children. Certainly, further more rigid clinical research studies are necessary. Until that occurs, clinicians and professionals would benefit from further study of this methodology and its application to auditory processing disorder and other behavior and/or communication disorders.

The study’s purpose is to determine the efficacy of the Tomatis Method of auditory stimulation as a therapeutic intervention for Auditory Processing Disorders (APD). 41 subjects (18 females, 23 males; 4.3 to 19.8 years old) were evaluated for A.P.D. All subjects demonstrated improvement with skills of immediate auditory memory, auditory sequencing, interpretation of directions, auditory discrimination and auditory cohesion. Results are significant, e.g. an average improvement in overall auditory processing skills of 49.93%.

The primary goal of this study is to determine the efficacy of the Tomatis Method of auditory stimulation in treating the auditory processing skill weaknesses in children who have been identified as having auditory processing disorder. Specific deficits may include: auditory perception, auditory discrimination, auditory association, auditory vigilance, auditory memory, auditory analysis, auditory synthesis, auditory conceptualization, auditory endurance, auditory latency, and auditory cohesion.

Forty one subjects were studied for a pre-test post- test retrospective case review. The subjects ranged in age from 4.3 years to 19.8 years. All subjects were presented with symptoms and characteristics of auditory processing disorder. All of the subjects were not receiving other therapies during the time of participation in the Tomatis Method of auditory stimulation.

Rationale

Auditory processing disorder is a very complex and controversial issue. The diagnosis of APD is typically given by way of testing by audiologists and speech-language pathologists. Treatment and therapy programs are typically provided by speech-language pathologists and would be characterized by a variety of strategies that are not standardized or necessarily proven to be effective. Many of the effects of therapeutic interventions rely heavily on parent and teacher reports as well as standardized testing.

The Tomatis Method is an auditory stimulation intervention that has been effective in reducing symptoms of auditory processing disorder. The Tomatis Method is a non-invasive therapeutic intervention that has been widely used in Europe and Canada since the 1940s. It was introduced to the United States in the late 1980s.

The Tomatis Method is a 90 hour protocol of auditory stimulation involving both active and passive listening. It’s focus is developmental in nature, corresponding with what is believed to be the earliest experiences of sound to the human ear (during fetal development). Beginning with the Passive Phase, the child listens to filtered sounds of Mozart music and Gregorian Chants which are believed to be physically relaxing and stimulating, similar to the earliest experiences of sound, those of prenatal and early life (DeCaspaar, Lechanuet, Busnel, Granier-Deferre &Maugeais, 1994). As the Tomatis protocol for listening progresses, the child is gradually introduced to the Active Phase that is designed to stimulate processing through first listening to recorded discourse and eventually through audio-vocal exercises. The progression of the Tomatis Method parallels processing, language development, acquisition and mastery with regard to sound perception, discrimination and attention.

Research projects studying the effects on auditory processing and learning have originated from Europe and Canada. Gilmore (1999) studied the efficacy of the Tomatis Method for children with learning and communication disorders. His findings reported that the Tomatis Method resulted in positive changes in the following domains: auditory processing, cognitive, linguistic, personal and social adjustment and psychomotor. He further reported that his findings were consistent with clinician’s reports of beneficial effects. Additionally, investigators have also demonstrated that the Tomatis Method has proven to be effective in the areas of communication, learning and social pragmatics (Rourke & Russel, 1992, Kershner, et al, 1986, Mould, 1984 & Gilmore, 1985).

Given that alternative interventions are being pursued and implemented by parents and professionals, the use of the Tomatis Method has become increasingly more popular.

Hypothesis

The Tomatis Method is based on the evidence that the neurophysiological construction of the auditory system has important connections with entire body as well as the cortex and sub-cortical structures, which are stimulated when stable and normal auditory perceptions occurs. It has been hypothesized that the human auditory system has specific functional capabilities that include: transmission of energy, (a cortical change to the brain), establishment of equilibrium, perception of sound, attention and discrimination of sound, localization of sound and integration of auditory information for the development of laterality and language development. Typically, children with auditory processing disorder, depending on the severity of the deficit, will have difficulty perceiving and discriminating sound, attending to sound, localizing sound as well as other auditory skills that comprise the hierarchy of auditory processing skills (Bellis, 1996; EAA, 1996; DeConde & Gillet, 1993). The Tomatis Method serves as an auditory stimulation/re-education intervention to stimulate listening and processing as opposed to hearing. It reproduces the developmental steps of listening, language acquisition and use, and learning.

Finally, the Tomatis Method hypothesizes that auditory stimulation, particularly with high frequency sounds, is an important source of stimulation to the brain’s ability to receive and process sound. Scientists have demonstrated that 80% of the 24,000 hair cells in the cochlea respond to sounds of 3000 Hz and above. The Tomatis Method offers stimulation up to 10,000 Hz.

