162001 - alexorl.edu.egalexorl.edu.eg/alexorlfiles/pptorl2007/162001.pdf · prof. dr. abdelzaher...
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Mohammad Ramadan HassanMohammad Ramadan Hassan
Lecturer of Audiology Lecturer of Audiology –– Zagazig Zagazig universityuniversity
MD thesis MD thesis -- 20052005Audiology unit Audiology unit –– Ain Shams universityAin Shams university
Discuusion committee:Discuusion committee:
Prof. Dr. Abdelzaher Tantawy Prof. Dr. Abdelzaher Tantawy
Prof. Dr. Nadia KamalProf. Dr. Nadia KamalProf. Dr. Somaia TawfikProf. Dr. Somaia Tawfik
Supervisors:Supervisors:
Prof. Dr. Somaia Tawfik MohammadProf. Dr. Somaia Tawfik MohammadProf. Dr. Iman Mohammad SadekProf. Dr. Iman Mohammad SadekProf. Dr. Amany Ahmad ShalabyProf. Dr. Amany Ahmad Shalaby
Central auditory processing is an Central auditory processing is an umbrella term for all operations umbrella term for all operations executed on peripheral auditory executed on peripheral auditory inputs, and which are required for inputs, and which are required for the successful generation and the successful generation and identification of auditory percepts.identification of auditory percepts.
(Phillips, 2002)(Phillips, 2002)
Central auditory processing disorder Central auditory processing disorder (CAPD) refers to difficulty in the (CAPD) refers to difficulty in the processing of auditory information in the processing of auditory information in the central auditory nervous system (CANS). central auditory nervous system (CANS). This is demonstrated by poor This is demonstrated by poor performance in one or more the performance in one or more the following auditory behaviors:following auditory behaviors:
��Sound localization and lateralization.Sound localization and lateralization.
��Auditory discrimination and auditory Auditory discrimination and auditory pattern recognition.pattern recognition.
��Temporal auditory processing.Temporal auditory processing.
��Auditory performance with competing Auditory performance with competing acoustic signals.acoustic signals.
��Auditory performance with degraded Auditory performance with degraded acoustic signals.acoustic signals.
Other neuroOther neuro--cognitive mechanisms such as cognitive mechanisms such as ATTENTION and MEMORY ATTENTION and MEMORY are deployed in are deployed in performing these behaviors.performing these behaviors.
(ASHA, 1996)(ASHA, 1996)
ScholasticScholasticUnderUnder--
achievementachievementCAPDCAPD
DeficiencyDeficiencyin languagein languageacquisitionacquisition
CAPD management:CAPD management:
Auditory Auditory remediation remediation ProgramsPrograms
EnvironmentaEnvironmental modificationl modification
CompensatoCompensatory strategiesry strategies
(Bellis, 1996)(Bellis, 1996)
Experience dependant Experience dependant auditory plasticityauditory plasticity
CANS can undergo organizational CANS can undergo organizational changes in response to intensive changes in response to intensive
auditory trainingauditory training
The auditory remediation programs rely on the concept of ………….
The auditory remediation programs rely The auditory remediation programs rely on the concept of on the concept of ……………………..
AuditoryRemediation
programs
Formalprograms
Informalprograms
Informal remediation programs:Informal remediation programs:
�� LanguageLanguage--based auditory tasks with nonbased auditory tasks with non--sophisticated arrangements.sophisticated arrangements.
�� Practicing occurs in the context of meaningful Practicing occurs in the context of meaningful communication.communication.
Powerful means of fostering listening skills.Powerful means of fostering listening skills.�� They tap other central auditory abilities beside the They tap other central auditory abilities beside the
targeted one.targeted one.Helpful in training integrative auditory Helpful in training integrative auditory
functions.functions.�� These programs can be undertaken at home and in These programs can be undertaken at home and in
school.school.They allow for additional practice.They allow for additional practice.
