May 29, 2014 - directed more of their talk to what the girls were actually engage in doing. Increased ..... The use of images to elicit written productions is a common task for children taught in sign language, ..... It is worth mentioning, just as a parameter, in ..... Students had to choose their snack and drink daily from symbols.
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SPELLING ERRORS IN THE GREEK LANGUAGE. CAN BE DESCRIBED IN TERMS OF PHONOLOGICAL PROCESSES? Article · August 2010
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WELCOME ADDRESS It is a great honour and privilege to hold the 28th International Congress of the International Association of Logopedists and Phoniatrics (IALP), in Athens Greece. IALP is the oldest organization representing persons involved with scientific, educational and professional issues related to communication, language, voice, speech, hearing and swallowing disorders and sciences in children and adults. IALP was founded in Vienna, Austria, by Dr Emil Froeschels, in 1924. Our members are in more than 55 countries around the world. IALP holds its scientific congresses every three years. It is the first time that the IALP Congress is coming to Athens, in a vibrant city with great history, and many places of interest. The Organizing Committee and the Panhellenic Association of Logopedics have chosen as the philosophy for the Congress to be: “where the sciences of communication meet the art and culture”. This reflects our philosophy that the Congress has three dimensions: sciences, art and culture. The dimension of sciences departs from our objective that the congress is a strong meeting point for worldwide clinicians, professionals and scientists in communication, voice, speech, language, audiology and swallowing sciences and disorders. The dimensions of art and culture will be met through the cultural and social activities that are planned including a visit to the Acropolis. The aim is to host a meeting with a very high scientific quality while the participants will enjoy the traditional Greek hospitality in the capital of Democracy.
Mara Behlau, PhD IALP President President of 28th IALP Congress
Ilias Papathanasiou, PhD IALP Vice President Chair of Organizing Committee of 28th IALP Congress
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MESSAGE OF THE PRESIDENT OF THE PANHELLENIC ASSOCIATION OF LOGOPEDISTS Dear colleagues,
On behalf of the Governing Board and all the members of the Panhellenic Association of Logopedists (PΑL) I welcome you to the 28th International Conference of IALP. It is our honor and great joy to host you in Greece. Despite the difficult situation at the global level, it is our pleasure to have such distinguished scholars in the field of speech and language pathology come to participate in this conference. Your presentations at the various sessions will offer great value to this event. The mission and role of PΑL from its formative stages to its present form is the exchange of scientific information and the sharing of research results through the on-going interaction of its practitioners. In our country, the ultimate goal is to reach the highest level of professionalism in the field which we are still striving to achieve. We believe that the unique opportunity this conference presents will not only benefit the specialists but ultimately the members of the public to be served by our profession. We thank all those who are here to support and enrich this gathering, including members of the audience. We are also grateful to the Governing Board of IALP, as well as, to members of the scientific committee and the organizing committee of the Conference. To each of you we acknowledge the tireless efforts that went into planning this special event. Our best wishes to the success of the 28th IALP International Conference.
Konstandinos Rogas, President, Panhellenic Association of Logopedists
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PREFACE It has been our honour to edit this volume which contains the scientific advances in the field of communication and swallowing sciences and its disorders which will be presented at the 28th World Congress of the International Association of Logopedics and Phoniatrics, in Athens Greece, 22-26 August 2010. The Congress promises to provide outstanding main papers from world renowned scholars and researchers in Neuroplasticity, Autism and The complexity of social/cultural dimension in communication disorders. This volume contains contribution from more than 50 countries, additional to major programmes provided by the international committees of the IALP on voice disorders, motor speech disorders, dysphagia, hearing and hearing disorders, fluency, child language, and many others. We hope that we have achieved our objective to present you the most comprehensive and global view of research and issues challenging the professions, research and science in our field today. Athens, August 2010
Ilias Papathanasiou Athena Fragouli Angeliki Kotsopoulos Nikos Litinas
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CONTENTS Alternative and Augmentative Communication Title of paper ..………………………………………………………….Page Aphasia Title of paper ..………………………………………………………….Page Audiology Title of paper ..………………………………………………………….Page Child Language Title of paper ..………………………………………………………….Page Education for speech and Language Pathology Title of paper ..………………………………………………………….Page Dysphagia Title of paper ..………………………………………………………….Page Education for Speech and Language Pathology Title of paper ..………………………………………………………….Page Fluency Title of paper ..………………………………………………………….Page Motor Speech Disorders Title of paper ..………………………………………………………….Page Multilingual Affairs Title of paper ..………………………………………………………….Page Phoniatrics Title of paper ..………………………………………………………….Page Voice Title of paper ..………………………………………………………….Page
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ALTERNATIVE AND AUGMENTATIVE COMMUNICATION FP04.3 THE EFFECTS OF COMMUNICATION INTERVENTION DURING MEALTIME IN RETT SYNDROME Bartolotta T.E., Remshifski P.A. Seton Hall University
Introduction Rett syndrome (RTT) is a neurodevelopmental disorder that affects 1 in 10,000 females. The occurrence of the disorder is extremely rare in males. It is characterized by loss of hand skill and communication and significant psychomotor retardation (Fyfe et. al., 2007). Girls with RTT are described in the literature as having significant cognitive impairment, no speech, poor motor skills, and at a preintentional level of communication (Sandberg, Ehlers, Hagberg, & Gillberg, 2000). As a result they are often not considered candidates for speech therapy or augmentative and alternative communication (AAC) systems. In recent years there has been improved diagnosis of girls with the disorder. The discovery in 1999 of mutations in the gene MECP2 on the X chromosome (Xq28) provided insight into the cause of RS. Over 95% of RTT cases are found to have a MECP2 mutation. MECP2 is a messenger gene that influences other genes critical in brain development (Amir & Zoghbi, 2000; Percy, 2008). The number of girls diagnosed with RTT is rising because of advances in genetic testing and increased awareness of the disorder. Previously, many girls now known to have RTT received an incorrect diagnosis of autism or cerebral palsy. In recent years, there have been a number of studies published that have examined communication in small groups of girls with RTT. As a result, there is a growing body of evidence suggesting girls with RTT display a range of abilities in cognition, motor skills, and communication (Johnston, Mullaney & Blue, 2003). The previous finding that all girls with RTT lacked the capacity for intentional communication is now in question (Bartolotta, 2005). In a recent study examining behaviors in girls with RTT, four girls were found to use alternating eye gaze intentionally (Hetzroni & Rubin, 2006). In a training study to enhance communication, Skotko, Koppenhaver, & Erickson (2004) noted that girls with RTT could learn to communicate in meaningful ways during the context of storybook reading with their mothers. Training was provided to mothers of 4 girls with RTT between the ages of 3 – 7 years. All girls were severely communicatively impaired. The mothers were trained to attribute meaning to the girls’ behaviors by asking questions and increasing waiting time to allow the girls to respond. These adaptations resulted in increased numbers of communicative attempts by the girls with RTT (Skotko et. al., 2004). These studies suggest that some girls with RTT can communicate intentionally though there is a strong need for additional clinical research that describes the communicative potential of this population. The studies also indicate that familiar communication partners play a role in interpreting behaviors of girls with RTT to assess intentionality. The role of the communication partner is key to the evolution of intentionality in persons with severe disabilities (Rowland, 2003) and therefore must be further explored to understand the dynamic components of the relationship. Poor communicators have limited opportunities for communication in educational settings (Ryan et. al., 2004) and it has been suggested that a strategy to increase communicative effectiveness of children with severe disabilities in schools is to modify the behavior of the teacher (Sigafoos, et. al., 1994). The aim of this study was to investigate the effect of communication training of adults working with girls with RTT on the numbers of communicative initiations (bids) and responses during a classroom routine at school. Mealtime was chosen as the context to the studied, as feeding occurred daily as part of the typical routine, and feeding sessions usually last 20 minutes or longer, which provided multiple opportunities for interaction. Children who require feeding assistance are typically fed by a trained feeder who is familiar with behavior patterns of the child. Four dyads of girls and their typical feeders were studied for this project. It was hypothesized that training the feeders (communication partners) of the girls with RTT to recognize the girls’ behaviors as communicative and intentional would result in an increased number of bids for
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communication from the girls. In addition, it was hypothesized that girls with RTT would produce an increased number of communicative responses as a result of changed feeder behavior.
Method The participants were 4 girls with RTT (ages 5-15 years) and their communication partners, who were adults who fed the girls during lunchtime at school. There were 4 phases to the study. In the first phase, the girls and their feeders were videotaped during a typical meal at school. The investigators reviewed the videotapes and coded each tape using a coding matrix, identifying behaviors produced by the girls during the meal that were potentially communicative, and those behaviors which were acknowledged by the feeder as communicative. The following behaviors were analyzed: student bids for communication, feeder bids for communication, student responses, feeder responses, and feeder comments that did not require a response. Operational definitions for the behaviors in the coding matrix were adapted from Ryan et. al., (2004) and appear at the end of this narrative. These behaviors included vocalizations, head and body movements, gestures, facial expressions, or use of available AAC strategies (i.e. picture/symbol boards, switches, etc.). An individualized training protocol was then developed for each dyad designed to increase communication. In the second phase of the study, the investigators returned to the school and met with each feeder and provided training to enhance the communication interaction in each dyad utilizing the protocol. Training consisted of strategies that improve the communicative interactions of girls with RTT (Skotko et. al., 2004). These strategies included: attributing meaning to the girls’ behaviors even if meaning was unclear/uncertain; providing sufficient wait time and support after asking a question; consistently asking questions and providing comments during the meal; and using available AAC techniques. Each protocol contained a maximum of four strategies that could easily be implemented on a daily basis by the feeder in the classroom. Investigators provided multiple examples of how feeders could implement the strategies during the meal. The typed protocol was posted in a visible location in the classroom so that it could be readily viewed during mealtime. Feeders were instructed to implement the strategies listed in the protocol on a daily basis at mealtime. In the third phase, the investigators returned to the school 2 weeks post-training to videotape a mealtime to learn if the communication enhancement strategies were being utilized and if there was a measurable increase in communication bids. In the fourth phase, the investigators returned 1 month later (6 weeks post-training) for follow-up taping to identify if earlier gains were maintained.
Results All videotapes were transcribed by a graduate assistant who had been trained in transcription by the investigators. The middle 10 minutes of each mealtime was chosen for data analysis. The interactions were coded by each investigator according to operational definitions using the coding matrix. To ensure consistency and reliability, coding of behaviors by the two investigators was done simultaneously. Independent judgment was maintained by the investigators sitting separately and recording their observations individually. Reliability checks were conducted by calculating percentage agreement. The overall percentage of agreement was 85%. Disputed behaviors were then viewed again by the two investigators together and consensus was reaching on coding of behaviors. Data analysis revealed that the number of student bids for communication increased over time for all girls with RTT. A total of 7 bids for communication were identified at Phase 1 for all girls, and a total of 88 bids were identified at Phase 4. All feeders produced increased responses to the girls with RTT. Total feeder bids increased from 23 at Phase 1 to 122 at Phase 4. Feeder comments that did not require a response from the girls decreased for 2 dyads (118 to 55) and increased for 2 dyads (66 to 83). Student responses to communication increased for 3 of the 4 girls with RTT (from 13 to 36 overall). Feeder bids for communication increased for 2 of the 4 dyads. Qualitatively, feeders were noted to use fewer conversational fillers and directed more of their talk to what the girls were actually engage in doing. Increased waiting time for all dyads was noted. Interestingly, recent reports recommend that educators utilize patience in waiting when interacting with girls with RTT, as studies have documented delayed and poorly organized processing in the population (Percy, 2008).
Discussion 6
The results of this study indicate that communication partners can be trained to recognize bids for communication by girls with Rett syndrome. The girls with RTT in this study did initiate communication and their feeders were able to recognize and respond to those communication bids as a result of training. Behaviors that were previously viewed as random were attributed as intentional and communicative. These results confirm previous findings that modification of partner behavior can result in enhanced communicative effectiveness in girls with RTT. Replication of this study is needed with a larger sample of girls and with varied partners in other settings. A study with parents of girls with RTT is planned. An area for further exploration is examining ways to develop an objective measure to document communicative behaviors to improve the evidence for communicative intent in girls with RTT.
Operational Definitions: 1) Student bid (SB) – any communication from the student that requires a verbal or nonverbal response from the feeder. Examples include student vocalizations, body movements, gaze behaviors (e.g. looking at a cup and then establishing eye contact with the feeder), signs, use of AAC devices, gestures. 2) Feeder bid (FB) – any communication (verbal or nonverbal) from the feeder that requires a response from the student. 3) Student response (SR) – any communication from the student that is produced in response to the feeder’s bid. This may include: vocalizations, body movements, gaze behaviors, signs, use of AAC devices, gestures. 4) Feeder response (FR) – any communication from the feeder that is produced in response to the student’s bid. 5) Feeder’s comments that do not require a response (NRR) – examples include rhetorical questions, statements, instructions, or encouragers. (Adapted from Ryan et.al., 2004)
References Amir, R. E., & Zoghbi, H. Y. (2000). Rett Syndrome: methyl-CpG-Binding Protein 2 Mutations and PhenotypeGenotype Correlations. American Journal of Medical Genetics, 97, 147-152. Bartolotta, T. E. (2005). Communication skills in girls with Rett syndrome: Perceptions of parents and professionals. Unpublished doctoral dissertation, Seton Hall University, South Orange, NJ. Fyfe, S., Downs, J., McIlroy, O., Burford, B., Lister, J., Reilly, S., Laurvick, C.L., Philippe, C. Msall, M. , Kaufman, W.E., Ellaway, C., & Leonard, H. (2002). Development of a video-based evaluation tool in Rett syndrome. Journal of Autism and Developmental Disorders, 37.1636-1646. Hetzroni, O. & Rubin, C. (2006). Identifying patterns of communicative behaviors in girls with Rett syndrome. Augmentative and Alternative Communication, 22 (1), 48-61. Johnston, M.V., Mullaney, B., & Blue, M.E. (2003). Neurobiology of Rett syndrome. Journal of Child Neurology, 18(10), 688-692. Percy, A. (2007). Rett syndrome: Recent research progress. J Child Neurology Online December 3. Sage Publications Koppenhaver, D. A., Erickson, K. A., & Skotko, B. G. (2001). Supporting Communication of Girls with Rett Syndrome and their Mothers in Storybook Reading. International Journal of Disability, Development and Education, 48(4), 395-410. Rowland, C. (2003). Cognitive skills and AAC. In Light, J.C., Beukelman, D.R., & Reichle, J. (Eds.). Communicative competence for individuals who use AAC: From research to effective practice. (pp. 241-275). Baltimore, MD: Paul H. Brookes. Ryan, D., McGregor, F., Akermanis, M., Southwell, K., Ramke, M. & Woodyatt, G. (2004). Facilitating communication in children with multiple disabilities: Three case studies of girls with Rett syndrome. Disability and Rehabilitation, 26 (21/22), 1268-1277. Sandberg, A. D., Ehlers, S., Hagberg, B., & Gillberg, C. (2000). The Rett Syndrome complex: communicative functions in relation to developmental and autistic features. Autism: The International Journal of Research and Practice, 4(3), 249-267. Sigafoos, J., Roberts, D., Kerr, M. Couzens, D., Baglioni, J.A., (1994). Opportunities for communication in classrooms serving children with developmental disabilities. Journal of Autism and Developmental Disorders, 24, 259-279.
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Skotko, B. G., Koppenhaver, D. A., & Erickson, K. A. (2004). Parent Reading Behaviors and Communication Outcomes in Girls with Rett Syndrome. Exceptional Children, 70(2), 1-22.
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FP04.5 DEVELOPMENT OF ALTERNATIVE AND AUGMENTATIVE COMMUNICATION IN KOSOVO Luljeta KABASHI, M.A., logopedist ( speech and language therapist) Aferdita Dragaj, prof.logopedist ( speech and language therapist) - coauthor Behlul Brestovci, Ph.D.,logopedist ( speech and language therapist) – coauthor AAC is usage of the methods of nonverbal communication for individuals who have disabilities in speech and language or whose language production is limited. For developing of AAC in Kosovo we have trained teachers, we have used Board Maker, and its production capabilities adapted in Albanian Language. The usage of AAC would help children with special needs, teachers who work with them as well as speech therapists ( logopedics) in Kosovo. Key words: Alternative and Augmetative Communication, Syndrom Down, Teachers, Kosovo
INTRODUCTION “Communication is the essence of the human life, and every person has the right to communicate” ASHA, 1991, and at the other hand according to John A. Piece “Communication is not only the essence of being human, but furthermore it is one of the main qualities of life…” Communication is a learned skill; many people are born with the ability to speak. Development of speech, language, listening and the ability to understand verbal and nonverbal communication is in different forms. Alternative and Augmentative Communication (AAC) implies the usage of the methods of nonverbal communication for persons who are not able to speak or have limited language production.
MAIN OBJECTIVE The objective of this study is the verification of the experiment in the field of development of the verbal and nonverbal communication in two case studies. The main objective is development of communication for inclusion of the children in social network. The application of the main methods like concrete things, photos as well as development of gestures for influence on the development of different forms of communication with the idea of preparing pupils for the learning process. Interpersonal communication of the persons with difficulties in development is often different from communication of ‘normal’ persons and furthermore there are reports that children with Down syndrome often have difficulties in interaction and communication with their mates. (Guralnik, 2002) The communication abilities of the persons with Down syndrome mainly are not characterized with weakness or difficulties. Their pragmatic abilities are good and they tent to use a kind of ‘compensation’ strategy in order to become understandable through gestures, mimicry and motion. ( Bray & Woolnough, 1988.)
METHODOLOGY OF RESEARCH THEORIES AND DEFINITIONS According to Lisina, M (1989):” Communication is a interaction between two or more persons which consist of information exchange in order to coordinate and unify the aims of these persons in order to establish relationships amongst them as well as to achieve common goal”. This theory is more to clarify the theory of communication in order to establish the connection with Alternative and Augmentative Communication (AAC).
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Besides the Lisina’s definition, I have chosen two other theories: - Systematic Functional linguistics theory, developed by Michael Halliday through his works in language development and - Socio Cultural theory developed by Lev Semenovich Vygotsky.
INSTRUMENTS VIDEO recordings of the situations of communication during the learning process as well as activities in the classroom: teacher – student and student – student according to the ideology of the method Marte Meo. Furthermore, in my focus were situations where contact and interaction amongst the recorded persons were detected. My main interest is the relationship of understanding the fact what was exchanged during the interaction and how did this happened. Unsuccessful attempts were not in our main interest, nevertheless I felt that knowledge about the successful part will overdue the unsuccessful attempts. Recordings have been conducted in 10 minutes slices and were used as tools for analyzing and reflection. The interview was half structured. The data analysis were conducted according to several references (Sollied dhe Kirkebæk 2001, f. 78 ,79): • Where is the child’s focus of concentration •
Direction of sight ( where is child looking)
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The direction of hearing
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Touching and feeling using hands, foots, face / mouth, body
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Which are the expression forms of the child
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Usage of gestures
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Which perception channels are used by child in order to meet the environment and use it?
RESULTS After analyzing video recordings, we have concluded as a result that there is a lack of capability of teachers to create an order in talking with child ( pupil) in the classroom, most often by asking to many questions and often giving the answers by themselves. At the other hand, to achieve the process in order to understand properly the communication in the classroom, it would be appropriate to develop a “Order in communication” ( Turn Talking), which represents a group of practices and exercises which are used to help to conduct a conversation in a certain order. Conversation in order is one of the most difficult exercises for children, in our case for children with Down syndrome. For children is hard to believe that during the conversation their turn will occur to talk. A child with Down syndrome knows that others have the chance to talk and they do not have. Furthermore, they often have the difficulties to believe that others who started the conversation at the beginning will have a good will to stop and give the opportunity for others to talk too. Most important is that the meaning of the statements in conversation to be oriented towards the certain thing, which attracts the attention of a child, or towards the communicated message. We might say that this form of input is the most important for the child developed enough to learn the receptive vocabulary. Children start to understand the words and to communicate on purpose at the time when they start to show and give different things to adults. Ohen, Bondy and Frost, according to their research, have concluded that the language will start to develop after a child is capable to use 30 to 100 symbols. Despite the well known benefits regarding the application of AAC, some parents as well as professionals still hesitate to start with the intervention with AAC, because of the doubt that AAC might stop the development of the language production (Beukelman, 1987; Silverman, 1995). AAC creates the linkage between children and their parents and friends, and give them courage to take place more intensively in their life at home, school and society.
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The barriers for using AAC systems consist of lack of information of a part of family and professionals regarding the potential benefits and technological capabilities, low ability for evaluation and estimation for new technological needs, limited access for quality training and finally, high cost and complexity of new technologies (Thompson, Siegel, & Kouzoukas, 2000; ). This is a study based in the intervention with the objective of development of AAC with two Cases with Down syndrome in two different periods, in the Resource Center “Përparimi” in Prishtina. To analyse the information and development of AAC we have formulated the following question: “Which is the level of knowledge of the two teachers about AAC?” According to the analysis of the recorded interview, teachers have basic knowledge from the training they attended. They have a basic idea that different photos should be used during the learning process and they are aware of the fact that specific software programs for generating them exists and can be adapted in Albanian language too. Parents do not have the knowledge about AAC, they did not hear for the notion so far. The usage of AAC should be developed in all situations and places where the child spends his/her time, especially at home where they spend most of the day. The main question is “How to develop AAC and create the conditions and opportunities for implementation in two classrooms?” In order to answer to abovementioned question we will tent to focus on the fact, which are the needs of recourse Center “Përparimi” in Prishtina to implement and develop AAC.
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Things to do are as follows: Evaluate the state of development of communication at all children of the school, difficulties in communication,
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Create symbols to structure the day, week etc
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Organize the materials according the subjects, e.g. biology etc
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Continue with trainings of teachers regarding AAC
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Work with concrete and real tools
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Prepare the passport for communication of the child
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The booklet “Gate – Book” which is wider than the passport
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The concept of time covering days which can be done according to colors: e.g. Monday – green
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Structure of the materials of school, in drawers where we put the photos to show what is inside
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Creation of everyday situations – where signs are needed
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Creation of tables and books for communication
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Changing the symbols according to the child’s progress In addition, the other question is “What the special school / recourse center needs to develop the communication?” The school / recourse center should have more than one logopedist for individual work with pupils and to support teachers in their work with children who do not have developed verbal communication, work with IT specialist, teachers should attend training programs, the usage of video recordings and analyses of those recordings in the recourse center in order to advance the communication. To develop the current state in whole territory of Kosova, in special schools, joint classrooms, special institutions, furthermore the awareness and education of parents for development of AAC, we have stated the following question: “Which experiences Kosova needs to develop AAC?” The experiences gained during my visit in several Recourse center / Special schools in Jyvaskyla and Helsinki in Finland, AAC system used to develop communication with children who have no communication ate all or have it in very low level.
CONCLUSION
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We had two case studies and interviewed two teachers as well as two parents of the children in two cases. At the beginning, both two pupils had difficulties in the field of communication and two cases were different. The case of ALBA ( false name), we have detected faster progress in learning of different forms of AAC, whereas at the other case SARA ( false name) this process was slower, that is why early intervention should be the priority in all education institutions in Kosova. In this case, for Kosova in particular, there is a result that in cases where children with special needs are educated there is a slight movement in understanding and awareness of usage of AAC. The important is the suggestion to teachers, parents and logopedists who serves children with needs for AAC, that they should create the opportunities in order to encourage children for real conversation regarding concrete things ( at the beginning) and more complicated and abstract concepts, fantasies as well as the situations from the past and the future. Usually, teachers and other professionals are the ones who decide about the environment, objects and gestures that are relevant for promotion and development of AAC, in school as well as at home. Offering an alternative way of communication for children and adults with difficulties in speech or limited speech abilities, the quality of their life will increase. At the same time, we can offer them an better opportunity for their lives and more self-respect, therefore they will have the opportunity to feel equal in the society.
LITERATURE Baukelman, D & Mirenda, P (2005): Augmentative and Alternativ Communication, Management of Severe Communication Disorders in Children and Adults, Third Edition Guralinck, MJ. (2002). Involvement with peers: Comparisons betëeen young children with and ëithout Down's syndrome. Journal of Intellectual Disability Research. Vol. 46(5), 379-393. Mayer-Johnson, R (1989), The Picture Communication Symbols, Kanada. Tetzchner , S, Martinsen,H ( 2001): Introduction to Augmentativ and Alternativ Communication , Second edition, , University of Oslo. Hellermann . J (2005) Turn-Taking and Opening Interactions Volume 8, November 2005 NCSALL Sunic, N (2008) ;Govor djece s Downovim sindromom, Logopedija, Vygotsky, L.S(1978). Mind in Society. The development of higher psychological process. Cambridge. Massachusetts: Harvard University press
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P001 INTERFERENCES OF VISUAL STIMULI IN THE WRITTEN PRODUCTION OF DEAF STUDENTS USERS OF SIGN LANGUAGE WITHOUT COMPLAINTS OF WRITING DISORDERS Rodrigues, MGG (Author)*, Ferreira, CL(Collaborator)**; Abdo, AGR (Collaborator)**; Almeida, MLG (Collaborator)***; Cárnio, MS (Supervisor)**** Department of Physiotherapy, Speech and Language Pathology and Occupational Therapy of Medical School – University of São Paulo (FMUSP), São Paulo - Brazil *Scholarship student - scientific initiation (FAPESP), researcher of this study at the Reading and Writing Laboratory of the Department of Physiotherapy, Speech and Language Pathology and Occupational Therapy. Student of the 4º year of the Speech and Language Sciences Course of FMUSP. ** Scholarship student - technical training (FAPESP), collaborator of this research at the Reading and Writing Laboratory of the Department of Physiotherapy, Speech and Language Pathology and Occupational Therapy. Speech pathologists. ***Deaf instructor at the Reading and Writing Laboratory of the Department of Physiotherapy, Speech and Language Pathology and Occupational Therapy. Student of the Letras/Libras Course of the Federal University of Santa Catarina- Pólo USP. *** Speech pathologist. PhD in Semiotics and General Linguistics by FFLCH – USP. Associated professor of the Speech and Language Sciences Course of the Department of Physiotherapy, Speech and Language Pathology and Occupational Therapy of Medical School – University of São Paulo (FMUSP).
Introduction Many studies verify that deaf children approach school age with no established language, that is, they didn’t develop nor oral neither sign language (Mayer, 2007 Guarinello et al, 2008). Given the importance of a linguistic base for the alphabetization (Burman et al. 2008; Guarinello et al. 2008), many studies have been developed in order to clarify how those children may acquire the written modality of a second language. In order to understand the development of written language, Mayer (2007) used three levels of the writing analysis proposed by Ferreiro (1990). The author describes that in the first levels, where there is a relation between drawing and writing or even in the second level where a less figurative representation begins to appear, there are no differences between the writing of deaf and hearing children. Children try to associate writing to the size and characteristics of the object that should be written and not to the heard/signed form. Only at level 3, where children start to create hypothesis about the relation between spoken/signed language and written symbols, that differences between deaf and hearing are more established. For the author, it is in this phase that both, hearing and deaf children, will try to solve conflicts that emerge during the acquisition of written language. In the case of hearing children, they could use the regularities of oral language through the phonological band; deaf children users of sign language, however, may use strategies such as writing words whose corresponding signs begin with the letter with which the word is written. Thus, deaf children users of sign language are capable of act as knowledge builders, and regarding this aspect, there is a similarity with hearing students. Beijsterveldt and Hell (2008) found in their study that, on the one hand the high proficiency in sign language may enrich the narrative of deaf children, nevertheless it may lead to an excessive number of mistakes in writing once there will be an influence of the knowledge on the structure of sign language upon the written language. In Brazil there are some typical characteristics of deaf individuals’ written production, such as: simple syntactic structure, restrict vocabulary, inadequate use of punctuation marks, limited use of link elements, flexion and verbal concordance difficulties, use of cohesion elements and gender and plural formation, which are characteristic that are always reported in studies about written production of Brazilian deaf students (Gonçalo, 2004; Meirelles & Spinillo 2004).
