French
physician, Dr Alfred Tomatis, developed the Tomatis Listening Program about 50
years ago. The development of his technique for auditory training was based on
the fundamental principle that the voice produces what the ear hears - a concept
referred to as the Tomatis Effect [38]. The Tomatis Effect had considerable
implications for the area of music (singing in particular), but also for the
understanding of auditory processing difficulties. An important distinction to
Tomatis was that the passive act of hearing is quite different to active
listening, and it is the listening skill that his method concentrates on.
The
Tomatis Method can be used on both adults and children to treat, enhance and
control various areas including voice training for acting or singing, public
speaking and foreign language learning. Insofar as it relates to adults,
listening and the attention it requires is not only important for audible sounds
but for identifying one's own feelings. The ability to listen extends to the
realm of self-awareness - in effect, listening to an inner voice or feelings.
The importance of this is reflected in emotional well being [45]. Because APD is
more often recognised in children however, the Tomatis Method as it applies to
this particular group for this particular disorder will be exclusively
discussed.
Alfred Tomatis
and auditory processing
Alfred
Tomatis proposed a number of factors fundamental to auditory processing. Sound
processing is known to begin in the womb and plays a major role in the
development of the foetus. At this point, sound is mostly acquired through
bone-conduction in a liquid medium (amniotic fluid). When the baby is born,
sound is then received in two ways - through bone-conduction, and through
air-conduction. If these two processes work in harmony, it assists the child to
develop. If the two types of sound-reception cause confusion for the child,
auditory processing difficulties will arise.
The
ear must be able to interpret sound waves as electrical impulses that send a
message to the brain. It is not enough just to register that sound is being
produced (passive hearing) - a person must be able to identify the purpose and
meaning of the sound (active listening). For a person who cannot listen well,
language acquisition comes much more slowly and development in all areas is
adversely affected. The good news is that listening can be trained to improve
through exposure to appropriate sounds, best heard in the context of music or
vocal activity.
Tomatis
also viewed the vestibular and cochlear systems as indivisible - that is, he
treated them as two parts of a functioning whole and his method reflects this
belief [62].
Aims of the
Tomatis Method
In
a general sense, the Tomatis Method aims to promote improved language,
communication, listening and learning, all of which are often seen to lead to
considerable emotional development. More specifically, the Tomatis Method
operates on three distinct levels. Firstly, it trains the functioning of the two
vital auditory systems: the vestibular system (balance and coordination) and the
cochlear system (language processing). Secondly, it encourages a willingness and
desire to exercise the auditory system which is a major contributor to the
success of the program. Lastly, the Tomatis Method integrates the social and
environmental aspects of auditory processing which is the practical application
of the learning [15].
The
Tomatis Method trains important aspects of listening:
Such
training is irrelevant without practical application however - therefore, the
above issues are addressed alongside conversation, vocabulary development and
correct grammar. This often involves listening to and repeating words, phrases
and other text. Because the vestibular system is concerned with physical
movement, neurosensory integration exercises for improving fine and gross motor
coordination are often done while listening to the program [45].
The Electronic
Ear
The
most integral piece of equipment used in the Tomatis Method is the Electronic
Ear, specifically designed to filter out and simultaneously accentuate selected
frequencies in music and voice [37]. The Electronic Ear is an electronic device
that replicates the operation of an ideal ear. The theory behind this follows
the idea that people reproduce what they hear - the Electronic Ear helps sound
to be received as if the ear was working perfectly, thereby allowing the best
possible reproduction of sound. In this way, the Tomatis Method is able to
couple two of the three interventions suggested for APD by both strengthening
the auditory system and improving the quality of sound received by the ear [43].
The
Electronic Ear has three functions that allow it to operate as a superior
listening device. Firstly, it is responsible for gating the sound, which
strengthens the middle ear; secondly, it controls the timing delays that often
accompany the reception of sound; and thirdly, it amplifies the sound in the
right ear so that right ear dominance is encouraged [48].
