Athens 2010 IALP - PROCEEDINGS PDF

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
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
(PL) 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 PL 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
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
CONTENTS
Alternative and Augmentative Communication
Title of paper ...Page
Aphasia
Audiology
Child Language
Education for speech and Language Pathology
Dysphagia
Education for Speech and Language Pathology
Fluency
Motor Speech Disorders
Multilingual Affairs
Phoniatrics
Voice
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
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 feeders
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 students
bid.
5) Feeders 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.
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.
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).
Besides the Lisinas 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 Kirkebk 2001, f. 78
,79):
Where is the childs focus of concentration
Direction of sight ( where is child looking)
The direction of hearing
Touching and feeling using hands, foots, face / mouth, body
Which are the expression forms of the child
Usage of gestures
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.
10
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 Prparimi 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 Prparimi in Prishtina to implement and develop AAC.
Things to do are as follows:

Evaluate the state of development of communication at all children of the school, difficulties in
communication,
Create symbols to structure the day, week etc
Organize the materials according the subjects, e.g. biology etc
Continue with trainings of teachers regarding AAC
Work with concrete and real tools
Prepare the passport for communication of the child
The booklet Gate Book which is wider than the passport
The concept of time covering days which can be done according to colors: e.g. Monday green
Structure of the materials of school, in drawers where we put the photos to show what is inside
Creation of everyday situations where signs are needed
Creation of tables and books for communication
Changing the symbols according to the childs 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
11
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 beteen young children with and ithout 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
12
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)***; Crnio, MS (Supervisor)****
Department of Physiotherapy, Speech and Language Pathology and Occupational Therapy of
Medical School University of So Paulo (FMUSP), So 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 4 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- Plo 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 So Paulo (FMUSP).
Introduction
Many studies verify that deaf children approach school age with no established language, that is, they
didnt 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
(Gonalo, 2004; Meirelles & Spinillo 2004).
13
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 (Arf & Perondi, 2008).
Lima and Crnio (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 & Crnio, 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 & Crnio, 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.
14
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 & Crnio, 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 & Crnio, 2007; Guarinello et al. 2008), however it seems that they dont 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 (Gonalo, 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 (Arf & Perondi, 2008 and Crnio 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, Crnio MS. Protocolos para avaliao de Leitura e Escrita Laboratrio de Investigao Fonoaudiolgica em
Linguagem Oral, Escrita e de Sinais de Deficientes Auditivos do Curso de Fonoaudiologia da FMUSP,1999.
Arf 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):223.
Burman D, Evans D, Nunes T, Bell D. Assessing deaf childrens writing in primary scholl: grammar and story
development. Deafness and Education International, 2008; 10 (2): 93-110
Crnio, MS; Silva, EC; Couto, MIV. Relao entre nveis de compreenso e estratgias de leitura utilizadas por surdos
sinalizadores em um programa teraputico. Soc Bras Fonoaudiol; (no prelo).
Crato NA, Crnio MS. Protocolo de anamnese para surdos 2007. Adaptado de Gonalo SF 2004. Anamnese
fonoaudiolgica. Protocolo de uso restrito nesta pesquisa.
Crato NA, Crnio MS. Anlise da flexo verbal de tempo na escrita de surdos sinalizadores. Revista Brasileira de
educao Especial, v.15, p.233-250, 2009.
15
Ferreiro E. Literacy development: Psychogenesis. In Y. Goodman (Ed.), How children construct literacy (pp. 1225).
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 Educao
Especial 2007; 13(2):205-218.
Gonalo SF. Perfil da produo escrita e da trajetria escolar de alunos surdos de ensino mdio. [Dissertao] So Paulo:
Faculdade de Educao da Universidade de So 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, Crnio MS. Anlise da produo escrita de surdos do ensino superior. So Paulo, 2007. Adaptado de RomanoSoares S. Prticas de narrativas escritas em estudantes do ensino fundamental. [Dissertao] So Paulo:
Faculdade de Educao da Universidade de So Paulo, 2007.
Maingueneau D. Anlise de textos de comunicao. So 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 Anlise da coeso textual e da estrutura narrativa em textos escritos por adolescentes
surdos. Estudos de Psicologia 2004; 9(1):131-144.
Neira PRQ. Anlise da leitura das imagens das histrias em quadrinhos a partir de produes escritas de adolescentes
surdos. [Dissertao]. So Paulo: Faculdade de Educao da Universidade de So Paulo, 2003.
16
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
17
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.
18
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.
19
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.crianas 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
20
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.
REFERNCIAS
1. World Health of Organization. World report on violence and health. WHO, 2002.
2. Schraiber LB. Romper com a violncia contra a mulher : como lidar desde a perspectiva do campo da sade.
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 Dinmica Familiar:Aspectos
observados em processos jurdicos. Psicologia: Teoria e Pesquisa Set-Dez 2005, Vol. 21 n. 3, pp. 341-348.
4. Pino, A. Violncia, educao e sociedade: um olhar sobre o Brasil contemporneo. Educao e Sociedade.
Campinas, v. 28, n. 100, 2007.
5. Minayo
MCS.
Entrevista
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. Violncia, criana, escola, trabalho e comunidade. Seminrio Internacional Violncia e Criana. So
Paulo, 6 a 8 de novembro de 2000.
7. Cunha JM. Violncia interpessoal em escolas no Brasil: caractersticas e correlatos. [Dissertao] Programa de
Ps-Graduao em Educao da Universidade Federal do Paran. 2009.
8. Ministrio da Educao. Ensino fundamental de nove anos: orientaes para a incluso da criana de seis anos
de idade. Braslia: MEC; 2006.
9. World Health of Organization. World Report on Violence against Children. United Nations Secretary-Generals
Study. WHO, 2003.
10. Rede Nacional de Preveno de Violncias, Promoo da Sade e Cultura de Paz (Portaria 936/2004).
21
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 Downs Syndrome (one
wheelchair bound), one student with Angelmans Syndrome, one student with Rhetts 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.
22
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
23
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
childs 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 childs
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 students 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.
24
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 Johnsons Boardmaker, Photographs, Mayer Johnsons 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
25
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 students
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. Students 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 students 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 units 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.
26
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 students 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.
27
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. Mouro3
1 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.
28
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, So 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.
29
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. Dirio de Narciso: discurso e afasia: anlise discursiva de interlocues com afsicos. 3 ed. So 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. Validao da escala de avaliao da qualidade de vida na doena cerebrovascular isqumica para a lngua
portuguesa. Validation of the stroke specific quality of life scale to Portuguese language. Tese [Doutorado]. Faculdade
de Medicina da Universidade de So Paulo, So Paulo, 2007.
30
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 childrens 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 childrens communication and their
communication aids.
Research questions are:
What are the challenges for parents regarding their childrens 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 childrens
communication and related challenges based on the childrens severe communicative limitations and their
needs for alternative communication modes, independent of the childrens other abilities.
31
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 childs 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 childrens 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 childs
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 childs 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 childs 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 childs 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 childs emotional situation, independent of the
capacity of the childs SGD.
Parents are aware of family members different ways to deal with the childs 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 childs communicative
abilities (Pickl, 2008).
32
Discussion
The common patterns in parental statements served as the base for answers to the research questions:
Major challenges for parents regarding their childrens limited communication are the childs inability
to share events, to explain emotions and to ask questions. Parents also express frustration regarding their own
inability to understand the child.
The childs inability to share his/her feelings is an emotional issue for all parents, independent of the
childs developmental and communicative level. Parents experience it as a challenge to mostly have to rely on
guesses when it comes to read the childs 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
childs skills in using the device, choice making situations, aiming to increase the childs 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
mothers 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 childs
inability to share his/her emotional state and the reaction of family members to the childs 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 familys life world.
33
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 phnomenologischen Philosophie, 1. Buch. Dordrecht: Kluwer Academic
Publishers.
Kristen, U. (1994). Praxis Untersttzte Kommunikation. Dsseldorf: 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.
34
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 childrens 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 childrens communication and their
communication aids.
Research questions are:
What are the challenges for parents regarding their childrens 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 childrens
communication and related challenges based on the childrens severe communicative limitations and their
needs for alternative communication modes, independent of the childrens 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
35
foci communication between parents and child, the childs 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 childrens 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 childs 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 childs 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 childs 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 childs 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 childs emotional situation, independent of the capacity
of the childs SGD.
Parents are aware of family members different ways to deal with the childs 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 childs 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 childrens limited communication are the childs inability
to share events, to explain emotions and to ask questions. Parents also express frustration regarding their own
inability to understand the child.
The childs inability to share his/her feelings is an emotional issue for all parents, independent of the
childs developmental and communicative level. Parents experience it as a challenge to mostly have to rely on
36
guesses when it comes to read the childs 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
childs skills in using the device, choice making situations, aiming to increase the childs 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
mothers 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 childs
inability to share his/her emotional state and the reaction of family members to the childs 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 familys 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 phnomenologischen Philosophie, 1. Buch. Dordrecht: Kluwer Academic
Publishers.
Kristen, U. (1994). Praxis Untersttzte Kommunikation. Dsseldorf: Verlag
37
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.
38
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 persons 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 populations 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 hostels 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 hostels 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
39
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 hostels patients everyday activities and secondly the
Derbyshire Language Scheme test was given in order to evaluate the patients 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).
40
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.
41
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
anothers 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
42
The role of the speech therapist to enhance communication skills is the link to adjustment of Music-SpeechMovement program into patients 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.
43
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 solation. 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
44
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).
45
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 Brocas aphasia), while four participants
were characterized as having a moderate Brocas 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 PWAs 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
Cohens (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
46
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 patients 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.
47
P129
M1-ALPHA APHASIA TEST: A PROPOSAL FOR READJUSTMENT TO PORTUGUESE
F.C. Garcia, O.M. Takayanagui
School of Medicine in Ribeiro Preto of So Paulo University, Ribeiro 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, its 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 So 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 Ribeiro Preto of the So 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.
48
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 tests 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 Fishers 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<0,05) for the
other tests.
The Wilcoxon test also allowed to notice that the number of mistakes in the repetition test (p<0,05)
was greater than in the reading and naming test.
Regarding the criticism made by the literature, we found a lack of assessment of communicative and
textual competence6, absence of grapheme opposition on the tests of written language 6, failures in pictorial
stimuli6,7,8, absence of increased complexity in the writing comprehension test 8 and difficulty in collecting
data and fulfilling the linguistic profiles6,8.
Concerning the pictorial stimuli, during the description of all illustrations belonging to M1-Alpha
tests, there were a lot of illustrations with faulty interpretation which presented significant differences
verified by the comparison of proportions test, such as the pictures corresponding to matches (82,86%), plate
(62,86%), candy (57,14%), bread (40%), rake (34,29%), bridge (28,57%) in the word comprehension test; The
dog follows the woman and the car (20%) in the complex sentences comprehension test; cat (91,14%), bowl
(51,43%), rose (54,29%), other flowers (54,29%), thread ball (51,43%), roll (48,57%), network (42,86%), bell
(25,71%), barrel (22,86%) in the writing comprehension test; the cat plays (51,43%) in the writing simple
sentences comprehension test, the bus follows the boy and the horse (40%), The horse and the bus follow
the boy (31,43%), The fat man pushes the thin man on the chair (28,57%) in the writing complex sentences
comprehension test; ear (25,71%) and mustache (22,86%) in the denomination test.
In previous researches, the pictorial characteristics were the most responsible for the great number of
inadequate answers in all M1-Alpha tests.
Another criticism refers to the lack of increased complexity in the writing comprehension test. There
were more mistakes in the words tests than in the simple sentences comprehension test, which agreed with
this studys findings. In fact, this study observed more mistakes in words than in complex sentences, which
showed statistically significant difference between the subtests of words and simple sentences through the
Wilcoxon Test.
In regard of collecting data and fulfilling the linguistic profiles, a greater difficulty can be attributed to
the instruments application, ignoring some of its advantages such as fast and easy application 6,8. However, it
is important to say that it is essential the use of a scale to classify the degree of alteration, the establishment of
a prognosis and the possibility of retest9,10.
49
Conclusions:
Based on a combination of all data obtained, the need for restructuring this tool and improving the
tests in several linguistic aspects was proved, in order to readjust them to the cultural and linguistic reality of
the Brazilian population.
Thus, some suggestions were made, such as the readjustment of the Montreal-Toulouse Protocol for
Aphasia Exam M1-Alpha: insert the item narrative deviation in the second part of interviews noting,
directed to assess the alterations in pragmatic abilities during this test; exclude the article in the given order in
the writing and oral comprehension test in order to not offer any extra hint and not facilitate the patients
answer; change the words in the writing test so it can create grapheme oppositions; create a degree of
complexity among the subtests in the writing comprehension tests; modify the sentences in the reading test
and the words and sentences in the repetition test, giving importance to the Brazilian cultural and linguistic
peculiarities, but keeping the syntactic structure; change some illustrations in all tests that had significant
errors, in order to maintain their proper relationship to reality and the fulfillment of their function; insert a
new way of collecting data fast and efficiently using a scale to classify the degrees of language impairment;
and the establishment of a prognosis and the possibility of retest.
References:
Seron, 1979 apud Jakubovicz; Cupello Testagens das afasias. In: ______. Introduo afasia: elementos para diagnstico
e terapia. Rio de Janeiro: Revinter, 1996c. cap. 13, p. 153-195.
1 Pracharitpukdee, N.; Phanthumchinda, K.; Huber, W.; Willmes, K. The Thai version of Aachen aphasia test (THAIAAT). Journal of the Medical Association of Thailand, Bangkok, v. 83, n.6, p. 601-610, jun. 2000.
1 Seron, 1979 apud Jakubovicz; Cupello Testagens das afasias. In: ______. Introduo afasia: elementos para diagnstico
e terapia. Rio de Janeiro: Revinter, 1996c. cap. 13, p. 153-195.
1 Pracharitpukdee, N.; Phanthumchinda, K.; Huber, W.; Willmes, K. The Thai version of Aachen aphasia test (THAIAAT). Journal of the Medical Association of Thailand, Bangkok, v. 83, n.6, p. 601-610, jun. 2000.
1 Mansur, L.L.; Radanovic, M.; Regg, D.; Mendona, L.I.Z.; Scaff, M. Descriptive study of 192 adults with speech and
language disturbances. So Paulo Medical Journal / Revista Paulista de Medicina, So Paulo, v.120, n.6, p.170174, 2002.
6 Junqueira, A.M.S. Adaptao do exame de afasia M1-Alpha ao portugus. 1983. 131f. Dissertao (Mestrado em Letras)
Pontifcia Universidade Catlica de Campinas, Campinas, 1983.
7 Lecours, A.R.; et al. Illiteracy and brain damage: 1. Aphasia testing in culturally contrasted populations (control
subjects). Qubec, Canad: Centre de recherche du Centre Hospitalier Cote-des-Nieges, 1985. 42p.
8 Ortiz, K.Z.; Osborn, E.; Chiari, B.M. O teste M1-Alpha como instrumento de avaliao da afasia. Pr-fono Revista de
Atualizao Cientifica, Barueri, v. 5, n.1, p. 23-29, mar. 1993.
9 Goodglass, H.; Kaplan, E. La naturaleza de las perturbaciones del lenguaje. In: _______. Evaluacin de la afasia y de
trastornos similares. Buenos Aires, Argentina: Panamericana, 1974a. cap. 2, p. 16-25.
10 Pea-Casanova, J. Diguez-Vide, F.; Pamies, M.P. Explorao de base da linguagem para orientao teraputica. In:
Pea-Casanova, J.; Pamies, M.P. Reabilitao da afasia e transtornos associados. 2. ed. Barcelona, Espanha:
Masson, 2005b. cap. 2, p. 27-63.
1
50
FP33.5
FSTIMULATION OF AUDITING VERBAL PERCEPTION AT AWAKE CRANIOTOMY
Klzov M., Galanda M., Galanda V., Donth V., Bullov J.
Neurosurgical Clinic and 2nd Neurological Clinic, University Hospital Bansk Bystrica, Slovakia
Since 2006 Neurosurgical Clinic of Roosevelts University Hospital has carried out awake brain
operations with stimulation of the phatic functions. Up to now we have stimulated the motor elements of
speech (nominative function) with all patients. With dependence on the lesion of the tumour it was necessary
to stimulate the sensory element of speech with some patients, with other patients we stimulated the motor
elements of speech, and afterwards the patient was anesthetized and we continued into surgery; when the
patient awoke again, we stimulated the sensory elements of speech. With some patients we stimulated a
patient with speech during the whole extirpation of the tumour. With the purposeful stimulation and the
auditing of verbal perception we have met a requirement that comes from the specificities of stimulation with
awake craniotomy. The following is a demonstration of the procedure:
Video record:
In specific situation, in which a patient under going awake craniotomy, his manifestations are
extremely individual during the awake phase he has the sense of feel.DISCOMFORT: p o s i t i o n, obtained
by the force of the surgical operation, can be a burden for him, immediately after awakening he can be c o l d,
during stimulation he can be t h i r s t y, sometimes t i r e d.
Therefore it is inevitable for us: to modify flexibly verbal stimulation of the phatic functions according
to the patients situation, as well as through the whole operation, it is necessary to constantly motivate him
towards cooperation during the whole stimulation act.
However, there can also be situations when in spite of wakeful consciousness and repeated appeals
the patient cooperates with us only with closed eyes. From knowledge we learned with stimulation of
auditing verbal perception in awake craniotomy that the application of visual verbal stimuli can be
complicated. This can be seen in the frequent diagnostic batteries stated in publications about the given
problems (BDAE, Token test, Luria test, etc.).
With regard to the fact we came to formulating a system of verbal stimulation items which would
fulfil the following criteria:
1. The time from the moment of setting the item up to its fulfilment by a patient will not exceed 4
seconds.
2.
The item will have: graduating variability from the semantic viewpoint,
3.
graduating phonological and morphological variability,
4.
graduating syntactical variability,
5.
lexical variability.
6.
To a minimum extent, items will determine the response of a patient.
7.
The whole stimulation process will not require any visualisation.
Setting up time limit in the stimulation of the phatic functions with awake craniotomy forced us to
settle the following when compiling the system of stimulation items:
1. It is not our ambition to quantify phatic function directly in the course of awake craniotomy, we
specialize on qualitative approach.
51
2. We drop the ambition to completely examine phatic functions in the course of operation (the state
of phatic functions is evaluated 24 hours before the surgical operation and after it), we prefer the
stimulation of the function of brain area that is to be touched later by the surgical operation.
3. The time of 4 seconds also limits us in quantitative levels of evaluation of the phatic functions. It is
impossible to apply repetition of longer verbal complexes in a set time extent, which is related to, e.g.
lesions in the back part of temporal area.
We paid great attention to the reality that the measurement of working out of verbal stimulus in its
complexity during the auditing of the sounding is individual, and is also determined by the way of submitted
items, on which pace, rhythm, dynamics, accent.
When formulating verbal stimuli at an extremely exact limit of 4 seconds, set for phatic stimulation,
we did not insist on its rigorous division on the time devoted for verbal stimulus and the time defined for a
response. In spite of this we created time space for the patient to be able to correct the verbal stimulus in his
consciousness, while the time of activation of the stimulus is not identical with the time which we offer to a
patient for accepting a stimulus and reacting to it. In our system of stimulation, items of verbal stimulus does
not exceed half of the defined time for the total task, i.e. our setting does not take more than 2 seconds. The
remaining 2 seconds were left to patient for choosing his response.
Our stimuli determine minimization of patients response for expressing the approval, or disapproval,
in the sense: yes/no. The contribution of our choice is in that the stimulation of auditing verbal perception at
awake craniotomy can also be carried out in cases, when:
A patient is not able to accept visualized stimulus (in spite of good verbal cooperation, he does
not open his eyes).
He is unable to move his right hand, because of the position on the operation table, medication in
left arm and operation in the dominant hemisphere, or a motor deficit makes it impossible.
-
Patient is not capable of verbal response (bipolar choice yes/no is done in non-verbal way).
It is necessary to emphasize that every task given to a patient is done with him before the operation,
and during the operation we apply only those stimuli that did not cause any problems to a patient before the
operation.
The qualitative picture of pre-operational examinations is determined by the character of verbal
stimulation in awake craniotomy. As far as the orientation in expressing the value of the effects of stimulation
of phatic functions in craniotomy in awake regimes, it is also helped by a quantitative index, i.e. we
completed our system of stimulating verbal items in the above mentioned factor according to the degree of
their semantic, phonological, morphological, syntactical and lexical demands. After brain operation we
examine auditing verbal perception by our battery as soon as it was possible after 24 hours. A complex system
of auditing verbal stimuli used by us takes into consideration the present frequent diagnostic methods, e.g.
BDAE, Lurija test, and shows high correlate also with the Token test.
Even though the demonstration of our battery can only be informative or of an inspirational character
due to language specific features, we can present it in the following form.
52
SY01.2
INTERVENTION APPROACHES TO APHASIA IN CZECH
Helena Lehekov
Department of Modern Languages, University of Helsinki, Finland
Logopedics in aphasiology
Czech logopedics has concentrated for a long time on special pedagogy and developmental
impairments in children, and thus aphasia has not been the focus of interest. The situation has changed lately
due to the gradual development of complex rehabilitative care of adults and more specialized education of
clinical logopedists in the Czech Republic. However, in practice problems in cooperation between different
aphasiologic disciplines persist. There are no multidisciplinary centres for the treatment of aphasia. Speech
pathologists work either in logopedic ambulances or in neurosurgical departments in hospitals where
logopedists are subordinate to medical staff (Neubauer, 2007).
Assessment of aphasia
Czech is a very intricate language, both phonetically and grammatically. The prevalence of consonants
appearing in long sequences (a whole sentence can be constructed purely of consonants) makes it difficult to
pronounce. The strong inflecting character of the language with hundreds of grammatical forms for each
inflected word makes it difficult to use the correct morphology and syntax (Lehekov, 2001).
The aim of a clinical logopedic test is:
1.
to assess the actual state of linguistic communication; and
2.
to define the residual abilities that can be used for starting the rehabilitation process.
There is no standardized aphasia test that is universally used in the Czech Republic. It is up to each
logopedist as to what form of assessment s/he uses.
For a complex linguistic assessment the Prague Aphasia Test (Budnov-Sml, Bohmov, Mimrov,
1964) has been used. It is a screening quantitative assessment of different aspects of communication and it
enables the percentages of successful achievement in different linguistic modalities to be shown graphically:
spontaneous speech, repetition, understanding, naming, automatic sequences, singing, reading, oral counting,
written counting, drawing and writing. This approach has been further developed (e.g. Kiml, 1969; Polkov
- Slezkov, 1993; echkov, 1998). The priority of this type of testing is to find out what the patient can do,
and thus to provide him with the feeling of successful communication.
Translated versions of the Boston Diagnostic Aphasia Examination and the Western Aphasia Battery
do exist but they have been used only experimentally without being standardized for the Czech language.
However, the assessment according to the Prague Aphasia Test leads to the same therapeutic measures as
BDAE or WAB.
The Assessment of Phatic Functions (Csfalvay, Kolov, Klimeov, 2002) is a qualitatively oriented
Czech clinical test consisting of six parts: spontaneous speech, understanding of speech, reproduction and
repeating, answering questions, reading and writing. The aim of this assessment is to define the aphasia
syndrome on the one hand and to detect impaired and intact language components on the other.
The Mississippi Aphasia Screening Test (Kolov et al., 2008) and Bilingual Aphasia Test (Paradis,
2009) have lately appeared in Czech versions.
Of the broad range of neuropsychological test batteries used abroad, two have been applied in the
Czech Republic: Lurias Neuropsychological Test (Christensen, 1977) and the Halstead-Reitan
Neuropsychological Battery (Preiss et al., 1998).
Psycholinguistic methodologies: Profiling Linguistic Disability (Crystal, 1982),
Communicative Abilities in Daily Living (Holland, 1980) or Functional Communication Profile (Grohler, 1988), mapping
communicational skills in everyday situations and defining the spheres of the possible development, have been reviewed
(Lehekov, 1987) but not standardized for Czech.
53
For the screening of perception, the Token Test (Czech translation: Preiss 1996) or the Czech version
of the Aphasia Screening Test (Preiss,1998) have been used.
Treatment of aphasia
Logopedic care must be indicated by the medical doctor in charge of the patient. Assessment and
treatment methods, on the other hand, lie within the competence of the logopedist.
In intensive care units clinical logopedists start to work with aphasic patients as early as the first day
after the stroke. Patients with tumors start their rehabilitation after the neurosurgical operation. The intensity
of logopedic treatment is stated by the contract with medical insurance companies. Inpatients are usually
given one therapeutic session (45 minutes) per day. When their hospitalization is over, it is possible for them
to continue their logopedic treatment on an outpatient basis, with at most two sessions a week. On top of that,
chronic patients may take part in group therapy and recondition stays (Stejskalov, 2001).
Czech clinical logopedists have been successfully using psychologically oriented individual
reeducation (Mimrov (in Kulik et al.), 1997, Stejskalov, 2003). The general idea is to get language
production, perception, reading and writing to a similar level in order that different linguistic functions will
support one another. All modalities of communication are trained at the same time and their mutual positive
influence is made use of. Articulation is not unnecessarily stressed. The treatment concentrates on reeducation
on the one hand, and compensation on the other hand. Visual and auditory associations are strengthened and
short-time memory is trained. Picture material based on the most frequent lexicon is used for the elicitation of
spontaneous speech, answering questions, completing sentences and writing. Global reading is trained. In
severe cases nonverbal communication is supported.
Pragmatic communicational skills are trained by functionally oriented techniques: PACE - Promoting
Aphasics Communicative Effectiveness (Davis Wilcox, 1985), conversational coaching, nonverbal
communication and group therapy.
In the acute phase of aphasia logopedic care concentrates on consulting and guiding the patient and
his/her family. An intensive therapy (every day over a period of 2 weeks) has proved to be more effective
than 2-3 sporadic sessions per month. As intensive logopedic care is limited both as to duration and
frequency, other forms of speech reeducation must be used.
In the chronic phase of aphasia specific therapy is offered, both individually and in groups. This
activity is later transformed into self-help communities. Some patients who had not been improving during
individual therapy can develop their skills after being included in group therapy.
Stejskalov (2001) describes her experiences from working in an open psychotherapeutic community
of at most 45 aphasics over a ten-year period. Members of the group are stroke patients, their partners and
staff. The professional staff comprises a clinical logopedist with psychotherapeutic training, a medical doctor,
a clinical logopedist and two rehabilitation workers. The group organizes two recondition ten-day stays in the
countryside, a one-day trip and a Christmas party on an annual basis. The recondition stays are used mainly
for learning nonverbal communication and memory training. Training of language production is not a
primary goal. Individual logopedic care is administered half an hour daily. The activity is financed by funds
from the Ministry of Health, sponsors gifts, membership fees and charges of the participants.
Czech aphasiologic material

An interdisciplinary approach was applied in the handbook Afzie presenting aphasia from the
neuropsychological, linguistic, logopedic and neurological point of view (Kulik, Lehekov, Mimrov,
Nebudov, 1997).
The Czech material used in the assessment of aphasia comprises, for example, The Dictionary for
Aphasics (Truhlov, 1984), Therapeutic Methodic Material and Graphs (Mimrov, 1997), Diagnostics and
Therapy of Aphasia, Alexia, Agrafia (Csfalvay, Kolov, Klimeov, 2002).
A set of computer programs, MENTIO, was created (Petrlkov, 2005) and constantly developed. For
the time being it includes the following programs: Lexicon (naming, reading, writing and pronunciation),
Verbs (sequences of actions, morphology, syntax and sentences), Memory Management, Puzzles (visual
perception), Shopping (counting, using money), Riddles (understanding, logical thinking), Sounds
(differentiation, auditory memory), Voices (voice formation, pitch, sound and modulation).
54
There is no Czech periodical for aphasiology. However, the journal of the Association of clinical
logopedists in the Czech Republic Diagnostics and therapy of communication impairments (Diagnostika a
terapie poruch komunikace, previously (1994-1997) Clinical logopedics in practice (Klinick logopedie v
praxi) has been an important achievement. Czech articles from the realm of aphasiology do also appear in the
journal Neurologie and other specialized journals.
Qualification of clinical logopedists

Logopedics has been studied at the pedagogical faculties of universities within the realm of special
pedagogy. A qualified logopedist must have a masters degree in logopedics which can be obtained after a
five-year period of university studies, a final exam and a masters thesis. A clinical logopedist must in
addition go through post-graduate studies of at least two years and pass a special examination. Only then is
s/he allowed to work independently and later establish a private practice. Clinical logopedists are obliged to
participate in all-life education, that is, special courses for updating their professional knowledge and skills.
Nowadays many specialized courses on neurogenic language and speech impairments are organized by the
Association of clinical logopedists and by the Institute of postgraduate education in medicine.
The Association of clinical logopedists of the Czech Republic (Asociace klinickch logoped v esk
republice) is a voluntary and independent professional organization the aim of which is to promote the
professional interests of its members, coordinate their activities and follow the fulfillment of its ethical
charter. It is a counterpart to the Chamber of medical doctors (kodov, 2003).
Regulations of aphasiologic care

Clinical logopedics was established as an independent discipline within medical care in 1992. The
work of clinical logopedists is guided by two laws about non-medical professions in medical care (1966, 2004).
Logopedic treatment in the Czech Republic is realized under the authority of three ministries: (a) The
Ministry of Education, Youth and Sports; (b) The Ministry of Health; and (c) The Ministry of Work and Social
Care. It is provided in three types of institutions: (i) state institutions (clinics, hospitals, spas, etc.); (ii) nonstate institutions (communal, church, charitable, etc.); and (iii) private institutions.
All aphasic inpatients are entitled to logopedic treatment. Outpatients who were indicated speech
therapy by their doctor can choose any of the three above mentioned institutions and attend it for treatment
(cf. 3). The costs are normally covered by medical insurance. The length of therapy is not explicitly stated. It is
available as long as it is considered useful by the clinical logopedist and approved by the doctor in charge.
The evaluation of the effect of treatment is not guided by any generally accepted measure.
References:
Budnov-Sml, J., Bohmov, E., Mimrov, M. 1964. Pokus o kvalitativn hodnocen fatickch poruch. eskoslovensk
psychiatrie, 60, p. 221-225.
Christensen, A.L. 1977. Lurijovo neuropsychologick vyeten. Psychodiagnostick a didaktick testy. Bratislava:
Psychodiagnostika.
Csfalvay, Z., Kolov, M., Klimeov, M. 2002. Diagnostika a terapie afzie, alexie, agrafie. Praha: AKL R.
echkov, M. 1998. Cviebnice pro nemocn s poruchou ei afzi. Brno: Bioxer.
Davis, G. - Wilcox, M.J. 1985. Adult Aphasia Rehabilitation: Applied Pragmatics. San Diego: College Hill.
Kiml, J. 1969. Afzie a reedukace ei. Praha: SZN.
Kolov M. et al. 2008. Standardization study of the Czech version of the Mississippi Aphasia Screening Test (MASTcz)
in stroke patients and control subjects. Brain Injury, vol. 22, no. 10, p. 793-801.
Kulik, P., Lehekov, H., Mimrov, M., Nebudov, J. 1997. Afzie. Praha: Triton.
Lehekov, H. 1987. Dva typy testovn afatik. Rehabilitcia, 20, p. 13-20.
Lehekov, H. 2001. Manifestation of aphasic Symptoms in Czech. Journal of Neurolinguistics, 14, p. 179-208.
Neubauer, K. 2007. Neurogenn poruchy komunikace u dosplch. Diagnostika a terapie. Praha: Portl.
Paradis, M. 2009. Bilingual Aphasia Test (Czech Version). http://www.mcgill.ca/linguistics/research/bat/
Petrlkov, M. 2005. Speciln vukov programy. Mentio, verze 2.2. Praha: MENTIO.
Polkov, B. Slezkov, E. 1993. Zklady diagnostiky a reedukace v logopedick praxi. Praktick lka, 73, p. 9-12.
Preiss, M. 1996. Token test aplikace zkrcen verze. Klinick logopedie v praxi, III, p. 20-24.
Preiss et al. 1998. Klinick neuropsychologie. Praha: Grada.
Stejskalov, J. 2001. Psoben klinickho logopeda v psychoterapeutick komunit. Brno: Acta aphasiologica, p. 44-46.
Stejskalov, J. 2003. Pe klinickho logopeda o neurologick pacienty. Neurologie, p. 77-80.
55
kodov, E. Jedlika, I. 2003. Klinick logopedie. Praha: Portl.

Truhlov, M. 1984. Obrzkov slovnk pro afatiky. Praha: Avicenum.
References:
Breshears J., Sharma M., Anderson N. R., Rashid S., Leuthardt EC.: Awake craniotomy for monitoring of language
function: benefits and limits. Acta neurochirurgica 2007, 149, 12
Duffau H., Denvil D., Capelle I.: Long term reshaping of language, sensory and motor maps after glioma resection
a new parameter to integrate in the surgical atrategy. Journall of Neurosurg Psychiatry 2002. 72: 511- 516
Fandino J., Kolias SS., Wieser HG., Valavanis A., Yonekawa Y.:Intraoperative validation of functional magnetic
resonance imaging and cortical reorganization patterns in patients with brain tumours involving the primary
motor cortex. Journall of Neurosurg 1999. 91: 238- 250
Galanda M., Babicov A., Patr F., ulaj J.,Bre A.: Intraoperative electrical stimulation at operation in central lesions
of brain. Czech and Slovak Neurologie and Neurosurgery 2001, 64/97, 338- 343
Keles GE, Lundin DA, Lamborn KR, Chang EF, Ojemann G, Berger MS.: Intraoperative subcortical stimulation mapping
for hemispheric perirolandic gliomas located within or adjacent to the descending motor pathways: evaluation
of morbidity and assessment of functional outcome in 294 patients. Journall of Neurosurg 2004, 100: 369- 375
Kenneth, M. Little, Allan, H. Friedman: Awake craniotomy for malignant glioma resection. International Congress
Series, Volume 2004, 409- 414
Petrovich Brennan NM, Whalen S., de Morales Branco D, Oshea JP, Norton IH, Golby A.J.: Object naming is a more
sensitive measure of speech localization than number couting: Converging evidence from direct cortical
stimulation and fMRI. Neuroimage 2007, 37,1
Ruge MI, Iimberger J, Kreth FW, Biegel J, Reulen HJ, Tonn JC: Awake craniotomy for intra operative cortical stimulation
of languge sensitive areas: Clinical and neurolinguistic results of a prospective, longitudinal evaluation of 153
cases. Arq. de Neuro-Psiquiatria 2008, 66, 3
56
SS01.1
A MODEL FOR COMMUNICATION INTERVENTION WITH THE ELDERLY
R. Lubinski
University at Buffalo. Buffalo, NY, USA
Statistics indicate that the population of elders is increasing world wide. For example, the number of
persons age 65 or older in the U.S. is now 37 million people (12%). By 2030, projections forecast that there will
be 20% of the total U.S. population (Aging Stats, 2006). In Europe, a fall in both mortality and fertility has
resulted in the creation of 19 of the worlds 20 oldest countries. Even in Asia and Latin America, the elderly
population is increasing (Allianz, 2009). Not only are more people living to old age, but more are living
longer. Further, with aging the prevalence of speech, language, and hearing disorders is likely to increase.
While there are few good statistics on communication problems of elders, it is known that the prevalence of
stroke resulting in aphasia, progressive neurological disorders such as dementia, and hearing loss increases
with age.
As persons age, communication success becomes increasingly important for both those with adequate
communication skills and those with communication disorders. Lubinski (2010) states that communication is
important for elders and communication disorders professionals serving them for four reasons: (1) service
delivery is more likely to be successful when professionals, elderly clients, and their families communicate
effectively; (2) communication facilitates understanding of disorders and compliance with recommendations;
(3) professionals provide support to elders and their families through communication; and (4) communication
fosters a positive therapeutic partnership whereby elders and families become independent communication
dilemma problem solvers.
The question becomes how best to serve elders and achieve the goals of improved communication.
Effective service delivery is served by working from a comprehensive model that encompasses the elderly
individual, communication partners, and the communicative context. he tripartite model presented here
focuses on (1) communication skills of the elderly that underlie communication including vision, hearing, and
cognition; (2) communication effectiveness which is the ability to receive, interpret, and send messages
successfully despite the possibility of message imperfection; and (3) communication opportunity which is
physical, psychosocial, linguistic, and cultural accessibility to communication partners of choice and to
activities that generate meaningful conversations/interaction (Lubinski, 2008).
Assessment and Intervention of Communication Skills

Communication skills are traditionally assessed through administration of standardized or clinician
made tests. These tests vary in their appropriateness for elders from a variety of cultural, linguistic, and
educational backgrounds. Clinicians should check tests for the relevancy to their clinical populations.
Clinicians should also review functional batteries that might be administered to elders in long term care
settings (e.g. Minimum Data Set 3.0, Centers for Medicare and Medicaid Services, 2010) or home health care
(Outcome and Assessment Set- C, Centers for Medicare and Medicaid Services, 2009) as these have items
relevant to communication. Intervention methods focusing on traditional receptive and expressive
communiction skills should be appropriate to the disorder, have functional relevance, be easily incorporated
by caregivers during daily interaction, and have a scientific evidence base, if possible.
Clinicians should also be aware that other skills affect communication and should be routinely
assessed including vision, hearing, and cognition. Elders vision skills are affected by the normal aging
process, vision disorders, and numerous other age-related health isorders. These vision difficulties range from
mild and moderate (low vision) to severe (blindness). Thus, vision should be assessed prior to assessment as
these elders may not be able to see clinicians, access nonverbal cues, and see visually presented materials.
Vision may be assessed through review of health records, questioning elders about vision needs, having them
respond to common vision charts and reading materials placed at a comfortable distance, and completion of
vision questionnaires (e.g. Low Luminence Quesionnaire, Owlsley, McGwin, et al, 2006). Be sure clients wear
57
their corrective lenses for vision screenings, and that the lenses are clean and placed correctly on the
individual. Some elders may use readers for reading close materials.
Vision intervention begins by being sure there is adequate, modifiable lighting in the clinical and
elders customary environments. Elders require about 3 times as much light and benefit best in natural
lighting or full spectrum incandescent bulbs. Clinicians should also ask where to sit or place visual materials
so that the elder can best see them. For those with macular degeneration, this may be to the side to facilitate
eccentric viewing. Vision assistive devices should also be used including task lighting, corrective lenses,
telescopes, and magnifiers. Keep in mind that elders may have some difficulty with glare and adapting to
brightness changes. Size, color, and contrast of visual materials should also be considered. Clinicians should
also monitor the quality of visual materials presented via web sites (Trace Center, ND)
Hearing should also be screened. Ideally, a bilateral pure tone hearing screening should be done in a
sound proof booth. When not possible, a screening should be done with a portable audiometer in a quiet
environment. At the least, elders should be asked if they are Able to carry on a one-to-one conversation?
and Can you follow the conversation of a small group of people? (Van Schaik et al, 1997). Macphee et al
1987) found that even free-field voice whispered voice testing at 2 feet was sensitive at 100% in identifying
individuals who might benefit from a hearing aid.
Creating a listening friendly environment is critical and begins by reducing background noises.
Encourage those with hearing aids or other assistive listening devices to wear them. Always check that these
devices are working and worn properly. Again, ask elders where is the best place to sit or stand so that they
can both hear and take advantage of visual cues. Clinicians should modify their speech but avoid overly loud
speech, over-articulation, and sing-song type intonation. Using simple, well-constructed, short sentences in an
active voice is helpful.
Results of cognition assessment by other professionals may be found in elders medical/clinical charts.
When not available, cognition can be assessed through administration of common brief assessment scales (e.g.
Mini Mental State Examination, Folstein et al, 1975). The Arizona Battery for Communication Disorders of
Dementia (Bayles and Tomoeda, 1993), the Ross Information Processing Test-Geriatric (Ross-Swain and Fogle,
1996) and the Neurosensory Center Comprehensive Examination for Aphasia (Spreen and Benton, 1977) also have
subtests for cognition.
Intervention for cognitive skills includes minimizing environmental distractions and maintaining
attention and eye contact with the elder during communication. Communication should be relevant to the
present and use well-constructed, simple sentences that include one idea at a time in familiar vocabulary.
Pronouns should be avoided. It is also important to prime the elder as to the topic and repeat key ideas
without adding new information. Be sure to give the cognitively challenged elder time to respond and ask
questions. Avoid correcting memory errors. In general, having a positive, adult-like and supportive verbal
and nonverbal style will be facilitating (Lubinski, 2010).
Assessment and Intervention of Communication Effectiveness

Communication effectiveness defines how well elders are able to get their message across despite level
of communication impairment. Effectiveness requires that elders have partners who know how to support
communication and the availability of assistive communication devices to facilitate interaction. There are few
assessment tools that focus on caregivers perceptions of communicating with elders. The Perception of
Communication Index (Orange, Lubinski, et al 2008) contains subtests that identify the conversational
difficulties of persons with dementia, the burden they have in this context, and the strategies that family
members perceive as facilitating communication. Observation of natural interactions during daily care also
provides data on what facilitates communication. Clinicians should also identify the assistive communication
devices and alternative strategies that elders use including those related to vision, hearing, and expressive
communication (e.g. communication boards, writing, gestures, computers).
Intervention should focus on working with family and professional caregivers to help them use
communication facilitating strategies. Both benefit from inservices and modeling that focus on problemsolving difficult communication dilemmas. Rather than provide lists of Communication Dos and Donts, it is
more profitable to provide some basic information about communication disorders and strategies and then
role-play difficult scenarios. The goal should be to create communication partners who are willing to work
through difficult communication contexts rather than avoid communication with elders.
58
Assessment and Intervention of Communication Opportunities

Opportunity to communicate requires a physical and social environment that supports partners and
activities that engender conversations. Lubinski (2008) and Hickson, Worrall, et al (2005) provide
observational techniques to evaluate the physical and social environment. Clinicians should also include in
their interviews questions that focus on access to communication opportunities, availability of communication
partners, and activities to stimulate interactions. The Quality of Communication Life Scales (Paul-Brown,
Frattali, Holland,. et al, 2005) can provide important information about the relationship between
communication and quality of life.
Creating a positive communication environment begins with easy and independent physical access to
communication opportunities. Physical access is enhanced through universal design principles. A physically
hospitable design includes private places for communication that reflect the interests and personal style of the
elder. The physical environment should also focus on visual and acoustical treatment of areas where
interactions occur, flooring, wall coverings and seating design, conversational space arrangement, and
personal or environmental listening devices. Written signage in the environment should be clear, have strong
contrast, use universal icons, and be at eye level in key areas.
The social environment is enhanced by the presence of desired communication partners and activities
that kindle interaction. Many elders with physical access limitations will be dependent on caregivers as
socialization partners and those who facilitate access to communication partners and events. Thus,
communication partners need to be aware of their critical role as the mediators of the social environment.
Caregiver education should focus on topics such as their role in creating and maintaining an active
communicative environment and strategies for communicating effectively with elders.
Speech-language pathologists and audiologists may be the best professionals to address the wider
scope of communication needs of elders with and without communication disorders. A tripartite approach
that focuses on skills, effectiveness, and opportunities is comprehensive, innovative, and responsive to the
needs of elders and their communication partners across living settings.
References
Aging
Stats. (2006). The Federal Interagency Forum on Aging-Related Statistics. Retrieved from
http://www.agingstats.gov/aging.
Allianz.
(2009).
Demographic
change:
Aging
societies.
Retrieved
from
http://knowledge.allianz.com/en/globalissues/demographic_change/aging_societies/population
Bayles, K. & Tomoeda,C. (1993). Arizona Battery for Communication Disorders of Dementia. Austin: Pro-Ed.
Centers for Medicare and Medicaid. (2010). Minimum Data Set 3.0 (MDS 3.0). Retrieved from
http://www.cms./hhs.gov/NursingHomeQualityInits/25_NHQIMDS30.asp.
Centers for Medicare and Medicaid. (2009). Outcome and Assessment Information Set (OASIS). Retrieved from
http://222.cms.hhs/HomeHealthQualityInits/06_OASISC/asp.
Folstein, M., Folstein, S., & McHugh, P. (1975). Mini-mental state. A practical method for grading the cognitive state of
patients for the physician. Journal of Psychiatric Research. 12, 189-98.
Hickson, L. Worrall, L.et al. (2005). Evaluating communication for resident participation in an aged care facility.
International Journal of Speech-Language Pathology, 7, 245-57.
Lubinski, R. (2008). Environmental approach to adult aphasia. In R. Chapey (Ed.) Language Intervention Strategies in
Aphasia and Related Neurogenic Communication Disorders 5th Edition. ( p. 319-348.). Philadelphia: Wolters Kluwer.
Lubinski, R. (2010). Strategies for communicating with elders and their family members. ASHA Leader, 15.
Macphee, J., Crother,J. & Mcalphine, C. (1987). A simple screening test for hearing impairment in elderly patients.
Ageing. Retrieved from http://ageing.oxfodjournals.org/cgi/content/abstract/17/5/347.
Orange, J. B. Lubinski, R. (2008). Psychometric data of a measure of convesation in dementia. Poster presented at the
Annual Convention of American Speech-Language and Hearing Association. November.
Owsley, C., McGwin, G., et al (2006). Development of a questionnaire to assess vision problems under low luminance in
age related maculopathy. Investigative Ophthalmology and Visual Science, 47, 528-535.
Paul-Brown, D., Frattali, C., Holland, A., et al. (2005). Quality of Communication Life Scales. Rockville, Md: American
Speech-Language and Hearing Association. .
Ross-Swain, D. & Fogle, P. (1996). Ross Information Processing Assessment-Geriatric. Austin: Pro-Ed.
Spreen, O. & Benton, A. (1977). Neuroscensory Center Comprehensive Examination for Aphasia. Victoria, BC: University of
Victoria Neuropsychology Laboratory.
Trace Center. (ND) Designing More Usable Web Sites. Retrieved from http://trace.wisc.edu/world/web.
59
FP13.1
PORTUGUESE TRANSLATION AND ADAPTATION OF THE COMMUNICATION
DISABILITY PROFILE (CDP) AND THE PARTICIPATION OBJECTIVE, PARTICIPATION
SUBJECTIVE (POPS) TOOLS
Matos, M.; Jesus, Luis M. T.; Cruice, M.; Allen Gomes, A.
ESSUA, IEETA and DCE, Universidade de Aveiro, Aveiro, Portugal; SCHS and LCS, City University, London,
UK
1. Introduction
In the nineties, there was significant progress to develop models of intervention in aphasia focusing on
the most functional and social aspects [7]. Several reasons led to these developments, namely: the political
and social restructuring which occurred in different countries, including the modalities of funding of health
services [5,9,10], as well as the pressure of people with aphasia (PWA) and their family members (FM) who
had access to more information [5,9]. The pressure to demonstrate the effectiveness of therapy, specifically the
impact of therapeutic intervention in the daily life of these individuals and the needs of each group, urges
health professionals to review current methods of assessment and intervention.
The International Classification of Functioning, Disability and Health (ICF) [10], emphasises the need
for health professionals to consider disability in terms of multiple dimensions. That means considering the
different possible consequences of the disease, in this case, brain injury after stroke, in their different domains,
i.e., the individual's linguistic and mental processes and the impact of residual deficits in their performance in
daily activities and participation in real life situations. It also highlights the influence of contextual factors
(environmental and personal) in this process.
In Portugal, literature on the topic of assessment and intervention with PWA is scarce. Similarly to
what happens in other countries, there is a tradition of using the Medical Model, focusing on therapeutic
intervention addressing the persons language deficits directly caused by aphasia, and neglecting the
consequences described in terms of activity and participation in real life situations.
In order to provide Portuguese Speech and Language Therapists (SLTs) with assessment tools that
include the different areas considered by the ICF, with consequent changes in their intervention approaches,
two existing tools were translated and adapted to the Portuguese practice: the Communication Disability
Profile (CDP) [8] and the Participation Objective, Participation Subjective (POPS) [2].
The CDP enables people with aphasia to express their views and experience of what life with stroke
and aphasia is like for them regardless of his/her access to spoken or written language. It provides
information that supports joint decision-making (and goal-setting), enables discussion about identity as a
person living with aphasia, and allows the exploration of how external factors affect life with aphasia [8].
The POPS reflects two different perspectives: disability insiders perspective of his/her participation
in home and community activities and societal/normative (outsider) valuations [2].
The purpose of this paper is to describe the methodology used to translate and adapt both tools to the
Portuguese reality as well as to present the preliminary results in terms of suggested
modifications/adaptations.
2. Method
A methodology of triangulation of data obtained from three different groups was used: SLTs, PWA
and their FM. The opinion of professionals routinely involved with this disorder was considered extremely
important [1,4,6] as well as the collaboration and close involvement with the population in study. The aim
was to produce tools that were adapted to the real needs and expectations of the true experts on the subject
(PWA) and those who live with them more directly in their daily lives (FM).
Informed consent to participate was obtained from all participants. An aphasia-friendly informed
consent sheet was used with the PWA.
60
The following research questions were defined:

1. How does the CDP and POPS (Portuguese versions) assess the communicative activities and day-today activities, and social participation of PWA, respectively?
2. What are, in the view of SLTs in Portugal, the consequences of aphasia and related sequelae of stroke
in the daily lives of people with whom they work with?
3. What are the consequences of aphasia and related sequelae and stroke in daily life, according to PWA
and their FM?
4. What are the barriers and facilitators that interfere with PWAs social participation, as identified by
PWA and their FM?
The original tools were independently translated into European Portuguese (EP) by the first and the
second authors of this paper, with good knowledge of English. A common version was agreed.
2.1. SLTs
The common version of both tools was assessed qualitatively, on an individual basis, by a group of
SLTs who were considered to be representative of the Portuguese SLTs involved with PWA. Inclusion factors
were considered. Eighteen SLTs were invited and ten participated in the study.
The SLTs assessed both tools based in the conceptual equivalence, use of colloquial language and
clarity of the translations. The relevance and significance of all their items was also discussed.
The SLTs group was also asked several questions relating to the research questions described above. A
focus group method was used for this purpose.
2.2. PWA
All PWA were recruited and assessed by the first author at the Hospitais da Universidade de Coimbra,
Portugal. Fourteen PWA participated in the study, meeting the following inclusion criteria: over 25 years of
age; native speakers of EP; having at least 3 months post onset following a stroke; living at home; aphasia
diagnosis; a reliable yes/no response; no cognitive or depression disturbance; no hearing problems that
interferes in the communication process.
The sample comprised eleven men and three women, with an average age of 65 years, in the range 4180 years. They were, on average, 29 months post-stroke, in the range 3-89 months, and had a mean education
of 7 years (range 3-20 years). Eight had a physical impairment but were ambulant. Seven had Anomic
Aphasia, three had Motor Transcortical Aphasia, one had Sensorial Transcortical Aphasia, one had
Conduction Aphasia, one had Broca Aphasia and one had Global Aphasia. Nine were retired, two lived from
their own income, two had medical support and one was working part time.
This group was analysed using two different types of methodology, both qualitative, based on the
severity of aphasia. The severity scale from the Bateria de Avaliao da Afasia de Lisboa (BAAL) [3] was
used.
For those with a more severe aphasia, an aphasia-friendly topic guide was prepared. These PWA were
interviewed individually (n=7), using an in-depth semi-structured interview. Total communication strategies
were used and incentivized, and some possible written options as well as some scales previously
prepared.Those with a less severe aphasia participated in a focus group (n=7).
The interviews focused on aspects related to the consequences of stroke and aphasia in PWAs levels
of disability, activity and participation. These were recorded in video format, in order to allow further
analysis and interpretation of all given answers. They were entirely transcribed and are currently being
analysed using content analysis methods.
A smaller group of PWA (n=4), deemed representative of the study population, was then assessed
using POPS and CDP. Inclusion factors were considered. The acceptability of the tools was initially tested by
observing the participants reactions to the items in order to see whether they asked for clarification or needed
prompting to answer them. After the assessment, each individual was asked for an overall opinion on the
relevance of items as well as for a commentary on the understanding, clarity, practicality and acceptance of
instrumental issues involved. A topic guide interview was used for this purpose.
61
2.3. FM
PWA self-selected their FM as a proxy (n=14). For FM with low education levels (fewer than or equal
to 4 years of schooling) an individual in-depth semi-structured interview was used (n=8). FM with higher
education level were enquired within a semi-structured group (n=6). A topic guide was also prepared to this
effect, centred in stroke and aphasia consequences in their lives as well as in their family members with
aphasia. These interviews were audio and/or video recorded. They were entirely transcribed and are
currently being analysed using content analysis methods.
A smaller group of FM (n=4), representative of the involved FM population (inclusion factors were
considered), individually examined both of the translated tools. At the end, the whole group discussed the
issues considered to be most important.
3. Results
All SLTs considered CDP items were clear, not ambiguous and relevant. Six SLTs considered some of
the used pictures were ambiguous. One SLT considered scales too diverse and difficult to understand by
people with severe aphasia. One SLT considered the pictures too difficult for PWA with a low educational
attainment and suggested colour as a facilitator. Nine SLTs suggested pictures modifications. Four SLTs
suggested a new translation of some items. One SLT stated that Emotions is not a SLT area of intervention.
FM considered CDP easier and more complete than POPS. Items were considered clear, not
ambiguous and relevant. Two FM considered some pictures not clear enough and suggested that CDP would
be more attractive if coloured. One FM considered it too long and another suggested that FM related items
should also be considered.
All PWA were satisfied with CDP. No criticisms were made. They all considered pictures as a good
facilitator. Some doubts occurred during the assessment that could indicate some ambiguity in some pictures.
Six SLTs considered POPS items to be clear. 4 SLT considered it too complex to use with PWA. Most of
the items were considered not ambiguous and relevant by all SLTs but some new items were proposed to be
added based in Portuguese reality. Two SLT considered instructions very complex for PWA.
FM considered POPS had a complex visual presentation, with too much information, small print and a
very complicated answering scale. It was not too long or too tiring, if presented slowly and calmly. They
suggested: including items related with psychological disorders; considering open answers in order to avoid
frustration; creating an independent notation sheet just for the SLTs.
Both groups (SLTs and FM) suggested: improving the visual presentation using an easier scale and a
bigger font; using supportive images for each item; the need to add a comparison of current and previous life
situation.
All PWA considered items were clear, not ambiguous and easy to understand. One PWA considered
some items not relevant. One of the PWA considered POPS a general tool and suggested that a more precise
questionnaire was needed.
4. Conclusions
CDP and POPS can be important therapeutic tools and are the first of the kind in Portugal, but they
need to be modified. CDP was perceived as easier for PWA then the POPS, which perhaps is related to the
consideration of the communication access needs that went into its initial development. Visual presentation of
POPS needs to be improved. Their content was generally considered clear, not ambiguous and relevant for
Portuguese PWA. In Portugal, PWA and FM are not used to be consulted in the rehabilitation process as well
as in projects like this one. During the whole project their critical capacities were minimal and only some
suggestions were made. A larger field study should be done in the future.
5. Bibliography
1. Byng, S., J. Duchan (2005). Social Model philosophies: Their applications to therapies for aphasia. Aphasiology 19 (1011): 906-922.
2. Brown, M. (2006). Participation Objective, Participation Subjective. The Centre for Outcome Measurement in Brain
Injury. New York: Mount Sinai School of Medicine.
3. Caldas, A. (1979). Diagnstico e evoluo das afasias de causa vascular. Ph.D. Thesis. Faculdade de Medicina da
Universidade de Lisboa, Lisboa, Portugal.
62
4. Davidson, B., L. Worrall, L. Hickson (2008). Exploring the interactional dimension of social communication: A
collective case study of older people with aphasia. Aphasiology 22(3): 235-257.
5. Martin, N., C. Thompson, L. Worrall (2008). Aphasia Rehabilitation The impairment and Its Consequences. Oxford:
Plural.
6. Pound, C., S. Parr, J. Lindsay, C. Woolf (2001). Beyond Aphasia - Therapies for Living with Communication Disability.
Oxford: Speechmark.
7. Sarno, M. (1993). Aphasia rehabilitation: psychosocial and ethical considerations. Aphasiology 7: 321-334.
8. Swinburg, K.,S. Byng (2006). The Communication Disability Profile. London: Connect.
9. Worrall, L., L. Hickson (2003).Communication Disability in Aging From Prevention to intervention. New York:
Delmar.
10. (2001). World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF).
Geneva: WHO.
Acknowledgements
The authors would like to thank Dr. Kate Swinburn, at the Communication Disability Network
(Connect), London in the UK, for granting permission to adapt the CDP, and Dr. Margaret Brown, at the
Mount Sinai School of Medicine, New York in the USA, for granting permission to adapt the POPS. This work
was developed as part of a Ph.D. in Health Sciences at the Universidade de Aveiro in Portugal
63
FP37.6
THE DEVELOPMENT OF A TOOL TO GATHER INFORMATION REGARDING THE
ACTIVITIES AND PARTICIPATION OF PERSONS WITH APHASIA IN PORTUGAL
Matos, M.; Jesus, Luis M. T.; Cruice, M.; Allen Gomes, A.
ESSUA, IEETA and DCE, Universidade de Aveiro, Aveiro, Portugal; SCHS, LCS, City University,
London, UK
1. Introduction
The most recent literature on working with people with aphasia (PWA) propose that Speech and
Language Therapists (SLTs) consider in their intervention the effects of a clients communication and/or
swallowing disorder on his/her everyday life [2].
The World Health Organizations International Classification of Functioning, Disability and Health
(ICF) [4] describe components that should be considered when working with someone who has a health
disorder or disease. It considers Functioning (Body Function and Body Structure), Activities and
Participation and Contextual Factors. The Activities and Participation component of the ICF describes the
complete range of human functioning from both an individual and a societal perspective. The individual
perspective is expressed through the concept of Activity which is defined as the execution of a task or action
by an individual [4], and the societal perspective is expressed through the concept of Participation, defined
as involvement in a life situation [4].However, both concepts are still represented in a single list and it is not
clear yet which domains reflect Activities or Participation [2]. There are many discussions about this
distinction in literature but a consensus is still not a reality.
There is a gap in the profession generally about collecting information on aphasic peoples Activities
and Participation domains. There is a lack of tools or questionnaires to do this adequately [3].There is also a
lack of research or evidence based practice concerning the activities and participation of PWA.
In Portugal, most of the SLTs working in the aphasia field work in the hospital setting in the acute
phase and/or with PWA coming from their homes in an ambulatory system. When it is possible, their family
members are involved in the therapeutic intervention. The Medical Model is still widely used, and people
(medical professionals and the public alike) expect SLTs to solve the consequences of stroke. SLTs
assessment and intervention practices are restricted to this setting, making it difficult to practically determine
and intervene to address the reality of peoples lives, that is, the psychosocial part of the biopsychosocial
model presented in the ICF. They miss out on the valuable opportunities to observe PWA interacting in their
daily life and observe the impact that their local community contexts/environments have on their ability to
participate socially. SLTs assessment or information gathering/interviewing tools in Portugal are limited to
translations of various impairment assessments which also constrain the whole intervention process
described above.
The purpose of this paper is to present a tool, The Activities/Participation Profile (TAPP), devised as part
of a larger PhD project developed by the first author.
There is a paucity of data on the real life functioning of PWA in Portugal. TAPP was developed to
explore the usual activities of PWA and thus better understand the consequences of stroke and aphasia.
Evaluating those persons with more limited communication skills is especially challenging because they
cannot often participate in in-depth semi-structured interviews. The preliminary data obtained during the
project with PWA using TAPP will be presented.
64
2. Method
In theory, it is easy to understand the separate nature of the ICF Activities and Participation concepts;
however, in reality, there is significant overlap and interdependence in the concepts. Thus, the TAPP reflects
the combined and integrated approach to viewing Activities and Participation.
SLTs can have an important role facilitating the whole communication processes needed to
understand how a disorder impacts the quality of life and life satisfaction of those who they are working
with. SLTs, especially those working in hospital setting, need to be able to see beyond the limitations of
their defined work settings, and explore PWAs Activity and Participation, and then consider those in
intervention.
TAPP includes all domains of the ICF Activities and Participation, and not just the chapter entitled
Communication because communication is essential to the other domains of the ICF such as learning and
applying knowledge, interpersonal interactions and relationships, and community, social, and civic life.
Thus, all domains are included so that SLTs can determine how best to support the client in their daily life
and help him/her to define the best goals to achieve in therapy.
The content of TAPP was derived from a range of sources: different assessment tools described in the
literature; previously published research about the impact of aphasia on activities and participation; the
professional opinions of 10 SLTs who participated in a focus group in the larger PhD research project; and
reflections based on 17 years of clinical practice as a SLT in the field of aphasia by the first author.
The participants in this research project were 14 PWA, recruited and assessed by the first author at the
Hospitais da Universidade de Coimbra, Portugal. The inclusion criterions included the following: over 25
years of age; native speakers of European Portuguese; at least 3 months post onset following a stroke; living
at home; aphasia diagnosis; demonstrated reliable yes/no response; no overt cognitive or depression
disturbance; and no hearing problems that were judged to interfere in the communication process.
Informed consent to participate was obtained from all participants. An aphasia-friendly informed
consent sheet was used with the PWA.
The sample included eleven men and three women, with an average age of 65 years and ranging from
41-80 years. They were, on average, 29 months post-stroke (range 3-89 months) and had a mean education of 7
years (range 3-20 years). They had the following occupations before stroke: two drivers, one car mechanic,
one farmer, one civil engineer, one librarian, two merchants, one army lieutenant colonel, one salesman, one
potter, one house keeper, one hotel owner/manager and one businessman. Nine of the participants were
retired, two lived from their own income, two had medical support and one was working part time. Eight of
them had a physical impairment (right hemiparesis) as a consequence of stroke but were ambulant. In terms
of aphasia classification types, seven had Anomic Aphasia, three had Motor Transcortical Aphasia, one had a
Sensorial Transcortical Aphasia, one had Conduction Aphasia, one had Broca Aphasia, and one had Global
Aphasia.
The first version of TAPP comprised 154 items. After being piloted with three people, TAPP was
modified based on both their reactions to the tool and their suggestions. As TAPP was considered too long
and tiring, the main change was a reduction in items. This was achieved by eliminating some items and
grouping similar ones.
Items such as going to a wedding were eliminated because of their low frequency of occurrence.
Items such as going to the hospital were considered too general. Items such as choosing what to do or
staying in bed were considered too ambiguous in formulation and too obvious as happening in daily life.
Items such as listening to a conversation or telling a secret were considered offensive. Other items such
as going to a bar, disco, casino were grouped.
The second version, used in the data collection, comprised 110 items. Each activity was explored in
terms of whether carried out before stroke, how often (daily, weekly, fortnightly, monthly, rarely or never),
still carried out after stroke or not and why, would like to do it again. At the end, the PWA was questioned
about the actual global degree of satisfaction with the developed activities.
TAPP was designed to be completed by the PWA with the SLT assistance. Each of the items was
explored individually. It was read aloud by the first author and PWA could point to their answer in the paper
sheet which described a range of frequency options, as well as a 1 to 5 point scale organised for that purpose.
65
Repetition and simultaneous reading was used whenever necessary as well as a slow rate of speech to
facilitate comprehension.
Depending on the severity of aphasia, the TAPP takes 30-40 minutes to be administered
Results
Before stroke, 108 activities in a total of 110 were referred as being carried out sometime at least by one
of the 14 PWA. The only activities not referred at all were to participate in political activities and going to
physiotherapy or other treatments. Of these 108 activities, 5 of them were referred by all the 14 PWA. These
were reading the newspaper, watching television, answering and talking on the telephone signing the
name and talking to family.
After stroke, 91 activities out of the 108 carried out before stroke were referred as not being carried out
anymore by any of the 14 PWA. The main motives pointed for leaving these activities were: the stroke in
general (42); language and other related disorders such as aphasia, writing and reading, vision and memory
(85); motor disorders (47); emotional reactions such as unwillingness, disinterest, discouragement, fear,
feeling greater difficulty, irritability, lack of patience and tiredness (46); usual family reactions, as the
replacement of functions and roles and overprotection by the spouse and/or children (13); unemployment
and/or early retirement with consequent changes in economic status (23); adaptation of functions and
activities to the new situation (8); changing health-related habits and other related activities (8); lack of time
(1), sexual disorders (2) and without company (3).
Thirty five of the 108 activities carried out were referred by at least one of the 14 PWA as being
modified in terms of frequency. According to the Wilcoxon test, there were statistical significant differences (p
<0, 05) in the frequency of 20 of the 108 realized activities before and after stroke.
Sixteen new activities were reported as being initiated after stroke by some of the 14 PWA, including:
household activities and family dynamics (4); activities related to health (6); activities involving reading and
writing skills (3); religious activities (1); and other leisure activities (2). The main motives presented were:
more spare time; the need to work on language and memory skills; a greater concern for health after stroke;
the need to accompany the spouse.
Despite these significant changes in life activities and participation, 5 PWA reported being maximally
satisfied (reported 5 on 1-5 scale of satisfaction); 4 PWA reported 4, 4 PWA reported 3 and only 1 PWA
reported 1.
4. Conclusions
The consequences of stroke are enormous and diverse. TAPP was useful in determining the previous
and current activities and participation of Portuguese PWA, and appears to clearly illustrate activities and
participation post-stroke. It is suggested that TAPP can be used in daily therapy helping SLTs to collect and
discuss with the PWA which are the most important activities that are not being done at the moment and
explore why this is so. Determining which activities the person would like to do again, can assist SLTs in
collaboration with the PWA to define goals for intervention. These activities should then be explored in terms
of where the activity is occurring, with whom, with what purpose, what kind of facilitators would be needed,
and what to do about the explored barriers [1]. In the future, TAPP should be complemented with coloured
drawings to illustrate each of the items as well as items being organised in semantic categories, so it can be
used with people with more severe aphasia. Normative studies as well as other studies involving different
populations should be done
5. Bibliography
1. Davidson, B., L. Worrall, L. Hickson (2003). Identifying the communication activities of older people with aphasia:
Evidence from naturalistic observation. Aphasiology, 17 (3), 243-264.
2. OHalloran, R., B. Larkins (2008). The ICF Activities and Participation related to speech-language pathology.
International Journal of Speech- Language Pathology, 10, 1-2, 18-26.
3. Ross, K., R. Wetz (2005) Forum: Advancing Appraisal: Aphasia and the WHO. Aphasiology, 19 (9): 860-900.
4. (2001). World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF).
Geneva: World Health Organization.
66
Acknowledgements
This work was developed as part of the PhD in Health Sciences at the Universidade de Aveiro in
Portugal.
67
FP13.2
NUMERICAL PROCESSING AND CALCULATION IN APHASIC PATIENTS
G.C.P. De Luccia 1, K. Z. Ortiz 2
1,2UNIFESP, So Paulo, Brazil
1 Speech Pathologist, PHd, Main author
2 Speech Pathologist, PHd, associate researcher
Introduction and aims of the study: Changes that compromise ability to calculate, the subsequent
brain damage, is known as dyscalculia. This difficult could be defined as a partial or complete inability to deal
with numbers and represents a commitment on the numerical processing and calculation. Several authors
have reported that aphasic patients have changes in numerical processing and calculation and these are being
investigated more frequently in the international and national. In this study, we attempted to verify the
performance of aphasic subjects in task and numerical calculation by the EC 301 battery.
Methods: We evaluated 32 patients with aphasia, with brain damage only on the left. All subjects
underwent assessment of skills and numerical calculation by EC301 battery. The development of the EC301
calculation battery was guided by information processing models of mathematical cognition.
Results: Difficulties were found in several tests battery EC301, suggesting changes in activation for the
calculation procedures and their arithmetic rules. The aphasic patients showed worse scores in mental
calculations simple addition, subtraction, multiplication and division, presented in oral form and graphics.
Simply adding the operation was performed better in relation to subtraction and multiplication. We believe
that this fact cold be related to difficulties in understanding, difficulties lexical, graphic and visual-spatial,
frequently found in patients with aphasia.
Conclusions: The results suggest that there is a deleterious effect on the occurrence of lesion in the left
hemisphere, and consequently of aphasia, skills and numerical calculations, and the transcoding tasks that
have been shown to be most affected.
Keywords: Aphasia, mathematics, mental processes.
Introduction
The acalculia is defined as a partial or complete inability to deal with numbers, represents a
commitment of numerical processing and calculation (1). Some studies show that aphasic patients are more
susceptible to these changes (2, 3, 4). It is not unusual to have changes in numerical processing and calculation
in individuals with aphasia. Basso et al (6) conducted a study aiming to investigate the arithmetical
difficulties in aphasic patients. The data indicated that the disturbances of calculation may suggest a cooccurrence with language impairments found in these patients.
The difficulty caused by visual-spatial disorders in patients with brain damage and a loss in
calculation skills were also studied (2). Grafmans results showed that patients with brain injury, in general,
performed the tasks significantly worse than expected, and that patients with lesions in the left hemisphere
showed a worse performance. These results suggest that although different factors may contribute to
disturbances of calculation, such as loss of intelligence, visuo-constructive difficulties and foremost aphasia,
injury to the left are particularly likely to produce greater losses in skills assessment.
Thus, considering the importance of numerical processing and calculation in activities of daily living
and the need to investigate the changes of numerical processing and calculation in aphasic patients, we
conducted this study.
Method
This study was approved by the Ethics Committee in Research of UNIFESP, protocol number 0346/04.
We selected 32 participants diagnosed with speech aphasia. All patients were from the Center for Research in
Neuropsycholinguistical in Federal University of So Paulo- Brazil - UNIFESP. Had the following inclusion
68
criteria: age over 18 years, at least one year of schooling, presence of ischemic stroke only in the left
hemisphere, confirmed by neuroimaging examination and neurological evaluation. We excluded participants
who were diagnosed and / or history of hearing disorders and /or psychiatric or who used psychotropic
drugs. The selected subjects were submitted to the 31 subtests that make up the EC 301 battery for evaluation
of numerical processing and calculation, are: 1. Numerical sequence (C1, C2, C3), 2. Dot Counting (C4, C5, C6,
C7, C8), 3. Transcoding (C9, C10, C11, C12, C13, C14, C15), 4. Arithmetic Signs (C16, C17), 5. Numeric
comparison (C18, C19), 6. Mental Calculation (C20, C21), 7. Estimation of the Result of an Operation (C22), 8.
Number Positioning on an Analogical Scale (C23, C24), 9. Writing down an Operation. (C25), 10. Written
calculation (C26, C27, C28), 11. Perceptive Estimation of Quantity (C29), 12. Perceptive Estimation of Quantity
(C30), 13. Numerical Knowledge (C31), developed by Deloche (7).
Results
The characterization of the sample, the average age among the aphasics was 51.4 13.7 years and
average schooling and 8.0 5.2 years. 16 patients (50%) had amnestic aphasia type, 3 (9.4%) of driving, 4
(12.5%) of Broca, 1 (3.2%) transcortical sensory, 5 (16%) and 3 ( 9.4%) overall. Regarding the location of brain
damage, in individuals with aphasia after CT, we found: 10 (32%) patients lesion left parietal region, 9 (28%)
fronto-temporo-parietal, 3 (9.4%) left temporal, 3 (9.4%) left cortico-subcortical, 3 (9.4%) left fronto-temporal, 3
(9.4%) left temporo-parietal-occipital and 1 (3.2%) left parietal -occipital.
As shown in the figure below, the average percentage of correct answers in each subtest of the EC 301
battery in aphasic patients.
%correct
EC 301 Battery
1. Numerical Sequence (3 subtasks, C1, C2, C3)

2. Dot counting (5 subtasks, C4, C5, C6, C7, C8)
3. Transcoding (7 subtasks C 9, C10, C11, C12, C13, C14, C15)
4. Arithmetical Signs (2 subtasks, C16, C17)
5. Number Comparison (2 subtasks, C18, C19)
6. Mental Calcultation (2 subtasks, C20, C21)
7. Estimation of the Result of an Operation (1 subtask, C22)
8. Number Positioning on an Analogical Scale (2 subtasks, C23,
C24)
9. Writing down an Operation. (1 subtask, C25)
10. Written Calculation (3 subtasks, C26, C27, C28)
11. Perceptive Estimation of Quantity (1 subtask, C29)
12. Contextual Magnitude Judgments (1 subtask, C30)
13. Numerical Knowledge (1 subtask, C31)
69
Discusion
The difficulties observed in aphasic patients, the subtest C1 - oral counting the numbers, C2 and count
backwards and C3, score of 3 on 3 suggest that familiarity with counting numbers, even automatically, may
be impaired in aphasic patients especially when praxic components are involved (8). Changes to the subtests
C16 - arithmetic signs to name aloud and C17 - write arithmetic signs dictated call a kind of acalculia
assimblica, where the exchange of signals or failure in the appointment would be directly related to semantic
changes and the anomie that are commonly found in aphasics (9). Regarding comparisons of magnitude,
investigated when the patient should point to the many written orthographically, the change could be related
to difficulties in reading the numbers or the understanding of the quantity expressed by the numbers (2, 10).
In fact, it was observed during the implementation of this evidence, that some patients would be
defined by the length of written numbers, not the quantity expressed by it.
The aphasic patients showed worse scores in mental calculations simple addition, subtraction,
multiplication and division, presented in oral form and graphics. Simply adding the operation was performed
better in relation to subtraction and multiplication.
The aphasic patients performed significantly worse in
the accounts of multiplication, compared to the subtraction and division. This fact can be explained by the
way the rules are perceived multiplication, as the tables, which are trained through rhyming verbal or
decorated. That does not happen with other operations that are less systematically studied, suggesting that
the rules of multiplication are stored in a phonological level, and thus generate a greater impairment of braindamaged patients. (11, 12). However, visual-spatial interference can not be ruled out, especially when asked
to display resolution of the calculation with more than one digit, in which arithmetic rules are directly
involved. It is worth noting that the evidence transcoding showed the worst results. According to Mc Closkey
(5), numerical skills transcoding depend on a central component, which performs all the transcoding and
calculation operations. For the numeracy, calculation is performed, mechanisms are needed to translate the
numeric entries, both in form and spelling in Arabic and verbal form. In Moreover, the mechanisms of
production number have implications that need translation and abstract representation of appropriate forms
of output for each system of notation (verbal, spelling or Arabic).
Conclusion
Aphasic patients had difficulties in performing most of the tasks of numerical processing and
calculation proposed in the EC 301 battery. Transcoding tasks were more difficult for this group of patients.
The results suggest that there is a deleterious effect on the occurrence of lesion in the left hemisphere, and
consequently of aphasia, skills and numerical calculations.
Acknowledgments: Financial support-FAPESP (process number 04/04082-2)
References
1. Ardila A, Rosselli, M. Acalculia e Dyscalculia. Neuropsychol. Rev. 2002.; 12(4): 179-231.
2. Grafman J, Kampen D, Rosenberg J, Salazar AM, Boller F. The progressive breakdownof number processing and
calculation ability: A case study. Cortex. 1989; 25: 121133.
3. Delazer M, Girelli L, Semenza C, Denes G. Numerical skills and aphasia. J.Int.Neuropschol. Soc. 1999; 5: 213-221.
4. Basso A, Burgio F, Caporali A. Acalculia, aphasia and spatial disorders in left and right brain-damaged patients.
Cortex. 2000; 36 (20): 265-279.
5. Mc Closkey M. Cognitive mechanisms in numerical processing: Evidence from acquired dyscalculia. Cognition. 1992;
44: 107-57.
6. Basso A. Caporali, P. Faglioni. Spontaneous recovery from acalculia. J. Int. Neuropsych. Soc. 2005; 11: 99-107
7. Deloche G, Mansur LL, Rodrigues N In: Mansur LL, Rodrigues N. Temas em Neurolingustica: Acalculia e Afasia. So
Paulo: Tec Art; 1993. p. 103-106.
8. Martins, F. C. , Otriz, K. Z. The relationship between working memory and apraxia of speech. Arq Neuropsiquiatr
2009;67(3-B):843-848.
9. Ferro JM, Botelho MAS. Alexia for arithmetical signs: A cause of disturbed calculation. Cortex. 1981; 16:175-180.
10. Dehaene S, Cohen L. Two mental calculation systems: A case study of severe acalculia with preserverd
approximation. Neuropsychologia. 1991; 29:1045-1074.
11. Dehaene S. Varieties of numerical abilities. Cognition. 1992; 44:1-42.
12. Dehaene S, Cohen L. Cerebral pathways for calculation: Doubl dissociation between rote verbal and quantitative
knowledge of arithmetic. Cortex. 1997; 33 (2): 219-251
70
P007
THE INTERFERENCE OF THE LANGUAGE OF MATHEMATICAL PROCESSING IN
APHASIA
G.C.P. De Luccia 1, K. Z. Ortiz 2
1,2UNIFESP, So Paulo, Brazil
1 Speech Pathologist, PHd, Main author
2 Speech Pathologist, PHd, associate researcher
Introduction and aims of the study: The ability to calculate a cognitive process is extremely complex.
It consists of multifactorial processes, including verbal, spatial, memory and executive functions. Thus, the
performance of mathematical calculations may be impaired in cases of dysfunction and / or brain injury and
in dementia. Objective: This study aims to determine the correlation between changes in numerical processing
and calculation with language disorders in aphasic patients.
Methods: We evaluated 32 patients with aphasia, with brain damage only on the left. Participants
underwent assessment of numerical processing and calculation through Battery EC301 and evidence to
evaluate the language, through the Montreal Protocol, Toulouse.
Results: The performance of aphasic patients demonstrated a deleterious effect on the occurrence of
lesion in the left hemisphere, and consequently of aphasia on most tasks that involve numerical processing
and calculation, and the transcoding tasks were those that were more correlated with the evidence of
language.
Conclusions: The language skills of listening and graphics, repetition, reading and writing are directly
related to the difficulties found in tests of oral and graphical calculation and evidence of transcoding, in
which tasks are also involved conversion of numerals. Our results showed that aphasic patients with lesions
of the left cerebral hemisphere are highly likely to have difficulties in numeracy skills and in making
calculations. In general, the EC301 battery of tests in which the performance of patients with aphasia was
significantly worse than normal population, were strongly correlated with the evidence of language.
Keywords: mathematics, language, aphasia.
Introduction
Studies show that aphasic patients are more susceptible to alterations in numerical processing and
calculation (1.2). Since then, authors investigate (3.4) if the numerical processing and calculation, and
language processing activities are dependent or independent. In some reports, we found dissociations in these
processing (5,6), characterized by deficits in mathematical skills without injury to the language (7.8).
Furthermore, studies in patients with brain lesions show the simultaneous occurrence of dyscalculia and
language, suggesting that verbal skills have a key role in the calculation (9). The objective of this study was to
investigate the possible correlation between changes in numerical processing and calculation and language
disorders in aphasic patients.
Methodology
This study was approved by the Ethics in Research of Federal University of So Paulo - UNIFESP,
protocol number 0346/04. All patients signed informed consent forms prior to participation. Patients illiterate
were excluded from this study inclusion criteria for the study included native portuguese proficiency, a single
left stroke, and no previous neurologic, pychiatric, or substance abuse history. All patients selected for the
study were right-handed.
The participants were 32 patients diagnosed with speech aphasia and presence of ischemic stroke only
in the left hemisphere. Patients were examined for calculation through Battery EC301, which is composed of
13 tests (2). For evaluation of language, we use the Montreal Protocol Toulouse. The tests used in this study
were as listening comprehension, repetition, reading, graphics comprehension, nomination and dictation.
After obtaining the data on tests of language, these were correlated with the evidence of the EC 301 battery.
71
Results
Were 32 patients (37% female) who had suffered a single left hemisphere cerebrovacular accident.
Mean age of patient was 51,4 13,7 years, and mean education was 8,0 5,2 years.
Among the patients with aphasia, 16 (50%) had amnestic aphasic, 3 (9,4%) condiction aphasic, 4
(12,5%) Broca, 1 (32%) transcortical sensory, 5 (16%) and 3 (9.4%) global. Regarding the location of brain
damage, in individuals with aphasia after CT (Tomografia Computadorizada), we found: 10 (32%) patients
lesion left parietal region, 9 (28%) fronto-temporo-parietal, 3 (9.4%) left temporal, 3 (9.4%) left corticosubcortical, 3 (9.4%) left fronto-temporal, 3 (9.4%) left temporo-parietal-occipital and 1 (3.2%) left parietal occipital.
Observed in Table 1, the relationship between performance in language tasks and performance in the
EC301 battery of tests in aphasic patients.
Tabela 1 - Correlao entre o desempenho na bateria EC 301 e linguagem em pacientes com afasia
Prova
Prova
Prova
Prova
Prova
Prova
Prova
Prova
Prova
1
3
4
5
6
7
10
11
12
Listening Comprehension
r
0.73
0.68
0.67
0.52
0.64
0.46
0.55
0.57
0.73
P
<0.001*
<0.001*
<0.001*
0.003*
0.000*
0.008
0.001*
0.001*
<0.001*
Repetition
r
0.81
0.87
0.84
0.76
0.81
0.56
0.68
0.57
0.72
P
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
0.001*
<0.001*
0.001*
<0.001*
Reading
r
0.59
0.72
0.57
0.44
0.68
0.48
0.53
0.54
0.35
P
<0.001*
<0.001*
0.001*
0.012
<0.001*
0.006*
0.002*
0.001*
0.051
Graphics Comprehension
r
0.81
0.86
0.86
0.73
0.87
0.75
0.78
0.68
0.63
p
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
Nomination
r
0.74
0.79
0.72
0.47
0.76
0.50
0.55
0.62
0.59
P
<0.001*
<0.001*
<0.001*
0.006
<0.001*
0003*
0.001*
<0.001*
<0.001*
Dictation
r
0.86
0.91
0.78
0.63
0.83
0.51
0.75
0.63
0.56
P
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
0.003*
<0.001*
<0.001*
0.001*
p < 0,005 considered to indicate significance according to Bonferroni correction tests.1. Numerical sequence, 3.
Transcoding, 4. Arithmetic Signs, 5. Numeric comparison, 6. Mental Calculation, 7. Estimation of the Result of an
Operation, 10. Written calculation, 11. Perceptive Estimation of Quantity, 12. Perceptive Estimation of Quantity.
Discussion
Our results showed that aphasic patients with lesions of the left cerebral hemisphere are highly likely
to have difficulties in numeracy skills and in making calculations. In general, the EC301 battery of tests in
which the performance of patients with aphasia was significantly worse than normal population (2-10), were
strongly correlated with the evidence of language. Correlation between linguistic performance and some
evidence of the EC 301 battery. We note that for tests 1, 3, 4 and 6, took a direct or indirect involvement in
skills: oral counting, alphabetic writing and spelling of numbers, and graphics comprehension and repetition
(Table 1). We believe that these correlations were due to the reduction of resources and language processing,
also hypothesized that the comprehension could interfere in the oral evidence in the trial of magnitude and
the estimated result and quantity. Thus, most of the correlations could be due to changes in naming,
repetition, reading, writing, listening and understanding graphics in different degrees of commitment,
showing the involvement of language in numerical processing and calculation, taking into to the different
procedures that each task requires.
72
Analyzing the evidence of reading and spelling (Table 1), we also observed strong correlations with
the tests 1, 3, 4, 7, 10, 11 and 12. We can justify these results considering that the biggest difficulty in the
aphasic group was the evidence of transcoding, that semantic errors may have been generated by lexical
errors in linguistic tasks, suggesting that the evidence transcoding depend on language processing and may
reflect specific difficulties in numerical processing (11). Memories of arithmetic rules were also correlated
with the evidence of language. These changes can be explained by analyzing the difficulties of each
individual, since most patients recognize the symbols, but had difficulty in naming some of the arithmetic
signs (+, -, x, =). However, we found that many of these people performed computations orally without error
when the signal was mentioned by the examiner. This type of difficulty has been described by Ferro, Botelho
(12), they called these changes acalculia assimblica. Our findings corroborate this study were observed
difficulties in naming and writing of the arithmetic signs of addition, multiplication, division and equal.
At the semantic level, one can consider that the different representations of number systems (oral,
spelling, Arabic) share a number of semantic representations. In return, we can also say that all three systems
of representation have in common a single semantics. Explaining this paradigm, Deloche (13), argues that the
assumption of a single number for each semantic representation seems unrealistic, taking into account the
constellation of uses and meanings that numbers can be covered. This would explain the strong correlation
that we find when we relate the evidence of calculation with proof of name and other language tests.
Conclusion
The performance of aphasic patients in numerical processing and calculation showed that there is a
deleterious effect on the occurrence of lesion in the left hemisphere, on most tasks involving numerical
processing and calculation. In considering the aphasic population in general, we observed that the language
skills listening comprehension and graphics, repetition, reading and writing are directly related to the
difficulties encountered in calculating oral evidence and graphic evidence and transcoding.
Acknowledgments: Financial support-FAPESP (process number 04/04082-2)
References
1. Delazer M, Girelli L, Semenza C, Denes G. Numerical skills and aphasia. J.Int. Neuropschol. Soc. 1999; 5: 213-221.
2. Dellatolas G, Deloche G, Basso A, Salinas DC. Assessment of calculation and number processing using the EC-301
battery: Cross-cultural normative data and application to left-and-right brain damage patients. J. Int.
Neuropsychol. Soc. 2001; 7: 840-859.
3. Ardila A, Rosselli, M. Acalculia e Dyscalculia. Neuropsychol. Rev. 2002.; 12(4): 179-231.
4. Klessinger N, Szczerbinski M, Varley R. Algebra in a man with severe aphasia. Neuropsychologia. 2007; 45: 16421648.
5. Rossor MN, Warrington EK, Cipolotti L. The isolation of calculation skills. J. Neurology. 1995; 242 (2): 78-81.
6. Varley RA, Klessinger NJ, Romanowski CA, Siegal M. Agramatic but numerate. Proceedings of the National Academy
of Sciences. 2005; 102 (9): 3519-3524
7. Dehaene S, Cohen L. Cerebral pathways for calculation: Doubl dissociation between rote verbal and quantitative
knowledge of arithmetic. Cortex. 1997; 33 (2): 219-251.
8. Warrington EK. The fractionation of arithmetical skills: A single case study. Q. J. Exp. Psychol. A. 1992; 34 (pt 1): 31-51.
9. Baldo JV, Dronkers NF. Neural correlates of arithmetic and language comprehension: A common sobstrate?
Neuropsychologia. 2007; 45: 229-235.
10. De Luccia, Ortiz. Performance of a Brazilian population in the EC301 calculation and number processing battery. Arq
Neuropsiquiatr 2009;67(2-B):432-438.
11. Seron XE, Deloche G. From 4 to four: A supplement to from three to 3. Brain. 1983; 106: 735-44.
12. Ferro JM, Botelho MAS. Alexia for arithmetical signs: A cause of disturbed calculation. Cortex. 1981; 16:175-180.
13. Deloche G, Mansur LL, Rodrigues N In: Mansur LL, Rodrigues N. Temas em Neurolingustica: Acalculia e Afasia.
So Paulo: Tec Art; 1993. p. 103-106.
73
SY01.3
CROSSCULTURAL COMMUNICATIVE CLUSTERS FOLLOWING A RIGHT-HEMISPHERE
STROKE
Ferre P.1, Paz Fonseca2, de Mattos Pimenta Parente M.A.3, Abusamra V.4, Ferreres A.4, Giroux F.1, Ska B. 1, Joanette Y. 1
Centre de Recherche de lInstitut Universitaire de Griatrie de Montral (CRIUGM), Universit de Montral, Canada; 1
Centre de Recherche de lInstitut Universitaire de Griatrie de Montral (CRIUGM); 6 Pontifcia Universidade Catlica
do Rio Grande do Sul, PUCRS2
Federal do Rio Grande do Sul, UFRGS, Brazil.3
5 Universidad de Buenos Aires, Facultad de Psicologia, Argentina4
Clinical and research literature presently report that the contribution of both cerebral hemispheres is
necessary for a rich and effective verbal communication. However, for more than a century, the ubiquitous
theory of cerebral dominance has entitled the left hemisphere as almost exclusively responsible for language
abilities. This notion seems to keep influencing clinical interpretation of language and communication
impairment following a right brain damage (RBD).
Based on clinical observation, authors have claimed since the mid-twentieth century the potential of
the right hemisphere (RH) to process language (Eisenson, 1959; Critchley, 1962, Weinstein, 1964). However,
due to the impetus of neuro-imaging techniques and to the development of psycholinguistics (new models
embracing pragmatics and discourse) (Chomsky, 1999) the forgotten RH started being considered in
language/communication processing. Indeed, since 1990s, a relation between a RBD and pragmatic, prosodic,
lexico-semantic and/or discursive impaired language components has been consolidated (Joanette et al, 1990;
Myers, 1999; Tompkins, 1995; 2004). It has been estimated that about 50% of the individuals with RHD are
likely to present with one or more of these communication impairments (Benton & Bryan, 1996).
Although each isolated component has been described at length in the literature, only a few
observations have been sketched so far regarding their possible coexistence in a same individual (see Myers,
1979, 2005, Joanette et al., 1990, Blake et al., 2002). Overall, authors agree on the heterogeneity of cognitive and
communicative disorders following a stroke, thus suggesting that these impairments could be categorized
according to specific patterns, as it is the case of aphasia syndromes following a left hemisphere stroke. But no
sufficient studies so far seem to have focused on the identification of communicative profiles following a
RBD.
The lack of specific tools has for a long time limited the exploration of the communicative components
for which RH is specialized. The Protocole MEC (Joanette et al., 2004) has therefore been developed, allowing
the systematic evaluation of all four components of communication in French language. Due to international
collaborations, adapted, validated and normalized versions of the Protocole MEC are now available for
Spanish (Ferreres et al., 2007) and Brazilian Portuguese (Fonseca et al., 2008), while Italian and English
versions are currently being achieved. The availability of these versions offers a unique opportunity to
compare across three Latin languages the impact of a RBD on communication.
In the last years, preliminary data could be gathered by our group with a small sample of adults with
RBD showing the existence of clinical profiles of communication impairments (Ct et al., 2007; Ferr el al.,
2009). Keeping up the reflections about the classification of clinical subgroups in RBD populations, with a
tripled sample with more patients representing each country, this paper aims at characterizing subgroups of
RBD adults regarding communicative performance, with a transcultural approach. In addition, it remains to
be known if the clinical sub-types found are influenced by their clinical, demographic or culture represented
by the country of origin- features.
Like the sub-types of aphasia universally drawn after left brain damage, the identification of patterns
of communication disorders will probably contribute to greater clinical expertise when it comes to the
assessment and rehabilitation of patients with a right stroke.
74
Method
Participants
The sample is composed of 112 right handed individuals with a single right hemisphere stroke and no
history of other neurological or psychiatric disorders and no drug and alcohol addiction. Participants have
been recruited in several hospitals and rehabilitation centers in their countries of residence, not considering
the presence of communication impairment as an inclusion factor. No restriction has been set regarding the
time post-stroke, but no participant received any kind of cognitive or language treatment for more than two
months after the onset. Demographic and clinical variables for the sample are described in Table 1.
Procedure
Participants have initially been assessed by an examiner trained in speech and language pathology
and/or in neuropsychology, using 14 tasks of the Protocole MEC and its adapted versions. Table 2 briefly
describes each task, according to their respective assessed communication component. The whole assessment
battery took from 2 to 3 sessions of 50 minutes each.
Each answer, audio-recorded and transcribed, has been scored based on each countrys scoreform. A
blind judgment by another evaluator was afterwards accomplished and consensus was found by a third
clinician.
Table 1
Global description of the demographic data for the sample, in number, means and percentage
N
Country of origin
Time post onset (in months)

Mean age
Education level (years of schooling)
Lesion type
Lesion site
112 RBD individuals

45 Canadians individuals (40%)
48 Brazilians individuals (43%)
19 Argentineans individuals (17%)
Mean= 5,29 (sd*=8,94)
Mean= 61,04 (sd=15,07)
Mean= 9,15 (sd=4,73)
26 ischemic (28%)
68 hemorrhagic (72%)
(18 unreported) (16%)
40 cortical (52%)
27 sub-cortical (35%)
10 cortico-subcortical (13%)
(35 unreported) (31%)
52/112 (46%)
Full description (lesion + site) of lesion site in the

medical file**
Notes: *sd= standard deviation; **52 patients had their neurological condition -in terms of type and site of the lesion- fully
described in their neuro-imaging records.
75
Pragmatics
Discourse
Prosody
Lexico-semantic
Communication component
20 metaphorical statements (10 creative, 10 idioms). Participants are asked to explain each
one
Metaphor interpretation
Nine short situational paragraphs inducing an emotion (three situations, three target
sentences). Participants produce the target sentence orally with the appropriate intonation
10-minute natural conversation between examiner and participants on two different topics.
Conversational discourse
17-point observation grid filled by examiner
Narrative
discourse
A narrative (including an inference) first recalled one paragraph at a time and then globally
recall
Narrative
discourse
12 comprehension questions regarding the content and the inference
questions
Metaphor interpretation
See above: this task addresses simultaneously the semantic and pragmatic components
Indirect
speech
acts 20 situations of which 10 end with a direct speech act, 10 end with an indirect speech act.
interpretation
Participants are asked to explain each one.
12 pre-recorded sentences (4 sentences of neutral content, each said with three different
emotional intonations). Participants identify the intonation by pointing to the right icon
With the same stimuli, participants repeat the sentences
12 pre-recorded sentences (4 sentences of neutral content, each said with three different
linguistic intonations). Participants identify the intonation by pointing to the right icon.
With the same stimuli, participants repeat the sentences
Participants indicate the presence or absence of semantic relationship
Semantic Judgement
Linguistic
prosody
comprehension
Linguistic
prosody
repetition
Emotional
prosody
comprehension
Emotional
prosody
repetition
Emotional
prosody
production
Participants say as many words as possible in 2.5 minutes, without any criterion
Verbal fluency free
Verbal
fluency
Participants say as many words as possible starting by the letter p in 2 minutes

orthographic criterion
Verbal fluency semantic
Participants say as many clothes as possible in 2 minutes
criterion
Description
Task
Table 2
Tasks of the Protocole MEC for each communication component
76
Data analysis
Participants performance on each task was first scored in terms of age (18-30, 30-49, 50-64, 65-85 years
old) and education-adjusted performance, based on the normative data of each country. The raw score for
each individual and each task has thus been transformed into a z-score to allow comparison between
participants of different countries.
Considering the variability of z-scores and their relation with severity level of impairment, a category
number was attributed to the three following ranges. To z-scores ranging till -0.9 a category number of 0 was
given; for z-scores between -1 and -1.49, category 1; for a z- score between -1,5 and -2, 2; finally, for z-scores
from 2.1 and above, a category number 3 was attributed.
Individuals category numbers were submitted to a Clustan hierarchical cluster analysis (Aldenderfer
& Blashfield, 1985). A clinical description of each profile as a group has then been undertaken. A task was
considered impaired by the cluster when the average z-score for the cluster was equal to or less than -1.5
(Schoenberg et al, 2006) and when at least 50% of the individuals showed results below -1,5. Aiming at
comparing age, education and time post-onset between clusters, a Kruskall Wallis test was applied.
Distribution of site (cortical versus sub-cortical) and nature (ischemic versus hemorrhagic) of the lesion, as
well as country of origin was compared between clusters by Fishers Exact Test.
Results
Five distinct communication clusters arose from the Clustan analysis. Table 3 describes the profiles
obtained, including their demographic, clinical characteristics and their performance in the Protocole MEC.
When it comes to socio-demographic variables, no statistically significant differences were found between
clusters, except for country variable, which showed differences between clinical subgroups. In general, all
countries are represented in each cluster; however, cluster 4 displayed no Argentinean individuals, followed
by a striking majority of Argentineans in cluster 5.
The comparative analysis between clusters showed no statistical differences regarding neurological
features. All clusters were characterized by a majority of ischemic stroke. Cortical and subcortical sites were
evenly distributed among the clusters. Time post-onset happened to be the most heterogeneous among
individuals, as shown by the standard deviations described in Tables 1 and 2.
An analysis of clusters communication performance showed that each subgroup presented a distinct
profile of language impairment. The first cluster is characterized mainly by prosodic impairments, followed
by a diminished semantic verbal fluency and a disturbed conversational discourse. Cluster 2 displays only
conversational discourse disorders. On the other hand, cluster 3 shows no communication impairments. The
forth cluster presents low-to-moderate impairments in the narrative discourse retelling as well as in the free
verbal fluency, in the semantic judgment and in the emotional prosody (repetition). Cluster 5, interestingly,
shows extensive and more severe impairments.
77
Conversational
Narrative: Recall
Narrative: Questions
Indirect speech acts
Metaphors
Fluency without constraint
Orthographic fluency
Semantic fluency
Semantic judgment
Metaphors
Linguistic comprehension
Linguistic repetition
Emotional comprehension
Emotional repetition
Emotional production
Mean age
Mean education
Mean months post onset
Hemorrhagic strokes
Ischemic strokes
Cortical strokes
Sub-cortical strokes
Cortico-subcortical strokes
Distribution
(A= Argentina, B= Brazil, C=Canada)
Demographic and lesion datas
Prosody
Semantic
Pragmatics
Discourse
62
8,9
6,10 (sd=9,42)
37%
63%
57%
36%
7%
A=3 (12%)
B=13 (52%)
C=9 (36%)
-6,24
-1,26
-1,32
-0,75
-0,08
-1,16
-0,89
-1.96
-3,17
-0,08
-1
-3.18
-1,67
-2,61
-2.31
Performance for each MEC communication task (z-score)
Cluster 1
N=25 (22%)
62
8,36
6,14 (sd=9,49)
39%
61%
45,5%
45,5%
9%
A= 3 (13)
B= 12 (55%)
C= 7 (32%)
Cluster 2
N=22 (20%)
-3,84
-0,03
0,24
-0,40
-0,18
-0,69
-1.10
-0,81
0,24
-0,18
-0,12
-0,10
-0,78
-0.27
-1,01
Table 3
Clinical and demographic variables for each cluster
78
62
9
2.5 (sd=2,97)
9%
91%
45%
45%
10%
A= 1 (4%)
B= 12 (48%)
C=12 (48%)
0,02
0,07
0,08
0,14
0,17
-0,10
-0,42
-0.39
-0,36
0,17
-0.27
-0,18
-0,61
-0,55
-0,89
Cluster 3
N=25 (22%)
A= 0 (0%)
B= 5 (42%)
C= 7 (58%)
62
7,7
2.44 (sd=3,20)
30%
70%
47%
47%
6%
-0,33
-1,58
0,05
-1,15
-1,35
-1.89
-0.77
-1,03
-1,82
-1,35
-1,03
-1,40
-0,44
-1.70
-1,34
Cluster 4
N=12 (11%)
A= 12 (43%)
B= 6 (21%)
C= 10 (36%)
59,5
14,2
7,32 (sd=8,77)
26%
74%
50%
32%
18%
-10,96
-1,33
-1,27
-1,51
-4,14
-1,43
-1,21
-1,30
-2,18
-4,14
-3,31
-2,30
-2,95
-2,16
-2,30
Cluster 5
N=28 (25%)
Discussion
This study brought to evidence the postulation that distinct clinical profiles of
communication processing can be distinguished among the RHD individuals. Results were
validated in part by their repetitive clusters characteristics compared to former studies
developed by our group (Ct et al, 2007; Ferr et al., 2009). The large number of participants
also allowed confirming the initial hypothesis: there are different clinical subgroups with
distinct impaired communicative components, seeming to be, in general, universal, as
represented by the patterns observed on patients from three different countries and cultures.
There are two relevant aspects to be discussed about communicative features of the five
resulting clusters: (1) observation of specificities of the processing of the communication
components in each clinical group, and (2) confirmation of the absence of a RBD impact on
communication in all individuals. When it comes to the first aspect, four of the five clusters
presented at least one impaired linguistic component. Discursive processing was impaired in all
the four profiles. Conversational discourse and emotional prosody (repetition) were more
frequently impaired in three clusters. Pragmatic processing was the least affected, probably due
to the fact that RBD patients tend to show a lower performance when the comprehension of the
context is required and in the most natural -versus formal- settings (Moix et Ct, 2004). These
aspects are more specifically addressed in the conversational discourse task, when compared to
metaphors and speech acts interpretation, composed mainly by isolated sentences. Moreover,
concerning the second issue, this study suggested that approximately half of the estimated
incidence of 50% of RBD people did not demonstrate communicative impairment after this
neurological disorder. This low proportion is particularly striking when the context of
recruitment is considered. Some individuals were selected more than two years post-stroke and
could consequently be expected to have benefited from spontaneous recovery. An explanation
might be that former studies did not propose a sensitive-enough assessment of communication,
and particularly of the conversational discourse. Indeed, one cluster is characterized by unique
impairment in this task. If the Protocole MEC did not accurately address this aspect, the
individuals from this cluster would be distributed in the other groups, and the proportion of
individuals with no impairment as a group would consequently increase, virtually up to 42%
and more.
Regarding the not sufficiently explored impact of socio-demographic factors on
communication profiles after a RBD, the clusters seem not to have been influenced by age or
education. It was expected that schooling could influence the communication processing by RBD
patients, as far as education variable had shown to override the impact of the lesion itself
(Beausoleil et al, 2003). Results regarding the country of origin suggested that cultural
background can influence, to some extent, the communicative behavior of individuals.
However, this result might be biased by the distinct normative data originated in different
countries. Indeed, cluster 3 is characterized by the absence of Argentinean individuals, but also
by the low-to-moderate degree of impairment in all tasks. On the contrary, cluster 5, exhibiting
the more severe deficits, also shows the highest proportion of Argentinean individuals.
Incidentally, Argentineans, as a group, show more severe deficits in all tasks compared to
individuals from other countries. This could be explained by more homogeneous normative
scores among Argentinean control individuals.
Concerning neurological features, the type and global site of stroke did not appear to
determine the grouping either. The proportion of ischemic stroke lies usually between 60 and
90%, in accordance with former studies (Caplan, 2000), a range that includes the percentage of
79
this type of neurological disorder found in each cluster of the present study. Regarding the site
of the lesion, more studies are necessary to better explain the relation between damaged regions
and communication processing following a RBD, based mainly on magnetic resonance data
rather than tomography results, as ischemic lesions can sometimes not be identified by a
tomography taken during the first days post-stroke. Moreover, as stroke is more frequent in
elderly adults, phenomena of brain reorganization in aging such as PASA or HAROLD (Cabeza,
2002, Davis et al., 2008) should also be considered during systematic analysis of lesion sites in
order to fully understand the expected impact on the clinical manifestations.
Effect of the time post onset was not conclusive. Although this variable was the most
heterogeneous, there was no direct effect of post onset time and clusters characterization.
Cluster 5, for example, showed the most severe scores, but was also the group with the longest
post-onset time. This could suggest that the evolution of the manifestation could be very
heterogeneous among individuals. Although very little research has been conducted so far
regarding the language recovery over time in RBD individuals, mismatching results can be
found in the literature: Brady et. al (2006) demonstrated that no spontaneous recovery was
found in discourse until six months post onset, while Mackenzie et. al (2001) reported significant
improvement between one, six and 12 months. In any case, the time course variable would
preferably be better controlled in future experiments, what is great challenge in cross-cultural
studies as far as each country has different clinical settings with distinct post-onset phases.
In conclusion, the distinctive clusters are essentially better defined by the type and
severity of the communicational impairment and poorly to cultural, lesion or demographic
background. In addition, profiles could be correlated with other cognitive disorders, including
disexecutive syndrome (mental flexibility, inhibition, shared attention mechanisms) (see Myers,
2005) or theory of mind deficits (Champagne, 2009), for example. The relationship between
cognitive and communicative components must be further explored.
Besides this, the inclusion of other linguistic groups, such as Italian or English-speakers,
would offer expanded information on cross-cultural aspects. In the near future, correlation
between tasks in the MEC battery should be specifically addressed. Indeed, researchers start to
find clues demonstrating that some tasks might be predictive of other abilities (Tompkins, 2009).
Meanwhile, the conversational discourse task could be analyzed by itself, as it concentrates all
aspects of communication.
Despite this studys caveats, results demonstrated that there are four distinct groups of
communication impairment following a RHD. Interestingly, they seem to be characterized by a
kind of universality among the Latin languages implicated. This investigation will continue with
an increasing sample thanks to the contribution of other countries and will aim at exploring
more thoroughly the impact of culture, lesion site and other cognitive aspects so as to achieve an
accurate classification of communicative disorders associated with a RBD.
References
Abbott, R. D., Curb, J. D., Rodriguez, B. L., Masaki, K. H., Popper, J. S., Ross, G. W., & Petrovitch, E. (2003).
Age-related changes in risk factor effects on the incidence of thromboembolic and hemorrhagic
stroke. Journal of Clinical Epidemiology, 56(5), 479-486.
Aldenderfer, M. S., & Blashfield, R. K. (1985). Cluster analysis. Beverly Hills, CA : Sage Publications.
80
Beausoleil, N.; Fortin, R.; Le Blanc, B.; Joanette, Y. (2003). Unconstrained oral naming performance in
right- and left-hemisphere-damaged individuals: When education overrides the lesion. Aphasiology.
17(2), 143-158.
Benton, E., & Bryan, K. (1996). Right cerebral hemisphere damage: incidence of language problems.
International Journal of Rehabilitation Research, 19 (1), 47-54.
Blake, M.L. (2009). Inferencing processes after right hemisphere brain damage: maintenance of inferences.
Journal of Speech, Language and Hearing Research, 52(2), 359-372.
Blake, M. L., Duffy, J. R., Myers, P. S., & Tompkins, C.A. (2002). Prevalence and patterns of right
hemisphere cognitive/communicative deficits: Retrospective data from an inpatient rehabilitation
unit. Aphasiology, 16 (4), 537-547.
Brady, M., Armstrong, L., & Mackenzie, C. (2006). An examination over time of language and discourse
production abilities following right hemisphere brain damage. Journal of Neurolinguistics, 19, 291
310.
Broca, P. (1861). Remarques sur le sige de la facult du langage articul, suivies dune observation
daphmie (perte de la parole). Bulletin de la socit danthropologie, 38, 330-357.
Cabeza, R. (2002). Hemispheric asymmetry reduction in older adults: The HAROLD model. Psychology and
Aging, 17 (1), 85-100.
Caplan, L. R. (2000). Caplan's stroke: a clinical approach (3rd ed.): Butterworth-Heinemann.
Champagne-Lavau, M., & Joanette, Y. (2009). Pragmatics, theory of mind and executive functions after a
right-hemisphere lesion: Different patterns of deficits. Journal of Neurolinguistics, 22, 413426.
Chomsky, N. (1999). Derivation by Phase. MIT Occasional Papers in Linguistics. No. 18.
Code, C., Wallesch, C. W., Joanette, Y., & Lecours, A. R. (2002). Classis cases in neuropsychology. Vol. II.
Hove, England: Psychology Press.
Collins, C. (2007). Pathophysiology and classification of stroke. Nursing Standard, 21(28), 35-39.
Ct, H., Payer, M., Giroux, F., & Joanette, Y. (2007). Towards a description of clinical communication
impairment profiles following right-hemisphere damage. Aphasiology, 21(6/7/8), 739-749.
Critchley, M. (1962). Speech and speech-loss in relation to duality of the brain. In (V.B. Mountcastle d.)
Vol. Interhemispheric relations and cerebral dominance. Baltimore, MD: John Hopkins Press.
Davis, S. W., Dennis, N. A., Daselaar, S. M., Fleck, M. S., & Cabeza, R. (2008). Qu Pasa? The posterioranterior shift in aging. Cerebral Cortex, 18, 1201-1209.
Eck, K., Ct, H., Ska, B., & Joanette, Y. (2001). Analyse critique des protocoles dvaluation des troubles
de la communication des crbrolss droits. Paper presented at the VII Congresso
Latinoamericano de Neuropsicologia, Sao Paulo, Brazil, 30 October3 November.
Eisenson, J. (1959). Language dysfonctions associated with right brain damage. American Speech and Hearing
Association, 1(117).
Ferr, P., Clermont, M.F., Lajoie, C., Ct, H., Ferreres, A., Abusamra, V., Ska, B., Paz Fonseca, R., &
Joanette, Y. (2009). Revista Neuropsicologia Latinoamericana, 1 (1), 32-40.
Ferreres, A., Abusamra, V., Cuitio, M, Ct, H., Ska, B., & Joanette,Y. (2007). Protocolo MEC. Protocolo
para la Evaluacin de la Comunicacin de Montreal. Buenos Aires: Neuropsi Ediciones.
Fonseca, R. P., Parente, M. A. M. P., Ct, H., Ska, B., & Joanette, Y. (2008). Bateria Montreal de Avaliao
da Comunicao - Bateria MAC. So Paulo: Pr-Fono.
HSFC
(2008).
Stroke
risk
factors
http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484177/k.D04E/Stroke__Risk_factors_y
ou_cant_control.htm
Jarema, G. (1984). Les problmes de la terminologie aphasiologique. Meta: journal des traducteurs/Meta:
Translators' Journal, 29(1), 99-109.
Joanette, Y., Goulet, P., & Daoust, H. (1991). Incidence et profiles des trouble de la communication verbale
chez les crbrolss droits. Revue de Neuropsychologie, 1 (1), 3-27.
Joanette, Y., Ska, B., & Ct, H. (2004). Protocole Montral dvaluation de la communication (Protocole
MEC). Isbergues, France: Ortho dition.
Mackenzie, C., Brady, M., Begg, T., & Lees, K. R. (2001). Communication ability following right
hemisphere brain damage: The family perspective. Advances in Speech-Language Pathology, 3, 8195.
81
Moix, V., & Ct, H. (2004). Intervention orthophonique chez les crbrolss droits. Rducation
Orthophonique, 219, 123-133.
Myers, P. S. (1979). Profiles of communication deficits in patients with right cerebral hemisphere damage:
Implications for diagnosis and treatment. In R. H. Brookshire (Ed.), Clinical Aphasiology Conference
Proceedings (pp.38-46). Minneapolis, MN: BRK Publishers.
Myers, P. S. (1999). Right hemisphere damage: Disorders of communication and cognition. San Diego: Singular.
Myers, P. S. (2005). CAC Classics Profiles of communication deficits in patients with right cerebral
hemisphere damage: Implications for diagnosis and treatment. Aphasiology, 19 (12), 1147-1160.
Sagui, E., M'Baye, P. S., Dubecq, C., Fall, K. B., Niang, A., Gning, S., Bellefleuer, J. P., Sane, M., & Debonne,
J. M. (2005). Ischemic and hemorrhagic strokes in Dakar, Senegal: a hospital-based study. Stroke ,
36(9), 1844-1847.
Schoenberg, M.R., Dawson, K.A., Duff, K., Patton, D., Scott, J.G. & Adams, R.L. (2006). Test performance
and classification statistics for the Rey Auditory Verbal Learning Test in selected clinical samples.
Archives of Clinical Neuropsychology, 21, 693-703.
Tompkins, C. A. (1995). Right hemisphere communication disorders: Theory and management. San Diego:
Singular.
Tompkins, C. A, Fassbinder, W, Lehman-Blake, M. T., & Baumgaertner, A. (2002). The nature and
implications of right hemisphere language disorders: issues in search of answer. In A.E. Hillis (Ed.),
The handbook of adult language disorders integrating cognitive neuropsychology, neurology, and
rehabilitation (pp. 429-448). New York: Psychology Press.
Tompkins, C.A. (2009). Can high-level inferencing be predicted by Discourse Comprehension Test
performance in adults with right hemisphere brain damage? Aphasiology, 23 (7-8), 1016-1027.
Weinstein, E. A. (1964). Affection of speech with lesions of the non-dominant hemisphere. Research
Publications of the Association for Research in Nervous and Mental Disease, 42, 220-228.
Yang, Z. H., Zhao, X. Q., Wang, C. X., Chen, H. Y., & Zhang, Y. M. Neuroanatomic correlation of the poststroke aphasias studied with imaging. Neurological Research, 30(4), 356-360.
82
P060
THE PROCESSING OF AMBIGUOUS SUBJECT PRONOUN ANAPHORA:
EVIDENCE FROM BROCAS APHASIA IN GREEK
E. Peristeri, I.M. Tsimpli
Aristotle University of Thessaloniki
Introduction. The phenomenon which has been examined in the present study is
ambiguous pronoun resolution in both intra-sentential and inter-sentential contexts. More
specifically, pronoun ambiguity resolution has been tested with sentences such as (1) & (2) for
the intra-sentential condition and (3a) & (3b) for the inter-sentential condition:
(1) I mitera filise tin kori tis kathos pro evaze to palto tis.
(2) I mitera filise tin kori tis kathos afti evaze to palto tis.
The mother-F kissed her daughter-F while pro/she was putting her coat on.
(3) Giati o Giorgos heretai ton Niko toso lipimena?
Why does George say goodbye to Nick so sadly?
(3a) Giati pro fevgi gia pada stin Ameriki.
(3b) Giati aftos fevgi gia pada stin Ameriki.
Because he is leaving to America for ever
Greek is a typical null subject language (NSL) and, therefore, both the null pronoun in
(1)/(3a) and the overt pronoun in (2)/(3b) can in principle refer to either the subject or the object
of the main clause (Tsimpli et al. 2004). Carminatis (2002) Position of Antecedent Hypothesis
(PAH) predicts that in Italian there is a division of labour between null and overt pronouns with
regard to structural configuration.
(4) Position of Antecedent Hypothesis
The null pronoun prefers an antecedent which is in the [Spec,IP] position, while the overt pronoun prefers
an antecedent which is not in the [Spec, IP] position.
Following such an account, a null subject pronoun should be preferentially interpreted as
referring to the main clause subject or the subject of the interrogative clause in the intrasentential and the inter-sentential condition, respectively. On the other hand, according to PAH,
the overt subject pronoun should signal disjoint reference by being interpreted as referring to
the main clause object or the object of the interrogative clause in the intra-sentential and the
inter-sentential condition, respectively. Though the exact nature of the external pragmatic
conditions claimed to regulate the distribution of null and overt subject pronouns in NSLs is
hotly debated, further psycholinguistic evidence suggests that overt subject pronouns in typical
NSLs is a marked option, and that their pragmatically acceptable/felicitous use in two
potential antecedent contexts always involves a shifting of the discourse topic from the syntactic
subject to the non-topic/object ( Tsimpli et al. 2004; White 2008).
Further studies also highlight the great processing cost associated with the evaluation of
the external discourse conditions in such cases of referential ambiguity, whereby the critical
83
subject pronoun (null/overt) may be potentially anteceded by either of the two antecedents till
the human parser integrates the discourse constraints and resolves the ambiguity in favour of
the pragmatically felicitous antecedent. The greater cost and processing limitation inflicted by
the incremental access to discourse knowledge read by the conceptual/intentional system of
cognition has been repeatedly registered in monolingual native speakers (especially
monolingual children) who have been reported to make a greater effort when integrating
syntactic information with discourse-derived cues (Roberts, Gullberg & Indefrey 2008; Hopp
2007). These studies evince that in cases of prolonged referential ambiguity the human parser
resorts to the most cognitively prominent antecedent which is most of the times identified with
the grammatical subject.
Aims
To explore the functional weight assigned by eight Greek-speaking Brocas aphasic

patients to the discourse constraints regulating the interpretation of subject pronouns in
referentially ambiguous contexts. If it is indeed the case that the symptomatology in
Brocas aphasia derives from performance (vs. competence) limitations stemming from
limited processing (especially, deficient working memory and allocational) capacities,
then we speculate that our aphasic patients linguistic performance will be most
compromised in the processing of overt subject pronouns requiring the integration of
discourse constraints/interface-conditioned informational cues in real-time.
To gain an insight into the type and nature of the parsing heuristics employed by the
aphasic parser under computationally demanding experimental conditions, like those
involved in the inter-sentential (vs. intra-sentential) paradigm. We speculate that the
patients will have more difficulty recovering antecedent information in the intersentential (vs. intra-sentential) contexts which assumingly impose greater memory
demands due to the prolonged spatial memory load and the non-canonical Object-VerbSubject (OclVS) word-order assigned to half of the stimuli by means of Clitic Left
Dislocation (CLLD).
Methods
Subjects & Experiments. Eight Greek-speaking agrammatic patients with Brocas
aphasia and a group of fifteen age-matched language-unimpaired controls were recruited for the
present study.
(i) On-line self-paced listening sentence-picture matching task checking pronoun
resolution intra-sententially.
The self-paced listening sentence-picture matching experiment was based on a crossmodal decision paradigm. More specifically, participants were shown visual picture-probes on a
computer screen and were instructed to make a match or a mismatch decision according to their
best judgement while listening to a concurrent sentence. Subjects match and mismatch decisions
indirectly reflected their preferences regarding the possible linking relations established
between the postulated null or overt subject pronouns and the candidate antecedents in each
experimental sentence.
The experimental stimuli consisted of twenty test items taken from Tsimpli et al.s paper
(2004). Two definite NPs (the first in grammatical subject position and the second in
grammatical object position) were introduced in the main clause. Each matrix clause was
followed by a subordinate clause, in which the form of the referring expression in preverbal
subject position was manipulated and was represented as either an overt or a null pronoun.
84
Both arguments of the matrix clause shared the same gender and they were matched with the
(overt) pronoun in the subordinate clause on the appropriate morphosyntactic dimensions, i.e.
gender and number.
Figure (1) below represents the picture triplet corresponding to a sentence with an overt
subject pronoun across the single match and the two mismatch readings. The leftmost picture
corresponds to the matching condition by portraying the subordinate agent as the main clause
object, while the middle and the rightmost picture correspond to the mismatching conditions
by portraying the subordinate agent as the main clause subject and an obviate referent,
respectively.
(5) I mitera filise tin kori tis kathos afti evaze to palto tis
The mother kissed her daughter while she was putting her coat on
a.Match reading
b.Mismatch reading i
c.Mismatch reading ii
(ii)
On-line
self-paced
listening antecedent identification task checking pronoun resolution intersententially.
A set of twenty four brief two-sentence semantically coherent discourses was
constructed. The first sentence was an interrogative and introduced two entities using either
SVO (6a) or OclVS (6b) word order. In order to neutralise any marked referential interpretation
that could favour one of the two entities as the pronouns most felicitous antecedent and ensure
total reversibility, both NPs had proper names as nucleus. In the second sentence the form of the
referring expression was manipulated resulting in two alternative versions: one with a null
pronoun in the syntactic subject position (7) and the other with an overt pronoun (8). The overt
pronoun in the second sentence could legitimately refer to either of the two proper names in the
first sentence which were of the same gender. Furthermore, the verbs included in the fist clause
(6a & 6b) were pragmatically neutral so as not to bias the experimental subjects towards the
subject or the object of the first clause while resolving the pronoun. Finally, the number of
syllables between the two candidate referents in the first clause was also controlled for (Mean
number of syllables: 5 & 6 syllables for the SVO and the OclVS condition, respectively) and it
was held constant throughout all the experimental items in order to avoid any distance effect
between the pronoun and its antecedent. After listening to each discourse set on-line, each
subject was asked by the examiner to name the most plausible antecedent of the pronoun.
(6a) Giati o Giorgos heretai ton Niko toso lipimena?
SVO word-order condition
(7) Giati pro fevgi gia pada stin Ameriki.

(8) Giati aftos fevgi gia pada stin Ameriki.
Null pronoun condition

Overt pronoun condition
85
(6b) Giati ton Niko ton filai o Giorgos toso lipimena?

