Practical Interventions for

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Practical Interventions for Hyperacusis/
Hyperreactivity in ASD
Lillian Stiegler, Ph.D and Rebecca Davis,
Au.D. Southeastern Louisiana University
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Hyperacusis An unusual intolerance of ordinary
environmental sounds (Andersson, 2002 ASHA, 2008)

• Many possible etiologies
• Is it physiological?
• Is it psychoemotional?
• Commonly discussed in ASD contexts

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When I was little, loud noises were also a
problem, often feeling like a dentists drill
hitting a nerve. They actually caused pain. I
was scared to death of balloons popping, because
the sound was like an explosion in my ear. Minor
noises that most people can tune out drove me to
distraction. When I was in college, my
roommates hair dryer sounded like a jet plane
taking off (Grandin, 1995).
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Sirens and sudden like, sudden like hammers or
something like thatI gotta get my plugs in my
ears or Im outta there. Fire alarms! The fire
alarms, oh boy, whoo! Yes, sir, I carry my plugs
around basically whenever I can, or Ill use my
trusty indexes (Monahan, 2002).
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A waitress was setting two glasses of water on
our table. Sean leaped to his feet, upsetting the
water and sending his chair flying backwards it
crashed into the window and thudded to the floor.
He threw himself down next to the chair,
writhing and yelling, his hands clasped tightly
over his ears (Barron, 2002).
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She still hates certain sounds, like a baby
crying, the car alarm telling you your seatbelt
isnt fastened, or the sound of a bathtub
draining. When she hears them she gets agitated,
holds her hands over her ears, and vocalizes to
block out the sound. She has the same reaction
when she hears me clear my throat, or when
someone says words associated with bathing, such
as bath, shower or shampoo. (Grinker,
2007).
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And he reacts to certain scenes in the video or
lines in the songs or things Davy says by putting
his fingers in his ears, curling up, blushing and
staring at the floor (Hughes, 2003).
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People with ASD may REACT to sensory stimuli in a
less conventional way than their typical peers
(Prizant Meyer, 1993).
We use both hyperacusis and hyperreactivity
to discuss difficulties with sound tolerance in
the ASD population.
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HAVE YOU SEEN THESE BEHAVIORS?

• Hands over ears
• Fingers in ears
• Arms over head
• Pinnae folded forward
• Crying/tantrums in response to sounds
• Fleeing the area where sound is occurring

• Humming/vocalizing in the presence of sound
• Trembling
• Increased muscle tone
• Pupil dilation
• Hives
• Hyperventilation
• Self-injury in the form of blows to the ears

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• ISSUES
• The auditory channel is critical for language
  learning.
• Habitual sound avoidance may lead to isolation
  from typical peers.
• Certain sound avoidance behaviors are
  stigmatizing and may limit the ways individuals
  are able to use their hands.
• Overuse of ear protection is not a long term
  solution, and may make matters worse.

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Hyperacusis may result in ACTIVITY LIMITATIONS
and PARTICIPATION RESTRICTIONS as defined by the
World Health Organizations International
Classification of Functioning, Disability
Health (ICF).
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RESEARCH PHYSIOLOGICAL PERSPECTIVE

• Definitions of hyperacusis differ (e.g., Khalfa
  et al, 2004 Gravel et al, 2006)
• No evidence (so far) of a physiological
  difference between individuals with ASD and
  typical peers

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RESEARCH PSYCHOEMOTIONAL PERSPECTIVE

• Sounds need not be loud/high-pitched to be
  offensive
• Phonophobia Fear of sounds, accompanied by
  autonomic and limbic reactions
• Misophonia Learned, emotional reaction to
  sounds

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• Clinical experience shows that people with ASD
  may exhibit aversions to
• Loud sounds
• High-pitched sounds
• Reverberating sounds
• Unexpected sounds
• Sounds/words associated with undesirable topics
• Sounds/words associated with negatively-remembere
  d events
• Sounds considered unpleasant for unknown reasons

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• Otherwise-typical individuals with phonophobia
  have the following in common (Jastreboff
  Jastreboff, 2000)
• Belief that sound can be harmful
• Attempts to overprotect the ears
• Reactions to sounds are context dependent
• May react strongly to specific sounds, yet have
  no reaction to louder sounds

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Is it possible that interventionists and
caregivers may misinterpret sound avoidance
behaviors that occur due to phonophobia or
misophoniaand believe there is an actual
pathology along the auditory pathway?
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Our beliefs, interpretations and reactions are
IMPORTANT!
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If an interventionist/caregiver believes that a
person with ASD is physiologically and
permanently hyperacusic
the individuals exposure to worthwhile social
and educational activities may be needlessly
limited.
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OPTIONS FOR INTERVENTION