Gating the
sound received by the ear
All
muscles in the body are strengthened when they are continually contracting and
relaxing. The same is true for the muscles in the ear, but these muscles cannot
be deliberately manipulated or exercised. Over time, the ear muscles lose their
tone, desensitising themselves to certain sounds in the environment, most
commonly the unpleasant frequencies in sounds like traffic and electrical
appliances [37]. The ear perceives such sounds as an assault and reacts against
them.
The
Tomatis Method uses special music modified in certain ways to ensure that the
muscles in the ear are being exercised appropriately by exposing the listener to
classical music. There are two muscles in the middle ear - the tensor tympani
and the stapedius. The stapedius plays a protective role in reducing the volume
of sound reaching the inner ear and, according to Alfred Tomatis, is the one
muscle in the human body that never stops moving [58].
Not
only does classical music cover the full spectrum of sound, but it is also a
pleasant source of high frequency stimulation. The music involved in the Tomatis
Method is gated, which means it is delivered to the ear in continuously
alternating way - first by emphasising the low frequencies, then by emphasising
the high frequencies. Although this was originally done to tense and contract
the muscles in the middle ear, a second effect of gating is the promotion of
active listening as the quality of music is always changing. The gating can be
individually tailored and is then randomly administered through the Electronic
Ear [67].
Some
of the benefits of using the Electronic Ear include the toning of muscles
through increased coordination for motor activity, an improvement in attention
levels, increased creativity and decreased aggression, more healthy sleeping and
eating patterns, and better memory for auditory, verbal and visual information [48].
Filtered
sound
The
Tomatis Method is concerned with manipulating sound for auditory training, not
unlike certain machines in a gym that isolate particular muscles. Sound
filtering describes the act of altering sound so that the ear is only receiving
particular frequencies. For example, an orchestra is made up of many different
instruments playing at different pitches (high and low). If the sound of an
orchestra is 'filtered at high frequencies', this refers to the fact that all
instruments playing lower than the specified frequency will be cut out of the
recording. Therefore it may sound as though only the violins are playing.
Frequencies are measured in hertz, where one hertz is equal to one cycle per
second. That is, the higher the pitch of a sound, the greater the number of
cycles per second.
One
of the reasons for re-exposing the ear to high frequency sound is that as people
are continually in noisy environments, the ear gradually becomes desensitised to
high frequencies. The rationale behind using filtered sound is that the ear is
gradually retrained to attend to high frequencies again [30]. Why are high
frequencies, rather than low frequencies, given so much attention? Studies show
that exposure to high-frequency sound not only tones the muscles in the middle
ear but boosts energy levels and a general sense of well being. Also, 80% of
the cells in the cochlea are attuned to these sounds, and studies have shown
that babies in utero hear mainly high frequency sounds in the mother's voice, a
principle fundamental to the Tomatis Method [17].
The
foetus matures in a liquid environment. Similarly, the auditory system develops
with reference to the kind of sound experienced in a liquid environment.
Amniotic fluid is similar to water in that it mainly conducts high frequency
sounds. When the baby is born, the liquid remains in the inner ear for a number
of days, giving the organ time to adapt to air-conducted sound and the lower
frequencies that can then be received. The Tomatis Method relies on filtering
sound at high frequencies so that the listener re-experiences the foetal
auditory environment and the auditory system is encouraged to retrace an ideal
and systematic development. This listening training aims to take the listener
through the entire range of frequencies with the intention of re-sensitising the
ear to everything within the workable spectrum of sound [64].
Right ear
dominance
Research
has shown that in the early stages of development, until the age of 11, the
right ear is mainly responsible for listening to and decoding speech sounds. By
this age, the left ear is expected to be at the same level. Most children of
this age also have an auditory scope covering 125-8000 hertz (cycles per
second), but occasionally this is not the case [64]. The Tomatis Method
specifically aims to re-establish the dominance of the right ear by manipulating
sound to be louder on this side [50]. The strength of the right ear is the platform
on which language acquisition is based as it provides the shortest neurological
route to the left hemisphere of the brain: the language centre [57].