Study Method

Subjects: The pre-treatment post-treatment testing results of forty one subjects between the ages of 4.3 and 19.8 years were review for purposes of determining the effects of the Tomatis Method on auditory processing skill weaknesses. All children received 90 hours of auditory stimulation with the Tomatis Method and were not receiving any other therapy at the time (e.g. speech-language therapy, occupational therapy, tutoring, etc.).

References

American Speech-Language Hearing Association (1996). Central Auditory Processing: Current Status of Research and Implications for Clinical Practice.  American Journal of Audiology, 5, 41-52.
 Anderson, K.L. (1996). Thirteen Facts on the Impact of Hearing Loss on Education. The Hearing Review, September, 19.
Bellis, T.J. (1996). Central Auditory Processing Disorders. San Diego: Singular Publishing Group, Inc.
Bellis, T.J., & Ferre, J.M. (1996). Multidimensional Approach to the Differential Diagnosis of Central Auditory Processing Disorders in Children. Journal of the American Academy of Audiology. 10, 319-26.
Bellis, T,J.. (2002) When The Brain Can’t Hear: Unraveling the Mystery of Auditory Processing Disorder. Pocket Books. Bishop, D.V.M. (1997. Language impairment: Listening out for subtle deficits.  Nature, 129-130.
Cacace, A. & McFarland, D. (1998). Central Auditory Processing Disorder in School Aged Children: A Critical Review.  Journal of Speech Language Hearing Research, 41, 355-73. Chermak, G.D., & Musiek, F.E. (1997).
Central Auditory Processing Disorders. San Diego: Singular Publishing Group, Inc. Chermak, G.D. (1998). Managing central auditory processing disorders: Metalinguistic and metacognitive approaches. Seminars in Hearing. 19,379-391.
Cook, J., Mausback, T., Gascon, G., Slotnick, H., Patterson, G., Johnson, R,, Hankey, B., & Reynolds, B. (1993). A Preliminary Study of the Relationship Between Central Auditory Processing Disorder and Attention Deficit Disorder. Journal of Psychiatry and Neuroscience. 18:3, 130-7.
Friel-Patti, S. (1999). Clinical decision-making in the assessment and intervention Of central auditory processing disorders.  Language, Speech and Hearing Services in the Schools, 30, 363-370.
Feakes, D.R. (1996). Chronic Ear Infections: The Silent Deterrent to Academic and Social Success. Paper presented at the Annual Childhood Education conference (18th Menomonie WI) (ERIC) Document Reproduction Service No. ED 404 004.
Foli, K.J. (2002). Like Sound Through Water: A Mother’s Journey Through Auditory Processing Disorder. New York. Pocket Books
Gillet, P. (1993). Auditory Processes. Novato, CA: Academic Therapy Publications
Grievink, E.H., Peters, S.A.F., von Bon, W.H.J., & Schilder, A.G.M. (1993) The Effects of Early Bilateral Otitis Media with Effusion on Language Ability. A Prospective Cohort Study. Journal of Speech and Hearing Research, 36, 1004-1012.
Hall, J.W. (1999). CAOD in Y2K: An Introduction to Audiologic Assessment and Management. The Hearing Journal, 52, 35-40.
Hamaguchi, Patricia (1995). Its Time To Listen. Communication Skill Builders, San Antonio, Texas.
Iskkowitz, M. (1999). Assessing and Managing CAPD. Advance for Speech-Language Pathologists & Audiologists. July, 6-8.
Katz, J., & Wilde, L. (1994). Auditory Processing Disorder. In J. Katz (ed.) Handbook of Clinical Audiology (pp. 490-502). Baltimore: Williams & Wilkins.
Keith, R. (1989), SCAN:  A Screening Test For Auditory Processing Disorders. Texas: The Psychology Corporation.
Keith, R. (1994). SCAN: A Test for Auditory Processing in Adolescents and Adults. Texas: The Psychology Corporation.
Keith, R. (1996). Understanding Central Auditory Processing Disorders: Diagnosis and Remediation. The Hearing Journal. November p. 19-28.
Leeds, J. (1999). The Sonic Alchemy. Conversations with Leading Sound Practitioners. Sausalito. InnerSong Press.
Levin, M. (2002). A Mind At A Time. New York. Simon & Schuster.
Lindamood, P.C. (1998) The need for phonological awareness. ASHA, 40(2), 44-45.
Lindamood, C., & Lindamood, P. (1975). Revised. Auditory Discrimination in Depth Program. Texas. ProEd Publishers.
McFarland, D., & Cacade, A. (1995). Modalitiy Specificity as a Criterion for Diagnosing Central Auditory Processing Disorders. American Journal of Audiology. 4, 36-47
Musiek, F. (1999). Habilitation and management of auditory processing disorders: Overview of selected procedures.  Journal of The American Academy of Audiology, 10, 329-342.
Musiek, R.E., & Schochat, E. (1998). Auditory training and central auditory Processing disorders. Seminars in Hearing, 19, 357-365.
Musiek, F., & Chermack, G. (1995). Three Commonly Asked Questions About Central Auditory Processing Disorders: Management.  American Journal of Audiology. 4, 15-8.
Schow, R.L., & Chermak, G. (1999). Implications from factor analysis for central auditory processing disorders. American Journal of Audiology, 8, 137-142.
Smoski, W., Brunt, M., & Tannahill, J. (1992). Listening Characteristics of Children with Central Auditory Processing Disorders.  Language, Speech, & Hearing Services in the School. 23, 145-52.
Stach, B.A., & Loiselle, L.H. (1993). Central auditory processing disorder: diagnosis and management in a young child.  Seminars in Hearing, 14, 288-295.
Tallal, P., Miller, S., Bloedi, G., Wang, X., Nagarajan, S., Schreiner, C., Jenkins, W., & Merzenich, M. (1996). Language Comprehension in Language Learning Impaired Children Improved with Acoustically Modified Speech. Science. 271, 81-4.
Task Force on Central Auditory Processing Consensus Development. (1996). Central Auditory processing: Current status of research and implications for clinical Practice. American Journal of Audiology: A Journal of Clinical Practice, 5 (2), 41-54.Wallace, I.F., and Hooper, S.R. (1997). Otitis Media and Its Impact on Cognitive, Academic, and Behavioral Outcomes: A Review and Interpretation of the findings. In Roberts, J.E. Wallace I.F. & Henderson F.W. (Eds.).
Otitis Media in Young Children: Medical Developmental, and Educational Considerations. (pp. 163-193). Baltimore, Md. Paul Brooks Publishing.