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However, Guarinello et al. (2007) affirmed that the elements lacking in deaf students’ written productions are mostly those that do not exist or are differently manifested in sign language. In a further study, the author adds that deaf individuals are capable of learning to use reference strategies in the Portuguese language if they interact with a interlocutor that master the idiom. (Guarinello et al. 2008). Thus, as reported by Neira (2003), although some cohesive elements may lack in their written production, the cohesion and coherence may be obtained by the situational context, or even by the recurrent use of terms of the same semantic domain. This way, several authors have decentralized the attention in grammatical aspects of deaf individuals’ written production, since it is known that deaf children have great difficulty in writing (Beijsterveldt & Hell, 2008). The communicative competences are the focus of the analysis, and they have showed that deaf individuals’ difficulties in comparison to their hearing peers are not so different. The capacity to organize the narrative content has been investigated as a mark of the development of competences in those individuals’ discourse (Arfé & Perondi, 2008). Lima and Cárnio (2007), have also assessed the written production of deaf university students and concluded that the generic competence was adequate however the encyclopedic and the linguistic ones were behind the expected for the age. The use of images to elicit written productions is a common task for children taught in sign language, besides being a method that provides a standard stimulus from which children may start their composition (Burman et. al., 2007).
Aim The main purpose of this research is to analyze the relation between different types of visual stimuli and the written production of deaf students users of sign language with no complaints of reading and writing disorders.
Methods The subjects of this research were 14 deaf students with severe to profound bilateral sensorial hearing loss, male and female, ranging in age from 8 to 13 years old, users of Brazilian Sign Language (Libras), and enrolled in the 3rd and 4th grade of a bilingual primary school for deaf students. The inclusion criteria were: severe to profound sensorial hearing loss; no complaints of reading and writing disorders; and alphabetical level of writing according to the Protocol of Reading and Writing Assessment (Alves & Cárnio, 1999). The school files of the students were analyzed for the acquisition of information about academic performance. An “Informative Questionnaire for Teachers” containing information about the level of Libras of the students and their individual performance concerning the grades was applied. An anamnesis was carried out with the parents (Crato & Cárnio, 2007), in order to investigate general data regarding the use of hearing aids, lip reading (LR) and history of speech therapy for reading and writing disorders. For the investigation of the main purpose of this study, subjects were assessed in small groups, by writing production tasks based in sequence figures and action figures. Data were treated and analyzed qualitative and quantitatively according to the communicative competences (linguistic, generic and encyclopedic), based on Maingueneau (2002). Each production received a score. Due to the difficulty in the quantitative analysis using only the written production, five judges were used (all authors of this paper) in order to search for greater concordance in the analysis, once the written production of deaf individuals has particular characteristics which make the analysis of the production itself difficult without the support of sign language.
Results and Discussion Concerning the qualitative results, it was possible to observe differentiated phrasal structure in the written productions, sometimes with grammatical elements ordination according to the sign language structure, sometimes with the use of figured elements in substitution of unknown written words.
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Furthermore, the influence of sign language was also noted in the absence of verbal flexion, in the inadequate use of cohesion elements once in sign language they are substituted by facial and/or body expression, “classificators” or by other time marker elements (Crato & Cárnio, 2009). On the one hand, as deaf individuals go to school and learn written Portuguese, they realize the necessity to use marker elements of this language, as it may be observed in the use of punctuation marks, capital letter, and accents which are frequently inappropriately used. It was observed that most of the subjects have an idea about the importance of contextualizing the writing (Lima & Cárnio, 2007; Guarinello et al. 2008), however it seems that they don’t know how to register the setting, which may explain the presence of descriptive data inside the narratives. Concerning the encyclopedic competence, results corroborate data from literature regarding the characteristics of written productions (Gonçalo, 2004; Meirelles & Spinillo 2004). Deaf students presented written productions, for both, action and sequence figures, difficult to be analyzed considering only the written Portuguese. The analysis performed by the five judges confirms that written productions of deaf students users of sign language should be analyzed also based on data of sign language production. It is observed that even establishing and discussing structured criteria among the judges, the analysis of textual competence (generic, encyclopedic and linguistic) implies in some subjective criteria that depend on the experience of each judge. In general, it was verified that most of the deaf students used non conventional phrasal structure with inadequate syntax, inversion or absence of phrasal elements such as articles, prepositions and conjunctions demonstrating that the analysis of written production itself does not express the linguistic and encyclopedic knowledge of these subjects by the influence of the sign language in their productions (Beijsterveldt & Hell, 2008; Hermans et. al, 2008). The written productions showed absence and/or inadequate use of cohesive elements and repetitive and incomplete phrases. Thus, textual cohesion was affected mainly due to the lack of linguistic competence mastery, however, the encyclopedic competence concerning the organization of ideas may be rescued if we consider the strategies used (Arfé & Perondi, 2008 and Cárnio et al, in press).
Conclusion This study aimed to analyze each competence separately, since the difficulty in the linguistic competence interferes directly in the presentation of the other competences. It was verified that deaf students are capable of producing narratives with partial organization of ideas, but further investigations are necessary for the detailed assessment of such competences, also considering the mother tongue of these subjects, the sign language. Concerning the initial hypothesis, it was verified that although sequence figures provide better concordance with the theme, action figures provided better authorship in their productions, exposing more ideas and expressing more creativity, besides producing a more narrative than descriptive text.
References Alves D, Cárnio MS. Protocolos para avaliação de Leitura e Escrita Laboratório de Investigação Fonoaudiológica em Linguagem Oral, Escrita e de Sinais de Deficientes Auditivos do Curso de Fonoaudiologia da FMUSP,1999. Arfé B, Perondi I. Deaf and hearing students’ referential strategies in writing: What referential cohesion tells us about deaf students’ literacy development. First Language, vol 28, 2008 Beijsterveldt LM, Hell JG. Evaluative expression in deaf children's written narratives. International Journal of Language & Communication Disorders, 2008 Burman D, Nunes T, Evans D. Writing profiles of deaf children taught through british sign language. Deafness and Education International 2007; 9(1):2–23. Burman D, Evans D, Nunes T, Bell D. Assessing deaf children´s writing in primary scholl: grammar and story development. Deafness and Education International, 2008; 10 (2): 93-110 Cárnio, MS; Silva, EC; Couto, MIV. Relação entre níveis de compreensão e estratégias de leitura utilizadas por surdos sinalizadores em um programa terapêutico. Soc Bras Fonoaudiol; (no prelo). Crato NA, Cárnio MS. Protocolo de anamnese para surdos 2007. Adaptado de Gonçalo SF 2004. Anamnese fonoaudiológica. Protocolo de uso restrito nesta pesquisa. Crato NA, Cárnio MS. Análise da flexão verbal de tempo na escrita de surdos sinalizadores. Revista Brasileira de educação Especial, v.15, p.233-250, 2009.
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Ferreiro E. Literacy development: Psychogenesis. In Y. Goodman (Ed.), How children construct literacy (pp. 12–25). Newark, DE: International Reading Association 1990. Guarinello AC, Cunha MC, Massi GB, Santana AP, Berberian AP. Anaphoric reference strategies used in written language productions of deaf teenagers. American annals of the deaf 2008; 152(5):450-8. Guarinello AC, Massi G, Berberian AP. Surdez e linguagem escrita: um estudo de caso. Revista Brasileira Educação Especial 2007; 13(2):205-218. Gonçalo SF. Perfil da produção escrita e da trajetória escolar de alunos surdos de ensino médio. [Dissertação] São Paulo: Faculdade de Educação da Universidade de São Paulo, 2004. Hermans D, Knoors H, Ormel E, Verhoeven L. Modeling reading vocabulary learning in deaf children in bilingual education programs. The Journal of Deaf Studies and Deaf Education, 2008; 13:155-174. Lima FT, Cárnio MS. Análise da produção escrita de surdos do ensino superior. São Paulo, 2007. Adaptado de RomanoSoares S. Práticas de narrativas escritas em estudantes do ensino fundamental. [Dissertação] São Paulo: Faculdade de Educação da Universidade de São Paulo, 2007. Maingueneau D. Análise de textos de comunicação. São Paulo, Cortez, 2002. Mayer C. What Really Matters in the Early Literacy Development of Deaf Children. Journal of Deaf Studies and Deaf Education, vol 12:4, 2007. Meirelles V, Spinillo AG. Uma Análise da coesão textual e da estrutura narrativa em textos escritos por adolescentes surdos. Estudos de Psicologia 2004; 9(1):131-144. Neira PRQ. Análise da leitura das imagens das histórias em quadrinhos a partir de produções escritas de adolescentes surdos. [Dissertação]. São Paulo: Faculdade de Educação da Universidade de São Paulo, 2003.
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FP25.2 SPEECH THERAPY IN PALLISTER-KILLIAN SYNDROME: CASE STUDY Giacchini V.1; Oneda F.F.2 School of Special Education Love and Life - APAE Marau/RS, Marau, Brazil 2 Clinical School of Special Education Love and Life - APAE Marau/RS, Marau, Brazil
1 Clinical
The Pallister-Killian Syndrome (PKS) is a rare genetic disease characterized by multiple malformations and mental retardation, caused by malfunction of isochromosome 12. Among the clinical findings include the PKS grotesque facies, abnormal pigmentation of the skin, localized alopecia, congenital heart defects and hypotonia. Children with PKS have frequent seizures, especially in the first two years of life, hypotonia and contractures develop between five and ten years of age. In most cases the patients have profound mental retardation and language development is limited. Approximately 50% of fetuses are stillborn or die in the neonatal period, some patients survive to 10 or 15 years of age. The holder of PKS earlier described in literature was in 1987, a patient with 45 years, this had profound mental retardation and could not walk because of multiple joint contractures. The diagnosis is made through the phenotype and the examination of skin fibroblasts, and the isochromosome, is generally absent in peripheral blood lymphocytes. As one of the main characteristics of this syndrome is profoundly retarded and general hypotonia of the muscles, causing several changes in the speech, this study is to present the results of an ongoing speech therapy performed in a patient with PKS. Child "P", target of this study are male, have PKS, diagnosed by the Clinical Hospital of Porto Alegre, Rio Grande do Sul (RS). The child started speech therapy at 3 years of age to join the Clinical School of Special Education Love and Life (APAE Marau/RS), is currently 11 years. Patient's family consented to the production of this study signed an informed consent, as regards the use of the case for scientific purposes, according to Resolution 196/96 of CONEP (National Committee for Ethics in Research). The pregnancy went smoothly. The delivery was normal, at term, with weight and length within the expected, did not cry immediately after birth, and color pigmented skin had reddened. Fifteen days had hypopigmented patches on the skin, and inflammation in the eyes. Baseline characteristics observed in children were syndromic faces, flattened nose, deformed ears shaped eyes, different color, eye deviation, head out of proportion with the rest of the body, laryngomalacia, hypotonia body, partial control of the trunk, could not hold objects, had inappropriate laughter to the situation, producing sounds without meaning, followed objects with her eyes Speech evaluation was observed: oral hypotonic muscle tone, posture lips parted, tongue protruded, decreased mobility of the cheeks, tongue, lips, and thermal hypersensitivity in the face, lip incompetent with marked drooling, swallowing reflex present; gag reflex anterior; effective sucking, and breathing mode oronasal, abdominal type. The language, followed her mother's voice, producing sounds without meaning, did not respond to stimuli, or the conventional gestures, denoting language scarce. From the observed features and the diagnosis presented by the child of PKS, he started speech therapy care in the institution APAE Marau/RS twice a week. Speech therapy "P" focused on the aspects relating to structures and functions of the stomatognathic system, a new plan to improve muscle tone and posture, especially of tongue and lips, and exercise that would promote the efficiency of mastication, swallowing, sucking and breathing. Along with the work of oro-facial motility was stimulated the patients' language, using music, toys with sound and visual stimuli, understanding of conventional gestures, understanding simple instructions, and improvements in the expression of the will of the patient. Audiometry was also performed on Responses of Auditory Brainstem, showing hearing thresholds within normal limits. "P" held hippotherapy, 6 years to 7 years, during this period has shown a good balance, gait, the control of saliva, and interaction with others. Was off the program due to a dislocated hip. Throughout the treatment the child the family had received counseling and psychological support. The presence of the family of the patient throughout the therapeutic process was fundamental, as advised by
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therapists and driven by a psychologist provided a favorable environment and emotional development of children. Currently P. attends APAE Marau/RS once a week for individual sessions, session of speech therapy and physical education. The results obtained with the longer-term intervention are evident in aspects of speech-language P. made progress in producing language babbling, showing interest in sound objects, improved play, exploring some toys, managing to get fit with assistance, search objects of interest, comprises conventional gestures such as "yes", "no", "goodbye" and responds to them. Regarding the functions of the stomatognathic system, is fed with the help, no change in chewing and swallowing, her breathing is predominantly oro-nasal use. The posture, tone, and mobility of the orofacial muscles, we highlight the position of the tongue in the mouth floor, with good mobility despite decreased muscle tone, improved posture of the lips, but little improvement has been achieved in the control of saliva.
Discussion The PKS was first described by Pallister, in adults, in 1977, and Killian, in 1981, in children. It is also known as aneuploidy in mosaic Pallister Syndrome Pallister-Killian-Teschler-Nicola or mosaic tetrasomy 12p. It is a rare disease caused by the presence of isochromosome 12p (short arm of chromosome 12) supernumerary, pattern (genetic abnormality present in the cells of the affected patient). The clinical manifestations of PKS are usually severe. The most frequent complications at birth, including prematurity, anoxia and severe hypotonia. Most newborns have appropriate weight and stature, as the patient described. The most frequent abnormalities in infants consist of grotesque facies, low nasal bridge, wide forehead, bitemporal alopecia, hypertelorism, abnormal ears, pigmentary dysplasia, short limbs, abnormalities in the extremities, mental retardation, seizures and hypotonia. Among the physical characteristics of the patients with PKS present facies with sparse hair, with bitemporal alopecia, prominent forehead, ptosis, strabismus, hypertelorism, epicanthus, macrostomia with corners of the mouth turned down, low set ears, short neck and macroglossia. In clinical aspects, the most common stains are pale skin, localized alopecia, profound mental retardation and seizures. Yet these physical characteristics change with age: the smoker's face takes on a more coarse, micrognathia progresses to prognathism, alopecia decreases or disappears, and hypertonia and contractures develop between five and ten years old, after the initial hypotonia. Phenotypic expression is variable, ranging from perinatal death to multiple congenital anomalies, in addition to the classic phenotype of facial dysmorphism. In the case above we can see some of these features as ptosis, hypertelorism, epicanthus, macrostomia with corners of the mouth turned down, macroglossia, despite the misshapen skull face the patient can keep the tongue in proper position, doing the sucking, chewing and swallowing efficiently. The aspect of language, studies report that patients with the SPK have a little language, accompanied by a profound mental retardation, there was this case in particular, agree in this case a small development of language, merely gestures, looks and sounds without production of meanings in a significant proportion, however, the patient's understanding seems to be better, because it seems to understand simple commands, running them only with oral order, without accompanying gestures. Conclusion The patient studied has clear speech pathology, motor and cognitive areas of expressive language and motor skills and general understanding. The treatment options suitable for each case will depend on the recognition of the features found in each patient, but it is clear that the focus of therapy will work on motion and its functions, for a better quality of life of patients. Furthermore, it is necessary to stimulate and develop some kind of language, within the limits of the patient, in order to create a communication between the patient and others.
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P058 VIOLENCE AND COMMUNICATION: WHAT THE TEACHERS PERCEIVE Machado M.A.M.P. , Rocha A.B. Universidade de Sao Paulo The World Report on “Violence and Health” by the World Health Organization (2002)1 adopts the definition of violence as "the intentional use of physical force or power, real or threatened, against the same person, another person, or against a group or community that might result in or has a high probability of resulting in death, injury, psychological damage, developmental problems or deprivation." Assume a classification by type and nature. Thus, the established types of violence self-inflicted, interpersonal or collective may have a physical, sexual, psychological, and by deprivation or negligence. The self-inflicted violence is related to conduct self-suicide and self-abuse, ignoring the sexual interpersonal refers more directly to family and community (known, unknown), and collective violence (social, political and economic) is linked to policy of the dominant groups and historically installed in Brazil. Physical violence boils down to any physical act belligerent. Sexual violence is directly related to the sexual act without the permission of the other, or with children and adolescents, as they may be submitted by the persuasiveness of the violent. Since the sexual abuse includes situations in which there is no physical contact, such as voyeurism, exhibitionism and harassment. Psychological violence can be characterized by speeches threatening or humiliating or extremely competitive, which generate strong conflicts for the understanding skills of the child or adolescent. Violence by negligence is classified by the reduction or absence of conditions that, in some way, affect or hinder development, or that lead to death. The incidence of type and nature of violence occurs in all social classes, but is best known in groups with lower purchasing power. Family violence is the most powerfull, when stresses and nurture the emergence of other types, largely because of the naturalization of the process. The school is a institution that resonate in all social events and place of occurrence of the various faces of violence, more or less exposed. In a study conducted in four cities of medium to large dimension in Brazil was concluded that 66% of students engaged in aggression at school, being more common physical acts (such as punching, kicking) and psychological aggression (such as derogatory nicknames). The results indicated also that there are four times greater presence of signs of depression among students who are victims and seven times between aggressors and aggressive victims. The perception of insecurity in schools reached 67% of respondents. It is worth mentioning, just as a parameter, in the United States this perception is only 40%. The Brazilian National Indicators report that between the schoolchildren 96.4% are enrolled in schools, within this group 81.7% of children under six years are included, 21.7% are repeating the same series, 51% will complete the Fundamental School in 10.2 years on average. However, approximately from 2,800,000 children between seven and fourteen years of age are working, 800 thousand are involved in degrading forms of work, including child prostitution. With this number of people involved the violence is a social problem and also a public health subject. It is a subject that should be treated intersectorally, but also on a local and individual because its specific role. Further investigation on violence indicates that those who have been exposed to risk has also a significantly worse mental health, feelings of unhappiness and dissatisfaction by reducing the welfare the higher the victimization to which they were submitted. In general, early exposure to violence in children and adolescents may be related to impaired physical and mental development, and diseases in later life. It is recommended by the World Health Organization, the promotion of a culture of peace in the face of violence involving actions that sensitize and mobilize society dialogue with children and adolescents focusing on the risks of violence in daily life and its prevention, and adopt proactive attitudes in the face of any situation of violence and discuss the subject in schools, communities, families, health services, among other sectors of society. The purpose of this research was to identify learning problems observed by teachers who suffer domestic violence or violence in the school and / or in their neighborhood, or provoke violence in schools and / or in their neighborhood, compared with other students.
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Approved by the Ethics Committee of the Faculty of Dentistry of Bauru, USP, process n. 159/200. They understood the application form, with 12 closed and open questions, to the teachers of the public school system regarding the impact of violence on the performance of pupils. I were invited all the teachers of municipal schools in Bauru - Brazil, operating in the public education sistem, and basic education for youth and adults, totaling 78 schools: 58 school children (EMEI or EMEII), 16 elementary schools (EMEF) , 04 education centers for young people and adults (CEJA). The responsiveness was 12% of teachers, since 128 of a total of 1000, filled out the form: 02 from EMEI and EMEII, 105 of EMEF and 21 from CEJA. Children and adolescents who are undergoing or who manifest violence had been previously identified by teachers. Only one school participating in the research is part of downtown. The others all belong to the periphery, where the social problems are concentrated of the city. The subjective and objective responses were categorized and analyzed quantitatively by Excel (Microsoft Co.). The results were distributed as follows: A. children and adolescents who suffer domestic violence: 64 teachers felt their school performance worst, 02 better and 05 did not notice the difference. The signs and symptoms observed in the worst performance by the amount of teachers: difficulty to learn (53), relationship with other children and adolescents (45), inattention (37), difficulty understanding what is required (36), relationship adults (36), to write (33, to read (29), of memory (29), to stop moving (27), to calculate (22), to stop talking (21), to talk (20 ), stuttering (13), other (12) insecurity and fear of all, difficulty in literacy, lack of organization of ideas and thought decontextualized, always laughing and calling attention of the room, the total disinterest of school activities, says nothing, apathy, defensive, not socializing, low self-esteem, shyness, do not venture to participate in activities, confused writing, sad look, hit speech, thought, speech or writing without consistency, guaranteed by force, an exchange of letters, sleeps all the time in the classroom when some activity is better always want to be noticed). The signs and symptoms observed in the better performance: it's quiet in the classroom (2) and attentive to teachers (1). B.crianças and adolescents who suffer violence in the school and / or their surroundings: 43 teachers felt their school performance worse, no one better considered, 08 did not notice the difference. The signs and symptoms observed in the worst performance by the amount of teachers: difficulty to learn (48), relationship with other children and adolescents (34), difficulty in writing (28), inattention (27), difficulty in relationships with adults (25 ) to read (24), to understand what is required (24) of memory (21), to stop talking (21), to calculate (19), to stop talking (14), to talk (13 ), stuttering (9), other (8) - does not express any interest in learning, is always complaining, with difficulty making autonomy, childish speaks, responds aggressively, cries, yells, acts as if he or she were cornered, on the defensive, does not accept compliments, the child always feels worse, thinks only of revenge. C. children and adolescents who cause violence in school and / or their surroundings: 47 teachers felt their school performance worst, 01 better and 06 did not notice the difference. The signs and symptoms observed in the worst performance by the amount of teachers: difficulty to learn (40), relationship with other children and adolescents (38), difficulty understanding what is required (36), relationship with adults (32), to write (31), to stop moving (31), to read (29) of memory (28), to calculate (25), to stop talking (25), inattention (19), difficulty in speaking ( 9), other (9) - restless, have lost patience for any misunderstanding, swearing, does not measure impact, disruptive to the classroom, gets all the students, lack of interest in learning, not intimidating, challenges the teacher, does not meet orders, do not worry about school performance, authoritarian, without limitation, delay school, bully other children, negative leaders, compulsive talking, gibberish, does not stop what started, do not understand written instructions, does not interpret properly, refuses to write. The signs and symptoms observed in the better performance: learning within the deadline (1), is obedient (1), is quiet (1), is smart. While devolution of the forms were a small sample (12%), with great possibilities to present bias (significant majority of schools is from the periphery), teachers with some experience in the recognition of violence, reported that all children and adolescents who live the day itself under the pressure of this phenomenon, have difficulties in communication or learning, including the aggressors. Violence, even with educational sense, does not pay, since only points to the way of learning - the play of aggressive attitudes and behavior to resolve conflicts. In this way, the education and learning are affected by violence, whether committed or suffered in any environment. To change this situation it is important to
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make use of entities required to help reduce violence and to provide subsidies for teachers to strengthen actions, attitudes and proactive behaviors. Considering that Education is currently working with the valuation of differences in the communities, the formation of citizenship, multiculturalism and diversity, in an attempt to add the tolerances in the recovery of the links between culture and learning, control spaces and scenarios for directing the violence creativity and imagination, widen the possibilities of achieving different levels of information, knowledge, learning and education in any school system.
REFERÊNCIAS 1. World Health of Organization. World report on violence and health. WHO, 2002. 2. Schraiber LB. Romper com a violência contra a mulher : como lidar desde a perspectiva do campo da saúde. Scientificcommons. 2008. en.scientificcommons.org/lilia_blima_schraiber. Visitado em 2010/01/29. 3. Habigzang LF, Koller SH, Azevedo GA, Machado PX. Abuso Sexual Infantil e Dinâmica Familiar:Aspectos observados em processos jurídicos. Psicologia: Teoria e Pesquisa Set-Dez 2005, Vol. 21 n. 3, pp. 341-348. 4. Pino, A. Violência, educação e sociedade: um olhar sobre o Brasil contemporâneo. Educação e Sociedade. Campinas, v. 28, n. 100, 2007. 5. Minayo MCS. Entrevista à Sociedade Brasileira de Pediatria. http://www.sbp.com.br/show_item2.cfm?id_categoria=65&id_detalhe=2047&tipo_detalhe=s. Acessado em 2010/01/29. 6. Roberts R. Violência, criança, escola, trabalho e comunidade. Seminário Internacional Violência e Criança. São Paulo, 6 a 8 de novembro de 2000. 7. Cunha JM. Violência interpessoal em escolas no Brasil: características e correlatos. [Dissertação] Programa de Pós-Graduação em Educação da Universidade Federal do Paraná. 2009. 8. Ministério da Educação. Ensino fundamental de nove anos: orientações para a inclusão da criança de seis anos de idade. Brasília: MEC; 2006. 9. World Health of Organization. World Report on Violence against Children. United Nations Secretary-General’s Study. WHO, 2003. 10. Rede Nacional de Prevenção de Violências, Promoção da Saúde e Cultura de Paz (Portaria 936/2004).
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SE02.1 GETTING STARTED WITH AAC Permelia A. McCain Sunny Days Incorporated. This project demonstrated how the use of easy to provide augmentative alternative communication helped twelve individuals meet four Augmentative/Alternative Communication (AAC) goals :the communication of needs and wants: the transfer of information: development of social closeness: development of social etiquette.
Objectives The objective of this program was to provide a simple, easy and inexpensive way to provide augmentative and alternative communication systems in a developmentally appropriate way for students in a class for multiply disabled individuals making it possible for them to participate fully, communicate their wants and needs, transfer information, develop social closeness with family and peers and develop social etiquette. Augmentative communication was used throughout the day within all programs, and at home.
Methods Population: Twenty-one students attending a class for multiply disabled children were provided with a variety of augmentative systems. Their ages ranged from 5 to 13 years of age. These children were classified multiply disabled with the following medical diagnoses: five students with Cerebral Palsy (three wheelchair bound, two ambulatory , two students with Autism, five students with Down’s Syndrome (one wheelchair bound), one student with Angelman’s Syndrome, one student with Rhett’s Syndrome, one student with acquired brain damage, and six students with Static Encephalopathy. There were eleven girls and ten boys with communication skills ranging from non-verbal to developing speech skills affected by severe articulation disorders. They entered the class having no communication system accept their vocalizations, gestures or the limited speech they had developed. The program lasted for eight years with some children entering and leaving the program as they aged out or were moved to academically advanced programs and a lesser restrictive environment. Materials : Materials were both developed by the staff and purchased to provide symbolic representations for, communication boards, PowerPoint presentations, interactive song and reading boards, graphic organizers, interactive computer programs, literacy materials, daily classroom activity sheets, schedules, visual strategies, social stories and props for plays and presentations. These symbolic representations were found on Mayer Johnson Boardmaker and Writing With Symbols, clip art from the internet, Intellikeys, readily available household objects, labels and photos, pictures cut from books and hand drawings. As the program progressed materials increased to low tech voice output communication devices that were used both at school and home and the computer. Two children advanced to high tech voice output devices. Techniques: Picture Communication Exchange techniques, simple inexpensive communication boards and voice output communication aides, and a communication partner, were provided to each student throughout their day at school. The communication partners were trained in correct use of the materials and assistance techniques, participated in board development and device programming, and as a personal assistant and partner for one individual. Communication of Wants and Needs: Choice Making was the initial process used. For every activity, snack, project and often academic tasks a choice was given. The individual was given at least two choices initially and the number of choices was increased until the individual could chose from an array of items. The choices were the actual items, miniature items, pictures, and symbols. As choice making became successful simple voice output devices were used beginning with a two choice overlay and advancing to a 24 choice overlay.