(7) Giati pro fevgi gia pada stin Ameriki.
(8) Giati aftos fevgi gia pada stin Ameriki.
OclVS word-order condition
Null pronoun condition

Overt pronoun condition
Results. With respect to the intra-sentential task, between-subject analyses have revealed
that the performance of the aphasic patients was not considerably different from that of controls,
at least in the testing conditions involving a null pronoun in subject position. More specifically,
almost all the patients preferred to interpret the null subject pronouns as referring to the main
clause subject, followed by the main clause object and the other referent. In fact, the null
pronoun-main clause subject co-reference condition was the only whereby controls and the
patients performances were highly comparable, since no significant dissociation was reported
between the control group and any of the patients. On the other hand, the patients and controls
performances slightly differed in the overt pronoun trials. First, while controls preference for
the other antecedents occupied the second position in the hierarchical ordering of their parsing
preferences, all the patients proved less prone to assign to the overt subject pronoun an
antecedent which was not sententially-anchored. Furthermore, in contrast to controls who have
systematically treated the subject referent option as the most infelicitous for the resolution of the
overt subject pronoun relative to the rest of the candidate antecedents, the patients appeared to
be less stable with respect to their matching decisions for the overt pronoun trials; half of the
patients have considered the subject and the object antecedents as equally appropriate for the
resolution of the overt subject pronoun, while three patients were found to prefer the object over
the subject antecedent.
With respect to the inter-sentential task, the patients and controls have demonstrated
some interesting differences with respect to their parsing preferences. The first notable
difference pertains to the fact that aphasics tended to interpret the critical pronoun as referring
to the subject significantly more times than controls. In fact, such pattern was reported for all but
the SVO-null pronoun condition, whereby both controls and aphasics rates were positively
correlated. Furthermore, the fact that controls tended to interpret the overt pronouns as referring
to the object considerably more times than aphasics in the SVO-overt pronoun condition implies
that the former were more sensitive to the discourse-marked status of the overt subject
pronouns, at least when the subject was in pre-verbal position. On the other hand, aphasics and
controls pattern of performance in the trials having the object in pre-verbal position suggests
that the syntactic position of the object appeared to be more relevant to pronoun resolution for
control subjects relative to the aphasic patients; controls tended to interpret the pronoun as
referring to the CLLDed object considerably more times than aphasics, who appeared to resolve
both null and overt pronouns at random.
Conclusions. Both tasks evince that the patients were considerably less sensitive to the
discourse constraints regulating the interpretation of overt subject pronouns relative to controls
who appeared to be constrained by the pragmatically-marked status of overt pronouns in both
tasks. Most crucially, the process of resolving ambiguous pronouns in inter-sentential contexts
by means of relying on both structurally (i.e. CLLD of the object) and grammatically-determined
operations (i.e. marked status of the overt pronouns) was probably the most demanding
condition for the eight patients, who either tended to perform at random or attempted to
compensate for their deficiency by resorting to the subject antecedent as the default choice. The
86
patients performance across the two tasks is explained in terms of processing limitations rather
than a lack of grammatical knowledge representations.
References
Carminati, M. (2002). The Processing of Italian Subject Pronouns. PhD dissertation, University of
Massachusetts Amherst.
Hopp, H. (2007). Cross-Linguistic Differences at the Syntax-Discourse Interface in Off- and On-line L2
Performance. In Proceedings of the 2nd Conference on Generative Approaches to Language Acquisition
North America (GALANA), (Eds.) Alyona Belikova, Luisa Meroni, and Mari Umeda, pp. 147-158.
Somerville, MA: Cascadilla Proceedings Project.
Roberts, L., Gullberg, M., & Indefrey, P. (2008). On-line pronoun resolution in L2 discourse: L1 influence
and general learner effects. Studies in Second Language Acquisition, 30, 3, 333-357.
Tsimpli, I. M, Sorace, A., Heycock, C., & Filiaci, F. (2004). First language attrition and syntactic subjects: A
study of Greek and Italian near-native speakers of English. International Journal of Bilingualism, 8,
3, 257-277.
White, L. (2008). Definiteness effects in the L2 English of Mandarin and Turkish speakers. In Harvey
Chan, Heather Jacob and Enkeleida Kapia, (Eds.), Proceedings of the 32nd Annual Boston
University Conference on Language Development, 550-561.
87
FP07.3
PRODUCTION AND COMPREHENSION OF SPATIAL LANGUAGE IN FRENCH
AGRAMMATIC AND ANOMIC APHASICS: CROSS-LINGUISTIC PERSPECTIVES
Efstathia Soroli1, Maya Hickmann1, Jean-Luc Nespoulous2, Thi Mai Tran3
Laboratory Formal Structures of Language,
French National Centre for Scientific Research (CNRS) & University of Paris 8
2 Laboratory Jacques Lordat,
University of Toulouse Le Mirail & Institute of Brain Sciences of Toulouse
3 Laboratory Knowledge, Texts and Language,
French National Centre for Scientific Research (CNRS) & University Lille North of France
1
Background
Although human spatial understanding is thought to be universal, languages present
striking differences in how they organize and encode spatial information. This diversity has
raised a number of questions in recent psycholinguistic research about the relationship between
language and cognition (Bowermann & Choi, 2003; Hickmann et al., 2009a). Talmy (2000)
proposes a typological distinction between satellite-framed vs. verb-framed languages (hereafter Sand V-languages, respectively). S-languages lexicalize the Manner of motion in the verb and use
satellites to express Path information within a single compact structure. In contrast, V-languages
lexicalize Path information in the verb root, leaving Manner implicit or peripheral (e.g. She ran
across the street vs. Elle a travers la rue [en courant] Lit. She crossed the road running). Some
languages are harder to classify into these two categories, such as serial-verb languages which
may be better classified as equipollent (e.g. Chinese, cf. Slobin, 2004) and languages that present a
parallel system in which both V- and S-framed structures may be available in equally frequent
contexts (e.g. Greek, cf. Talmy). Although some authors (e.g. Papafragou et al., 2006) consider
Greek to be a clear V-language, motion in Greek can be expressed either by lexicalising path
information in the verb leaving manner of motion implicit or peripheral as in French, (e.g. Mpike
trehontas. Lit. [She] entered running) or by expressing Manner and/or Path of motion in nonbare verbs, often followed by additional spatial adverbials and/or locative/directional elements
similar to English satellites (e.g. Etrekse mesa [sto spiti] Lit. [She] ran into [to the house]). Such
striking differences and debates are of great relevance for the study of aphasic patients who
typically present dissociations between lexical and grammatical capacities.
Despite a few cross-linguistic studies of aphasia (Nespoulous, 1999; Menn & Obler, 1990),
little is known about universal vs. language-specific aspects of the linguistic deficits and
compensation strategies of aphasics. This question can not only contribute to the debates
concerning the relationship between language and cognition, but also opens new perspectives
for language rehabilitation. The present research investigates whether language-specific factors
can influence how two French aphasic speakers (agrammatic, anomic) vs. control speakers of
typologically different language (French, English, Greek) construct spatial representations about
motion events in two controlled tasks: production and comprehension.
Method
88
Participants
We tested a total of 44 subjects: 42 controls all right-handed, native speakers of French,
English and Greek (14 per language) and 2 French aphasics (1 male anomic right-handed and 1
male agrammatic left-handed). Inclusion criteria for all participants were (a) to be a native,
monolingual speaker of the above languages older than 18 years old, (b) to report no known
psychiatric disorder, (c) seeing or hearing impairment and (d) reading/oral language
difficulties. In addition aphasics had to be institutionally identified and diagnosed in term of
aphasia
type
through
the
Boston
Diagnostic
Aphasia
Examination
(BDAE:
Goodglass and Kaplan, 1972) on the French version (Mazaux and Orgogozo, 1982), conducted
by a speech therapist. All participants were given a questionnaire concerning their language
background. They all reported that they were monolingual and that they had been exposed to
only one language since birth. They were almost all late bilinguals (due to compulsory foreign
language teaching at school), but none had learnt a second language before age 10 and none had
lived in a foreign country for more than six months.
General procedure
Aphasic participants underwent the diagnostic battery (BDAE: French version) during a
first session to ensure that they met the inclusion criteria, then the experimental test in a second
separate session. Testing started with the production task and ended with the comprehension
task. For these tasks we constructed visual and auditory stimuli, implying voluntary motion
events, which varied along the two variables Manner and Path. Four different paths were
selected (up, down, into, out of, across). Half of the Manners involved the use of an instrument
(bicycle, scooter, rollers) and half did not (run, jump, crawl, and walk).
Hypotheses
French, English and Greek speakers were expected to show different performances as a
function of the typological properties of their language, specifically: 1) English speakers should
equally rely on Manner and on Path information, given the compact structures provided by their
language; 2) French speakers should focus on Path information which is lexicalised in the verb
and therefore more salient; 3) as for Greek speakers, we expected them to show parallel V- and
S-framed performance (as proposed by Talmy), rather than a clear V- pattern with a focus on
Path.
With respect to the French aphasic patients, the following predictions were made: 1) their
deficit should affect their production, but not necessarily their comprehension; 2) their deficit
should lead to particular difficulties and strategies, resulting in different productions between
the two patients (e.g. searching verbs for the anomic patient, lack of some relational devices such
as prepositions for the agrammatic patient).
Experiment 1: Production task

Materials
The production task consisted of 43 trials: 2 training, 8 controls, 5 distractors and 28
experimental trials. Experimental trials presented animated events (cartoons and videos)
implying voluntary motion events with several Manners and Paths. Control items solicited only
the expression of Manner. Distractors showing motion of inanimate objects were used in order
89
to vary the task and to eliminate possible repetitive strategies on the part of subjects.
Participants were asked to describe what was happening in the videos and cartoons.
Analysis
The analysis examined which of these two types of information were expressed (Path,
Manner or both), by what linguistic means (verbs, particles, prepositions, adverbials), how much
information was expressed (density), and the particular strategies used by aphasic participants.
We predicted that speakers should produce structures based on the features of their language.
Although speakers should express Path in all three languages, they should also express Manner
more frequently in English than in French. As for Greek, they should show variations between
the two co-existent systems performance if their language is a parallel system (Talmy, 2000) or
perform similarly to the French pattern if it is a clear V-framed system.
Results
In this task English speakers typically encoded Manner in verbs together with Path in
other devices within compact structures, whereas French speakers focused on Path and encoded
this information in verbs. Results concerning Greek mainly show the existence of parallel Verband Satellite-framed systems in this language. Speakers used more Manner verbs in Greek than
in French, but fewer than in English, and they relied on more diverse types of Path markers
outside of the verb root as compared to either French or English.
Aphasics produced utterances of lower density in comparison to controls of the same
language and developed some compensation strategies related to the typological properties of
French together with their specific deficit, as illustrated below. In (1) the agrammatic uses a
noun (trottinette) and omits the verb (faire de la trottinette) in order to express Manner. As for the
preposition, a lexical approximation serves to compensate a grammaticalized element in this
mother tongue (juste istead of jusqu). In (2) he replaces the inflected form of the verb by its
infinitival form (se promener) without the reflexive pronoun (se).
(1) Agrammatic [item: enter - scooter]
Une fille trottinette [= fait de la trottinette] il euh, une une fille euh, trottinette euh euh, la
porte juste [= jusqu' ] la porte.
(A girl scooter hmm he a girl hmm, scooter hmm hmm, the door, until the door.)
(2) Agrammatic [item: enter walk]

euh, il euh promener.
(hmm, he hmm walk.)
90
As for the anomic, in (3) he looks for the appropriate lexical item and gives the
approximate semantic form of drag. In (4) he omits the Path verb and focuses on Manner both in
the verb and in an adverbial???. In order to compensate his lexical deficit he produces a
periphrastic construction (marcher pieds joints) for the verb sauter (to jump).
(3) Anomic [item: enter push slide/drag]

le petit vieux trimballe une table.
(the old man draggles the table.)
(4) Anomic [item: exit - jump]

il marche pieds joints.
(he walks [at] feet joint.)
Table 1 shows the types of spatial information that were expressed by French aphasics
and controls. Table 2 shows how this information was distributed in the utterances.
Voluntary Motion I (cartoons)
Experimental items
Controls Agrammatic Anomic
PM 37%
22%
22%
CP 1%
0%
0%
P
55%
67%
50%
M
3%
5,5%
17%
NR 4%
5,5%
11%
Control items
PM 20,5%
0%
0%
P
3%
12,5%
0%
M
77%
87,5%
100%
NR 0%
0%
0%
Voluntary motion II (videos)
PM 54%
30%
40%
P
39%
30%
40%
M
6%
40%
20%
NR 1%
0%
0%
P = Path, C = Cause, M= agents manner of motion, NR = no response
Table 1. Focus
Voluntary Motion I (cartoons)
91
Controls
Verb
Other
PM
24%
2%
CP
0,5%
0%
P
68,5% 41%
M
5%
11%
NR
1%
46%
Voluntary motion II (videos)
Controls
Verb
Other
PM
26%
14%
P
59%
32%
M
14%
16%
NR
1%
37%
Agrammatic
Verb
Other
22%
0%
0%
0%
67%
6%
5,5%
0%
5,5%
94%
Anomic
Verb
22%
0%
50%
17%
11%
Other
0%
0%
11%
6%
83%
Agrammatic
Verb
Other
20%
0%
30%
10%
50%
0%
0%
90%
Anomic
Verb
20%
50%
30%
0%
Other
0%
20%
30%
50%
Table 2. Locus
Experiment 2: Comprehension task

Materials
The comprehension task was meant to ensure that aphasics had no comprehension
deficit. It consisted in 75 triads (one sentence-two choices): 1 training, 8 distractors and 66
experimental trials. Experimental trials involved a sentence presented auditorily that described a
motion event while two videos were shown on a PC screen simultaneously. Participants were
asked to choose the video that best corresponded to the sentence and to press a key to indicate
their choice. Accuracy and reaction times were measured.
Results
Controls reached ceiling performance in comprehension. Similarly, aphasics had no
difficulty in correctly interpreting target sentences, despite their slower performance in
comparison to controls as shown in Table 3.
Participants
French Controls
Agrammatic
Anomic
Table 3. Accuracy and Reaction times
Accuracy rates
96%
92%
92%
Reaction Times (msc)

1793
2203
3074
Conclusion
In conclusion typological properties of languages must be taken into account to improve
rehabilitation in aphasia, since this factor can affect performance in various ways. Language
properties invite certain ways of expressing events and generate strategies that do not only vary
as a function of specific deficits.
Further research in progress compares these data with the performance of speakers in
other languages, as well as with that of monolingual and bilingual aphasics, providing new
92
perspectives for the study of the relation between language and cognition and for future
rehabilitation strategies.
References
Bowerman, M. and Choi, S. (2003). Space under construction: Language specific spatial categorization in
first language acquisition. In D. Gentner and S. Goldin-Meadow (Eds.) Language in Mind: Advances
in the study of Language and Cognition, 387-428. Cambridge: MIT Press.
Goodglass, H. & Kaplan, E. (1972). Assessment of Aphasia and Related Disorders. Philadelphia: Lea and
Febinger.
Hickmann, M., Tarrane, P. & Bonnet, Ph. (2009). Motion in first language acquisition: manner and path in
French and in English. Journal of Child Language, Vol 36, Issue 04, 705-741.
Mazaux J.-M., Orgogozo J.-M. (1982), chelle dvaluation de laphasie, daprs : Boston Diagnostic Aphasia
Examination (Goodglass et Kaplan, 1972), Issy les Moulineaux: E.A.P. ditions cientifiques et
psychologiques.
Menn, L. & Obler L.K. (1990). Language data and theories of agrammatism, in : L. Menn & L.K. Obler, (Eds.),
Agrammatic Aphasia. A cross language narrative sourcebook, Amsterdam: John Benjamins Publishing
Company.
Nespoulous, J-L. (1999). Universal vs language-specific constraints in agrammatic aphasia, in C. Fuchs &
S. Robert (eds.) Language diversity and cognitive representations, John Benjamins, 195-207.
Papafragou, A., Massey, C. & Gleitman, L. (2006). When English proposes what Greek presupposes: The
cross-linguistic encoding of motion events. Cognition, 98, B75-87.
Slobin, D. (2004). The many ways to search for a frog: linguistic typology & the expression of motion
events. In S. Strmqvist & L. Verhoeven (Eds.) Relating Events in Narrative, Vol 2, 219-257.
Mahwah, NJ: LEA.
Talmy, L. (2000). Toward a cognitive semantics. Volume 1: Concept structuring systems. Volume 2: Typology and
process in concept structuring. Cambridge, MA: MIT Press.
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FP07.1
RELIABILITY AND VALIDITY OF THE MANDARIN TOKEN TEST WITH THREE
SCORING METHODS
Chin-Hsing Tseng, Ph.D.
Yi-Hsiu Chen, M.Ed.
Graduate Institute of Audiology and Speech Therapy
National Kaohsiung Normal University
Kaohsiung, Taiwan
Introduction
The Token Test (TT; De Renzi & Vignolo, 1962) is a well known test of auditory
comprehension for persons with aphasia. Through the years, many modified versions of the test
have been proposed, published and circulated in different languages and across countries. The
Revised Token Test (RTT; McNeil & Prescott, 1978) is among the best known revision of the TT
with a multidimensional scoring system as its most prominent feature. Recently, the TT was
introduced and modified for the Chinese-speaking children and adults in Taiwan. We have
documented the reliability and validity of the Mandarin Token Test, or MTT (Lin, Tseng, & Wu,
2010). In this paper, we examined the reliability and validity of the MTT as different scoring
methods were employed. In particular, two multidimensional scoring methods were compared
with the conventional binary method.
Originally employed in the Porch Index of Communicative Ability (Porch, 1967, 1981),
the multidimensional scoring system assigns a score up to 15 or 16 points to describe a response
in terms of dimensions including accuracy, responsiveness, promptness, completeness, and
efficiency. Given the wide range of a single score, a patients response is said to be more
sensitively and reliably quantified in such a scoring method (Porch, 2008). However, as can be
imagined, the simultaneous attention to the multiple dimensions of a response is daunting even
for an experienced test administrator. Thus, the cost-benefit of multidimensional scoring has
been questioned (e.g., Odekar & Hallowell, 2005). As a side note, to eliminate the negative
impact of multidimensional scoring, a computerized version of the RTT was developed (Pratt et
al., 2006).
The purpose of this study was to document the reliability and validity of the MTT under
different scoring conditions: traditional multidimensional scoring (TMS), a simpler form of
multidimensional scoring (SMS), and the correct/incorrect scoring (CIS). We used Cronbachs
to indicate internal consistency, the test-retest correlation as another reliability index, and the
correlation between MTT and Concise Chinese Aphasia Test (CCAT; Chung, Lee, and Chang,
2001), an overall aphasia test, as the validity index.
Method
Participants
Thirty stroke and TBI patients with aphasia above sixteen years of age (M = 47.17)
participated in this study. Twenty-three of them were above-one-year postonset and seven
under one year. Twenty-five were diagnosed as having nonfluent aphasia, the rest fluent
aphasia. All participants had hearing thresholds of at least 25dB HL or less for a hearing
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screening at pure-tone frequencies at 1K Hz, 2K Hz, and 4K Hz. All of them also passed the
Chinese Short Mini Mental Test (Kuo & Liu, 1988) to exclude signs of mental deterioration.
Stimuli and Procedure

Each participant was tested individually with the MTT and the CCAT. Half of the
participants were tested with the MTT twice for reliability checking within two weeks.
The MTT was modified after the TT and consists of 39 commands unevenly divided
among three subtests. The materials for the test include tokens that vary in color (white, green,
red, black, or yellow), shape (square or circle), and size (small or big). Each command involves
an action of manipulating the tokens in some way. For example, Put the small green circle to
the right of the big black square. The test items differ from one another in command length and
sentence type.
The data obtained from the MTT were scored in three methods. The TMS method
followed the instructions given by McNeil and Prescott (1978). In the SMS method, the 15
scoring categories of the TMS method were reduced to five categories, representing ratings 1514, 13-10, 9-8, 7-2, and one, respectively. In the CIS method, the response for the entire
command was given 0 as long as one or more than one element of the command was incorrect.
The CCAT is similar in format and structure to PICA and is widely used in Taiwan for
aphasia assessment. Like PICA, the CCAT was designed to elicit verbal, graphic, and gestural
responses from an aphasic patient with the aid of ten everyday objects. It consists of nine
subtests and each is comprised of ten items. The test also adopts a multidimensional scoring
system but yields a maximum score of 12 points.
Results
Internal Consistency
The Cronbachs of the MTT was .91, .99, and .99 for the CIS, the SMS, and the TMS,
methods, respectively. All achieved high level of internal consistency, with the CIS method
yielding the least desirable outcome.
Retest Reliability
The Pearsons correlations between the two testing of the MTT were .91, .94 and .95 for
the CIS, the SMS, and the TMS, methods, respectively (ps <.01).
Concurrent Validity
The Persons correlations between the CCAT overall scores and scores from each method
on the MTT and were .67, .72, and .72, respectively for the CIS, the SMS, and the TMS methods.
As another index of concurrent validity, the correlations between the auditory comprehension
subtest of the CCAT and the MTT scores were examined and they were .80, .81, and .82 for the
three methods in the above order.
Conclusion
To our surprise, despite its delicate and complex description of command response, the
15-point multidimensional scoring did not outperform other simpler scoring methods, when
two indicators of reliability and two criterion-related validity markers were scrutinized. It is true
that the conventional correct/incorrect method led to the least desirable result on each measure,
but the differences among the methods were hardly noticeable. Odekar and Hallowell (2005)
had a similar observation about the non-supremacy of the traditional multidimensional scoring
95
method. Of course, the advantages of the TMS should not be overlooked just because it did not
outperform alternative scoring methods, which could not bring up with similar scope of rich
information when planning and evaluating an intervention program. It is all about the balance
between the cost and the benefit when a scoring method is considered.
References
Chung, Y. M., Lee, S. E., & Chang, M. H. (2001). The Concise Chinese Aphasia Test. Taipei: Psychological
Corporation.
De Renzi, E., & Vignolo, L.A. (1962). The Token Test: A sensitive test to detect receptive disturbance in
aphasia. Brain, 85, 665-678.
Kuo, N., & Liu, H. (1988). The administration and the norms of the Chinese Mini Mental Test. Journal of
Rehabilitation Medicine (Taiwan), 16, 52-59.
Lin, Y., Tseng, C.-H., & Wu, Y. (2010). Rasch modeling of the Mandarin Token Test.Submitted to Journal of
Psychological Testing (Taiwan).
McNeil, M.R. & Prescott, T.E. (1978). Revised Token Test. Austin, TX: Pro-ed.
Odekar, A., & Hallowell, B. (2005). Comparison of alternatives to multidimensional scoring in the
assessment of language comprehension in aphasia. American Speech-Language Pathology, 14, 337345.
Porch, B. E. (1967). The Proch index of communicative ability. Palo Alto, CA: Consulting Psychologists Press.
Porch, B. E. (1981). The Proch index of communicative ability. Albuquerque: Pica Programs.
Porch, B. E. (2008). Treatment of aphasia subsequent to the Porch index of communicative ability (PICA).
In R. Chapey (Ed.), Language intervention strategies in aphasia and related neurogenic communication
disorders (pp. 800 813). Philadelphia: Woters Kluwer.
Porch, B. E. , & Callaghan, S. (1981). Making predictions about recovery: Is there HOAP? In R. H.
Brookshire (Ed.), Clinical Aphasiology Conference proceedings. Minneappolis, MN: BRK.
Pratt, S., Eberwein, C., McNeil, M., Ortmann, A., Roxberg, J., Fossett, T., Szuminsky, N., Durrant, J., &
Doyle, P. (2006). The Computerized Revised Token Test: Assessing the Impact of Age and Sound
Intensity. In International Aphasia Rehabilitation Conference: International Aphasia Rehabilitation
Conference.
96
AUDIOLOGY
SY07.2
INTRODUCTION OF CHINAS NATIONAL PLAN OF PREVENTION AND
REHABILITATION OF HEARING IMPAIRMENT (2007-2015)
X.K.Bu,
WHO Collaborating Center for PDH, Nanjing Medical University, China
In order to reduce the social and economic burden from hearing impairment, Chinas
government issued Chinas national plan of prevention and rehabilitation of hearing
impairment (2007-2015) in 2007. The plan consisted of five parts summarized bellow:
Present status and problems.
According to the second China national sample survey on disabilities in 2006, there were
27.80 Million hearing disabled people. Hearing impairment hurt affected individuals both in
physical-physiological and psychological; in addition, it was not only to influence person, but
also to family even society. Chinas government highly concerned prevention and rehabilitation
of hearing impairment and had great achievement. But because of huge population, particularly
fast increased ageing people and complex causes of hearing loss, China was facing severe
challengers in this field. Main problems were how to control and reduce hereditary and noise
induced hearing loss, how to develop newborn hearing screening program well, how to
improve hearing aids services, how to balance the development both in urban and rural area
and so on.
Policies
1). Prevention first, combination with treatment and rehabilitation;
2). Community based and children priority;
3). Multi-resources integration.
3. Aims
General aim: Every one has the rights to obtain hearing health care and rehabilitation
services.
Detailed aims by 2015:
1). Coverage rate of primary ear and hearing health care will reach 80 % (county level);
2). Coverage rate of hearing and speech rehabilitation services will reach 80 % (county
level);
3). Comparing with 2006 data, the incidence of ototoxic, infection and noise induced
hearing loss will reduce 10 % respectively;
4). Comparing with 2005 data, the coverage rate of newborn hearing screening will
increase 30 %;
5). Coverage rate of hearing aids and/or cochlear implant for children will reach 90 %;
6). Spread rate of knowledge of hearing health care in hearing impairment population
will reach 60 %.
4. Management
1). Enhancing government leading role. Local plan should be made and issued by local
government in 2008.
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2). Enhancing manpower development, particularly focusing on primary ear/hearing

health care and NHSP training; completing services net work.
3). Promoting PDH in multiple approach such as women and children health care,
vaccine, drug monitor, noise control, OME treatment, injury prevention systems etc.
4). Promoting hearing rehabilitation system; setting up connecting mechanism among
diagnosis, medical treatment, hearing aids fitting, cochlear implant, rehabilitation and special
education.
5). Promoting public awareness, more activities around national ear care day,
distributing hearing care leafs and public hearing health education will be held.
5. Evaluation
1). Annual evaluation should be taken by local government self and spot-check by
central government.
2). Middle evaluation will be taken in 2010 and the final assessment will be in 2015.
In order to implement the national plan, MOH China issued Administration of newborn
screening and updated the national NHS plan and the technical criteria in 2009. Approximately
20 million babies were born every year in China. About 60000 hearing impaired newborns were
added per year. A large sum of those hearing impairment newborns was a severe public health
and social problem. NHSP was strongly recommended by Chinas government since 1999.
Targeted hearing loss of screening was congenital permanent bilateral or unilateral hearing loss
(30-40 dB above, 0.5 4 K Hz in average). Sensory, neural (AN in NICU) or conductive hearing
loss are included.
There were screening center, usually located in women and children health care center,
responsible for administration connected with newborn PKU and CH screening, diagnosis
center, usually located in ENT/Audiology department, and (re)habilitation center in each
province.
Because huge population and less economic, manpower and technical resources, it was
impossible to take one model in China. Tri-basic sustentation strategy for NHS was used.
First, hospital-based universal screening (US) was essential and strongly recommended
by government and professionals. The first screening tool is OAE in WBN and AABR in NICU.
Re-screen for failed infants was conducted in 42 days. Diagnostic procedures were available
between 3-6 months. After diagnosis, (re)habilitation was in rehabilitation centers for hearing
impaired children. The updated plan showed that the screening rate of UNHS in WBN would be
80%, 40% and 30% in east, middle and west region of China respectively, the screening rate in
NICU would be 90% in all regions by 2012. To 2015, NHS system would be completed at
national-provincial-city-county levels (data base included) and all indices would be increased.
Secondly, targeted screening (TS) was recommended in rural and remote areas, newborn
with high risk factors should refer to screening center within one month after birth.
Thirdly, community screening (CS), every childs hearing should be monitored by
childrens health care system with questionnaire and simple tests at community level.
There was no accurate incidence data of hearing impairment of newborns yet, results
varied from 2.87 to 5.90 in different reports.
Current problems were:
1. There was lake of manpower, especially audiological professionals.
2. Screening usually conducted quite well, diagnosis and follow up were difficult.
3. There was lack of national and provincial database.
4. There was unbalanced development. In the capital and coastal cities such as Beijing,
Shanghai, Nanjing, Jinan etc. the screening coverage rates were between 95-98 %. In addition,
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hearing screening was not only for newborns, but also extended to 6-year old children in these
cities. Simultaneous screening for hearing and ocular diseases in newborns conducted over
20000 cases in Jinan maternal and children hospital since 2002. The pilot studies on NHSP plus
screening Mt.12SrRNA 1555G, GJB2 and SLC26A4 genes mutations conducted in a few
hospitals. As a contrast, even most delivery was at home in a few remote areas, the screening
rates were very low.
NHSP provided the earliest opportunity to identify and deal with hearing impairment in
ones life and had precious value. It was a net work, multidisciplinary cooperation was the keypoint for success; government played significant role in the public health program.
Chinas government issued the official document to set up hearing aid dispenser as a
formal career in 2008. People should pass the national examination and have the license before
their providing hearing aids to hearing impairment persons.
In order to fit Chinas national plan of prevention and rehabilitation of hearing
impairment (2007-2015), the government initiated National rescue program of cochlear
implant and hearing aids services for poor deaf children 2009-2012. 1500 deaf and 9000 hearing
impaired children in poor family would receive cochlear implant and hearing aids services
respectively with free of charge including (re)habilitation training. There were special funds
400 Million CNY (near 40 Million Euro) from China government for the program. It was the
largest funds for cochlear implant and hearing aid services in Chinese history. Besides the
government programs, there were also private donations in this field. In addition, free hearing
aids services were not only for poor children, but also for poor hearing impaired aging people in
Shanghai since 2009; hopefully, it would be extended to more places soon. Medical rehabilitation
devices and services will be covered in the national basic medical insurance in Jiangsu province
by 2012.
China has been great progressing in prevention and rehabilitation of deafness and
hearing impairment. WHO designated three WHO collaborating centers for PDH in China (two
in Beijing, one in Nanjing) 2008-2009. More work for the national PDH plan will be done; more
and more hearing impairment people would be well-being in China.
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SE14.1
(C)APD MANAGEMENT: HOW TO CREATE STRATEGIES FOR AUDITORY
TRAINING
I. Gielow
CEV - Centro de Estudos da Voz; UNIFESP Universidade Federal de So Paulo Brazil
When a (C)APD is diagnosed, the auditory skills which are failing can be stimulated
concerning the CNS plasticity. The auditory training consists in intensive experiences to
improve the auditory abilities, allowing the processes and skills involved to become stronger,
and to develop compensatory mechanisms.
As suggested by the main literature, the intervention for (C)APD management might
include parents and teachers orientation, special care at school, auditory and language training
and home stimulation what is desirable, but many times an unrealistic expectation in the real
practice.
The auditory skills which are failing can be stimulated concerning the central nervous
system plasticity. Due to this plasticity, the synapses' neural transmissions are strengthened
with repetitive use, indicating a neurophysiological correlation with learning processes. Thus,
auditory training consists in intensive experiences to improve the auditory abilities.
The processes and skills involved become stronger, and it becomes easier for the brain to
develop compensatory mechanisms. The basis for the auditory processing disorders
intervention for management are environmental modifications at school and at the study place
at home; compensatory strategies to be developed by the patient and direct intervention that
means therapy for developing the auditory abilities.
The specific rehabilitation program to be presented is based on the literature suggestions
(Bellis, 1996, Chermak & Musiek, 1997, Ferre, 1999, Gielow, 2008). There are some standardized
materials available for the clinicians use. However, after a series of repetitions of the same
exercises, the interest of the patient may reduce. It is possible to create, considering the patients
context and settings, monotic and dichotic strategies using softwares and simple computer
resources.
Although a general program will be described with all levels that usually can be
stimulated, the therapy program has to be customized for each patient, according to their
particular deficits.
It is suggested to start the rehabilitation program plan from the audiologist diagnosis,
looking for the fails in the auditory processing tests. More than just developing auditory
abilities, the therapy aim must be to bring the auditory abilities developed into the patients real
life.
For didactic purposes, the program will be separated by levels of stimulation. It doesnt
mean that all patients have to take every step of the program it will depend on the auditory
profile of each case. The speech therapist is also allowed to prepare strategies with mixed goals,
optimizing the desired results.
If the child fails to localize the sound source, it might be necessary to stimulate him/her
with different sound sources, with different frequencies and by asking him/her to indicate the
source of the sound, which may be presented close to or far away from his/her ears, in isolation
100
or in sequence. Optionally, the child might be asked to discriminate the sound type, as well as
asked to follow the sound source. If it is easy for the child to localize the sound source in a silent
environment, it will be possible to try to do the same with some competitive sound or noise in
the therapy room.
For auditory memory stimulation, it is suggested to work with verbal and non verbal
sounds, asking the child to repeat sequences of words, to associate sequences of sounds with
pictures, words to other words like if the therapist says cold, bad and dark, the child has to
say the opposite hot, good and light. You might work asking the child to close his/her eyes
and to point to where the door is, where the window is, where the telephone is, or to say what
color t-shirt he or she is wearing. All strategies with language stimulation, such as questions to
be answered after listening a story, categorization of words in similar or semantic groups or
retelling a story, will match the objective of auditory memory stimulation.
To help someone to complete incomplete auditory information, it might be necessary to
work with different levels of closure. For acoustic closure, we can create special materials, such
as words recorded with some degree of acoustic distortion. The auditory closure is also
stimulated when someone is asked to complete words, and with the grammatical level when we
ask him or her to complete sentences. To improve the ability to understand the meaning of
unknown words through the context, it might be useful to work with the verbal auditory level,
in which the patient will have to derive information by analyzing a context. For example: you
can say to the patient something like: A world without wars and misery is a utopia. Do you
think that UTOPIA is something easy or difficult to achieve?
Many of the individuals with (C)APD complain of speech-in-noise comprehension
difficulties. To help with the development of the ability to highlight the auditory stimulus that
has to be followed, it is very helpful to create situations in which the child has to pay attention to
the main auditory information, while other sounds or noises are surrounding him or her. The
competition may be white noise, orchestral or vocal music, connected speech or multiple stimuli,
such as the sound of a cafeteria or of a party. The competitive stimuli in both ears can be
presented in the open field, or with earphones, in the opposite or in the same ear of the main
information.
With the purpose of creating unlimited strategies for binaural and monaural stimulation,
a software called Ear Mix was developed by CTS Informatica (Brazil) which is very easy and
intuitive to use. With Ear Mix as well as with other similar programs, as the free internet
available ACID it is possible to prepare countless strategies, mixing the therapy goals
according to patient necessities. For instance, in one channel, to be presented to the right ear, one
might record a sequence of 4 words to be repeated by the patient. In the other side, a story or a
music will be recorded or inserted, and will work as a competitive sound.
To engage the patient to the strategies creation, his or her voice reading or telling a story
might be used as a background competition. The patients participation preparing and recording
part of the strategies is a nice language stimulation, and usually stimulate their repetition of the
exercises what they tend to find kind of boring when the therapist doesnt change the
strategies over time.
The softwares also allow the insertion of white noise as monaural or binaural
competition. The same can be done with pure tones, ranging from 250 to 8000Hz, working with
divided attention, when the patient has to pay attention in a story and count, at the same time,
the stimuli presented.
When the (C)APD assessment suggests problems with auditory analysis and/or
synthesis, it is indicated to help the patient to develop the ability to perceive and to processes
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similarities and differences between sounds, trying to find their meaning, as well as to improve
the abilities of decoding and encoding sounds.
For the auditory discrimination, beyond the traditional proprioceptive strategies that are
familiar to all Speech Pathologist, the use of softwares of simple narrow band acoustic analysis
might be suggested. Watching, the image may help them to understand the differences that they
cannot listen, particularly regarding the sound and soundless phonemes. However, if a software
support is not available, the therapist can use other concrete examples, as a keyboard or
perceiving the sound effects of two glasses with different amount of water.
To improve the phonological awareness, which tend to be a challenge for kids with
decoding deficits, turning the phonemes, which are abstract units especially for the AP
disordered children, into pictures of their mouths producing the phonemes might be an nice,
interesting and efficient strategy. A mirror also can be used to help the perception of the
articulatory image and the gesture done for each phoneme of the Language.
With the development of the articulatory self-image, it is possible to start associating
alphabetic letters to their own mouth-phabet an alphabet with pictures of their own mouth
saying the phonemes. After that, the child might be ready for the introduction of specific tasks,
as rhyme detection, segmentation, blending, and others. While the therapist is constructing the
patients mouth-phabet, taking pictures and pasting them on a power point template, he or
she might be internalizing the phoneme-grapheme association.
With simple power point resources, the therapist can create many possible strategies
associating the articulatory image to sound and letters, analyzing which are the sounds of a
given word or connecting sounds to discover what word is being said.
Thus, working with sound analysis and synthesis may help the development of auditory
discrimination, phonological awareness, phoneme-grapheme association, improving writing
abilities, association of ideas and metalinguistic and cognitive flexibility.
When there is a lack of frequency and temporal patterns discrimination, the therapist
shall work with strategies with sequences for discrimination, regarding frequency (perceiving
higher and lower sounds), duration (short and long), intensity (strong or weak) and the gap
between sounds (working with different intervals).
Improving those perceptions, the individual may improve language comprehension
through a better accent and prosody aspects perception, as well as a better ability to discriminate
his or her own speech production, remembering that there are prosodic and emotional aspects of
voice and speech perception to be perceived as when one says very nice (angry) and very
nice! (happy).
When a given patient has difficulties with dichotic auditory information, it might be
necessary to offer him or her interhemispheric activities. The interhemispheric transference
through corpus callosum happens when we require the integration between information
processed in different hemispheres. Thus, for interhemispheric stimulation, it can be offered
exercises with different information presented to each ear, asking for:
1. Divided attention paying attention, for instance, at words to be repeated, presented to the
right ear, and counting the number of times that pure tone quick stimuli are presented to the
left ear.
2. Selective attention requirement - asking the child to repeat the stimuli words in the presence
of a background story presented to the opposite ear.
Working with the integration of any other sensory systems will reinforce the general
connections between both brain hemispheres. Thus, it is possible to create uncountable
strategies as:
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Finding or guessing rubber letters only by touch

Guessing different smells
Following a choreography with rhythm
Playing games or drawing with both hands simultaneously
Or simply repeating verses following a rhythm, throwing a ball from one
hand to the other one.
And what about the formal auditory training in a sound proof cabin, performed by the
audiologist? Especially for decoding disorders, it is a good way to start a (C)APD management
program, but it will work as a workout program for a soccer player: it will improve the muscles
structure and force, helping the athlete to run faster and to kick stronger the ball, but wont
improve his performance at the game. For that, he will need to practice playing the game, and the
patient will need to be submitted to metalinguistics strategies. Knowledge, technology and
creativity are fundamental requirements for SLP working in the field of (C)APD. Thus, the
patient must be exposed to metalinguistics and behavioral training to receive the benefits of the
cabin practice to the patients language.
To achieve metalinguistic goals, activities as the following might be asked to the patient:
To organize and categorize words
To answer questions from dichotic auditory training with attention to the context,
To find multiple meaning words
Phonological awareness activities
To understand figurative language, such as metaphors, jokes and idiomatic expressions
Following instructions
Answering questions
To summarize and paraphrase stories
To analyze temporal logic for actions and facts
To read and to listen stories, every day, if possible
To create stories.
All the activities listed above might be supported by the use of power point templates
created with pictures, clip arts, photos and short videos produced with the patient. It is also
possible to mix sounds and auditory training strategies to the presentations. In those cases, the
use of headphones connected to the computer might be indicated.
Finally, there are the metacognitive aspects of the management. Metacognition is the
knowledge and the experiences we have about our own cognitive processes, and it consists of
three basic elements: developing a plan of action, maintaining/monitoring the plan and
evaluating the plan.
During the intervention, it is desirable that the patient develop compensatory strategies,
starting with monitoring his/her comprehension, then identifying his/her difficulties, and
finally elaborating alternative solutions to changing his/her profile from being passive to being
an active listener.
Besides the (C)AP battery of tests performed by the audiologists, objective assessments
methods, as the P300 registers, can be indicated to track the results of therapy programs.
However, as is possible to perceive, considering the items mentioned above, that there are too
many parameters to be controlled during a (C)APD therapy process and during scientific
investigations. Even so, clinical findings and recent efforts as the IALPs Composium on Central
Auditory Processing Disorders, occurred in Egypt, 2009, might permit one to conclude that with
the auditory training it is possible to help the central auditory nervous system to develop skills
and abilities. And when someone who has any level of difficult on processing, understanding
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and learning the auditory information improve, he/she tend to become a better listener and a
better communicator.
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FP44.5
SPEECH ADJUSTMENTS TO THE ELDERLY IN COGNITIVELY DEMANDING
SITUATIONS
T.E. Hautala1
1 University of Oulu, Oulu, Finland
Introduction
Ageing affects auditory speech processing, especially in cognitively demanding
situations. The amount of moderate hearing defects is increasing fast with the years. Peripheral
hearing problems do not explain everything, because many central functions are also needed in
speech reception. Both peripheral and cognitive factors explain the age-related disturbance in
recognition of words (Pilotti et al., 2001). Important cognitive factors for the auditory speech
processing of the elderly are speed of processing, working memory, and executive control for
directing and dividing attention and prohibiting disturbing factors (Tun et al., 2002). Speech
perception becomes more difficult for the elderly, when the complexity and presentation speed
of the message increase. Prosodic contextual cues are very important for parsing the syntactic
structures of the sentences, and supporting the memory of elderly listeners (Wingfield & StineMorrow, 2000).
People usually make some adjustments to their speech when they are communicating
with the elderly. This so-called elderspeak uses simplified linguistic structures, and
exaggerated prosodic features (wide range of pitch variations and emphatic stress), greater
loudness of voice, and very clear articulation, are typical for it (Kemper & Harden, 1999). Young
speakers adjusted their speech for elderly listeners in a referential communication task by
slowing the speech tempo and simplifying the linguistic structures (Kemper et al., 1996). This
improved the performance of the elderly, but they showed some dislike towards the speaking
style. Also, in the study of Gould and Dixon (1997) the elderly did not like the speaking style,
even when the strong emphasis on the prosodic features helped them to better remember the
instructions heard. In Finnish, a rhematic accent is realised as a more prominent rise and fall of
fundamental frequency, as is contrastive accent as well, but the latter is also combined with
increased segmental duration (Suomi et al., 2008).
The material of my study is from a project where a multidisciplinary research team at the
University of Oulu and Laboratory of Applied Ergonomics and gerontechnology, with VoiceBit
Ltd, developed an automatic phone service system for the elderly. The system was developed
together with local social and health care department and the elderly users in various projects
(Hautala et al.,2000).
Aims of the study

The aim of the study was to clarify how the features of different speakers affect the
performance of the elderly in a user trial test of automatic phone service system. What was the
significance of quality of voice, and how important were the prosodic features in auditory
speech processing of the elderly in a test situation. An important objective was also to try to
identify, what kind of speaking strategies were used and whether a certain type of strategy was
more favorable for speech perception, and for acting according to the instructions heard. One
objective was also to study how the elderly acted as judges when estimating speech and voice.
105
Methods
There were 36 participants in the user-trial study of the automatic phone service system
(1996) in laboratory conditions. 28 of them were women and 8 men. Their ages ranged from 70
to 91 yrs, the mean age being 78 yrs. Most of them were living in sheltered housing. In the usertrial, the subjects carried out three pre-programmed tasks with varying degrees of difficulty.
Task contents were randomly chosen in each task. The participants received test instructions
from a simulated phone service system in a voice randomly chosen out of four alternative
human voices. Two speakers were females (both of them speech therapists, FemA 31 yrs and
FemB 33 yrs) and two were males (MalA with merits as an accomplished speaker in language
teaching programs, age 23, and MalB a phonetician, age 52). Besides performing the tasks, all
subjects filled in a questionnaire to evaluate the properties of the voice and speech heard from
the system. They evaluated loudness, pleasantness, clarity, and tempo and gave their general
evaluation of the voice on a scale of 410. After the phone service test, they listened to a short
sample passage from all four speakers and evaluated them as mentioned above. Fundamental
frequency was measured by a PC-based speech and voice analysis program and speech tempo
by SoundEdit program. The measurements were made from the recorded menu of the system.
The length and parts of the text used for analysis were same for all speakers.
Results
Only slight differences in performance were found across different speakers voices.
There was a statistically significant difference in performance only with the voice of one female
speaker (FemA). The elderly who heard the tasks in her voice performed more poorly: 37,5 % of
her listeners managed the tasks. The best results in the tasks were reached with the voice of the
other female speaker (FemB), but the difference was not significant compared to the other
speakers. With her voice 68 % of the elderly subjects made the right choices in the tasks. There
was no significant difference in the results across the male speakers. Only one participant
managed better with the voice of MalB (60 %) than with the voice of MalA (56 %). There was a
statistically significant difference in performance across the tasks. As expected, the performance
of the elderly was poorer in the menu, where the instructions were longest and there were more
choices to remember.
All the speakers accommodated their speech for the elderly listeners. They adjusted their
speech either by using slow speech and articulation rates and lot of pauses, or by stressing key
words in the instructions, or using both strategies. Female speakers speech and articulation
rates were slower than those of the males, and they paused more than males. On the other hand,
the duration of the pauses of the male speakers were longer. FemB had many focus pauses
before the alternative choices and the instructions as to what digits the elderly had to press to
make a choice. The males had pauses only in linguistical boundaries. In comparison with tempo
measurements in studies of Finnish speaking and reading styles (Lehtonen, 1985), speaker FemB
had an articulation rate (4,3 syllables/s), that was the same as the minimal measured reading
tempo, and her speech rate (2,6 syll/s) was slower than the tempo of impromptu speech. FemA
had somewhat higher values (4,8 syll/s, 3,5 syll/s), but her articulation rate was also in the class
of reading tempo and speech rate resembling those used in retelling a story. Both males had
articulation and speech rates (MalA 5,9 syll/s and 4,4 syll/s and MalB 5,7 syll/s and 4,1 syll/s),
that were slower than used in reading the news, but about the same as used in reading a
scientific text. In the most difficult task all speakers slowed down their speech and articulation
rates.
106
The greatest variation of average fundamental frequency in the focus utterances was
used by speaker MalB. Especially, in the most difficult task the mean of the semitone changes
were the highest compared to other speakers. He used a rhematic and contrastive accent for
signaling the focus of the instructions. FemB also used variation of F0, but not as consistently as
MalB. She had lot of pausing, and she stressed the verb more than the digit name, so the peak of
F0 came earlier in the utterance than is usually typical for Finnish.
The elderly were polite judges, and overall they gave quite good ratings for the speakers.
There were differences in the subjective evaluations in different situations. The elderly were
more positive immediately after the user trial, when they rated the speaker they had heard. They
were more critical, when they focused only on evaluating the short speech sample passage.
There were also some contradictions between the performance and the speech evaluations. The
elderly who heard the instructions with the voice of FemB, performed better, but she received
the worst general voice evaluation. Also, some of the listeners rated her voice unpleasant. The
loudness of the voice of FemA was estimated to be too silent by 36,1 %, the listeners, and some
of them thought her voice to be a bit unpleasant and unclear (30,6 %, 38,9 %). The males were
ranked better speakers and as having more pleasant voices than the females. The voice of MalB
was estimated by 5 listeners as somewhat unpleasant, and only 2 listeners gave the same grade
for MalA.
Conclusions
There were no big differences in how the elderly performed in the tasks different
speakers voice. One reason for this was probably the fact that all speakers were very good. The
results would have been quite different, if there had been more varied speakers, e.g.
professionals and non-professionals, and more participants. With regard to the prosodic
features, it is problematic trying to separate them to explore which of the features would be the
most important in facilitating the auditory processing of speech and supporting working
memory. Also, the text in the menu is very important, as seen clearly in this research. Very long
text with many choices puts a load on working memory. This would be an important theme for
further research.
The loudness of the voice of FemA was weaker than that of the other speakers, so agerelated hearing problems could partly explain performance. The elderly seem to benefit from
speech adjustments. They reached the best results with the voice of the least preferred speaker
who accommodated her speech the most. But the most preferred was the young male speaker,
who adjusted his speech the least. Maybe speech adjustments were interpretated as patronizing
and underestimating, although they enhanced the performance. It is a big challenge for the
design of a voice-based user-interface to find a compromise between the aforementioned
contradictions. In this study, only the stimulus features of the speakers utterance were analyzed
and that is just one side of the coin. The other side is the elderly listeners themselves: their
physical, cognitive and psychological capacities and social and personal features all affect the
performance. From the clinical point of view, it is very important to learn about normal agerelated changes concerning auditory speech processing. When is something not normal
anymore? Also, it would be important to pay attention to our own communication strategies as
speech therapists when we are working with elderly patients and their relatives. How could we
support communication respectfully?
References
107
Gould, O.N. and Dixon, R.A. (1997). Recall of medication instructions by young and elderly adult woman:
Is overaccommodative speech helpful? Journal of Language and Social Psychology, 16 (1), 5069.
Hautala, T., Kivel, E-M., Tornberg, V., Prykri, T., Mtt, T. & Saajanto, E. (2000). Development of a
shopping service system for the elderly using the NextInfo phone service system. In proceedings
of XIVth Triennial congress of the International Ergonomics Association and 44th Annual Meeting of the
Human Factors and Ergonomics Society (p. 6871). Santa Monica, USA: Human Factors and
Ergonomics Society.
Kemper, S. & Harden, T. (1999). Experimentally disentangling whats beneficial about elderspeak and
from whats not. Psychology and Aging, 14 (4), 656670.
Kemper, S., Othick, M., Warren, J., Gubarchuk, J. & Gerhing, H. (1996). Facilitating older adults
performance on a referential communication task through speech accommodations. Aging,
Neuropsychology, and Cognition, 3 (1), 3755.
Lehtonen, J. (1985). Speech rate in Finnish. In P.Hurme (Ed.), Papers in speech research (p.1627). University
of Jyvskyl.
Pilotti, M., Beyer, T. & Yasunami, M. (2001). Encoding tasks and the processing of perceptual information
in young and older adults. The Journals of Gerontology Series B: Psychological Sciences and Social
Sciences, 56 (2), 119128.
Suomi, K., Toivonen, J. & Ylitalo, R. (2008). Finnish sound structure. Phonetics, phonology, phonotactics and
prosody. Studia Humaniora Ouluensia, 9. University of Oulu.
Tun, P., OKane, G. & Wingfield, A. (2002). Distraction by competing speech in young and older adult
listeners. Psychology and Aging, 17 (3), 453467.
Wingfield, A. & Stine-Morrow, E.A.L. (2000). Language and speech. In F.I.M. Craik & T.A. Salthouse
(Eds.), The handbook of aging and cognition (p.359416). Lawrence Erlbaum Associate Publishers.
108
SS06.1
AUDITORY BRAIN EVENT-RELATED POTENTIALS (ERPS), CENTRAL
AUDITORY PROCESSING, AND LANGUAGE DEVELOPMENT IN CHILDREN
E. Jansson-Verkasalo 1 & P. Korpilahti 2
1 Faculty of Humanities, Logopedics, University of Oulu and Department of Clinical
Neurophysiology, Neurocognitive Unit, Oulu University Hospital, Finland
2 Department of Behavioral Sciences and Philosophy, University of Turku, Finland
Central auditory processing (CAP) means perceptual processing of auditory information
in the central nervous system, and neurobiological activity that underlies that processing, and
gives rise to the electrophysiological auditory potentials (ASHA, 2005). More broadly, central
auditory processing refers to the efficiency and effectiveness by which the central nervous
system (CNS) utilizes auditory information. Current conceptualization of CAP holds that
information is processed via distributed and parallel neural networks with significant
contributions from both bottom-up and top-down factors. CAP involves the entire auditory
mechanisms responsible for auditory discrimination, sound localization and lateralization as
well as temporal aspects of audition, and auditory performance with degraded and/or
competing signals (ASHA, 2005). Much of what constitutes CAP is preconscious.
Central auditory processing deficit (CAPD) is a deficit in neural processing of auditory
stimuli that is not due to higher order language, cognitive or related factors (ASHA, 2005). The
cause is not an impairment of peripheral hearing. Predisposing factors for CAPD include delay
in neural maturation, and insults or pathologies having effect to the central nervous system.
Identifying children with CAPD is important since adequate processing of acoustic information
is critical for speech and language development as well as learning. CAP(D) can be assessed by
using behavioral methods. However, more in-depth knowledge may be achieved by using
auditory event-related potentials.
Several distinct stages of central auditory processing can be assessed by using auditory
event-related potentials (ERPs). ERPs are especially useful in the study of language processing
since they reflect precise temporal and spectral information of language processing (Korpilahti
et al., 2001). ERPs are manifestations of neural activity that is specifically related, or time-locked,
to sensory stimulation (Stapells & Kurtzberg, 1991). ERP waveform consists of a sequence of
positive (P) and negative (N) deflections or peaks that are named according to their polarity and
latency (timing relative to the stimulus onset), their serial order or cognitive meaning (Ntnen
1992). During the childhood (1-10 years), long latency obligatory (standard sound) auditory
ERPs are dominated by positivity at about 85-120 milliseconds (ms) and negativity at about 200240 ms, called mostly the P1 and N2 peaks, respectively. A P1-N1-P2-N2 complex is typical for
adults (Ponton et al., 2000). N1 is elicited in children from about the age of 3 years onwards but
with interstimulus intervals of over 1 ms only (eponien et al., 2002). The early components of
the auditory ERPs reflect the neural correlates of reception and encoding of the stimulus.
Positive response following the N2, is called P3, and reflects e.g. involuntary attention shifting.
A more complete picture of CAP(D) can be obtained if, in addition, a component of
cognitive ERPs called Mismatch negativity, MMN, will be determined. MMN, elicited 150-400
ms after sound-change onset, is especially well-suited to assess speech-sound perception and
language representations for several reasons. MMN emerges early in life. MMN is mainly
109
independent of ones attention, and requires no behavioral response from the subject. MMN is
elicited by any discriminable auditory change, and reflects central auditory discrimination and
sensory memory.
Thus, MMN can be used to measure the accuracy of speech-sound representations, and
improvements in this ability from infancy onwards.
Basic auditory skills constitute a foundation for language development. The early phases
of language acquisition are mainly unconscious, and therefore cannot be measured by direct
tests or inspection (Diamond, Werker & Lalonde, 1994). In healthy children, phoneme
discrimination abilities improve and specialize for native phonemes and degrade for unfamiliar,
socially irrelevant phoneme contrasts between 6 and 12 months of age (Kuhl et al., 2008) This
process is known as perceptual narrowing (Lewkowicz & Ghazanfar, 2009), and has been found
to predict normal native language acquisition (Kuhl et al. 2008). In accordance with these
findings, studies have shown that atypical central auditory discrimination, as indexed by the
MMN, is evident in infants at risk for language deficits (Friederich et al., 2004; Leppnen et al.,
2002), which is further linked to language deficits later in life (Holopainen et al., 1997; JanssonVerkasalo et al., 2003, 2004; Korpilahti & Lang 1994; Kraus et al., 1996; see also Kujala 2007;
Kujala & Ntnen, 2010).
Very prematurely born children are at an increased risk for language and learning
deficits, and CAPD early in life (Fellman et al. 2004). CAPD has been found to be an marker of
language development at the age of two years (Jansson-Verkasalo et al., submitted), and later in
childhood, (Jansson-Verkasalo et al., 2003, 2004). Similarly, CAP has been found to be atypical in
infants (Friederich et al., 2004) and children with SLI (Holopainen et al., 1997; Korpilahti, 1995;
Korpilahti & Lang, 1994), and in children with dyslexia (Kujala et al., 2001; Lovio et al., 2010).
Early diagnosis of language deficits is crucial for later language development. Therefore, we
need methods to diagnose deficits early in life, even as infants. Furthermore, the assessment of
the efficacy of the rehabilitation is important both for single subjects and for organizations
giving funding for the rehabilitation
The benefits of the MMN as a tool for investigating language development and its
impairments are evident. MMN reflects central auditory discrimination accuracy, which can be
separately determined for linguistic and non-linguistic functions, and their neural generators
(see Kujala 2010). Furthermore, it is elicited whether or not the subject attends to the sounds.
MMN analyses are carried out with effective computer programs, so very large amounts of
information can be compared with a fair degree of statistical accuracy. This increases the
reliability of the results, even though the number of subjects in the experiment may be quite
small. Furthermore, a large number of studies comparing behavioral performance and MMN
parameters have shown a close association between these two measures (Kuhl et al. 2008;
Jansson-Verkasalo et al., 2003; Kujala et al., 2001).
Using ERPs as a measure of CAP(D) have both strengths and limitations. Several distinct
stages of central auditory processing can be assessed by using auditory ERPs. The specifity of
the MMN is good (see Kujala, 2007). It is well-known that it reflects central auditory
discrimination and sensory memory. However, while MMN reflects a specific auditory
discrimination process, one has to be careful when making generalizations based on MMN
results only. Although MMN response is intact, the performance may be impaired. This may
result from the impairment in information processing stage higher than that reflected by the
MMN (Kujala et al. 2007). Speech contains many kinds of encodedness; for example, the
meaning of a word is closely related to the persons knowledge of the language. On the other
hand, the auditory perception of separate acoustic features may not ensure decoding of larger
110
language units, such as words (Korpilahti et al., 2001). Using ERPs at the individual level is still
problematic. Reasons may be due to the methods used or due to subject-related factors (e.g.
brain structures, maturation, individual experiences and their effect on brain structures). During
language learning, auditory perception is automatized. As a consequence, the brains functional
architecture is changed by language-related experiences (Karmiloff & Karmiloff-Smith, 2001). In
addition, the source orientation of the ERP generators in each individual affects on the scalprecorded ERP response. In order to understand atypical neural maturation, and the meaning of
separate ERP components, e.g. MMN, normative data in different developmental stages is
needed. Late ERPs show both maturational changes and large individual differences, which may
overlay abnormal developmental features in auditory ERPs. The typical ERP pattern for newborn children, toddlers, and children at school age look quite different, even at the same
recording condition. Anatomical and physiological capacity of human brain is compound with
cognitive state of the individual under inspect. The cognitive development has strong effects on
the amplitudes of the late ERPs, reflecting the task demands (Cheour et al., 2001). While defining
the time window of ERP components, maturational aspects have to be taken into account. Thus,
the researcher needs broad expertise to be able to use ERPs as a tool to assess CAP. However, in
the future, when auditory ERPs are combined with other approaches like methods investigating
brain structures, and with behavioral assessments, we will obtain deeper understanding of CAP
both in typical and atypical language acquisition.
References
American Speech-Language Hearing Association. (2005). (Central) auditory processing disorders. Technical
report: Working group on auditory processing disorders. Rockville, MD: Author.
eponien, R., Rinne, T., & Ntnen, R. (2002). Maturation of cortical sound processing as indexed by
event-related potentials. Clinical Neurophysiology, 113, 870882.
Cheour, M., Korpilahti, P., Martynova, O., & Lang, A. H. (2001). Mismatch negativity and late
discriminative negativity in investigating speech perception and learning in children and infants A review. Audiology & Neuro-Otology, 6, 211.
Diamond, A., Werker, J. F., & Lalonde, C. (1994). Toward understanding commonalities in the
development of object search, detour navigation, categorization, and speech perception. In G.
Dawson and K.W. Fisher (eds.) Human behavior and the developing brain. New York: Guilford Press,
380426.
Fellman, V., Kushnerenko, E., Mikkola, K., eponien, R., Leipl, J., & Ntnen, R. (2004). Atypical
auditory event-related potentials in preterm infants during the first year of life: a possible sign of
cognitive dysfunction? Pediatric Research, 56, 291297.
Friederich, M., Weber, C., & Friederici, A. (2004). Electrophysiological evidence for delayed mismatch
response in infants at-risk for specific language impairment. Psychophysiology, 41, 772782.
Holopainen, I., Korpilahti, P., Juottonen, K., Lang, A. H., & Sillanp, M. (1997). Attenuated auditory
event-related potential (Mismatch negativity) in children with developmental dysphasia.
Neuropediatrics, 28, 253256.
Jansson-Verkasalo, E., Korpilahti, P., Jntti, V., Valkama, M., Vainionp, L., Alku, P. et al. (2003).
Neurophysiologic correlates of deficient phonological representations and object naming in
prematurely born children. Clinical Neurophysiology, 115, 179187.
Jansson-Verkasalo, E., Ruusuvirta, T., Huotilainen, M., Alku, P., Kushnerenko, E., Suominen, K. et al.
(2010). Delayed perceptual narrowing in prematurely born human infants is associated with
compromised language acquisition at 2 years of age. Submitted.
Jansson-Verkasalo, E.,Valkama, M., Vainionp, L., Pkk, E., Ilkko, E., & Lehtihalmes, M. (2004).
Language development in very low birth weight preterm children: A follow-up study. Folia
Phoniatrica et Logopaedica, 56, 108119.
111
Karmiloff, K., & Karmiloff-Smith A. (2001). Pathways to language. From fetus to adolescent. Cambridge:
Harvard University Press.
Korpilahti, P. (1995). Auditory discrimination and memory functions in SLI: A comprehensive study with
neurophysiological and behavioural methods. Scandinavian Journal of Logopedics and Phoniatrics, 20,
131139.
Korpilahti, P., & Lang, A. H. (1994). Auditory ERP components and MMN in dysphasic children.
Electroencephalography and Clinical Neurophysiology, 91, 256264.
Korpilahti, P., Krause, C.M., Holopainen, I., & Lang, A.H. (2001). Early and late mismatch negativity
(MMN) elicited by words and speech-like stimuli in children. Brain and Language, 76, 332339.
Kraus, N., McGee, T. J., Carrell, T. D., Zecker, S. G., Nicol, T.G., & Koch, D. B. (1996). Auditory
neurophysiologic responses and auditory discrimination deficits in children with learning
problems. Science, 273, 971973.
Kuhl P., Conboy, B., Coffey-Corina, S., Padden, D., Rivera-Gaxiola, M., & Nelson, T. (2008). Phonetic
learning as a pathway to language: new data and native language magnet theory expanded
(NLM-e). Phil Trans R Soc B 2008, 363, 9791000.
Kujala, T. (2007). The role of early auditory discrimination deficits in language disorders. Journal of
Psychophysiology, 1, 239250.
Kujala, T., Karma, K., eponien, R., Belitz, S., Turkkila, P., Tervaniemi, M. et al. (2001). Plastic neural
changes and reading improvement caused by audio-visual training in reading-impaired children.
PNAS, USA, 98, 1050910514.
Kujala, T., & Ntnen, R. (2010). The adaptive brain: A neuropsychological perspective. Progress in
neurobiology, 91, 5567.
Leppnen, P., Richardson, U., Pihko, E., Eklund, K., Guttorm, T., Aro, M. et al. (2002). Brain responses to
changes in speech sound durations differ between infants with and without familial risk for
dyslexia. Developmental Neuropsychology, 22, 407423.
Lewkowicz, D., & Ghazanfar, A. (2009). The decline of cross-species intersensory perception in human
infants. PNAS, USA, 25, 67716774.
Lovio, R., Ntnen, R., & Kujala, T. (2010). Abnormal pattern of cortical speech feature discrimination in
6-year-old children at risk for dyslexia. Brain research, 1335, 5362.
Ntnen, R. (1992). Attention and brain function. New Jersey: Lawrence Erlbaum Associates.
Ponton, D., Eggermont, J., Kwong, B., & Don, M. (2002). Maturation of human central auditory system
activity: evidence from multichanel evoked potentials. Clinical Neurophysiology,111, 220236.
Stapells, D., & Kurzberg, D. (1991) Evoked potential assessment of auditory system integrity in infants.
Clinics in Perinatology, 18, 497518.
112
FP38.1
DETECTING HEARING LOSS IN PERSONS WITH INTELLECTUAL
DISABILITIES AT THE SPECIAL OLYMPICS NATIONAL GAMES IN JAPAN
H. Itoh1, H. Takeuchi2, K. Nishiwaki3, T. Kojima4, G.R. Herer 5, and J.K. Montgomery6
1Bunkyo Gakuin University, Tokyo, Japan
2Nagano Prefectural Kiso Hospital, Nagano, Japan
3Tthe Hospital affiliated with Nippon Dental University, Tokyo, Japan
4Shinshu University, Nagano, Japan
5Childrens National Medical Center, Washington, DC, USA
6Chapman University, Orange, USA
Introduction
Under the Special Olympics Healthy Hearing Screening Program, international
audiologists and ear-nose-throat (ENT) doctors screened the hearing acuity of athletes with
intellectual disabilities at the World Games. In Japan, using Japanese speech-language-hearing
therapists (SLHTs) and ENT doctors, we have administered the Healthy Hearing Screening
Program at every National Games since the Special Olympics National Games were held in
Nagano in 2004. Adequate hearing is necessary to perform any sport and in everyday life. It is,
however, particularly difficult to detect hearing loss in individuals with intellectual disabilities.
They sometimes fail to indicate that they can hear when they are screened using the pure tone
test. Our screening program uses evoked otoacoustic emission (EOAE), which is an objective
screening method for hearing loss. EOAE can screen automatically, so that persons with
intellectual disabilities need not respond.
In this study, we analyzed the hearing screening data collected at the Special Olympics
National Games in Japan from 2004 to 2008.
Methods
Subjects: Athletes (individuals with intellectual disabilities) attending the Special
Olympics National Games.
Place: The venue for the Healthy Athlete Program at the National Games in Japan.
Screening program: Hearing was screened in several steps.
Station one: The external ear canals were examined using an otoscope. An ENT doctor
observed the canal and surface of the eardrum to determine whether it was partially blocked or
blocked with cerumen.
Station two: Hearing acuity was screened using EOAE. A small probe tip was placed in
the ear canal. EOAE delivers sounds into the ear canal at 2000, 3000, 4000, and 5000 Hz and
measures the response sound produced by outer hair cells in the cochlea. If the athlete passed
the EOAE, he was finished with the screening. If the athlete did not pass in either ear, he
continued the screening at the next station.
Station three: The condition of the middle ear and mobility of the eardrum were tested
with a tympanometer.
Station four: Hearing was evaluated using a pure tone audiometer. Athletes were
required to raise their hand when they heard the sound through the headsets. If the athlete
113
failed during a training session, we asked someone to assist him or her. The screening test was
conducted at a 25-dB hearing level at two frequencies: 2000 and 4000 Hz. Athletes who did not
pass this pure tone test may have had hearing loss.
Results
We analyzed the data using the Healthy Hearing data tabulation sheets. The percentages
of participants who passed the hearing screening, had ears partially blocked or blocked with
cerumen who passed or failed the hearing screening, and those who required more than EOAE
screening were analyzed. The results are shown in Table 1.
Sports Events
Pass screening
Fail screening
2004 Nagano
279
79.0%
21.0%
32.7%
52.7%
2005 Nagano
58
81.0
19.0
30.6
45.8
2008 Yamagata
183
85.8
14.2
20.0
31.8
81.9
18.1
27.8
43.4
76.0
24.0
39.2
46.4
Average
2009 Idaho, USA
(World Games)
1060
Pass: PB/B
Refer PB/B
Table 1. The results of hearing screening
Hearing loss was confirmed in an average of 18.1% (14.221%) of the Japanese athletes
with intellectual disabilities; the average at the World Games was 24%. The ear canals were
partially blocked or blocked (PB/B) with cerumen in an average of 27.8% (20.032.7%) of the
Japanese athletes who passed the hearing screening, versus 39.2% of the athletes at the World
Games. The proportions of athletes with PB/B who did not pass the hearing screening were
similar in Japan and at the World Games.
Conclusions
The 1630% hearing loss that has been detected in the study population is much higher
than the 2% in a typical population (Montgomery et al., 2006). In this study, we confirmed a
similar tendency in Japanese athletes. Hearing loss has profound effects on communication,
social interactions, academic skills, and daily life. About 20% of individuals with intellectual
disabilities may improve their skills and their quality of life if they receive adequate treatment or
use hearing aids. We may think that their intellectual disabilities are the cause of their behavior
problems if we are unaware of their hearing loss. Herer and Montgomery (2009) stated that
people with intellectual disabilities deserve annual hearing evaluations and medical
examinations of their earsto detect those needing important intervention services that will
improve their quality of life.
References:
Gilbert R. Herer and Judy K. Montgomery (2004) Healthy Hearing A Worldwide Hearing Screening Program.
Adewuate Hearing Helps Athletes with Developmental and Learning Disabilities to Be the Best They Can Be.
114
Gilbert R. Herer and Judy K. Montgomery (2006) Healthy Hearing Program. Guidelines for standardized
screening procedures. Special Olympics Inc.
Gilbert R. Herer and Judy K. Montgomery (2009) Outcomes from the Healthy Hearing Program 2009 Special
Olympics World Games, Boise, Idaho February 7-13, 2009.
Judy K. Montgomery, Gilbert R. Herer, Patric Chan, and Hideo Itoh (2004) Hearing Of Persons with
Developmental Disabilities Worldwide: Unexpected Findings. ISAAC Biennial International Conference,
Natar, Brazil.
Judy K. Montgomery, Gilbert R. Herer, Hideo Itoh, and Katrin Neumann (2006) Undetected, Unserved,
Underserved: Hearing Loss in Persons with Intellectual Disabilities (ID). ISAAC Biennial International
Conference, Duesseldorf, Germany
Kumar Shinha A, Judy K. Montgomery, and Gilbert R. Herer (2008) Hearing screening outcomes for
persons with intellectual disabilities: a preliminary report of findings from 2005 Special Olympics
World Winter Games. International Journal of Audiology 47(7): 399-403.
115
P069
EARING SCREENING IN PRIMARY HEALTHCARE CONTEXTS.
Gomes, MSR; Lichtig,
University of Sao Paolo
Introduction
The audiology literature has been characterized by a continuous influx of data regarding
the growth of newborn hearing screening (NHS) and the benefits of early intervention for
infants with hearing loss. Efforts at identifying children with this difficulty have spread as
technology has improved.
Despite the efforts towards NHS in Brazil since 1998 (Azevedo,2004), the services
available for the identification of hearing impairment are often urban based, requiring highly
skilled professionals, and have very low coverage rates.
The consequences of such services are delayed diagnosis, treatment and enrollment in
intervention programs, when necessary. The reality in developing countries such as Brazil is that
the majority of hearing impaired children are neither identified nor do they receive any
intervention.
A more appropriate approach to screen hearing impairment in developing countries
would be to use low cost technology and community resources, that is, emphasizing the
participation of the community in the planning of the services. These are some of the principles
of community based rehabilitation, a strategy introduced by the World Health Organization to
assist people from developing countries where access to prevention and rehabilitation services is
unequal and inadequate to the real needs of disabled people.
A questionnaire could be a simpler and more cost-effective method of audiological mass
screening of children, which could be implemented in a primary health assistance context in
areas where other methods of screening are not available
Gomes & Lichtig (2005) reported that community agents participation and the use of a
low cost hearing screening questionnaire are viable and positive as they enabled the
acknowledgement of non-specialists for risk situations for hearing impairment. The use of
questionnaires as a hearing screening tool has also been discussed by several authors (Zaman, et
al, 1990; McCormick, 1991, Haggard & Hughes, 1991, Dube, 1995, Hammond et al, 1997, Lichtig
& Wirz, 1998, Hind et al, 1999, Atenius et al, 1999, Stewart et al, 1999, Newton et al, 2001).
The aims of the present study were: to train health community agents and kindergarten
managers to apply a parent report questionnaire to identify hearing loss in children aged 0 to 3
years old in a poor community in So Paulo city; and to compare the results of parents report
questionnaire with objective audiological measures (otoacoustic emissions screening test).
Methods
The Ethics Committee of the Clinics Hospital of University of So Paulo approved this
project before any data was collected.
A hearing screening program was implemented at two kindergartens and at one
healthcare clinic in Brasilndia District, So Paulo city.
116
During the research period, 238 infants between the ages of 0 and 3 years old were
enrolled in the study. Infant gender was evenly distributed (47,7/52,3%). The mean age of the
sample was 15,7 months with 61,7% of the infants older than 12 months of age.
Thirty two health community agents and four kindergarten managers were trained to
use a parent report questionnaire with parents of children from 0 to 3 years of age, while their
children underwent TEOAE screen and the Cochleopalpebral reflex (RCP) testing. Infants
referring either or both ears were scheduled for a follow-up visit within 4 weeks time. The
follow-up screening consisted of the same protocol followed by a 226 Hz probe tone
tympanogram. If a second refer result was obtained a diagnostic evaluation was scheduled.
Data derived from parental questionnaires were statistically compared to data derived
from otoacoustic emission screenings, and the sensitivity, specificity, positive predictive values,
negative predictive values of the questionnaire were calculated.
Results
Parent report questionnaires were applied to parents of 238 children. A small percentage
(6,72%) of the 238 enlisted subjects attending the two kindergartens and the healthcare clinic
during the period of data collection did not receive any hearing screening due to irritability and
restlessness. The remainder of the sample (n = 222) resulted in 33 subjects referring (14,86%). Of
these, 21 referred both ears, 12 referred either the left or right ear. Twenty six subjects (78,8%)
returned for follow-up evaluations, 10 passed and 16 referred. In these 16 subjects both TOAE
and tympanometry results were obtained. Fifteen subjects (93,75%) referred TOAE and
tympanometric screen, presenting types B or C curves, and only one subject passed
tympanometric screen and referred TOAE bilaterally.
The relationship between TOAE and RCP results was also statistically analyzed. Positive
results were specified as a pass for a TOAE and the presence of RCP. Negative results were
specified as a TOAE refer result in combination with an absence of RCP. According to the
Kappas test analysis there was a strong and highly significant association between the TOAE
and the cochleopalpebral reflex result (p < 0.001).
Results from the parent report questionnaires were compared to the audiological
screening and showed sensibility of 73,33% ,specificity of 60%, positive predictive value of
96,5%, negative predictive value of 13,04%.
Discussion
Coverage of 93,28% for bilateral screening of subjects in the sample was obtained with
TOAE screening. Some subjects could not be tested due to irritability and restlessness and were
lost during the initial screening process. This coverage rate is close to the benchmark of 95%
recommended by the Joint Committee in Infant Hearing- JCIH (2007) for bilateral screening.
Reports on hearing screening coverage at primary healthcare contexts have not been previously
reported since the vast majority of neonatal and infant hearing screening programs are hospital
based. In Brazil, literature reports coverage rates varying from 94,8% (Durante et al 2003) to
67,9% (Barreira-Nielsen et al, 2007).
The initial referral rate (14,87%) was significantly higher than the benchmark of a 4%
follow-up referral rate recommended by the JCIH (2007), evidencing that a single TOAE screen
requires a second step to obtain lower referral rates.
A comparison of the TOAE and tympanometric results obtained in subjects returning for
follow-up evaluations allowed investigation of the effect of middle-ear effusion on screening
results The results of the current study indicates that around 50% of failures in initial TOAE
117
screening for infants aged 0 to 3 years old may be due to middle-ear effusion and/or obstruction
of the external ear canal. The follow-up screening revealed that 93,75% of referrals were due to
middle-ear disorders. Only one subject presented sensorioneural hearing loss confirmed by a
diagnostic evaluation.
The strong and highly significant association between the TOAE and the
cochleopalpebral reflex indicates that this simple and low cost method could be used by nonspecialists in primary healthcare contexts, such as kindergartens, to screen the childrens hearing
status.
The parent report questionnaire was not able to identify the most frequent type of
hearing loss found in this study, the conductive type, which means that the degree of these
losses varied from mild to moderate. Therefore, the questionnaire presented low sensitivity and
specificity. Nevertheless, the use of a questionnaire creates a learning situation that contributes
for hearing health promotion, once it enabled the acknowledgement of non-specialists for risk
situations for hearing impairment.
Conclusion
The proposed plan of action indicates a feasible innovation in audiological services
delivery in Brazilian Public Health System and in other developing countries.
References
ATEUNISL.J.,ENGELJ.A,HENDRIKSJ.J.,MANNIJ.J.A longitudinal study of the validity of parental
reporting in the detection of otitis media and related hearing impairment in infancy.
Audiology;1999;38(2):75-82.
AZEVEDOM.F.Triagem Auditiva Neonatal. In: FERREIRA,C.P., BEFI-LOPES,D.M., LIMONGI,
S.C.O.(org) Tratado de Fonoaudiologia. SoPaulo: Roca,p.604-16,2004.
BARREIRA-NIELSEN,C.,NETO,H.A.F.,GATAZZ,G. Processo de implantao de Programa de Sade
Auditiva em duas maternidades pblicas. Revista da Sociedade Brasileira de Fonoaudiologia; 2007;12
(2): 99-105.
DUBE,S. Identification of hearing loss in rural Zimbabwe. [Master of Science Dissertation]. London: University
of London,1995.
DURANTE,A.S,CARVALLO,
R.M.M.,COSTA,
M.T.Z.,CIANCIARULLO,M.A.,VOEGELS,
R.L.,
TAKAHASHI,J.M.,SOARES,A.V.N.,SPIR,E.G. Triagem Auditiva Neonatal justificativa, possvel
e necessria. Revista Brasileira de Otorrinoaringologia; 2003;69(2):11-18.
GOMES,M.S.R.;LICHTIG,I. Evaluation of the use of a questionnaire by non-specialists to detect hearing
loss in preschool children of a poor community in So Paulo. International Journal of Rehabilitation
Research,28(2),2005
HAGGARDM.,HUGHESE.Screening childrens hearing: A review of literature and the implication of otitis media.
London: Medical Research Council,1991.
HAMMONDP.D.,GOLDM.S.,WIGGN.R.,VOLKMERR.E. Preschool hearing screening: Evaluation of a
parental questionnaire. Journal of Paediatrics & Child Health;1997;33(6):528-530.
HINDS.E.,ATKINSR.L.,HAGGARDM.P.,BRADYD.,GRINHAMG. Alternatives in screening at school
entry: comparison of the childhood middle ear disease and hearing questionnaire (CMEDHQ)
and the pure tone sweep test. British Journal of Audiology;1999;33:403-414.
JCIH-Joint Committee on Infant Hearing Year 2007 Position Statement: Principles and guidelines for early
hearing detection and intervention programs. Pediatrics 120 (4):898-921.
LICHTIGI.,WIRZS.H lugar para a fonoaudiologia na reabilitao baseada na comunidade. PrFono,
Revista de Atualizao Cientfica;1998;10(2):78-86.
McCORMICK,B. Screening for hearing impairment in young children. London: Chapman & Hall,1991.
118
NEWTONV.E.,MACHARIAI.,MUGWEP.,OTOTOB.,KANS.W. Evaluation of the use of a questionnaire to

detect hearing loss in Kenyanpre- school children. International Journal of Pediatric
Otorhinolaryngology; 2001;57(3):229-34
STEWARTM.G.,OHLMSL.A.,FRIEDMANE.M.,SULEKM.,DUNCANN.O.,FERNANDEZAD.Is
parental
perception an accurate predictor of childhood hearing loss? A prospective study. Otolaryngol Head
Neck Surg; 1999;120(3):340-4.
ZAMANJ.S.,KHANN.Z.,ISLAMS.,BANUS.,DIXITS.,SHROUTP.,DURKINM.Validity
of
the
Ten
Questions for Screening Serious Childhood Disability: Results from Urban Bangladesh.
International Journal of Epidemiology, 1990;19(3):613-9.
119
FP44.1
PROOF OF COMMUNICATION AND LANGUAGE FOR BETTER
QUALITY OF LIFE
Tatiana Lima Santos
Rayana Mara de Sousa
Karine Medeiros Coelho Carvalho
INTRODUCTION
The hearing, to any degree the cause of developmental communication and language
that hinder learning and use of language in everyday life, which greatly influence the quality of
life with hearing loss, because it can not communicate properly with most people, listening and
using spoken language as a means of communication, this disconnection with others can
generate implications for his social and emotional development of children affected by it (Ibid.,
2007). Whereas good hearing is critical to language development, and the existence of a hearing
disability to influence the development of language, one of the key components in the process of
hearing habilitation and rehabilitation is the use of hearing aids, which aims to increase noise in
the most appropriate and satisfying as possible (NORTHERN, DOWNS, 2005).
OBJECTIVES
a) Home
Analyze the published literature the link between quality of life and possibilities hearing.
b) Secondary
Identify the behavior of the prosthesis deaf patients;
The interference of deafness in the communicative capacity.
METHODS
a) Type of study
It is an exploratory research of the type literature.
b) Material used
The survey was developed based on literature in the field which was used technical
scientific journals indexed (journal articles and Appendix). In addition to books, dissertations
and monographs. To identify scientific articles published databases were used databases such
as: search by subject, using some descriptors according to the keywords chosen for the article:
communication, language, hearing aids, quality of life. We used databases such as: BIREME,
LILACS, SCIELO.
HISTORY
According to Seidl and Zannon (2004), there are indications that the term first appeared
in the medical literature in the 30s, from a survey of studies that were aimed at determining and
making a reference to evaluate the quality of life .The term "quality of life" according to Fleck
and others (1999) was first used by United States President, Lyndon Johnson in 1964, stating
120
that: "Goals can not be measured by the balance sheet of banks. They can only be measured by
the quality of life that our people ".
According to the study group on quality of life of the World Health Organization, this
could be defined as "the individual's perception of their position in life in the context of culture
and value systems in which they live and in relation to their goals, expectations , standards and
concerns ". Being included in the domains: physical health, psychological state, levels of
independence, social relationships, environmental characteristics and spiritual pattern
(WHOQOL Group, 1995 apud. DANTAS, SAWADA, Malerba, 2003).
QUALITY OF LIFE
The concept of quality to reach the current parameters for various reformulations steps
and can be seen in many ways, the most widespread is the taxonomy of definitions of quality of
life, according to Farquhar, which follows below.
I - Global setting
First definitions in the literature. Predominant until the mid 80's. Very generally, do not
address the possible dimensions of the construct.
There operationalizing the concept. They tend to focus only on evaluation of satisfaction
/ dissatisfaction with life.
II - Definition based
Definitions based on components appear in 80 years. Starts for the fractionation of the
overall concept in various components or dimensions. Begin the prioritization of empirical
studies and the operationalization of the concept.
III - Definition focused
Settings value specific components, in general aimed at functional abilities or health.
Appear in works that use the term quality of life related to health. Emphasis on empirical and
operational aspects. Develop various tools for assessing the quality of life for people suffering
from different diseases.
IV - Definition combined
Definitions incorporate aspects of Types II and III: aspects favor the concept overall and
cover various dimensions that comprise the construct. Emphasis on empirical and operational
aspects. Develop tools for assessing global and factorial (WHOQOL Group, 1998, apud SEIDL,
Zannoni, 2004).
The measure, there are several ways to measure quality of life of a people, but the most
widespread is the Human Development Index (HDI) prepared by the United Nations
Development Program (UNDP). It was created in order to disrupt the debate on development of
purely economic, to aspects of social and cultural. Stuck in this identifier is the understanding
that income, health and education subsidies are three essential elements of quality of life of a
population (MINAYO, Hartz, 2000).
This is an abbreviated indicator of quality of life in simple sum and divide by three
income levels, health and education of a population. The rent is weighted by real GDP per capita
on health, the life expectancy at birth and education, the percentage of adult literacy and
enrollment rates at primary, secondary and tertiary sectors combined. Income, education and
121
health would be attributes with equal importance as an expression of human capacities (Id.,
2000).
However, despite Since the 1960s the quality of life was extended to the subjective
quality of life or perceived quality of life for people. Largely influenced by the World Health
Organization (WHO), where health is not restricted to the absence of disease but brings together
the individual perception of a complete physical well-being, mental and social, the concept has
expanded beyond the definition economic growth, trying to cover the multiple aspects of social
development (ZHAN, 1992 apud GONALVES, CICONELLI, 2006).
COMMUNICATION AND LANGUAGE

Human speech is a sound of massive complexity, whose perceptual processing,
production and affinity with language and cognition require an integrated analysis, both in
terms of available knowledge and also the specific methodology (TRISTAN, FEITOSA, 2003).
Oral communication distinguishes humans from other living beings, is obtained by
means of a stream of acquisitions, the most important link is the hearing. Promptly language
requires for its full growth, the functions: hearing and phonation, which comprise the two poles
connecting the subject of oral communication by setting the so-called electro-acoustic circuit of
human communication (COSTA, 1999).
Without the auditory feedback necessary for the development of communication, the
child does not match the sounds and do not develop control over voice, breathing and
articulation. So, without sufficient airflow, the deaf have a tendency to make big speech effort,
with difficulty of intonation, frequency, intensity, prosody, rhythm, articulation, resonance and
vocal quality. (PRADO, 2007; RUSSO, MOMENSONHN-SANTOS, 1994).
In the therapeutic process, which involves the voice of the deaf, the auditory perception,
tactile and kinesthetic are critical because these individuals need to increase the capacity to
monitor their speech to an efficient voice production. From these considerations, it can be
observed that the literature on the characteristics of the voice of deaf people is extensive. The
connection of these knowledge resources therapy reveals the possibility of changes in voice
quality and phonatory adjustments, which may provide greater intelligibility of speech of these
subjects (PRADO, 2007).
ASSESSMENT HEARING
The hearing impaired children with disabilities can be seen from birth, through auditory
tests, which are observed behavioral responses. But to ensure the consistency of audiological
findings, the examiner must make more of a test (CARVALHO, LICHTIG, 1997).
In auditory tests, it is imperative to start with a history in which it is a collection of data
from parents and / or caregivers closer to characterize the complaint and the constraints they
feel the child. This step is a phase of rapprochement between the examiner, child and members
of the family environment of children (Russo, MOMENSONHN-SANTOS, 1994).
There are several techniques to evaluate the hearing of the child from zero to two years,
including: research on the behavioral responses to auditory stimuli, Boel test, audiometry
through conditioning of orientation reflex (COR), visual reinforcement audiometry (VRA)
(NORTHERN , Downs, 2005; MOMENSONHN-SANTOS, RUSSO, 2007).
In assessing the hearing of a child, not only evaluates the route on physiology that makes
the sound to reach the central nervous system, but we evaluate all the influences that the loss
will bring the child and how his hearing. The audiological evaluation should not only be
attached to obtain the pure tone thresholds and may be a wider process where there has been a
122
subject, his hearing and his behavior towards the sound world (RUSSO, MOMENSONHNSANTOS, 1994).
It is difficult for the deaf learn spoken language. For this reason, many fail to convey
their thoughts to others, except through gestures and other actions. However, the use of hearing
and a good training as soon as possible, facilitate access to oral communication (Godoy, 1999).
Hearing loss can occur before, during or after birth. They are called congenital hearing
loss, those that occur before or during birth and acquired hearing loss, those that occur after
birth. These hearing losses can be classified into hereditary and non-hereditary (Godoy, 1999;
MOMENSONHN-SANTOS, RUSSO, 2007).
It is necessary for the professional who will evaluate the hearing of the child to know the
most common causes that appear in the outer ear, middle and inner to adequately assess
whether the type of problem to be worked as hereditary (Godoy, 1999; MOMENSONHNSANTOS, RUSSO, 2007; NORTHERN, DOWNS, 2005):
Accurate diagnosis of the cause of hearing impairment is necessary for its prevention and
for adequacy of speech therapy and educational methods to be used. It should be understood
that the process of rehabilitation and / or enabling a child with sensory problem is different
from children with neural or central problem. As fundamental knowledge of the causes of
hearing loss, to further evaluate the type of problem to be worked. Having knowledge about the
location, extent and source of the problem may indicate the adaptation of hearing aids and
organized the therapy that will come after the confirmation of the loss (Carvalho LICHTIG,
1999; NORTHERN, Downs, 2005).
Prosthesis
Among the types of hearing aids that can be employed, it is important to seek the
improvement of communication to improve the development and interaction of the hearing
impaired in social life. Hearing aids aids (HA) have as a basic principle to capture sound, and
amplifies the acoustic signal processing, and directing the amplified signal and treated for ear
via the external ear canal or transmission via bone, while there are some hindrance, as some
types of malformations (PEREIRA, FERES, 2005).
The successful adaptation of hearing aids in individuals with hearing loss, especially the
light and / or asymmetrical, is not an easy task. Advances in prosthetic technology collaborate
in shaping the flexibility of frequencies, making the adjustment more individual and effective,
however, improvements in speech understanding in noise is still a challenge (NORTHERN,
Downs, 2005).
Another major obstacle is the proper adjustment of ear molds. Due to some formats of
the external auditory canal, there are patients who reported having difficulty using their hearing
aids because they cause discomfort, promoted by the type of earmold adapted, in this case it is
necessary to reassess what mold is most appropriate to the patient (PEREIRA, FERES , 2005;
NORTHERN, DOWNS, 2005).
Before beginning the process of selection of hearing aids, should be viewed the ear canal
by otoscopy. This procedure is necessary because factors such as excessive ear wax, infections or
congenital malformations of the external auditory canal interferes with the adaptation of ear
molds (PEREIRA, FERES, 2005).
The cast is well developed facilitating factor in the use of devices, by providing better
placement and removal. There are actually several different types of materials for making ear
molds, from acrylic, more rigid, to the more flexible silicone comfortable and suitable for allergic
patients and children (Id., 2005).
123
The molds should be frequently reassessed, particularly in children, because the rapid
growth can adversely affect the external ear, changing your settings. This adaptation is
necessary because it is in childhood that man is more likely to develop their knowledge and
skills, and to that end, it receives large amounts of environmental stimuli and hearing is the
primary means by which verbal language is acquired (PEREIRA , FERES, 2005; NORTHERN,
DOWNS, 2005).
Thus, any child with a significant hearing loss should be considered as a candidate for
the use of amplification. Children must be adapted to a hearing as early as possible, avoiding the
effects of sensory deprivation on the overall development and language. In children with
hearing loss, it is essential the physician to focus on the need for early prosthesis and subsequent
treatment enabling communication with therapists. The family must realize that it is not enough
only to place the prosthesis, but that the monitoring work of adaptation is essential for the
development of oral language (Id., 2005, 2005).
It is very important in clarifying for the patient benefits that hearing aids will provide
the patient, adjusting to the expectations of family members. It is now necessary to encourage
home trial, it is during this period that he will be able to experience what the hearing will
provide you with in other environments. It is also advisable to binaural where indicated, to
better use (ibid., 2005, 2005).
FINAL
Childhood is the critical moment for the development of knowledge and skills, so it is
essential that the child has at his disposal a large amount of stimuli in the environment in which
they live. The hearing is fundamental to the development of verbal language. Being considered
that hearing loss may pose a minimal risk to language development and lead to problems of
learning, influencing the quality of life is considered here as an opportunity for better
participation in society.
It is then paramount to fitting a hearing aid in children with hearing loss as early as
possible, so you can avoid the effects of sensory deprivation on the overall development of
language. A hearing loss makes a child to play a beep and a significant influence on their
education, one of the indicators considered in this study as a measure of quality of life, because
without hearing the possibility of access to education is without prejudice, because society is
basically listener and knowledge is passed mainly in spoken language and even to the
understanding of written language are required parameters of the spoken language. The
exclusive access to education for the deaf does not cover all walks of life and becomes nonexistent in some cities, public schools and unfortunately are not adapted to this reality.
REFERENCES
BUCUVIC, E.C; IRIO, M.C.M.; Benefcios e dificuldades auditivas:um estudo em novos usurios de
prtese auditiva aps dois e seis meses de uso. Fono Atual, Barueri (SP), v.29, n.7, p. 19-29,jul.set., 2004.
CARVALHO, R e LICHTIG I. Audio: Abordagens Atuais. So Paulo: Prfono, 1997.
COSTA, S. S. da. Audio, comunicao e linguagem: um convite reflexo. Revista HCPA, Porto Alegre,
n. 19, p.147-166, ago., 1999.
FLECK, M. P. de A. e outros. Desenvolvimento da verso em portugus do instrumento de avaliao de
qualidade de vida da OMS (WHOQOL-100). Rev. Brs. Psiquiatr.,v. 1, n. 21, p.7-18, abr., 1999.
GIL, A.C. Como elaborar projetos de pesquisa. 4. ed. So Paulo: Atlas, 2002.
GODOY, T. C. F. Deficiente auditivo: o retorno para o mundo dos sons. 1999. Monografia
(Especializao) CEFAC, centro de especializao em fonoaudiologia clnica audiologia, Goinia,
124
1999. Disponvel em: <http://www.cefac.br/publicar/conteudo.php?id=52>. Acesso em: 10 jan.

2009.
LIMA, G.S. Tipos de estudo. In: CARVALHO, B.D. Metodologia de Trabalho Cientfico. So Paulo: Atlas,
2004, p.110.
MINAYO, M. C. de S.; HARTZ, Z. M. A; BUSS, P. M. Qualidade de vida e sade: um debate necessrio.
Cincia & Sade Coletiva, Rio de Janeiro, v.5, n.1, p.7-18, abr., 2000.
MYNAYO, M. C. de S. O desafio do conhecimento: pesquisa qualitativa em sade. 4 ed. So Paulo/ Rio
de Janeiro: HUCITEC/ABRASCO, 1996. p. 89.
NORTHERN, J. L. ; DOWNS, M. P. Audio na infncia. 5 ed. Rio de Janeiro: Guanabara Koogan S.A.,
2005.
PEREIRA, M. B., FERES, M. C. L. C. Prteses auditivas. In: SURDEZ: IMPLICAES CLNICAS E
POSSIBILIDADES TERAPUTICAS, n. 38, 2005, Ribeiro Preto. Simpsio de Medicina de
Ribeiro Preto: Medicina, jul./dez., 2005, p. 257-261.
PRADO, A. C. Principais caractersticas da produo vocal do Deficiente auditivo. Rev. CEFAC, So
Paulo, v.9, n.3, p. 404-410, jul./set., 2007.
RUSSO, I.C.P.; MOMENSONHN-SANTOS, T.M.M. Audiologia Infantil. So Paulo: Cortez, 1994.
______. Prtica da Audiologia Clnica. So Paulo: Cortez, 2007.
SEIDL, E. M. F.; ZANNON, C. M. L. C. Qualidade de vida e sade: aspectos conceituais e metodolgicos.
Cad. Sade Pblica, Rio de Janeiro, v. 20, n. 2, p. 580-588, mar./ abr., 2004.
TRISTO, R. M.; FEITOSA, M. A. G. Percepo da fala em bebs no primeiro ano de vida. Estudos de
Psicologia, Braslia, v. 8, n. 3, p. 459-467, mar., 2003.
WHOQOL GROUP. The World Health Organization Quality of Life assessment (WHOQOL): position
paper from the World Health Organization. Soc Sci Med 1995; 41(10):1403-9. apud DANTAS,
Rosana Aparecida Spadoti; SAWADA, Namie Okino; MALERBO, Maria Bernadete. Pesquisas
sobre qualidade de vida: reviso da produo cientfica das universidades pblicas do estado de
So Paulo. So Paulo, Rev. Latino-am. Enfermagem, v. 11, n. 4, p. 532 538, jul. / ago., 2003.
WHOQOL GROUP. The World Health Organization quality of life assessment (WHOQOL): development
and general psychometricproperties. Soc. Sci. Md. 1998; 46:1569-85. apud SEIDL, E. M. F.;
ZANNON, C. M. L. C. Qualidade de vida e sade: aspectos conceituais e metodolgicos. Rio de
Janeiro, Cad. Sade Pblica, v. 20, n. 2, p. 580-588, mar. / abr., 2004.
ZHAN, L. Quality of Life: Conceptual and measurement issues. J. Adv. Nurs. 1992; 17(7):795800. apud
GONALVES, A. C.; CICONELLI, R. M. Qualidade de vida e medidas de utilidade: parmetros
clnicos para as tomadas de deciso em sade. Rev. Panam. Salud. Publica/Pan. Am. J. Public.
Health. v.19, n.2 , mar., 2006.
125
SY10.4
DEVELOPMENT OF AUDITORY MEMORY IN COCHLEAR IMPLANTED
CHILDREN OVER TIME
Miki Branka, Miri Danica, Ostoji Sanja, Asanovi Maja, Miki Mina
Clinical Center of Serbia, Institute of ENT and HNS, Audiology Rehabilitation
Department
Belgrade University, Faculty of Special Education and Rehabilitation
Short term auditory memory is extremely important for speech development in hearing
or hearing impaired children.Objective of this study was to assess development of auditory
memory in a group of cochlear implanted children and to discover the factors that affect it.A
group of 30 CI children aged 3 to 12 has been tested using a Test of immediate verbal memory
developed by Spasenija Vladisavljevi.The test consists of four subtests of increasing
complexity.Children were divided in three subgroups according to hearing age: A. With less
than 1 year, B. 1- 2 years and C. More than 2 years. Two subgroups were compared regarding
age at implantation: those implanted before the age of 3 and those implanted later than 3 years
of age.Results have shown that short-term auditory memory is constantly improving over time
in all of the cochlear implantees. Scores are increasing after tree years of rehabilitation,especially
for the most complex subtest of short sentences.Children that were implanted before the age of
3, have show considerably better scores in all four subtests, which implies that development of
auditory memory is dependent on central nervous system plasticity. Improvement of short-term
auditory memory is consistently seen over time in postoperative rehabilitation of cochlear
implanted children. Early implantation, before the age of 3, enables maximal achievement in
hearing, speech and auditory memory.
Key words: cochlear implant, short-term auditory memory

Introduction
Short-term auditory memory is an important factor contributing to receptive speech

development in young children, besides auditory perception and processing and other higher
cortical functions such as intelligence, cognition and attention. The auditory system must wait
until sufficient information has been presented before processing even the smallest units of
speech (Kartik et al, 2005). The normal auditory system is capable of retaining peripherally
processed information from the cochlea, long enough to identify the smallest units of the
pattern.Deficit of auditory memory could be responsible for impaired sentence comprehension .
It is very important to follow and improve auditory memory in hearing impaired children
during rehabilitation (Ertmer, 2002). Auditory capacity and cortical functions are entwined, and
estimates of cortical acitivities could help in prognosis of cochlear implantation outcome.
Auditory memory could be tested by different tests using words, non-words, sentences or digit
spans- forward or backward (Dillon et al. 2004, Burkoholder, 2004, Pisoni 2004). All segements
of auditory memory are essential to speech recognition and comprehension leading to speech
and language development and cognitive processes. Immediate or short-term auditory memory
is extremely important for understandingwords and sentences both in normal hearing and
heaaring impaired subjects. It has been recently recognized that degraded speech signal such as
126
perceived by cochlear implant users largely affect peformance on immediate memory tests
(Burkholder et al, 2005). It is specially important for young prelingually deaf children, because it
can significantly influence development of receptive and expressive speech (Niparko,2003).
Objectives of the study

The objectives of this study were the assessment and follow-up of short-term auditory
memory in congenitally deaf children with cochlear implants. The authors have tested shortterm auditory memory using phonological material: two syllable words consisting of vocals and
plosives, two syllable non-words and sentences. Test of immediate verbal memory used in this
study consisted of four subtetsts of increasing complexity. Comparison was made between early
and late implanted children. Hearing age, i.e. time since the implant was switched-on was
considered, as well as the duration of postoperative speech and hearing rehabilitation.
Hypotheses were that the outcome regarding short-term auditory memory is better:
if the children were implanted under the age of 3 years
if the hearing age is longer than 2 years
if the duration of rehabilitation is more than 3 years
Material and methods

A group of 30 prelingually deaf cochlear implanted children was enrolled in this study.
The age span was 3 to 12 years. All of the children had normal intelectual capacity.
According to the age at implantation the children were divided in two subgroups: 1.
Implanted before the age of 3 years and. 2. Implanted after 3 years of age
They were divided in 3 subgroups regarding hearing age: A. Less than 1 year
B. 1-2 years and C. More than 2 years
There were two subgroups according to duration of postoperative rehabilitation: 1. Less
than 3 years of rehabilitation and 2. More than 3 years of rehabilitation.
Phonological Test of immediate verbal memory developed by Spasenija Vladisavljevi in
Serbian language has been used in this study. The test consists of four subtests using phonetic
material. Subtests I-III consist of two syllable words and non-words and subtest IV of sentences.
Complexity is increasing from subtest I to subtest IV.
Results were compared across subgroups of children and subtests of immediate verbal
memory. Statistical analysis has been done.
Results and discussion

Comparing the children implanted before 3 years of age to those implanted later we have
found that short-term auditory memory was considerably better developed in children
implanted at younger age. Their performance was superior in all four subtest. That could be
attributed to central nervous system plasticity in young children which enables development of
auditory memory thorugh early intervention.
Both groups of children have shown better performance in first two subtests (76% and
67% respectively in subtest I and 84% and 63% in subtest II) and worst performance in most
complex subtext IV sentences (54% and 38% respectively). The biggest difference was observed
in subtest III (76% over 45%) with clear advantage of children implanted before the age of 3
years.
127
Graph 1
SHORT-TERM AUDITORY MEMORY AND AGE AT IMPLANTATION
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
84%
76%
76%
67%
63%
45%
54%
38%
BEFORE 3Y
AFTER 3 Y
II
III
IV
Comparison of three subroups of children according to hearing age (less than 1 year, 1-2
years and more than 2 years) have shown continuous improvent of auditory memory over time
Table 1). The children who had longest hearing age in this study (more than 2 years since
swithch on of CI) have shown superior results in all four subtests of sort-term auditory memory
(I-88%, II-90%, III-85%, IV-75%). Children with hearing age less than 1 year had poor
perfomance especially in more complex subtests (III-17%, IV-10%). This is very important
argument regarding postoperative development and outcome assessment. It should be pointed
out in preoperative discussion with parents of young cochlear implant candidates.
Table 1
SHORT-TERM AUDITORY MEMORY AND HEARING AGE
HEARING AGE
II
III
IV
< 1 year
47%
40%
17%
10%
1-2 year
72%
74%
48%
38%
> 2 year
88%
90%
85%
75%
Postoperative rehabilitation is essential for obtatining best results after cochlear

implantation. This study have shown that duration of rehabilitation considerably affects shortterm auditory memory (Graph 2). Children who were enrolled in speech and hearing
rehabilitation for more than 3 years have considerably better scores in all four subtests. The
advantage was especially clear in more complex subtest (III 86% over 34% and IV 89% over
34%).
Graph 2
SORT-TERM AUDTORY MEMORY AND DURATION OF REHABILITATION
128
86%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
90%
86%
89%
68%
57%
34%
34%
<3Y
>3Y
II
III
IV
Conclusion
Short-term auditory memory is developing over time in cochlear implanted children. The
best results are obtained in children implanted before 3 years of age due to central nervous
system plasticity. The results are improving with hearing age and the best results are observed
in children after two years since switch-on. Postoperative rehabilitation is essential for
development of auditory perception and memory. After 3 years of postoperative rehabilitation
cochlear implanted children have shown superior performance in most complex tasks regarding
immediate verbal memory.
References
Burkholder R., Pisoni D.: Digit span recall error analysis in pediatric cochlear implant users;
International Congress Series Volume 1273, November 2004, Pages 312-315
Burkolder R.; Pisoni D.; Svirsky M.: Effects of a cochlear implant simulation on immediate memory in
normal-hearing adults; International Journal of Audiology, Volume 44, Number 10, Number
10/October 2005 , pp. 551-558(8)
Dillon C.M., Burkholder R. A., Cleary M, Pisoni D.B.: Nonword Repetition by Children With Cochlear
Implants ; Journal of Speech, Language, and Hearing Research Vol.47 1103-1116 October 2004
Ertmer D. J., Leonard J.S., Pachuilo M.L.: Communication Intervention for Children With Cochlear
Implants ; Language, Speech, and Hearing Services in Schools Vol.33 205-217 July 2002
Lee H-J, Giraud A-L, Kang E et al: Cortical Activity at Rest Predicts Cochlear Implantation Outcome;
Cerebral Cortex 2007 17(4):909-917;
Miki B, Miri D, Ostoji S, Asanovi M, Miki M: Development of auditory memory in cochlear
implanted children over time, Abstracts of EFAS conference, Tenerife 2009, p 97
Mikic B, Miric D, Ostojic S, Arsovic N, Asanovic M :Assessment Of Auditory Performance In Cochlear
Implanted Children-Ling Test And Short-Term Auditory Memory; Abstracts of 10th Intl
Conference on Cochlear Implants and Other Implantable Auditory Technologies, San Diego,
April 2008, p. 277
Miki B,Miri D, Ostoji S, Arsovi N, Asanovi M: Short-term auditory memory in cochlear
implantees and children with auditory processing disorder; Abstracts of Composium on Central
Auditory Processing Disorders, Cairo 2009, p.19-20
Miki B: Razlozi za ranu intervenciju kod dece sa uroenim oteenjem sluha; Specijalna edukacija i
rehabilitacija, 1-2, 2006, ISSN 1452-7367, COBISS.SR-ID 136628748, p.111-118,
Niparko J. K., Blankenhorn R. :Cochlear implants in young children; Mental Retardation and
Developmental Disabilities Research Reviews.Volume 9, Issue 4 , Pages 267 275
129
Pisoni D.: The Forbidden Experiment: Speech Perception Skills of Deaf Children following Cochlear
Implantation; Brain and Cognitive Sciences, University of Rochester, 12.09.2004
Pisoni D.B.: Information-processing skills of deaf children with cochlear implants: some new
process measures of performance; International Congress Series Volume 1273, November

2004, Pages 283-287
130
FP44.4
PERSONAL DEVELOPMENT EXERCISES FUNCTIONS LISTENING AND
SPEAKING
Slavka Nikolic1, Savic Mirjana 2, Filipovic Verica3, Petrovic Jelena 4, Savic Marija5, Savic Vesna5
Primary School for Children with Damaged Hearing Zemun, Belgrade, Serbia1
Specialist Surdology General Hospital Sabac, Sabac, Serbia2
Ph D General Hospital Sabac, Serbia3
DZ Sabac, Serbia4
Student anglistike Faculty, Novi Sad, Serbia5
Introduction to the Theory

Monografy consider the impact of the implementation process of the individual exercises
focused on the imitation normal hearing and speech development in children. Monografy gives
significance level of development testing of the active / passive vocabulary, determines the level
of lexical semantics and after a year of intense stimulation of development of hearing and
speech.
The basis of this process is targeted learning.
Exercises are correctly planned and directed procedures in order to partial/full
consequences
of
disorders
of
hearing
status.
The development of features of speech, they need healthy for the speech centers in the brain,
intelligence, hearing, sight, touch, speech organs and welcoming environment.
In children, hearing impaired and verbalization is incomprehensible.
Hearing loss in childhood disrupts the development of speech and opinion. Speech is
reduced
depending
on
the
degree
of
hearing
impairment.
Children imitate adults, identify and develop communication. For use in speech communication
are necessary words, remember and repeat. The word is a verbal expression of thought, speech,
and is in the form of the unity of words and thoughts. Dictionary as a dynamic form of speech
and language behavior has its own specificities in terms of reduction of disability.Children with
hearing impairment may develop speech communication
Deafness destructive effect on the development of speech and directly affects the
dictionary. Hearing is mehanoreceptiv feel that is accessible to people due to the ability of
transformation of sound waves in the electro-physiological nerve impulses, biochemical nature
that takes place through the transmission device to the brain. Listening and imitation establish
the nerve connections and pathways between the senses of hearing, which differentiate and
develop speech centers in the brain. In the period epigonism child develops motor speech
differentiate auditory and visual analyzer, forms the speech centers, establishes a link between
the nervous and acquire spontaneous/aware of the speech. For a proper perception of a voice
signal is needed hearing. Receive tone begins at the moment of receiving and forwarding
through the hearing to the brain. The system of hearing and speech articulation are the basis of
the process. Speech and language development undergo mutual phase which comprises a
continuous process. The variety of speech and language development in children should be fit in
developmental norms. Acoustical characteristics of the votes as duration, intensity and
frequency structure. In the speech of children with hearing special attention should be paid to
131
proper pronunciation of all votes. Adoption of the vote should be immediately in words and
logic units. Formation of speech associated with the child and the adoption of native language
grammatical structure is impossible without overcoming the voice of speech. Overcoming the
language as a means of communication consists of the development process of perception votes
language, phonemic hearing and pronunciation. Speech is the creation, possession, construction
and establishment of the dictionary. Rich vocabulary runs through understanding and active use
of the word. The ability to understand the word as a sign for the case develops gradually.
Understanding the passive vocabulary of words and refers to the understanding of
words that preceded the use of words. To properly use the word, one must previously know its
meaning/semantics. Passive vocabulary is larger than active vocabulary.
A little child understands the word in the context of thoughts and sentences. Active
vocabulary is the number of words which the child is. There are two types: general/everyday
vocabulary, and special vocabulary/word for a particular situation.
General words are taught before because they are practical and always is greater than the
particular. Children learn first concrete meaning of the word. The word is linked to specific
objects, persons and situations. Children with hearing impairment should know the meaning of
words. While the child does not achieve the maturity to understand the word as a sign for the
case, the word must be spent through three stages; 1.ward is a sign for the subject; 2.ward the
subject property; 3.ward is an entity for itself.
When the word is used as a sign for the course or event, it causes reactions that are
associated with marked subject or event. When it is matured it is no longer associated with the
object or action, but stands alone as the term denoting the subject or action.
Word has three functions: 1.like sign, 2.like properties, 3.like subject.
The development of speech is a sequence that is biologically and psychologically and
that is:
1.knoweled that word has some meaning and that it transferred certain messages,
thoughts and feelings;
2.using word starts listening, imitation, and its use in inappropriate and in proper form;
3.meaning words that are constantly repeated is easier than the one word that is not
present in the child's cognitive sphere;
4.wards develop as children develop and cognition, and speech runs parallel to learning;
5.ward can say otherwise: write, draw, daktil mark and gesture present.
Difficulties in forming speech, communication, intellectual development and behavior,
there depending on the degree of hearing impairment.
Negative effects are more distinct if the hearing loss greater.
Speech and the word represents a specific unity thoughtful content. Every word is
meaningful/semantic content. Think hearing impaired can get content only on the basis of
images and memories of performances that accrues during the life of organs due to hearing,
sight, touch and smell that come in contact with the objects, phenomens and relationships that
exist between the bodies.
Speech only where there is semantics/meaning, which has a material carrier in the form
of voice and visual images.
Lexemes-concepts are essential part of the language without which one can not imagine
the speech and language communication. Volume, quality and quantity of lexemes that should
be given to the child with hearing impairment caused by the nature of the hearing loss, and how
the formation of a special lexicon requires methodical procedure.
132
You must know that the richness of the lexicon does not consist in the number of
lexemes, but in developing the meaning of lexemes capture. For it is the analytic/synthetic
method.
Under the influence of life experience, language is constantly expanding, and the lexicon
becomes richer. One of the most important segments in the work on speech and language
development of children with hearing impairment is working on forming a lexicon. To be able to
form a general lexicon of the child is required work on the formation of concepts. Proper
formation of concepts hearing child acquires the ability to present that exist on the object to be
denominated.
There is no development without the development lexicon of terms.
Child with hearing impairment is not enough to prove the case and mark it
lexemes. Concept-lexeme is defeated only when you use a child in your question, in his speech
expression when it wishes to use acquired concepts in an appropriate time, then the concept is
alive and active fund children's speech.
Development of concepts of children, is associated with the development of the lexicon
(from concrete to abstract, from vague to clear, from imprecise to precise, from general to
specific, from simple to complex, from whole to parts of the description to the definition).
The aim
Investigation of lexical semantics and classifying lexemes arranged in meaningful class
with superior and subordinate members of the research goal.
In addition they have their individual meanings, words are to each other in various types
relations. The description of the semantic structure encountered in meaningful relations between
lexemes: sintagmatic and paradigmatic relations.
Due to the nature of disorders of hearing people who are affected by this disorder is very
slow and train speech content and quickly forget it. Exercise for children with hearing
impairment is based on overcoming speech and language.
In children with hearing impairment, improper develop perception, and an excuse to
ignore. Daily training in the beginning to the child's challenges and connect to recall auditory
images with language content, and then through the speech training, the child forms a linguistic
expression.After some time with the child's auditory image will definitely put the auditive
memory and become part of the auditive capacity and vocabulary of the fund. Constant
repetition of the learned speech-language content is the only way of overcoming speech and
language.
When not practicing the overdrive with Echolalia certain votes, words and
sentences. Training must be based on well-formed, and wording of the question. Training
development functions of listening and speech training is the process of multiple incentives and
repeat exactly the planned content for the purpose of adoption, automation and spontaneous
use. The basic nature of disorders of hearing function in patients with hearing impairment is the
slow adoption of voice content and easy to forget.
Application development exercises, listening to children with hearing impairment is
based on overcoming speech and language functions.
Research methodology
The paper used experimental methods. The sample included eighty-one hearing
impaired children from the third to eighth grade.
133
The research is subjective audiometry, three test images/.Kosti, Semantic

test/S.Vladisavljevi, in four parts:the acquisition of homonyms, synonyms, Antonyms and
Metonyms and Test hiponimys/Z.Kai.
Done is the first test and after a year of systematic exercise conducted in the stimulation
of development of the functions of listening and speaking. in children with hearing school
children and other retesting.
Test results
Results were analyzed in relation to age, degree of hearing impairment, evaluation of the
Serbian language and gender, and comparative analysis of the results of the first and second
tests after one year of intensive implementation of the exercise stimulation.
Statistical results it was concluded that stimulation of development exercises the
functions of listening and speaking significantly affect the process of formation of active and
passive lexicon and the lexical-semantic development.
For all students in the whole sample the results of passive vocabulary were higher than
in the active vocabulary, which means that children are much more fond of them but the terms
are not used in your active vocabulary.
Depending on the degree of hearing loss, it was found that the best success of the
students had moderate to severe hearing impairment, and students with severe and weakest
pupils with very severe hearing impairment.
Conclusion of examination
The conclusion is that students with hearing impairment with low achievements in the
first test to achieve lower results in the second test, and that students with hearing impairment
with higher achievements in the first test achieved higher scores in the second test.
The conclusion is that students with hearing impairment who show greater progress in
enriching their active and passive vocabulary in describing one of the three images at the same
time achieve greater progress in the active vocabulary when describing the other two images.
Results relating to the relationship between progress in the standby dictionary in
accordance with the results relating to the active vocabulary.
The results show that students with severe hearing impairment, after one year of
systematic exercise conducted in the stimulation of development of the functions of listening
and speaking, the most advanced in the development of semantics. This group of students
achieved significantly greater progress in the acquisition of homonyms, synonyms, and
Antonyms.
This research showed that students from the three categories of hearing impairment
equally advanced in the acquisition of Hippo Regius.
Within the different groups of primary school achieve better results using individual
exercises the functions of development of listening and speaking. In the various achievements of
school success is achieved better results using individual exercises, development of listening and
speech functions in children with hearing impairment.
In different gender groups of children with hearing impairment there are no differences
in the development of listening and speech functions using individual exercises.
Recommendation
It should be every day to work on vocabulary enrichment of students with hearing
impairment.
134
Keywards:
Vokabular,
achievements,
SemanticTest/S.Vladisavljevi, TestHiponimys/Z.Kai.
TestThreeImages/.Kosti,
135
P011
DIFFERENCES BETWEEN FREQUENCIES OF FORMANTS F1 AND F0 AND F2
AND F1 IN CHILDREN WITH NORMAL HEARING AND PROFOUND OR
SEVERE HEARING IMPAIRMENT
Martina Ozbi1, Damjana Kogovek2
1 Faculty of education, Ljubljana, Slovenija, Europe
2 Faculty of education, Ljubljana, Slovenija, Europe
Introduction and aims of the study: The purpose of the present study was to discover the
differences in the frequencies of vowel formant production in 33 children, aged 5-9 years, with a
different hearing status. The aim is to document contrasts in differences of formant frequencies
in three groups with a different hearing status.
Methods: differences between formant frequencies (F2-F1 and F1-F0) associated with 6
Slovenian vowels ([i, closed e, open e, a, open o, closed o, u]), produced during naming pictures
or reading words from the Slovenian articulation test by 11 children with normal hearing (NH),
9 children with prelingual severe (SHI) (mean of hearing loss in dBHL, better ear=68,53,
SD=18.90) and by 13 children with prelingual profound hearing impairment (PHI) (mean of
hearing loss in dBHL, better ear=106.70, SD=4.82), were computed.
Results: Spectral analysis and subsequent ANOVA Welch analysis revealed that the
variables differences F2-F1 and F1-F0 of /i/, closed /e/, open and closed /o/ and /u/ failed to
pass the robust test of equality of means (Tables 1, 2, Figures 1, 2). The differences of high front
vowels and back rounded vowels of the speakers with hearing impairment were significantly
different from those of the normal-hearing children. The values of F1-F0 differences were greater
and significantly different for the vowels /i/ (342.7847.10 Hz in PHI and 311.1536.72 Hz in
SHI compared to 263.7420.14 Hz in NH group, p=0.000) and for the vowel closed /e/
(354.76107.82.76 Hz in PHI and 351.5286.31 Hz in SHI compared to 274.2525.89 Hz in NH
group, p=0.012); the differences for the back rounded vowels were smaller and significantly
different for the vowels of open /o/ (500.47112.38 Hz in PHI and 521.64136.71 Hz in SHI
compared to 356.75126.49 Hz in NH group, p=0.027), closed /o/ (391.7996.60 Hz in PHI and
383.9182.87 Hz in SHI compared with 296.3153.36 Hz in NH group, p=0.008), /u/
(324.4659.27 Hz in PHI and 293.8734.24 Hz in SHI compared to 276.1419.19 Hz in NH group,
p=0.034).
The values of F2-F1 differences were smaller and significantly different for the vowels
/i/ (1831.13336.87 Hz in PHI and 1889.30275.17 Hz in SHI compared to 2378.5121301.70 Hz
in NH group, p=0.001) and for the vowel closed /e/ (1468.13425.70 Hz in PHI and
1732.32233.58 Hz in SHI compared to 2149.92266.73 Hz in NH group, p=0.000); the differences
for the back rounded vowels were greater and significantly different for the vowels of open /o/
(742.26120.45 Hz in PHI and 649.1863.46 Hz in SHI compared to 598.2496.37 Hz in NH
group, p=0.021), closed /o/ (657.41132.22 Hz in PHI and 630.5058.48 Hz in SHI compared
with 556.3963.37 Hz in NH group, p=0.019), /u/ (582.18143.16 Hz in PHI and 514.52144.90
Hz in SHI compared to 423.85129.93 Hz in NH group, p=0.038). Concerning F1-F0 differences
(Table 3), the Bonferroni Post hoc Analysis showed that significant differences between NH and
136
SHI and between NH and PHI in production of /i/ and closed /e/ occur. Concerning F2-F1
differences, the Bonferroni Post hoc Analysis showed that significant differences between NH
and PHI production of front high vowels /i/ and closed /e/, and back rounded vowels open
and closed /o/ and /u/ occurred. Correlation between the degree of hearing loss on better ear
and the differences between formants are statistically significant in front high and back rounded
vowels (Table 4).Conclusions: The findings suggest the role of the auditory feedback in vowel
production, consequently in differences between formants among speakers with hearing
impairment, especially in front high and back rounded vowels. The knowledge may be used in
speech sciences, in speech therapy in visual monitoring vowel production in HI speakers and in
acoustical engineering, to give more stress on high frequencies during acoustic processing and
to give more stress on front and back vowel distinction in vowel elicitation among deaf
speakers.
Key words
Hearing impairment, vowel production, differences between formant frequencies.
Table 1: descriptives (mean, SD, min, max) of the differences between formants in normal
hearing, SHI and PHI group
Mea
Nn
diff_F0_F1_i
Std.
Devia Mini
tion
mum
Std.
Devia Mini
mum
N Mean tion
Maxi
mum
Maxi
mum
diff_F2_F1_i
NH
1 263,7 20,135 228,33 287,67 NH

1 424
27
1 2378,5 301,70 1911,5 2910,6

1 121
146
0
7
SHI
9 311,1 36,716 240,88 355,50 SHI

506
60
9 1889,2 275,16 1443,8 2191,5

979
936
0
0
PHI
1 342,7 47,096 250,38 451,67 PHI

3 801
17
1 1831,1 336,87 1100,1 2249,1

3 253
010
7
1
diff_F0_F1_cl
osed_e
diff_F2_F1_cl
osed_e
NH
1 274,2 25,886 231,80 321,00 NH

1 480
89
1 2149,9 266,72 1814,0 2788,0

1 247
868
0
0
SHI
9 351,5 86,307 256,00 506,89 SHI

170
27
9 1732,3 233,58 1386,5 2047,0

237
005
6
0
PHI
1 354,7 107,82 213,79 625,73 PHI

3 571
002
1 1468,1 425,70 384,19 2002,6

3 290
237
7
diff_F0_F1_o
pen_e
diff_F2_F1_o
pen_e
NH
1 481,0 153,31 260,00 790,00 NH

0 000
403
1 1662,3 278,11 1341,0 2293,0

0 333
511
0
0
SHI
9 420,7 129,71 234,67 605,00 SHI

593
464
9 1574,5 253,60 1248,3 1984,0

926
592
3
0
137
PHI
diff_F0_F1_a
1 446,6 188,73 247,00 830,00 PHI

3 859
715
1 1415,4 403,40 733,00 1940,3

3 615
467
3
diff_F2_F1_a
NH
1 630,9 121,07 476,00 780,00 NH

1 955
132
1 692,99 162,32 415,50 951,00

1 09
690
SHI
9 719,6 91,132 571,60 830,33 SHI

610
37
9 736,43 108,50 593,83 908,50

81
861
PHI
1 718,9 135,88 541,56 982,78 PHI

3 762
454
1 746,81 146,30 522,50 964,00

3 78
796
diff_F0_F1_o
pen_o
diff_F2_F1_o
pen_o
NH
9 356,7 126,48 250,67 584,33 NH

482
615
9 598,23 96,365 459,00 758,00

70
35
SHI
9 521,6 136,70 372,43 789,25 SHI

378
999
9 649,18 63,463 564,38 774,63

48
31
PHI
1 500,4 112,36 367,50 644,92 PHI

3 666
759
1 742,25 120,44 587,88 949,00

3 88
977
diff_F0_F1_cl
osed_o
diff_F2_F1_cl
osed_o
NH
1 296,3 53,357 254,00 443,40 NH

1 068
74
1 556,39 63,367 473,00 691,50

1 44
64
SHI
9 383,9 82,870 297,10 547,38 SHI

107
36
9 630,50 58,482 525,23 693,80

43
98
PHI
1 391,7 96,603 231,56 637,44 PHI

3 915
62
1 657,40 132,21 503,00 930,17

3 99
795
diff_F0_F1_u
diff_F2_F1_u
NH
1 276,1 19,188 249,00 307,00 NH

1 439
12
1 423,84 129,93 236,00 542,33

1 85
362
SHI
9 293,8 34,244 247,20 335,80 SHI

715
30
9 514,52 144,90 311,00 747,60

25
372
PHI
1 324,4 59,265 221,13 415,56 PHI

3 601
89
1 582,18 143,15 388,63 862,43

3 16
501
138
Table 2: Test of homogeneity of variances and robust test of equality of means Welch method
Test of Homogeneity of Variances
Robust Tests of Equality of Means
Levene Statistic df1 df2 Sig. Statistica
df1
df2
Sig.
1,191
30
,318 17,460
16,987
,000
diff_F0_F1_closed_e 2,697
30
,084 6,054
14,443
,012
diff_F0_F1_open_e
,832
29
,445 ,416
19,124
,666
diff_F0_F1_a
1,869
30
,172 1,998
19,875
,162
diff_F0_F1_open_o
,049
28
,952 4,531
16,544
,027
diff_F0_F1_closed_o 1,035
30
,368 6,463
17,925
,008
diff_F0_F1_u
5,165
30
,012 4,158
16,722
,034
diff_F2_F1_i
,119
30
,888 10,415
19,499
,001
diff_F2_F1_closed_e ,845
30
,439 12,895
19,902
,000
diff_F2_F1_open_e
1,710
29
,199 1,456
19,256
,258
diff_F2_F1_a
,741
30
,485 ,375
19,587
,692
diff_F2_F1_open_o
2,575
28
,094 4,818
17,820
,021
diff_F2_F1_closed_o 3,532
30
,042 4,888
19,706
,019
diff_F2_F1_u
30
,983 3,915
18,802
,038
diff_F0_F1_i
,018
139
Figure 1: Differences between formants F1 and F0 in vowel production of normal hearing, severe
and profound hearing impairment group
Figure 2: Differences between formants F2 and F1 in vowel production of normal hearing, severe
and profound hearing impairment group
140
Table 3: Post Hoc Tests - Multiple Comparisons - Bonferroni of differences of F1 and F0 and F2
and F1 between NH, SHI and PHI groups
Dependent
Variable
iff_F0_F1_i
(I)
(J)
hearing_ status
status
NH
SHI
iff_F0_F1_closed_e
NH
SHI
iff_F0_F1_open_e
NH
SHI
iff_F0_F1_a
NH
SHI
iff_F0_F1_open_o
NH
SHI
iff_F0_F1_closed_o
NH
SHI
iff_F0_F1_u
NH
SHI
hearing_ Mean
Difference
(I-J)
Dependent
Variable
(I)
(J) h
hearing_ statu
status
diff_F2_F1_i
NH
Std. Error
Sig.
SHI
-47,40819*
16,70818
,024
PHI
-79,03767*
15,22893
,000
NH
47,40819*
16,70818
,024
PHI
-31,62948
16,11945
,177
SHI
-77,26897
37,22665
,140
PHI
-80,50908
33,93080
,073
NH
77,26897
37,22665
,140
PHI
-3,24011
35,91492
1,000
SHI
60,24073
75,04449
1,000 diff_F2_F1_ope
n_e
PHI
34,31411
68,69980
1,000
NH
-60,24073
75,04449
1,000
PHI
-25,92663
70,82420
1,000
SHI
-88,66558
54,09798
,335
PHI
-87,98076
49,30844
,253
NH
88,66558
54,09798
,335
PHI
,68482
52,19177
1,000
SHI
-164,88968*
58,35201
,026
PHI
-143,71846*
53,67605
,037
NH
164,88968*
58,35201
,026
PHI
21,17122
53,67605
1,000
SHI
-87,60397
36,27408
,066
PHI
-95,48476*
33,06257
,021
NH
87,60397
36,27408
,066
PHI
-7,88079
34,99592
1,000
SHI
-17,72755
19,28216
1,000 diff_F2_F1_u
PHI
-48,31613*
17,57502
,030
NH
17,72755
19,28216
1,000
PHI
-30,58858
18,60273
,332
SHI
PHI
SHI
NH
PHI
diff_F2_F1_clos
ed_e
NH
SHI
PHI
SHI
NH
PHI
NH
SHI
PHI
SHI
NH
PHI
diff_F2_F1_a
NH
SHI
PHI
SHI
NH
PHI
diff_F2_F1_ope
n_o
NH
SHI
PHI
SHI
NH
PHI
diff_F2_F1_clos
ed_o
NH
SHI
PHI
SHI
NH
PHI
NH
SHI
PHI
SHI
NH
PHI
141
Table 4: Correlations between degree of hearing loss on better ear and the differences between
F1and F0 and F2 and F1 in Slovenian vowels
BETTER_EAR
diff_F0_F1_i
Pearson Correlation
Sig. (2-tailed)
,000
,000
33
33
diff_F0_F1_closed_e Pearson Correlation ,445**
diff_F0_F1_open_e
diff_F0_F1_a
diff_F0_F1_open_o
diff_F2_F1_i
-,595**
diff_F2_F1_closed_e -,682**
Sig. (2-tailed)
,009
,000
33
33
Pearson Correlation -,022
diff_F2_F1_open_e
-,337
Sig. (2-tailed)
,906
,059
32
32
Pearson Correlation ,303
diff_F2_F1_a
,183
Sig. (2-tailed)
,086
,309
33
33
Pearson Correlation ,493**
diff_F2_F1_open_o
,511**
Sig. (2-tailed)
,005
,003
31
31
diff_F0_F1_closed_o Pearson Correlation
diff_F0_F1_u
BETTER_EAR
,713**
,473**
diff_F2_F1_closed_o ,457**
Sig. (2-tailed)
,005
,008
33
33
Pearson Correlation
,432*
Sig. (2-tailed)
,012
,010
33
33
diff_F2_F1_u
,441*
142
P065
HEARING AND OTOSCOPIC OUTCOMES CORRELATION IN INFANTS FROM
AN UNIVERSAL HEARING SCREENING PROGRAM
L.M. Resende1, J. Ferreira1, S.A.S. Carvalho1, I.S. Oliveira1
1 Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
Introduction and aims of the study: Middle ear conditions are not well documented for
the newborn population. Many studies raise the question of the better probe tone to be used in
the timpanometric assessment of infants, however few peer-reviewed studies point out
prevalence and etiology of conductive hearing conditions in infants. This study aimed to
describe and correlate outcomes of neonatal hearing screening, otoscopic examination and
tympanometric results from infants in the newborn nursery.
Methods: Double-blinded, prospective study. Study sample was randomly selected from
the infants enrolled in Universal Neonatal Hearing Screening Program from a public hospital in
Minas Gerais Brazil. No infant in the study presented risk indicator for hearing loss following
the Joint Committee on Infant Hearing recommendations. Study was approved by the university
ethical committee and parents of infants gave their signed consent. Neonatal hearing screening
was performed through Auditory Brainstem Responses (ABR) recordings. After hearing
screening, infants were submitted to otoscopic examination done by an otologist and undertook
timpanometry with 226Hz probe tone testing. All procedures were performed by different
professionals who werent aware of prior assessment results. Statistical analysis was conducted
through the SPSS program (Statistical Package for the Social Sciences) 17.0 version. A descriptive
analysis of data was done and association between exams was studied using Mc Nemar test to
dichotomic variables and paired samples with confidence level of 95%.
Results: From the twenty-one (21) infants studied, 100% showed normal tympanometric
results with type A curve obtained with 226Hz probe tone. Otoscopic results showed 13 infants
(61,9%) with normal results, abnormalities were seen in 3 infants (14,3%) and were primarily
charactherized by tympanic membrane opacity. 5 infants (23,8%) did not perform otoscopic
examination and were withdrawn from the correlation analisys of the study. For right ear
results, 19 infants (90,5%) passed neonatal hearing screening with normal ABR results and 2
(9,5%) failed screening, meaning they had no wave V present at 35 dBHL. For the left ear, 16
(76,2%) passed screening and 5 (23,8%) failed. Association analysis between audiological test
results showed a positive correlation between otoscopic examination and screening (ABR)
results with significant P value present. However no positive correlation was obtained
comparing otoscopy and ABR results to the timpanometry.
Conclusions: Significant prevalence of otoscopic abnormalities was present in the study,
and showed positive association with neonatal hearing screening outcomes. Lack of positive
association showed 226Hz probe tone timpanometry may not be a suitable diagnostic tool for
the newborn. Researchers will continue data collection including in the comparison high probe
tone timpanometric testing.
143
FP44.6
AUDITORY AND LANGUAGE OUTCOMES IN CHILDREN WITH EARLY
DIAGNOSTIC AND TREATMENT FOR CONGENITAL TOXOPLASMOSIS
L.M. Resende1, G.M.Q. Andrade1, M.F. Azevedo2, J. Perissinoto2, A.B.Q. Vieira1, CTBG
Congenital toxoplasmosis Brazilian Group1
1Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
2Universidade Federal de So Paulo, Belo Horizonte, Brazil
INTRODUCTION: Congenital toxoplasmosis, highly prevalent infection in the state of
Minas Gerais, 1:770 living births, is associated to auditory impairment since the 1950s decade.
Vertically infected children may present severe neurological, visual and hearing deficits at birth
or are born assymptomatic and develop long term sequels.
Early diagnostic and treatment have been associated to a better prognosis, with
significant reduction of both incidence and severity of sequels. Long term follow-up studies
noticed that all congenitally infected children without treatment in the first year of life
developed some disability, specially ophthalmologic impairment. This was true even in the
absence of symptoms at birth.
Conflicting results are described regarding audiological impairments. Some recent
studies found no sensorineural hearing impairment in congenitally infected children who
received early treatment, though they lack accurate description upon the type and nature of
auditory results studied. Other studies point out that hearing problems are among parents major
concerns towards their infected children.
In a two year study at the city of Belo Horizonte, between 2003 and 2004, IgM antiT.gondii was searched in 31,808 newborns through the State Neonatal screening Program (PETNMG) and 20 infants were identified with congenital toxoplasmosis infection. Prevalence was 1
infected newborn per 1,590 living births. All infected children received one year treatment and
undertook complete hearing evaluation. Four children (21.1%) presented sensorineural hearing
loss and 2 (10.5%) were diagnosed with conductive hearing loss. Mild and/or moderate and also
unilateral sensorineural hearing loss were found in this study. From the 4 compromised
children, three had no other risk factor for hearing loss other than congenital toxoplasmosis.
This study aimed to describe audiological and language outcomes of children born
between november 2006 and march 2007. Study also points out prevalence of impairments and
compares variables studied such as language results and types of hearing impairment.
METHODS: A cross-sectional descriptive study was performed. Sample included all
living births between november 2006 and may 2007 screened by the Minas Gerais neonatal
screening program (PETN-MG).
Children with positive or undetermined results in dry blood IgM testing were submitted
to serum confirmatory tests (IgG, IgM e IgA anti-T.gondii), as well as their mothers. Congenital
toxoplasmosis diagnosis was confirmed by IgM and/or IgA presence in the two first months of
life or by IgG persistence at the end of one year.
All confirmed cases received 12 month treatment with pyrimetamine, sulfadyazine and
folinic acid, starting at a mean age of 50 days (SD=15.4). Childrens age at the beginning of
treatment meets Brawns criteria (before 2.5 months). They also performed neuroimage exams
144
and received, periodical follow-up with pediatrician, ophtalmologyst and speech-language

therapist and audiologist.
The following procedures were performed as a part of the hearing test battery:
behavioral observation audiometry, audiometric brainstem response (ABR), transient and
distortion product otoacoustic emission and also tympanometry. Hearing tests were performed
with children awake or in natural sleep, without the need for sedation.
Tests results were classified as: normal hearing, conductive hearing loss, sensorineural
hearing loss, central dysfunction.
Language domains were evaluated through receptive and expressive scales. Knowledge
of language content is based in tasks concentrating concepts of quantity, quality (adjectives),
spatial and temporal relations and sequence. Language structure is assessed through
morphology and syntax tasks. Results indicate if an impairment is present and which is the
nature (receptive, expressive or global). In this sample study we analysed deficiencies as present
or absent, and the language assessment follow-up initiated after 12 months of age (after medical
treatment for the infection).
The following variables were studied: audiologic result, neurologic and ophthalmologic
condition, language performance and presence of risk indicator for hearing loss other than
congenital toxoplasmosis. Ophtalmologic and neurologic data were taken from the childrens
medical files.
Data analysis was conducted through EPI INFO for windows software version 3.5. Data
descriptive analysis was made and Qui-square statistical tests were used to compare categorical
variables (Fishers exact test), confidence interval was 95% and significant P value was
considered less than 0.05.
This study is part of a major project with the participation of CTBG/UFMG (Congenital
Toxoplasmosis Brazilian Group UFMG) and was approved by the Ethical Research Committee
from Federal University of Minas Gerais (UFMG) under the approval code ETIC 0298/06.
RESULTS: During the seven months of screening, 190 newborns were identified with
congenital toxoplasmosis infection, resulting in a prevalence rate of 1:770 living births, though in
this paper are presented preliminary results from 106 children identified in the first 5 months of
screening, whose evaluations were completed at the moment of the study.
Results description include data obtained at the last hearing and language evaluation,
when children were between 18 and 24 months old. All children received early treatment
starting at a mean age of 50 days (SD=15.4), during 12 months. From the 106 congenital
toxoplasmosis infected children studied, 48 were female (45.3%) and 58 male (54.7%). Eleven
children (10.4%) had additional risk factors for hearing loss, including very low birth weight,
family history of congenital hearing loss, prolonged permanence in Neonatal Intensive Care
Unit (more than five days).
From the 106 children assessed, 60 (56.6%) had normal hearing and 46 (43.4%) showed
some kind of hearing impairment. Most common auditory finding was central dysfunction
(n=29) which corresponded to 27.4% of studied sample. Four children (3.8%) had sensorineural
hearing loss and thirteen (12.3%) had conductive hearing loss confirmed.
Abnormal auditory findings did not vary when additional risk factors were present.
From the 46 hearing impaired children, 4 (8.7%) presented additional risk and 42 (91.3%) had
congenital toxoplasmosis as the single auditory risk factor. Comparison was not statistically
significant (p=0.75).
Language assessment revealed 28 children (26.4%) with performance below expected
range, according to the applied tool. Language impairments were significantly associated with
145
hearing impairment, and occurred only in its presence. This significant association was seen in
the total sample analysis and also at the comparative analysis which considered only congenital
toxoplasmosis as a risk factor (withdrawing neurological abnormal findings and additional risk
factors). Considering the type of auditory finding, there was significant association between
central dysfunction and conductive hearing losses with language impairment.
DISCUSSION: High prevalence of hearing problems was observed in this study, even
with early diagnostic and treatment. Rethinocoroiditis, a frequent finding in this same studied
group raised the question upon a more virulent parasite and/or increased individual
susceptibility to explain the findings. This hypothesis is currently under investigation for this
study sample and corroborates with another relevant study which compared prevalence of
ocular sequelae of congenital toxoplasmosis in Brazilian and European populations. According
to this study, more severe ocular disease is observed in Brazil when compared with Europe,
including larger and more numerous lesions with a greater probability of affection to the central
vision. Risk of developing eye lesions in Brazilian population is 5 times higher than in Europe
and this is likely due to more virulent genotypes of the Brazilian parasite.
Central auditory dysfunction, rarely mentioned in peer reviewed data studied, was
prevalent in this study. The major negative impact of this type of hearing problem is language
delay and/or impairment. Language impairments found in this study were due to central
hearing dysfunction in the absence of other neurological abnormal findings.
A recent systematic review, discuss the discrepancy between the cited prevalences in
different peer reviewed data published. One argument presented sustains that studies in which
beggining of anti-parasitic treatment took place before 2.5 months of life, no sensorineural
hearing impairment or late onset hearing loss is observed. Therefore, differences among
treatment regimens decisively influences audiological outcomes found in the different published
studies. Same authors sustain the need for repeated assessment of hearing until the age of 24-30
months of age.
Nevertheless, this present study found significant prevalence of hearing deficits in a
sample receiving treatment prior to 2.5 months of age, which raised the question upon parasitic
virulence and individual susceptibility in the studied region. Its important to notice that these
are preliminary results and a more substantial contribution will certainly be possible with the
larger sample in a long term follow-up.
Hearing and language outcomes in this population of congenital toxoplasmosis infected
children are of major interest in a follow-up program and could help directing the actions of a
public program.
ACKNOWLEDGEMENT: This research project has the support of Minas Gerais State
health secretary and the NUPAD/UFMG (Ncleo de Aes e Pesquisas em Apoio Diagnstico
da UFMG).
146
P068
TEMPORAL RESOLUTION IN MILD HEARING LOSS
R.M.M. Carvallo, S.G. Sanches, A.K. Nishiyama, K.A.L. Silva, N Vilela
University of So Paulo, School of Medicine (FMUSP)
Introduction:
The tools for assessment of auditory processing have been useful in clinical practice.
Gaps-in-Noise Test (GIN) assesses the ability of auditory temporal resolution.
Temporal resolution is a subcategory of auditory temporal processing and refers to the
minimum time required to divide or solve acoustic events and can be measured by gap
detection tasks. Gap detection threshold is the shortest duration gap within a sound that a
person can detect (Musiek et al. 2005). Studies have shown the GIN test as a clinically feasible
tool, with good sensitivity and specificity (Musiek et al. 2005, Samelli and Schochat, 2008).
Oxenham and Bacon (2003) suggest that cochlear changes could interfere with mechanisms of
cochlear amplification, also affecting the ability of auditory temporal resolution. Hearing
impaired listeners should be expected to have difficulty in performing gap detection tasks
(Fitzgibbons and Wightman, 1982; Glasberg et al., 1987; Oxenham and Bacon, 2003; Rawool,
2006; Zamyslowska-Szmytke et al., 2009). The loss of cochlear nonlinearity caused by cochlear
hearing loss may result the following effects: the presence of recruitment, reduced frequency
selectivity and changes in temporal processing, which can influence the perception of speech,
especially in complex acoustic environments (Oxenham and Bacon, 2003).
Certain conditions of damage of outer hair cells cannot be detected by audiometric tests
that assess only the conventional frequencies (0.25 to 8 kHz), but may result in elevation of
hearing thresholds at extended high frequencies (9 to 20 kHz) (Arnold et al., 1999). Information
obtained by the measurement of extended high frequencies hearing thresholds (9 to 20 kHz)
contribute to the evaluation of initial damages of the cochlea in patients with tinnitus and
normal hearing threshold assessed by conventional pure-tone audiometry. The study of
peripheral hearing and their influence on the ability of auditory temporal resolution can
contribute to the understanding of auditory perception in individuals with mild hearing loss.
The aim of the study was to evaluate the influence of pure-tone threshold on temporal
resolution task in subjects with mild sensorineural hearing loss.
Method:
The study protocol used in this investigation of human subjects was approved by the
Ethics Committee for the Analysis of Research Projects (protocol 227/05). Fifty-one adults were
evaluated, divided into 3 groups: Control Group consisted of 23 subjects (46 ears) with hearing
thresholds from 0.25 to 8 kHz within the normal range ( 25 dB HL) without tinnitus, with ages
between 22 to 40 years (mean 29.7), 8 men and 15 women; Study Group I consists of 18 subjects
(36 ears) who presented hearing thresholds between 0.25 and 8 kHz within the normal range (
25 dB HL) and complaint tinnitus, with ages between 21 and 45 years (mean 31.3 years) and 3
men and 17 women, and Study Group II consists of 11 individuals (22 ears), 5 men and 6
women, with ages between 23 and 53, sensorineural hearing loss, average hearing thresholds at
frequencies of 2 to 4 kHz from 30 to 40 dB HL. Were excluded Individuals with more than 55
years old, and ears with tympanometric disorder. The subjects underwent tympanometry
147
(Middle ear analyzer GSI 33 - Grason Stadler) to verify exclusion criteria. Pure-tone audiometry
was performed using a GSI 61 audiometer (Grason Stadler). First, frequencies from 0.25 kHz to 8
kHz were tested using the ascending-descending method with a step size of 5 dB HL. Then the
Speech Reception Threshold (SRT) was obtained. Subsequent extended high frequencies (9, 10,
12.5, 14, 16, 18 and 20 kHz) were then tested. GIN Test was applied to assess the temporal
resolution, held in each ear of each subject separately. Stimuli were delivered monoaurally at 50
dB SL. The requested task was to identify the gaps distributed throughout 6 seconds of white
noise presentation. Each test list was composed of 0 to 3 gaps contained within each 6 seconds
segment of white noise. The duration of each gap was 2, 3, 4, 5, 6, 8, 10, 12, 15 or 20 ms, and they
were randomly distributed so that 60 gaps (6 of each duration) would be presented in each list.
The results obtained for each ear were analyzed based on the gap perception threshold. The GIN
threshold was achieved when the subject had identified 4 or more gaps in 6 of the same duration
in the shortest duration. For the statistical analysis nonparametric tests were applied because the
sample did not meet the necessary requirements for application of parametric tests. Thus, the
comparison between groups was applied Kruskal-Wallys Test and Spearman correlation
coefficient. The confidence intervals were calculated at 95%. Significance level adopted was 0.05.
Results:
Table 1 shows statistical difference between groups for pure-tone thresholds and
extended high frequencies. Study Group II had higher thresholds that Study Group I, in turn,
showed higher thresholds than the Control Group. Regarding the GIN Threshold, Study Group
II identified threshold with longer duration gaps than the Study Group I and the Control Group
detected the shortest gaps threshold in comparison to the other groups.
Table 1- Comparison of the results obtained in pure-tone audiometry, extended high

frequency and the GIN test between the three groups.
Control
Study
Study
Group
Group I
Group II
Pure
tone Mean
4.79
7.15
31.96
Threshold
Median 4.06
7.50
29.38
(0.25 to 8 SD
2.71
3.33
9.53
kHz)
p-value p<0.001
Pure
tone Mean
8.95
17.66
52.32
Threshold (9 Median 7.19
16.88
53.04
to 20 kHz)
SD
8.29
9.94
13.67
p-value p<0.001
GIN
Mean
4.67
5.78
10.48
Threshold
Median 5.00
5.00
10.00
SD
0.9
1.31
3.86
p-value p<0.001
148
Considering the entire data set, the correlation between pure-tone thresholds and the
thresholds of the GIN test was analyzed (Table 2). The correlation was found positive and
significant.
Table 2- Spearman Correlation between pure-tone thresholds and GIN threshold.
GIN
(rho)
0.25 to 8 0.721
Pure tone Thresholds

kHz
Pure tone Thresholds 9 to 20 kHz
0.639
Threshold p-value
<0,001
<0,001
Discussion:
In the comparison between groups for audiometry is, as expected, statistical difference
between the group of sensorineural hearing loss and others. The data is due to sample selection.
Regarding extended high frequencies, the same differences are observed between the Study
Group II and others and between the Control Group and Study Group I. In this study, the mean
of GIN thresholds for the Control Group was consistent with the literature (Musiek et al. 2005;
Weihing et al. 2007; Samelli and Schochat, 2008), but the other groups had thresholds with
longer duration for the GIN test. The Study Group II showed very poor performance,
confirming the influence of hearing loss on performance in gap detection tasks (Glasberg et al.,
1987; Oxenham e Bacon, 2003).
Although the Study Group I subjects have hearing thresholds within the normal range at
0.25 to 8 kHz, they also had higher hearing thresholds in the extended high frequencies (9 to 20
kHz) than the control group. The alterations found in the extended high frequency threshold
and in GIN test in patients with tinnitus and normal hearing thresholds at 0.25 to 8 kHz (Study
Group I) might reflect the degree to which hearing loss can impair temporal resolution.
According to some authors, hearing impaired listeners should be expected to have difficulty in
performing gap detection tasks (Fitzgibbons and Wightman, 1982; Glasberg et al., 1987;
Oxenham and Bacon, 2003; Rawool, 2006; Zamyslowska-Szmytke et al., 2009). Fitzgibbons and
Wightman (1982) believe that these deficits can occur due to a loss of redundancy in temporal
coding.
Ami et al. (2008) stated that subtle damage to the outer hair cells can provoke tinnitus
before the impairment alters the audiogram. In the present study, it was possible to identify
differences between the Study groups (in comparison to the Control Group) in extended high
frequency audiograms, suggesting subtle cochlear impairment also in the Study Group I.
For the Study Group I, the performance on auditory temporal resolution task was worse
than the Control Group. For the Study Group II (sensorineural hearing loss detected at least at
frequencies 2 to 4 kHz of the audiogram), the performance was even worse than the Study
Group II (Table 1). Moore and Oxenham (1998) reported that cochlear hearing loss provokes
basilar membrane responses that are more linear, which results in poorer temporal resolution. In
the present study, there was a difference between the three groups in terms of temporal
resolution, suggesting that hearing loss, even in extended high frequency audiometry, had an
effect on temporal resolution ability.
The marked difference in the performance of individuals with hearing loss in this test
suggests that the impairment in the ability of temporal resolution should have begun in earlier
stages of advancement of the hearing loss. For this reason, individuals with complaints of
149
hearing difficulty and normal hearing thresholds for conventional audiogram, should have their
hearing assessed with extended high frequencies audiometry, and also with tests of auditory
temporal processing. The results certainly can be a better guide the conduct monitoring of
changes in auditory skills after auditory training.
Conclusion:
The performance in the GIN Test may be affected by hearing loss, even in subtle or mild
hearing loss.
Acknowledgments
We are grateful for the financial support provided by the Fundao de Amparo Pesquisa
do Estado de So Paulo (FAPESP, Foundation for the Support of Research in the State of So Paulo;
grant no. 05/02474-3).
References:
Ami M, Abdullah A, Awang MA, Liyab B, Dip, Saim L. Relation of distortion product otoacoustic
emission with tinnitus. Laryngoscope. 2008;118:712-717.
Fitzgibbons PJ, Wightman FL. Gap detection in normal and hearing-impaired listeners. J Acoust Soc Am.
1982 Sep;72(3):761-5.
Glasberg BR, Moore BCJ, Bacon SP. Gap detection and masking in hearing-impairedand normal-hearing
subjects. J Acoust Soc Am. (1987); 81 (5):1546-56.
Moore BC, Oxenham AJ. Psychoacoustic consequences of compression in the peripheral auditory system.
Psychol Rev. 1998;105(1):108-24.
Musiek FE, Shinn JB, Jirsa R, Bamiou DE, Baran JA, Zaidan E. GIN (Gaps-In-Noise) test performance in
subjects with confirmed central auditory nervous system involvement. Ear Hear. 2005;26(6):608-18.
Oxenham AJ, Bacon SP. Cochlear Compression: Perceptual Measures and Implications for normal and
impaired hearing. Ear Hear. 2003;24(5):352-66.
Rawool VW. The effects of hearing loss on temporal processing. Part 2: Looking beyond simple audition.
Hearing Review 2006; 13(6): 30,32,34.
Samelli AG, Schochat E. The Gaps-in-Noise test: Gap detection threshold in normal-hearing young adults.
Int J Audiol. 2008; 47(5):238-45.
Weihing JA, Musiek FE, Shinn JB. The effect of presentation level on the Gaps-In-Noise (GIN) test. J Am
Acad Audiol. 2007 Feb;18(2):141-50.
Zamyslowska-Szmytke E, Fuente A, Niebudek-Bogusz E, Sliwinska-Kowalska M Temporal Processing
Disorder Associated with Styrene Exposure. Audiol Neurootol. 2009;14(5):296-302.
150
P134
LEARNING GENERALIZATION OF AUDITORY TEMPORAL PROCESSING
SKILLS
C.F.B. Murphy, E. Schochat
University of So Paulo, So Paulo, Brasil
Introduction
Researchers have demonstrated a significantly worse performance in children with
dyslexia in a specific skill of auditory temporal processing: temporal order detection (1,2). Based
on this hypothesis, a number of studies have investigated the effect of training auditory
temporal processing on reading skills. Results have shown that this is a controversial topic. One
of the hypotheses considered is related to the type of learning taking place during auditory
training. The improvement of the performance seems to be associated with the improvement
regarding the procedure carried out (procedure or task learning) and it might be related to
perceptual discrimination (perceptual learning) (3). Therefore, there is the hypothesis that the
post-training improvement found in the auditory tests might demonstrate the learning of the
procedure used instead of demonstrating the learning of the processes involving perceptual
skills as a whole. Thus, learning restricted to the task could explain the absence of improvement
of verbal skills.
The objective of the present study was to investigate the occurrence of learning
generalization of temporal order detection skill. To do so, a frequency order discrimination task
training was applied in children with dyslexia and its effect after training was analyzed in the
same trained task and in a different task (duration order discrimination) involving the temporal
order discrimination too.
Material and Method