(Musiek et al., 2002)(Musiek et al., 2002)
Musiek (1999) Developed An Informal Musiek (1999) Developed An Informal Remediation Program, Which Proved Remediation Program, Which Proved
To Be Effective In Management Of To Be Effective In Management Of many children with CAPD.many children with CAPD.
Availability Of Such Program In Arabic Availability Of Such Program In Arabic Language Will Be Helpful In Language Will Be Helpful In
Management Of A Lot Of Children Management Of A Lot Of Children With CAPD.With CAPD.
�� To develop an informal auditory To develop an informal auditory remediation program in remediation program in Arabic language.Arabic language.
�� To standardize the program on a sample To standardize the program on a sample of normal Egyptian children.of normal Egyptian children.
�� To assess the effectiveness of the To assess the effectiveness of the program on a sample of children with program on a sample of children with central auditory processing disorders.central auditory processing disorders.
They were distributed in three groups:They were distributed in three groups:
�� Pilot study group: 42 children.Pilot study group: 42 children.
�� Control group: 60 normal hearing children.Control group: 60 normal hearing children.
�� Study group: 21 children with CAPD.Study group: 21 children with CAPD.
Children included in this study were Children included in this study were of both genders and ranged in age of both genders and ranged in age between 6 between 6 –– 12 years.12 years.
�� Age subAge sub--group I: 6 group I: 6 -- >8 years.>8 years.
�� Age subAge sub--group II: 8 group II: 8 -- >10 years.>10 years.
�� Age subAge sub--group III: 10 group III: 10 -- 12 years.12 years.
These groups were further subdivided These groups were further subdivided into three age subgroups:into three age subgroups:
�� TwoTwo--channel audiometer Madsen, model Orbiter channel audiometer Madsen, model Orbiter 922.922.
�� Immittancemetry Interacoustics model AZ7.Immittancemetry Interacoustics model AZ7.
�� Evoked potentials audiometer Amplaid, model MK Evoked potentials audiometer Amplaid, model MK 12.12.
�� DoubleDouble--wall soundproof room IAC, model 2001.wall soundproof room IAC, model 2001.
�� TwoTwo--channel cassette tape recorder Nasr Sharp, channel cassette tape recorder Nasr Sharp, model GS 500.model GS 500.
�� Arabic central auditory tests recorded on tapes: Arabic central auditory tests recorded on tapes: LPF, SPIN, CST, DPT and memory tests for LPF, SPIN, CST, DPT and memory tests for recognition, content and sequence.recognition, content and sequence.
�� Missing word exercise for auditory closure Missing word exercise for auditory closure training.training.
�� Auditory vigilance exercise for auditory attention Auditory vigilance exercise for auditory attention training.training.
�� Auditory memory exercise for auditory memory Auditory memory exercise for auditory memory training.training.
�� Phonemic awareness exercise for auditory Phonemic awareness exercise for auditory decoding skills.decoding skills.
�� Auditory directives exercise to enhance interAuditory directives exercise to enhance inter--hemispheric transfer of auditory information.hemispheric transfer of auditory information.
PILOT STUDY
�To exclude too easy and too difficult items.
�To select the best approaches to introduce the materials to children.
STANDARDIZATION
To derive age-appropriate normative
data for each stage in all remediation
materials
REMEDIATION
To study the efficacy of the
developed remediation program
� Basic audiological evaluation: pure tone audiometry, speech audiometry and immittancemetry.
� Questionnaire (to thier mothers).
� Arabic central auditory tests for children:�Low pass filtered speech test.�Competing sentences test.�Speech in noise test.�Duration pattern test.�Memory tests for content, sequence and recognition.
� Psychosocial evaluation using Hiskey Nebraska and Good-enough tests.
� P300 testing with active paradigm.
� Testing with marker items to determine the baseline scores in different remediation materials.
standardization
�All items of the developed informal remediation material were presented to the children of the control group in two sessions.
�Scores of those children in the remediation materials were collected to standardize each exercise material for each of the three age subgroups.
8 weeks training period as:
� 2 sessions / week in the audiology unit.