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Transfer of Information: The most personal transfer of information technique was the letter home completed by the students each day. This provided a way for the student to share his daily activities with their family. Information transfer was applied daily using a single switch repeating VOCA for taking messages, running errands, participating in general education programs and performing in class programs and plays. Throughout all educational activities programs communication boards, preprogrammed lessons on the computer and VOCAs using symbols were provided for academic programming and assessments. Social Closeness: The letters for home, adapted books, VOCA recorded books, and using the choice system to produce personal letters, gifts and messages for loved ones were used to build relationships. Programs and plays were also used to help build pride and pleasure that families could share. Social Etiquette: Social etiquette not only includes please and thank you, but learning to wait your turn, and give and take of communication skills. These skills were emphasized in all activities as part of the expected behaviors. Interaction is the key to developing proper etiquette.
Results Communication of Wants and Needs: A hierarchy was used to help children learn that they could communicate their wants and needs. 1. Choice making was the simplest and most effective system used. In every activity at least two choices were given initially increasing to choices from a group of items. Examples: choice of snack, choice of toys, choice of books, choice of colors for projects, choice of items to complete projects and ultimately choice of answers on evaluations and discrete trials. This process gave each student the ability to gain control over areas of their life that were often controlled by the caregiver or teacher, improved behavior, motivated communication, and developed pride in their work. Students who were unanimated, angry and had refusal behaviors became cooperative, enjoying activities and showing pride in what was completed. Families were aware of these changes, began to implement them at home, include all family members and noted that the projects began to show that the student now had ownership of their work because they made the choices even if they had to be assisted physically to complete the project. 2. Engineering the Environment: Voice output communication aids and symbols were placed around the room to allow the students to express their needs: a. A computer with Speaking Dynamically or Power Point was set up with one symbol on the touch screen or with switch access to express the need to go to the bathroom. This required more assistance for many of the children and the students in wheelchairs had difficulty accessing it. Other systems were set up and were more successful. b. Symbols were placed on the door that requested the door be opened so they could exit to go to classes. This skill became consistent for all ambulatory children. c. Symbols were placed on tables and trays to request food and drink. These ranged from single photos, single symbols to communication boards. This was successful for all students. d. All personalized communication devices had a bathroom symbol on every page for those students toilet training. Pages for needs, academic lessons and communication letters were individualized so that needs could be addressed as well. e. Symbolic schedules were placed in the room as an overall schedule and in each students work area so that they were able to learn where they needed to go and help control their time. 3. Low Tech Voice Output Communication Devices: Once choices began to be made consistently with symbols low tech voice output communication devices were used beginning with a two choice rocker switch, advancing to overlays from 2 to 24 choices. The use of choices was the most successful technique because it allowed each student to be more satisfied, built self esteem, take possession of their opportunities, food, drink, projects and realize that communication can control the actions of others. Transfer of Information: A strong connection between home and school are always important. Using easily completed home communication letters children were able to share their day at school with the family and a return letter was able to share home news to the teachers and classmates. The initial letter was paper and glue , advancing to simple voice output communication devices or computer programs that were also
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available at home (PowerPoint, IntelliKeys). This was the most successful of all techniques developed. Sharing knowledge is one of the biggest skills a communication system can assist a child to perform. Using communication boards and programmed voice output communication devices students could participate in the academic program within the classroom. This allowed the teacher and therapist to learn more about the child’s abilities, skills and cognitive abilities. Augmentative communication was used for presentation, evaluation, daily programming and lesson support, and program presentation. Using PowerPoint, symbols for discrete trials, voice output devices programmed for circle time activities, individualized boards relating to activities, boards developed for response to books, music and art activities, and sign language lessons were developed that allowed every individual to participate, communicate and share the knowledge the possessed. Some sample activities were using a repeating one step to count the days of the week, read books, relay information to family, deliver messages, and answer simple questions. Development of Social closeness: To interlink the strategies families were asked to share their child’s letter as if they were talking together after school or reading a book together. Sit together, sit as a family, talk about what they did and talk about what they would write back for the next day. Reports from families indicated they enjoyed their child being able to respond with their siblings about their day and that it improved their family relationships so that siblings wanted to write the letters, read the letters and offer choices for their disabled sibling to participate. Social closeness also occurred among age peers. Communication devices were taken into the general education classroom to share information, participate in class activities, and read stories to peers. As these relationships developed the children wanted to play at recess, eat together in the cafeteria, and come to the classroom to participate in their special classroom activities. This also improved the students relationships in the community through invitations to parties and play dates. Participation in classroom programs and plays helped to build pride and pleasure for families. This resulted in more social interaction with age appropriate peers and families opportunities to see their students perform with others. Social Etiquette: Through using their communication systems within all setting and learning to wait their turn to participate they learned the social skills of waiting. Communication systems were provided with please and thank you as well as the signs being taught. Children were required to used these skills, required to wait their turn when they delivered messages, greet people in the halls, greet the person they were delivering messages to as well as learning to greet by waves and smiles.
Conclusions Practical AAC solutions can be developed and used successfully to assist nonverbal individuals in all areas of their life if used consistently by all parties involved. Following a developmental model allowing for successful learning and participation before moving to a more advanced system was the most successful process providing a stable background of core strengths and critical information about language and communication needed for successful use of higher tech VOCAs. Including the family into all processes, sharing materials, including them in training sessions and communicating consistently was a definite positive outcome. This allowed both the individual and family to progress through the AAC continuum to higher technology products. The use of the low tech materials assisted individuals through their language development, increasing their communicative skills and providing them with the ability to share their cognitive knowledge. An additional outcome that was beneficial to five individuals was their progress to a higher educational level once they were able to communicate and use their systems to participate in a more advanced educational program. Three of the individuals learned to read and were moved to more academically based programs. Three students learned to read basic words, colors, days of the week and to recognize numbers. Choice making skills increased the student’s ability to participate in discrete trail assessment and training, for developing vocabulary, portfolio assessment and gaining control of certain areas of their environment. It was also concluded that using simple, progressive materials that can be produced by staff for minimal cost, using materials that are easily available and can be used comfortably by family can support a successful AAC system that provides development in all areas as well as securing a core vocabulary and skills that are necessary for a more advanced voice output device.
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SSY02.2 ENGINEERING THE ENVIRONMENT FOR SUCCESSFUL AAC P. McCain Sunny Days Incorporated, Manalapan United States Introduction and aims of the study: The aims of this study were to develop, multiple ways that AAC could be included into the natural environment to provide the most success in daily communication. As ideas progressed not only concrete ways were developed but the entire concept of what the engineering could do and what needed to be considered as each different opportunity was added to the environment. Universal design, universal design for learning and universal design for instruction were utilized in making decisions, developing materials and planning strategies. Methods: Research, production, application and use were the main procedures used to find and implement new ways to engineer the environment to become a plethora of opportunities to communicate. Low Tech: Iconic symbols from Mayer Johnson’s Boardmaker, Photographs, Mayer Johnson’s Writing with Symbols, line drawings and cut outs were used to make the environment a learning experience as well as a communication experience. This technique helped to accomplish several goals: a) building vocabulary, b) following directions, c) requesting assistance, d) following a routine, e) getting needs met, f) class participation and g) understanding and following the classroom rules. Basic symbols labelled all items within the classroom, strategic locations within building, on buses and offered to parents to use at home as well. This allowed for building vocabulary and following directions. Class schedules and individual student schedules assisted in following a routine and making transitions. Medium Tech: All medium tech devices that were available provided multiple communication opportunities. Language Masters, tape recorders, switches, single and dual medium tech voice output communication aides (VOCA) provided easy to obtain and easy to use speaking opportunities. Language master programming provided communication of needs, answering questions, developing vocabulary, literacy, and listening. Tape recorders provided a message delivery system, communication with family, attention getting, and book reading. Switches provided access attached to tape recorders, simple voice output devices that could have multiple switches attached for requesting multiple choices, and to computers. The VOCAS that were available were both personal and classroom pre-programmed to allow daily participation in activities, lessons, following directions, following recipes and building vocabulary that was later developed for their VOCAS. High Tech: Computers software included Power Point, Speaking Dynamically, Intellikeys and a touch window or switch for access. Programs design accommodated meeting needs, portfolio assessment, family communication, and participation in the general education classroom. Some computers used the software with Speaking Dynamically as a classroom communication system and were on and available at all times. The Intellikeys served as an academic learning system as well as a communication device for reading mail from home and performing in class programs. Results: Because the engineering of the environment spanned several years and multiple students with varying needs different procedures were required to make all opportunities accessible to all students. Using communication partners to guide and facilitate, students were successful in using all of the communication opportunities. Building Vocabulary: Labels throughout the class assisted the students in learning what things were, where these were and increased their receptive understanding. Following Directions: Once a receptive understanding of the classroom, where things were located, item names, and symbols were recognized students began to be able to follow simple directions for obtaining items, moving to different locations and putting things away. When delivering messages they became more responsible and independent as they navigated the building. Requesting Assistance: The ability to request assistance for their needs was the least successful of the areas addressed. Understanding their need for assistance was the area that gave students the most difficulty. Not completing a task or ignoring a task was the more typical response to need for assistance than asking
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even with consistent and repeated facilitation. The only completely successful request option was “Open the door.” This request was consistently used by all students each time the approached the door. Following a Routine: Following the routine of the general class activities became part of the student’s innate inner clock and after several weeks of repeating the schedule students knew the routine so well they would move through the program independently in many situations. Student’s personal schedules were more difficult to follow therefore a visual schedule was consistently used with required facilitation by a communication partner. Getting Needs Met: Communication boards, photographs, and behaviour reward charts were successful for getting food needs met. Students had to choose their snack and drink daily from symbols. Throughout the classroom symbols, VOCAS and computers were programmed to ask for things all students needed such as food and bathroom. Class Participation: Every lesson presented within the class was supported by iconic symbols, communication boards, specifically programmed computer activities, medium tech VOCAS and adapted materials. Calendars, weather, understanding and following the classroom rules were all emphasized with these techniques. Conclusions: In conclusion these areas were considered important in having a successfully engineered environment: Communication: A system that successfully moves an individual into the world of communicating with other. Systems need to be easy, convenient, and assessable to all so that communication flows consistently. This is the number one priority and must be developed with a wide variety of levels using multiple types to provide the opportunity to learn different methods and different types of communication: relating information, getting needs met, assessing knowledge, and social interaction. Accommodation: Location and communication partners increased accommodation and use. Some of the most successful locations for communication were near the door, large communication systems during circle time, posted in the students individual spaces, and at the table or desk as the students was working. Communication partners were one of the most effective accommodations. Using a communication partner made board development, communicator transport, care and maintenance and consistent use a smooth and efficient process. Each communication partner was trained in the operation, programming, and maintenance of their student’s communication system. They were then responsible for programming throughout the day, assisting the student in transporting their device within the school setting, and using their device to communicate in multiple settings and situations (programs and plays, socially with classmates, sharing stories, letters to family and academic lessons). Receptive and Expressive Communication Emphasize the complete understanding of the communication process. The ultimate purpose of the communication system is to allow a student to communicate in all situations. One of the most important ways is helping the student to communicate the knowledge he possess, share what he knows and what he is learning. Assessment is an integral piece of learning the receptive language the student possesses. Using different augmentative systems, integrating the computer, communication boards and individual communication systems assists the therapist and teacher in determining the abilities of the children. The most successful were evaluations developed on the computer using Microsoft PowerPoint and Discrete Trial format using both iconic symbols and photos. Expressively the student needs to be able to share their knowledge on a daily basis and with their families. Using letters home, thematic communication boards for lessons and units, computer programs designed to assess skills, story units from field trips activities class activities, and lesson unit’s students were able to share their activities and increase their ability to communicate with a variety of people. Developmentally Correct: Using a developmentally appropriate vocabulary, voice output communication aide and strategies provided sequential language development that guaranteed success. Simple Picture Exchange Communication Systems were used initially, simple step by step communication switches were initially used, moving upward to choice making rocker switches, two and four position overlays for different voice output devices and then further advancing language to produce sentences, answer questions, and take simple tests. Building an iconic vocabulary was one of the most important strategies used because it was twofold: increase in receptive vocabulary and the foundation for expressive use through voice output communication aides.
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Communicable Moments: Take opportunities for communication and learn to use a variety of AAC modes to make these successful and teachable. Every moment can be a communicable moment but we often need to be ready and build these moments into a student’s life. Because moments occur when we least expect them to communication devices, boards, signs, all need to be available at all times. Throughout the classroom different types of systems were available: a computer with a system set up for communication, boards on the desks and tables, boards and devices in pockets on the backs of chairs, portable systems that can be easily carried into all inclusion situations Visual Strategies: Use appropriate symbolic representations throughout the environment. The environment was inundated with labels and markers and guidelines to assist the students in finding their way, knowing locations, finding items within the classroom, locating their things, being able to request quickly, and understanding rules so that they can complete tasks in socially appropriate ways. Social stories were used to assist in planning and assisting students in knowing what was going to happen. It was found very useful to use photos from past experiences that could be integrated into the stories. Families also helped to develop some of the stories. Communication of Challenging Behaviors: Learn to read the language of behaviors. When communication is deficient a student cannot tell you when things are wrong, they are unable to complete a task, or tell you they are uncomfortable with the things you are asking and often these feelings develop into a behavior that is inappropriate resulting in discipline that just escalates the problems. One technique used to help eliminate these problems was choices for everything. All activities began with a choice of what the student wanted: a) which task to complete first, b) what snack they wanted, c) what project, colors they wanted. No project was ever set it was flexible so that each student could express themselves in their own way. Social Behavior: Communication provides the ability to share information and relate to others.The best way for disabled students to socialize during the school day is through inclusion programs, recess, lunch and delivering messages. This was accomplished through using voice output devices to read stories for others, participate in general education plays for families, participate in general assemblies, and deliver messages and greet staff and peers in the hall. These devices were small single switch devices that had repeating messages or simple rocker switches. All Day Every Day. Communication is a 24 hour a day activity with everyone in the environment. Often programs in the schools only set to function in the schools and do not consider communication to be a 24 hour a day activity. This was addressed by providing a communication system that went home each day with the child with communication, activities and boards that were useful for home. Families appreciated this information and were consistent and expressed enjoyment in being able to send back information about family activities that were done at home especially after weekends when the family often did special activities. By having labels throughout the class, available communication systems and a communication partner that has the skills to encourage communication and take advantage of every communicable moment within the school day.
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P126 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION IN APHASIA: LANGUAGE AND QUALITY OF LIFE OF AAC USERS AND NON-USERS M. M. Bahia1, R. Y. S. Chun2, L.F. Mourão3 1 Faculty of Medical Sciences/University of Campinas, Campinas-SP, Brazil 2 Faculty of Medical Sciences/University of Campinas, Campinas-SP, Brazil 3 Faculty of Medical Sciences/University of Campinas, Campinas-SP, Brazil
INTRODUCTION It is of interest to study aphasia, among the pathologies that affect the quality of life (QL), due to its consequences in daily life, social relationships and language and it is also important to study the processes of signification that occur in/through language. In this context, the Augmentative and Alternative Communication (AAC) plays an important role improving the aphasics' language. According to Lasker et al (2007, p.163), a more traditional understanding of aphasia “emphasizes the relationship between language loss and the underlying brain injury that caused that loss”. On the other hand, the authors point that “the AAC definition emphasizes the relationship between language loss and the social changes that result from that loss”. The authors also indicate that in the traditional linguistic approach the professionals might not be accustomed to the use of AAC for these people. Thus, it is of interest in this study an approach of the AAC on aphasia close to what Lasker et al (2007) state. So, it is adopted a theoretical framework developed in by a Brazilian neurolinguist Coudry (1986/2001), specialist in aphasia. The author highlights the importance of language (re)construction of the aphasic individuals based upon an interactional and discursive perspective. This theoretical framework is called Discursive Neurolinguistics. According to the Discursive Neurolinguistics it is necessary to evaluate and understand the aphasic individuals through meaning processes that occur in/through language and through the linguistic re(construction) of the aphasiacs subjects (Coudry, 1986/2001). Coudry (1986/2001) points out that the linguistic difficulties in aphasia occur not only due to the brain damage, but also because of the dialogic situation. If the words are not produced by the official/convencional means, they may be produced as alternative/creative meaning processes, leading to a discursive approach of language. Therefore, to study AAC under the Discursive Neurolinguistics perspective is essential. Particularly, it was studied the meaning processes practiced by the aphasiac as a solution to face their linguistics difficulties through the implementation of AAC. These processes involve different systems (gestures, objects, pictures, drawings, AAC symbols) that are related to verbal meaning processes (oral and writing production). The linguistic productions, important for social interactions and for expression, are related to Health Promotion and to the quality of life in aphasia. The concept of quality of life in health, have been modified in the last decades. The growing interest for the quality of life in health occured, mainly, after modifications regarding the comprehension of the determinants of health-disease process and the establishment of Health Promotion principles in the last World Health Conferences. Several instruments have been developed to measure the quality of life in health such as the Stroke Specific Quality of Life Scale – SSQOL, specific for cerebrovascular diseases, translated and validated for Portuguese (Brazil), by Santos (2007), and which was used in the present study.
AIMS The aim of this paper is to investigate QL of a group of aphasics AAC users and non-users and to study language issues regarding the meaning processes from a group of a non-fluent aphasics through the implementation of AAC.
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METHOD This is a longitudinal research with qualitative and quantitative approach. The corpus is composed by two groups: 6 non-fluent aphasics AAC users (NFG) and 6 fluent aphasics (FG), participants of the Aphasia Center - Institute of Language Studies/Faculty of Medical Sciences, University of Campinas – UNICAMP (Campinas, São Paulo, Brazil). This study was approved by the Ethical Committee under #417/2006. The data were collected through 3 different ways: (i) subjects records (ii) video recording of the Speech and Language Pathology intervention with AAC, during the period from August 2006 to June 2009 and (iii) Stroke Specific Quality of Life Scale – SSQOL, translated and adapted to Portuguese (Brazil). Considering the social, economical and cultural reality in Brazil, this study aimed to use low technology resources such as communication boards created with the use of Picture Communication Symbols, and the Voice-Poid. There were developed several activities of language such as reading and discussions about the subjects' interests, games, songs, reading and discussion of newspaper, construction of messages and texts, pictures of the subjects, holidays topics (Easter, Mother's Day, Christmas, etc), construction of poetries, calendar of the group activity, among others. When applying the SSQOL, the questions were read by one of the researchers, and the boards with AAC symbols were used for the answers. The subjects answered by the ways they were used to comunicate to other people or by using AAC communication board. The SSQOL is composed of 49 items divided into 12 areas and 2 parts. The first part has questions about mobility, upper limb function, work/productivity, personal care, language and vision. The second, with subscale of 12 areas, evaluate each area at the moment comparing to the moment before the brain lesion considering the aspects of energy, way of thinking, behavior, social relationships and family relationships (Santos, 2007). The quantification of the answers is set by summing the points from 1 to 5, in which the minimum score possible is 49 and the maximum 245.
RESULTS AND DISCUSSION It is presented part of the results. The findings show that the subjects use different ways to express themselves; in other words, they produce different meaning processes by using AAC. They use different examples of “translations”, as according to Jakobson, through language/use of AAC, that is, the results indicate operations: from the symbol to the word and or/gesture, from the word to the symbol, from the AAC to the word and the AAC as an important alternative of prompting to eliciate speech. The SSQOL findings show that the most affected domains in NFG were: language, social relationships and way of thinking, and in the FG: behavior, social relationships and way of thinking. The least affected domains in NFG were: vision, family relationships and energy, and in the FG: vision, way of thinking and mobility. When comparing the subjects impressions between the current moment and the period before the Cerebrovascular Accident (CVA), all subjects, for both group, referred that their quality of life are worse after the brain damage. Lasker e Bedrosian (2001) point that studies show that people with acquired disorders of communication may benefit from AAC to improve communication effectiveness and participation in daily life activities, which corroborates our findings. Hodge (2007) states that for a better effectiveness of AAC it is necessary greater attention to health, education and social politics.
CONCLUSION In the theoretical perspective adopted, the professional, as interlocutor specialized in intervention using AAC, assumes an important role in the production of meaning for/with the aphasic subject. The aphasic produces operations/processes that show different processes of language/speech production. It is worth considering that many times, the use of non-verbal resources in aphasia may be emphasized because the verbal/oral condition of language is affected. We observed a more effective use of language and a greater access to what is intended to say, from the implementation of AAC in a discursive perspective, once the use of AAC in many moments is an important alternative of prompting for the subjects to access the desired word.
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The findings show that the study with AAC enabled a greater participation in different situations of communication, contributing for a better quality of the linguistics and social interactions of the subjects studied. The results emphasize the AAC contribution to better language organization and expression, as well as the articulate work with psychological processes related to memory and attention – which, in turn, has positive effects on the subjects’ emotional status. Changes were identified in linguistic productions, particularly regarding increased oral production and access to what one means to say. The results show the impact of aphasia in the QL of both groups, yet the language was less affected in group FG, comparing to NFG. Thus, we could verify the importance of AAC in improving language and QL of the subjects, by changing the linguistic aspects and the quality of their interactions, what supports the findings from the SSQOL. The findings emphasize that AAC use based on Discursive Neurolinguistics benefits the linguistic activity of aphasic subjects that no longer have the expressive means to make their meaning clear, but may experiment, in interlocution, other meaning processes made possible by AAC. The adoption of the perspective of discursive neurolinguistic in aphasia intervention with AAC, enabled the participants of this study to be recognized as subjects of language and to overcome the linguistic, cognitive and psychic conditions caused by aphasia.
REFERENCES Coudry MIH. Diário de Narciso: discurso e afasia: análise discursiva de interlocuções com afásicos. 3ª ed. São Paulo: Martins Fontes, 1986/2001. Hodge S. Why is the potential of augmentative and alternative communication not being realized? Exploring the experiences of people who use communication aids. Disability & Society. 2007, v.22, n.5, p.457-471. Lasker JP; Bedrosian JL. Promotion acceptance of Augmentative and Alternative Communication by adults with acquired communication disorders. Augmentative and Alternative Communication. 200, p.141-152. Lasker JP; Garrett KL; Fox LE. Severe Aphasia. In: Beukelman DR; Garrett KL; Yorkston KM (org). Augmentative Communication Strategies for adults with Acute or Chronical Medical Conditions, 2007, p.163-206. Santos AS. Validação da escala de avaliação da qualidade de vida na doença cerebrovascular isquêmica para a língua portuguesa. Validation of the stroke specific quality of life scale to Portuguese language. Tese [Doutorado]. Faculdade de Medicina da Universidade de São Paulo, São Paulo, 2007.
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FP25.1 CHILDREN WITH COMPLEX COMMUNICATION NEEDS - THE PARENTS' PERSPECTIVE Pickl G. B. (SPZ Graz)* Sonderpadagogisches Zentrum Sprachheilschule Graz
In the center of this study are parents of children with severe and multiple disabilities and complex communication needs. The children’s verbal speech either is not existent or too limited to allow effective communication.
The study aims to investigate the phenomenon that speech generating devices (SGDs) are rarely used within families of children with severe disabilities and complex communication needs, although most parents are highly interested in supplying their child with an SGD. Apparently the device fails to meet the challenges parents are facing in daily communication with their child. The results of studies which investigated the meaning of information and communication technology for families with children with complex communication needs (e.g., Brodin & Lindstrand, 2004; Salminen, 2001; von Tetzchner & Martinsen, 1996) indicate the seemingly contradiction that although communication devices are considered useful tools for persons with complex communication needs, they seem to be used rather infrequently by the families of these persons. Family members rather rely on the users’ own limited possibilities, e.g., a few intelligible utterances, pointing, mimics or eye gaze. They seem to prefer possible misunderstandings and incorrect interpretations of these expressions to the many times slower mode of technically aided communication with its restricted vocabulary, especially when the output is recorded speech. Objective The aim of this study is to increase the understanding of how parents of children with severe and multiple disabilities and complex communication needs view their children’s communication and their communication aids. Research questions are: What are the challenges for parents regarding their children’s limited communication? What are the reasons for using versus not using SGDs? What are the reasons for a preference of technical versus non technical communication aids?
Method The study is based on qualitative research interviews (Kvale, 1996) with ten families with children with multiple disabilities and complex communication needs, with the parents being the interview partners. The study is influenced by both the phenomenological tradition as a life world philosophy (Husserl, 1913/1998; Merleau-Ponty, 1945/1995) as well as the hermeneutic approach, where the researcher must recognize prejudices or pre-understandings and their possible influence upon the interpretations (Giorgi, 1989). The children of the interviewees differ in age, in their developmental and communicative levels as well as in their socio-cultural backgrounds, but have in common that they all are using one or more modes of augmentative and alternative communication (AAC), involving no, low or high technology. Some of the children belong to the impressive language group – they have difficulties not only expressing, but also comprehending and processing language – and some to the expressive language group – they are able to understand language, but are unable to produce verbal speech. The purpose for choosing such a diverse group was to find out whether there are common patterns in how parents experience their children’s communication and related challenges based on the children’s severe communicative limitations and their needs for alternative communication modes, independent of the children’s other abilities.
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All interviews were based on an open questionnaire and transcribed verbatim. The transcripts were then handed back to and approved by the interviewees. The questionnaire was organized according to the foci communication between parents and child, the child’s communication aids and their use, and the social situation (issues of acceptance, inclusion, support). That already established categorization made it easier to look for meaning units and find essences or patterns and their relationships (Giorgi, 1997). First the compiled results of the interviews with the parents whose children belong to the impressive language group were presented and common patterns in the interviewees’ answers were highlighted. Quotations were included for clarification and to strengthen certain phenomena.
The same principles were applied for analyzing the interviews with the parents whose children belong to the expressive language group. Finally common patterns in the answers of parents of children of both language groups were presented, as they seem to be of special significance for increased understanding of the parents’ challenges related to their children’s communication.
Results Despite of the differing abilities and needs of the children there still are common patterns in parents’ answers, which seem to be related to the dominating phenomenon of the children not being able to communicate in a typical way, independent of how well the children are able to compensate their communicative deficits by using other means of communication.
For the children in this study there is no correlation between the severity of the child’s cognitive and/or physical disability and the frequency or regularity the communication aid is used at home. Parents express the desire to see the SGD used outside the family, and that desire is independent of the amount of time and frequency the aid is used within the family. Parents feel that the communication aid facilitates their child’s social inclusion and helps to break barriers and to keep conversations going. They report generally positive reactions from people who had not been confronted with similar devices before. Most parents stress that peers find it less difficult to cope with the child’s communicative limitations than adults, who find communicating easier when the communication aid is used.