This research was approved by the CAPPesq of HCFMUSP. Data were collected at the
Laboratory of Auditory Processing from January through December 2007.
Two studies have been conducted. In Study 1, the performance of the experimental
group (trained group with dyslexia) in the above mentioned tests was compared with a
control group (untrained group with dyslexia) before and after training. In Study 2, a group
with dyslexia was compared at three different time intervals: 2 months before auditory training,
at the start and at the end of training. During the 2 months previous to auditory training,
participants only attended speech therapy sessions; which was considered a control
intervention. During the last 2 months, participants underwent auditory training in combination
with speech therapy. Hence, it was possible to compare the effect of both types of intervention
on the same group.
The inclusion criteria were: to have a diagnosis of dyslexia established according to the
Brazilian Association of Dyslexia (ABD); to be between 7 and 14 years old; to achieve normal
results on the Basic Audiologic Assessment no evidence of cognitive, psychological, neurologic,
and ophthalmologic abnormalities or delayed oral language acquisition. The trained group was
made up of 12 children with dyslexia (9 boys and 3 girls, mean age 10.9 1.4) and the untrained
151
group comprised 28 children with dyslexia (19 boys and 9 girls, mean age 10.4 2.1). Based on
the Students t test, statistics indicated that the age distribution in both groups was similar (p =
0.329). Furthermore, considering the fact that both groups are made up of individuals of varied
ages, analysis of group performance on each test was carried out considering the division into
the following age groups: 7-10 years and 11-14 years. In Study 2, the untrained group of Study 1
was submitted to the auditory training after participating in the first study and a third
evaluation was performed following the first study, containing the same tests. As a result of
dropouts between both studies, of the 28 children in the untrained group of Study 1, 18
remained in Study 2 (12 boys and six girls, mean age 10.1 2.1).
The tests applied before and after the training are: Frequency Pattern Test and Duration
Pattern Test (4). The auditory training was performed using a software program to train
frequency ordering skills. Tasks of frequency order with two stimuli were initially performed,
followed by frequency ordering with three stimuli. The screen shows symbols that should be
associated with their corresponding sound stimuli. Therefore, ascending or descending acoustic
stimuli had initial or final frequencies of 500, 1000 or 2000 Hz, ranging 6.7 octaves per second.
Stimulus duration, as well as interstimulus interval (ISI) ranged automatically. The game started
with stimuli lasting for 200 ms and separated by 500 ms of ISIs. Automatic reduction of values
occurred after 70% of right answers in each step, which was composed of 12 trials. If less than
70% of answers were right, the phrase GAME OVER appeared on the screen and the child
returned to the previous step.
Training was carried out during two months in each participants home and,
periodically, the results were sent automatically to the researcher through the internet for
follow-up.
Results
Analysis of variance for repeated measures, non-parametric analysis of variance of
repeated ordinal data, and Bonferronis correction were used to compare groups and evaluate
treatment effect. Significance level was set in 0.05.
Study 1
FREQUENCY PATTERN - There was effect of age (p=0.005) and group (p<0.001). There
was no difference between mean scores in both periods in the untrained group in the age group
7-10 years (p=0.096); however, in the trained group mean score in post-training was higher than
in pre-training (p<0.001); conclusions were similar for the age group 11-14 years: mean in posttraining was higher than in pre-training in the trained group (p=0.050), but there was no
difference between means in both intervals in the untrained group (p>0.999).
DURATION PATTERN - There was a marginal effect of age in mean scores (p=0.060)
and there was no difference between means in both periods (p=0.147), regardless of group
(p=0.273).
Study 2
FREQUENCY PATTERN There is no effect of age in mean scores (p=0.692). There
was no significant difference between means in pre-training 2 and 1 (p=0.326), but mean in
post-training was higher than in pre-training 2 (p<0.001).
DURATION PATTERN There is no effect of age group in mean scores (p=0.506). There
was no significant difference between means in pre-training 2 and 1 (p=0.140), and mean in
post-training was higher than in pre-training 2 (p=0.010).
Discussion
152
Results in both studies showed significant improvement after training for the Frequency
Pattern Test, confirming training efficacy regarding learning of the trained task. The studies
yielded different results for the Duration Pattern Test: significant improvement only in posttraining in Study 2; and absence of significant differences between pre- and post-training results
for both groups in Study 1. While in Study 2 results suggest learning of the trained skill based on
learning generalization, in Study 1 results suggest only task learning. In addition, based on the
results of Study 2, it is also possible to state that the port-training improvement is actually a
consequence of auditory training since the training considered as control did not have an
influence on the results.
Based on these results, learning generalization is controversial, since the studies showed
different results in terms of learning generalization. These differences might be explained by the
methodological differences between the studies, considering, for instance, the smallest number
of participants in Study 1, and differences between pre-training performances in the Duration
Pattern Test in both studies. Another methodological issue is related to the test administration.
Maybe the improvement found in Study 2 could be connected with the number of times the tests
were applied. Unlike Study 1, in which each test was applied twice, in Study 2, the same test
was applied three times, which might have had a positive influence on test performance,
perhaps because the situation was more familiar or due to task learning itself.
Another hypothesis that may be taken into consideration is that maybe the tests selected
have had an influence on the observation of a possible generalization. Maybe the applied tests
might require different skills other than the temporal order judgment. Perhaps these differences
between tests are related to the presence of spectral cues in the Frequency Pattern Test.
Although this test involves analysis of temporal ordering, stimuli must be spectrally
discriminated first to be ordered later. Therefore, these differences between tests might have had
a negative influence on the analysis of a possible learning generalization.
Conclusion
In conclusion, the studies showed different results in relation to the presence of learning
generalization of temporal order detection. Study 2 showed a possible occurrence of
generalization, evidencing that, after auditory training, there might be improvement of verbal
skills since there is learning of the perceptual skills. Study 1 showed the opposite, questioning
the occurrence of learning of auditory skills and the use of auditory training as a method of
effective intervention in children with dyslexia. Further studies are necessary so that a better
understanding of this phenomenon can be achieved.
References
1. Murphy CF, Schochat E. How auditory temporal processing deficits relate to
dyslexia.
Braz J Med Biol Res. 2009;42(7):647-54.
2. Cacace AT, McFarland, DJ, Ouimet JR, Schrieber EJ, Marro P. Temporal processing deficits in
remediation-resistant reading-impaired children. Audiol Neurootol. 2000; 5(2):83-97
3. Robinson K, Summerfield AQ. Adult auditory learning and training. Ear Hear 1996; 17:5165.
4. Musiek FE, Baran JA, Pinheiro ML. Duration pattern recognition in normal subjects and patients
with cerebral and cochlear lesions. Audiology 2000; 29:304-13
153
P008
USEFLNESS OF POLISH LANGUAGE LOW REDUNDANCY AND DICHOTICH
TESTS IN DYSLECTIC CHILDREN
Waldemar
Wojnowski1,
Boena
1
Maciejewska Grayna Demenko2,
Wiskirska-Wonica1Antoni
Pruszewicz1,
Barbara
1. Department of Phoniatrics and Audiology K. Marcinkowski University School of Medical

Sciences, Poznan, Poland
2.Insitute of Phonetics University A. Mickiewicz, Poznan, Poland
Summary
Developmental dyslexia in children can affect auditory and linguistic skills. Due to the
impairment of hearing discrimination, attention, memory and perception, dyslexia causes the
inability to process and interpret linguistic and verbal information effectively. Standard
audiological examination is much less useful than low redundancy speech tests and electrophysiological examination, which are the only objective measure of central auditory processing.
The aim of the study was to assess the usefulness of low redundancy speech tests and dichotic
tests in the diagnosis of developmental dyslexia in children. 20 children aged 7-15 were tested by
a low redundancy speech test, dichotic numeral test, a dichotic verbal minimal-pair test, a Calearo
test. The experiments have shown that the dyslectic group achieved worse results in mentioned
tests in comparison with the control group. It suggests information exchange disorders between
the hemispheres, the lack of synchronization of acoustic perception in dichotic tests and the
damage of the structures responsible for central auditory processing in the dominating
hemisphere.
Introduction
Dyslexia is a specific reading and writing disorders diagnosed in people with normal
intellectual development and learning abilities [1]. The prevalence of dyslexia ranges from 5 to
10 percent of the population.
Genetic and familiar origin of dyslexia is taking under consideration 65 percent of
children inherit dyslexia from dyslectic parents. Genetic research identified a gene on
chromosome 2 as possibly linked to dyslexia [2]. Developmental dyslexia in children manifests
itself with several cognitive disorders it affects mainly auditory and linguistic skills, but also
visual, visually-spatial, and motor skills. Due to the impairment of hearing discrimination,
attention, memory and perception, dyslexia causes the inability to process and interpret
linguistic and verbal information effectively.
Dyslexia-related linguistic disorders are not, however, caused by an impairment of
semantic processing, but by problems in recognizing elements of speech, such as phonemes or
prosody, which are indispensable in central auditory processing. In these cases standard
audiological examination is much less useful than low redundancy speech tests and electrophysiological examination, which are the only objective measure of central auditory processing.
Aim:
154
The purpose of the paper is to assess the usefulness of low redundancy speech tests and
dichotic tests in the diagnostics of developmental dyslexia in children above the age of seven.
Materials:
The research was conducted on a group of 20 children aged 7-15 (with the average age of
10.8), which included 3 girls and 7 boys with developmental dyslexia diagnosed by means of
psychological, audiological and phoniatric examination. The control group consisted of 22
children from the same age bracket, who were not dyslectic. Hearing disorders were ruled out in
all subjects. Average hearing levels in pure tone audiometry (PTA) for the right and left ear were
determined at the level 15dB and 13dB respectively.
Methods:
The experiment included the following tests: a dichotic numeral test, a dichotic verbal
minimal-pair test, where the pairs were divided onto two separate channels with the use of Cool
Edit Pro 2.0 at the level of 55dB HL, and a monaural test, where the filtered signal was presented
to the right and left ear. Additionally the same software was used in order to prepare a Calearo
test, presented to both ears alternately. Normally no central auditory disorders are present, the
speech signal is heard without interruption and is fully intelligible at the alteration frequency of
2-40x/s. For the purpose of the experiment, the Calearo test included 3-, 5- and 10-syllable
phrases.
The filtering of low redundancy test was performed with the use of Cool Edit Pro 2.0 at
the level of 55dB HL. The following filters were used: a high pass filter > 500Hz, a low pass filter
< 500Hz, a high pass filter > 1000Hz, a low pass filter < 1000Hz, a high pass filter > 1500Hz and
low pass filter < 1500Hz. Characteristic of the filters: slope 24dB, depth 85dB.
All tests were conducted with the use of Aurical audiometric equipment (GN Otometrics
A/S) with circumaural HOLMOCO headphones 95-01-08307 (Holmberg GmbH), a B-71 bone
conduction headphone (Radioear) and an external Panasonic CD-player SL-S113.
The subjects were moreover tested to determine N1, P2, P300 potentials and the auditory
MMN with the use of equipment for the electro-physiological assessment of the hearing organ
(ERA Centor C). The results were statistically processed with the use of a Mann-Whithney test.
Results:
The experiments have shown that the dyslectic group achieved best recognition results in
the high pass filter test lower than 500Hz an average of 89.9% for the right ear and 90.4% for
the left. The control group results for this test reached 95% and 98.6% respectively. The results of
speech understanding in all high pass filter tests were slightly worse. There were no statistically
significant differences between the right and left ear. Similar results were obtained for the
control group.
The lowest average comprehension was achieved in the first low pass filter test above
500Hz 28.1% of recognized words for the right ear and 34% for the left ear (62.2% and 69% in
the control group). Better results were recorded for the second low pass filter test (< 1000Hz)
53.1% (right ear) and 60.4% (left ear). The control group achieved 89.3% and 93% respectively.
In the third low pass filter test (< 1500Hz) the results amounted to 78.1% (RE) and 79%
(LE) and were not much different from the results achieved in the third high pass filter test (>
1500 Hz) 80.9% (RE) and 83.1% (LE).
155
The differences between the right and left ear in all low pass filter tests were not
significant in both the dyslectic group and the control group [see Table 1].
However statistically significant difference in the percentage of recognized words
between the dyslectic group and the control group was found in all filter tests [see Table 2] [Fig.
1, 2].
The results of the dichotic tests show worse dichotic recognition in comparison with the
control group in both the numeral and verbal test. In the numeral test the dyslectic group
achieved 35% for the right and 35% for the left ear, but only 30% for both (RE/LE). The
respective results for the control group were: 24% for the right ear (RE), 10% for the left (LE) and
66% for both (RE/LE), which entails a statistically significant difference for the left ear and
binaural hearing.
In the verbal test, where speech perception is more challenging, the dyslectic group
recognized only 7% of cues in the binaural part (RE/LE) and 53% and 40% for the right and left
ear respectively. The results in the control group were much different: 47% for both ears
(RE/LE), 33% (RE) and 20% (LE). The discrepancy was statistically significant for all parts of the
test [see Table 3]. What is most noticeable in both the verbal and the numeral test, are the very
poor results of the dyslectic group in binaural hearing, which could suggest lack of binaural
interaction [see Table 4].
Similarly, the Calearo test revealed a statistically significant difference between the
examined groups in the overall percentage of recognized words. The dyslectic group achieved
worst results in recognizing 3-syllable words 20,9%, compared with 84% in the control group.
The difference for longer words and phrases, which were characterized by greater redundancy,
was not statistically significant.
Discussion:
Willeford [3] was the first to use low redundancy verbal tests to examine children with
learning disability . His research showed that 85% of dyslectic children achieved significantly
different results, especially in dichotic tests, which indicated the lack of binaural interaction and
left hemisphere deficit. Similar results were reported by Dougherty et al., he prove the
usefulness of dichotic tests in the diagnostic process of dyslexia [4]. According to Hugdahl et al.
[5] dyslexia is a functional and structural disorder of the temporal lobe, manifested by anomalies
of cell migration, polymicrogyria, asymmetricality of cerebral hemispheres in the posterior area
of the superior temporal gyrus and planum temporale, and even size abnormalities of the left
angular gyrus.
It leads to deficits in audio-phonetic processes connected with the domination of the left
hemisphere [6,7,8,9]. The latest research by Ramsey and Temple [10,11] conducted with the use
of PET (positron emission tomography) and fMRI (functional magnetic resonance imaging)
showed a decrease in activity of the temporoparietal area (inferior, middle and superior
temporal gyrus) during reading. In phonological processes loud reading in dyslectics, the
activity of the posterior cortical area responsible for language (Brodmann area 39) is not
observed. Dyslectics' brains display activity only in the left frontal area responsible for language
(Brodmann area 44), unlike the rest of the population, where loud reading triggers simultaneous
activity of both areas.
According to Temple, this observation shows a 'disconnection' of areas 39 and 44 caused
by disorders in the development of the commissural white matter manifested in medical
imaging by an increased size of the corpus callosum in patients with dyslexia. Shywitz's
156
research, based on fMRI, showed an increased activity of the right temporo-occipital area in
dyslectics. The above studies prove the neurobiological origin of dyslexia.
The results of our study confirm the existence of information exchange disorders
between the hemispheres and the lack of synchronization of acoustic perception in dichotic tests,
where the signal is presented to both ears simultaneously. Much worse results in low
redundancy tests reveal, moreover, the damage of the structures responsible for central auditory
processing in the dominating hemisphere. All in all, the research proved the usefulness of
conducted tests in the diagnostics of central auditory processing disorders in patients with
dyslexia.
Bibliography:
1. Siegel LS. Definitional and theoretical issues and research on learning disabillities J Learn Disabil
1988;21,264.2. Shaywitz BA, Shaywitz SE, Pugh Kr, Fulbright RK The neurobiology of dyslexia. Clin Neuroscienc Res
2001, ,1, 291.3. Willeford JA, Bilger JM Auditory perceptron in children with learning disabilities. in Katz J, Ed.
Handbook of Clinical Audiology, 2nd ed. Baltimore: Wiliams&Wilkins, 1978:410.4. Dougherty RF, Cynader M, Bjornson B, Edgell D, Giaschi D; Dichotic pitch: a New stimulus
distinguishes normal and dyslexic auditory function. NeuroReport 1998,9,13, 3001.5. Hugdahl K, Heiervang E, Norby H, Smievol AI, Steinmetz H; Central Auditory Processing, MRI
Morphometry and Brain Laterality: Aplication to Dyslexia. Scand Audiol 1998, 27Suppl 49, 26.6. Galaburda AM, Sherman GF, Rosen GD, Aboitiz F, Geshwind N; Developmental dyslexia; four
consecutive patiens with cortical anomalies. Ann Neurol 1985, 18, 222.7. Beaton AA The relation of planum temporale asymmetry and morphology of the corpus callosum to
handedness, gender and dyslexia; a review of the evidence Brain Lang 1997, 60, 255.8. Tallal P. Auditory temporal perception, phonetics and reading disabilities in children Brain Lang 1980,
9, 182.9. Duarab, Kushch A, Gross-Glenn K: Neuroanatomic differeneces between dyslexics and normal readres
on magnetic resonance imaging scans Arch Neurol 1991, 48, 410.10. Temple E.; Brain mechanism in normal and dyslexic readers Curr Opin Neurobiol 2002, 12, 178.11. Rumsey JM, Casanowa M., Mannheim G: Corpus Callosum Morphology, as measured with MRI in
Dyslexic Men Biol Psychiatry 1996;39, 769.
157
CHILD LANGUAGE
FP17.4
LANGUAGE DISORDERS IN CHILDREN CONCEIVED BY THE ASSISTED
REPRODUCTIVE TECHNOLOGIES(ART).
Abou-El-Ella MY*, El-Assal NN*, Aboulghar HM**, Shoeib RM*, Zaky EA***,
*Unit of Phoniatrics, Department of Otolaryngology, Ain Shams University.
** Department of Pediatrics, Cairo University.
*** Unit of Phoniatrics, Department of Otolaryngology, Minia University.
> 1. The study discusses a relevant question which is a desideratum for future research projects.
> 2. However, the applied methods do not concentrate on the announced problem of language
disorders, but includes various other consequences, e.g. different influencing factors in the
language development of children conceived by ARt procedures, distribution of language delay
in subgroups of the population (twins, autism etc.). Thus a great variety of different factors is
examined.
The aim of this stud is to examine the effect oh the ART procedures in their ART children
and the types of language disorders common with these procedures. In another word , is the
ART procedures increase incidences of language disorders in their children or no. there for, we
study the prenatal, perinatal and postnatal history and matched these items between the ART
and natural conceived children to evaluate effect of the ART procedures. And we study the
developmental milestones, Neurological examination, audiological assessments as they are
important influencing factors in language acquisition in any population. And we did sub
grouping of language disorder to show if specific type of delayed language is common with the
ART procedures or no.
> 3. The term language disorders are not precisely defined. What do the authors
understand by language disorders? Speech and language testing is only performed in selected
areas. On the following pages the term "communication disorders" is used in the headline of the
former
proposed
term "language disorders". Why?
It is mis-write word communication disorders we only do language evaluation
> 4. Introduction: The thereby part hardly accounts for the rationale of the study. A large part of
the cited studies deals with broad medical question and thus is not very purposeful for
investigation the problem of language disorders in children conceived by ART procedures.
158
This multiple medical question was cited to show wither the procedures of the Art or the
prenatal, perinatal and post natal factor influencing the outcome of the ART children.
> 5. Subjects and methods: There is no differentiation in descriptions between criterion governed
selection, parallelization as well as description of experimental and control group and
instruments for examining speech and language disorders. The description of the applied
language testing instruments is insufficient. Also the statistical descriptions are not sufficient.
We applied the details of language disorder in page 4
> 6. Description of results: Parts of the discussed results have nit been described before and are
not focused on the question of language delay in children conceived with ART procedures. In
contrast crucial results concerning the language development are only described superficially.
Likewise the following discussion does not concentrate on the results concerning language
development, but considers results which do not contribute to the description of language
problems in ART children.
> Conclusions for the early detection of language
> Recommendation: Intensive revision with focusing
> and stronger specification of the population.
disorders are not drawn.

on the research question
159
P190
WORD LEARNING IN CHILDREN WITH AUTISM: THE ROLE OF ATTENTION
Bean A., McGregor K.
The University of Iowa
Introduction and aims of the study: Attention plays a critical role in development.
Impairments in attention place children at a disadvantage when developing social, cognitive
and language skills (Allen & Courchesne, 2001). A positive association has been found between
attention following, word-referent pairing and later vocabulary acquisition (McDuffie, Yoder, &
Stone, 2006). During the first year of life, the attention-orienting system undergoes considerable
developmental change. These changes influence the level of support an adult provides to help a
child perform a task, or scaffolding, necessary during word learning (Wood & Wood, 1996).
Successful allocation of attention during early word learning involves three particular
skills: 1) shifting attention to the speaker once a novel word has been heard, 2) following the eye
gaze of the speaker to determine the speakers attention focus, and 3) ignoring distracters
present in the word learning environment. The emergence of these skills enables children to
engage in episodes of coordinated attention which facilitate learning. Whereas the first two
skills emerge by the age of 18-months, it is not until 24-months of age that childrens learning
becomes less influenced by extrinsic distracters. Because typically-developing children, between
12-15 months of age, have not developed the prerequisite attention skills, their word-learning is
scaffolded by adults who talk about objects and events that are currently within the focus of the
childs attention (Carpenter, Nagell, Tomasello, Butterworth, & Moore, 1998).
Attention impairments, though not a core feature of ASD, are well documented in this
population (Burack, 1994; Jarvinen-Pasley & Heaton, 2007; Kaland, Smith, & Mortensen, 2008;
Maestro et al., 2002). Differences in attention have been found in infants as young as 6-months
who are later diagnosed with ASD (Maestro et al., 2002). Word learning is frequently targeted in
intervention with mixed results. Examining this process will provide important insight
regarding the interventions that provide varying levels of attention scaffolding to children with
ASD.
The aim of this research study was to examine the role of attention in learning for
children with ASD by manipulating the attention scaffolding provided by the examiner and the
environment within a novel word learning task. Specifically, we examined 1) whether children
are better able to share focus of attention when the examiner either directs their focus or follows
their focus when introducing a novel word, and 2) also whether children ignore distracters
present in the word learning environment.
Failure of children with ASD to monitor the speakers attention during word learning
makes their behavior, hypothetically, similar to younger typically-developing children. It is
hypothesized that, like young typically-developing children, children with ASD will be better
able to share focus of attention if the examiner follows in on the childs focus of attention. It is
predicted that, as a group, children with ASD will perform as well as their receptive-vocabulary
mates when attention scaffolding is provided by the examiner during labeling and poorer than
their receptive-vocabulary mates when no attention scaffolding is provided.
160
Learning environments can be made more complex by the introduction of non-target

stimuli, or distracters. Distracters placed in close spatial proximity to a target object add
demands on the attention resources of the child, thus diminishing the efficiency of attention
(Enns & Girgus, 1985). Children with ASD demonstrate difficulty with more complex learning
environments. Children with ASD also do not monitor their communication partners (e.g.,
Baron-Cohen, Baldwin, & Crowson, 1997). Because typically-developing children monitor their
communication partners and use the cues available in the environment to aid in word learning,
additional demands of distracters on attention should not influence word learning to the same
degree. It is predicted that children with ASD will perform worse than their receptive
vocabulary mates when there are more objects in the test array but will perform equally well
when there are fewer objects in the array. It is predicted that the performance of the receptive
vocabulary mates will not be as affected by increasing the number of objects in the array.
Methods:
The ASD group consisted of nine children with ASD with a mean chronological age of 60
months (range= 40-93 months). The Autism Diagnostic Observation Schedule (ADOS; Lord et al.,
1990) was used to confirm the diagnosis of ASD. The typically-developing group consisted of
nine children with a mean chronological age of 30 months (range = 16-53 months). Pairing was
determined by matching for receptive vocabulary according to raw scores on the Receptive One
Word Picture Vocabulary Test (ROWPVT; Brownell, 2000). Two children with ASD could not
complete the ROWPVT. These children were matched on the basis of words understood on the
MacArthur-Bates Communicative Development Inventory Words and Gestures (CDI; Fenson, 1989).
Stimuli
Stimuli consisted of 12 familiar objects, 120 unfamiliar objects and five replacement
unfamiliar objects. Each child saw up to 60 novel objects per visit, 20 of which were targets. The
relatively large number of targets was possible because the task involved referent selection only;
retention was not a goal. Target assignment was randomized across participants. Forty novel
words were used as labels for targets.
Procedures
The typically-developing children completed two visits and children with ASD
completed three visits. For both groups of children, the first two visits consisted of the
experimental task and standardized language testing. Administration of the ADOS occurred
during the third visit. All visits were videotaped. Parents completed the MCDI if their child
was unable to participate standardized language testing or was below the age of 18 months.
Procedures in the word learning tasks were based on methods presented in Woodward,
Markman and Fitzsimmons (1994) and Luyster (2007): multiple objects were placed on a tray in
front of the child. The examiner labeled the target object and used a neutral phrase to talk about
the distracter object(s). Depending on the teaching condition, the child handled each object
either while the examiner talked about the object or immediately following. For all tasks
described below, the order of presentation, placement of objects in front of the child (from left to
right), and object assignment (target versus distracter) were randomly assigned prior to
administration
Each visit was organized as follows; warm-up, 10 teaching trails (five trials with two
unfamiliar objects and five trials with four unfamiliar objects), five minute break, 10 additional
teaching trials (five trials with two unfamiliar objects and five trials with four unfamiliar
objects). Within each set, teaching was discontinued when children stopped choosing objects or
161
consistently chose more than one object at test. Testing immediately followed each teaching
trial.
Warm-Up
Two familiar objects were placed on a tray. The child was instructed to place one
familiar object in the bucket (e.g., Put the duck in the bucket.). To be eligible to participate in the
study, children needed to independently place a target object in the bucket on three trials.
Teaching Conditions
Teaching occurred immediately following the warm-up. Children participated in two
teaching conditions, one per day, designed to provide varying levels of attention scaffolding.
The teaching conditions differed in how the examiner introduced the novel word. At the start of
each trial all of the unfamiliar objects were placed on a tray out of the childs reach.
Directing Attention Teaching Condition
The examiner looked at one object and either labeled the object (e.g., Wow, look a modi.
What a neat modi. Wow thats a modi.), or used a neutral phrase to talk about the object (e.g.,
Wow, look at that. Thats neat. Wow thats cool.). The examiner handed the object to the child
immediately after she finished talking about the object. After five seconds the examiner took the
object back from the child. This was repeated for every object on the tray.
Following Attention Teaching Condition
The examiner handed the child the object that was the focus of his her attention (an
object was determined to be the focus of the childs attention if he or she fixated his or her eye
gaze on the object) and either labeled the object (e.g., Look a modi. What a neat modi. Wow
thats a modi.) or used a neutral phrase to talk about the object (e.g., Look at that. That is
neat. Wow that is cool.), while the child handled the object. After she finished talking about
the object the examiner took it back from the child (like the directing attention teaching
condition this allowed the child to handle the object for five seconds). This was repeated for
every object on the tray.
Testing
Testing occurred immediately after teaching. The examiner removed the tray from the
table and rearranged the objects on the tray. The examiner placed the tray back onto the table
and instructed the child to select the target (e.g., Put the modi in the bucket.). One point was
given for choosing the target.
Results: A 2 (Group) x 2 (Teaching Condition) x 2 (Object number) mixed model
Analysis of Variance (ANOVA) with one between subject factor (group) and two within subject
factors (condition and object number) was used to examine whether word learning varies as a
function of the method used to introduce the novel word and the number of items in the test
array. Number of points earned was the dependent variable. There was no main effect of
Teaching Condition (F=.055, p= .816). However, there was main effect of object number
(F=15.194, p<.001), with children performing better when there were two objects in the teaching
set. As a group, the typically developing receptive-vocabulary mates performed significantly
better in the two object teaching trials (F=4.351, p=.041).
Discussion This study examined whether word learning performance of children with
ASD would vary based on the level of attention scaffolding provided by the examiner and the
number of distracters present. This was done by comparing two methods of introducing a novel
word, either following the childs attention or directing the childs attention. Contrary to our
predictions, children with ASD did not perform differently than their receptive vocabulary
mates on either teaching condition. This finding is in line with recent research results from
Luyster (2007) who found that children with ASD showed similar patterns to their receptive
162
vocabulary mates in learning contexts where the examiners focus of attention differed from the
child. Like their receptive vocabulary mates, children with ASD performed better when there
were fewer distracter objects present. These results support recent research suggesting that
children with ASD are capable of using social information to guide their word learning (Luyster,
2007)
Allen, G., & Courchesne, E. (2001). Attention function and dysfunction in autism. Frontiers in Bioscience, 6,
105119.
Baron-Cohen, S., Baldwin, D. A., & Crowson, M. (1997). Do Children with Autism Use the Speaker's
Direction of Gaze Strategy to Crack the Code of Language? Child Development, 68(1), 48-57.
Burack, J. A. (1994). Selective attention deficits in persons with autism: preliminary evidence of an
inefficient attentional lens. J Abnorm Psychol, 103(3), 535-543.
Carpenter, M., Nagell, K., Tomasello, M., Butterworth, G., & Moore, C. (1998). Social cognition, joint
attention, and communicative competence from 9 to 15 months of age. Monographs of the Society for
Research in Child Development, 63, 1-174.
Enns, J. T., & Girgus, J. S. (1985). Developmental changes in selective and integrative visual attention.
Journal of experimental child psychology(Print), 40(2), 319-337.
Jarvinen-Pasley, A., & Heaton, P. (2007). Evidence for reduced domain-specificity in auditory processing
in autism. Developmental Science, 10(6), 786.
Kaland, N., Smith, L., & Mortensen, E. L. (2008). Brief report: Cognitive flexibility and focused attention in
children and adolescents with asperger syndrome or high-functioning autism as measured on the
computerized version of the Wisconsin card sorting test. Journal of Autism and Developmental
Disorders, 38(6), 1161-1165.
Luyster, R. J. (2007). Word learning in children with autism spectrum disorders. Unpublished Dissertation, The
University of Michigan.
Maestro, S., Muratori, F., Cavallaro, M. C., Pei, F., Stern, D., Golse, B., et al. (2002). Attentional skills
during the first 6 months of age in autism spectrum disorder. Journal of Amer Academy of Child &
Adolescent Psychiatry, 41(10), 1239.
McDuffie, A., Yoder, P., & Stone, W. (2006). Fast-mapping in young children with autism spectrum
disorders. First Language, 26(4), 421.
Wood, D., & Wood, H. (1996). Vygotsky, tutoring and learning. Oxford review of Education, 5-16.
163
P071
USEFULNESS OF THE TEST OF EARLY LANGUAGE DEVELOPMENT TO
DETECT CHIILDREN WITH LANGUAGE DISORDERS
DM Befi-Lopes, E Giusti, ML Puglisi, JP Gndara
Department of Physiotherapy, Communication Sciences and Disorders and Occupational Therapy
School of Medicine University of So Paulo, USP, Brazil
Introduction
Formal and standardized tests provide huge advantages for language evaluation,
particularly for testing objectivity. The study on the adaptation and translation of the Test of
Early Language Development (TELD-3) into Brazilian Portuguese provided similar results to the
original (American) version and showed that the Brazilian version of the TELD might be used
without further socio-cultural or linguistic adaptations.
Language disorders can be found in various developmental associate disorders. In the
present study we opted to test language abilities of children from different groups, considering
the severity of language impairments: children with history of prematurity and low birth
weight, Specific Language Impairment (SLI), Mild Intellectual Disability (MID) and Down
Syndrome (DS).
Children born preterm have increased risks for developmental disorders when compared
to children born full term. They usually show delayed language development for both receptive
and expressive measures, which might be more or less persistent depending on birth conditions,
and frequently need additional support to learn language.
SLI diagnosis can be divided into, at least, two subtypes considering affected linguistic
domains: expressive and mixed expressive-receptive SLI. The expressive SLI has usually highest
incidence in the population. Linguistic deficits of SLI children frequently vary a lot among
different cases and depend on its severity.
Intellectual Disability (ID) is characterized by limitations in the intellectual functioning
and adaptive behavior and its classification is based on severity levels. Children with MID show
Intelligence Quotients between 50/55 to approximately 70, and correspond to 85% of ID
diagnosis. MID diagnosis include problems in creating concepts, which involves receptive and
expressive language, and adaptive behavior limitations, and there are evidences that adults with
MID show mental age from 9 to 12 years of age.
Subjects with DS present great problems with language development, given that
linguistic deficits are usually higher than cognitive ones. There is evidence to support that
language impairments have genetic etiology, which interferes on brain structures responsible for
linguistic processing. Some authors reported that most children with DS achieve language
abilities compatible to 3-year-olds linguistic performance, and that expressive language
development does not follow mental age increase.
The aim of this study was to verify linguistic performances of children with
developmental disorders, from different etiologies, on the Brazilian version of the TELD-3. We
also aimed to analyze whether this instrument was useful to detect language impairments and
discriminate diagnostic groups, based in childrens performances.
164
Our hypotheses were that: H1) the test will be sensible to distinguish between clinical
and non clinical groups; H2) childrens performances on the test will discriminate diagnostic
groups.
Methods
This research was approved by the Ethics Committee (CAPPesq n 226/05) and all
participants had their informed consent signed by parents or caregivers.
Participated in this study 79 subjects aged from 2:1 to 10:9 years, from both genders.
Subjects were recruited from the Speech and Language services of the Medicine School of
University of So Paulo and from one specific Association for children with intellectual deficits
(APAE). Children were selected according to the following groups:
1- 14 subjects with history of prematurity and low birth weight, aged 2:1 to 5:6 years
(M=4:2). From this group, 8 children were being followed up by systematic reevaluations (preterm in follow up group - PTFU) and 6 were receiving speech-language
therapy (preterm in therapy group - PTT)
1. 25 subjects with SLI, aged 3:3 to 8:0 years (M=5:10)
2. 19 subjects with MID, without syndromes, from 5:4 to 10:4 years (M=8:7)
3. 21 subjects diagnosed as having DS, from 3:0 to 10:9 years (M=5:8)
Subjects who were aged above 7:11 (maximum limit of the TELD-3) were only included
in this study if their equivalent linguistic age was below 7:11.
The Brazilian version of the TELD-3 was administered to all participants. The test
provides an index of three different quotients: the receptive quotient (RQ), the expressive
quotient (EQ) and the total quotient (QT). Each quotient is then converted into six linguistic
classifications depending on language level: very poor, poor, below mean, mean,
above mean or superior. For the purposes of this study, we used another criterion to define
childrens language status in the receptive, expressive and total measures, besides the original
linguistic classification. Children were classified as normal in each measure if they felt into
mean, above mean or superior original categories. Oppositely, subjects were defined as
impaired in each measure if their original classification was very poor, poor or below
mean.
Results
Statistical analyses were carried out and the significance level was defined as p.05. In
order to test the H1, which states that the TELD-3 would be sensible to distinguish between
clinical (PTT, SLI, MID and DS) and non clinical groups (PTFU), a Chi-square test was
employed. For this analysis, the dichotomous classification (normal vs. impaired) was used. The
results revealed significant association between childrens classification and the group from
which they belonged to for all measures (receptive, expressive and total), as shows Table 1.
165
Table 1 Association between childrens linguistic classification and the group from which they
belonged to
Receptive
Chi-square
22.490
df
4
sig
<.001*
* statistical significance
Expressive
40.409
4
<.001*
Total
17.313
4
<.001*
The follow up of this finding revealed that, regarding the linguistic classification, the
PTFU group statistically differed from the MID and SD groups in all measures (receptive,
expressive and total). PTFU also differed from the SLI group specifically in the expressive
domain and did not differ from the PTT group in any measures (Table 2). Thus, the expressive
subtest of the TELD-3 was the most sensible measure to detect clinical groups.
Table 2 Association between childrens linguistic classification and group

(2x2 Contingency Table)
PTFU x PTT
PTFU x SLI
PTFU x MID
PTFU x SD
Receptive
Expressive
Total
Receptive
Expressive
Total
Receptive
Expressive
Total
Receptive
Expressive
Total
Chisquare1
0,21
1,58
1,13
0,74
4,58
1,04
3,05
3,82
3,61
4,08
4,08
3,84
df
1
1
1
1
1
1
1
1
1
1
1
1
1.00
.138
.301
.418
<.001*
.205
.004*
.001*
.004*
<.001*
<.001*
.003*
1 Fisher
Test
* statistical significance
With regard to differential diagnosis using TELD-3 (H2), we analyzed whether it was
possible to discriminate childrens groups based on their performances (linguistic classification).
For this purpose, a correspondence analysis (ANACOR) was employed, having group and the
original classification of TELD-3 as variables. Statistical analysis revealed that that the model
166
was significant for all measures (receptive, expressive and total - Table 3), meaning that it was
possible to differentiate childrens group regarding their linguistic classification.
Table 3 ANACOR statistics
Chi-square
Sig
Receptive Expressive Total

56.552
70.562
63.078
<.001
<.001
<.001
The figures 1, 2 and 3 show how the variables were grouped together in the receptive,
expressive and total measures, respectively.
Figure 1 ANACOR grouping for receptive classification
1=very poor; 2=poor; 3=below mean; 4=mean; 5=above mean; 6= superior
In the receptive measure, it is possible to verify that DS children were related to very
poor classification; MID children were grouped to poor and SLI children were closer to
below mean, although some were also near above mean. The remaining groups were linked
167
to normal classifications on this measure (PTT was mostly related to mean and PTFU to
superior).
Figure 2 ANACOR grouping for expressive classification
For expressive measures, again, children with DS were related to very poor
classification and MID children to poor category (although some children of this group were
also close to below mean). For the remaining groups, expressive performance was worse than
the receptive one. Similarly to MID children, SLI were closer to poor, albeit there was a group
linked to below mean. PTT children were related to below mean, while PTFU were grouped
together with mean (and above mean, in less extent).
168
Figure 3 ANACOR grouping for total classification
Finally, total measures showed that both DS and MID children were closer to very
poor classification, indicating that these children presented the most severe language deficits.
SLI were mainly linked to poor category, but there was also a group placed close to mean.
Again, PTT children were related to below mean, and PTFU were grouped together with
above mean (and below mean, in less extent).
Discussion
The first hypothesis was partially confirmed. The TELD-3 was useful to discriminate
PTFU children (non clinical) from DS and MID children (clinical) in all measures (receptive,
expression and total), but was less sensible to distinguish the remaining groups. SLI children
differed from PTFU only in the expressive domain, and no differences were found between
PTFU and PTT children. These results evidenced that the TELD-3 was very useful to detect
severe language impairments that affect both receptive and expressive domains (MID and DS
findings). SLI children, who usually show heterogeneous language performance and can be
subclassified as having pure expressive or mixed receptive-expressive deficits, were
distinguished from the non clinical group only in the expressive measure. As the incidence of
expressive SLI is higher than mixed SLI, it is possible that receptive language abilities of SLI
169
children, as a group, might have achieved similar levels to PTFU, which leaded to no differences
between both groups on this measure. It would be interesting, thus, to analyze both subgroups
separately in order to test whether the TELD-3 is also accurate to detect mixed SLI in all
measures, as happens in MID and DS. Despite the findings described above, the test was not
sensible to discriminate between PTFU and PTT children in any measures. It is important to
highlight, however, that sample sizes in both groups were the fewest of this study, which might
bring the need of further research in order to confirm this pattern of results.
Broadly, it is possible to conclude that the expressive classification on the TELD-3 is more
accurate to detect language impairments in developmental associate disorders than receptive
and total measures.
The second hypothesis was also partially confirmed. For the receptive measure, each
linguistic classification was linked to a single group of children. Groups were arranged in the
following order, from the highest to the lowest degree of language impairment: DS, MID and
SLI. Children from the PTT group achieved lower scores than PTFU, but both presented
adequate receptive performance. In the receptive domain, only PTFU children achieved normal
rates on the test and other groups ranks were, from the most to the less impaired children: DS,
MID/SLI and PTT. We can conclude, from these findings, that while children with intellectual
disabilities (DS and MID) had a severe language impairment that equally affects receptive and
expressive language abilities, SLI children showed atypical language development characterized
by normal (or almost normal) language comprehension and an important expressive deficit.
This is in line with SLI literature that indicates expressive deficits as one of the major problems
of this group. The PTT was characterized by mild problems that are specific for the expressive
domain. The results suggest, thus, that differential diagnosis between groups should take into
account both the severity of language impairments and the difference between receptive and
expressive language performance. This was true for groups discrimination, as a whole.
However, it is important to consider that a group of mixed receptive-expressive SLI does exist,
and might constitute a challenge for differential diagnosis, particularly between SLI and MID
children. Findings for the total measure were also relevant for diagnosis, since they help to
clarify SLI and MID differences. Also, total measures are useful to contribute to PTT and PTFU
distinction. We suggest that the combination of TELD-3s measures, altogether, might contribute
to differential diagnosis, but should be use in addition to other language and cognitive
instruments and procedures.
Conclusion
This study showed that TELD-3 might be an useful instrument to detect language
impairments in developmental associate disorders and may constitute a complementary tool to
differential diagnosis.
Acknowledgments
This study was supported by a research grant (n473160/2007-2) from the Conselho
Nacional de Desenvolvimento Cientfico e Tecnolgico (CNPq). The authors are grateful to the
children and parents who participated in the study.
170
P077
CHILDREN'S SENTENCE COMPREHENSION ABILITIES: THE ROLE OF SLI AND
SOCIO-ECONOMIC DIFFERENCES
ML Puglisi, DM Befi-Lopes
School of Medicine University of So Paulo, USP, Brazil
Introduction
Language development usually depends on a variety of factors such as biological
predisposition, adequate stimulation and optimal environment. The more the quality of those
factors, the best is the language acquisition process. However, some aspects are more important
than others for language development: neurobiological deficits might cause more severe
consequences than problems in the environmental input. This is the case of Specific Language
Impairment (SLI), a pathology in which language failures to develop without any other primary
deficit that may justify it. Because there might be structural or functional neurobiological deficits
in SLI, symptoms are usually atypical and persist throughout adult life. Differently, language
influences that are caused by poor stimulating environments commonly consist on mild
linguistic problems that are overcome with speech-language therapy. Frequently, insufficient
stimulation does not even cause real language impairments, but just does not provide children
with their best potentialities, as happens with children from low socio-economic status (SES).
That is the reason why many children raised in poor socio-economic environments develop
language below average.
Because of the different natures and prognosis of the language problems experienced by
these groups of children, one might expect that the effects of SLI on language abilities are
stronger than SES effects. This work will explore this prediction by comparing sentence
comprehension abilities of SLI, low-SES and high-SES children.
Methods
This research was approved by the Ethics Committee (CAPPesq n 226/05) and all
participants had their informed consent signed by parents or caregivers.
Participants
Two hundred and six children aged 4:0 to 6:11 (years:months) participated in this study.
Subjects belonged to three different groups:
1) 39 children diagnosed with SLI (SLI group). All children met diagnostic criteria for SLI
since they performed under expected for their ages in at least two tests of the language battery
and showed adequate nonverbal intelligence indexes;
2) 102 normally developing children who attended state schools in low-SES boroughs
(BraState group). According to the 2000 Brazilian Demographic Census, there is a higher
concentration of families that earn from one and a half to three minimum-wages per capita
(25%);
3) 63 normally developing children who attended private schools in high-SES boroughs
(BraPriv group). According to the 2000 Brazilian Demographic Census, the majority of the
population (48-64%) earns more than 10 minimum-wages per capita.
171
Materials and procedure

Two tasks, created for the purposes of this study, were used: the first one measured
childrens ability to identify only the number grammatical morpheme; the second one analyzed
childrens performance on a sentence comprehension test. The former was employed in this
study in order to detect whether a failure to comprehend the number morpheme, in the sentence
comprehension test, was due to the unfamiliarity with the plural linguistic concept or to a
difficulty in detecting singular and plural information embedded in sentences. The sentence
comprehension task was composed of 48 reversible sentences in the active voice. Reversible
sentences were employed in order to guarantee that no other information (e.g.: animate vs.
inanimate characters) besides word order cues were facilitating childrens detection of thematic
roles. For the number morpheme variable, we used sentences in which the singular and plural
forms were present in different clauses (subject or object). Therefore, if the subject was marked
for plural, the object of the same sentence was necessarily in the singular form, and vice-versa.
Children were encouraged to point to the picture that correctly represented the sentence spoken
by the examiner, among four possibilities.
Response analysis
Given that the possibility of hits by chance in the singular and plural detection task was
high for each item (50%), a scoring system was used to analyze if childrens responses were
above chance, as shows Table 1. Cut off criterion was a minimum of 70% of correct responses in
the singular as well as in the plural task.
Table 1 Singular and plural scoring criteria
Singular
Plural
Preliminary scores
70% of hits
<70% of hits
1
0
1
0
The preliminary scores in both the singular and plural detection tasks were then
considered in order to calculate the total score, which was understood as an index of mastery of
the number morpheme. According to the adopted criteria, only children who scored 1 in both,
the singular and the plural, showed a consistent mastery of the number morpheme, since they
could reach a minimum ratio of 70% of correct responses in both tasks. These children received a
final score of 1, while all other subjects scored 0 (even if they have scored 1 in one of the two
tasks).
For sentence comprehension analyses, there were four possible types of responses, since all trials
had one target-picture (Target) and three types of distracters (number, word order, and numberword order). The number distracter (N Error) was the picture that kept the same agents and
patients from the target, but inverted their quantities; oppositely, the word order distracter (WO
Error) changed the characters that represented the agent and the patient, but kept their quantity;
finally, the number-word order distracter (N-WO Error) shifted both grammatical features in
relation to the target sentence. This sentence comprehension test, therefore, depended on the
detection and retention of word order and plural/singular information, simultaneously.
172
Results
Mastery of the number morpheme
Table 2 shows descriptive statistics. The Chi-Square test revealed statistical significance
between variables ( = 43.75, gl = 2, p < .001), showing an association between the mastery of
the number morpheme and the group to which the children belonged to. The follow up using
adjusted residual values showed significant statistical difference only between BraPriv and SLI
children (5.5 and 5.2, respectively). When only BraState and SLI childrens performances were
compared, Chi-Square also revealed significant statistical association between variables ( =
13.62, gl = 1, p < .001).
Table 2 Mastery of the number morpheme for each group
SLI
BraState
BraPriv
Percentage of children
Mastered
Did not master
13%
87%
48%
52%
81%
19%
Comparisons between childrens performances in the sentence comprehension test
Table 3 Childrens performance in the sentence comprehension test for each group
and age
Targets
N Errors
WO Errors
N-WO Errors
M
SD
M
SD
M
SD
M
SD
4 years 16,18
3,97
14,32
3,59
5,18
3,09
4,29
2,74
5 years 22,41
5,02
13,88
4,23
2,09
1,66
1,62
1,41
BraState
6 years 24,32
5,46
12,44
5,00
2,12
1,89
1,12
1,23
Total
20,97
5,95
13,55
4,34
3,13
2,70
2,34
2,36
4 years 23,33
5,16
11,57
3,20
2,86
2,59
2,24
2,49
5 years 25,90
5,08
10,67
3,44
2,24
1,76
1,19
1,57
BraPriv
6 years 30,81
5,51
7,48
5,44
1,33
1,28
0,38
0,67
Total
26,68
6,04
9,90
4,45
2,14
2,02
1,27
1,88
4 years 13,42
4,08
10,42
2,11
8,92
2,35
7,25
1,82
5 years 16,25
6,27
11,42
2,84
6,08
4,14
6,25
4,54
SLI
6 years 18,27
4,92
14,20
2,86
3,33
2,85
4,20
3,43
Total
16,15
5,41
12,18
3,07
5,90
3,88
5,77
3,60
The Table 3 showed data descriptive statistics on the sentence comprehension test. Data
were statistically analyzed using multivariate analysis of variance (MANOVA) and univariate
analysis of variance (ANOVA) was carried out to follow up MANOVAs effects. Significance
level was defined as p.05. The MANOVA demonstrated statistical differences for all analysis.
173
There was a multivariate effect of age (Wilks =0.709, F(8,384)=9.01, p<.001); multivariate effect
of group (Wilks =0.517, F(8,384)=18.76, p<.001); and a significant interaction between age and
group (Wilks =0.836, F(16,587)=2.22, p<.01). Complementary ANOVAs and post-hoc results
(using Games-Howell test) are shown in Table 4.
Table 4 Age and group comparisons on the sentence comprehension test
Age effects
Group
effects
Interactions
ANOVA
1 vs. 2
1 vs. 3
2 vs. 3
ANOVA
1 vs. 2
1 vs. 3
2 vs. 3
ANOVA
Targets
F
df
27.23 2,195
56.76
2,195
1.47
4,195
p
<.001
<.001
<.001
.06
<.001
<.001
<.001
<.001
.213
N Errors
F
df
0.58
2,195
16.16
2,195
4.49
4,195
p
.560
<.001
.096
<.001
<.01
<.01
WO Errors
F
df
30.22 2,195
4.31
2,195
4.33
4,195
p
<.001
<.001
<.001
.210
.015
<.01
<.01
<.05
<.01
N-WO Errors
F
df
21.66 2,195
34.14
2,195
1.55
4,195
Age: 1 = 4 years; 2 = 5 years; 3 = 6 years

Group: 1 = SLI; 2 = BraState; 3 = BraPriv
Statistical significant interactions reflected different patterns of responses for each group,
in function of age. For N Errors, whereas there were no differences between BraState childrens
performances regarding age, BraPriv children presented a reduction of N Errors from 4 to 6
years of age. The most discrepant pattern, however, was shown by SLI children: there was an
increase of N Errors in function of age, particularly from 5 to 6 years, indicating a distinct
developmental pattern. Concerning WO Errors, there was no difference between BraPriv 4-, 5and 6-year-old childrens performances, but there was a decrease of WO Errors from 4- to 5year-old children and from all ages in the SLI group.
Discussion
The first important finding was that all groups of children differed in their ability to
detect the number grammatical morpheme, indicating that Brazilian Portuguese-speaking
children with SLI showed difficulties to detect the singular and plural information in nominal
morphemes, which corroborates findings from other studies. It is important to note that
although the same measure also distinguished BraState from BraPriv children, the percentage of
SLI children that mastered the number morpheme was even worse than the same percentage for
the BraState group. Given that SLI children also belonged to low-SES regions, it is possible that
the combination of socio-economic disadvantages and language impairments produced
significant difficulties in acquiring the number grammatical morpheme.
Regarding childrens performance on the sentence comprehension test, the first finding
concerned the main effect of age, which reflected the difference between 4-year-old and older
childrens performance for Targets, WO and N-WO Errors. The second and main important
finding concerns group comparisons. Children from the three groups differed between them
regarding all types of response in the sentence comprehension test, except for the N Errors.
Thus, the quantity of Targets, WO Errors and N-WO Errors differed in function of childrens
diagnosis (having SLI or not) and SES (belonging to low- or high-socio-economic environments).
In respect to N Errors, only BraPriv children differed from others, since they presented the
174
p
<.001
<.001
<.001
.219
<.001
<.01
<.01
<.01
.189
fewest errors, but there was no difference between SLI and BraState childrens performance. The
absence of differences between SLIs and BraStates N Errors is caused by the significant
interaction (the third relevant finding): in spite of reducing the number of errors, children with
SLI made more N Errors as they grew older, reflecting an atypical pattern of responses. At 4
years of age, SLI children showed almost aleatory responses in the sentence comprehension test
(ratios were close to answers by chance 25%). From 4 to 6 years of age, they turned to produce
more N Errors and less WO and N-WO Errors (there was a significant interaction between
group and age for WO Errors as well, indicating that the decrease of these errors in function of
age was greater for SLI children), showing a similar pattern, although worse, to the normally
developing group. Therefore, SLI childrens atypical performance was restricted to the youngest
group.
Conclusions
Socio-economic differences influenced the number morpheme acquisition, but language
impairment produced even greater effects on the mastery of the same grammatical feature.
Regarding the sentence comprehension test, SLI effects were stronger than SES ones, since the
first group showed atypical patterns of response and lower indexes of targets. SLI atypical
performance was attributed only to 4-year-old children, who showed almost aleatory responses.
From 5 years on, SLI children performed worse than controls, but showed the same types of
errors. BraState children presented worse performance than BraPriv children in all measures,
indicating a delayed but typical development.
Acknowledgments
This study was supported by a research grant (06/50660-3) from the Fundao de
Amparo Pesquisa do Estado de So Paulo (FAPESP). The authors are grateful to the children
and parents who participated in the study.
175
P154
THE ESTABLISHMENT OF THE CONTRAST BETWEEN /T/ AND /K/ BY
CHILDREN WITH PHONOLOGICAL DISORDER: DATA FROM PRODUCTION
AND PERCEPTION SPEECH.
L. C. Berti1
a.
1So
Paulo State University, Marlia, Brazil
Introduction
Phonological disorder (henceforth PD) occurs when a child does not develop the ability
to produce and use some or all sounds necessary for speech that are generally used at his or her
age.
From the linguistic point of view, the literature indicates that children with PD have
similar speech characteristics, such as: reduced sound phonetic inventory; simple syllabic
structures; use of a limited number of phonological processes, usually similar to a normal child
and some use idiosyncratic processes. In addition, children with PD may present a different
sequence of phonological acquisition when compared to a normal child, and have difficulty in
phonological contrast maintenance, showing a great variability in his/her production (Elbert &
Gierut, 1986; Oliveira & Wertzner, 2000; Wertzner, 2003).
In terms of speech production there are some very common mistakes that are made by
children with PD. When their productions were judged perceptually, the common mistakes
included the omission of sounds, (i.e., frequently at the end of words), the distortion of sounds,
or the substitution of one sound for another (Wertzner, 2004; Wertzner et. al., 2005).
Although the cause of PD has not been defined yet, several authors (Fox et. al., 2002;
Shiriberg et. al., 2003) have addressed the issue of phonological disorders etiology considering
different causes that may be related to the biological, psycho-social, environmental and, most
recently, to the familial aspect.
Concerning the biological aspect, the perceptual auditory difficulties have been related to
the occurrence of PD. Fey (1992), for example, states that a phonological acquisition deficit
suggests potential difficulties in several levels, including phonetic discrimination, phonological
contrasts recognition among other factors. In a more recent study, Caumo & Ferreira (2009)
suggested the existence of a close relationship between the occurrence of deficits in the auditory
abilities (auditory processing) and phonological disorder.
Although some studies relate perceptual auditory difficulties to PD, the use of perceptual
testing on the same children (with PD) who produce speech data is relatively rare. Thus, the
purpose of this research was to examine both: the production and perception (specifically, of the
acoustic phonetic characteristics) of voiceless dental and velar stops in Brazilian Portuguesespeaking children with PD. In other words, the aim of this study was: (a) to analyze the
establishment of the contrast between /t/ and /k/ in children with PD; and (b) to investigate
the perceptual performance of these children regarding their own productions and typical adult
productions.
176
Methods
This research was approved by the Ethics Committee of the Institution (protocol
3499/2006) and the consent forms were signed by a legal responsible of each subject.
Participants were 03 children with PD (mean age 64 months) who presented
neutralization of the contrast between /t/ and /k/, in perceptual judgment. The subjects
inclusion criteria were: a phonological disorder diagnosis; no previous speech-language
treatment; difficulties of speech production (in terms of judgment perceptual substitutions) of
the contrast investigated; and absence of auditory problems.
Two experiments were conducted: acoustic analysis of the speech production and an
identification experiment.
Regarding the experiment of speech production, the stimuli consisted of familiar
disyllabic minimal pairs of words with penultimate stress combining initial /t/ and /k/ with
/a, u/ in stressed position. The context vowel /i/ was excluded because /t/ coming before is
produced as the affricate /t/. The words used were: /taku/ (baseball bat) x /kaku/ (shard)
and /kuba/ (sink) X /tuba/ (tuba).
The production experiment consisted of randomized repetition of the target word in a
carrier sentence after the experimenter said the target word as a prompt. There were five
repetitions of each word, computing a total of 60 tokens (04 words x 03 subjects x 05 repetitions
= 60 tokens). The recordings were made with a digital tape recorder and analyzed with a
sampling rate of 44 kHz using the PRAAT software (Boersma & Weenink, 2008).
The acoustic parameters analyzed were: 1) spectral acoustic characteristics of the noise
burst; 2) acoustic characteristics of formant transitions; 3) acoustic parameters related to the time
pattern of closure and burst production (Forrest et. al., 2000).
Duration parameters were analyzed by Friedman ANOVA, while other parameters were
analyzed using two-way ANOVA and Hierarchical Linear Modeling (Raudenbush et al., 2004),
to determine which acoustic parameters are needed to categorize the two stops. Statistical
significance was set at 0,05 (p< 0,05).
It is important to point out that previous study based on typical-adult was conducted to
determine which acoustic parameters were primary or secondary cues.
The second experiment, the identification task, was conduced with the same children
with PD using PERCEVAL software (Andr, et. al, 2003, 2009). The stimuli used in the
identification task consisted of a typical adults recordings of the target words (minimum pairs)
and the recorded and edited productions of the subjects themselves.
The acoustic stimulus was presented by children and they needed to choose which
stimulus-correspondent picture was shown on the computer screen. Both presentation time and
reaction time of the stimulus were measured by PERCEVAL software. The statistical analysis
used was one-way ANOVA - Post-hoc Scheff. Statiscal significance was established below 0,05
(p < 0,05).
Next section, we will present the main result this study.
Results
o
Experiment of production
3.1.1. Acoustic analyses Adult productions
177
We performed one two-way ANOVA for adult speaker. The within-subject factors were
stops and vowel, and the dependent variables were the eight acoustic measures. Table 1 bellow
shows the results of this analysis.
Table 1
F-values from two-way ANOVA analyses on each of the eight acoustic parameters for
productions of adult speaker.
CV
transitions
Burst Spectrum
Durational
pattern
Talker
Spectral
peak
M1Centroid
M2standard
deviation
M3
Skewness
M4Kurtosis
Onset F2
frequency
% of
closura
% of
burst
Adult
52,85 ***
8,46 ***
5,85 **
10,42 ***
4,29 *
101,88 ***
33,33
***
40,00
***
***p<0.001; **p<0.01; *p<0.05
It can be observed that the F-values for the onset F2 frequency and spectra peak are an
order of magnitude greater than the F-values for the other acoustic parameters, suggesting that
both are the primary acoustic parameters for to distinguish the two stops in adult production.
Subsequently, we also used logistic regression in a hierarchical linear model (Raudenbush et. al.
2004) to determine which acoustic parameters are needed to predict the categories of the two
voiceless stops. The results of this analysis are summarized in Table 2.
Table 2
Results of hierarchical linear model for adult productions of /t/ and /k/.
Coefficient for
Multiple R2
Adjusted R2
df Model
F-Value
p-Value
Spectral peak
0,908343
0,891157
16
52,8547
0,000***
Centroid
0,613475
0,541002
16
8,4648
0,001***
Standard
deviation
0,523206
0,433807
16
5,8525
0,007**
Skewness
0,661618
0,598171
16
10,4279
0,000***
Kurtosis
0,445864
0,341963
16
4,2913
0,021*
Onset F2 freq.
0,950255
0,940928
16
101,8809
0,000***
178
% of closura
0,862073
0,836212
16
33,3346
0,000***
% of burst
0,882367
0,860311
16
40,0055
0,000***
Significant p-values are in bold.
In summary, the largest p-values and F-values indicate primary phonetic cues to
distinguish /t/ and /k/; such as, onset F2 frequency, spectral peak and % of burst; while the
lower p-values and F-values suggest secondary phonetic cues to differentiate this contrast in
adult productions; such as, kurtosis, standard deviation, centroid, and so on.
3.1.2. Acoustic analyses children with PD productions
We used the same acoustic analysis for the productions of all of the children with PD
who produced a contrast between the two stops or who produced a substitution between /t/
and /k/. We then performed the same set of two-way ANOVAs for these childrens
productions, so that we could identify instances of covert contrast. Tables 3 and 4 below present
the results of these analyses.
Table 3
F-values from two-way ANOVAs on all eight acoustic parameters for children with neutralized contrast
(italic) or covert contrast (boldface). The abbreviator R1, R2 and so on relate to repetitions of speech
production of children.
Childrens production in context vowel /a/
Children Burst Spectrum
Spectral peak M1
CV transitions Durational pattern

M2
M3
M4
Onset F2
% of closura % of burst
C1_R1
C1_R2
117,5818*
385,01 *
C1_R3
C1_R4
238,03*
C1_R5
C2_R1
C2_R2
112,1940*
C2_R3
81,62667*
C2_R4
C2_R5
61,82291*
6422,5*
C3_R1
C3_R2
C3_R3
1005,08 * 330,08 **
C3_R4
C3_R5
161,43 **
58,48438*
674,94 *
428,93 *
307,71 *
Empty cells indicate a non-significant main effect of stop type.
179
***p<0.001; **p<0.01; *p<0.05.

Table 4
F-values from two-way ANOVAs on all eight acoustic parameters for children with neutralized contrast
(italic) or covert contrast (boldface). The abbreviator R1, R2 and so on relate to repetitions of speech
production of children.
Childrens production in context vowel /u/
Children
Burst Spectrum
Spectral peak
C1_R1
M1
M2
M3
Durational pattern
M4
Onset F2
% of closura
74,75*
113,06*
% of burst
124,87*
C1_R2
C1_R3
CV transitions
67,16*
198,58 *
C1_R4
C1_R5
92,02*
101,62*
C2_R1
C2_R2
112,19*
C2_R3
81,62*
C2_R4
C2_R5
61,82*
74,35*
6422,5*
57,35*
C3_R1
C3_R2
C3_R3
1005,08*
330,08*
C3_R4
C3_R5
161,43*
58,48*
674,94 *
428,93 *
307,71 *
Empty cells indicate a non-significant main effect of stop type.

***p<0.001; **p<0.01; *p<0.05.
According to the Tables above two observations can be made. First, children present two
types of speech production of the contrast investigated: neutralized contrast and covert contrast.
It is important to highlight that the operational definition in the literature for mastery of a
speech sound typically is 75% accuracy for an individual child in a particular word position
(e.g., Smit et al., 1990). Similarly, the criterion used for mastering the contrast between two
sounds is 75% accuracy for both sounds in a particular word position. We adopted these
operational definitions to determine how many of the children had mastered each of the two
stops and the contrast between them. Thus, if the children didnt use at least 75% of the acoustic
parameters, it was characterized as a covert contrast. Therefore, acoustic analysis revealed the
presence of covert contrast in 70% of the substitutions between /t/ and /k/ made by children
with PD (Scobbie, 1998; Scobbie et. al., 2000; Li et. al., 2009).
In the second observation, children with PD begin to establish the contrast between /t/ and
/k/ in two ways preferably: mastering secondary phonetic cues, for instance, % of closure,
kurtosis, etc; or using primary phonetic cues with insufficient target values.
180
Finally, we also verified that the two stops are less stable in the productions of the children with
PD, if compared to those of the adult.
3.2. Experiment of perception
Figure 01 shows the auditory perceptual performance of children with PD in
identification task of adult productions. Table 05 presents the reaction time of children with PD
in identification task of adult productions.
Figure 1: Perceptual performance of children with PD regarding adult productions.
Table 05
Mean reaction time of children with PD in identification task of adult productions.
Identification Task
Mean reaction time (ms)
Correct identification
2433,22
Incorrect identification
2334,58
Examining both Figure 01 and Table 05, a robust difference between percentage and
reaction time in correct and incorrect identification in adult productions was not observed. Even
though the adult productions are stable, they dont facilitate a higher percentage of correct
identification by children with PD.
Figure 02 shows the auditory perceptual performance of children with PD in
identification task of their own productions. Table 06 presents the reaction time of children with
PD in the identification task regarding their own productions.
181
Figure 02: Performance of children with PD regarding their own productions.
Table 06
Mean reaction time of children with PD in identification task regarding their own productions.
Type of stimuli
Perceptual performance
Mean reaction time (ms)
2235,2
2529,37
2381,78
2229
Categorical
Gradient
Concerning Figure 02 the children showed a better performance in the correct

identification of covert contrast overt contrast (67% and 20%, respectively).
According to Table 06, when we compare the reaction time of correct identification of
categorical and gradient stimuli a statiscally significant difference cant be observed
(F(2,4)=0,84818, p=0,49). Similarly, when we compare the reaction time of incorrect identification
of categorical and gradient stimuli a statiscally significant difference cant be observed either
(F(2,4)=0,84818, p=0,49). These results are illustrated in Figures 03 and 04.
Comparis on between reaction time of gradient and categorial stimuli
Wilk s lambda=,70220, F(2, 4)=,84818, p=,49309
4000
Reac tion time in incorrec t res pons e
3500
3000
2500
2000
1500
1000
500
G
C
Ty pe of s timuli
182
Figure 03: Comparison between reaction time of incorrect response in function of types of stimuli.
Comparison between reation time of gradient and c ategoric al stimuli

F(2, 4)=,84818, p=,49309
4500
Reation time of correct response
4000
3500
3000
2500
2000
1500
1000
500
C
Types of stimuli
Figure 04: Comparison between reaction time of correct response in function of types of stimuli.
Conclusions
This study verified that children with PD begin the establishment of phonic contrast
investigated by making use of secondary phonetic cues or making insufficient use (target value)
of primary phonetic cues.
Furthermore, children with PD seem to have a strong support on secondary phonetic
cues, both to produce and to perceive the establishment of the contrast between /t/ and /k/.
We must highlight the non-developmental aspect of children with PD because they seem
to be able to perceive their own covert contrast. This fact has important ramifications for the
treatment of these children. They are not mastering their cues appropriately. There could be an
underling perceptual problem (misidendification of cues from adult speech) or the perceptual
difference could be caused by learning based on self-experience of their own productions.
These results call for future research to continue investigating both speech production
and speech perception of contrast and covert contrast in children with PD.
Acknowledgments
This research was supported by FAPESP, the So Paulo State research agency (grant no.
06/61816-4). We thank the children who participated in the task, the parents who gave their
consent, and the school in which the data were collected. We also thank the research groups
DINAFON (coordinated by Dra. Eleonora Albano) and GPEL (coordinated by Dr. Loureno
Chacon).
References
ANDR C., GHIO A., CAV C., TESTON B. PERCEVAL: a Computer-Driven System for Experimentation
on Auditory and Visual Perception. Proceedings of XVth ICPhS, Barcelona, Espanha, 1421-1424,
2003.
________________________________________. PERCEVAL: PERCeption EVALuation Auditive & Visuelle
(Verso 5.0.30) [Programa de computador]. Compilado de http://aune.lpl.univaix.fr/~lpldev/perceval/ em janeiro de 2009.
BOERSMA, P.; WEENINK, D. Praat: doing phonetics by computer (Verso 5.0.30) [Programa de
computador]. Compilado de http://www.praat.org/ em novembro de 2008.
CAUMO, D. T. M.; FERREIRA, M. I. D. C. Relao entre desvios fonolgicos e processamento auditivo. R.
Soc. Bras. Fonoaudiologia, v. 14, n. 2, p. 234-240, 2009.
183
ELBERT, M.; GIERUT, J. Handbook of clinical phonology: Approaches to assessment and treatment. 2. ed.
Austin: Pro-ed, 1986.
FEY, M. E. Clinical forum: phonological assessment and treatment articulation and phonology:
inextricable constructs in speech pathology. Lang. Speech Hear. Serv. Schools, v. 23, n. 3, p. 225-232,
1992.
FORREST, K.; WEISMER, G.; MILENKOVIC, P.; DOUGALL, R. N. Statistical analysis of word-initial
voiceless obstruints: preliminary data. Journal of the Acoustical Society of America, 84, p.115-123,
1988.
FOX, A V.; DODD, B.; HOWARD, D. Risk factors for speech disorders in children. J. Lang. Com. Dis., v. 37
n. 2, p. 117-131, 2002.
LI, F.; EDWARDS, J.; BECKMAN, M. Contrast and covert contrast: the phonetic development of voiceless
sibilant fricatives in English and Japanese toddlers. Journal of Phonetics, 37(2). 189-211, 2009.
OLIVEIRA, M. M. F.; WERTZNER, H. F. Estudo do distrbio fonolgico em crianas. R. Soc. Bras.
Fonoaudiol., v. 7, p. 68-75, 2000.
RAUDENBUSH, S.W.; BRYK, A.S.; CHEONG, Y. F.; CONGDON, R. HLM 6: Hierarquical linear and
nonlinear modeling. Lincolnwood, IL: Scientific Software International, 2004.
SCOBBIE, J. M. Interactions between the acquisition of phonetics and phonology. In M. Catherine Gruber,
Derrick Higgins, Kenneth Olson and Tamra Wysocki (eds.) Papers from the 34th Annual Regional
Meeting of the Chicago Linguistic Society, Volume II: The Panels. 343-358. Chicago: Chicago
Linguistics Society, 1998.
SCOBBIE, J.M.; GIBBON, F.; HARDCASTLE, W.J. e FLETCHER, P. Covert contrast as a stage in the
acquisition of phonetics and phonology. In: Michael Broe and Janet Pierrehumbert (eds.) Papers in
Laboratory Phonology V: Language Acquisition and the Lexicon, 194-207. Cambridge: Cambridge
University Press, 2000.
SMIT, A. B.; HAND, L.; FREILINGER, J. J.; BERNTHAL, J. E.; BIRD, A. The Iowa articulation norms
project and its Nebraska replication. Journal of Speech and Hearing Disorders, 55, p. 779-798, 1990.
SHRIBERG, L. D.; FLIPSEN JR, P.; KWIATKOWSKI, J.; McSWEENY, J. L. A diagnostic marker for speech
delay associated with otitis media with effusion: the intelligibility speech gap. Clin. Ling. Phonet.,
v. 17, n. 7, p. 507-528, 2003.
WERTZNER, H. F. Distrbio Fonolgico. In: ANDRADE, C. R. F.; MARCONDES, E. (Org.). Fonoaudiologia
em Pediatria. 1. ed. So Paulo: Savier, p.70-78, 2003.
WERTZNER, H. F. Fonologia: desenvolvimento e alteraes. In: FERREIRA, L. P.; BEFI-LOPES, D. M.;
LIMONGI, S. C. O. (Org.). Tratado de Fonoaudiologia. 1. ed. So Paulo: Roca, p. 772-786, 2004.
WERTZNER, H. F.; AMARO, L; TERAMOTO, S. S. Gravidade do distrbio fonolgico: julgamento
perceptivo e porcentagem de consoantes corretas. Pr-Fono Revista de Atualizao Cientfica, v. 17, n.
2, p. 185-194, 2005.
184
P014
A COMPARATIVE ANALYSIS BASED ON DISTINCTIVE FEATURES USING
THE MODIFIED MAXIMAL OPPOSITIONS MODEL IN THE TREATMENT OF
PHONOLOGICAL DISORDER
Bolli Mota H., Keske-Soares M., Bagetti T., Ceron M.
UFSM
Introduction
This study aims to verify the distinctive features approach in target segment, contrast
or reinforce, which leads to large generalizations in children with phonological disorders
treated with the Modified Maximal Opposition Model.
Methods
It was selected to be part of this research a group of seven subjects (4 boys and 3 girls),
ages between 3:10 to 6:9. All the children were assisted in the project Analyses of generalization
in different degrees of severities of phonological disorder in children submitted to the
therapeutic model of Maximal Oppositions, registered at Projects Office (PO) of the Center of
Health and Science (UFSM) and approved by the Ethical and Research Committee under the
number 070/03. In order to the subject participate in the research, parents or legally responsible
assigned a term of agreement authorizing the research and probable publication of the results.
All the subjects were submitted to the following speech and hearing evaluations:
anamneses, language evaluation, stomatognatic system, psychomotor evaluation, phonologic
awareness evaluation, simplified evaluation of the central hearing processing) as well as
complementary evaluations such as otorrinolaringological, hearing, neurological and
psychological evaluation.
In order to obtain the speech data was applied the Phonological Evaluation of each child
(Yavas et al., 1992), making use of spontaneous naming of figures, which contained all the
contrastive sounds, in BP in every position of the syllable and the word. To analyze the data
were done the following analyses; contrastive and by distinctive features. With the contrastive
analysis was possible to obtain the phonetic inventory and the phonological system of each
subject. One sound was considered present in the phonetic inventory when occurred once or
more, independent of the position in the word. When the phonological system was obtained,
one segment was considered acquired when it occurred from 80% to 100% of times (Bernhardt,
1992).
In order to select the target segments, were approached the initial phonological system of
the subjects and the distinctive features that they presented difficulties. The most difficult
distinctive features were the ones which involved substitutions that were presented in a higher
number of phonemes. The chosen target segments should differ at least in two distinctive
features, in order to obtain pairs of segments with maximal oppositions.
The researched group was composed of two subjects in each level of phonological
severity disorder, using the Percentage of Correct Consonants (PCC) determination proposed by
Shriberg & Kwiatkowski (1982). One exception has occurred in the moderate severe degree,
which was constituted of just one subject. Within each severity, one subject was treated with
contrast and the other with reinforce of distinctive features that presented difficulty. It was
185
considered as a contrast approach the use of target segments that presented values contrary to
the same feature (e.g. // [+voz] e /s/ [-voz]) reinforce approach the use of target segments
with identical values for the same feature (e.g. // [+voz] e /g/ [+voz]).
For facilitating the comprehension and characterization of the groups, the subjects
submitted to contrasts were identified with odd numbers and the ones submitted to
reinforce with even numbers. Thus, S1, S3, S5 and S7 were stimulated with contrast and S2,
S6 and S8 with reinforce.
The subjects treated by the Modified Maximal Oppositions Model (Bagetti et al., 2005),
based on the Model of Gierut (1992). In this work were considered 20 therapeutic sessions,
except the S7 who was treated by 10 sessions and was discharged from the speech and hearing
assistance service.
For verifying and comparing the changes in the phonological systems of the subjects
treated with contrast and with reinforce in different phonological disorder severity were
compared the initial phonological evaluations (IPE) and the final phonological evaluations (FPE)
of the same ones. These data were analyzed qualitatively and quantitatively and when it was
possible were submitted to Wilcoxon Test (p<0,05).

All the subjects treated with contrast have presented an increase in the PCC and in the
number of acquired segments. Although the difference between these results, comparing the IPE
and the FPE werent statistically significant (p=0,067). Pagan and Wertzner (2002) have also
verified higher PCC values in the final evaluation. The highest PCC occurred in the MSD group.
On the other hand, Blanco (2003) verified the highest PCC increase in the MMD group. It is
relevant to say that the author has used Modified Cycles Model.
The subject with SD happen to present MMD in FPE and the subjects with MSD and
MMD happen to present MD. The subject with MD was the only one to remain with the same
degree of severity in FPE, despite of presenting a PCC near 100%. This result may suggest a
possible failure in the classification process regarding the PCC when it is near to this value
(100%), because when the subject presents PCC near 100%, generally has the phonological
system almost all acquired, not being correct to be classified as patient with phonological
disorder.
Regarding the number of acquired segments, it is observed that the subject with MSD
was the one who has acquired the highest number of acquired segments (6), followed by the
subject with MMD (3), the subject with SD (2), and the subject with MD (1). It was verified that
the group who presented intermediate phonological alterations (MSD and MMD) were the ones
with the highest number of acquired segments after therapy. Blanco (2003) applying the
Modified Cycles Model has seen that the greatest number of acquired segments occurred in
MMD groups, followed by MD and then MSD.
Every subject treated with contrast have presented generalization in items not utilized
in the treatment, and the highest increase in the average of this generalization occurred in MMD,
followed by MSD, MD and then SD. The subjects with an intermediate degree of severity (MS
and MM) were the ones who more presented this kind of generalization.
Referring to generalization for other positions in the word, it is observed that S3 with
MSD have presented a higher increase of correct production of segments in other positions of
the word, followed by subject with MMD and with SD. The subject with MD was the one who
less presented this kind of generalization.
186
The generalization within a class of sounds was the highest for the subject with MSD,
because presented the highest increase in the average of segments correct productions pertained
to the same class of the target-segments. In a second hand, this kind of generalization occurred
expressively in the subject with MMD, and in the subject with SD. The subject with MD has not
presented any possibility of occurrence of this kind of generalization.
As regards generalization for other classes of sounds, the subjects with MMD and MD
have not presented any possibility of occurrence of this kind of generalization. Just the subjects
with more severe disorders had the possibility to present this kind of generalization, because
they presented very impaired phonological systems.
It is verified that the subjects treated with reinforce presented a PCC increase after
therapy, meanwhile, this increase was not statistically significant (p= 0.108). The subject with SD
obtained the highest PCC increase. This result agrees with the findings of Pagan & Wertzner
(2002) and disagrees with Blanco (2003).
The subject with SD happened to present MMD in the FE and the subject with MMD
happen to present MD. The subject with MD remained with this degree of severity in the final
evaluation. The highest PCC number has occurred with SD, followed by MMD, and then MD.
It is seen that every subject treated with reinforce have presented an increase in the
number of acquired segments and this increase was not statistically significant (p= 0.108). The
subjects with SD and with MMD were the ones who have presented higher numbers of
segments after therapy, because each subject has acquired three different sounds within the
therapeutic process. The subject with MD has acquired just two segments, thus remained with
its phonological system complete. The result of this study disagrees with Blancos findings
(2003), who have verified a higher number of acquired segments in the final phonological
system in the group with MMD, followed by MD and then MSD.
The subjects treated with reinforce also presented an increase in the correct
productions of the target segment in other words that were not stimulated in therapy, but this
increase was not statistically significant (p=0.067). The subject with MMD was the one who
presented higher generalization to items not utilized in the treatments, followed by MD.
It was observed an increase in the correct productions of the target segment in other
positions of words that were not seen in the therapy, but this increase was not statistically
significant (p= 0.067). This generalization has occurred in a similar way in subjects with MMD
and SD.
Every subject presented an increase in their correct productions of segments pertaining
to the same class of the target-sound, but this increase was not statistically significant (p=0.126).
The increase regarding to this kind of generalization was similar among groups with MD, MMD
and SD.
The subjects presented an increase in their correct productions of segments pertaining to
other classes and this increase was statistically significant (p=0.017).The subject with SD was the
one who presented this kind of generalization, followed by MMD and MD.
Comparing the PCC values and the number of acquired segments after therapy, it is
verified a similar increase between the group treated with contrast and the group treated with
reinforce.
As the subjects treated with contrast as the subjects treated with reinforce, presented
generalization to items not utilized in the treatment, to other word positions, to the same class of
segments as well as to other classes of segments. The results of this research agree with the
findings of Bagetti (2003), Blanco (2003), Elbert & Mc Reynolds (1985), Forrest & Elbert (2001),
Mota & Pereira (2001) and Weiner (1981) that also find some of these generalizations in their
187
studies. On the other hand, Blanco (2003) verified that as higher the alteration in the speech is,
higher the generalization to items not utilized in the treatment is too. This statement disagrees to
the result found in this research, in which, the subjects with severe degree were the ones who
less obtained this kind of generalization.
The generalization to items not utilized in the treatment and within a class of sounds,
was higher to the subjects treated with contrast and the generalization to other positions of the
words, to other classes of sounds was higher to the subjects treated with reinforce.
Conclusion
It was noticed that the group of subjects with different degrees of phonological disorder
treated with contrast or with reinforce presented an increase in the PCC, in the number of
acquired segments after therapy, as well an evolution regarding the generalizations (to items not
utilized in the treatment, to other positions of the words, within a class of sounds an to other
classes of sounds).
Through a comparison between the groups was verified a similarity in the PCC increase
as well as of the numbers of acquired sounds.
Despite no differences between the groups treated with contrast and with reinforce
regarding the increase in the PCC and in the number of acquired segments after therapy, were
observed some differences regarding generalization. The subjects treated with contrast
presented higher generalization to items not utilized in the treatment and within a class of
sounds, while the subjects treated with reinforce presented higher generalization to other
positions of the words, to other classes of sounds.
The results of this study together with the knowledge of the phonological system of a
disorder child and the kinds of generalizations necessary to each case, may be useful in the
choice of a more effective target-sound (contrast or reinforce), and it may contribute with
the acquisition of the phonological system as well with the improvement in the intelligibility of
the childs speech.
188
P080
AVERAGE TIME FOR SPEECH THERAPY DISCHARGE BASED ON THREE
PHONOLOGICAL MODELS
Bolli Mota H.1, Wiethan F.M., Melo R.M.
1UFSM
Introduction and aims of the study

The literature in the area of phonological disorders (PD) often deals with the already
established phonological models, by comparing them with each other in terms of generalization
(Ceron & Keske-Soares, 2007), acquisition of sounds (Keske-Soares et al., 2008) and distinctive
features (Mota et al., 2007), or even by making comparisons of these traditional models with new
therapy approaches (Wren & Roulstone, 2008). Still, several authors propose new models of
therapy, as the Parents and Children Together Approach: PACT (Bowen & Cupples, 2006) or the
Multiple Oppositions Approach (Williams, 2006). However, few studies have been found
considering the time required for determining the speech therapy discharge.
Thus, the goal of this paper is to compare the average time for speech therapy discharge
between three therapy models for phonological disorders - Modified Cycles Model (Tyler,
Edwards and Saxman, 1987); ABAB-Withdrawal and Multiple Probes Model (Tyler and
Figurski, 1994) and Maximal Oppositions Approach (Gierut, 1989).
Methods
The data from this study are from the database of two research projects linked to an
institution of higher education in Brazil and duly approved by its Ethical Research Committee
(ERC) with the numbers 052/04 and 046/02.
The database of the two projects is comprised by a total of 197 subjects, all of them
diagnosed with PD. Considering the inclusion and exclusion criteria, the corpus of this research
consisted of speech data of 38 subjects, aged between five and six years and eleven months.
The following inclusion criteria were adopted: age between five and six years and eleven
months; having parent or guardian permission to participate in the research by signing the
Consent Form; presenting diagnosis of phonological disorder classified as mild deviation (PCCR between 86% and 100%) or mild-moderate deviation (PCC-R between 66% and 85%) and
having received speech therapy through one of the following phonological models: Modified
Cycles Model (Tyler, Edwards and Saxman, 1987); ABAB-Withdrawal and Multiple Probes
Model (Tyler and Figurski, 1994) or Maximal Oppositions Approach (Gierut, 1989); besides
having had speech therapy discharge.
The adopted procedures for the treatment were the following:
Modified Cycles Model: It started with the evaluation of the phonological system of
choice for phonological processes. Thus, for each phonological process chosen were
determined two target sounds to be stimulated by means of six to ten words in pictures
presented to the child. Each target sound was stimulated during an entire session of
therapy lasting 50 minutes, with two sessions per week. The session started and ended
with the reading of auditory bombardment for the child; following activities that enabled
the production of target words were performed. A phoneme could be stimulated by two
189
subsequent sessions unless there was a minimum of 20% of correct production in one
session. At the end of the cycle the survey was carried out (six figures for spontaneous
naming for each target sound, other than those worked in therapy) to determine whether
there was generalization. If the poll had 50% or more of correct production, the sound
target could be stimulated again in the context of sentences. If the correct production was
less than 50%, the cycle was repeated using single words again (Tyler, Edwards and
Saxman, 1987).
ABAB-Withdrawal and Multiple Probes Model: The model started with the collection
and analysis of speech data (A1) to determine the target sound. The intervention began
with the first cycle of treatment (B1), which lasted for nine sessions, held in five weeks
(two weekly sessions of 45 minutes). During the first cycle of treatment, there were polls
of the target sound through the Targeted-basic tests (BAPs - figure nomination used for
treatment and over 24 pictures that contained the target sound in different positions and
syllable structures). After the first cycle, there was the withdrawal period (A2) with no
direct intervention with the target sound (five sessions). During this period, the survey of
the phonological system through the Generalization Tests (naming and spontaneous
speech) was conducted. At the beginning and end of each therapy session, the auditory
bombardment of fifteen words was read. If the child obtained a percentage of over 50%
of correct production of target sound in BAPs, it would be possible to change the target
sound in the next cycle of treatment (Tyler and Figurski, 1994).
Maximal Oppositions Approach: Based on the evaluation of the phonological system,
targets for therapy were chosen. They consisted of pairs of words, differing only in one
phoneme and with distinction in meaning. The treatment was conducted in two phases:
spontaneous production and imitation. In both phases, pairs of drawings of words were
presented to the child. In the imitative phase, the child repeated the verbal model of the
therapist. The treatment continued until the child kept 75% of correct imitative
production in two consecutive sessions within a minimal pair form or for at least seven
consecutive sessions. The treatment then passed to the spontaneous phase with the
childs production of the words without modeling the therapist. This phase remained the
same until the child was able to maintain a correct production of 90% in three
consecutive sessions, with a minimum pair form or for at least twelve consecutive
sessions (Gierut, 1989).
The criteria adopted to verify the therapeutic efficacy, and thus determining speech
therapy discharge were: having acquired and automated all phonemes of the phonetic and
phonological inventory of Brazilian Portuguese, considering all the structural and functional
components of generalization (Elbert and Gierut, 1986).
The sample consisted of 38 children, eight treated by the Modified Cycles Model, 18 by
ABAB-Withdrawal and Multiple Probes Model, and 12 by the Maximal Oppositions Approach.
The data analysis counted the number of sessions in which there was direct speech
therapy. After that, the data were tabulated by the Excel program and analyzed statistically by
the Statistical Analysis System program, version 8.02, using the Kruskal-Wallis test with level of
significance at 5%.

Based on the data analyzed, it was found that the average number of sessions for the
Modified Cycles was of 23.0, with a minimum of six sessions and a maximum of forty-eight, and
standard deviation of 15.5. Hodson (2006) conducted a case study using the Cycles Model
190
(Hodson & Paden, 1991) with a 7-year-old boy who had essentially unintelligible speech. The
author found that it took this child 16 sessions to promote change in the phonological system in
a single cycle because of the severity of his phonological disorder. The patient could only be
discharged from speech therapy after this period. By correlating data from Hodson (2006) with
the data from this research, it is possible to suggest that the higher the severity of phonological
disorders is, the greater number of sessions is required for speech therapy discharge.
This study also pointed out that the average number of sessions for the ABABWithdrawal and Multiple Probes was of 18.5, with a minimum of nine sessions and a maximum
of thirty-six, and standard deviation of 9.5.
Keske-Soares (2001) applied the ABAB-Withdrawal and Multiple Probes for Portuguese
speakers in Brazil, and analyzed the first cycle of therapy. According to the data from the
author, it could be observed that the less severe the phonological disorder is, the closer to the
phonological pattern of their native language the children got during the analyzed period. Thus,
a possible forecast for the continuity of treatment of these subjects would be that fewer cycles
were needed to obtain speech therapy discharge.
This research also found that the average number of sessions for the Maximal
Oppositions was of 20.6, with a minimum of six sessions and a maximum of forty-seven, and
standard deviation of 12.0.
Dodd et al. (2008) showed that both the Minimal Oppositions and the Maximal
Oppositions had a good improvement after six therapy sessions. However, the authors did not
specify the degree of phonological disorders presented by the children studied, neither the
criteria for determining these developments.
After comparing the three therapy models in this study, it was observed no statistically
significant difference between the number of sessions held in each of them (Chart 1).
Chart 1: Comparison of the three therapy models
Legend: The statistical Kruskal-Wallis test with level of significance at 5% was used. The p value
found was of 0.776.
In a study, Ceron and Keske-Soares (2007) reported that all subjects who underwent
speech therapy by means of Modified Cycles, ABAB-Withdrawal and Multiple Probes and
Maximal Oppositions showed gains in the phonological system related to the generalization of
items not used in the treatment; however, the last two models tested by her proved to have
191
higher percentages of generalization. It is emphasized that her study did not consider the
number of therapy sessions in each model, which, if considered, could affect these results.
Keske-Soares et al. (2008), in a similar study, concluded that the three phonological models
studied were effective in the treatment of different degrees of severity of the PD from equal
proportions; however, the study also found that the group with more severe deviation had the
highest changes in the phonological system.
Thus, this study showed that there is a need for more research comparing the
phonological models related to the number of sessions required to determine speech therapy
discharge, including other models of therapy, in addition to other degrees of severity of
phonological disorders and other age groups.
Conclusion
The three therapy models were equally effective, since they promoted the speech therapy
discharge and showed no significant difference in the average time of therapy for the cases of
phonological disorder.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
BOWEN, C.; CUPPLES,L. PACT: Parents and children together in phonological therapy. Advances
in SpeechLanguage Pathology, September 2006; 8(3): 282 292.
CERON, M.I.; KESKE-SOARES, M. Terapia fonolgica: a generalizao a itens no utilizados no
tratamento (outras palavras). Rev CEFAC, So Paulo, v.9, n.4, p. 453-460, 2007.
DODD, B. et al. The impact of selecting different contrasts in phonological therapy. International
Journal of SpeechLanguage Pathology, 2008; 10(5): 334 345.
ELBERT, M.; GIERUT, J.A. Handbook of clinical phonology. London: Taylor & Francis; 1986.
GIERUT, J. A. Maximal opposition approach to phonological treatment. Journal of Speech and
Hearing Disorders, 54, 9-19, 1989.
HODSON, B.W. Identifying phonological patterns and projecting remediation cycles: Expediting
intelligibility gains of a 7 year old Australian child. Advances in SpeechLanguage Pathology,
September 2006; 8(3): 257 264.
______; PADEN, E. P. Targeting intelligible speech: A phonological approach to remediation. 2nd
ed. Austin, TX: ProEd, 1991.
KESKE-SOARES, M. Terapia fonoaudiolgica fundamentada na hierarquia implicacional dos
traos distintivos aplicada em crianas com desvios fonolgicos. Thesis (Doutorado em Letras)
Faculdade de Letras, PUCRS, Porto Alegre, 2001.
______, et al. Therapy effectiveness for phonological disorders with different therapeutic
approaches (original title: Eficcia da terapia para desvios fonolgicos com diferentes modelos
teraputicos). Pr-Fono Revista de Atualizao Cientfica. 2008; 20(3):153-8.
MOTA, H. B. et. al. Anlise comparativa da eficincia de trs diferentes modelos de terapia
fonolgica. Pr-Fono R. Atual. Cient., Barueri (SP), 19(1), p.67-74, 2007.
TYLER, A.; EDWARDS, M. L. e SAXMAN, J. Clinical application of two phonologically based
treatment procedures. Journal of Speech and Hearing Disorders, v. 52, p. 393 409, 1987.
TYLER, A.; FIGURSKI, R. Phonetic inventory changes after treating distinctions along an
implicational hierarchy. Clin. Linguist. Phon. 1994; 8 (2):91-107.
WILLIAMS, L. A systematic perspective for assessment and intervention: A case study. Advances
in SpeechLanguage Pathology, September 2006; 8(3): 245 256.
WREN, Y.; ROULSTONE, S. A comparison between computer and tabletop delivery of phonology
therapy. International Journal of SpeechLanguage Pathology, 2008; 10(5): 346 363.
192
FP40.4
AN ALTERNATIVE METHOD OF READING IMAGE-VOICE-GRAPHEME
V. Bougiotopoulou, Ph. D
Logopedist, private practice, Athens
Aim: We are going to introduce you in an alternative method of teaching children with
speech and language disorder (dysphasia, phonological disorder, learning disabilities, dyslexia)
how to read.
Method: For the best comprehension of reading we will incorporate a conventional
segmentation of it. The reading faculty according to Yegorof T.G. (1963) begins and is being
completed through from the following stages:
The stage of sound-grapheme analysis acquisition (Phonological awareness).
The stage of syllable reading acquisition.
The stage of overall methods of perception determination.
The stage of knowledge of synthetic reading.
Within the stage of sound-grapheme analysis children analyze the continuous sound
flow of oral speech in sentences, sentences in words, words in syllables, and syllables in the
phonemes that constitute them. So, when a child is in position to segment oral speech in its
structural elements, then it means that he/she has good phonological awareness. This enhanced
phonological awareness constitutes the base for the development of reading. Only after this
segmentation, letters should be proposed, as optical mirroring of phoneme.
Then, during reading the child accomplishes the composition graphemes on the syllable
and on the word, correlates the written word with the oral word of articulated speech. In order
this to be accomplished, child should be totally aware of the acoustic form of phoneme since
only then he/she will not confuse that particular phoneme with other phonemes that have
acoustic-articulate resemblances (f-v, p-b, etc).
For the child that begins reading, letter is not a simple graphic component. It is complex
in its graphic constitution. It is constituted from a number of different elements which have
different positioning and orientation in space. (Lalaeva 1998).
The acquisition of optical representation of letters could only be achieved through the
satisfactory development of child optical-spatial faculties, furthermore, the direct capability of
child for fast retraction and reproduction of optical form of letter in his/her memory.
As a result, the successful and fast acquisition of knowledge of the first stage of reading
process can only be achieved when the following operations have been shaped at a satisfactory
level:
Phonological perception (recognition and differentiation phonemes).
Phonological analysis (segmentation phonemes in the syllable).
193
Optical analysis and composition (faculty of differentiation of resemblances and letters

differences)
Optical-spatial perception (faculty for right placement of graphic elements in space).
The basic difficulty in this stage is the blending of phonemes in the syllable, at the very
moment when natural transfer is taking place between one articulation position to another.
Reading at this stage is very slow. The conceptual comprehension is almost impossible if
repetitive reading doesnt take place.
At the stage of syllable reading graphemes recognition and decoding in their phonemes
at the ending of syllable is completed without difficulty. The syllables are correlated relatively
fast with the sound combination represented by their graphemes. At this point the syllable
constitutes a unit of reading. Reading pace, at this stage is slow enough since reading is still
analytic. The child reads the word from its constituted pieces, that is to say the syllables, and
only after these are linked by word, he/she can comprehend their meaning. At this stage,
conceptual forecast of the last syllables of word takes place.
The stage of creation of overall methods of perception is the transient stage from the
analytic method of reading to synthetic. At this stage simple and known words are read in total,
while low frequency and unknown words are still read in syllabus. A child conceives words, not
individually within the text but as parts of phrases. Nevertheless, composition during
perception process of perception is characterized still by immaturity.
At this point conceptual forecast plays an important role. The child tries to hold on the
meaning of what has read without yet having the ability to check precisely and fast the
projection that he made with the help of text, perception; since this process did not reach in the
required maturity level.
At this stage a gap is created between perception and comprehension of reading text,
resulting to one process stopping the other. The conceptual forecast takes place only at the end
of proposal and not in the content of all text. This stage is completed with the connection of
words between them in the proposal. The pace of reading is satisfactory and the reading
continuous.
At the stage of synthetic reading, reading is total, meaning that words are read entirely
as well as groups of words. The technical part of reading is not an obstacle for the reader. The
objective is the direct and fast comprehension of what he/she reads. In this stage not only the
connection of words in the proposal is completed as in previous stage but also the connection of
proposals between them within the text. The reading becomes fast and expressively. Thus the
comprehension of text presupposes rich vocabulary and high level of grammatical and syntactic
structure of language.
The basic principles of image-voice-grapheme reading method are based on the
theoretical theses formulated by Russian psychologists and logopedists: Vygotski L.S. 1935,1960,
Galperin P.G. 1969, Leontev A.N. 1975, Elkonin D.B. 1995, Levina R.E 1961, Lalaeva R.I.
1986,1998.
The first principle is based on multi sensor approach. The attendance of all senses, sight,
hearing, articulation and touch. The attendance of all these senses ensures the multiple coding of
one and only symbol (in this case this symbol is the phoneme, the syllable, the word, the
proposal) in different code systems.
The second principle is based on sensor operations that are healthy and do not present
any deficits. Children with language disorder acoustic perception or even articulation is
disturbed. The choice of sensor ways of perception and information interpretation is based on
194
the senses without deficits, in the optical perception, in the touch perception and in the
phonemes articulation, for those phonemes that articulation is not disturbed.
The third principle zone of proximal development (Vygotski L.C.). The escalation of
difficulty level in activities that are included in the method is strict so that each activity
proposed presents minimal and smaller level of difficulty from the immediately previous. The
method begins by activities that present a difficulty degree very little below a child can
accomplish. In this way we achieve the direct satisfaction of child, but also his engagement to
keep on with the following activities that become more and more difficult, without exceeding
his capabilities.
The next principle takes into account the stages of acquisition of any intellectual action
(Galperin P.G.). Each intellectual action becomes a reality through 4 stages. At the first stage the
preliminary perception for the future action is created. It is the basis on which the individual
directs himself towards the future action that it is called to materialize. At the second stage
action is materialized and is acquired with the help of practical "tools". In the third stage the
action is only materialized with the help of intensed oral speech. At the fourth and last stage the
ability is acquired internally, at the level of mental representation.
According to the theoretical principle by Vygotski L.C. "circularity of mental
development" the development has complex organization in the time. Each stage of mental
development is a circle that has its own pace and its own content. The pace can change in
various periods of the child life. The transient process from one stage to another presupposes the
re-creation of soul structural elements in total. These re-creations are materialized due to the
dominant activity of the particular stage of mental development in which child is. There Are 6
stages of dominant type of activity in the life of a person. In the preschool age the game is the
dominant type of activity.
The method was also based on the difficulties of children with language disorder that we
faced in our logopedist practice (for 15 years) trying to develop the phonological awareness and
to teach these children reading.
READING WITH IMAGE-VOICE-GRAPHEME METHOD

Each phoneme of Greek language is reflected on a particular image. In each image the
visual representation of graphemes that corresponds to the particular phoneme "is hidden"
having unique color. Each phoneme also corresponds to a particular, unique movement of hand
for each phoneme (we call it phonetical-rhythmic) (Vlasova T.M. & Pfafenrodt A.N.).
The order by which phonemes are imported and accordingly graphemes is not regulated
by their frequency of use in the words; it depends on the following factors:
a) Easiness of phonemes acoustic perception (the vowels are imported before the consonants).
b) Difficulty of composition of phonemes in one syllable.
c) Level of dexterity cultivation in child articulation.
Image-voice-grapheme method has a strict order of steps:
1. Presentation of Picture image -voice-grapheme and picture name.
2. Presentation of phoneme that corresponds to the image-voice-grapheme
3. Search and Find of the symbol-grapheme that is hidden.
4. Presentation of articulation profile as an image.
5. Presentation of "Phonetic rhythmic"-movement that corresponds.
6. Acoustic discrimination of phonemes that was taught with image-voice-grapheme.
7. Presentation grapheme. Optical search,find & corresponds with image- voice-grapheme.
8. Verbal Connection of grapheme and image-voice-grapheme with poem.
195
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Conundrum that they reveal concrete grapheme.

Search and Recognition of grapheme with the touch.
Stress with image-voice-grapheme.
Intonation with image-voice-grapheme.
Points of punctuation with image-voice-grapheme.
Analysis syllable with image-voice-grapheme.
Composition syllable with image-voice-grapheme.
Reading syllable with image-voice-grapheme.
Analysis word with image- voice-grapheme.
Reading word with image-voice-grapheme.
Significance and use of stress with image-voice-grapheme.
Results: 100% of children with children dysphasia and phonological disorder learned
reading prior first class. 90% of children with dyslexia and learning disabilities read
satisfactorily. 100% of children without language disorder aged 5-5,5 years learned how to read
easily and satisfactorily in 32 sessions. Last 5 years the method keeps on being applied in the
daily logopedist practice with on going results.
Conclusions: "image-voice-grapheme" method constitutes functional and essential tool
in the development of phonological disorder and in the acquisition of reading of children with
language disorder beginning from the age of 4 years with pleasant and funny way. The children
without language disorder learn reading with pleasant and amusing way playing.
References
Elkonin, D.B. (1995). How to learn children reading. Psychological development of child p.323-349 Moscow,
(in Russian).
Galperin, P.G. (1969). Method successive stages of intellectual action. Journal Psychological questions Issue
1, 97-101 Moscow, (in Russian).
Lalaeva, R.I. (1986). Aspects of study of written speech disorder in children. Study and therapy of speech
disorder. Leningrad, (in Russian).
Lalaeva, R.I. (1998). Reading Disorder. Saint-Petersburg, (in Russian).
Vlasova, T.M. & Pfafenrodt, A.N. (1989). Phonetic rhythmic. Moscow, (in Russian).
Levina, R.E. (1961). Reading and writing disorder in children with language disabilities. Moscow, (in
Russian).
Vygotski, L.S. (1935).Intellectual development in educational processes. Moscow,(in Russian)
Vygotski, L.S. (1960). Development of higher mental operations. Moscow, (in Russian).
Yegorof, T.G. (1963). Psychology of reading process acquisition. Moscow, (in Russian).
196
FP40.2
SOCIAL AND EMPLOYMENT INTEGRATION OF ADOLESCENTS WITH
AUTISM: AN EDUCATIONAL TEACHING PROGRAM MOVING FROM SCHOOL
TO WORKING PLACE.
A. Bovoli
EEEEK, SERRES, GREECE
INTRODUCTION AND AIMS OF THE STUDY

The literature regarding vocational training for adolescents and adults with autism is
limited internationally and considerably less in the Greek reality. This is contradictory since
autism is a lifelong developmental disorder (Hawlin, 1997). The professional training is one of
the serious issues that concern the adolescents and the adults with autism. More generally, the
professional integration of individuals with autism is considered one of the more basic
dimensions of integration of adults in the community and in order to achieve this, needs to
begin in a very early age. This has particular application for individuals that belong in the
autistic spectrum disorders, given the difficulties that they face with social skills (Jordan, 1995).
In the opposite other side, for the individuals that are in the autistic spectrum disorder,
working in the community, can be proved particularly important, as it is connected with their
need for routine or the use of their free time and therefore contribute in their quality of life
(Jordan, 2001 Howlin, 1997). The results from other countries, where have been applied
programs for vocational training of individuals with autism, show that with suitable preparation
certain individuals with autism and high function autism can be part of the working force of
their country (Mesibov, Shea and Schopler, 2004). Based on these issues, a pilot program was
developed in order to train student to move from school to a specific working place which is
presented and is analyzed according to the observations of the team that worked together with
the student.
In this work is presented a first approach towards a students with autism practical
experience in a real working place. The student with autism is enrolled in a public Special school
for vocational training in Greece. This pilot program aims to teach students with autism
vocational skills and to apply them in a working practical experience. This practical experience
had 6 months duration with weekly visits in the working place. For the transition of the
vocational skills from the school environment to the working place, the principles of Supported
Employment and Structured Teaching (Treatment and Education of Autistic and
Communication Children Handicapped-TEAACH) were applied. What presents particular
interest in this case is that the student with autism has the potential to be included afterwards,
i.e the end of school, in real working place with small degree of support. The first conclusions
from her attendance in the program are particularly important for the better planning and the
preparation of such undertaking.
METHODOLOGY
The student was enrolled in a Weaving factory(W.F) that is situated in the outskirts of
the city. In this factory, other three people are working and use four looms. During students
197
placement a special space was organised in order for her to work there. The student visited also
the factory once a week and towards the end of the school year up to twice a week.
A. Teaching Organization
For the last three years, the student studies in a public Special School for vocational
training and she enrolled in the Weaving Class. For this, was considered suitable integrate her
in a Weaving Factory. The process of working placement integration began with the
educational evaluation, which estimated her skills, the strengths as wells as her difficulties and
was continued with the application of a specific model(TEACCH) of employment such as the
Supported Employment and Structured Teaching(TEACCH) (Mesibov, Sea and Schopler, 2004).
After that, the working place was selected according to the interests and the education that
already had received the student at the school. Following that, were used systematically visual
instructions, which constitute the corner stone of this particular program. With regard to the
layout of the physical environment (i.e working place) a special space was created for the
student where a loom was placed in order for the student to weave the carpet that she had to.
Afterwards, the team of teachers and therapists that were responsible for the student, created
the daily program using visual cues (pictures). The use of the daily program began from the first
day of her work using public transport going to the working place, and back to school. The
student was taught to use the daily program by herself, so that she can maximize her
independence.
The bigger challenge for the team of teachers, therapists and employer was the steps of
such a working system i.e of what activities that it would be completed by the student in the
working place, because this structured methodology was not followed in the weaving class at
her school and the teachers were called to apply the knowledge in a new level. The working
system had the form of list of pictures and concerned the process of weaving (i.e lines, knots) a
carpet. The activities were analyzed in small steps (task analysis). The presentation of steps
became mainly with the use of pictures (visual instructions). For example, after weaving a line,
she checks the implementation of a step by turning upside down the relevant picture (i.e. the
picture that signaled the line for visual clarity). The list with the pictures that were given in the
student, were placed in the right side of the wooden frame of the loom.
Initially, what was observed by the team of teachers, therapists and employer was that
student presented a resistance in the use of visual instructions. Possibly it had difficulty to
develop her independence, self-monitoring and also monitoring of her work. However, this
students reaction was reduced progressively.
With regard to the activities, some were already familiar to the student, while others
were new. One of the activities with which she was familiarized was the creation of knots. A
particular activity for the Weaving factory was the creation of different patterns in the carpet
using various colors. The student was practicing in this during her working placement,
extensively. Furthermore, she learnt to choose the right colors and she learned to use them for
the right pattern in the carpet. Afterwards, the student tried to follow the right drawings (i.e the
carpet had specific drawings). The organizational skills such as storage and classification of tools
and materials are particularly important for a Weaving Factory and simultaneously they are
skills that individuals with autism need (i.e the need for order and organization).
More generally, as the student practiced the tasks, which she could not practice at school,
had the opportunity to participate actively and to comprehend the complete circle of production
The student was enrolled in a Weaving factory(W.F) that is situated in the outskirts of
the city. In this factory, other three people are working and use four looms. During students
198
placement a special space was organised in order for her to work there. The student visited also
the factory once a week and towards the end of the school year up to twice a week.
B. Teaching Strategies and Aims
The strategies that were used for the student in this particular working place, concerned
mainly with the practical application of the principles of structured teaching. The student had
not been trained before to use this approach in the school environment. It was considered that
the particular approach would help her to become as independent as possible and also strength
her self-confidence. The main objective was the reduction of her dependence from the teachers
or her future employer. Still, it was important for her (student) to be able to apply what she has
learned without supervision and to evaluate the results of her work and to correct it where it
needs. The general objectives that developed based on her skills in the working place were: a) to
learn working based on her individual program and b) to be able to follow steps in order to
complete her work. More specifically, the aims while she was working in the weaving factory
were: a) to learn to work based on the individual program b) to learn to follow steps in order to
complete her work. More specifically, the objectives that were placed for the work were: 1) to
learn to handle independently more equipment 2) to develop self-confidence for her skills at
work, for example different colour lines and 3) to develop skills that will help her to wave
carpets with different shapes and forms. Moreover, she will learn to coexist and work next to her
trainee in the same loom, to control her anxiety and force, and to improve her social skills
especially her communication. As a last goal was to learn to take her own initiative in the work
that she undertook.
With regard to her social behaviour, the main objective was to learn to behave
appropriately in the working place. According to the skills assessment, student has all formal
conditions in order to achieve these objectives. Moreover, she is a teenager that with suitable
support can become independent and she can have a place in the job market. The main goals
that were placed in the sector of social behaviour was A) to focus on her work and do not speak
a lot when she works, as this can have negative results for the outcome of her work. For this
reason the goal was to talk to specific people at work and to discuss with these people specific
issues. For a long-term goal, it was important to learn to follow the rules that concerned a real
working place and to comprehend that these are different from the rules that are in the school
environment. Still, it was considered as important objective for her independency to learn to use
public transport.
RESULTS
The students attendance in this pilot program presented difficulties but had also
important outcomes. With regard to the students opportunity of practicing her skills, was that
she exposed in different conditions from those of schools and comprehend that she was in a real
working place where she was called to respond in structured duties. Her weaving skills were
improved considerably, especially when she had to weave complicated carpet drawings.
According to the students working supervisor, the student undertook gradually more
initiatives of her own on her work. Student felt responsible and proud that participated by
herself in the program. Moreover, she was more concentrated in her work in the Weaving
Factory, than at school. This was, perhaps, because she learnt to follow her working schedule
and in the working place were few people working. With regard to the students social
behaviour were presented certain challenges. Often, in the Weaving Factory were visits from
people that she did not know. Also, she was not aware of the time of their visit. This caused
199
agitation and it was a reason to interrupt her work. According to the working supervisor and
the team of the teachers progressively helped her to show tolerance for those visits.
Another issue that needs to be addressed was that while initially she refused to follow
her work schedule, progressively she adapted to that. Something that influenced her behaviour
was the use of the public transport. This, activity was not familiar to her before. She had to travel
from her home to school and afterwards from school to working place and again back to school
and then she had to return back home. These continuous alternations of places and people made
her often feel upset and this had sometimes affected her work. Also, this had important effect in
her behaviour. According to her working supervisor and the team, if this travelling was limited,
that is to say if she returned in the working place straight from her home, certain problems
would have been avoided.
With regard to the working place and the working supervisor important role appears to
be that the supervisor was a well-known person to the student. Thus, we earned some time in
order the student to familiarize herself with the supervisor. With regard to the students
adaptation, the requirements were decreased as she knew already the supervisor. Hence, the
student had to familiarize herself only with the other employees and the working place.
One of the basic questions that were addressed was the lack of time for the completion of
the program. Generally speaking, if there was the possibility to apply such a program for longer
period of time, perhaps during the whole academic year, the results would have been even more
encouraging. More time was needed for the team of teachers in order to adapt the data that
concerned the students integration in a real working place as the conditions in this differ by far
from the conditions in a protected school class.
CONCLUSION
The main conclusion that results from this pilot application of program that concerns this
transition of individuals with autism in working place is that the good preparation and
organisation of such transition can contribute in the success of integration of individual with
autism. This conclusion is supported by the team of the teachers , therapists as well as from
working supervisor. Also this is in an agreement with the relative international bibliography
(Howlin, 1997 Mesibov, Shea and Schopler, 2004).
This preparation includes various parameters, as for example the step by step
preparation of student in the working place, the familiarization with the place, with the workers
and the setting. This dimension partly had been successfully satisfied in this study because the
student knew well the working supervisor. However, the other employees should be informed
in time and more substantially for the student. Employees that are not informed for
fundamental subjects that concern the integration of such a student, will show little tolerance
and is likely to reject the individual with autism. Therefore, it is proved through this study that
the process of integration could become with the discussion and with the use of audiovisual
means (video), in order that the recipients comprehend the person with whom they are going to
work with.
The good comprehension can lead to the acceptance and to the positive attitude. The
third dimension concerns the preparation of the school team which will integrate the student to
the working environment. Teams competences should be explicit, that is to know well the
individual with autism and has good collaboration with the working supervisor. What we
realised during this program was that it is important and useful to set the limits among teamstudent working supervisor. More specific, the team suggested that the working supervisor
should know beforehand the tasks that the student needs to learn and afterwards trains this
200
individual in the particular activities, in order the individual with autism to be ready for his/her
new place in the working place.
In our case the student confirmed the basic conclusion that is recorded in the
bibliography with regard to the employment opportunities of individuals with autism: that the
basic obstacle is the lack of suitable social behaviour in the working place (Mesibov et al, 2004).
However, with the appropriate education in the social skills, which is important to begin as
early as possible for an individual with autism and no just before the student goes from the
school environment to the community, this obstacle can be overcome(Howlin, 2003). This is the
basic way that can ensure the success and the long term integration in the community and the
harmonious coexistence with the others in the future.
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FP19.2
EFFICACY OF THREE DIFFERENT MODELS OF REMEDITION PROGRAM FOR
BRAZILIAN STUDENTS WITH DYSLEXIA
Simone Aparecida Capellini UNESP
Lara Cristina Antunes dos Santos UNESP
Maria Dalva Lourenceti UNESP
Niura Aparecida de Moura Ribeiro Padula - UNESP
INTRODUCTION
Dyslexia is a specific learning disorder of neurological origin, characterized by difficulty
with the correct fluency in reading ability and difficulty in decoding and spelling, from a deficit
in the phonological component of language (Lyon, Shaywitz & Shaywitz, 2003).
Studies (OShaughnessy & Swanson, 2000, Odegard et al., 2008, Kipp & Mohr, 2008, Salgado &
Capellini, 2008, Germano & Capellini, 2008) developed to verify the effectiveness of the
remediation program in students with dyslexia concluded that that there was an improvement in the
phonological processing, which led to the emergence of syntactic and phonological awareness (Strehlow et al., 2006; Bonte,
Poelmans & Blomert, 2007).
AIM
This study aimed to verify the therapeutic efficacy of phonological remediation program,
reading program, and phonological and reading remediation program in Brazilian students with
dyslexia
METHODS
The study included 60 Brazilian students from 2nd to 4th grades of elementary school in
the city of Marilia - SP, from both genders, aged 8 to 12 years old. The students were divided
into three groups:
Group I (GI): 20 students with interdisciplinary diagnosis of developmental dyslexia
were subdivided into Group IE (GIE): 10 students with developmental dyslexia submitted to the
phonological remediation program and Group IC (GIC): 10 students with developmental
dyslexia not submitted to the phonological remediation program.
Group II (GII): 20 students with interdisciplinary diagnosis of developmental dyslexia
were subdivided into Group IE (GIIE): 10 students with developmental dyslexia submitted to
the reading remediation program and Group IC (GIIC): 10 students with developmental
dyslexia not submitted to the reading remediation program.
Group III (GIII): 20 students with interdisciplinary diagnosis of developmental dyslexia
were subdivided into Group IE (GIIIE): 10 students with developmental dyslexia submitted to
the phonological and reading remediation program and Group IC (GIIIC): 10 students with
developmental dyslexia not submitted to the phonological and reading remediation program.
This study was elaborated according to research about phonological and reading
remediation programs (Hatcher, Hulme & Ellis, 1994). The procedures for pre and post-testing
included Cognitive-Linguistic Test, collective and individual parts (Capellini et al., 2007)
composed by alphabetic recognition, copy of form, arithmetic, words and nonwords spelling,
202
short memory with digits, words and nonwords reading, rhyme, alliteration, sound
discrimination, number repetition, words and nonwords repetition, visual memory, rapid
automatized naming of number and pictures, sequence of days of the week and months of the
year and counting numbers in reverse order, and pictures reversion. Reading and
Comprehension Test (Capellini, 2001).
After these procedures were applied, the phonological and reading remediation was
applied in 3 phases: pretest, training, pos-testing. Each program involved 22 sessions,
established by the researcher in 50 minutes with each child individually, twice a week, being 18
sessions for the remediation procedure and 4 sessions to realize the procedures of the pre and
post-tests.
The phonological remediation program was composed by 10 activities: sound and letter
identification, identification of word inside the phrases, identification and manipulation of
syllables in the word, phonemic synthesis, rhyme, sound identification and discrimination,
phonemic segmentation, phonemic deletion, phonemic substitution, phonemic transposition.
The reading program was composed by 18 books with the syllabic complexity of the
Portuguese Language. The students read one book for the session and the complexity of the
book was only modified when the students obtained 94% of accuracy in the reading.
The phonological and reading program was a combination of strategies of the
phonological and reading programs.
The results were statistically analyzed by the program SPSS (Statistical Package for Social
Sciences), version 13.0. The Friedman Test and the Wilcoxon signed-rank test were also used. A
level of significance of 5% (0,050) was adopted for the application of the statistical tests