� 2 home-sessions / week by the parents.
Each session lasted 20 – 30 minutes.
REMEDIATION
Post-remediation evaluation:To assess the program efficiency.
3-months post-remediation evaluation.To assess the stability of the program
outcome.
REMEDIATION
All children of the control group revealed normal scores in central auditory tests
and psychosocial measures.
Results
Mean ( ) standard deviation (SD) and 95% confidence Mean ( ) standard deviation (SD) and 95% confidence range of auditory closure material in the control group. range of auditory closure material in the control group.
AuditoryAuditoryclosureclosurestage III stage III
AuditoryAuditoryclosureclosurestage II stage II
AuditoryAuditoryclosureclosurestage Istage I
18.7 (13.8) 18.7 (13.8) 52.7 (24.4) 52.7 (24.4) 98.7 (2.5) 98.7 (2.5) (SD)(SD)AgeAgeSubgroupSubgroup
II 12.212.2 -- 25.125.141.341.3 -- 64.164.197.597.5 -- 99.899.895%95%confidenceconfidencerangerange
54 (18.5) 54 (18.5) 89.5 (9.9) 89.5 (9.9) 99.5 (1.6) 99.5 (1.6) (SD)(SD)AgeAgeSubgroupSubgroup
IIII 45.345.3 -- 545484.984.9 -- 89.589.598.798.7 –– 100#100#95%95%confidenceconfidencerangerange
76.8 (14.4) 76.8 (14.4) 96.2 (5.5) 96.2 (5.5) 100 (0) 100 (0) (SD)(SD)AgeAgeSubgroupSubgroup
IIIIII 70.170.1 -- 83.683.693.693.6 -- 98.898.8100100 –– 10010095%95%confidenceconfidenceRR
X
X
X
X
Results
Mean ( ), standard deviation (SD) and 95% confidence range Mean ( ), standard deviation (SD) and 95% confidence range ofofauditory vigilance material in the control group.auditory vigilance material in the control group.
AuditoryAuditoryvigilancevigilancestage III stage III
AuditoryAuditoryvigilancevigilancestage II stage II
AuditoryAuditoryvigilancevigilancestage Istage I
62.7 (13.5) 62.7 (13.5) 70.9 (13.2) 70.9 (13.2) 97.6 (3.6) 97.6 (3.6) (SD)(SD)AgeAgeSubgroupSubgroup
II 56.456.4 -- 69.369.364.764.7 -- 77.177.19696 -- 99.399.395%95%confidenceconfidencerangerange
82.1 (4.9) 82.1 (4.9) 85.3 (4.136) 85.3 (4.136) 99.9 (0.4) 99.9 (0.4) (SD)(SD)AgeAgeSubgroupSubgroup
IIII 79.879.8 -- 84.484.483.483.4 -- 87.287.299.799.7 -- 100 # 100 # 95%95%confidenceconfidencerangerange
86.4 (6) 86.4 (6) 87.8 (5.4) 87.8 (5.4) 99.95 (0.2) 99.95 (0.2) (SD)(SD)AgeAgeSubgroupSubgroup
IIIIII 83.683.6 -- 89.289.285.385.3 -- 90.390.399.999.9 -- 100 # 100 # 95%95%confidenceconfidenceRR
X
X
X
X
Results
Mean ( ), standard deviation (SD) and 95% confidence range oMean ( ), standard deviation (SD) and 95% confidence range offauditory memory material in the control group.auditory memory material in the control group.
Seq.Seq.memmem
..55--ww
Seq.Seq.memmem
..44--ww
Seq.Seq.memmem
..33--ww
ContCont..
MemMem..
55--ww
ContCont..
MemMem..
44--ww
ContCont..
MemMem..