All interviewees confirm that communication between parents and child is least problematic in situations within a familiar frame and during family routines, when the child’s expressions, signs or vocalizations are clearest in their meaning. Mealtimes seem to be among situations when communication works best. For parents wants and needs are easier to understand than worries or excitements. All report difficulties when it comes to precisely understand the child’s emotional situation, independent of the capacity of the child’s SGD. Parents are aware of family members’ different ways to deal with the child’s communication problems and as a consequence the child responding differently as well. All interviewees mentioned family members who would never use the communication aid when interacting with the child. Parents seem to care less when distant family members are less at ease in communicating with the child, but express open grief when close family members like grandparents have difficulties interacting with the child. Parents express frustration about therapists and pedagogues who lack expertise in AAC, the need of having to take initiatives themselves and problems of reimbursement. Parents report having perceived the interviews as positive experiences. They appreciate the fact that someone had been listening to them for an extended period of time, and that there was a special quality to that listening. Many also acknowledge how much they had enjoyed talking about sensitive issues without the aspect of evaluation, as it typically is the case when they are asked to talk about their child’s communicative abilities (Pickl, 2008).
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Discussion The common patterns in parental statements served as the base for answers to the research questions: Major challenges for parents regarding their children’s limited communication are the child’s inability to share events, to explain emotions and to ask questions. Parents also express frustration regarding their own inability to understand the child. The child’s inability to share his/her feelings is an emotional issue for all parents, independent of the child’s developmental and communicative level. Parents experience it as a challenge to mostly have to rely on guesses when it comes to read the child’s emotional state of mind, which also is true for the children belonging to the expressive language group, who have a good understanding of spoken language and in theory have access to a vocabulary that would express their emotions. When parents use communication aids at home these are training situations, aiming to increase the child’s skills in using the device, choice making situations, aiming to increase the child’s independence and empowerment, and playing situations. When parents are not using the communication aid this decision is based on their preference for unaided communication, e.g., partner assisted scanning, which is perceived being faster and less complicated. Other situations when communication aids are not or only rarely used are interactions with other children siblings or peers - or times when families are on holidays. Although parents do not express preferences of technical versus non technical communication aids, there are common patterns regarding the use of signing versus SGDs: With few exceptions the main responsibility of using the SGD in interaction with the child is on the mother’s part, while for the children who also use signing that mode is used with all family members and not restricted to specially dedicated situations. In some families who participated in this study at least one parent has a different native language, which to a large extent also is spoken at home. Two of these children are using individual signs in addition to their SGDs. While signing at home is used with the language that is spoken in a given situation, the SGD always is recorded in the language the children are using in school. Except for one child, who is able to indicate the need for new vocabulary on her high tech device, the children are dependent on parents, teachers or therapists to supply them with new words or phrases. Most children are highly dependent on others whether or not they are getting to use their communication aids; someone needs to create an appropriate overlay, do the recording and then make the device accessible for the child. Unlike with speaking children others decide whether or not to give the child a voice for making requests or telling a message, so clearly the issue of power is involved in the relationship, interaction and communication between the non speaking child and close caregivers.
Possible implications for intervention The two topics to which parents reacted most emotionally during the interviews are the child’s inability to share his/her emotional state and the reaction of family members to the child’s communicative challenges. Both issues might be of relevance regarding changes in intervention strategies. Despite intervention efforts to help the child express emotions, in many cases AAC-users seem to be at loss when it comes to explain their emotional state. However, emotions which are not clearly explained many times are not recognized by the environment in their full amount and thus will remain hidden from the child as well (Kristen, 1994). There seems to be a need for new ways in intervention, starting at an early age, to help the child to understand his/her own feelings and to acquire means to express those. The issue of family members having problems communicating with the child might be an indication to directly involve these persons in intervention whenever possible and thus help them understand the prerequisites to successfully communicate with an AAC-user. Increased involvement of parents of children with complex communication needs from the beginning of intervention and encouraging the parents to explain the challenges they are facing in their daily communication with the child could aid to supplying a child with a communication aid that not only is useful in dedicated situations, but also within the family’s life world.
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Literature Brodin, J. & Lindstrand, P. (2004). Are computers the solution to support development in children in need of special support? Technology and Disability, 16, 137-145. Giorgi, A. (1989). One type of analysis of descriptive data: Procedures in following a scientific phenomenological method. Methods 1, 39-61. Giorgi, A. (1997). The theory, practice and evaluation of the phenomenological method as a qualitative research procedure. Journal of Phenomenological Psychology, 28 / 2, 235-260. Husserl, E. (1913/1998). Ideen zu einer reinen phänomenologischen Philosophie, 1. Buch. Dordrecht: Kluwer Academic Publishers. Kristen, U. (1994). Praxis Unterstützte Kommunikation. Düsseldorf: Verlag Selbstbestimmtes Leben. Kvale, S. (1996). InterViews: An introduction to qualitative research interviewing. Thousand Oaks, CA: SAGE Publications Inc. Merleau-Ponty, M. (1945/1995). Phenomenology of perception. London: Routledge. Pickl, G. (2008). Children with complex communication needs. The parents’ perspective. Doctoral thesis in special education at Stockholm University, Sweden 2008. Salminen, A.-L. (2001). Daily life with computer augmented communication: Real lives experiences from the lives of severely disabled speech impaired children. Research reports 119. Helsinki: Stakes. von Tetzchner, S. & Martinsen, H. (ed., 1996). Augmentative and Alternative Communication: European Perspectives. London: Whurr.
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SSY02.1 SERVING FAMILIES OF CHILDREN WITH SEVERE AND MULTIPLE DISABILITIES AND COMPLEX COMMUNICATION NEEDS Pickl G. B. osterr. Gesellschaft fur Sprachheilpadagogik The center of this study are parents of children with severe and multiple disabilities and complex communication needs. The children’s verbal speech either is not existent or too limited to allow effective communication. The study aims to investigate the phenomenon that speech generating devices (SGDs) are rarely used within families of children with severe disabilities and complex communication needs, although most parents are highly interested in supplying their child with an SGD. Apparently the device fails to meet the challenges parents are facing in daily communication with their child. The results of studies which investigated the meaning of information and communication technology for families with children with complex communication needs (e.g., Brodin & Lindstrand, 2004; Salminen, 2001; von Tetzchner & Martinsen, 1996) indicate the seemingly contradiction that although communication devices are considered useful tools for persons with complex communication needs, they seem to be used rather infrequently by the families of these persons. Family members rather rely on the users’ own limited possibilities, e.g., a few intelligible utterances, pointing, mimics or eye gaze. They seem to prefer possible misunderstandings and incorrect interpretations of these expressions to the many times slower mode of technically aided communication with its restricted vocabulary, especially when the output is recorded speech.
Objective The aim of this study is to increase the understanding of how parents of children with severe and multiple disabilities and complex communication needs view their children’s communication and their communication aids. Research questions are: What are the challenges for parents regarding their children’s limited communication? What are the reasons for using versus not using SGDs? What are the reasons for a preference of technical versus non technical communication aids?
Method The study is based on qualitative research interviews (Kvale, 1996) with ten families with children with multiple disabilities and complex communication needs, with the parents being the interview partners. The study is influenced by both the phenomenological tradition as a life world philosophy (Husserl, 1913/1998; Merleau-Ponty, 1945/1995) as well as the hermeneutic approach, where the researcher must recognize prejudices or pre-understandings and their possible influence upon the interpretations (Giorgi, 1989). The children of the interviewees differ in age, in their developmental and communicative levels as well as in their socio-cultural backgrounds, but have in common that they all are using one or more modes of augmentative and alternative communication (AAC), involving no, low or high technology. Some of the children belong to the impressive language group – they have difficulties not only expressing, but also comprehending and processing language – and some to the expressive language group – they are able to understand language, but are unable to produce verbal speech. The purpose for choosing such a diverse group was to find out whether there are common patterns in how parents experience their children’s communication and related challenges based on the children’s severe communicative limitations and their needs for alternative communication modes, independent of the children’s other abilities. All interviews were based on an open questionnaire and transcribed verbatim. The transcripts were then handed back to and approved by the interviewees. The questionnaire was organized according to the
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foci communication between parents and child, the child’s communication aids and their use, and the social situation (issues of acceptance, inclusion, support). That already established categorization made it easier to look for meaning units and find essences or patterns and their relationships (Giorgi, 1997). First the compiled results of the interviews with the parents whose children belong to the impressive language group were presented and common patterns in the interviewees’ answers were highlighted. Quotations were included for clarification and to strengthen certain phenomena. The same principles were applied for analyzing the interviews with the parents whose children belong to the expressive language group. Finally common patterns in the answers of parents of children of both language groups were presented, as they seem to be of special significance for increased understanding of the parents’ challenges related to their children’s communication.
Results Despite of the differing abilities and needs of the children there still are common patterns in parents’ answers, which seem to be related to the dominating phenomenon of the children not being able to communicate in a typical way, independent of how well the children are able to compensate their communicative deficits by using other means of communication. For the children in this study there is no correlation between the severity of the child’s cognitive and/or physical disability and the frequency or regularity the communication aid is used at home. Parents express the desire to see the SGD used outside the family, and that desire is independent of the amount of time and frequency the aid is used within the family. Parents feel that the communication aid facilitates their child’s social inclusion and helps to break barriers and to keep conversations going. They report generally positive reactions from people who had not been confronted with similar devices before. Most parents stress that peers find it less difficult to cope with the child’s communicative limitations than adults, who find communicating easier when the communication aid is used. All interviewees confirm that communication between parents and child is least problematic in situations within a familiar frame and during family routines, when the child’s expressions, signs or vocalizations are clearest in their meaning. Mealtimes seem to be among situations when communication works best. For parents wants and needs are easier to understand than worries or excitements. All report difficulties when it comes to precisely understand the child’s emotional situation, independent of the capacity of the child’s SGD. Parents are aware of family members’ different ways to deal with the child’s communication problems and as a consequence the child responding differently as well. All interviewees mentioned family members who would never use the communication aid when interacting with the child. Parents seem to care less when distant family members are less at ease in communicating with the child, but express open grief when close family members like grandparents have difficulties interacting with the child. Parents express frustration about therapists and pedagogues who lack expertise in AAC, the need of having to take initiatives themselves and problems of reimbursement. Parents report having perceived the interviews as positive experiences. They appreciate the fact that someone had been listening to them for an extended period of time, and that there was a special quality to that listening. Many also acknowledge how much they had enjoyed talking about sensitive issues without the aspect of evaluation, as it typically is the case when they are asked to talk about their child’s communicative abilities (Pickl, 2008).
Discussion The common patterns in parental statements served as the base for answers to the research questions: Major challenges for parents regarding their children’s limited communication are the child’s inability to share events, to explain emotions and to ask questions. Parents also express frustration regarding their own inability to understand the child. The child’s inability to share his/her feelings is an emotional issue for all parents, independent of the child’s developmental and communicative level. Parents experience it as a challenge to mostly have to rely on
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guesses when it comes to read the child’s emotional state of mind, which also is true for the children belonging to the expressive language group, who have a good understanding of spoken language and in theory have access to a vocabulary that would express their emotions. When parents use communication aids at home these are training situations, aiming to increase the child’s skills in using the device, choice making situations, aiming to increase the child’s independence and empowerment, and playing situations. When parents are not using the communication aid this decision is based on their preference for unaided communication, e.g., partner assisted scanning, which is perceived being faster and less complicated. Other situations when communication aids are not or only rarely used are interactions with other children siblings or peers - or times when families are on holidays. Although parents do not express preferences of technical versus non technical communication aids, there are common patterns regarding the use of signing versus SGDs: With few exceptions the main responsibility of using the SGD in interaction with the child is on the mother’s part, while for the children who also use signing that mode is used with all family members and not restricted to specially dedicated situations. In some families who participated in this study at least one parent has a different native language, which to a large extent also is spoken at home. Two of these children are using individual signs in addition to their SGDs. While signing at home is used with the language that is spoken in a given situation, the SGD always is recorded in the language the children are using in school. Except for one child, who is able to indicate the need for new vocabulary on her high tech device, the children are dependent on parents, teachers or therapists to supply them with new words or phrases. Most children are highly dependent on others whether or not they are getting to use their communication aids; someone needs to create an appropriate overlay, do the recording and then make the device accessible for the child. Unlike with speaking children others decide whether or not to give the child a voice for making requests or telling a message, so clearly the issue of power is involved in the relationship, interaction and communication between the non speaking child and close caregivers.
Possible implications for intervention The two topics to which parents reacted most emotionally during the interviews are the child’s inability to share his/her emotional state and the reaction of family members to the child’s communicative challenges. Both issues might be of relevance regarding changes in intervention strategies. Despite intervention efforts to help the child express emotions, in many cases AAC-users seem to be at loss when it comes to explain their emotional state. However, emotions which are not clearly explained many times are not recognized by the environment in their full amount and thus will remain hidden from the child as well (Kristen, 1994). There seems to be a need for new ways in intervention, starting at an early age, to help the child to understand his/her own feelings and to acquire means to express those. The issue of family members having problems communicating with the child might be an indication to directly involve these persons in intervention whenever possible and thus help them understand the prerequisites to successfully communicate with an AAC-user. Increased involvement of parents of children with complex communication needs from the beginning of intervention and encouraging the parents to explain the challenges they are facing in their daily communication with the child could aid to supplying a child with a communication aid that not only is useful in dedicated situations, but also within the family’s life world.
Literature Brodin, J. & Lindstrand, P. (2004). Are computers the solution to support development in children in need of special support? Technology and Disability, 16, 137-145. Giorgi, A. (1989). One type of analysis of descriptive data: Procedures in following a scientific phenomenological method. Methods 1, 39-61. Giorgi, A. (1997). The theory, practice and evaluation of the phenomenological method as a qualitative research procedure. Journal of Phenomenological Psychology, 28 / 2, 235-260. Husserl, E. (1913/1998). Ideen zu einer reinen phänomenologischen Philosophie, 1. Buch. Dordrecht: Kluwer Academic Publishers. Kristen, U. (1994). Praxis Unterstützte Kommunikation. Düsseldorf: Verlag
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Selbstbestimmtes Leben. Kvale, S. (1996). InterViews: An introduction to qualitative research interviewing. Thousand Oaks, CA: SAGE Publications Inc. Merleau-Ponty, M. (1945/1995). Phenomenology of perception. London: Routledge. Pickl, G. (2008). Children with complex communication needs. The parents’ perspective. Doctoral thesis in special education at Stockholm University, Sweden 2008. Salminen, A.-L. (2001). Daily life with computer augmented communication: Real lives experiences from the lives of severely disabled speech impaired children. Research reports 119. Helsinki: Stakes. von Tetzchner, S. & Martinsen, H. (ed., 1996). Augmentative and Alternative Communication: European Perspectives. London: Whurr.
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FP04.2 COMMUNICATION AND SPEECH & LANGUAGE GROUP THERAPY IN ADULTS SUFFERING FROM SEVERE MENTAL HEALTH DISORDERS A. Tzimara, A. Antoniou, A. Frangouli, I. Lazogiorgou-Kousta, Chr. Zaharopoulou Society of Social Psychiatry and Mental Health, Fokida, Greece
INTRODUCTION Every social interaction consists of a continuous, two-way communication of exchanging messages. Socialization skills are learned gradually through a bio-psycho-socio process in the person’s life and environment. Various situations might interrupt this process of learning. Even, in some cases, when social skills have been gained, this could be disturbed if the person goes through a period of intense emotional disturbance. It has been implied that patients suffering from severe psychiatric disorders display cognitive impairment that is directly connected to the planning and implementation of compatible social behavior. Additionally, institutionalization and extended social isolation in psychiatric clinics, has resulted in permanent disability in all aspects of personal and social life and further, in speech and communication problems. The present study examines problems related to language, speech and communication found in patients who suffer from severe psychiatric disorders. The aim is to investigate whether the use of alternative communication combined to speech therapy helps to improve speech and communication skills in those patients. Presentation of the services hosted by the Society of Social Psychiatry and Mental Health in the Fokida domain. The county of Fokida with the capital of Amfissa in central Greece has an estimated population of 44.183 citizens. The Society of Social Psychiatry and Mental Health (SSP&MH) is a non – profit, non – governmental organisation which was founded in 1981, in order to provide high quality psychiatric and psychological support services to ensure the population’s mental health and well being. The SSP&MH undertakes community sensitization activities and promotes the prevention of mental health problems, the early intervention, the social inclusion and employment of people with mental health problems, advancing their human rights and equal opportunities. The Mobile Psychiatric Unit is the main service offered to the citizens. One of the main SSP&MH services are the rehabilitation units aim to provide high quality care for patients suffering from Mental Health disorders and to prevent relapses, crisis and re-hospitalization. Such Unit in the prefecture of Fokida is the Hostel called “Euriklia”. Presentation of the Hostel “Euriklia” and the patients profiles. The Hostel “Euriklia” which resides in Amfissa, was established in December 2002, and hosts patients with Severe Psychiatric Disorders (SPD) and or Severe Mental Retardation (SMR). The hostel’s function corresponds to the program: “Health – Provision, 2000-2006”, which targets at closing down the psychiatric asylums. Consequently, it aims at transferring the chronic patients back to the community, in order to live in rehabilitation units such as hostels, residential houses, protected apartments etc. The hostel “Euriklia” houses fifteen patients, mainly males and with an average age of 51 yrs. They come from sections of chronic patients in the Psychiatric Hospital of Athens, and the average duration of their hospitalization exceeds the 15 years. The basic diagnosis for the majority is Primary Mental RetardationEncephalopathy, while the minority is diagnosed with Chronic Psychotic Syndrome in concurrence with Severe Cognitive Impairment. The main target of the hostel’s therapeutic plan consists of the provision of a house in the community offering basic care such as board and lodging, clothing, clinical care, assurance of physical health, personal hygiene, assurance of pharmaceutical care, psychological support and work rehabilitation. The disruption in
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communication found between the patient and their environment and in between the patients, led to the forming of a Speech-Communication group.
METHODOLOGY The design, structure, and appliance of systems and means of alternative ways of communication represent one of the most modern ways of treating and providing help to adults with severe psychiatric disorders and/or speech and communication impairment. The present study aims to present: • The theory and the prospective effectiveness of the principles of A.A.C in adults with S.P.D. • How does the role of the speech-language therapist and speech-language therapy along with the methods of A.A.C contribute to the enhancement of Communication-Speech skills in adults with S.P.D? • The needs for communication that were expressed by the patients. • In what way the patients responded to their needs for communicating and to their commitments? • What ways of communication (for example use of speech, texts, graphic symbols, sign language) were used in each case in order to apply to the patients’ needs and communicative skills? • What criteria were used in order to decide on the use of one or more alternative ways of communication? Augmentative and alternative communication : Theoretical background The term Alternative communication refers to the cases where an individual cannot communicate with other people by using speech and has replaced speech with the use of a symbolic system. The term Augmentative communication refers to the cases where the symbolic system is used in order to enhance speech or it is used as an alternative form of communication in cases that oral speech has failed. At present, the terms Alternative, Augmentative Communication (A.A.C) incorporates a wide range of applied methods of communication and it is distinguished in: a. Unaided Communication (U.C) and b. Aided Communication (A.C). The U.C refers to communication by using the body, gestures or structured Sign Languages that include sign-gestures, facial expressions, or even body language. The term A.C refers to communication by using specific means or communicative tools. The most popular means of “low” technology are papers, cartons, paper boards, files, or books that are displaying pictures, letters or words that represent meanings that the person uses. Alternately, there are specific means of “high” technology like computers that deliver or print messages that the person chooses or creates. Evaluation of the patients’ speech, language and communication skills At first, there was a clinical observation of the hostel’s patient’s everyday activities and secondly the Derbyshire Language Scheme test was given in order to evaluate the patient’s speech and communication skills. According to the results a speech-communication group was formed. The results of the evaluation were: • Lack of eye contact and frequent intervals of distractions. • Impulsive usage of gestures or usage of primitive communication manners (head movements/ body movements) complementary to speech. • Use of slow-whisper voice. • Limited number of communicative interactions. The patients used their language as a way to meet their personal needs (need for food, or need for objects) and not for intergroup communication. • Speech was characterised by stereotypes. • Disorders in language expression included “telegraphic speech/telegraphia”, meaning the use of very short sentences 1-2 words maximum, the sentences included mainly nouns, but did not include verbs, adverbs, pronouns, and articles).
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•
The vocabulary was redacted (less diversity) and it was restricted to words with extensive meaning. The subject categories contained more cases of nouns than verbs.
Participants and Procedures The speech-communication group is a specific/adhoc, guided, and structured but not rigid form of group. It took place the period during May 2003 and June 2005, once a week. In the group participated seven out of the fifteen patients. The choice of selection was the patients’ weakness, for any cause, to communicate with their environment and between them by using speech. The basic tool that was used was the programme Music-Speech-Movement (model J.Reynell, 1978) (see table below). This is based on the principles of A.A.C.
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Music – Speech, Language - Movement (based on the model of J. Reynell, 1978)
4. Imitation of movement, including kinesthetic perception – speech - language 3. Visual perception of another’s movement and the pattern it makes (later auditory perception of the other speech)
6. Coordination of body parts moving in space
5. Concept formation of body image and personal space
2. Auditory perception of music – environment - speech
1.Attention - visual - auditory - visual/auditory
8.Improvisation, including symbolic imagination
7. Symbolic understanding suggested by music
9. Execution of improvisation
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The role of the speech therapist to enhance communication skills is the link to adjustment of Music-SpeechMovement program into patient’s everyday activity. Specifically, the speech therapist transmits the experience of music, movement and speech by using the basic principle of A.A.C. The Alternative and Augmentative means used were: sign language, gestures, graphic-symbolic A.A.C systems, communicative boards, pictures, photos, television, paper boards etc. These were used as verbal and non verbal stimuli for an active participation in similar everyday activities. The aim was to relieve old memories, ego-reconstruction, and communication. Moreover, the target was to evaluate the ability to learn with the use of convenient therapeutic and educative programs like: • Story-telling group • Handicraft group • Everyday-activity group • Music-speech-movement group
• •
The abilities under training were: Non-verbal: eye-contact, facial expression, gestures, body posture. Verbal: tone/pitch, voice intonation and intensity, opening – retention – continuation – closure of discussion, active listening, demanding behavior, emotional expression.
The group activities were changing according to the hostels function and were used to induce the patients’ interest according to their needs. The procedure was supported by the staff. At the end of the program the patients’ communication and speech skills were re-evaluated for a review of their progress and for readjustment of the goals of the speech – communication program.
RESULTS During the three years of the program, many patients used and were encouraged, enriched and empowered to create various ways of communication in the everyday life. The methods used were a combination of speech and other methods in order to facilitate patients’ communication with other people and between them. Through the use of the A.A.G group, emphasis was given to the individual needs, skills and tendencies of each patient. Specifically, eye-contact was induced and concentration was strengthened with little distraction periods. The patients’ voice tone and intensity gained fluctuation and became sentimental according to the occasion, and finally their faces were no longer expressionless. The patients’ vocabulary of expressions was enhanced gradually in a slow pace and as a result they could imitate firstly one word that was produced by a third person and only afterwards they could name and use spontaneously a larger number of words. As time progressed, they developed a more active speech while they were using phrases with compound syntactic structure. The patients took initiative to open, and continue a conversation with the therapist of the group or with the rest of the patients. They were capable of exchanging views, and information, fruitfully. Changes occurred in patients’ emotional status as well. They enhanced their creativity skills, and they could express their feelings, wishes, and thoughts openly and more conveniently. Their participation in everyday life in the community was active and rewarding to the patients, the therapists as well as the citizens.
DISCUSSION Population that was so far excluded from wide interpersonal communication, achieved equal rights, while they gained access to new means of communication that were easily approachable and adjustable to their needs. The selection of appropriate means and strategies for improving communication, contributed to enhanced social skills, strengthened self-esteem, and the quality of life.
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Particularly, the use of A.A.C systems combined with Speech and Language Therapy proves to be one of the main interventions when treating adults with severe psychiatric difficulties for rehabilitation and socialization. Following a holistic approach to therapy and rehabilitation the procedures of the A.A.G are supportive and complementary to individual therapy. Very often, the practice and training of people who use A.A.C takes place in restricted and controlled environment. Consequently, it has been found, that the patients react in non acceptable social manners when they are out in real life environments. Therefore, when people follow training should be gradually introduced to real life environments among non patients, and non users of A.A.C. For that matter, the programs of A.A.G target not only in reducing the impairment but in generalizing the gains in everyday life in the community. The model movement-speech, language-music proved to be a stimulating framework for the deprived people to gain again the joy of life.
REFERENCES 1) Baert A. (1980): “Why Do We Need Alternatives? European Mental Health Organization, WHO, Alternatives to Mental Hospitals, Belgium, Nationale Vereniging Voor Geestelijke Gezondheidszorg v.z.w. pp.11-13 2) Beukelman D. R. and Mirenda P (June, 1994).: “Augmentative and Alternative Communication”. Paul H. Brookes Publishing Co. 3) Liakos A.(1995): “ Introduction in Psychiatric Reformation and Psychosocial Rehabilitation”. In: Lemperie T., Feline A., and Associates: “Handbook of Adult Psychiatry”. Papazisi Publishing, 2nd Edition, Athens, pp389-402. 4) WHO (1992): “The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Description and Diagnostic Guidelines”. Beta Publishing, Athens. 5) Sakellaropoulos P., (1981, 1982): “Psychopathology and Ιsolation. Thoughts emerging from the Greek-French Symposium in Social Psychiatry”. Grammata and Arts, 9th Edition. 6) Sakellaropoulos P. (1995): “Introduction in Applications of Modern Psychiatry”. In: Lamperie et al (1995): “Handbook of Adult Psychiatry”. Papazisi Publishing, 2nd Edition, Athens, pp.27-30. 7) Fragouli – Sakellaropoulou A., (2008): “Mobile Psychiatric Unit of the Fokida Prefecture. Prevention, Early Intervention and Treatment in Community”. Papazisi Publishing, Athens. 8) Fragouli A., Tsouflidou P., Mpaka K., Xenou N., (2000): “Using the function of a Hostel with Chronic Psychotic Patients as a Tool for PrimaryCare”. Research presented in Pan-Hellenic Psychiatry Conference, Pafos-Cyprus. 9) Fragouli A., (1984): General Issues in the Organization of Prevention, Applications in the Prefecture of Fokida. Tetramina, Amfissa, pp.1787-1788. 10) hhtp://becta.org.uk 11) hht://thecommunicationtrust.org.uk
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APHASIA SSY06.1 RATIONALE, PROCEDURES AND PATIENT-REPORTED OUTCOMES OF A DRAMA CLASS FOR INDIVIDUALS WITH CHRONIC APHASIA L. R. Cherney1,2, A. Oehring3, K. Whipple4, T. Rubenstein4,5 1Rehabilitation Institute of Chicago, Chicago, USA 2Northwestern University, Feinberg School of Medicine, USA 3Chicago Speech and Language Services, Chicago, USA 4Institute for Therapy through the Arts, Evanston, USA 5Chicago School of Professional Psychology, Chicago, USA
INTRODUCTION Despite linguistic gains following treatment, people with aphasia (PWAs) experience residual communication problems that significantly impact their daily lives. They report social isolation, loneliness, loss of autonomy, restricted activities, role changes, and stigmatization.1,2 As a result, there has been increased emphasis on approaches that focus on enhancing the “living of life with aphasia”. The major goal of these “Life-Participation Approaches to Aphasia" (LPAA) is to facilitate participation in personally relevant activities to help PWAs achieve and maintain a good quality of life.3 Consistent with the goals of the LPAA, we used drama and drama therapy to create an innovative communication experience in which individuals with chronic aphasia conceptualized, wrote and produced a play addressing their experiences of having, living with and coping with the effects of aphasia. Drama therapy has been defined by the National Association of Drama Therapy as the systematic and intentional use of drama/theater processes, products, and associations to achieve the therapeutic goals of symptom relief, emotional and physical integration and personal growth.4 Drama therapy is an active, experiential approach that facilitates the client's ability to tell his/her story, solve problems, set goals, express feelings appropriately, achieve catharsis, improve interpersonal skills and relationships, and strengthen the ability to perform personal life roles while increasing flexibility between roles. Since drama therapy emphasizes the interplay between thought and speech, and allows communication of ideas through both nonverbal and verbal means, it offers an important authentic medium through which people with aphasia can interact and share their experiences. In this session, we use video-taped samples to describe the rationale and procedures of this creative arts therapy class for aphasia, and focus on the patient-reported outcomes of a representational group of seven participants.