The results obtained in the Cognitive-Linguistic Test, collective and individual parts in
the pre and post-testing showed that the students presented difficulties in the words and
nonwords reading, sounds discrimination, rapid automatized naming, phonological awareness
and verbal memory, according to the literature (Paul et al, 2006, Bont, Poelmans & Blomert,
2007, Puolakanaho et al., 2008).
The effectiveness of the three remediation programs of this study was observed due to
the fact that the students presented statistically significant difference between the two moments
of the evaluation, which showed improvement in post-testing compared to the pre-testing in the
field of cognitive linguistic skills evaluated.
In general, the cognitive-linguistic skills that presented superior performance after the
programs were: recognition of the alphabet, word reading, nonword reading, repetition of
words and nonwords, memory for digits, alliteration, rhyme, rhythm, rapid automatized
naming for figures and digits, sequence of days of the week and months of the year and
counting numbers in reverse order. This probably occurred because the programs directly
focused on the skills of auditory discrimination. This skill according to the literature (Dufor et
al., 2007, Boets et al., 2007) is altered in the dyslexic students, resulting in the impairment of the
letter-sound mechanism necessary for the achievement of reading and spelling of words and
nonwords, memory and sequencing information.
Thus, it can be considered that the remediation programs used in this study, with a
phonological focus, with a reading focus or a phonological and reading focus, used attention,
discrimination and auditory memory directly in all sessions, both in the particularity of the task
or in the reading aloud, which favored the development of the phonological awareness of the
203
Portuguese Language, as described in the literature (OShaughnessy & Swanson, 2000, Kipp &
Mohr, 2008, Germano & Capellini, 2008, Capellini, Padula & Ciasca, 2004).
The students of this study presented superior performance after the programs, by a
decrease of the number of words read per minute, decrease in the total time of reading and
comprehension of the reading. However, although students with dyslexia and the control
groups were not submitted to the remediation programs, they showed improvement in the
comprehension of reading. This demonstrates a lack of agreement between the work in the
classroom with the fluency and reading comprehension as described in the literature (Alves et
al., 2009).
After analyzing the number of cognitive-linguistic skills of students with dyslexia
submitted to the three remediation programs of this study, it was observed that the students
submitted to the phonological remediation program, and the reading remediation program,
presented higher number of cognitive-linguistic skills (19 and 20) with statistically significant
difference. The students with dyslexia submitted to the phonological remediation program
associated with the reading presented only 15 skills with superior performance in post-testing,
according to international studies (Magnan & Ecale, 2006, Joffe & Pring, 2008) and in
disagreement with the results of the research that offered theoretical basis for this study
(Hatcher, Hulme & Ellis, 1994). This can be explained by the Brazilian Portuguese Language
writing system, which has more standard of transparency for the conversion letter-sound than
the English language.
CONCLUSION
The realization of the phonological remediation program, the reading remediation
program and the reading and phonological remediation program was effective for the students
with dyslexia because there was improvement of cognitive-linguistic skills in post-testing
compared with the pre-testing. However, the phonological remediation program and reading
remediation program developed higher number of cognitive-linguistic skills in the students of
this study.
The findings this study showed that it is necessary to use the phonological instruction
associated with the reading in the classroom to teach the alphabetic principle of the writing
system of the Brazilian Portuguese.
REFERENCES
1. Alves, LM, Reis C, Pinheiro AMV, Capellini SA. Aspectos prosdicos temporais da leitura de escolares
com dislexia do desenvolvimento. Rev soc bras fono. 2009; 14 (2): 197-204.
2. Boets B, Wounters J, Wieringen A, Ghesquire P. Auditory processing, speech perception and
phonological ability in pre-school children at high-risk for dyslexia: a longitudinal study of the
auditory temporal processing theory. Neuropsychologia. 2007; 45 (8): 1608-20.
3. Bonte ML, Poelmans H, Blomert L. Deviant neurophysiological responses to phonological regularities
in speech in dyslexic children. Neuropsychologia. 2007; 45(7):1427-37.
4. Capellini SA. Eficcia do programa de remediao fonolgica em escolares com distrbio especfico de
leitura e distrbio de aprendizagem. [Tese]. Campinas (SP): Universidade Estadual de Campinas;
2001.
5. Capellini SA, Padula NAMR, Ciasca SM. Desempenho de escolares com distrbio especfico de leitura
em programa de remediao. Pr-fono Rev Atual Cient. 2004; 16(3): 261-274.
6. Capellini AS, Silva C, Gonzaga J, Tegeiro MG, Villa PC, Smythe I. Desempenho cognitivo-lingstico de
escolares de 1a a 4a sries do ensino pblico municipal. Rev. Psicopedagogia. 2007; 24(73): 30-44.
204
7. Dufor O, Serniclaes, W, Sprenger-Charolles L, Dmonet JF. Top-down processes during auditory

phoneme categorization in dyslexia: a PET study. Neuroimage. 2007; 46(1):241-8.
8. Germano, GD, Capellini, SA. Eficcia do programa de remediao auditivo-visual computadorizado em
escolares com dislexia. Pr-fono Rev Atual Cient. 2008; 20(4): 237-242.
9. Hatcher PJ, Hulme, C, Ellis AW. Ameliorating early reading failure by integrating the reaching of
reading and phonological skills: the phonological linkage hypothesis. Child Develop. 1994; 65: 4157.
10. Joffe V, Pring T. Children with phonological problems: a survey of clinical practice. Int J Lang
Commun Disord. 2008; 43(2):154-64.
11. Kipp KH, Mohr G. Remediation of developmental dyslexia: tackling a basic memory deficit. Cogn
Neuropsychol. 2008; 25(1):38-55.
12. Lyon GR, Shaywitz SE, Shaywitz BA. Defining dyslexia, comorbidity, teacher's knowledge of language
and reading. Ann Dyslexia. 2003; 53: 1-14.
13. Magnan A, Ecalle J. Audio-training in children with reading disabilities. Comp. Educ. 2006; 46 (4): 40725.
14. Odegard TN, Ring J, Smith S, Biggan J, Black J. Differentiating the neural response to intervention in
children with developmental dyslexia. Ann Dyslexia. 2008; 58(1):1-14.
15. OShaughnessy TE, Swanson HL. A comparison of two reading interventions for children with
reading disabilities. J. Learn. Disab. 2000; 33(3): 257-277.
16. Paul I, Bott C, Wienbruch C, Elbert TR. Word processing differences between dyslexic and control
children. BMC Psychiatry. 2006; 27(6):5.
17. Puolakanaho A, Ahonen T, Aro M, Eklund K, Leppnen PH, Poikkeus A.M, Tolvanen A, Torppa M,
Lyytinen, H. Developmental links of very early phonological and language skills to second grade
reading outcomes: strong to accuracy but only minor to fluency. J Learn Disab. 2008; 41(4):353-70.
18. Salgado CA, Capellini SA. Programa de remediao fonolgica em escolares com dislexia do
desenvolvimento. Pr-fono Rev Atual Cient. 2008; 20(1): 31-6.
19. Strehlow U, Haffner J, Bischof J, Gratzka V, Parzer P, Resch F. Does successful training of temporal
processing of sound and phoneme stimuli improve reading and spelling? Eur Child Adolesc
Psychiatry. 2006; 15(1): 19-29.
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SY05.1
PHONOLOGICAL AWARENESS: DO EDUCATORS NEED PROFESSIONAL
DEVELOPMENT?
J Carroll & G Gillon
University of Canterbury, Christchurch, New Zealand.
Aims: The importance of explicit phonological awareness instruction in literacy

acquisition of children has been much discussed in the research. The debate about the level of
explicit language knowledge, and in particular the phonological awareness knowledge of
educators working with children is also growing. The focus of some research is shifting from the
children to the adults working within classrooms, and in particular the professional
development required to prepare them to facilitate early literacy success for all children.
Method: This study investigated the phonological awareness skills of 617 educators in New
Zealand through their participation in a predominately oral 40 item Teachers Phonological
Awareness Test (Love, 1995). Participants included junior school and early childhood teachers,
speech speech-language therapists, literacy specialists, teacher aides, and pre-service teachers.
The six subtests of the Teachers Phonological Awareness Test evaluated various aspects of
phonological awareness, including syllable and phoneme identification and manipulation and
were designed to examine participants understandings of phonological awareness in some
detail. Results: The results indicated that the participants had widely differing understandings
of phonological awareness. Speech-language therapists performance was significantly better
than the other groups. Early childhood teachers demonstrated the weakest overall performance.
Phoneme identification and segmentation tasks proved problematic for teachers. Conclusions:
The results of this study suggest professional development in phonological awareness and in
particular phoneme level skills for educators this is warranted. The level and intensity of
professional development required for educators to be able to provide explicit feedback within
the New Zealand classroom contexts is yet to be investigated in detail.
Explicit phonological awareness instruction and its importance in literacy acquisition for
children has been well documented in research. Recent research has been focused on examining
the professional knowledge of eductors and para-professionals and in particular the professional
knowledge required to prepare educators to facilitate early literacy success for all children. This
research indicates that there is a wide variation in their understanding of the structure of English
necessary for explicit literacy teaching. Debate regarding what expert teachers do in the
teaching of literacy continues (Hattie, 2009; Nuthall, 2007; Snow, Griffin, & Burns, 2005) and
focuses on explicit feedback and how educators constantly and expertly adapt their teaching in
response to childrens needs.
Moats and Foorman (2003) describe in their longitudinal study how American teachers
when given a multi-choice test had difficulties with specific essential language and literacy
knowledge components e.g. differentiating between letters and sounds, detecting sounds within
words particularly when the spelling of words was not transparent. Within classroom
observations confirmed these difficulties were affecting classroom instruction e.g. teachers were
observed blending words letter-by-letter rather than sound-by-sound. Stainthorpes research
with British teacher trainees suggested that even with direct instruction about the structure of
206
words, a pencil and paper post test did not demonstrate that many trainees had sufficient
insight into the sound structure of words to effectively instruct children (Stainthorp, 2004). In a
more recent study in the USA comparing the phonemic awareness of professionals working in
literacy education, again using a pencil and paper test format, showed that speech-language
therapists had the most in-depth knowledge, although it could still not be described as
consistently proficient. Teachers had a wide range of proficiency. (Spencer, Schuele, Guillot, &
Lee, 2008)
One of the key underpinnings of teaching literacy, educators phonological awareness, is
examined in this research project.
Questions addressed are:
- How do educators perform on tasks that require demonstration of their own awareness of
the sound structure of spoken words?
- Do professional groups differ in their phonological awareness abilities?
- Do educators have the skills necessary to provide explicit instruction necessary for all the
children in their classrooms?
Method
The phonological awareness understandings of 617 educators working in New Zealand
schools early childhood centres, special education services or training to be teachers were
investigated through their participation in a predominately oral 40-item Teachers Phonological
Awareness Test (Love and Reilly, 1995). The first author administered the test to groups of up to
thirty participants under standard test conditions. All participants were given the same
instructions e.g. Write down the number of sounds in the word rust. If requested, verbal
repetitions of the test items were permitted but participants were asked not to write the words
down. No explanations of terminology e.g. phoneme or sound were given, even if requested.
Participants
Participants were recruited during their participation in an oral language / literacy
workshop with the exception of the Bachelor of Teaching and Learning students who
participated as part of a lecture within their usual university programme.
Participants included.
1. Speech-language therapists (n=34) employed by the Ministry of Education and
experienced in working in New Zealand schools.
2. Junior School Teachers (n=160) working in mainstream New Zealand schools in a range
of socio-economic areas.
3. Early Childhood Educators (ECEs) (n=20) working in mainstream New Zealand Early
Childhood facilities in a range of socio-economic areas.
4. Resource Teachers of Literacy (RTLits) (n=80). All were experienced teachers with a Post
Graduate Diploma in Literacy Education.
5. Resource Teachers of Learning and Behaviour (RTLBs) (n=23) All were experienced
teachers with a Post Graduate Diploma in Special Needs Resource Teaching.
6. Teachers aides (n=48) employed by schools to assist teachers in oral and written
language instruction in junior school classrooms. Most of the teachers aides indicated
that they had no formal qualification and learnt skills as they worked.
207
7. Students in their final (third) year (Yr3BT) (n=99) of their undergraduate degree in
primary education.
8. Students in their first year (Yr1BT) (n=153) of their undergraduate degree in primary
education.
Measurement
The Teachers Phonological Awareness Test has six subtests evaluating various aspects
of phonological awareness. The first four sub-tests (one syllable and three phoneme awareness)
were administered orally e.g. How many syllables in the word animal? with the participants
noting their answers on a score sheet. The syllable subtest had multi-syllabic words ranging
from two syllables e.g. caution to five syllables e.g. inconceivable and required the
participants to identify the number of syllables in each of the ten words.
The first phoneme identification subtest required to participants to count and record the
number of phonemes in ten words. The words varied from words with direct phoneme grapheme correspondence e.g. rust; to more complex phoneme - grapheme mapping e.g.
thought. The words ranged between 3 and 10 phonemes in length.
The second phoneme identification subtest required the participants to identify and
record the grapheme or graphemes that represented the second phoneme in a given word. The
second phoneme included consonants within a blend e.g. scream or vowels e.g. whim.
The third phoneme identification subtest required the participants to identify and record
the grapheme or graphemes that represented the last phoneme in a given word. The last
phoneme included vowels e.g. though, and consonants e.g. laugh.
The last two subtests (rhyme and alliteration) required the participants to read and
match words within a set of words. The words in the rhyme task could not be matched visually
by spelling pattern e.g. basin / hasten. The alliteration task required the participant to match
words by initial sound e.g. joke / gentle.
Participants self marked their answer sheets. Where the participants were required to
write a grapheme or graphemes to represent the phoneme, all legitimate representations were
accepted as correct e.g. both f and ph were accepted as the grapheme representing the last
sound in laugh. 250 randomly selected papers were checked for scoring accuracy by two
speech-language therapists, with 98% reliability.
Results
The performances of the groups on each of the 6 phonological awareness subtests were
compared. Multivariate Analysis of Variance (Wilks Lambda) showed a significant group effect
(F(42,2836)=18.576, p<0.001) Univariate F tests showed significant group difference on each of
the subtests at p<.001.
A univariate ANOVA on the total score showed significant mean differences in the
groups. (F(7,609)=102.941, p < 0.001). The SLTs had a mean correct of 39.09 (SD=1.026); RTLits
35.63 (SD=3.882); RTLBs 31.91 (SD=5.720); teachers 29.73 (SD=5.096); teachers aides 25.52
(SD=5.040); ECE 23.25 (SD=2.751); Yr3BTStudents 27.57 (SD=4.790) and Yr1BT students 22.42
(SD=4.507). The standard deviation of the SLTs was significantly smaller than that of the other
groups so a non-parametric equivalent (Kruskal-Wallis ANOVA) was performed, again
showing significant differences in total scores across the groups (Chisquare= 330.6, df=7, p<
0.001).
SLTs performed significantly better than all the other groups on the three phoneme tasks
and rhyme knowledge. There was no difference between the SLTs, teachers, RTLits, and RTLBs
208
on syllable and alliteration tasks, but the ECEs, students and teacher aides performances were
significantly worse. Discussion with the participants and qualitative analysis of the answer
sheets, suggested that the participants were confused about what a sound or phoneme was.
Consonant blends were often considered to be one phoneme, and the use of onset and rime units
was evident e.g. rust was segmented as r-u-s-t or r ust or r-u-st or ru-st.
Discussion
For effective literacy instruction educators must be able to draw upon their implicit
language knowledge and make it explicit for the children in their classroom, and in small nextstep chunks. This requires a high level of pedagogical and content knowledge. Teachers who
have more in-depth understanding of the alphabetic principle and phonology have the ability to
provide more effective classroom instruction (Moats, 2009). However, as Stainthorp (2004)
stated, and subsequently has been validated by this study, phonological awareness knowledge
cannot be assumed for literate people as for some it is implicit. Studies have shown that the
effect size is stronger where professional development programmes for educators are
implemented alongside the classroom programme on reading outcomes (McCutchen, Green,
Abbott, & Sanders, 2009)
Clinical Implications
This study has validated previous research that educators personal phonological
knowledge is highly variable (Al-Hazza, Fleener, & Hager, 2008; Cunningham, Perry, Stanovich,
& Stanovich, 2004; Foorman, et al., 2003; Moats, 2009) Phonological awareness instruction is a
critical component within literacy instruction. A focus on the professional knowledge of teachers
and within pre-service training programs on explicit phonological awareness will have a
significant impact on the quality of literacy programmes, and therefore outcomes for children
Al-Hazza, T. C., Fleener, C., & Hager, J. (2008). Primary Teachers' Knowledge and Knowledge Calibration
of Early Literacy Practices. Reading Matrix: An International Online Journal, 8(2), 1-11.
Cunningham, A. E., Perry, K. E., Stanovich, K. E., & Stanovich, P. I. (2004). Disciplinary Knowledge of K-3
Teachers and their Knowledge Calibration in the Domain of Early Literacy. Annals of Dyslexia,
54(1), 139-167.
Foorman, B. R., Chen, D.-T., Carlson, C., Moats, L., Francis, D. J., & Fletcher, J. M. (2003). The necessity of
the alphabetic principle to phonemic awareness instruction. Reading & Writing, 16(4), 289-324.
Hattie, J. (2009). Visible Learning: A Synthesis of Over 800 Meta-Analyses Relating To Achievement. New York:
Routledge.
Love, E. R., S. (1995). A Sound Way; from awareness to practice. Melbourne: Longman.
McCutchen, D., Green, L., Abbott, R. D., & Sanders, E. A. (2009). Further evidence for teacher knowledge:
supporting struggling readers in grades three through five Reading and Writing, 22(4), 401-423.
Moats, L. (2009). Knowledge foundations for teaching reading and spelling Reading and Writing, 22(4), 379399.
Moats, L. C., & Foorman, B. R. (2003). Measuring Teachers' Content Knowledge of Language and Reading.
Annals of Dyslexia, 53, 23-45.
Nuthall, G. (2007). The Hidden Lives of Learners. Wellington: NZCER Press.
Snow, C. E., Griffin, P., & Burns, M. S. (2005). Knowledge to Support the Teaching of Reading: Preparing
Teachers for a Changing World. San Francisco: Jossey-Bass.
Spencer, E. J., Schuele, C. M., Guillot, K. M., & Lee, M. W. (2008). Phonemic Awareness Skill of SpeechLanguage Pathologists and Other Educators. Language, Speech, & Hearing Services in Schools, 39(4),
512-520.
209
Stainthorp, R. (2004). W(h)ither Phonological Awarenss? Literate teachers' lack of stable knowledge about
the sound structure of words. Educational Psychology, 24(6 ), 753- 765.
210
SY05.3
COMPUTER-BASED PHONOLOGICAL AWARENESS ASSESSMENT AT
SCHOOL-ENTRY: A PILOT STUDY
K. Carson1, G. Gillon1, & T. Boustead1
1College
of Education, University of Canterbury, New Zealand
Study Aim: Young childrens phonological awareness (PA) ability is one of the best
predictors of early reading success. It is critical, therefore, that classroom teachers can
effectively and efficiently monitor childrens phonological awareness development from schoolentry and ensure enhanced phonological awareness knowledge is transferring to word decoding
and spelling tasks. It is possible that time efficient measurement of childrens PA within
classroom environments can be achieved through the use of computer-based assessment (CBA).
This paper reports the results of a pilot study that investigated if CBA could generate
comparable results to conventional methods of assessing PA. Method: Thirty-three children
aged between 4 years 10 months and 5 years 0 months participated in the study. Twenty-one
children presented with typical speech and language development and twelve children
presented with a moderate-severe speech delay. A cross-over research design was employed
whereby each participant was randomly allocated to one of two groups matched for age, gender
and spoken language competency. Group A received an assessment of their PA skills using a
conventional assessment method with an examiner. Group B received the same assessment
delivered by a computer program that the child could self-administer. Two weeks later Group
A received the CBA and Group B received the conventional assessment. Results: The results
indicate that a) CBA generated equivalent results to the conventional method of assessing PA
ability for both children with and without moderate-severe speech delay, b) no gender
differences were identified between the performance on the CBA and conventional assessment,
and c) the CBA took approximately 20% less time to administer compared to the conventional
assessment. Implications: The implications of introducing computer-based universal screening
and progress monitoring on the reading outcomes of at-risk children will be discussed.
Classroom-based literacy assessment is an integral component towards lowering the
prevalence of reading difficulties amongst school-aged children. Research shows that more than
one in three children struggle with reading and writing development (Adams, 1990; Nicholson,
2009), and that these early difficulties at school-entry are strongly associated with academic
underachievement in the later school years. For example, Juel (1988) demonstrated that the
probability that children who were poor readers at the end of first grade would continued to be
poor readers at the end of fourth grade was 0.88. In essence, children who struggle throughout
beginning literacy instruction are highly unlikely to catch up to their typically developing peers
without specific interventions. Early assessment and progress monitoring of skills that are
highly predictive of later reading success not only ensures children at-risk for literacy disorder
are identified at school-entry but also ensures that instructional planning is continually tailored
to the meet the learning needs of children before they fall behind in early reading development.
Research indicates that to be effective in measuring and monitoring early literacy
development assessment tools should be a) grounded in developmental theory and research on
211
variables important to early literacy development, b) sensitive enough to detect changes in

literacy growth, c) inform instructional content and adaptations, and d) time efficient for both
child and educator (Croft, Strafford & Mapa, 2000). Developing measures that assess skills that
are predictive of early reading development and can differentiate between children who are
likely to become good and poor readers plays a vital role in lowering the prevalence of reading
disorder amongst school-aged children. A considerable body of evidence suggests that
phonological awareness and letter knowledge ability at school-entry are two of the most
powerful predictors for identifying how well children will learn to read and writing during the
early school years (Ehri et al., 2001). Computer-based assessment of phonological awareness
and letter knowledge ability may be one way in which time efficient and wide spread
assessment and monitoring of these high priority reading targets can be achieved within the
classroom setting.
Several researchers have highlighted the benefits of using computer-based assessment
over traditional pen and paper assessment with an examiner to measure broad aspects of
student achievement in the classroom (Martin, 2008; Tymms, 2001). Advantages of using
computers within classroom assessment include reduced administration and scoring time for
educators, the potential for the child to self-administer the test, increased consistency and
reliability with data analysis, reduced bias resulting from human differences in administration
and scoring procedures, immediate scoring and reporting of data leading to faster decision
making, global availability through mediums such as the internet contributing to savings in cost
and increased use and delivery (Tymms, 2001; Singleton, 1997). The first step towards
examining the use of computer-based assessment as a reliable, valid, cost, and time effective
screening tool within the classroom context is to ensure computer-based versions of
phonological awareness assessment can generate equivalent results to conventional assessment
methods (Singleton, 1997).
This paper in the symposium will report the results of a pilot study that investigated the
comparability of computer-based versus a conventional method of assessing phonological
awareness and letter knowledge ability in young children at school-entry.
METHOD:
Participants:
Thirty-three children (15 boys; 18 girls) aged between 4;10 and 5;00 (M = 4:11)
participated in this study. Twenty-one children presented with typical speech and language
development and twelve children presented with a moderate-severe speech delay with receptive
language ability within normal limits. The participants were recruited from eight early
childhood education settings and represented a range of socio-economic backgrounds. All
participants spoke New Zealand English as their first and only language and were pre-enrolled
to begin formal schooling around their fifth birthday.
Materials:
Baseline Assessment: As each child entered the study they received a thorough baseline
assessment of their spoken language skills using the Clinical Evaluations of Language
Fundamentals Preschool-2, the New Zealand Articulation Test and Computerized Profile of
Phonology, the Preschool and Primary Inventory of Phonological Awareness, a Single Word
Reading Test, and a Parental Home Literacy Questionnaire. Baseline assessment was conducted
to determine which children had typical spoken language development and which children
were at-risk for literacy disorder due to moderate-severe speech delay.
212
Computer-Based and Conventional Assessment Modalities: Assessment content from

the Gillon (2005) Phonological Awareness Probes were adapted and formatted into Adobe Flash
to produce a computer-based assessment. The computer-based assessment provided all
instructions verbally, presented all test items as pictures on the screen in a controlled format,
enabled the child to respond independently by clicking a mouse, and recorded, stored and
scored all responses. The conventional method of assessing phonological awareness ability
employed the use of picture cards and six-by-two grids of letters on A4 paper. This assessment
modality requires an examiner to have time available to complete the assessment, to present all
test items and instructions, to be familiar with test administration procedures, and be able to
accurately score and interpret the childs responses to inform instructional content.
Computer-Based and Conventional Assessment Content: Four skills that are highly
predictive of early reading development were assessed by the computer-based phonological
awareness assessment and in a conventional format with an examiner. Each assessment
condition was identical except for the use of some animated graphics in the phonemic awareness
and single word recognition subtests. These skills are outlined below:
1. Phonemic Awareness: Children are required to identify a word from a choice of three
that began with the same initial phoneme as a specific target word. For example, the
computer/examiner would show the child a picture of a dog and say, This is my friend
Dog. Dog starts with the /d/ sound. What word starts with the /d/ sound? Three
pictures would then appear on the computer screen or be placed on the table and the
child was required to click/point to the picture that started with the same sound as dog.
Two practice items were given prior to ten test items.
2. Rhyme Awareness: This task required children to identify which word from a choice of
three words did not rhyme with the other two words.
For example, the
computer/examiner would show the child three pictures and say, Which word does not
rhyme with the rest: book, hook, sail? The child was then required to click/point to the
picture of the word that did not rhyme with the rest. Two practice items were given
prior to completing ten test items.
3. Letter Knowledge: Letter knowledge was assessed using Letter-Name and Letter-Sound
identity tasks. In both the letter-name and letter-sound tasks, the computer/examiner
presented six letters on the screen/table in a three-by-two grid format and asked the
child to click/point to the prescribed letter-name or letter-sound. For example, in the
Letter-Name Task the computer/examiner would ask, Show me the letter m. Twentysix letter names and twenty-six letter sounds were assessed in lowercase century gothic
font. Two practice items were presented for both the Letter-Name and Letter-Sound
tasks.
4. Single Word Recognition: This task required children to identify which word from a
choice of three words spelt the word spoken by the computer/examiner. For example,
the computer/examiner would show the child a picture of a dog and say, This is my
friend dog. What word spells dog? The child was then required to click/point to the
word that spelt the target word.
Procedure:
213
A cross-over research design was used to determine if computer-based assessment can

generate equivalent results to conventional methods of assessing phonological awareness and
letter knowledge ability. Children entered the study on a rolling-basis from September-October
2009. As each child entered the study they received a baseline assessment of their spoken
language abilities and were then randomly allocated to one of two assessment conditions (i.e.,
Group A or Group B) matched for age, gender and spoken language ability. Group A received
an assessment of their phonological awareness skills using a conventional method with an
examiner while Group B received the same assessment delivered by the computer program
(time one). Two weeks later Group A received the computer-based assessment and Group B
received the conventional version of the assessment (time two).
RESULTS:
Data from each groups performance on the computer-based and conventional
phonological awareness assessments were compared using a two tailed t-test at time one (i.e.,
conventional assessment for group A and computer assessment for group B) and again at time
two (i.e., computer assessment for group A and conventional assessment for group B). No
significant differences between the mean performance of group A and group B at time one (T1)
or at time two (T2) on measures of phoneme identity (T1 t(31) = 0.64, p = 0.52; T2 t(31) = 0.44,
p=0.67), rhyme oddity (T1 t(31) = 0.05, p = 0.96; T2 t(31) = -0.12, p = 0.91), letter-name
recognition (T1 t(31) = -0.72, p = 0.48; T2 t(31) = 0.62, p = 0.54), letter-sound recognition (T1 t(31)
= -0.31, p = 0.76; T2 t(31) = -0.44, p=0.67), and single word reading ability (T1 t(31) = -0.41, p =
0.68; T2 t(30) = -0.18, p = 0.86) were identified despite differences in assessment modalities used.
These results suggest that the computer-based assessment in this study generated equivalent
results to a more convention method of assessing a childs phonological awareness ability with
an examiner for both children with typical spoken language development and children with
moderate-severe speech delay.
Strong correlation coefficients were also identified between each participants
performance between time one and time two on measures of phoneme identity (r(31) = 0.94,
p<.05), rhyme oddity (r(31) = 0.95, p<.05), letter-name recognition (r(31) = 0.99, p<.05), lettersound recognition (r(31) = 0.99, p<.05), and single word reading ability (r(31) = 0.76, p<.05).
These results indicate high test-retest reliability of assessment content.
Additionally, no significant gender differences between each participants performance
on the CBA and conventional assessment methods were identified. It was also identified that
the computer-based assessment took 20% less time to administer compared to the conventional
version of the assessment which is important when considering time constraints for both
educator and child within a busy classroom setting.
The rhyme oddity (r(31) = 0.83, p<.05), initial phoneme identity (r(31) = 0.88, p<.05) and
the letter-sound (r(31) = 0.89, p<.05) subtests of the computer-based phonological awareness
assessment also correlated positively with subtests of the Preschool and Primary Inventory of
Phonological Awareness (PIPA) which is a conventionally administered standardized
phonological awareness test.
DISCUSSION/IMPLICATIONS:
Findings from this study suggest that a computer-based approach to phonological awareness
assessment can generate comparable results to conventional assessment methods for children
with typical development and children who are considered at-risk for literacy difficulties. These
findings are consistent with previous studies indicating that CBA can generate comparable
214
results to conventional test forms and offers several advantages such as reduced testing time,
immediate scoring, and data interpretation. Further investigation in the use of CBA as an
assessment tool for high priority reading skills at school-entry provides promise not only for
assisting educators with instructional planning, progress monitoring and determining a childs
need for reading support services but also for ensuring a focus on prevention is fostered within
classroom literacy environments particularly for children at-risk for reading disorder.
References:
Adams, M.J. (1990). Beginning to Read: Thinking and Learning About Print. Cambridge, MA: Massachusetts
Institute of Technology.
Croft, C., Strafford, E., & Mapa, L. (2000). Stocktake/evaluation of existing diagnostic tools in literacy and
numeracy, in English: A report to the Ministry of Education. Wellington: New Zealand Council for
Educational Research.
Ehri, L. C., Nunes, S. R., Willows, D. M., Schuster, B. V., Yaghoub-Zadeh, Z., & Shanahan, T. (2001).
Phonemic Awareness Instruction Helps Children Learn To Read: Evidence from the National
Reading Panel's Meta-Analysis. Reading Research Quarterly, 36(3), 250-287.
Gillon, G. (2005). Facilitating phoneme awareness development in 3- and 4- year old children with speech
impairment. Language, Speech and Hearing Services in Schools, 36, 308-324.
Juel, C. (1988). Learning to reading and write: A longitudinal study of 54 children from first through
fourth grades. Journal of Educational Psychology, 80(4) 443-447.
Nicholson, T. (2009). Should beginner readers rely on context clues or not: The case for and against.
Presentation at the Literacy Research Symposium, 1st-2nd October 2009, Christchurch, New
Zealand.
Retrieved
15th
October
2009
http://www.education.canterbury.ac.nz/literacy_symposium/index.shtml
Tymms, P. (2001). The development of a computer-adaptive assessment in the early years. Educational and
Child Psychology, 18(3), 20-30.
Singleton, C.H. (1997). Computerised assessment of reading. In J.R. Beech and C.H. Singleton (Eds.), The
psychological assessment of reading (pp. 257-278). London: Routledge.
215
FP30.5
AUTISM SPECTRUM DISORDERS SCREENING AND DIAGNOTIC PRACTICES:
A SURVEY OF PHYSICIANS
Coufal K.L., Self T., Rajagopalan J.
Wichita State University
Purpose:
The purpose of this study was to identify Kansas physicians professional training and
continuing medical education (CME) in the area of ASD, as well as their screening and
diagnostic practices specifically related to ASD. This study will help to identify the following: (1)
the amount of training these physicians have accrued in the area of ASD, (2) if these physicians
have been trained to screen/diagnose for ASD, (3) if they routinely screen children at 9, 18 and
24 months according to AAP guidelines, (4) if they screen, what screening tools they use, (5)
their knowledge and practices about use of complementary alternative medicine (CAM) for
children with ASD, and (6) the amount of CME received in the area of ASD. The survey will
also provide participants the opportunity to indicate what would help them be better prepared
to screen children for ASD.
Autism spectrum disorders (ASD) are pervasive developmental disorders affecting as
many as 1 in 100 births (Center for Disease Control, 2009). A national survey of parents in 2007
indicated the prevalence of parent-reported diagnosis of ASD was approximately 1 in 91 U.S.
children (Kogan, Blumberg, et al., 2009). Despite the differences in the reported prevalence
figures, it is evident the numbers of children diagnosed with ASD is rising. With the very high
prevalence rate of ASD, primary care physicians and pediatricians, who are often the first point
of contact for these children and their families, play a critical role in recognizing the early signs
of ASD. A 2004 survey of primary care pediatricians showed that 44% of them cared for at least
10 children with ASD; but, only 8% of them routinely screened for ASD (Dosreis, Weiner, et al.,
2006).
Early identification of ASD is essential as it allows for appropriate early intervention. It is
important that children with ASD receive early intervention specifically designed for their
unique learning needs. There are many advantages of early diagnosis of ASD including: earlier
educational planning and treatment, provision for family supports and education, reduction of
family stress and anguish, and delivery of appropriate medical care to the child (Filipek,
Accardo, et al., 1999). Studies show that children who receive intervention by age 3 years show
significant developmental gains and significantly reduce associated deficits like impaired
communication and social skills that affects their development (Robins, Dumont-Mathieu, 2006).
Though there is widespread increase in the awareness of ASD and its early manifestations
within first 2 years of life, most children with ASD are not identified clinically at a very early age
(Robins, Dumont-Mathieu, 2006).
In 2006, the American Academy of Pediatrics (AAP) issued a policy statement recommending
physicians screen all children for developmental disorders during regular doctor visits at age 9,
18 and 24 months, respectively. This statement was released by the AAP in response to a
national survey of AAP members which indicated that despite efforts to improve screening for
early identification of developmental disorders, only 23% of surveyed pediatricians used
216
standardized screening instruments to screen for developmental disorders. Additionally, a 2004

survey of Maryland and Delaware licensed pediatricians found that only 8% of these
pediatricians routinely screened for ASD. In 2007, AAP released a clinical report as a follow up
to the policy statement which urged that physicians conduct surveillance at every well-child
visit and screen for ASD at 18 and 24 months and at any other time when parents raise a concern
about a possible ASD (Johnson, Meyers, 2007). Based on the AAPs recommendation, this study
was initiated to conduct a state-wide survey of physicians in the state of Kansas who regularly
care for young children (i.e., family practice physicians, internal medicine physicians,
pediatricians, and psychiatrists) to identify their current screening and diagnostics

practices for ASD.
Methods:
Participants
The survey participants included a random sample of 450 physicians (family practice
physicians, internal medicine physicians, pediatricians, and psychiatrists) in Kansas, selected
from a list of 1350 physicians acquired from Kansas Medical Society.
Procedures
A survey method was used to examine the pre-professional and continuing education
training of physicians relative to the characteristic features of ASD and instruments used to
screen for these disorders. The study instrument was a survey questionnaire consisting of 16
items regarding demographics as well as training and practice information specifically related to
screening, diagnosis, and treatment of ASD. The study instrument was based on, and questions
derived from, a related investigation in which allied health professionals were participants. The
original survey instrument was developed by an advisory group of professionals who
represented the multiple allied health disciplines surveyed (i.e., interim CEO of a major medical
center, family medicine physician, pediatric physician, developmental pediatrician, PA, SLP,
PT). After the survey was constructed, it was piloted using faculty members and clinical
educators across the College of Health Professions at Wichita State University (WSU).
Participants, representing the School of Nursing and the Departments of Physician Assistants,
Physical Therapy, Communication Sciences and Disorders, and Public Health Sciences,
completed the survey and provided feedback relative to its content and overall construction.
Based on the comments provided through the pilot, the survey was revised, reviewed, and
approved by the advisory group and WSUs Institutional Review Board. The items included in
the study of physicians were edited slightly to reflect the appropriate demographics of the
participants.
Participants were asked to indicate if they routinely screened for ASD as part of patients
regular medical check-ups and, if not, whether other members of their office medical team
conducted such screenings. Second, they were asked about frequency of screenings and the
instruments used in the screening process. The third area included questions regarding whether
the physician had knowledge of appropriate referral sources for children and families who were
in need of additional diagnostic evaluations and resources for family information and
intervention services. The final area sought to determine physicians medical-professional
preparation in the area of ASD, specifically seeking to assess their knowledge of the screening
and diagnostic processes, their residency experiences with ASD, and their current patient
population diagnosed with any form of autism. Finally, the survey sought to determine
217
participation in continuing medical education related to the characteristics of ASD and desirable
formats for future educational offerings to assist them in their practice.
Surveys were mailed to the participants and returned in an addressed, stamped envelope
which was included. The participants were informed that the purpose of the survey was to
determine the potential CME/CE needs for those individuals who are or would be required to
screen children for ASD. They were told that it would take them no more than five minutes to
complete the survey and their participation was voluntary. Participants were assured that all
data would be aggregated and reported as group trends.
All surveys were coded with an identification number to maintain individual anonymity
and to monitor the return rates among the professional groups. A second mailing was to
increase the overall return rate. Participants who did not respond to the initial mailing received
a second survey approximately one month following their receipt of the initial mailing.
Data were entered by a trained research assistant, and reliability checks were performed
by the first author. After data were entered, the first author double-entered two separate 10%
random samples. Any discrepancies were compared to the original survey.
Data analysis:
The data from the returned surveys will be aggregated and analyzed as group data.
Demographic variables will be compared between physicians who routinely screen for ASD and
those who do not using chi square analyses, to identify if gender or years of practice or any
other information contribute to the differences in their screening and diagnostic practices.
Simple linear regression analysis will be used to identify the relationships between the training
and practice information.
Results:
The data analyses are in progress and therefore final results and conclusions cannot be
reported at this time. All analyses and results will be finalized in time for submission of the full
paper in April, 2010 and ready for presentation at the conference, if accepted.
Summary:
Because primary care physicians and pediatricians are often the first point of contact for
parents, they play an important role in early recognition of ASD. Thus, it is imperative that these
physicians are well trained and stay current with screening and diagnostic practices in the area
of ASD. The results of this study may help us to understand the level of knowledge and training
in the area of ASD as well as the screening and diagnostic practices of physicians who regularly
care for young children in Kansas. This study may also help to identify the barriers to providing
such assessments in routine clinical practice. Additionally, the need for any continuing medical
education discovered through the survey responses will be discussed.
218
P086
LURIA-NEBRASKA NEUROPSYCHOLOGICAL BATTERY FOR CHILDREN AND
LONG LATENCY AUDITORY EVOKED POTENTIAL EVALUATION IN THE
DIAGNOSIS OF DYSLEXIA AND LEARNING DISABILITIES
Patrcia Abreu Pinheiro Crenitte1
Thas dos Santos Gonalves1
Slvia Maria Ciasca2
1University of So Paulo, Bauru, Brazil
2State
University of Campinas, Campinas, Brazil
Introduction
The lack of standardized speech-language evaluation for performing an accurate
differential diagnosis, including the writing language area, make the speech therapy seek
knowledge in other areas to subsidies their clinical practice.
Giacheti and Capellini (2000) differentiated the two diagnostic among specific reading
disabilities (dyslexia) and learning disabilities. In learning disabilities, the individual has normal
intelligence or amended, phonological disorders, failure in the syntactic, semantic and
pragmatic abilities, history of language impairment, narrative skill altered to counting and
recounting stories, deficits in receptive and expressive functions, and deficits in the processing
of auditory and visual information. In the specific reading disability, the individual has normal
intelligence, phonological disorders, failure in the syntactic, semantic and pragmatic abilities,
difficulties in language in its written form during childhood, impaired narrative ability to
recount stories, deficits in expressive function and alteration in the auditory and visual
information processing.
The Neurology in educational practice brings the possibility of correlation between
higher cortical functions (gnosis, mnemonic processes, praxis of speech, linguistic thought) and
problems in the acquisition of reading and writing, through evaluation procedures of these
functions, based on qualitative and quantity aspects that may interfere or determine the
presence of difficulties in the learning.
The research of the Long Latency Auditory Evoked Potential (P300), beyond allows the
investigation of peripheral hearing of the individual, evaluates the integrity of central auditory
pathways, and their maturation during the process of development and dysfunction. In this
context, highlighted the contribution of the P300 in the investigation of cognitive skills that
involve the information processing (attention, memory and discrimination) (Papanicolaou, 2003,
Torkildsen et al, 2007). There are very few studies in literature that relate the P300 and learning
problems.
Based on collected informations, the purpose of this study was to compare the
performance of children with dyslexia and learning disabilities in the Luria-Nebraska
Neuropsychological Battery (LNNBc), to verify its effectiveness in the differential diagnosis and
to compare these results with data obtained in the Long Latency Auditory Evoked Potential
(P300) evaluation, capable of measuring important components in the learning of children with
dyslexia and learning disabilities.
219
Methodology
Description of the subjects:
The subjects were 30 children, 20 children diagnosed with Learning Disabilities and 10
diagnosed with Dyslexia, with 8-10 years old, both genders, education level between 1st and 4th
graders, public and private schools, and had diagnosis of learning disabilities or dyslexia by the
Clinical Diagnostics of University of So Paulo (FOB-USP) or by State University of Campinas
(UNICAMP). The exclusion criteria were: children who have sensory alterations, cognitive and
behavioral disorders.
Material and Methods
The research was approved by the Ethics Committee in Research of the Faculty of
Dentistry of Bauru - University of So Paulo (process number 77/2005). The Statement of
Consent was sent to the parents or guardians, to formalize the commitment of their children's
participation in the procedures of research.
It was used the Luria-Nebraska Neuropsychological Battery - Revised for Children
(LNNB-C) - (GOLDEN, 1987). Were evaluated the visual, receptive language, expressive
language, writing, reading, arithmetic and processes mnemonic (memory function) scales.
To obtain results that characterize the presence or absence of deficits in the tested
functions, the score was calculated according to the sum of the scores obtained in the respective
items.
In the research of the Long Latency Auditory Evoked Potential (P300), was adopted the
following parameters:
Parameters
Stimulus
P300
Tone burst 1 e 2 KHz
(ratio 80% and 20%)
Intensity
70 dBNA
Speed
1 stimulus / sec
Filter
1 a 100 Hz
Electrodes
Cz
Window
400ms
Criteria
P300 Latency
P300 Amplitude
220
It was established the following values of normality for the P300: average of 329.17 ms in
Cz with a standard deviation (SD) of 45.88 ms and 48.81 ms respectively. The amplitude average
at Cz was 12.85 V with SD of 7.74 V (Visioli-Melo and Rotta, 2000; Brayner, 2004).
Given the above data, particularly the sharp variation values of P300 in the younger age
group, highlights the need for caution in interpreting the test alone and this data should always
be examined in conjunction with other behavioral evaluation and language.
Statistical Analysis
The Fisher's Exact Test was used to compare the groups, and the significance value
adopted was p<0,05.
Results
The results of the groups in the LNNB-C are described in the table below:
Table 1: Performance of children with dyslexia and learning disabilities in the LNNB-C
A=
Altered
B=
Normal
p
value
adopted
0,05
Functions
Visual
Diagnosis
Learning
Disabilitie
s
Dyslexia
Total
p value
(C4)
Receptive
Expressive
Language
Language
(C5)
(C6)
Writing
Reading
Arithmetic
Memory
(C7)
(C8)
(C9)
(C10)
12
14
16
13
10
10
17
18
40%
60%
30%
70%
80%
20%
65%
35%
50%
50%
85%
15%
10%
90%
10%
90%
30%
70%
80%
20%
60%
40%
60%
40%
40%
60%
10%
90%
21
21
24
19
11
16
14
21
27
30%
70%
30%
70%
80%
20%
63%
37%
53%
47%
70%
30%
10%
90%
0,100
0,656
0,694
0,548
0,450
0,018
0,719
T
he
table 2
shows
the P300 latency and amplitude values in both groups:
Table 2: Performance in P300 of children with dyslexia and learning disabilities
Average
P300
P300 Latency
Latency
Learning
Dyslexia
Disabilities
358,85
346,24
Sig.
(p
value)
0,245
P300
P300 Amplitude
Amplitude
Learning
Sig.
Dyslexia
Disabilities
value)
8,10
6,05
0,439
(p
221
Discussion
In
all
the
neuropsychological
functions
evaluated,
only
Arithmetic
showed a statistically significant difference between the groups. According to Geary (2004)
between 5% and 8% of school-age children have some type of loss of memory or cognitive deficit
that interferes in their ability to learn concepts or procedures in one or more mathematical
domains.
In the visual function, children with learning disabilities showed 40% of the alteration,
and children with dyslexia showed 10%. In contrast, it is argued that the dyslexics present
more phonological errors than the visual ones. (Pinheiro, 1995).
The alteration in the expressive language was observed in 80% of children with learning
disabilities and dyslexia. Capellini Salgado and (2003) verified the presence of alteration in oral
language and writing in more than 50% of students from 1st to 3rd grade, featuring delayed
development of phonological and syntactic abilities.
In the receptive language, alterations were observed in 30% of children with learning
disabilities and dyslexia. Stojanovik and Riddell (2008) observed that children with dyslexia
performed better on tests of expressive function when compared to tests of receptive function,
which was not observed in this study, because between the children diagnosed with dyslexia, 80
% showed alteration in expressive language, and only 30% had alteration in receptive language.
In the reading function, were found a greater number of children diagnosed with
dyslexia that showed alteration in this function when compared to children diagnosed with
learning disabilities (60% and 50% respectively). Psychological research in the field of
neuroscience found that the main problem of reading dyslexics is slow and inaccurate word
recognition, and this area lies the difficulty in phonological decoding process: the transformation
of letters in a phonological code. This is code that allows access to the pronunciation of the word
and also to their significance. In contrast, dyslexics do not have problems in reading
comprehension, fact witch confirms that the phonological decoding is the phenomenon leading
in dyslexia and word recognition (Pinheiro, 2002).
Regarding writing function, 65% of the children with learning disabilities and 60% of the
children with dyslexia showed alterations in this function. The results are in agreement with
Crenitte et al (2008), who reported that children with learning difficulties have the written
function amended. According to Berninger et al (2008), children with dyslexia may have
problems in automatic writing, which may be related to inhibition loss and verbal fluency,
explaining the spelling problems.
Regarding memory, 10% in both groups with learning disabilities and dyslexia showed
alteration. For Steinbrink and Klatte (2007), poor memory is indicated as an underlying factor in
learning disabilities. Zucoloto and Sisto (2002) report that the memory is necessary for learning
to write, because to write is necessary that in some time past, the subject has stored information,
graphemes and phonemes to be evoked when the writing is requested. In this present study,
both groups (learning disabilities and dyslexia), showed less alteration in memory function
when compared to the writing function.
Since the first studies by Sutton (1965), many researchers have found correlations
between evoked potentials and higher brain functions. However, for the P300 component, both
groups presented amplitude significantly decreased. The alteration in P300 amplitude and
latency was described by several authors (Daines et al, 1981, Ortiz et al, 1990; Erez & Pratt, 1992;
Mazzotta & Gallai, 1992, Toroyan et al., 2007, Stoodley et al, 2008), confirming the deficits shown
by individuals with dyslexia and learning disabilities.
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The statistical test showed similar behavior of this potential when comparing both
groups. This finding is probably justified by the fact that the P300 involve skills that are
commonly altered in both disturbs. This finding is consistent with that was described by
Shibasaki and Miyazaki (1993), and Dahr (2008).
Conclusion
There was statistically significant difference between the groups only in arithmetic
function, but, children diagnosed with dyslexia showed greater alteration in reading function,
and the learning disorder group showed more alteration in writing function. The results
obtained in the P300 evaluation concluded that it did not provide enough information to
differentiate the groups (learning disorder and dyslexia) but allowed the identification of
children with abnormal and normal cognition.
It is also concluded that it is possible to use the LNNB-C, together with other evaluate
procedures, to assist in the diagnosis of children with learning disorders, among them, learning
disabilities and dyslexia, but is necessary that other similar studies are conducted, especially
using larger number of subjects of similar and higher age to confirm the data found, beyond the
description of others which are important for these differential diagnosis.
References
BERNINGER, V. W.; NIELSEN, K. H.; ABBOTT, R. D.; WIJSMAN, E.; RASKIND, W. (2008). Writing
Problems in Developmental Dyslexia: Under-Recognized and Under-Treated. Journal of school
psychology, 46, 1-21.
BRAYNEr, ICS. (2003). Aplicao do paradigma auditivo oddball no estudo do P300: normatizao para
faixa etria de 7-14 anos e avaliao de crianas com dificuldade de aprendizagem com e sem
transtorno de dficit de ateno / hiperatividade. Master Dissertation. Universidade Estadual de
Campinas.
Capellini, S. A..; Salgado, A. C. Avaliao fonoaudiolgica do distrbio especfico de leitura e distrbio de
aprendizagem: critrios diagnsticos, diagnstico diferencial e manifestaes clnicas. In:
CIASCA, S. M. (Org.). Distrbios de aprendizagem: proposta de avaliao interdisciplinar. So
Paulo: Casa do psiclogo, 2003. p. 141-163.
CRENIITTE, P. A. P.; CALDANA, M. L. (2008). Estimulao da linguagem oral e reflexos no aprendizado
da leitura e da escrita. In: LAMNICA, D. A. C (Orgs.). Estimulao da Linguagem: aspectos tericos e
prticos. So Jos dos Campos: Pulso. 287-312.
GEARY, D. C. (2004). Mathematics and Learning Disabilities. Journal of Learning Disabilities,37,1,4-15.
GIACHETI, C. M.; CAPELLINI, S. A. (2000). Distrbio de aprendizagem: avaliao e programas de
remediao. In: Associao Brasileira de Dislexia (Org.). Dislexia: crebro, cognio e aprendizagem.
So Paulo: Frontis, 41-59.
LURIA, A.R. (1973). The working brain. Basic Books, New York.
223
PAPANICOLAU A. C., CASTILLO, E., BREIER, J.I., DAVIS, R.N., SIMOS, P.G., DIEHL, R.L. (2003).
Differential brain activation patterns during perception of voice and tone onset time series: a MEG
study. Neuro Image. 18, 448-59.
PINHEIRO, A.M.V. (1995). Dificuldades especficas de leitura: a identificao de dficits cognitivos e a
abordagem do processamento da informao. Psicologia: Teoria e Pesquisa, 1995, (11)2, pp, 107-15.
SELIKOWITZ, M. (2001).Dislexia e outras dificuldades de aprendizagem. Rio de Janeiro: Revinter.
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P150
A PRELIMINARY INVESTIGATION OF EYE-GAZE PATTERNS ON FASTMAPPING ABILITIES OF CHILDREN WITH AUTISM SPECTRUM DISORDER
D. Crumrine1, T. Self2
1Wichita State University, Wichita, USA
2Wichita State University, Wichita, USA
There have been numerous studies conducted to examine the factors that influence the
reading and writing skills of typically developing children. Phonemic awareness has been
shown to play an important role in the development of the reading and spelling abilities among
typically developing children (Cunningham, Perry, & Stanovich, 2001). More recent research
with typically developing children has indicted that the acquisition of mental orthographic
representations (MORs) might be independent of phonemic awareness skills and may contribute
to the development of literacy proficiency (Apel, 2009).
Children learn new words through a process termed fast-mapping, which involves the
rapid, associative pairing of objects with labels to form words (Carey & Bartlett, 1978). Through
fast-mapping, children create an initial mental representation of the phonological structure of a
spoken word which is then refined following subsequent exposures to match the adult
representation of the spoken word. Children with typical language development quickly store
some initial phonological information about new spoken words after minimal exposure at a
young age (Storkel & Rogers, 2000).
The fast-mapping of spoken words requires the ability to participate in joint attention.
Joint attention includes the ability to effectively gain, follow, and share information with another
by following anothers eye-gaze or gestures (Leekam, Baron-Cohen, Perrett, Milders, & Brown,
1997). A core deficit of ASD is the delay or inability to engage in joint attention tasks. Dawson,
Abbott, Osterling, Munson, Estes, et al. (2004) found that joint attention was the best indicator of
concurrent and future language ability. Children with ASD performed significantly worse on
measures of social orienting, joint attention, and attention to another persons distress. A failure
to orient to social stimuli has profound effects on language development. There has been limited
research to investigate the relationship between eye-gaze and language development as it relates
to fast-mapping processes.
Deficits in Eye-gaze Patterns of Children with ASD
Recent research indicates that deficits in eye-gaze processing might be related to the
impaired language and social development typically seen with children on the spectrum. The
foundation for language acquisition could be in eye-gaze processing. Eye-gaze processing is
thought to develop into joint attention, which leads to the ability to perceive and process stimuli
that is crucial for imitation and acquiring new knowledge and skill (Brenner, Turner, & Muller,
2007). For example, expressive labels for objects are thought to be partially acquired by a child
following joint eye-gaze to an object while the person pronounces the corresponding label for
the object. This process could be delayed or interrupted if there are deficits in eye-gaze
processing.
Individuals with ASD tend to show less interest in looking at faces and are less likely to
look at the eye area of the face (Klin, Jones, Schultz, Volkmar, & Cohen, 2002). Research has
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primarily been conducted with older children who either have high functioning autism or
Aspergers syndrome. Children on the autism spectrum are very difficult to test and this could
account for the lack of research involving lower functioning children with ASD. The research
that has been conducted regarding eye-gaze and children with ASD has revealed distinct
deficits.
There is some evidence to suggest that eye-gaze cues may be achieved through different
nonsocial processing mechanisms as compared to those used by typically developing peers.
Children with ASD appear to attend to different cues and process eye-gaze differently as
compared to typically developing (TD) children. It appears that children on the autism spectrum
use featural information to detect gaze, where as, TD children use configural information (Senju,
Hasegawa, Tojo, & Osanai, 2007). TD children orient to the spacing among facial features (e.g.,
eyes, nose, mouth); however, children with ASD only notice the shape of individual key features
(e.g., eyes are round or oval shape) and do not key into facial spacing.
Ames and Jarrold (2007) revealed that children with ASD have difficulty inferring desire
from an eye-gaze cue. This study also indicated that children with ASD do not always perceive
eye-gaze cues as the most important cues. Children with ASD were found to have deficits using
eye-gaze as compared to arrow cues. These findings suggest that children with ASD may have
difficulty in using arbitrary cues to make inferences.
Fast-mapping
Research on eye-gaze patterns with typically developing children has suggested that
storybook reading is a picture-focused activity, implying that childrens eye-gaze is primarily
focused on the picture versus the text (Evans, Williamson, & Purrsoo, 2008). The acquisition of
new word learning through fast-mapping is similar to the process in which children develop
written words. Research with written fast-mapping skills has indicated that typically developing
children acquire mental orthographic images of words within implicit storybook reading
contexts after minimal exposures (Apel, Wolter, Masterson, 2006). Mental orthographic
representations (MORs) are stored mental images of a written word or a prefix or suffix (Apel &
Masterson, 2001). These MORs appear to be crucial for successful reading and writing skills.
Typically developing children with well developed MORs can recognize or recall the visual
representations of the word and, therefore, free up memory and attentional resources for
comprehending or composing text (Apel, 2009). A study conducted by Wolter and Apel (2008)
found that children with language impairments developed MORs at a significantly lower rate
when compared to typically developing children. These results suggest that children with
language impairments are less able to create mental representations of words, regardless of the
modality.
Fast-mapping Skills in Children with ASD
Research has been conducted on the fast-mapping abilities of children with ASD in
relation to the verbal word learning process. The fast-mapping abilities of school-aged children
with ASD (mean chronological age 9 years 2 months, range 7-12 years) have been found to be
impaired as a result of using personal focus of attention as a strategy for forming word object
associations instead of using the speakers eye-gaze (Baron-Cohen, Baldwin, & Crowson, 1997).
It is should be noted that the children with ASD did not fail to learn the novel words, but
instead, selected items of self-importance as referents versus following the speakers eye-gaze to
the target stimuli. Baron-Cohen, Baldwin, and Crowson (1997) discovered that the ability to
226
make appropriate word-object connections is impaired in children with ASD as a result of

deficits in attention-following abilities.
McDuffie, Yoder, and Stone (2006) investigated the impact of fast-mapping skills on the
relationship between attention-following and vocabulary size in young children with ASD. The
attention-following skills of children with ASD were found to have a significant predictive
relationship with fast-mapping and vocabulary development. The findings of this study suggest
the importance of targeting attention-following tasks to increase vocabulary development in
children with ASD.
Research related to the written fast-mapping or orthographic processing skills of children
with (ASD) has been limited. Previous research has focused on the fast-mapping abilities of
children with ASD in relation to verbal word learning. It is important, therefore, that studies be
conducted to investigate the written fast-mapping skills of children with ASD, as well as explore
the eye-gaze patterns of children on the autism spectrum when presented with both images and
text. The information gained from this type of research could be critical in understanding the
process of literacy development in children with ASD. Furthermore, a more succinct
understanding of the relationship between eye-gaze patterns and written fast-mapping skills in
children with ASD could provide fundamental information in the development and
implementation of literacy curriculums for children with ASD. The purpose of this study is to
investigate the eye-gaze patterns of children with ASD when presented with novel words and
pictures to assess the orthographic and written fast-mapping abilities.
Method
Participants
Twin six-year-old boys with ASD and two 5-year-old typically developing children will
participated in this pilot study. All of the participants have passed vision and hearing
screenings. The participants were assessed to determine nonverbal intelligence (TONI-3),
reading (WRMT-R) and spelling abilities (spelling test), receptive vocabulary skills (PPVT-4),
and phonological processing ability (CTOPP) prior to initiating the protocol to investigate fastmapping skills.
Procedure
The fast-mapping skills were assessed by presenting 12 stories containing a novel word
paired with a picture of novel objects through a storybook context presented on a computer
screen. As each slide of the story appeared, an image of the novel object was paired with a
female voice reading the sentence that contained the target novel word. The sentence with the
novel word was printed below each picture. Each of the target words was heard and seen four
times within the context of the story. After each storybook presentation, the participants were
asked to generate the novel word through a written response and via receptive identification.
The written answer required the child to spell the novel word in response to the verbal prompt,
Write what this thing is called. For the receptive identification task, the child was asked to
point to the target novel word when given a set of four words on the computer screen. Eye-gaze
patterns were recorded and analyzed using the Tobii Studio 2.0.1 eye tracking software
program.
The visual work systems, physical structure of the environment, reinforcers, and mental
load were standardized across participants. The participants used a work system that included
both picture icons and photographs that indicated what activities would occur and in what
sequence. The work system was implemented to give participants a systematic strategy to
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complete the activities required for the research study. Each work system included information
on what activities needed to be done, how much work was required, when the research study
would be done, and what would happen next.
The physical structure of the room was adapted to clarify boundaries and minimize both
distractions and stimulation for each participant. The computer and desk were arranged to face
a bare wall to minimize distractions and to create a physical barrier. A fan was used to create a
white noise effect in order to eliminate noises that might be distracting or stimulating to
participants. Objects, pictures, and other physical stimuli were also removed from the
environment to prevent further distractions. The physical structure of the room was adapted to
organize the environment to create a calm and orderly setting for the research study.
Each participant selected an item from the vending machine prior to the initiation of the
research study. The vending machine item was used as a reinforcement to maintain motivation
and concentration among participants throughout the study. After the completion of the study
the participant was given the previously selected vending machine item.
Results
Data will be analyzed using an Analysis of Variance (ANOVA) and stepwise regression
analyses to determine fixation time of eye-gaze spent on novel words versus novel pictures,
ability to fast-map novel words, and the effect of eye-gaze patterns on written fast-mapping
skills. The ANOVA will be used to determine the fast-mapping abilities of novel words among
typically developing children and children with ASD. The relationship between the amount of
eye-gaze devoted to each target word and the written fast-mapping task will also be analyzed
using an ANOVA. The stepwise regression will be used to predict the influence of eye-gaze
patterns on fast-mapping abilities beyond other known literacy predictors such as letter
identification, phonological awareness, or orthographic awareness.
Conclusions
The results of this study will be used to determine whether there is a difference in eyegaze patterns with relation to fast-mapping skills of children with ASD when compared with
typically developing children. The data from this study could have a global impact on the
assessment, instruction, and intervention methods for early literacy development among
children with ASD. Many literacy programs currently focus on teaching children reading and
spelling concepts through a traditional approach where phonemic awareness components are
targeted first followed by orthographic knowledge (Wasowicz, Apel, Masterson, & Whitney,
2004). The outcomes from this study could encourage new literacy curriculums that focus on
both phonemic awareness and orthographic concepts in conjunction to facilitate reading and
spelling skills of children with ASD. In addition, the processes underlying fast-mapping abilities
of children with ASD could be better understood with the investigation of eye-gaze patterns
when presented with text and images.
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FP20.4
MULTISENSORY CHANNEL STIMULTION APPROACH ASSISTED WITH
COMPUTER SOFTWARE IN HABILITATION OF SPECIEFIC LANGUAGE
IMPAIRMENT SLI
Amal Salaheldin Darwish
Hearing & Speech Institution Embaba, Egypt.
Physical Medicine & Rehabilitation Hospital, Kuwait
Introduction
A child's brain is a magnificent engine for learning. A child learns to crawl, then walk,
run and explore. A child learns to reason, to pay attention, to remember, and learning is more
dramatic than in the way a child learns language. Babies learn to speak by listening. And all of
us all over the world help them, modulating our sounds of the quicksilver flow of speech in
fundamentally the same way. Simply, when confronted with a baby, adults produce a signal
that is raised about an octave in pitch and slows down very carefully and creates these
swooping contours. It's not a job interview voice. It's a very distinct voice that's fetching to a
baby. Why would every person on the planet do it if it's not important?
Language acquisition is the primary area of concern as the child grows and develops.
*SLI is a developmental language disorder in the absence of frank neurological, sensorimotor, non-verbal cognitive or social emotional deficits (Watkins, 1994).
*Children with SLI lag behind their peers in language production and language
comprehension, which contributes to learning and reading disabilities in school.
*There are no obvious related causes such as hearing loss or low IQ. The condition
appears in young children and is known to persist into adulthood. Although the causes are not
clear until now, current research focuses on possible inherited tendencies. The genetic origin of
SLI has not yet been proven, but studies show that fifty to seventy percent of children with SLI
have at least one other family member with the disorder. Several researchers are studying twins,
looking for the genetic link. In 2001, British researchers successfully found the chromosome that
affected 15 of 37 members of a London family with a profound speech and language
impairment.
A second hypothesis is that these children have a deficit in processing brief and/or
rapidly- changing auditory information, and/or in remembering the temporal order of auditory
information. For example, Paula Tallal has found that some children with SLI have difficulty
reported the order of two sounds when these sounds are brief in duration and presented rapidly
(Tallal, et al., 1985). Laurence Leonard suggests that these deficit may underlie difficulties in
perceiving grammatical forms (e.g., "the", "is"), which are generally brief in duration (Leonard et
al., 1997).
A third hypothesis is that children have poor short-term memory for speech sounds (e.g.,
Gathercole, 1998). Children with SLI perform worse than children with typical language skills
on repeating nonsense words (for example, "zapanthakis"). In a number of recent studies shortterm memory for speech sounds has been shown to correlate highly with vocabulary acquisition
and speech production. This has led to the hypothesis that a primary function of this memory is
to facilitate language learning.
229
SLI is just one of the many communication disorders that affect students in the public
schools. Its other names: developmental language disorder, language delay. Specific language
impairment is the precise name that opens the door to research about how to help a child grow
and learn.
Incidence of the SLI is more common than you might think. Research over the past ten
years has generated accurate estimates of the numbers of young children that are affected by
SLI. We now know it could be as high as 7 to 8 percent of the children in kindergarten. In
comparison, Down syndrome or autism affects less than one percent of the five-year olds.
Late talking may be is early sign of SLI, it is expected when the children enter their
two's and grow into three and four, they will have a remarkable number of ways to tell adults
what they need. Even if the words don't all sound right, a normally developing child will make
many efforts to communicate and will make his point effectively. Young children ask so many
questions.
Children who don't ask questions or tell adults what they want may have a
communication disorder. Children with SLI may not produce any words until they are nearly
two years old. At age three, they may talk, but can't be understood. As they grow, they will
struggle to learn new words, make conversation and sound coherent.
Five-year old children with SLI sound about two years younger than they are. Listen to
the way a child uses verbs. Typical errors include dropping the -s off present tense verbs and
asking questions without the usual "be" or "do" verbs. For example, instead of saying "She rides
the horse" the child will say "She ride the horse." Instead of saying "Does he like me?" the child
will ask "He like me?" Children with SLI also have trouble communicating that an action is
complete because they drop the past tense ending from verbs. They say, "She walk to my house
yesterday" instead of "she walked to my house." An incomplete understanding of verbs is an
indicator of SLI.
Today, research is underway to determine which children do not outgrow this pattern of
delayed speech. By age 4 to 5 years, SLI could be a signpost of a lasting disability that persists
throughout the school years. Early identification and intervention are considered best practices,
in order to minimize possible academic risks.
This work is aiming To create an easy software with auditory melodic slow rate speech,
augmented with visual, tactile, and gesturing animated pictures to give SLI children chance for
prolonged exposure to natural (GOD gift) language and speech stimulation to develop their
language properly.
Patients Method:
50 children with SLI age from 4-6 years 25 boys, and 25 girls. These children the primary
diagnosis will be SLI. Mental retardation, or autism, or hearing loss, or cerebral palsy should be
excluded. A child with SLI scores within the normal range for nonverbal intelligence. Hearing
loss is not present. Emerging gross motor skills, social-emotional development and the child's
neurological profile are all normal. The only setback is with language.
i.e. SLI is the primary diagnosis.
Children with SLI do not have a speech disorder like stuttering or any kind of
articulation disorders e.g. nasality. This means that the child has difficulty understanding and
using words in sentences.
Therapeutic plan depending on the use of computer software in serial programs level as
follow:
1- Pictures Semantic groups.
230
2- Animated pictures for sentences &syntax.

3- Video-phonetic program for phonology.
4- Complex animated pictures for pragmatics if needed.
4-6 weeks each level period, (2 -3 sessions per week according to response).
*Home practice with copy of the software for each level will be given to the parents or
caregivers.
*The child will receive individual therapy in the first 2 months, then he will start group
therapy and may or may not return to individual therapy in case of persistent phonological
errors after the 4 months duration.
*Putting in mind that all facilities available in computers is used for each child according
to his needs(i.e. full screen monitor at least 17"to 21" adjustable volume with high Pitch and slow
rate speakers. Some children needed auditory feedback modalities to overcome their delayed
auditory response which is the characteristic for undeveloped binaural hearing, in cases of
underdeveloped corpus callosum.
*Language test will be applied before the appliance of the therapy, and the results for the
collected group will show a developmental delay in the language developmental parameter
chart at least 1year delay of their chronological age.
-4 months after therapy, re-appliance language& articulation test may be applied.
Therapeutic plan will be discussed with the parents, as they should understand the
expected target score for software, and how they will share in its appliance.
* The following abilities are subsumed under expressive language: semantics, syntax,
phonology, morphology, and pragmatics. Semantics refers to knowledge of word meanings.
Syntax refers to the underlying structure of language and the rules that guide word order.
Phonology referred to the sound system of a language. Morphology refers to the meaning units of
language. Just as a phoneme refers to the smallest unit of sound, a morpheme refers to the
smallest unit of meaning. For example, the word boys is composed of two morphemes, the
meaning unit boy and the plural markers. Pragmatics refers to the social aspects of language and
the varied use of language in different social contexts. A child with a pragmatic language
disorder may fail to alter his or her delivery on the basis of the situation and the listener. As a
result, he or she may speak to the school principal in the same tone and manner as to a peer on
the playground (e.g., "Hey, man, what's happening?"').
Results& discussion:
*73% (17 male - 15female) of the children showing improvement at all levels within the 4
months.
*25% (8 male- 9 female) are improved in semantic with limited improvement in
phonology & syntax as they were having some deficit in manual complex activity which
appeared with appliance of therapy as they were not able to manipulate small toys and the
mouse of the computers, and they needed occupational therapy which was achieving a goal to
adjust the visual manual coordination, and improve the fine motor activity of the child. After
more than 4 months of combined speech therapy with occupational therapy the children started
to correct phonology.
231
* 2% (1 female)did not show significant improvement as there was associated mild MR

which was having social IQ test scoring was 75-80.
* there is no apparent correlation between male & female progress.
Statistical chart Results.
Conclusions
1. Early intervention can begin during preschool age as early as 3-6 years of life, and could
be very effective to overcome SLI, and avoid the incidence of learning disability.
2. Computerized speech therapy programs facilitate the job for the speech pathologist to
reach good results in short duration.
3. Multisensory stimulation program is a very effective, potent therapeutic plan to be used
with the child with fine motor skills defect,
4. The child fine motor and fine sensory skills should be evaluated as early as possible in
cases of delayed language development to avoid more delay in other habilitation
prospective.
5. Parents can secure an early conclusive diagnosis, but being proactive in the preschool
years is often better.
6. Equipping a child for success at ages three and four with proper habilitation program
with speech and occupational therapy will lead to positive experiences in kindergarten,
and the signs of SLI are variably reduced.
7. Preschool programs should consider special programs designed to enrich the language
development of students with disabilities. This classroom may include normallydeveloping children who will act unknowingly as models. The focus of class activities
may be role-playing, sharing time, or hands-on lessons with new, interesting vocabulary.
This kind of preschool will encourage interaction between children, and will build rich
layers of language experience. It may even include techniques from speech pathology
with the proper computerized software that solicit from children the kinds of practice
they need to build their language skills.
232
8.
When children have trouble remembering what they hear, make sure that they
understand oral directions. Ask them to paraphrase, repeat, or explain instructions.
Allow children to repeat the questions they are being asked, having them rephrase the
question in their own words, before answering.
9. Encourage children to ask questions and to use multiple modalities for reinforcement
(i.e., encourage them to read the information, say it aloud, and to try and develop a
visual image). Several techniques, outlined in the section on visual imagery, can help
students learn how to form mental pictures.
10. Activities, and materials can send home for enrichment the therapeutic program.
References
1. Leonard, L.B. (1998). Children with specific language impairment. Cambridge, MA: MIT Press.
2. National Information Center for Children and Youth with Disabilities, fact sheet number 11
(FS11), January 2004. www.nichcy.org/pubs/factshe/fs11txt.htm
3. Rice, M. L. (2002). A unified model of specific and general language delay: Grammatical tense as a
clinical marker of unexpected variation. In Y. Levy and J. Schaeffer (Editors), Language competence
across populations: Toward a definition of Specific Language Impairment, (pp. 63-95). Mahwah, New
Jersey: Lawrence Erlbaum.
4. Rice, M. (2000). Grammatical symptoms of specific language impairment. In D.V.M. Bishop and
L.B. Leonard (Editors) Speech and language impairments in children: causes, characteristics, intervention
and outcome (pp. 17-34). East Susex, England: Psychology Press.
5. Rice, M. and Wilcox, K. (Editors) (1995) Building a language-focused curriculum for the preschool
classroom: a foundation for life-long communication. Baltimore: Brookes Publishing Company.
6. Schuele, C.M. and Hadley, P. (1999). Potential advantages of introducing specific language
impairment to families. American Journal of Speech-Language-Pathology, 8, 11-22.
7. Tager-Flusberg, H. and Cooper, J. (1999). Present and future possibilities for defining a phenotype
for specific language impairment. Journal of Speech, Language, and Hearing Research, 42, 1275-1278.
8. Tomblin, J.B. (1997). Prevalence of SLI in kindergarten children. Journal of Speech, Language, and
Hearing Research, 40, 1245-60.
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FP40.1
PROFILE OF METALINGUISTIC AND READING SKILLS OF BRAZILIAN
STUDENTS FROM 1ST TO 4TH GRADES
Simone Aparecida Capellini (UNESP)
Vera Lucia Orlandi Cunha (UNESP).
Introduction
For the acquisition of reading in a language whose writing system is alphabetic it is
necessary to understand that letters correspond to smaller sound segments, i.e., to understand
that letters represent phonemes.
The child needs to develop specific skills so that he/she can acquire this understanding.
One of these is the metalinguistic skills, which enables him/her to identify and manipulate units
of speech, distinguish two types of analysis, depending on the unit, if syllable or phoneme.
Phonological awareness is an integral part of metalinguistic ability. This ability is defined as
awareness that is related to the ability to reflect and manipulate speech segments, covering also
the capacity for reflection (seeing and comparing), the ability to work with rhymes, alliteration,
syllables and phonemes (counting, segmenting, uniting, adding, deleting, replacing and
transposing). These skills are related to working memory and are used in the processing of
reading, which can occur through a process involving phonological mediation (phonological
route) or through a direct visual process (lexical route). The development of metalinguistic skills
will be favored as the child is subjected to complex linguistic tasks, including learning to read.
(GINDRI; kESKE-SOARES; MOTA, 2007; SALGADO; CAPELLINI, 2008; McQUISTON;
O'SHEA; McCOLLIN, 2008; AL OTAIBA ET AL, 2008; CUNHA; CAPELLINI, 2009a, 2009b;
DEUSCHLE; CECHELA, 2009).
Given the propositions above, this study aimed to verify the profile of metalinguistic
skills and reading in Brazilian students from 1st to 4th grades.
Methods
The study included 120 students from public schools from 1st to 4th grades of public
elementary schools, from both genders, aged seven years and four months to twelve years and
nine months divided into four groups, respectively GI, GII, GIII and GIV of 30 students each.
The exclusion criteria considered were: students with sensory, motor or cognitive
impairment and non-submission of the Term of Consent signed by parents or guardians. And as
inclusion criteria were considered: students with the Term of Consent signed by parents or
guardian and without hearing or visual complaints in medical profile.
The assessment protocol PROHMELE (CUNHA; CAPELLINI, 2009a) was the procedure
used as evidence of metalinguistic skills and reading. The tests which are the components of this
protocol are intended to verify the ability of students to perceive the auditory parts that make
up a word and that the same part may be in other words in different positions, being
manipulated to form new words. Since this perception in oral language will be transferred to
234
reading and writing, the school must use the same skill to the grapheme-phoneme
correspondences for students to understand the generative mechanism of the constituent parts
of a written word.
The reading tests verify the accuracy of reading both real words and non-words. The list
of words of evidence of reading real words and pseudo-words is based on the rules for decoding
the Portuguese of Brazil described by Scliar-Cabral (2003).
Tests from PROHMELE were applied in the following order:
A. Test of metalinguistic abilities
A.1-syllabic skills: Identification of initial syllables, final and medial segmentation,
addition, substitution, subtraction and combination of syllables.
A.2-phonemic skills: Identification of initial phonemes, final and medial segmentation,
addition, substitution, subtraction and combination of phonemes.
A.3-Repeating Non-words (from 1 to 7 syllables)
B. Test of Reading
B.1-Reading real words: submitted list of isolated real words (133 words)
B.2-Reading non-words: list of non-words was presented (27 non-words)
The tests were applied individually in a 50-minute session. Test of reading and repetition
of non-words were out aloud and recorded for later analysis.
Statistical analysis was performed using the SPSS (Statistical Package for Social Sciences),
in version 13.0, based on the number of errors made by the four groups. The tests used were
Kruskal-Wallis, Mann-Whitner and the Test of Wilcoxon signed-rank. The results were analyzed
statistically with a significance level of 5% (0.050).

Tests of metalinguistic skills, performance on syllabic tasks were higher than phonemic
tasks in the four groups (GI, GII, GIII and GIV), with statistically significant results. The
literature reports that awareness of syllables is acquired as early as larger units such as syllables
are more visible and therefore more easily manipulated. This seems to happen because the
development of metalinguistic ability is the syllable, which develops in the pre-school, for
awareness of the phoneme, which is gained in school, along with formal learning of reading and
writing (TIRAPEGUI et al, 2005; SALGADO; CAPELLINI, 2008).
The performance in both tasks as syllabic phonemic tasks became higher with the
seriation, which suggests a reciprocal relationship between the written language and
metalinguistic skills, with influence between phonological awareness and acquisition of literacy
and levels and phonological awareness skills, which are enhanced from the systemic exposure to
writing, because a higher level of education is related to a greater proficiency in reading, which
can provide better performance on tasks that assess language skills, which corroborate the
studies of Gindri; Keske-Soares; Mota (2007), Crnio et al (2006), Salgado; Capellini (2008),
McQuiston; O'Shea; McCollin (2008), Cunha; Capellini (2009b), Nunes; Frota; Mousinho, (2009)
and Germano; Pinheiro; Capellini (2009).
The groups showed poorer performance in phonemic manipulation in relation to the
syllable, this was because, according Queiroga; Borba; Vogeley (2004), some additional metalinguistic skills are simpler, requiring only one operation followed by answer, as the
segmentation of syllables, however, more complex tasks requiring the execution of two
operations, i.e., saving a memory unit is made as a new operation. Furthermore, the answers
vary with the type of operation that is required.
235
The results of the tests of non-words also showed statistically significant differences,
with greater differences between the number of incorrect responses of GI and GIV, falling in the
latter, suggesting that the seriation makes superior performance in these tasks. The performance
of working memory is associated with chronological age and learning, as there is a relationship
between working memory and performance on tasks of metalinguistic skills, and it is expected
that older children perform better on memory tasks than young children. This is explained by
the fact that the phonological memory, more specifically the effect of word length, increase with
age, according to Gindri; Keske-Soares; Mota (2007) and Gray; McCutchen (2006).
There were statistically significant differences for the results of reading time, which
indicated that the time decreases with seriation both in the reading of real words and nonwords, confirming the provisions of literature, which, from experience, the reader begins to use
more lexical route as argued by Capellini; Salgado (2008), Stivanin; Scheuer (2007) and Al Otaiba
et al (2008). This suggests that in the early grades, when reading new words or less frequent,
extensive ones and irregularities which have not been learned or are being learned, the child
must use rules of conversion between graphemes and phonemes which increase the recovery
time, as the child increases the frequency of contact with written words, representations stabilize
and allow an increasingly automated and quick recovery of written words, allowing the use of
the lexical route.
Our findings on tests of reading real words and non-words, according to the criteria of
the rules of decoding the Portuguese of Brazil described by Scliar-Cabral (2003) indicated that
there were statistically significant differences, and the incorrect answers decreased from GI to
GIII, and increased in GIV.
The results indicated that with education and development, the child learns and
establishes spelling relations, which allows automatic and appropriate recovery of words and
leads to a less frequent use of the phonological route. In an attempt to retrieve the word directly
from the lexicon, let's regularize it and segment it, looking for words with similar phonological
structure. Thus, our data seem to indicate that when the child encounters a word with a familiar
structure to spell, he/she tries to read it by the lexical route, occurring errors of confusion with a
similar word, the rules are not decoded, as explained Stivanin; Scheuer (2007), Salgado;
Capellini (2008) and Cunha; Capellini (2009a, 2009b). Thus, the use of the lexical route may have
caused more errors in decoding the rules in the fourth grade.
Our findings suggest also that there seems to be a relationship between the skill of
phonemic manipulation with the seizure of the rules, whereas in the GIV difficulties in
phonemic abilities persist. This suggests that there is a relationship between phonological skills
and learning of spelling rules.To Scliar-Cabral (2003) and Salgado; Capellini (2008), the child will
master the spelling of the language conversion by living with practices of reading and writing
and not just through the use of graphophonemic phonographemic conversion and thus these
practices need to be encouraged and taught by teachers so that the child makes his/her spelling
vocabulary, learning the rules of the writing system of the Portuguese language.
Conclusion
The results allowed us to conclude that: there was a relationship between metalinguistic skills
and reading, metalinguistic skills to the syllables are acquired before the phonemic abilities,
skills of identification are previously acquired to the skills of manipulation, there are different
levels of development of these skills; metalinguistic skills are related to phonological working
memory, metalinguistic skills evolved with the seriation; phonemic skills are developed along
236
with the development of written language, confirming a causal relationship established
between these skills.

References
AL OTAIBA, S.; CONNOR, C.; LANE, H.; KOSANOVICH, M. L; SCHATSCHNEIDER, C; DYRLUND, A.
K.; MILLER, M. S.; WRIGHT T.L. Reading First kindergarten classroom instruction and students'
growth in phonological awareness and letter namingdecoding fluency. Journal of School
Psychology 46. 281314. 2008.
CRNIO, M. S; STIVANIN, L.; VIEIRA, M. P.; AMARO, L., MARTINS, V. O.; CARVALHO, E,; ELIAS, J.
Habilidades de conscincia fonolgica e letramento em crianas do ensino fundamental. Rev Soc
Bras Fonoaudiol. Vol 11. n 4. pp. 231-242. 2006.
CUNHA, V. L.O; CAPELLINI, S. A. PROHMELE Protocolo de Avaliao de habilidades
metalingsticas e de Leitura. Revinter: Rio de Janeiro. 2009a.
CUNHA, V. L.O; CAPELLINI, S. A. Desempenho de escolares de 1 a 4 srie do ensino fundamental nas
provas de habilidades metafonolgicas e de leitura - PROHMELE. Rev. soc. bras. fonoaudiol., 14
(1), 56-68. 2009b.
DEUSCHLE, V.P; CECHELLA, C. O dficit em conscincia fonolgica e sua relao com a dislexia:
diagnstico e interveno. Rev. CEFAC [online], 11( suppl.2), 194-200.
GERMANO, G.D., PINHEIRO, F.H., CAPELLINI, S.A. (2009, Abril/junho). Desempenho de escolares com
dislexia do desenvolvimento em tarefas fonolgicas e silbicas. Rev CEFAC, 11 (2), 213-220. 2009.
GINDRI, G.; KESKE-SOARES, M.; MOTA, H. B. Memria de trabalho, conscincia fonolgica e hiptese
de escrita. Pr- Fono R Atual Cient. 19 (3): 313-322. 2007.
GRAY, A.; MCCUTCHEN, D. Young readers use of phonological information: phonological awareness,
memory, and comprehension. Journal of Learning Disabilities. vol 39, n 4. pp 325-333. 2006.
MCQUISTON, K.; OSHEA, D.; MCCOLLIN, M. Improving phonological awareness and decoding skills
of high schools students from diverse backgrounds. Preventing School Failure. vol. 52. n 2. pp. 6770. 2008.
NUNES, C., FROTA, S., MOUSINHO, R. Conscincia fonolgica e o processo de aprendizagem de leitura
e escrita: implicaes tericas para o embasamento da prtica fonoaudiolgica. Rev. Cefac, 11(2),
207-212. 2009.
QUEIROGA, B. A.M.; BORBA, D. M.; VOGELEY, A. C.E. Habilidades metalingsticas e a apropriao do
sistema ortogrfico. Rev Soc Bras Fonoaudiol. vol. 9 n 2.pp. 73-80. 2004.
SALGADO, C. A.; CAPELLINI S. A. Programa de remediao fonolgica em escolares com dislexia do
desenvolvimento. Pr-Fono R Atual Cient. vol. 20. n 1. pp. 31-6. 2008.
SCLIAR-CABRAL L. Princpios do sistema alfabtico do portugus do Brasil. So Paulo: Contexto. 2003.
STIVANIN, L.; SCHEUER, C. I. Tempo de latncia para a leitura: influncia da freqncia da palavra
escrita e da escolarizao. Rev soc bras fonoaudiol, v. 12, n. 3, p. 206-213, 2007.
TIRAPEGUI, C. J.C.; GAJARDO, L. R.C.; ORTIZ, Z.D.B. Conciencia fonolgica y lengua en nios con
trastorno especfico del lenguaje expressivo. Rev CEFAC, So Paulo, vol.7, n 4. pp. 419-25. 2005.
237
SY14C.1
ASSESSING LANGUAGE THERAPY RESULTS IN ADOLESCENTS OF THE
AUTISM SPECTRUM
F.D.M. Fernandes
School of Medicine. U of So Paulo
Introduction
The autistic spectrum disorders involve impairments in three developmental areas, with
some degrees of variation: language, cognition and interaction. The nature of the associations
between these areas has been the object of a great number of studies for the last decades.
Regardless of the theoretical framework, language is always considered a fundamental
characteristic within the autism spectrum and prior research has already identified its
association to several aspects of the social cognitive development.
The systematic evaluation of the communicative competence allows the professionals to
better understand how and when a child uses his/her linguistic skills. Thus, the assessment
methods must focus on the differential diagnosis and on questions about the improvement of
communicative functionality.
The speech-language professional must consider the relationship between the language
skill and the communicative competence. The language skill refers to the individuals
competence to understand and formulate a spoken or written symbolic system, while the
communicative competence refers to the skill of using language as an interactive instrument in
different social contexts. This competence involves the communicative intention, independently
of the communication means used.
The issue about the need to provide early intervention to individuals with autism is
frequently mentioned in the literature. However, there are very few reports about the results
obtained when it doesnt occur.
Unfortunately, late access to specialized services is not a rare occurrence and therefore
the speech-language pathologist is frequently confronted with situations in which older children
and even adolescents received no prior language intervention. Decisions about whether to start
this process or to opt for other educational alternatives must be based in evidence of results
obtained in similar situations.
This presentation will discuss the results of two studies with adolescents and the results
of language therapy.
The first study aimed to verify progress in the Functional Communicative Profile and in
the Social-Cognitive Performance of adolescents with autism treated in a specialized institution,
in three different communicative situations: individual speech-language therapy, group activity
with and without adult coordination after a twelve-month period.
The second study compared the progress of children and adolescents after a period of
six-month of individual language-therapy.
Adults responsible for the subjects signed the approved consent form before the beginning of the research.
Study 1
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Method
Subjects were five adolescents with ages varying from 12:4y to 16:3y with psychiatric
diagnosis of autism according to the DSM-IV and ICD-10 and no previous language therapy.
Three specific communicative situations were video-recorded at the onset of the study
and after 12 months in which they attended to weekly individual language therapy. The
communicative situations were established and the communicative contexts varied according to
the individual or group activities proposed by the adult or chosen by the subjects. They were:
Situation I: child during speech-language therapy.
Situation II: child in a group with an adult coordinator (not the speech-language
therapist).
Situation III: child in a group without an adult coordinator.
The recordings were analyzed concerning each subject's performance in the three
situations after the 12 months period and the comparison of social-cognitive performance and
functional communicative profile in the two moments of data gathering.
The criteria proposed to the analysis of the Functional Communicative Profile (FCP)
identify the number of communicative acts expressed per minute, the communicative means
used and a series of 20 categories:
Object Request (OR); Action Request (AR); Social Routine Request (SR); Consent Request
(CR); Information Request (IR); Protest (PR); Recognition of other (RO); Show-off (S); Comment
(C); Self-regulatory (SR); Labeling (L); Performative (PE): Expressive (EX); Reactive (RE); Nonfocused (NF); Play (P): acts involving; Exploratory (XP); Narrative (N); Protest expression (EP)
and Joint play (JP).
The Social-Cognitive Performance (SCP) was determined in the areas of:
Gestural Communicative Intent (GCI)
Vocal Communicative Intent (VCI)
Tool Use (TU)
Gestural Imitation (GI)
Vocal Imitation (VI)
Combinatory Play (CoP)
Symbolic Play (SP)
Results
The subjects presented similar increasing number of communicative acts per minute in
all communicative situations.
In Situation I the Functional Communicative Profile (FCP) showed: increase in the
number of communicative functions in 4 of the 5 subjects and in the proportion of interpersonal
communicative acts for all subjects. In what refer to the Social-Cognitive Performance (SCP), all
subjects presented the higher possible scores in VCI, CoP and SP after 12 months of language
therapy.
In Situation II it was possible to observe improvements in different areas of the FCP:
proportion of interpersonal communicative functions and of use of verbal communicative means
for all subjects. All subjects presented the highest possible scores in two areas of the SCP: GCI
and SP.
In Situation III were observed the highest proportion of communication interactivity for
all subjects. In what refer to the SCP, imitation and tool use was not observed in either subject
and the best possible scores were presented by 5 subjects in GCI and 4 in VCI and SP.
239
Discussion
The results demonstrate that the performance throughout the variables studied
presented variations in all analyzed items.
The assessment of FCP indicates that the number of communicative acts per minute may
be confirmed as an important element to identify progress.
The different performance in situation III may be due to the communicative demands
determined by the peer-situation, without the adults facilitation.
Conclusion
It can be suggested that the subjects understand the differences and demands of each
communicative situation and are able to adapt to them, changing their functional
communicative profile.
The important conclusion is that all subjects presented improvement in their Functional
Communicative Profile as well as in their Social-Cognitive Performance.
These results confirm the indication of language therapy for adolescents with autism.
Study 2
Method
Subjects were 24 individuals with psychiatric diagnostic of autism according to the DSMIV and ICD-10 criteria. They were divided in two groups:
Group 1: 12 adolescents with ages from 12 to 17 years (mean 13.5)
Group 2: 12 children with ages from 4 to 9 (mean 6.9)
All subjects were receiving individual language therapy for 12 to 18 months, had
psychiatric and/or neurologic assistance when needed and attended special schools or special
classes in normal schools. Psychological evaluation was conducted in the beginning of the
language therapy intervention and placed all subjects in the lower normal to mild deficient
range.
FPC and SCP were assessed twice, with a six-month interval. During this period the
subjects continued their educational and intervention programs. In the beginning of the study
both groups had similar averages in the areas of number of communicative acts per minute,
communication interactivity, proportion of use of the verbal mean and vocal and gestural
communicative intent.
Results
Group 1 presented significant improvement in performance only in Vocal
Communicative Intent.
Group 2 presented a significant improvement in the number of communicative acts per
minute, proportion of use of the verbal mean, Vocal Imitation, Combinatory Play and Symbolic
Play.
It was observed an increase in the use of the verbal mean, as well as in the performance
in CP for the subjects of both groups.
Discussion
The results of this study refer to 10 items of observable performance. Prior studies have
shown significant variations after 6-month period of language intervention. The groups of
adolescents presented significant progress in just one area while the group of children presented
significant progress in five aspects.
240
These data demand individualized analysis and consideration about possible causes.
The differences between the two groups seem to suggest that the delays in the
determination of the correct diagnosis and appropriate therapeutic intervention may have a
negative impact in the prognosis of individuals with autism.
Conclusion
Although these data refer to a short period of time and the need for studies about larger
periods of time is clear, they should be taken into account when considering the continuity of
therapeutic processes. Issues such as educational adaptation and pharmacotherapy should be
carefully addressed.
The notion of developmental slopes should be reconsidered based in these results once
they strongly reinforce the early inclusion of children with autism in language therapy
programs.
These data are not enough to suggest that this intervention is not useful to adolescents.
But they demand the consideration of factors that may be present bigger difficulties to
adolescents than to children, such as educational inclusion, familiar attitudes about physical
development and changes due to puberty. These issues may interfere with the progress of
adolescent subjects and therefore demand studies about larger periods of time.
Conclusion
Due to the characteristics of the institutions where these studies were conducted, all
subjects were on the lower levels of intelligence and had families with basic educational levels.
These elements may also have influenced on the results.
The assessment tools sometimes produced a limiting effect, where all subjects presented
the higher possible score and it also demands that the results are carefully considered. The
determination of each subjects individual profile of abilities and inabilities can not be restricted
to only a few instruments. The instruments presented here were the ones that allowed some data
comparisons.
It seems safe to state that the results of these studies reinforce the notion that, although
the early correct and apt intervention is the best alternative to autistic children, adolescents with
autism should also be included in language intervention programs.
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FP06.3
PRAGMATIC, LEXICAL AND GRAMMATICAL ABILITIES IN AUTISTIC
SPECTRUM CHILDREN
Fernanda Dreux Miranda Fernandes (1)
Liliane Perroud Miilher (2)
(1), (2) University of So Paulo School of Medicine
Introduction
Autism is presently considered by the American Psychiatry Association a pervasive
developmental disorder with impact on the areas of communication, socialization and cognition
(imagination and symbolization). Due to heterogeneity of the features, the notion of an autistic
spectrum is useful. The boundaries regarding which conditions should be included in this
spectrum are still subject of some discussion, but Autism, Asperger syndrome and High
Functioning Autism are invariably present. Regardless of the theoretical perspective or etiology,
the linguistic issues are important features of the descriptions of autism, varying from lack of
verbal communication to pedantic speech. Language is considered an important diagnostic and
prognostic factor.
The exact nature of language impairments is still unclear, especially due to the variations
of symptoms. Approximately half of the autistic children do not use language functionally and
present persistent communicative delay. Other children present language development similar
to normal children but with pragmatic inabilities. Some studies suggest that there are at least
three differences between autistic and normal childrens language: articulation abilities seem to
be better developed then the others; verbal expression seem to be more advanced then verbal
comprehension and lexical comprehension is superior then grammatical comprehension.
Several authors pointed out that the pragmatic inabilities are a central feature of autistic
disorders and thus are the focus of many researches since de 1980 decade. However, since the
beginning of the 21st century, the interest about formal and semantic issues has been restored.
Generally, literature points out to grammatical, lexical and pragmatic deficits in autistic
children. However, it is still not clear how these abilities relate and mutually interfere.
The aim of this research was to verify and analyze the relation between grammatical,
lexical and pragmatic development in autistic children in a period of 12 months of language
therapy.
Method
Subjects
Subjects were 10 male individuals with diagnosis within the autistic spectrum. The
diagnostics were determined by psychiatrists according to criteria proposed by the DSM-IV and
ICD-10. All parents signed the approved consent form. All subjects were evaluated and attended
to language therapy on a specialized service.
The average age on initial assessment was 7:2y (varying from 2:7 to 11;2 years) and they
had received no prior language therapy.
Video-taped samples of initial assessment, six and twelve months after language
therapy.
Material and Procedure
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1) To the assessment of the Functional Communicative Profile a 15-minute video-taped

sample recording regular language therapy sessions were used. Child and language therapist
interacted in a familiar environment with each childs favorite toys.
The Functional Communicative Profile (FCP) includes the analysis of the number of
communicative acts expressed and the communicative functions they expressed. These
communicative functions were divided in more interpersonal and less interpersonal. The FCP
also considers the communicative means used to express each communicative act: verbal
(emission with more than 75% of the correct form), vocal (emission with less than 75% of the
correct form) and gestural (facial and body movements).
Communicative functions were also divided according to Halliday proposal:
instrumental, regulatory, interactive, personal, heuristic and imaginative.
2) To the assessment of the Mean Length of Utterance (MLU) the same videotaped
therapy sessions described above were used. To the MLU analysis 100 speech segments were
used.
Singing and delayed echolalia were excluded from the analysis. Grammatical
morphemes were divided in two sub-groups: GM1 (nouns, verbs and articles) and GM2
(prepositions, conjunctions and pronouns). The total sum of GM1 and GM2 constituted the
MLU-total. The ratio of MLU-words and MLU-morphemes was also determined. The
grammatical classes considered were: adverbs, adjectives, articles, conjunctions, prepositions,
pronouns, nouns and verbs.
3) To the assessment of Vocabulary the same 100 speech segments described above were
used. The terms of psychological state (physical, emotional, of desire and cognitive) and of
designation (natural and cultural entity, body parts, action, artifacts, time and space location and
peoples names) were counted by occurrence.
Non parametric statistic tests (ANOVA, Mann-Whitney and Kuskal-Wallis) were used to
explore studied factors. Spearmans correlation coefficient and Pearson correlation test were
used to assess the degree of correlation between data.
Results
Of the total assessed variables the ones with larger number of correlations were: MLUwords (34 correlations), verbs (31 correlations) and GM1, MLU morphemes and proportion of
interpersonal communicative acts (29 correlations each). Each one of these five variables will be
further analyzed.
Table 1 presents the variables that were associated to MLU-words on each of the three
studied moments.
Table 1: Variables correlated to MLU-words
Moment 1
Moment 2
Total number of functions
acts/minute
%
interpersonal % interpersonal communicative
communicative acts
acts
verbal mean
Verbal mean
gestural mean (-)
gestural mean (-)
artifacts
communicative space
total of designative terms
use of instrumental function (-)
desire terms
use of regulatory function
different cognitive terms
Moment 3
acts/minute
communicative space
use
of
function
interactional
243
Table 2 presents the variables that were associated to Verbs on each of the three studied
moments.,
Table 2: Variables correlated to Verbs
Moment 1
Moment 2
action terms
space location terms
acts/minute
% interpersonal communicative %
interpersonal
acts
communicative acts
use of instrumental function (-)
use of instrumental function
(-)
use of interactive function
verbal mean
verbal mean
gestural mean(-)
gestural mean(-)
Moment 3
%
interpersonal
communicative acts

gestural mean (-)
Table 3 presents the variables that were associated to MLU-morphemes on each of the
three studied moments.
Table 3: Variables correlated to MLU-morphemes.
Moment 1
Moment 2
artifact
acts/minute
communicative space
total of functions (-)
%
interpersonal
communicative acts
use of regulatory function
verbal mean
verbal mean
gestural mean (-)
Moment 3
artifact
Table 4 presents the variables that were associated to GM-1 on each of the three studied
moments.
Table 4: Variables correlated to Grammatical Morphemes type 1.
Moment 1
Moment 2
Moment 3
cultural entity
acts/minute
artifact
instrumental function (-)
artifact
regulatory function
desire terms
interactional function
%
interpersonal %
interpersonal
communicative acts
communicative acts
verbal mean
verbal mean
Gestural mean (-)
Table 5 presents the variables that were associated to the Proportion of Interpersonal
Communicative Acts on each of the three studied moments.
244
Table 5: Variables correlated to the proportion of interpersonal communicative acts.

Moment 1
Moment 2
Moment 3
action
time location terms
artifact
MLU-morphemes
GM-1
GM-1
unintelligible terms (-)
MLU - words
MLU-words
adverbs
adverbs
verbs
verbs
verbs
prepositions
articles
pronouns
Legend: MLU: mean length of utterance; GM1: grammatical morphemes type 1.
Discussion
The correlations with statistical significance show the association between lexical,
grammatical and pragmatic aspects. Language components seem to be linked and function
harmonically and independently.
MLU-words was the item with the largest number of correlations. There were more
associations on the first and second moments then on the third moment. MLU-words may be an
indicator of the grammatical development as well as of the phrasal extension. However, since it
doesnt differentiate structure and morpho-syntactic complexity, MLU-words may be better
used as a linguistic development indicator. The MLU-words was larger in subjects with better
pragmatic abilities and more socio-emotional engagement during communicative exchange.
Generally MLU-words presented more associations with pragmatic variables then with lexical
abilities.
As can be seen in Table 1, in what refers to the pragmatic variables, the second moment
seems to have a transition role. On the first moment all the variables referred to each childs own
performance, with internal parameters (number of communicative functions and number of
interpersonal communicative acts). On the third moment the two variables referred to the childs
performance in relation to an external parameter (acts per minute, where the parameter is time
and communicative space, where the parameter the other). The second moment presented both
types of parameters and seemed to function as a rehearsal to the third moment. That is, on the
second moment the association between phrasal extension and performance factors with
external and internal parameters coexists.
The second variable with the largest number of correlations was the grammatical class:
Verb. The variables proportion of interpersonal communicative acts, use of interpersonal
communicative functions and gestural mean were correlated to the Verbs on the three moments
of the study. Although the correlation cannot be taken as a causal relation, a strong correlation
suggests that the variables have important common ground. Children do not learn the meaning
of new words only by time-space contiguity clues; they focus on clues about the speakers
intentional references such as gaze direction. Considering that verbs convey less evident
meaning then most nouns, a larger use of verbs seem to indicate more attention to other people,
what may suggest better social abilities not just in more attention to other people but also in
more interactive interpersonal communication. While many nouns refer to concrete objects,
verbs may refer to transient events or to complex changes with multiple organizational
principles. The concepts associated through verbs can be more complex than those conveyed by
nouns.
245
In most languages the nouns are apprehended by object concept mapping while the
knowledge about verbs is language-specific. The role of self-other interaction is important in
learning and using verbs and factors such as verbal meaning, social-pragmatic clues and input
(frequency, positional salience and syntactic structural diversity on which they are used) have
important influence on the order of verbal acquisition.
The negative association with the gestural mean may indicate one of two things: either the use of
gestures is replaced by verbalization or the use of verbal utterances doesnt exclude the gestural delay that
is observed even in children with better linguistic abilities.
The third more frequent correlations involve MLU-morphemes, type 1 grammatical morphemes
(GM-1) and the proportion of interpersonal communicative acts. MLU-morphemes presented correlations
on the first and third moments with artifacts and with the total of designative terms. Artifacts are words
that express entities that are dependent on the human action, as clock, house or others and in several cases
they are expressed by words that refer to objects. These words are included in the category of nouns
whose maximum score is three points (morphemes that express gender, number and degree) and are the
grammatical class with higher scoring possibilities on MLU.
There was association of the first and second moments on the proportions of interpersonal
communicative acts and the verbal communicative mean. The association of the first and the third
moments involved artifacts and the total of designative terms. Nouns, verbs and articles are the basic
phrasal components in Portuguese; this way the link between artifacts and designative terms and the use
of the verbal communicative mean is not surprising. Besides this link with the language it is possible that
the association with designative terms and artifacts is related to the fact that autistic children tend to
speak about less complex, more concrete, events and therefore use more words that designate real objects
as the artifacts. The correlation with interactivity indicates that the intention in socially participate in
communicative situations is essential to the effective use of linguistic knowledge. The linguistic
idiosyncrasies widely reported in literature may hide the fact that autistic children present communicative
intent. The association of interpersonal communicative acts with other variables shows that there is a link
between linguistic and social-pragmatic abilities. The correlation analysis does not determine the
association path. What can be stated is that there is an association and that it may be related to socialpragmatic structures that function as language facilitators or it may be a mechanism of reciprocal
influence.
Conclusion
There was association between functional and formal aspects of language in this sample. The number of
subjects imposes a limit to the generalization of the findings and further research with an even more
homogenous sample is necessary. The study of grammatical abilities showed the delay already reported
in the literature.
246
FP06.6
LANGUAGE THERAPY AND AUTISM: RESULTS OF INTERVENTION
Fernandes F.D.M.
Molini-Avejonas D.R.
Amato C.A.L.H.
Dept. of Physiotherapy, Communication Sciences and Disorders and Occupational Therapy
School of Medicine
University of So Paulo
Introduction
The best therapeutic approach to children of the autism spectrum is still undetermined
and probably depends on several factors such as individual profile, family characteristics,
educational and intervention alternatives. The determination of the meaningful variables is
essential to the better use of the available resources.
This presentation proposes to discuss the theoretical basis of language therapy within the
pragmatics framework, describe the different therapeutic models within the same approach,
present the results of a study assessing results of language therapy (specifically the results of
family-oriented approaches) and propose conclusions about the best therapeutic intervention
alternatives.
Theoretical basis
The concept of autism spectrum involves a wide range of neuro-developmental disorders

whose central axles include three great domains (social interaction deficits, verbal and non
verbal communication deficits and restrict behavioral patterns). Language and communication
disorders are essential features of autistic spectrum disorders, and are part of the diagnostic
criteria. The studies evolved to the notion that the central feature is related to the functional use
of language, especially regarding the interface with social cognitive development.
Therapeutic Framework
The proposed therapeutic framework focus on the individual communicative profile that
considers: communication interactivity (acts per minute and communicative functions);
communicative means; initiative for interaction; discursive abilities and social cognitive
performance. The individual profile is the base of individually designed language intervention
processes.
The alternative models considered were: individual therapy (based in building the
communicative partnership through supportive interaction); language workshop (where two
subjects allowed symmetric interaction and provided communicative challenges) and motherchild language therapy (designed to provide a more comprehensive intervention and improve
communicative settings at home).
The general purpose of the present study was to determine more efficient intervention
procedures designed to improve communication abilities of children with disorders of the
autism spectrum. It also aimed to identify differences in the functional communicative profile
and in the social cognitive performance of 36 autistic children and adolescents receiving
language therapy in three different models.
247
Method
Subjects:
Adults responsible for the subjects signed the approved consent form prior to the
beginning of the research. They were 36 children and adolescents with mean age 8:3y, with
psychiatric diagnosis included in the autism spectrum starting language therapy processes.
- Group A: Language workshop: 10 participants with mean age 9:7 y (sd 2:4), receiving
language therapy for a minimum of 6m, and a maximum of 1 year, paired according to
development and interests, were included in language workshops during a six-month period (20
therapeutic sessions). After that, they returned to individual sessions for another period of 20
sessions
- Group B: mother-child language therapy: 9 participants with mean age 7:11y (sd 4:6m),
receiving language therapy for a minimum of 6m and a maximum of 1 year, received language
therapy with their mothers for a six-month period (20 therapeutic sessions). After that, they
returned to individual sessions for another period of 20 sessions.
- Group C: Individual language therapy: 17 participants with mean age 9:6y (sd 3:4y),
individual language therapy for a minimum of 6m and a maximum of 1 year, received
individual language therapy sessions for a period of twelve months (40 sessions).
Procedures:
All therapists received the same orientations: to emphasize functional and inter-personal
communication with the subjects as often as possible. All participants were video recorded
during play interaction situations with their therapists in three moments: before starting the
period of the modified language therapy situations, after the period of modified situations (20
sessions of double, with the mother or individual language therapy sessions), and after the
following period of 20 individual sessions.
Analysis
Functional Communicative Profile identified and quantified the proportion of use of the
different communicative means, proportion of interpersonal communicative functions,
communication interactivity, communication initiative, number of communicative acts per
minute and the occupation of the communicative space.
Social Cognitive Performance identified the best performance of each subjects in the
areas of Vocal and Gestual Communicative Intent; Vocal and Gestual Imitation; Tool Use;
Combinatory and Symbolic Play.
Results
Differences in the mean performances of the first and second periods were not significant
to neither of the considered pairs of variables.
Number of communicative acts expressed per minute: the situation that produced the
best results was the Language Workshop.
Use of communication means: Subjects of groups A and B presented similar
performances, demonstrated by an increase in the proportion of verbal mean use and a decrease
in the use of gestures.
Interactive communication: increased for all groups after the first studied time interval
(i.e., after the modified therapy situation). This increase was not observed after the second
studied time interval.
248
The group that presented more progress indicators was the language workshop - where
the subjects received therapy in groups of two.
Individual results indicate that subjects continued to show improvements afterwards.
Discussion
It is premature and deceiving to suggest that one sole therapeutic approach is more
effective than the others and that there is a method that is more effective with all children. It is
suggested that the intervention program should be individualized, considering each childs
actual development level and identifying personal profiles of abilities and inabilities
The subjects of this study were divided in groups according to subjective clinical criteria
and responding to each ones objective demands referring to week-day and hour of appointment
Data referring to the number of communicative acts per minute show that the subjects
attending language workshops presented greater development of this aspect
Apparently peer communication situations provide a symmetry that is not obtained in
situations with adults. This symmetry provides affective performance demands in which
subjects must use their communicative abilities.
Clinical experience suggests that each individual goes through periods of development
and balance some may even experience periods of regression that are absolutely unique and
can almost never be anticipated.
These results indicate the possibility of using temporary changes, if these are
standardized, during therapeutic process, maintaining the progress rhythm of in the long term.
These results yielded to the conclusion that language therapy process can benefit from
specific orientations about language and communication processes focused on individual
profiles of abilities and inabilities of each communicative dyad. Thus, another study was
conducted to verify the results obtained by 10 sessions of specific instruction about language
and communication to 26 mothers of autistic spectrum children attending language therapy in
the same specialized service. Five instruction sessions and five accompanying sessions were
conducted with small groups of mothers, parallel to the childrens language therapy. The results
compared each childs performance prior and after de instruction sessions in the domains of
communicative profile and social-cognitive performance and have shown that all subjects
presented at least one index of progress. All mothers involved in the process considered it very
useful to better understand their children and to be able to share their troubles with other people
involved in similar situations. They also pointed out, however, that they wouldnt be able to
participate in other similar activities if they were held in other periods, not while their children
were receiving language therapy, due to specific issues such as transport, lack of time and not
being able to leave their children with someone else. Besides that, data about quality of life and
functionality pointed out to the need of other studies where the use of these instruments is
dissociated from the therapeutic intervention.
Conclusion
The main purpose of the present study was to verify the existence of observable
differences in the functional communicative profile and in the social cognitive performance of
autistic children and adolescents receiving language therapy in three different situations.
Variations were observed after a pre-determined experimental intervention period.
Maintenance of the results was also observed after an equal period of regular speech-language
therapy.
249
The obtained results indicate that temporary changes can be made in the therapeutic
scheme for autistic children, as an alternative for obtaining better results.
This type of intervention, however, requires specific control of the results after short
periods of intervention.
Results also reinforce the requirement for the adaptation of procedures to obtain
individual profiles of abilities and inabilities as the basis to determine an intervention model.
The inclusion of mothers in the therapeutic process during a set period of time is a
proposal that requires other studies. They should aim at the search for parameters that indicate
when to begin this type of intervention, its duration and the procedures for a long time support.
Long term therapeutic processes, as is the case with autistic children, also demand
consideration about the long term results obtained from short term interferences.
The question about the possible identification of the best therapeutic approach to these
children has yet to be further discussed.
It can also be concluded that the proposition of systematic and flexible orientations
directed to families with children of the autism spectrum may produce short term results that
should be further assessed about their duration and comprehensiveness.
The effectiveness of different therapeutic approaches suggests that any conclusion must
take into account data about social and familiar contexts that play central roles in practical issues
such as frequency of attendance, continuity of the intervention process and involvement with
the therapeutic proposals.
250
SY13.4
HERITABILITY OF DISABILITY TO READ SUBTITLES - 33,000 ADULT TWINS
SELF-REPORTED THEIR DISABILITY WITH A DICHOTOMOUS ANSWER
Steen Fibiger
Rehabilitation Centre, Odense, Region of Southern Denmark
Jacob v. B. Hjelmborg
Department of Biostatistics, University of Southern Denmark
Lena Erbs
Department of Mathematics and Computer Science, University of Southern Denmark
Axel Skytthe
The Danish Twin Registry, University of Southern Denmark
Corrado Fagnani
Italian National Institute of Health, Rome, Italy
INTRODUCTION
Disorders of reading ability

There is now abundant evidence that reading problems are in part due to the fact that
families share genes and not just environments (Byrne et al., 2009). The heritability of dyslexia is
put between 0.5 and 0.6, and variability in reading ability across the normal range is at least as
heritable, with estimates ranging from 0.5 to 0.8 for various aspects of reading and spelling
(ibid.; Olson & Byrne, 2005; Pennington & Olson, 2005). Genetic factors contribute substantially
to the development of reading disability, and family linkage studies have implicated many
chromosomal regions containing reading disability susceptibility genes. Putative loci at 1p34p36 (DYX8), 2p (DYX3), 6p21.3 (DYX2), and 15q21 (DYX1) have been frequently replicated in
linkage and association studies, but from both family and twin studies it is clear that reading
disability is not monogenic (Petryshen & Pauls, 2009). Twin studies have shown strong genetic
influences on word reading and reading comprehension in Grade 2 (Byrne et al., 2009). Both
traits are more prevalent in boys than girls. Self evaluation of reading difficulties depends on
what kind of reading task you ask for. If you ask about reading an insurance policy, 39 percent
have difficulties (Elbro, Mller & Nielsen, 1991, p.102). 28 percent have difficulties with reading
a declaration on contents, 27 percent with the former income tax declaration, 19 percent with
manuals. The texts you more or less may choose by yourself have a much lower rate.
Advertisements, 6 percent, newspaper 5 percent and television subtitles, 4 percent (ibid.). To ask
about difficulties with reading subtitles in Denmark is a very useful question because all foreign
TV-programs and movies have subtitles and are not dubbed, and Elbro et al, 1991 have shown
that asking a question on reading subtitles is a reliable self evaluation on reading abilities in
adults. This question is also used in a test battery for referral to special needs education in
reading for adults (Elbro, Haven & Jandorf, 2006). Subtitles in Danish TV are running with a
maximum of about 100 words per minute, and 10 grade high school students are able to read
between 117 and 594 words per minute, with a mean of 284 words (Elbro, 2001). Therefore a
simple and reliable test of reading abilities is to ask if you are able to follow the TV subtitles.
251
To this end, based on nationwide questionnaire answers from a large cohort of Danish
twins, we used the twin method and estimated heritability of the trait and the genetic correlation
between them. Reading ability is normally distributed in the population (Rodgers, 1983), and
dyslexia represents the extreme tail of that distribution. Therefore average genetic and
environmental influences on group membership in this low tail of the reading-ability
distribution can be estimated precisely by comparing average monozygotic (MZ) and dizygotic
(DZ) cotwins to the population mean regression. We used self-reported answers from a
dichotomous question on having difficulties in reading the Danish subtitles on foreign TV
programs. Using a population wide register of Danish twins born 1931-1982, we study the
genetic and environmental influences for this trait.
MATERIALS AND METHODS

The study was based on data from a large twin omnibus survey in 2002, reported by
Fibiger, Tranebjrg & Skytthe (2004), and we investigated to what extent the persisting slow
and/or inaccurate reading ability may result from a genetic vulnerability common to the trait. A
paper and pencil questionnaire was sent to a population-wide cohort of 46,418 twins, born 1931
to 1982 in Denmark, and we used this question to screen the twins for a history of slow and/or
inaccurate reading ability:
Do you have or have you had difficulties in reading the subtitles on TV?
Of the 46,418 questionnaires, 35,312 (76%) were returned by mail, with 33,794 twins
being MZ, SSDZ (same gender dizygotic) or OSDZ (opposite gender dizygotic). Of these twins,
33,424 (11,150 complete pairs, 11,124 unmatched twins) answered the question on reading
difficulties. The answers to this question were self-reported, and behavior identification was
based on self-experienced behavior and not a clinical diagnosis.
Summary counts along with lifetime prevalence rates of readings difficulties by gender
and zygosity (MZ, SSDZ and OSDZ) were computed using the STATA software, version 9.
Probandwise concordance rates and tetrachoric correlations were estimated separately
for MZ and SSDZ pairs, and for males and females.
Probandwise concordance is the probability that the trait occurs in a twin given that it
has already occurred in the co-twin, and can be estimated as 2n11/(2n11+nd), where n11 and nd are
the numbers of concordant and discordant twin pairs, respectively (Witte, Carlin & Hopper,
1999). Difference in concordance rate between MZ and DZ pairs suggests genetic effects.
Tetrachoric correlation is defined under the so called liability-threshold model.
According to this model, there exists a latent liability to the trait, bivariate normally distributed
in the population, with a threshold such that the trait occurs when the individual liability level
exceeds the threshold. Tetrachoric correlation is the correlation in twin liabilities to the trait
(Neale & Cardon, 1992), and is independent of the trait prevalence. A significant higher
correlation in MZ compared to DZ pairs points to genetic influences on liability to the trait. To
estimate tetrachoric correlations, saturated models were fitted to raw dichotomous data on the
trait reading difficulties, with the software Mx (Neale, Boker, Xie & Maes, 2006). This model was
specified constraining the threshold of the trait to be the same for the twin and the co-twin in
MZ and DZ twins.
252
Univariate gender-limitation modeling

We applied standard gender-limitation twin modelling with the software Mx (Neale et
al., 2006) to estimate the genetic and environmental variance components of liability to reading
difficulties in males and females. The model allows for the partition of total variance into
contributions due to additive genetic effects (A), either common (shared) environmental effects
(C) or non-additive genetic effects (D), and
unshared (unique, individual-specific)
environmental effects (E). Additive genetic influences originate from the additive effects of
alleles at all contributing genetic loci, without allelic or gene-gene interaction. Dominance (allelic
interaction within a gene) or epistasis (gene-gene interaction) is responsible for non-additive
genetic effects. Shared environmental influences relate to exposures which are common to all
members of a family and make children growing up in the same family similar. Unshared
environmental factors are those factors that are specific to an individual, thus contributing to
make children growing up in the same family different, e.g. adequacy of blood supply, position
in the womb, birth complications, different home, infections, and traumas. Measurement errors
are also included in this latent source. Alternative models (ACE, ADE, AE, CE, and E) can be
compared to detect the best-fitting model.
Results
The 11,150 twin pairs who answered the question on reading difficulties had a mean age
of 44 years. No significant differences emerged between twins from complete pairs and twins
from unmatched pairs with respect to age, gender, zygosity, or lifetime prevalence rates for
reading difficulties.
Summary counts of twins who reported reading difficulties and lifetime prevalence rates
for reading difficulties by zygosity and gender are given in table 1. Reading difficulties were
significantly more common in males than in females. For reading difficulties, lifetime
prevalences were higher for dizygotic twins, especially for females.
Table 1
MZ, SSDZ Number

of
reported Number
of Total lifetime
or OSDZ
negative
or
positive positive answers prevalence
answers to this question
to this question
Males from same gender pairs

Slow reading
MZ
3942
Slow reading
SSDZ
6018
Females from same gender pairs
Slow reading
MZ
4974
Slow reading
SSDZ
6708
325
511
0.0825
0.0849
283
452
0.0569
0.0674
Males (M) and Females (F) from opposite gender DZ pairs

Slow reading
OSDZ(M) 5201
461
Slow reading
OSDZ(F)
5681
428
0.0886
0.0650
MZ = Monozygotic twins
SSDZ = Dizygotic twins from pairs with same sex/gender
OSDZ = Dizygotic twins from pairs with opposite sex/gender
Slow reading = Slow and/or inaccurate reading ability
(M) = Male
253
(F) = Female
Table 2 shows, separately for MZ and SSDZ pairs, males and females, the numbers of complete
twin pairs, concordant pairs, and discordant pairs, along with lifetime prevalence rates,
probandwise concordance rates, and tetrachoric correlations.
Both probandwise concordance rate and tetrachoric correlation were significantly higher in MZ
than in SSDZ pairs, indicating substantial genetic influence on individual liability. Tetrachoric
correlations suggested possible non-additive genetic effects.
Table 2
MZ or
SSDZ
Number
of pairs
Males from same gender pairs

Slow reading
MZ
1386
Slow reading
SSDZ
1766
Females from same gender pairs
Slow reading
MZ
1968
Slow reading
SSDZ
2418
Number of
concordant
pairs
Number of
discordant
pairs
Lifetime
prevalence
Probandwise
Concordance
Rate (95% CI)*
Tetrachoric
correlation
(95% CI)
43
25
125
229
0.076
0.079
0.41 (0.32,0.50)
0.18 (0.12,0.25)
0.67 (0.56,0.76)
0.28 (0.15,0.41)
32
20
141
265
0.052
0.063
0.31 (0.23,0.40)
0.13 (0.08,0.19)
0.61 (0.50,0.71)
0.22 (0.08,0.34)
Slow reading = Slow and/or inaccurate reading ability

SSDZ = Dizygotic twins from pairs with same gender
95% CI = 95% Confidence Interval
* p0.001 for the probability that dizygote twins have the same probandwise concordance rate as
monozygotic twins.
Univariate genetic analysis showed that additive genetic (A) and unique (unshared)
environmental (E) factors best explained the observed concordance patterns for males. For
females, and possible also for males, a small proportion of non-additive genetic factors (D) were
included. But the AE-model had the same goodness-of-fit as the ADE-model, so therefore we
select the simplest model, the AE-model. The heritability was 0.63 with the 95% confidence
interval [0.55,0.68], adjusted for effects of age and gender. Both age and gender have significant
influence. For males, the heritability was 0.59 [0.48,0.68], and for females 0.65[0.55,0.73].
Discussion and conclusion

Reading difficulties have to a great extent a genetic background, but the non-additive
genetic factors are not the most important genetic factors. The additive genetic factors are much
more important in understanding the genetic background for reading difficulties. Additional,
individual environmental factors are responsible for more than one third of the reading
problems. We found also higher lifetime prevalence for problems with reading subtitles than
Elbro et al., (1991) did.
254
References
Byrne, B., Coventry, W. L., Olson, R. K., Samuelsson, S., Corley, R., Willcutt, E. G., Wadsworth, S.
&DeFries J.C. (2009). Genetic and environmental influences on aspects of literacy and language in
early childhood: Continuity and change from preschool to Grade 2. Journal of Neurolinguistics.
22, 219-36.
Elbro, C. (2001). Lsning og lseundervisning [Reading and teaching reading]. Copenhagen: Gyldendal
Uddannelse.
Elbro, C., Haven, D. & Jandorf, B. D. (2006). Rapport om afprvning af visitationstest til brug i
ordblindeundervisning
for
voksne.
Dansk
Videncenter
for
Ordblindhed
for
Undervisningsministeriet, Kbenhavn. [Report on a test for referral to special needs education in
reading, Ministry of Education, Copenhagen].
Elbro, C., Mller, S & Nielsen, E. M. (1991). Danskernes lsefrdigheder. En undersgelse af 18-67-riges
lsning af dagligdags tekster. Projekt Lsning og Undervisningsministeriet, Kbenhavn.
[Reading abilities in Denmark, Ministry of Education, Copenhagen].
Fibiger, S., Tranebjrg, L. & Skytthe, A. (2004) Language, Speech, Hearing, Reading and Communication
Disorders in 35,000 Twins Born in Denmark 1931-1982. 2004 IALP Congress Proceedings. The
International Association of Logopedics & Phoniatrics, 29 August to 2 September, Brisbane
Convention & Exhibition Centre, Queensland, Australia. ISBN 1 876706 07 8 (Compact Disc).
Neale, M. C., Boker, S. M., Xie, G. & Maes, H. (2006) Mx: Statistical modelling, 7th ed. Richmond, Virginia:
Department of Psychiatry, Virginia Commonwealth University.
Neale, M.C. & Cardon, L.R. (1992). Methodology for genetic studies of twins and families. Dordrecht, The
Neatherlands: Kluwer Academic.
Pennington, B.F., & Olson, R.K. (2005). Genetics of dyslexia. In M. Snowling, & C. Hulme (Eds.), The
science of reading: A handbook (pp.453-472). Oxford: Blackwell Publishing.
Petryshen T.L., & Pauls, D.L. (2009). The genetics of reading disability. Current Psychiatry Reports. 11(2),
149-155.
Roberts, J.E., Rosenfeld, R.M. & Zeisel, S.A.(2004). Otitis Media and Speech and Language: A Metaanalysis of Prospective Studies. Pediatrics, 113, e238-e248.
Rodgers, B. (1983). The identification and prevalence of specific reading retardation. British Journal of
Educational Psychology, 53, 369-373.
Witte, J., Carlin, J. & Hopper J. (1999). Likelihood-based approach for estimating twin concordance for
dichotomous traits. Genetic Epidemiology, 16, 290304.
255
FP20.3
EFFECTIVENESS OF AUDIO-VISUAL COMPUTER REMEDIATION PROGRAM
IN BRAZILIAN STUDENTS WITH DYSLEXIA
Giseli Donadon Germano, UNESP
Fbio Henrique Pinheiro, UNESP
Simone Aparecida Capellini, UNESP
Introduction
Dyslexia is a specific learning disorder of neurological origin, characterized by difficulty
with the correct fluency in reading ability and difficulty in decoding and spelling, from a deficit
in the phonological component of language (Lyon, Shaywitz & Shaywitz, 2003).
Due to the phonological deficit, some training programs of phonological awareness have
shown to be effective to improve the phonological skills of letter-sound conversion, impaired in
individuals with dyslexia. There are few Brazilian studies on the subject. Studies to determine
the effectiveness of a phonological remediation program in students with specific reading
disorder and learning disabilities found that there was an improvement in the phonological
processing, which led to the emergence of syntactic and phonological awareness (Capellini,
2001, Germano, 2008, Capellini, Germano & Cardoso, 2008, Germano & Capellini, 2008,
Germano, Pinheiro, Capellini, 2008).
The international literature, however, presents more studies of remediation programs in
students with developmental dyslexia, with emphasis on training of phonological awareness.
The results indicated that the training of phonological awareness has lasting effects, and it was
possible to observe its effects including the improvement of reading comprehension (Richards et
al, 2002, Temple et al, 2003, Elbro & Petersen, 2004, Moore, Rosenberg & Coleman, 2005, Magnan
& Ecalle, 2006, Regtvoort & Leij, 2007)
Aim
This study aimed to verify the effectiveness of an audio-visual computerized
remediation program in Brazilian students with developmental dyslexia. The aim of this study
was to verify the efficacy of an audio-visual computerized remediation program in Brazilian
students with developmental dyslexia. The specific goals of this study involved the comparison
of the linguistic-cognitive performance of Brazilian students with developmental dyslexia to that
of students considered good readers; to compare the results obtained in pre and post-testing
situation of students with dyslexia who were and were not submitted to the program; and to
compare the results obtained with the remediation program in Brazilian students with
developmental dyslexia to those obtained in good readers.
Method
The study included 20 Brazilian students from 2nd to 4th grades of elementary school in
the city of Marilia - SP, from both genders, aged 8 to 12 years old. The students were divided
into two groups:
Group I (GI): 10 students with interdisciplinary diagnosis of developmental dyslexia,
from both genders, with a mean age of 10 years and 3 months old were subdivided into Group
IE (GIE): 5 students with developmental dyslexia submitted the remediation program. Group IC
256
(GIC): 5 students with developmental dyslexia not submitted to the remediation program in
reading.
Group II (GII): 10 good readers from both genders, with a mean age of 10 years and 3
months old, in paired by gender, age and grade level with GI, subdivided into: Group IIe (GIIe):
5 good readers submitted to remediation program, and Group IIc (GIIc): 5 good readers, not
submitted to remediation program.
The procedures for pre and post-testing included evaluation of central auditory
processing, and verbal dichotic tests, such as the dichotic listening test and alternate disyllables
(Pereira, 1997) and Phonological Awareness Test - Instrument of Sequential Assessment
CONFIAS (Moojen et al, 2003)
As remediation, we used the software "Play on - Jeu d'entranement la lecture", in
groups GIE and GIIe adapted to Brazilian Portuguese (Germano, 2008). The program was
chosen because it is based on listening skills to promote the auditory perception of graphemephoneme necessary for learning the alphabetic writing system of English, being granted
permission to use the program by the authors for research purposes. The activities of the
program included phoneme discrimination in logatoms, words and phrases, deletion of
phonemes in logatoms, and three-syllable words. The program involved 13 sessions, established
by the researcher in 40 minutes with each child individually, twice a week.

The results showed improvement in performance of students remedied when comparing
(GIE and GIIe) pre- and post-testing, the tests of dichotic digits and spondaic. When performing
an intragroup comparison to the procedure of Phonological Awareness Test - CONFIAS, we
observed a statistically significant difference in post-testing between GIE and GIC obtained on
the initial syllable identification, syllable identification of medial transposition of syllables,
phonemic, phonemic segmentation, production of rhyme, phoneme deletion and phoneme
transposition. There was also a statistically significant difference in post-testing between GIE
and GIC in the total phonemic skills, showing an improvement in the performance of GIE in
relation to GIC. Furthermore, it demonstrates a difficulty in implementing these subtests for
students without learning disabilities, suggesting a lack of mastery in the use of phonological
awareness.
We also observed that the performance of students with dyslexia (GI) was lower than the
performance of good readers (GII), showing improved performance of GIE in post-testing and
the effectiveness of remediation. We found no statistically significant difference when
comparing pre-and post-testing of GIE and GIC at the phonemic level, showing an average
increase for GIE in post-testing, suggesting the effectiveness of the remediation program. There
was also no statistically significant difference in the phonemic level between GIIe and GIIc when
comparing pre-and post-testing, indicating an improvement in the performance of the two other
groups after being subjected to the remediation program. There was also a statistically
significant difference between the groups of dyslexics (GI) and good readers (GII) on phonemic
and syllabic levels in pre and post-testing, indicating that the performance of GI is lower than
the GII, indicating the presence of phonological deficit in GI and effectiveness of the remediation
program in post-testing.
We finally noticed that the performance of good readers (GIIe) is higher than that of
students with developmental dyslexia (GIE) in performing the tasks of dropout and
discrimination. The results of this study revealed the difficulty in integrating information found
on tests of dichotic listening and alternate disyllables in pre-testing, because the average
257
achieved by students with developmental dyslexia was lower than that of students without
learning disabilities. We found no statistically significant difference in the performance of GIE
and the two other groups, when compared to the situations before and after testing the right ear
and left ear, indicating better performance of students from GII. However, students with
dyslexia submitted to the remediation program improved when comparing the pre and posttesting. The central difficulty in dyslexia is related to the processing of sounds, known as
phonological processing, which is also the difficulty in processing brief and rapid auditory cues
and resulting in the inability to understand the critical elements of speech accurately, making it
impossible for the students to access the phonological coding (Temple et al, 2003)
The results of this study suggest that children with developmental dyslexia have changes
in auditory processing, or change the handling and use of sound signals by changing aspects
ranging from the presence of sound to the analysis of linguistic information (Temple et al, 2003,
Moore et al 2005, Magnan & Ecalle, 2006, Regtvoort & Leij, 2007, Parmetier et al, 2008)
Regarding the Phonological Awareness Test, we found that students with developmental
dyslexia have lower average balance than good readers. In addition, both groups performed
better on tests of syllabic skills than in phonemic ones. Among students undergoing remediation
program, we see improvement in the performance of syllabic skills and, especially, the
phonemic ones, indicating the effectiveness of the remediation program.
Conclusion
The findings of this study allowed us to conclude: Students with developmental dyslexia
have lower performance compared to good readers on auditory processing skills and
phonological awareness. Students with developmental dyslexia undergoing remediation
program had improved their performance in post-test when comparing the performance of
students with developmental dyslexia not subjected to the remediation program. The good
readers submitted to the remediation program showed improvement in auditory processing
skills and phonological awareness, demonstrating the need for formal instruction in
metalinguistic skills during literacy, due to the alphabetical basis of Brazilian Portuguese. The
audio-visual program "Play-on" was effective because of the improvement in auditory and
phonological skills of students with developmental dyslexia and of the good readers.
References
1.02.0-
3.0-
4.05.0-
Capellini A.S., Germano G.D., & Cardoso A.C.V. (2008, jan/jun). Relao entre habilidades
auditivas e fonolgicas em crianas com dislexia do desenvolvimento. Abrapee, 12 (1), 235-53.
Capellini, S.A. (2001). Eficcia do programa de remediao fonolgica em escolares com distrbio especfico
de leitura e distrbio de aprendizagem. (Unpublished doctoral dissertation). Universidade Estadual
de Campinas, Campinas, So Paulo, Brasil.
Elbro, C., & Petersen, D.K. (2004). Long-term effects of phoneme awareness and letter sound
training: an intervention study with children at risk for dyslexia. Journal of educational Psychology,
96 (4), 660-670.
Germano G.D., & Capellini S.A. (2008, oct/dec). Efficacy of an audio-visual computerized
remediation program in students with dyslexia. Pr-Fono, 20(4), 237-242.
Germano G.D., Pinheiro, F.H., & Capellini, S.A. (2008). Desempenho de escolares com dislexia do
desenvolvimento em tarefas fonolgicas e silbicas. Rev. Cefac, Available from
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S15168462008005000004&lng=pt&nr=is
o ..
258
6.0-
7.08.09.010.0-
11.0-
12.013.0-
14.0-
15.0-
Germano G.D. (2008). Eficcia do programa de remediao fonolgica Play On em crianas com dislexia
do desenvolvimento. (Unpublished masters degree dissertation). Universidade Estadual Paulista,
Marilia, SP, Brasil.
Lyon G.R., Shaywitz S.E., & Shaywitz, B.A. (2003). Defining dyslexia, comorbidity, teachers
knowledge of language and reading. Ann Dyslexia, 53, 1-14.
Magnan A, & Ecalle J.(2006). Audio-training in children with reading disabilities. Comp. Educ., 46
(4), 407-425.
Moojen S , Lamprecht R, Santos R.M., Freitas G.M., Brodacz R., Siqueira M, et al (2003).
Conscincia fonolgica: Instrumento de avaliao seqencial. So Paulo: Casa do Psiclogo.
Moore D.R., Rosenberg J.F., & Coleman J.S. (2005, jan.). Discrimination training of phonemic
contrasts enhances phonological processing in mainstream school children. Brain Lang., 94 (1), 7285.
Parmentier F.B.R., Maybery M.T., Huitson M., & Jones D.M. (2008). The perceptual determinants
of
repetition
learning
auditory
space.
J.
Mem.
Lang.
Available
from
www.elsevier.com/locate/jmldoi:10.1016/j.jml.2008.02.001
Pereira L.D., & Schochat E. (1997). Processamento Auditivo Central: manual de avaliao. So Paulo:
Lovise.
Regtvoort A.G.F.M., Leij A. (2007). Early intervention with children of dyslexic parents: effects of
computer-based reading instruction at home on literacy acquisition. Lear. Ind. Differences, 17 (4),
35-53.
Richards, T.L. et al. (2002, November/december). Reproducibility of proton MR Spectroscopic
Imaging (PEPSI): comparison of dyslexic and normal-reading children and effects of treatment on
brain lactate levels during language tasks. Am J Neuroradiol., 23, 1678-1685.
Temple, E. et al (2003, mar). Neural deficits in children with dyslexia ameliorated by behavioral
remediation: evidence from functional MRI. PNAS,100 (5), 2860-2865.
259
P083
SPECTROGRAPHIC ANALYSIS IN THE STUDY OF ACQUISITION OF THE
CONSONANT CLUSTER AS FOR THE VARIABLE SEX
V.Giacchini1; R.F.Dias2; H.B.Mota3; C.L. Mezzomo4
1Federal University of Santa Maria, Santa Maria, Brazil.
2Federal University of Santa Maria, Santa Maria, Brazil.
3 Federal University of Santa Maria, Santa Maria, Brazil.
4 Federal University of Santa Maria, Santa Maria, Brazil.
In Brazilian Portuguese, the phonological acquisition shows patterns defined domain of
syllable structures, and the consonant cluster the last to be acquired by the child. As with typical
phonological development, identifies the consonant cluster as the structure that is more often
compromised in cases of phonological disorders.
For procurement of consonant cluster, when the child does not produce the correct
target, have different repair strategies such as simplifying the structure or failure to make the
complex syllable onset. The simplification of consonant cluster occurs most frequently in both
cases of normal phonological development, and in children with phonological disorders. Thus,
the stage of acquisition of consonant cluster can be designed in two stages: simple production,
followed by correct production.
Studies using instruments for the facilitation of phonological description, such as
acoustic analysis, have shown that other features can be checked during the acquisition of
syllabic structure consonant cluster and coda, as compensatory lengthening.
So the goal was to investigate with the help of acoustic analysis, the use of the strategy of
extending compensation in cases of simplifying the consonant cluster in relation to sex in the
speech of children with normal phonological development and deviant.
The method of research is talk of recording sessions for 28 children aged 1:0 to 8:0. The
subjects were divided into two groups, one group with normal phonological development and
the other with phonological disorders. Each group consisted of 14 children, 7 boys and 7 girls.
All subjects in the sample are monolingual in Portuguese Brazilian.
Inclusion criteria for the group with normal phonological development were: having
phonological acquisition within the normal range; not be getting any kind of speech therapy and
has no neurological, psychological and cognitive evident. For the group with deviation was
considered as inclusion criteria: age has less than 4:0, perform simplification of consonant
cluster, and had not started speech therapy. And for both groups to permit parents or guardians
by signing the consent form.
In the group with normal phonological development data were obtained through
interviews every two weeks, the fun, for a period of 6 months, which were intended to elicit a
spontaneous speech and naming of children and/or possibly delayed imitation. With the
children with phonological speech data were obtained through the appointment of pairs of
figures that contrasted the consonant cluster structure and simple structure (eg. Prato X pato),
and made only one recording.
260
Data were transcribed using narrow phonetic transcription and reviewed by two judges
with experience in phonetic transcription - separately. These were analyzed acoustically in
software audio-processing PRAAT. For this procedure, were considered only those recordings
that had sufficient signal quality for the processing of the analysis of the duration of vowels and
consonants.
With spectroscopy were measured in seconds (s), time of issue of the vowel in the
syllable consonant cluster simplified and time of issue of the same vowel in a syllable with
simple onset (eg. prato - [ 'patu] x pato - [ 'patu]). Thus, they faced the transmission time for
analyzing the presence or absence of compensatory lengthening. In addition, to verify the
occurrence of lengthening and consonant/vowel or in cases of consonant cluster of fricative, was
compared also the time voiced the issue of simplified consonant cluster to the time of issuing
the same simple fricative in onset (eg .: 'frio' - [ 'fiw] x 'fio'- [' fiw]).
The data were analyzed statistically using the chi-square, with a significance level of 5%.
In groups, normal phonological development and phonological, no statistically
significant difference in the use of compensatory lengthening the structure of the consonant
cluster formed by fricative by sex.
In children with normal phonological development, there was the use of the strategy
studied in males, and only one of the girls uses this feature. And the group with phonological
disorders has been observed that in both sex, there is the presence of compensatory lengthening,
and 85.71% among males and 71.43% female.
The consonant cluster of plosive, 100% of boys and 85.72% of girls in the group with
normal phonological development held compensatory lengthening. This result is similar to that
found in the group with phonological disorders, in which all individuals have made use of the
strategy, showing that there was no prevalence and in relation to sex.
The results of the neutrality and the use of the strategy of extending compensation
agreement with a study of Vidor (2001) for the group with normal development in the
acquisition of net non-side, where there were no differences in the application of these resources
between the sexes.
Moreover, the data presented in this study do not corroborate the results of the children
with phonological analysis of Vidor (2001), nor with the study of Ckmann et al. (2001), who
found a higher incidence of repair strategy by male children with atypical development, buying
non-liquid side.
Due to the discrepancy between the results in relation to sex, it is suggested further
research on this variable, since it is considered an important player in the acquisition and
phonological normal and deviant.
The use of compensatory lengthening occurred in the groups of children studied
suggests maintaining the position of the consonant cluster layer of time, providing evidence that
the prosodic structure above the segmental in the procurement process. Those points to a more
sophisticated phonology by the infant, when it has underlying patterns in the mold syllable,
however, perhaps because of motor disability, still can not produce the articulators gesture
appropriate phoneme target.
Through this research, we attempted to contribute not only to aid the normal
phonological description and diagnosis of children with speech problems, but also contribute to
the therapeutic process. As this research examines one aspect of phonological acquisition, would
be valuable if there could be other studies linking the study of phonetic disorders. This fact
would provide the opportunity for a new way to describe the normal phonological acquisition
and deviant. Moreover, it is necessary to conduct studies that prioritize the use of acoustic
261
spectroscopy, in order to obtain more accurate diagnoses and speech therapy, thereby directing
the therapeutic process for the type of disability - phonetic or phonological - each child.
262
SY05.2
SYMPOSIUM INTRODUCTION: THE GLOBAL LITERACY CHALLENGE
G.T. Gillon
College of Education, University of Canterbury, New Zealand
Contributing to a global literate society is a desire of many communities within our

developed world. Yet at an international level, children from minority groups, lower
socioeconomic backgrounds, and children with spoken language difficulties in their native
language continue to underachieve in written language acquisition. This underachievement is
despite rapid research advancement in our understanding of reading development and
significant expenditure by governments to raise reading achievement for all children. There is an
urgent need to refocus our energies in meeting the global literacy challenge. We must continue
to research, examine and reinforce more effective literacy programme delivery for children who
are most in need.
This paper will introduce a symposium that focuses on the importance of phonological
awareness for facilitating early literacy development along a continuum of literacy success. It is
recognised that no single strategy is likely to be sufficient in enhancing literacy development in
young children at particular risk. Rather, the integration of a range of strategies to facilitate early
reading development may be necessary.
This symposium will draw upon research evidence to build a framework of how we can
integrate strategies to enhance our current educational practices in reading instruction.
Strategies within the framework include a Home Literacy Strategy, Initial Teacher Education
Strategy, Effective Classroom Strategy, Specific Intervention Strategy, Assessment Monitoring
Strategy and a Research Strategy
The framework presented will provide the context for subsequent papers delivered in
this symposium that examine examples of effective interventions aimed at facilitating
phonological awareness in the home context, classroom context, and speech-language therapy
withdrawal context. Issues related to monitoring childrens phonological awareness
development over time and ensuring our educators are well prepared to deliver effective
phonological awareness interventions are discussed in the symposium.
We are in the last quarter of the United Nations Literacy Decade 2003-2012: A decade
focused on meeting the global literacy challenge of ensuring literacy achievement for all people.
We know that we are making progress in meeting this challenge. At an international level
literacy rates are rising and there is increased awareness as to the importance of literacy in
addressing major global economic, health, and environmental issues.
We must, however continue to accelerate progress in facilitating literacy success. It is
estimated that over 774 million young people and adults do not have basic literacy skills to
participate fully in their society (Richmond, Robinson, & Sachs-Israel, 2008). The United Nations
is calling upon us as an international community to harness our efforts in accelerating progress
in global literacy and build meaning international partnerships with renewed focus and energy.
263
Access to quality education remains a significant barrier to literacy for many children in
developing nations or in countries where there is political unrest. Research evidence, however,
also indicates that despite our current best efforts to improve literacy standards clearly
identified groups of children within developed countries continue to be disadvantaged because
of their low literacy levels. These groups include:
1. Children from Indigenous and minority populations

At an international level indigenous and minority populations continued to be
disadvantaged in their written language development. Data from a wide range of studies has
consistently demonstrated lower reading achievement for minority populations compared to the
majority populations. Recent analyses from the American National Assessment of Education
Progress in reading achievement (NAEP, 2007) showed that minority groups are still
significantly lower than white American groups. However, the gap for children described in
the report as Black American (including African American) was smaller in 2007 than in other
years. This was not the case for Hispanic or American Indian population where the gap
between these groups and the performance of white American 4th grade children was not
significantly different to gap that was evident in 1992.
The findings from a large scale longitudinal investigation of childrens reading
performance across the United States of America (Morgan, Farkas & Hibel, 2008) suggested that
from Kindergarten to Grade 3, children from ethnic minority groups fell further behind their
peers over time in their early reading development. There is an urgent need to review current
early interventions and classroom instruction to ensure such instruction or specific intervention
programme is effective in accelerating literacy achievement for those entering school most in
need.
In New Zealand, the national report on Maori achievement shows Maori underachieve in
literacy compared to non Maori, but interestingly, data indicate the difference between Maori
and Non Maori students who met both literacy and numeracy standards in year 11 at school is
greatly reduced when Maori students are educated in Maori language immersion and cultural
contexts.
2. Children raised in low socioeconomic environments

A recurring research finding internationally is the underachievement in reading for
children from families that can be characterised as having lower socioeconomic status ( as
determined by factors such as parents level of education, employment or income status, or
government classification of school area) (Chatterji, 2006; Duncan & Magnuson, 2005; Tunmer,
Chapman, & Prochnow, 2006). In examining this issue researchers have considered the effects of
socioeconomic status in facilitating factors that are known to be powerful predictors of early
reading success such as phonological awareness. Lonigan and colleagues (Lonigan, Burgess,
Anthony, & Barker, 1998) demonstrated a remarkable difference in phonological awareness
growth trajectory at the syllable, rhyme, and phoneme level between subgroups of the
population between the ages of 2 and 5 years. The majority of children in their sample from low
socioeconomic backgrounds demonstrated poor awareness of the sounds structure of words
prior to commencing reading instruction and did not demonstrate the same accelerated growth
in awareness between 4 and 5 years of age.
Children with disabilities
264
Dramatic and positive changes in educational practices for children with disabilities have
occurred in recent decades. With the breakdown of the historic segregation of children with
learning differences, more inclusive education practices are now widespread in many countries.
Yet despite rapid advancement in our knowledge and practices for children with disabilities
these children remain at high risk for underachieving against their learning potential in literacy.
For example, children with speech and language impairment are 4 to 5 times more likely to have
reading difficulties than their peers with typical speech and language development (Catts, Fey,
Zhang, & Tomblin, 2001). Children with apraxia of speech may demonstrate severe and
persistent reading and spelling disorders (Gillon & Moriarty, 2007)
The 2008 UNESCO report states that at a global level people with disabilities form the
worlds largest and most disadvantaged minority group with literacy rates as low as 3% for
adults with disabilities in some countries (Richmond, et al. 2008 p.31). It is critically important
that literacy instruction is effective in enhancing literacy skills in children with disabilities and
ensuring that their potential for literacy achievement is realised.
Gender
There are also clear gender differences in literacy achievements and these vary by
regional area. For Example, in sub- Saharan Africa in South and West Asia women form a higher
proportion of those without literacy while in some western countries it is boys that will have
lower literacy levels on average that girls. The Progress in International Reading Literacy Study
which measured grade 4 reading achievement of children in 39 countries and 5 provinces within
Canada revealed that in all but two countries Spain and Luxemburg girls achieved higher
reading achievement scores than boys. In New Zealand, the difference between girls and boys
average reading scores is amongst the highest of the countries studied and this is mainly
accounted for by significant differences in girls and boys performance within the lower range of
literacy achievement (PIRLS, 2005/2006)
In meeting the challenge of global literacy we must look to well designed research
studies to inform our practice. Evidence based literacy instruction that is committed to ensuring
we are realising the learning potential in each and every child is essential.
We are increasingly focusing on models of success and in examining what is working in
enhancing literacy in young children considered to be at risk for literacy difficulties. There is
now a move away from the literacy versus illiteracy dichotomy and a focus instead of viewing
literacy levels on a continuum targeting interventions and programmes that will improve an
individuals abilities along this continuum.
This symposium will focus on the importance of phonological awareness interventions
for facilitating early literacy development along a continuum of literacy success. Phonological
awareness is a powerful predictor of childrens early reading development and is critical to
word decoding ability (Gillon, 2004). Specific interventions aimed at facilitating phonological
awareness development have shown encouraging results for enhancing reading and spelling
development in children with known risk factors for persistent literacy difficulties. It is
recognised, however, that no single strategy is likely to be sufficient in enhancing literacy
development in young children who are most at risk.
In this presentation a framework for integrating a range of strategies is described. The
framework presented will raise for discussion a broad range of issues that must be addressed to
ensure long-term improvement in reading outcomes for all children. The framework will
highlight the need for the integration of a range of strategies that include:
265
1. Home Literacy Strategy: How can we best engage the involvement of family in
encouraging the development of childrens underlying skills that are essential for
reading development? The findings from a study examining the home literacy
environment of young children with Down syndrome and strategies to enhance
phonological awareness letter knowledge and print concepts within the home context
will be presented.
2. Initial Teacher Education Strategy. How can the preparation of early childhood
teachers, junior school teachers and speech-language pathologists be enhanced to ensure
graduates are well prepared to facilitate early literacy success in all children? A study
examining the phonological awareness skills of a range of educators including teachers,
speech pathologists, reading specialists and teacher aides is presented which highlights
the need for professional development and enhanced training initiatives.
3. Effective Classroom Teaching Strategy: What do we consider are the most effective
classroom strategies to facilitate early reading success in children at risk? The importance
of effective classroom based interventions to enhance phonological awareness for
children in low-socioeconomic areas will be highlighted and the effectiveness of an
intervention that delivers classroom phonological awareness in an enhanced acoustic
environment will be examined.
4. Specific Intervention Strategy. What types of specific interventions are effective in
improving reading development in children most at risk? The implications from the
longitudinal outcomes from a phonological awareness intervention for children with
childhood apraxia of speech will be discussed.
5. Monitoring Strategy. How can we effectively monitor the development of children most
at risk to ensure sustained literacy growth following early successful interventions? The
findings from a pilot investigation examining the usefulness of a self administered
computer based phonological awareness test to efficiently monitor phonological
awareness in young children are described.
6. Research Strategy. What areas of continued research are critical to help inform strategies
aimed at raising reading achievement for all learners?
The symposium will close with suggestions for future research needs in our quest for
meeting the global literacy challenge.
References
Catts, H., Fey, M., Zhang, X., & Tomblin, B. (2001). Estimating the risk of future reading difficulties in
kindergarten children: A research-based model and its clinical implementation. Language, Speech
and Hearing Services in Schools, 32, 38-51.
Chatterji, M. (2006). Reading achievement gaps, correlates, and moderators of early reading achievement:
Evidence from the Early Childhood Longitudinal Study (ECLS) kindergarten to first grade
sample. Journal of Educational Psychology, 98(3), 489-507.
Duncan, G. J., & Magnuson, K. A. (2005). Can family socioeconomic resources account for racial and
ethnic test score gaps? Future of Children, 15(1), 35-54.
Gillon, G. T. (2004). Phonological awareness: From research to practice. New York: The Guilford Press.
Gillon, G. T., & Moriarty, B. (2007). Childhood Apraxia of Speech: Children at risk for persistent reading
and Spelling Disorders. . Seminars in Speech and Language, 28(1), 48-57.
Lonigan, C. J., Burgess, S. R., Anthony, J. L., & Barker, T. A. (1998). Development of phonological
sensitivity in 2- to 5-year-old children. Journal of Educational Psychology, 90(2), 294-311.
266
NAEP.
(2007). National Assessment of Educational progress: 4th grade reading. Available:

http://nces.ed.gov/nationsreportcard/pubs/.
PIRLS. (2005/2006). Progress in International Reading Literacy Study: A summary of findings for New Zealand.
Ministry of Education: Education Counts. Available:
www.educationcounts.govt.nz/goto/pirls.
Richmond, M., Robinson, C., & Sachs-Israel, M. (2008). The Global Literacy Challenge: A profile of youth and
adult literacy at the mid-point of the United Nations Literacy Decade 2003-2012. UNESCO, Paris: The
United NationsEducational Scientific and Cultural Organisation.
Tunmer, W., Chapman, J., & Prochnow, J. (2006). Literate cultural capital at school entry predicts later
reading achievement: A seven year longitudinal study. New Zealand Journal of Educational Studies
267
SY05.4
ENHANCING PHONOLOGICAL AWARENESS WITHIN THE CLASSROOM
CONTEXT
P.V. Good, G.T. Gillon & R. Socklingham
University of Canterbury, Christchurch, New Zealand
Aim: This paper summarises a study that investigated phonological awareness (PA)
effectiveness when presented in a classroom context with sound-field amplification (SFA) to
ensure a higher quality acoustic environment for learning. The study also considered the
effectiveness of intervention in a naturalistic context when a traditional model of teachers
professional development is used to provide instruction in PA intervention. Method: The study
employed a comparative group design to determine the effectiveness of treatment condition:
SFA plus PA intervention versus SFA alone. The effects of each treatment condition upon
childrens PA and word decoding was examined. Participants were 38 children aged 5-6 years
from two classes at one primary school in a low socioeconomic area. All children were hearing
screened at baseline, pre- and post-intervention. PA, letter-sound knowledge, real and non-word
decoding were measured three times over 10 weeks (Term 1) prior to SFA installation in both
classrooms, as well as pre- and post-intervention. In Term 2, children in class 1 were randomly
assigned to receive SFA plus an eight-week PA programme. Class 2 received SFA only. The PA
intervention was a classroom adaption of the Gillon Phonological Awareness Training
programme and was implemented 20 minutes daily for eight weeks. Results: Following
intervention children in both classes had significantly improved their performance from
baseline. Class 1 demonstrated a significantly greater improvement compared to class 2 in one
measure of phoneme awareness. At a group level other measures failed to show any differences
between classes. Visual data analyses, however, revealed particular improvements for poor
readers in class 1 who received PA intervention. These children outperformed poor readers in
class 2 on all measures. Implications: The results suggest that the combination of enhanced
classroom acoustic environment and PA intervention actively improved PA development for
children most at risk.
Understanding of the importance of phonological awareness (PA) to early reading
development has led to a rapid increase in classroom based PA instruction. The effectiveness of
this instruction for children most at risk for reading difficulty requires careful consideration.
Previous research often suggests that although an intervention may be effective at a group level
not all children show significant improvements following class intervention. Indeed those
children with the lowest levels of PA or reading ability may show limited benefit from
classroom based interventions (See Gillon, 2004 for a review). In addition to considering the type
of programme content and how teachers are engaging childrens attention during PA
intervention it is also important to consider the classroom learning environment and the childs
ability to adequately hear the teachers instruction during PA activities.
Mainstream classrooms are typically auditory-verbal environments in which children
spend 45% of their school day engaged in listening activities (Berg, 1987), and where
information is presented orally by the teacher (Flexer, 1997). In the last decade, mounting
research has appraised the acoustical conditions in classrooms focusing on optimising classroom
acoustics (e.g., Whitlock & Dodd, 2008). Speech recognition may be compromised by the
268
acoustic design of the classroom, distance, reverberation, noise and the resulting signal-to-noise
ratio (SNR). These acoustical parameters are critical variables and may detrimentally impact the
ability for children to understand speech (Crandell & Smaldino, 2000).
Without full auditory access to spoken information in classrooms students do not learn
at a normal rate. Flexer (1999) has suggested that the auditory neurological foundations for
learning, language and reading are crucial to a childs development. However, the importance of
hearing in the educational process may be underestimated because hearing loss is invisible
(Flexer, 1997). Children may experience hearing loss or fluctuating loss unknowingly but this
may affect childrens ability to attend to and hear their teacher (Berg, 1996).
Children from lower socioeconomic groups and some ethnic groups appear more
vulnerable to hearing difficulties due, for example, to Otitis Media with effusion (OME). New
Zealand studies have reported that Mori and Pacific Island children have higher rates of OME
and higher hearing screening failure rates (National Audiology Centre, 2006). The impact of
hearing difficulties needs to be considered in relation to their performance on classroom based
PA interventions which typically involve auditory instruction from the teacher in a classroom
that may have poor acoustic properties.
Sound-field amplification systems (SFA) have proven effective in overcoming classroom
listening difficulties associated with noise, distance and reverberation (See Good, 2010 for a
review). However, whether improving the classroom listening environment is sufficient to
enhance young childrens learning in areas critical to early reading acquisition, such as
awareness of the sound structure of spoken words (i.e. PA), is unclear. This study aimed to
examine the effectiveness of an enhanced listening environment combined with PA intervention
which aimed to specifically increase childrens PA compared to an enhanced listening
environment alone.
METHOD:
The study employed a comparative group design to determine the effectiveness of
treatment condition, i.e., SFA+PA versus SFA alone, and the subsequent effects of each
treatment condition upon PA and word-decoding for children in both classes.
Thirty eight school children from two year 2 classrooms in a metropolitan primary
school participated in the study (18 children in class 1 and 20 in class 2). The school was in a
lower socio-economic area as rated by the New Zealand Ministry of Education. The average age
in class 1 was 6.1 years (SD = 4.8 months) and 6 years (SD = 5.8 months) in class 2. The majority
of children in both classes were New Zealanders of European descent. Eleven percent in class 1
identified their heritage as Mori along with 15% in class 2. In class 1, 11% self-identified as
Pacific Islander. In class 2, 15% self-identified as Pacific Islander.
The following assessment battery was selected to gather baseline, mid- (i.e. preintervention) and post-intervention assessment data on all participants.
(a)
(b)
(c)
(d)
Test of Phonological Awareness (TOPA-2+) (Torgesen & Bryant, 2004).

