We are commonly asked whether we recommend that children with severe concentration difficulties (such as AD/HD) undergo auditory training or Neurofeedback,
either in isolation or in combination. The following is intended as a guide to help understand why the recommendation of certain treatments depends on each child’s
individual profile.
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.
| Gestational Age |
Developmental Observation |
| 4 weeks |
Divisions in the brain can be observed |
| 5 weeks |
Division of brain lobes, early development of the auditory system |
| 6 weeks |
Cells of cochlear ganglion
move towards brainstem |
| 7 weeks |
Appearance of cochlear nerve |
| 23 weeks |
Inner ear well-developed, like
that of an adult |
| 30 weeks |
Pathways between ear and auditory brainstem 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 into a person’s 30s – 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 dysfunction. 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 assess each child with a view to understanding whether their 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 result of auditory immaturity. We believe that auditory re-education is a more appropriate starting
point for children experiencing a range of problems.
Assessment tools for evaluating the child’s difficulties
We use a number of tools to assess children’s attention and their auditory processing skills. We utilise a battery of normed assessments to investigate auditory processing abilities and additionally, we use the TOVA (Test Of Variables of Attention both auditory and visual versions) as well as the IVA (Integrated Visual and Auditory Performance Test) to assess attention, impulsivity, response time and combined sustained attention.
The Visual TOVA involves a computerised presentation of two stimuli. The target visual cue is a square box in the upper section of the computer screen and the non-target is a square box in the lower section of the screen. The individual is instructed to press the button only when they see the square box in the upper section of the screen. The images are randomly presented every 2 seconds for a tenth of a second.
The Auditory TOVA uses auditory cues with the target sound being a high-pitched tone and the non-target being a low-pitched tone. The individual is instructed to press the button only when they hear the higher tone and ignore the low-pitched tone. The sounds are either a low or high pitched tone which is randomly presented every 2 seconds.
The Visual and Auditory TOVA operate as two halves – the first is the Target Infrequent Half where the target randomly appears at a rate of one for every 3.5 presentations of the non-target. This infrequent appearance of the target tests the individual’s ability to maintain concentration for a relatively boring task. If the person does not respond to the target, this is described as an error of omission and many of these errors indicate inattention. The second half is the Target Frequent Half where the target is presented 3.5 times for every one presentation of the non-target. This reversal of frequency means that the individual is now responding to targets often, and must inhibit his or her tendency to press the button incorrectly. Such incorrect responses are known as errors of commission and many of these errors indicate impulsivity.
Both tests measure impulsivity (errors of commission) and inattention (errors of omission), the speed of the child’s responses, and multiple and anticipatory responses. The length of the TOVA is 21.8 minutes for 6 year-olds and over, and 10.9 minutes for 4-5 year-olds.
The IVA which is another test of attention that measures responses to 500 intermixed auditory and visual stimuli are spaced 1.5 seconds apart, and requires the individual to click the mouse when the stimulus is an auditory or visual “1” and to refrain from clicking when the stimulus is an auditory or visual “2”. The test taker is required to maintain attention for 13 minutes. This assessment gives information as to the individual’s auditory and visual attention, and combined sustained attention under challenging conditions.
The duration and monotony of these two assessments poses a great challenge for children who experience concentration problems because it is a deliberately boring and repetitive task – in this way, both tests are excellent instruments by which to understand how a child maintains attention under difficult conditions. It is also repeatable over time to demonstrate progress in one or both areas.
Our clinical experience
We use the various assessment tools before, during and after treatments to monitor the child’s progress. Children with attentional difficulties associated with poor auditory processing, specific learning difficulties, mild autism or AD/HD have demonstrated more sustained concentration and quicker response times up to two standard deviations through undergoing only auditory training programs. These gains often correlate with improvements in other executive functions.
Using auditory training before Neurofeedback
We advise auditory training for children who have AD/HD in conjunction with auditory processing difficulties that are manifesting learning difficulties. 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 attention at a more conscious level through Neurofeedback.
We suggest this order of interventions for children who display more than simply attentional problems because auditory training addresses the physiology of auditory processing at brainstem level – this should still improve concentration as a primary symptom. If there are attention problems after a complete program of auditory training, Neurofeedback is recommended to build on a system that has already been strengthened and is therefore more open to change.
Clinical example
‘Stewart’ came to see us at the age of 6.5 years having been diagnosed with severe AD/HD 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 hypersensitivity to sound, being extremely inattentive when spoken to, and having poorer attention when unmedicated. His parents consulted us to improve his concentration and attention but were extremely concerned about his learning difficulties. Stewart underwent auditory training and his medication was reduced by 5 mgs by the end of this program. Most importantly, his concentration improved enough to enable him to attend to learning for longer periods of time; he continued to make improvements over the next twelve months in reading and writing, achieving grade level appropriate performance. Behavioural issues remained a concern, so Neurofeedback was commenced three months after completing the auditory training. Through Neurofeedback training, Stewart’s behaviour and self-control has improved considerably and he is currently taking 10 mgs of Ritalin per day.
Using Neurofeedback on its own
If auditory processing problems are detected by the battery of auditory processing assessments but the child
is not notably impaired in any domain besides concentration, Neurofeedback would probably be recommended on its own. For children who display attentional difficulties but no auditory processing deficits, Neurofeedback would clearly be the preferred intervention.
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