METHODS Participants in the drama class met once weekly for 90 minutes over 18 weeks. Sessions were cofacilitated by a speech-language pathologist and a drama therapist. Each session was audio- and videotaped and then transcribed for use in planning and script development. Initially, general theater games and activities provided the foundation to maximize communication opportunities and communication exchanges. Intermediate sessions incorporated improvised storytelling, scene generation, and script development and revision. Later sessions incorporated practice and rehearsal, culminating in performance of a production in front of a live audience.
Subjects Core group members included 14 (9 male; 5 female; 12 white, 2 black) individuals with chronic aphasia. Mean age was 55.85 years (range: 31-76 years). Etiology was predominantly stroke, with a range of physical residuals and aphasia classifications. Educational, vocational, ethnic, and socio-economic backgrounds were diverse. Mean time post onset was 6.1 years (range:11 months - 27 years).
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A representative sample of seven participants (5 male, 2 female; 6 white, 1 black) were evaluated before and after participation in the theater class. Mean age was 56.7 years (SD=9.71; range 41-73 years). Mean time post onset was 8.29 years (SD=8.6 years; range 3-27 years). Clinically, three participants were characterized as having a mild anomic aphasia (all recovered from Broca’s aphasia), while four participants were characterized as having a moderate Broca’s aphasia. Etiology was stroke in 6 participants and a gunshot wound in one participant. All but one of the participants was right-handed premorbidly. Mean education level was 15.7 years (SD=3.4 years, range 12-21 years) and premorbid occupations included the following: history professor; janitor; actor; retail store owner; housewife; lawyer; commercial real estate manager.
Patient-Reported Outcomes Measures of patient-reported outcomes were administered before and after participation in the theater class using selected subscales of the Burden of Stroke Scale (BOSS)5 and the Communication Confidence Rating Scale for Aphasia (CCRSA)6. All testing was conducted by a speech-language pathologist who was independent of the treating speech-language pathologist. The BOSS is a comprehensive, patient-reported measure of functioning and well-being. It is a 64 item scale, comprising 12 internally consistent and unidimensional scales.7 The Communication Difficulty (CD) subscale consists of seven items; the Social Relations subscale consists of 5 items, and the Mood subscale consists of 4 items representing a negative mood (lonely, anxious, angry, sad) and 4 items representing a positive mood (confident, happy, calm, optimistic about the future). Each of these subscales has an associated psychological distress scale (communication associated distress; social relations associated distress; mood associated distress). The CCRSA is a 10-item self-report scale that assesses the PWA’s confidence in communication in various situations. Participants indicate their degree of confidence on a horizontal visual analogue scale with markings from 0-100. Preliminary analyses indicate that the CCCRSA is internally valid and reliable.6
Analysis Means and standard deviations of each BOSS subscale and CCRSA score were calculated at each assessment period. Because of the small number of subjects, effect size measures were computed from pre- to post-participation in the drama class. Effect size measures the magnitude of a treatment effect and, unlike significance testing, is independent of sample size. Cohen's d was calculated for dependent measures using the original means, standard deviations, and correlation coefficient.8 Effect sizes were benchmarked against Cohen’s (1988) definition of effect size as “small, d=0.2,”, “medium, d=0.5,” and “large, d=0.8.”9
RESULTS Table 1 shows the means, standard deviations, and effect sizes. On the CCRSA and the BOSS mood subscale (positive), a positive effect size represents improvement. On all other BOSS subscales, a negative effect size represents improvement as indicated by a decrease in burden or associated distress. None of the effect sizes were large; however, several effect sizes demonstrating perceived improvements following participation in the drama class could be benchmarked as medium. These included responses on the BOSS communication burden and communication distress scales and the positive mood scale. Perceived improvements that could be benchmarked as small included increased communication confidence as measured by the CCRSA and decreased negative mood and mood distress.
DISCUSSION AND CONCLUSIONS Participation in a drama class for aphasia resulted in perceived improvements in both communication and mood. Communication changes included medium decreases in both communication difficulty and the distress associated with communication, as well as small, but increased communication confidence. Mood changes included moderate increases in positive feelings, and small decreases in negative feelings and the distress associated with these negative feelings and emotions. Notable improvements did not occur on all BOSS subscales. Interestingly, there were no perceived changes in the participants’ difficulty with social relations or associated distress. Such findings are not surprising given the chronicity of the aphasia, and the fact that the PWAs were all living in the community and had previously attended other sessions of community aphasia groups. However, the lack of perceived
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change in social relations serves to highlight the impact of the drama class specifically on communication and mood. Factors contributing to perceived changes in communication and mood, including use of specific drama therapy techniques that focus on communication skills and the success associated with the live performance, will be discussed. Finally, patient-reported outcomes have been called the new “gold standard” for many chronic conditions, and there is broad agreement on the importance of incorporating the patient’s own perspectives about the impact of treatment.10,11 Given that aphasia is a chronic condition, the value of the PWAs own selfreport and perceptions of their condition should be considered.
REFERENCES LeDorze, G. & Brassard, C. (1995). A description of the consequences of aphasia on aphasic persons and their relatives and friends based on the WHO model of chronic diseases. Aphasiology, 9, 239-255. Parr, S. (1994). Coping with aphasia: Conversations with 20 aphasic people. Aphasiology, 8, 457-466. Chapey R, Duchan JF, Elman RJ, Garcia LJ, Kagan A, Lyon J, Simmons-Mackie, N. Life Participation Approach to Aphasia: A Statement of Values for the Future. Retrieved April 5, 2009: American SpeechLanguage and Hearing Association website: http://www.asha.org/public/speech/disorders /LPAA.htm National Association of Drama Therapy. What is drama therapy? Retrieved January 18, 2010: http://www.nadt.org/faqs.htm Doyle, PJ, McNeil MR, Hula WD. (2003). The burden of stroke scale (BOSS): validating patient-reported communication difficulty and associated psychological distress in stroke survivors. Aphasiology,17, 291304. Babbitt, E., Cherney, LR, Heinemann, A., Semik, P. (2009). Using Rasch Analysis to develop the Communication Confidence Rating Scale for Aphasia (CCRSA). Clinical Aphasiology Conference, May,2009. Doyle PM, McNeil MR, Mikolic JM, Prieto L, Hula WD, Lustig AP, Ross, K, Wambaugh JL, GonzalezRothi LJ, Elman RJ. The burden of stroke scale (BOSS) provides valid and reliable score estimates of functioning and well-being in stroke survivors with and without communication disorders. Journal of Clinical Epidemiology 2004; 57: 997-1007. Morris, S. B., & DeShon, R. P. (2002). Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs. Psychological Methods, 7, 105-125. Cohen J. Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Earlbaum Associates; 1988 Wiklund, I. (2004). Assessment of patient-reported outcomes in clinical trials: the example of healthrelated quality of life, Fundamental & Clinical Pharmacology, 18(3), 351-363. Fries, J. F., Bruce, B., & Cella, D. (2005). The promise of PROMIS: Using item response theory to improve assessment of patient-reported outcomes. Clinical & Experimental Rheumatology, 23 (Suppl. 39):S53-S57. Table 1. Effect Sizes of Patient-Reported Outcomes Following Participation in a Theater Class: Test Pre-Participation Post-Participation Mean SD Mean SD Effect Size BOSS Communication - Burden 12.29 4.99 10.21 3.83 - 0.46 Communication - Distress 7.00 2.77 5.86 2.19 - 0.51 Social Relations - Burden 7.14 3.44 6.71 3.64 - 0.16 Social Relations - Distress 5.43 3.21 5.64 3.22 0.07 Mood (Negative items) 6.71 4.57 6.14 2.54 - 0.33 Mood (Positive items) 8.29 2.75 9.93 3.01 0.61 Mood - Distress 1.57 1.13 1.71 1.38 0.22 CCRSA 71.71 14.12 74.43 9.13 0.38 Highlighted items indicate a medium effect size.
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P129 M1-ALPHA APHASIA TEST: A PROPOSAL FOR READJUSTMENT TO PORTUGUESE F.C. Garcia¹, O.M. Takayanagui¹ ¹School of Medicine in Ribeirão Preto of São Paulo University, Ribeirão Preto/SP, Brazil
Introduction and aims of the study: The Montreal-Toulouse M1-Alpha Protocol is one of the most applied aphasia test batteries in Brazil because it offers several advantages concerning to application, language disorders diagnosis and isolation of each language aspect assessed. This exam is characterized as a screening test that, as well as other screening tests, it’s criticized for privileging the sensibility in detriment of the specificity, causing high rates of false positives. The more detailed the evaluation, more elements are collected for the establishment of a good therapeutic plan. However, the tests become very extensive. An option is to use a screening test, which scans possible language disorders, and then, to run specific tests for each function detected as having alteration. Nevertheless, the M1-Alpha has been suffering several criticisms since its adaptation to the Portuguese Language. The absence of validated or adapted tests for the population which is applied is target of much criticism1,2,3,4,5 Brazilian researchers and health professionals usually face the challenge of using tests developed in foreign languages and standardized for populations of other countries, causing distrust in using assessments that are inadequate to our social and cultural reality 3. The advantages of the validation of aphasia test in Brazil are to reflect the culture and the communicative profile of the Brazilian population, to observe the social and demographic differences and to have better quality data and parameters for assessment 4. Among the researches which show that need, there are several reasons that stimulate the authors to develop them, such as the adaptation or validation of the test for the social, cultural, linguistic and geographical level of a certain community, the different schooling levels, the performance of different groups of subjects in some tests or specific exams, as well as the influence of the interfering factors in language. Thus, the present study aimed to analyze the imperfections of the M1-Alpha Aphasia Exam exposed by the literature, to apply this evaluation tool in individuals without neurological alterations, to analyze the need for cultural and linguistic readjustment for the conjugation of previous results, and to suggest modifications for its improvement.
Methods: The present study was approved by the Ethics and Researches Committee of São Paulo University (no. 2621/2004). All the participants were informed about the study and then they signed the Free and Informed Consent Term. For the elaboration of this study, a bibliographical research was carried out evaluating the critics and suggestions for the M1-Alpha and investigating the difficulties found in the application of this protocol by the national and international literature. The participants were selected with minimum age of 20 years old, absence of current or previous neurological, psychiatric or language disorders, absence of use of psychotropic drugs, absence of visual and auditory disorders and to be family, preferentially spouse, of patients from the clinics of Neurology Department of Clinical Hospital of the School of Medicine in Ribeirão Preto of the São Paulo University (HCFMRP-USP), where the anamneses and evaluation were collected. The sample was composed by 35 individuals, which were 25 female and 10 male, age averaged 49,5 years-old (standard deviation of 13,12) and schooling averaged 7,26 years-old (standard deviation of 4,14). As materials of this study, an anamnesis protocol and the Montreal-Toulouse Protocol for Aphasia Exam, version M1-Alpha adapted to the Portuguese were used. Initially the participants were submitted to the anamnesis and the clinical evaluation of the language by the M1-Alpha. The difficulties found in the application of this instrument and the participants’ performance were analyzed.
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The anamnesis addressed issues such as: age, gender, schooling, nationality, multilingualism, reading and writing habits, profession and manual dominance, since all mentioned aspects have great influence on language. Besides the application of the M1-Alpha tests, it was asked individually the nomination of all illustrations that compose the boards of verbal and writing comprehension tests and denomination test, in order to verify if the real aim of the illustrations is being executed (semantic, phonological, formal opposition and placebo) in each board. For the test’s accomplishment, the Confidence Interval of 95% was applied. The probability (p) of less than 0,05 was considered as statistically significant. All tests were two-tailed. Initially the descriptive statistics of the results of all applied tests was done, as well as the whole nominated illustrations. Then, the non-parametric test of Comparison of Proportions was employed for paired samples, since there was no normal distribution for all variables. The Wilcoxon Test was chosen for paired samples when the tests were compared by its number of mistakes. After that, the Pearson Correlation Analysis was used to establish the correlation among the groups (gender, age, schooling, reading and writing habits) and the results of the oral and writing language tests. Besides those tests, the Chi-square test was applied to investigate if there is a significant difference in the results of each test inside of each group. The Fisher’s Exact Test was used when needed, that is, when there was an expected value lower than 5 in at least a square.
Results: In this study, it was observed that 97,1% of the participants committed some mistake in the M1-Alpha tests. The greatest number of errors occurred in the oral expression tests (71,43%) and written comprehension tests (82,86%), which showed through Wilcoxon Test, a statistically significant difference (p ‘knife’). Unrelated responses included real-word responses lacking a relationship, of any form, with the target word. All errors are shown in Table 2.
SLI object semantic error (single) 8.0% semantic description 3.8% word class 0.89% omissions 17.8% visual 1.5% unrelated —
WFD action object 6.2% 12.6% 16.0% 2.0% 0.6% 0.18% 8.9% 1.7% — 1.1% — 0.36%
TLD action object 16.3% 8.2% 14.8% 3.4% — 1.0% 6.2% 8.7% — 0.95% 0.73% 0.87%
action 5.4% 17.5% — 3.4% 0.15% 0.79%
Table 2: Mean percentages of errors for object and action names Interestingly enough, the qualitative analysis of errors revealed different error patterns for object and action names. Overall, there was a higher rate of omissions for object names, in contrast to greater semantic description or circumlocution errors for action names. A one-way ANOVA carried out between the groups yielded the following results: 1. Children with WFD made significantly more semantic errors on object names than those with TLD. 2. Children with WFD made significantly more semantic errors for action names compared to both children with SLI and those with TLD. 3. Children with SLI made significantly more omission errors than those with TLD for object names. Regression analyses were conducted with the object and action naming responses in relation to lemma frequency, rated AoA, rated imageability, syllable length, and rated picture complexity. Overall, there was a significant effect of AoA on object and action name retrieval, with more errors on words in both classes that were acquired at a later age. The fact that there were fewer errors with words earlier acquired supports findings from previous studies (cf. Masterson et al., 2008). There was no effect of syllable length for either object or action naming. Moreover, no other psycholinguistic variable had a significant effect on action naming accuracies.
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We can now summarize our results as follows: 3. All three groups showed an effect of AoA, word imageability, and picture complexity. 4. None of the three groups (SLI, WFD, TLD) showed an effect of syllable length. 5. Only the children with TLD showed a frequency effect; object naming by the children with SLI and WFD was not affected by the frequency of a given item. 6. AoA had a significant effect on retrieving action names for all three groups. 7. Word imageability and picture complexity significantly affected action naming for the children with SLI and WFD. 8. Word frequency had no effect on any of the three groups. 9. The children with SLI and those with TLD had similar error types for action (semantic descriptions) and object names (omissions).
4. Discussion The present study investigated object and action picture naming accuracy in three groups of CG-speaking children: six-year-olds with TLD, and two older groups of children with SLI and WFD, respectively, in a highly inflected language (CG, patterning morphosyntactically for all items tested just as the better studied standard variety of Modern Greek), where nouns and verbs are clearly differentiated on the basis of inflectional suffixes. Furthermore, this is only the second study in the literature, after the recent research by Masterson et al. (2008), to control for a range of variables that might affect picture naming performance in TLD: frequency, word length, imageability, AoA, picture complexity. Performances of children with WFD on object and action naming can be differentiated from TLD and children with SLI based on error type: They make significantly more semantic errors on both word types (#A, #B), while children with SLI made more omission errors for object names than those with TLD (#C). Children with TLD and those with SLI had similar error types for both object and action naming (#7). In addition, children with WFD also showed a grammatical class effect: action names are significantly more difficult to produce than object names plus same error type for verbs and nouns. No effect, however, was found for word frequency or syllable length (#6, #2), that is, variables that operate at the level of the form (apart from object naming in TLD, #3). Moreover, object and action naming was affected by the same variables for children with SLI and WFD (#4, #5). For TLD, AoA affected action naming (#4), and all variables affected object naming (#1). Generally, children with SLI are less accurate in naming than those with TLD, but interestingly, error type cannot differentiate the two groups. This suggests strongly that children with SLI are delayed — but not atypical. Why, then, are action names more difficult for children with TLD and those with WFD? We suggest that the factors mentioned above already all play a role: (i) naming actions involves different processes to the naming of objects, (ii) verbs are acquired later, (iii) verbs are semantically more complex, and (iv) verbs are grammatically more complex. The reason why we don’t find such a for the children with SLI is the general delay in acquiring words these children present; in addition, individual lexical items are poorly differentiated in their semantic-lexical representations and these representations may not be well organized. The larger
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point to make, which one might want to pursue further, is this: Inaccuracies in naming, and perhaps even word-finding problems in general, may vary with the pattern of language deficit. Let us close with some methodological issues that arose throughout this study. First, standard and standardized testing for SLI inclusion criteria (including non-language specific measures) are not available in CG for preschool and schoolaged children. Second, hearing was screened as within the normal limits, but this is not adequate to detect ‘subtle’ auditory processing deficits. Note also that neither the amount of speech and language therapy individual children (may) have received at the time of testing or the exact subtype of (SLI) disorder (e.g., grammatical versus phonological) were not taken into consideration. As unfortunate as this may be, it is a flaw that underlies the majority of studies on SLI, certainly in the linguistic literature, and it might be a factor that wants to be controlled for more carefully in future investigations, independent of the language(s) the research is carried out in.
References Kambanaros, M. (2003). Verb and noun processing in late bilingual individuals with anomic aphasia. Doctoral dissertation, Flinders University, Adelaide. Masterson, J., J. Druks & D. Gallienne (2008). Object and action picture naming in three and five year old children. Journal of Child Language 35, 373-402.
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FP17.3 EFFECTS OF MATERNAL DEPRESSION ON A CHILD’S LANGUAGE DEVELOPMENT A. Kavvada1, E. Konstantaki2 1Social Intervention Center of Municipality of Korydallos, Korydallos, Greece 2EPSYPE hospice MELIA, Athens, Greece
Introduction
The unspoken part of human communication is present long before the infant can speak. (Trevarthen, 1979, p. 321) Every view of research concerning language acquisition takes into account the definitive action of the environment or at least the interaction between inborn factors and the environment (Bruner, 1975). Some form of genuine, reciprocal communication starts taking place very early in an infant’s life (Donaldson, 1984); the mother looks at the baby and the baby looks back, the mother speaks gently and the baby smiles, the baby cries and the mother soothes it, the mother vocalizes and the baby starts making mouthing gestures (Stone & Menken, 2008). This interactive sequence of maternal and infant responses is characteristic of the healthy motherinfant dyad (Lemaitre-Sillère, 1998). Imitation, mutual activity and intentional communication mirror primary intersubjectivity within the mother-infant communicative dyad (Trevarthen, 1979). The mother’s ability of interpreting the child’s communicative intent helps the child establish a secure attachment. Joint attention, comments upon, joint reference and joint action, firstly through holding, handling and presenting an object (Winnicott, 1971) and moving from simple to complex play interactions, between infants and their mothers lay the foundations for speech and language development (Bruner, 1975). … playing is an experience, always a creative experience, and it is an experience in the space-time continuum, a basic form of living. (Winnicott, 1971, p.67) A mother’s verbal and non verbal reactions in daily routines and her emotional availability to turn them into sequential play interactions encourage and support exploratory skills (Vygotsky, 1978). All concepts of language are first realized in action (Bruner, 1975). The mother’s ability to provide and expand utterances during play draws the child’s attention to communication itself and helps him develop his own internal representations. Moreover, play space is a space where intimate relationships and creativity occur, where a child discovers his self, as a unique, active agent in the environment (Winnicott, 1971). What happens when a mother cannot respond consistently and sensitively over time? Chronic maternal depression seems to be a case of disrupted primary mutuality. The sadness and social withdrawal that characterize depressed mothers diminish their ability to adapt and respond in a sensitive manner to infants’ cues and inputs in situations of daily routine, to provide a holding environment and to engage in mutual play with their infant (Winnicott, 1975). The interactional patterns of
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depressed mothers decrease feedback provided for infants to explore their environment and try to speak. Postpartum depression that persists and becomes chronic may place a child on the path of language delay (Sohr-Preston & Scaramella, 2006). The aims of our case study were to examine the association between maternal depression and the adverse effects on a child’s language development and the effectiveness of interventions targeting maternal depression, mother–child interactions and language development in a toddler exposed to chronic maternal depression.
Case history and interventions M., a 2;10 years old boy with severe speech and language delay, was referred to a multidisciplinary child development centre by his mother. During the initial interview, the speech and language therapist and M.’s parents completed an extensive case history form. The following information was included in M.’s case history. A year before M’s birth, his parents had undergone a period of losses and unexpressed mourning. Three months prior to the mother’s pregnancy, M’.s father suffered leg amputation as a result of a work accident – his brother was his employer. One month after the accident, the father’s brother died of acute myocardial infarction, feeling guilty for M.’s father’s amputation. The parents’ stoic compensation for these losses involved no communication with each other. The mother’s pregnancy started and it had to relieve their unexpressed mourning. During the pregnancy, M.’s father experienced intense pain in the amputated limb. A neurologist diagnosed him with depression and prescribed antidepressant medication. M.’s birth intensified his parents’ fears and worries. According to his parents, M. was a crying, fretful and difficult baby and they did not know how to cope with him. The parents had not been talking to M., since neither of them was in the mood for conversation. M.’s mother developed postpartum depression and felt constantly exhausted, sad and very disappointed for not being a good enough mother. As most depressed mothers, she did not breastfeed M. Thus, M. lost one more opportunity of interaction with his mother. She gave up taking care of her newborn baby and herself. She gained 40 kg, stayed at home all day with M., hoping M. would change her mood. She neither talked to M. nor played with him, since she believed he was not able to understand her, just like her parents. The next year passed with the mother attached to M., who continued to be “fretful”, with bursts of anger and very restless sleep. The parents shared their bed with M., expecting him to give them joy and pleasure but instead, he frustrated, tired and angered them, thus causing them to sleep badly. The parents tried to integrate M. at a nursery school. However, his mother found it very difficult to let him go. As a result, M. could not enjoy the socialization of nursery school and the solicitude of his teachers, when his mother had no one to take care of her and soon, he was totally unwilling to attend nursery school. When the parents were referred to us for M.’s communicational problem, he was 2;3 years old. According to them, he could not speak, did not respond when talked to and avoided eye contact. He had bursts of anger, during which he hit, bit and scratched them and also hurt himself. During the speech and language assessment, M. revealed his need for communication. He sought to contact the speech therapist, he responded to her speech with babbling as well as nonverbally. He longed for other people’s presence
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and connected with them in an infantile and immature way, but he was relieved with other people’s speech, when they talked to him thinking he could understand them. The child-psychiatric evaluation excluded the diagnosis of pervasive developmental disorders and mental retardation. This helped the parents to view their child as normal and healthy. Given all family members’ need for personal help and support, an interdisciplinary team approach was designed, comprising: a) speech and language evaluation and intervention to improve M’s mother’s communicational patterns and to develop M’s communication skills, b) child’s psychiatric assessment, parenttoddler psychotherapy as well as parent consulting, c) individual psychiatric treatment for the management of maternal depression, and d) individual psychiatric treatment for the management of paternal depression. During the parents’ consultation, M.’s mother realized that her own needs did not allow her to cope, understand and look after M.’s needs. She could not feel and put into words all what was happening with the child, as well as between them. His father also realized that he was not emotionally available to help and support his wife and their child. After a while, the mother was referred to the psychiatrist of the unit. She was given pharmaceutical support and soon her mood and functionality improved. M.’s father was reluctant to see a psychiatrist at first, believing he could manage by himself. But when the child psychiatrist connected his as well as his wife’s need for expert support with their desire to unburden little M. from burden of taking care and relieving his parents’ sadness and mourning, the father accepted psychiatric help. Finally, Μ. started receiving speech-language pathology services. As a result, every member of the family found a unique space to communicate and correlate in a different way in contrast to the one they had until then. Parent-toddler psychotherapy proved to be of extreme importance. M.’s presence facilitated the understanding of the parents’ own emotions and projections as well as understanding their child’s behaviors and reactions making them respond accordingly, with the assistance of the child psychiatrist. The parents themselves were able to discuss – at first among them – and then with M., past events that they had been trying in vain to forget by not talking about them. M.’s progress gave them positive feedback, decreasing their guilt that they were to blame for his difficulties. They understood how much their pasts – for which they certainly were not to blame – were related with the image they had of themselves, their relationship and their child. The roles were normally reversed and then they looked after their child and not the opposite. There was a network of specialists, who had undertaken their care and support and M. was moved to his own room to enjoy his toys, leaving his parents to discover and fulfill their needs as a pair, as well as each one’s individually. This way, the parents helped their child develop a healthy sense of independence. During speech and language treatment sessions, through playing and singing (Crystal & Varley, 1993), M. started to verbally express himself and to communicate, albeit in a rather immature way with his family and peers. During most sessions, the parents were encouraged to speak to him frequently, read often, play and sing with him. Through playing, he became creative and his creation of imaginary situations amazed himself and his parents. Although his language was still “immature” for his age, his mother had allowed him to progress from the symbiotic relationship with her to individualization, thus leaving space for speech and language symbols to emerge.
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Our interdisciplinary team approach brought about several positive results. Maternal depressive symptoms were reduced and both parents became emotionally available. The mother began to engage in interactional activities with her toddler and sensitively respond to his needs. Interaction in the mother-toddler dyad facilitated the emergence of the toddler’s representational and symbolic thought and significantly enhanced the development of his verbal and nonverbal communication.
Conclusions
Mother and child act upon each other like living mirrors. (Lemaitre-Sillere, 1998, p.509).
An infant of a depressed mother looks in the mirror and cannot see himself. He must forget himself in order to understand his mother so as not to lose her. Severely depressed mothers, being apathetic and emotionally withdrawn, cannot recognize, tolerate, keep within themselves and give meaning to their infants’ needs, desires, primitive agonies and outbursts. They become scared and are drawn away, leaving their infant alone with many intense, incomprehensible emotions. Depressed mothers make diminished eye contact, are unable to use infantdirected speech, speak in a flat tone of voice and talk to their child less than nondepressed mothers (Reissland et al., 2003). They do not engage in play interactions with their children, depriving them of any possibility to develop and reach their creative potential. The maternal patterns described above lessen infants’ motivation and interest in communicating. A child who does not speak reflects his image of his depressed mother withdrawn in silence. Chronic maternal depression seems to indirectly impact upon speech acquisition and language development through the function of behavioral mechanisms and intrapsychic processes. When possible, the active involvement of a non-depressed father significantly supports a depressed mother and improves her functionality and well-being. Nondepressed fathers and other adult caregivers may not compensate for maternal influences but they certainly provide a facilitative environment for the depressed mother to adjust to a major life transition of carrying and raising a child and they also expose infants and toddlers to positive affect, infant-directed speech and joint actions (Sohr-Preston & Scaramella, 2006). Mitigation of the effects of maternal depression on an individual child is possible through an interdisciplinary approach in which all family members become involved. An interdisciplinary approach to the management of maternal depression and child communication disorders aims to improve the mother’s well-being, increase the amount and quality of parent-child interactions and, consequently, develop and improve the child’s language competencies.