Burt Single-Word Reading Test (Gilmore, Croft, & Reid, 1981).
Phoneme awareness assessment probes (S&M) (Stahl & Murray, 1994) Including phoneme
blending, isolation, segmentation and deletion tasks.
Informal non-word reading task (Calder, 1992).
269
Interventions:
The Phonic Ear FrontRow Pro Digital four-speaker, pendant microphone sound-field
amplification system (Phonic Ear A/S., Denmark) was installed in both classrooms. This system
maximises the even distribution of sound and increases the SNR. Because both classrooms were
similarly designed the location for speaker placement was also similar.
PA intervention was implemented in Class 1 only. The whole-class programme used was
part of a pilot study for the development of a teacher-administrated classroom-based PA
programme (Gillon & Carroll, 2009). The programme involved daily 20-minute sessions
conducted each morning, before the instructional reading programme. Sessions were designed
to follow a set structure and were graduated. Weeks one to three targeted lower levels of PA
comprising syllable, rhyme, and onset-rime awareness. Final weeks targeted higher levels of PA
comprising phoneme level tasks and revision of syllable, rhyme or onset-rime. This programme
was part of a concurrent study investigating models of how teachers implement teaching
techniques (Carroll Gillon and McNeill, 2009). In this study, teachers are encouraged to make
their own choices regarding which activities and resources to use and implement as may be
typically seen in consultancy models. The teacher was provided with two in-service instruction
periods and programme resources and was encouraged to use the resources and integrate the
activities each morning prior to instruction reading. The teacher was left to decide which
elements she felt were most beneficial to students. PA sessions were monitored by the
researchers on four occasions over the eight-week intervention block. Both teachers were in
contact with and supported by the main researcher throughout the study.
RESULTS:
Analysis using multiple single-factor RM ANOVAs revealed no significant group
difference (at p<.05) between groups on PA, non-word reading and single-word reading
measures during the baseline monitoring period prior to intervention.
RM ANOVAs performed on all pre- and post-intervention tests revealed a significant
time effect on all measures but a non-significant difference between the classes. However,
follow-up ANCOVAs were also conducted. These analysed the post-intervention scores with
pre-intervention scores used as the covariate. ANCOVAs revealed that gains made between
immediate pre- and post-intervention scores were significant for the Stahl and Murray PA
probes while non-significant for the other measures.
The scores of the children who consistently ranked lowest in baseline and preintervention measures of PA (S&M, informal non-word reading, TOPA) were also separately
visually analysed. Seven children were identified in each class due to their consistent low-level
scoring which continually fell outside of the average scores of their classmates during a baseline
monitoring phase. The trend consistently illustrated that poor readers in class 1 who received
SFA plus PA outperformed poor readers in class 2. The poor readers in class 1 scored lower than
the poor readers in class 2 prior to the pre-intervention assessment. Following intervention all
mean scores for the poor readers in class 1 had surpassed the poor readers in class 2. Four of the
seven poor readers in class 1 exhibited accelerated progression beyond the expected trajectory of
the two standard deviation band analysis method in their PA development.
DISCUSSION:
The results from this study add to the mounting body of evidence demonstrating the
positive effects of SFA on academic achievement and, the effectiveness of PA in fostering early
reading development by specifically enhancing PA skill. Children in both classes responded
270
positively to SFA, the benefits of which were observable by both teachers within a few days of
installation. Given that findings were based on a small number of children, interpretation of the
results warrant caution. However, the findings are encouraging and merit further investigation.
This study suggests that classroom based PA intervention for young school children should not
be limited to focusing on the content of the intervention. Other variables such as the listening
environment of the classroom should be considered, particularly for children at increased risk
for persistent reading difficulties.
References:
Berg, F. S. (1987). Facilitating classroom listening: A handbook for teachers of normal and hard of hearing students.
Boston, MA: College-Hill Press/Little, Brown.
Berg, F. S., Blair, J. C., & Benson, E. V. (1996). Classroom acoustics: The problem, impact, and solution. Language,
Speech & Hearing Services in Schools, 27(1), 16-20.
Calder, H. (1992). Reading freedom teacher's manual. NSW, Australia: Pascal Press
Crandell, C. C., & Smaldino, J. J. (2000). Classroom acoustics for children with normal hearing and with hearing
impairment. Language, Speech & Hearing Services in Schools, 31(4), 362-370
Flexer, C. A. (1997). Individual and sound-field FM systems: Rationale, description, and use. The Volta Review,
99(3), 133-162.
Flexer, C. A. (1999). Facilitating hearing and listening in young children. San Diego: Singular Publishing Group.
Flexer, C. A., Biley, K. K., Hinkley, A., Harkema, C., & Holcomb, J. (2002). Using sound-field systems to teach
phonemic awareness to pre-schoolers. The Hearing Journal, 55(3), 38-44.
Gillon, G. T. (2004). Phonological awareness: From research to practice. New York: The Guilford Press.
Gillon, G. T., & Carroll, J. L. D. (2009). The Gillon and Carroll phonological awareness classroom based programme:
PAC-B. Christchurch: NZ: University of Canterbury.
Gilmore, A., Croft, C., & Reid, N. (1981). Burt word reading test: New Zealand revision. Wellington: NZ: New
Zealand Council for Educational Research.
Good, P.V. (2010) An investigation of the effectiveness of integrating sound-field amplification and
classroom-based phonological awareness intervention on the early reading development of young
school children . Unpublished thesis (Masters of Audiology). University of Canterbury,
Christchurch, New Zealand.
National Audiology Centre. (2006). New Zealand vision and hearing screening report. Auckland: NZ: Auckland
District Health Board.
Stahl, S. A., & Murray, B. A. (1994). Defining phonological awareness and its relationship to early reading.
Journal of Educational Psychology, 87, 221-234.
Torgesen, J., & Bryant, B. R. (2004). Test of phonological awareness (2nd ed.). Austin, Texas: Pro-ed.
Whitlock, J. A. T., & Dodd, G. (2008). Speech intelligibility in classrooms: Specific acoustical needs for primary
school children. Building Acoustics, 15(1), 35-47.
271
FP30.1
NOUN INFLECTION MORPHOLOGY IN THE GREEK LANGUAGE. A
COMPARISON STUDY OF DYSLEXICS AND NORMALLY DEVELOPING
CHILDREN.
Grammenou Anastasia
DEMOCRITUS UNIVERSITY OF THRACE
DEPARTMENT OF PRIMARY EDUCATION
Greek language is a language with rich and complex morphology. Nouns for example
are characterized by gender, case and number coded in the suffixes. The present study
investigated the ability of thirty dyslexic, thirty normally developing students of the same
chronological age and twenty five reading age control students to use homophone suffixes as
the correct forms in noun inflections. For this purpose three testing conditions were used. In the
first condition subjects were asked to identify exemplars and homophone foils of nouns in
various cases in both numbers. The second condition involved presentation of nonwords ending
in homophone suffixes and subjects were again to decide on true and foil suffixes. The third
condition involved sentence completion requiring noun production in the correct form of
number and case.
Normally developing children outperformed learning disabled in the nonword and the
sentence completion .conditions. Dyslexics were unable to recognise gender and case from the
preceding article and to decide on the suffix used. The same profile exhibited in the sentence
completion task where subjects had to imply the gender and the case of nouns from the sentence
meaning. Results are discussed in the light of previous reported studies in English Language
(Nunes, Bryant & Bidman, 1997a,b,) as well as in the Greek Language (Chliounaki & Bryant,
2002). Dyslexics and normally developing childrens profiles fit well with the developmental
model of verb inflection morphology proposed by the aforementioned researchers.They are
focused on most salient features of words and miss out less obious information such as wors
stress. More over dyslexics use stored information in long terma memory of whole words to
performe on the inflection identification task.
Key words: morphology, Greek Language, dyslexia, primary education.
Introduction
Morphemes are the indivisible word units that convey a meaning and (or) have syntactic
properties (Catamba, 1993). According to linguists, morphology sets up the rules for word
formation. In this account inflectional morphology deals with the syntactic properties of words,
whereas derivation morphology is used to create new lexical items (Chomsky, 1986). Inflections
change a limited set of linguistic information such as verb tense, number or case in nouns and
verbs. Inflected words belong to the same grammatical category as the base form. Noun
Inflections in the Greek language note gender, number and case and carry all the necessary
information to create grammatical sentences (Petrounias, 1993).
Childrens morphological awareness is defined as the explicit knowledge of
morphological relation between base forms and inflected and derived words (Carlisle, 1987,
272
2000). Despite the fact that morphemes play a central role in childrens understanding of new
words and sentences, that were not encountered before in spoken language, morphological
awareness does not emerge systematically before the third grade in reading and writing
(Carlisle, 2000; Singson, Mahony & Man, 2000). A series of grammatical phenomena such as the
/s/ sound representation in noun plurals and the third person singular in verbs, the
apostrophes representation in possessive nouns, and the past tense formation have been well
documented in normally developing children (Bryant, Devine, Ledward, & Nunes, 1997; Nunes,
Bryant & Bindman 1997). Childrens morphological processing skills is positively correlated to
reading and spelling performance and to spelling of morphological complex words once
phonological awareness is controlled (Leong , 2000; Carlisle 2000; Casalis, Cole, & Sopo, 2004).
Studies in dyslexics and normally developing children have shown that reading and
spelling affixed and derived words pose a grater difficulty to the former group when compared
to chronological age and reading age matched controls (Carlisle, 1987; Joanisse, Manis, Keating
& Seindeberg 2000; Egan & Pring, 2004). This phenomenon cannot be attributed only to
dyslexics difficulty when encounter multisyllabic words (Tsesmeli & Seymour, 2006), A limited
source of linguistic information operated above the phonological process was identified to cause
these problems (Carlisle, 1987; Nunes et all 1997). Morphological processing limitation in
dyslexics remains a controversial issue. In a most influential study Carlisle (1988), found that
spelling of derivation words and morphological processing of base and derived words differing
in phonological complexity correlates with reading ability. Leong (2000) also noted that
dyslexics score lower in processing phonologically transparent derived words, in a word
naming task. In the same token Casalis et al (2004) found that in French low readers could not
use morphological knowledge to facilitate priming of morphologically related words before
second grade. Modality of the morphologically related items used in studies is another factor
which determines dyslexics performance. Champion (1997) found that dyslexics are impaired in
detecting morphological relation in a visually presented task but not in the oral condition. Egan
and Pring (2004) compared dyslexics and reading age (R.A.) and chronological age (C.A.)
control students in a morphological detection task. In the oral condition, dyslexics and R.A.
performed in the same way, but R.A. were faster in the visual presented task and were affected
by morpheme boundary disruption in a modified version of the visually presented task.
Furthermore dyslexics tended to omit the /ed/ regular past tense morpheme more often than
R.A. controls.
The aim of the present study is to determine orthographic processing of noun inflection
in the Greek language. Greek language is a language with rich and complex morphology. Nouns
for example are characterized by gender, case and number coded in the suffixes. In written form
ambiguity results from various aspects of representing the phonemes / i/, /e/ and /o/. The
word /anrpi/ (men ) for example is the nominative case of the mesculine plural
form of the word / anrpos/ (man ), the word /oi/ (streets ) is the feminine,
nominative, plural form of the word /oos/ and the word /poli/ is in the
nominative case of the feminine singular form. Notice that all homophone suffixes represent the
/i/ phoneme. Formulation of genitive singular, nominative plural and genitive plural
differentiate the 32 types of nouns ( 5 types of masculine nouns ending in /as/, - /os/
and- /is/ in the nominative singular, 14 types of feminine nouns ending in //,-/i/,
/u/ -/ os/ and /o/, in the nominative singular and 13 types of neutral nouns ending in / os/ , -/o/, - /i/, -/ ma/, -/mo/ - / as/ , and /os/ in the nominative singular
case ( Triantafyllidis, 2001).
273
2. Method
2.1 Participants Eighty five students (30 Dyslexics, 30 Chronological Age Control
students and 25 Reading Age Control Students participated in the study. There were all native
speakers of Greek with no history of hearing or neurological problems; they have received
monolingual education, and at the time tested Dyslexics and Chronological Age Controls were
attending Grade 6, whereas Reading Age control group were grade 4 students. The control
groups came from the three Experimental Primary Schools in Alexandroupolis, Greece, after
obtaining permission from the Department of Primary Education Supervision Board, and the
parents. Dyslexics were informed about the study at the local Diagnostic, Evaluation and
Support Centre, after completing the evaluation procedure. The inclusion criteria for all three
groups regarded nonverbal I.Q. >90 as measured by the Raven Matrices Progressive Test and
Reading Comprehension Score >85, as measured by the Triga Reading Ability Test (2001).
Moreover, the dyslexics criteria included an inferior performance on three phonological
awareness task of the Athina Test. Reading and spelling ability was tested with two test
constructed for the purpose of the present research project. Each test comprised of a 92 word
and a 92 nonword list with all possible combinations of consonant-vowel (CV), consonant
cluster-vowel (CCV, CCCV), vowel-consonant(VC) of the Greek Language. Particular interest
was given to include allophones and letter strings that result in phonological processes observed
in spoken language. Test retest reliability, for the reading tests, after a two months period, was
reported 0.80 (word list reading) and 0.83 (nonword list reading). Reliability of the spelling test
was somewhat higher 0.91 (word spelling) and 0.90 (nonword spelling).
2.1The childrens mean ages, reading time, spelling score and nonverbal I.Q (Standard
Deviation in brackets in months)
Group
Age
I.Q.
Reading
Spelling
Reading
Dyslexics
11years,3Months
105.7
(N=30)
(5.3)
(19.3)
Grade
6 11 years,5Months 13.6
(N=30)
(3.8)
Grade
10 years,5Months 105.6
4(N=25)
(4.8)
time (sec)
errors
Ability test
240 (55)
38 (11)
98 (8.3)
176 (29)
13 (4)
105 (12.7)
210 ( 34)
15 (8)
107 (9.4)
(13.5)
(9.06)
2.2. Procedure
All control students were individually tested in a quiet room at schools and the inflection
morphology tests were administrated as a part of a larger screening process in a Research
Project. Dyslexics were tested by the author in the Diagnostic, Evaluation and Support Centre.
The material (word task, nonword task and sentence completion) was presented in a random
order to all students
274
2.3. Material
In order to evaluate dyslexics ability to use the correct noun inflection three tasks were
used. The first task involved identification of exemplars and homophone foils of nouns in
various cases in a paper and pencil task. Subjects were to decide whether the word in the second
column were a correct form of the word given in the nominative case of singular number
presented in the first column. The articles preceding nouns guided subjects to decide on the case
and the number appropriate. In the same token, the second task involved identification of
nonword foils resulting again from the nonwords given in the nominative case of singular
number. Articles again were guided the subjects. The third condition examined noun inflection
in a sentence completion close test. Subjects used the nouns in the nominative case of singular
number to formulate nouns in appropriate case and number so as to fit the meaning. All
conditions contained 32 items, one item for each type of nouns and the non words came from
real words belonging to the same noun type. For each item the inflected noun had a violation in
stress, orthography or both, which subjects were to identify.
2.4 Results
Table 2.2 shows performance of the groups on three tasks (word, nonword and text
production) and the four conditions (stress violation, orthographic violation, combined type
violation and no violation (no change condition). A 3 groups X 2 tasks X 4 conditions ANOVA
with repeated measures was performed. Four main effects were observed for group
(F(2,12)=50.16, p=0.001), type of violation conditions ( F(3,12)=192.76, p=0.001), a group x task
interaction (F(4,12) = 4.47, p=0.001), and a group X condition interaction ( F(6,12)=3.00, p=0.001).
The overall interaction group X task X violation condition was not significant (F(6, 915) = 1.14,
p=0.33). Furthermore, the Kruskall Wallis test was used to further investigate the differences
between the groups X task interaction and the group X condition interaction.
Graph.1. Persentances of correct responces on three tasks and four
Wallis H=23.083 df=2, p=0.01), combined
conditions
105
type violation condition (Kruskall Wallis
95
85
75
65
55
45
35
TR
.S
.
P L MB
M
O
CO . C
N
T.
PL
N
HA
M
O
SE
NC
C
T.
P L TH
N
M
R
SE CO
.O
T.
PL
N
M
SE CO N
T.
CH
N
.N
SE
D
B
R
M
O
O
W
C
.
N.
D.
R
TH
O
R
W
O
N.
D
SS
R
O
RE
W
ST
N.
RD B.
O
M
NW CO
.
D
CH
R
N
O
O
W
N
.
D
H
R
O
RT
W
O
S
D
ES
R
R
O
W
ST
D
R
O
W
Grade 6
Grade 4
Dyslexics
Grade 6 and grade 4 students differentiated

on the orthographic violation condition of
the nonword task (Kruskall Wallis H=3.97
df=1,
p=0.05).
No
other
statistically
significance difference was found. Grade 6

students scored higher than dyslexics on
orthographic violation condition (Kruskall
275
H=23.37 df=2, p=0.01), and the no violation condition of the nonword task (Kruskall
Wallis H=14.42 df=2, p=0.01). They have outperformed dyslexics on all conditions ofthe
sentence completion task (Kruskall Wallis H=20.092 df=2, p=0.01, for the stress violation
condition, Kruskall Wallis H=18.95 df=2, p=0.01 for the orthographic violation condition
Kruskall Wallis H=21.73 df=2, p=0.01 for the combined violation condition and Kruskall Wallis
H=21.09 df=2, p=0.01 for the no violation condition). There was also a group effect on the total
scores of the word task (Kruskall Wallis H=13.28 df=2, p=0.01) the nonword task (Kruskall
Wallis H=32.017, df=2, p=0.010 and the sentence completion task (Kruskall Wallis H=25.59df=2,
p=0.01).
Comparison of dyslexics and reading age controls followed the same pattern. Grade 4
students scored higher than dyslexics on orthographic violation condition (Kruskall Wallis
H=11.22, df=2, p=0.01), combined type violation condition (Kruskall Wallis H=10.31, df=2,
p=0.01), and no-violation condition (Kruskall Wallis H=12.22, df=2, p=0.01), of the nonword
task. They have scored higher on the four conditions of the sentence completion task (Kruskall
Wallis H=9.42, df=2, p=0.01for the stress violation, Kruskall Wallis H=8.39, df=2, p=0.01, for the
orthographic violation condition, Kruskall Wallis H=13.11, df=2, p=0.01for the combined
violation and Kruskall Wallis H=7.82, df=2, p=0.01 for the nonviolation condition). Again the
total scores of the word task, the nonword task and the sentence completion task differentiated
grade 4 and dyslexics students (Kruskall Wallis H=5.30, df=2, p=0.05, Kruskall Wallis H=15.50,
df=2, p=0.01, and Kruskall Wallis H=11.69, df=2, p=0.01).
2.5 Conclusions
This study aid to shed light in the way dyslexics and normally developing children spell
noun inflection in the Geek language. Previous studies in English language have clearly
demonstrated a developmental model through which verb inflections are mastered. Normally
developing children adopt a phonetic spelling of the present progressive and the past tense at
first grade. Systematic use of the appropriate inflection does not arise before second grade and
its quite immature as the orthographic conventions are missing. Even six grade children fail to
apply the consonant doubling. Nunes, Bryant and Bidman (1997a) proposed a more elaborative
model taking into account the processes which are operated through each stage. Children go
through the unsystematic use of affixed morphemes to the phonetic representation of the
present progressive and simple past tense. It is at this stage when they notice the violation in
letter-sound rule which leads them to overgeneralisation of the affexed morphemes in other
grammatical categories. Reading experience and growth of metalinguistic knowledge limits
overgeneralisation to irregular verbs and finally to verbs only. (Nunes, Bryant & Bidman,
1997b). Chliounaki & Bryant (2002) described a three stage model in the acquisition of the
correct spelling of affixed ending /e/ and /o/ in verbs in the Greek Language. Both endings
have two alternative spellings o and for /o/ and e and for /e/. Interestingly, 40% of
initial readers did not use the , when necessitated and this portion went even greater (88,6 %)
with regard to morpheme. Five months later, children from the exclusive one spelling group,
overgeneralized the alternative suffixes and 10.5% of the times in /o/ endings and 17,8%
of the times in /e/ endings.
Results of the present experiment fit well with the developmental processes described
above. Normally developing children appeared to have reached a pick in spelling noun
inflections. They focus on salient features of words and identify the combined type of violation,
at a level above 80% and the orthographic type violations at 75% of the cases. Stress type of
violations which is a less obvious type of violation and requires automatization is found in a
276
chance level of 50% in the word and nonword type of tasks, but when it comes to sentence
completion stress omission errors are 75%. Morphematic spelling abilities of dyslexics are built
through overgeneralisations and even six grade children are confused on choosing the
appropriate noun inflection. It seams that dyslexics have acquired knowledge of basic inflection
morphology which apply to real words to the same extent as counter peers. Difficulties arise
when they have to generalize linguistic rules in nonwords, despite the fact that these
orthographic-morphosyntactic rules are incorporated into the Greek Language Curriculum since
second grade. A possible explanation is that nonwords come at odds to dyslexics who, at least
for the written form, prefer to store the whole words in the orthographic cipher. In this account,
they are unable to apply the linguistic knowledge of the word content and to recognise
morpheme boundaries even when word classes are made prominent with the presenting article.
Alternativelly, morphemes may are represented autonomously in the orthographic lexicon as
suggested by Egan & Pring L. (2000).Furthermore, limitations in noun inflection spelling were
prominent in the sentence completion task when syntactic properties and other linguistic factors
above the word level were at their disposal.
277
(5.58)
(2.45)
(SD)
(SD)
23.88
Mean
21.17
(3.75)
( SD )
Mean
25.29
(4.23)
19.81
(2.85)
24.35
(4.58)
26.18
TOTAL
TOTAL
Mean
NWORD
WORD
(12.65)
18.25
(6.87)
25.65
(8.09)
27.01
TOTAL
SENT.
(4.02
4.10
(1.56)
3.06
(2.27)
3.21
STRES
WORD
(2.56)
8.03,
(1.33)
9.07
(1.38)
9.69
ORTH.
WOR
8.3 (1.56)
(0.89)
9.38
(1.39)
(0.80)
2.44
(0.51)
2.53
(0.66)
2.71
COMB.
NONCH.
9.25
WORD
WORD
(2.68)
3.56
(2.06)
3.41
(2.12)
3.48
COMB.
NWORD
Table 2.2 Groups Performance on three tasks and four conditions.
Grade 6
Grade 4
Dyslexics
(2.73)
6.81
(1.22)
9.00
(2.13)
10.27
ORTH.
N.WOR
(2.93)
4.40
(2.01)
6.82
(2.16)
7.07
NONCH.
N.WORD.
(1.86)
7.3
(1.12)
9.00
(2.26)
(0.76)
1.94
(0.49)
2.65
(0.69)
(5.90)
6.20
(2.0)
6.88
(1.06)
8.35
8.00
(2.74)
(2.21)
(2.91)
9.00
8.87
278
(1.64)
1.83
(0.56)
2.76
(0.84)
2.54
COMB..
NCHAN
ORTH.
STR
2.54
COMPL.
COMPL
COMPL
COMPL.
STRESS
9.81
SENT.
SENT.
SENT.
SENT.
N.WOR
References
1.
Bryant, P., Devine,M., Ledward, A.,& Nunes, T,. (1997). Spelling with apostropes and
understanding possession, British Journal of Educational Psychology, 67, 93-112.
2.
Bryant, P. Nunes, T,& Bindman, M.(2000). The relations between childrens linguistic
awareness and spelling: The case of the apostrophe. Reading and Writing: An
interdisciplinary Journal, 12, 253-276.
3.
Catamba, F. (1993). Morphology. Macmillan Press, London,U.K.
4.
Casalis, S., Cole, P., & Sopo, D.(2004). Morphological awareness in developmental
dyslexia. Annals of Dyslexia, 54(1), 114-138.
5.
Chliounaki, k. & Bryant, P.(2002). Construction and learning to spell. Cognitive

Development, 17, 1489-1499.
6.
Egan, J. & Pring L. (2000). The processing of inflectional morphology: A comparison

of children with and without dyslexia. Reading and Writing: An interdisciplinary
Journal, 17, 567-591.
7.
Carlisle, J. F(1987). The use of morphological knowledge in spelling derived forms by

learning-disable and normal students. Annals of Dyslexia, 37, 90-108.
8.
Carlisle, J.(1988). Knowledge of Derivation Morphology and Spelling Ability in

Fourth, Six, and Eight Graders. Applied Psycholinguistics, 9, 247-266.
9.
Carlisle, J. F (2000). Awareness of the structure and meaning of morphologically

complex words: Impact on Reading. Reading and writing: An Interdisciplinary Journal,
12, 169-190.
10. Champion, A.(1997). Knowledge of suffixed words: A comparison of reading

disabled and nondisabled readers. Annals of Dyslexia, 47, 29-55.
11. Chomsky, N. (1986). Knowledge of Language: Its nature Origins and Use (New York,:
Harper and Row.
12. Joanisse, M.F., Manis, F.R., Keating, P. & Seidenberg, M.S. (2000). Language deficits
in dyslexic children: Speech perception, phonology and morphology. Journal of
Experimental Child Psychology 71, 30-60
13. Leong, C. K. (2000). Rapid processing of base and derived forms of words and grades
4, 5, and 6 childrens spelling. Reading and writing: An Interdisciplinary Journal 12, 277302.
14. Nunes, T., Bryant, P., & Bidman, M. (1997). Morphological Spelling strategies:
Developmental Stages and Processes. Developmental Psychology, 33,637-649.
15. Paraskevopoulos, I., Kalantzi-Azizi, A., & Giannitsas, N.(1999). Athena Test for the
Diagnosis of Learning Disabilities. ( ), Hellenic
Letters, Athens, Greece.
279
16. Petrounias,
E.
(1993).
Modern
Greek
and
Comparative
Analysis.
Part
A.( : ). University Studio

Press, Thessaloniki, Greece.
17. Singson, M., Mahony, D., &Mann, V.(2000). The relation between reading ability and
morphological skills: Evidence from derivational suffixes. Reading and writing: An
Interdisciplinary Journal, 12, 219-252.
18. Tsesmeli, S.N., & Seymour, P.H.K. (2006). Derivational morphology and spelling in
dyslexia. Reading and Writing, 19, 587625.
19. Triantafyllidis, M. (2001). Modern Greek Grammar. 18th Ed. (
, 18 .), Foundation of Publishing Scholar Books, Greek Ministry of
Education and Religious Affairs, Athens, Greece.
20. Triga, A. (2004) Reading Ability Test. Evaluation of the Reading Ability of Students
from 4rth to 8 th grade. ( -

) Atrapos- Perivolaki, Athens, Greece.
21. Walker, J., Hauerwas., L.B. (2006). Development of Phonological, morphological, and
orthographic knowledge in young spellers: The case of inflected verbs. Reading and
Writing: An Interdisciplinary Journal, 19, 819-843.
280
FP16.6
SPELLING ERRORS IN THE GREEK LANGUAGE. CAN BE DESCRIBED
IN TERMS OF PHONOLOGICAL PROCESSES?
GRAMMENOU ANASTASIA
DEMOCRITUS UNIVERSITY OF THRACE
DEPARTMENT OF PRIMARY EDUCATION
Writing is a more demanding processes compared to spoken language and
have come into the scene of the evolutionary scale rather recently. A basic question
that linguists and psychologists have articulated is whether these two
communication skills share common processes. This study describes the spelling
errors, in term of linguistic processes, in thirty dyslexics who attend second grade,
thirty normally developing children of the same chronological age and twenty five
reading age control students.
Keywords: spelling, Greek Language, dyslexia, phonological processes
Introduction
Becoming a literate student, in the alphabetic scripts requires more than
putting graphemes in the correct order so as to represent the word soundings. Its an
effortless process, extended to three to four years of typical schooling, as it is
suggested by the advocates of constructivism and the phonological processing
approach. The former hold that students adopt and transform a series of
internalising schemata regarding writing and the purpose used by (Ferreiro &
Teberosky, 1982, Ferreiro, 1990). A milestone in this process is the acquisition of the
alphabetic principle, the ability to discriminate phonemes and
to correctly
representing them into script by graphemes and graphemes combination. Studies in
the light of constructivism were curried out in the roman languages which are fairly
transparent in grapheme-phoneme correspondence, syllables consist of ConsonantVowels combinations and words contain more than one syllable. (Ferreiro,
Pontecorvo & Zuchermaglio, 1996, Pontecorvo, 1996). Three stages in the literacy
acquisition were described by this approach, the pre-syllabic, the syllabic, and the
alphabetic stage. Syllable representation operates as the vehicle through which
writing skills are evolved and it is the experience, which forces students to grasp the
alphabetic principle.
Contrary to the constructivism theory stands the phonological processing
approach. Frith (1980, 1985), and Ehri (1991,1994,1998) also used developmental
stages to describe the literacy acquisition, but this time it was the phonological
processes which characterized each stage. Words in Ehris logographic stage, the
first stage, are read as ideograms and are reproduces by rote without internalizing
the relation of the sounds to the script. The rudimentary alphabetic stage follows, as
young readers learn some letter names and recognize letter shapes at the beginning
and at the at end of the words (Ehri & Wilce, 1985). Visual - phonetic connections
between letters and pronunciation of words becomes more systematic and by the end
281
of this stage representation of phonemes involves not just letters, but graphemes as
well (full alphabetic stage), (Ehri, 1992). The ability to represent words phonemically,
not just phonetically, characterises the consolidated alphabetic stage, the final stage
in literacy acquisition. Readers form connections between letter sequences to
represent phoneme blends.
Childrens misspellings were described to formulate the phonological
processing approach. Treiman for example (1994), explained increasing prevalence
of some letters, in beginning readers scripts, by connecting them to childrens
names. Phonological rules determine transition from full alphabetic stage to
consolidate alphabetic stage. Read (1975) and Treiman (1985a, 1993) site examples of
phonological plausible spelling in words beginning with /d/ plus /r/ consonant
cluster). Furthermore, voiceless stop consonants are realized as voiced stops
following the /s/ sound (Treiman, 1985b), and liquids (/r/, /l/) and nasals
consonants (/m/, /n/,) are deleted in final consonant clusters (Treiman, 1984,
Snowling, 1994, Treiman, Zucowski, & Richmond-Welty, 1995). Similar phenomena
are observed in consonant clusters with second and third consonant to be omitted
when found in word initial or middle syllable (Bruck & Treiman 1990, Treiman,
1991). But its not only consonants to be affected by phonological processing rules.
Vowels are omitted as well when preside the liquids /r/, and /l/ or follow nasals
/m/ and /n/. This phenomenon is attributed to the letter-name spelling strategy
when a consonant name stands for the phonemes of a vowels and a consonant ( Ehri,
1986, Treiman, 1994).
It was not until 1994 when McCormick drew attention to the similarities
between the aforementioned types of spelling errors and the phonological processing
rules in first language acquisition (Dodd, 1994). Mc Cormick used also Firths stages
of literacy development to determine levels of complexity in singe word writing.
Forty-two children from Grades1, 2, and 3 wrote 90 words (Firth, 1980). Data analysis
revealed a strong developmental trend for word complexity and numbers of errors.
Mc Cormick also found that phonological processes cloud explain around 40% of
spelling errors. Those processes were grouped into two main categories the
structural and the systemic processes. Final consonant deletion, cluster reduction,
weak syllable deletion, vocalisation, assimilation, deletion SIWW, epenthesis and
addition belong to the former, whereas fronting, stopping, gliding, context sensitive
voicing and backing to the latter (McCormick, 1994).
The aim of the present study was to describe the types of errors made by
dyslexics and normally developing children when writing words and pseudowords
in the Greek language.
2. Method
2.1 Participants
2.1 Eighty five students (30 Dyslexics, 30 Chronological Age Control students
and 25 Reading Age Control Students participated in the study. There were all native
speakers of Greek with no history of hearing or neurological problems; they have
received monolingual education, and at the time tested Dyslexics and Chronological
Age Controls were attending Grade 6, whereas Reading Age control group were
grade 4 students. The control groups came from the three Experimental Primary
Schools in Alexandroupolis, Greece, after obtaining permission from the Department
of Primary Education Supervision Board, and the parents. Dyslexics were informed
about the study at the local Diagnostic, Evaluation and Support Centre, after
completing the evaluation procedure. The inclusion criteria for all three groups
282
regarded nonverbal I.Q. >90 as measured by the Raven Matrices Progressive Test
and Reading Comprehension Score >85, as measured by the Triga Reading Ability
Test (2001). Moreover, the dyslexics criteria included an inferior performance on
three phonological awareness task of the Athina Test. Reading and spelling ability
was tested with two test constructed for the purpose of the present research project.
Each test comprised of a 92 word and a 92 nonword list with all possible
combinations of consonant-vowel (CV), consonant cluster-vowel (CCV, CCCV),
vowel-consonant(VC) of the Greek Language. Particular interest was given to
include allophones and letter strings that result in phonological processes observed
in spoken language. Test retest reliability, for the reading tests, after a two months
period, was reported 0.80 (word list reading) and 0.83 (nonword list reading).
Reliability of the spelling test was somewhat higher 0.91 (word spelling) and 0.90
(nonword spelling).
2.1The childrens mean ages, reading time, spelling score and nonverbal I.Q
(Standard Deviation in brackets in months)
Group
Age
I.Q.
Reading time
Spelling errors
(sec)
Dyslexics (N=30)
Grade 6 (N=30)
Grade 4 (N=25)
11years,3Months
105.7
240
38
(5.3)
(19.3)
(55)
(11)
11 years,5Months
13.6
176
13
(3.8)
(13.5)
(29)
(4)
10 years,5Months
105.6
210
15
(4.8)
(9.06)
( 34)
(8)
2.2. Procedure
All control students were individual tested in a quiet room at schools and
writing test were administrate as part of a screening material in a Research Project.
Dyslexics were tested by the second author in the Diagnostic, Evaluation and
Support Centre.
2.3. Material
For the purpose of the study, a spelling test were developed, consisting of 70
words and 70 nonwords with all the possible combination of phonemes, allophones,
consonant clusters and diphthongs of the Greek Language ( P.A.L., 2001). All
targeted words were controlled for character and syllable length, as well as for
surface frequency based on the Hellenic National Corpus (47,000,00 words, 1.2.2007).
Wilcoxon non parametric test revealed no statistical differences between words and
non words ( Z=- 1.050, N=2, ns).
3. Results
Performance on writing test was determined by the numbers of correct
responces and types of errors explained by phonological processing rules. Epenthesis
and cluster reduction (1st and 2nd consonant deletion) were the structural errors
283
observed. Fronting, backing, voicing, stopping and affrication on the other hand
consist the Systemic errors category. Furthermore, there were two types of
orthographic processing errors in stems and in the affixes of real words
Table 3.1. Phonological and structural errors in three groups.

1st.
con.
2st.
voicing
fronting
backing
Del
n.w
n.w
n.w
n.w
Grade 6
15
17
17
20
17
Grade 4
15
14
23
10
Dyslexics
56
120
27
92
con.
Del
stem
affix
stopping
aspiration
Epenthsis
errors
errors
n.w
n.w
n.w
n.w
126
17
25
251
54
47
37
24
22
15
337
172
A series of one-way ANOVA were performed to investigate any statistical

difference between the three groups of participants with regard to voicing errors (
F(2,50) =11.9, p=0.001 for nonwords, and (F(2,82)=15.29 , p=.0.01), for words, with
dyslexics to show considerable greater number of errors than grade 4, and 6,
students( Tukey HSD=0.01, no other statistical differences found). Fronting errors (F(
2,82)= 8.17, p=0.001, for nonwords and (F(2,82)=1.40, p>.0.05), n.s. for words,.
Dyslexics made considerable number of fronting errors in nonwords only ( Tukey
HSD=0.01, no other statistical differences found). Backing errors (F(2,82)=21,56,
p=.0.01 for non-words and (F(2,82)=0.50, p>.0.05), n.s. for words, again Tukey
HDS=0.01 differentiated dyslexics from grade 4 and 6 students in non-words
only).First consonant deletion (F(2,82)=7.56, p=.0.01 for non-words and (F(2,82)=4.31,
p=.0.05), for words. Tukey HSD differentiated dyslexics over Grade 6 students for
non-word writing, p=0.001, as well as the two control groups for words p=0.01, no
other significant difference were found). Second consonant deletion (F (2,82)=15,71,
p=.0.01 for nonwords and (F(2,82)=1.10, p>.0.05, n.s. for words. Again Tukey HSD
(p=0.01) revealed that the two control groups made less errors than dyslexics in
nonwords. The same pattern holds for stopping errors ((F(2,82)=6,49, p=.0.05 for
words and (F(2,82)=0.42, p>.0.05), n.s. for nonwords, Tukey HSD (p=0.01) for
dyslexics errors in non-word writing over the control groups) and aspiration
substitution errors ((F(2,82)=6,99 p=.0.05 for nonwords and (F(2,82)=0.78 p>.0.05),
n.s. for words, once again Tukey HSD differentiated dyslexics over the control
groups in non-words p=0.001). Epenthesis errors (F(2,82)=7.99, p=.0.01 for nonwords
and (F(2,82)=1.90, p>.0.05), n.s. for words), and orthographic stem (F(2,82)=14,75,
p=.0.01.) and suffix errors(F(2,82)=40.72, p=.0.01 for words only.
4. Discusion
The aim of the present study was an attempt to describe the spelling errors
made by dyslexics, normally developing peers, and reading age control students, in
terms of phonological processes observed in first language acquisition
With regard to spelling errors, voicing errors was the most prevalence type of
errors observed not only in liquids and nasals but in velars and labiodentals as well.
35.48 % were the errors in C+/liquid/ clusters, in initial and intermediate syllabic
place, and 19.08% concerned devoicing of liquids. Voicing errors in nasals were the
26.42% of all in this category and were found in C+/ nasal clusters only. For velars
284
and labiodentals, the number of voicing errors was significantly lower, 13.67% and
5.03% respectively
Backing errors observed in nonwords mostly (88.00 %). Dyslexics
performance in words was similar to normally developing childrens but they made
twice as many errors (68.15%) than both control groups in nonwords (14.8% for
grade 6 and 17.03% for reading age controls). Analysis of errors in nonwords
revealed a very interesting pattern with substitution of bilabial and alveolar
consonants to velars (/p/ or /t/ /k/ ) having the same percentage of occurrence
as substitution of interdentals (// and // ) to velars (38.35% and 39.72%
respectively).
Fronding of velars to alveorals and labiodentals had an equivalent percentage
of occurrences in both words and nonwords. This type of errors preferred mostly by
the two groups of normally developing children (44.45% grade 6 & 47.22% grade 4),
as it was the only type of errors in which their performance was inferior to dyslexics
(13.89%). The picture is reversed when it comes to nonwords. It is dyslexics again
who score 73.75% of errors.
Stopping of fricatives /v/or /f/ /p/, in isolation or in clusters, dominated
this category of spelling errors. However, this type of errors was nonexistent in real
words and represented a small percentage (11.29%) of those observed in nonwords.
There was no differentiation between the two groups of normally developing
children and the rule of 3:1 in dyslexics errors against normally developing
childrens were validated once again. To the same token aspiration of stop
consonants was found only in nonwords, with normally developing children
outperforming dyslexics (6.67% grade 4, 20.5% grade 6, and 64.76% dyslexics).
Finally, the structural errors consisted of three categories namely the first
consonant deletion, the second consonant deletion, and the epenthesis of a vowel in
consonant clusters. First consonant deletion differentiated only grade 6 students over
dyslexics and grade 4 students, suggesting a rather late acquisition of the /s/+ C and
velar + C clusters in written language acquisition. This type of omission consisted
51%.34 and 34.89% of this category, in both words and nonwords. Second consonant
deletion was observed only in nonwords, resulting in the omission of liquids in the
case of C+/r/ clusters or of an obstruent consonant in the velar + C clusters. The
later is the only syllable structure in which epenthesis occurred.
With regard to the scope of the present study, it can be concluded that
spelling errors can be described it terms of phonological processes. Written language
acquisition is a developmental process, which is extended for several years in typical
and atypical developing children. Dyslexics spelling are more immature as far as the
number of errors and the phonological processes observed.
It is worth noticing that the present study gives only a brief account of the
patterns of spelling errors observed, in written language acquisition, as it does not
report data from early years of schooling and leaves out the issue of the
developmental changes during the acquisition course.
References
Bruck, M. & Treiman, R. (1990). Phonological awareness and spelling in normal children and
dyslexics: The case of initial consonant clusters. Journal of Experimental Child
Psychology, 50, 156-178.
Ehri, L. C.(1986) Sources of difficulty in learning to spell and read. In M. L. Wolraich & D.
Routh (Eds.), Advances in developmental and behavioral pediatrics. Greenwich, Conn.: Jai
Press, pp. 121-195.
285
Ehri, L. C. (1991). The development of reading and spelling in children: An overview. In M.

Snowling & M. Thomson (Eds.), Dyslexia: Integrating theory and practice (pp. 6394).
London: British Dyslexia Association.
Ehri, L. C. (1992). Reconceptualizing the development of sight word reading and its
relationship to recoding. In P. B. Gough, L. C. Ehri, & R. Treiman (Eds.), Reading
acquisition (pp. 107143). Hillsdale, NJ: Erlbaum.
Ehri, L.C. (1994). Development of the ability to read words: Update. In R. Ruddell, M.
Ruddell & H. Singer (Eds.), Theoretical models and processes of reading. (4th edn,(pp. 323
358). Newark, Del: International Reading Association.
Ehri, L. C. (1998). Graphemephoneme knowledge is essential for learning to read words in
English. In J. L. Metsala & L. C. Ehri (Eds.), Word recognition in beginning literacy (pp.
340). Mahwah, NJ: Erlbaum.
Ehri, L. C., & Wilce, L. S. (1985). Movement into reading: Is the first stage of printed word
learning visual or phonetic? Reading Research Quarterly, 20, 163179.
Ferreiro, E. (1990). Literacy development: Psychogenesis. In Y. Goodman (Ed.), How children
construct literacy: Piagetian perspectives (pp. 1225). Newark, DE: International Reading
Association
Ferreiro, E., Pontecorvo, C., & Zucchermaglio, C. (1996). Pizza or piza? How children interpret
the doubling of letters in writing. In C. Pontecorvo, M. Orsolini, B. Burge, & L.
Resnick (Eds.), Childrens early text construction (pp. 145163). Mahwah, NJ: Erlbaum.
Ferreiro, E., & Teberosky, A. (1982). Literacy before schooling. New York: Heinemann.
Frith, U. (1980). Unexpected spelling problems. In U. Frith (Ed.), Cognitive Processes in Spelling.
(pp 495-515). London: Academic Press.
Frith, U. (1985). Beneath the surface of developmental dyslexia. In K. E. Patterson, J. C.
Marshall, & M. Coltheart (Eds.), Surface dyslexia: Neuropsychological and cognitive
studies of phonological reading (pp. 301330). London: Erlbaum.
Pontecorvo, C. (1996). Introduction. In C. Pontecorvo, M. Orsolini, B. Burge, & L. Resnick
(Eds.), Childrens early text construction (pp. 345357). Mahwah, NJ: Erlbaum.
Read, C. (1975). Childrens categorization of speech sounds in English. (NCTE Research Report
No. 17). Urbana, IL: National Council of Teachers of English.
Snowling, M.J. (1994) Towards a model of spelling acquisition: the development of some
component skills. In Brown, G.D.A. & Ellis, N.C. (Eds) Handbook of Spelling: Theory,
Process and Intervention. (pp111-128). London: John Wiley and Sons..
Treiman, R. (1984). Individuall defferences among children in spelling and reading styles.
Journal of Experimental Child Psychology, 37, 463-477.
Treiman, R.(1985a).Phonemic awareness and spelling: childrens judgments do not always
agree with adults. Journal Of Experimental Child Psychology, 39, 182-201.
Treiman, R. (1985b).Spelling of stop consonants after /s/ by children and adults. Applied
Psycholinguistics, 6,261-282.
Treiman, R. (1991). Childrens spelling errors on syllable initial consonant clusters. Journal of
Educational Psychology, 83, 346-360.
Treiman, R. (1993).Begging to spell.: A study of first grade children. New York: Oxford University
Press
Treiman, R. (1994). Use of consonant letter names in beginning spelling. Developmental
Psychology, 30, 567580.
Treiman, R., Zukowowski, A., & Richmond -Welty (1995). What happened to the nof sink?
Childrens spelling of final consonant clusters. Cognition, 55, 1-38.
286
FP12.4
THREE CHILDREN WITH AUTISM SPECTRUM DISORDERS ENTER
GRADE 1 REGULAR CLASSES
Gyftogianni Maria , Georgiou Anastasia, Kolosioni Dimitra, Sakellari Marigo,
Kotsopoulos Sotiris
Day Centre for Children with Developmental Disorders
Introduction: This is a report on the effect of intensive individual therapy
targeting specific deficits on three children (A, B, C) with autism spectrum disorders
(ASD) with regard to their ability to attend regular grade 1 classes. .
Method: The diagnosis was made on the criteria of DSM-IV (PDDNOS). The
psychosocial functioning was assessed with the Vineland parent questionnaire. An
observation scale (EDALFA) developed by the treatment team to obtain a
developmental profile of the child was used to set specific treatment objectives. This
scale provides nine behaviour-cognitive measures. The children were boys and
started treatment at age A &B 3y,C 3y 10m. They were treated by the same treatment
team using consistently behavioural and cognitive methods in the context of a warm
relationship with the child. Child A was 5y.3m when referred to the present Centre
from another service. The total number of individual therapy sessions at the Centre
per child were: A 166 (since referral to present Centre), B 694, C 450. The parents of
all children participated actively in the treatment of their children, particularly the
mother of child C who presented with severe language-speech deficit. While
attending grade 1classes all continued with individual and with group therapy
sessions which were added. Individual and group sessions were video-recorded.
Results: At age A 6y.3m., B 6y.4m., C 6y.11m.all entered regular grade
1classes (B child with resource help) in different schools and towns in a Greek
province with minimal preparation of their teachers. At the completion of the first
three months in school all were well adjusted and accepted in the new environment
and their academic performance was considered satisfactory.
Conclusions: Intensive individual therapy sessions which targeted specific
deficits of each individual child led to significant improvement and to integration in
regular grade 1 classes. It is expected the diagnosis of ASD will not apply to them in
the near future. A negative prognosis for child C because of severe linguistic
handicap has been falsified.
287
FP12.3
DELIVERING EFFECTIVE SUPPORT AND THERAPEUTIC
INTERVENTION PROGRAMS TO PDD CHILDREN
E. Kalos1, A. Fragkouli2, S. Mantzioura 3, A. Sarela4, P. Papadimas 5,I.Koutri6
1, 2, 3, 4, 5, 6: Institute of Mental Health of Children & Adults in Lamia
1. Intoduction
During 20 years of presence in the prefecture of Fthiotida, the Institute of
Mental Health of Children and Adults, dealt with a significant number of incidents
of Pervasive Developmental Disorder (PDD).
Our interest for a more detailed investigation of cases related to children with
PDD originated from the fact that this disorder requires a multi-dimensional
therapeutic intervention, a multidisciplinary cooperation, as well as a close
collaboration with the family and school environment in order to achieve the
therapeutic targets.
2. Institute of Mental Health of Children & Adults in Lamia: Introduction

on the services
The Institute of Mental Health of Children and Adults is a non-profit,
scientific association which was founded in 1996 in Athens and has been licensed by
the Mental Health Directorate of the Ministry of Health to preserve a Day Centre for
children, adolescents and adults with mental disorders and mental retardation. Its
headquarters are located in Kallithea (Attica) and provide services for more than
fifteen years to the local community, following the principles and the methodologies
of Community and Social Psychiatry. The branches of the Institute operate in the
prefectures of Fokida, Fthiotida and Rodopi.
Lamias branch has two departments: the Department of Children and
Adolescents and the Department of Adults. The former deals with learning
disabilities, speech problems, affective disorders, phobias, behavior disorders and
developmental disorders, providing diagnostic and curative
treatments.
Additionally, the Institute offers counselling to parents.
The multidisciplinary group of the Institutes branch in Fthiotida is
constituted by a child psychiatrist, a clinical psychologist, psychologists,
psychotherapists, speech and language therapists (SLT) and a specialist in special
physical education. There are two main axes in the operation of the Institute for
dealing with the difficulties of the child: an interdisciplinary work, in order to
effectively respond to the needs of each case, and the collaboration between the
therapists and the families, and - if necessary - with the school framework.
3. The interdisciplinary team and the collaboration with parents in

treatment of P.D.D.: Theoretical framework and presentation of the
working therapeutic team of I.M.H.C.A.
Although there is no specific treatment for PDD, a diverse range of therapies
are available which target various core symptoms of autism (Ospina, Krebs Seida,
Clark, Karkhaneh, Hartling, et al., 2008). Timely detection and treatment are
considered to be very important factors for improving the condition. The best
288
treatment begins early, in preschool years, is individually tailored, targets both

behavior and communication and involves a variety of therapists and parents or
primary caregivers (Callias, 1989; Makrygianni and Phil Reed, in press).
As far as the Institute of Mental Health in Lamia is concerned, the planning of
the treatment is done after an accurate evaluation by an inter-disciplinary team
comprising a child and adolescent psychiatrist, SLT, psychologists, special educators
and occupational therapist.
Initially a first interview with parents regarding developmental history takes
places. In parallel, the child and adolescent psychiatrist collects information about
the medical condition, any accidents or head injury, prenatal, perinatal history etc. In
certain cases a referral to a clinical genetist is needed to rule out genetic syndromes
with developmental consequences.
The current status of the child is evaluated next by collecting data relevant to
current behaviors, mental status, social competence, communication and adaptive
behavior. The clinical observation of the child is the final component of the
assessment. During these assessments we appraise how the child interacts with the
environment, with his or her parents and siblings, and how he/she plays. We assess
speech, eye contact, aberrant, repetitive or self harm behaviors, motor activity,
mental status etc. Direct observation and evaluation is carried out by all the members
of the inter-disciplinary team individually.
Upon completion of the evaluation, the team discusses about the collected
data and proposes a therapeutic plan which targets each childs developmental and
psychosocial profile. The main aim is to plan the treatment with respect to the needs,
priorities and resources of the family.
Most of the times the intervention begins with speech language, special
education and occupational therapy sessions.
A critical aspect of any intervention in the diagnosis of Pervasive
Developmental Disorders is the information conveyed to the parents. They may
develop anxiety, fear and anger due to the diagnosis of their child. An accurate
description of the condition in terms of clinical manifestations, treatment and
prognosis is therefore needed.
We try to maintain family involvement during therapy. The therapist sets
long-term and short-term goals for the child to reach. The family is being informed at
a constant basis and participates actively (American Academy of Child and
Adolescent Psychiatry, 1999; Gena, 2002).
The SLT is an equal member of the interdisciplinary diagnostic, therapeutic,
and mainstreaming team (Frangouli et al.1989). In respect to PDD, the SLT can
support and organize the education program of the child, assist the family on issues
concerning their behavior to the child and advise other experts about childs
understanding and expression (Sherratt & Vogindroukas, 2008).
4. The present study

The objective of this research was to present the way in which the various
specialists planned the therapeutic intervention on PDD in the Institute of Mental
Health over the course of the last 10 years. At a second stage, the aim was to
investigate and verify the following hypotheses:
(a) Parents counselling can be an important factor for childrens successful
response to the therapy and their maximum maintenance in treatment.
(b) Speech, language and communication problems are the dominant
harmless symptoms that lead parents to seek advice and help for their child.
289
(c) The place of residence plays an important role in interrupting or

continuing the treatment.
5. Methodology
To conduct this research, information collected from 48 children and their
families over the last 10 years has been used. The variables that we were interested
in, were: a) the gender, b) the age c) the place of residence, d) parents requests e) the
therapeutic intervention program, f) the parents attendance in the counselling
programme. Using the Pearson Correlation (r), we investigated whether our initial
assumptions were verified.
6. Results
Our initial findings indicated that the PDD appears in a larger percentage to
boys (79, 2%) rather than girls (20.8 %). The display ratio is 4: 1, which is also
confirmed by the existing bibliography on PDD, according to which, boys
predominate in relation to girls (Lazaratou, 2004).
The parents requests:
Overall 42 requests (87.5%) concerning speech, language and communication
difficulties were recorded, such as: they dont talk , they dont communicate , they
only say mom and dad etc., as well as difficulties in behaviour such as: difficult
behaviour, playful kid, they dont obey to orders, they move around continuously, they
do not cooperate, they demonstrate hyperactivity, yelling etc. The remaining six cases
included 4 requests (8.3%) for attending a therapeutic program, whilst they had
already been diagnosed with PDD from a public hospital, and 2 requests (4.2%) that
concerned moving difficulties.
The therapeutic intervention that followed:
(A) 18 families (37.5%) attended a special education and counselling program.
Ten of them (55.5%) continue until today. The rest remained in the therapeutic
programme for a minimum of 5 and up to 10 years. It is stated that in the latter case,
the interruption was associated with improvement of the childs condition and/or
referral to another frame.
(B) 14 children (29.2%) attended only a special education program. 8 of them
(57.1%) interrupted the therapy due to external factors, 4 of them (28.5%) stopped
prematurely, (during the 1st or 2nd month of therapy),1 continues until today (7.1%)
and 1 interrupted the therapeutic program after 4 years with no improvement (7.1%).
(C) 3 children (6.25%) attended a special education along with speech and
language therapy program and their parents attended counselling program as well.
Two of them (66.6%) continue until today.
(D) 4 children (8.3%) attended the occupational therapy only. One of them
continues until today.
(E) 3 children (6.25%) attended a special education program, along with
occupational therapy and their parents attended counselling program as well. Two
(33.3%) of them continue until today.
(F) 2 children, (4.2%) underwent occupational therapy and their parents
attended the counselling program as well. Both of them continue until today.
(G) 2 children (4.2%), underwent speech and language therapy and their
parents attended the counselling program. Both of them continue until today.
(H) 2 children (4.2%) attended only to the speech and language therapy
programme for a short period of time (3 months).
290
Overall, 20 (41.6%) of the initial 48 cases are still attending the therapeutic
programs. The parents of 18 (90%) of these children are still attending the counselling
program. Eight (28.5%) out of 28 children (58,3%) which interrupted their treatment,
have completed a significant part of their therapeutic intervention along with their
parents for more than 5 years, and, consequently, they had to be referred to another
framework. The remaining 20 cases interrupted prematurely their therapeutic
programs.
The place of residence:
21 families, (43.75%) were inhabitants of Lamia city, while 27 (56.25%) of
them were staying in the suburbs. It does not seem to appear statistically significant
correlation between the place of residence (Lamia/suburbs) and the outcome of
treatment (interruption/continuation until today). The initial assumption that the
place of residence may affect the constant participation in the therapeutic program is
not confirmed (r =-0.98), since the latter seems to be related to other factors.
Nevertheless, it would be useful in the future to further explore the above case, using
a larger sample.
Notably, a positive correlation (r = 0.655) between the parents attendance to
the counseling program and the interventions outcome was revealed. This means
that the parents attendance may affect the outcome of the therapeutic intervention
on their children.
7. Conclusions
What is considered to be important for the diagnosis and therapeutic
intervention of children with PPD in the Institute of Mental Health of Children and
Adults is the cooperation between different disciplines which will enable the
designation of an integrative intervention.
The present study indicates also that, although the majority of requests
concerned speech and language difficulties, the majority of children with PPD did
not attend a program of speech and language therapy, at least at the beginning.
The multidisciplinary team evaluates and proposes a program taking under
consideration primarily the child's needs, rather that their parents requests.
The special education program in many cases was considered to be crucial.
However, in most cases, the treatment by the multidisciplinary team included a
broader program aiming at developing childrens skills through SLT, physical
therapy, occupational therapy and cognitive development programs. Nevertheless
parents financial problems along with the limited insurance coverage were the main
reasons behind their decision to enter the treatment course by selecting initially only
one or two programs and adding or replacing certain of them at a later time. In this
respect, the SLT is not selected at the beginning but at a certain point during the
course of the cooperation between the family and the Institute.
Furthermore, it is of critical importance for parents to understand the need of
the counseling sessions. The research revealed that counseling affects the outcome of
treatment, since there is a positive correlation between attendance in counseling and
the outcome of the childs treatment. The parents of the 20 children who gave up the
treatment prematurely either did not attend counseling programs at all or did so for
a short period of time, demonstrating resistance to counseling and stopping
treatment. In contrast, parents who attended counseling sessions demonstrated
stability in their collaboration with the Institute and the minimum duration of the
treatment was 5 years with an average of 6.3 years. Through counseling, issues
related to childs behavior as well as parents emotions are being defined and
291
efficiently managed, so that parents who have mastered adequately the above, can
effectively contribute to their childs treatment and more efficiently cope with
potential personal emotional difficulties.
To conclude, good collaboration between therapists and parents as well as the
multidisciplinary approach to the treatment of the Pervasive Developmental
Disorder are two of the most important factors that ensure the effectiveness of the
therapeutic intervention. Only a speech and language therapist that is aware of these
two parameters can ensure the constancy of the therapeutic relationship, which is
necessary in order to work with a child with PPD.
References
American Academy of Child and Adolescent Psychiatry. Practice Parameters for the
assessment and treatment of Children, Adolescents and Adults with Autism and
Other Pervasive Developmental Disorders. 1999, 38(12) Supplement, 32S-54S.
, . & Sherratt, D. (2008),
, .:
Callias, M. (1989). . . &
. (.), , ,
. .
Frangouli A., Sakellaropoulos P., Sorokou T., Dambasina-Latarjet L. (1989) , Mobile
Psychiatric Unit in a Rural Area of Greece : The Role of the Speech and Language
Pathologist , CST Bulletin , No 445 , May 1989.
, . (2002), , .
, . (2004), , ., ( ),
634-635. : .
Makrygianni, M. K., & Reed, P. (in press). Factors impacting on the outcomes of Greek
intervention programmes for children with autistic spectrum disorders Research in
Autism Spectrum Disorders, Corrected Proof Ospina MB, Krebs Seida J, Clark B,
Karkhaneh M, Hartling L, et al. (2008) Behavioural and Developmental
Interventions for Autism Spectrum Disorder: A Clinical Systematic Review. PLoS
ONE 3(11): e3755. doi:10.1371/journal.pone.0003755
http://www.childdevelopmentinfo.com/disorders/communication_in_autism.shtml
292
Appendix
1. Correlation of place of residence and treatments outcome
therap Pearson
y
Correlation
therapy
place
-,098
Sig. (2-tailed)
place
,509
48
48
Pearson
Correlation
-,098
Sig. (2-tailed)
,509
48
48
2. Correlation of attendance to counseling and treatments outcome
therap Pearson
y
Correlation
therapy
couns
,655(**)
Sig. (2-tailed)
couns
,000
48
48
Pearson
Correlation
,655(**)
Sig. (2-tailed)
,000
48
48
** Correlation is significant at the 0.01 level (2-tailed).
293
FP27.1
OBJECT AND ACTION NAMING PATTERNS IN CHILDREN WITH SLI
AND WFD: A NEW LINGUISTIC PERSPECTIVE FROM CYPRIOT
GREEK
Maria Kambanaros and Kleanthes K. Grohmann
European University Cyprus & University of Cyprus
1. Introduction
This research is the first picture-naming study involving children with
specific language impairment (SLI) that investigates the lexical category of verbs
(actions) and compares performances for the same children with noun retrieval
(objects). The participating children are all speakers of Cypriot Greek (CG) and come
from three groups: in addition to SLI, children with word-finding difficulties (WFD)
and typical language development (TLD). Beyond reporting whether children with
SLI and/or WFD are less accurate than age-matched peers with TLD acquiring CG
on naming pictures of objects and actions, the aims of this study are to:
1.
look for grammatical word class effects in naming performances in SLI

and/or WFD;
2.
determine whether error types differentiate SLI and/or WFD from

peers with TLD;
3.
assess effects of psycholinguistic variables on naming accuracies.
2. Methods
Three groups of children participated in this study:
thirty children with TLD (15 girls and 15 boys), aged 6;0-6;11 years, with an
average age of 6;3 (recruited randomly from three public primary schools)
seven children (2 girls and 5 boys), aged 6;4-11;0 years, with an average age of
8;10 (diagnosed with SLI and recruited from speech-language therapists in
private practices)
thirteen children (6 girls and 7 boys), aged 6;3-11;11 years, with an average age
of 8;2 (with expressive language impairments, including WFD and poor
vocabulary development, recruited from speech-language therapists working
in public primary education schools)
Subject selection criteria included a monolingual CG-speaking background,

medium-high socio-economic status, with normal articulation, adequate
hearing/vision, normal performance on screening measures of non-verbal
intelligence, and no gross motor difficulties, obvious learning difficulties, and history
of neurological, emotional, or behavioural problems.
The Greek Object and Action Test (GOAT) developed for SMG by
Kambanaros (2003) was adapted to CG and administered to assess retrieval of object
and action names. For the present study, 84 coloured photographs measuring
294
10x14cm in size were used, 42 depicting actions (verbs) and 42 objects (nouns).
Furthermore, object and action names were measured for key psycholinguistic
variables, including age of acquisition (AoA), imageability, picture complexity, and
frequency (to the extent possible, since no normative data exist for CG).
The order of the task (comprehension or production) was counterbalanced
across the children tested. The object and action tasks were presented in one session.
Testing was conducted in a quiet room at the school. Each child was tested
individually by the first author of this study, who was assisted by a CG-speaking
speech and language therapist.
In the competence task, children were asked to point to the correct
photograph from a set comprising the target object/action and two semantic
distracters, matching the spoken word heard. Two examples were provided before
testing. If children failed to point to the correct picture, they were corrected. Children
who pointed to more than one photograph were told that only one picture was
correct. The instructions were repeated for children who did not point to any
pictures. No time limits were placed and self-correction was allowed. (Only once was
the target word repeated upon request.) If further repetitions of the same word were
required the answer was scored as incorrect.
On the production side, children were asked to name the object or action
represented in the photograph in a single word. Action names were required in the
third person singular. Two examples were provided before testing. The stimulus
question was repeated once for children who did not respond. If no response was
given, the item was scored as incorrect. No time limits were placed and selfcorrection was allowed. Responses were recorded and transcribed verbatim by the
first-named author and checked by the second.
3. Results
All three groups scored (close to) ceiling on the noun/verb comprehension
tasks. Therefore, the results of two subtests of the GOAT are reported here: object
naming (nouns) and action naming (verbs). The percentages of correct responses
were calculated for object and action names. A summary of the results is given in
Table 1 according to picture type.
SLI
WFD
TLD
Object names
67%
71%
77%
Actions names
68%
61%
72%
Table 1: Correct production percentages for object and action names

Overall, the children with TLD and WFD, but not those with SLI,
demonstrated a grammatical word class effect, with object names significantly easier
to retrieve than action names for both groups. A one-way analysis of variance
(ANOVA), carried out on the results from object naming performances between the
three groups, revealed a statistically significant difference between the children with
TLD and those with SLI, with the latter showing significantly more difficulties
retrieving object names compared to their peers with TLD. In contrast, the children
with WFD were significantly worse at retrieving action names compared to the
group of children with TLD.
295
Errors made by the children for object and action names were classified into
semantic errors, grammatical word class substitutions, omissions, visual errors, and
unrelated responses. Semantic errors were divided into semantic types and semantic
descriptions or circumlocutions. The latter involved describing the target
action/object concept using more than one word (e.g., hitting the nail for
hammering). Semantic errors included coordinate (e.g., comb for brush),
superordinate (e.g., tool for hammer), and associative errors (e.g., bucket for mop),
all semantically-related single lexical labels for the target word. Noun-to-verb
substitutions (word-class errors) were those in which the action name was provided
instead of the object name, or vice-versa (e.g. instead of sweeping, broom was
produced). Visual errors included responses where there is no semantic relationship
between the childs response and the target object/action word (e.g. (nail) file >
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.
296
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 dont 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
297
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.
298
FP17.3
EFFECTS OF MATERNAL DEPRESSION ON A CHILDS 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 infants 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-Sillre, 1998). Imitation, mutual activity and intentional
communication mirror primary intersubjectivity within the mother-infant
communicative dyad (Trevarthen, 1979). The mothers ability of interpreting the
childs 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 mothers 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 mothers ability to provide and expand
utterances during play draws the childs 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
299
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 childs language development and the
effectiveness of interventions targeting maternal depression, motherchild
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 Ms birth, his parents had undergone a period of losses and
unexpressed mourning. Three months prior to the mothers 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 fathers brother died of acute
myocardial infarction, feeling guilty for M.s fathers amputation. The parents stoic
compensation for these losses involved no communication with each other.
The mothers 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 peoples presence
300
and connected with them in an infantile and immature way, but he was relieved with
other peoples 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 Ms mothers communicational patterns and
to develop Ms communication skills, b) childs 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 wifes 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, . 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 childs 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 ones 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.
301
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 toddlers 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 mothers well-being,
increase the amount and quality of parent-child interactions and, consequently,
develop and improve the childs 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). Childrens minds. London: Fontana Paperbacks.
Lemaitre-Sillre, 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.
302
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.
303
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 cant be used to establish targets for intervention. Criterionreferenced assessments are needed for that task. However, given the need for
evidence-based practice, its 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 childrens 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. Its 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
304
found in the story determine the storys 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 dont 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 dont 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 doesnt want to go.
Jack hit her on the head.
Why wont 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:
305
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 childrens 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 childrens 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, dont happen, the cake doesnt 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

Childrens 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, its
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
306
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.
307
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 ones
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 childs cognitive ability, though there is controversial
evidence regarding the role of the level of cognition in language development. There
are claims that ones 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 Childrens
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
310
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:
/kalaaci/ 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.
311
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 So 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
7m
1y6m
3y
3y
4m
9m
2y3m
1y6m
6m
2y9m
No
3y
8m
1y2m
3y2m
2y
5m
8m
2y3m
3y4m
2y4m
3y2m
4y
3y
3m
7m
2y3m
1y1m
4m
8m
1y11m
2y
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
41m
13m
11m
5m
13m
43m
39m
33m
43m*
24m
47m
12m
16m
15m
18m
47m
16m
21m
36m
24m
313
55m
20m
13m
33m
18m
65m
41m
24m
21m
39m
66m
42m
39m
66m*
48m
67m
31m
31m
24m
41m
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. Mtt T, Tervo-Mtt 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 dficits 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 sndrome de
Down.Rev Bras Ed Esp; 12(1): 123-38, 2006.
9. Mancini MC, Silva PC, Gonalves SC, Martins SM. Comparao do desempenho funcional
de crianas portadoras de sndrome de Down e crianas com desenvolvimento
normal aos 2 e 5 anos de idade. Arq Neuro-Psiquiatr; 61(2):409-15, 2003.
10. Ferreira AT, Lamnica DAC. Estimulao da linguagem de crianas com sndrome de
Down. In: Lam6onica DAC. Estimualo da linguagem: aspectos tericos e prticos.
So Jos dos Campos, So 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- Brando SRS. Desempenho na linguagem receptiva e expressiva de crianas com
sndrome de Down. Dissetao 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.
316
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, neuroembriognese
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 So 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 parents
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
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
319
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, Snchez M, Spinelli S, Van der Velde J. Deteccion e
tratamiento del mielomeningocele por um equipo interdisciplinario. Rev Hosp Mat
Inf Ramn 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.
320
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
Childrens paced auditory serial addition test. J Int Neuropsychol Society. 12;305313,2006.
13. Dunn LM, Padilla ER, Lugo DE, Dunn LM. Teste de Vocabulrio por Imagens Peabody.
Adaptao Hispano-americana. Espanha: Circle Pines: American Guidance Service,
1986.
14. Bogossian MADS. Teste de Illinois de habilidades psicolingustica: crtica do modelo
mediacional e de diversos aspectos da validade do instrumento. Rio de Janeiro; 1984.
[Tese de Doutorado, Fundao Getlio Vargas].
15. Alvarez AMMA, Carvalho IAM, Caetano AL. Perfil de Habilidades Fonolgicas: Manual.
So Paulo: Via Lettera Editora, 2004.
16.Stein LM. TDE: Teste de Desempenho Escolar: Manual para aplicao e interpretao. So
Paulo: Casa do Psiclogo, 1994.
17. Dias RS, vila CRB. Uso e conhecimento ortogrfico no transtorno especfico da leitura.
Rev Soc Bras Fonoaudiologia. 13(4):381-90;2008.
18. Guimares SRK. O aperfeioamento da concepo alfabtica de escrita: Relao entre
conscincia fonolgica e representaes ortogrficas. In: Maluf MR. Metalinguagem e
aquisio da escrita. So Paulo.149-184. 2003.
321
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.
322
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.
323
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 childs 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 /us/ is used for at least six different morphs, and each one of them
encodes more than two morphemes.
324
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 lexemes 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, childrens 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
325
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 childs spontaneous utterances
in order to better identify childrens 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 childs individual needs and the SLPs 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.
326
10. Rollins, P.R., Snow, C.E. And Willett, J. (1996), Predictors of MLU: Semantic and
Morphological Developments, First Language, 16, 243-259.
327
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 posttreatment 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 childs 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
328
(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.
ACs 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 ACs information processing speed relative to the control group
for both the congruent and incongruent conditions.
ACs 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. ACs 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 ACs
performance.
Results
ACs 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. ACs 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 tests 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
ACs 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
329
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). ACs 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 ACs 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 ACs 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 ACs 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.
330
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.
331
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
Calhouns (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
332
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 Gillbergs (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.
333
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 DSMIVs 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 groups 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.
334
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 DSMs 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.
335
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.
336
P026
GRAMMATICAL ASPECTS IN SPONTANEOUS COMMUNICATION IN
CHILDREN WITH DOWN SYNDROME
SCO Limongi, AMA Carvalho, SF Marques, P Mello, RV Andrade
University of So Paulo , So 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 childrens 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 childrens 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.
337
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 So
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
So 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=<0,001 for G2; p=0,001 for G3).
The table below shows descriptive data (means) for the PG (children with DS)
and the CG (TD children) arranged in groups based on their mental age.
GM-2
MLU-total
MLU-m
GM-1
MLU-w
CG
PG
GC
PG
CG
PG
CG PG
CG PG
3 years 305
206.1
67.2 23.1
372.2 229.3
3.72 2.3
2.83 1.6
4 years 355.4 310.6
99.6 43.0
455
353.6
4.55 3.5
3.52 2.6
338
5 years
476.6 317.0
124.7 52.0
601.3 369.0
6.01 3.7
4.73 2.6
The comparison between PG and CG showed that children with DS

presented lower performance in all MLU values when compared to their TD pairs,
considering the mental age arrangement. In spite of this observation, the data
showed that MLU values increased with mental age in both PG and CG. These
results are reinforced by the literature4. The results also indicated that the largest
gains in the grammatical aspects occurred between the 3rd and 4th year of mental
age in children with DS.
Concerning word classes, all words produced were analyzed, including
adjectives, adverbs, interjections, numerals, and onomatopoeias. Results showed
significant differences among groups for verbs (p=0,006), numerals (p=0,016), and a
tendency to significance was observed for adjectives (p=0,119).
The within-group analysis showed significant differences among word
classes (p=<0,001 for G1, G2, and G3), especially for comparisons between
substantives, verbs and pronouns with the other word classes.
The table below shows descriptive

DS) concerning word classes.
SBT VER ART PRN PRP
G1 42.6 44.4 8.6
14.6 2.4
G2 40.6 81.4 10.4 22.6 6.8
G3 73.2 95.4 20.8 24.2 12.6
SBT=substantive;
COJ=conjunction;
NUM=numeral
VER=verb;
ADJ=adjective;
data (means) for the PG (children with

COJ
0.6
2.0
5.8
ART=article;
ADV=adverb;
ADJ
2.0
4.0
6.8
ADV
24.8
32.0
34.0
ONO
3.6
2.0
6.8
ITJ
6.6
6.4
7.4
NUM
0.0
1.6
7.4
PRN=pronoun;
PRP=preposition;
ONO=onomatopoeia; ITJ=interjection;
The results showed that the use of all word classes increased with mental
age3. It can be observed that verbs, pronouns, prepositions, and adverbs were the
word classes that presented largest use in G1 and G2. Nevertheless, G3 presented
higher use of substantives, articles, prepositions, conjunctions, adjectives,
onomatopoeias, and numerals when compared to G1 and G2.
Preliminary studies8 involving language acquisition in Brazilian young
children aged between two and four years reported the sequence of word classes
acquisition as verbs, substantives, pronouns, articles, and conjunctions. The same
order was observed for the research participants.
The figure below shows the evolution of each word classes for the PG.
339
Although the literature3,4 have showed that children with TD use more
substantives than verbs in the first years of the language development, our data
indicated that children with DS had preference for the use verbs. One possible
explanation is that, in Brazilian Portuguese, verbs play a role as organizational
element in the syntactic structure, making its use easier for children in the early
stages of language development 8.
It is interesting to make some commentaries about the increase of substantive
use and its influence on the other word classes acquisition. Researchers 1-4 have
argued that substantives present an inherent conceptual simplicity that makes its
acquisition and use easier for the child. In the present study, increases in substantives
use lead children to use more articles and adjectives in their oral emissions. In the
same way, the increase of substantives and adjectives lead children to use more
prepositions and numerals. Prepositions, numerals and conjunctions were later
observed in language development, probably because they refer to word classes that
express relation between elements9. The onomatopoeias were studied considering
their role as a replacement element for substantives. The results showed that its use
by children with DS influenced the increase of other word classes.
Although there are no data in literature about the influence of the increasing
of substantives use on acquisition and use of articles, adjectives and numerals in DS,
this is an important observation, once these word classes are responsible for
substantives modification and the combinations between them lead to improves in
the quality of oral language.
Conclusions
Our findings suggest that children with DS have difficulty on using
grammatical morphemes related to words, whose learning depends on the
understanding and use in communicative contexts. Besides that, these children tend
to use words with more semantic value, as nouns and verbs, than closed class words,
as prepositions, pronouns and conjunctions that have grammatical meaning and are
linked to the syntactical structure. Moreover, MLU-w can be used as an efficient
mean of assessment and analysis of childrens general linguistic development. The
results point out important aspects to be considered in speech-language therapeutic
process for children with DS.
This research was funded from grants from the Brazilian National Institute of
Research (CNPq).
340
References:
Bassano D. Early development of nouns and verbs in French: exploring the interface
between lexicon and grammar. J Child Lang, 27:521-59, 2000
Ninio A. Testing the role of semantic similarity in syntactic development. J Child Lang,
32:35-61, 2005
Roberts JE, Price J, Malkin C. Language and communication development in Down
syndrome. Mental retardation and Developmental Disabilities Research Review,
13:26-35, 2007
Vicari S, Caselli MC, Gagliardi C, Tonucci F, Volterra V. Language acquisition in special
populations: a comparison between Down and Williams syndromes.
Neuropsychol, 40:2461-70, 2002
Brown R. A first language. Cambridge, MA: Harvard University Press, 1973
Malakoff ME, Mayes LC, Schottenfeld R, Howell S. Language production in 24 month old
inner city children of cocaine and drug using mothers. Journal of Applied
Developmental Psychology, 20:159-70, 1999
Ehrler DJ, McGhee RL. Primary Test of Nonverbal Intelligence PTONI. Texas, Pro-ed,
2008
Araujo K. Grammatical performance in children with typical development and children
with SLI [thesis]. So Paulo, University of So Paulo, 2007
Grela B, Rashiti L, Soares M. Dative prepositions in children with specific language
impairment. Applied Psychology, 25:467-80, 2004
341
P088
PARENTS APPROACHES TO ENGAGE THEIR CHILDREN WITH
DOWN SYNDROME IN A VISUAL-PERCEPTUAL TASK: THE
INFLUENCE OF CHILDRENS CHARACTERISTICS
F. C. Flabiano1; L. A. Daunhauer2; L. F. Silva1; D. J. Fidler2; S. C. O. Limongi1
of So Paulo, So Paulo, Brazil
2Colorado State University, Fort Collins, United States of America
1University
Introduction
Parent-child interactions, particularly the ability of the mother-child dyad to
initiate and maintain episodes of joint engagement, are associated with language
outcomes in both typically developing (TD) children and children with
developmental delays (Silller & Sigman, 2002). The patterns of challenges associated
with the Down syndrome (DS) such as poor attention to external stimuli and poor
responsiveness and interactions (Voivoidc & Storer 2002), may affect how children
with DS engage or elicit interactions with parents and participate in everyday
activities (Hodapp, 2004). Additionally, children with DS have been reported to
demonstrate a distinct personality motivation profile characterized by poorer task
persistence, which has a potentially negative effect upon learning opportunities
(Pitcairn & Wishart, 1994). Researchers have found differences in interactions
between parents and their children with DS in contrast to parents and their TD
children (Spiker, Boyce & Boyce, 2002). For example, when compared to mothers of
TD children, mothers of children with DS tend to adjust their language to give
instruction or use more physical guidance and teaching strategies to engage their
children in learning (Marfo 1990; Pino 2000; Kim & Mahoney, 2004;) and to be more
directive (Landry & Chapieski, 1989; Glenn, Dayrus, Cunningham, & Horgan, 2001)
possibly to adjust to their childs profile of strengths and challenges. A critical
question that remains to be answered in this body of research is how and when
parent-child interactions promote development in children with behavioral
phenotypes associated with intellectual disabilities such as DS (Hodapp, 2004).
Therefore, the aim of the present study was to characterize the parent
approaches and child responses during a visual-perceptual task, for school-aged
children with DS in order to identify which types of parent approaches would be
associated with child on-task responses. Furthermore, we investigated whether
childrens characteristics (chronological age (CA), mental age (MA) and vocabulary
age (VA)) influence the amount and type of approaches used by parents to engage
them in the task.
Methods
Participants were 20 children with DS (7 males, 13 females), ages ranging 5:015:11 years, and their parents. All children attended 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 So Paulo, Brazil. Only
children with documented good health condition, normal vision or vision corrected
to within the normal range, and normal results on audiological evaluation
participated in this study.
342
This research was approved by the Ethics Committee for Research Projects
Analysis of the School of Medicine of the University of So Paulo, under protocol n
0808/08. The consent form was signed by all participants legal guardians prior to
data collection.
To examine the effect of child characteristics on parent approaches
participants were arranged in sub-groups according to their chronological age (CA,
Group 1 - 5:0- 9:11 years; Group 2 -10:0-15:11); mental age (MA, Group 1 -2:0- 4:5
years; Group 2 4:6 -7:0 ) and vocabulary age (VA, Group 1 2:0 - 4:5 years; Group 2
4:6-7:0).The Primary Test of Nonverbal Intelligence - PTONI (Ehrler & McGhee,
2008) was used for measuring childrens mental age; and the Brazilian Children
Language Test - ABFW (Andrade, Befi-Lopes, Fernandes and Wertzner, 2004) was
used for measuring childrens expressive vocabulary age.
Each parent-child dyad was asked to play together for ten minutes with a
book, I Spy a book of picture riddles by Jean Marzollo & Walter Wick, 2000. Data
were recorded in video and later transcribed in specific protocols. The transcribed
videos were reviewed starting 2:00 minutes into the task to allow the parent and
child time to habituate to the camera. In the same way, the last 2:00 minutes were not
coded. Thus, only six minutes of each dyad interaction were considered for analysis.
Parent approaches and child responses were analyzed using the ApproachResponse Coding Scheme (ARCS) for the I Spy Task (Daunhauer, 2007), based on the
coding scheme developed by Doussard-Roosevelt and colleagues (2003). All the
parents attempts (approaches) to involve the child in the I Spy task were coded as
social in nature or specific to the task.
A parent approach was defined as any behavior made by the parent that is
meant to engage the child in the I Spy task. An approach continued until the child
responded, or until the parent changed the goal or until > 2 seconds has elapsed
since the last approach.
Social approaches included the parents attempts to engage their child with
feedback and cues related to emotional support such as positive reinforcement and
demonstrating affection. Task approaches included cues and feedback related to
specific activity demands such scanning strategies and organizing the task.
Child responses to parent approaches were coded as on-task behavior, social
behavior, or off-task behavior.
We conducted agreement analysis with 30% of the taped dyads, randomly
selected. The inter-agreement ranged from 92.6-99.6% and the mean agreement was
97.1%. The mean agreement for parent approaches and child responses was 97.3%
and 96.3%, respectively. Any disagreements in behavioral coding were resolved
through discussion among the coders. Analyses were tested using an alpha level of
.05.

Descriptive data (mean and standard deviation) for the entire sample
concerning the amount and types of approaches used by parents to engage their
children with DS during the visual-perceptual task (I Spy Book) as well as childrens
responses are presented in Table 1.
343
Table 1 Descriptive data for parents approaches and childrens responses.

Parents Approaches
No.
Mean
SD
84.10
5.62
Child Responses
On
TaskSoc
Off
Task
19.80
11.20
1.05
10.70
7.12
7.25
Task
Verb
Task
NVerb
Social
Verb
Social
NVerb
TaskSocial
On
Task
Social
71.65
48.95
22.45
21.50
28.50
74.35
12.51
15.00
9.46
10.53
12.42
15.88
N=20
The Spearman correlation test showed significant positive correlations
between childrens on-task responses and parents task verbal (r = 0.87; p < .001) and
task nonverbal approaches (r = 0.49; p = .028), while no significant correlations were
found between childrens on task responses and parents social approaches.
Additionally, parents nonverbal social approaches were significantly
correlated to childrens social responses (r = 0.51; p = .020), as well as to childrens
off-task responses (r = 0.52; p = .017).
These results suggest that these children with DS seem to follow parents
interaction style, responding more frequently with on-task responses to task
approaches and more frequently with social responses to social approaches,
especially concerning social nonverbal approaches. In addition, task approaches
(verbal and nonverbal) were found to be more effective to engage the children in ontask behaviour than social approaches.
These findings are consistent with previous researches that have reported
that children with DS are more passive and tend to wait for parents directions during
play activities instead of initiate the interaction (Mundy, Signman, Kasari, &
Yirmiaya, 1988; Cielinski, Vaughn, Seifer & Contreras, 1995).
Concerning the influence of childrens characteristics on parents approaches,
comparisons between the sub-groups using ANOVAs revealed that parents of
younger children used more social nonverbal approaches than parents of older
children concerning both CA [F (1, 18) = 4.77; p = 0.042] and MA [F (1, 18) = 6.20; p =
0.023]. In addition, parents used more task combined with social approaches with
children from the younger MA group (F (1, 18) = 5.60; p = 0.029). These results
suggest that the parents adjusted their strategies based on childrens chronological
and mental ages. Thus, parents of children from younger CA and MA groups
provided more social cues related to emotional support, such as looking to the child
or smiling to the child during the I Spy task, than parents of children from the older
CA and MA groups.
Although there is no study specifically about this subject, the finding that the
parents of younger children in our sample used more task approaches combined
with social approaches is congruent with research indicating that parents are more
directive when their children are younger and present lower levels of development
(Spiker, Boyce & Boyce, 2002).
The VA did not influence parents approaches, that is, no differences between
parents approaches types were found to be statistically significant in the comparison
between VA groups. Finally, parents presented similar amounts of approaches in all
subgroups (CA1 and CA2; MA1 and MA2; VA1 and VA2), which means that while
344
some childrens characteristics, specifically CA and MA had influenced on the type

of approach used by the parent, CA and MA did not affect the amount of approaches
performed by the parents.
Conclusions
The findings of the present study suggest that the verbal task approaches
seem to be the most effective strategy to engage children with DS in a visualperceptual task. In addition, these children seem to follow parents style of
interaction, giving social or on-task responses to respective social or task approaches.
Concerning the influence of childrens characteristics on parents approaches, the
results indicated that the parents tended to adjust their strategies based on childrens
chronological and mental ages, using more task approaches combined with social
approaches and more social nonverbal cues with younger children.
References
Andrade CRF, Befi-Lopes DM, Fernandes FDM, Wertzner HF. ABFW - Brazilian Children
Language Test on Phonology, Vocabulary, Fluency and Pragmatics. Pro-Fono Editorial
Department. Barueri, 2004. (in Portuguese)
Cielinski KL, Vaughn BE, Seifer R, Contreras J. Relations among sustained engagement
during play, quality of play, and mother-child interaction in samples of children with
Down syndrome and normally developing toddlers. Infant Behavior and Development.
1995; 18:163-176.
Daunhauer LA. ARCS: Approach-Response Coding Scheme for I Spy Task. Unpublished
manuscript, Colorado State University, 2007.
Doussard-Roosevelt JA, Joe CM, Bazhenova OV, Porges SW. Mother-child interaction in
autistic and nonautistic children: Characteristics of maternal approach behaviors and
child social responses. Development and Psychopathology. 2003; 15: 277-295.
Ehrler DJ, McGhee RL. Primary Test of Nonverbal Intelligence PTONI. Texas, Pro-ed, 2008
Glenn S, Dayus B, Cunningham C, Horgan M. Mastery motivation in children with Down
syndrome, Down syndrome Research and Practic. 2001; 7: 52-59.
Hodapp RM. Behavioral phenotypes: Going beyond the two-group approach. International
Review of Research in Mental Retardation. 2004; 29:1-30.
Kim JM, Mahoney G. The effects of mothers style of interaction on childrens engagement:
Implications for using responsive intervention with parents. Topics in Early Childhood
Education. 2004; 24: 31-38.
Landry SH, Chapieski ML. Joint attention and infant toy exploration: effects of Down
syndrome and prematurity. Child Development. 1989; 60:103-18.
Marfo K. Correlates of maternal directiveness with children who are developmentally
delayed. American Journal of Orthopsychiatry. 1992; 62: 219-233
Mundy P, Sigman M, Kasari C, Yirmiya N. Nonverbal communication skills in Down
syndrome children. Child development 1988; 59(1):235-49.
Pino O. The effect of context on mothers interaction style with Downs syndrome and
typically developing children. Research in Developmental Disabilities. 2000; 2: 329-346.
Pitcairn TK, Wishart JG. Reactions of young children with Downs syndrome to an impossible
task. British Journal of Developmental Psychology. 1994; 12: 485-489.
Siller M, Sigman M. The behaviors of parents of children with autism predict the subsequent
development of their childrens communication. Journal of Autism and Developmental
Disorders. 2002; 32: 77-89.
Spiker D, Boyce GC, and Boyce LK. Parent-child interactions when young children have
disabilities. International Review of Research in Mental Retardation. 2002; 25: 35-70.
Voivodic MAMA, Storer MRS. Cognitive development of Down syndrome children related to
family relations. Psicologia: Teoria e Prtica. 2002; 4(2): 31-40. (in Portuguese)
345
P012
THE SIMULTANEOUS USE OF ASSISTIVE TECHNOLOGY AND
PERCEPTUAL MOTOR APPROACH IN THE ACQUISITION OF
READING AND WRITING SKILLS: A CASE STUDY.
Nikos Litinas, Yota Zergioti.
Assistive technology has been used in a wide range of speech and language
disorders proven to be a helpful therapeutic tool as a successful alternative mean for
writing and expression. The use of perceptual motor approach in teaching
handwriting empowers perceptual abilities that are necessary in a variety of
functional tasks. The aim of this paper is to study the effectiveness of the
collaboration of two different disciplines on the subjects readiness for elementary
school.
In the present case study, seven year old male presenting learning disorders
will be described. Assistive technology was selected by the speech/ language
pathologist to be used in treating this patient. Perceptual motor approach was
selected by the occupational therapist in treating this patient. Both methods selected
will be discussed as well as the effectiveness of the combination of the methods used.
Learning disorders are characterized by an inability to acquire, retain, or
generalize specific skills or set of information because of deficiencies or defects in
attention, memory or reasoning, or deficiencies in producing responses associated
with a desired and skilled behavior. (Reed, 1991). The causes can be genetic and/ or
neurologic. The ratio male: female is 5:1.Problems associated with learning disorders
can be motor, sensory, cognitive, intrapersonal, interpersonal, self care abilities and
play difficulties.
Assistive technology is technology used by individuals with disabilities in
order to perform functions that might otherwise be difficult or impossible. (The
National Center on Accessible Information Technology in Education, 2010).
Nowadays, a variety of assistive technology products are available. These products
range from walkers to all kind of hardware, software and peripherals. At the patient
described in this case study the speech/ language pathologist used a laptop
computer and the program of words.
Perceptual motor approaches hypothesize that by using specific training
activities to improve the underlying perceptual motor deficit, learning would be
improved. (Kephart,1971). For example, if a child has a problem with kinesthesia,
he/ she would benefit from the practice of graded activities that require kinesthesia,
e. g drawing circles in the air. This practice in turn, would be expected to improve
his/ her writing skills. In this way, the use of perceptual- motor approach facilitates
the learning of handwriting by improving an underlying perceptual- motor deficit.
(Laszlo & Bairstow, 1985).
Subject: B.C. is a seven year old boy diagnosed as learning disordered. He
has an I.Q. 70-80. He attends the first grade at a regular school class with the
simultaneous help of a special teacher. The school is located in Athens, Greece. B.C.s
receptive language skills show a one year delay and his expressive language skills
show a two year delay, according to normal development. His speech shows a one
year delay according to the Test of Greek Phonology. The results of the speech/
language evaluation impacts upon the acquisition of phonological and reading skills.
The occupational therapy results of B.C.s performance are as follows: According to
346
the Developmental Programming for Infants and Young Children, vol. 5 (PDP),
B.C.s gross and fine motor skills appear to be integrated by 90% at the 5.0 year level.
In the Motor- Free Visual Perception Test- Revised (MVPT-R), B.C. obtained a raw
score 19, which is equivalent to a perceptual quotient 84 and a perceptual age of 4.11
years. In the VMI, B.C. obtained a raw score 6 which is equivalent to a standard score
65 (very low) and a visual- motor age of 5.8 years. Overall, B.C.s performance is
significally decreased because of his nystagmus and his poor visual- motor abilities.
Functionally this impacts upon his acquisition of motor and writing skills.
Method: During speech therapy emphasis was given at phonological
awareness. This process is defined as the knowledge of the sound units (phonemes)
used in a language. Phonological awareness is a listening skill which develops
through the language developmental processes. Songs, rhymes, sound games are
used in early infancy and beyond in order to enhance these skills. Subset of the
phonological awareness process is the phonemic awareness that requires students to
know and match letters with sounds, learn the rules of spelling and use this
information to read (decode) and write (encode) words. During occupational therapy
emphasis was given at kinesthetic awareness of the right hand and visual motor
control as well as the spatial analysis and synthesis of the letters that have been
taught by the speech/ language pathologist. Speech therapy sessions carried out at
the speech/ language pathologists office twice a week for 45 minutes per session for
two months. Occupational therapy sessions carried out at the speech/ language
pathologists office immediately after speech therapy twice a week for 45 minutes per
session for two and a half months.
Goals: SPEECH THERAPY: B.C. will be able to acoustically recognize the
capital letter sound of the greek alphabet, presented orally by the therapist, punch
the corresponding letter on the computers keyboard with 100% accuracy in three
consecutive sessions. Verbal positive reinforcement will be imposed on every effort.
OCCUPATIONAL THERAPY: B.C. will hold with fingers a toy car (6 cm long
and 1 cm height) which he will drive with 100% accuracy on a pathway (3 cm wide)
on a vertical surface in five consecutive sessions. The pathway will be a capital letter
of the greek alphabet already taught by the speech/ language pathologist.
Results: After two months of speech therapy B.C. was able to acoustically
recognize, and write on the computers keyboard all 24 capital letters of the greek
alphabet. After two and a half months of occupational therapy, B.C. was able to drive
accurately the car on the vertical surface. This indicated that B.C. had acquired the
kinesthetic skills of the capital letters of the greek alphabet.
Discussion/ conclusion: Over the two month period these therapy sessions
lasted, it was proven that assistive technology with the developed, through speech
therapy, phonological awareness skills helped B.C. acquire reading skills. At the
same time the collaborative work of the speech/ language pathologist and the
occupational therapist in building the sub skills needed for letter recognition
enhanced B.C.s ability in reading and writing. Despite the controversial beliefs for
the effectiveness of perceptual motor approaches, in this particular study proved to
be effective. B.C. had to practice specific skills (kinesthesia, visual-motor control,
spatial analysis and synthesis) in a playful activity.(driving a toy car, constructing
with sticks). Despite, the success of the collaboration of the two disciplines described,
further practice is needed with other patients in order to conclude in more precise
assumptions about the effectiveness of the collaboration of different disciplines.
347
BIBLIOGRAPHY
Griffith,P. and Olson,M.W.(1992). Phonemic Awareness Helps Beginning Readers Break the
Code. Reading Teacher, 45(7), 516-23.
Kephart, N. C. The slow learner in the classroom. Colombus, Ohio: Merrill Publishing, 1960.
Lazslo,J.L. and Bairstow, P.J. Perceptual-motor behavior: Developmental Developmental
assessment and therapy. New York: Praeger, 1985.
Olson,M.W. and Griffith,P.(1993). Phonological Awereness: The What, Why, and How.
Reading and Writing Quarterly: Overcaming Learning Difficulties, 9(4) 351-60.
Tsipra,I. Occupational therapy and writing. Ergotherapy, V. 10, 7-13.
Websters. Encyclopedic dictionary of the English language. New York: Lexicon Publications,
1988.
www.washington.edu/accessit/articles?109
348
P025
LANGUAGE ABILITY PROFILE OF INDIVIDUALS WITH CLEFT LIP
AND PALATE
Maximino Luciana1, Marcelino Fabiana2, Abramides Dagma 1, Feniman Mariza 1, Carvalho
Fernanda 2
Departament of Speech and Language Pathology, Facultty of Dentistry of Bauru, University
of Sao Paulo1
Hospital for Rehabilitation of Craniofacial Anomalies2
INTRODUCTION
Individuals with cleft lip and palate are a wide field for studies in
communicative disorders which are common in this population given structural and
functional alterations related to cleft. Structural alterations compromise aesthetics
and functioning of the stomatognathic system for the performance of oral functions.
It affects the communication process interfering in social interaction given the
alterations in speech and facial aesthetics which may affect their self-image (Nguyen
e Sullivan 1993, Minervino-Pereira 2000).This malformation also compromises the
speech since it affects important structures that are responsible for its production
resulting in alterations related to velopharyngeal dysfunction, dentofacial
malformation and middle ear function (Genaro et al 2004, Pegoraro-Krook et al
2004).
Phonetic difficulties in subject with complete unilateral cleft lip and palate are
studied all over the world thoroughly by researchers (Snyder e Scherer 2004). In
Brazil few studies describe the importance of phonology in the speech production of
these children and studies on the language development were not found,
considering all the linguistic abilities (syntax, semantics, phonology and pragmatic).
Researches indicate the presence of speech production, language and
understanding alterations in children with cleft, and these children have larger
predisposition to present delay in the acquisition of first words, in the production of
short sentences, difficulty in the words recovery, in language understanding and
deficiency in reasoning, when compared with their pairs with normal development
(Schnweiler et al 1999, Pamplona et al 2000, Melgao et al 2002, Morris e Ozanne
2003, Sharp et al 2003, Bzoch 2004).
As for linguistic abilities, some authors suggest that children with isolated
cleft lip and palate tend to present as many alterations in language abilities as
children without cleft, except for the language delay which is overcome at the age of
4 (Golding-Kushner 2001, Bzoch, 2004). These days, studies have pointed out
significant differences in the development of language abilities that are directly
related to school performance. (Broder et al 1998, Richman et al 2005, Goldsberry et
al 2006).
Individuals with cleft lip and palate are often affected by ottites media with
effusion which may result in peripheral hearing loss. It may indicate risk for the
development of the auditory processing, language, speech and learning. These
cognitive and linguistic damages may be minimized or prevented by the early
identification and rehabilitation.
Thus, it is fundamental to know the linguistic profile of individuals with
complete unilateral cleft lip and palate, since they are exposed to several risk factors,
349
in addition to interdisciplinary team work importance for diagnosis and appropriate

treatment planning.
OBJECTIVE
The aim of this study was to characterize the language ability profile (oral
and written) and auditory and visual abilities of individuals with cleft lip and palate
(CLP), aged 7 to 9 years. The following variables were clinically evaluated: semantic,
syntax, phonology, and pragmatics. Auditory and visual memory, auditory and
visual association, grammar and visual closure, language reception, receptive
vocabulary, phonological processing, writing, Arithmetic, reading were also
evaluated as a complement.
METHODS
The study was approved by the Committee of Ethics in Research of the
Hospital for the Rehabilitation of Craniofacial Anomalies of the Universidad de So
Paulo (HRAC-USP).
24 individuals with CLP, aged 7 to 9 years, both male and female, patients in
the HRAC-USP, with complete unilateral cleft lip and palate, with palatoplasty
accomplished until the 18 months of age by the Furlow or Von Langenbeck surgical
technique participated: prospective study. The study was done at the Department of
Clinical Genetics at the HRAC-USP.
Parents signed a Term of Free and Illustrious Consent, answered to the
anamnesis protocol, containing gestation, birth and information on the development
of the child. The diagnosis process consisted of clinical and formal speech and
language pathology assessment and cognitive evaluation.
Clinical Speech and Language Pathology Evaluation
The evaluation included phonological, semantic, syntactic and pragmatic
language aspects from the receptive and expressive point of view.
Formal Speech and Language Pathology Evaluation
Variables assessed included: auditory and visual memory, auditory and
visual association, grammar and visual closure, language reception, receptive
vocabulary, phonological processing, writing, Arithmetic, reading by examinations
and tests (Illinois Test of Psycholinguistic Abilities - ITPA, Peabody Picture
Vocabulary Test - PPVT, Token Test, Phonological Abilities Profile - PAP, School
Performance Test SPT).
Hearing Processing and Hearing Attention Evaluation: diagnoses the
hearing functional use. The tests used were: detection of random intervals of silence
(Random gap detection test); Digits Dichotic; Non Verbal Dichotic, Sustained
Auditory Attention Ability Test (SAAAT).
Cognitive evaluation
Performed by psychologist, it aimed to discard possible associated alterations
regarding the general intelligence. It was used the Ravens Colored Progressive
Matrices.
Data were analyzed qualitatively and quantitatively with the results shown in
tables.The chi-square test or Fisher exact test (Agresti, 1990) and the Pearson
correlation coefficient (Neter et al., 1996) ) were used for inferential statistics. Results
are shown in tables and graphs. All tests used significance level of 5% (p<0,05).
350
RESULTS
According to interview, 84% of the individuals with cleft lip and palate had
ottitis episodes and 42% of these were recurrent.
In the clinical observation, ten individuals presented normality in the
expression of all the oral language aspects (components), both in the receptive and
the expressive point of view and 14 were diagnosed with language disorder.
In the formal speech and language pathology evaluation, comparing
chronological and psycholinguistic ages of the individuals obtained by the ITPA
Test, visual association, visual closure and auditory memory. Children presented
higher scores for visual memory and grammar closure.
At the PPVT 84% of the sample had results under the expected for the age
range on the receptive vocabulary. At Token Test, 54% had lowered results for oral
comprehension. As for phonologic abilities 63% evaluated by the PAP showed
normality and 38% had results under the expected for the age.
Results regarding the academic performance (SPT) showed that 50% (12
individuals) presented inferior classification, 4% (1 individual) had low to medium
classification, 25% (6 individuals) medium classification, 8% (2 individuals) superior
medium classification and 12% (3 individuals) superior classification. 58% showed
lowered performance in writing and 42% in Arithmetics and reading.
Regarding data analysis of the auditory processing and auditory attention
evaluation, 17 individuals (71%) had difficulty and 7 (29%) showed normal
standards for selective attention abilities and auditory background figure in the
dichotic test. Normal standards were classified as appropriate results for the 3 stages:
free attention, attention to the right and to the left).
At the Digit dichotic test 11 individuals (46%) showed normal Standards and
13 (54%) had difficulties when the ability of binaural integration and auditory
background figure were evaluated. At the SAAAT, 7 children (29%) showed normal
Standards and 17 71%) showed lowered results for sustained attention and auditory
vigilance. 4 children (17%) presented normal standards and 20 (83%) showed deficit
in the ability of temporal resolution at the Random gap detection test.
The cognitive capacity was inside normality in all the analyzed individuals.
Among the variables of auditory processing and the other variables of formal
evaluation, there was significant correlation (p<0,05) between the Digit Dichotic Test
and the Token (p = 0,037); The Digit Dichotic and ITPA at the hearing association
subtest (p = 0,043); the Digit dichotic and SPT (p = 0,037);the Digit Dichotic and
Writing at the SPT (p = 0,011) and between the Digit Dichotic and reading at the SPT
(p = 0,047).
Data regarding the academic performance and the other complementary
instruments of evaluation, there was significant correlation among the SPT, PPVT,
Token Test, PAP and ITPA at the Grammar closure and auditory memory subtests.
There was significant correlation between Raven and the following
instruments: PPVT, PAP, and ITPA at the hearing association, Grammar closure,
visual closure and auditory memory subtests.
CONCLUSION
Results indicate that the language ability performance was below the
expected for the age in most of the evaluated individuals with CLP. The most
damaged abilities were: written, auditory association, receptive language, visual
association, reading and Arithmetic. Auditory attention and processing abilities were
lowered in almost all the assessed individuals.
351
Based on these findings, this study suggests a language abilities evaluation in

children with complete unilateral cleft lip and palate aiming to optimize the oral
language and writing development.
352
SY05.5
PHONOLOGICAL AWARENESS INTERVENTION MAINTENANCE FOR
CHILDREN WITH CHILDHOOD APRAXIA OF SPEECH
B. C. McNeill1, G. T. Gillon1, B. Dodd2
College of Education, University of Canterbury, New Zealand
2City University London
Aim The long term benefits of phonological awareness intervention for
children with specific speech disorders requires investigation. In particular, very
little is known about the benefits of interventions to enhance reading development in
children with Childhood Apraxia of Speech (CAS). This study aimed to examine the
maintenance of phonological awareness treatment effects for 14 children with CAS
aged between 4 to 7 years across. Data from two related studies were examined.
Method: Two children with CAS aged 6;3 and 7;3 (pilot study 1) and 12 children
aged 4-7 years (study 2) participated in the study. In study 1 the children
participated in an intensive 3 week (9 hours) pilot intervention that integrated speech
and phonological awareness goals. In study 2, the children participated in 18 hours
of the intervention over 12 weeks. Phonological awareness intervention activities
focused at the phoneme level and included activities to enhance phoneme identity at
the beginning and ends of words, phoneme blending, phoneme segmentation and
phoneme manipulation skills. Speech, phonological awareness, letter-knowledge,
word decoding, and spelling were assessed 6-months (study 2) and 12-months (pilot
study 1) following completion of the intervention and compared to pre-intervention
and post-intervention scores. Results: The improvement in the participants
phonological awareness, decoding, and spelling immediately post-intervention was
maintained. Further accelerated growth, however, over the follow-up period was not
evident. Conclusions: Children with CAS require ongoing support through multiple
literacy strategies to enable continued growth in written language skills following
intensive phonological awareness intervention. They may require a longer
intervention period that actively targets the transfer of enhanced phonological
awareness knowledge to reading and spelling.
Introduction
The implementation of specific intervention strategies is essential for children
with specific phonological awareness deficits within a framework for literacy success
for all children. There is a large body of evidence demonstrating the effectiveness of
such phonological awareness interventions within withdrawal settings (see Gillon,
2004 for review). However, the long-term benefits of such interventions for children
with severe literacy deficits may be more muted (Bowyer-Crane et al., 2008; Torgesen
et al., 2001). Children with childhood apraxia of speech (CAS) present with severe
and persistent deficits across speech, phonological awareness, reading and spelling
(Gillon & Moriarty, 2007). The current study monitored the maintenance of
phonological awareness intervention gains in a pilot and treatment study at 6
months and 1 year. The importance of integrating specific intervention strategies
with other strategies in a framework for literacy success for children with specific
deficits will be emphasized.
353
CAS Literacy Risk

The poor written language outcomes of children with CAS are likely due to
the multiple risk factors for reading and spelling difficulty exhibited by those
affected. Phonological awareness, the ability to reflect on the sound structure of
words separate from their meaning, is one of the strongest predictors of early
reading success (see Gillon, 2004, for review). Children with CAS exhibit deficits in
awareness of syllables, rhymes, and phonemes within words that persist until the
adolescent years (Marion, Sussman, & Marquardt, 1993; Marquardt, Sussman, Snow,
& Jacks, 2002; McNeill, Gillon, & Dodd, 2009; Stackhouse & Snowling, 1992).
Children with CAS are at further risk for reading and spelling difficulty due to their
poor letter-sound knowledge (McNeill et al., 2009; Stackhouse & Snowling, 1992), cooccuring language deficits, and persistent speech production difficulties (Lewis,
Freebairn, Hansen, Iyengar, & Taylor, 2004; Nathan, Stackhouse, Goulandris, &
Snowling, 2004).
Phonological awareness intervention for children with CAS

Preliminary evidence supports the use of an integrated phonological
awareness approach that incorporates speech production and phonological
awareness goals, and follows evidence-based principles of phonological awareness
intervention for children with CAS. In a pilot investigation employing a controlled
multiple single-subject design, Moriarty & Gillon (2006) trialled an integrated
phonological awareness intervention on three children with CAS aged six and seven
years. The intervention produced promising results despite a short treatment period
(three 45-minute sessions per week for three weeks). Phoneme awareness gains were
demonstrated for the three children, two children generalised improved phoneme
awareness to a non-word reading task, and these two participants improved their
targeted speech production skills.
McNeill et al. (in press) evaluated the effectiveness of an integrated
phonological awareness approach in more detail on 12 children with CAS aged four
to eight years. Children with CAS participated in two six-week blocks of intervention
(two sessions per week) separated by a six-week withdrawal block. Treatment effects
were monitored for trained and untrained speech and phonological awareness
targets along with a control measure within a multiple single-subject design.
Additional phonological awareness, decoding (real and non-word), spelling, and
speech measures were conducted pre and post intervention and examined at group
level. The multiple single-subject analysis revealed that 10 children improved their
speech production skills while nine participants exhibited gains in phoneme
awareness skills.
The current study evaluated the phonological awareness, letter knowledge,
decoding, and spelling development at 6 months (intervention study) and 12 months
(pilot investigation) post-intervention.
Methodology
Study 1 (pilot investigation): Two children (Derek 1 and Katie) participated in
the follow up study. Derek was aged 8;3 at follow-up assessment and Katie was aged
7;3. Following the intervention, Derek received speech-language therapy support
once every three to four weeks during the school year administered by his local
speech-language therapist. The therapist administered her own intervention which
generally followed a traditional approach to speech production and focused on
1
Pseudonyms are used in this paper.
354
improving his receptive and expressive language skills. Katie did not receive any
further speech-language therapy support following the intervention programme. The
children were not involved in any specialist reading programmes over the follow-up
period.
Speech and phonological awareness probes used over the intervention period
were re-administered at one year post-intervention along with a standardized
phonological awareness and decoding measures, and an informal non-word reading
task.
Study 2 (intervention study): Twelve children with a confirmed diagnosis of
CAS participated in the original intervention and current follow up study. At the
study outset the children were aged 4 to 7 years, demonstrated severe speech
disorders, and the school aged children in the group showed severe reading and
spelling difficulties. Twelve children with typical development (TD) also
participated. There was no significant difference between in the age, receptive
vocabulary and socioeconomic status of the CAS and TD groups. Children in the
CAS group participated in the integrated phonological awareness programme
(Gillon & McNeill, 2007). The programme was administered in two 6-week blocks
(two 45 minute individual sessions per week) with a 6-week withdrawal period
between the two intervention blocks.
Speech and phonological awareness probes used over the intervention period
were re-administered at 6 months post-intervention along with a standardized
phonological awareness, decoding and reading comprehension measures, and an
informal non-word reading and spelling tasks.
Intervention programme: The integrated phonological awareness programme is
described in Gillon and McNeill (2007). The programme aimed to simultaneously
improve speech production, phoneme awareness and letter-sound knowledge and
follows key principles of phonological awareness intervention.
Results
Study 1
Derek continued to perform below the expected range on the decoding and
phonological awareness measures at follow-up assessment. However, his ageequivalence score for the phonological awareness measure increased by two and a
half years from pre-intervention to follow-up. Katie performed within normal limits
on the decoding and phonological awareness measures at follow-up, despite
exhibiting phonological awareness deficits at pre-intervention. Both children
continued to improve their non-word reading performance over the follow-up
period. Descriptive analysis indicates that the gains achieved in the intervention
period are more marked than that achieved over the follow-up period. Analysis of
the childrens performance on the standardizes reading comprehension measure at
follow-up revealed that both children performed within the expected range on the
accuracy measure, but below the expected range on the comprehension measure.
Study 2
Children with CAS exhibited no significant change in speech, phonological
awareness, decoding, and spelling measures at the six month follow-up assessment
when compared to performance at post intervention assessment. Results showed that
in contrast to the accelerated change made in the intervention period by the CAS
group compared to their typically developing peers continued accelerated progress
was not evident during the follow-up period.
355
Conclusion
The results indicate that children with CAS may require a longer intervention
period that actively targets the generalisation of treatment gains to other contexts to
ensure sustained development in target skills. A key component of this
generalization stage is the integration of the intervention strategy with other
strategies outlined in our framework for literacy success.
References
Bowyer-Crane, C., Snowling, M., Duff, F. J., Fieldsend, E., Carroll, J., & Miles, J. (2008).
Improving early language and literacy skills: differential effects of an oral language
versus a phonology with reading intervention. Journal of Child Psychology and
Psychiatry, 49(422-432).
Gillon, G. T. (2004). Phonological awareness: From research to practice. New York: The Guilford
Press.
Gillon, G. T., & McNeill, B. C. (2007). An integrated phonological awareness programme for
preschool
children
with
speech
disorder,
from
http://www.education.canterbury.ac.nz/people/gillon/integrated_phonological_a
wareness.shtml
Gillon, G. T., & Moriarty, B. C. (2007). Childhood apraxia of speech: Children at risk for
persistent reading and spelling disorder. Seminars in Speech and Language, 28, 48-57.
Lewis, B. A., Freebairn, A., Hansen, A. J., Iyengar, S. K., & Taylor, H. G. (2004). School-age
follow-up of children with childhood apraxia of speech. Language, Speech and Hearing
Services in Schools, 35(2), 122-140.
Marion, J., Sussman, H. M., & Marquardt, T. P. (1993). The perception and production of
rhyme in normal and developmentally apraxic children. Journal of Communication
Disorders, 35(1), 31-49.
Marquardt, T. P., Sussman, H. M., Snow, T., & Jacks, A. (2002). The integrity of the syllable in
developmental apraxia of speech. Journal of Communication Disorders, 35(1), 31-49.
McNeill, B. C., Gillon, G. T., & Dodd, B. (2009). Phonological awareness and early reading
development in children with childhood apraxia of speech. International Journal of
Language and Communication Disorders, 44, 127-144.
McNeill, B. C., Gillon, G. T., & Dodd, B. (in press). The effectiveness of an integrated
phonological awareness intervention for children with Childhood Apraxia of Speech
(CAS). Child Language Teaching and Therapy.
Moriarty, B. C., & Gillon, G. T. (2006). Phonological awarenss intervention for children with
childhood apraxia of speech. International Journal of Language & Communication
Disorders, 41, 713-734.
Nathan, L., Stackhouse, J., Goulandris, N., & Snowling, M. (2004). The development of eary
literacy skills among children with speech difficulties: A test of the "critical age
hypothesis". Journal of Speech, Language and Hearing Research, 47(2), 377-391.
Neale, M. D. (1999). Neale Analysis of Reading: Third Edition. Melbourne: ACER Press.
Stackhouse, J., & Snowling, M. (1992). Barriers to literacy development in two cases of
Developmental Verbal Dyspraxia. . Cognitive Neuropsychology, 9(4), 273-299.
Torgesen, J. K., Alexander, A. W., Wagner, R. K., Rashotte, C. A., Voeller, K. K. S., & Conway,
T. (2001). Intensive Remedial Instruction for Children with Severe Reading
Disabilities: Immediate and Long-Term Outcomes from Two Instructional
Approaches. Journal of Learning Disabilities, 34(1), 33-58,78.
356
P027
ADAPTATIVE AND COMMUNICATE PERFORMANCES AS
MEASURES OF THE EVOLUTIONAL PATTERN IN AUTISM
SPECTRUM DISORDERS
Ana Carina Tamanaha1; Marcos T Mercadante2; Mrcia RF Marteleto;3Jacy
Perissinoto4
Universidade Federal de So Paulo - Brasil
(1) Speech and Language Therapist. PhD. Colaborator Professor at Federal

University of So Paulo Brazil
(2) Psychiatrist. PhD. Adjunt Professor at Federal University of So Paulo - Brazil
(3) Psychologist. PhD. Colaborator Professor at Federal University of So Paulo - Brazil
(4) Speech and Language Therapist. PhD. Associate Professor at Federal University of
So Paulo Brazil
INTRODUCTION
Conditions that make up the Autism Spectrum Disorders are characterized by
severe chronic impediments to social interaction, communication and interests.(1,2)
Although there are numerous clinical manifestations of these disorders, we judge it
important to highlight the difficulties in both verbal and non-verbal communication,
as these have a significant impact on the social and cultural inclusion of individuals
affected by these clinical conditions.
In recent decades, language and speech intervention has been emphasized as
a method for social adaptations of communicative behavior, enabling better inclusion
of autistic children in their social environment.
With the belief that the identification of deviations in the development of
children with Autism Spectrum Disorders as well as family involvement are
fundamental steps in speech and language therapy, the aim of the present study was
to use the adaptative and communicative performances as measures of the
evolutional pattern of these children.
METHOD
Study Design
This was a clinical pilot trial, approved by the Research Ethics Committee of
the Federal University of So Paulo, under process n 1570/05. All
parents/guardians of the children signed terms of informed consent.
Sample
The sample was composed by 11 children diagnosed by a multidisciplinary
team with Autism (6) and Asperger syndrome (5) based on the criteria of the DSM-
357
IV-Tr (1) and under care at the Language and Speech Laboratory for Autism Spectrum
Disorders of the Federal University of So Paulo.
All the children were male, between four and 10 years of age, with an
intelligence quotient indicating mild to moderate degrees of mental retardation (3)
and a social quotient classified in the categories normal/mild-moderate or severeprofound impairment. (4)
Both neurological and hearing development were determined based on
normality parameters. Three children were considered non-verbal, presenting
vocalizations as the predominant means of communication at the beginning of the
study. Eight children were classified as verbal, as they produced verbal emissions
involving at least 75% of the phonemes in the Portuguese language. All the children
were regularly enrolled in public schools six in preschools and five in elementary
schools, the latter group attended special education classes.
Inclusion criteria were a multidisciplinary diagnosis of autism spectrum
disorder, enrollment in an educational institution and the adherence of at least 70%
of the parents and children to the study. The exclusion criteria were co-morbidities
involving motor, sight, hearing and/or physical impairment. The children were
randomly divided into two groups: six children in direct and indirect care (TG) and
five children in indirect care alone (OG).
The mothers had a mean age of 33 years, a mean of ten years of schooling and
pertained to socioeconomic class C [Brazilian socioeconomic classification from A
(highest) to E (lowest)]. During the 12 months of the study, the mothers in the TG
participated in 48 care sessions and received instructions as to language stimulation
in daily life situations in approximately 15 sessions, without the presence of the
children. The mothers in the OG participated in encounters held every two weeks
with the researcher and without the presence of the children, totaling 15 orientation
sessions.
Procedures
All children and their families were treated by the same speech and language
therapist to guarantee the entail and reliability in the execution of the procedures.
To measure the childrens progress as assessed through the mothers
observations, the Autism Behavior Checklist (ABC) was employed. The ABC was
proposed by Krug et al. and translated into Portuguese by Marteleto.(5,6) It contains a
list of 57 different behaviors that allows a detailed description of the non-adaptive
characteristics in the following areas: Sensory (9); Body and Object Use (12);
Language (13); Social Self Help (11); and Relating (12). It incorporates balanced
scores from 1 to 4 points that vary according to the occurrence of each behavior. A
behavioral profile is outlined from the overall score, which allows the evaluator to
analyze the severity of the pathology of each individual and keep track of his/her
development. A score of 68 is considered a high probability of childhood autism.
Scores between 67 and 54 points indicate a moderate probability and scores between
53 and 47 points indicate a low probability.
The questionnaire may be filled out by parents, teachers or clinical
professionals involved in the childs care. In the present study, the ABC was
administered to mothers in interview form by the speech therapist in charge of the
therapy process in order to minimize the possible effects of the mothers schooling.
To measure the childrens progress as assessed through the speech and
language therapists observations, the Sample of Vocal Behavior (SVB) was
employed. The SVB was proposed by Krug et al. and translated into Portuguese by
358
Tamanaha et al. (5,7) It contains three areas: Average Length; Characterization of

Speech (atypical verbalization) e Full Language (typical verbalization).
Three occasions were considered: the beginning of the intervention (T0); after
six months (T1) and at the end of 12 months (T2).
The data for assessment was analyzed by two blinded observers and
agreement between these measures was obtained using the Intraclass Correlation
Coefficient.
Statistical analysis
The data on the sample were summarized by constructing tables. In the
inferential analysis, analysis of variance (ANOVA) for repeated measurements was
employed to determine the effect of group, social quotient and time on the mean
scores. Due to the small sample size, only two social quotient categories were
established in this part of the analysis: Category 1, formed by normal/mild-moderate
impairment; and Category 2 formed by severe-profound impairment. When ANOVA
revealed significant effects, the Bonferroni criterion was used to locate the differences
between the means involved. A p-value of 0.05 was adopted for the effect of the
interaction between group and time.
RESULTS
The descriptive statistics on the overall ABC score and the score of each of its
components, obtained through the mothers observations, are displayed in the tables
below for both groups and the three assessment occasions.
Table 1 Descriptive statistics of the ABC per group on the three
assessment occasions.
Occasion
(months)
T0 (0)
Group
Mean
SD
Median
Maximum
21.62
31.9
Minimu
m
93
54
TG
OG
6
5
124.67
101.8
132
115
146
134
T1 (6)
TG
OG
6
5
95.67
94.2
23.67
30.4
60
52
104.5
104
118
132
T2 (12)
TG
OG
6
5
86.0
79.0
22.31
28.3
54
42
88.5
86
113
114
In the inferential analysis, the mean ABC score in the severe-profound

impairment scale was higher (p=0.000), regardless of the group (p=0.542) or time
(p=0.610), meaning there were no interaction effects between social quotient and
group or social quotient and time. The means of both groups showed different
behavior over time (p=0.003), indicating a group/time interaction. Using the
Bonferroni criterion, the mean value at TO for the TG was higher than that at T1
(p=0.000), which, in turn, was higher than that at T2 (p=0.049). In the OG, there was a
difference between mean values at T1 and T2 (p=0.004). There was only a difference
between the means of the two groups at T0 (p=0.000), with higher values in the TG.
359
Table 2 Descriptive statistics of the ABC areas per group on the three
Occasion Group
(months) o
N Mean SD
SE
T0 (0)
TG
OG
6
5
22,3
17,6
2,6 24,3
8,1 27,4
T1 (6)
TG
OG
6
5
16,0
15,4
T2 (12)
TG
OG
6
5
13,7
12,6
Mean SD
BOUse
Mean
LGG
SD
Mean
SSH
SD Mean SD
RE
14,7 22,5
14,8 17,0
6,4
6,4
19,8
16,8
5,0 35,2
5,3 25,0
3,4
13,7
4,9 20,3
7,6 25,2
11,9 21,5
14,0 15,4
7,0
5,1
15,2
16,6
4,7 22,7
3,8 24,0
6,6
12,9
5,6 16,5
5,6 17,2
11,2 17,8
10,8 14,0
8,8
6,0
15,3
15,6
3,3 22,7
5,2 22,0
9,6
15,7
On the Sensory and Body and Object Use components, the mean values in the
severe-profound impairment category were higher in both groups (p=0.046 and
0.005, respectively). No differences were detected between groups (p=0.431 and
0.388). The Bonferroni criterion revealed a significant difference between mean
values at T0 and T1 (p=0.010) in the Sensory component. Mean values in the Body
and Object Use component were higher for T1 than T2 (p=0.004).
In the Language component, an interaction effect was detected between time
and social quotient (p=0.014). When comparing mean values for the different
assessment occasions within each social quotient category and considering time,
there was a decrease from T1 to T2 (p=0.015) in the normal/mild-moderate
impairment category. There was a difference between the mean value in the two
social quotient categories only at T2 (p=0.015), with a higher mean in the severeprofound impairment category.
An interaction effect was only detected between time and social quotient
(p=0.035) in the Social Self Help component. In the severe-profound impairment
category, there was a significant decrease in the mean value from T0 to T1 (p=0.041).
At T0, the mean value in the normal/mild-moderate impairment category was
lower.
In the Relating component, an interaction effect was detected between group
and social quotient (p=0.006) as well as between assessment occasions (p=0.011). The
interaction effect between group and social quotient signified that the difference
between mean values in the two categories was different in the two groups. At T0,
the mean value in the normal/mild-moderate impairment category was lower
(p=0.000) and the mean value of the TG was higher in this category. At T1, a
significant difference was only detected between the mean value in the OG (p=0.019),
with a higher mean value in the severe-profound impairment category. Similar
conclusions were reached at T2 (p=0.029). The Bonferroni criterion revealed a
decrease in the mean value in the Relational component between T0 and T1
(p=0.010).
The descriptive statistics on the SBV areas obtained are displayed in the table
3.
360
Table 3 - Descriptive statistics of the SVB areas per group on the three
Occasions
(months)
T0 (0)
Group
Mean AL SD
Mean CS
SD
Mean FL SD
TG
OG
6
5
1,8
0,9
1,0
1,3
38,5
7
21,12
8,43
85
56,6
49,5
74,8
T1 (6)
TG
OG
6
5
1,9
1,0
1,1
1,3
20,5
17,6
16,68
22,5
111,3
68
49,1
74,2
T2 (12)
TG
OG
6
5
1,8
1,0
0,8
1,3
35,8
22,4
60,4
30,9
119,7
73,8
47,3
69,2
When employing ANOVA the Average Lenght and Characterization of

Speech data, there were no effects of group, time, social quotient and their
interactions. Time effect (p = 0.002) was detected in the analysis of Full Language
data results. When applying the Bonferroni criterion, in average T1 was higher
than T0 (p = 0.026) and the average in T2 was greater than in T1 (p = 0.030).
DISCUSSION
In the analysis of the total ABC scores considering the means obtained from
the reports of the mothers (Table1), there was an evolutional pattern in both groups,
with a better performance in TG (direct and indirect therapy). In the inferential
analysis, a greater extension and velocity of progress was detected in the TG, as the
mean values underwent a significant decrease over time. In the OG, a statistically
significant difference between mean values was only detected in the last semester of
the study. There was a difference in mean values between groups only at T0
(p=0.000), with a higher mean value for TG than that of the OG.
Analyzing the components of the ABC considering the means values
obtained per group on the three assessment occasions, there was, once again, a
tendency toward a better performance of the TG in the Sensory (Table 2), Language,
Social Self Help and Relating (Table 3) components. In the Body and Object Use
component, the mothers reported no significant changes in behavior among the
children (Table 2).
Although there was a tendency toward a more accentuated progress in the
TG, as analyzed by the overall ABC score and the scores on its individual
components, the evolutional pattern in both groups reveals that the mothers in the
OG and TG alike were sensitive in recognizing behavioral changes in their children.
It should be stressed that the evidence of greater extension and velocity in the
evolutional pattern observed by the mothers of the children in the TG must be the
result of the effectiveness of direct intervention associated to indirect interventions
(counseling) rather than any lack of perception on the part of the mothers in the OG
in recognizing behavioral changes in their children.(6-13)
The reports of non-adaptive behavior mentioned by the mothers and
classified as severe-profound impairment (social quotient) were generally higher.
The inferential analysis confirmed this finding, as the social quotient affected the
performance of the groups in practically all the ABC components. The importance of
obtaining adaptive function indexes has been mentioned by a number of authors in
the study of children with autism spectrum disorders. Along with an assessment of
361
intellectual level, the social quotient more accurately describes the social abilities and
disabilities of individuals.(7-14)
We also noticed that the extension and velocity of the evolutional process
were generally more evident in the first six months, especially in the TG. It is during
the first semester that the orientations and the direct intervention with the children
had the greatest impact, thereby allowing the identification of a more expressive
therapeutic gain by the mothers. Furthermore, at the end of the 12-month study, the
behavioral changes in both groups had become quite noticeable. Even when
considering the Body and Object Use component (the values of which did not
undergo significant changes in the first semester), the mothers in both groups
identified a reduction in non-adaptive behavior between T1 and T2. Thus, the ABC
proved to be a useful tool in recognizing non-adaptive behavior (15-22) as well as
efficient instrument when assessing mothers observations regarding the evolutional
process of their children.
It is important to value the indirect actions produced in the present study, as
the mothers in the OG proved themselves attentive to disabilities and the
identification of qualitative differences in their childrens performance. This likely
occurred because these mothers were awared as to observing atypical patterns as
well as establishing greater communicative harmony with their children. These
findings confirm the need to stress not only direct therapeutic action, but also
indirect actions, aiming mainly to ensure assistance to parents and broaden the social
and communication contexts of children with Autism Spectrum Disorders.
In the SVB tendency for better performance of the TG on all three times in the
Average Length area was observed. In the Characterization of Speech area, we found
that echolalia and unintelligible verbalization tended to decrease, especially in the
TG. In the Full Language area there was a statistically significant increase in both
groups.
Children with Asperger Syndrome showed greater extension and velocity in
the evolutional process in the analysis of the ABC and SVB. (12-14)
Overall in this study, children with normal-mild-moderate social quotients
and older children had better performances. (7,10,11-14,17-22)
Even though the Sample of Vocal Behavior encompasses specifically
llinguistic productions, it was possible to assess atypical communication forms using
the Speech Characterization item, and also by registering the observed advances
through analyzind the Average Length and Full Language.
The exposure of children to different situations, whether or not there was
scaffolding by na adult, allowed a careful look into the childs communicative
abilities and disabilities. (7,10-11)
It is important to observe that advances in both the extension and velocity of
the evolutional process of the children could be identified by their mothers, as well
as by the speech and language therapist. This composition of different looks
provided complementary information and a deeper undestanding of the impacts of
social deviations in the daily inter-personal relationships and a deeper refletions on
the communicative dynamics of children with Autism Spectrum Disorders in this
study.(2,8,,9,19,20,21,22)
CONCLUSION
The tendency toward better scores in the TG for both the ABC values and the
SVB values was likely due to the effectiveness of the direct intervention associated to
the indirect interventions rather than any lack of attention on the part of the parents
362
in the OG in recognizing behavioral differences in their children.It was possible for

the mothers and for the speech and language therapist to identify significant
behavioral changes in the first six months of intervention.
The tendency towards better performance of the children who attended both
direct and indirect interventions showed that this association was fundamental.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
American Psychiatric Association Manual Diagnstico e Estatstico de Transtornos

Mentais DSM IV-Tr. Porto alegre, Artes Mdicas, 2002.
American Speech-Language-Hearing Association. Guidelines for Speech- Language
Pathologists for diagnosis, assessment, and treatment of autism spectrum disorders
across the life span. acessado: www. asha.org/members
Thorndike RL; Hagen EP; Satter JM. Stanford Binet Intelligence Scale: Technical
Manual. 4 ed, Riverside Publishing Company, Chicago, 1986.
Sparrow SS; Balla DA; Cicchetti DV. Vineland Adaptative Behavior Scales. Circle
Pines: American Guidance Service, 1984.
Krug D A; Arick J R; Almond P J Autism screening instrument for
educational
planning ASIEP 2 , Pro-ed, Austin, 1993
Marteleto MRF Validade e confiabilidade da escala de comportamentos autsticos
(ABC): estudo preliminar. Tese de Mestrado. Universidade Federal de So Paulo, So
Paulo, 2003.
Tamanaha AC A eficcia da interveno teraputica nos quadros de Distrbios do
Espectro Autistico. Tese de Doutorado. Universidade Federal de So Paulo, 2008.
Koegel LK Interventions to facilitate communication in autism. Journal of Autism
Dev Disord, 2000, 30 (5): 383-391
Perissinoto, J Linguagem da criana com Autismo In Perissinoto, J (Org).
Conhecimentos essenciais para atender bem a criana com Autismo. So Jos dos
Campos, Pulso, 2003: 39-45
Fernandes FDM - Terapia de Linguagem em crianas com Transtornos do Espectro
Autstico In Ferreira LP; Befi-Lopes DM; Limongi SCO (Org). Tratado de
Fonoaudiologia, Roca, So Paulo, 2004: 941-953
Lord C Commentary: achievements and future directions for intervention research
in
communication and autism spectrum disorders. J Autism Dev Disord, 30 (5): 393-398,
2000
Aldred C; Green J E; Adams C A new social communication intervention for
children with autism: pilot randomised controlled treatment study suggesting
effectiveness. J Child Psychol Psychiatr, 45 (8): 1420-1430, 2004
Bishop DVM Autism, Aspergers Syndrome and Semantic-Pragmatic Disorders:
where are the bounderies? British Journal of Disorders of Communication. 1989, 24
(2): 279-293
Wing L Aspergers Syndrome: a clinical account. Psychological Medicine, 1981,
11:513-515
Organizao Mundial de Sade Classificao Estatstica Internacional de Doenas
e Problemas Relacionados Sade: CID 10, 10@ reviso, Edusp, So Paulo, 1998
Stone WL, Yoder PJ Predicting spoken language level in children with autism
spectrum disorders. Autism. 2001, 5 (4): 341-361
Siller M, Sigman M The behaviors of parents of children with autism predict the
subsequent development of their childrens communication. Journal of Autism Dev
Disord. 2002, 32 (2): 77-89
Bildt A, Sytema S, Kraijer D, Sparrow S, Minderaa R Adaptative functioning and
behavior problems in relation to level of education in children and adolescents with
intellectual disability. Journal Intellectual Disabilities Research. 2005, 49 (9): 672-681
363
19. Klin A; Saulnier CA; Sparrow SS; Cicchetti DV; Volkmar FR; Lord C - Social and
communication abilities and disabilities in higher functioning individuals with
autism spectrum disorders: the vineland and the ados. J Autism Dev Disord. 37 (4):
748-59,2007
19. Tamanaha, AC Interveno na linguagem da criana com Autismo In Perissinoto, J
(Org). Conhecimentos essenciais para atender bem a criana com Autismo. Pulso,
So Jos dos Campos, 2003: 55-60
20. Scheuer CI, Andarade RV Teorias cognitivas e Autismo. In Assumpo Jr, FB,
Kuczynski E - Autismo Infantil Novas tendncias e perspectivas. Atheneu, So
Paulo, 2007: 81-90
21. Drew A; Baird G; Baron Cohen S; Cox A; Slonims V; Wheelwright S; Swettenham J;
Berry B, Charman T A pilot randomised control trial of a parent training
intervention for pre-school children with autism. Eur Child Adolesc Psych, 11: 266-72,
2002
22. McConachie H; RandleV; Hammal D; Le Couteur A A controlled trial of a training
course for parents of children with suspected autism spectrum disorder. J Pediatr,
147: 335- 340, 2005
364
P142
LANGUAGE DEVELOPMENT OF PRETERM BORN CHILDREN:
MATERNAL FACTORS ASSOCIATES
J.Perissinoto1; S.M. Isotani1
1Federal University of So Paulo UNIFESP; So Paulo, Brasil
Introduction: The prematurity and the low birth weight compose a singular
situation for the child development and development of the language. Once the
process of language evolution can be influenced by the biological, psychic and social
factors condition and interaction in the human being, this suffers the influence from
child circumstantial and constitutional factors. Amongst the constitutional factors are
that conditions related to biological and psychic factors, acting in such a way as
elements of risk as of protection to the development, in the same way, the
circumstantial factors, as the familiar environment, the social chances, the schooling
level and the access to the health assistance, act on this development. The maternal
social economic and schooling level can act directly on the development of the
language, acting as protection factors, in situations of biological risk, as in the
preterm birth (Isotani, 2008).
Objective: To verify the relevance of social economic level, age and schooling
level of mother, in the development of the language of preterm born children in the
aspects of emission and reception.
Method: Were considered 31 protocols of preterm born children with birth
weight below 2000g, and chronological age between 6 and 36 months, taken care of
in the Premature Children Multidisciplinary Follow-up Program at Federal
University of So Paulo - UNIFESP. For the language evaluation was used PLS-3
Preschool language scale 3 (Zimmerman, Steiner and Ponds, 1992), translated and
adapted for the Portuguese for research (Perissinoto and Farias, 2002). The PLS-3 has
as objective to evaluate the abilities of Language, considering the aspects of reception
and emission, of children from 2 weeks to 6 years of age. The subtests are organized
in: Auditory comprehension (CA) and Expressive communication (CE) and three
optional suplemental measures: speech, checklist for sample of Language and form
of information and suggestions for the family. For this study subtests CA and CE and
the total test had been considered. The information to the birth conditions: weight
and gestacional age, and to the variable: social economic level (NSE) and age and
schooling level of mother, had been removed of the children handbook. The results
gotten for the children had been analyzed by two evaluations in distinct ages, in such
a way, considered the results of a first evaluation in comparison to the second,
carried through by means of the PLS-3 in expression (CA) and comprehension (CE)
and in the total test. After that was analyzed the relevance of the variable: social
economic level, schooling level and age of mother, in relation to the results gotten in
the evaluation of the language by the PLS-3, in the total test and the two subtest. For
the statistical analysis of the results was made calculations of descriptive measures,
have tested student t test for paired samples, non parametic Wilcoxon test and
linear regression analysis.
Commented results: It was not verified statistical significant difference in the
performance of language in the PLS-3, between the first one and the second
365
evaluation, in the total test (p=0,556) and in subtests CA (p=0,974) and CE (p=0,351).
However, a significant addition of the punctuation was evidenced in such a way
enters the two moments of evaluation in the total test (p< 0,001*) as in subtests CA
(p< 0,001*) and CE (p< 0.001). Such result indicates that the children had evolved in
elapsing of the time, having acquired abilities of bigger complexity, pointing with
respect to a positive correlation between age and gotten punctuation, directly
proportional, agreeing to the study of Belcher et al. (1997). Vieira (1985/1989),
considers the language development can be followed by the comment of behaviors
that throughout the time are modified reaching more complexity, characterizing
stages of the development. When analyzed the performance in relation to the interest
variables, the schooling of mother was verified that it was excellent factor, in the
analysis of linear regression (p=0,010*), being that bigger, better the performance of
the child in the total test, indicating this variable as protective factor (Rutter, 1985) of
the development of preterm children. The mother schooling level of preterm child,
added to the assistance received for this in differentiated service, created in intention
of its accompaniment, must act of form to propitiate conditions favorable to its
development as described for Fawer at al. (1995); Chermont et al. (2005), that point to
child environment factors as those determinative ones to development, also to the
Language. Linhares et al. (2006) had standed out the importance to prepare the
families of preterm born babies and low weight to value and to stimulate the
confrontation characteristics gifts in these children, so that they can act as factor of
protection for the development.
Conclusion: The mother schooling level is excellent factor in the development
of the language of preterm weighting below of 2000g born children.
Bibliographical references
Belcher HME, Gittlesohn A, Capute AJ, Allen MC. Using the Clinical Linguistic and Auditory
Milestone Scale for developmental screening in high-risk preterm infants. Clin
Pediatr. 1997; 36: 635-642.
Chermont AG, Cunha MS, Sales LMM, Moraes AN, Malveira SS. Avaliao do
desenvolvimento pela escala Denver II, de recm-nascidos prematuros de baixo peso.
Rev para md. 2005; 19(2):59-66.
Fawer CL, Besnier S, Forcada M, Buclin T, Calame A. Influence of perinatal, developmental
an environmental factors on cognitive abilities of preterm children without major
impairment at 5 years. Early Hum Dev. 1995; 43: 151-164.
Isotani SM. Desenvolvimento da linguagem de crianas nascidas pr-termo com peso abaixo
de 2000gna primeira infncia [tese doutorado]. So Paulo: Universidade Federal de
So Paulo; 2008.
Linhares BM, Carvalho AEV, Correia LL, Gaspardo CM, Padovani FHP. Psicologia peditrica
e neonatologia de alto risco: promoo precoce do desenvolvimento de bebs
prematuros. In: Crepaldi MA, Linhares MB, Pedrosa GB (org). Temas em psicologia
peditrica. So Paulo: Casa do Psiclogo; 2006.
Rutter M. Resilience in the face of adversity. British Journal Psychology. 1985;147: 598-611.
Vieira RM. A mente humana: uma aproximao filosfica no seu conhecimento [tese
doutorado]. So Paulo: Escola Paulista de Medicina Universidade Federal de So
Paulo; 1985.
Vieira RM. O corpo humano: uma interpretao fenomenolgica de sua significao
existencial [tese doutorado]. So Paulo: Escola Paulista de Medicina Universidade
Federal de So Paulo; 1989.
Zimmerman IL, Steiner VG, Pond RE. Preschool Language Scale 3: Examiners manual. San
Antonio: The Psychological Corporation; 1992.
366
FP27.5
THE ROLE OF MORPHO-PHONOLOGICAL SALIENCE IN TENSE
MARKING IN GREEK AND CYPRIOT SLI CHILDREN
Maria Mastropavlou1, Kakia Petinou2, Ianthi Maria Tsimpli3
1University of Ioannina, 2 European University of Cyprus, 3 Aristotle University of
Thessaloniki
Introduction and aims:

The aim of this study is based on the hypothesis that mopho-phonological
salience on [past] tense marking plays an important role in the development of the
tense system in typical and SLI monolingual grammars. Based on previous empirical
evidence (Mastropavlou 2006), we maintain that Greek SLI children appear to
perform better on past tense marking compared to English (e.g. Rice and Wexler,
1996), German (Clahsen and Dalalakis, 1999), French (Jakubowicz, 2003) SLI children
due to the combination of morphological (verb ending) and phonological (stress-shift
/ augment) changes associated with this tense feature in Greek. In particular, SLI
children were shown to perform better on the past tense production of bisyllabic real
and pseudo-verbs than in trisyllabic ones: the former require a syllabic augment to
carry the shifted stress to the antepenultimate syllable, while the latter require stressshift alone.
In Standard Greek (SG) and in Cypriot Greek (CYG), the use of the stressed
augment is obligatory with bisyllabic verbs. In trisyllabic (and other polysyllabic)
verbs, however in CYG, the unstressed augment is also pronounced, contrary to
SGreek, where no augment is required in these cases:
(1)
GR:
CY:
PRESENT
IMPERFECT
fevgho (=leave) fevgha
dhiavzo (=read)
dhivaza
fevgho
fevgha
thkiavazo
ethkivaza
Furthermore, 2nd conjugation verbs (contractible verbs of type A, ending in ao e.g.

klots-klots) in SG and CG differ:
(2)
GR:
CY:
klotso (=kick)
klots
klotssa / kltsaga
eklotssa / ekltsun
Based on the above, the aim of this study is to investigate the effect of
morphophonological salience of tense marking on the performance of SG and CYG
children with SLI. Specifically, the effect of salience on SLI performance is
investigated in the SG and CYG language varieties, aiming to determine the extent to
which children are affected by language-specific features relevant to the
morphophonological realisation of grammatical features that are claimed to be
inaccessible to them under the Interpretability Hypothesis. It is therefore
hypothesised that children with SLI will be affected by salience variations to a
greater extent than typically developing children. Furthermore, if children with SLI
compensate for grammatical deficits through phonology, the performance of CYG
367
should be worse than that of their SG peers given the increased salience of past
formation in SG compared to CYG. We further hypothesize than on object clitic
realization tasks performance of CYG children would be superior to that of SG
control as in the former the permission of post verbal cltics creates a favourable
phonological template on which children can base their productions.
Methodology
Participants
The participants were two groups of children with SLI (8 Greek (GR/SLI) and
8 Cypriot Greek (CYG/SLI)) between the ages of 5;0-6;0 years (GR M=5;7; CYG M=
5;6 ). The two SLI groups were matched to comparable controls with typical course of
language development (TD). Both groups were matched for chronological age, SES
status, and non-verbal cognitive skills as measured with Ravens Color Progressive
Matrices ( RCPM).
Procedures
Language assessment
Assessment of verbal language skills was completed with the use of
Diagnostic Verbal Intelligence Quotient (DVIQ) (Stavrakaki & Tsimpli, 1999) with
necessary adaptations for CYG. The test battery included testing items such as
expressive vocabulary, morphological and syntactic expression, meta-linguistic
knowledge, grammatical comprehension and sentence recalling. Phonological
working memory problems were ruled out with the use of Phonological Working
memory Tasks (PWMT).
Experimental tasks & Stimuli
Children engaged in sentence completion tasks. Stimulus sentences referred
to picture pairs, aiming to elicit past imperfective forms in real verbs (RV) and in
pseudo-verb (PVs). Stimuli included 60 test verb items (30 real and 30 pseudo verbs)
of the following categories: +SS, +A (vafa),+SS, -A ((e)jvaza) and +/-SS, (+)A
Contractible (kltsaa/(e)klotssa)
RV task : To koritsi trxi. Xes oli mera to koritsi...? Target response: tree
The girl is running. Yesterday all day the girl? (=was running)
PV task:
To koritsi flzi. Xes oli mera to koritsi? Target response: flize

The girl is flz-ing. Yesterday all day the girl?.)
Data Reduction
Responses were transcribed in IPA and were coded according to the
following categories: (a) T: Target responses, (b) NT: Non-target responses, (c)
NT[Perf]: Use of perfective instead of imperfective, (d) NT[Pres]: Use of present
instead of past, (e) NT[+aug,pr]: Use of the present form with an augment, e.g. ezirni
instead of (e)zrene, (f).NT[other]: Other kinds of errors and (g) NA: No response.
Results
A 2x2x2x2 analysis was performed on the results, aiming at the investigation
of three main variables: augment effect (+A vs. A), verb category (contractible vs. non
contractible), and group (SLI vs. TD groups). Finally, the main effects found were also
tested across dialects (SG vs. CYG). Statistical analyses of main effects and
interactions were performed through two-way mixed ANOVAs, while post hoc
368
analyses were performed where necessary for between-groups (Tukey HSD) and
within-groups effects (paired-samples t tests).
Discussion
Regardless of language group and language category, more errors were noted
in the pseudo-verb category in favour of the phonologically less salient stimuli (e.g.,
no augment and/or no stress shift). Detailed analysis of the supported the positive
impact of phonological saliency in the realization of grammatical targets as a
compensatory mechanism to grammatical representations. That is, children with SLI
benefited more by the presence of phonological cues that made up grammatical
paradigms.
GR/ SLI groups performance was significantly affected by all variables
tested, i.e. the presence of the augment, the status of the verb (real or pseudo-) and
the conjugation (+/-contractible such as klotsao-klotso). In contrast, the GR/TD
children were not affected by the presence of the augment; they were affected by
verb status (better performance on real verbs) and by conjugation. According to the
between-group comparisons, the SLI and the controls differed in their performance
on pseudo-verbs but not on real verbs.
CYG/SLI children performed significantly worse than their TD counterparts
with more errors specific to the contracted verb condition on pseudo-verb task. The
same tendency was found in real verbs as well, although the difference did not reach
statistical significance.
Turning to the comparison between SG and CYG the differences were
significant only between the SLI groups. They differed in the performance on real
verbs (GR/SLI >CY/SLI) but not on pseudo-verbs, despite the tendency of CYG/SLI
to make less errors on optional augment targets. In particular, GR/SLI children
perform better on real verbs in both [+/-augment] conditions as well as in the
contractible verb conjugation. Isomorphic and isometric performances were noted
between GR/TD and CYG/TDI. The results suggested that the presence of the
optional augment cues did not assist the CYG/SLI group in marking target
morphological paradigms contrast. In addition, all CYG subjects showed higher
performance on target realization of clitics as compared to their SG counterparts as
predicted a-priori.
We argue that these results better our understanding of the effects of
morphophonological properties as compensation strategies implemented by SLI
grammars to overcome deficiencies in tense marking. In particular, it is suggested
that the generalized use of the (unstressed) augment in CYG is more salient than the
obligatory use of the stressed augment in Greek in which the augment rule is more
robust/categorical than in CYG. In other words, whereas in SG the presence of the
augment is an unambiguous cue of the verbs phonological properties (bisyllabic,
augment always stressed) in CYG the augment marks [past] independently of other
phonological properties. This triggered an increased number of overgeneralizations
of the syllabic augment in present forms of pseudo verbs by the CYG/SLI children
(e.g. stragin turned to estragin instead of estraginse or estagina while fewer
overgeneralizations were evident in the SG data, which mainly involved altering the
stem of the pseudo verb (e.g. lamzi turned to lame instead of lmze). These patterns
strengthen the argument that the morpho-phonological salience of tense marking in
SG and CYG provide strong cues aiding acquisition by SLI children. Furthermore,
the co-occurrence of different morpho-phonological properties (+/-stressed
369
augment, stress-shift, suffix) and their interdependence seems to gives rise to further
differences between the two dialects.
Bibliography
Chomsky, N. (1995). The Minimalist Program. Cambridge: MIT Press.
Clahsen, H., & Dalalakis, J. (1999). Tense and Agreement in Greek SLI: A Case Study. Essex
Research Reports in Linguistics , 24, 1-25.
Leonard, L. B. (1998). Children with Specific Language Impairment. MIT Press.
Mastropavlou, M. (in press). Morphophonological salience as a compensatory means for
deficits in the acquisition of past tense in SLI. Journal of Communication Disorders ,
Accepted manuscript, available online at http://dx.doi.org/10.1016/j.jcomdis.2009.12.005.
Rice, M. L., & Wexler, K. (1996). Toward tense as a clinical marker of specific language
impairment in English-speaking children. Journal of Speech and Hearing Research , 39,
1239-1257.
Stavrakaki, S. (1996). Specific Language Impairment in Greek: Evaluation of person and
number agreement, case assignment to overt subject pronouns and tense marking. MA
Thesis, University of Essex .
Tsimpli, I. M. (2001). LF-Interpretability and language development: A study of verbal and
nominal features in Greek normally developing and SLI children. Brain and Language ,
77, 432-448.
Tsimpli, I. M., & Stavrakaki, S. (1999). The effects of a morphosyntactic deficit in the
determinern system: the case of a Greek SLI child. Lingua , 108, 31-85.
van der Lely, H. K., & Ullman, M. T. (2001). Past tense morphology in specifically language
impaired and normally developing children. Language and Cognitive Processes , 16 (2/3),
177-217.
370
FP17.6
EFFECTIVENESS OF AUDITORY PROGRAM IN BRAZILIAN
STUDENTS WIT LEARNING DISABILITIES
Fbio Henrique Pinheiro, UNESP
Simone Aparecida Capellini, UNESP
Introduction
Learning disability is a condition recognized by mental health and medical
professionals as a neurobiological disorder of cognitive processing and / or language
caused by atypical brain functioning as a result of its dysfunction (Silver et al, 2008).
Students with learning disability diagnosis present altered characteristics in
skills such as word identification or decoding, reading comprehension, calculus,
mathematical reasoning, spelling and written expression, and may also have
problems in academic areas which involve, in a wider way, oral expression and
comprehension (Wu, Huang & Meng, 2008).
Academic difficulties of students with learning disabilities may be related,
among other symptoms, to a disorder of auditory processing, which suggests a
change in the mechanisms and processes used by the auditory nervous system
(Koslowski et al, 2004).
A study of Margall (2002) investigated the relationship between auditory
processing disorder and difficulties in reading and writing showed that around 80%
of children with complaints related to reading and writing have auditory processing
disorder and 100% of children with graphemic changes related to sound have
auditory processing disorder.
Therefore, the association between school difficulties and disorders in the
development of auditory skills has become the focus of works (Sauer et al, 2006) and,
more recently, some studies have focused on the work with auditory training
programs in students with learning disabilities (Tremblay et al, 2009; Pinheiro &
Capellini, 2009). These studies have indicated the efficacy of such programs;
however, there are few researches which focus on international literature.
Aim
This study aimed verifying the efficacy of an auditory training program in
Brazilian students with learning disabilities and comparing the findings of the
procedures used in pre and post-testing in Brazilian students with learning
disabilities and without learning difficulties, submitted and not submitted to the
auditory training program.
Method
The participants of the study were 40 Brazilian students aged between 8 and
14 years old, from both genders, attending from 2nd to 4th grade of municipal schools
in Marlia SP. These students were divided into two groups:
Group I (GI): 20 Brazilian students with diagnosis of learning disability, from
both genders, who were subdivided into:
Group Ie (GIe): 10 students with interdisciplinary diagnosis of learning
disabilities who were submitted to the auditory program;
371
Group Ic (GIc): 10 students with interdisciplinary diagnosis of learning

disabilities who were not submitted to the auditory training program.
Group II (GII): 20 students without difficulties, from both genders, paired
according to gender and school level to GI and subdivided into:
Group IIe (GIIe): 10 students without learning difficulties submitted to the
auditory training program;
Group IIc (GIIc): 10 students without learning difficulties who were not
submitted to the auditory training program.
The control group was formed by Brazilian students without learning
difficulties, who were indicated by the teachers from 2nd to 4th grades based on
satisfactory performance in exams in two consecutive semesters. Furthermore, these
students did not present a history of auditory, cognitive, motor or visual deficiency
in the school records.
The procedure used for the evaluation during pre and post-testing was a
basic audiological exam and the evaluation of auditory processing, composed of
verbal dichotic tests, being used the dichotic test of digits and alternate disyllables
and the test of phonological awareness sequential evaluation instrument (Confias)
developed by Moojen et al (2003),
The groups GIe and GIIe were submitted to the auditory training by the use
of the Audio Training Software developed by Nunes & Frota (2006).
The activities of the program were done individually in 18 sessions of 50
minutes each. The frequency of the students submitted to the training program was
twice a week. The activities of the training were worked in the following order of
skills: identification of the duration pattern of sounds, identification of the frequency
pattern of sounds, evocation of non-verbal sounds in sequence (memory for nonverbal sounds), discrimination and evocation of verbal sounds and auditory
attention.
The results were statistically analyzed by the program SPSS (Statistical
Package for Social Sciences), version 13.0. The Mann-Whitney Test and the Wilcoxon
signed-rank test were also used. A level of significance of 5% (0,050) was adopted for
the application of the statistical tests (*).
Results
The results revealed improvement in the performance of the students who
were submitted to the training program when compared (GIe and GIIe) in pre and
post-testing in the dichotic digits test and alternated disyllables, suggesting
performance improvement in the ability to group components of the acoustic signal
in the background and to identify them.
There was no significant difference to the performance of students from GII
and GI in the Speech with noise test.
In the syllabic subtests of CONFIAS statistically significant difference
occurred in GIe in relation to GIc in the subtests of rhyme production and syllable
transposition, revealing a superior performance of GIe. When the total scores of the
subtests were analyzed, it was verified that the groups GIe and GIIe presented
averages of performance which were superior in relation to GIc and GIIc after the
application of the auditory training program.
Regarding the performance in the phonemic subtests of the test of
phonological awareness sequential evaluation instrument (Confias), a statistically
significant difference was verified in the results of GIe in relation to GIc in the
372
subtests of phonemic synthesis, phonemic transposition and total score in the

subtests of phonemic skills.
When comparing the performances of groups GIIe and GIIc, a statistically
significant difference was verified in the subtests of identification of final phoneme,
phonemic segmentation and phonemic transposition, suggesting better performance
of GIIe. The total score in the subtest of phonemic skills presented by GIIe and GIe
after the auditory training revealed statistically significant difference in post-testing,
indicating better performance of the groups submitted to the auditory training
program.
In relation to the time average for the execution of the tasks, it was verified
that group GII performed the activities in a time average inferior to GI, ratifying,
thus, the better performance of GII in the tests.
Discussion
The findings of this study revealed that the students with diagnosis of
learning disability presented a delay in the development of auditory skills, what may
hinder the appropriate processing of information and, in consequence, affect normal
development of language and writing (Nunes, 2006; Pinheiro & Capellini 2009).
According to international literature (Wu, Huang & Meng, 2008; Silver et al,
2008), the average performance in auditory processing tests of students with learning
disabilities is inferior to the one of normal students. This fact may be verified in the
findings of this study when the performance of the groups with and without learning
disabilities was compared, showing a prevalence of superior performance of the
students without difficulties.
The analysis of the auditory test results of the students from GI suggests
inefficacy in the integration of auditory information, made evident in the
performances of these groups in the Dichotic Digits and Alternate Disyllables Tests.
The performance of the group with learning disabilities was lower in all tests of
auditory processing as compared to those of students without difficulties. However,
in the post-testing, the averages of performance in the auditory processing tests of
the students with learning disabilities improved in relation to the pre-testing. Studies
have brought similar data about the efficacy of the use of auditory training programs
and its effects on the tests of auditory processing evaluation (Tremblay et al, 2009;
Pinheiro, Nunes & Capellini, 2009).
The performance of the students in the phonological awareness tasks showed
that the performances of the students from all groups were superior in the syllabic
tasks in what concerns the phonemic tasks, what is in accordance to the findings in
the literature (Moojen et al, 2003).
When the average of the total of the performances in the syllabic subtests was
compared, it was verified that the experimental groups presented superior
performances in relation to their respective control groups, indicating improvement
in the average of performance for the groups submitted to the auditory training
program, and the same was found in the performances of phonemic skills. This
suggests an improvement in the levels of auditory attention, perception of speech
sounds and word recognition.
Based on the results of this study, we verified the effectiveness of an auditory
training program offered and the best performance in the auditory processing of
students without learning difficulties, compared in pre-and post-testing.
373
References
Kozlowisk, L.; Wiemws, G. M. R.; Magni, C. & Silva, A. L. G. (2004). A efetividade do
treinamento auditivo na desordem do processamento auditivo central: estudo de
caso, Revista Brasileira de Otorrinolaringologia, 70 (3), maio/junho, pp. 427-432.
Margall, S.A.C. (2002). A funo auditiva na terapia dos distrbios de leitura e escrita. In..
Moojen, S.; Lampracht, R.; Santos, R.M.; Freitas, G.M.; Brodacz, R.; Siqueira, M.; Costa, A.C. &
Guarda, E. (2003).Conscincia fonolgica: Instrumento de avaliao seqencial. So Paulo,
Casa do Psiclogo.
Nunes, C. (2006). udio Training: fundamentao terica e prtica / Cristiane Nunes, Silvana Frota.
So Paulo, AM3 Artes.
Pinheiro, F. H.; Capellini, S. A. Desenvolvimento das habilidades auditivas de escolares com
distrbio de aprendizagem, antes e aps treinamento auditivo, e suas implicaes
educacionais. Revista Psicopedagogia, v.26, n.80, p.231-241, 2009.
Pinheiro, F.H; Nunes, C.L. ; Capellini, S.A. . Eficcia do programa de treinamento auditivo em
escolares com distrbio de aprendizagem. Cadernos de Comunicao e Linguagem,
v. 1, p. 85-100, 2009.
Sauer, L.; Pereira, L.D.; Ciasca, S.M.; Pestun, M. & Guerreiro, M. M. (2006). Processamento
auditivo e SPECT e crianas com dislexia, Arquivos de. Neuropsiquatria, 64 (1), pp.108111.
Silver, C.H.; Ruff, R.M.; Iveson, G.L.; Barth, J.T.; Broshek, D.K.; Bush, S.S.; Koffer, S.P. &
Reynolds, C.R. (2008). Learning disabilities: The need for neuropsycological
evaluation, Archives of Clinical Neuropsychology, 23, pp. 217-219.
TREMBLAY, K. L; SHAHIN, A. J.; PICTON, T.; BERNHARD, R. C. Auditory training
alters the physiological detection of stimulus-specific cues in humans. Clinical
Neurophysiology, v.120, p. 128-135, 2009.
Wu, T.K.; Huang, S.C. & Meng, Y.R. (2008). Evaluation of ANN and SVM classifiers as
predictors to the diagnosis of studentes with learning disabilities, Expert Systems with
Appplications, (34), pp. 846-856.
374
FP27.4
INFANTS' LISTENING BIAS TO THE COMMON STRESS-PATTERN IN
HEBREW:
AN EVIDENCE FOR LANGUAGE SPECIFIC INFLUENCE
Osnat Segal & Liat Kishon-Rabin
Department of Communication Disorders, Sackler Faculty of Medicine,
Tel-Aviv- University
Infants are faced with the developmental task of segmenting fluent speech
into words in order to build a vocabulary. For this purpose infants utilize sub lexical
acoustic-phonetic cues (Jusczyk, Hohne & Bauman, 1999; Mattys & Jusczyk, 2001;
Johnson & Jusczyk, 2001). One main cue for word segmentation in infants is the
stress pattern of the word (Juszyk, Houston & Newsome, 1999). There is an ongoing
debate, however, whether infants develop segmentation procedures based on stress
through distributional learning of the regularities of stress patterns in their language
or whether they are tuned to the strong-weak stress pattern universally (Allen &
Hawkins, 1978; Echols & Newport, 1992; Echols).
During the second half of their first year of life (but not before), English and
German-learning infants become attuned to the predominant strong-weak (e.g.,
/dddy/) stress-pattern in their language. This bias for the strong-weak pattern is
demonstrated by longer listening time to lists of strong-weak words as compared
with lists of weak-strong words (Jusczyk, Cutler & Redanz, 1993; Hhle, BijeljacBabic, Herold, Weissenborn & Nazzi, 2009). Two main hypotheses have been
suggested to explain the preference to the strong-weak stress-pattern (Hhle et al,
2009; Jusczyk et al, 1993; Turk, Jusczyk & Gerken, 1995). The first hypothesis is
language-specific, suggesting that infants identify the frequent stress-patterns of
their native language and consequently demonstrate attention bias for the common
stress-pattern (e.g., Hhle et al, 2009; Jusczyk et al, 1993). According to this
hypothesis it is predicted that infants in trochaic languages will show listening
preference to the strong-weak stress-pattern whereas infants in iambic languages will
show listening preference to weak-strong stress-patterns. The second hypothesis is
auditory-universal. According to this hypothesis the bias for the strong-weak stresspattern is based on acoustic cues. It is assumed that the first stressed syllable in the
strong-weak stress pattern is associated with increased pitch and amplitude, whereas
the final weak syllable is associated with a possible final lengthening. These acoustic
cues may draw infants' attention to the strong-weak template in favor of the weakstrong one universally (Echols & Newport, 1992; Echols et al, 1997; van Heuven &
Menert, 1996). According to this hypothesis one may predict that infants in both
trochaic and iambic languages will show preference to the strong-weak stresspattern.
To-date, evidence on stress-pattern preference comes primarily from trochaic
languages (mainly English and German). The language-specific and the auditory
universal hypothesis cannot be separated in trochaic languages such as English, in
which the common stress-pattern (strong-weak) is also the salient one. These
hypotheses can be tested, however, in an iambic language with a common weakstrong stress-pattern, such as Modern Israeli Hebrew (Segal, Nir-Sagiv, Kishon-
375
Rabin, Ravid, 2009). Data IN Hebrew will help to understand how infants develop
segmentation procedures based on stress in languages differing in their prosodic
characteristics. It will also provide insight to the theoretical question concerning the
role of language specific experience versus auditory universal tendencies in the
evolvement of initial pre-lexical segmentation procedures in infants.
The aim of the present study was, thus, to assess listening preference to weakstrong versus strong-weak stress pattern in Hebrew-learning infants.
Materials and Methods

Participants:
A total of Fifty-four infants initiated this study. Of these, 24 infants (44%)
were excluded from the study for the following reasons: crying (2) restlessness (18)
coding mistakes (2) program running mistakes (2). Thus, the data reported here are
on the remaining 30 infants (14 males and 16 females). Their ranged from 8 months
and 15 days to 10 months (M=8.93 months and 11.5 days, SD=0.3 months and 10
days). All infants came from monolingual Hebrew-speaking environment, and
Hebrew was the only language that was spoken by their primary caregivers. In order
to establish normal development, infants parents filled a questionnaire with detailed
medical-developmental information as well as auditory behavior and speech
production questionnaires (The ITMAIS: Infant Toddler Meaningful Auditory
Integration Scale, and the PRISE: Production Infant Scale Evaluation, Robbins et al.,
2004; Kishon-Rabin et al., 2005, respectively). Inclusion criteria included: full-term at
birth with an APGAR (Activity, Pulse, Grimace, Appearance, Respiration) score of 910, normal development as reported by well-care baby clinics, ITMAIS and PRISE
score within 2 SE of normal auditory and production functioning (KishonRabin et
al., 2005). All infants passed a hearing screening test at well-baby care clinics, had no
more than two ear infections during the last 6 months, and their parents reported no
upper respiratory infections (including ear infection) at testing day. Infants were
from upper-middle class homes. All parents had 12 years of education or more.
Stimuli
The stimuli consisted of 16 prerecorded lists of words in Hebrew. Each list
included 12 bi-syllable words with a total duration time of approximately 17 ms. In
half of the lists, the words followed a strong-weak stress-pattern, and in the other
half, the words followed a weak-strong stress-pattern. The strong-weak and weakstrong words were matched in their phonetic structure as closely as possible. All
Hebrew words were meaningful but not familiar to infants (according to corpuses of
child directed speech in Hebrew) in order not to influence their preference by word
familiarity.
The stimuli were produced by a female Hebrew-native speaker. A total of 192
Hebrew words were recorded. Stimuli were digitally recorded in a sound proof
room via a JVC MV 40 microphone using the Sound -Forge software (version 4.5 a),
at a sampling rate of 48,000 Hz and 16 bits quantization level. In order to prevent
intensity differences between words, word amplitudes were normalized.
Acoustic measurements were taken for each word and syllable. The acoustic
measurement included duration, and maximum peak for pitch and amplitude of
vowels at stressed and unstressed syllables as shown in Appendix 1. For Hebrew
words, stressed syllables had longer duration (M=117.18, SD=29.15; M=115.93,
SD=24.35 sec for the strong-weak and weak-strong words, respectively) than
unstressed, weak, syllables (M=87.39, SD=25.09; M=60, SD=13.68 sec for the strong-
376
weak and weak-strong words, respectively). Two t-test for paired samples confirmed
that the stressed syllables were longer [(t(95)=10.38, p<0.01; t(95)=21.4, p<0.01), for
strong-weak and weak-strong words, respectively]. Additionally, stressed syllables
had higher amplitude (M=81.321, SD=1.98; M=81.27, SD=1.77 amplitude (in relative
units), for the strong-weak and weak-strong words, respectively) than unstressed
syllables (M=75.9, SD=2.14; M=78.97, SD=2.55 amplitude (in relative units) for the
strong-weak and weak-strong words, respectively). Two t-test for paired samples
confirmed that amplitude was higher in stressed syllables [(t(95)=24.5, p<0.01;
t(95)=8.32, p<0.01), for strong weak and weak-strong words, respectively]. Stressed
syllables had also higher pitch (M=213.65, SD=10.9; M=207.09, SD=12.34 Hz for the
strong-weak and weak-strong words, respectively) than unstressed, weak, syllables
(M=172.11, SD=15.96; M=196.18, SD=18.14 Hz for the strong-weak and weak-strong
words, respectively). Two t-test for paired samples confirmed that pitch was higher
in stressed syllables [t(95)=22.42, p<0.01; t(95)=4.83, p<0.01, for strong weak and
weak-strong words, respectively].
Procedure
The Head turn Preference procedure (HPP) was used to test preference of one
stress-pattern over the other (e.g., Jusczyk, Cutler & Rendaz, 1993). The infant was
seated on the caregivers lap in front of the monitor. The experimenter was seated
outside the booth in the control room. Both the caregiver and experimenter were
listening to masking music over headphones and therefore blind to the nature of
stimulus on a particular trial. All trials began by drawing infants attention to the TV
monitor by using an attention getter (e.g., a small dynamic video display of a
laughing babys face). Once infants' attention was at midline, the attention getter
disappeared and a flashing red light above one of the two loudspeakers started to
blink. When the infant turned his head at least 30 degrees in the direction of the
loudspeaker, the auditory stimuli was introduced and continued until its completion
or until the infant failed to maintain the 30 degrees head turn or was not looking for
2 sec. Listening time was measured as looking time towards the loudspeaker. The
experimenter in the control room observed the infant's responses. When the infant
changed his head-turn to less than 30 degree, the experimenter pushed a special
panel on the computer. A designated software written for this experiment in our lab
calculated gazing times for each infant and stimulus and controlled the order of
presentations. The two type of stimuli (e.g., strong-weak and weak-strong words)
were heard by each infants from both sides of the booth alternately. Order of stimuli
and order of locations were independent from infant's behavior. All infants
responses were also videotaped for later validation of the experiments coding
during the test using the Supercoder software. Stimuli were presented to the infants
via loudspeakers at a comfortable level of 65 dBSPL.
Results
The results of 30 infants were scored. The looking time for each trial was
measured on line and off line. The off line measures were conducted independently
by two graduate students in Speech and Language Pathology. Both are experienced
coders who were unaware of trial type. They judged infants looking times on the
basis of frame-by-frame observation using the digitized video record software
Supercoder (frame rate = 1/30 s). Agreement between the mean on line results and
the two coders' judges for each infant for strong-weak and weak-strong trials were
tested using the Cronbach Coefficient Alpha. High agreement was found between
377
the three judgments as for the strong-weak (0.98) and the weak-strong (0.99) trials.
Thus, we used the mean of these three judgments for further statistical analysis.
The mean and individual preference results for each infant are summarized
in figures 1 2 and 3. Overall, the total of 30 infants showed significant mean
preference towards the WS words (M= 5.57, SD=2.07 sec) in comparison to the SW
words (M=4.22, SD=1.39 sec) [t(29)=5.32, p<0.001], as shown in figure 1.
7
SW Words
WS Words
SW Words
WS Words
Looking
time
in sec
Looking
time
in sec
5
5
4
4
3
3
00
TypeType
of words
of words
Figure 1: Mean listening preference to strong weak and weak-strong

Hebrew words.
Twenty-four infants (80%) showed preference to the WS words (M= 6.16,
SD=1.9 sec) in comparison to SW words (M= 4.37, SD= 1.44), as shown in
Figure 2. Only six infants (20%) showed preference for the SW (M= 3.60,
SD=1.05 sec) words in comparison to the WS words (M=3.05 SD=1.01 sec) as
shown in figure 3.
10
SW Words
WS Words
Looking time in sec
8
7
6
5
4
3
2
1
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Infants
378
Figure 2: Individual listening preference to weak-strong Hebrew words

compared to strong-weak words in 24 (80%) of the infants.
10
SW Words
WS Words
Looking time in sec
8
7
6
5
4
3
2
1
0
1
Infants
Figure 3: Individual listening preference to strong-weak Hebrew words

compared to weak strong words in 6 (20%) of the infants.
In sum, the present results indicate that most 9-month-old Hebrew-learning
infants showed
preference to the lists of words following the common
weak-strong pattern in Hebrew.
Discussion
The results of the present study show that 9-month-old Hebrew-learning
infants prefer the common weak-strong stress pattern of their native Hebrew
language. This may support the notion that English and German learning infants
preferred the strong-weak stress pattern because it is the common stress pattern in
their language (Hhle et al, 2009; Jusczyk, Cutler & Redanz, 1993). Moreover,
acoustical analysis showed that both the weak-strong and strong-weak words used
in the present study had similar acoustic cues to sign stress in terms of duration,
amplitude and pitch. Thus, listening preference shown in the present study was not
based on acoustic characteristics of the weak-strong versus the strong-weak words
but possibly on distributional learning of the common stress pattern of the language.
Distributional learning from the input was also reported for other
characteristics of speech. During the last two decades there is an increased number of
evidence showing that infants are sensitive to frequencies (regularities) of elements in
the input. For example, infants learn the probabilities of syllable co-occurrence in the
input of an artificial language and show different listening time to sequences with
high versus low transitional probabilities (Saffran, Aslin, & Newport,1996). Infants
also recognize familiar phonotactic patterns in their language (e.g., Jusczyk,
379
Friederici, Wessels, Svenkerud, & Jusczyk, 1993; Jusczyk, Luce, & Charles-Luce, 1994)
and learn distributional information of stress-patterns in an artificial language
(Theissen & Saffran, 2007).
The findings of the present study show that infants become tuned to the
frequent stress pattern of their language. Because such tuning assists infants to
segment words from fluent speech (Jusczyk et al, 1999), it is suggested that the
development of segmentation procedures are language specific and involve
distributional learning from the input.
References
Allen, G. D.,& Hawkins, S. (1978). The development of phonological rhythm. In A.
Bell, & J. B. Hooper (Eds.), Syllables and segments. Amsterdam: North-Holland.
Echols, C.H., Crowhurst, M.J., & Childers, J.B. (1997). The perception of rhythmic units in
speech by infants and adults. Journal of Memory and Language, 36, 202-225.
Echols, C.H., & Newport, E.L. (1992). The role of stress and position in determining first
words. Language Acquisition, 2, 189-220.
Hhle, B., Bijeljac-Babic, R., Herold, B., Weissenborn, J., & Nazzi, T. (2009). The development
of language specific prosodic preferences during the first half year of life: evidence
from German and French. Infant Behavior and Development, 32, 262-274.
Jusczyk, P.W., Cutler, A., & Redanz, N.J. (1993). Infants' preference for the predominant stress
patterns of English words. Child Development, 64, 675-687.
Jusczyk, P. W., Friederici, A. D.,Wessels, J. M., Svenkerud, V. Y. & Jusczyk. A. M.
(1993b).Infants sensitivity to the sound patterns of native language words. Journal of
Memory and Language, 32, 40220.
Jusczyk, P.W., Hohne, E.A., & Bauman, A. (1999). Infants sensitivity to allophonic cues for
word segmentation. Perception & Psychophysics, 61, 1465-1476.
Jusczyk, P.W., Luce, P.A., & Charles-Luce, J. Infants (1994). Sensitivity to phonotactic
patterns in the native language. Journal of Memory and Language, 33, 630-645.
Johnson, E.K., & Jusczyk, P.W. (2001). Word segmentation by 8-month-olds: When speech
cues count more than statistics. Journal of Memory and Language, 44, 458-567
Jusczyk, P.W., Houston, D.M., & Newsome, M. (1999). The beginnings of word segmentation
in English-learning infants. Cognitive Psychology, 39, 159-207.
Kishon-Rabin, L., Taitelbaum-Swead, R., Ezrati-Vinacour, R., et al. (2005). Prelexical
vocalization in normal hearing and hearing - impaired infants before and after
cochlear implantation and its relation to early auditory skills. Ear Hear, 26, 17S-29S.
Mattys, S.L., & Jusczyk, P.W. (2001). Phonotactic cues for segmentation of fluent speech by
infants. Cognition, 78, 91-121.
Robbins, A.M., Koch, D.B., Osberger, M.J., et al. (2004) Effect of age at cochlear implantation
on auditory-skill development in infants and toddlers. Archives of Otolaryngology Head & Neck Surgery, 130, 570-574.
Saffran, J.R., Aslin. R.N., & Newport, E.L. (1996). Statistical learning by 8-month-old infants.
Science, 274, 1926-1928
Segal, O., Nir-Sagiv,B., Kishon-Rabin,L. & Ravid, D. (2009). Prosodic Patterns in Hebrew
Child Directed Speech. Journal of child language, 36: 629-656.
Thiessen, E.D., & Saffran, J.R. (2007). Learning to Learn: Infants Acquisition
of Stress-Based Strategies for Word Segmentation. Language Learning and Development, 3, 73
100
Turk, A. E., Jusczyk, P. W. & Gerken, L (1995). Do English-learning infants use syllable
weight to determine stress?. Language and Speech, 38, 143-158.
van Heuven, V. J., & Menert, L. (1996). Why stress position bias? Journal of the Acoustical
Society of America, 100, 24392452.
380
Appendix 1
Table 1. Acoustic measurements of strong-weak and weak-strong Hebrew
words taken from one speaker. Mean (M) and standard Deviation (SD) of
duration (in ms) and maximum amplitude (in relative units) and pitch (in
Hz) at the center of stressed and weak -strong syllables.
Acoustic measurements
Hebrew strong-weak words
Hebrew weak-strong words
Duration (ms)
strong syl
117.18
29.15
weak syl
87.39
25.09
strong syl
115.93
24.34
weak syl
60
13.68
81.31
1.98
213.65
10.9
75.9
2.14
172.11
15.96
81.27
1.77
207.09
12.34
78.97
2.55
196.18
18.14
Amplitude
M
Pitch (Hz)
M
SD
(R.U)
SD
M
SD
R.U.=relative units
381
P147
ALLIED HEALTH CARE PROVIDERS' ROLE IN SCREENING FOR
AUTISM SPECTRUM DISORDERS
Self T.L., Coufal K.L., Parhan D. F.
INTRODUCTION
Autism spectrum disorders (ASDs) are no longer considered rare. According
to a 2007 report from the Autism and Developmental Disabilities Monitoring
Network the prevalence of ASD is estimated to be 1:150 or 6.6 per 1000 8-year-old
children. As the prevalence rate has increased, so too has awareness. The medical
communitys, health- related professionals, and the general publics knowledge
about autism and related disorders has expanded due to heightened media coverage,
the availability of information on the internet, and a growing body of relevant
published literature (Johnson, Meyers, & The Council on Children with Disabilities,
2007).
Despite increased awareness, many children are not properly diagnosed until
years after the symptoms common to ASD have emerged. Oslejskova, Kontrova,
Foralova, Dusek, and Nemethova (2007) affirmed that a childs ASD diagnosis was
delayed even when the parents had suggested to the physicians and/or educational
professionals prior to the childs second birthday that something was wrong. At
the conclusion of a six-year study of 204 children, it was determined that the average
age for diagnosing children with ASD was 6.8 years (81.5 months). Additionally, the
average delay from the acknowledgment of the first symptoms of ASD to an official
diagnosis for 201 of the participants was 51.3 months, with the shortest reported
delay being 44.4 months. Howlin and Moore (1997) reported similar findings from a
study of 1,300 families in Great Britain. In this study, children were diagnosed with
ASD at a mean age of 6.0 years, even though parents had reported concerns for their
child by 18 months of age and had sought medical assistance before the child was
two years of age. Less than 10% of the children participating in the study were
diagnosed on their first medical visit, whereas families from another 10% were told
to schedule a return visit if they continued to be concerned, or they were told that the
child would most likely grow out of it. The remaining families were referred to
another professional (at an average age of 40 months).
It has been proposed that the delay in identifying a child with ASD may be
due to the clinical nature of the diagnostic criteria. That is, with no pathognomonic
marker for ASD, diagnosticians are continually challenged by the heterogeneity of
features presented both across children and within the same child over a period of
time. Other possible reasons for the delayed diagnostic process include the lack of
well-defined diagnostic tools and/or the professionals apprehension over
misdiagnosing a child with ASD at an early age and the subsequent affect a
misdiagnosis might have on the family (Spence, Sharifi, & Wiznitzer, 2004).
Yet, amid these diagnostic challenges, an early diagnosis of ASD is essential.
It provides answers for parents who are perplexed and anxious because they have
believed for some time that something was not right with their child, but have
been unable to determine the reason for their childs atypical development
382
(Oslejskova et al., 2007). Furthermore, there has been agreement among clinicians
that children with ASD receive the most benefit from treatment when it has been
initiated prior to age four.
In 2000, responding to a growing concern that children were not being
diagnosed with ASD until approximately six years of age, a multidisciplinary panel
supported by the American Academy of Neurology and Child Neurology Society,
and endorsed by the American Academy of Pediatrics (AAP), recommended that
pediatric primary care providers complete a standardized developmental screening
in conjunction with the developmental surveillance performed during well-child
visits (Filipek, Accardo, Ashwal, et al., 2000). One year later, the AAP issued a policy
statement reinforcing the need for primary care physicians to perform routine
developmental surveillances and screenings to identify children at risk for ASD
(Robins & Dumont-Mathieu, 2006). By 2007, the AAP outlined an ASD-specific
surveillance and screening algorithm to assist with the identification process. Within
this report, a policy statement directed physicians to include an autism-specific
screening at the 18- and 24-month well-child visits (Johnson, et al., 2007).
Because delays in the identification process have reportedly affected parents
ability to get access to appropriate and timely services for their child, there is
motivation for other professionals to consider incorporating ASD-specific screenings
into their clinical practice settings. Further, because children presenting with
symptoms of ASD often have communication delays and exhibit unusual patterns of
behavior, it is not atypical for parents to consult an allied health professional (e.g.,
Speech-Language Pathologist [SLP], Occupational Therapist [OT], Physical Therapist
[PT]) before considering the need to contact a physician. Consequently, the accuracy
of the information provided to the family by this initial contact followed by a proper
referral, may increase the likelihood of a proper and timely diagnosis for the child.
Support documenting the need for other qualified professionals to take
responsibility for conducting timely ASD-specific screenings has been provided.
Leach and Collins (2009) described the important role physician assistants (PA) play
in early detection of ASD symptoms in children by citing the AAP recommendations
for medical personnel to conduct a developmental surveillance at all well-child visits
and to use a developmental screening tool at the 9-, 18-, 24-, and 30-month visits.
Additionally, Leach and Collins (2009) cited the recommendations provided by
Johnson, Myers, and the Council on Children with Disabilities, which stated that
diagnostic teams should collaboratively participate in the screening, evaluation, and
subsequent treatment for a child with ASD. These teams may include, but are limited
to, pediatricians, PAs, SLPs, child psychologists, social workers, and/or pediatric
OTs. Finally, a multidisciplinary panel organized by the Child Neurology Society
and the American Academy of Neurology concluded that all professionals engaged
in early healthcare should be able to identify the signs and symptoms of ASD and
recognize when further evaluation is warranted (Filipek, et al., 2000). This position is
consistent with the expectation that all the allied health professionals working with
children are expected to provide developmental screenings and referrals.
PURPOSE
The purpose of this study was to conduct a state-wide survey of allied health
care professionals (i.e., PAs, SLPs, OTs, PTs) who do not independently diagnosis
children with ASD but who would be eligible to conduct ASD-specific screenings if
properly prepared to do so to determine the current state of: (1) knowledge for ASD
characteristics, and (2) screening practices in various professional settings. The
383
specific areas explored included the following: (1) the amount of pre-professional
education/training these health care professionals accrued in the area of ASD, (2) if
they were trained to screen for ASD during their pre-professional
education/training, (3) what screening tools they were trained to administer for
suspected ASD, (4) the amount and most recent date of continuing medical
education (CME) or continuing education (CE) received in the area of ASD, (5) their
professional responsibility to screen children for ASD (based on the requirements of
their workplace), and (6) the professionals knowledge of available referral resources
for a child to receive a complete ASD diagnostic, when appropriate. The survey also
provided participants the opportunity to indicate what would help them be better
prepared to screen young children for ASD.
METHOD
Participants
Participants were selected for this study via two public databases that
included the state Board of Healing Arts, which represented PAs, OTs, and PTs; and
the state Speech-Language-Hearing Association, representing the SLPs.
Administrators of the mailing lists confirmed that all professionals identified on the
lists were licensed and professionally-active allied health-care professionals within
the selected Midwestern state.
Procedure
Because the number of professionals from each mailing list was unevenly
distributed (e.g., 1,252 OT, 450 SLP, etc.), it was determined that 85% of each group
would be randomly selected as the initial participant pool (1,074, OT; 652, PA; 1,475,
PT; 383, SLP). Using this participant pool, 20% of the professionals representing each
group were randomly selected to receive surveys. Surveys were distributed so that
zip code regions throughout the state were represented. The total number of surveys
(832) sent was as follows: 130 PA, 215 OT, 295 PT, and 192 SLP.
All surveys were coded with an identification number to maintain individual
anonymity and to monitor the return rates among the professional groups. A second
mailing was done in an attempt to increase the overall return rate. Participants who
did not respond to the initial mailing received a second survey approximately two
months following their receipt of the initial mailing.
Data Analysis
Chi-square statistics were used in bivariate tests of association between allied
health group membership and responses to each survey question. Follow-up
analyses on selected questions also tested the degree of association between (a) the
role of the allied health professional and length of time in service, (b) the role of the
allied health professional and whether the individual received CME/CE training for
the characteristics of ASD/PDD, and (c) the individuals length of time in practice
and whether his or her training included ASD/PDD assessment/screening.
RESULTS & SUMMARY

The number of surveys returned by each professional group was as follows:
PA -26; OT - 55; PT - 69; SLP- 62. Overall, 212 surveys were returned, rendering a
25% overall return rate.
Based on the results of this survey, it appears SLPs and OTs received more
pre-professional education/training on the characteristics of individuals with ASD
than did PAs and PTs. Additionally, a relationship was discovered between those
professionals who had reportedly received this information during their preparatory
384
coursework and the length of time they had been in the field. Overall, SLPs, OTs, and
PTs reported being in their respective fields of practice longer than PAs, one third of
which reported being in the field five years or less (Langdon, 2009). These results
may be due to the fact that the field of PA is relatively new. It is unexpected,
however, that PAs coming out of their pre-professional training would not have
received information relative to ASD, a disorder which has been steadily increasing
in prevalence over the past several years.
As a group, respondents did not report training during their pre-professional
coursework to screen for ASD. While this type of training may not have focused on
particular disorders, such as ASD, students participating in SLP, OT, PT, and PA
programs should have received training to assess and intervene on behalf of
individuals across the life span within their particular discipline given their
professional scope of practice. Thus, information concerning developmental norms
and potential discrepancies should have been provided to these professionals during
their pre-professional courses. It is expected, therefore, that these professionals
would have received ample information to acknowledge when a child is not
developing typically and recognize the need to access appropriate screening
instruments to determine whether a child is presenting with development
differences that may be in need of additional attention/evaluation.
A number of respondents indicated they had accessed CME/CE
opportunities on topics related to ASD. Given the identified work settings among the
participants (e.g., hospital, preschool, education), this result would seem
appropriate. When respondents were asked what would help them be better
prepared to screen children for ASD, they indicated a preference for a one-day
workshop whether it be held on or off site. Therefore, it appears allied health care
professionals who participated in this study would be open to receiving information
on how to screen children with ASD.
Given the frustrations and delays families have reportedly experienced
during the ASD diagnostic process, it is crucial that health care preparation
programs educate their students on proper screening and referral protocol so that
when the need presents itself, they will be better equipped to respond. Additionally,
it should be reinforced that although SLPs, OTs, PTs, and PAs cannot officially
diagnose ASD, these professionals can provide the necessary screening information
and referral resources for families. While ASD-specific tools may not become part of
the regular screening protocol for all professionals who work with children, they
should become resources that can be readily accessed. In turn, this will allow the
receiving diagnostician (i.e., family physician, pediatrician) the opportunity to move
more expeditiously to provide families with an appropriate and well-timed
diagnosis.
385
P013
CONTINUUM OF COMPLEXITY AND STRUCTURE OF
PHONOLOGICAL AWARENESS BY BULGARIAN CHILDREN
K. A. Shtereva
St. Kliment Ohridski University of Sofia, Bulgaria
This study examines the components of phonological awareness of the
Bulgarian children and the factor structure of this phenomenon. The following
characteristics of the Bulgarian children are: lower scores of rhyming, almost
identical results for segmentation of words and sentences, and high average results
by the items of manipulation. Results: Rapid naming is a separate factor in
phonological structure.
Introduction
Phonological awareness is a widely accepted term and is used as an
umbrella term, labelling all levels of aware cognition about the sound elements in
speech. This term refers to a general appreciation of the sounds of speech as distinct
from their meaning (Clark & Uhry, 1995).
Adams (1990) operationally categorized phonological awareness into five
different tasks, including knowledge of rhymes, sound categorization, blending,
segmentation, and manipulation. Skills that represent children's phonological
awareness lie on a continuum of complexity (Chard & Dickson, 1999). At the less
complex end of the continuum are activities such as initial rhyming and rhyming
songs as well as sentence segmentation that demonstrates an awareness that speech
can be broken down into individual words. At the center of the continuum are
activities related to segmenting words into syllables and blending syllables into
words. Next are activities such as segmenting words into onsets and rimes and
blending onsets and rimes into words. Finally, the most sophisticated level of
phonological awareness is phonemic awareness.
The phonological awareness is accepted as a unified cognitive ability, which
is manifested by the behaviour through various abilities. Anthony characterizes this
sequence with the following regularity: First, with the growth of age children
become more sensitive to the smaller parts of the words. Secondly, children can
identify similar and different sounds within a word, before they are able to
manipulate with sounds. Lastly, children refine their abilities of the already gained
task of the phonological awareness simultaneously with the studying of the next
more difficult level of phonological awareness. Although, the rate that speakers of
different languages progress through (the sequence and the proficiency), varies at
each level (Anthony, 2005).
Here there are some examples. Vowel and consonant harmony are likely to
influence on the development of phoneme awareness (Durgunoglu, Oney, 1999).
Saliency and complexity of onsets in spoken language may influence on the
development of onset awareness and phoneme awareness. Karpova (1987, by
Tsenova, 2008) determines about the Russian phonological system that only 22%
from 5-7-year-old children can separate consonants as well as vowels in words.
Caravolas and Bruck (1993) found preliterate English-speaking children were better
386
than preliterate Czechspeaking children at isolating single onsets (onsets with one
consonant), which is an onsetrime awareness skill. Another conclusion is that
children in linguistic environments where spoken syllables are highly salient, as
determined by a number of factors, develop syllable awareness sooner than children
in linguistic environments where syllables are less salient (Demont & Gombert, 1996,
Stoyanova, 2009). According to the examinations of Lipovska, connected with the
Polish phonological system (by Germakovskay, 2005), a normally developing child
manages to make a syllable analysis and synthesis of words and to differentiate
auditorily quasi-homonyms in its mother tongue round the fourth year. The
development of phoneme awareness is also affected by articulatory factors that
contribute to the linguistic complexity of words. Data on the articulatory complexity
of the Bulgarian sounds we can get from Tsenova (2008).
Traditionally, rapid-naming skills (measures of automatic color, object,
number, or letter naming) have been considered as a part of phonological skills
(Torgesen, Wagner, Rashotte, Burgess & Hecht, 1997). Wolf and her colleagues
provided evidence that a naming-speed deficit is another core deficit, along with a
phonological processing deficit (Double-Deficit Hypothesis), by showing a modest
correlation between the variability of phonological awareness and rapid-naming
(Wolf et al., 2000). Researchers argued that even though rapid naming may rely on
and share variance with some phonological tests, some aspects of rapid naming such
as speed of processing and sensitivity to temporally ordered information cannot be
explained by phonological processing (Manis et al., 1999).
In conclusion, phonological awareness follows the common sequence of
development, characteristic of different language systems, but it passes through
specific variants of sequence and gaining experience, determined by the
characteristics of single language.
Aim
The aim of this study is to examine the components that form the
phonological awareness of the Bulgarian children from 4 to 7 years old and their
continuum in degrees of complexity and on the other hand what the factor structure
is based on 18 used subtests included in the present procedure of studying this
phenomenon.
Methods
Participants of the study include 137 Bulgarian children aged between 4 and 7
years (72 boys - 53% and 66 girls - 47%). Certain restrictions are included - the
Bulgarian language is essential for children and they havent special educational
needs.
Criteria of selection of implements cover: five types of tasks: rhyme, sound
categorization, blending, segmenting, and manipulation; two response method recognition and production; sound representation oral representation and
picture representation.; linguistic unit - sentence, words, multisyllable, singlesyllable, onset-rime, phoneme; phoneme position - beginning, middle, end;
phonological properties variety of phoneme, phoneme combination, syllable,
lexical and sentence structures.
Assessment Battery - Several instruments were taken directly from previous
research and some were created specifically for the present study by its author and
are the basis of her doctoral dissertation.
387
. Rhyme - Test 1: Rhyme Recognition - The child was asked to recognize

whether two orally presented words rhymed. st 2: Rhyme Production - It was
composed of 10 items that ask the child to produce a rhyme when given a stimulus
word.
. Classification - Test 3, 4, 5: Identification of phoneme (beginning, middle
and end position). The child was required to orally produce the sounds (beginning,
middle and end position) in the word. st 6, 7: Categorization of phoneme
(beginning and end position) - this 10-item measure asked children to identify one
picture out of three that had the same initial/ending phoneme as a target picture..
Test 8, 9: Categorization Production (beginning and end position). The child was
asked to produce an oral response to a specific linguistic unit.
. Manipulation Recognition - st 10 and 11 (syllable, phoneme): The
examiner presented the child with four pictures and identified each of them. The
examiner then asked the child to mark the picture that showed the word that would
become when a specific linguistic unit was removed (syllable, phoneme).
V. Blending Recognition - st 12 and 13 (syllable, phoneme): The examiner
identified four pictures for the child. Next, the examiner spoke the stimulus linguistic
units (syllable, phoneme) at a rate of one unit per second. The child was required to
mark the picture that depicted the stimulus linguistic units when blended together.
V. Segmenting Recognition - 14, 15 16 (sentence, syllable, phoneme).
The examiner made an utterance, presented by pictures (sentence, syllable,
phoneme), and the child recognized the number of words, syllable and phonemes
articulated by tapping a pencil on a hard surface. For example, the examiner stated,
Tap this pencil for every . Partial point was not given.
V. Rapid Serial Naming Production - Test 17 and Test 18: Colors and Objects.
This tests ware modelled after Denckla and Rudel. This test required the child to
identify black, blue, red, green, and yellow squares or 5 objects randomly repeated
on a page. The entire test was 50 items (10 rows with 5 color or 5 objects squares per
row).
The results are reported on individual test protocols, where correct answers
are marked with "1" point and wrong - with "0" points. Children perform the tasks in
two sessions lasting between 20 and 30 minutes. In carrying out statistical process is
used the program SPSS. To test the common sequence in the development of
phonological awareness in Bulgarian children, data from the descriptive statistics
have been used. To check the factor structure of the phenomena studied (16 tests
covering the five tasks of phonological awareness and two subtests about rapid
automatic naming colours and objects) is applied classic factor analysis using the
method of main components - Rotated Component Matrixa and Varimax Rotation.

By Table 1 is presented continuum of degrees of complexity of the 16 subtests
of phonological knowledge concerning the Bulgarian children aged 4 to 7 years (from
the easiest skill to implement the most complex).
388
Table 1- verage means of task of Phonological Awareness

Measure
Blending Recognition /syllable/
Classification Identification Recognition /beginning phoneme /
Classification, Categorization Recognition /beginning phoneme/
Rhyme Recognition
Blending Recognition /phoneme/
Segmenting Recognition /sentence/
Segmenting Recognition /syllable/
Manipulation Recognition / syllable /
Manipulation Recognition / phoneme /
Classification Identification Recognition /end phoneme /
Classification Categorization Recognition /end phoneme /
Classification Production /beginning phoneme /
Classification Identification Recognition /middle phoneme /
Segmenting Recognition / phoneme /
Rhyme Production
Classification Production /end phoneme /
verage
means
9.5
8.1
7.7
7.3
7.0
6.6
6.5
5.9
5.9
5.8
5.8
5.2
5.1
3.4
3.3
2.8
In a more detailed overview of the development of phonological knowledge

of Bulgarian children, we should note that the task of blending a word by its syllabic
structure, while the most difficult task is to reproduce, i.e. refer to any word that
rhymes with the model or ends with the same sound as suggested by the examiners.
Children cope with the categorization of initial phoneme comparatively well, either
by separating it from the word or by locating a picture that begins with the target
sound. Interestingly, as noted in most research, Bulgarian children deal better with
recognition of words that rhyme, but this is not the easiest operation for them, as it
is, for example, by English speaking children (Chard & Dickson, 1999). This is most
likely due to the fact that a much greater variety of sound combinations is manifested
at the beginning of words in the Bulgarian language than at the end of them
(Boyadjiev, Tilkov, 1999; Anthony, 2005). Of course, the reason may be held in the
Bulgarian educational system for kindergarten children, in which there is no covered
program for working with rhymes and rhyme-forms, unlike English. The present
study also shows that by children of Bulgarian origin segmentation of sentence into
words and segmentation of words into syllables are the next level components (in
difficulty) that are almost at the same level. On the next hierarchical step are the
tasks of manipulation with syllable and phoneme. Before the most difficult tasks
associated with the reproduction of rhymes and reproduction of words with the
same ending phoneme, ranks the ability of children to classify phonemes in the
middle of a word.
As regards the results of the rapid naming it may be noted that the average
values are 69.8 seconds. Bulgarian children aged 4 to 7 years cope with the rapid
naming of colours (X = 69.5 s) at almost equal speed to that of subjects (X = 70.1 s).
There are 14 subtests when determining the factor structure of the studied
phenomenon "phonological awareness" in the first factor with high functional
weights (55.38%): Classification Identification Recognition /middle phoneme/;
Classification Production /beginning phoneme/; Classification Identification
Recognition /end phoneme/; Classification Categorization Recognition /end
phoneme/; Manipulation Recognition /syllable/; Classification Production /end
389
phoneme/; Manipulation Recognition /phoneme/; Segmenting Recognition

/phoneme/; Classification, Categorization Recognition /beginning phoneme/;
Classification Identification Recognition /beginning phoneme/; Blending
Recognition /phoneme/; Rhyme Recognition; Segmenting Recognition /sentence/
Rhyme Production. There are two tasks related to the linguistic level of the syllable
as a second factor with high functional weights (7.27% similarity in the range of
variability): Blending Recognition /syllable/; Segmenting Recognition /syllable/. As
a third factor with a score of 6.08% of the total range of variability appear both tests
for Rapid Serial Naming Production - Colours and Objects (Table 2).
Table 2 - Classic factor analysis using the method of main components
Rotated Component Matrixa and Varimax Rotation
Measure
Components
1
2
.836
Classification Identification Recognition /middle phoneme/
.169
.821
Classification Production /beginning phoneme/
.213
.819
Classification Identification Recognition /end phoneme/
.244
.815
Classification Categorization Recognition /end phoneme/
.274
.809
Manipulation Recognition / syllable/
.215
.804
Classification Production /end phoneme/
.793
Manipulation Recognition /phoneme
.333
.773
Segmenting Recognition /phoneme/
.166
Classification, Categorization Recognition /beginning phoneme/ .755
.422
.748
Classification Identification Recognition /beginning phoneme/
.196
.716
Blending Recognition / phoneme/
.532
.713
Rhyme Recognition
.684
Segmenting Recognition /sentence/
.236
.656
Rhyme Production
-.118
Blending Recognition / syllable/
Segmenting Recognition / syllable/
.591
Rapid Automatic Naming - Objects

Rapid Automatic Naming - Colors
-.189
.793
.600
-.479
3
.219
.291
.162
.236
.376
-.140
.273
.361
.120
-.736
-.587
In this study it was ascertained that phonological knowledge and rapid serial
naming are not directly associated with and they are not blended into one factor
upon inspection of the factor structure of the studied phenomena. It is interesting
that the studied phenomenon is realized in the ternary structure. Except the expected
differentiation of rapid automatic naming of the basic levels of phonological
awareness the results of the two tasks at linguistic levels of syllable / segment and
blending / were also separated. This probably relates to the fact that Bulgarian
language is defined as the language of stress-timed rhythm (Tsenev, 2007), similar
to English, but not as a language with syllable-time rhythm, as is the French
language, which determines the different role of awareness of syllabic linguistic level
by Bulgarian children.
Conclusion
This study duplicates the results, defining the laws of common sequence of
development of phonological awareness, proven through many tests, surveys of
people of different ages, with different languages and reading levels. The presented
390
study determines the following more specific characteristics of the Bulgarian

children: lower scores in tests of rhyming, almost identical results when testing for
item segmentation of words and sentences, and finally, relatively high average
results by the items of manipulation (syllable and phoneme level).
The conclusion from the factor analysis that RAN is a separate factor in the
structure of the studied phenomenon is confirmed by a number of convincing
arguments from other authors. The opposite argument that RAN belongs entirely to
the field of phonological processing is not supported by the current research.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Adams, M. J. (1990). Beginning to read: Thinking and learning about print.

Cambridge, MA: MIT Press.
Anthony J. L., D. J. Francis (2005). Development of Phonological Awareness 2,
Volume 14Number 5, American Psychological Society, 255-259
Boyadjiev T., Tilkov D. (1999): , ., . , .
, 1999
Caravolas, M., & Bruck, M. (1993). Effect of Oral and written language input on
childrens phonological awareness. Journal of Experimental Child Psychology, 55, 1
30.
Chard D., Dickson S., (1999). Phonological Awareness Instructional and ssessment
Guidelines, Intervention in School and Clinic, T., Vol. 34, No. 5, 261-270
Demont, E., & Gombert, J.E. (1996). Phonological awareness as a predictor of
recoding skills and syntactic awareness as a predictor of comprehension skills. British
Journal of Educational Psychology, 66, 315332.
Durgunoglu, A.,&Oney, B. (1999). Cross-linguistic comparison of phonological
awareness and word recognition. Reading and Writing, 11, 281299.
Germakovskay A. (2005): , .
. , ., 4 /10/,
2005, 12-18
Manis, F. R., Seidenberg, M. S., & Doi, L. M. (1999). See Dick RAN: Rapid naming and
the longitudinal prediction of reading subskills in first and second graders. Scientific
Studies of Reading, 3, 129-158.
Stoyanova, J. (2009): , . ,
, , 2009
Torgesen, J. K., Wagner, R. K., Rashotte, C. A., Burgess, S., & Hecht, S. (1997).
Contributions of phonological awareness and rapid automatic naming ability to the
growth of word-reading skills in second- to fifth-grade children. Scientific Studies of
R., 1, 161-185
Tsenev, P. (2007): , .
, . , , .3., 2007, 43- 47
Tsenova, TS. (2008): ., . , 2008
Wolf, M., Bowers, P. G., & Biddle, K. (2000). Namingspeed processes, timing, and
reading: A conceptual review. Joumal of Learning Disabilities, 33, 387-407.
391
FP11.2
DEVELOPMENT OF EPISODIC STRUCTURE OF NARRATIVES IN
PRETEND PLAY OF FINNISH CHILDREN WITH SLI: AN
INTERVENTION STUDY
A. Suvanto, A. Yliherva & M. Lehtihalmes
University of Oulu, Logopedics, Finland
INTRODUCTION
Telling a story is more challenging task for children with speech and
language impairment (SLI) than their typically developing (TD) peers. Children with
SLI produce narratives that are limited in lexical diversity, grammatical complexity
and fluency (Boudreau, 2008). There are fewer story grammar units, episodes and
overall information in SLI childrens stories as compared to TD children. These
deficits have proved to be quite persistent (Paul & Smith, 1993).
Preschool childrens narratives have been studied intensively using the story
grammar structure based on Stein and Glenns (1979) model. Mainly retelling or
generation elicitation procedures have been used in those studies. However, only
few studies have focused on play context. Ilgaz and Aksu-Koc (2005) suggested that
preschool children can produce more complex structures in their narratives with the
help of actions and objects. When comparing narratives of four- and five-year-olds in
pretend play and storytelling settings, Benson (1993) noticed that five-year-olds had
stronger mental model of a story than four-year-olds. According to Nicolopoulou
(2007) childrens play and narrative should not be separated. Instead they should see
as complementary modes of their narrative activity.
Story grammar approach has been successfully used to improve oral
narratives of children with delayed language development (Davies, Shanks &
Davies, 2004; Hayward & Schneider, 2000). Still there is no survey how intervention
effects on narration when using toys. The aim of the present study was to find out
how SLI childrens story structure in their narratives develops during pretend play
sessions after nine months intervention compared to that of TD children.
METHODS
Participants
Ten children with SLI participated the study. At entering the study the mean
age of the SLI children was 56.7 months (range 4;06;1). TD control children (n=10,
mean age 56.8 months) were matched according to age, gender and mothers
education. All except one of the mothers in SLI and control groups had upper
secondary level of education.
Children with SLI were diagnosed at the University Hospital of Oulu,
Finland according to ICD-10 (WHO, 1993). The inclusion criteria were either speech
and language delay (R62.0, five children) or speech and language impairment (F80.1,
five children) and normal hearing and vision. In Wechsler Preschool and Primary
Scale of Intelligence-test childrens nonverbal IQ was at least 80 and verbal IQ 70 or
more. In addition, childrens comprehension skills were supposed to be within
normal variation according to Reynell Developmental Language Scales III. The aim
was to screen children whose main problems were in speech production, and
especially in narration.
392
To collect the normative data the kindergarten teachers were asked to screen
ageappropriate children with no developmental problems. When appropriate
children were found, the parents filled a questionnaire concerning childs health and
development. Only children with no problems in delivery or in motor and language
development were included.
Procedure
Each child was assessed individually either in a childs home or nursery. The
old teddybear, who loves stories, was introduced to the child. The aim in using the
teddy-bear was to have a so-called naive listener with bad hearing and seeing, to
whom child should tell stories loud and clear. During the assessment, seven different
story tasks were elicited, but for the present study, only one pretend play with toy
animals was selected.
The child was asked to name five toys and was allowed to arrange them in
the table. After that the following instruction was given to a child: Now you can
play with these toys and tell me and Teddy-bear about it. The researcher prompted
the child with neutral expressions or repetitions of childs utterances.
Time-table and content of the intervention

The childrens narration was assessed five times during the nine months
period (Figure 1). After one month baseline, two different speech therapy
periods in counter-balanced order was organized for children with SLI. In semantic
approach (therapy 1) children were introduced 18 different categories through
picture and item material. Diverse semantic elaboration was done for example
through play. A simple narrative structure was taught (therapy 2) to the children
through colour coding and symbols based on WIG 1, Semantic and Listening
Through Narratives (Shanks & Ribbon, 2003). Both periods consisted 20 sessions (
45 minutes). During the intervention parents were asked to read picture books
(PDR, parents dialogic reading) to children regularly at home. They were

trained to use dialogic reading prompts and to fill a simple diary. After 20
weeks intervention the children were re-tested and finally after 10 weeks
follow-up.
Narrative analysis
For this study, 100 video- and audiotaped play situations were transcribed
using raw orthography in CHAT (Codes for the Human Analysis of Transcripts)
computerized transcription format (MacWhinney, 2007). Only the meaningful and
understandable words, interjections and onomatopoeic utterances were accepted to
the analysis. Language samples were divided in communication units (CU). One CU
contained main clause only or main clause and subordinate clause(s). Besides, the
nonverbal actions and gestures were marked under the spoken utterance row.
393
Finally, the CUs were coded into story grammar units using the episodic system by
Stein and Glenn (1979) including introduction and ending (Table 1). The traditional
story beginning was accepted as one unit. The child was given one score from
each verbal or nonverbal unit.
RESULTS
Slight but not significant differences in story grammar units were found
between the groups when averaging all five assessments. Introduction was
mentioned verbally in 56% of SLI childrens and in 66% of TD childrens stories in
every five assessment. Story beginning, internal response, internal plan and ending
were the least mentioned categories in both SLI and TD groups and excluded from
this analysis. Also the setting category was not established in childrens stories. In
SLI-group 23% (in assessment A2A4) and in TDgroup 36% (in every assessment) of
stories contained verbalized setting. Pretending with action was used almost equally
(in 24% of SLI children and in 28% of TD children).
A simple episode contains an initiating event, an action or an attempt and a
direct consequence (Stein & Glenn, 1979). These categories were found in pretend
play narratives in both groups at each assessment (Figures 24).
394
Number of initiating events in stories increased in both groups during the

intervention (Figure 2 A), especially in children with SLI. Children in SLI-group
developed to use more often pretend means without words than peers in TD-group
(Figure 2 B).
The toy set used in this study elicited lots of attempts (or actions) both
verbally and nonverbally (Figure 3). However, the children with SLI expressed
themselves more often with incomplete linguistic utterances and phrases or
onomatopoeic utterances than TD children.
395
Most children with TD mentioned the consequences at the first assessment

and this skill became more prominent during the follow-up despite the sudden drop
in the final assessment (Figure 4 A). Of all story grammar categories this unit showed
greatest development in SLI-children. Children in SLI-group used more nonverbal
means (Figure 4B) than TD-children in expressing their consequence.
In Table 2 there is summary of the development of episodic structure in
childrens oral narration. Intervention affected positively on SLI-childrens story
telling but the outcome was not persistent. Instead, six out of ten TD children
established episodic structure in their stories.
DISCUSSION
The aim of the present study was to find out if there is an episodic structure
in pretend play narratives of Finnish speaking children with SLI and their TD peers.
Secondly, the effects of 20 weeks intervention on narration were evaluated. The
quantitative results showed that children with SLI were poorer than TD children in
verbalizing their play but they used more pretend actions than TD children. Thus,
nonverbal actions would assume to function as alternative means of deficient
linguistic expressions in children with SLI. Also, these findings support the view by
Nicolopoulous (2007) that pretend play can be a mode of childs narrative activity.
Tupically developing children were able to create a well-structured story
with a simple set of toys and that this skill became stronger during the nine months
follow-up. Thus, the present study supports the statement that actions and objects
scaffold both the conceptual organization of episodic narrative and its expression
(Ilgaz & Aksu-Koc, 2005).
Children with SLI practiced story structure model in one therapy period and
vocabulary through semantic classification on the other therapy period (see Figure
1). Besides, parents used dialogic reading prompts at home. This intervention model
seemed to have strong positive effects on episodic pretend play narratives in
396
children with SLI (Table 2) although the effect was declining after 10 week follow-up.
Presumably the intervention should be more intensive, longer or implementing in
group therapy as in a study by Davies et al. (2004). In future, more detailed analysis
is needed to ensure the effects of intervention by comparing the matched pairs. It is
also important to make sure that coherence including cohesive ties is appropriate in
childrens stories.
References
Benson, M. (1993). The structure of four- and five-year-olds narratives in pretend play and
storytelling. First Language, 13, 203223.
Boudreau, D. (2008). Narrative abilities. Advances in research and implications for clinical
practise. Topics in Language Disorders, 28, 99114.
Davies, P., Shanks, B., & Davies, K. (2004). Improving narrative skills in young children with
delayed language development. Educational Review, 56, 271286.
Hayward, D., & Schneider, P. (2000). Effectiveness of teaching story grammar knowledge to
pre-school children with language impairment. An exploratory study. Child Language
Teaching and Therapy, 16, 255284.
Ilgaz, H., & Aksu-Koc, A. (2005). Episodic development in preschool childrens playprompted
and direct-elicited narratives. Cognitive Development, 20, 526544.
MacWhinney, B. (2007). The CHILDES Project. Tools for Analyzing Talk Electronic Edition.
http://childes.psy.cmu.edu/manuals/chat.pdf.
Nicolopoulou, A. (2007). The interplay of play and narrative in childrens development:
Theoretical reflections and concrete examples. In A. Gnc & S. Gaskins (Eds.), Play
and development. Evolutionary, sociocultural and functional perspectives (pp.
247273). Mahvah: Lawrence Erlbaum.
Paul, R., & Smith, R. L. (1993). Narrative skills in 4-year-olds with normal, impaired and latedeveloping language. Journal of Speech and Hearing Research, 36, 592598.
nd
Shanks, B., & Rippon, H. (2003). Speaking and listening through narrative. WIG1, 2 edition.
Keighley: Black Sheep Press.
Stein, N. L., & Glenn, C. G. (1979). An analysis of story comprehension in elementary school
children. In R. O. Freedle (Eds.), New directions in discourse processing (pp.
53120). New Jersey: ABLEX Publishing.
397
P089
NEUROPSYCHOLOGICAL STUDY OF CHILDREN WITH
HEMIPARETHIC CEREBRAL PALSY AND LEARNING DISORDERS
MARIA DE LOURDES MERIGHI TABAQUIM
Universidade Sagrado Coração
Summary: The objective of this study was the neuropsychological analysis of
children from seven to twelve-years old, both sexes, attending the regular and
specialized academic education. It was analyzed the relation of the learning process
in 85 children classified in four categories: hemiparethic cerebral palsy, without (IPC/SDM) and with mental deficiency (II-PC/CDM), with learning disorder (IIIN/CDA) and the control group (IV-SDM), without academic and development
complaint. The evaluation procedures of mental, pedagogic, visuo-motor level and
higher cortical functions were complemented with the data of the Neurological
Evaluation and neuroimage, statistically compared in the light of the literature,
regarding the concept, classification and referential of the learning disorders. The
results allowed to evidence that the lesional condition of the hemiparetic child does
not constitute disadvantage in the development and acquisition of cortical functions,
related to the learning. Correlated standard of reply among the groups, suggested
the occurrence of neurologic connections due to neuronal plasticity, in the lesional
groups.
Key Words: neuropsychology cortical functions cerebral palsy

disorders - learning
(*) Psicloga.Doutora em Cincias Mdicas/Neurologia.Faculdade de Cincias

Mdicas/UNICAMP. Docente do Departamento de Psicologia. Universidade do Sagrado
Corao de Bauru/SP.
Grupo de Pesquisa CNPq EP Estudo da Psicologia sobre o desenvolvimento humano e
seus transtornos: preveno, avaliao e interveno.
Dr Maria de Lourdes Merighi Tabaquim. Rua Bandeirantes, 9-60 Apt 61 Centro. CEP 1701512 bauru-SP Brasil.
398
INTRODUCTION
Searching for the understanding of the learning processes and their
disorders, it is necessary to know the neuropsychological aspects, considering that
the occurences are, in their majority, a reflex of altered functions, as the model of
cognitive processing proposed by Luria(1), involving areas of reception (input),
processing (cognitive-integrative) and expression (output) of information. The brain is
the integrator, co-ordinator and regulator system between the environment and the
organism, between the brain and learning-behavior. The recognition of the effects of
cerebral lesions or dysfunctions, allows better understanding of the childs learning
difficulties. Neuropsychological evaluation is usually structured in a series of tests
and sub-tests, however the cerebral organization is much more beyond the
simplifications and abstractions. A test or sub-test is rarely specific of an independent
mental function.
Every interpretation out of a clinic and a defined functional
context, may conduct to great topographic-diagnostic misinterpretation. The studies
in this field changed the way of understanding certain learning problems and
contributed to evaluation procedures, especially in the field of dyslexias, dyspraxias,
aphasias, agnosias and other neurolopsychogical difficulties (2-3-4).
The neuropsychological infantile examination must be constituted and
managed in order to conclude, not only regarding the injured intelectual, conative
and
emotional
functions,
but
also
to
correlate
them
to
the
neuroanatomophysiological mechanisms, responsible for the difficulties presented,
as well as, to be useful to establish, clearly, the distinguishing diagnosis,
demonstrating the aspects primarily affected and which are the derived or secondary
symptoms.
In the understanding of the learning processes, the diagnosis can be used as
an effective form of prevention to the child who presents academic problems
deriving from some physical, psychological, social, school, sensorial deficit or in face
of the interaction of these various aspects. Associated to this, there is lack of research
in the neuropsychological diagnostic area that makes possible the analysis, either the
evaluation process or the methods and specific instruments (5).
This study had the objective of investigating the child that presents difficulty
in the learning process, focusing the one with unilateral cerebral lesion and another
without any damage in its neurological development, by means of the cortical
analysis of the higher functions. It is justified by the lack of specific instruments of
neuropsychological evaluation in the literature, particularly in the population with
cerebral lesion. Besides this quite limited perspective, the children with HC is usually
labeled as a mental deficient, or difficult to evaluate (3). For the purpose of this
study, it was considered that child with hemiparesis, that, theoretically would have
one standard of more similar reply to the control-group, in view of the similarity of
functional replies, not to correlate exclusively with motor areas.
METHODOLOGY
Eighty-three children were part of this study, they were 7 years and 0 month
and 12 years and 11 months, both sexes, middle-class and lower-class, divided in
groups: 1-PC/SDM: formed by 12 children, being 6 males (m) and 7 females (F), with
Hemiparetic Cerebral Palsy, of the spastic-type without mental deficiency or another
associated; II-PC/CDM: composed by 16 children, being 9(M) and 8(F), with
Hemiparetic Cerebral Palsy, spastic-type, classified with mild mental deficiency, and
399
other neurological alterations with levels of mild damage, associated with a delay in
speech acquisition, auditive sensory loss and epilepsy; III-N/CDA: with 20 children,
being 14(M) and 6(F), without neurological lesion, mental deficiency or other
associated disorders, presenting learning disorders; IV-N/SDM: as a control-group,
formed by 35 children, from 7 to 10 years old, being 16(M) and 19(F), with middle
social-cultural level, attending from 1st. to 4th. grades of the basic regular education.
The instruments used were the following: Raven Colored Progressive
Matrices (6); SPT-School Performance Test (7); NE-Neuropsychological Examination
(8); Wescheler Intelligence Scale for Children-WISC (9); Gestaltic Viso-Motor Bender
Test (10).
RESULTS
The experimental groups I-PC/SDM and II-PC/CDM, composed by
individuals with lesions (Table 1), were related regarding the performance levels,
having as reference the classification proposed by the employed instruments. The IIIN/CDA Group, with Learning Disorder(11), had close family antecedents with
school difficulties, with serial relapsing failure and school abandonment. In 30% of
the cases, the parents were semi-illiterate; in 80% were related misadjusted behavior
as indiscipline, aggressiveness and lack of interest in the studies. And 15% were data
of family disorganization, separation and abandonment.
INSERT TABLE 1
The values, demonstrated in percentiles, showed heterogeneous levels of the
discrepancy between the higher and lower scores. When Kruskal-Wallis Test was
applied in comparison to the sub-tests of the WISC, there were significant differences
in the groups (p=0,0001 p=0,0402), with exception of the Figures Completion (FC),
where there was no significant difference (p=0,0810), as demonstrated in Table 2.
INSERT TABLE 2
When analyzing the results of the Neuropsychological Examinations, it has
been observed that the area with a better performance of the individuals, in all the
groups, was the one related to the higher cutaneous sensations and kinesthetic
functions (sens). This area has investigated the stereognostic condition and corporal
tactile functions, exploring the propioception regarding the intensity, sensorial
spatial orientation and tactile identification of the direction of the moment.
Comparing the representations of groups N/CDA and PC/SDM, expressive
similarity in 90% of the areas is evidenced, being the motor differentiated. The
diversity of scores between the areas was of 3.7 points, in favor of group PC/SDM
(Graphic 1).
INSERT GRAPHIC 1
When the Test of Kruskal-Wallis was applied, a significant difference
between the groups N/CDA>PC/SDM in all the sub-areas of the NE was observed.
The level of significancy has occurred between 0,0001 and 0,0268. These data
indicated that the mean scores were highly differenciated. In 80% of the areas, the
group PC/SDM obtained higher mean than the others; only in the motor functions of
the hands and cutaneous sensations/kinesthetic functions the group N/CDA was
superior, excluding the profiles of the control-group (Table 3).
INSERT TABLE 3
400
In the comparision of the leasional groups, the Qui-square Test, Fisher Test
and Kruskal-Wallis Test, observing significancy of the brachial prevalence in the
group II-PC/CDM (66%) and the crural in the PC/SDM (55%). In the risk factors, the
pre-natal condition was prevalent for the II-PC/CDM group. It was verified that the
same group II, had normal term pregnancy in 79% of the cases. The sensorial
damages (visual) occurred in 20% of the cases in both groups. The Epilepsy
associated to the Cerebral Palsy occurred in 66% of children from Group II, in
counter position of 33% in Group I. Considering the site of the lesion, Group I had a
prevalence (41%) in cortical levels and Mean Percentile. In Group II, predomination
to cortic-subcortical lesion in 38% in P-25, below the average.
DISCUSSION
The occurrence of the lesion in a specific area of the brain disturbs such area
or prevents such area from performing its normal function, originating the primary
disturbance, and in turn it produces secondary symptoms, altering all mental activity
forms which require the participation of these cerebral systems. However, a local
cerebral lesion does not lead to the direct loss of a particular mental condition, due
to the possibility of intact parts of the brain to reorganize, so that the disturbed
function can be performed in new and different manners.
In this study, it was evidenced that the population that presented diagnosis of
cerebral lesion, of the I-PC/SDM group had conditions to promote important rearrangements, capable of making possible compatible answers with cognitive
patterns of normality, in a sense that the functions that could have been troubled,
were performed in a compensatory way. In the II-PC/CDM group, the deficits
related to cognition, demonstrated by the difficulty in accessing, retaining and
generalizing information, necessary to the learning, made possible to understand
that the resources of the re-organization in this population, were more limited. In the
N/CDA group, where there was no neurological history and the function in some
specific tasks was impaired (many times inferior to the lesional group), there were
indicative data of a possible neurological dysfunction, bringing about learning
disorders.
The lesions found in children from group I and II were: Periventricular
Leucomalacia, Stroke, Hypoxic Ischemic Encephalopathy and Malformations of the
Central Nervous System. The development disorders, which are the malformations,
represent 14% of this study. The schizencephaly was the most frequent finding
demonstrated in the RNM. It is defined as a cleft that goes all the way from the
ventricle to the cortical surface, covered with grey, abnormal and unilateral matter
(determining hemiparesis).
In the literature (3-12), the malformations represent between 15% to 20% of
the development disorders, And they are better demonstrated in the RNM, being the
schizencephaly the most common discovery. Destructive cortic-sub-cortical lesions,
with cavities of the schizencefalic type, had predominance in the II-PC/CDM group,
which presented inferior performances (compared to I-PC/CDM).
The observed motor impairment was predominantly from mild to moderate.
Regarding the affected hemicorpus, the greatest incidence in the II-PC/SDM was of
the hemiparesis to the right, which confirms, in the literature, this preference (3-12).
(UVEBRANT, 1988; PIOVESANA, 1993).
Another diagnosis frequently associated to the PC is the Epilepsy. In this
study, the II-PC/CDM group, with more impaired resources had half of the sample
characterized by episodes defined as epileptic crisis. AICARDI (1990), COHEN E
401
COLS (1991) e PIOVESANA (1999), among others, have related clinical data from PC
and laboratory data from Epilepsy in hemiparesis.
The risk factors in pre-natal period represented prevalence on the peri-natal,
coinciding with the present theories (13) which say that the PC is much more derived
from lesions in the pre-natal period, than the lack of oxygenation in the peri-natal
period, being the asphyxia itself a result of the evolution of various intercurrences, as
well as the prematurity and the low weight (PIG).
Related to sex, UVEBRANT (1988) e PIOVESANA (1993; 2001) found
predominance for the male sex. In this study there was no association of these data,
considering that the sample was equitable.
Related to the aspects of the learning disorders, the literature is unanimous in
defining how a condition affects more males than females (MORAIS, 1986; GERBER,
1996; BOSSA, 2000). In this study, the student population, which presented diagnosis
of learning disorder (III-N/CDA group), had the biggest percent rate of male
children.
Children coming from an environment where people are literate find it easier
to learn how to read and write than those coming from illiterate environments,
deriving from the model and motivation to read that parents are able to transmit to
their children (14). In an environment lacking stimulus of this nature, it is possible
that the learning difficulties become more determinant. In this study, several families
presented school difficulties, related to the teaching of reading and writing, with a
serial failure relapsing history and school abandonment, besides semi-illiterate
parents and illiterate grandparents. It was observed that in the III-N/CDA group the
influence of the heredity in the learning problems, therefore there were two groups
of siblings, The first group formed by a boy and a girl and the other by three brothers
- two boys and a girl, all of them with difficulties in reading, writing and arithmetics.
The learning problems, when related to language, usually present phonological
alterations, manifested by the difficulty in accessing and retaining necessary
information for reading and writing (GERBER, 1996). The impairments in the
language abilities with phonological alteration may be due to family conditions
(CAPPELLINI & CIASCA, 2000). This evidence was found in this studied
population, evidenced by parents, siblings and cousins of the same family with
school damage, specific of reading and writing.
The mental capacities related to cognition, such as attention, perception,
memory, emotion and language, are basic and essential elements to the learning
process. The child with learning disorder presents normal intellectual level; however,
his intra-individual cognitive profile arises discrepant and heterogeneous, that
means between verbal and non-verbal performances there is still a difference in
levels (FONSECA, 1995). The data obtained in the Raven Progressive Matrices Test,
being a nonverbal instrument, attested to the N/CDA group median levels of
performance. The results of the WISC offered information that illustrate the
discrepancies between QIV and QIE, in this group.
WERNER (1981), in a study about intellectual profiles of children with
learning disorders, concluded that the profiles of the sub-tests are unmistakably
different from the children regarded as normal (control), being the data obtained in
the nonverbal scale (execution) almost always superior to the verbal scale, with a
minimum discrepancy of 10 points. The current study confirms these findings, where
most children with learning disorders presented differences between verbal scores
and execution, with a maximum discrepancy of up to 38 points between QIV and
QIE (verbal and execution).
402
The WISC, only considered in the global rates, offers little information about
the performance of the individuals. However, it may be a priceless and powerful
diagnostic process if analyzed neuropsychologically. FONSECA (1995) proposes
what he called a re-categorization: special category (cubes, complete the figures
and set up objects); conceptual category (information, vocabulary, similarities and
comprehension), and sequential category (arithmetics, numbers, figure arrangement
and code). Based on this categorization, the same author verified that children with
learning disorder get better results in the spatial category and worse in the
sequential, with intermediate results in the conceptual category. In the current study,
the findings coincided in all the studied groups, highlighting that the lesional groups
guaranteed this categorical organization. This datum can be justified by the plasticity
that, according to BARBIZET (1986), occurs in a defined order, with a kind of
neuronal organization and connection, allowing the rising of functional neuronal
configurations, which will support the experiences of the child.
The observed difference between QIV and QIE still suggests the existence of
linguistic difficulties as a cause of this performance. However, authors like NUNES,
BUARQUE & BRYANT (1997) defend that low performances in verbal tests can be
the result and not the cause of the learning disorder.
In its development, the hemiparetic child doesnt go through the important
phase of symmetry, due to the intense action of the asymmetric tonic-cervical
reflexes (RTC-A). From the fourth to the sixth month the maturation of the
intentional movements occurs: the head tends to turn to the sane side, you dont take
your hand with hemiparesis to the mouth nor to the median line, which impairs the
sensory-motor integration and the development of the bilaterality. This way, praxic
and corporal activities which need direct or indirect participation of the affected side,
have the limitation originated from the lesioned motor areas (ZOPPA 1998). In this
study, it was observed that the motor difficulties that need refinement and praxia of
the movement, were more difficult in all the tasks, for the group with cognitive
damage. However, In the PC group, where the cognition was preserved, the
difficulties occurred only in those where the construction of the voluntary movement
was involved using the hands distinctively and alternatively. This datum has
expressive diagnostic conformity, considering that lesions in the area 4 of Brodman,
of motor cortex, unbalance the afferent systems of the contralateral hemisphere, and
therefore, activities that needed the employment of the paretic side, was impaired.
So, in the N/CDA group, the expressiveness of the right answers was more
significant, demonstrating that the domain of these functions implies in the
maturation and integrity of the motor and cortical areas, of the hemispheric afferent
paths, and in the integration of the associative areas of the motor, primary and
superior cortex.
The investigation of the functional aspects of the perception, through the
activities of discrimination, detail identification, figure-background perception and
spatial orientation, is related to the structure of the visual perception, of the receptive
fields and the vision projection, of the acuity of the visual adaptation, necessary to
the cerebral interconnective establishment and to the recognition of the essential
characteristics of object comprehension. The parietal, temporal and occipital region
of the left hemisphere is an important area of confluence of information deriving
from the visual, auditive and somestesic analyzers, performing a fundamental role in
the spatial organization of the excitement impulses which arrive to the different
cerebral zones and in the conversion of succeeding stimuli in simultaneously
processed groups (LURIA, 1981, KAJIHARA, 1993). This way, disorders in this area
lead to some difficulties in carrying out simultaneous spatial synthesis, in how to get
403
oriented in space, in distinguishing right from left, and still in understanding

simultaneous spatial relations existing among objects. These aspects were observed,
specifically, in the Raven Progressive Matrices Tests, WISC Weschler Intelligence
Scale for Children, graph-perceptive-motor Bender test and NEP
Neuropsychological Exam.
The occurence of lesions or dysfunctions in the left temporal zone, produces
the disorder of the complex forms of the phonemic hearing (KAJIHARA, 1993). The
results pointed out that, for all children, regardless of the group, the difficulty in
carrying out performing low scores compared to the other results.
This way it is possible to observe the instruments and performances and
verify that most of the tests required phonemic or verbal audition. In the event of
cerebral lesion or functional disorder in the regions responsible for these functions,
some damages were evidenced, to several degrees, in the making of the tests.
The retention and recuperation using word resources, followed by
ideographic symbols, were difficult for all groups, opposing the mnemic evaluation
situation, when using pictographic stimulation. These data reflect the conformity
close to the memory and learning, which depends on the attention, language and
perception, besides the lived experiences. LRIA (1981) affirms that lesions and/or
dysfunctions in the parietal lobe or left occipital-parietal result in difficulties in the
performance of simultaneous synthesis, as the disorder of the memory processes is a
continuation of these gnosic disorders.
The effects of hemispherical, unilateral and bilateral lesions in children of
school age are related specially to language damage. In this study, the data
evidenced expressive difficulties in this area. HAGBERG et al. (1996) reported study
results which indicated bi-hemispherical disfunction in cases of direct damage to
both hemispheres or damage related to the disfunction in the opposite lateral side. It
was suggested that a bigger lesion in the left hemisphere can result in language
compensatory control by the right hemisphere. However, the limited lesion of the left
hemisphere can be of an insufficient degree to cause this compensatory deviation to
the right hemisphere. Although the hemispheres work - to a certain extent
independently - and obtain similar information, there is a parallelism that allows the
effective integration of the function.
CONCLUSIONS
I - In the age range of the subjects of this study, reading, calculations and
language, were some of the tasks with lower performance demonstrating the
difficulties as a result of the neurological disfunction/lesion, added by other aspects,
such as experiencial, psychological ans social matters.
II The mean values obtained by the Groups I-PC/SDM and III-N/CDA, did
not represent statistically significant differences in all the instruments applied. These
findings had evidenced a standard of similar answer between children with lesions
and others without cerebral lesion, being the fact of lesional condition of the
hemiparetical children is not a disadvantage in the development of functions related
to learning. Considering that the hemiparetic children, having the possibility of the
unilateral function preserved, learning areas related to language, memory visuotemporal-spacial perception, reading, writing, numerical ability and cognition, had
the expressiveness of the reply preserved.
404
III Correlated standards of replies among the groups suggest the occurence
of neurological connections derived from the neuronal plasticity, in the lesional
groups.
IV - The II-PC/CDM group paired with III-N/CDA, in tasks related to the
reading and writing. In the aspects related to the expressive language, the groups
had similar scores, however far from the control-group performance.
V - Data evidenced compatibility of motor performance, confirming findings
of the literature, where the child with learning difficulties(LD) presents dyspraxia
and psychomotor disorder, a common characteristic among those with cerebral
lesions.
VI - Prevalence of pre-natal conditions and prematurity as risk factors.
VII - The I-PC/SDM Group, formed predominantly by children with
subcortical lesional factors, presented verbal intelligence (WISC) significantly higher
than the other groups. This finding suggests the action of plastic-regenerative
phenomena of the NS, which are important in the processes of adaptation, that, in a
compensatory way could have decreased the deficits and neurological functions of
these children.
REFERNCIAS BIBLIOGRFICAS
1. LURIA, AR. Higher Cortical Functions in Man. New York. Basic Books:Moscow, 1963.
2. NUNES, T.; BUARQUE, L. & BRYANT, P. Dificuldades na aprendizagem da leitura e escrita:
teoria e prtica. SP: Cortez, 1997.
3. PIOVESANA, A.M.S.G.; CIASCA, S.M. & KIBRIT, A. Aspectos neurolgicos da deficincia
mental e da paralisia cerebral. Infanto-Revista de Neuropsiquiatria da Infncia e
Adolescncia, 6 (supl 1): 7:7-25, 1998.
4. TABAQUIM, M.L.M. Avaliao Neuropsicolgica da criana com hemiparesia congnita.
Arquivos de Neuro-psiquiatria (Sup 1) v.59, set/2001, p.116-117.
5. CIASCA, S.M. Diagnstico dos distrbios de aprendizagem em crianas: anlise de uma prtica
interdisciplinar. Dissertao de Mestrado. Instituto de Psicologia USP: So Paulo,
1990.
6. RAVEN, J.C. Colored Progressive Matrices, Ed. Lewis Co. Ltda, London, 1964.
7. STEIN, L.M. Teste de desempenho escolar.Sp: Casa do Psiclogo, 1994.
8. TABAQUIM, M.L.M. & CIASCA, S.M. Evaluation of the global development of children
with chronic infantile non-progressive encephalopaty. Revista Salusvita Cincias
Biolgicas e da Sade. 2000, v. 19.n.2.
9. WESCHLER, D. Manual for the Weschsler Intelligence Scale for Children. New York:
Psychological Corporation, 1974.
10. ZAZZO, R. Manual para exame psicolgico da criana.SP:Mestre Jou, 1964.
11. DSM-IV. Manual diagnstico e estatstico de transtornos mentais. 4 ed. Porto Alegre: Artes
Mdicas, 1995.
12. UVEBRANT, P. Hemiplegics Cerebral palsy etiology and outcome. Acta Paediatr Scand.
Supl, 1988, p.345.
13. AICARDI, J.J. Epilepsy in brain-injured children. Dev Med Child Neurol., 1990; 32:191-202.
14. MORAIS, AP.M. Distrbios da aprendizagem: uma abordagem psicopedaggica. SP:Edicom,
1986.
15. GERBER, A. Problemas de aprendizagem relacionados linguagem.Porto Alegre:Artmed, 1996.
16. FONSECA, V. Introduo s dificuldades de aprendizagem.Porto Alegre:Artes Mdicas, 1995.
17. BARBIZET, J. & DUIZABO, B. Manual de Neuropsicologia.Porto Alegre: Artes Mdicas,
1985.
405
b. Table 1 Group Characterizations I-PC/SDM e II-PC/CDM

Condition
I-PC/SDM
II-PC/CDM
5
8
Hemiparesis to the left

Hemiparesis to the right
Crural
Brachial
Proportional
Periventricular leucomalacia
Cerebral Vascular Accident
Ischemic
Encephalopathy
7
5
4
3
4
3
Hypoxic 2
CNS Malformation
Amniotic Infection
Cortical Lesion
Subcortical Lesion
Indeterminate Lesion
Bilateral Lesion
Cortical-subcortical Lesion
Pre-natal risk factor
Peri-natal risk factor
Both risk factors
Pre-term Birth
Normal Term Birth
Epilepsy
Visual Deficiency
2
1
5
5
2
2
0
4
3
5
7
5
4
1
8
4
8
2
1
9
1
3
0
5
3
1
1
4
7
5
4
3
11
8
4
406
TABLE 2 Comparasions of the WISC subtests Weschler Intelligence

Scale for Children, among the experimental groups, in relation to the
medium (Md), standard deviation (SD) and the mean (Mn).
PC/SDM
PC/CD
M
N/CDA
8,83
9,50
8,33
SD 2,98
2,24
Mn 9,50
5,06
CF
12,17 7,25
7,67
2,84
3,41
1,48
10,0
5,44
8,00
5,00
2,72
2,31
Mn 4,50
AO
CD
11,00 8,50
10,25 8,33
9,08
3,14
2,45
2,34
2,98
3,00
11,00 7,50
9,25 4,00
8,50
3,56
11,50 8,00
8,00 4,81
10,00 8,50
5,19 3,13
8,50
4,69
3,10
3,94
3,06
2,48
4,08
2,26
3,87
2,33
3,46
5,50
5,00
9,00
4,50
3,50
7,00
4,50
4,00
3,50
4,00
8,35
8,40
7,50
12,10 8,45
5,60
9,70
7,70
10,15 8,85
8,00
3,12
3,62
2,21
2,77
3,30
2,64
2,32
2,39
3,17
3,56
3,11
7,00
7,00
7,00
11,50 8,50
5,00
10,00 8,50
11,00 10,0
8,50
AF
2,58
CB
p = 0,000 0,001 0,003 0,040 0,000 0,002 0,081 0,000 0,000 0,000 0,006
7
1
8
2
3
8
0
9
8
1
8
Subtitles: I (Information); C (Understanding); A (Arithmetic); S (Similarity); N

(Numbers); V (Vocabulary); CF (Figure Completion); AF (Figure
Arrangement); CB (Cubes); AO (Set up Objects); CD (Code).
407
Graph 1 Representation of the comparison of the areas of investigation of the

Neuropsychological Examination among the study group. Areas: mot (motor), rit (rhythm),
sens (cutaneos and kynestesic sensation), perc (perception), LgR (receptive language), LgE
14
12
10
8
6
4
2
0
mot
rit
se ns
pe rc
N/CDA
LgR
PC/SDM
LgE
PC/CDM
LE
me m
arit
cog
N/SDM
(expressive language), LE (Reading and Writing), mem (memory), arit (arithmetics) and cog
(linguistic-cognitive).
TABLE 3 Representation of the mean and standard deviation (SD) obtained by the
experimental groups in the sub-tests of the Neuropsychological Examination.
PC/SDM
PC/CDM
N/CDA
Sub-tests
MEAN
SD
MEAN
SD
MEAN
SD
01
8,91
1,49
6,36
1,92
10,76
1,69
02
7,60
3,95
3,22
3,28
6,98
3,88
03
11,97
1,89
10,91
2,57
12,77
1,56
04
9,14
2,30
6,02
2,57
8,94
2,09
05
9,08
2,20
5,71
2,06
8,56
1,86
06
10,63
2,97
6,02
2,91
9,23
2,77
408
07
7,93
3,86
4,12
2,50
6,09
3,11
08
9,55
2,52
4,57
3,47
9,39
2,55
09
8,68
4,65
3,09
2,93
7,59
4,18
10
7,48
4,22
2,71
2,75
6,37
3,77
409
FP20.6
THE RELATION BETWEEN LANGUAGE DEVELOPMENT AND SOCIAL
SKILLS DEVELOPMENT
Maryam Vahab(1)*,Maryam Faham(2),marzieh Dehghan(3)
1)shyraz university of medical sciences,shyraz,Iran
2)shyraz university of medical sciences,shyraz,Iran
Introduction:
Language and social skills are differentiating characteristics of human kinds
that imply effective roles in improving his quality of life. In developmental process of
a child they help him to be involved in his environment and go through a selfcentered child to a social adult (4).
When we use language for verbal or other forms of communication in fact we
are trying to make connection with our environment thorough our language
knowledge and social competence. We need language, for making ideas in the mind
and talking about them, and social skills for conveying our ideas to the audiences in
the best manner (8). May be it is more correct to say that communication is a social
act (1).
Language development is a complicate process. There are many factors that
been involved in this process and however social environment is one of the most
important7). The child starts to learn language from his environment in an
interacting manner. Mother is the first one that child interact with her. He learns that
each of his act (crying at first) cause a reaction on the mother. This will be continued
until the child development. This act-reaction is the basis of his interaction with the
world (1). On the other hand, having good social competencies are necessary for
being involved in society. As in children with language disorders one of the
difficulties is that the peers dont accept them (5). In school they experience such
problems that will be effective on educational success. So, not just for their language
problems but also for their social skills insufficiencies they have difficulty in social
interactions. So language and social development seem to be connected.
Today studying about relation between language development and social
skills is very important because of its affects on interactional-educational and
treatment affairs (3). However Investigating about this correlation between language
development and social skills development can be helpful in treatment of a child
with language disorders in order to help the child to be more involved in society. We
studied this correlation in 5-6 years old children in order to find if:
There is any correlation between language development and social skills
development?
We do this study on children who seem have had normal language
development because first we need to know about the nature of this correlation in
normal children then apply the results in pathologic fields.
Methods:
This is a descriptive study on 50 Persian speaker children (25 girls, 25 boys) in
the range of 5-6 years old. We choose them in accidental manner. We use TOLD-P3
battery (Newcamer & Hammill-1998) (Persian normalized version-2002) and Vinland
Social Maturity Scale to assess the children (2).
410
TOLD-P3 battery has a two dimensional pattern. One is linguistic features

and the other one is linguistic system. In Table 1 the relation between
concepts of the pattern and subtests of TOLD-P3 battery was shown.
Table 1
Linguistic system
Listening (receptive language)
Organization
(integration skills)
Speaking
language)
Linguistic features
Semantics
Picture vocabulary
Relative vocabulary
Oral vocabulary
Syntax
Grammatic understanding
Sentence imitation
Grammatic completion
Phonology
Word Discrimination
Phonemic analyses
Word articulation
The subtest of semantics and syntax are the main subtests and those of the
phonology are for completing the test. The results of the six main subtests are
compound and form the combination of the scores (spoken language, Listening,
Organization, Speaking, Semantic, and Syntax). This separation between
phonological scores and other scores cause a better discrimination between spoken
competency and language competency. Each subtest is as below (2):
1) Picture vocabulary: consist of 30 items. For example show the examiner says
baby. There are 4 pictures and child should choose the best.
2) Relative vocabulary: consists of 30 items without any pictures. The examiner
says two words and the child express its relation. For example shoes and
socket.
3) Oral vocabulary: consist of 28 items without any pictures. The examiner says
a word and the child explain about it and at least says 2 features of the item to
get the score. For example she says what is an apple? and the child can say
it is a fruit that we eat it.
4) Grammatic understanding: consist of 28 items. The examiner says a sentence
and the child choose the best picture among 3 pictures in front of her/him.
5) Sentence imitation: It consists of 30 items. The child should repeat the same
sentence that the examiner says.
6) Grammatic completion: it consists of 28 items. The child should complete the
sentence that the examiner says.
7) Word discrimination: it consists of 20 items. The examiner says 2 words that
have only one different phoneme like hat/cat. The child should judge if
they are same or not.
8) Phonemic analyses: it consists of 14 items. It examines the ability of word
break up into smaller phonological units.
9) Word articulation: it consists of 20 items. The examiner shows a picture and
explains about it and then child should say the name of it. For example the
examiner show picture of bicycle the examiner explain that we ride it the
child say bicycle. It shows childs phoneme articulation abilities.
As we said the subtests with regard to their systems and shared features can
be compound make these clusters:
1) Listening (Picture vocabulary + grammatic understanding)
411
(expressive
2) Organization (Relative vocabulary + Sentence imitation)

3) Speaking (Oral vocabulary + Grammatic completion )
4) Semantic (Picture vocabulary + Relative vocabulary + Oral
vocabulary)
5) Syntax(Grammatic understanding + Sentence imitation + Grammatic
completion)
6) Spoken language(Picture vocabulary + Relative vocabulary + Oral
vocabulary + Grammatic understanding + Sentence imitation +
Grammatic completion)
With this battery we can find and measure children language competencies. It
takes 15-20 minutes for main subtests and 20 minutes for completing subtests. The
child has 10 second to answer the question and get the score (=1) if he doesnt the
examiner go through the next item and the score is 0. If the child get 5 continues 0 the
examiner stops that subtest and starts the next subtests but in completing subtests
the examiner give all the item to the child. For each child there is a chart that gives us
his scores and quotients so that we can interpret it according to the normalized data
that are in reach at the end of the battery book.
For social skills we use The Vinland Social Maturity Scale. It measures social
competence, self-help skills, and adaptive behavior from infancy to adulthood. It is
used for therapy and/or individualized instruction for persons with mental
retardation or emotional disorders. The Vinland Scale, which can be used from birth
up to the age 30, consists of a 117-item interview with a parent or other caregiver.
Personal and social skills are evaluated in the following areas: daily living skills
(general self-help, eating, and dressing); communication (listening, speaking, and
writing); motor skills (fine and gross, including locomotion); socialization
(interpersonal relationships, play and leisure, and coping skills) occupational skills;
and self-direction. The test is untimed and takes up to 30 minutes. Raw scores are
converted to an age equivalent score expressed as social age and a social quotient.
For data analyzing we use descriptive analyzing (Mean and Standard
deviation) statistical inference, simple correlation coefficient and T-test for
nomination of the differences between groups.
ETHICS:
1. We send a letter to the parents and explain all steps of the test. If they were
agreeing to be involved in the test, they send back the letter.
2. If the child didnt like to answer the question we exclude him and tell to the
parents.
3. We have a break among doing the main subtests and complement subtests
and allow the child to play with the examiner.
Results:
Mean and standard deviation of girls and boys scores on Language test are
shown at Table2. The mean was 10 and standard deviation was 3.
412
Table 2:
Language subtests
Picture vocabulary
Relative vocabulary
Oral vocabulary
Grammatical
understanding
Sentence imitation
Sentence completing
Discrimination
Phonological analyses
Word articulation
Girls(N=25)
Boys(N=25)
Mean
9.60
13.20
11.52
11.80
SD
4.12
2.10
1.78
2.40
Mean
8.60
13.32
11.96
11.76
SD
3.47
1.97
2.71
2.38
15.80
11.84
12.24
9.76
11.32
2.27
2.46
1.36
2.68
2.82
15.48
12.48
11.25
9.48
9.72
2.48
2.50
2.77
3.12
2.31
The Mean and SD of the linguistic features and systems are shown at Table 3
&4:
Table 3: mean and SD of the language development subgroups scores
language development Girls(N=25)

subgroups
Mean
Semantic
34.32
Syntax
39.40
Listening
23.40
Organization
29.00
Speaking
23.36
Spoken language
73.32
Boys(N=25)
SD
4.99
5.63
6.92
2.84
3.61
10.32
Mean
34.72
39.72
21.16
28.80
24.44
74.28
SD
7.13
6.15
5.52
3.52
4.94
12.33
Table 4: mean and SD of the language development subgroups quotients:
language development Girls(N=25)

subgroups
Mean
Semantic
108.08
Syntax
118.12
Listening
106.16
Organization
125.72
Speaking
108.76
Spoken language
113.68
Boys(N=25)
SD
9.27
11.46
15.33
8.45
9.46
10.62
Mean
108.92
118.76
101.88
124.92
110.88
114.60
SD
13.16
12.65
14.18
10.12
14.30
12.67
In Table 5 the correlation matrix of language development and social

development scores are shown. For more comforting view each item gets a number.
413
Table 5: correlation matrix of language development and social development scores
Tests
1
2
3
1
1
0.70
0.38
4
5
6
7
8
9
0.48
0.71
0.71
0.75
0.07
1
0.017
0.43
0.43
0.31
0.36
0.13
0.47
0.20
0.04
0.18
0.08
0.56
0.20
0.24
1
0.43
0.62
0.64
0.10
0.58
10
0.37
Social
0.54
development
*P<0.01
0.19
0.19
0.08
0.39
0.28
0.39
1
0.47
0.42
0.15
1
0.54
0.86
0.29
0.52
1
0.08
0.56
0.38
0.58
0.33
0.41
0.28
0.38
10
1=language development
3=relative vocabulary
5=grammatic understand
7=grammatic completion
9=phonemic analyzes
1
0.14
0.28
0.07
1
0.53
0.46
1
0.40
2=picture vocabulary
4=oral vocabulary
6= sentence imitation
8=word discrimination
10=word articulation
Positive correlation between language development and social skills

development (r=54%) is clear that is significant in P<0.001.
For detailed investigation we represent correlation matrix between language

development clusters and social development in Tables 6&7.
Table 6: correlation matrix between language development clusters and social development
Tests
Spoken
Listening organization speaking
semantics
syntax
language
Spoken
1
language
Listening
0.53
1
organization 0.76
0.22
1
speaking
0.84
0.31
0.70
1
semantics
0.83
0.58
0.60
0.67
1
syntax
0.87
0.38
0.73
0.84
0.53
1
Social
0.54
0.23
0.56
0.43
0.29
0.56
developmen
t
Social
development
Correlation matrix declared that social development scores have positive

correlation with spoken language, organization, semantics, syntax; they are
significant (P<0.05) but in listening this is not significant (P>0.05)
Table 6: correlation matrix between social development items and language development
Tests
general
self-help
general self-help
self-help
in
dressing
self-help
in eating
Communication
motor
skills
selfdirection
socialization
Social
development
414
Language
development
self-help
in
dressing
self-help
in
eating
communication
motor skills
self-direction
socialization
Social
development
Language
developmet
0.04
0.43
0.48
-0.22
-0.32
0.30
0.41
0.06
0.28
-0.05
0.10
-0.16
-0.08
0.21
-0.18
-0.18
-0.02
-0.26
1
-0.48
0.37
-0.17
0.25
1
-0.40
-0.04
-0.46
1
0.08
0.27
1
0.22
-0.06
0.15
-0.17
0.06
-0.38
-0.06
0.22
0.54
As shown in table 7 the correlation between social and language development

is positive and significant (P<0.01).
We didnt find any differences between girls and boys in these tests.
Conclusion:
Language development has significant correlation with social skills. This
means that by improving in language competence the social skills (according to
Vinland Scale) improve too. All language development subtests explain about how
using and understanding language, so social linguistics attend to pragmatics feature
of language. People and environment around the child effect on his pragmatics (5).
Hence those children who getting higher scores in language development also get
higher scores in social development. This positive correlation should be considered
in language disorders treatments and child's upbringing because these findings can
tell us that delay in language development can cause social insufficiencies (6).
REFRENCES:
1. Gallagher, T.M. (1993)." Language Skill and the Developments of Social Competence
in School age Children". Language ,Speech , and Hearing services in school , 2,199205.
2. Hasan zade,S, Minayi A (2002). Adaptation and Normalize TOLD-P3 Test for
Persian Language. Special Educations Association, Tehran, Iran.
3. Marton,k., Abramoff,B.,Rosenzweiog, sh.(2004)."Social Cognition and Language in

Children with Specific Language Impairment (SLI)," Journal of Communication
DSisorders , 38. 143-162.
4. Mc Leod sh.(2007)."The international Guide to speech acquisition .Clifton Park, NY.

Thomson Delmar Learning. First Edition.
5. Paul,P.V. (2009). "Language and Deafness. Fourth Edition. JONES AND BARTLETT
PUBLISHERS , Sudbury Massachusette.
6. Robertson,Sh.B.& Weismer,S.E., (1999)." Effect of Treatment on Language and Social

Skill in Toddlers with Delayed Language Development ." Journal of speech language
, and hearing research , 42,5;1234-1249.
7. Seyf S, Et.al (2008) . Developmental Psychology. Tehran .S.A.M.T Publication.

8. Zandi ,B(2005). Language Learning. Tehran .S.A.M.T Publication.
415
416
SY05.6
A HOME LITERACY STRATEGY TO SUPPORT YOUNG CHILDREN
WITH DOWN SYNDROME

A K. van Bysterveldt1,2, G.T. Gillon1, S.Foster-Cohen2
1University of Canterbury, Christchurch, New Zealand
2Champion Centre, Christchurch, New Zealand
Phonological awareness and letter knowledge are recognized as critical

factors for early reading and spelling development (e.g. Anthony & Lonigan, 2004)
yet controversy exists regarding the importance of these skills in early reading and
spelling development of children with Down syndrome (DS) and little research into
the effectiveness of phonological awareness intervention for this population. Many
factors influence the development of phonological awareness including the home
environment and family interactions. A home literacy strategy is vital to enhance the
home literacy environment (HLE) for young children, especially for children at risk.
Investigations into the influence of the HLE on emergent literacy skills have typically
included pre-school children, but its influence on these skills in school aged children
with DS has yet to be examined. Print referencing techniques have been shown to be
an appropriate and effective way of facilitating print concepts, alphabet knowledge,
phoneme awareness and name writing ability in young children, including preschool children with DS, children with communication impairment and children
who are socially or economically disadvantaged (Ezell, Justice, & Parsons, 2000;
Justice, Kaderavek, Fan, Sofka, & Hunt, 2009; van Bysterveldt, Gillon, & Moran,
2006). The suitability of these techniques for school-aged children with DS with
emergent literacy skills is an area which clearly requires further investigation. The
current study sought to address these issues by examining the HLEs of young
children with DS and the effectiveness of a home literacy strategy as part of an
integrated intervention designed to simultaneously facilitate speech and early
literacy development in this population.
METHODS AND RESULTS:

This study investigated the HLE of 85 children with Down syndrome (DS).
The children were 38 girls and 47 boys aged from 5;4 to 14;11 (M = 8;11, SD = 2;6)
who attended mainstream schools (64 participants) and special schools (21
participants) from around New Zealand representing a range of socioeconomic level
(New Zealand. Ministry of Education, 2007). Survey data were gathered via parent
questionnaire. Parents reported on their priorities for their childs literacy
development and the ways in which this development was facilitated in the home.
Parents also reported on the frequency and duration of literacy interactions with
their child and the ways in which their child participated in these.
Supporting their childs literacy development was reportedly a high priority,
with 90% of parents reading with their child and nearly half of all parents reported
spending time every day reading together with their child. The majority beginning to
read together when their child was a baby however nearly one in five parents
417
reported their child was aged between 2 and 5 years when they began reading
together with them. Progress in International Reading Literacy Study (PIRLS,
2005/2006) (Mullis, Martin, Kennedy, & Foy, 2007) report revealed high numbers of
books in the homes of typically developing New Zealand 4th grade average children.
The PIRLS figures are consistent with reported book ownership in the current study
where on average children owned between 50 and 75 books.
One quarter of parents also reported playing language games and 61%
reported actively teaching their child letter names and sounds, important underlying
skills for later literacy acquisition. There is a substantial body of research which
demonstrates that HLEs which feature frequent exposure to joint book reading and
where parents engage in explicit teaching of letter knowledge and concepts of print
are associated with improved reading outcomes for children (Snchal & LeFevre,
2002; Snchal, LeFevre, Thomas, & Daley, 1998). However, in the current study
many children had yet to acquire these prerequisite skills with parents reporting 48%
of children did not yet know all letter names and 68% did not yet know all letter
sounds. Children were more engaged with pictures than with text, and many were
reported to never or rarely verbally participate during story telling activities.
Intervention studies investigating the role of parents in facilitating their childs active
participation in shared reading, using a dialogic reading technique, demonstrated
gains in expressive language by children who received the intervention, with active
rather than passive participation in a shared book reading activity resulting in
greater improvement on childrens vocabulary measures (e.g. Hargrave & Snchal,
2000; Whitehurst et al., 1988).
Given the contribution of the HLE to literacy development reported in the
literature, these findings highlight the need for a home literacy strategy to enhance
the HLE for children with DS. To address this need, the effectiveness of an integrated
intervention that incorporated a home literacy component was examined.
Participants were 10 children (5 girls and 5 boys) with DS aged 4;4 to 5;5 (M= 4;11)
who attended a transition to school clinic at a specialist early intervention centre. The
experimental integrated intervention aimed to simultaneously facilitate speech and
early literacy development and included three components: a parent implemented
home programme, and early intervention centre-based speech therapy and learning
through computer sessions. The intervention was presented at the early intervention
centre in two six-weekly cycles separated by a six week break, however the parent
implemented home programme continued right throughout the 18 week intervention
period.
Within the parent implemented home programme parents used print
referencing techniques at home to bring their childs attention to targeted letters and
sounds during joint story book reading, four times per week for 10 minutes per
session throughout the 18 week intervention period, equating to 12 hours in total.
These targeted letters formed a particular focus of the parents print referencing
component.
Prior to the intervention, parents attended an information and training
evening outlining the three components of the intervention and detailing the parent
print referencing techniques. The parent training procedures followed the same
format as for the print referencing pilot study (van Bysterveldt et al., 2006) whereby
parents viewed a videotape of a parent working with her child with DS,
demonstrating the intervention techniques. Parents practiced the techniques in pairs
or small groups and received feedback from the researcher. Written information was
also given, along with a laminated prompt sheet specifying the three key parts of the
technique: letter name, letter sound, first/last sound in a word. Parents also received
418
training in suitable book selection to maximise the opportunities for using the print
referencing techniques. One parent who was unable to attend the training evening
received a training session in her own home. Parents understanding and application
of the print referencing techniques was also discussed with an experienced speech
therapist on a weekly basis the intervention. While their main focus was to be on the
target letters and sounds, parents were instructed to include references to nontargeted letters and sounds when for example, the child pointed to a non-target letter
or misidentified a non-target letter or sound.
Parents were videotaped administering the print referencing techniques
between 2 and 4 times and received feedback during the intervention period after
any which parents were given further opportunity to demonstrate correct
administration of the print referencing protocol. Additionally, 23 videotaped sessions
of parents delivering the intervention were viewed by an independent reviewer
trained in the print referencing protocol. The reviewer recorded that nine of the ten
parents consistently and accurately implemented the intervention as per their
training. One parent however did not consistently use all three strategies in one
session, that is, they may have pointed out a letter name but did not identify the
letter sound or the letter in a word. Additionally the parent frequently required the
child to repeat the text in the story, which was not part of the protocol. Despite
additional training feedback the parents implementation of the protocol remained
inconsistent.
Parents completed a weekly report with an experienced speech-language
therapist. While all parents reported they abandoned at least one session due to noncompliance during the intervention period, all reported completing four 10 minute
sessions of print referencing per week for the full 18 week period. Print referencing
sessions were largely presented by mothers; 100% in six families, 90% in three
families and 70% in the remaining family. Seven of the reviewed sessions
(approximately 30%) were affected or abandoned due to interaction breakdowns
including screaming, grabbing the book, running away, and refusing to listen to the
story.
All parents reported occasional reference to non-target letters and sounds.
Occurrences most frequently involved the initial letter in the childs or siblings
names and the names of favourite book characters.
Children were assessed on measures of speech, phonological awareness and
letter knowledge using standardised and experimental measures at pre- and post
intervention and at follow-up after they had received 2 terms (approximately 20
weeks) of formal schooling. All participants made significant gains on speech
measures post-intervention, however there was considerable variability between
participants speech production skills both pre- and post-intervention. Standardised
speech assessment results revealed percent consonant correct- revised (PCC-R) at
pre-intervention ranged from 22.4% to 76.1%. Selection of childrens target sounds
was made on the basis of this initial assessment. Correct production of childrens
target sounds at pre-intervention ranged from 8.3% to 54.3% and from 41.9% to
78.0% at post-intervention. Participants response to intervention on measures of
speech production was found to be independent of receptive language, age or
hearing thresholds. At follow-up, eight participants demonstrated continued speech
gains.
Two children had strong letter knowledge at pre-intervention and five
showed improvement in letter knowledge at post-intervention. Although
participants also showed increased awareness of initial phonemes in words at postintervention, all scores were still below chance. Continued growth in letter
419
knowledge and awareness of initial sounds in words was apparent at follow-up

assessment, with five children showing evidence of transfer to real word decoding
and three showing evidence of transfer to real word spelling. Transfer was associated
with receptive language skills.
DISUSSION/CONCLUSION:
Results at post-intervention and at follow-up support the claim that an
integrated intervention which combines a home literacy component with traditional
therapy to simultaneously facilitate speech and early literacy development is
effective for young children with DS. These results also suggest that in order to
achieve the prerequisite letter knowledge or phoneme level skills to facilitate
independent reading (Share, 1995), children with DS may require an instructional
approach in which the links between spoken and written language are more explicit
and integrated than they currently appear to receive and that home literacy strategy
utilised in the current study may provide one such approach.
Anthony, J., & Lonigan, C. (2004). The nature of phonological awareness: Converging
evidence from four studies of preschool and early grade school children. Journal of
Educational Psychology, 96(1), 43-55.
Ezell, H. K., Justice, L. M., & Parsons, D. (2000). A clinic-based book reading intervention for
parents and their pre-schoolers with communication impairment. Child Language
Teaching & Therapy, 16, 121-140.
Hargrave, A. C., & Snchal, M. (2000). A book reading intervention with preschool children
who have limited vocabularies: The benefits of regular reading and dialogic reading.
Early Childhood Research Quarterly, 15(1), 75-90.
Justice, L. M., Kaderavek, J., Fan, X., Sofka, A. E., & Hunt, A. (2009). Literacy development
through classroom-based teacher-child storybook reading and explicit print
referencing. Language, Speech and Hearing Services in Schools, 40, 67-85.
Mullis, I. V. S., Martin, M. O., Kennedy, A. M., & Foy, P. (2007). IEA's Progress in
International Reading Literacy Study in Primary School in 40 Countries
New Zealand. Ministry of Education (2007). Deciles information. Retrieved August 20, 2007,
from
http://www.minedu.govt.nz/index.cfm?layout=document&documentid=7693&data
=l
Snchal, M., & LeFevre, J. (2002). Parental involvement in the development of children's
reading skills: A five-year longitudinal study. Child Development, 73(2), 445-460.
Snchal, M., LeFevre, J., Thomas, E. M., & Daley, K. E. (1998). Differential effects of home
literacy experiences on the development of oral and written language. Reading
Research Quarterly, 33(1), 96-116.
Share, D. (1995). Phonological recoding and self-teaching: Sine qua non of reading
acquisition. Cognition, 55, 151-218.
van Bysterveldt, A. K., Gillon, G. T., & Moran, C. (2006). Enhancing phonological awareness
and letter knowledge in preschool children with Down syndrome. International
Journal of Disability, Development and Education, 53(3), 301-329.
Whitehurst, G. J., Falco, F. L., Lonigan, C. J., Fischel, J. E., DeBaryshe, B. D., Valdez-Menchaca,
M. C., et al. (1988). Accelerating language development through picture book
reading. Developmental Psychology, 24(4), 552-559.
420
FP40.3
DYSLEXIA +: FACT OR FICTION? COMORBIDITY IN LEARNING
DISABILITIES
R. Vanderswalmen1, J. Van Borsel2, A. Desoete1+2,
1 University College Arteveldehogeschool Ghent
2 Ghent University
(*)Introduction and aims of the study: Dyslexia is a developmental
condition, characterized primarily by sever difficulty in the mastery of reading
despite average intelligence and adequate education (e.g., Grigorenko, 2001). The
percentage of school-age children having dyslexia ranges from 1% (in Japan and
China) to about 20% in English-speaking countries and between 2 and 10% in the
Dutch speaking population (e.g., Grigorenko, 2001; ). Co-morbidity refers to the cooccurence of one or more diseases or disorders in an individual. Language disorders,
dyscalculia and Attention Deficit Hyperactivity Disorder (ADHD) are common
called in association with dyslexia. In addition across studies, around 25-40% of
children with dyslexia also meet criteria for ADHD (Dyckman & Ackerman, 1991,
Semrud-Clikeman et al., 1992; Wilcutt & Pennington, 2000). In literature several
hypothesis for the causes of comorbity between two disorders are made (Klein &
Riso, 1993;, Neale & Kendler, 1995). According to the fenocopy model the first
disorder produces a copy of the second disorder (e.g., Pennington et al., 1993) and
the symptoms of the comorbid group are equal to one of the two groups. The Three
Independent Disorders model (also called cognitive subtype hypothesis), explains
comorbidity as a separate condition and disorder (e.g., Rucklidge & Tannock, 2002).
The comorbid group performes significantly worse than the single-disorder groups.
The model of Correlated Liabilities shows there is a continuous relationship between
the liability to one disorder and the liability to the second disorder. The comorbidity
group should have the deficits of both groups (Rhee, 2005).
Controls
First
Disorder
Second
Disorder
Comorbid
group
Fenocopy hypothese
Model of Correlated Liabilities
b+b
Cognitief subtype hypothese
> 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
421
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, Nol & 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; p<.05). On the univariate level, children with dyslexia scored
significantly lower on the reading of existing words (F (3,147)=46,04; p<.05) and on
the reading task of non-existing words (F (3,147)=45,04; p<.05) as well as on the
spelling task(F (3,147)=41,75; p<.05) but not on comprehensive reading task (F
(3,147)=1,79; p=NS)). Post-hoc analysis revealed no significant differences between
the three clinical groups.
Controls
M (SD)
Technical Reading 10.02 (1.93)a
(existing words)
Technical Reading 10.79 (1.98)a
(non-existing
words)
Reading
50.19 (29.50)a
Comprehension
Spelling
46.40 (26.58)a
Dyslexia
M (SD)
4.53 (2.50)b
Dyslexia
dyscalculia
M (SD)
6.20 (3.37)b
+ Dyslexia
ADHD
M (SD)
4.32 (3.16)b
5.74 (2.36)b
7.50 (3.36)b
5.68 (2.72)b
45.04*
39.32 (26.97)b
36.40 (23.72)b
43.88 (31.75)b
1.79
6.15 (10.94)b
12.20 (23.92)b
7.60 (17.18)b
41.75*
422
F (3,147)
46.04*
* = p<.05
a, b = post-hoc indexes
Table 2: Results on the reading en spelling tests
To compare the mathematic skills of the children a MANOVA was conducted
with the results on the TTR and three subscores (of the Tedi-Math as dependent
variable and the group as independent variable. The MANOVA was significant on
the multivariate level ( F (4, 148) = 5,12; p<.05). Children with dyslexia performed
significantly worse on automatisation (F(3,151) = 14,54; p<.05), the dealing with
number words (F(3,151)=13,71; p<.05) and the exercises on Arabic Numbers
(F(3,151)=4,24; p<.05). Post-hoc analyses showed no difference between the three
clinical groups. There was no difference between the groups on non-symbolic
magnitiude comparision (F(3,151)=1,44; p=.NS).
Controls
Dyslexia
M (SD)
54.32 (28.66)a
M (SD)
28.06 (23.38)b
Dyslexia
+ Dyslexia
+ F
dyscalculia
ADHD
(3,151)
M (SD)
M (SD)
25.74 (23.53)b
22.30 (25.36)b
14.54*
76.79 (32.42)a
56.19 (38.63)b
49.61 (42.55)b
56.83 (42.36)b
4.24*
Number words
68.54 (29.64)a
43.17 (30.48)b
32.22 (32.03)b
30.57 (28.90)b
13.71*
Magnitude
Comparison
17.57 (1.46)
17.6 (0.99)
17.04 (1.52)
17.17 (1.47)
1.44
Automatisation
(TTR)
Arabic
Numbers
* = p<.05
a, b = post-hoc indexes
Table 3: Results on mathematical tests
(*)Conclusions:
The prevalence of comoribidity in dyslexia in Flanders is similar as the
percentages found in international literature. In 60% of the children dyslexia was not
an isolated disability. ADHD and dyscalculia were present in almost one out off
three children with dyslexia.
There was no significant difference between the children with isolated
dyslexia (and no comorbid disorders) and the children with dyslexia and ADHD or
dyslexia and dysalculia, neither on reading, writing or mathematics tasks. These
results are in line with the fenocopy hypothesis since the scores of the comorbid
group were equal to the scores of the isolated dyslexia group.
In mathematics the dyslexia groups differed from the age-matched controle
children on automatisation. This could point to a more general automatisation
problem in children with dyslexia. In addition we also found significant differences
between the control group and the clinical groups on the symbolic comparison tasks
but not on the non-symbolic task
The results of this study indicate that co-morbidity is more rule then
exception. So it seems important to go beyond just looking for reading and writing in
children with dyslexia. The assessment should also focus on the mathematical skills
as well as possible attention and concentrationproblems to gauge comorbid
disabilities as dyscalculia and ADHD. The results are in line with the fenocopy
423
hypothesis, since
isolated dyslexia
appropriate care
multidisciplinary
with dyslexia.
the scores of the comorbid group were equal to the scores of the
group. Still children with dyslexia and ADHD or dyscalculia need
which takes into account all disorders. Our results urge for a
and integrated approach in diagnostics and guidance of children
Aarnoutse, C. (1996). Begrijpend Leestest Aarnoutse. Harcourt. Amsterdam

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders.
Fourth Edition. American Psychiatric Association: Amsterdam.
Brus, B.Th. & Voeten, M.J.M. (1997). En Minuut Test (EMT) Harcourt: Amsterdam.
Cornoldi, C., Venneri, A., Marconato, F., Molin, A., & Montinaro, C. (2003). A rapid screening
measure for the identification of visuospatial learning disability in schools. Journal of
Learning Disabilities, 36, 299-306.
De Vos, T., (1992). Tempo Test Rekenen (TTR). Harcourt: Amsterdam
Dyckman, R.A. & Acerman, P.T. (1991). Attention deficit disorder and specific reading disability:
separate but often overlapping disorders. Journal of Learning Disabilities, 2 (2), 96-103.
Geelhoed, J. & Reitsma, P. (1999). PI-dictee. Harcourt: Amsterdam
Grgoire, J., Nol, M.-P., Van Nieuwenhoven, C., Desoete, A., Roeyers, H., & Schittekatte, M.
(2004). TEDI-MATH. Harcourt: Amsterdam.
Grigorenko, E.L. (2001). Developmental Dyslexia: An Update on Genes, Brains and Environments.
Journal of Child Psychology Psychiat, 42 (1), 91-125.
Klein, D.N. & Riso, L.P. (1993). Psychiatric disorders: problems of boundaries and comorbidity. In
C.G. Costello (Ed.), Basic issues in psychopathology. New York: Guilford Press.
Neale, M.C. & Kendler, K.S. (1995). Models of Comorbidity for Multifactorial Disorders. American
Journal of Human Genetics, 57 (4), 935-953.
Pennington, B.F. (2006). From single to multiple deficit models of developmental disorders.
Cognition, 101, 385-413.
Pennington, B.F., Groisser, D. & Welsh, M.C. (1993). Contrasting cognitive deficits in attention
deficit hyperactivity disorder versus reading disability. Developmental Psychology, 29,
511-523.
Rhee, S.H., Hewitt, J.K., Corley, R.P., Wilcutt, E.G. & Pennington, B.F. (2005). Testing
Hypotheses Regarding the Causes of Comorbidity: Esamining the Underlying Deficits of
Comorbid Disorders. Journal of Abnormal Psychology. 114 (3), 346-362.
Semrud-Clikeman, M., Biederman, J., Sprich-Buckminster, S., Lehman, B.K., Faraone, S.V., &
Norman, D. (1992) Comorbidity between attention deficit hyperactivity disorder and
learning disability: a review and report in a clinically referred sample. Journal of the
American Academy of Child and Adolescent Psychiatry, 31 (3), 439-448.
Van den Bos, K.P., Spelberg, H.C., Scheepstra, A.J.M., & de Vries, J.C. (1998). De Klepel
pseudowoordentest. Harcourt: Amsterdam.
Wilcutt, E.G. & Pennington, B.F. (2000). Comorbidity of reading disability and attention
deficit/hyperactivity disorder: differences by gender and subtype. Journal of
LearningDisabilities, 33, 179-191.
424
FP05.4
TEST OF RECEPTIVE AND EXPRESSIVE LANGUAGE ABILITIES
PRELIMINARY DATA OF GREEK PRESCHOOL AGE CHILDREN
Ioannis Vogindroukas, Evmorfia Grigoriadou
Medicopedagogical Center of North Greece, Psychiatric Hospital of
Thessaloniki
Elementary Special School for Deaf and Hard of Hearing Children,
Thessaloniki
Introduction and aims of the study The Test of Receptive and Expressive
Language Abilities (Vogindroukas, Grigoriadou 2009) is an evaluation test for
young children and pupils with language and communication difficulties. The goal
of the test is to determine specific problematic developing language issues in
children with communication disorders and to use the results in order to plan a
therapeutic schedule. The structure of the test follows the developmental stages of
typically developing children and it consists of six developmental parts. The first
part is the Preverbal stage which focuses on play and social communication
abilities, the second part is the One Word stage, which focuses on cognitive abilities
regarding the functional level of the child, the third part is the Two Words stage,
which focuses on the receptive and expressive language level, the next part is the
Three Words stage and the last two parts are the Early Grammar stage and the
Advance Grammar stage which focus on the specific features of Greek Grammar
and on fields of language such as pragmatic and narrative abilities. A number of
cognitive abilities such as the knowledge of colors, sizes, the classification of
concepts and reasoning skills are also included. Methods: The Test of Receptive and
Expressive Language Abilities was used with a group of typical developing children.
The group included 160 children with an average age of 58 months. Results:. In
general all the items of the test are succeeded by the sample of the study. Difficulties
were found in the story sequencing, passive voice expression, the use of beside
and between and in the use of third declination of singular number of nouns.
Conclusions: The benefits of the test are discussed.