A
study has demonstrated that children who read well gain most of their auditory
information through their right ear. The left ear is less relied upon and it
appears this system produces positive results. In contrast, poor readers appear
to take stimuli from both ears or have a left-ear dominance, which is clearly
not a preferable way to process auditory information [65]. Alfred Tomatis also
conducted research that showed considerable differences in the vocal qualities
in the same people who were switched between listening with their left and right
ears. It was found that listening with both ears caused no effect; listening
with the left ear caused a flat voice lacking in expression; but listening with
the right ear actually improved the overall quality of the voice [38].
An outline of
the Tomatis Method
The
Tomatis Method relies primarily on carefully controlled sound stimulation. On
average, it requires 30-40 listening sessions divided into three phases
(otherwise known as 'intensives'). The phases consist of 8-15 days with rest
periods of 4-6 weeks between them. Each
listening session involves a two-hour listening period with the Electronic Ear
during which time air-conducted sound and bone-conducted sound is transmitted to
the ear. In addition to this, adults, children and mothers use microphones so
that their voices are integrated into the listening process. The important thing
to realise is that the Tomatis Method improves not only overall auditory
processing, but is more specific in regard to language. The use of microphones
with voice filtration trains the child to receive language signals more
effectively, both from the mother and from himself or herself. This audio-vocal
feedback mechanism assists in monitoring one's own discourse, and the
amplification of the voice encourages the listener to self-correct their
individual language issues.
It
is vital that the program is administered in the timeline described. The
sessions are necessarily intense and repetitive so the auditory system can be
trained to function differently. The break between the intensives is essential
for two reasons: firstly, the brain needs space and time to integrate the new
knowledge and secondly, the brain's dependence on the training must be
discouraged [48].
The
sound delivered to the child includes Mozart music and Gregorian chant. For
children, the mother's voice is used while the child is encouraged to actively
imitate or repeat the messages. Adults repeat and recite words, poems and
stories. Each program is tailored to the child or adult's individual needs as
identified through the initial assessment. Listening assessments are undertaken
every 10-15 hours throughout the program and the listening schedule is
continually adjusted to reflect the client's progress.
The
delivery of the Tomatis Method involves listening to low frequency sound and
gradually building up through the middle frequencies to the highest frequencies
within a comfortable range. The program then gradually returns through the full
spectrum, this time from the high to the low frequencies. The listener is
thereby guided through the full range of sounds to encourage a stronger and more
structured development of the auditory system. The Tomatis Method has shown to
improve auditory sequencing, phonemic discrimination, phonological awareness,
auditory memory, sound localisation, and the ability to selectively listen to or
inhibit irrelevant sounds in the environment. These are all of the utmost
importance in auditory processing and expressive and receptive language.
Changes
commonly noticed with the Tomatis Method
It
is difficult to generalise about the way a child will change once the Tomatis
Method is administered. Children undertake the program to address different
deficits or problems. The simplest way to explain what can be expected is to say
that the child's functioning will shift from an extreme to a more moderate
position. The Tomatis Method aims to improve reception and expression of
language communication - once this is underway, the indications of the progress
are reflected behaviourally.
Highly
hyperactive children often become calmer, while introverted children become more
interested in the world around them. Some parents have noticed greater affection
being displayed and the child having a desire to interact and communicate with
the family. Behaviour usually becomes more purposeful and self-motivated, and
greater awareness is given to social cues. Response speed usually improves
along with a more flexible approach to what were rigid routines. Fine and gross
motor coordination both become better which gives children greater confidence
in themselves and their bodies. Not surprisingly, self-esteem is raised and
independence is gained [51].
A
number of studies have been conducted to gauge the effectiveness of using the
Tomatis Method to alleviate communication disorders - however, most of these
studies used relatively small samples of participants. A meta-analysis conducted
by Gilmor (1999) combined five of these studies involving 231 children by
standardising the results, taking the amount of error in each study into
account and calculating the average effect size of the Tomatis Method on
different areas of functioning. The greatest gains were found in linguistic
ability, with social, motor and cognitive skills also showing improvement.
Though studies such as this indicate strong empirical support for the Tomatis
Method as a form of treatment for language disorders there is much research yet
to be conducted [63].