References Bruner, J. S. (1975). The ontogenesis of speech acts. Journal of Child Language. 2(1), 1-19. Crystal, D. & Varley, R. (1993). Introduction to Language Pathology. London: Whurr. Donaldson, M. (1984). Children’s minds. London: Fontana Paperbacks. Lemaitre-Sillère, V. (1998). The infant with a depressed mother: Destruction and creation. Journal of Analytical Psychology. 43(4), 509-521. Reissland, N., Shepherd, J. & Herrera, E. (2003). The pitch of maternal voice: a comparison of mothers suffering from depressed mood and non-depressed mothers reading books to their infants. Journal of Child Psychology and Psychiatry 44(2), 255-261.
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Sohr-Preston, S. L. & Scaramella, L. V. (2006). Implications of Timing of Maternal Depressive Symptoms for Early Cognitive and Language Development. Clinical Child and Family Psychology Review. 9(1), 65-83. Stone, S. D. & Menken, A. E. (2008). Perinatal and Postpartum Mood Disorders: reatment Guide for the Health Care Practitioner. New York: Springer Publishing company. Trevarthen, C. (1979). Communication and Cooperation in Early Infancy: A Description of Primary Intersubjectivity. In M. Bullowa (Ed.). Before Speech: The Beginning of Interpersonal Communication, Cambridge: CUP. Vygotsky, L. S. (1978). Mind in society: The development of higher mental functions. Cambridge, MA: Harvard University Press. Winicott, D. W. (1971). Playing and reality. Harmondsworth, Middlesex: Penguin Books. Winicott, D. W. (1975).Through Paediatrics to Psycho-Analysis: Collected Papers. New York: Basic Books.
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SE05.1 UTLIZING CRITERION-REFERENCED ASSESSMENTS AS A BASELINE FOR NARRATIVE INTERVENTION. Joan S. Klecan-Aker, Ph.D., CCC-SP Texas Christian University, Department of Communication Sciences and Disorders P O Box 297450, Fort Worth, TX 76129, (817) 257-6885
There are two types of test instruments that are used to assess children with language disabilities. These instruments include standardized tests and criterionreferenced measures. Standardized tests are useful in providing a diagnosis, but, typically, they can’t be used to establish targets for intervention. Criterionreferenced assessments are needed for that task. However, given the need for evidence-based practice, it’s important that these measures be valid and reliable. One criterion-referenced measure that has been widely used for providing baseline data for primary school children with language disabilities is narrative analysis or the analysis of language organization. There are several reasons why researchers and clinicians have found the narratives of children’s narratives useful. First, nearly every child can respond to the task of being asked to tell a story about something. Additionally, having a child tell a story provides the clinician with an uninterrupted flow of discourse from the child; thereby avoiding certain artificialities of data from conventional elicitation techniques. Finally, early reading and writing tasks center around the narrative structure. There a number of ways to elicit and analyze narratives, but the one described in this paper has been developed by Klecan-Aker and Bruegemann (1991). Many studies have been done since the procedure was developed, both in terms of the reliability of the procedure and the use of the data as a framework for intervention.
Elicitation and Transcription Procedures First, a minimum of two narratives are always elicited. The reason for eliciting more than one is to ensure that the baseline is stable. Narratives are elicited by first providing the child with the model of what a story is. The clinician shows the child a picture and then generates a story about the picture. The reason for this procedure is that research has shown that just showing a child a picture and asking him/her to tell a story is not sufficient. Children will label or describe the picture. By providing a model, the child understands the type of task that is being requested. All narratives are audiotaped and then transcribed. When transcribing, the stories need to be triple-spaced and written as one run-on sentence with no capital letters or punctuation.
Story Analysis After the story is transcribed, it will be divided into t-units. A t-unit is a simple sentence or a complex sentence. It’s never a compound sentence because that would be the equivalent of two t-units (2 simple sentences). After the story has been divided into t-units, words/t-unit, words/clause and clauses/t-unit are calculated. Then, each t-unit is assigned a story grammar component. This component shows the role of the t-unit in the story. The type of story grammar components that are
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found in the story determine the story’s developmental level. The developmental level of both stories determines the starting point of intervention. For example, if children are telling level 2 stories, the clinician might decide to begin intervention with level 3 or level 4 stories. Story grammar components include the following: 1) setting statement-who the story is about and when and where the story takes place 2) initiating event-the problem or the main point of the story 3) internal responses-the reaction of the main character to the initiating event (thinking and feeling statements) 4) action-an attempt to solve the problem 5) consequence-the result of the action 6) dialogue-asking or telling statements (they don’t need to be direct quotations) 7) ending-the tells the final resolution of the story There are also seven developmental levels of stories. Level 1 stories occur when a child simply talks randomly. Level 2 stories occur when a child labels or describes items in the picture. Level 3 stories have the story core of initiating event, action and consequence. Level 4, 5, 6 and 7 happen which children add additional story grammar components, one for each level. The reason why the component is not specified is because different children add different components. Research has not revealed any specific pattern. Some children add setting statements; others add internal responses; and girls tend to add dialogue statements. Level 0 stories are stories that don’t fit into any other category.
Types of Baseline Data Collected from the Stories In addition to the t-unit analysis, assignment of story grammar components and the determination of developmental level, other analyses can be completed as well. The most common analysis is an assessment of cohesive ties, specifically the use of conjunctions to tie clauses together and the use of references. Conjunctions are examined in terms of how they are used to tie clauses together. The number and type of conjunction is tallied. For example, conjunctions can either be coordinating or subordinating. Research suggests that the ratio of coordinating to subordinating should be approximately 4:1. References are either appropriate or inappropriate when used as a noun substitution for subjects and objects. Nominative or subject pronouns include I, you, he, she, it, we and they. In contrast, objective pronouns are those pronouns that are used when the pronoun serves as the object. They are me, you, him, her, it, us and them. Consider the following examples in which the personal pronouns are in bold. – – – –
He will not leave. Lisa told Susan that she doesn’t want to go. Jack hit her on the head. Why won’t Susan talk to him?
In these examples, the pronouns are serving as the doers of the action. In the latter two examples, the objective pronouns are used because they are serving as the recipients of the action (Justice & Ezell, 2002). Once a noun has been stated, a child may use a pronoun substitution for two additional sentences or clauses. After that point, the noun needs to be restated or the pronoun is said to be inappropriate. Another way to determine inappropriate is that if the reader cannot determine who or what the pronoun is referring to. In conclusion, narrative elicitation and analyses yield a variety of possible intervention targets. These targets include:
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• • • • • •
increasing the use of all the story grammar components increasing the developmental level of the stories improving the use of subordination to add complexity to the children’s stories improving the use of appropriate references decreasing words per t-unit increasing clauses per t-unit.
Because the use of narratives is a criterion-referenced measure, there are no developmental norms. However, we know that the narrative genre presented in this paper is similar to the genre used in children’s academic material in grades kindergarten through third.
Intervention Intervention typically begins with level three stories for the younger children, unless baseline data indicate otherwise. Intervention can begin with an analogy. Children are told that telling a narrative is like baking a cake. One has to have all the ingredients and the steps of the recipe have to be followed in the right order. If these two factors, don’t happen, the cake doesn’t turn out very well. Recall that the level three stories consisting of an initiating event (problem) action and consequence (result). After a discussion of the analogy, example story sequences are presented by a clinician. These story sequences were introduced during therapy as containing a “problem” that was followed by an “action” that created a “result”. Twelve age appropriate scenarios are then presented to the students. Each problem is introduced with two possible actions; one action that was ‘good” and one action that was “bad”. In other words, one action is always more appropriate than the other. A discussion about what constitutes the best action is part of the instruction. At this point, no responses are required from the students. Then, the children are asked to participate in the process by determining whether or not statements provided by the clinician are an appropriate action that might solve the problem. As therapy progresses, the children begin to generate original problems, actions and results. Once the children display mastery of these concepts, they are introduced to internal responses or feelings. This introduction means that students are ready to learn level four stories. Five feelings are initially targeted; mad or angry, scared, surprised, frustrated and confused. “Sad” and “happy” are not typically targeted because baseline data usually indicates that children have good awareness of those two feelings. Just like with the other components, the clinician provides examples of the feelings, asks for class participation, and prompts children to share stories about their feelings. Positive behavior is encouraged and reinforced through a behavior modification program. The program can vary depending on the grade level of the clients.
Summary and Conclusions Children’s narratives provide a rich source of objective data from which a variety of treatment targets can be selected. This information is then used as baseline data and, therefore, as a way of measuring progress in therapy. The school setting provides an excellent time-table for using this type of criterion-referenced measure. For example, narratives can be elicited at the beginning of the school year, at the end of the first half of the academic year (Christmas), after the Christmas holidays when school begins again and finally, at the end of the academic year. Finally, it’s important to understand that the best way to measure progress in therapy is not only to calculate change from a specific target such as improving the use of appropriate
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references, but to also elicit the complete narrative again. By doing that, the clinician can see if what she or he has taught has generalized to the stories themselves. Without this final step, it is difficult to ascertain if the discrete skills that were targeted in intervention, were mastered and utilized by the children in a consistent fashion.
Useful References Justice, L. M. & Ezell H.K. Use of storybook reading to increase print awareness in at risk children. American Journal of Speech-Language Pathology, 11, 17-29. Klecan-Aker, Joan S. & Brueggeman, L. (1991). The Expression Connection. Speech Bin, Vero Beach.
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FP16.4 DEVELOPMENTAL LANGUAGE DISORDERS: A CASE STUDY OF A MIXED TYPE (RECEPTIVE AND EXPRESSIVE) LANGUAGE DISORDER G. Koiliari S. L. T., Athens, Greece It is universally accepted that there is a close relationship between higher level cognitive processes, senses and language acquisition. The sense of hearing is essential for one to perceive the complex frequency and temporal information contained in the signal received as auditory information. Furthermore, ability to represent concepts, experiences and ideas, to store all information received, focus attention and last but not least, problem solving are only some basic cognitive processes that lead one to successful language acquisition. When communication failure is a fact, one does not possess adequate language skills, thus leading us to a Language Disorder diagnosis. There are two major subtypes of Language Disorders: 1) Developmental Language Disorders 2) Acquired Language Disorders In the following presentation a case study of a four year-old boy with a Mixed Receptive- Expressive Developmental Language Disorder will be presented. Developmental Language Disorders (D. L. D.) are a group of problems in language development, first detected at the early stages of language acquisition, persisting throughout childhood and go on till adulthood. Literature defines three subtypes of Developmental Language Disorders: 1) Receptive Language Disorders, which cause difficulty to understand spoken and sometimes written language 2) Expressive Language Disorders, a learning disability affecting communication of thoughts using spoken and sometimes basic written language and expressive written language 3) Mixed type (Receptive and Expressive) Language Disorders
Clinical Characteristics Mixed Receptive- Expressive Developmental Language Disorders are of an unknown etiology. Ongoing research is conducted to determine whether biological/ genetic or environmental factors are involved. According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revised (DSM-IV-TR ), four general criteria for diagnosing mixed receptive-expressive language disorders are specified. The first criterion states that the child communicates using speech and appears to understand spoken language at a level that is lower than expected for the child's general level of intelligence. Second, the child's problems with self-expression and comprehension must create difficulties for him or her in everyday life or in achieving his or her academic goals. If the child understands what is being said at a level that is normal for his or her age or stage of development, then the diagnosis would be expressive language disorder. If the child is mentally retarded, hard of hearing, or has other physical problems, the difficulties
308
with speech must be greater than generally occurs with the other handicaps the child may have, in order for the child to be diagnosed with this disorder. Various language tasks are involved in the process of speech and language evaluation as far as D. L. D. is concerned, since D. L. D. is in fact a pattern of delays in both the developmental and the growing process of speech, always in relevance with meeting one’s community needs and expectations. When dealing with D. L. D. one should also take under consideration the concomitant factors that are the principal influence on Developmental Language disorders. An acute hearing ability is more likely to help a child in the process of language acquisition. A home environment that exposes a child to language offers the child the means to acquire language easier, faster and in a more sufficient level. Another concomitant factor is a child’s cognitive ability, though there is controversial evidence regarding the role of the level of cognition in language development. There are claims that one’s neurological status referred to as subtle brain differences may be responsible for the existence or absence of Language Disorders. When a lesion is localised, one could assume a brain damage is present and be referred to a neurologist.
Initial evaluation Four year-old P. K. is a very sweet little boy who visited my private practice with the company of his mother for the first time on October 2007. He was diagnosed with a Developmental Language Disorder- mixed type, Dysphasia, by the Children’s Hospital, department of Child Psychiatry. From the case history- medical and family- interesting information occurred. P.’s perinatal history involved decrease of his heartbeats with no more information available as to what caused the phenomenon. He went through a stage of severe tactile defensiveness between the ages of 2 and 3 and at present has trouble eating meat and fish especially with swallowing the bolus .P.’s mother is bilingual with English as her native language and five more relatives of first and second degree (the father and four cousins) also appeared to have had either a delay in language development or learning difficulties with concomitant difficulties like attention deficits, hyperactivity and/ or aggressive behavior. Evaluation was conducted using a Speech and Language Screening Test for 45 year-olds in collaboration with the mother. Three sections were measured: –
Language Structure
–
Language Content
–
Ability to communicate
→Sound Articulation →Grammar →Attention and Comprehension →Vocabulary and Expressive Language →One to One Situation with an adult →Group Situation with Peers
P.’s scores were actually quite low in both criterion cut-offs since he scored a 3 in sound articulation (referral criterion cut- off : 5 or less) and a total score of 15 (referral criterion cut- off 35 or less, leading us to a clear assumption of existing difficulties in phonology, morphology, syntax, pragmatics, and semantics. Elements from an informal observation of P. and his mother (the father never attended a session due to professional obligations) were also taken under consideration. Receptive Language Testing involved different kinds of tasks:
309
–
–
Recognition/ identification ability was tested by asking P. to point to a picture of an object (show me “ball”), an animal (show me “horse”), an action (show me “running”), e. t. c. with increasing difficulty. Acting out and judgment was tested by showing relevant pictures and asking P. to show e. g. “the kid pulls the dog” Expressive Language Testing involved:
• • • • • •
Immediate imitation by asking P. to “say potato” Delayed imitation, by telling P. “This is potato. What is this?” Close procedure, by telling P. “Look! I have one potato.” “Look! I have two ___________” Identification, where P. was expected to name an object e.g. “What is this?” “This is a/an _______” Story retelling, where P. was told a story and was given the command “Now you try to tell me what happened/ the story” Spontaneous sample collection which was all about his spontaneous speech within session settings.
It was suggested to P.’s mother that he visited an optometrist and an E. N. T. doctor as soon as possible, in order to obtain information regarding his eyesight and his hearing ability.
Curriculum In an effort to provide P. with an inclusive curriculum, an I. E. P. was created, involving all areas of interest as resulted from the initial evaluation. The evaluation revealed severe difficulties in both receptive and expressive language. Emphasis was originally given in the tasks he had the lowest scores at (sound articulation, vocabulary and expressive language). Gradually, tasks involving grammar and comprehension exercises were added. During the first semester a token system helped to induce P.’s attention span. By the fourth semester of our sessions, we started a group session on a weekly basis. The group consisted of two more kids of the same age, a boy and a girl. A cognitive- behavioral approach was used throughout our sessions, with very clear and simple limits, guidelines and commands, to secure the maximum of P.’s understanding and attention. Cooperation with P.’s mother in home settings was established through guidance and consultation after each session. P. visited an optometrist in September 2009 who detected a very mild astigmatism and suggested a re-evaluation within a six- month time. He has not yet visited an E. N. T. doctor, although it was strongly recommended that he should.
Re-evaluation In January 2010 a re-evaluation was conducted, using the checklist for 6- 10 year-olds. 6 year-old P. K. scored 7 as a total (with a referral criterion cut- off 10 or more). Almost all areas of interest from the initial assessment showed great improvement. His speech is now very clear with /r/ remaining to be generalized; he uses correct grammar rules, does not make syntactic errors, uses correct morphemes and has sufficient vocabulary for a kid of his age. He is now able to read words of a cvcv (c: consonant, v: vowel) structure as he has developed very good phonological
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awareness skills and recognizes some of the alphabet letters. He can orally compose or analyze words of a cvcv: /kota/, cvcvcv: /kapelo/, ccvcv: /skali/, cvcvcvcv: /kalaθaci/ cvcccv: /kastro/ structure.
Conclusion Efforts must be made towards mastering complex instructions and instructions given in group settings. P. seems to be easily disrupted by sounds (environmental or not) and by internal stimuli, hence his difficulty to cope with tasks of increased difficulty and literacy involving exercises, especially in the classroom. He still has some trouble expressing himself in a more sophisticated way when excited and sometimes shows difficulty responding to a given command. A reevaluation from an optometrist and an evaluation from an E. N. T. doctor are essential at this point as P. tends to use inappropriate volume when he speaks.
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P022 PERFORMANCE OF CHILDREN WITH DOWN SYNDROME IN SCRRENING TEST DEVELOPMENT DENVER-II Lamonica D.A.C.1 , Prado L.M.1 , Gejão M.G.1 , Silva G.K.2 (Prefecture of Uru, Uru, Brazil), Ferreira A.T. 1 Department of Speech and Language Pathology, Faculty of Dentistry of Bauru, University of São Paulo, Bauru, Brazil 1 Prefecture of Uru, Uru, Brazil2
Introduction Children with Down syndrome (DS) have global developmental delays influencing the social, mental and emotional areas(1-7). The phenotypic characterization of abilities development in DS is related to structural and functional abnormalities of the central nervous system(8) and although these individuals present similar physical phenotypes, the competence for learning is diversified, depending on countless variables intervening in the development processes. The literature shows that the functional performance in children with DS is lower than that of typical children, however this lower performance is never constant in the continuous development(9). It is provided delay in he psychomotor development of children with DS, but studies affirm that even with this delay is kept the same order of development of children without alterations. It is difficult to establish a language acquisition pattern in DS and it is due to large variations presented for each child and to the multifactorial character involving this development process(10). The performance of children with DS shows that the ability less altered is the social, and they appear to be effective in socialization and relatively weak in communication and motor skills(9-13). Before the exposed, the study objective is to report the performance of children with Down syndrome on development abilities through the Screening Test Development Denver-II.
Methods The study was approved by the Ethics in Human Research Committee of the Faculty of Dentistry of Bauru, University of São Paulo. Participated nine children with DS, aged between 41 and 69 months, with normal hearing and no significant visual problems that could interfere with the procedures accomplishment. The legal responsible answered an interview protocol, containing information about the child's past life and the Screening Test Development Denver-II (STDD-II) was applied(14) to assess the global performance in four development areas: gross motor, fine-adaptive motor, personal-social and language. The results analysis was accomplished in a descriptive and statistical way through the Wilcoxom test.
Characterization of participants 312
All children had karyotype confirming the diagnosis of DS (single 21 chromosome Trisomy). Also performed auditory screening with normal results. As for the visual accurate, three children presented alterations with varied diagnoses (strabismus; myopia, hyperopia, astigmatism and nystagmus) and are in ophthalmologic attendance. As for the general health, 45% presented heart alterations, 55% pneumonia episodes and 33% alimentary alterations. All the participants frequent school and participated in programs of global development stimulation. Picture 1 shows the chronological age of the psychomotor development emergence on the balance cervical (BC), sit without support (SWS), independent gait (IG) and first words (FW) in years (y) and months (m).
Picture 1: Emergence of the psychomotor development stages Participants
BC
SWS
IG
FW
1
7m
1y6m
3y
3y
2
4m
9m
2y3m
1y6m
3
6m
2y9m
Não
3y
4
8m
1y2m
3y2m
2y
5
5m
8m
2y3m
3y4m
6
2y4m
3y2m
4y
3y
7
3m
7m
2y3m
1y1m
8
4m
8m
1y11m
2y
9
6m
8m
1y9m
3y6m
Results Table 1 shows the individual results of the STDD-II application. The performance was referred in months.
Table 1: Performance of participants in STDD-II in months (m).
Chronological age
Gross motor
Fine-adaptive
Personal-
motor
social
Language
1
41m
13m
11m
5m
13m
2
43m
39m
33m
43m*
24m
3
47m
12m
16m
15m
18m
4
47m
16m
21m
36m
24m
313
5
55m
20m
13m
33m
18m
6
65m
41m
24m
21m
39m
7
66m
42m
39m
66m*
48m
8
67m
31m
31m
24m
41m
9
69m
50m
57m
69m*
57m
Table 2 presents the results of the mean, median and p-value (Wilcoxom) when performed comparison of the scores obtained by participants with their respective age ranges in each evaluated area.
Table 2: Results of the mean, median and p-value (Wilcoxom) comparison of chronological age and the performance in each evaluated area. Mean
Median
Chronological age
55,5
55
Gross motor
29,3
31
Chronological age
55,5
55
Fino-adaptive motor
27,2
24
Chronological age
55,5
55
Personal-social
34,6
33
Chronological age
55,5
55
Language
31,3
24
p-value (≤0.005) 0,002*
0,002*
0,014
0,002*
* statistically significant difference Discussion Table 1 presents the individual scores values obtained in the STDD-II application. It is observed in this casuistry that the values obtained in the gross motor, fine-adaptive motor and language areas are less than expected for their chronological age. In the phenotype of individuals with DS are expected motor and language development delays. In DS physical syndromic, cognitive and environment aspects are critical in determining the level of global development, which although foreseen with delay, have particular character and occur with personal variations(1,2,4,6,7,11,13). Delays in development are limits to learning. The psychomotor development in DS occurs later than in typically development children(6), what does with that, probably, the child loses concrete opportunities to enlarge repertoire, causing gaps in the perceptive, cognitive, linguistics and social areas. That is based, once the child acquires the knowledge through the environment exploration, the
314
objects manipulation, actions repetition, corporal schema control domain and through the established relationships in situations lived(10). In relation to the language development, studies show that these children have difficulties in the acquisition process, which started from birth, however there are many questions regarding this process, as the differences in the usual pattern of acquisition has not been fully dimensioned(15). Despite this assertion, authors reported that in DS are expected specific phenotypes related to the language behavior including alterations in all linguistic levels(16,17). Also in table 1, it is observed in the personal-social area that three participants obtained scores consistent with their chronological age. In fact, children with DS are seen as extremely sociable and affectionate. One study(8) showed that individuals with DS are seen as extremely sociable, affectionate and of easy temperament, but that these characteristics are not uniform. Children from the age group studied show behaviors that favor the establishment of interpersonal, intentional and significant eye contact. Another study showed that the ability less altered in children with DS was the personal-social, since the children had shown to be effective in socialization and relatively weak in communication and motor abilities(11,13). Table 2 shows statistically significant differences in gross motor, fineadaptive motor and language areas, confirming the development delay in these areas. Even with delay it is possible to verify that the development of these abilities occur in a heterogeneous way for these children. The fact that there is a group of children with similar physical characteristics, does not mean that competence for learning is equal to everyone(8-10). Each child has their own development rhythm, depending on the anatomical, physiological and environmental conditions. In any case, it should be noted that alterations in motor and language development interfere in other development fields and in such circumstances, the child can lose opportunities to make possible their repertoire, because the development happens for integrated actions of the own organism to the psychomotor dispositions, with interference of the envirment, influencing in maturational process and in the information processing development (10). There was also no statistically significant difference between the performance expected for their chronological age and the performance obtained by the group only for the personal-social area, what can be justified with the observation made in the results of Table 1, where three participants had compatible performance with their chronological ages in this development area. As discussed earlier, the literature shows that the personal-social area is the most preserved and developed in most children with Down syndrome(8,11,13). To enable better stimulation plan and therapy for children with DS is required prior stages and characteristics knowledge of the development of children without alterations, as well as children with DS. Based on these knowledge the professionals involved with children with DS can enrich their service and guide parents in the development and ways to optimize it, exploring the full potential of these children and providing a better quality of life to them.
Conclusion The participants showed alterations in the development areas: gross motor, language, fine-adaptive motor and personal-social, and the last one was the less affected. To Know the typical stages of development and to study the development
315
in Down syndrome since early childhood will favor that the involved professionals can plan strategies and contribute for these children's full development.
References 1. Määttä T, Tervo-Määttä T, Taanila A, Kaski M, Livanainen. M. Mental health, behaviour and intellectual abilities of people with Down syndrome. Down Synd Res and Pract; 11(1):37-43, 2006. 2. Kroeger KA, Nelson WM. A language programme to increase the verbal production of a child dually diagnosed with Down syndrome and autism. J Intellect Dis Res; 50(2):101-8, 2006. 3. Camarata S, Yoder P, Camarata M. Simultaneous treatment of grammatical and speechcomprehensibility déficits in children with Down syndrome. Down Synd Res and Pract; 11(1):9-17, 2006. 4. Feinstein C, SinghS. Social phenotypes in neurogenetic syndromes.Child Adolesc Psychiatr Clin N Am; 16(3):631-47, 2007. 5. Howell A, Hauser-CRAM P, Kersh JE. Setting the stage: early child and family characteristics as predictors of later loneliness in children with developmental disabilities. Am J Ment Retard; 112(1):18-30, 2007. 6. Vicari S. Motor development and neuropsychological patterns in persons with Down syndrome. Behav Genetic; 36(3):355-64, 2006 7. Lorusso ML, Galli R, Libera L, Gagliardi C, Boegatti R, Hollebrandse B. Indicators of theory of mind in narrative production: a comparison between individuals with genetic syndromes and typically developing children. Clin Linguist Phon; 21(1):37-53, 2007. 8. Silva MFMC, Kleinhans ACS. Processos cognitivos e plasticidade cerebral na síndrome de Down.Rev Bras Ed Esp; 12(1): 123-38, 2006. 9. Mancini MC, Silva PC, Gonçalves SC, Martins SM. Comparação do desempenho funcional de crianças portadoras de síndrome de Down e crianças com desenvolvimento normal aos 2 e 5 anos de idade. Arq Neuro-Psiquiatr; 61(2):409-15, 2003. 10. Ferreira AT, Lamônica DAC. Estimulação da linguagem de crianças com síndrome de Down. In: Lam6onica DAC. Estimualção da linguagem: aspectos teóricos e práticos. São José dos Campos, São Paulo: Pulso, 2008. 11. Fidler DJ, Hepburn S, Rogers S. Early learning and adaptative behavior in toddlers with Down syndrome: evidence for an emerging behabioural phenotype? Downs Syndr Res Pract. 2006,9(3):37-44. 12- Dolva AS, Lilja M, Hemmingsson H. Functional performance characteristics associated with postponing elementary school entry among children with Down syndrome. Am J Occup Ther; 61(4):414-20, 2007. 13- Volman MJ, VIsser JJ, Lensvelt-Mulders GJ. Functional status in 5 to 7-year-old children with Down syndrome in relation to motor hability and performance mental ability. Disabil Rehabil; 29(1):25-31, 2007. 14- Frankenburg WK, et al. Denver II Training Manual. Denver: Denver Developmental Materials; 1992. 15- Brandão SRS. Desempenho na linguagem receptiva e expressiva de crianças com síndrome de Down. Dissetação de Mestrado – Universidade Federal de Santa Maria, 2006. 16- Price JR, Roberts JE, Hennon EA, Berni MC, Anderson KL, Sideris J. Syntatic Complexity during conversation of boys with Fragile X syndrome and Down syndrome. J of Speech Lang and Hear Res; 51:3-15, 2008. 17- Jarrold C, Thron As, Stephens E. The relationships among verbal short-term memory, phonological awareness, and new word learning: evidence from typical development and down syndrome. J Exp Child Psychol; 102(2):196-218, 2009.