Introduction
Child language development is one of the most crucial fields of human
communication sciences. The specific ways which are used by the children in order
to develop language is in the interest of a great number of researchers all over the
world. There are a huge amount of tests used in this field. The Greek language is one
of the least researched languages due to lack of University Departments specifics in
the field of human communication sciences,but this was the case until 1999. Over
the last decade, though, different teams of researchers have tried to adapt or even to
create specific tests on the development of Greek language. Examples of such tests
are the Phonological and Phonetics Tests (Research Team of Panhellenic
Association of Logopedics 1999), Anomilo 4 (Research Team of Panhellenic
Association of Logopedics 2005) , METAPHON (Giannetopoulu, Kirpotin 2007) ,
Test of Speech and Language (Oikonomou, Mpezevegkis, Milonas, Varlokosta 2007)
Test of Expressive Vocabulary (adaptation of Word Finding Test, Renfrew 1995)
(Vogindroukas, Protopapas, Sideridis 2009) and the Test of Receptive and
425
Expressive Language Abilities (TRELA) (Vogindroukas, Grigoriadou 2009). The

reasons why these tests are useful, in each language, are well known. Their use
permits the specialists to diagnose the impairments, to evaluate the level of language
for each child and to plan the therapeutic program, accordingly. TRELA has been
structured with this aim in mind. It consists of an evaluation test for children with
language and communication difficulties. The goal of the test is to determine the
problematic developing language aspects of children with communication
disorders and to use the results in order to plan the most precise and
individualized therapeutic schedule for each child. The structure of the test follows
the developmental stages of typically developing children and it consists of six
developmental parts.
The first part consists of the Preverbal stage which focuses on the play
abilities and social communication abilities. The second part is the One Word stage,
which focuses on cognitive abilities regarding the functional level of the child. The
third part is the Two Words stage, which focuses on the receptive and expressive
language level. The next part is the Three Words stage and the last two parts concern
the Early Grammar stage and the Advance Grammar stage. These two focus on the
specific features of Greek Grammar and on the fields of language which are regarded
as pragmatics abilities and narratives. Through the different stages referred to
there are inserted some cognitive abilities such as knowledge of colors, of sizes,
classification of concepts and reasoning skills. TRELA evaluates the receptive and
expressive ability in all six stages. For each stage there are protocols provided with
the appropriate information for the examiner and instructions for the evaluation. It is
up to the examiner to choose the appropriate protocol which will be used through
the clinical observation. If, for example, a child has no speech at all or its speech is
extremely poor, then the examiner should use the first and second protocols that
focus on play development, non verbal communication and behavior and on the
one word stage, respectively. But if the child has well developed speech then the
examiner should use the Advanced Grammar stage which evaluates personal
pronouns, possession, pragmatics abilities and narrative. The application of the test
covers the age range of between 12 months and 6 years in typically developing
children and can also be used for all ages if there is a developmental disorder. The
first stages use materials that include different sets of toys, single objects and single
pictures of objects and verbs. From the two words stage the examiner uses the
picture book which presents each item of the test on a different page. Each page
contains four pictures. The examinee is asked to listen to and point at the designated
picture ( two pictures are asked for) in order to assess the receptive ability. The
expressive ability is assessed immediately after by asking the child to name the other
two pictures. At the end of the assessment the examiner fills in the Ability Profile,
where all the pass, failed and emerged items are to be collected and noted. In this
way the examiner has all the appropriate information about the examinees skills
and failures on the levels that language has been assessed. Collected information
helps the examiner to first clarify if the difficulty of the examinee lies in social
communication problems, cognitive problems or language problems. Secondly, he
gets information on the level of the examinees functioning (object, picture, abstract
language level). The third point is to evaluate the emerging abilities and skills in
order to use them in the therapeutic program and fourth is to help him to determine
which adaptations have to be made for the specific difficulties of a child (level of
attention, way of learning, alternative ways of communication for better
understanding, the way of presenting the materials e.t.c). Recently, the receptive
scale of TRELA has been used in comparison to the Preschool Language Scale -3
426
(PLS 3), in order to determine the adequacy of TRELA in the assessment of

language skills. The results show a great correlation between the two instruments
and the researchers conclude that TRELA is an appropriate instrument for the
assessment of
receptive language skills in the Greek language (Xanthou,
Fountoulaki 2010).
There are few studies on language development in preschool age Greek
speakers. Some of them give useful information about the specific features of Greek
language development. Regarding morphological development, it is well known that
Greek preschool age children have a great number of morphemes which are used
correctly, although it is clear that Greek children during this period are not able to
recognize and separate the morphemes in the word (Kati 1992). According to a
relative study (Vogindroukas 2000), in Greek preschoolers from the age of 30 months
to the age of 54 months, morphemes of regular and irregular verbs in active and
passive voice have been observed, in all persons and in Simple Present, Simple Past
and in Future tenses. Concerning nouns, morphemes in all declinations and in all
numbers have been noted. There are also definite and indefinite articles, morphemes
related to adjectives in all genders, adverbs, causative conjunctions and personal and
possessive pronouns. Difficulties, though, appear with the third person of plural
in male and female gender of possessive pronouns. The study of TheofanopoulouKontou (1973), underlines a difficulty in the development of the plural in the
male gender. Reference is made to the fact that the Greek children may develop this
type of morpheme in some cases at the age of 78 months. Related results are also
referred to in the study of Porpodas (1999), that show that the Greek preschoolers
develop at about 72 months of age the numbers of the nouns and the verbs, the
declinations and the personal pronouns.
In relation to syntaxes the phrases appear simple and early in life, they
developed in paratatctic axis in the beginning and later they became anaphorical
(Kati 1992, Pita 2001). In the same period the negative sentences appear and there
is a difficult point regarding the use of negatives in grammar. In Greek, two words,
den and min are used to refer to the notion of the negative but in a specific
structured way . The Greek children replace the word den by the word min
which is not correct and that shows the difficulty they experience in understand
this specific syntactical rule (Pita2001).
According to Pita (2001) the development of syntax is not completed until 72
months of age in Greek preschoolers. Until this age the development of grammar
rules for agreement subject predicate and the declination system of personal
pronouns are not yet completed.
Two studies on pragmatic abilities in Greek language focus on the preschool
age of development (Nisioti 1994, Vogindroukas2002). Both studies show the same
results according to pragmatic abilities in children with a mean age of 66 months.
Difficulties in the development were found at the levels of greetings, conversation,
humor and trading. In comparison to related results in other civilizations there are
differences in the use of thank you and please. Greek children at this age dont
use the above words systematically.
The aim of this paper is to present the preliminary results of TRELA, used
in two groups of Greek children with typical development at preschool age. The
used stages go from the Two words stage to the Advance grammar stage. The
preliminary results are expected to further the understanding of the acquisition
of Greek language.
427
Method
Participants
The Test of Receptive and Expressive Language Abilities was used in a
group of typically developing children. The group included 160 children with the
average age of 58 months. 80 of them were boys and 80 were girls, from
kindergartens in Thessaloniki. For all participants in the test, there are ethical
approvals, consent of parents and teachers while they dont seem to appear with
any developmental or sensory disorders through to clinical observation and parental
and teacher information.
Assessment
The Test of Receptive and Expressive Language Abilities (Vogindroukas,
Grigoriadou 2009) was used for the evaluation of the language abilities of the
participants. The RAVEN TEST and more specifically the coloured progressive
matrices Sets A, AB, B (J. C. Raven 1998) were used in order to evaluate the
Intellectual Quantity of the participants.
Results
Table 1 presents the correct answers of the participants in the chosen items
from the Test of Receptive and Expressive Language Abilities. The results are
presented in the form of percentages.
Table 1
Correct answers
Items
Receptive Abilities Expressive Abilities
Nouns
100%
97.5%
Active Verbs
99.2%
95.4%
Passive Verbs
79%
74.6%
Adjectives
100%
100%
Adverbs
98.2%
70%
Personal Pronouns 100%
46.7%
A
Personal Pronouns 85.6%
60.9%
B
Possessive
92.9%
100%
100%
87.7%
Pronouns
Noun Declinations
428
Single and Plural 100%
100%
Nnumbers
Verb Tenses
86.3%
67.6%
Pragmatic
72.7%
23.2%
Abilities
Story Sequencing
Difficulties with
nouns are noticed in
the expression of the item
thermometer.
Concerning the active verbs, there are some difficulties in the receptive
abilities of the items cut and going up and in the expressive abilities in the items
read and write.
Regarding the passive verbs items there is some difficulty in understanding
the verbs combing her hair and wiped and in the expression of the items be
dressed and be painted.
Difficulties in adverbs regarding receptive abilities appear at the item
between and in the expression of the items between and by.
Difficulties in the expression of personal pronouns A, are present due to
the absence of use of the personal pronoun of the third person in plural number, in
male and female gender (afti, aftes). The personal pronouns B, seem problematic
both in understanding and in expression. This is obvious in the use of the personal
pronoun of the third person, in plural number, in male and female gender (tous, tis).
Regarding the possessive pronouns the difficulties in understanding concern
the third person of the plural number (tous = their).
The declination of nouns is also problematic at the male and female
gender of the plural number (oi, ton, tous, tis).
The difficulty in the use of tenses relates to the future tense at the receptive
as well as to the expressive component.
The difficulties in pragmatic abilities concern the understanding of items
which asses the body posture.
Finally, as regards the story sequencing, only 23.2% of the participants
were able to pass the item.
Discussion
The results of this study are close to previous studies in the Greek language at
the preschool age of children. In this study the participants are at the age of 58
months and are integrated in main stream kindergartens of Thessaloniki. The
finding regarding the naming of thermometer is also mentioned and in other
related studies (Vogindroukas, Papageorgiou & Gatzori 2001. Koskina & Lazaridou
2006. Vogindroukas, Protopapas & Sideridis 2009). It is possible that the problem in
naming it is not only due to the unknown word (two children are only familiar with
it) but also because the picture presents a wall thermometer and not a clinical one
with which most of the children are more familiar.
Concerning the difficulties with Passive Voice of verbs, at the receptive and
expressive ability there is a related finding referring to the study of Koskina &
Lazaridou 2006, and Antoniadis & Karagiannis 2007. In the first study the
429
participants were 4.5 years of age and in the second 5.5 years of age. In both studies
difficulties with Passive Voice at the expression and also in the receptive ability are
referred to. A difference is noticed concerning the percentage of the correct answers
in the first study where the correct answers reach 66.5% percentage for the
receptive and 69% for the expressive. In the second study the results are different
due to the older age of the participants. The results for receptive ability was 91.5%
and for the expressive 80.2%. Also, according to Stefany (1981) there are some verbs
in passive voice which appear earlier in life while others appear later, and this might
depend on the communication power of the verb meaning that a powerful verb is
a verb used often for the everyday needs of the child and consequently its
appearance is early.
Difficulties with personal pronouns A in expression are present due to the
absence of use of the personal pronoun of the third person, in plural number, in
male and female gender (afti, aftes). Also the personal pronouns B cause difficulties
in understanding and expressing it (the personal pronoun of the third person, in
plural number, in male and female gender (tous, tis). These findings agree with the
findings of Porpodas (1999). According to him the adequate use of personal
pronouns is completed at the age of 72 months. The participants of this study were at
the age of 58 months and for this reason half of them encountered problems by
using them inappropriately.
The declination difficulties which are present in this study concern the
female and male gender in plural number. This finding has been referred to
Theofanopoulou Kontou (1973) and also by Pita (2001), who mention that the
declination system in Greek preschoolers is completed by the age of 72 months.
Recently, TRELA has been used in a study with preschoolers aged between 41
months and 52 months (Xanthou, Fountoulaki 2010). The results show a difficulty in
understanding the third person declination of male and female gender. In this study
the problem occurs at the expression of the declinations but a large number of the
participants, 87.7%, have succeeded on this item.
The difficulties with the future tense may depend on the struggle of the
children of this age to understand and to develop the concepts of time, or may be in
some cases the problem appears due to difficulties in understanding the items and
what the examiner requires as an answer. This comment is based on the findings of a
related study (Vogindroukas 2000), according to which the Greek preschoolers from
30 to 54 months of age present morphemes of future tense.
The findings about the pragmatic abilities, regarding the understanding of
the body posture are referred to in the studies of Koskina & Lazaridou 2006, and
Antoniadis & Karagiannis 2007. There is a difference in the results in these two
studies due to the different chronological ages of the participants. In the first study
(Koskina & Lazaridou 2006) the percentage of success was 70% and in the second
study (Antoniadis & Karagiannis) 75% and these results show that this item is
difficult for the Greek preschoolers but it is also obvious that there is an increase of
understanding through age development.
Finally, the finding with regard to the story sequencing in the present study
shows a success percentage of 23. This result shows that it is difficult for children to
sequence a five picture everyday story at the age of 58 months while the same
results have occurred in the studies of Koskina & Lazaridou 2006, and Antoniadis
& Karagiannis 2007, but with a large difference between the participants. In the first
study (Koskina & Lazaridou 2006) the percentage of success was 15.5% and in the
second study (Antoniadis & Karagiannis) 31%. The percentage is double in the
430
second study and this finding supports the idea that there is an increase
ability due to chronological age development.
of this
References
1. Antoniadis, M., Karagiannis, S. (2007).
. .. .
2. Giannetopoulou, A. Kirpotin , L. (2007). Panhellenic association of Logopedics.
3. Kati, D. (1992), , ,
4. Koskina, X., Lazaridou K. (2006).
. .. .
5. Levanti, E., Kirpotin, L., Kardamitsi, E., Kampouroglou, M., (1995),
, , .
6. Nisioti, M., (1994), Pragmatic Abilities in Normally Developing Greek Children, City
University London.
7. Oikonomou, A. , Mpezevegkis, I., Milonas, K., Varlokosta, S. (2007). Test of Speech and
Language. Ministry of Education.
8. Panhellenic Association of Logopedics, (2005). ANOMILO 4. Ellinika Grammata, Athens
9. Pita, R. (2001), , , .
10. Porpodas, D., K. (1999) . - /
, 2 ,
11. Raven J. C., (1998). The coloured progressive matrices Sets A, AB, B. Pearson
12. Stephany, U., (1981), Verbal Grammar in Modern Greek Child Language, In P.S. Dale &
D. Ingram (eds.), Child Language: An international Perspective, Baltimore, University Press
Park.
13. Theophanopoulou Kontou, D. ( 1973) . Aquicition of noun morphology by children
learning Greek as a native language. M.A. thesis. Ohio State Univ., Columbus, Ohio.
14. Vogindroukas, I. (2000). H
, 8 ,
15. Vogindroukas, I. (2002).

. . .
16. Vogindroukas, I., Grogoriadou, E. (2009). Test of Receptive and Expressive Language
Abilities. Glafki
17. Vogindroukas, I., Papageorgiou, V., Gatzori, M. 2001, :
; 2
, . 109
18. Vogindroukas, I., Protopapas, A., Sideridis, G. (2009), Test of Expressive Vocabulary. Glafki
19. Xanthou, V., Fountoulaki, E., (2010). Administration of the subtest Comprehension of
Language of the new test Comprehension and Expression of Language (Vogindroukas
Grigoriadou- Kambouroglou) and comparison with a similar subtest Auditory
Comprehension of the test Preschool Language Scale -3(UK). TEI Patras, Department of
Speech Pathology.
431
P020
ELETROGLOTOGRAPHY IN PHONOLOGICAL DISORDERED
CHILDREN USING DEVOICING PHONOLOGICAL PROCESS
WERTZNER, HF1, PAGAN-NEVES, LO2
PHD, Associated professor from Speech Pathology course, University of So Paulo, So
Paulo, Brazil
2 PHD, Speech pathologist, University of So Paulo, So Paulo, Brazil
1

Phonology develops during first infancy as children learn which sounds are
part of the language, how to combine them to form words and how sounds are
produced according to the coordination of lips, tongue, jaw, vocal folds and
breathing muscles (Stoel-Gammon & Dunn, 1985). When phonological rules are not
internalized correctly we can say this child is phonological disordered.
Phonological disorder (PD) is characterized by speech disorders in the
presence of inadequate production of sounds and inappropriate use of phonological
rules including phonemes and their distribution as well as the types of syllabic
structure of each language (Wertzner, 2002a).
Phonological disorder is one of the most frequent communicative disorders
diagnosed in pre-school and school children (Gierut, 1998).
There are several ways to evaluate children with phonological disorder. The
one adopted in this study is the phonological process evaluation. This term is
referent to a class of sounds that should be eliminated so the child can use
phonological rules appropriately (Pea-Brooks & Hedge, 2000).
Phonological process of fricatives and stops devoicing are the most observed
in Brazilian Portuguese speaking children with phonological disorder (Oliveira et al.
2000; Wertzner, 2002a; Wertzner, 2002b; Papp & Wertzner , 2006; Wertzner et al.,
2007; Wertzner et al., 2009). Such processes are characterized by the absence of the
distinctive voiced feature for stop and fricative phonemes. The process of stops and
fricatives devoicing in isolation usually occurs between 6 and 9 years-old but it also
may be accompanied by other phonological processes (Gurgueira, 2000). It is
expected that both processes disappear around 24 months of age in typical
development (Galea, 2003).
Fricatives and stops devoicing are frequent in Brazilian Portuguese (BP)
speaking children and that is why many studies have been done in the attempt to
understand the reasons it occurs. Gurgueira (2006) acoustically analized voice onset
time (VOT) from voiced and devoiced stops and duration from preceding and
following vowels to the stops in children with and without PD. Results
demonstrated differences between VOT from typically developing children and the
ones with communicative disorders as well as for some vowels.
Devoicing of consonants may be related to cognitive-linguistic and/or to
difficulties at the motor processing of speech. Considering motor processing
difficulties besides acoustic analysis, eletroglotography (EGG) is an important
evaluation procedure that permits the observation of the vocal folds movement
during speech.
432
EGG is a non-invasive method executed by the positioning of two electrodes

one on each side of the thyroid cartilage. Electric conductivity is measured at the
vocal folds level during phonation. Changes in opening and closing movement from
the vocal folds are registered in a chart represented by a change in the amplitude of
the waves captured by the equipment (Hacki, 1996; Kania et al., 2004).
EGG analysis permits to verify the opening quocient (OQ) from the vocal
folds. This measurement is related to the time proportion in which vocal folds
remain opened during a vibration cycle (Verdolini et al., 1998). This measurement
permits the clinician to verify the opening efficiency or inefficiency from the vocal
folds (Weinrich et al., 2005).
A previous study measuring the OQ values from BP voiced and devoiced
fricatives in children with and without phonological disorder demonstrated that
phonological disordered children presenting phonological process of devoicing
presented higher OQ time than typically developing children. The authors suggest
that the results indicate the existence of difficulty at the vibration of vocal folds by
phonological disordered children (Wertzner et al., 2009).
The aim of this study was to compare the opening quocient values in children
with and without phonological disorder inter and intra groups.
Methods:
Twenty two children participated from the study divided into two groups.
The first one was the Control Group (CG) containing seven children aged from 7:5 to
9:8 years-old and the other one was the Phonological Disordered Group (PDG) with
15 children aged from 5:3 to 6:9 years-old. Inclusion criteria to participate from the
study were typically developing children without communicative disorders for CG
and the presence of phonological process of fricatives and/or stops devoicing for
PDG. Children were solicited to repeat once a list of vehicle sentences containing
words with fricative voiced and devoiced sounds /f/,/v/,/s/,/z/,/S/,Z/ as shown
in Table 1.
Table 1: Vehicle sentences to be repeated
Phoneme
Vehicle sentence in Brazilian Vehicle senteces in English*
Portuguese
/v/
Fale vaca bonita
Say beautiful cow
/f/
Fale faca bonita
Say beautiful knife
Fale giz bonito
Say beautiful chalk
//
Fale xis bonito
Say beautiful X
//
/z/
Fale doze bonito
Say beautiful twelve
/s/
Fale doce bonito
Say beautiful candie
* Translated to English just for readers comprehension. Not applied to children.
The selection of these words was made using minimal pair criteria in which
they differentiated only by the voicing features.
Repetitions were collected and analyzed using EGG real-time analysis, a
program attached to Computerized Speech Laboratory (4300B).
Statistical analysis was applied using T test for comparisons (p value: 0,005).
Results and Discussion:
Intra group analysis compared the OQ values from each minimal pair inside
the groups. Table 2 demonstrates mean values for each group and results after T test
application.
433
Table 2: Mean OQ for intra group comparison.
GROUP
MEAN
CG
SD
MEAN
PDG
SD
MEAN
SD
MEAN
PDG
SD
CG
GROUP
GROUP
MEAN
CG
SD
MEAN
PDG
SD
PAIRED T TEST
(p VALUE)
RESULTS
<0,001 *
v<f
<0,001 *
PAIRED T TEST
(p VALUE)
v<f
4,93
95,39
<0,001 *
<
22,76
9,60
<
/z/
/s/
<0,001 *
PAIRED T TEST
(p VALUE)
53,37
3,93
64,81
20,06
97,90
5,56
93,46
12,75
<0,001 *
z<s
<0,001 *
z<s
/v/
/f/
49,41
7,03
70,53
22,74
96,88
8,25
100,00
0,00

54,97

98,14
3,79
66,71
RESULTS
RESULTS
Results demonstrated that for both groups the OQ values for devoiced
fricatives were always significantly higher than for voiced ones. As expected for
typical developing children this result indicates that vocal folds were opened for a
longer time during devoiced production. The interesting result is that the same was
observed for the three minimal pairs during PDG production as well. This result
indicates that even though listeners do not listen to this differentiation between
voiced and devoiced fricatives produced by these children, they do demonstrate a
cognitive knowledge that such difference exist. PDG seems to try to produce this
differentiation so listeners can perceptually perceive their pronunciation as correct
but they are not able to reduce vocal folds opening duration (represented by the OQ
measurement) to produce voiced sounds.
Table 3: Mean OQ for inter group comparison.
Group
CG
MEAN
49,41
/v/
SD
7,03
MEAN
96,88
/f/
SD
8,25
MEAN
54,97
/ /
SD
3,79
MEAN
98,14
//
SD
4,93
MEAN
53,37
/z/
SD
3,93
MEAN
97,90
/s/
SD
5,56
PDG
70,53
22,74
100,00
0,00
66,71
22,76
95,39
9,60
64,81
20,06
93,46
12,75
T TEST
(p VALUE)
RESULTS
0,004 *
GC < GTF
0,356
GC = GTF
0,071
GC = GTF
0,487
GC = GTF
0,050 *
GC < GTF
0,269
GC = GTF
434
Inter group results demonstrated that PDG opening quocient values were
significantly higher for /v/ and /z/. Even though for / / this difference was not
statistical significant the observation of the mean value demonstrates that this
difference is also true. These results show once again the differences observed in
intra analysis group showing that PDG tend to produce voiced sounds with their
vocal folds more opened than CG children. It is important to remember that PDG
children did not produce voiced sounds (voiced fricatives was produced as
devoiced) what reinforces the differentiation they make in their own production
between these two sounds categories.
No differentiation between groups was found to other fricative sounds, especially for
the devoiced sounds what indicates that devoiced sounds are produced with almost the same
vocal folds opening for both groups of children. Even the mean values are very similar for
them confirming this similarity.
Conclusions:
Even though PDG produced voiced fricatives as devoiced the opening

quocients values were different from their own productions. It means that
phonological disordered children were capable of maintaining their vocal folds
opened for a longer time when they were producing a real devoiced sound (/f/, /s/,
//) in comparison to the voiced sounds that they produced as devoiced (/v/, /z/,
/ /). The fact that PDG opening quocient values were higher when compared to CG
reinforces that CG tended to open vocal folds for a shorter period when producing
voiced sounds. Maybe this difference in opening quocient time is why listeners can
hear as voiced the sound produced by CG but as devoiced the ones produced by
PDG. Further studies have to be done to confirm this studys initial hypothesis.
References:
Galea DES. Anlise do sistema fonolgico em crianas de 2,1 a 3,0 anos de idade [mestrado].
So Paulo (SP): Faculdade de Filosofia, Letras e Cincias Humanas da Universidade
de So Paulo; 2003.
GIERUT, JA. Treatment efficacy: functional phonological disorders in children. Journal of
Speech, Language and Hearing Research, 41: S85-S100, 1998.
Gurgueira, AL. Estudo acstico dos fonemas surdos e sonoros do portugus do Brasil, em
crianas com distrbio fonolgico apresentando o processo fonolgico de
ensurdecimento [dissertao]. So Paulo: Universidade de So Paulo - Faculdade de
Filosofia Letras e Cincias Humanas. 2000.
Gurgueira AL. Estudo acstico do Voice Onset Time (VOT) e da durao da vogal na
distino da sonoridade dos sons plosivos em crianas com transtorno fonolgico
[doutorado]. So Paulo (SP): Faculdade de Filosofia, Letras e Cincias Humanas da
Universidade de So Paulo; 2006.
Hacki, T. Electroglottographic Quasi-Open Quotient and Amplitude in Crescendo Phonation.
Journal of Voice, 10(4): 342-347, 1996
Kania, RE; Hans, S; Hartl, DM; Clement, P. Variability of Electroglottographic Glottal Closed
Quotients Necessity of Standardization to Obtain Normative Values. Arch
Otolaryngol Head Neck Surg, 130, 2004.
OLIVEIRA, M. M. F.; WERTZNER, H. F. Estudo do distrbio fonolgico em crianas. Revista
da Sociedade Brasileira de Fonoaudiologia, 7: 68-75, 2000.
Papp, ACCS; Wertzner, HF. O aspecto familial e o transtorno fonolgico. Pr-Fono Revista de
Atualizao Cientfica, Barueri (SP), 18(2):151-160, 2006.
PEA-BROOKS, A & HEDGE, MN. Assessment e treatment of articulation phonological
disorders in children. Texas: Pro-ed, 2000.
STOEL-GAMMON, C. & DUNN, C. Normal and Disordered Phonology in Children. Austin,
Texas: Pro-ed., 1985.
435
Verdolini, K; Chan, R; Titze, IR; Hess, M; Bierhals, W. Correspondence of electroglottographic

closed quocient to vocal fold impact stress in excised canine larynges. Journal of
Voice, 12(4): 60-71, 1998
Weirich, B; Salz, B.; Hughes, M. Aerodynamic measurements: normative data for children
ages 6:0 to 10:11 years. Journal of Voice, 9(3): 326-39, 2005
Wertzner, HF. O distrbio fonolgico em crianas falantes do portugus: descrio e medidas
de severidade. Tese (Livre-Docncia, Departamento de Fisioterapia, Fonoaudiologia e
Terapia Ocupacional) - Faculdade de Medicina, Universidade de So Paulo, So
Paulo. 2002a.
Wertzner, HF; Oliveira, MMF. Semelhanas entre os sujeitos com distrbio fonolgico. PrFono,14(2):143-52, 2002b
WERTZNER, H. F., PAGAN, L. O.; GALEA, D. E. S.; PAPP, A. C. C. S. - Caractersticas
fonolgicas de crianas com transtorno fonologico com e sem histrico de otite
mdia. Revista da Sociedade Brasileira de Fonoaudiologia. , v.12, p.41 - 47, 2007.
Wertzner, HF; Pagan, LO; Gurgueira, AL. Influncia da otite mdia no transtorno Fonolgico:
anlise acstica da durao das fricativas do portugus brasileiro. Rev. CEFAC,
11(1):11-18, 2009.
436
P076
AGE AND GENDER EFFECTS IN SPEECH INCONSISTENCY
BRAZILIAN PORTUGUESE CHILDREN
M.M. Castro1, H. F. Wertzner2
1University of So Paulo, So Paulo, Brazil
2 University of So Paulo, So Paulo, Brazil
Introduction and aims of the study: In Brazilian Portuguese (BP)
Phonological disorder (PD) children is frequently identified as in other languages.
Brazilian PD children show higher incidence in boys between 5:00 to 8:00 years. PD
children are heterogeneous in terms of severity, type of errors, and causal factors,
auditory perception, sound production and cognitive linguistic processing. In order
to clarify the most important underlying deficit of this children some procedures
have been used to identify specific deficits in perceptual, cognitive, structural,
affective or motor areas [1,2,3,4].
Speech inconsistency is characterized by variable productions of the same
lexical items within the same context. Procedures to assess Phonological Disorders
have to be specific to each language; in Brazilian Portuguese there is a recent tool to
assess speech inconsistency. Speech inconsistency may be helpful to identify
subgroups markers in Phonological Disorders, and these markers can contribute to
indicate which skills the child needs to be implemented. A child may be classified as
consistent if the production of a word is always the same and inconsistent if there are
multiple types of productions of the same word either in the same and different
context [5].
Children whose speech is characterized by inconsistent errors may have
difficulty in selecting and sequencing phonemes for the production of phonological
structure, which indicates a deficit in phonological planning with effects on phonetic
planning [6]. Authors explain that inconsistency refers to the sequence of sounds
involved in the phonological structure in question, the selection of the phonological
structure through different pathways.
Variability of speech is defined as different productions, attributed to factors
observed in normal acquisition as complex syllabic structures and sounds,
maturation or cognitivelinguistic influences. For typically developing children the
multiple types of productions of the same word, is referred in literature as variability
of speech.
This study aimed to describe how age and gender affect inconsistency of
Brazilian Portuguese speaking children with and without phonological disorder.
Methods: Study sample included children between 5:0 and 10:10 years of age,
both gender, 51 with phonological disorder and 50 without speech-language
disorders. Parents or legal guardians signed the informed consent. Children with
Phonological Disorders (PDG) were diagnosed as phonologically disordered after
the application of a protocol that includes: Brazilian Portuguese phonology tests
(imitation and picture naming [7] and continuous speech), phonological awareness
tests, reading and writing tasks, vocabulary test, among others. The inclusion
criteria in this group were presence of phonological processes not expected to the
child age; also the child could not have been submitted to any previous speech
437
pathology treatment and, have to present hearing thresholds till 20 dBHL. The
criteria for inclusion in the Control Group (CG) was absence of language, speech, or
hearing problems, as stated on the questionnaire completed by the parents and
confirmed through the phonological evaluation.
Brazilian Speech Inconsistency Test was based on the criteria adopted in
English studies [8]. Thus, the test is composed of words from one to four syllables,
with all syllabic structures of BP, words of high and low frequency in the sample
analyzed and composed of variable number of phonemes (from two to nine). We
included all singletons and consonantal clusters of PB, as well as oral and nasal
vowels.
The Brazilian Portuguese Speech Inconsistency Test was applied in both
groups. The test includes 25 pictures named three times in different sequences in
same session. The three naming of each word were analyzed and classified as
consistent when the child named the same word equally the three times and
inconsistent when at least one of the production of a certain target was different.
During the test application, if the child did not name the target word,
prepared statements were provided with clues of each figure. If the child still did not
name the target word, the stimulus was presented and named, and explained to the
child that would be asked again. After five figures, the picture was taken. In cases
where the word was not named, this target was overlooked. Then, the Speech
Inconsistency was calculated and the inconsistent number of words were divided by
the total number of words (25) generating the result in percentage
Results: Inconsistency average of children with phonological disorder
(27.4%) was higher than typically developing children (9.8%). Regarding gender, the
averages were higher in boys (CG = 12% and PDG = 30.3%) than in girls (CG = 8.4%
and PDG = 22.5%), the gender effect was observed in both groups (p = 0.016). There
was also the age effect, Speech Inconsistency decreases with age (p = 0.001). Thus,
Speech Inconsistency depends on gender and decreases, on average, 2.6% with the
increase of one year of age in both groups (p = 0.425).
As linear regression showed age and gender effects, four Receiver Operator
Characteristic (ROC) curves were built for Speech Inconsistency with combined
gender and age cut-off values. The values of the areas under the curves were 0.80,
indicating good discriminatory power of the test. The diagnosis of typical speech or
PD was used as a criterion in the construction of ROC curves and all subjects of the
study were considered.
Thus, children were grouped by age from 5:0 to 7:6 years (younger) and more
than 7.6 years (older) The cut-off values of Speech Inconsistency for younger girls
was 21.5% and for younger boys 31.9%.; to the older girls was 14.5% and for older
boys 17.6%. Inconsistency were found in phonological disorder children, 10 boys up
to 7:6 years and 11 boys over this age, seven girls up to 7:6 years and six girls over 7:6
years.
Out of 101 children evaluated, 38 (38%) were above SI cut-off values, being
four children of the CG and 34 of the PDG. The inconsistent subjects among CG (8%)
were two younger boys and two older girls. In PDG (67%), inconsistency was found
in 10 younger boys and 11 older boys, seven younger girls between 5:0 and 7:6 years
and six older girls.
Conclusions: Speech Inconsistency is commonly applied both to diagnostic in
order to identify subgroups and to plan intervention in English speaking children. In
CG, four children have Speech Inconsistency above the cut-off values, despite
presenting typical phonological process inappropriate to the age. We observed that
438
inconsistency happened in low frequency, polysyllabic and complex syllabic

structures words, which may explain this variability.
On the other hand 34 (67%) of PDG children presented Speech Inconsistency
and the results suggests the difficulty in phonological planning [6,9] for most PDG
children corroborating with a previous study for English speaking children [4]. The
multiple productions suggest lack of stability of the phonological system and have a
negative impact in the acquisition of the sounds [8]. This situation indicates a deficit
in phonological planning with effects on phonetic planning [5,6,9].
Two interesting aspects were highlighted in this study, one of them concerns
gender. As Speech Inconsistency was higher in boys of the PDG, that demonstrate
they were more inconsistent and it seems that their maturation is slower than girls
maturation.
The other aspect was age influence, showing that Speech Inconsistency
decreases with age, on average, 2.6% per year. The constant use of language and
maturation improves the phonological planning in PD children. The number of
phonological features that children may include in phonological planning is limited
and it develops gradually. The fact that PDG younger boys are more inconsistent,
may indicate a delayed maturation in boys which may explain the increased
incidence of PD in boys.
The analysis of the BP Speech Inconsistency showed gender and age effect
and indicated the need of four values of cut-off in ROC curves. These cut-off values
differed from the one for English speaking children which considered that 40% of
inconsistency characterize the inconsistent PD [8]. But as the authors do not discuss
the criteria set in their study it is difficult to compare the results. Thus the cut-off
values for BP are lower and most children with PD were considered inconsistent,
differently from the English language study.
The sensitivity and specificity obtained for Speech Inconsistency demonstrate
that in diagnoses children below the established cut-off for gender and age have high
probabilities of having development within the expected, while children above the
cut-off values show the high possibility of presenting PD and should be referred for
diagnosis in specialized service.
The heterogeneity of PD children challenges the researchers to understand
what tools can help to identify the subgroups. Speech Inconsistency evaluation
seems to be a helpful instrument in diagnoses approaching the desired practice in
evidence to guide clinical decisions.
This research suggests that in the language system the phonological planning
is developed in each year of childrens life and occurs differently between genders.
References:
1. Ingram D. The measurement of whole-word productions. J Child Lang 2002;29:713-33.
2. Dodd B, McComark P. A model of speech processing of phonological disorders. In Dodd B.
The differential diagnosis and treatment of children with speech disorder. 65-89. San Diego, CA:
Singular Publishing Group. 1995.
3. Shriberg LD. Diagnostic markers for child speech-sound disorders: introductory comments.
Clin Linguist Phon. 2003;17:501-5.
4. Betz SK, Stoel-Gammon C. Measuring articulatory error consistency in children with
developmental apraxia of speech. Clin Linguist Phon. 2005;19: 53-66.
5. Forrest K, Elbert M, Dinnsen DA. The effect of substitution patterns on phonological
treatment outcomes. Clin Linguist Phon..2000;14:519-31.
439
6. McIntosh B, Dodd B. Evaluation of Core Vocabulary intervention for treatment of

inconsistent phonological disorder: Three treatment case studies. Child Lang Teach Ther.
2008;24:30727.
7. Wertzner HF. Fonologia. In: Andrade CRF, Befi-Lopes DM, Fernandes FDM, Wertzner HF.
ABFW Teste de linguagem infantil nas reas de fonologia, vocabulrio, fluncia e pragmtica.
Carapicuba, Pr-Fono, 2004.
8. Crosbie S, Holm A, Dodd B: Intervention for children with severe speech disorder: a
comparison of two approaches. Int J Lang Commun Disord 2005;40:467- 91.
9. Dodd B, Holm A, Crosbie S, Mcintosh B. A core vocabulary approach for management of
inconsistent speech disorder. Advances in SpeechLanguage Pathology.2006;8:22030.
440
P078
COMPARISON OF PHONOLOGICAL PROCESSES AND SPEECH
INDEXES IN BRAZILIAN CHILDREN WITH AND WITHOUT
PHONOLOGICAL DISORDERS
Wertzner, H.F.1, Galea, D.E.S.2, Pagan-Neves, L.O.2, Barroso, T.F.3
1 PHD, Associated professor from Speech Pathology course, University of So Paulo, So
Paulo, Brazil
2 PHD, speech pathologist, University of So Paulo, So Paulo, Brazil
3 Speech pathologist, University of So Paulo, So Paulo, Brazil
Introduction:
From 1:6 to 4:0 years of age, when a lot of words are produced incorrectly,
there are simplification processes that affect whole classes of sounds (Ingram, 1976).
Such simplifications are eliminated as children develop their perception abilities and
acquire a broad inventory of phonetic elements.
During the period of development, some children may not be effective in
creating new rules, presenting some problems of perception, organization of
phonological rules or production, characterizing the phonological disorder.
Children with phonological disorder of unknown origin do not present
anatomical abnormalities, the comprehension of speech is within the normal range
for their age as so as their vocabulary (Stoel-Gammon e Dunn, 1985; Grunwell,1989).
These children present phonological processes beyond the expected age of
elimination and/or idiosyncratic processes (Elbert, 1992; Wertzner, 2002).
There are some indexes that try to measure the phonological disorder. The
great application of these indexes is related to the diagnosis of such disorder and
usually they are calculated through the consonants produced by the children or even
by the number of phonological processes presented.
Shriberg e Kwiatkowski (1982) created the Percentage of Consonants Correct
(PCC) in which the result is obtained by the division of correct consonants by the
total amount of consonants of a speech sample, and multiplied by 100. Omissions,
substitutions and distortions are considered as errors.
Latter, Shriberg et al., (1997) made a revision of the PCC and created the PCCR (Percentage of Consonants Correct Revised), as the distortion was not considered
an error.
Another measure well studied in the literature is the PDI Phonological
Processes Index (Edwards, 1992). This measure is calculated by the number of
processes presented by the subject divided by the number of words in the sample.
So, the aim of this study was to compare typically developing children and
phonological disordered children according to phonological processes and two
indexes of speech measures.
Methods:
Took part in this study 94 children divided into two groups: Phonologically
Disordered Group (PDG) and Control Group (CG). The PDG was constituted by 42
phonological disordered children with mean age of 7:2 years (17 girls and 26 boys).
441
52 typically developing children formed the CG, with mean age of 7:7 years (31 girls
and 21 boys).
For the PDG, all subjects caregivers answered a questionnaire containing
developing information about their children. Latter, all subjects underwent several
tests to confirm the diagnosis of phonological disorder as: phonology tests of the
ABFW (Wertzner, 2000), continuous speech test, stimulability of speech for liquid
sounds, diadochokinesic test, phonological processing tests. All tests were recorded
with a digital camera and voiced-recorded directly in a computer with a professional
microphone.
Children from the CG attended public schools linked to the So Paulo City
and they did not have any language or hearing complaints. They were all BrazilianPortuguese monolingual children. Three phonology tests were conducted:
continuous speech and the imitation and picture naming tests of the ABFW
(Wertzner, 2000). The same recording methods of the PDG were used for this group.
After, phonological processes of all children were analyzed and the PCC-R
and PDI indexes were calculated from the imitation and picture naming tests.
Each phonological process was analyzed separately. The processes observed
are listed with their example on Charter 1. Besides these processes, idiosyncratic
processes were listed in the group of others.
Charter 1 Phonological Processes analyzed
Phonological process
Example
Syllable reduction: one or more syllables of a

word is omitted
/patU/ - [pa] duck
Assimilation a certain characteristic

phoneme influences another phoneme.
/makakU/ - [kakaku] monkey
of
Stopping of fricatives: fricatives are substituted

by plosives
/sapU/ - [tapu] frog

/vaka/ - [baka] cow
Backing to velar: an alveolar, either /t/ or /d/ is

substituted by a velar /k/ or /g/.
/sapatU/ - [sapaku] shoe

/dosI/ - [gosi] sweet
Backing to palatal: an alveolar /s/ or /z/ is

substituted by // or //
/sapU/ - /apu/ frog

/zebra/ - /ebra/ zebra
Velar fronting: a stop velar either /k/ or /g/ is

substituted by /t/ or /d/
/karu/ - [taru] expensive

/gaRfU/ - [daRfu] fork
442
Palatal fronting: a fricative palatal // or // is

substituted by /s/ or /z/
/avI/ - [savi] key

/elu/ - [zelu] ice
Liquid Simplification: the liquid is ommited,

substituted by another liquid or semivocalized
/kara/ - [kala] face

/bolU/ - [boyu] cake
/paredI/ - [paedi] wall
Final consonant simplification: a coda of a

syllable, either /s/ or /R/ is ommited or
substituted
/barkU/ - [bayku] boat

/pasta/ - /pata/ paste
Cluster reduction or simplification: the second

consonant of a cluster (a liquid) is ommited or
substituted
/pratU/ - [patu] plate

/klubI/ - [krubi] club
Stop voicing: an unvoiced stop is substituted by

its voiced pair.
/patU/ - [batu] duck

/kara/ - [gara] face
/tia/ - [dia] aunt
Fricative voicing: an unvoiced

substituted by its voiced pair.
/faka/ - [vaka] knife

/sapU/ - [zapu] frog
/a/ - [a] tea
fricative
is
Stop devoicing: a voiced stop is substituted by its

unvoiced pair.
/baRkU/ - [partu] boat

/goRdo/ [kordu] fat
/dia/ - [tia] day
Fricative devoicing: a voiced

substituted by its unvoiced pair.
/vaka/ [faka] cow

/zebra/ [sebra] zebra
/a/ - [a] now
fricative
is
Statistical analysis was conducted through the t Test (sig. level: .05) to
compare the indexes and each phonological process between groups.
Results:
- Comparison of PDG and CG according to PCC-R and PDI
Results from Table 1 show that indexes were significantly different between
groups, in all tests, indicating that GC presented higher PCC-R and lower PDI scores.
443
Table 1: PCC-R and PDI comparison between groups in all tests

Indexes
PCC-R
Naming
PDI Naming
PCC-R
Imitation
PDI Imitation
Mean - CG
0.99
Mean - PDG
0.82
T Test (p)
<0.001*
Result
CG>PDG
0.03
0.99
0.47
0.84
<0.001*
<0.001*
CG<PDG
CG>PDG
0.04
0.44
<0.001*
CG<PDG
- Comparison of PDG and CG according to Phonological Processes

Table 2 and 3 show the comparison of each phonological process between
groups. GC and PDG were statistically different for the following process: Velar
fronting, palatal fronting, liquid simplification, cluster simplification, final consonant
simplification, fricative devoicing, stop devoicing and others. Moreover, backing to
palatal was also significant different in the picture naming test. In all comparisons,
GC presented lower occurrence of these processes.
Table 2 Comparison of Phonological Processes in the Imitation Test
Phonological
Mean - CG
Mean - PDG
T Test (p)
Process
SR
0
0
0.056
A
0
0
0.056
FS
0
0.02
0.107
BV
0
0.04
0.108
BP
0.01
0.03
0.246
VF
0
0.07
0.033*
PF
0
0.14
<0.001*
SL
0.04
0.37
<0.001*
CS
0.04
0.37
<0.001
FSS
0.02
0.16
<0.001*
SV
0
0
0.103
FV
0
0
Not applicable
SD
0
0.20
<0.001*
FD
0
0.29
<0.001*
OTHERS
0.13
0.87
0.048*
Result
CG=PDG
CG=PDG
CG=PDG
CG=PDG
CG=PDG
CG<PDG
CG<PDG
CG<PDG
CG<PDG
CG<PDG
CG=PDG
CG=PDG
CG<PDG
CG<PDG
CG<PDG
Legend: SR: syllable reduction, A: assimilation, FS: fricative Stopping, BV: backing to velar, BP: backing
to palatal, VF: velar fronting, PF: palatal fronting, LS: liquid simplification, CS: cluster simplification,
FCS: final consonant simplification, SV: stop voicing, FV: fricative voicing, SD: stop devoicing, FD:
fricative devoicing.
Table 3 Comparison of Phonological Processes in the Picture Naming Test

Phonological
Mean - CG
Mean - PDG
T Test (p)
Result
Process
SR
0
0
0.616
CG=PDG
444
A
FS
BV
BP
VF
PF
SL
CS
FSS
SV
FV
SD
FD
OTHERS
0
0
0
0.01
0
0
0
0.05
0.05
0
0
0
0.01
0.02
0
0.02
0.04
0.05
0.07
0.10
0.14
0.38
0.20
0
0.01
0.29
0.33
1,24
0.297
0.105
0.125
0.031*
0.049*
0.012*
<0.001*
<0.001
<0.001*
0.323
0.083
<0.001*
<0.001*
0.006*
CG=PDG
CG=PDG
CG=PDG
CG<PDG
CG<PDG
CG<PDG
CG<PDG
CG<PDG
CG<PDG
CG=PDG
CG=PDG
CG<PDG
CG<PDG
CG<PDG
Legend: SR: syllable reduction, A: assimilation, FS: fricative Stopping, BV: backing to velar, BP: backing
to palatal, VF: velar fronting, PF: palatal fronting, LS: liquid simplification, CS: cluster simplification,
FCS: final consonant simplification, SV: stop voicing, FV: fricative voicing, SD: stop devoicing, FD:
fricative devoicing.
Discussion:
Regarding the PCC-R and PDI, the GC always presented better indexes
compared to the PDG. The PCC-R, that verifies the correct consonants, was higher
and the PDI, that observes the amount of phonological processes, was lower.
This was expected as children with phonological disorder tent to be less
accurate in phonology tests presenting more processes and, consequently, lower
PCC-R and higher PDI.
Use of those indexes are well described in international studies that observe
phonological disorders as they turn out possible the follow-up of subjects and also
comparison among subjects. Researches are trying to find relation between the PCCR value and the variation of the phonological disorder.
Brazilian-Portuguese studies showed that this index helps classifying the
severity of speech disorders.
Phonological analysis permits to verify the rules of a language that subjects
present difficulty. Phonological processes are tools of great importance for the
diagnosis of speech disorders.
Results of this research showed that velar fronting, palatal fronting, liquid
simplification, cluster simplification, final consonant simplification, fricative
devoicing, stop devoicing and others occurred in different frequencies in the two
groups.
According to previous research (Wertzner, 2002; Wertzner and Oliveira,
2002), cluster simplification and liquid simplification are the most common processes
used by phonological disordered children. Also, the most determinant processes for
phonological disorder are liquid and cluster simplification, palatal fronting and
fricative and plosive devoicing, all of them were seen as more frequent in the PDG of
this research (Wertzner et al, 2001).
It is important to notice that assimilation, syllable reduction and fricative
stopping are processes presented in the beginning of the phonological development
and, usually, are already eliminated by the phonological disordered subjects. As the
subjects of this research were older, this difference may not have appeared. Studies
445
with younger children are required to compare the frequency of occurrence of these
processes in children with and without phonological disorder.
Conclusion:
Comparison between CG and PDG showed differences between the
phonological processes of velar fronting, palatal fronting, liquid simplification,
cluster simplification, final consonant simplification, fricative devoicing, stop
devoicing and others
In relation to the speech indexes, PDI was higher in the PDG and PCC-R was
lower in this group compared to the CG.
References:
EDWARDS, M. L. Clinical Forum: Phonological Assessment and Treatment in Support of
Phonological Processes. Language Speech and Hearing Services in Schools. v. 23, p. 233240, 1992.
ELBERT, M. Clinical Forum: phonological assessment and treatment: consideration of error
types: a response to Fey. Language, Speech, and Hearing Services in Schools. v. 23, p.
241-246, 1992.
GRUNWELL, P. Os desvios fonolgicos evolutivos numa perspectiva lingstica. In Yavas,
M.S. Desvios Fonolgicos em crianas Teoria, Pesquisa e Tratamento. Porto Alegre,
Mercado Aberto, cap 3: 51-82, 1989.
INGRAM, D. Phonological Disability in Children. London: Edward Arnold, 1976.
SHRIBERG, L. D. e KWIATKOWSKI, J. Phonological Disorders III: A Procedure for Assessing
Severity of Involvement. Journal of Speech and Hearing Disorders. v. 47, p. 256-270, 1982.
SHRIBERG, L. D., AUSTIN, D., LEWIS, B. A., McSWEENY, J. L. e WILSON, D. L. The
Percentage of Consonants Correct (PCC) Metric: Extensions and Reliability Data.
Journal of Speech, Language and Hearing Research. v. 40, p. 708-722, 1997.
STOEL-GAMMON, C; DUNN, C. Normal and Disordered Phonology in Children. Austin, Texas:
Pro-ed., 1985.
WERTZNER, HF. Fonologia. In: ANDRADE, CRF; BEFI-LOPES, DM; FERNANDES, FDM;
WERTZNER, HF. ABFW Teste de linguagem infantil nas reas de fonologia,
vocabulrio, fluncia e pragmtica. Carapicuba: Pr-Fono, 2000.
WERTZNER, HF. O Distrbio Fonolgico em Crianas Falantes do Portugus: descrio e medidas
de severidade. Tese (Livre Docncia Departamento de Fisioterapia, Fonoaudiologia e
Terapia Ocupacional) - Faculdade de Medicina da Universidade de So Paulo, So
Paulo, 2002.
WERTZNER, H. F.; HERRERO, S.,F.; PIRES, S. C. F. et al. Classificao do distrbio
fonolgico por meio de duas medidas de anlise: porcentagem de consoantes corretas
(PCC) e ndice de ocorrncia dos processos (PDI). Pr-Fono Revista de Atualizao
Cientfica, 13(1): 90-97, 2001.
WERTZNER, H. F., OLIVEIRA, M. M. F. Semelhanas entre os sujeitos com distrbio
fonolgico. Pr-Fono: Rev Atual Cient, v.14 n.2 p.143-152, 2002.
446
P084
ARTICULATORY INDEXES IN PHONOLOGICALLY DISORDERED
CHILDREN ACCORDING TO THE PRESENCE OF OTITIS MEDIA
HISTORY
Wertzner, H.F.1; Santos, I.P.; Pagan-Neves, L.O.3
1 PHD, Associated professor from Speech Pathology course, University of So Paulo, So
Paulo, Brazil
2 Graduation speech and language pathology student, University of Sao Paulo, Brazil
3 PHD, speech pathologist, University of So Paulo, So Paulo, Brazil
BACKGROUND: Phonological Disorder (PD) is marked by changes in
phonological system with the presence of substitutions, omissions and distortions of
oral sounds production. These errors can be related either to difficulties in
organization of phonological rules, or to auditory perception or to speech sounds
production ,. The use of simplifications from phonological rules, so called
phonological processes, generate different degrees of speech unintelligibility.
Omission is understood as the absence of a target sound in speech while substitution
occurs when there is an exchange of the target sound by another sound. These two types of
errors are usually more easily identified by the therapist. Distortion of a sound is commonly
considered as a phonetic change characterized by difficulties in motor skills involved in
sounds production such as place, time, effort and velocity. In this case it does not represent
changes in the use of phonological rules and therefore the meaning of words is not
committed4.
There are several possible classifications for phonological disorder especially related
to the subtypes identification. There is a classification frequently cited by literature that
considers the most affected place either the processing or the nosological problem 5,6,7. In a
more recent version of this classification authors proposed seven subtypes of PD: genetic
speech delay, otitis media with effusion, developmental apraxia, dysarthria, involvement of
psychosocial development, speech error-sibilant and speech error-rotic 8.
The concern about the presence of recurrent otitis media is specifically based on the
risk that it represents to the phonological representations stability which are responsible to
the verbal learning and may occur due to a deficit in auditory perception 7,9 .
To measure the severity of phonological disorder one of the indexes developed was
the percentages of consonants correct (PCC) which reflects the percentage of sounds correctly
produced during speech and results in a classification of speech severity based on clinical
manifestations: mild (value exceeding 85% ), mild-moderate (value between 65-85%),
moderate-severe (between 50-65%) and severe (less than 50%). This index considers as error
either the three types of errors (omission, substitution and distortion) 10,11,12,13. Moreover
Percentage of Consonants Correct-Revised (PCC-R) is calculated the same way as the

PCC, but distortions are scored as correct 13. The same authors have also proposed
absolute and relative percentages for the types of errors in speech. The Absolute
Indexes (AI) reflect the division from the number of specific errors (omission,
distortion or replace) by the number of speech sounds while the Relative Indexes (IR)
are calculated by dividing the number of specific errors by the total number of errors
produced12.
Another index used to articulatory measurement is the Articulatory
Competence Index (ACI) which gives a different weight to the distortions. It is
calculated
based
on
PCC
and
RDI
(Relative
Distortion
Index).
447
RDI is obtained by dividing the total number of distortions obtained in a speech

sample by the total number of articulation errors what reflects the percentage of
errors for a subject based on the sum of common and uncommon distortions 12.
The aim of this study was to describe and to quantify different articulatory
competence indexes from children with phonological disorder according to the
presence or absence of otitis media history.
METHODS: This study was retrospective and transversal. Phonology tasks
from Infantile Language Test ABFW (Wertzner, 2004) were applied and articulatory
indexes were applied afterwards. Subjects from this study were 21 children aged
between 7:9 and 5:2 years-old. Fifteen were male and six were female. Fourteen
presented otitis media history and seven did not.
Inclusion criteria were the presence phonological disordered diagnosed by a
complete phonological evaluation at the Phonological Investigation Laboratory (LIF)
from the Department of Physical Therapy, Speech, Language and Audiology
Pathology and Occupational Therapy from the Medical School from university of So
Paulo, the presence of, at least, three episodes of otitis media in their history and the
age of 5:0 to 7:11 years-old.
Data were collected using a picture naming and an imitation of words tasks
from ABFW (Wertzner, 2004) as well as a history protocol in order to investigate
otitis media history specifically.
The quantity of erros (distortions, omissions and substitutions) were
calculated based on picture naming and imitation words tasks (Wertzner, 2004).
Afterwards eight indexes were applied and calculated: Percentage of Consonants
Correct (PCC), Percentage of Consonants Correct-Revised (PCC-R), Relative
Substitution Index (RSI), Relative Distortion Index (RDI), Relative Omission Index
(ROI), Absolute Substitution Index (ASI), Absolute Distortion Index (ADI), Absolute
Omission Index (AOI), and Articulatory Competence Index (ACI).
PCC was calculated by dividing the number of consonants correct by the total
number of consonants correct. The result was multiplied by 100. Picture naming task
is composed by 90 possible consonants correct while words imitation task has 107
possible consonants correct. PCC-R was calculated likewise PCC however this index
does not consider distortions as errors so when calculating the number of consonants
correct the distortions were considered as correct productions.
RSI, RDI and ROI indexes were calculated by dividing specific errors such as
substitution (for RSI), distortions (for RDI) and omissions (for ROI) by the total
number of errors from both tasks separately. Result was multiplied by 100.
ASI, ADI and AOI indexes were calculated by dividing specific errors such as
substitution (for RSI), distortions (for RDI) and omissions (for ROI) by the total
number of possibilities of errors in both tasks (90 consonants in picture naming task
and 107 consonants in words Imitation task). Result was multiplied by 100.
ACI index was calculated by dividing the sum of PCC plus RDI by 2.
RESULTS: Results indicated that for both picture naming and words
imitation tasks greater medium values of substitution were observed. Both
substitution indexes RSI and ASI demonstrated that substitution is the speech sound
error presenting most occurrence considering each task possibilitites.
Regarding to the subjects with and without otitis media history it was
observed that mean values from PCC and PCC-R were higher for the imitation task,
indicating the occurrence of more consonants correct production. Comparison
between PCC and PCC-R mean values demonstrated that occurrence of distortions
was not significant.
448
A difference in subjects' performance was observed when comparison

between tasks was analyzed. Otitis media history group presented a greater mean
value when RSI was applied to words imitation task while for picture naming task
these values were greater to the group with no otitis media history.
Observation of the comparison between subjects with and without otitis
media history revealed for both words imitation and picture naming tasks that mean
values of RDI were higher while ROI were smaller for otitis media history group. For
the group with absence of otitis media history the opposite was true: the second error
that most occurred in subjects with otitis media history were distortions while for the
other group (with no history) omission was the most common error. Both tasks
revealed PCC and PCC-R values higher to the group of subjects without otitis media
history.
DISCUSSION: In all cases it was observed that the values of RSI and ASI
were the largest among the absolute and relative indexes respectively. Therefore we
can consider substitution as the most occurring type of error presented besides being
the most frequent error among all the possibilities. This find can be explained by the
fact that phonological disordered children present many sounds substitution during
speech.
Interestingly children without otitis media history presented both ROI and
AOI as higher mean values after RSI and ASI. It means that inside this group with no
otitis media history omissions is not so frequent as substitutions but are more likely
to appear than distortions. This may indicate that despite the fact that distortions
when compared to substitutions and omissions are considered biologically and
cognitive-linguistically as articulatory errors (indicating low maturity") distortions
can assist the search for an etiology to phonological disorder since they were in the
present study more common in children with otitis media history than in the other
group14.
At the comparison between otitis media history group and no otitis history
group RDI was more qualified to distinguish them since the values of ACI were not
significantly different and therefore not effective in distinguishing the etiology of
phonological disordered children. One fact that must be considered is the influence
that occurs from PCC at ACI and as RDI is independent from PCC it has an
advantage over ACI12.
Considering PCC and PCC-R at the comparison between subjects with and
without otits media history it was observed subjects with otitis media history
presented lower scores of PCC demonstrating that this population commits more
articulatory errors. The difference between the indexes was small indicating that
distortions did not produce significant differences. This increase in articulatory
errors demonstrates that the difficulties in auditory perception during episodes of
otitis media may bring as a consequence changes at the construction of phonological
representations which in turn culminates in articulatory imprecision resulting in a
possible environmental impact on the acquisition of speech9.
In general terms, subjects did not present high scores in absolute rates
within the range of possibilities which indicates that although the subjects
with phonological disorders commit more errors than children without this
disorder the frequency of errors were not so high as it was expected.
CONCLUSIONS: Based on data analysis it can be concluded that all indexes
used (except ICA) were able to an important differentiation between children with
and without otitis media history considering their articulatory performance. ACI
does not seem to be a good articulatory competence discriminator since subjects from
449
this study presented low occurrence of distortions. In addition it was also observed
that the presence of otitis media history caused higher number of substitutions and
distortions when compared to the number of omissions.
REFERENCES
1. Ingram D. Phonological disability in children. London: Edward Arold;1976.
2. American Psychiatric Association.diagnostic and statistical manual of mental disorders
DSM-IV. 4 ed. Washington DC: APA; 1994.
3. Fey ME. Phonological and treatment articulation and phonology: inextricable constructs in
speech pathology. Language, Speech, and Hearing Services in Schools.1992; 23: 22532.
4. Wertzner HF, Sotelo MB, Amaro L. Analysis of distortions in children with and without
phonological disorders. Clinics. 2005; 60(2):93-102.
5. Shriberg LD, Flipsen PJ,
Karlsson HB, Mcsweeny JL. Acoustic phenotypes for
speechgenetics studies: An acoustic marker for residual /Z / distortions. Clin Ling
Phonetics, 2001;15(8): 631-50.
6. Shriberg LD. Classification and misclassification of child speech sound
disorders. Paper presented at the America Speech-Language-Hearing
Association Convention, Atlanta, GA, November 2002.
7. Shriberg LD, Flipsen PJ, Kwiatkowski J, Mcsweeny JL. A diagnostic marker for speech
delay associated with otitis media with effusion: the intelligibility-speech gap. Clin
Ling Phonetics. 2003; 17(7): 507-28.
8. Shriberg LD, Lewis BA, Tomblin JB, McSweeny JL, Karlsson HB, Scheer AR. Toward
diagnostic and phenotype markers for genetically transmitted speech delay. J Speech
Lang Hear Res. 2005; 48: 83452.
9- Shriberg LD, Kent RD, Karlsson HB, Mcsweeny JL, Nadler CJ, Brown RL. A diagnostic
marker for speech delay associated with otitis media with effusion: backing of
obstruents. Clin Ling Phonetics. 2001; 15(8): 631-50.
10- Shriberg LD, Kwiatkowski J. Phonological disorders I: A diagnostic classification system. J
Speech Lang Hear Dis. 1982; 47: 226-41.
11- Shriberg LD, Kwiatkowski J. Phonological disorders III: a procedure for
Assessing severity of involvement. J Speech Lang Hear Dis. 1982; 47: 256-70.
12- Shriberg LD. Four new speech and prosody-voice
measures for genetics research and other studies in developmental phonological disorders. J
Speech Lang Hear Res. 1993; 36: 105-40.
13- Shriberg LD, Austin D, Lewis BA, Mcsweeny JL, Wilson DL. The percentage of
consonants correct (PCC) metric: extensions and reliability data. J Speech Lang Hear
Res. 2005; 48: 70822.
14- Anthony A, Bogle D, Ingram TTS, Mclsaac MW. The Edinburgh Articulation Test.
Edinburgh: E & S Livingstone;1971.
450
SY03A.5
EVALUATING EXPOSITORY TEXT SUMMARIES
Westby C.1, Culatta B 2, Hall K 2
Bilingual Multicultural Services1
Brigham Young University2
Introduction
As students move through school, increasing amounts of information are
presented in a variety of expository formats. Students experience more difficulty
understanding expository passages than they do narrative passages (Dubravac &
Dalle, 2002: Saenz & Fuchs, 2002). Because expository text plays such an important
role in academic success, educators want to assess and develop students expository
text comprehension and production. To do so, they need to know how students
develop the skills underlying expository texts. At this time, relatively little
information is available on development of expository texts. A few researchers
(Nippold, Mansfield, & Billow, 2005; Nippold, Mansfield, Billow, & Tomblin, 2008)
have provided data on the development of childrens and adolescents syntactic
patterns in oral and written expository texts. Currently, there are no data that link
syntactic microstructure patterns to expository text macrostructures. Two primary
questions were addressed in this study:
What microstructure and macrostructure differences do 4th and 5th grade
students exhibit in their written expository text summaries?
What effect does teaching of text structure have on the microstructures and
macrostructures exhibited by students in their written summaries of expository
texts?
Research has shown that explicitly teaching students expository text structure
improves their comprehension of expository texts (Weaver & Kintch, 1991; Williams,
Hall, & Lauer, 2004), yet little developmental data is available on students
comprehension and production of expository text structures. This paper presents the
results of a classroom-implemented intervention for 4th and 5th grade students
designed to teach comprehension of cause-effect and compare-contrast texts.
Methods
Participants: 243 fourth grade students (156 treatment and 87 control) and 257
fifth students (169 treatment and 88 control) from two school districts.
Teacher Training: Treatment teachers attended 2 full-day professional
development workshops. In addition, literacy specialists conducted monthly
planning and evaluation meetings with the teachers. The focus was on providing
teachers with ways to support students comprehension of expository texts (e.g.,
orchestrating discussions around relevant topics, highlighting text structure,
451
representing the organization of texts, and identifying relevant connections among

ideas).
Text Structure Analysis (TSA) Assessment Measure. Reliable and valid
assessments were created that replicated authentic curricular task demands and were
tied to curricular content. The TSA consisted of three expository passages: wildfires
(a cause/effect structure), bears (a compare/contrast structure), and tigers (a
cause/effect structure). All three passages were written at the fourth grade level
according to the Chall readability scale. In the wildfires and bears tasks, the students
were given a cloze organizational map with some main ideas and cohesive
connections (signal words) provided. The students filled in missing information in
the graphic representation and identified the correct relationships by filling in the
connecting links between main ideas (represented by a blank link or line with arrows
pointing between two cells on flow chart). In the tigers passage, students created
their own graphic representation to determine if students could represent the text
organization without any guiding support. Students wrote summaries based on their
graphic representations.
Data Analyses
Evaluation of student summaries included both a microstructure analysis of
their summaries using CLAN (Computer Language Analysis [MacWhinney, 2000])
(mean length of T-units, number and type of connectives and dependent clauses) and
a holistic macrostructure scoring of their summaries (using a rubric based on number
of elements of working memory used in the production of the summary). The holistic
scorning rubric used a 0 to 5 point scale. Table 1 presents the characteristics of each
of the levels with an example from student summaries.
Results/Discussion
There was an interaction of syntactic microstructures and the organization,
conceptual macrostuctures in which students clearly identify the relationships
between propositions in the texts and the relationship of the propositions to the
overall theme of the texts. At the end of the instruction period, there were more
treatment students than controls who made greater than 1-year-equivalency growth.
Repeated measures ANOVAs indicated that the children in the treatment classroom
condition performed significantly better than the children in the control on Gates
reading comprehension measures (F = 29.63 and p < .001) and the constructed
response measures.
There were fewer differences between 4th and 5th grade control classes than
between 4th and 5th grade treatment classes. Treatment appeared to heighten
developmental differences.
Differences between treatment and control groups were greater on passages
where a Cloze map was provided (wildfires and bears) than on the task where
the students had to create their own representation (tigers passage), suggesting
that graphic organizers provided more support to the treatment group than the
control group.
The majority of both control and treatment students received scores of 2 on the
holistic scoring, indicating they were either chaining sentences or linking
sentences to the passage topic, but they were not doing both. To achieve a 3 or
better, students needed to identify the overall theme of the passage and they
needed to write enough to show the relationships between individual ideas and
the theme and among individual ideas. Many students received 2s because they
452
did not write enough to be able to show these multiple relationships. Simply
stating many isolated ideas from the texts, however, was also not sufficient. The
relationships among the ideas and to the overall theme needed to be made
explicit. This required appropriate use of connectives and dependent clauses.
Use of connective words correlated significantly with MLT and with higher
rubric scores evaluating macrostructure aspects of text.
Awareness of developmental micro- and macrostructure patterns can provide
educators with guidelines regarding the specific content of expository text
instruction needed by students. Use of graphic organizers should be
accompanied by explicit teaching of connective words and dependent clauses so
that students are able to express the conceptual relationships that underlie the
texts.
Table 1. Expository Macrostructure Developmental Levels

Level 0
Random statements; not related
to the passage/topic
No clear topic
Statements do not link to a
central topic or to one another

Statements not related to the
assigned passage
Statements may have some
content that has a link to the text,
but in no way attempt to
summarize the text
Level
1
(operating on
short-term
memory,
not
using working
memory)
Level 2 (holds
and
manipulates
two concepts in
working
memory

If youre trieing
to start a fir by
prepared to bring
sum water.
Polar
bears
diggin there to
look for babi sils
Combination of relevant and

irrelevant statements/ideas
Relationships
not
clearly
represented; summary too brief
to indicate relationship
Statements
that
are
not
sentences; fragments, key words
from graphic organizer
Nearly all statements/phrases
taken from graphic organizer
Tigers are a tip of

cat that wathing
400 pounds. They
live in Asia. Most
of them died
from hunters.
People can start
wildfires
with
campfires.
Wildfires harm
people, plans and
animals.
Wildfires can be
started
by
lightning.
Listing of information but does

not follow one another in a
sequential, logical order that
correctly represents the order in
the passage
Sequential/logical order, but
Brown Bears live

in mountains and
forests. There fur
is blonde, bown,
or black. They eat
meat. Polar Bears
453
chaining
or
centering, but
not
both
simultaneously)
relationships between sentences

or between sentences and topics
are general (e.g., and, then, so)
rather
than
specific
(e.g.,
because, as a result, but,
ifthen.)
Response may be brief but
indicates some understanding of
relationship (e.g., use of causal
verb)
Not clear that student is aware of
text structures
Notes
Cannot be above a level 2 if
information in the text is
misinterpreted, if overall gist is
not captured, or if the child
copies only the connectors from
the graphic organize
Level 3 (holds
and
manipulates
three concepts
in
working
memory
chaining
and
centering
integrated
simultaneously)
A passage may be at this level if

it coveys the overall gist, but
uses only the connectors from
graphic
organizer
if
the
connectors
are
all
used
appropriately and the sentences
are well structured
Clear sense of text structure, but
may not use explicit topic
sentence
that
signals
text
structure
Statements link to one another
and to overall topic, but passage
length is limited
Some explicit links, but limited
variety/complexity; some errors
in use of connectives
May have inconsistent use of
organizational structure
Captures full gist of passage; for
cause effect, must be explicit
about cause and effect (not
sufficient to talk only about
cause, even if well done)
live in the fozen

tundra. There fur
is black or white.
They eat meat
like the Brown
Bears
Once many types
of tiger roamed
in Asia. Today
three types are
extinct. Several
others are rare.
With the loss of
tiger
habitats
they began to
hunt near farms.
The decline of the

tigers is caused
by
people
hunting tigers or
farmers burning
their
habitats.
There are people
trying to protect
tigers by making
reserves and zoos
and
stuff.
Hopefully tigers
will
have
a
comeback
and
start rising in
number
again
because
three
species of tiger is
already extinct.
454
Level
4
(simultaneous
chaining
and
centering with
specific
relationships)
And use of explicit connectives

in clauses that make the
relationships between ideas
explicit [e.g., before, because,
consequently, when, ifthen,
but, in contrast, similarly]
Text structure is obvious in
summary, using topic sentence
Statements link to one another
and to overall topic; must have
several sentences/ideas linked
together and to topic
Variety of explicit connectors
used
correctly;
dependent
clauses
used
to
express
relationships
Brown Bears and

Polar Bears are
dislike and alike
in these way.
Brown bears live
in mountains and
forests however
Polar Bears live
in the frozen
tundra.
Brown
bears
fur
is
blonde, brown, or
black. But Polar
bears fur looks
white
but
is
really
clear.
Although they are
different in these
ways they are
alike because they
both eat meat.
References
Dubravac, S., & Dalle, M. (2002). Reader question formation as a tool for measuring
comprehension: Narrative and expository textural inferences in a second language.
Journal of Research in Reading, 25, 217-232.
MacWhinney, B. (2000). The CHILDES project: Tools for analyzing talk. Mahwah, NJ:
Erlbaum.
Nippold, M., Mansfield, T.C., & Billow, J.L. (2007). Peer conflict explanations in children,
adolescents, and adults: Examining the development of complex syntax. American
Journal of Speech-Language Pathology, 16, 179-188.
Nippold, M., Mansfield, T.C., Billow, J.L., & Tomblin, J.B. (2008). Expository discourse in
adolescents with language impairments: Examining syntactic development. American
Journal of Speech-Language Pathology, 17, 356-366.
Saenz, L.M., & Fuchs, L.S. (2002). Examining the reading difficulty of secondary students with
learning difficulties. Remedial & Special Education, 23, 31-42.
Weaver, C. A., & Kintsch, W. (1991). Expository text. In R. Barr, M. Kamil, P. Mosenthal, & P.
D. Pearson (Eds.), Handbook of reading research (pp. 230245). New York: Longman.
Williams, J.O., Hall, K.M., & Lauer, K.D. (2004). Teaching expository test structure to young
at-risk learners: Building the basics of comprehension. Exceptionality, 12, 129-144.
455
SY03A.3
SYSTEMATIC ENGAGING EARLY LITERACY: A DYNAMIC SYSTEMS
APPROACH
Westby C.1, Culatta B 2, Hall K 2
Bilingual Multicultural Services1
Brigham Young University2
Researchers recommend providing intense and systematic instruction for

children who are at-risk for language and literacy learning problems. In addition,
instruction should be engaging and interactive. Interactive encounters with reading,
writing, and oral language can draw childrens attention to targeted language and
literacy patterns. Teachers and speech-language pathologists (SLPs) can collaborate
to provide intense and meaningful instruction by engaging children in instructional
interactions and embedding instruction across themes, activities, and contexts.
Project SEEL (Systematic Engaging Early Literacy) strengthens literacy skills
by calling childrens attention to target patterns during motivating interactions
across an array of contexts and activities. Teachers and SLPs highlight examples of
targets as they provide playful reasons for children to practice using skills. Activities
that provide frequent and meaningful opportunities to notice and practice using
target patterns are embedded into large and small group settings, snack, transitions,
class routines, and supplemental centers or small group rotations. The SEEL
language and literacy activities expose children to skills and targets in activities that
relate to compelling unit or book themes. Instruction is implemented in hands-on
activities (dramatic story telling, scripted play, story enactments, exploration of
hands-on materials, food and art projects, and interactive routines). Extension
activities surrounding the themes permit language and literacy skills to be
strengthened and deepened.
Many research-based reading interventions rely on highly structured,
teacher-led activities that teach one or two skills at a time. Although there is research
evidence for many of the programs that are used and children generally do learn the
specific skills that are taught, there has no change in the numbers of children
achieving reading proficiency on Reading First evaluations and on the National
Assessment of Educational Progress in Reading (NAEP, 2007). What might
contribute to the limited effectiveness of the teaching of specific language/literacy
skills that are considered to form the basis of literacy? In practice, children do not
learn one aspect of language at a time the components of language are interactive
and children are acquiring all components simultaneously. Current theories of
language development view language as an emergent process (Evans, 2008;
McWhinney, 1999). An emergent prospective on language and literacy relies on a
dynamic systems approach or what Nelson and colleagues (2004; 2008) have termed
a dynamic tricky mix to explain how language emerges in both neurotypical
children and children with language impairments. A complexity of factors influences
childrens language learning. The approach is considered a tricky mix, because there
is no one mix that is ideal for every child. These factors interact in different ways in
different children. Intervention with children involves keeping track of the
complexity of factors influencing childrens language performance and providing
456
ways of boosting childrens depth of engagement so that their learning emerges.

Nelson and colleagues propose that it is possible to dramatically accelerate a childs
language/literacy learning when one considers a convergence of conditions that
promote learning.
How can one address the complexity of multiple language skills that children
require for development of the decoding and language skills essential for literacy?
SEEL employs a dynamic tricky mix framework to promote the cognitive/language
skills essential for emergent literacy. According to Nelsons concept of a dynamic
tricky mix, to promote development, educators need to ensure that the following
elements related to lesson structure and what individual children bring to the
literacy learning task. A dynamic tricky mix approach considers the multiple
complex conditions that need to converge at or above threshold levels to support
learning at the highest rates. When all the components contribute to learning,
children develop a deep enjoyment and absorption in the activity of learning. Nelson
proposed the LEARN acronym as a way of organizing these components. The nature
of the SEEL curriculum exemplifies the LEARN components.
Launching Conditions. Children will become more involved in tasks and will better
remember tasks, if they are motivated to participate and challenged appropriately by the
tasks. SEEL employs engaging, playful activities, rather than drill or worksheet activities to
promote phonological awareness and discourse comprehension. SEEL teachers have
commented that the activities hook the children so that they excitedly become engaged in
the activities. Drill and worksheet can develop semantic memory (for words and concepts)
and procedural memory (scriptal memories for how activities are to be done), but they are
unlikely to promote episodic or autobiographical memory. Episodic memory links the
emotional experience of the event with the what, when, and how of the event. Episodic
memory enables children to have memory for their subjective experiences throughout time
and to perceive the present moment as both a continuation of their past and as a prelude to
their future (Tulving, 1993). This type of memory makes it possible for children to have
conscious recollection of personal happenings and events from ones personal past and
mental projection of anticipated events into ones future. Episodic memory enables children
to better recall the experience and to transfer the learning to other situations. Episodic
memory enables making predictions and inferences (which are essential for text
comprehension). Teachers have reported that children are remembering the SEEL activities
from day to day and week to week.
Enhancing Conditions. Language and literacy are socially constructed. Language

learning is dependent on the guidance or scaffolding support of others that promotes
shared meaning. Social interactions enhance learning, particularly when in this
process children develop self-regulation.and begin to be able guide and monitor their
own learning. Within the context of engaging, playful activities, the SEEL curriculum
involves teachers in carefully scaffolding their interactions with children in both the
phonological awareness and comprehension components of the program. Teachers
provide explicit, intense instruction in phonological awareness skills and model
language that:
Clearly describes the childrens activities and the activities of characters in

books
Explains reasons for the childrens SEEL activities and the reasons for
characters behaviors in books. Children learn to use language to reason about and
evaluate their own behavior and the behavior of characters in stories.
457

Refers to thoughts and feelings of the child and characters in stories. If
children are to comprehend stories, they must be able to understand the perspective
of the characters.
Predicts what will happen if in activities and stories. Children must be

able to predict consequences of their own behaviors and the consequences of the
behaviors of characters in stories. Such prediction is dependent on the use of episodic
memory (mentioned in the Launch Conditions section). One cannot predict if one
cannot connect the present situation without other experiences and such
connections are dependent on episodic memory which is dependent on an emotional
base. When modeling predicting language, teachers must link the present experience
to past experiences and knowledge, and then suggest logical relationships to future
situations. Predictions cannot be just wild guesses.
Adjusting Conditions. Adjusting Conditions are of two types: (1) the adjustments
teachers make to lessons based upon their observation and evaluation of childrens
response to activities, and (2) the adjustments children make as a result of their
attitudes about the task and their capability to do the task. Children are not all at the
same developmental levels. Consequently, teachers identify the degree of support
and practice that individual children require.
Children themselves make adjustments to how they approach learning activities.
Children, with both high and low ability, who desire to the learn material for the
sake of learning or because they enjoy the learning activities are likely to persist as
tasks become more challenging. In contrast, children who view focus on a final
product or evaluation of performance (especially if they are of lower ability), are less
likely to persist as tasks become challenging (Elliot & Dweck, 1988
Readiness Conditions. Readiness conditions refer to childrens language/literacy
skills when they enter the program. Teachers must know the language/literacy skills
children have when they enter the program and they must monitor childrens
development over the course of the program so that they can adapt the program as
needed for individual children. Children entering a SEEL program are evaluated
using the Phonological Awareness of Literacy-K (Invernizzi, Meier, Swank, & Juel,
2003).and an assessment of narrative comprehension (Paris and Paris, 2003). Teachers
monitor childrens ongoing progress by using their district assessment protocols.
Network conditions. Knowledge is best remembered and used when it is
consolidated or linked to/networked with other knowledge. This is essential for
developing the neural networks essential for representational thought. All SEEL
activities involve theme-based, playful experiences rather than isolated skill-based
drills or lessons. Hence, networking of knowledge is facilitated. For example,
children play with words rhyming with uck. They listen to a story, One Duck Stuck,
of a duck who gets stuck in the muck. As the teacher reads the story, she encourages
the children to describe how the duck became stuck in the muck and explain how the
duck was finally able to get out of the muck. They discuss how the duck might have
felt while she was stuck and how she felt when she got out of the muck. They
compare this story with Duck in the Truck. The children make muck (with pudding;
or ground, moistened oreos; or water and dirt). They feel the muck and get items
stuck in muck; they pluck items from the muck; they stick their hands in the muck
and proclaim, Yuck, Im stuck in muck. They report their experiences of getting
things stuck in muck. They explain why things can get stuck in muck, but not water.
They re-enact the stories of One Duck Stuck and Duck in the Truck. They sing a song
about duck behaviors. Throughout the day (and week), teachers highlight other
examples of uck and vocabulary and concepts from the story. Such experiences are
458
multi-sensory -- they integrate visual, auditory, tactile (and potentially taste and
smell) experiences, thus promoting neural networking.
Playful practice promotes neural networking because in the process of
playing and re-enacting stories, children are using all of their senses. They are using
language in meaningful contexts and in so doing they are developing an
understanding of the relationships among people, objects, and events that are
reflected in narrative and expository texts and in developing the complex oral
language skills necessary to convey these relationships.
References
Elliot, E.S., & Dweck, C.S. (1988). Goals: An approach to motivation and achievement. Journal
of Personality and Social Psychology, 54, 5-13.
Evans, J. (2008). Its all about change: Emergentism and language impairments in children. In
M.Mody & E.R. Silliman (Eds.), Brain, behavior, and learning in language andreading
disorders. New York: Guilford.
Invernizzi, M., Meier, J. D., Swank, L. & Juel, C. (2003). Phonological Awareness Literacy
Screening for Kindergarten (PALS_K). Charlottesville: University of Virginia
Printing.
McWhinney, B. (1999). The emergence of language. Mahwah, NJ: Erlbaum.
Nelson, K.E., & Arkenberg, M.E. (2008). How childrens progress in language and reading is
dramatically affected by on-line dynamic mixes of social, executive function,
emotional, biological, and input-interactive factors. In M.Mody & E.R. Silliman (Eds.),
Brain, behavior, and learning in language and reading disorders. New York:
Guilford.
National
Assessment
of
Educational
Progress
Reading
2007.
http://nationsreportcard.gov/reading_2007.
National Evaluation of Early Reading First. (2007). Retrieved 5/508 from
http://ies.ed.gov/ncee/pdf/20074007_execsumm.pdf
Nelson, K.E., Craven, P.L., Xuan, Y., & Arkenberg, M.E. (2004). Acquiring art, spoken
language, sign language, text, and other symbolic systems: Developmental and
evolutionary observations from a dynamic tricky mix theoretical perspective. In J.M.
Lucariello, J.A. Hudson, R. Fivush, & P. J. Bauer (Eds.), The development of the
mediated mind: Sociocultural context and cognitive development. Mahwah, NJ:
Erlbaum.
Paris, A. H. & Paris, S. G. (2003). Assessing Narrative Comprehension in Young Children.
Reading Research Quarterly, 38(1), 36-76.
Reading First Impact Study: Interim Report (2008). Retrieved 5/5/08 from
http://ies.ed.gov/ncee/pdf/20084019.pdf
Tulving, E. (1993). What is episodic memory? Current Directions in Psychological Science, 2,
67-70.
459
SSY04.3
LANGUAGE SKILLS OF FINNISH-SPEAKING PRETERM SINGLETONS
AT THE CORRECTED AGE OF TWO YEARS - OUTCOME AFTER
CLINICAL TRIALS DURING NEONATAL INTENSIVE CARE
A. Yliherva1, L. Kuukasjrvi1, M. Ylisuvanto1, O-M. Peltoniemi2
1
Faculty of Humanities, Logopedics, University of Oulu, Oulu, Finland
Department of Pediatrics, University of Oulu, Oulu, Finland
Introduction
There is a growing interest to study how treatment during the neonatal
intensive care (NIC) could help preterm children to survive better without any
neurodevelopmental problems. The main aim in treatments of preterm babies is to
prevent and treat the acute and chronic respiratory diseases, respiratory distress
syndrome (RDS) and bronchopulmonary dysplasia (BPD) and intracerebral
complications (intraventricular hemorrhage = IVH, periventricular leukomalacia =
PVL). For example antenatal corticosteroid (ANC), which treatment is given to a
mother within a week before expected preterm delivery, has been found to decrease
neonatal mortality, RDS as well as IVH (Liggins & Howie, 1972; Peltoniemi, 2007).
According to randomized trials and meta-analysis ANC does not have an effect on
the incidence of BPD in preterm babies. Postnatal corticosteroid (HC) treatment is
given to those preterm babies who are very or extremely preterm and have severe
problems in lung functions. According to randomized control studies (RCTs) the HC
treatment has been reported to increase survival without BPD among infants
exposed to chorioamniotis (Wattenberg et al., 1999) or infants with low serum
cortisol levels soon after birth.
There are not many studies on the effect of treatments during the NIC on
later speech and language outcome. According to the studies by Peltoniemi et al.
(2009; 2009) multicenter follow-up of HC or ANC treatment randomly given to
preterm infants did not have notably effect on their speech development when
children were at the corrected age of two years assessed by their parents or
pediatricians at clinical settings compared to the placebo treated preterm controls.
Speech development was assessed by parents using MacArthur Communicative
Development Inventory (MCDI, Fenson et al., 1994). In the present study more
detailed language measurements are used to assess the language outcome in preterm
singletons after NIC treatments in the district of Oulu University Hospital.
The aim of the present study was to find out if HC or ANC treatments have
an effect on preterm childrens language outcome such as productive vocabulary and
maximum sentence length (MSL) at the corrected age of two years measured by play
situation.
460
Method
The preterm children in the present study were recruited from a larger
sample of preterm children who participated in two placebo-controlled multi-center
studies comprising all the University hospitals in Finland. There were altogether 52
children in the study sample born in the district of Oulu University Hospital who
were participating speech and language evaluations. After excluding twins, triplets,
bilingual children and one child of whom we did not get a video-recorded play
situation there were altogether 32 preterm singletons in the study sample. There
were 9 preterm singletons in the HC group and 6 in the HC placebo (HC/PL) group
(total N = 15, mean 26 gestational weeks), and 6 in the ANC group and 11 in the
ANC placebo (ANC/PL) group (total N = 17, mean 31 gestational weeks). The
groups were randomized into the treatment and placebo groups. In addition, there
were 20 full-term control children. The age of the full-term control children was two
years (+ two months) and the ratio of boys and girls was similar as in treatment and
placebo groups.
Productive vocabulary and maximum sentence length (MSL) were analyzed
from spontaneous speech samples based on video-recorded play situation when the
preterm and control children were playing with their mothers. From the video
sessions first 15 minutes were analyzed if possible. In the HC and HC/PL groups all
children did not reach the 15 minutes play session for different reasons (poor
concentration etc.). The data was transcribed using broad phonetic transcription.
Firstly, each childs transcript was analysed to derive the size of the productive
vocabulary. Each possible word candidate was identified following a procedure
devised by Vihman and McCune (1994). The size of the vocabulary was assessed by
calculating each intelligible word produced spontaneously during the session. The
cut-off of 50 words was used based on earlier studies on vocabulary size in Finnishspeaking children. Secondly, the MSL for each child was calculated from three
utterances with the largest number of morphemes. A mean was computed from
these three utterances. The cut-off of 3.0 was used in analyzing MSL based on same
criterion as mentioned concerning vocabulary. To examine the reliability of
morpheme calculation, 50 % of the utterances were coded independently by a second
rater. The interrater reliability for the MSL was 92.6 % for the HC and HC/PL groups
and 99.0 % for the ANC and ANC/PL groups.
The HC and ANC groups were compared to their placebo control groups and
all four groups, HC, HC/PL, ANC, ANC/PL, to the full-term control group using
nonparametric Kruskal-Wallis Test.
Results
According to the results there was no statistically significant difference
between the HC and ANC groups when compared to their placebo control groups in
productive vocabulary size. Instead, when comparing the HC and ANC and their
placebo groups and the full-term control children to each other there was a
significant difference (p < 0.0001) (see also Figure 1). The mean productive
vocabulary size was 23.6 + 16.8 in the HC and 29.8 + 17.8 in the HC/PL, and they
were the poorest groups having mostly less than 50 words when compared to the
full-term children (mean 139.3 + 82,4) or to the ANC (mean 124.0 + 86,5) and the
ANC/PL (mean 147.0 + 85,3) groups of which the ANC/PL group had largest
productive vocabulary.
461
Figure 1 Productive vocabulary size measured in a play situation

in HC (hydrocortisone), ANC (antenatal corticosteroid) and their
placebo groups and in the full-term control group.
There was not statistically significant difference in MSL between the HC and
ANC groups when compared to the placebo groups. The MSL of the HC (mean 2.2 +
1.5) and ANC (mean 1.8 + 1.2) and the placebo (HC/PL mean 2.4 + 1.6, and ANC/PL
mean 2.3 + 0.7) groups differed significantly from the full-term control children
(mean 4.6 + 2.0) (p<0.0001). Especially the HC and HC/PL group had the shortest
MSL, but also the children in the ANC group had short MSL as seen in the Figure 2.
462
Figure
The
Maximum
Sentence
Length
in
HC
(hydrocortisone), ANC (antenatal corticosteroid) and their

placebo groups and in the full-term control group.
Discussion
The HC and ANC treatment groups did not differ from their placebo groups
in productive vocabulary or in MSL. When compared the HC, HC/PL, ANC,
ANC/PL and the full-term groups to each other it was seen that HC and HC/PL
groups had poorest productive vocabulary size. All preterm groups did differ
significantly from the full-term control children in MSL. To summarize, the treatment
did not show any effect on language outcome in preterm singletons at the corrected
age of two years which might be due to relatively small number of children in the
treatment and placebo groups after excluding twins, triplets and bilinguals. In the
study by Peltoniemi (2007) the difference was either not seen in a bigger group of
preterm children when speech outcome was assessed by parents or pediatricians.
The variation of the size of productive vocabulary is huge in Finnishspeaking two-year-old children (Nieminen, 2007) and that is why it is also difficult to
prove the possible effect of treatment at that age. Overall, studies focusing on the
acquisition of productive vocabulary in preterm children have revealed that the
number of words produced seems to decrease with decreasing gestational weeks and
increasing disability (Foster-Cohen et al., 2007; Kern & Gayrayd, 2007) which was
seen also in the present study concerning especially the HC and HC/PL groups. On
the other hand, ANC/PL group had the largest productive vocabulary which might
be due to the bigger amount of children in the ANC/PL group. In addition they were
born with higher birth weight than the HC and HC/PL preterm children.
Concerning the MSL the ANC group was the poorest. There was e.g. one case
with very poor vocabulary and it was impossible to count the MSL. In addition,
many ANC singletons had MSL less than 2.0. Instead, in the HC and placebo groups
463
there were two children with MSL being 5.0. However, all the preterm children had
shorter MSL than the full-term control children.
During the present study it was difficult to show any potential difference
between the groups because of the small number of cases. The original sample size
was not calculated to evaluate difference in neurosensory outcome between the
treatment and placebo groups. Two-year-old childrens language outcome is varying
extensively, and e.g. Aylward (2005) recommended that the effect of treatment
during the NIC should be evaluated at school age to find out their effect on e. g.
speech development and academic skills.
Conclusion
In the present study the HC and ANC treatments did not have an effect on
preterm childrens language outcome at the corrected age of two. However, all the
preterm groups (treatment and placebo) were poorer in language skills compared to
that of the full-term control children except the ANC/PL children performing the
best in productive vocabulary. The possible effect of these NIC treatments on later
language and learning skills are going to be followed when children are at schoolage.
References
Aylward, G.P. (2005). Neurodevelopmental outcomes of infants born prematurely.
Developmental and Behavioral Pediatrics, 26, 42740.
Fenson, L., Dale, P.S., Renick, J.S., bates, E., Thal, D.J. & Pethick, S.J. (1994). Variability in early
communicative development. Monographs of the Society for research in Child
Development 59, 5, serial No 242.
Foster-Cohen, S., Edgin, J.O., Champion, P.R. & Woodward, L.J. (2007). Early delayed
language development in very preterm infants: Evidence from the MacArthurBates CDI. Journal of Child Language, 34, 65575
Kern, S. and Gayraud, F. (2007). Influence of preterm birth on early lexical and grammatical
acquisition. First Language, 27, 15973.
Liggins, G. C. & Howie, R. N. (1972). A controlled trial of antepartum glucocorticoid
treatment for prevention of the respiratory distress syndrome in premature infants.
Pediatrics, 50, 515525.
Nieminen, L. (2007). A complex case. A morphosyntactic approach to complexity in early child
language. Jyvskyl studies in Humanities 72. Jyvskyl: Jyvskyl University
Printing House.
Peltoniemi, O-M. (2007). Corticosteroid treatment in perinatal period. Efficacy and safety of
antenatal and neonatal corticosteroids in the prevention of acute and longterm
morbidity and mortality in preterm infants. Doctoral dissertation. Acta Universitatis Ouluensis,
D 927.
Peltoniemi, O. M., Lano, A., Puosi, R., Yliherva, A., Bonsante, F., Kari, M. A., & Hallman, M.
(2009). Trial of early neonatal hydrocortisone: two-year follow-up. Neonatology, 95,
240247.
Peltoniemi, O., Lano, A., Yliherva, A., Puosi, R., Lehtonen, L., Kari, Ma., Hallman, M; for the
Repeat Antenatal Betamethasone (RepeatBM) Follow-Up Study Group.(2009). Twoyear follow-up of a randomized trial with repeated antenatal betamathasone.
Archives of Disease in Childhood Fetal neonatal Ed, 94, F402F406.
Watterberg, K.L., Gerdes, J.S, Gifford, K.L. & Lin, H.M. (1999). Prophylaxis against early
adrenal insufficiency to prevent chronic lung disease in premature infants.
Pediatrics, 104, 12581263.
464
Vihman, M.M. & McCune, L. (1994). When is a word a word?. Journal of Child Language, 21,
517 42.
465
FP19.4
LETTER KNOWLEDGE, PHONOLOGICAL AWARENESS AND
SENSITIVITY TO THE SYBLEXICAL UNITS IN INVENTED SPELLING:
EVIDENCE FROM THE YEAR-LONG KINDERGARTEN STUDY.
Zaretsky E.,1 Core C. 2, Currier A. 1
University of Massachusetts Amherst1
George Washington Univeristy (Previously Florida Atlantic University)2
Introduction:
Research in the area of early literacy development is rich in evidence that PA,
alongside the vocabulary, is regarded among the best predictors for early reading
acquisition, although there is a view that explicit PA may not be essential for linking
print and speech sounds (Castles &Coltheart, 2004). Researchers also investigate the
effects of letter-sound knowledge as an important predictor for learning to read (de
Jong, 2007). It has been postulated that knowledge of the alphabet, both naming and
production, children have before the onset of formal reading instruction may be one
of the most powerful predictors of later reading ability and is considered to be a prerequisite on the par of PA (Mann & Wimmer, 2002; Hulme, Snowling, Caravolas, &
Carroll, 2005).
The logic behind this assumption points to the fact that letter
knowledge provides initial connections between print and speech, as the letter
contains not only visual properties but phonological properties as well. The deeper
view of the relationship between letter knowledge and early reading development
maintains that it accounts for more variances in early reading than home reading
activities. Letter knowledge may also be viewed as a stand in for the variances
associated with phonological memory process, as it requires to learn and recall
phonologically coded information involved in saying the letter name (Share, 2004).
From the point of view that reading acquisition is partially a code-related skill
(Gougth and Tanmer, 1986), i.e., it requires specific cognitive skills, like phonological
memory, as essential for reading acquisition, letter knowledge and the ability to say
the letter name directly relates to the phonological awareness skills as both rely on
phonological memory (Share and Stanovich, 1995; Share, 2004).
Another important component of early literacy acquisition is the language of
exposure. Evidence suggests that children exposed to the deep orthography, such as
English, may have a different trajectory in the development of PA than children
acquiring literacy in language that enjoys one-to-one letter sound correspondence, or
shallow orthography (Zaretsky, Kuvac Kraljevic, Core, & Lancek, 2009). Therefore,
the predictive power of PA awareness in early literacy development among Englishspeaking children becomes evident only by the end of the kindergarten year.
Less literature is dedicated to the relationship between letter knowledge and
early spelling. However, the limited number of available empirical research points to
strong correlation between alphabet knowledge and childrens inventive spelling
(Treiman, Pennington, & Shriberg, 2008; Zaretsky, Kuvac Kraljevic, Core, & Lancek,
2009). Indeed, early spelling attempts can provide an insight into the role the
alphabet knowledge is playing in providing representations of sounds in the word,
and some studies propose the predictive relationship between the invented spelling
and early reading (Shatil, Share, & Levin, 2000).
466
Throughout the initial stages of literacy acquisition, strong support is found

for the theory that children begin to be aware of the larger units of written language,
such as whole words and syllables, and then progress to identification of onsets and
rimes, and finally individual phonemes (Treiman, 1992; Symour & Duncan, 1997).
However, there is no unity within the research community regarding the best
predictors, i.e., onset-rime awareness vs. PA, to early reading achievements (Hulme,
Hatcher, Natiaon, Brown, Adams, & Stuart, 2002), or to the sensitivity of children to
either onsets or rimes in their early reading attempts (Savage, Blair & Rvachew,
2006). Even less is known of how PA, sensitivity to the onsets and rimes and the
letter-name knowledge influence the development of early spelling throughout the
kindergarten year.
This study represents and attempt to follow a possible trajectory in spelling
development during the kindergarten year by investigating the relationship between
alphabet knowledge, PA and sensitivity to the sublexical units within the words, i.e.,
onsets and rimes, in early spelling attempts. Specifically, we tested the hypotheses
that alphabet knowledge is a better predictor than PA in childrens ability to
represent onsets and rimes as part of the development of spelling skills.
Methods:
31 kindergartners (M=5;5, SD=3.2) were assessed at the beginning and the
end of the kindergarten year on measures of PA (segmentation, initial and final
sound isolation, phoneme deletion, substitution and blending) at T1, and given an
invented spelling task at T1 and T2. The spelling attempts were coded for
representation of onsets and rimes. A series of correlations and regressions were
utilized for analyses.
Results:
Our results indicate that alphabet knowledge, both naming and writing
letters, is very important for early spelling. Lower case letter naming was most
predictive of phonetically accurate representation of both, onsets and rimes in
spelling task at T1. PA did not add any significant variance at T1. At T2 PA influence
on the representation of onsets approached significance, and was a significant
predictor for the representation of rimes. However, lower case letter naming
continued to be the strongest predictor for representation of both, onsets and rimes at
the end of the kindergarten year. These results support the notion that children in
North America use letter names as a bridge to representation of letter sounds.
(Ellefson, Treiman, & Kessler, 2009). Despite the strong developmental growth
throughout the year in the ability to accurately represent sublexical units in spelling,
children continuously showed preferences for the onset representation over rimes.
Among individual PA tasks, only phoneme segmentation showed strong and
significant correlation with the onset-rime representation.
Conclusion:
This study provides important clues on the nature of the relationship
between letter knowledge and subsequent attempts at early spelling. As pointed out
in previous research, sensitivity to the initial sounds within the word is prevalent at
the beginning of reading development (Hulme, et al., 2002). It appears that this
sensitivity is applicable to the beginning of spelling development as well. However,
it is undisputable that knowledge of the alphabet, specifically naming of the lower
case letters, plays an important role in early spelling attempts and representations of
sublexical structure of the word, while PA begins to show its influence only by the
end of the kindergarten year, consistent with the proposed developmental trajectory
among children exposed to deep orthography, such as English. The study also
showed that not all PA awareness tasks are equal predictors of the success in spelling
467
development. It appears that PA tasks that require higher level of metalinguistic

awareness, such as segmentation, are better suited to account for success in
childrens sensitivity to the structures of the word. More studies should look at the
relationship between PA, letter knowledge and childrens spelling attempts.
468
FP06.2
PROGRAM OF INTERVENTION IN DEAFBLIND STUDENTS: THE
FRAMEWORK OF THE COGNITIVE AND COMMUNICATIVE PROFILE OF
DEAFBLIND STUDENTS AND THE APPLICATION OF EDUCATIONAL PLAN
OF INTERVENTION
M. Zeza1 , P. Stavrou2
1Doctorate PhD, Researcher of Laboratory of special and curative education,
(LABESPEC), University of Ioannina, Greece
2Stavrou
Pilios, Clinical Psychologist, Laboratoire de Psychologie Clinique et

Psychopathologie, Universit Paris V - Sorbonne, France
Introduction
Children understand the world through their interaction with people and
objects. Without the need to be taught the child explores, using all his senses, in
order to learn about the people and the objects in its environment. Students with
deafblindness may, due to sensory loss, miss or misinterpret natural cues and
incidental information which provide an understanding of the world (Alsop, 2002)
Therefore, cognition and communication are seriously affected by the combined loss
of vision and hearing (Aitken, 2000).
Towards a definition
Deafblindness is defined as: concomitant hearing and visual impairment, the
combination of which creates such severe communication and other developmental
and educational needs that they cannot be accommodated in special educational
programs solely for children with deafness or blindness (Mamer & Alsop, 2000)
The basic concept of uniqueness is especially apparent among the deafblind
population. Each child has a particular degree of visual and auditory loss, ranging
from moderate to total. The sensory losses may occur before birth or at any age and
may be lost independently or at the same time. The sensory loss may be gradual or
immediate and may be accompanied by the loss of other body functions or other
health problems. The deafblind child is multisensory deprived because he is unable
to receive undistorted information from the distance senses. The deaf-blind student
may:
lack the ability to have a meaningful communication with its environment
have a distorted perception of the word
have difficulties in anticipating future events or the results of their actions
be deprived of external motivation
have serious medical problems
be misidentified as retarded
have difficulties in concept formation. (McInnes & Ttreffry, 1993, Murdoh,
1999, Alsop, 1993, Stavrou, Gibello & Sarris,1997)
469
The deaf-blind population: implications in communication and learning

Deafblind children cannot learn from interaction with their environment as
easily as all the non-handicapped children due to multi-sensory deprivation. They
are unable to access the essential information from the surrounding environment in a
clear, simultaneous and consistent way. Their environment is limited to what is
approachable from their hands, or from their sensory potential. Their motivation to
explore is minimal. The limited channels of access (touch, small, taste), affect the
importance of external stimuli in motivation of communication, motor development,
the concept formation and the cognitive development (McInnes & Ttreffry, 1993)
The child's level of cognitive functioning and his ability to establish and
elaborate on meaningful concepts depends, to a large extent, on his ability to receive
and integrate input from the world about him. The ability to integrate sensory input
influences the development of communication and the concept development
(McInnes&Treffry, 1993). Multisensory deprivation imposes limitations on
communication and the perception of primary concepts (e.g. time, space), which are
important for the concept formation of the natural and social environment (Prickett,
Welch. 1995).
Most of the children follow the 5 Piagetian stages, but the children with
multisensory impairments receive limited, distorted sensory information, the
perception may differ and the concept development may be impeded, through which
the child defines its relation to the word and formats his conceptual background.
Children who cannot rely on their distance senses to provide information about their
world may learn less effectively, because the received information are unreliable,
distorted and inadequate and therefore learning and experience are restricted in
quality and quantity (Stavrou, 2002, 2003, Hodges, 2000, Stavrou & Sarris, 1997,
Stavrou, Zgantzouri & Stavrou, 2004).
Rationale
Types of assessment
The assessment of students abilities consists of an important section of each
educational program. Undoubtedly, the assessment of a deafblind student is a
complex procedure. The types of assessment with standardized tests may have little
place when working with deaf-blind students due to the uniqueness of each
student's learning difficulties and strengths (Eyre, 2000). Usually many tools require
the person to use vision and/or hearing because and they may point out the
hierarchical skills and knowledge that children will acquire, but it should not be
expected from deafblind students to follow the same routes to a goal (McInnes &
Treffry, 1993, Drigas, Kouremenos, Vrettaros, Karvounis & Stavrou, 2009).
In addition, such instruments may focus on knowledge and skills that the
person is expected to have learned incidentally or to have discovered and practiced
through non-directed interaction with the environment. It is highly unlikely that the
infant, child or youth who is deafblind will have an extensive collection of
knowledge and skills developed in this way (McInnes,1999). Another point refers to
the fact that special adaptations or intervention guidelines are not usually included
and considered (Eyre, 2000, Friedman & Calvello, 2001). The process is differentiated
for the deafblind student and does not refer only to the use of tests, but emphasizes
the multimethodological approach that tends to confirm whether the student has the
ability to interfere and express a learned behavior. The goal of using a screening
inventory approach is to provide the educators with efficient information that will
470
help them to plan and individualize the educational program (Walsh, Holzberg,
1981, Crook 1970, Stavrou & Christoforidou, 1999, Dimitriou & Stavrou, 2009).
Methodology
Where do we start?
This is the most common and in the same time hardest question to answer by
the professionals who work with deafblind students. Tried approaches and
assessment methods applied to other students may be completely ineffective and
inappropriate. (McInnes & Treffry,1993). But the question remains: where do I start?
How to communicate with a deafblind student? How to assess his cognitive abilities?
The profile's framework
This crucial question we try to answer with the research program we are
presenting here. The Laboratory of Special and Curative Education (LABESPEC), of
the University of Ioannina, Greece, embarked in a research program to develop a
screening inventory of the cognitive and communicative profile of deafblind
students, using direct observation and adapted material for composing the students
profile and applying the program of intervention, in the form of case study. The
research for the modification and application of the profile and the educational
program of intervention is in progress. The profile consists of 6 sections referred to:
1. communication development (receptive, expressive)
2. sensory development
3. social development
4. motor development
5. cognitive development
6. daily living skills
The screening inventory of the cognitive and communication profile of
deafblind student highlights the difficulties and the unique challenges faced by the
students. The monitored difficulties direct the planning and the application of the
individualized intervention through the implementation of adapted methods and
material.
This profile will combine the use of alternative and adapted methods for
collecting data in order to compose the cognitive and communicative profile of the
student. The elements gathered and the difficulties noticed will define the planning
of the individual educational interventional program. The uniqueness of each deafblind person and the heterogeneous among the deafblind population lead us to the
application of the methodological approaches of observation and case study.
The profile is theoretically founded through the axes of communication,
social-emotional development and cognitive development. Its structure consists in
the elaboration of selected, modified and adapted elements from tests used in
Greece and widely and in construction-creation of items and its application is
implemented through the use of adapted material through multi sensory
approaches. The profile aspires to present an initial structured and composed
framework of the deafblind students' potential focused on specific sections. The
gathered elements will be used for the purpose of developing an interventional
educational plan addressed to the unique student's need, incorporated into an
adapted curriculum.
The individual educational plan consists of and elaborates the elements of
communication, motor, cognitive and social-emotional development, thus the limited
interaction with the environment and the restricted reception of visual and auditory
stimulation may impede the concept formation and the acquisition of the concepts of
471
time and space, on which is the concept background of learning and communication
founded. The individual educational plan aims to enforce the encouragement for
active presence, direct interaction of deafblind students into their environments
through their inclusion to an adapted learning and reactive environment which they
can control, comprehend, understand, anticipate through multi sensory and
accessible approaches.
Conclusion
In the case of deafblind students, whose condition consists of a combination
of visual and hearing loss, the deprivation of environmental stimuli is often
profound and of primary concern of the educators. The facility for learning is so
greatly reduced that special intervention in the form of alternate communication and
teaching techniques is required. Because of the multiplicity of handicaps, the
uniqueness of every deafblind person and the tremendous frustration that is
experienced with communication problems the education of deafblind students
presents a special challenge to teachers (Hodges, 2000, Jan van Dijk, 1986).
There is a key concept referred to the education of deafblind students; when
the life and the childs environment become more structured, predictable, adapted
and accessible, the communication and concept development are enforced, the
independence, the participation and choices making are fostered, since external
world and the received information and stimuli become controlled, intelligible and
anticipated.
References
Aitken, S. (2000). Understanding deafblindness. n Aitken, S. et al. (2000). Teaching
children who are deafblind. (pp.1-34). London: David Fulton Publishers.
Alsop, L. (2002). Understanding Deafblindness. Issues, Perspectives and Strategies. SKI-HI
Institute, Utah.
Blacha, R. (2001). Calendars for students with Multiple Impairments Including
Deafblindness. Texas School for the Blind and Visual Impairment. Texas: Morgan
Printing.
Crook, J. (1970). Deaf-Blind Education: Developing Individual Appropriate Communication
and Language Environments. Massachussets: Perkins School for the Blind.
Dimitriou, M. & Stavrou, L. (Athens, 3-5 July 2009). Attention deficit hyperactivity disorderGreek test (ADHD-GT). International thematic conference: From inhibition to
hyperactivity: psychopathological approach.
Drigas, A., Kouremenos, D., Vrettaros, J., Karvounis, M. & Stavrou, P-D. (2009).The diagnosis
of the educational needs of the hearing Impaired. Int. J. Social and Humanistic
Computing, 1(2),138-148.
Eyre, J.T. (2000) Holistic assessment. n Aitken, S. et al. (2000). Teaching children who are
deafblind. (pp.119-140). London: David Fulton Publishers.
Friedman, C.T. & Calvello, G. (2001). Developmental Assessment. In PAVII. Massachusetts:
Perkins School For the Blind.
Hodges, L. (2000). Effective Teaching and Learning. In Aitken, S., Buultjens, M., Clark, C.,
Eyre, J.& Pease, L. (2000). Teaching Children who are Deafblind. (pp. 167-199).
London: David Fulton Publishers.
Jan van Dijk (1986). An educational Curriculum for Deaf-Blind Multi- Handicapped
Persons. In Ellis, D. (ed). (1986). Sensory Impairments in Mentally Handicapped
People.(pp.374-382). London : Croom Helm Ltd.
Mamer, L & Alsop, L. (2000). Intervention. In Alsop, L. (2002). Understanding
Deafblindness. Issues, Perspectives and Strategies. (pp. 57-94). SKI-HI Institute,
Utah.
472
McInnes, J. & Treffry, J. (eds). (1993). Deaf-Blind Infants and Children. Canada: University
of Toronto Press.
McInnes, J. (1999). Deafblindness: a unique disability. In McInnes, J. (1999). A guide to
planning and support for individuals who are deafblind. Canada: University of
Toronto Press.
Miles, B., Riggio, M. (eds). (1999). Remarkable Conversations. Massachusetts: Perkins
School for the Blind.
Prickett, . &, Welch, T. (1995). Deaf-Blindness: Implications for Learning. In Huebner,T.,
Prickett,J., Welch, T. & Joffee, E. (eds) (1995). Hand in Hand. (pp.25-60). NY : AFB
Press.
Stavrou, L., Gibello, B. & Sarris, D. (1997). Les problmes de symbolisation chez lenfant
dficient mental: Approche conceptuelle et tude clinique. Scientific Review of School
of Education, University of Ioannina, v. ( pp. 187-217).
Stavrou, L., Sarris, D. (1997). Limage du corps chez les infirmes moteurs crbraux
(IMC) au travers des preuves projectives. European Journal On Mental Disability,
4(16), 17-23.
Stavrou, L., & Christoforidou, C. (1999). Parfaire la formation des Professionnels In C.
Gardou et collaborateurs, Connatre le handicap, reconnatre la
personne,
Col.
Connaissances de lducation, Lyon: ERES.
Stavrou, L. (2002). Teaching Methodology in Special Education. Athens: Anthropos.
Stavrou, L. (ed). (2003). Body Image and Body Schema. Athens: Anthropos.
Stavrou, L., Zgantzouri, K. A. and Stavrou, P.-D. (2004). Mechanisms involved in the
formation of body and self image in individuals with psychotic symptoms, 6th
International Psychoanalytic Symposium of Delphi, Delphi, Greece, October 27-31, p. 29.
Walsh, S. & Holzberg, R.(1981). Understanding and Educating the Deaf-Blind Severely and
Profoundly Handicapped. USA: C.C.Thomas Publisher.
473
DYSPHAGIA
FP45.5
ASSESSMENT AND BEHAVIOR THERAPY FOR SWALLOWING PROBLEMS IN
BRAIN DAMAGED MOTOR HANDICAPPED CHILDREN
Tamer Abou-Elsaad1 MD, PhD, Safaa El-Sady2 MD, PhD and
Gehan Abdel-Latif1 MD, PhD.
Units of Phoniatrics, ORL Departments, Faculty of Medicine, Mansoura
Mansoura1 and Ain Shams University, Cairo2, Egypt.
University,
Introduction:
Brain Damage Motor Handicap (BDMH), commonly known as cerebral palsy

(CP) may be defined as a stationary non-progressive disorder of posture and
movement, often associated with epilepsy and communication disorder, and
problems with hearing, vision and intellect resulting from a defect or lesion of the
developing brain (Hagber et al., 1993). Severity of BDMH is graded as mild (ability to
perform age appropriate activities of daily living without help), moderate (semi
independence in activities of daily living with ability to communicate using speech
or formalized methods only and feeding skills limited to use of aids) and severe
(total dependence of activities of daily living with no oral communication and no self
feeding capability (Patwari et al., 2006). Many BDMH individuals manifest oralingestive problems, in addition to other developmental problems. These problems
may affect the formation of a swallow-safe bolus and the initiation of swallow
(Kenny et al., 1989).
The aim of this prospective study is to evaluate the swallowing problems in a
group of BDMH children in order to identify the physiological breakdown in their
swallowing functions and to help in formulation of proper management strategies.
Subjects and method:
(I) Subjects: This prospective study was conducted in the Phoniatrics Unit,
Mansoura University Hospitals, Egypt on 50 children with BDMH (34 males and 16
females) with their ages ranged between 2 years 1month and 11years (X=5.122.06
ys). The studied children had different types of BDMH [spastic (40)- dyskinetic (4)ataxic (2)- mixed (2)- atonic (2)] and degrees of severity [mild (12)- moderate (26)severe (12)].
(II) Assessment of BDMH children: The children were evaluated through a specially
designed diagnostic protocol that was structured in the Phoniatrics Unit, Mansoura
University Hospitals, Egypt that included:
A- Patient/parents interview: that included detailed history of the child's feeding routine.
B- Clinical examination: that included vocal tract and neurological examinations.
C- Communicative abilities of the child.
D- Oral-Motor Structure and Function Assessment: Each structure was evaluated for
precision, strength and range and symmetry of movement.
E- Formal testing for cognitive and perceptual abilities of the child. I.Q and mental age were
assessed by Stanford Binet test (Thorndik et al., 1986).
F- Swallowing assessment: The swallowing function was evaluated for all

children using Videofluoroscopy (modified barium swallow = MBS). The
474
radiographic images of the MBS procedure were recorded using Philips fluoroscopic
unit and a Panasonic video VHS recorder (NV-SD570). The child was seated in an
upright support chair, and swallows were imaged in the lateral, and antero-posterior
views (figures 1, 2).
Each child was asked to swallow two presentations of each of the following:
(a) 3 and 5 ml thin liquid barium (20% barium sulfate [Prontobario H.D.] and 80%
water); (b) 3 and 5 ml thick liquid barium (50 % barium and 50% water); (c) 3 and 5
ml semisolid (pudding mixed with barium powder) and (d) of cookie (coated with
pudding + barium powder). The volumes of the boluses were calibrated using a
measuring spoon. The fluoroscopy unit was turned on every 15-30 seconds to
minimize radiation exposure which was kept to a limit of 1-2 minutes.
Fig. (1): MBS procedures (lateral view).
Fig. (2): MBS procedures (A-P view).
The videofluoroscopic images were then transferred to the computer to be

analyzed using EO software program (Version 1.36, 2003) which place numbers (to
the hundredth of a second) on each video frame for frame-by-frame analysis. The
swallowing observations and measures were made on the Pediatric Modified Barium
Swallow Checklist (Appendix) (Abou-elsaad and Abdellatif, 2008) that included:
A- Temporal measures of the bolus movement during swallowing:
(1) Oral transit duration (OTD): From the initiation of posterior bolus movement to arrival of
the bolus head at the ramus of the mandible (fig 3).
(2) Oral clearance duration (OCD): From initiation of posterior bolus movement to arrival of
bolus tail at ramus of mandible.
(3) Pharyngeal transit duration (PTD): From arrival of bolus head at ramus of the mandible
to bolus head enter upper esophageal sphincter (UES).
(4) Pharyngeal clearance duration (PCD): From arrival of bolus head at ramus of the
Fig. (3): Head of the bolus at the angle of the
mandible to bolus tail through UES.
mandible.
(5) Stage transition duration (STD): From first barium at ramus of mandible to beginning of
maximum hyoid excursion.
(6) Total swallow duration (TSD): By summing both OTD and PCD.
(7) Masticatory duration (MD): From once the child masticate the bolus to beginning of
posterior movement of the bolus.
B- Temporal measures of hyoid movement during swallowing:
(1) Pharyngeal response duration (PRD): From beginning of maximum hyoid movement to
hyoid return to rest.
(2) Duration of hyoid maximum elevation (DOHME): From first frame showing maximum
hyoid elevation to last frame showing maximum hyoid elevation (fig. 4).
(3) Duration of hyoid maximum anterior excursion (DOHMAE): From first frame showing
maximum anterior hyoid movement to last frame showing maximum anterior hyoid
movement (fig 5).
Four additional observations and measurements were determined:

(4): Maximum
hyoidper
elevation.
Fig.(5): Maximum
anterior hyoid excursion.
(1)Fig.
Number
of swallows
bolus in different consistencies
and volumes.
475
(2) Oro-pharyngeal residue: A three-point scale (0= no residue, 1= coating, 2= pooling) was
used to assess the amount of residue in the oro-pharynx (Fig. 6).
(3) Penetration/aspiration observation: Penetration means the bolus enters the airway down
to the level of the vocal folds. Aspiration means the bolus enters the airway below the level of
the vocal folds.
Fig. (6): Oro-Pharyngeal
(4) Oro-pharyngeal Swallow Efficiency (OPSE) score (Rademaker
et al., 1994): % residue.
bolus
swallowed (minus % oro-pharyngeal residue + % amount aspirated) on the first swallow
attempt on a bolus divided by TSD. Normal OPSE score is 50 or better (100 % swallowed in 2
seconds or less).
(III) Intervention:
Each BDMH child was subjected to Behavioral Re-Adjustment Therapy (BRAT) to correct the
most evident breakdown of his/her swallowing problems. The training was conducted 30
minutes biweekly sessions for 3 months. A home program was provided to the child's
caregivers to maximize training opportunity and hopefully the effect could be generalized.
The BRAT technique included the following:
(1) Modification of the manner of feeding: It included scheduling of mealtime, pacing
during mealtimes for regulating the time interval between bites and swallows, and
environmental modification through reducing or increasing visual and auditory stimulation.
Chocking was dealt with by using a rhythmic pattern of drinking and stopping when
chocking occurs during cup drinking.
(2) Positioning and posture changes: The optimal body position used was an upright 90degree sitting position. The chin was slightly flexed with arms and hands near midline of the
body. Chin down posture was used for children with delayed triggering of the pharyngeal
swallow and tracheal aspiration. Head back posture was used for children with inefficient
oral transit and with reduced post propulsion motion of tongue base. These postural
techniques were the mostly compliant by the caregivers.
(3) Modification of the food variables: The bolus volume and consistency were adjusted
according to MBS findings to improve bolus formation and transit and to provide a swallow
safety.
The patients were reassessed after treatment to evaluate the effectiveness of BRAT. The
observations and measures of swallowing were compared among the groups with different
degrees of severity in pre-test versus end-test evaluations.
Frequency, mean and standard deviation were used to describe data. To test for significance
of change, the paired-T test and the Chi-Square test were used to compare quantitative and
qualitative data respectively in the same group. One-way ANOVA test was used to test for
significance of change among groups. P value was considered significant if < 0.05 and highly
significant if < 0.01.
Results:
A) Results of qualitative swallowing assessments:
1-Oral residue observation:
Most of BDMH children (96%) demonstrated oral residue. The degree of the residue increases
as both the severity of BDMH and consistency of the bolus increase. These children
demonstrated statistically significant (p<0.05) improvement in end-test when compared to
pre-test except solid bolus consistency in severe BDMH children which demonstrated
statistically non-significant (p>0.05) improvement (table 1).
2-Pharyngeal residue observation:
All BDMH children (100%) demonstrated pharyngeal residue. The degree of the residue
increases as both the severity of BDMH and consistency of the bolus increase. Mild BDMH
children demonstrated statistically significant (p<0.05) improvement in the end-test with
solid consistency only. Moderate BDMH children demonstrated statistically highly significant
(p<0.01) improvements in end-test with thin liquid consistency only in different volumes.
Severe BDMH children demonstrated statistically non-significant (p>0.05) differences with
different consistencies in different volumes (table 2).
3-Number of swallows per bolus observation:
The number of swallows per bolus increases as both the severity of BDMH and consistency of
the bolus increase. Statistically significant (p<0.05) decreases in the number of swallows per
476
bolus were found in end-test with solid and large volume semi-solid consistencies in
moderate BDMH and with thin liquid consistency in severe BDMH children (table 3).
4-Pentration/aspiration observation:
No penetration/aspiration (P/A) with different bolus consistencies in different volumes
was observed in all mild BDMH children. No P/A was observed in moderate BDMH with
semi-solid and solid bolus consistencies and no P/A in severe BDMH with solid bolus
consistency only.
Solid
5ml
Semi-solid
Thick
Thin
liquid
liquid
3ml 5ml 3ml 5ml 3ml
Bolus
Post 12(100%) -
26(100%)*
10(83.3%)*
26(100%)
8(66.7%* 4(33.3%)
3(11.5%)* 23(88.5%) Wilcoxon signed ranked test *=P < 0.05 (significant).
Table (2): Comparison of pharyngeal residue in pre-test
according to the degree of severity of BDMH:
Mild BDMH (n=12)
Moderate BDMH (n=26)
No
Poolin No
Coating
Coating
residue
g
residue
Pre 12(100%) 16(61.5%)
10(38.5%)
Post 12(100%) 24(92.3%) ** 2(7.7%)
Pre 12(100%) 14(53.8%)
12(46.2%)
Post 12(100%) 24(92.3%)** 2(7.7%)
Pre 12(100%)
26(100%)
Post 2(16.7%) 10(83.3%) 2(7.7%)
24(92.3%)
Pre 12(100%)
26(100%)
Post 2(16.7%) 10(83.3%) 26(100%)
Pre 12(100%)
26(100%)
Post 12(100%)
26(100%)
Pre
2(16.7%) 10(83.3%)
Post
Thick
liquid
3ml 5ml 3ml
Thin
liquid
5ml 3ml
Bolus
Pooling
2(16.7%)
2(16.7%)
2(16.7%)
2(16.7%)
8(66.7%)
1(8.3%)
1(8.3%)
4(33.3%)
8(66.7%)
6(50%)
6(50%)
versus end-test evaluations
12(100%)
18(69.2%)
Severe BDMH (n=12)

No
Pooling
Coating Pooling
residue
12(100%) 3(25%) 9(75%)
12(100%) 3(25%) 9(75%)
12(100%) 12(100%) 12(100%)
2(16.7%) 10(83.3%)
12(100%) 12(100%) 8(30.8%) 12(100%)
Post -
12(100%)
20(76.9%)
6(23.1%) -
Pre
5ml
Semi-solid
Both moderate and severe BDMH children demonstrated P/A with thin and thick liquid
consistencies in pre-test evaluations. The P/A observations increase as the severity of BDMH
and the volume of the liquid bolus increases. The severe BDMH also demonstrated P/A with
semisolid consistency in pre-test evaluations. In end-test evaluations, statistically significant
improvements of P/A observations were found in moderate BDMH children and with large
volume of thin and thick liquids in severe BDMH children (table 4).
Table (1): Comparison of oral residue in pre-test versus end-test evaluations according to
degree of severity of BDMH:
Mild BDMH (n=12)
Severe BDMH (n=12)
No
Poolin No
Poolin No
Coating
Coating
Coating
residue
g
residue
g
residue
Pre 12(100%) 16(61.5%) 10(38.5%) 12(100%)
Post 12(100%) 26(100%)* 8(66.7%)* 4(33.3%)
Pre 12(100%) 16(61.5%) 10(38.5%) 12(100%)
Post 12(100%) 26(100%)* 7(58.3%)* 5(41.7%)
Pre 12(100%) 4(15.4%)
22(84.6%) 12(100%)
Post 12(100%) 26(100%)* 4(33.3%)* 8(66.7%)
Pre 12(100%) 2(7.7%)
24(92.3%) 10(83.3%)
Post 12(100%) 24(92.3%)* 2(7.7%)
4(33.3%)* 6(50%)
Pre 12(100%) 26(100%)
10(83.3%)
Post 12(100%) 19(73.1%)* 7(26.9%)
10(83.3%)
4(33.3%)
Pre 12(100%) 26(100%)
-
12(100%)
477
Solid
Pre
2(16.7%) 10(83.3%)
18(69.2%)
8(30.8%) -
Post
6(50%)*
20(76.9%)
6(23.1%) -
6(50%)
12(100%)
12(100%)
Wilcoxon signed ranked test *=P < 0.05 (significant) and**p <0.01 (highly significant)
No
sw.
2
4 3
Post
3
(25%)*
9
(75%)
-
Thin Liquid
Bolus
of
Table (3): Comparison of number of swallows in pre-test versus end-test evaluations

according to the degree of severity of BDMH:
Mild BDMH (n=12)
Severe BDMH (n=12)
3ml
5ml
3ml
5ml
3ml
5ml
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
12
12
12
12
6
6
6
6
7
(100%) (100%) (100%) (100%) (23.1%) (23.1%) (23.1%) (23.1%)
(58.3%*
18
18
14
14
12
5
10
(69.2%) (69.2%) (53.8%) (53.8%) (100%) (41.7%) (83.3%)
2
2
6
6
2
(7.7%) (7.7%) (23.1%) (23.1%)
(16.7%)
4
4
4
4
(33.3%) (33.3%)
(15.4%) (15.4%)
8
8
12
12
10
12
8
8
2
2
(66.7%) (66.7%) (100%) (100%) (38.5%) (46.2%) (30.8%) (30.8%) (12.5%) (12.5%)
18
10
10
12
16
10
(46.2%)
(61.5%)
(87.5%)
(83.3%)
(69.2%)
(87.5%)
2
2(16.6%)
(7.7%)
10
10
8
8
4
4
(83.3% (83.3%) (66.7%) (66.7%) (15.4%) (15.4%)
2
2
4
4
20
22
18
23
8
8
(16.6%) (16.6%) (33.3%) (33.3%) (76.9%) (84.6%) (69.2%) (88.5%) (66.7%) (66.7%)
3
2
8
4
4
12 (100%)
(7.7%)
(30.8%)
(33.3%) (33.3%)
(11.5%*
4 (33.3%)
4 (33.3%)
8 (66.7%)
8 (66.7%)
14 (53.8%)
19 (73.1%)
12 (46.2%)
7 (26.9%)*
12 (100%)
12 (100%)
Wilcoxon signed ranked test *=P < 0.05 (significant).
Table (4): Comparison of bolus penetration/aspiration in pre-test versus end-test
evaluations according to the degree of severity of BDMH:
Mild BDMH (n=12) Moderate BDMH (n=26)
Severe BDMH (n=12)
No
No
No
Bolus
P A
P
A
P
A
P/A
P/A
P/A
1 4
10
(83.3%)
2(16.6%)
-
12 (100%)
4 3 2 1 4
Solid
Semi-solid
Thick Liquid
12(100%)
26(100%)
Post 12(100%)
Pre 12(100%)
Post 12(100%)
26(100%)
20(76.9%)
26(100%)*
10(83.3%)
3(11.5%) 3(11.5%) 8(66.7%)*
2(16.7%)
7(58.3%) 5(41.7%)
1(8.3%) 3(25%)
Pre
12(100%)
12(53.8%)
6(32.1%) 6(32.1%) -
2(16.6%) 10(83.3%)
Post 12(100%)
24(92.3%)* 1(3.8%)
1(3.8%)
2(16.7%)
1(8.3%)
9(75%)
Pre 12(100%)
Post 12(100%)
26(100%)
26(100%)
12(100%)
12(100%)
3ml drinkin 5ml 3ml

g
k
Thin liquid
liqui Cup
Pre
10(83.3%)
2(16.7%)
478
3ml 5ml
5ml
Solid Semi-solid
Pre
12(100%)
22(84.6%)
4(15.4%) -
6(50%)
6(50%)
Post 12(100%)
26(100%)*
6(50%)*
4(33.3%) 2(16.7%)
Pre 12(100%)
Post 12(100%)
26(100%)
26(100%)
12(100%)
12(100%)
Pre
12(100%)
26(100%)
10(83.3%)
2(16.7%)
Post 12(100%)
26(100%)
10(83.3%)
1(8.3%)
1(8.3%)
Pre
12(100%)
26(100%)
12(100%)
Post
12(100%)
26(100%)
12(100%)
Wilcoxon signed ranked test *=P < 0.05 (significant), P=penetration, A=aspiration
B) Results of temporal measures of bolus and hyoid movements during swallowing
(quantitative assessments):
(a)Mild BDMH children:
Mild BDMH children demonstrated statistically highly significant (p<0.01)

decreases in durations of all the temporal measures of bolus and hyoid movements
during swallowing of large volume thick liquid, small and large volumes semi-solid
and solid consistencies in end-test when compared to pre-test. OTD and OCD
demonstrated statistically highly significant (p<0.01) decreases in their durations
during swallowing of small volume thick liquid in end-test when compared to pretest. The OCD is the only parameter that demonstrated statistically significant
(p<0.05) decrease in its duration in end-test evaluation in small and large volumes
thin liquid consistency (table 5). Mild BDMH children demonstrated statistically
highly significant (p<0.01) increases of oro-pharyngeal swallow efficiency scores in
end-test when compared to pre-test evaluations with large volume thick liquid, small
and large volumes semi-solid and solid consistencies (table 8).
(b) Moderate BDMH children:
Moderate BDMH children demonstrated statistically highly significant

(p<0.01) decreases in durations of all the temporal measures of bolus and hyoid
movements and increases of oro-pharyngeal swallow efficiency scores in end-test
when compared to pre-test with different bolus consistencies in different volumes
(tables 6,8).
(c) Severe BDMH children:
Severe BDMH children demonstrated statistically significant (p<0.05)

decreases in durations of OCD, PCD, PRD and TSD with thin liquid bolus
consistency in small and large volumes in end-test when compared to pre-test. These
children demonstrated statistically non-significant differences (p>0.05) in durations
of all the temporal measures of bolus and hyoid movements during swallowing of
thick liquid, semi-solid and solid consistencies in end-test when compared to pretest. Also the later consistencies demonstrated below 50 OPSE scores at pre-test
evaluations. Statistically highly significant (p<0.01) increases of OPSE scores were
found with only thin and thick liquid bolus consistencies in small and large volumes
in end-test when compared to pre-test evaluations(tables 7,8).
Table (5): Comparison of different bolus consistencies durations in small and
volumes in Mild BDMH children (n=12) in pre-test versus end-test evaluations:
Temporal Thin Liquid
Thick liquid
Semi-solid
measures 3ml
5ml
3ml
5ml
3ml
5ml
Pre 0.250.01
0.260.01
0.290.01
0.340.05
0.480.08
0.490.08
OTD
0.260.01
0.300.03**
0.310.02**
0.350.04**
0.360.04**
Post 0.260.01
large
OCD Pre
0.780.13
0.350.01
0.360.01
0.420.00
0.530.13
0.700.11
0.750.11
Solid
0.500.08
0.390.05**
479
STD
PTD
PCD
PRD
TSD
DOH
ME
DOH
MAE
MD
Post 0.350.01
0.350.01*
0.370.02**
0.390.01**
0.430.08**
0.510.06**
Pre 0.250.01
0.260.01
0.300.01
0.370.05
0.390.08
0.480.06
Post 0.250.01
0.260.02
0.300.02
0.320.00**
0.330.02**
0.370.02**
Pre 0.260.01
0.260.02
0.300.02
0.390.05
0.440.09
0.510.07
Post 0.260.01
0.260.02
0.300.02
0.340.01**
0.360.02**
0.420.04**
Pre 0.650.01
0.650.01
0.700.01
0.760.06
0.790.08
0.860.06
Post 0.650.01
0.650.02
0.700.02
0.710.01**
0.730.02**
0.750.02**
Pre 0.690.01
0.700.01
0.760.01
0.810.06
0.880.08
0.950.06
Post 0.690.01
0.700.01
0.750.00*
0.760.01**
0.800.01**
0.840.04**
Pre 0.910.01
0.910.01
0.990.01
1.100.10
1.280.13
1.350.14
Post 0.910.01
0.920.01
0.990.01
1.020.02**
1.080.05**
1.120.06**
Pre 0.230.01
0.240.02
0.270.01
0.330.05
0.380.06
0.430.06
Post 0.240.01
0.240.02
0.270.01
0.290.01**
0.310.02**
0.350.03**
Pre 0.340.01
0.350.01
0.400.02
0.450.06
0.470.07
0.560.08
Post 0.330.01
0.350.01
0.400.02
0.400.02**
0.430.02**
0.470.04**
Pre
Post
Paired T-test (2-tailed), * p < 0.05 (significant) and **p<0.01 highly significant.
Temporal
measures
Pre
OTD
Post
Pre
OCD
Post
Pre
STD
Post
Pre
PTD
Post
Pre
PCD
Post
Pre
PRD
Post
Pre
TSD
Post
DOH Pre
ME Post
DOH Pre
MAE Post
Pre
MD
Post
Table (6): Comparison of different bolus consistencies durations in small and

volumes in Moderate BDMH patients (n=26) in pre-test versus end-test evaluations:
Thin Liquid
Thick liquid
Semi-solid
3ml
5ml
3ml
5ml
3ml
5ml
0.300.02
0.300.02
0.370.05
0.390.03
0.530.05
0.580.07
0.270.01**
0.280.01**
0.330.04**
0.380.03**
0.460.05**
0.510.07**
0.400.04
0.400.04
0.550.05
0.600.05
0.690.07
0.810.11
0.360.03**
0.370.02**
0.460.04**
0.510.04**
0.600.08**
0.740.11**
0.310.04
0.310.04
0.430.08
0.470.08
0.640.22
0.600.11
0.270.02**
0.27.02**
.360.05**
0.400.06**
0.440.08**
0.550.11**
0.330.05
0.340.05
0.440.08
0.460.1
0.540.08
0.630.11
0.280.02**
0.280.03**
0.380.06**
0.430.06**
0.460.08**
0.560.1**
0.700.04
0.700.04
0.810.08
0.850.09
0.920.1
0.960.11
0.670.02**
0.670.02**
0.750.06**
0.790.08**
0.840.09**
0.900.1**
0.730.04
0.750.05
0.870.07
0.910.09
0.980.08
1.040.1
0.700.03**
0.710.03**
0.780.05**
0.840.07**
0.910.07**
0.970.08**
1.000.07
1.010.07
1.190.12
1.250.12
1.460.14
1.550.18
0.940.03**
0.950.03**
1.090.08**
1.160.11**
1.310.14**
1.420.17**
0.290.04
0.30.05
0.420.09
0.440.09
0.510.1
0.550.12
0.250.02**
0.260.02**
0.370.07**
0.400.09**
0.440.09**
0.500.1**
0.400.05
0.400.05
0.510.1
0.550.1
0.630.1
0.680.11
0.340.02**
0.350.02**
0.430.06**
0.440.07**
0.520.07**
0.630.09**
0.520.07**
0.480.06
0.370.02**
0.520.07
0.430.04**
0.880.07
0.810.04**
1.040.14
0.890.05**
1.390.15
1.200.09**
0.490.08
0.400.06**
0.570.09
0.510.07**
8.670.88
7.830.89**
large
Solid
0.640.09
0.550.09**
0.880.12
0.790.12**
0.640.13
0.570.12**
0.700.13
0.600.11**
1.010.12
0.940.11**
1.090.09
1.020.08**
1.650.21
1.490.2**
0.600.13
0.530.1**
0.720.13
0.640.1**
15.32.9
13.22.5**
Paired T-test (2-tailed), * p < 0.05 (significant) and* *p<0.01 highly significant.
Table (7): Comparison of different bolus consistencies durations in small and large
volumes in Severe BDMH patients (n=12) in pre-test versus end-test evaluations:
Temporal Thin Liquid
Thick liquid
Semi-solid
measures 3ml
Solid
5ml
3ml
5ml
3ml
5ml
Pre 0.350.02
0.350.02 0.400.01
0.420.01
0.610.04
0.720.01
0.820.02
OTD
Post 0.330.03
0.330.03 0.400.01
0.420.01
0.610.01
0.710.02
0.810.04
Pre 0.530.04
0.540.04 0.590.04
0.640.02
0.770.04
0.950.01
1.10.01
OCD
Post 0.470.07* 0.480.07* 0.57.03
0.630.02
0.760.04
0.940.02
1.10.02
Pre 0.370.04
0.370.04 0.490.01
0.550.02
0.620.00
0.700.01
0.800.01
STD
Post 0.360.05
0.360.05 0.480.01
0.540.02
0.640.09
0.690.02
0.790.02
PTD Pre 0.380.05
0.380.04 0.530.03
0.580.03
0.670.04
0.730.05
0.840.04
480
Post 0.380.05
0.380.05 0.530.03
0.570.04
0.660.05
0.720.05
Pre 0.810.03
0.810.03 0.950.04
0.960.01
1.00.02
1.10.01
PCD
Post 0.760.05* 0.760.05* 0.940.04
0.950.03
1.00.03
1.10.02
Pre 0.840.01
0.840.01 0.990.02
1.020.02
1.130.01
1.20.01
PRD
Post 0.780.05* 0.790.05 0.980.03
1.00.04
1.10.03
1.20.02
Pre 1.160.02
1.16.02
1.350.05
1.390.02
1.70.02
1.80.01
TSD
Post 1.100.09* 1.100.09* 1.340.05
1.380.03
1.70.04
1.790.05
0.330.03 0.510.01
0.550.01
0.650.00
0.680.04
DOH Pre 0.320.01
ME Post 0.300.02
0.310.03 0.510.02
0.530.03
0.640.02
0.670.01
DOH Pre 0.470.02
0.470.01 0.600.01
0.640.01
0.750.02
0.780.1
MAE Post 0.450.05
0.450.05 0.600.01
0.630.01
0.740.03
0.780.02
Pre
MD
Post
Paired T-test (2-tailed), * p < 0.05 (significant) and **p<0.01 highly significant.
0.830.04
1.20.03
1.20.05
1.30.01
1.30.04
2.00.06
2.00.09
0.770.02
0.760.03
0.880.01
0.870.02
24.80.9
24.31.2
Table (8): Comparison of Oro-pharyngeal swallow Efficiency scores in BDMH groups in

pre-test versus end-test evaluations according to degree of severity of BDMH:
Mild BDMH
Moderate BDMH
Severe BDMH
(n=12)
(n=26)
(n=12)
Bolus
Pre
Post
Pre
Post
Pre
Post
MeanSD MeanSD
MeanSD MeanSD
MeanSD
MeanSD
Thin
3ml
liquid 5ml
Thick 3ml
liquid 5ml
109.51.4
108.81.4
92.04.5
109.61.5
109.01.5
92.34.3
92.414.3
89.216.9
94.512.2
104.54.7**
104.04.9**
83.77.5**
67.64.1
56.04.6
59.12.5
80.815.7**
75.416.6**
61.74.3**
83.89.5
91.13.5**
65.412.03
76.98.6**
43.54.5
51.912.0**
3ml
5ml
73.112.0
84.76.7**
55.97.7
67.310.0**
46.52.5
47.02.9
Semi84.215.0
80.28.7**
50.28.6
57.89.8**
35.04.3
36.24.7
solid
Solid
61.114.9
77.012.3**
46.59.5
53.69.9**
32.12.9
33.53.2
Paired T-test (2-tailed), * p < 0.05 (significant) and**p<0.01 highly significant.
Discussion:
Our previous study (Abou-Elsaad et al., 2009) demonstrated the feeding

difficulties in a group of BDMH children and the effectiveness of the BRAT
intervention on their feeding skills. This study evaluated the swallowing problems in
the same group of children with different types and degrees of BDMH and the
effectiveness of the BRAT intervention on their swallowing function.
Oral residue observation:
The observation of oral residue in most of our studied BDMH children

especially when both the severity of BDMH and bolus consistency increase could be
explained by the inadequacy of the requirements of their food manipulation (Gisel,
1999) that interfered with the ability to transport ingested material to the pharyngeal
area and led to more time that the bolus stays in the oral cavity. Those findings
support the notion of Prinz and Lucas (2003) who reported that if swallowing is
delayed, excessive saliva floods the bolus, separating food particles and reducing
cohesion. So, residues of small particles are found during and after swallowing.
The presence of statistically significant improvements of the oral residues of
all bolus consistencies in different volumes at end-test versus pre-test evaluations
proves the effectiveness of BRAT intervention. However, severe BDMH children
demonstrated statistically non-significant improvement in end-test with solid bolus
consistency which requires more intact and active buccal musculature and tongue
movement in addition to more chewing action.
481
Pharyngeal residue observation:
The observation of pharyngeal residue in all our studied BDMH children

with different bolus consistencies and volumes in pre-test evaluations could be
explained that these children have weak tongue movement, weak pharyngeal
motility and impaired swallow initiation. Moreover, the severe degree of pharyngeal
residue i.e. pooling was mostly observed with solid bolus consistency. This may
indicates that even chewed solid foods being high in viscosity and resisting flowing
through narrow spaces, are the most difficult to propel through the pharyngoesophageal sphincter, and most likely to be retained in the pharynx after swallowing.
No pharyngeal residue was observed with thin liquid boluses in mild BDMH
children. This could be explained that thin liquids have low viscosity, run freely and
do not maintain shape within the mouth or pharynx especially with fair tongue
movement and pharyngeal motility. The statistically non-significant differences at
the end-test of mild BDMH children with thick liquid and semi-solid consistencies
could be explained that these consistency still challenging their pharyngeal
peristalsis. However, these children demonstrated significant improvement in
pharyngeal residue of solid boluses that could be due to the beneficial effect of BRAT
in improving their chewing activity and tongue propulsive force. On the other hand,
moderate and severe BDMH children showed significant improvement only with
thin liquids in end-test as this consistency is the easier to be mastered and propelled
with any improvement of the tongue mobility.
Number of swallows observation:
The observation that the number of swallows per bolus increases as both the
severity of BDMH and consistency of the bolus increase in pre-test evaluations could
be explained by the presence of oro-pharyngeal residue in these children that elicit
multiple swallow behavior in an attempt to clear the oro-pharynx. This finding was
in agreement with Carrie et al. (2006) who proposed that thicker consistencies and
larger volumes are more likely to elicit multiple swallow behavior than thinner and
smaller boluses. The presence of statistically significant improvement with thin
liquid boluses only in severely impaired BDMH children could be explained that it
was the easiest consistency to be cleared with less number of swallows.
Penetration/aspiration observation:
The observations that both moderate and severe BDMH children

demonstrated P/A with thin and thick liquid consistencies in pre-test evaluations
might be explained by the absence of coordination of swallowing with respiration in
these children. Moreover, these children demonstrated multiple swallows per bolus
with the possibility of a greater risk of aspiration. On the other hand, no P/A was
observed in any child of mild BDMH children at pre-test evaluation. This indicates
that the degree of BDMH has an influence on the coordination of movements of
swallowing.
The observations that P/A increase in large volumes liquid could be
explained that the large volume requires an increase in the magnitude of structure
movements and the coordination of swallowing and respiration, which if
deteriorated may reveal abnormality of function. On other hand, solid boluses did
not show any laryngeal penetration in BDMH children as being more cohesive so,
have less risk than a liquid bolus to flow into the airway.
The statistically significant improvement in P/A in end-test specially in
moderate BDMH proved the effectiveness of the BRAT namely; positioning and
482
posture changing, and bolus modification (volume and consistency) in controlling