• Discontinue overprotection of the ears. Overuse
  of ear protection can lead to increased
  hypersensitivity to sound and more intense
  phonophobia.
• Jastreboff Jastreboff, 2000
• Mraz Folmer, 2003

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• Consider habituation to sound through systematic
  desensitization.
• Jackson King, 1982
• Koegel et al, 2004

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• Develop a detailed, individualized sound
  desensitization hierarchy.
• Implement over time very gradual exposure has
  often been effective, but may not be necessary.
• Try keeping sound level constant, but decreasing
  distance and/or barriers between the sound and
  the individual.
• Be persistent.
• Jackson King, 1982
• Koegel et al, 2004

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Koegel, Openden Koegel (2004) created
systematic desensitization protocols for three
very young children diagnosed with ASD.
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As the child and his mother engage in favorite
activities

• Animal sounds are played repeatedly outside of
  the clinic room (approx. 20 ft. from the door).
  The door is closed completely.
• Animal sounds are played repeatedly outside of
  the clinic room (approx. 10 ft. from the door).
  The door is closed completely.
• Animal sounds are played repeatedly outside of
  the clinic room (approx. 5 ft. from the door).
  The door is closed completely.
• Animal sounds are played repeatedly outside of
  the clinic room (approx. 4 ft. from the door).
  The door is closed completely.
• Animal sounds are played repeatedly just outside
  but held away from the door. The door is
  closed completely.
• Animal sounds are played repeatedly just outside
  the room and pressed against the door. The door
  is closed completely.

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• Animal sounds are played repeatedly just outside
  the room. The door is slightly cracked.
• Animal sounds are played repeatedly just outside
  the room. The door is ¼ way open.
• Animal sounds are played repeatedly just outside
  the room. The door is ½ way open.
• Animal sounds are played repeatedly inside the
  clinic room by the clinician.
• Animal sounds are played repeatedly inside the
  clinic room by the clinician. Child
  spontaneously verbally requests that the
  clinician play various animal noises
• Animal sounds are played repeatedly by childs
  mother and/or alternated between child and his
  mother.

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This program was successfully completed in ONE
session, with subsequent follow-up via phone and
email. The child maintained ability to
comfortably play at home with toys that made
animal sounds.
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Similar protocols were successfully implemented
for avoidance of toilet flushing and home
appliances (mixer, blender, vacuum) Koegel,
Openden Koegel (2004) .
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Consider rewarding instances of hearing
non-preferred sounds without hyperreaction.
So we explained the game to Isabel, and told her
that when she got 100 points she could visit the
new baby panda bear at the National Zoo. Within
just a few hours she was begging me to clear my
throat and to say bath and shower. She got
her prize, and the games over. Isabel still
hates those sounds, but she no longer reacts
defensively. It was a simple example of how
effective it can be to use a reward system, but
it felt like a miracle (Grinker, 2007, p. 299).
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Consider providing enriched sound environments
(Jastreboff Jastreboff, 2000).
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Consider targeting self-regulation and/or mutual
regulation strategies, as appropriate for the
individuals age and functional level (Prizant et
al, 2003).
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• For a person at a presymbolic level, socially
  acceptable self-regulation strategies might
  include holding a favorite object or engaging in
  rhythmic movement.
• Caregivers can provide support by being aware of
  indicators of dysregulation and perhaps reducing,
  but not eliminating, environmental sound.
• Individuals can learn more conventional ways
  (e.g., gestures, visuals) to communicate about
  sound and how it affects them.
• Individuals with language may be able to learn
  self-talk strategies (e.g., Thats the blender.
  Its a safe sound.)
• Caregivers can encourage individuals to request
  help or a break.
• Visual supports may be very useful, even for
  individuals with language.

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Consider creating a Social Story that is
individualized and written according to
prescribed guidelines (Gray, 1995).
The buzzing sound is loud, but it is safe. It is
okay!
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Beware of alternative sound therapies.

• Randomized clinical trials have shown that
  auditory integration training (AIT) is
  ineffective (Zollweg, Vance Palm, 1997 Mudford
  et al, 2000).
• There are clear statements from many
  professional organization (e.g., ASHA, AAA,
  American Academy of Pediatrics) that AIT and
  other sound therapies are investigational,
  non-evidence-based practices.
• Some professional licensure boards (e.g.,
  LBESPA) place strict limitations on the use of
  sound therapies, even experimentally.

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QUESTIONS?
COMMENTS?