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P023 PERFORMANCE OF ORAL AND WRITTEN COMMUNICATION OF BROTHERS WITH MYELOMENINGOCELE Lamonica D.A.C.1, Ferreira A.T.1, Prado L.M.1 , Crenitte P.A.P.1 Department of Speech and Language Pathology, Faculty of dentistry of Bauru, University of Sao Paulo, Bauru, Brazil 1
Introduction Myelomeningocele (MMC) is one of the neural tube closing defects that can cause urologic, orthopedic, neurological, gastrointestinal, psychosocial and intellectual difficulties(1). These individuals have strong potential to develop learning problems associated with the presence of motor, language, cognitive and information processing development alterations(2-6). They tend to have variable intellectual level, in the dependence of neuropathological abnormalities, neuroembriogênese anomalies, hydrocephalus surgical treatment complications, environmental stimulation among others(1,5). With this, they are risk individuals to develop learning problems associated to the cognitive function reduction, perceptive deficits and no verbal abilities alteration(2-4,6-8). As for language performance, these children can present alterations in all of the linguistic levels(2,6,10), however, the expectation is for alterations in no verbal abilities with involvement of visuo-spatial organization, perceptive processes, attention control, discrimination, selective memory and, especially, in tasks that involve serial learning(8-11), influencing negatively in the reading, writing and mathematics learning(5-12). Before the exposed, the study aimed to describe and reflect on the psycholinguistic and school performance of siblings with myelomeningocele.
Methods This study was approved by the Ethics in Research of the Faculty of Dentistry of Bauru, University of São Paulo. The study included a boy with 14 years and 5 months (P1) and a girl with 6 years and 6 months (P2), siblings. P1 and P2 are no consanguineous parent’s children, both diagnosed with low lumbar MMC at birth, and came with the difficulty in school learning complaint. Surgical correction of MMC and hydrocephalus happened when P1 had 30 days and 10 months and P2 had 2 and 20 days respectively. P1 frequents 7th series and P2 the 1st in regular school. P1 and P2 walk with aid of crutches and braces. The procedures consisted of interviews with family members, Communicative Behavior Observation (CBO), Peabody Picture Vocabulary Test (PPVT)(13), Illinois Test of Psycholinguistic Abilities (ITPA)(14), Phonological Abilities Profile (PAP)(15), School Performance Test (SPT)(16), and letters and numbers recognition (RLN). The results analysis was accomplished as described in the manuals of the applied instruments and it will be presented in a descriptive way.
Results
317
In CBO it was verified that P1 and P2 presented communicative intention with satisfactory interaction. As for the expressive conversational skills it was observed in P1 and P2 production of expansible, coherent and contextualized shifts. In the narrative speech it was observed use of personal pronouns, daily objects, places and verbs nomination and attributes with lexical meaning, possessive pronouns, space adverbs and time adverbs with grammatical meaning, elaborated without coherence and cohesion compromising. The participants demonstrated appropriate understanding. Table 1 shows the evaluation procedures results. Table 1: PPVT, ITPA, PAP, SPT and RLN results. Instruments
P1 (14y 5m)
P2 (6y 6m)
PPVT
Superior medium
Medium
Auditory Reception
10y 11m
7ª
Visual Reception
6y
10y 11m
Auditory Association
10y 11m
4y 3m
Visual Association
10y 11m
6y 6m
Auditory Memory
9y 6m
2y 10m
Visual Memory
10y 11m
8y
Auditory Closure
8y 3m
6y
Visual Closure
10y 11m
10y 11m
Grammatical Closure
10y 6m
4y
Verbal Expression
10y
4y 4m
Manual Expression
10y 11m
10y 11m
Sounds Combination
8y 6m
2y
ITPA*
Performance
PAP
SPT
for
children with 10 years Total Score
RLN
Performance attention
of
for children
under 5 years
Inferior classification Total recognition
Recognizes few letters and numbers
* The tes mazimum age is 10 years and 11 months (10y 11 m)
Discussion As for the MMC and hydrocephalus surgical corrections, international specialized centers in the tube neural defects treatment consider that the MMC surgery should happen until the first 72 hours of life, to avoid the complications
318
increase(1) and that these individuals might have associated the hydrocephalus with need of surgical procedure for ventricular derivations installation. Studies reveal that children with MMC and hydrocephalus have been demonstrating significant individual differences in the neurological and behavior functioning(2,6,8,11,), reinforcing the precocious surgical corrections need to avoid the deleterious effects for the neurological operation and behavior functioning. Such differences are reflexes of the combination of neurological, medical, familial, environmental influences which those children are exposed. The language development has multifactorial character and in spite of the risk factors involved in MMC, related to the Central Nervous System influence in the global, neuropsycomotor, perceptive and cognition performance added to the frequent periods of hospitalization and psychosocial aspects as stigma and overprotection, the no verbal abilities are more committed in these population(3,4,7) than the verbal abilities. Such aspects were proven in CBO, because P1 and P2 didn't present difficulties related to the communicative behavior and the language use in activities dialogic. It is stood out that specific abilities are not demanded in informal conversation and even with morphosyntactic alterations in the verbal expression, the content can be transmitted in an appropriate way, with the possibility of dialogic activities maintenance and linguistic contents understanding for speakers. These discoveries are described in studies that approach this issue(3,4,7,10). In PPVT they had medium classification. Children with MMC may show alterations in various linguistic levels, however oral language may be apparently normal and the expectation is for alterations in non-verbal skills(3-5,7,9-11). In ITPA and PAP, P1 and P2 presented difficulty in the performance of the auditory memory and closure, verbal expression, sounds combination and phonological conscience abilities. P1 still presented difficulty in the visual reception ability and P2 in the auditory association and grammatical closure abilities. They presented deficits in auditory abilities as for the capacity to reproduce a digits sequence memorized (auditory memory), to complete absent parts of a word captured through the auditory presentation (auditory closure) and to relate concepts presented orally through verbal analogies (auditory association). These abilities are prerequisite for complex orders understanding and execution, as well as for the learning abilities(2). Children with MMC present perceptual difficulties involving categories relationship, analogies, associations and coordination of the related perceptual representations(10). Both children demonstrated alteration to express verbal concepts as class or denomination, color, forms, composition, function, main parts, quantification, comparison (verbal expression) and to use the oral language redundancy in the syntax and grammatical inflections acquisition, what includes the morphologic aspects knowledge such as gender inflections, number and level, verbal forms in way, time, person and syntactic aspects of the connectives use pronouns and other (grammatical closure). According to studies, these children present the basic linguistic abilities frequently intact, however there is defectives in discursive abilities involving the flexibility in the language use(2,8,10,18). The ability that P1 showed greater difficulty was visual reception that includes the ability to extract meaning from visual nature symbols. Studies had described that individuals with MMC show alterations in the visual perception abilities and also in the interactions processing and visual associations(10). It was verified that the P2 more lagged ability is sounds combination, also presented with deficit by P1. This ability refers to the associative processes integration, more specifically as for the phonemic synthesis, one of the abilities
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involved in phonological awareness test, in which P1 and P2 presented score below the expected for the chronological age. Recent studies demonstrate that children with learning difficulty can present alterations in the phonological abilities and in the access to the mental lexicon, due to modifications in different levels of the information processing(6,17). In SPT P1 and P2 presented inferior performance to the expected for the school series that they frequent. P2 got to write just her first name and was not capable to accomplish the reading of any word. Before this, it was applied the letters and numbers recognition proof. In this, she recognized few letters and presented difficulty in producing the alphabet vocally. The writing learning includes differentiating the letters strokes, to know that the letters represent sounds, to establish quantitative correspondences, to identify the letter position inside of the word, to understand that a same letter can represent several sounds, as well as a same sound can be represented by several letters(17). The alphabetic principle understanding is based on the following facilitators factors: capacity to segment the spoken language in different units, conscience that these units repeat in different spoken words and knowledge of the correspondence rules between graphemes and phonemes(18). These difficulties were observed in the results obtained by the participants in phonological awareness tests of PAP and in the ITPA sounds combination subtest. Several factors influence in the learning acquisition and development, as the family atmosphere(14), the oral language development and also the perceptual abilities that will favor the apprehension of the strategies used in the learning process(7,11). Children with MMC are of risk for learning disturbance, which is associated to the cognitive and perceptive functioning and no verbal abilities(1,6,7,813,10,11). P1 arithmetic performance was more impaired than in the reading and writing abilities. P2 performed no arithmetic exercise and had difficulty in numeric recognition. Children with difficulties in reading decoding and difficulties in mathematics have shown deficits in verbal and visual working memory and in phonological processing, experiencing difficulties in problems resolution, in the concepts decoding and statements interpretation, as well as in the numeric estimate(9). Alterations in the psycholinguistic abilities presented influenced directly in the school performance, corroborating with the literature on the theme(3-8, 12,17,18). .
Conclusion The participants presented communicative behavior, oral language abilities and receptive vocabulary without obvious alterations. Regarding the psycholinguistic abilities, it was verified alterations that contemplated in the learning process. The perceptual alterations cause important impact in the academic activities, demonstrating cerebral vulnerability in the support system for learning activity.
References 1. Iglesias J, Ingilde M, Naddeo S, Sánchez M, Spinelli S, Van der Velde J. Deteccion e tratamiento del mielomeningocele por um equipo interdisciplinario. Rev Hosp Mat Inf Ramón Sarda. 19:11-17, 2000. 2. Lindquist B, Uvebrant P, Rehn E, Carlsson G. Cognitive function in children with myelomeningocele without hydrocephalus. Childs Nerv Syst.2009, on line. 3. Fletcher JM, Barners M, Dennis M. Language Development in Children with Spina Bifida. Seminars in Pediatric Neurology.9(3):201-208;2002.
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4 Russell C. Understanding Nonverbal Learning Disorders in Children with Spina Bifida. Teaching Exceptional Children 36(4):8-13;2004. 5. Vachha, B; Adams, RC. Memory and selective learning in children with spina bifida, mielomeningocele and shunted hydrocephalus: A preliminary study. http.//creativecommons.org/licence/by/2.0/November,2005. 6. Barnes MA, Dennis M, Hetherington R. Reading and writing skills in young adults with spina bifida and hydrocephalus. Journal of International Neuropysychol Society.10:655-663;2004. 7. Ris MD, Ammerman RT, Waller N, Walz N, Openheimer S, Brown TM, Yates KO. Toxanocity of nonverbal learning disabilities in spina bifida. J Int Neuropsychol Soc. 13:50-58,2007. 8. Lindquist B, Persson EK, Uverant P, Carlsson G. Learning memory and executive functions in children with hydrocephalus. Acta Paediatri, 97(5):591-601, 2008. 9. English LH, Barnes MA, Taylor HB, Landry SH. Mathematical Development in Spina Bifida. Developmental Disabilities Research Reviews. 15:28-34;2009. 10. Dennis M, Jewell D, Hetherington R, Burton C, Brandt ME, Blaser SE, Fletcher JM. Verb generation in children with spina bifida. J Inter Neuropsychol Soc. 14:181-191,2008. 11. Sawin KJ, Joy P, Bakker K, Shores EA, West C. Object-based visual processing in children with spina bifida and hydrocephalus: a cognitive neuropsychological analysis. J Neuropsychol. 3:229-244,2009. 12. Boyer KM, Yates KO, Enrile BG. Working memory and information processing speed in children with mielomeningocele and shunted hydrocephalus: Analysis of the Children’s paced auditory serial addition test. J Int Neuropsychol Society. 12;305313,2006. 13. Dunn LM, Padilla ER, Lugo DE, Dunn LM. Teste de Vocabulário por Imagens Peabody. Adaptação Hispano-americana. Espanha: Circle Pines: American Guidance Service, 1986. 14. Bogossian MADS. Teste de Illinois de habilidades psicolinguística: crítica do modelo mediacional e de diversos aspectos da validade do instrumento. Rio de Janeiro; 1984. [Tese de Doutorado, Fundação Getúlio Vargas]. 15. Alvarez AMMA, Carvalho IAM, Caetano AL. Perfil de Habilidades Fonológicas: Manual. São Paulo: Via Lettera Editora, 2004. 16.Stein LM. TDE: Teste de Desempenho Escolar: Manual para aplicação e interpretação. São Paulo: Casa do Psicólogo, 1994. 17. Dias RS, Ávila CRB. Uso e conhecimento ortográfico no transtorno específico da leitura. Rev Soc Bras Fonoaudiologia. 13(4):381-90;2008. 18. Guimarães SRK. O aperfeiçoamento da concepção alfabética de escrita: Relação entre consciência fonológica e representações ortográficas. In: Maluf MR. Metalinguagem e aquisição da escrita. São Paulo.149-184. 2003.
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P024 RECEPTIVE VOCABULARY ABILITY IN CHILDREN WITH PHENYLKETONURIA AND CONGENITAL HYPOTHYROIDISM Lamonica D.A.C.1, Ferreira A.T. 1, Silva G.K. 2, Anastacio-Pessan F.L.3, Gejao M.G.1 Department of Speech and Language Pathology, Faculty of Dentistry of Bauru, University of Sao Paulo, Bauru, Brazil1 Prefecture of Uru, Uru, Brazil2 Neonatal Screening Laboratory of Association of Parents and Friends of Exceptional, Bauru, Brazil 3
Introduction and study aim: The phenylketonuria (PKU) is an inborn error of metabolism of the amino acid phenylalanine, transmitted as an autosomal recessive disorder. According to literature, high blood phenylalanine concentration and its metabolites levels can cause severe brain commitments interfering in the global development and especially in language development. In congenital hypothyroidism (CH) there is insufficient thyroid hormones production, important for the nervous system development. The literature has been verifying alterations in development of motor, cognitive and language abilities. This study aimed to verify the receptive vocabulary comprehension in children with CH and PKU and compare the performance of children in the different pathologies. Methods: It was evaluated 7 children in the PKU group (57,14% female; 42,86 male) and 8 children in the CH group (50% female; 50% male). All children had low economical level and 85% of the children with PKU and 63% of the children with CH frequented the pre-school. All children had between 3 to 6 years, were diagnosed before 2 months by a neonatal screening program and had low socioeconomic level. The handbooks were analyzed and Peabody Picture Vocabulary Test was applied. The results application and analysis followed the proposed by the instrument. Results: It was observed that: 28,57% of the individuals with PKU and 25% of the individuals with CH present behavioral problems, manifested as attention time alteration and/or hyperactivity; on the proposal evaluation, 42,86% of children with PKU presented scores below the average and 14,29% presented indexes inside of the deviation medium-low pattern and these values were 12,5% and 25% respectively for individuals with CH. Conclusion: In that way the children with PKU showed more impairment in the receptive vocabulary ability and even diagnosed and treated early children with PKU and CH can present the metabolism alterations deleterious effects contemplating in their development.
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FP27.2 EVALUATING THE MORPHOSYNTACTIC DEVELOPMENT OF CHILDREN SPEAKING AN INFLECTED LANGUAGE: WORD AND PARADIGM (WP) MODEL VERSUS MEAN LENGTH OF UTTERANCE (MLU).
Irini Levanti Speech and language practitioners (SLPs) use MLU (Brown, 1973) in morphemes or in words as a clinical tool for identifying language delay or disorder, for assessing morphosyntactic development and planning intervention programs accordingly. But language typology influences the process of morphosyntactic development and this parameter should be taken into consideration when using clinical tools. The present study aims to demonstrate why SLPs who speak an inflected language should design and use clinical tools for morphosyntactic development based on the WP Model (Hockett, 1954) instead of using the MLU. .
INTRODUCTION In the twentieth century many structural linguists have played down the importance of morphology (the study of forms) and a large part of morphology has been assimilated into syntax. Moreover, they have given great importance in morphemes and not enough importance in the word. But for inflected languages morphology plays the basic role of the grammatical organization of an utterance and the word and not the morpheme, is the key-unit of grammatical organization. Grammatical distinctions are marked through inflections whereas semantic relations are expressed by changing the phonological form of the word. Inflection relates the word to the rest of the utterance.
THE PROCESS OF MORPHOLOGICAL DEVELOPMENT Children pass through different phases of development during which they gradually construct the morphosyntactic system of their language. Language typology influences the strategies that children develop. Children listening to an analytical language use mainly syntactically based strategies. They focus on the position of the word in the utterance in order to understand the semantic relations expressed. Children listening to a synthetic (inflected) language use mainly morphologically based strategies. They focus on the inflection in order to understand the semantic relations expressed. In analytical languages the lexemes appear without inflection which is then added to them. In synthetic languages inflectable lexemes never appear without inflection. So, when a child uses a word-form we have to distinguish between the lexicon-based use of this form and the productive use of it. Productivity means that the child, using the inflection she/he has detected, can construct new paradigms with other lexemes. Languages with a rich morphology make children more aware of the importance of the morphological system and as a consequence, morphological processing starts earlier than in languages with a poor morphological system.
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In conclusion, from a cross-linguistic perspective, the question arisen is whether and to what extent we can generalize information about patterns of language development and clinical tools, using data obtained from studies conducted solely in the English language. English is an analytical language with a fairly simple morphological system (it has only eight productive morphemes) and a strict word order. These characteristics set it apart from many other languages, German, Russian, Spanish, Greek and others, which are synthetic (inflected), have a great number of productive morphemes and flexible word order. Nevertheless, SLPs speaking inflected languages adapt and use English clinical tools in their language. One of these tools is MLU.
MEAN LENGTH OF UTTERANCE (MLU) MLU is a measure of morphosyntactic development suggested by Brown (1973). Brown conducted a longitudinal study based on three children and through these data he proposed five stages of morphosyntactic development. These stages were characterized by changes in the child’s utterance length and, in turn, in morphosyntactic complexity. Criticism of MLU began to appear shortly after its publication and skepticism has continued until the present time (Crystal, 1974; Eisenberg et al., 2001; Owens, R. 1996, Rollins et al., 1996, among others) and is related to the definition, the application and the interpretation of MLU. Professionals, who use MLU in inflected languages, recognize that MLU in morphemes is problematic and for that reason they use MLU in words, but this adjustment does not solve the problem. MLU is a quantitative, broad and time consuming measure, which does not offer enough information for establishing targets in language intervention programs. In inflected languages, morphological complexity does not necessarily increase the length of an utterance. The fact that children with the same MLU may use different morphological features is well known amongst SLPs. Children with Special Language Impairment (SLI) with persistent difficulties in morphological development may not have difficulties in putting words together in an utterance. Instead, they may have great difficulty in focusing and using inflections and free morphemes. When Brown proposed MLU, I attempted to adapt and use this clinical tool in the Greek language, but I had many difficulties especially with productivity. So I started to study Morphology trying to find a model more appropriate for an inflected language. Some of the statements cited in this study are the result of personal observation in my clinical work extending over three decades.
SOME CHARACTERISTICS OF INFLECTED LANGUAGES In languages of this type, there is more than one morpheme encoded in a morph. For example, in Modern Greek (MG) Nominal inflection includes three morphemes (gender, number, case), which are all encoded in a single morph. However, children during the earliest phases of morphological development may only identify a subpart of the morphemes encoded in one morph. Greek children, for example, may have identified the contrast between Singular and Plural, but not the contrast between Nominative and Accusative in Plural. In addition, the same morph may represent different morphemes. In MG the morph «ους» /us/ is used for at least six different morphs, and each one of them encodes more than two morphemes.
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Many of these problems may be solved by using another kind of grammatical analysis, an analysis according to language typology. Hockett (1954) pinpointed three models of grammatical analysis, (quoted in Matthews 1991:21, 22) and described which model is suitable according to each language typology. For inflected languages he proposed the Word and Paradigm (WP) model. This model is revised by Matthews (1972) and others. For this model, Katamba (1993:61) stated that “unfortunately, in spite of its inherent merits this approach has not been adopted by many linguists”.
WORD and PARADIGM MODEL The term “Word” means lexeme and the term “Paradigm” is the complete set of a lexeme’s inflections. Morphological paradigm is the complete set of phonological forms (patterns) of an inflectable lexeme. The WP model regards the word as the key-unit of morphological analysis and considers paradigms as the central principle of morphological organization. During the first years of life, children’s speech and language development is tremendous. The child observes the language used by his/her caregivers, forms hypotheses about the underlying rules and uses them in production. The process of development of these rules is gradual and progressive. The morphological system starts to develop when all the other systems (phonological, syntactic, lexicon) are already developing. At this phase, the strategies of morphological processing are depended on language typology. As already mentioned, children listening to an inflected language use mainly morphologically based strategies. They focus on the inflection of the word and start to construct words according to their inflection. Morphological process presupposes that children have detected the inflection and its function in an utterance. Children may use some words in the right semanticpragmatic context before their morphological system starts to develop, but the emergence of the morphological system is indicated by the use of different forms of a word spontaneously in different pragmatic contexts. The development of morphology is initiated with the emergence of the first mini-paradigms (MP), which are defined as a smaller piece of a total paradigm consisting of the most important and frequent phonological forms of a lexeme. MPs represent a qualitative change in language development and they allow children to start generalizing on morphological contrasts. They mark the transition from the lexicon-based use of the words to morphological processing. The term “miniparadigm” firstly was used by Pinker (1984:180,186). He proposed a progression from word-specific to general paradigms as ”a process whereby the child first creates word-specific mini-paradigms and only later abstracts the patterns of inflection contained within them to create general inflectional paradigms”. The criteria that represent the minimal requirement for assessing the beginning of morphological productivity (the emergence of the first MPs) and I believe them to be more convenient for SLPs speaking an inflected language are those formulated by Pizzuto and Casseli (1994:156) who stated: «We estimated that any given inflection was beginning to be used productively by each child when (a) the same verb root appeared in at least two distinct inflected forms, and (b) the same inflection was used with at least two different verbs.” We can also apply the same criteria of productivity for nouns. MP and the emergence of new productive forms enable the child to create morphological rules gradually. Through morphological development, syntactic relations are expressed. Morphological development concerns the development of the noun phrase and the
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verb phrase. For instance, in Modern Greek, Cases participate in the agreement system: Nominative suggests the noun phrase (subject) and Accusative suggests the verb phase (object). Therefore, based on researches that have been done in their language for morphosyntactic development (development of noun and verb phrase) and using the WP model, SLPs can formulate a more direct and descriptive tool of morphosyntactic development. This tool will be the navigator for exploring how a child uses morphosyntax in order to better communicate, in different pragmatic contexts.
ELICITATION METHODS From the SLPs point of view, the most important reason for evaluating children is to collect data that can be used as the basis for assessing language problems and planning intervention programs. SLPs must have a representative sample of the child’s spontaneous utterances in order to better identify children’s problems in language development, at least in two different contexts (free play, story generation, picture description, story retelling, interview and other). With young children at risk of having language delay or disorder or children with severe Special Language Impairment, it is recommended to collect a sample of communication with their parents and to check morphosyntactic productivity by using mini-paradigms. An intervention program ought to be adapted to the child’s individual needs and the SLP’s target should be to use morphosyntax in order to ameliorate communication.
CONCLUSIONS In conclusion, SLPs need qualitative assessment tools in relation to their specific language typology. Typologically similar languages may use some common general principles, but SLPs in different sociolinguistic environments must formulate their own tools according to their language typology and culture. From my clinical experience, I have ascertained that for inflected languages, the Word and Paradigm Model is the more convenient tool for measuring morphosyntactic development and planning a more effective intervention programme.
BIBLIOGRAPHY 1. Brown, R. (1973), A First Language: The Early Stage. Cambridge: Harvard University Press. 2. Crystal, D. (1974), Review of R. Brown, A First Language: The Early Stages, Journal Of Child Language, 1, 289-307. 3. Eisenberg, A., Fersko, T.M. and Lundgren, C. (2001), The Use of MLU for Identifying Language Impairment in Preschool Children: A Review. American Journal of SpeechLanguage Pathology, 10, 323-342. 4. Katamba, F. (1993), Morphology, Macmillan Press: London. 5. Klee, T., Schaffer, M., May, S., Membrino, I. and Mougery, K. (1989), A Comparison of the Age-MLU Relation in Normal and Specifically Language-Impaired Preschool Children. Journal of Speech and Hearing Disorders, 54, 226-233. 6. Matthews, P.H. (1991) Morphology, Cambridge University Press. 7. Owens, R. (1996), Preschool Development of Language Form in Language Development: An Introduction, Allyn and Bacon: Boston, 301-336. 8. Pinker, S. (1984), Inflection in Language Learnability and Language Development, Harvard University Press: Cambridge, 166-208. 9. Pizzuto, E. and Caselli, M.C. (1994), The acquisition of Italian Verb Morphology in a Crosslinguistic Perspective in Other Children, Other Languages: Issues in the Theory of Language Acquisition, edited by Yolanda Levy, 1994, Hillsdale: New Jersey, 137-187.
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10. Rollins, P.R., Snow, C.E. And Willett, J. (1996), Predictors of MLU: Semantic and Morphological Developments, First Language, 16, 243-259.