BIOGRAPHY

Deborah Ross-Swain, Ed.D. is the founder, owner and director of the Swain Center,
A clinic for speech, language and learning disorders and research, The Listening Center in Walnut Creek and Orange County. She is the former Chief of Speech-Language Pathology at the University of California, Davis Medical Center and held a clinical staff faculty appointment to the School of Medicine. She is the President of California Speech Pathologists and Audiologists in Private Practice (CALSPAPP) and was recently appointed to CSHA’s Task Force for developing evaluation and treatment guidelines for Auditory Processing Disorder (APD) and CSHA’s Encroachment Task Force. She is the author of six standardized test batteries: The Ross Information Processing Assessment-2; The Ross Information Processing-Geriatric; The Ross Information Processing Assessment-Primary; The Auditory Processing Abilities Test; The Bedside Evaluation and Screening Test; The Swallowing Ability and Function Test. She is the author of six manuals and books: Aphasia Rehabilitation: An Auditory and Verbal Treatment Hierarchy; Aphasia Rehabilitation: A Reading and Writing Treatment Hierarchy; The Cognitive Linguistic Improvement Program; The Voice Advantage; The Geriatric Treatment Manual; and The Geriatric Resource Manual. She is married and the mother of four children.

 

This non-invasive intervention and treatment method has been evaluated and studied in several research projects in Europe, Africa and Canada in the 1980s and 1990s. Surprisingly, there has been no single study examining the effects of the Tomatis Method on auditory processing disorders.

Children and adults with auditory processing disorder (APD) are a heterogeneous group of people who have difficulty using auditory information to communicate and learn. APD is a set of problems that occurs in different listening tasks. It is a deficit in the processing of auditory input which can be exacerbated in unfavorable acoustic environments and is associated with difficulty listening, speech understanding, language development and learning (Jerger & Musiek, 2000).

An auditory processing disorder is the inability or decreased ability to attend to, discriminate among or between, recognize or understand auditory information. Most language is learned by listening (or processing). In order to learn, a child must be able to attend to, listen to, and separate important speech from all of the other noises at school and home. When auditory skills are weak the child may experience auditory overload. This makes learning more challenging and sometimes too difficult without special assistance. Most people with auditory processing problems have normal intelligence and normal hearing sensitivity.

The purpose of this retrospective study is to determine if the Tomatis Method can be used as a clinical intervention in affecting changes in the auditory processing skills in children who have been identified as having auditory processing disorder. This study will demonstrate the effects of the Tomatis Method that produces improvements in skills of auditory perception and discrimination, immediate auditory memory, interpretation and following directions, auditory sequential memory, auditory cohesion and auditory latency.

Study Purpose and Methods