33--ww
Rec.Rec.MemMem
..33-- ww
Rec.Rec.memmem22--ww
72.872.8(15.3(15.3
))
90.890.8(15.4(15.4
))
96.596.5(10.8(10.8
))
7373(21.8(21.8
))
91.591.5(15.3(15.3
))99.899.8(1.1)(1.1)
8787(14.1(14.1
))9898(5)(5)(SD)(SD)AgeAge
SubgroSubgroup Iup I 65.665.6
-- 808083.583.5-- 9898
91.591.5-- 100100
##
63.163.1--
82.982.9
84.384.3--
98.798.7
99.399.3––
100#100#
80.480.4--
93.693.6
95.795.7-- 100100
##95% C. 95% C. R.R.
9393(9.5)(9.5)
100100(0)(0)
100100(0)(0)
95.395.3(8)(8)
100100(0)(0)
100100(0)(0)
93.893.8(8.4)(8.4)
100100(0)(0)(SD)(SD)AgeAge
SubgroSubgroup IIup II
88.688.6––
97.597.5
100100––
100100100100 ––100100
91.591.5-- 9999
100100––
100100
100100––
100100
89.889.8--
97.897.8100100 --100100
95% C. 95% C. R.R.
9797(5)(5)
100100(0)(0)
100100(0)(0)
100100(0)(0)
100100(0)(0)
100100(0)(0)
9898(8.9)(8.9)
100100(0)(0)(SD)(SD)AgeAge
SubgroSubgroup IIIup III
94.794.7--
99.399.3
100100––
100100100100 ––100100
100100 --100100
100100––
100100
100100––
100100
93.893.8-- 100100
##100100 ––100100
95% C. 95% C. R.R.
X
X
X
X
Results
Mean ( ), standard deviation (SD) and 95% confidence range Mean ( ), standard deviation (SD) and 95% confidence range of phoneme awareness material in the control groupof phoneme awareness material in the control group
PhonemePhonemeblendingblending
PhonemePhonemesegm.segm.stage IIstage II
PhonemePhonemesegm.segm.stage Istage I
PhonemePhonemecomp.comp.stage IIstage II
PhonemePhonemecomp.comp.stage Istage I
64.564.5(17.8)(17.8)
93.593.5(9.2)(9.2)
95.895.8(11.3)(11.3)93.8 (10) 93.8 (10) 98 (5.5) 98 (5.5) (SD)(SD)AgeAge
SubgroSubgroup Iup I 56.256.2 -- 72.972.989.289.2 --
97.897.890.590.5 --100 # 100 #
89.289.2 --98.498.4
95.495.4 -- 100100##
95% C. 95% C. R.R.
90.5 (7.6) 90.5 (7.6) 99.399.3(1.8)(1.8)100 (0) 100 (0) 100 (0) 100 (0) 99.5 (1.5) 99.5 (1.5) (SD)(SD)AgeAge
SubgroSubgroup IIup II 8787-- 94.194.198.498.4 --
100 # 100 # 100100 –– 100100100100 –– 10010098.898.8 -- 100100##
95% C. 95% C. R.R.
97.5 (4.1) 97.5 (4.1) 99.899.8(1.1)(1.1)100 (0) 100 (0) 100 (0) 100 (0) 100 (0) 100 (0) (SD)(SD)AgeAge
SubgroSubgroup IIIup III 95.695.6 -- 99.499.499.299.2 --
100 # 100 # 100100 –– 100100100100 –– 100100100100 –– 10010095% C. 95% C. R.R.
X
X
X
X
Results
Mean ( ), standard deviation (SD) and 95% confidence range of Mean ( ), standard deviation (SD) and 95% confidence range of auditory directives material in the control group.auditory directives material in the control group.