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FP16.1 PROCESSING SPEED AND LANGUAGE OUTCOMES FOLLOWING RISK-ADAPTED TREATMENT FOR MEDULLOBLASTOMA F. M. Lewis1, B. E. Murdoch1 1 University of Queensland, Brisbane, Australia
Introduction The use of cranial radiation therapy (CRT) in treatment protocols for medulloblastoma (MB) has improved rates of survival from 20 % to 65 – 80 % (Butler & Haser, 2006). Survival, however, may come at a cost, as CRT targeting the craniospinal axis is associated with deleterious neurocognitive treatment outcomes for children (Gottardo & Gajjar, 2006) including decreased rates of information processing (Mabbott, Penkman, Witol, & Strother, 2008). Information processing speed is important for skill and knowledge acquisition in normal development and it is possible that reduced information processing speed following CRT for MB may impede subsequent language skill development. The status of language skills following radiation therapy for MB is currently not clear. Hudson and Murdoch (1992), using a sensitive test battery designed to assess a range of language skills, identified transitory lexical-semantic deficits in the immediate post-treatment phase in three children treated for MB with 45-50 Gy, but language outcomes for the three children up to 28 months post–treatment were variable, ranging from marginal improvements over 19 months post-treatment to declining language over a period of 14 months post-treatment. Brown and colleagues (Brown, Felton, Key, Elster, & Hickling, 1992) described receptive and expressive language deficits in a child seven years after treatment for MB consisting of 40 Gy to the whole brain and neuraxis and a boost of 10 Gy to the posterior fossa. Callu et al. (2008), on the other hand, monitored a child’s development for 11 years following treatment for MB consisting of whole posterior fossa cranial radiation of 54 Gy, and described preserved language abilities, while Maddrey et al. (2005) determined language skill was the least impaired domain in a group of 10-year survivors of MB whose mean radiation dose was 37.9 Gy to the craniospinal axis and 15.5 Gy boost to the posterior fossa. The results of the four studies investigating treatment outcomes in the skill area of language listed above, however, have limited clinical applicability regarding the language outcomes following treatment for MB. Firstly, none of the studies employed language tests that cover a wide range of language skills. Callu et al.’s (2008) findings, for instance, were restricted to vocabulary skill alone, and naming abilities only were represented in the study undertaken by Maddrey et al. (2005). Although Hudson and Murdoch (1992) undertook a broad assessment of general language skills, they did not examine high level language abilities. Secondly, none of the findings from these language studies have current clinical relevance as the treatments administered at the time of the studies no longer reflect contemporary MB treatment protocols. Contemporary treatment protocols for MB employ risk-adapted strategies to reduce the neurocognitive deficits following CRT. These include lower dose craniospinal radiation for standard risk presentations and the delivery of smaller dose CRT “fractions” more frequently (Askins & Moore, 2008). The children investigated by Maddrey et al. (2005), Hudson and Murdoch
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(1992), Brown et al. (1992), and Callu et al. (2008) were not treated with risk-adapted treatments such as reduced-dose fraction-delivered craniospinal radiation. The aims of the study were to apply behavioural and neurophysiological measures to profile the general language, high level language, and information processing skills of AC, a 14; 1 year old female whose treatment for MB four years prior was initiated using risk-adapted strategies and included reduced craniospinal radiation dose via fractionated delivery.
Method AC, a female aged 14; 1 years at the time of current language assessment, was treated for MB four years prior with reduced dose (23.4 Gy) CRT delivered over 13 fractions to the craniospinal space and a CRT posterior fossa boost of 55.8 Gy delivered over 31 fractions. Prior to diagnosis, she was reported to be functioning academically in the high average range. AC’s information processing skills were assessed via an evaluation using event related potentials, triggered by an online semantic processing activity using a cross-modal picture-word matching task consisting of congruent and incongruent trials. Three females (M age = 13:9 years, SD = 1; 9 years, range = 12; 6 years – 15; 10 years) with unremarkable developmental, medical, and educational histories provided comparative neurophysiological data. A series of modified t tests were used to inform on AC’s information processing speed relative to the control group for both the congruent and incongruent conditions. AC’s general language skills were assessed using the Clinical Evaluation of Language Fundamentals-Fourth (CELF-4) and the Peabody Picture Vocabulary TestThird Edition, Form IIIA (PPVT). The Test of Problem Solving-2 Adolescent (TOPS) and the Test of Language Competence-Expanded Edition (TLC-E) were administered to assess high level language skills. AC’s Standard Scores equal to or within +/- 1 SD of the tests’ means were judged to be within the average range. Standard Scores > - 1 SD of the tests’ mean were viewed as indicative of significant deficit in AC’s performance.
Results AC’s latencies in attaining peak amplitude were similar to that of the control group for both experimental conditions, suggesting intact information processing speed. Her general language skills as assessed by the CELF-4 and the PPVT were within the average range, except on the Recalling Sentences subtest which was > - 1 SD of the subtest mean. AC’s high level language skills were below the average range. Problem solving skills (as assessed by the TOPS), skill with interpreting ambiguity, inferential, metaphorical, and figurative language and her ability to produce sentences that show evidence of correct language content, form, and use (as assessed by the four TLC-E subtests) were all > - 1 SD of the test’s means. Her overall metalinguistic competence in semantics, syntax, and/or pragmatics (as reflected by the TLC-E composite score) was well below the test mean score (> - 2 SD).
Discussion AC’s treatment for MB, consisting of reduced dose craniospinal radiation delivered over a number of fractions, was devised using risk-adapted treatment strategies to reduce the negative sequelae of CRT. The findings of the present study suggest that her information processing speed and general language skills were
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within the average range. Nonetheless, despite risk-adapted treatment regimens for MB, her high level language skill development was compromised. A reduction in processing speed has been suggested as one of the first cognitive skills to decline following the administration of CRT to tumour sites (Mabbott et al., 2008). AC’s current speed of processing information, which was on par with her peers, could suggest she has experienced no adverse effects of her riskadapted treatment, particularly when coupled with her intact general language skills. It is possible, however, that AC’s deficiencies in high level language skills may be indicative of deleterious treatment, notwithstanding her risk-adapted treatment. Intact white matter tracts play an integral role in the acquisition of new knowledge and the consolidation of skills, and irreversible changes to the white matter tracts have been reported following CRT (Khong et al., 2003). A failure to develop new language skills has been proposed as a reason for the increasing gap between test scores and age-matched normative samples rather than the loss of already acquired skills in children treated for brain tumours relative to their peers (Mabbott et al., 2008; Mulhern et al., 2004). The emergence and consolidation of general language skills, such as those assessed by the CELF-4 occurs in the early primary school years. AC was diagnosed at the age of 10 years, and it is likely that her general language skills were well established prior to the implementation of CRT. In contrast, the higher-order complex language skills assessed by the TOPS and the TLC-E emerge subsequent to the formative general language skills. It is therefore possible that AC was yet to acquire and/or consolidate the more complex skills language skills when her treatment began. Based on AC’s performance on the TLC-E, it is possible that the emergence of the more cognitively demanding, later developing language skills has been hindered due to reduced integrity of white matter tracts subsequent to CRT, as previous research has described intact general language skills but difficulties with high level language tasks associated with impaired functional or structural white matter (Lethlean & Murdoch, 1997). The significant deficits identified in the present study suggest that risk-adapted treatment for MB may still have a detrimental effect on the integrity of white matter tracts, resulting in reduced language outcomes for AC. Changes to the white matter tracts may not become apparent until several years post treatment (Palmer, 2008). As such, it is crucial that AC’s high level language skills, as well as her general language and processing skills, be monitored. The findings of the present study indicate that larger studies are required to determine if the potential increased risk of relapse associated with risk-adapted treatment are compensated by better language outcomes for children treated for MB.
References Askins, M. A., & Moore, B. D., III (2008). Preventing neurocognitive late effects in childhood cancer survivors. Journal of Child Neurology, 23, 1160-1171. Brown, I. S., Felton, R. H., Key, L., Jr , Elster, A. D., & Hickling, W. (1992). Six-year follow-up of a case of radiation injury following treatment for medulloblastoma. Journal of Child Neurology, 7, 172-179. Butler, R. W., & Haser, J. K. (2006). Neurocognitive effects of treatment for childhood cancer. Mental Retardation and Developmental Disabilities Research Reviews, 12, 184-191. Callu, D., Laroussinie, F., Kieffer, V., Notteghem, P., Zerah, M., Hartmann, O., et al. (2008). Remediation of learning difficulties in children after treatment for a cerebellar medulloblastoma: A single-case study. Developmental Neurorehabilitation, 11(1), 16-24. Gottardo, N. G., & Gajjar, A. (2006). Current therapy for medulloblastoma. Current Treatment Options in Neurology, 8(4), 319-334.
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Hudson, L. J., & Murdoch, B. E. (1992). Language recovery following surgery and CNS prophylaxis for the treatment of childhood medulloblastoma: A prospective study of three cases. Aphasiology, 6(1), 17-28. Khong, P.-L., Kwong, D. L. W., Chan, G. C. F., Sham, J. S. T., Chan, F.-L., & Ooi, G.-C. (2003). Diffusion-tensor imaging for the detection and quantification of treatment-induced white matter injury in children with medulloblastoma: A pilot study. American Journal of Neuroradiology, 24, 734-740. Lethlean, J. B., & Murdoch, B. E. (1997). Performance of subjects with multiple sclerosis on tests of high level language. Aphasiology, 11, 39-57. Mabbott, D. J., Penkman, L., Witol, A., & Strother, D. (2008). Core neurocognitive functions in children treated for posterior fossa tumors. Neuropsychology, 22(2), 159-168. Maddrey, A. M., Bergeron, J. A., Lombardo, E. R., McDonald, N. K., Mulne, A. F., Barenberg, P. D., et al. (2005). Neuropsychological performance and quality of life of 10 year survivors of childhood medulloblastoma. Journal of Neuro-Oncology, 72, 245-253. Mulhern, R. K., White, H. A., Glass, J. O., Kun, L. E., Leigh, L., Thompson, S. J., et al. (2004). Attentional functioning and white matter integrity among survivors of malignant brain tumours of childhood. Journal of the International Neuropsychological Society, 10, 180-198. Palmer, S. L. (2008). Neurodevelopmental impact on children treated for medulloblastoma: A review and proposed conceptual model. Developmental Disabilities Research Reviews, 14, 203-210.
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FP06.4 THE APPLICATION OF THREE DIFFERING THEORETICAL PERSPECTIVES IN AN EXAMINATION OF LANGUAGE SKILLS IN ASPERGER SYNDROME AND HIGH FUNCTIONING AUTISM F. M. Lewis1, G. C. Woodyatt1, B. E. Murdoch1 1 University of Queensland, Brisbane, Australia
Introduction Three theoretical perspectives define the research into language skills in Asperger disorder/syndrome (AS) and high functioning autism (HFA). The first approach emerged following the categorical distinction made in DSM-IV, based on the timing of onset and subsequent development of language, between AS and Autistic Disorder (AD). That distinction has led to ongoing debate regarding the
external validity of the diagnosis of AS from the diagnosis of AD with average intelligence (HFA). The theoretical basis for this research focus reflects the historical dilemma of determining the relationship, if any, between AS and AD. Validation studies, focusing on the relevance of developmental language history on linguistic outcomes in AS and HFA, have predominantly investigated linguistic skills (e.g., Mayes & Calhoun, 2001; Szatmari et al., 1995), although pragmatic aspects of language have also been examined (e.g., Paul et al., 2009; Barbaro & Dissanayake, 2007). Findings have been inconclusive. Mayes and Calhoun’s (2001) results, which refuted the validity of AS as distinct from HFA, led the authors to call for the removal of AS from the next DSM. In contrast, Szatmari et al. (1995), concluded differences between AS and HFA may be quantitative rather than qualitative. That is, both are part of the same autistic presentation, but differentiation can be made by the degree of their disability.
The second theoretical approach is based on the assumption that AS and HFA are similar presentations of a single disorder. A number of studies examining language and communication skills have been undertaken where participants have been AS and/or HFA, with no delineation attempted between the two groups (e.g., Shields, Varley, Broks, & Simpson, 1996). Compared to normally developing peers and/or language impaired controls, individuals with AS/HFA have been described as experiencing linguistic deficits, as well as difficulties with pragmatics and discourse, planning and problem solving. The third theoretical perspective, evident in a recent shift in the terminology used in research, acknowledges both the similarities and differences in the AS and HFA presentation. The term autistic
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continuum/autistic spectrum (ASD) was introduced by Wing (1989) as a means of acknowledging all individuals presenting with the triad of autistic characteristics, irrespective of the severity of the symptoms. It is now being used to describe research populations which have previously been referred to as AS or HFA (e.g., Myers et al., 2007) even though a diagnosis of ASD does not exist in the ICD-10 or DSM-IV. Some researchers, such as Volden (2004) and Paul et al. (2005), have adopted the ASD nomenclature in their studies and described significant differences between the ASD group and typically developing children on a range of linguistic and pragmatic measures. While conceptualising AS and HFA as disorders on an autism spectrum, Volden and Paul et al. failed to accurately apply the theoretical perspective of the spectrum studies; that is, viewing ASD as a continuum, with a range of skills represented within that continuum. Prior et al. (1998), however, accurately applied the theoretical perspective of a continuum of autistic disorders in their investigation of current functioning of a group of children with a diagnosis of either AS, HFA, or a related pervasive developmental disorder. Measures included social interaction, communication, imagination, chosen self-behaviour, first- and second-order theory of mind tasks, and verbal abilities. Unlike Volden (2004) and Paul and co-researchers (2005), Prior and colleagues examined the ASD group for differences within the combined group of children. Although all the children had intelligence close to normal range, Prior et al. described three clusters of children within the participant group. The clusters differed significantly on verbal abilities and theory of mind tasks. Interestingly, given the focus of the validation studies, developmental language history was not significant in determining the differentiation of the clusters, and Prior et al. cautioned against using developmental history for differential diagnosis.
The hallmarks of clinically useful findings from research into AS and HFA are encapsulated in Gillberg’s (1998) management guidelines for AS and HFA, where the first guideline states “appropriate assessment [italics added] and correct diagnosis [is] essential for optimal understanding and service” [italics added] (p. 208). All three theoretical approaches have the potential to further the clinical understanding of the language skills associated with AS and HFA, but methodological limitations, particularly the range of language skills investigated, limit the clinical relevance of research findings to date. This, in turn, may lead to an inadequate provision of intervention services to the AS/HFA population. For the three theoretical approaches to provide clinically applicable findings, it may be necessary for each approach to comprehensively assess a range of language and communication skills in AS/HFA. The present study aimed to comprehensively investigate language skills in a group of children of average intelligence with a diagnosis of AS/HFA/ASD using the three approaches found in the literature. The clinical applicability of findings from the different theoretical approaches will be discussed.
Method Participants Twenty children (16 male; M age: 11; 6) with average intelligence and a diagnosis of AS, HFA, or ASD (all diagnoses henceforth referred to as ASD unless otherwise stated) and 18 control children (14 males; M age: 11; 5) were recruited for the study.
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Measures Non verbal intelligence was assessed using the Test of Nonverbal Intelligence-Second Edition (Form A) (TONI-2). Core language was assessed using the Clinical Evaluation of Language Fundamentals-Fourth Edition (CELF-4). High level language skills were assessed using the Test of Language Competence-Expanded Edition-Level 2 (TLC-E). Critical thinking skills were assessed using age-appropriate tests from the Test of Problem Solving series (TOPS), and pragmatic language skills were assessed using the Right Hemisphere
Language Battery (RHLB). Procedure The three theoretical approaches were applied to three studies: general language skills (CELF-4), high level language skills (TLC-E), and pragmatic language (RHLB). Scoring limitations allowed only two of the three approaches to be undertaken with the TOPS. For the validation studies, children with a diagnosis of ASD were reclassified as AS or HFA based on their reported developmental language history. Using DSMIV’s language criterion, the reclassification of the children resulted in three groups: AS (onset of first words prior to two years of age): n = 10, M age: 12; 5, HFA (onset after two years of age): n = 8, M age: 11; 4, and those with unsure developmental language history (n = 2). The Unsure group data were excluded from the reclassification statistical analyses. For the combined studies, all ASD children were combined into the one group, and no delineation between AS/HFA/ASD was attempted. For the withingroup continuum studies, hierarchical cluster analyses were undertaken and the identified subgroups were descriptively compared to the control group’s means and standard deviations.
Results Validation studies Children reclassified as AS were more proficient than those reclassified as HFA on tasks requiring resolution of ambiguity (p = .036) and interpretation of metaphors presented pictorially (p = .031).
Combined studies The combined ASD group performed less well than the control group on Core Language (p = .001), Receptive Language (p = .037), Expressive Language (p = .001), Language Content (p = .001), Language Memory (p = .002), Ambiguous Sentences (p = .001), Listening Comprehension: Making Inferences (p = .005), Oral Expression: Recreating Sentences (p = .001), Lexical Semantic Test (p = .037), Comprehension of Inferred Meaning (p =.007), Production of Emphatic Stress (p = .002), and on the TOPS (p = .001) when the effect of language skill was removed. There were no significant differences between the two groups on Figurative Language, Metaphor Picture, Written Metaphor, or Appreciation of Humour (p ≥ .05). Descriptively, the spread of scores for the ASD across the range of measures was far greater than the control group, suggesting heterogeneous language skills within the ASD group.
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Within-group continuum studies The ASD group of children could be differentiated on language skills across the three studies (general language, high level language, and pragmatic language).
An examination of within-group differences in the current study revealed language competence in children with ASD ranged from above-average skills through to severe deficits. Nonverbal cognitive skill was a significant factor for some of the subgroupings. There was some consistency in performance across the three continuum studies, with some children either consistently in the above average range for all measures or consistently in the severe deficit range across all measures. There were children whose performance was inconsistent across the range of language measures. Discussion Although children reclassified as AS were more proficient than those reclassified as HFA on tasks requiring resolution of ambiguity and interpretation of metaphors presented pictorially, the validation approach to defining language and communication skills in AS and HFA provided findings that may have limited clinical applicability as the approach relies upon the retrospective recall of developmental language milestones, which may be inaccurate or the interpretation of which may lead to conflicting diagnoses (Woodbury-Smith, Klin, & Volkmar, 2005). The second approach, where AS and HFA were conceptualised as similar autistic presentations, revealed clinically useful information on the performance of the ASD group relative to controls, but heterogeneity of skills across the studies was noted. This conceptualisation provided no analysis of the range of skill within the combined ASD group, and hence offered limited clinical utility. The third approach, where AS and HFA were conceptualised, not as separate, or conversely, similar diagnostic categories, but as disorders on an autism spectrum, provided information that could be applied to formulate individual intervention plans for children with ASD. The provision of a diagnosis of AS and HFA allows access to intervention, and Speech Pathologists are front line service providers. The next DSM is due in 2011, and a recent update from DSM’s Neurodevelopmental Disorders Work Group indicates that the classification of AD and HFA is still under active discussion (Swedo, 2008). A conceptualisation of these disorders which provides clinical utility to Speech Pathologists needs to be considered in discussions for DSM-V.
References Barbaro, J. & Dissanayake, C. (2007). A comparative study of the use and understanding of self-presentational display rules in children with high functioning autism and Asperger disorder. Journal of Autism and Developmental Disorders, 37, 1235-1246. Gillberg, C. (1998). Asperger syndrome and high-functioning autism. British Journal of Psychiatry, 172, 200-209. Mayes, S. D., & Calhoun, S. L. (2001). Non-significance of early speech delay in children with autism and normal intelligence and implications for DSM-IV Asperger's disorder. Autism, 5(1), 81-94. Myers, S. M., Johnson, C. P., and the Council on Children with Disabilities. (2007). Management of children with autism spectrum disorders. Pediatrics, 120(5), 11621182.
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Paul, R., Augustyn, A., Klin, A., & Volkmar, F. (2005). Perception and production of prosody by speakers with autism spectrum disorders. Journal of Autism and Developmental Disorders, 35(2), 205-220. Paul, R., Orlovski, S. M., Marcinko, H. C., & Volkmar, F. (2009). Conversational behaviors in youth with high-functioning ASD and Asperger Syndrome. Journal of Autism and Developmental Disorders, 39, 115-125. Prior, M., Leekam, S., Ong, B., Eisenmajer, R., Wing, L., Gould, J., et al. (1998). Are there subgroups within the autistic spectrum? A cluster analysis of a group of children with autistic spectrum disorders. Journal of Child Psychology and Psychiatry, 39(6), 893902. Shields, J., Varley, R., Broks, P., & Simpson, A. (1996). Hemispheric function in developmental language disorders and high-level autism. Developmental Medicine and Child Neurology, 38, 473-486. Swedo, S. (2008). Report of the DSM-V neurodevelopmental disorders work group. Retrieved December 16 2009 from http://psychiatry.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivitie s/DSMVWorkGroupReports/NeurodevelopmentalDisordersWorkGroupReport.asp x Szatmari, P., Archer, L., Fisman, S., Streiner, D. L., & Wilson, F. (1995). Asperger's syndrome and autism: Differences in behavior, cognition, and adaptive functioning. Journal of the American Academy of Child and Adolescent Psychiatry, 34(12), 1662-1671. Volden, J. (2004). Conversational repair in speakers with autism spectrum disorder. International Journal of Language and Communication Disorders, 39(2), 171-189. Wing, L. (1989). The diagnosis of autism. In C. Gillberg (Ed.), Diagnosis and treatment of autism (pp. 5-22). New York: Plenum Press. Woodbury-Smith, M., Klin, A., & Volkmar, F. (2005). Asperger's syndrome: A comparison of clinical diagnoses and those made according to the ICD-10 and DSM-IV. Journal of Autism and Developmental Disorders, 35(2), 235-240.
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P026 GRAMMATICAL ASPECTS IN SPONTANEOUS COMMUNICATION IN CHILDREN WITH DOWN SYNDROME SCO Limongi, AMA Carvalho, SF Marques, P Mello, RV Andrade University of São Paulo , São Paulo , Brazil Introduction and mains of the study From the end of the first year of life, the children with typical development (TD) generally start to speak their first words to designate an object or a situation, which will later compose their first sentences. Researches have reported great vocabulary increase by the end of the second year. Some studies have argued that, during the lexical acquisition period, children with TD usually name objects and actions, prior starting naming their attributes. It is expected that the closed word classes (pronouns, prepositions, conjunctions) also will be used later in language development, once they indicate relationships between words referred to objects and actions. Adjectives are also acquired later because it involves ideas dependent of perceptual observation of the objects’ properties, concepts or semantic values 1,2. Considering the lexical-semantic development, some authors have pointed out that there is a gap between the beginning of words comprehension and their oral production. In comparison to children with TD, a larger gap between these abilities is observed in children with Down syndrome (DS) present. According to the literature, language in DS is characterized by the following traits: significant delays in oral production, with prolonged use of gestures; comprehension is better than expression; in the presence of oral expression, the speech is frequently unintelligible; generalized delay in linguistic aspects, with relative strengths in lexical and more significant deficits in morphological and syntactic aspects of language development 3. During the oral expression, the children with DS tend to use simple sentences in which articles, prepositions, pronouns and conjunctions are omitted. In this sense, some authors 4 have reinforced the idea of dependence between grammatical and lexical development in these children. On the other hand, other researches have pointed out that the gap between morpho-syntactic and lexical abilities decrease with age. The analysis of children´s spontaneous speech samples allows the identification of qualitative and quantitative aspects of language development and language disorders. One frequently used instrument for this purpose is the MLU, and since its description5, several studies have been conducted with different populations. MLU analysis involves morphemes (MLU-m), indicated as an index to verify grammatical development, and words (MLU-w), with the objective to supply data concerning children’s general linguistic development. Some researchers6 have reported strong correlations between MLU-m and MLU-w, showing that MLU-w is a reliable and sensitive measure to calculate the utterance extension as well as to analyze language complexity not only in TD children, but also in children with language deficits, as the children with DS. The aim of this study was to verify and characterize the grammatical aspects in spontaneous communication in children with Down syndrome (DS) using the MLU-m, including GM-1 (articles, substantives, verbs) and GM-2 (pronouns, prepositions and conjunctions), the MLU-w, and word classes.
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Methods Participants were 15 children with DS (participants group = PG) aged between 5 and 11 years were arranged in 3 groups according to their mental age, measured through PTONI7: G1 (3 to 3:11 years; mean cronological age 6:3); G2 (4 to 4:11 years; mean cronological age 8:4); G3 (5 to 5:11 years; mean cronological age 10:9). All participants had a free trissomy of chromosome 21 (confirmed by the karyotype exam); oral language as the main means of communication; absence of visual or hearing impairment (only children with normal social hearing confirmed by audiological objective tests were considered); and were being raised as monolingual Brazilian Portuguese speakers. All participants were attending speech-language therapy at the Speech Language Pathology Laboratory in Syndromes and Sensorimotor Deficits (SLPL-SSD) of the School of Medicine of the University of São Paulo. This research was approved by the Ethics Committee for the Analysis of Research Projects of the Clinical Hospital of the School of Medicine of University of São Paulo (protocol number 0940/2007). The data collection was carried out in a 30minute spontaneous interaction between child and therapist, in a free play situation with toys, miniatures of objects, and geometrical wood blocks. All sessions were videotaped. The speech samples were composed by the first 100 utterances produced by the participants, starting after the first five minutes of interaction. All utterances produced by the children were considered, including unintelligible segments. The oral emissions of each child were transcribed, as well as their gestures, in order to help the interpretation of oral emissions related to actions and activities. The analysis involved the MLU-m, MLU-w and word classes. All words produced were analyzed, including adjectives, adverbs, interjections, numbers and onomatopoeias. Data analysis was carried out using specific protocols. For statistical analysis, the following tests were used: ANOVA, Turkey, TStudent, Mann-Withney, Kruskal-Wallis, Friedman, and Wilcoxon. The threshold adopted for significance was 0.05. In order to check the reliability of the data, agreement analysis was conducted with 20% of the tapes and two judges were used for data recoding. The mean agreement level was 92%. For typical development parameters we adopted the references published for MLU in Brazilian children with typical language development (TD) (control group = CG) 8.
Results Results showed significant differences among groups for MLU-m (p=0,008) and MLU-w (p=0,007). Specifically for MLU-m, significant differences were found for all groups considering GM-1 (p=0,007), but not for GM-2. Considering the withingroup analysis, differences between MLU-m and MLU-w were statistically significant (p=0,043 for G1; p=0,002 for G2; p=0,005 for G3), as well as between GM-1 and GM-2 (p=0,004 for G1; p= b + b +*
a, b = scores with a = highest score and b = lowest score Table 1: symptoms according to the tree most common hypothesis Since there is no consensus on these models and a lack of information on the comorbidity of dyslexia with other disorders in Flanders in addition with a lack of studies on the impact of comorbidity on the reading-, spelling- and mathematical disabilities in children with dyslexia, this study was set up.
(*)Methods: Subjects
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Participants were 121 average intelligent children (81 boys and 40 girls) with dyslexia and 57 age-and gender-matched controle children (40 boys and 17 girls) between 7.6 and 10.6 years. All children with dyslexia had a clinical diagnose and scored in the past year several times beneath percentile 10 on reading or spelling tests. Children with ADHD had a clinical diagnosis and meet the Diagnostic criteria of DSM-IV (American Psychiatric Association, 1994). All diagnosis were checked in a pretest. Only children scoring < pc 17 on the pretests to assess their disability were included in this study
Instruments. Technical reading was evaluated with the EMT (Brus & Voeten, 1999) and Klepel (Van den Bos et al., 1994). Reading comprehension was tested with the Reading Comprehension Test Aarnoutse (1996). Spelling was evaluated with the PIdictation (Geelhoed & Reitsma, 1999). Mathematics was evaluated with: the Number Facts Test (Tempotest Rekenen, TTR, De Vos, 1992) and the shortened visuospatial teacher questionnaire (SVS, Cornoldi, Venneri, Marconato, Molin, & Montinari, 2003).In addition, the Tedi-Math (Gregoire, Noël & Van Nieuwenhoven,2004) was included to assess the skills according to the Triple code proposed by Dehaene (1992) , namely non-symbolic magnitude comparison skills, symbolic skills to deal with Arabic numbers and symbolic skills to deal with number words. All children were assessed by specially trained investigators and this at three different moments.
(*)Results: Of the 121 children with dyslexia 41% only had dyslexia, 30% also had dyscalculia and comorbitdity with ADHD was found in 33% . A MANOVA was conducted with the results on the reading and spelling tests (EMT, Klepel, Aarnoutse and PI dictation) as dependent variables and the group (controls, dyslexia, dyslexia and AHDH, dyslexia and dyscalculia) as independent variable. The MANOVA was significant on the multivariate level (F (4,149) = 12,49; p0.05) between the two groups in respect of type and number of disfluencies within words and at the end of words. Significant difference was found between the groups concerning some type of morphemes: nouns (p
