Auditory Training (also known as Listening Training) or Neurofeedback?
We are commonly asked whether we recommend that children with severe concentration difficulties (such as those found in ADD/ADHD) undergo auditory training or Neurofeedback, either in isolation or in combination, when there are listening difficulties and inattention. The following is intended as a guide to help understand why the recommendation of certain treatments depend on a child’s individual profile.
The relationship between the ear and the brain
Although Neurofeedback targets the brain through actively modifying some brainwave activity via operant conditioning, auditory stimulation also works at a neurological level. Auditory training stimulates the auditory pathways, impacts the vestibular system, and has rich connections to the reticular activating system (RAS).
The reticular formation is located in the brainstem and is responsible for consciousness and arousal (which includes concentration). The RAS also plays a principal role in the transmission of auditory information to the auditory cortex. Although Neurofeedback cannot stimulate or access brainstem activity, auditory training can. This is the physiological rationale for using auditory training to effect improvements in focus and attention when auditory difficulties are concurrently experienced.
Auditory processing is not simply a function of the ear. The auditory nerve is the first nerve to be fully myelinated in the body when the child is in utero. This is indicative of its fundamental role in development. There are a number of cranial nerves associated with the ear, including the Oculomotor (III), Trochlear (IV), Abducens (VI), Trigeminal (V) and Vagus nerves (X). The Vestibulocochlear Nerve (VIII) is responsible for hearing, balance and coordination, but the others assist with proprioception, visual tracking, control of the middle-ear muscles, and control of the facial muscles used for speech and language. The ear with its relationship to the brain, is fundamental to most developmental processes.
Background: understanding development and the hierarchy of functions
Children’s abilities grow hierarchically, with the most basic automated functions appearing first, and more complex processes developing once the physiological foundations are laid. Auditory processing given its early development, falls into the category of a primal process at a cortical level.
Divisions in the brain can be observed
Division of brain lobes, early development of the auditory system
Cells of cochlear ganglion move towards the brainstem
Appearance of the cochlear nerve
The inner ear becomes well-developed like that of an adult
Pathways between the ear and auditory brainstem are established
(Adapted from Bellis, T.J. (2003) Assessment and Management of Central Auditory Processing Disorders in the Educational Setting (2nd Ed.) Thompson Delmar Learning, Canada.)
Where auditory processing occurs early in the child’s development, higher order complex processing in the frontal cortex begins at a much later stage. Executive functions include both organisation (comprising concentration, memory, planning, sequencing, problem-solving and decision-making), and regulation (including self-monitoring, adaptation and control). The interplay of these functions means that a weakness in one area has consequences for the full range of abilities.
Relatively little is known about how the maturation of the frontal cortex in children correlates with the emergence of executive functions. However, it has been noted that as children practise executive operations, they are able to expend less neural energy to complete the same task over time. This reflects a partial automation of these functions which enables the advancement of new skills. The executive functions may still be developing in a person up to the age of 30. This demonstrates that the brain continues to be shaped by experiences long after primary development has taken place.
The deficits associated with poor concentration are directly related to executive difficulties. We take the approach that the auditory system operates at a basic biological level which, if not working efficiently, compromises all skills that depend on it. Concentration, as a component of executive functioning is one such ability. We therefore need to evaluate in order to understand whether a child’s poor concentration is an isolated symptom, or whether the attention problems exist in a spectrum of developmental difficulties including auditory dysfunction.
As previously discussed, Neurofeedback cannot address brainstem activity and is possibly less effective as a sole intervention for children whose concentration problems might be a by-product of auditory immaturity. Based on our experience, auditory training is a more appropriate starting point for children experiencing a range of developmental problems.
Our clinical experience: using auditory training before Neurofeedback
We recommend auditory training to be conducted first for children who have ADD/ADHD in conjunction with auditory processing difficulties, “poor listening”. Poor auditory processing can itself cause or add to concentration and attention problems – with this in mind, we aim to ensure that the auditory system is functioning at its optimum level before addressing inattention at a more conscious level through Neurofeedback.
We suggest this order of intervention for children displaying more than simply attentional problems, because auditory training addresses the physiology of auditory processing at brainstem level and above – which should impact and improve auditory attention and auditory sustained attention as a primary symptom.
If there are ongoing attention problems at a more generalised level after a complete program of auditory training, Neurofeedback is recommended as a secondary intervention to build on a system that has already been strengthened, and is therefore more open to change.
Stewart came to see us at the age of 6.5 years having been diagnosed with severe ADHD and taking 35mg of Ritalin per day. He was hyperactive, engaged in noisy behaviour, had poor gross and fine motor skills, could not read or write and had a history of glue ears. He also had auditory problems such as being hypersensitive to certain sounds, being extremely inattentive when spoken to, and having poorer attention when unmedicated. His parents consulted the centre to improve his concentration and attention, but were extremely concerned about his learning difficulties. Stewart underwent auditory training first and following improvements observed by his parents by the end of this program, his paediatrician reduced his medication by 5mg.
Most importantly, his concentration improved enough to enable him to attend for longer periods of time at school as reported by his teachers, and he continued to make improvements over the next twelve months in reading and writing, achieving grade level performance. Behavioural issues remained a concern specifically high levels of impulsivity, so Neurofeedback was commenced three months after completing the auditory training program. Through Neurofeedback training, Stewart’s behaviour and self-control improved considerably, and his medication was reduced further to 15 mg of Ritalin per day.
Using Neurofeedback on its own
For children who display attentional difficulties without auditory processing deficits or “poor listening”, Neurofeedback would clearly be the preferred intervention.
Martha Mack (2017)
Psychologist & Director
Listen And Learn Centre
Melbourne, Australia www.listenandlearn.com.au