AuditoryAuditorydirectivesdirectivesstage III stage III
AuditoryAuditorydirectivesdirectives
stage II stage II
AuditoryAuditorydirectivesdirectives
stage Istage I
90.8 (9.4) 90.8 (9.4) 95.5 (7.9) 95.5 (7.9) 100 (0) 100 (0) (SD)(SD)AgeAge
Subgroup ISubgroup I 86.486.4 -- 95.295.291.891.8 -- 99.299.2100100 –– 10010095% confidence 95% confidence rangerange
98.4 (3.9) 98.4 (3.9) 100 (0) 100 (0) 100 (0) 100 (0) (SD)(SD)AgeAge
Subgroup IISubgroup II 96.596.5 -- 100 # 100 # 100100 –– 100100100100 –– 10010095% confidence 95% confidence rangerange
99.6 (1.2) 99.6 (1.2) 100 (0) 100 (0) 100 (0) 100 (0) (SD)(SD)AgeAge
Subgroup IIISubgroup III 99.199.1 -- 100 # 100 # 100100 –– 100100100100 –– 10010095% confidence 95% confidence RangeRange
X
X
X
X
Results
All of the developed material scores revealedAll of the developed material scores revealed
Deceasing value withDeceasing value with
increasing the levelincreasing the level
Increasing performanceIncreasing performance
with increasing the agewith increasing the age
Auditory closure I Auditory closure I 0.060.06
Auditory closure II Auditory closure II 0.000*** (b a a)0.000*** (b a a)
Auditory closure IIIAuditory closure III0.000*** (c b a)0.000*** (c b a)
Auditory vigilance Auditory vigilance II
0.001** (b a a)0.001** (b a a)Auditory vigilance Auditory vigilance
IIII0.000***0.000*** ((b a a)b a a)
Auditory vigilance Auditory vigilance IIIIII
0.000*** (b a a)0.000*** (b a a)
R M 2R M 2--words stage words stage 0.05* (b a a) 0.05* (b a a)
R M 3R M 3--words stage words stage 0.008** (b ab a) 0.008** (b ab a)
C M 3C M 3--words stage words stage 0.40.4
C M 4C M 4--words stage words stage 0.004** (b a a) 0.004** (b a a)
C M 5C M 5--words stage words stage 0.000*** (b a a) 0.000*** (b a a)
S M 3S M 3--words stage words stage 0.10.1
S M 4S M 4--words stage words stage 0.002** (b a a)0.002** (b a a)
S M 5S M 5--words stage words stage 0.000*** (b a a)0.000*** (b a a)
Phoneme comparison Phoneme comparison ––II0.20.2
Phoneme comparison Phoneme comparison ––IIII0.001** (b a a) 0.001** (b a a)
Phoneme segmentation Phoneme segmentation ––II0.090.09
Phoneme segmentation Phoneme segmentation --IIII0.0002*** (b a a) 0.0002*** (b a a)
Phoneme blending Phoneme blending 0.000*** (b a a)0.000*** (b a a)
Auditory directives I Auditory directives I 0.10.1
Auditory directives II Auditory directives II 0.003** (b a a)0.003** (b a a)
Auditory directives III Auditory directives III 0.000*** (b a a) 0.000*** (b a a)
Effect of age on the remediation material Effect of age on the remediation material scores using onescores using one--way ANOVA test.way ANOVA test.
As observed from LSD values,As observed from LSD values,the significant differencethe significant difference………………
Plateau in maturation of these skills Plateau in maturation of these skills
No effect were found for gender or No effect were found for gender or psychosocial levels (within its normal psychosocial levels (within its normal range) on the performance in these range) on the performance in these
materialsmaterials
9293949596979899
100
Control Per-rem. Post-rem. Post rem. (3 m.)
L.P.F. test
0102030405060708090
Control Per-rem. Post-rem. Post rem. (3 m.)
75
80
85
90
95
100
Control Per-rem. Post-rem. Post rem. (3 m.)
SPIN test
Duration pattern test
0
20
40
60
80
100
Control Per-rem. Post-rem. Post rem. (3 m.)
CST
0
2
4
6
8
10
12
Control Per-rem. Post-rem. Post rem. (3 m.)
Memory tests
0
20
40
60
80
100
Per-rem. Post-rem. Post-rem. (3 m.)
Questionnaire
0
2
4
6
8
10
12
Per-rem. Post-rem. Post rem. (3 m.)
P300 amplitude
050
100150200250300350400
Per-rem. Post-rem. Post rem. (3 m.)