Research
in Toronto demonstrated the effectiveness of using listening therapy on more
than 400 children with histories of learning difficulties. Parents reported
phenomenal improvements in many areas, the major ones being communication,
attention, maturity, reading, and a reduction in frustration. The most
encouraging aspect of this study was that a follow-up evaluation revealed
maintenance of the changes or further improvements [48]. A recent unpublished study
at the Psychiatric Clinic for Children and Youth in Sweden used the Tomatis
Method to treat 26 children with AD/HD, learning difficulties and concentration
problems. The results indicated a considerable decrease in the problems, with a
concurrent increase in concentration span, energy levels, expressiveness,
behaviour, motor and social skills [68]. Other studies are currently underway in
Europe and the United States in collaboration with schools, universities and
hospitals.
The
effects of the Tomatis Method are not temporary. The program is not concerned
with developing extraordinary functioning but rather with restoring the
auditory system to a state of equilibrium. The body desires this natural and
normal state which is why the effects are lasting [48].
Mozart music
and Gregorian chant
The
Tomatis Method relies on two types of sounds for the auditory training: Mozart
music and Gregorian chant. There are three elements of music that have an effect
on people: rhythm has an impact on the body, melody is related to intellectual
functioning, and harmony affects emotions. The rationale for using Mozart music
is that these three characteristics are all well balanced within much of his
work [48] and that it contains many of the high frequencies essential to the
Tomatis Method [57]. Mozart music also retains its melodic quality after it has
been modified and this makes the experience more enjoyable for the listener [48].
Scientific
research has found that Mozart's music is the most beneficial in stimulating and
expanding the capabilities of the brain. This is attributed to the features
described above, but also to the music's long-term periodicity (music waveforms
that repeat regularly but not too closely together) in the range of 10-60
seconds. This periodicity is found in melody lines, which Mozart repeats far
more frequently than most other composers, and it was also found that he
emphasised certain notes more often than his counterparts. Research suggests
that it is this unique characteristic of Mozart music that stimulates the neural
network of the brain and facilitates the super-organisation of the cerebral
cortex [55].
Research
centred on the benefits of listening to Mozart music (the Mozart Effect) has
demonstrated significant improvements in people's spatial-temporal reasoning,
and also noted disorder-specific benefits. For example, a recent neurological
investigation by Jenkins showed that a number of people with epilepsy had
reduced epileptiform activity (steeply spiked brainwave activity) and had
significantly fewer seizures after sustained exposure to Mozart. This was the
case 90-100% of the time [56]. More information on the Mozart Effect
and supporting studies can be
obtained from the Listen and Learn Centre.
Gregorian
chants are vocal arrangements with no tempo (beat). What makes this important is
that instead of mimicking a pulse, this music closely resembles respiratory
(breathing) patterns [48]. This characteristic of the music is conducive to a
feeling of relaxation which assists in delivering the therapy [51]. Gregorian chant
also utilises the full range of frequencies contained in the human language and
thus prepares the ear to receive the complexity of frequencies within language.
Many
CDs are available with these types of music, but they are in no way related to
the Tomatis Method. It is only when this music is received through the
Electronic Ear, via bone and air-borne stimulation with appropriate filtering
and gating, that the Tomatis Effect is delivered [48].
The mother's
role
When
the Tomatis Method is administered to an adult, it is an individual venture.
However, this is not the case when it is used for children. Implementing the
Tomatis Method requires far more than the child's cooperation - it is a joint
effort by the child and his or her mother, a reflection of the Tomatis principle
that auditory development begins in the womb.
Part
of the Tomatis Method involves manipulating the mother's voice by gradual
filtering so that only the high frequency sounds in the mother's voice are
heard [51]. This is done so the voice resembles how it would have been heard in the
womb, recreating the child's first encounters with sound and language. For this
reason, no other voice will evoke the same potential and response from the
child. Without the commitment and involvement of the mother, the effectiveness
of the Tomatis Method is compromised for young children as the imprint of
language takes place in the womb via the mother's voice.
Enhanced
outcomes in individual development have been observed when the Tomatis listening
program is completed in conjunction with exercises in neurosensory integration,
best experienced through Neuro Developmental Therapy. Combining auditory and
vestibular therapy helps to assist a child with Auditory Processing Disorder.
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