P300 latency
0
20
40
60
80
100
Control Per-rem. Post-rem. Post rem. (3 m.)
Auditory vigilance
0
20
40
60
80
100
Auditory closure
Control Per-rem. Post-rem. Post-rem. (3 m.)
0
20
40
60
80
100
Control Per-rem. Post-rem. Post rem. (3 m.)
Auditory memory
0
20
40
60
80
100
Control Per-rem. Post-rem. Post-rem. (3 m.)
Auditory directives
SPIN right ear
76.3
96.3
1 2 3
Scor
e %
SPIN left ear
74.4
94.4
1 2 3
Scor
e %
Memory for recognition test
5.51 2 3
Memory for content test
2.561 2 3
Memory for sequence test
2.131 2 3
P 300 amplitude right
5.181 2 3
P 300 amplitude left
4.651 2 3
P 300 amplitude binaural
5.831 2 3
Recognition memory
8.8
28.8
48.8
68.8
88.8
1 2 3
Scor
e %
Content memory
3.8
23.8
43.8
63.8
1 2 3
Scor
e %
Sequence memory
1.3
21.3
41.3
61.3
81.3
1 2 3
Scor
e %
Phoneme segmentation I
10
30
50
70
90
1 2 3
Scor
e %
Phoneme segmentation II
10
30
50
70
90
1 2 3
Scor
e %
Questionnaire
56.1
76.1
1 2 3
Scor
e %
LPF right ear
94.51 2 3
Scor
e %
LPF left ear
93.51 2 3
Scor
e %
DPT right ear
13.3
33.3
53.3
73.3
1 2 3
Scor
e %
DPT left ear
15
35
55
75
1 2 3
Scor
e %
CST right ear
55.4
75.4
95.4
1 2 3
Scor
e %
CST left ear
54.6
74.6
94.6
1 2 3
Scor
e %
Auditory vigilance stage I
43.1
63.1
83.1
1 2 3
Scor
e %
Auditory Closure
55
65
75
85
95
1 2 3
Scor
e %
Auditory vigilance stage II
24.5
44.5
64.5
84.5
1 2 3
Scor
e %
Auditory vigilance stage III
21.6
41.6
61.6
81.6
1 2 3
Scor
e %
Phoneme comparison I
37.5
57.5
77.5
97.5
1 2 3
Scor
e %
Phoneme comparison II
30
50
70
90
1 2 3
Scor
e %
Phoneme blending
25
45
65
85
1 2 3
Scor
e %
Auditory directives
0
20
40
60
80
100
1 2 3
Scor
e %
P 300 latency right
340
360
380
400
1 2 3
P 300 latency left
358
378
398
418
1 2 3
P 300 latency binaural
340
360
380
400
1 2 3
1) An informal remediation program in Arabic language for auditory processing disorders was developed.
2) The remediation program was standardized on a sample of normal school children.
3) The developed program proved to be efficient in the remediation of children with central auditory processing disorders and reflected the presence of auditory plasticity in 6-12 years aged children.
4) There was a significant effect of age on the degree of improvement of children
5) The number of sessions needed to achieve age-appropriate normal levels was variable among age groups. Younger children achieved normal levels in memory materials more rapidly, while older children achieve normal levels in phonemic awareness material more rapidly.
6) Psychophysical tests and P300 amplitude could be considered objective indicators of improvement in central auditory abilities.
7) The developed marker items were useful in the process of evaluation before and after
1)1) To use the developed remediation To use the developed remediation program in rehabilitation of children program in rehabilitation of children with CAPD.with CAPD.
2)2) To study outcome stability over a longer To study outcome stability over a longer period of time.period of time.
3)3) To compare between the outcome of To compare between the outcome of informal remediation programs and the informal remediation programs and the outcome of formal programs.outcome of formal programs.
4)4) To study the applicability of marker To study the applicability of marker items as an informal screening tool for items as an informal screening tool for CAPD in school children.CAPD in school children.