P/A problem in BDMH children.
Quantitative swallowing assessment:
The different bolus consistencies in different volumes demonstrated

prolonged durations of all the temporal measures of bolus and hyoid movements
during swallowing in pre-test of BDMH children when compared to our previous
study on normal children (Abou-elsaad and Abdellatif, 2008). The increase in the
duration of the oral transit (OTD) and oral clearance durations (OCD) is due to
decrease of the tongue motor skills in BDMH children that are necessary to form the
bolus and transport it to the pharynx. Moreover, the impairment and inadequacy of
tongue propulsive force may explain the prolonged pharyngeal transit (PTD) and
pharyngeal clearance (PCD) durations of BDMH children in this study. The
masticatory performance was highly correlated to tongue motor skills (Koshino et al.,
1999). Also, the mastication of solid food is a complex skill that requires intact tongue
lateralization and rapid repetitive movements (Gisel et al., 2005). This could explain
the prolonged masticatory duration of our BDMH children.
Normally, the start of the pharyngeal response is related to the onset of hyoid
movement, which started before the bolus enters the pharynx (Logmman, 1983). The
tongue movement is one of the functional chains of the vocal tract that consist of
tongue and hyoid bone (Kotby and Haugen, 1970). So, any impairment of the tongue
movement, in turn, leads to the delay in the onset of the hyoid movement. This could
explain the prolonged stage transition duration (STD) and the increases in both
maximum hyoid elevation (DOMHE) and maximum hyoid anterior excursion
(DOMHAE) durations of BDMH children in this study.
Arvedson et al. (1993) postulated that the opening of the UES is achieved by
the upward and forward movement of the hyoid bone and larynx, relaxation of the
cricopharyngeal muscle and the intrabolus pressure. As UES and the hyoid bone are
anatomically and mechanically related to each other, the delayed onset of the hyoid
bone movement may cause delayed relaxation and opening of UES, thus delaying
the bolus transport from the pharynx to the esophagus (Jacob et al., 1995). This could
explain the prolonged pharyngeal response duration (PRD) of our BDMH children.
Normally the OPSE score should be 50 or higher. The presence of oropharyngeal residue and the increase of the total swallow duration will result in
decreased OPSE score. Thick liquid, semi-solid and solid consistencies challenged
severe BDMH children who demonstrated below 50 OPSE score. This attributed to
the more oro-pharyngeal residue and the increase of total swallow duration in these
children. BRAT significantly improved the OPSE in all BDMH children. However,
semi-solid and solid consistencies still demonstrated below 50 OPSE score without
significant improvement in severe BDMH. This finding should be considered when
feeding these children with a severe degree of BDMH.
The statistically highly significant decreases in durations of all the temporal
measures of bolus and hyoid movements during swallowing in end-test when
compared to pre-test proved the effect and the role of BRAT techniques in the
enhancement of the oral and sensory function in BDMH children. The mildly and
moderately impaired BDMH children showed the most significant improvement.
This indicates that the degree of impairment has a significant role in the success of
the BRAT technique in BDMH children.
This study demonstrated that BDMH children have impairment in various
swallowing domains especially with the moderate and severe degrees. This study
also demonstrated that application of BRAT techniques led to general improvement
483
of swallowing functions in end-test evaluations when compared to pre-test

evaluations which reflected the beneficial outcome of BRAT to control swallowing
impairment. Also, active participation of the caregivers contributed to the
maintenance of the newly acquired skills. However, the severe BDMH children
demonstrated the least response to BRAT. This proves that the severity of BDMH is
an important risk factor in the compliance of BDMH children to BRAT techniques.
Conclusions: BDMH children demonstrated impairment in various
swallowing domains especially with the moderate and severe degrees. BRAT has
improved the swallowing function especially with the mild and moderate degrees.
References:
Abou-Elsaad T and Abdelatif G (2008): Assessment of functional feeding and swallowing
biomechanics in normal children. Banha Medical Journal, Vol. 25, No 3, PP 273-293.
Abou-Elsaad T; Elsady S and Abdelatif G (2009): Assessment and behavior therapy of
feeding problems in neurologically impaired children. A paper presented in the 3rd
international conference on disability and rehabilitation: Scientific research in the
field of disability. 22-25, March, 2009, Riyadh, KSA.
Arvedson JC; Rogers B and Brodsky L (1993): Anatomy, embryology and physiology. In:
Arvedson JC. Brodsky L. Eds. Pediatric swallowing and feeding (pp5-51), singular
publishing Group, Inc.
Carrie, E; Robert, A; and Ruark, A (2006): Effect of bolus volume and consistency on multiple
swallow behaviors in children and adults. Journal of Medical Speech-Language
Pathology; 8:45-50.
Gisel EG (1999): Oral-motor skills following sensorimotor intervention in the moderately
eating-impaired child with cerebral palsy. Dysphagia; 12: 180-192.
Gisel E; Alphonce MA and Ramasy M (2005): Assessment of ingestive oral praxis skills:
children with cerebral palsy vs. controls. Dysphagia; 15:236-244.
Hagberg B; Hagberg G; and Olow I (1993): The changing panorama of cerebral palsy in
Sweden. Acta pediatric; 32:387-393.
Jacob P; Kahrilas P; Logemann J and Shah V (1995): Upper esophageal sphincter opening
and modulation during swallowing. Gastroenterology; 97:1469-1478.
Kenny DJ; koheil RM; Greenberg J; Reid D and Moran R (1989): Development of a
multidisciplinary feeding profile for children who are dependent feeders. Dysphagia
4: 16-28.
Koshino, H; Hirari, T and Ikeda, Y. (1999): Tongue motor skills and masticatory performance
in adult dentates, elderly dentates, and complete denture wearers. J Prosthet Dent.:
77(2): 147-152.
Kotby MN, Haugen LK (1970): The mechanics of laryngeal function. Acta Otolaryngologica
(Stockholm), 70: 203-211.
Logemann JA (1983): Evaluation and Treatment of Swallowing Disorders. San Diego, CA:
college-Hill Press.
Patwari AK; Aneja S; Ahuja B and Anad VK (2006): Feeding problems in children with
cerebral palsy. Indian pediatrics; 38: 839-846.
Prinz JF and Lucas PW (2003): An optimization model for mastication and swallowing in
mammals. Proceedings of the Royal Society of London. Series B. Biological Sciences;
264:1715-1721.
Rademaker AW; Pauloski BR; Logemann JA and Shanahan TK (1994): Oropharyngeal
swallowing efficiency as a representative measure of swallowing function. J speech
Hear Res.;37:314 -325.
Thorndike RI; Hagen EB and Sattler JM (1986): Guide for Administrating and Scoring,
Standford Binet Intelligence Scale 4th Ed. Chicago: Revised Publishing.
484
APPENDIX
Pediatric Modified Barium Swallow Evaluation Checklist
Mansoura University Hospitals
Phoniatrics Unit, ORL Department
Swallowing Disorders Clinic
Child Name :
Gender: M / F Age :
Date of evaluation : / /
Examiner :
Address :
Telephone # :
Tape # :
Purpose of the study : initial / recheck
Referring facility :
( inpatient / outpatient )
Diagnosis :
Thin liquid ( 1 ba x 4 water )
Thick
semisolid(pudding+ba)
cookie
liquid(1bax1water)
Stage of swallowing
3cc
5cc
cup
3cc
5cc
3cc
5cc
Lateral view
I - Oral preparatory stage:
1 ) Lip closure :
2 ) Mandib.mov./bolus mastic.:
3 ) Bolus formation:
4)No. of swallow to clear
II - Oral transport stage:
1 ) Tongue movement :
i - tongue-to-palate contact
ii - antero-post movement
2 ) Oral residue : *
i - anterior sulcus
ii - lateral sulcus
iii - on dorsum of the tongue :
iv - % oral residue :
3 )Premature swallow :**
4 ) Piecemeal deglutition :**
III - Pharyngeal stage:
1 ) Initiation ^ :
2 ) Velar elevation :
3 )Tong.base/post.Ph wall cont
4 ) Laryngeal elevation :
5 ) Ant. Hyolaryng. excursion:
6 ) UES opening :
7) Penetration ( % ) : "
before - during - after
8) Aspiration ( % ) :"
before - during - after
9) Pent/asp. Scale ( 1-8 ) :
10) Cough resp. to pent/asp # :
Degree of impairment of Structural movement and bolus
8-Point Penetration / Aspiration Scale
(Rosenbek et al., 1996)
flow: 0 = normal , 1= impaired
1- Doesn't enter airway
* Oro-Pharyngeal Residue Scale:
2- Enters airway / above folds / ejected
0 = no residue , 1 = coating , 2 = pooling
3- Enters airway / above folds / not ejected.
** Premature swallow & Piecemeal deglutition:
4- Enters airway / contact folds / ejected
0=absent , 1 = present
^ Degree of initiation:
5- Enters airway /contacts folds / not ejected
0=normal,1=delayed,2=very delayed , 3= absent
485
6- Enters airway / below folds / ejected

7- Enters airway / below folds / not ejected
despite effort
8- Enters airway / below folds / no effort.
Thin liquid ( 1 ba x 4 water )

Stage of swallowing
3cc
5cc
cup
" % of bolus penetrated / aspirated:

0= No pent/asp. 1= < 10 % 2= > 10 %
# Cough response: 0 = present , 1 = weak , 2 = absent
Thick
liquid(1bax1water)
3cc
5cc
semisolid(pudding+ba)
3cc
5cc
III - Pharyngeal stage (cont.):

11 ) Pharyngeal residue :*
i - base of tongue :
ii- post. pharyngeal wall :
iii- valleculae :
iv- aryepiglottic folds :
v- pyriform sinuses :
vi- % of pharyngeal residue :
12 ) % of bolus swallowed :
Mean degree of impairment
i - for bolus volume :
ii - for bolus consistency :
Total degree of impairment
Temporal measures
1) Oral transit duration (OTD):
2) Oral clearance duration
(OCD):
3) Stage transition duration
(STD):
4) Pharyngeal delay time (PDT):
5) Pharyngeal transit dur.
(PTD):
6)
Pharyngeal
clearance
dur.(PCD):
7)
Pharyngeal
response
dur.(PRD):
8) Dur of hyoid max. elevation
(DOHME):
9) Dur of hyoid max. ant. exc.
(DOHMAE):
10) Mastication duration (MD):
11)
Total
sw.
dur.(TSD):
(OTD+PCD)
OPSE Scores
(% bolus swallowed /TSD)::
i - for bolus volume :
ii - for bolus consistency :
Total OPSE score
Anterior - posterior view
1- Alignment of the mandible: _________
2- Symmetry of bolus movement: _______
3- Symmetry of pooling in oral cavity: _______
Circle if present:
ng tube
j tube
g tube
trach. tube
486
cookie
4- Symmetry of vallecular stasis: __________

5- Symmetry of stasis in pyriform sinuses: ________
6- Degree of vocal fold adduction: _________
7- Height of the vocal folds: equal / unequal
consistency: ______
volume: ______
Comment:
Trial therapy:
Recommendations :
487
FP45.2
INCIDENCE OF VOCAL FOLDS PARALYSIS IN PATIENTS WITH
BRAIN INSULT
IN PHYSICAL MEDICINE & REHABILITATION HOSPITAL IN KUWAIT
Amal Salaheldin Darwish
Hearing & Speech Institution Embaba, Egypt.
Physical Medicine & Rehabilitation Hospital, Kuwait
Introduction :
*The human larynx protects the airway during deglutition, regulates
respiration, and facilitates phonation, all of which are vital functions. The unique
anatomy and physiology of the larynx, coupled with complex cortical inputs and
organized brainstem reflexes, enable the execution of these diverse tasks. In humans,
the high position of the larynx not only facilitates phonation but also compromises its
protective and regulatory functions. Accordingly, the effects of stroke on this finely
balanced system manifest as deficits in swallowing, breathing, and communicating.
*Anatomical review The primary function of the larynx is to prevent, via
sphincter control, aspiration of foreign material into the trachea-bronchial tree. To do
this, the human larynx contains 7 intrinsic adductors (compared with only 1
abductor) and 7 extrinsic laryngeal elevators (compared with only 4 depressors).
Similarly, the airway protection functions of the larynx are involuntary, whereas the
respiratory and phonatory functions are voluntary, albeit modulated by complex
involuntary cortical feedback loops.
With the exception of the cricothyroid, which is derived from the fourth
branchial arch, the intrinsic musculature of the larynx is derived from the paraxial
mesoderm of the first and second occipital somites. Additional external laryngeal
muscles involved in phonation and deglutition are derived from the first arch
(mylohyoid, anterior belly of the digastric, tensor veli palatine), second arch
(posterior belly of the digastric, stylohyoid), third arch (stylopharyngeus), and fourth
arch (pharyngeal constrictors, levator veli palatine).
The superior laryngeal and recurrent laryngeal branches of the vagus nerve
are derived from the fourth and sixth branchial arches, respectively.
The epiglottis, thyroid cartilage, and cricoid cartilage are the 3 midline
cartilaginous structures that make up the laryngeal framework. Superiorly, the
laryngeal framework is associated with the hyoid bone, which does not articulate
with the larynx. Posteriorly, the paired arytenoid, corniculate, and cuneiform
cartilages are supported by the midline cartilages. The arytenoid cartilages articulate
inferiorly with the cricoid lamina, while the corniculate and cuneiform cartilages rest
above the arytenoids, within the aryepiglottic fold.
Motion of the larynx occurs via the cricothyroid and the cricoarytenoid
synovial joints. The cricothyroid joint rotates along a common transverse axis
between the inferior horns of the thyroid cartilage and the postero-lateral aspect of
the cricoid cartilage. The rocking motion of this joint change the distance between the
anterior aspect of the thyroid cartilage and the anterior cricoid cartilage, thereby
stretching and adducting the vocal folds. The cricoarytenoid joint is located between
the cricoid lamina and the broad base of the pyramidal-shaped arytenoid cartilage.
488
This joint has 3 degrees of freedom, which include sliding (medially and laterally),
rotating (medially and laterally), and tilting (anteriorly and posteriorly).
The functions of the intrinsic laryngeal musculature are summarized as
follows:
The posterior cricoarytenoid abducts the true vocal fold (TVF).

The cricothyroid stretches (lengthens) and adducts the TVF.
The lateral cricoarytenoid adducts the TVF.
The transverse arytenoids adduct the TVF.
The oblique arytenoids adduct the TVF.
The thyroarytenoid tightens the TVF.
The vocalis shortens the TVF.
The extrinsic suprahyoid muscles (stylohyoid, mylohyoid, geniohyoid,

digastric) elevate the larynx. The extrinsic infrahyoid muscles (sternohyoid,
sternothyroid, thyrohyoid, omohyoid) depress the larynx.
Neuroanatomy
Innervation of the larynx is provided by branches of the vagus nerve. The
lower motor neurons reside within the nucleus ambiguous of the medulla. Cell
bodies of the sensory nerves reside within the rostral nodose ganglion, with central
connections to the nucleus tractus solitarius. Some authors propose additional vagal
central sensory connections with the spinal trigeminal nucleus, cuneate nucleus,
and the dorsal horn of the C1 and C2 cord segments.
The superior laryngeal nerve (SLN) branches from the vagus just below the
nodose ganglion and then divides into separate motor and sensory branches. The
internal branch traverses the thyrohyoid membrane and provides sensation to the
laryngeal surface of the epiglottis and to the larynx. The basic arrangement of the
sensory innervation of the SLN is that the anterior, middle, and posterior branches
innervate the laryngeal surface of the epiglottis, the supraglottis above the vestibule,
and the posterior arytenoid/hypopharynx/caudal vocal fold, respectively. The
external branch descends with the inferior constrictor to provide motor innervation
to the cricothyroid muscle.
489
The recurrent laryngeal nerve (RLN) provides both sensory and motor
innervation to the larynx. This nerve branches from the vagus below the subclavian
artery on the right and the ligamentum arteriosum on the left. It then ascends within
the tracheoesophageal groove and enters the larynx via the thyrohyoid membrane.
The motor fibers innervate the ipsilateral intrinsic laryngeal musculature, with the
exception of the interarytenoid muscles, which receive bilateral innervation. The
RLN provides sensation to the true vocal folds and the subglottis, although Galen
anastomosis of the RLN and the SLN at the level of the anterior subglottis is well
described.( Migueis J, et al.1989)
The region of the supraglottis contains the highest density of sensory fibers.
The posterior aspect of the glottis contains more sensory receptors than the anterior
glottis. Diverse laryngeal sensory receptors, including chemoreceptors,
mechanoreceptors, and paraganglia, have been described throughout the larynx.
Chemoreceptors, specifically those that detect decreased chloride concentrations
(water, gastric fluid, and saliva), have been shown to stimulate reflexes, resulting in
apnea, bradycardia, hypertension.These reflexes gradually disappear as the central
nervous system matures. A wide variety of mechanoreceptors, including touch,
proprioception, flow, pressure, and articular joint receptors, have also been
described.
Neurophysiology
Microstimulation studies in animals have established the location of the
laryngeal motor cortex. The laryngeal motor cortex overlaps the lower lateral face
portion of the motor cortex. Stimulation of the motor cortex produces bilateral
adductor activity coupled with abductor inhibition. Most evidence suggests multiple
cortical, subcortical, midbrain, and brainstem connections between the motor cortex
and the nucleus ambiguous. Stimulation of these subcortical regions produces
nonverbal phonation associated with states of emotional arousal. The
periaquaductal gray plays an especially important role in the coordination of
490
cortical and subcortical inputs, with complete mutism resulting from ablative
lesions in this region. Although the dominant hemisphere is responsible for speech
production, the nondominant hemisphere modulates the inflection, intonation, and
timing of phonation. The cerebellum may also have a modulatory role.
The nucleus ambiguous has a rostral-to-caudal arrangement of lower motor
neurons. The cricothyroid is innervated by the most rostral neurons, followed by the
thyroarytenoid, the lateral cricoarytenoid, and the transverse/oblique oblique
arytenoids. Lower motor neurons that innervate the single abductor, the posterior
cricoarytenoid, are located ventrally to the adductor motor neuron pool. Some
authors interpret this arrangement to reflect the preferential connections between
the adductor and abductor lower motor neurons with the periaqueductal gray
(PAG) matter and the inspiratory centers of the medial reticular formation,
respectively( Brin MF, et al.1992).
Stroke and the larynx

*Stroke is the third leading cause of death, behind heart disease and cancer. It
affects as many as 5% of the population over 65 years old, and this number is
growing annually due to the aging population. A significant portion of stroke
patients that initially survive are faced with the risk of aspiration, as well as qualityof-life issues relating to impaired communication.
Laryngeal manifestations of stroke play a significant role in the morbidity
and mortality of stroke, via both direct and indirect mechanisms. Therefore, the
otolaryngologist "phoniatrist" is an important contributor to the multidisciplinary
team of specialists required to successfully manage the squeals of stroke in both the
short- and long-term rehabilitative stages of treatment.
Working in physical medicine & rehabilitation hospital is chance to examine
lots of cases with brain insult, with change of voice & associated with dysphagia.
good percentages of them showing mobility impairment of the vocal folds associated
with their physical disability present.
Of course this problem is usually diagnosed very late, as the medical staff
usually are caring about the patient general condition & never think to check the
vocal fold mobility before starting intubating the patient (tracheotomy & PEG
feeding tube).which may in some cases needs to lot of time to get rid of the
introduced infections by the respiratory& feeding tubes.
Aim of the study :

Putting the vocal fold mobility evaluation & grading of its affection as one of
the guideline in the brain insults patients to avoid & weaning from unnecessary
intubation & put the proper line of treatment considering improving the vocal
mobility & respiratory support as early as the patient can.
Method:
*This was a clinical prospective study of 70 consecutive patients with brain
insults during 1 year period of time who were admitted to Kuwait Physical medicine
and rehabilitation hospital with a primary diagnosis of acute stroke, of different
pathological causes(traumatic, hemorrhagic, and occlusive), and different age and
sex, with dysphagia or dysphonia.
Stroke diagnosis was made by a neurologist and the stroke location was
determined by a neuroradiologist, both were blinded to the endoscopic findings.
491
*In this study, stroke location was noted according to computer tomography
(CT) or magnetic resonance imaging (MRI) results as reported by the radiologist.
Stroke locations were categorized as: cerebral, brainstem, cerebellar, basal ganglia,
multiple CNS infarcts, or location not specified by MRI or CT report.
Management protocol in the phoniatric clinic

* Indirect or direct video laryngo-stroboscopy examination performed during
phonation enables the assessment of laryngeal mobility. Both adductor and abductor
function should be systematically evaluated. Abduction may be tested by having the
patient repeatedly take a deep breath, or sniff through the nose, and adduction may
be evaluated by having the patient phonate the sound /i/. The vocal folds should
move symmetrically and quickly.
*Detailed report for the laryngeal structure condition designed by KayPantax.
*Analysis of the history data to exclude any associated LMN lesion at the
level of recurrent laryngeal nerve.
Other diagnostic skills:

1- The evaluation of the patient vocal tract activity.
*Respiratory aerodynamic study to evaluate respiratory& glottis sufficiency
with phonation.
*Evaluation of the severity of the affection of velar movement (by nasometer)
as it is commonly to be affected & result in open nasality & associated nasal
regurgitation .
*Evaluation of the oro-motor power to control the bolus of swallowed meals
(tongue & muscles of mastication & oral closure)
*Evaluation of the swallowing events by vidiofluroscpic image study
&swallowing workstation study of the swallow reflex by( EMG respiratory
test) & the tongue mobility.
* Computerized voice analysis to check the patient voice parameter
dimensions.
* Cognitive test, to evaluate ability to start swallowing & oral feeding.
Therapeutic modality will be patronized according to the severity of
symptoms, and the patient general condition aiming to reach:
1- Proper respiratory support, to start remove the tracheaostomy tube.
2- Proper glottic closure during swallowing & phonation by voice therapy.
3- Improve the oral motor activity.
4- Velar exercise to avoid nasal regurgitation & post swallow choking.
Swallowing training with special maneuvers and, with the ora-light spoon
set for oromotor exercises.
7-Facial exercises in front of the mirror (visual feedback) to improve oral
leakage and the posture during meals.
8-Cognitive function rehabilitation if needed to tolerate the oral feeding.
Results
*More than 40 patients which is equivalent to 57% was having unilateral
weakness of the vocal folds.
* 4 patients (about 6%) was having bilateral vocal folds weakness.3 patients
(about 4%) on abduction and 1 patient( about 2%) in adduction.
492
* 26 patients (about 37%) are not having laryngeal mobility restriction, only
sensory receptors are
affected with risk of aspiration of premature
swallowing i.e. failure of swallowing reflex initiation.
*After 2 months of voice therapy & weaning training program
40 patients (about 90% of affected patients) showed great improvement &

started their normal meals & weaned from the tracheostomy & PEG
"percutaneous endoscopic gastric" feeding tube.
4 pateints (about 10% of the affected patients) are not tolerated for weaning
from tracheostomy and PEG because of COPD , bilateral paralysis in
adduction, poor concentration level, and sever spastic quadriplegia affecting
sitting balance of the patient.
Discussion:
*In this study, vocal fold paralysis is usually associated with a brainstem
stroke, or lateral medullary syndrome (Wallenberg syndrome), which is
characterized by severe pharyngeal dysphagia, palatal incompetence, vertigo, facial
pain, and Horner syndrome.
*Unilateral weakness suggests a lower motor neuron lesion, whereas global
weakness suggests upper motor neuron dysfunction.
*It is already known that cerebrovascular accident is an uncommon cause of
vocal fold paralysis.
*There was common findings in vocal fold paralysis include:
- Vocal fold atrophy.
- Anteromedial Displacement of the affected arytenoid cartilage, with
subsequent foreshortening and inferior displacement of the true vocal fold.
- There was a compensatory hyper-functional and hypertrophied arytenoids
and ventricular folds to overcome the paralyzed fold.
*CT scanning or MRI of the complete course of the recurrent laryngeal nerves
on the chest & neck, laryngeal glottography may be needed to exclude LMN lesion.
Conclusions:
* Indirect & direct laryngoscopes should be considered as one of routine
investigation protocol for brain insult patient with respiratory, phonatory, and
493
swallowing difficulties to reduce the timing to regain their physical wellbeing &
voiced speech as early as possible.
* Phoniatrist "Otolaryngologist" involvement in stroke patients is critical to
their rehabilitation, which often requires an interdisciplinary team of specialists.
* The position of the paralyzed vocal fold was once thought to be related to
the prognosis for recovery (Semon law); however, in this study and other recent
evidence supports the concept that vocal fold position is not correlated with the
either the location of vagal injury or the likelihood of clinical improvement.
* There is a well-defined set of diagnostic and therapeutic options for
laryngeal dysfunction in the stroke patient. Specialists should explores
epidemiological data regarding the impact of stroke and its complications on
hospitalizations.
* A review of neuroanatomical brain lesions is very important as it should be
correlated to laryngeal affection and functions, to avoid complications.
* State of the patient laryngeal condition as early as one week after stroke
incidence, will reduce the risk of aspiration & its consequences and may reduce the
insertion of unnecessary tracheostomy & PEG and their complications.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Pikus L, Levine MS, Yang YX, et al. Videofluoroscopic studies of swallowing

dysfunction
and
the
relative
risk
of
pneumonia. AJR
Am
J
Roentgenol. Jun 2003;180(6):1613-6. [Medline].
Nomura S, Mizuno N. Central distribution of efferent and afferent components of the
cervical branches of the vagus nerve. A HRP study in the cat. Anat Embryol
(Berl). 1983;166(1):1-18. [Medline].
Migueis A, Ucelay I, Migueis J, et al. [Galen's anastomosis, an anatomic study in
man]. Rev Laryngol Otol Rhinol (Bord). 1989;110(4):423-5. [Medline].
Harding R, Johnson P, Johnston BE, et al. Proceedings: Cardiovascular changes in
new-born lambs during apnoea induced by stimulation of laryngeal receptors with
water. J Physiol. Mar 1976;256(1):35P-36P. [Medline].
Sasaki, CT. Anatomy and development and physiology of the larynx. GI Motility
Online. 2006;[Full Text].
Jrgens U. Projections from the cortical larynx area in the squirrel monkey. Exp Brain
Res. Jun 30 1976;25(4):401-11. [Medline].
Gacek RR, Malmgren LT. Laryngeal Motor Innervation - Central. In: Blitzer A, Brin
MF, et al. Neurological Disorders of the Larynx. New York: Thieme; 1992:29 - 35.
Addington WR, Stephens RE, Widdicombe JG, et al. Effect of stroke location on the
laryngeal cough reflex and pneumonia risk. Cough. Aug 4 2005;1:4. [Medline].
Merati AL, Halum SL, Smith TL. Diagnostic testing for vocal fold paralysis: survey of
practice and evidence-based medicine review. Laryngoscope. Sep 2006;116(9):153952. [Medline].
Horner
J,
Massey
EW. Silent
aspiration
following
stroke. Neurology. Feb 1988;38(2):317-9. [Medline].
Smith Hammond C. Cough and aspiration of food and liquids due to oral pharyngeal
Dysphagia. Lung. 2008;186 Suppl 1:S35-40. [Medline].
Ramsey D, Smithard D, Kalra L. Silent aspiration: what do we
know?. Dysphagia. Summer 2005;20(3):218-25. [Medline].
Woodson GE, Blitzer A. Otolaryngology Head and Neck Surgery. In: Cummings CW,
et al. Neurologic Evaluation of the Larynx and the Pharynx. 4th ed. Philadelphia,
PA: Mosby; 2005:2054-2064.
Sulica L, Blitzer A. Vocal Fold Paralysis. Germany: Springer.
494
15. Freed ML, Freed L, Chatburn RL, et al. Electrical stimulation for swallowing disorders
caused by stroke. Respir Care. May 2001;46(5):466-74. [Medline].
16. Arai T, Yasuda Y, Takaya T, et al. ACE inhibitors and symptomless
dysphagia. Lancet. Jul 11 1998;352(9122):115-6. [Medline].
17. Flint PW, Purcell LL, Cummings CW. Pathophysiology and indications for
medialization thyroplasty in patients with dysphagia and aspiration. Otolaryngol Head
Neck Surg. Mar 1997;116(3):349-54. [Medline].
18. Brin MF. Movement disorders of the larynx. In: Blitzer, et al. In Neurological Disorders
of the Larynx. New York, NY: 1992.
19. Daniels SK, Brailey K, Priestly DH, et al. Aspiration in patients with acute stroke. Arch
Phys Med Rehabil. Jan 1998;79(1):14-9. [Medline].
20. Gordon C, Hewer RL, Wade DT. Dysphagia in acute stroke. Br Med J (Clin Res
Ed). Aug 15 1987;295(6595):411-4. [Medline].
21. Koufman JA, Walker FO, Joharji GM. The cricothyroid muscle does not influence
vocal fold position in laryngeal paralysis. Laryngoscope. Apr 1995;105(4 Pt 1):36872. [Medline].
22. Leder SB, Espinosa JF. Aspiration risk after acute stroke: comparison of clinical
examination
and
fiberoptic
endoscopic
evaluation
of
swallowing. Dysphagia. Summer 2002;17(3):214-8. [Medline].
23. Merati AL, Bielamowicz AS:. '. San Diego, CA: Textbook of Laryngology.; 2007.
24. Merati AL, Heman-Ackah YD, Abaza M, et al. Common movement disorders affecting
the larynx: a report from the neurolaryngology committee of the AAOHNS. Otolaryngol Head Neck Surg. Nov 2005;133(5):654-65. [Medline].
25. Negus,
VE. The
Comparative
Anatomy
and
Physiology
of
the
Larynx. London: Heinemann; 1949.
495
P091
ASSESSMENT OF SWALLOWING AND QUALITY OF LIFE RELATED TO
SWALLOWING IN TOTAL LARYNGECTOMY PATIENTS: A COMPARISON
BETWEEN MANUAL AND MECHANICAL (STAPLER) TECHNIQUES OF
PHARYNGOESOPHAGEAL RECONSTRUCTION
D.C.Figueiredo1, I.Gielow1, R.M.Takimoto1, O.Cervantes1
1UNIFESP - Universidade Federal de So Paulo, So Paulo, Brazil
Introduction
Total laryngectomy is a modality of treatment prescribed for tumors in an
advanced stage. To rebuild the pharynx and choose the type of closing a surgeon has
to evaluate the shape and the size of the pharyngeal defect, as well as the elasticity of
the remaining tissues.
Among the closing techniques, the manual closing of the pharynx is usually
done in two planes (mucous and submucous) and strengthened, whenever possible,
with a third plane, or muscular layer. The suture line is usually vertical or T-shaped
with the transversal part of the T at the base of the tongue1. Mechanical closing is
done with a linear stapler2 and consists of holding the borders of the wound together
with a stapler. It is a method of choice because it it takes less surgery time, its suture
line causes fewer lesions in the tissues and there are fewer post-surgery
complications3,4,5,6,7,8.
The total laryngectomy may cause an oropharyngeal dysphagia of
mechanical origin due to an anatomophysiological alteration in the cricopharingeal
segment after the surgery, and causes complaints usually about difficulties in
moving food from the pharynx to the esophagus 9,10,11; however, in some cases
dysphagia is asymptomatic..
There is no direct scientific evidence linking the best technique of pharyngeal
reconstruction and the results of swallowing after a total laryngectomy17.
Therefore, the objective of this study is to compare swallowing and quality of
life related to swallowing in total laryngectomy patients by considering two groups
according to the type of closing used in the pharyngoesophageal reconstruction:
manual or mechanical.
Material and methods
This study was conducted with 30 patients with prevalence of T3N0M0
(UICC, 2002), who had had total laryngectomy in the 12 months before the data
collection (July to October 2007). They were all former smokers and 13 (86.67%) were
former drinkers. The study was effected at the Rehabilitation of the Head and Neck
Surgeries Service of the Voice Clinic of the Escola Paulista de Medicina
Universidade Federal de So Paulo, Brazil.
They were divided into two groups:
I) 15 patients with manual pharyngoesophageal closing (control group), 13
out of which (86.67%) were men and two (13.33%) of which were women with ages
varying from 40 to 72 years (average = 55.06 years, SD = 9.6).
II) 15 patients with mechanical pharyngoesophageal closing (study group),
13 out of which (86.67%) were men and two (13.33%) of which were women with
ages varying from 50 to 71 years (average = 62 years, SD = 7.14).
Concerning the complementary treatment, in the manual closing group 13
patients (86.7%) had had radiotherapy and among those two (13.3%) had had
496
adjuvant chemotherapy. In the mechanical closing group 12 patients (80%) had had
radiotherapy and among those, seven (46.7%) had had adjuvant chemotherapy.
The exclusion criteria were (i) a pharyngolaryngectomy or a surgery that was
extended to the hypopharynx, oropharynx or esophagus; (ii) patients who had had
other modalities of previous treatments such as radiotherapy and/or chemotherapy;
(iii) patients who had had a recovery surgery; and (iv) patients who have had fistula.
The evaluation protocol was composed of an anamnesis to assess sociodemographic data, characteristics of the disease and of the treatment, complaints
about swallowing and main eating habits and, finally, a clinical assessment of
swallowing.
To assess swallowing clinically the patients were offered blue dyed foods
with liquid, thick-liquid, pureed and solid consistencies.
A head and neck surgeon and a speech therapist conducted the swallowing
endoscopic evaluation (SEE).
All tests were conducted by the same professionals and the surgeon did not
know to which group of the study the patient belonged. The equipment used was a
flexible nasofibrolaryngoscope (Machida ENT-30PIII, United States ), a light source
(Komlux HL2250, United States), a micro-camera (Elmo CCD, United States), a
monitor (HR Trinitron, Sony, United States) and, to record the exam and to analyze it
later, a stereo VCR ( NHR MTS stereo/ DA 4, JVC, United States). With the patients
seated and observing the swallowing; the nasofibrolaryngoscope was introduced
through the most permeable nostril without any topical anesthetic.
After the surgeon anatomically assessed the nasopharynx and oropharynx,
the speech therapist offered the patient food with the above mentioned consistencies.
First, theliquid food was offered, and the others followed. The patients were
requested to keep the food in the mouth so that oral contention and any occurrence
of early loss to the pharynx could be observed; next, they were asked to swallow and
immediately after it eventual stagnation was observed and the number of
swallowing movements required for the contrast to be fully cleaned. Between the
offering of every two consistencies, each patient cleaned the region with clear water.
The endoscopic assessment of swallowing was analyzed during the test
conduction, and later reanalyzed using recordings made, and only these results
were graded according to the severity of the swallowing disturbance as proposed by
MACEDO et al. (1996) 13, adapted to the conditions of laryngectomy patients. At the
end of the assessment each patient answered a questionnaire about quality of life
related to swallowing, the SWAL-QOL developed by McHorney et al (2000) 13,14 and
translated into Portuguese by Bandeira (2004)15.
To interpret the results, the scores used by Barros et al., (2007)16 were
considered, in which 0 to 49 means a severe impact, 50 to 70 means a moderate
impact, and 71 to 100 means a discreet impact or no impact on the quality of life
related to swallowing.
For the statistical analysis the qui-square test with the Yates continuity
correlation, the Fishers test and the t-independent test were used. The p<0.05 results
were considered as statistically significant.
Results:
Due to the size of the sample and the number of variables, the comparison
shown below between the stapler (mechanical) and manual closing results are
exclusively descriptive, except for two variables in Tables 5 and 6, with p<0.05.
497
Table 1 Correlation between the time of reintroduction of the food orally and type
of pharyngoesophageal closing.
Rehabilitation
Mechanical closing
Manual Closing
P Value
time (days)
Min Max
8 45
15 109
0,092*
Median
18
22
Average, SD
19.4 8.04
32 25.81
Confidence
-27.46 2.26
interval (95%)
Min Minimum, Max Maximum, SD standard deviation.
Table 2 Correlation between complaints related to swallowing and type of
pharyngoesophageal closing.
Stapler closing
Manual closing
Swallowing
complaint
N
%
N
%
P value
No
7
46.67
10
66.67
0.462
Yes
53.3%
33.3%
Table 3 Correlation between the modifications in food consistencies and the type of
Manual closing
Modification Stapler closing
of
P value
N
%
N
%
consistency
No
11
73.33
12
80
1.00
Yes
26.67
20
498
Figure 1 Characterization of swallowing complaint considering the type of

Figure 2 Characterization between the place of the food stasis with all consistencies
according to clinical assessment of swallowing and the type of pharyngoesophageal
closing.
499
Figure 3 Characterization of the location of the food stasis after swallowing

observed in the endoscopic assessment of swallowing for all consistencies and type
of pharyngoesophageal closing.
Table 4 Severity of the swallowing disturbance (Macedo, et al.,1996) after
endoscopic assessment considering the type of pharyngoesophageal closing.
Stapler closing
Manual closing
Grade
N
%
N
%
0
6
40.00
7
46.67
1
26.67
6.67
26.67
46.70
6.67
Table 5 Correlation between anatomical findings in the

swallowing and the type of closing.
Stapler closing
Characteristics
N
%
No
8
53.33
Pharyngeal fold
Yes
7
46.70
endoscopic assessment of
Manual closing
N
%
15
100
0
0
P-value
0.006*
Table 6 Distribution of scores in the questionnaire of quality of life related to

swallowing (SWAL-QOL) considering the type of pharyngoesophageal closing.
Stapler closing Manual closing P-value
Difficulty
0.749
Min Max
37.5 -100
25 100
Median
87.50
100
Average SD
79.16 24.39
75.83 31.50
Desire
Min Max
Median
Average SD
15 100
70
68.66 26.75
25 100
50
59.60 29.48
0.389
500
Frequency
symptoms
of Min Max
Median
Average SD
65.4 100
86.54
85.38 11.25
48.07 96.15
76.92
73.50 17.13
0.034*
Choice of foods Min Max

Median
Average SD
25 100
100
81.6 24.50
0 100
100
75.83 31.85
0.583
Communication Min Max

Median
Average SD
0 100
37.5
41.67 27.41
0 100
37.5
35.84 33.02
0.604
Continua
k.
l.
Fear Min Max

Median
Average SD
18.75 100
81.25
77.08 20.53
0 100
87.5
67.91 36.12
0.402
Mental health
Min Max
Median
Average SD
40 100
100
84.33 17.47
0 100
100
75.33 32.48
0.130
Social function
Min Max
Median
Average SD
15 100
100
75.66 30.75
0 100
100
71.66 39.76
0.706
Sleep
Min Max
Median
Average SD
30 100
90
80.66 22.74
0 100
80
70.33 29.36
0.290
Fatigue
Min Max
Median
Average SD
25 100
50
41.67 27.41
25 100
50
55 25.35
1.00
Final Score
Min Max
36.37 96
21.88 97,98
Median
75.97
76.44
Average SD 73.54 15.30
66.09 25.68
Min minimum, Max - maximum, SD standard deviation.
0.345
501
Figure 4 Characterization of the main symptoms reported in the SWAL-QOL, in the

domain of frequency of symptoms according to the type of pharyngeal closing.
Conclusion
Studying the swallowing and quality of life related to swallowing in total
laryngectomy patients that had manual or mechanical (stapler) closing in
pharyngoesophageal reconstruction, one may conclude that those with mechanical
closing , when compared with the ones with manual closing, had:
Reintroduction of food via the mouth in a shorter time;
More complaints related to swallowing when asked and with the
possibility of a better perception of both the pharyngeal region
and the symptoms presented;
Stronger presence of food stasis, mainly at the base of the tongue
and the pharyngeal region, due to the presence of a pharyngeal
fold;
Better classification in the endoscopic assessment of swallowing;
Better final score in the assessment of quality of life related to
swallowing.
References
1. DAVIS, K.; VINCENT, M.; SHAPSHAY, S.; STRONG, S. The anatomy and complications
of T versus vertical closure of the hypopharynx after laryngectomy. Laryngoscope 1982;
92: pg 16-20.
2.
PACHES, A.I; OGOLTSOVA, E.S.; TSYBYRNE, G.A., et al. Use of suturing
devices during laryngectomy (experimental study). Zh Ushn Gorl Bolezn 1972; 32:61-66.
3.
WESTMORE, G.A.; KNOWLESS, J.E.A. The use of a stapling instrument for postlaryngectomy pharyngeal repais. J. Laryngology and Otology 1983; 97: 775-778.
4. TALMI, Y.P.; FINKELSTEIN, Y.; GAL, R.; SHVILLI, Y.; SADOV, R.; ZOHAR, Y. - Use
of linear stapler for postlaryngectomy pharyngeal repair: a preliminary report. .
Laryngoscope 1990; 100: pg 552 555
5. SOFFERMAN, R.A.; VORONETSKY, I. Use of linear Stapler for pharyngoesophageal
closure after total laryngectomy. Laryngoscope 2000; 110: pg 1406 1409.
502
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
MONTOYA,S.; GALARRETA, J.C.R.; REY, A.S.; IBARGEN, A.M.; MATURAMA,

Z.L. Estudio comparativo entre el empleo de la sutura manual y la sutura mecnica em el
cierre del defecto mucoso em la laringectoma total. Acta Otorrinolaringol Esp 2002, 53: pg
343-350.
DEDIVITIS, R.A.; GUIMARES, A.V.- Uso do grampeador para fechamento da faringe
aps laringectomia total. Acta Cirrgica Brasileira 2004; 19(1):66-69.
BEDRIN, L.; GINSBURG, G.; HOROWITZ, Z.; TALMI, Y.P.- 25- year experience of
using a linear stapler in laryngectomy. Head & Neck 2005, 27: pg 1073-1079.
MULLER-MINY, H.; EISELE, D.; JONES, B. Dynamic radiographic imaging following
total laryngectomy. Head and Neck 1993; 15: 342-47.
CLAV, P.; ARREOLA, V.; VELASCO, M.; QUER, M .; CASTELLI, J.M.; ALMIRALL,
J.; PERES, P. G.; CARRAVW, R. Diagnstico y tratamiento de La disfagia orofarngea
funcional. Aspectos de interes para El cirujano digestivo. Cir. Esp. 2007; 82(2):62-76.
ACKERSTAFF, A.H.; HILGERS F.J.M.; AARONSON,N.K.; BALM,A.J.M.
Communication, functional disorders and lifestyle changes after total laryngectomy. Clin
Otoaryngol 1994; 19:295-300.
MACEDO, E.D.; GOMES, F.F.; BRANDEBURSKI, C Avaliao de Gravidade do
Distrbio de Deglutio pela Tcnica da Avaliao Endoscpica da Deglutio (AED). Anais
do XXXII Congresso Brasieliro de Endoscopia Peroral, 1996.
McMORNEY, C.A.; BRICKER, E.; KRAMER, A.E.; ROSENBEK, J.; ROBBINS,J.;
CHIGNELL,K.; LOGEMANN, J.A.; CLARKE, C. The SWAL-QOL outcomes tool for
oropharyngeal dysphagia in adults: I. conceptual foundation and item development.
Dysphagia 2000; 15: 115-121.
McMORNEY, C.A.; BRICKER, E.; KRAMER, A.E.; ROSENBEK, J.; ROBBINS,J.;
CHIGNELL,K.A. The SWAL-QOL outcomes tool for oropharyngeal dysphagia in adults:
II. Item reduction and preliminary scalingt. Dysphagia 2000; 15: 122-133.
BANDEIRA, A.K.C. Qualidade de vida relacionada voz e deglutio aps tratamento
para o cncer de lngua. [tese]. So Paulo: Fundao Antnio Prudente; 2004.
BARROS, A.P.B.; PORTAS, J.G.; QUEIJA, D.S.; LEHN, C.N.; DEDIVITIS, R.A.
Autopercepo da desvantagem vocal(VHI) e qualidade de vida relacionada deglutio
(SWAL- QOL)de pacientes laringectomizados totais Rev. Bras.Cir. Cabea e Pescoo
2007; v.36,no 1, p-32-37.
GANLY,I.; PATEL, S.; MATSUO, J.; SINGH, B.; KRAUS, D.; BOYLE, J.; WONG, R.;
LEE, N.; PFISTER, D.G.; SHAHA, A.; SHAH, J. Postoperative complication of salvage
total laryngectomy. Cancer 2005; 103(10):2073-2081.
503
FP45.1
CARBONATED LIQUIDS: HELPING CLINICIANS UNDERSTAND
THEIR VALUE AND USE IN DYSPHAGIA MANAGEMENT
Goldberg L., Rajagopalan J.
Introduction and aim of the study: Adults with dysphagia often have more
difficulty swallowing thin liquids than solid foods (Castellanos, Butler, Gluch, &
Burke, 2004; Logemann, 1998).Thin liquids include water, coffee, tea, soda, ices,
tomato juice and anything that will liquefy in the mouth within a few seconds
(American Dietetic Association [ADA], 2002). An increase in liquid consistency often
is recommended to ensure that these adults are able to drink an adequate amount of
liquid and do so safely. Increasing liquid consistency is achieved by adding other
beverages, pureed foods, or commercially-available starch- or gum-based products
to the base liquid (Garcia, Chambers, & Molander, 2005).
Thickened liquids are believed to move more slowly through the mouth. This
slowed movement may give the lingual, pharyngeal and laryngeal musculature more
time to react. The pressures from increased and coordinated tongue movement also
are believed to stimulate faucial and oropharyngeal receptors in readiness for
swallowing. For adults with swallowing difficulties, thicker liquids are less likely
than thin liquids to enter the laryngeal area prior to the initiation of the swallowing
reflex, and thus help to prevent aspiration pneumonia (Garcia et al., 2005; Goulding
& Bakheit, 2000; Steele &Van Lieshout, 2004).
The National Dysphagia Diet (ADA, 2002) identifies four levels of liquid
thickness (or viscosity) in diet modification: thin (1-50 cP), nectar-like (51-350 cP),
honey-like (351-1750 cP), and spoon-thick (>1750 cP). Recent work by Blow, Olsson
and Ekberg (2003) has shown that carbonated beverages may act in similar ways to
thickened liquids. Forty patients referred for a video-radiographic swallowing study
were asked to swallow pudding, puree thickened liquids, thin liquids and
carbonated thin liquids. When compared to the patients swallows of both puree
thickened and thin liquids, the carbonated thin liquids significantly reduced
penetration/aspiration, pharyngeal transit time and pharyngeal retention of liquid
(Blow et al., 2003). When individuals consume carbonated beverages, sensory
receptors in the nose and touch receptors in the mouth are stimulated as the bubbles
burst over the tongue. The bubbles serve as traps for aromatic molecules. As the
bubbles burst in the mouth they spray tiny droplets of highly concentrated aromatic
molecules. The pressure of these bursting bubbles emphasizes the flavor of the
beverage and enhances flavor perception (Dessirier, Simons, Carstens, OMahoney &
Carstens, 2000;). These sensory effects are considered an aspect of chemesthesis
(Cook, Hollowood, Linforth, & Taylor, 2003; Liger-Belair, 2003).
Blow et al. (2003) suggested that including carbonated beverages in the
treatment of adults with dysphagia could increase these patients fluid intake and
energy due to the palatability of the liquids, as well as increase the patients overall
quality of life. However, following the publication of their study, many clinicians
were skeptical about the results. These clinicians reasoned that if carbonated liquids
504
worked well, thickening the carbonated liquids to a nectar-like consistency would

work better (personal communication, Goldberg, 2004, 2007). The purpose of the
current study was to investigate and compare the viscosity of unaltered and
thickened carbonated liquids. The specific research questions were:
1. Is there a difference in the viscosity of carbonated and de-carbonated thin

liquids?
2. Is there a difference in the viscosity of carbonated and de-carbonated
liquids when thickened?
Methods:
Two commercially-available thickening agents, one starch-based and one
gum-based, were used. Thick it, a starch-based thickening agent (1999 Precision
Foods Inc.), was chosen based on its reliability when used to thicken traditional
liquid bases such as coffee, milk and juice (Colodny, 2005; Sandridge, 2004). Simply
Thick, a gum-based thickening agent (Phagia-Gel Technology), was used because of
the manufacturers claim that it mixes consistently with carbonated beverages and
retains excellent taste. These two thickening agents were mixed with four carbonated
(regular, rather than diet) liquids: water, Coke, Sprite and Dr. Pepper. These
carbonated liquids are common beverages in the United States and are frequently
available in institutional settings for patient consumption (French, Lin, & Guthrie,
2003).
The experiment was conducted in two phases. Phase 1 evaluated the effects of
carbonation on the viscosity of the four liquids at a thin consistency. The liquids were
compared in carbonated and de-carbonated states. The carbonated liquids were decarbonated over 24 hours using magnetic stirrers placed in a series of Erlenmeyer
flasks situated on stir plates. The stirring speed was set to create a small vortex in the
center of the carbonated liquid in each flask. Phase 2 investigated the effects of
carbonation on the viscosity of the liquids thickened with the starch- and gum-based
agents to a nectar-like consistency (51-350 cP; ADA, 2002). Viscosity was measured
using cone-plate geometrics on an AR 2000ex rheometer (TA Instruments). As
previous research revealed no significant difference in the viscosity of liquids when
refrigerated and at room temperature (Sandridge, 2004; Stagg, 2005), room
temperature was selected for the current study. Due to the nature of the study, the
investigators were not blind to the thickening agents or liquids.
The independent variables were liquid base (water, Coke, Sprite, Dr. Pepper),
consistency (thin, nectar-like), carbonation (plus or minus) and thickening agent
(starch- and gum-based). The dependent variable was viscosity. Viscosity
measurements were entered into the Statistical Package for Social Sciences (SPSS)
version 13.0 computer program. The data then were analyzed using univariate two
and three way analyses of variance (ANOVA). Tukey HSD t-tests (Silverman, 1998)
were used as a post-hoc measure.
Results:
A univariate two factor ANOVA (Table 1) showed a significant main effect
for carbonation [F(1, 152) = 219.89, p<0.01] verifying that the viscosity under
carbonation was greater than when liquids were de-carbonated. A significant main
effect also was documented for liquid [F(3, 152) = 35.35, p<0.01]. Post hoc Tukey HSD
t-tests for each liquid revealed statistically significant differences between water and
Dr. Pepper (t =4.50, p<0.01), water and Coke (t =4.25, p<0.01), and water and Sprite (t
=2.00, p<0.01). Sprite had a significantly higher viscosity than Dr. Pepper (t =2.50,
505
p<0.01) and Coke (t = 2.25, p<0.01). There were no statistically significant differences
between the viscosities of Coke and Dr. Pepper.
A significant interaction was present between liquid type and carbonation
[F(3, 152) = 63.59, p<0.01] and is illustrated in Figure 1. Carbonation increased the
viscosity of all four liquids but strongly so for Sprite and water. A comparison of each
liquid between its carbonated and de-carbonated state showed that there were
significant differences, at p < 0.01, for water (t = 15.16), Sprite (t = 6.27) and Dr. Pepper
(t = 3.13). A comparison of each of the carbonated liquids showed that the viscosity
of water was significantly greater than Sprite (t = 5.54, p < 0.01), Coke (t = 14.58, p <
0.01), and Dr. Pepper (t = 16.65, p < 0.01). The viscosity of Sprite was significantly
greater than Coke (t = 6.02, p < 0.01) and Dr. Pepper (t = 5.48, p < 0.01). There was no
significant difference between the viscosities of carbonated Coke and Dr. Pepper (t = 1.05, p = 0.31).
Table 1. Univariate ANOVA of the Effects of Carbonation on the Viscosity of

Thin Liquids.
df
F
Source
Mean
Significance
Square
Between subjects
Carbonation
1
1113.03
219.89
0.01
Liquid
3
178.96
35.35
0.01
Liquid
x 3
321.89
63.59
0.01
Carbonation
Error
152
5.06
Total
159
30
28
Mean Viscosity (cP
26
24
Water
22
Coke
20
Sprite
Dr. Pepper
18
16
14
12
10
Carbonation
No Carbonation
Figure 1. Comparison of Mean Viscosities and Standard Deviations of

Carbonated and De-carbonated Thin Liquids.
506
A univariate three factor ANOVA (Table 2) showed a statistically significant

main effect for carbonation [F(1, 319) = 43.16, p<0.01], verifying that the
viscosity of thickened liquids when de-carbonated was greater than when the
same thickened liquids were carbonated (see also Figure 2).
Table 2. Univariate three factor ANOVA of the Effects of Carbonation,

Thickening Agent and Liquid on Viscosity.
df
F
Source
Mean
Significance
Square
Between Subjects
Carbonation
1
5008.613
43.16
0.01
Agent
1
1178.11
10.15
0.05
Liquid
3
1350.41
11.64
0.01
Carbonation x Agent 1
9968.11
85.89
0.01
Liquid
x 3
540.78
4.66
0.05
Carbonation
Agent x Liquid
3
463.08
3.99
0.05
Carbonation x Agent 3
2246.28
19.36
0.01
x Liquid
Error
304
116.06
Total
319
85
80
75
Mean Viscosity (cP)
70
65
60
Water
55
Coke
Sprite
50
Dr.Pepper
45
40
35
30
25
20
Carbonation
No Carbonation
Figure 2. Comparison of Mean Viscosities and Standard Deviations of

Carbonated and De-carbonated Liquids When Thickened.
507
Conclusions:
1.
2.
3.
4.
The viscosity of carbonated thin liquids was greater than the viscosity of decarbonated thin liquids.
The effect of carbonation on the viscosity of thin liquids varied according to the
type of liquid. The ingredients in Dr. Pepper and Coke, particularly caramel color
and caffeine, may have decreased the effects of carbonation.
In contrast to the finding of the effect of carbonation on thin liquids, the
viscosity of de-carbonated thickened liquids was greater than the viscosity of
carbonated thickened liquids.
Following manufacturers directions to thicken carbonated and de-carbonated
liquids to a targeted nectar-like consistency did not result in viscosity
measurements at this level. All viscosity measurements for carbonated and decarbonated thin and thickened liquids measured in the thin range.
With regard to viscosity, carbonated liquids measured at the thicker end of

the accepted thin range (1-50 cP). Carbonation decreased the effect of both starchand gum-based thickening agents and rendered a thickened carbonated liquid
thinner than a non-thickened carbonated liquid. Therefore, it is counter-productive
to thicken carbonated liquids.
References:
American Dietetic Association (2002). National Dysphagia Diet: Standardization for
optimal care. Rockville, MD: Author.
Blow, M., Olsson, R., & Ekberg, O. (2003). Videoradiographic analysis of how
carbonated thin liquids and thickened liquids affect the physiology of swallowing
in subjects with aspiration on thin liquids. Acta Radiologica, 44, 366-372.
Castellanos, V.H., Butler, E., Gluch, L., & Burke, B. (2004). Use of thickened liquids in
skilled nursing facilities. Journal of the American Dietetic Association, 104(8),
1222-1226.
Colodny, N. (2005). Dysphagic independent feeders justifications for noncompliance
with recommendations by a speech-language pathologist. American Journal of SpeechLanguage Pathology, 14, 61-70.
Cook, D.J., Hollowood, T.A., Linforth, R.S.T., & Taylor, A.J. (2003). Oral shear stress
predicts flavour perception in viscous solutions. Chemical Senses, 28, 11-23.
Dessirier, J., Simons, C.T., Carstens, M.I., OMahony, M., & Carstens, E. (2000).
Psychophysical and neurobiological evidence that the oral sensation elicited by
carbonated water is of chemogenic origin. Chemical Senses, 25, 277-284.
Finestone, H.M., & Greene-Finestone, L.S. (2003). Rehabilitation medicine: 2.
Diagnosis of dysphagia and its nutritional management for stroke patients. Canadian
Medical Association Journal, 169(10), 1041-1044.
French, S.A., Lin, B., & Guthrie, J.F. (2003). National trends in soft drink consumption
among children and adolescents age 6 to 17 years: Prevalence, amounts, and sources,
1977/1978 to 1994/1998. Journal of the American Dietetic Association, 103(10), 13261332.
Garcia, J.M., Chambers, E., & Molander, M. (2005). Thickened liquids: Practice
patterns of speech-language pathologists. American Journal of Speech-Language
Pathology, 14, 4-13.
Goulding, R., & Bakheit, A.M.O. (2000). Evaluation of the benefits of monitoring fluid
thickness in the dietary management of dysphagic stroke patients. Clinical
Rehabilitation, 14, 119-124.
Liger-Belair, G. (2003). The science of bubbly. Scientific American, 288(1), 80-86.
Logemann, J.A. (1998). Evaluation and treatment of swallowing disorders. (2nd. Ed.).
Austin, TX: Pro-Ed.
508
Sandridge, K. (2004). Effects of liquid, base, time and temperature on viscosity.

Unpublished masters thesis, Southwest Missouri State University.
Silverman, F.H. (1998). Research design and evaluation in speech-language
pathology and audiology. Needham Heights, MA: Allyn & Bacon.
Stagg, M. (2005). Effects of juice base and temperature on the viscosity of thickened
liquids. Unpublished masters project, Southwest Missouri State University.
Steele, C.M. & Van Lieshout, P.H.H.M. (2004). Influence of bolus consistency on
lingual behaviors in sequential swallowing. Dysphagia, 19, 192-206.
509
P093
PROPOSAL OF PROTOCOL FOR ELECTROMYOGRAPHIC EVALUATION OF
MASSETER MUSCLE DURING DEGLUTITION
L.A. Pernambuco1,2, J.C. Leo2, R.A. Cunha2, G. M. Andrade2, P.M.M. Balata2,3, H.J.
Silva2
1Cancer Hospital of Pernambuco, Recife, Brazil; 2Federal University of Pernambuco,
Recife, Brazil; 3Institucional Human Resources of Pernambuco, Recife, Brazil
The masseter is a large, thick and rectangular muscle located on either side of
face prior to the parotid gland that has a superficial and deep part1. Its composed of
skeletal muscle tissue and its main function is to elevate the mandible1,2. The
adequacy of deglutition evaluation, which is the transportation of food from mouth
to stomach, requires the synergistic action of the muscles of mastication and
masticatory, laryngeal muscles and pharyngeal muscles3.
The masseter has an important role in the deglutitions physiology because it
helps to stabilize the mandible, working with the suprahyoid muscles3. One way to
evaluate the behavior of this muscle is by surface electromyography, defined as the
registration method of changes in muscles electrical activity of during its
contraction4-6. Evaluates the physiological and pathological conditions of muscle,
provides information on the principles of muscle function4 and can contribute to
diagnosis7.
The aim of this study is to present a proposal for a protocol of
electromyographic evaluation of masseter muscle during deglutition.
Methods
A group of Brazilian speech therapists researchers who have experience in
deglutition and voice area concern about the procedures used to evaluate the
participation of mandibular elevator muscles during deglutition, especially the
masseter muscle, used their experience and established regular discussions about the
topic. Can conclude that would be important to review the evaluation protocols
previous published, as well as those used daily in clinical practice. Initially, was done
a search in scientific literature to identify articles that assessed the electrical activity
of masseter muscle during deglutition.
Were selected the most important articles according to members of group and
its methodology was discussed. From these data, was developed an evaluation
protocol, considering the electrodes placement positioning in masseter muscle,
deglutition tasks to be performed and parameters to be extracted from the
electromyographic signal.
Results
510
Based on the methodology adopted, the procedures that have proved most
suitable for obtaining the recordings of masseter electromyographic in deglutition
were listed in Table 1.
Table 1 - Procedures for evaluation of masseter muscle in deglutition
Preparation for the Test:
Stage 1
Volunteer comfortably seating in a chair with back support and no
support for the head, hands on thighs, the feet soles on the ground,
head erect and look forward, based on Frankfurt plan. The volunteer
will not see the computer screen to avoid the visual feedback and
commitment evaluation. Before each experiment, will have a training
with each volunteer, with all necessary instructions and information.
The skin must be clean with gauze and alcohol 70.
Electrodes placement position:
Stage 2
It begins by placing the reference electrode, used to minimize
interference from external electrical noise. Its placed, conditionally, in
ulnar styloid process of the right arm of volunteer, far from the points
of muscles evaluated.
The other electrodes are positioned bilaterally in a bipolar
configuration, in the muscle belly of the masseter muscles, arranged
along the muscle fibers. To locate the region where the first electrode is
fixed, the volunteer will stay three seconds performing the dental
clenching, visualizing and palpating the midline of muscle belly of
masseter.
The second electrode is positioned 1.5cm below the first, also arranged
along the muscle fiber.
Stage 3
Stage 4
Proof of two channels in electromyographic.

Signal stabilization:
Signal stabilization through repetition of clenching for 3s once. Wait a
minute to start the next stage.
Deglutition tasks (adapted from Vaiman, Eviatar & Segal, 2004):
1. Liquid deglutition with comfortably volume: water deglutition at
room temperature in a single sip of 16,5ml in volunteers aged between
18 and 40; 14,5 ml in volunteers aged between 41 and 70 and 12 ml for
individuals over 70 years. The individual will be instructed to place the
sip in mouth, hold for three seconds and swallow when the evaluator
says. Repeat three times, with intervals of 10s between each deglutition.
2. Liquid deglutition with uncomfortably volume: water deglutition at
room temperature in a single sip of 20 ml (test to evaluate the ability of
adaptation of volunteers, using a large volume of water). The individual
will be instructed to place the sip in mouth, hold for three seconds and
swallow when the evaluator says. Repeat three times, with intervals of
10s between each deglutition.
3. Training deglutition: The individual will be instructed by evaluator
511
to water deglutition of 100ml, continuously and habitual, once.
The signal analysis is performed considering the highest peak of

electromyographic activity during the task of natural deglutition (100%) in each
channel. All other signals are analyzed in maximum percentage value9. From the first
two tasks, the average is calculated one of each 3 replications and calculated the final
average, to be compared with the maximum value in each channel. In natural
deglutition, the average is compared with the maximum value in each channel, being
considering the time and number of deglutitions.
Discussion
The electrical activity of masseter muscle during deglutition is has already
described in literature. Through electromyography studies, During deglutition, the
masseter and anterior temporal muscles are activated at the same time that of
sternocleidomastoid and suprahyoid muscles and the myoelectric potential increases
as muscles increase its strength to have an isometric contraction and stabilize the
mandible during deglutition10.
Another study showed an increase of electrical activity of masseter muscle in
deglutition, followed by a decline of this activity after deglutition. This increase of
masseter electromyographic activity is justified by the need to stabilize the mandible
during deglutation. The suprahyoid muscles are involved in the lower mandible and
in hyolaryngeal elevation and its necessary the masseter simultaneous contraction to
stabilize the mandible and prevent its lowering by the suprahyoid action3.
Despite these findings, the methodology adopted in works is heterogeneous,
difficult the reproducibility of experiments. The purpose of this protocol is to have a
better systematic collection such data from the review of methodology used in
previous research and in the experience of a researcher group in surface
electromyography. To the preparation for the test (stage 1), was stipulated to what
the literature refers and what the research group accepted.
The electrodes placement (stage 2) starts with the reference. Was referred the
ulnar styloid process of the right arm of volunteer because this is a region that meets
the recommendations for the adequate electromyographic recording. This region is a
bone surface distant from the muscle group studied and was agreed by the research
group, since the discussions about it was noted that other options mentioned in the
literature, such as the forehead, for example, would not meet all requirements.
The choice for use bipolar electrodes, bilaterally, due to the fact that its
important to consider the asymmetries, natural or not, that the subject can have. The
electrodes placement in only one side could loss important data of the untested.
Among the options of location of the best body spot to place the electrodes in
masseter muscle, the research group agreed that the palpation of belly muscles by
dental clench was the most appropriate and easier to apply in this muscle group.
Moreover, this is the most described method in previous studies.
The distance between the electrodes cannot be too small because the detection
surfaces can have a short-circuit if these surfaces becomes wet and conductive by
sweat from the patient11. It was agreed a distance of 1.5cm as it meets the technical
requirement mentioned above and is consistent with the literature. To stabilize the
signal, an intense activity of masseter should be ordered. The dental clench meet this
512
need, the task has been solicitated. One minute of rest before deglutition tasks, aims
to return the muscle to its baseline or rest condition.
There are several deglutition tasks required in methodological procedures of
previous work. The group of researchers considered more adequate the tasks applied
by Vaiman, Eviatar and Segal (2004)8 because their study involved a significant
number of volunteers and established parameters of volumes to be tested in different
age.
In electromyography studies, the signal normalization is essential.
Normalization techniques for the cycle or period of contraction and the amplitude
value permits convert absolute values of the registration and percentages of a
reference value. Therefore, normalizing is an attempt to reduce the differences
between the different records of the same subject or different people, in order to
make the interpretation of the data reproducible12.
In reviewed studies, there was lack by the authors to do the standardization.
In one of the few articles found that reference this9, the authors normalize the signal
as described in methods, considering the value of greater magnitude as 100% and
analyzing other values as a percentage of this maximum value. The literature states
that the deglutition function varies from individual to individual in terms of specific
muscles involved and how the patterns of activity are coordinated13. Thus, the type
of signal analysis by percentage rather than absolute values, was established as the
most appropriate for researchers, allowing more reliable comparison of the activities
performed by the individual and minimizing mistaking comparisons intra and interindividuals.
The group of researchers agrees the method of electromyography
applicability has some limitations. The electromyographic signals can be affected by
anatomical and physiological properties of muscles by the control of peripheral
nervous system, the instrumentation used in signs collection11, the presence of
malocclusions, occlusal interferences, muscle training, facial type and feeding14. The
thick and layer fat on skin, electrode placement and patient motivation during the
exam can also influence the results15. Furthermore, the interindividual differences
difficult to determine significant quantitative differences between individuals in this
type of examination16. Another limitation relates to a possible contamination of
record electrical activity coming from other muscles or adjacent muscle groups (the
crosstalk)12.
Nevertheless, there are advantages of this procedment because its noninvasive; the individuals are free of discomfort and radiation; its fast, inexpensive
and easily comprehension by the patient17. In speech therapy clinic,
electromyography is considered an important aid in the understanding of electrical
activity patterns of facial and masticatory muscles, contributing to a objective
diagnosis and more effective intervention18. The evaluations of muscle groups, such
as palpation or visual inspection are subjective and the EMG is objective that can
supplement the data of diagnosis, treatment and even predictions of cases in the
speech therapy clinic 19.
Conclusions
This protocol for electromyographic evaluation of masseter muscle during
deglutition proposes a more efficient systematization of therapeutic plan allowing
more reproducible and uniform results in future research and speech therapy clinic.
Acknowledgment
513
The authors thank the National Council of Technological and Scientific

Development (CNPq), which had a financial support with CTSAUDE / Edictal
MCT/CNPq/CT-Sade/MS/SCTIE/DECIT
n
67/2009
REBRATS
Process:559570/2009-0
References
1. Molina OF. Fisiologia craniomandibular-ocluso e ATM. 2nd ed. So Paulo: Pancast; 1995.
p. 19-64.
2. Grabowski SR, Tortora GJ. Princpios de Anatomia e Fisiologia, 9nd Ed. Rio de Janeiro:
Guanabara Koogan; 2002.
3. Hiraoka K. Changes in masseter muscle activity associated with swallowing. J Oral
Rehabil. 2004;31(10): 963-7.
4. Rodrigues AMM, Brzin F, Siqueira VCV. Anlise eletromiogrfica dos msculos masseter
e temporal na correo da mordida cruzada posterior. Rev Dent Press Ortodon
Ortop Facial. 2006; 11(3):55-62
5. Biasotto DC, Biasoto-Gonzalez DA, Panhoca I. Correlation between the clinical
phonoaudiological assessment and electromyographic activity of the masseter
muscle. J Appl Oral Sci. 2005;13(4):424-30.
6. Rahal A, Pierotti S. Eletromiografia e cefalometria na Fonoaudiologia. In: Ferreira LP,
Befi-Lopes DM, Limongi SCO, org. Tratado de Fonoaudiologia. So Paulo: Roca;
2004. p. 237-53.
7. Perlman AL, Van Daele DJ. Disfagia avaliao. In: Bailey BJ, Johnson JT. Coleo
Otorrinolaringologia Cirurgia de Cabea e Pescoo Vol.2 Vias areas,
deglutio, voz. Rio de Janeiro: Revinter; 2010. p.23-32.
8. Vaiman M, Eviatar E, Segal S. Evaluation of normal deglutition with the help of rectified
surface electromyography records. Dysphagia. 2004; 19:125-32.
9. Ding R, Larson CR, Logemann JA, Rademaker AW. Surface electromyography and
electroglottographic studiesin normal subjects under two swallow conditions:
normal and during the Mendelson maneuver. Dysphagia. 2002;17:1-12.
10. Monaco A. et al. Surface electromyography pattern of human swallowing. BMC Oral
Health [internet periodical]. 2008 [cited in 02/23/2003], 8(6). Available from:
http://www.biomedcentral.com/1472-6831/8/6.
11. Sampaio CRA. Avaliao eletromiogrfica dos msculos masseter e temporal anterior
aps o uso da placa de Hawley modificada em pacientes com DTM [dissertation]:
Universidade Federal of Pernambuco. Masters Degree in Biophysics.2003.
12. Regalo SCH, Vitti M, Oliveira AS, Santos CM, Semprini M, Sissere S. Conceitos bsicos
em eletromiografia de superfcie. In: Felicio CM, Voi Trawitzki LV. Interfaces da
medicina, odontologia e fonoaudiologia no complexo crvico-craniofacial. So
Paulo: Pr-fono; 2009. p. 31-50.
13. Gay T, Rendell JK, Spiro J. Oral and muscle coordination during swallowing.
Laryngoscope. 1994; 104: 341-9.
14. Rodrigues, KA, Rahal, A. A influncia da tipologia facial na atividade eletromiogrfica do
msculo masseter durante o apertamento dental em mxima intercuspidao. Rev
CEFAC. 2003; 5:127-30
15. Felcio CM, Couto GA, Ferreira CLP, Mestriner Junior, W. Reliability of masticatory
efficiency with beads and correlation with the muscle activity. Pr Fono R Atual
Cient. 2008; 20(4): 225-30.
16. Mangilli LD, Sassi FC, Sernik RA, Tanaka C, Andrade CRF. Avaliao eletromiogrfica e
ultrassonogrfica do msculo masseter em indivduos normais: estudo piloto. Pr
Fono R Atual Cient. 2009; 21(3): 261-4.
17. Vaiman, M, Eviatar, E. Surface electromyography as a screening method for evaluation
of dysphagia and odynophagia. Head & Face Medicine [peridico na internet].
2009 [cited in 02/23/2003], 5(9). 11p. Available from: http://www.head-facemed.com/content/5/1/9.
18. Ferla A, Silva AMT, Corra ECR. Atividade eletromiogrfica dos msculos temporal
514
anterior e masseter em crianas respiradoras bucais e em respiradoras nasais. Rev

Bras Otorrinolaringol. 2008; 74(4): 588-95.
19. Nagae, M, Brzin, F. Electromyography: applied in phonoaudiolgy clinic. Braz J Oral Sci.
2004; 3(10): 506-9.
515
FP34.5
CLINICAL MANAGEMENT OF DYSPHAGIC PATIENTS WITH KNOWN ASPIRATION
OF THIN LIQUIDS
Martha JP Karagiannis1,2 and Tom C Karagiannis3,4
1 Manager Community and Allied Health and Senior Speech Pathologist, West Wimmera
Health Service, Nhill, Victoria, Australia
2 Founding Director, Darebin Aged Care Health Service, Melbourne, Victoria, Australia
3 Head, Epigenomic Medicine, BakerIDI Heart and Diabetes Institute, The Alfred Medical
Research and Education Precinct, Melbourne, Victoria, Australia
4 Department of Pathology, The University of Melbourne, Parkville, Victoria, Australia
Introduction and aims of study
Oropharyngeal dysphagia is a very common problem, mainly in elderly

patients and is associated with various medical conditions such as cerebrovascular
accidents (CVA; stroke), degenerative neurological dysfunction and certain
advanced cancers (1, 2). A well known complication of oropharyngeal dysphagia is
aspiration and this condition significantly increases the risk of mortality due to
malnutrition, dehydration and the development of a specific type of pneumonia,
referred to as aspiration pneumonia (3-6).
It is well known that thin liquid is the most likely consistency to be aspirated
and unfortunately, the conventional treatment options that are recommended for
patients that aspirate thin liquids remain very limited (7). The conventional
intervention involves prescription of thickened liquids, typically to an extremely,
moderately or mildly thick consistency and in certain cases to a diet consisting of
modified solids.
However, there are major concerns associated with the consumption of
thickened fluids and modified solid consistencies which are typically related to
quality of life. Patient dissatisfaction, in many cases to the point of non-compliance
is the major issue (8, 9). This in turn, may lead to serious medical complications such
as dehydration and malnutrition. These are well known problems and have created
long-standing debates related to best practise regarding the management of
dysphagic patients who aspirate on thin liquids.
To overcome the problems associated with patient discontent to diets
consisting of thickened consistencies, a well-known protocol was developed at the
Frazier Rehab Center in Louisville, US about 25 years ago for the management of
patients with dysphagia (http://www.jhsmh.org/carecenters/re_sp_waterpro.asp).
This protocol permits oral intake of water for patients on oral diets according to a
concise set of guidelines.
The Frazier Rehab Center free water protocol is based on a solid rationale for
the provision of water to dysphagic patients. However, authoritative scientific
evidence to support the practise is very limited and there is still much debate in the
clinic. Although numerous hospitals, rehabilitation and aged-care centres have
adopted the Frazier Rehab Center guidelines, the counter-argument is that
implementation of the protocol is based predominantly on anecdotal evidence.
Further, numerous government hospitals and agencies are very reluctant to allow
implementation of the free water policy, given the lack of strong scientific evidence.
Therefore, we designed clinical trials to investigate the effects of oral intake of water
in dysphagic patients with previously identified aspiration, with the aim of
516
determining whether it is prudent to implement a free water protocol at regional

hospitals in our jurisdiction.
Methods
The first clinical trial was completed in 2008 at a Regional Tertiary Teaching
Hospital in the Gippsland region in Victoria, Australia and further clinical trial was
initiated in 2009 at regional aged-care residential facilities in the West Wimmera
region, Victoria, Australia. The Gippsland hospital is located approximately 200 from
Melbourne, the nearest capital city. The West Wimmera residential facilities are
located in between the capital cities of Melbourne and Adelaide (approximately 350
km from each). Trials were registered with the Australian New Zealand Clinical
Trials Registry (ACTRN12608000107325 and ACTRN12609000797279, respectively).
A total of 116 participants have been recruited to date and informed consent was
provided by the patients or medical enduring power of attorney before inclusion.
Dysphagic patients, who had been prescribed a modified or thickened fluid
diet by a Speech Pathologist, over the age of 18 and without a diagnosis of chronic
respiratory conditions or prior tracheostomy, were eligible for inclusion. All patients
were confirmed to aspirate thin liquids by independent assessment by experienced
speech pathologists and aspiration of thin liquids was also verified in selected
patients (~10%) using conventional radioactive barium videofluoroscopic swallow
evaluations.
In the first trial patients were recruited from either an acute unit (total 15) or
subacute units (total 85) and randomly assigned (age- and sex-matched) either to the
control group (thickened fluids only) or to the intervention group (thickened fluids
and free access to water). The mean standard deviation ages were 7911 and 807
years, in the control and intervention groups, respectively and the major condition
diagnosed upon admission was a CVA. In numerous cases, multiple ailments were
present, including CVA with accompanying depression and CVA and dementia. The
acute group represented unique problems related to data reliability, with the patients
included in the intervention cohort (eight) refusing thickened consistencies.
Problems with feeding at risk, including development of aspiration pneumonia,
highlights that acute patients should be strongly encouraged to adhere to the
modified diet and prompted us to evaluate only data from the subacute patients.
The recruited patients were monitored for 72 hours while they consumed
only the prescribed thickened fluids and modified consistencies. Following this
initial pre-intervention phase participants in the intervention group consumed the
prescribed thickened modified diet and under strict nursing guidance, were given
access to water as requested. Water could only be provided, at least 30 minutes after
a meal, following a thorough brushing of teeth or cleaning of dentures and use of
chlorhexidine mouthwash where necessary to ensure thorough cleaning of the oral
cavity. Participants in the control group continued to consume the prescribed
thickened diets only. All participants were monitored for a further five days.
In the second trial, a total of 16 participants from residential aged-care
facilities were recruited. The mean standard deviation age was 8110 years. In this
trial, patients were monitored for a five day pre-intervention period where only the
prescribed thickened fluid diet could be consumed. In the intervention phase all
participants were monitored for a further five days while they were allowed access
to water according to the guideline described above.
In both trials patients were examined for chest status daily and core body
temperature was recorded three times per day for the entire period. In addition,
total daily fluid intake for each participant was noted daily and quality of life
517
surveys consisting of simple related to satisfaction with the drinks, hydration and
mouth cleanliness were administered at the end of the pre-intervention and end of
intervention phases. The Wong and Baker pain rating scale was adapted to suit our
quality of life surveys.
Results
It is important to consider our findings in relation to an important study

published in 1997 which directly addressed the issues related to the effects of water
on aspiration pneumonia, hydration and quality of life in patients known to aspirate
thin liquids (10). In that one year randomised-control study two groups of stroke
patients who were known to aspirate on thin fluids were compared (10). The control
group of ten had only thickened fluids and the study group of ten had thickened
fluids as well as access to free water (10). The findings indicated that there were no
instances of pneumonia, dehydration or complications in either group (10). However
patient satisfaction was much superior in the study group whereas only one person
in the control group was happy with the thickened fluids (10).
Our findings indicate that a total of six subacute patients (six of 58 to date;
10.3%) in the intervention groups (allowed access to water) developed lung related
complications during the trials; three being diagnosed with aspiration pneumonia
and three had lower quadrant bibasal crepitations (indicative of aspiration
pneumonia but not confirmed). This is in contrast with the findings from the
previously published paper, in which it was found that none of the stroke patients
with identified aspiration of thin liquids developed lung complications (10). The
major differences between the two studies are the number of patients (ten per group
in the previous study compared to a total of 58 in the intervention groups in our
trials). The selection criteria represents another important point of difference in the
two studies. Only newly admitted CVA patients were included in the previous
study. Patients with previous CVA, chronic neurodegenerative diseases, multiple
medical diagnoses and those unable to self-feed were excluded from the study (10).
In contrast, our participants predominantly had multiple medical diagnoses and
patients with other neurologic dysfunctions as well as immobile patients were
included. In our study, of the six participants (two female and four male) that
developed lung complications in the intervention group, two had Alzheimers
disease, two had Parkinsons disease, one had a congenital intellectual disability and
the other suffered from cancer. Another feature of the patients that developed lung
complications was that three were classified as being immobile (bedridden and
unable to self-feed) and three had low mobility (able to self-feed and walk with
limited assistance). Notably, patients with similar characteristics in the intervention
groups (seven) did not develop lung complications, suggesting that neurological
dysfunction and immobility or low mobility may be increased risk factors but not
certainties for the development of aspiration-induced lung complications. Had we
considered only the newly admitted CVA patients with relative mobility (total of 12)
in the intervention groups, our findings would indicate no cases of lung
complications and be in accordance with the previously published observations (10).
Our findings of daily fluid intake indicate that patients in the intervention
groups (allowed access to water) consumed an average of >300mL more fluid per
day compared to the intake in the pre-intervention phases. Further, our findings
indicate the amount of water consumption did not exceed thickened fluid intake for
any of the patients when access to water was allowed. Finally, the results of our
quality of life surveys very strongly confirm the discontent of patients to diets
consisting of only thickened fluids and modified solid consistencies. Intriguing
518
differences were observed between the two groups in the follow-up survey at the
end of the study with the intervention group reporting much higher levels of
satisfaction with the drinks (mean 8.8 and 1.4 for the control and intervention
groups, respectively; higher scores represent greater dissatisfaction; Trial 1 data),
their level of thirst (mean 10 and 0.9) and mouth cleanliness (9.2 and 2.0) compared
to the pre-intervention phases. This disparity in responses highlights the importance
of considering quality of life issues in the clinical management of dysphagic patients.
Conclusions
We appear to have further defined subacute dysphagic patients at highest

risk of developing aspiration-induced lung complication.
Severe neurologic
dysfunction and immobility can be considered important risk factors. On the basis of
our findings, particularly, taking into account quality of life aspects (daily fluid
intake and survey data), we recommend subacute patients with relatively good
mobility should have choice as to whether they consume water after following the
oral hygiene protocols and being informed of the relative risk. Importantly, our
findings support the Frazier Rehab Center free water protocol and we have
implemented a variation of this protocol at the Teaching Hospital in the Gippsland
region.
References
1.
Koivula I, Sten M, Makela PH: Risk factors for pneumonia in the elderly. Am J Med
96: 313-320, 1994.
2.
Murphy BA, Gilbert J: Dysphagia in head and neck cancer patients treated with
radiation: assessment, sequelae, and rehabilitation. Semin Radiat Oncol 19: 35-42, 2009.
3.
Langhorne P, Stott DJ, Robertson L, MacDonald J, Jones L, McAlpine C, Dick F,
Taylor GS, Murray G: Medical complications after stroke: a multicenter study. Stroke 31:
1223-1229, 2000.
4.
Mann G, Hankey GJ, Cameron D: Swallowing function after stroke: prognosis and
prognostic factors at 6 months. Stroke 30: 744-748, 1999.
5.
Smithard DG, O'Neill PA, Parks C, Morris J: Complications and outcome after acute
stroke. Does dysphagia matter? Stroke 27: 1200-1204, 1996.
6.
Dubois RW, Brook RH: Preventable deaths: who, how often, and why? Ann Intern
Med 109: 582-589, 1988.
7.
Logemann JA: Treatment of oral and pharyngeal dysphagia. Phys Med Rehabil Clin
N Am 19: 803-816, ix, 2008.
8.
Macqueen C, Taubert S, Cotter D, Stevens S, Frost G: Which commercial thickening
agent do patients prefer? Dysphagia 18: 46-52, 2003.
9.
Colodny N: Dysphagic independent feeders' justifications for noncompliance with
recommendations by a speech-language pathologist. Am J Speech Lang Pathol 14: 61-70, 2005.
10.
Garon BR, Engle M, Ormiston C: A randomized control study to determine the effects
of unlimited oral intake of water in patients with identified aspiration. J Neuro Rehab 11: 139148, 1997.
519
P160
INTERDISCIPLINARY
REHABILITATION
PRACTICE
IN
LATE
MAXILLECTOMY
Martins VB.; Santana MG.; Sperb, LC

Speech Center of Porto Alegre / Private Clinic
Introduction: Female patient, 75 years, began rehabilitation treatment after

six years of maxillectomy, being preserved only the tubers, with their root fragments
of the third molars. In the lower jaw, only teeth 33-43. She underwent radiotherapy
(50 Gy, 35 sessions) presenting as sequelae after surgery and radiotherapy: severe
hypernasality, joint locked, intelligible speech under attention, muscle fibrosis,
decreased sensation and mobility of lips and mouth opening (24mm with prosthesis)
and changes in chewing and swallowing (nasal regurgitation, pyriform sinus stasis,
delayed triggering of the reflex, laryngeal penetration of all consistencies),
xerostomia and radiation caries. The patient had 6 years provisional partial denture
and due to fracture of teeth and the extent of bone loss and coronary fracture
coronary of remaining lower teeth. It was proposed the manufacture of total
dentures implant supported and Speech Theray rehabilitation.
Objective:
Improvement
of
the
changed
functions.
Methods: After surgical, prosthetics and speech therapeutic evaluation, began the
speech therapy for muscular and functional adaptation. At the same time it was
made a hyperbaric oxygenation (a protocol of 20 sessions before and 10 sessions after
implants insertion) prosthesis casting and wax up, surgery to insert a 6 upper and 4
lower implants. The implant used was slactive .. After the necessary period for
healing tissue and monitoring the response of bone tissue were prepared a lower
overdenture and an upper obturator prosthesis implant supported with retention
clip bar type.
Results: At the end of treatment the patient had mild hypernasality, effective
swallowing and chewing, intelligible speech, increased articulatory amplitude and
mouth opening of 33mm (with prosthesis).
Conclusions: The results confirm the importance of interdisciplinary work on
treatment outcome of major changes after resection in the oral cavity.
520
SE03.1
EARLY INTERVENTION: ORAL PLACEMENT
CHILDREN WITH DOWN SYNDROME (DS)
THERAPY
FOR
Sara Rosenfeld-Johnson, MS, CCC-SLP and Diane Bahr, MS, CCC-SLP,

NCTMB, CIMI
TalkTools Therapies and Ages and Stages, LLC
Problem Statement:
Infants and children with Down syndrome (DS) present with sensory and
motor disorders that impact feeding and speech development (Kumin & Bahr 1999;
Kumin, Von Hagel, & Bahr, 2001). The anatomic and physiologic characteristics that
hinder this development include: generalized hypotonia of the tongue, soft palate,
and oral facial musculature; ligament laxity in the temporomandibular joints; flat
facial features with a poorly developed mid-face region; a relatively small oral cavity
(i.e., small upper and lower jaws); abnormalities of the hard palate (e.g., short, high,
narrow palatal arch); irregular dentition (e.g., teeth emerging in an irregular
sequence and/or not properly formed); malocclusion (e.g., overbite, underbite,
crossbite, etc.); a low-tone tongue (appearing large relative to a small oral cavity);
abnormal neuromuscular junctions in the tongue; as well as frequently enlarged
tonsils and adenoids (Ardron, Harker, & Kemp, 1972; Borea, Magi, Mingarelli, &
Zamboni, 1990; Desai, 1997; Frostad, Cleall, & Melosky, 1971; Redman, Shapiro, &
Gorlin, 1965; Roche, Roche, & Lewis, 1972; Yarrow, Sagher, Havivi, Peled, & Wexler,
1986).
These characteristics contribute to open mouth resting posture, mouth
breathing, tongue thrust swallow, poor oral control of feeding and speech
movements, tooth grinding, and otitus media (Alper & Manno, 1996; Cobo-Lewis,
Oller, Lynch, & Levine, 1996; Frazier & Friedman, 1996; Kumin, 1996; Lauteslager,
Vermeer, & Helders, 1998; Spender, Dennis, Stein, Cave, Percy, & Reilly, 1995;
Spender, Stein, Dennis, Reilly, Percy, & Cave, 1996; Stoel-Gammon, 1997). While
children with DS are born with hypotonia and ligament laxity, most of the listed
deficits appear to manifest as the child grows (i.e., not seen at birth).
Speech therapists treat infants and toddlers with DS through early
intervention. Historically, language development and social play have been targeted
in treatment. Yet many children with DS have persistent speech intelligibility and
feeding disorders. Oral placement therapy (Bahr & Rosenfeld-Johnson, in press)
used in conjunction with language-based intervention can facilitate more typical
feeding development and support improved speech clarity.
Methods:
This seminar will discuss the importance of a prescribed therapeutic oralphase feeding program used in conjunction with treatment of language, cognitive,
and social development for infants with DS. Children with DS usually require
specific feeding treatment to obtain more typical eating and drinking patterns they
will use throughout life. A child with DS who received this treatment and attained
typical mouth development for feeding will be contrasted with a typically
developing child who developed a tongue thrust swallow (Kumin, VonHagel, &
Bahr, 2001). In this seminar, clinicians will be taught therapeutic feeding techniques
521
that can be used effectively to feed infants with DS and other disorders. These
intervention strategies target some feeding placements similar to placements used in
speech sound production. The discreet motor plans used in feeding vs. speech will
be discussed (Green, Moore, Ruark, Rodda, Morvee, & Van Witzenburg, 1997; Moore
& Ruark, 1996; Moore, Smith, & Ringel, 1988; Ruark & Moore, 1997, Steeve & Moore,
2009).
Conclusions:
Children with DS receiving appropriate early intervention in feeding,

speech, and language have superior outcomes to those left untreated.
Tactile-proprioceptive facilitation of actual feeding and speech placements
(OPT, Bahr & Rosenfeld-Johnson, in press) help children with DS develop
more typical feeding and speech skills.
This information supports the IALP vision/mission of advancing worldwide
clinical knowledge and improving the quality of life for children with DS.
References:
Alper, B. S., & Manno, C. J. (1996). Dysphagia in infants and children with oral-motor deficits:
Assessment and management. Seminars in Speech and Language, 17, 283-309.
Ardron, G. M., Harker, P., & Kemp, F. H. (1972). Tongue size in Downs syndrome. Journal of
Mental Deficiency Research, 16, 160-166.
Bahr, D., & Rosenfeld-Johnson, S. (in press). Treatment of children with speech oral
placement disorders (OPDs): A paradigm emerges. Communication Disorders
Quarterly.
Borea, G., Magi, M., Mingarelli, R., & Zamboni, C. (1990). The oral cavity in Down syndrome.
The Journal of Pedodontics, 14, 139-140.
Cobo-Lewis, A. B., Oller, K. D., Lynch, M. P., and Levine, S. L. (1996). Relations of motor and
vocal milestones in typically developing infants and infants with Down syndrome.
American Journal of Mental Retardation, 100 (5). 456-467.
Desai, S. S. (1997). Down syndrome. A review of the literature. Oral Surgery, Oral Medicine,
Oral Pathology, 84, 279-285.
Frazier, J. B., & Friedman, B. (1996). Swallow function in children with Down syndrome: A
retrospective study. Developmental Medicine and Child Neurology, 38, 695-703.
Frostad, N. A., Cleall, J. F., & Melosky, L. C. (1971). Craniofacial complex in the Trisomy 21
syndrome. Archives of Oral Biology, 16, 707-722.
Green, J. R., Moore, C. A., Ruark, J. L., Rodda, P. R., Morvee, W. T., & VanWitzenburg, M. J.
(1997). Development of chewing in children from 12 to 48 months: Longitudinal
study of EMG patterns. Journal of Neurophysiology, 77, 2704-2716.
Kumin, L. (1996). Speech and language skills in children with Down syndrome. Mental
Retardation and Developmental Disabilities Research Reviews, 2, 109-116.
Kumin, L., & Bahr, D. C. (1999). Patterns of feeding, eating, and drinking in young children
with Down syndrome with oral motor concerns. Down Syndrome Quarterly, 4(2), 1-8.
Kumin, L., Von Hagel, K. C., & Bahr, D. C. (2001). An effective oral motor intervention
protocol for infants and toddlers with low muscle tone. Infant-Toddler Intervention,
11(3-4), 181-200.
Lauteslager, P. E., Vermeer, A., & Helders, P. J. (1998). Disturbances in the motor behaviour of
children with Downs syndrome: The need for a theoretical framework. Physiotherapy,
84 (1), 6-13.
Moore, C. A., & Ruark, J. L. (1996). Does speech emerge from earlier appearing oral motor
behaviors? Journal of Speech and Hearing Research, 39, 1034-1047.
Moore, C. A., Smith, A., & Ringel, R. L. (1988). Task-specific organization of activity in human
jaw muscles. Journal of Speech and Hearing Research, 31, 670-680.
522
Redman, R. S., Shapiro, B. L., & Gorlin, R. J. (1965). Measurement of normal and reportedly
malformed palatal vaults: III. Downs syndrome (Trisomy 21, Mongolism). Journal of
Pediatrics, 67, 162-165.
Roche, A. F., Roche, J. P., & Lewis, A. B. (1972). The cranial base in Trisomy 21. Journal of
Mental Deficiency Research, 16, 7-20.
Ruark, J. L., & Moore, C. A. (1997). Coordination of lip muscle activity by 2-year-old children
during speech and nonspeech tasks. Journal of Speech, Language, and Hearing Research,
40, 1373-1385.
Spender, Q., Dennis, J., Stein, A., Cave, D., Percy, E., & Reilly, S. (1995). Impaired oral-motor
function in children with Downs syndrome: A study of three twin pairs. European
Journal of Disorder of Communication, 30, 77-87.
Spender, Q., Stein, A., Dennis, J., Reilly, S., Percy, E., & Cave, D, (1996). An exploration of
feeding difficulties in children with Down syndrome. Developmental Medicine and
Child Neurology, 38, 681-694.
Steeve, R. W., & Moore, C. A. (2009). Mandibular motor control during the early development
of speech and nonspeech behaviors. Journal of Speech, Language, and Hearing Research,
52, 1530-1554.
Stoel-Gammon, C. (1997). Phonological development in Down syndrome. Mental Retardation
and Developmental Disabilities Research Reviews, 3, 300-306.
Yarrow, R., Sagher, U., Havivi, Y., Peled, I. J., & Wexler, M. R. (1986). Myofibers in tongues of
Down syndrome. Journal of Neurological Science, 73, 279-287.
523
P090
THE EFFECTS OF CARBONATED LIQUIDS ON SWALLOWING IN ADULTS
WITH NEUROGENIC DYSPHAGIA: A CRITICAL APPRAISAL OF THE TOPIC.
K. Sdravou2, SLT, M.Sc. candidate

M. Walshe1, SLT, PhD
1 Trinity College, Dublin, Ireland
FOCUSSED CLINICAL QUESTION:

Do carbonated thin liquids affect swallowing physiology compared to non
carbonated thin liquids in adults with neurogenic oropharyngeal dysphagia?
SUMMARY of Search, Best Evidence appraised, and Key Findings:
Three references retrieved. Two references reporting two prospective clinical trials
relating specifically to the clinical question were located:
One published clinical trial with quasi experimental crossover design - Level evidence
2c (Bulow et al., 2003).
One unpublished clinical trial with experimental crossover design (a PhD dissertation)
- Level evidence 2c (Krival, 2007).
Results:
Bulow et al. (2003) reported statistically significant improvement on oropharyngeal
swallowing measures (reduced penetration/aspiration, shorter pharyngeal transit time,
less pharyngeal retention) in response to carbonated liquids compared to thin and
thickened liquids.
Krival (2007) found no significant differences on oropharyngeal swallowing measures
(STD, PTT, PR, PENASP, BPOS) between thin non carbonated liquids and carbonated
thin liquids.
There were significant methodological weaknesses in each of these studies that reduce
the confidence with which these results can be accepted and affect any clinical decision in this
area. The reports should act as an incentive for conducting further studies with methodological
improvements.
CLINICAL BOTTOM LINE:
There is weak evidence to support or refute the effects of carbonated thin liquids
compared to non carbonated thin liquids on the physiology of swallowing in adults with
neurogenic oropharyngeal dysphagia.
SEARCH STRATEGY
Terms used to guide Search Strategy
524
Patient Group: Adults with neurogenic oropharyngeal dysphagia

Intervention : Carbonated thin liquids (CTL)
Comparison: Non carbonated Thin liquids (NCTL)
Outcome: Improvement on swallowing physiology
m. Inclusion and Exclusion Criteria
Inclusion: Studies that evaluated the effects of carbonation on oropharyngeal
swallowing measures in neurogenic dysphagia.
Exclusion: Studies that evaluated the effects of carbonation on the oesophageal
stage of swallowing.
Databases and sites searched
Search Terms
Limits used
Pubmed
Web of Science
Science Direct
Scopus
EMBASE
ERIC
PsycINFO,
Cochrane Library
carbonated
liquids No limits have been used
carbonated
fluids,
carbonated
drinks
carbonated beverages
fizzy liquids, fizzy
fluids, fizzy drinks,
fizzy beverages
AND dysphagia".
RESULTS OF SEARCH
The most recent searches were conducted on October 30th 2009. Three
relevant studies were located and categorised as shown in Table 1 based on Levels of
Evidence, Centre for Evidence Based Medicine (Howick, 2009). Two of these studies
referred to another study by Nixon, (1997) who has also examined the effects of
carbonated liquids. This specific study was not published in a peer reviewed journal
and could not be retrieved by the author.
Table 1: Summary of Study Designs of Articles retrieved
Study Design/ Methodology of Level
of Number
Articles Retrieved
Evidence
Located
Non-Randomised Clinical Trials
2c
2 located
Author (Year)
Bulow et al, 2003;

Krival, 2007
Non experimental Retrospective 4

study
1 located
Jennings et al., 1992
BEST EVIDENCE
The following studies were identified as the best evidence and selected for critical
appraisal. The reasons for selecting these studies were:
They are the only two prospective clinical trials in the area.
They are the most recent studies (conducted after 2000).
They met the inclusion/exclusion criteria.
525
They addressed the focussed clinical question.
SUMMARY OF BEST EVIDENCE

Study 1 by Bulow et al. (2003)
Aim of the study: To evaluate the effects of CTL compared to NCTL and Thickened
Liquids (TL) on the physiology of swallowing in dysphagic patients.
Study Design: Quantitative study with prospective quasi- experimental crossover
design.
Setting: Department of diagnostic radiology, Malm University Hospital, Sweden.
Participants: 40 adults (36 neurologically impaired, 4 had no neurological disorders).
Inclusion criteria: aspiration on thin liquids during the Therapeutic
Videoradiographic Swallowing Study (TVSS), capacity to follow instructions and sit
in an upright position. TVSS is essentially the same as Videofluoroscopy/MBS.
Intervention Investigated: A SLP administered three liquid consistencies (NCTL,
CTL, TL) in doses of 3 x 5ml during the TVSS.
Outcome Measures: 1.Penetration/Aspiration (PENASP) was measured by a 3-point
rating scale. 2.Pharyngeal Transit Time (PTT). 3.Pharyngeal Retention (PR) was
measured by a 3-point rating scale.
Main Findings: CTL were found to reduce penetration/aspiration into the airways
compared with NCTL (p<0.0001 with 95% CI of 5.0 7.0). PTT with CTL was found
to be significant shorter than the one with NCTL (p<0.0001 with 95% CI of 4-8.4). PR
with CTL was found to be less than the one with NCTL (p=0.0013 with 95% CI of 0.01.5).
Original Authors Conclusions: CTL were found to reduce tracheal penetration, PR
and PTT when compared to NCTL and TL.
CRITICAL APPRAISAL
The evaluation of the validity and the importance of the studies were made in
accordance with appraisal criteria provided by Dollaghans (2007). Accordingly:
1. The study states a plausible rationale with regard to the research question.
2. Meets the criterion of involving experimental manipulation.
3. Meets the criterion of having a control condition.
526
4. Lack of randomisation in administration of the stimuli.

5. Does not provide enough information concerning the characteristics of the
participants to enable the readers to decide whether the evidence will apply to their
clinical practice. It does not provide exclusion criteria.
6. The inclusion of participants with non neurogenic dysphagia is an important
limitation of the study.
7. Provides enough information regarding the TVSS procedure and the research
protocol so that one could replicate the major part of the study. However, it does not
detail the brand of the thickener and the specific viscosities of the liquids trialled.
8. TVSS is considered to be a reliable and valid assessment tool of the swallow
physiology and of the efficacy of therapy techniques.
9. The validity of two of the three outcome measures (PENASP, PR) is questionable
as the investigators used arbitrary scales that have not been validated or used in the
published literature.
10. Lack of controls for systematic bias such as blinding or inter/intra rater reliability
indicators.
11. Two nuisance variables threat the validity of the study. Firstly, while the patients
were asked if they would like to try CTL, they were not asked if they would like to
try NCTL or TL. Secondly, the patients who consumed NCTL and TL were told to
keep the materials in their mouth and not swallow until told to do so, while when
they consumed carbonated liquids, were told to swallow it immediately.
12. An important statistical significant difference was found in the comparison of
NCTL with CTL for the PENASP.
13. No power and sample size calculations were reported.
14. Three measures of clinical significance for the comparison of NCTL with the CTL
were calculated in order to interpret the magnitude of the treatment effects in clinical
practice (Leung, 2001). Regarding the PENASP, the Relative Risk Reduction is 95%
(95% CI 86% to 100%), the Absolute Risk Reduction (ARR) is 0.925 (95% CI 0.842 to
1.008) and the Number Needed to Treat (NNT) is 1/ARR = 1.08 (95% CI 1to 1). This
means that almost every patient who aspirates NCTL will exhibit reduced
aspiration/penetration in the airway while drinking CTL. Consequently, this low
NNT (1,08) is considered to be of clinical importance and the carbonated liquids very
effective in reducing aspiration. For the PTT the NNT is 1.3 (95% CI 1to 2) and for the
PR the NNT is 2.8 (95% CI 2 to 5) which also indicate an important clinical
significance of using carbonated liquids in cases of abnormal PTT and PR.
527
Summary/Conclusion:
Evidence from this study is equivocal in terms of validity and suggestive in
terms of importance (Dollaghan, 2007).
Study 2 by Krival (2007)
Aim of the study: To evaluate the effects of CTL compared to NCTL, nectar-like and
honey-like thickened liquids on the physiology of swallowing in adults with
neurogenic dysphagia.
Study Design: Quantitative study with prospective experimental crossover design.
Setting: Drake Centre, USA.
Participants: 14 adults were included. Inclusion criteria: adults 18-85 years of age
with stroke who were referred for Modified Barium Swallow (MBS). Exclusion
criteria: people with peripheral nervous system disorders, crushing injuries/
surgical/ radiation therapy of the oropharynx, endotracheal intubation for more than
72 hours and tracheotomy.
Intervention Investigated: During MBS, a SLP administered four liquid types in
doses of 2 x 5ml in cool temperature, in a randomized order. (Varibar Thin, Varibar
Nectar, Varibar Thin-Honey, Varibar Thin+carbonation). Participants were not cued
to swallow (natural swallow).
Outcome Measures: 1.Penetration/aspiration was measured in the 8-point PENASP
scale (Robbins et al.,1999; Rosenbek et al., 1996). 2.Pharyngeal Transit Time (PTT)
(Kim et al., 2005; Robbins et al., 1992). 3.Pharyngeal Residue (PR) (Logemann et
al.,1995; Eisenhuber et al.,2002). 4.Stage Transition Duration (STD) (Ishida, Palmer, &
Hiiemae, 2002; Kim, McCullough, & Asp, 2005). 5.Bolus Position at the Onset of
Swallow (BPOS) (Martin-Harris et al.,2007).
Main Findings: PENASP means for CTL were 2.821 (SD=1.782, N=14) and for NCTL
were 2.714 (SD=2.136, N=14). PTT means for CTL were 1.140 (SD=0.150, N=13) and
for NCTL 1.147 (SD=0.143, N=13). Regarding PR 87.7% of the rated swallows
received no residue-minimal residue rating. Odds Ratio for NCTL vs. CTL = 0.153
(95% CI 0.007 3.228). STD means for CTL were 0.336 (SD=0.629, N=13) and for
NCTL were 0.443 (SD=0.777, N=13). Regarding BPOS the Odds Ratio for thin vs.
carbonated liquids = 1.536 (95% CI 0.486 4.856).
Original Authors Conclusions: There were no significant differences in STD, PTT,
PENASP, PR and BPOS between CTL and NCTL.
CRITICAL APPRAISAL
528
1. The study states a plausible rationale regarding the research questions.

2. Meets the criterion of involving experimental manipulation.
3. Meets the criterion of having a control condition.
4. The method of randomization used may introduce hidden bias because it
allowed the primary investigator to know the beverage order for every participant.
5. The study provides enough information on the characteristics of the participants to
enable the readers to decide whether the evidence would apply to their clinical
practice.
6. The study provides enough information to allow for replication of the study.
7. Use of reliable and valid assessment tool (MBS).
8. Use of reliable and valid at a certain point outcome measures.
9. Controls for systematic bias such as inter/intra rater reliability indicators. No
blinding is reported for the primary investigator and the three SLPs who rated the
most outcome measures. However, the student who rated the 25% of the temporal
measures was blind as to the liquid type.
10. Three important limitations threat the validity of the study. Firstly, the
participants were enrolled in the study regardless of the nature of the oropharyngeal
dysphagia. Sensation elicited by carbonation has been theorised to modify the
patterned swallowing response and thus, carbonated liquids have been proposed as
a sensory intervention to eliminate thin liquid aspiration. However, delay in the
triggering of the pharyngeal swallow or thin liquid penetration/aspiration were not
included in the inclusion criteria of this study. Secondly, the sample size appears
very small to examine the effects of carbonation compared to non carbonated thin
liquids. The study reports an estimated sample size of n=34. However, the author
maintained that with the use of PROC MIXED test, the 14 participants were an
adequate sample to answer the research questions. Moreover, the cool temperature
of the stimuli, not only might stimulate the temperature receptors but it might also
inhibit the perception of nocioceptive stimulus such as carbonated liquid. Thus, this
study inadvertently examined the effect of cool carbonated and cool non carbonated
thin liquid. The design therefore did not accurately reflect the research question.
11. There was no statistically significant difference in the comparison of NCTL with
CTL for the STD, PTT, PENASP, PR and BPOS.
12. For the PENASP, the Number Needed to Harm is 7 (95% CI 2 to infinitive),
meaning that seven people have to be given carbonated liquids so that one of them
will exhibit higher PENASP score. For the STD the NNT is 7 (95% CI 2 to infinitive),
529
meaning that seven people have to be given carbonated liquids so that one of them
will exhibit shorter STD. Both NNH and NNT are surrounded by wide confidence
intervals which make the clinical implications unclear.
Summary/Conclusion:
Evidence from this study is suggestive in terms of validity and equivocal in
terms of importance (Dollaghan, 2007).
REFERENCES
Bulow, M., Olsson, R., Ekberg, O. (2003). Videoradiographic Analysis of how Carbonated
Thin Liquids and Thickened Liquids Affect the Physiology of Swallowing in Subjects with
Aspiration of Thin Liquids. Acta Radiologica, 44 (4), 366372.
Dollaghan, C. A. (2007). The Handbook for Evidence-Based Practice in Communication Disorders.
Baltimore: Paul H. Brookes Publishing Co.
Eisenhuber, E., Schima, W., Schober, E., Pokieser, P., Stadler, A., Scharitzer, M., et al. (2002).
Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a
predictive factor for aspiration. American Journal of Roentgenology,178(2), 393-398.
Greenhalgh, T. (1997). How to read a paper: the basics of evidence based medicine. London: BMJ
Publications.
Ishida, R., Palmer, J. B., & Hiiemae, K. M. (2002). Hyoid motion during swallowing: factors
affecting forward and upward displacement. Dysphagia, 17(4), 262-272.
Jennings, K. S., Siroky, D., Jackson, C. G. (1992) Swallowing problems after excision of tumors
of the skull base: diagnosis and management in 12 patients. Dysphagia, 7, 4044.
Kim, Y., McCullough, G., & Asp, C. (2005). Temporal Measurements of Pharyngeal
Swallowing in Normal Populations. Dysphagia, 20(4), 290-296.
Krival, C. R. (2007). Effects of Carbonated vs. Thin and Thickened Liquids on Swallowing in Adults
with Neurogenic Oropharyngeal Dysphagia. (Doctoral dissertation, University of Cincinnati,
1997).
Leung, W-C. (2001). Balancing statistical and clinical significance in evaluating treatment
effects. Postgraduate Medical Journal, 77 (905), 201-204.
Logemann, J. A., Pauloski, B. R., Colangelo, L., Lazarus, C., Fujiu, M., & Kahrilas, P. J. (1995).
Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic
dysphagia. Journal of Speech and Hearing Research, 38(3), 556-563.
Martin-Harris, B., Brodsky, M. B., Michel, Y., Lee, F.-S., & Walters, B. (2007). Delayed
initiation of the pharyngeal swallow: normal variability in adult swallows. Journal of Speech,
Language and Hearing Research, 50(3), 585-594.
Nixon, T. S. (1997). Use of carbonated liquids in the treatment of dysphagia. Network: A
newsletter of dietetics in physical medicine and rehabilitation. American Dietetic Association, New
York.
Phillips, B., Ball, C., Sackett, D., Badenoch, D., Straus, S., Haynes, B., Dawes, M. (1998).
Updated by Howick, J. (2009). Oxford Centre for Evidence-based Medicine Levels of
Evidence. Retrieved October 25, 2009, from http://www.cebm.net/levels_of_evidence.asp
[On-line].
Robbins, J. A., Coyle, J., Rosenbek, J., Roecker, E., & Wood, J. (1999). Differentiation of normal
and abnormal airway protection during swallowing using the penetration-aspiration scale.
Dysphagia, 14(4), 228-232.
Robbins, J. A., Hamilton, J. W., Lof, G. L., & Kempster, G. B. (1992). Oropharyngeal
swallowing in normal adults of different ages. Gastroenterology, 103(3), 823-829.
530
Rosenbek, J. C., Robbins, J., Roecker, E. V., Coyle, J. L., & Woods, J. L. (1996). A penetrationaspiration scale. Dysphagia, 11, 93-98.
531
EDUCATION FOR SPEECH AND LANGUAGE PATHOLOGY
SY09A.1
EDUCATION OF SLPs FOR THE GLOBAL COMMUNITY
Li-Rong Lilly Cheng ,2 Helen Grech ,3 Fernanda Fernandes ,4 Claudia Andrade University of
So Paulo
1 San Diego StateUniversity, San Diego, U.S.A.
2University of Malta, Msida, Malta
3University of So Paulo,So Paulo, Brazil
4University of So Paulo, So Paulo, Brazil
1
Education of SLPs for the global community is a task that requires the work
of many. The Education Committee of Logopedics of the International Association of
Logopedics and Phonistrics has been engaged in the collection of data on the
education of SLPs/SLTs all over the world. In 1995, members and associates of the
education committee presented guidelines for starting initials programs for countries
that did not have a formal education program. The guidelines have been revised and
will be presented in this session. It took members of the Education Committee and
advisors two years to complete the task for organizing the revised guidelines. These
guidelines were published in the recent issue of Folia Logopedica and Phoniatrica.
This presentation includes the following topics:
Adoption of the education guidelines in the Bulkan countries of Bulgaria,
Former Yugoslavian Republic of Macedonia (FYROM),Turkey, Greece, Russia and
Croatia;
Issues of migration- communication assistance needs for migrant workers
and their children; Preparing students for mobility; A Step forward in harmonization
of SLT education programmes: The CPLOL Project Netques;
Development of Joint Programmes ;
Advanced Education and Specialization;
Development of New Programs.
In the developed world, the education of SLPs/SLTs is organized and highly
regulated. Europe has had a long history of educating and training SLTs. Further, in
countries such as England, Ireland, Canada, Australia, New Zealand and the United
States, formal agreements for mutual recognition have been signed.
For many countries, information is readily available and accessible through
browsing the internet and/or the use search engines to access websites. In the
European Union, special programs such the Intensive Programmes have been
organized to train students in the field of logopedics.
On the other hand, there are countries where information about education
programs is not readily accessible in English or other European languages and efforts
in obtaining information is met with linguistic/cultural barriers. For example, there
are many emerging issues about the education of SLPs and audiologists in South
America. Many of these programs that interfere wtih professional practice and
532
education are the same problems faced by many countries and regions. Argentina
has played a key role in the history of Fonoaudiologia in South America. There are
three undergraduate programs, 12 graduate programs and three doctoral programs
in Argentina.
On the other hand, the first undergraduate programs just started in 2008 in
Paraguay. The first fonoaudiologos were registered in 1991 and the majority of them
graduated in Brazil.
Another topic that will be covered in this presentation is from Japan. As of
December 2008, 14,329 individuals hold the national license (The Report from the
Foundation for Promotion of Medical Services under Japanese Ministry of Welfare
and Labor, 2009). There is a shortage of SLPs for children. 2/3 of clinical practicum
hours must be taken in the medical settings. This shortage has a strong impact on
the services to children. In addition, Japan receives labor assistances by foreign
workers coming from less economically developed countries. Their children face the
tasks of learning their mother tongue and the language of society they live. An
estimated 70,000 non-Japanese children attended public schools. These children
need special assistance and their mother tongues include 70% Brazilian Portuguese,
14% Spanish, 6% Tagalong and 3% Chinese.
Training in the area of child
development, learning disabilities, bilingualism/multiculturalism is needed in order
to serve this population. The Education Guidelines by IALP should be very useful in
the re-evaluation and re-building of the Japanese educational curriculum.
There is also great diversity in education and training of SLTs in parts of
Europe. A survey with 17 questions was sent to several countries including Bulgaria,
Greece, Former Yugoslavian Republic of Macedia, Russia and other countries. For
example, education of SLTs in Bulgaria started in 1956 at Sofia University in the
faculty of Philosophy and at SWU in the field of Defectology. In Greece, SLP
education started in 1996 in Patras and in Poland, the first program started in 1970.
There are great variations of the types of program and curriculum. Adoption of the
guidelines in the Bulkan countries will be presented in this session.
The Erasmus Programme in Europe creates a wide range of opportunities for
individuals to study, work, teach or be trained in another European country. One of
the possibilities to promote and increase Erasmus mobility is the Intensive
Programmes (IP) which is part of the new Life Learning programmes (2007-2013). IP
is a short programme of study ranging from ten days to six weeks of subject related
to work brining together students and faculty from at least three participating
countries in Europe. IP stimulates cooperation, enables transnational mobility and
enables less privileged target groups with low SES. Information about IP and the
CPLOL Netques will be shared in this presentation.
In Africa, the education of the SLPs exists in several countries including
South Africa and Egypt.
Most of the countries do not have formal
training/education programs. Some countries are still struggling with internal
unrest, civil wars, diseases and poverty. While others are building infractures and
industries. Some governments do recognize the need for educating SLPs/SLTs, but
internal unrest and poverty make such development difficult or impossible. Other
governments and agencies have begun to organize and plan for the education of
SLPs/SLTs. Presentation on the recent development will be shared.
In summary, this presentation will address some of the emerging issues of the
world due to mobility and development. In addition, it will address many of the
challenges SLPs face when working with the changing world. What is being
experienced in Japan can be shared with Ireland and what is being implemented in
Brazil might be useful to Kenya. The content of the revised education guidelines
533
serves the purpose as a guide to assist in those countries where there are no
standards, policies, regulations or guidelines. Lessons learned from all the
continents will be shared throughout the various presentations of the two sessions.
Further, recommendations for future development and education will be shared in
this double session.
534
FP09.1
CONSIDERING THE ICF AS A CONCEPTUAL FRAMEWORK FOR
UNDERSTANDING QUALITY OF LIFE OF ADULTS WITH ACQUIRED
COMMUNICATION DISORDERS: STRENGTHS AND LIMITATIONS
Madeline Cruice
City University London, United Kingdom
Introduction: This presentation explores the strengths and limitations of
using the International Classification of Functioning, Disability and Health (ICF,
World Health Organization, 2001) as a conceptual framework for understanding the
quality of life of adults with acquired communication disorders. Literature across the
range of adult acquired disorders will be reviewed, however, much from within
aphasiology will be drawn upon.
Methods: A comprehensive review of the research literature (published in
English over the past two decades) in acquired communication disorders will be
undertaken to identify relevant papers pertaining to Context, Activities, Participation
and Quality of life. Qualitative research into the consequences of acquired disorders
(such as Baylor et al., 2005; Le Dorze & Brassard, 1995; Walshe, 2002, 2004; Zemva,
1999) will be reviewed and framed in relation to components of the ICF. Quantitative
studies reporting on the relationships between communication and quality of life
(such as Cruice et al., 2003; Hilari et al., 2003; Hilari & Byng, 2009) and those that
evaluate the effectiveness of SLT intervention on quality of life (such as Ross et al.,
2006; Taylor Sarno, 1997; Van der Gaag et al., 2005) will be reviewed. Seminal papers
that explicitly use the ICF to classify the item content of existing measures in
healthcare (such as Geyh et al., 2007; Salter et al., 2008; Schepers et al., 2007 in stroke)
will be integral to this presentation and will be discussed with application to the field
of speech-language pathology. The development of new tools (such as the
Assessment for Living with Aphasia from Kagan et al) amongst existing tools will be
discussed in terms of how they address the features of Activity, Participation and
Quality of life.
Proposed Discussion: The strengths of using the ICF are evident in enabling
professionals understanding the breadth of life activities and participation
undertaken (or not undertaken) by adults with communication disorders, which
ultimately influence the quality of life experience. The limitations relate primarily to
(1) the assumption that quality of life is a gestalt concept of functioning/
impairments; activities and limitations; and participation and restrictions, and (2) the
inability of the ICF classification codes to account for quality of life items in formal
measurement and evaluation tools. Finally, the difficult relationship between the ICF
and wellbeing (including wellness models in positive psychology, see Cruice, 2009)
will be discussed.
References:
Baylor, C., Yorkston, K., & Eadie, T. (2005). The consequences of spasmodic dysphonia on
communication-related quality of life: A qualitative study of the insiders
experiences. Journal of Communication Disorders, 38, 395-419.
Cruice, M. (2009). The contribution and impact of the International Classification of
Functioning, Disability and Health on quality of life in communication disorders.
International Journal of Speech-Language Pathology, 10, 1-2, 38-49.
535
Cruice, M., Worrall, L., Hickson, L., & Murison, R. (2003). Finding a focus for quality of life
with aphasia: Social and emotional health, and psychological well-being. Aphasiology,
17(4), 333-353.
Geyh, S., Cieza, A., Kollerits, B., Grimby, G., & Stucki, G. (2007). Content comparison of
health-related quality of life measures used in stroke based on the international
classification of functioning, disability and health (ICF): a systematic review. Quality
of Life Research, 16, 833-851.
Hilari, K., Wiggins, R., Roy, P., Byng, S., & Smith, S. (2003) Predictors of health-related quality
of life (HRQL) in people with chronic aphasia. Aphasiology, 17(4), 365-81.
Hilari K. & Byng S. (2009). Health-related quality of life in people with severe aphasia.
International Journal of Language and Communication Disorders, 44(2), 193-205.
Le Dorze, 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(3), 239-255.
Ross, A., Winslow, I., Marchant, P., & Brumfitt, S. (2006). Evaluation of communication, life
participation and psychological well-being in chronic aphasia: The influence of group
intervention. Aphasiology, 20(5), 427-448.
Salter, K., Moses, M., Foley, N., & Teasell, R. (2008). Health-related quality of life after stroke:
what are we measuring? [Review]. International Journal of Rehabilitation Research, 31(2),
111-117.
Schepers V., Ketelaar M., van de Port I., Visser-Meily, J., & Lindeman, E. (2007). Comparing
contents of functional outcome measures in stroke rehabilitation using the
International Classification of Functioning, Disability and Health. Disability &
Rehabilitation, 29(3), 221-30.
Taylor-Sarno, M. (1997). Quality of life in aphasia in the first post-stroke year. Aphasiology,
11(7), 665-679.
Van der Gaag, A., Smith, L., Davis, S., Moss, B., Cornelius, V., Laing, S., and Mowles, C.
(2005). Therapy and support services for people with long-term stroke and aphasia
and their relatives: A six-month follow-up study. Clinical Rehabilitation, 19(4), 372-380.
Walshe, M. (2002). You have no idea. You have no idea what it is likenot to be able to talk.
Exploring the impact and experience of acquired neurological dysarthria from the
speakers perspective. Unpublished doctoral thesis. Dublin: Trinity College.
Walshe, M. (2004). The impact of acquired neurological dysarthria on the speakers selfconcept. Journal of Clinical Speech & Language Studies, 12/13, 9-33.
Zemva, N. (1999). Aphasic patients and their families: Wishes and limits. Aphasiology, 13(3),
219-234.
536
SY13.1
THE SOCIAL CONSTRUCTION OF COMMUNICATION DISORDERS: AN EXAMPLE
FROM ANCIENT GREECE
Duchan Judith
State University of New York at Buffalo
Contrary to popular belief, communication disorders are not found in an

objective reality, but rather they are socially and culturally created. That is, they are
construed from prevailing social and cultural beliefs about the nature of
communication and about the causes of communication abnormalities. Treatments
for communication disorders are also socially constructed. Like communication
disorders, such treatments depend upon how people render communication and its
breakdown.
This view that communication disorders are created rather than discovered is
not always apparent to professionals who often take their ideas and practices for
granted. One way to reveal the important role of social constructivism plays in
research and clinical practice is to examine ways communication disorders have been
rendered in other places at other times.
This paper considers the nature and importance of socially constructed
clinical practice by examining what our Greek ancestors said about communication
and its disorders. The focus is on the 5th and 4th century contributions of five wellknown ancient figures and their followers. The ideas of Asclepios, Hippocrates,
Aristotle, Plato and Demosthenes will be analyzed for their implications for
understanding and treating communication breakdowns and their associated
therapies.
I begin with Asclepios, a physician whose practices were so revered in
ancient Greece that, following his death, he was worshipped as a Greek God in
charge of healing. The worship of Asclepios became well established in Greece in the
3rd century BCE. The Asclepiad was an ancient guild of doctors who were devotees
of the god Asclepios. By 200 BCE every large town in Greece erected a temple to
Asclepios where people could go to receive a cure for their ailments. The most
famous centre was at Epidaurus, on the Greek Island of Cos, off the coast of presentday Turkey.
The Asclepeion temples offered religious as well as secular treatments. They
provided places where supplicants could pay tribute to the god Asclepios. They also
fostered an atmosphere of religious healing by having sacred animals such as snakes
and dogs aroundanimals who were associated with Asclepios and who were
thought to have supernatural healing powers. And Temple priests served as
spokesmen for Asclepios.
Secular treatments were also part of the offerings at Asclepeion temples. For
example, temples had spas, gymnasia, and theaters of entertainment to foster sick
pilgrims sense of well-being, uplift their spirits, and promote their health. The
temple priests also practiced secular medicine. They performed surgeries, cauterized
wounds, and prescribed medications.
Greek citizens who were ill would travel to an Asclepeion temple to offer
sacrifices and to appeal to Asclepios for a cure. The pilgrims would go to sleep in the
temple and enter a period of what was called incubation. Non-poisonous sacred
snakes would crawl on the floor around or over the sick person during the night.
While the pilgrims slept, Asclepios would appear to them in a dream. When they
537
awoke they would either be cured or, if not, they would report their dream to a
temple priest to have it interpreted. The priest would then recommend a treatment
based on his interpretation of the persons dream and on the priests own medical
training.
Hippocrates, known widely as the father of medicine, was trained in an
Asclepeion temple. But, Hippocrates argued for separating medicine from religion,
for making it more secular, and for placing medical decisions under the direct control
of physicians. He did this by adopting an already existing secular theory of bodily
humors that served to explain bodily functions. His humor theory became the
dominant model for diagnosing and treating disease during his time and lasted
through the middle ages and up to the enlightenment period in the 17th century.
Humor theory portrayed health as being dependent upon the balance of four
humors in the body: blood, phlegm, yellow bile (choler) and black bile. Blood was
the source of vitality, choler or yellow bile was the gastric juice crucial for digestion,
phlegm was a lubricant and coolant, and black bile functioned to darken other fluids.
Weather, temperature, and seasons were thought to influence the balance of
humors. The imbalance caused different kinds of illnesses. The cold in winters
lowered body heat causing phlegm to be produced. This additional phlegm resulted
in colds and coughs. In the summer people got hot, resulting in more bile, which in
turn caused diarrhea and vomiting. Mania also occurred in summers and was seen
as due to bile boiling in the brain.
The role of the physician, then, was to examine the humors, diagnose
imbalances and design treatments to restore the balance. By carefully examining the
patient, for instance by looking at his or her urine, inspecting the feces, listening to
the patients breathing, and asking questions, a doctor could discover whether the
humors were in balance. If they were not, the doctor worked to restore the proper
balance and remove excess humors. This restoration involved making a patient
vomit, heating or cooling them, or submitting them to bloodletting or having other
fluids purged.
Humor theory was used by Hippocrates and his followers to treat all diseases
and disorders, including speech problems. For example, Hippocrates theorized from
humor theory that stuttering was due to an excess of black bile resulting in dryness
of the tongue. His remedy was to administer blistering substances so as to drain
away the black bile.
Aristotle (384-322 BCE), the Greek philosopher, researcher, logician, and
mathematician lived around the same time as Hippocrates. He, like Hippocrates,
subscribed to humor theory. When construing causes of speech problems, Aristotle
focused on how bodily temperature can create humor imbalance. Here is and
example of Aristotle theorizing from within humor theory about why cold
temperatures result in difficulty speaking:
Why does the tongue of men who are chilled stumble like that of a drunkard?
Is it because it becomes congealed and hardened by cold and so is difficult to move,
and when this occurs it cannot articulate clearly? Or is it because, when the outward
parts thicken through cold, the moisture collects and soaks the tongue, wherefore the
tongue cannot perform its own proper function... (Aristotle, 1957)
Plato, another Greek philosopher, was a student of Socrates and teacher of
Aristotle. When considering the nature of speech, Platos focus was on the mind and
on life forces, rather than bodily function associated with humor theory. Plato
subscribed to pneuma theory (as did Aristotle). He saw life as involving three levels
of pneuma or natural spirit or soul. All three levels arose from the vital organs. The
pneuma of the body originated from god whose spirit was in the air. The inhaled air
538
was transformed into the first form of pneuma. Another form of pneuma or natural
spirit was in the veins, which moved with a tidal motion through the alimentary
canal. When this venous fluid entered the heart it became transformed into a third,
and higher form of pneuma, the vital spirit. This enriched pneuma passed to the
base of the brain where it was again transformed into the highest form of pneuma
animal spirit. Animal spirit, the essence of life, was diffused through the body via
the hollow nerves, according to Plato (Lorenz, 2009).
Platos pneuma theory portrayed speech as flowing from the soul, or animal
spirit. Plato used the term logos to refer not only to the spoken word but also of the
unspoken word, the word still in the mind. When applied to the universe, logos was
taken to mean rational principles that govern all things. Plato viewed speech and
hearing as arising from such principles, and as having god given contents (Jowett,
1892).
This view that reason and speech were both divinely inspired led Plato to
propose that knowledge was given or innate rather than acquired through the
senses. This, in turn, led to Platos forwarding the educational use of Socratic
dialogues in which a teacher, through dialogic questions, guides a students
educationa method that might today be called self discovery or non-directive
counseling (see Platos Meno for an example, Plato, 380 BCE).
Demosthenes (384-322 BCE) was another figure who achieved prominence
during this period. He did so through his exceptional oratory and political skills. His
speeches concerned contemporary issues in Athens. Several hundred years later
Plutarch, a Greek historian, wrote about how Demosthenes overcame his own speech
problem.
Demetrius, the Phalerian, tells us that he was informed by Demosthenes
himself, now grown old, that the ways he made use of to remedy his natural bodily
infirmities and defects were such as these; his inarticulate and stammering
pronunciation he overcame and rendered more distinct by speaking with pebbles in
his mouth; his voice he disciplined by declaiming and reciting speeches or verses
when he was out of breath, while running or going up steep places; and that in his
house he had a large looking-glass, before which he would stand and go through his
exercises (Plutarch, 75 CE).
Demostheness self-directed speech therapies reflect his beliefs that speech,
like walking, was a physical act involving the coordination and strength of the
muscles of the body. This construal was in keeping with the more general cultural
view of the time that exercise produces a healthy body (Finney, 1966). Indeed,
Finney has reported on a commonly adopted exercise of vociferation in which people
vocalize loudly as part of a general exercise regimen. These remedies are in stark
contrast to those emanating from the humor theory of Hippocrates and Aristotle and
the pneuma theory of Plato.
Table 1 summarizes the various ways ancient Greeks construed
communication and its disorders and how their construals affected their actions as
practitioners. While current renditions have moved away from divine intervention
and from humor and pneuma theories to explain communication problems, they still
embrace the exercise theory that treats the problem and remedy for speech errors as
located in the muscles of the articulators. Other of todays social constructions make
use of information processing theory, social model theory, and the medical model
(Duchan, 2004), with each leading to a different social construction of
communication, its disorders, and what needs to be done to remediate those
disorders.
539
Table 1. Constructs or theories that Ancient Greeks used to construe their world and
their views of speech and communication
Proponent
Construct or Theory
Asclepios and his school of Divine intervention
physicians (1)
Asclepios (2)
Medical
intervention
(general health)
Asclepios (3)
Medical
intervention
(specific remedies)
Hippocrates(460-377 BCE)
Humor theory, focus on

bodily fluids
Aristotle(384-322 BC)
Humor theory, focus on

body temperature
Plato(427-347 BCE)
Pneuma theory and divine

communication
Demosthenes(384-322 BC)
Exercise theory (Physical

exercise is important for
skill building)
General Practice
In order to get better and
receive advice about how
to cure ones illness, one
needs to pay homage to
the god of healing.
One can achieve health
and well being through
general exercise, rest,
baths, entertainment etc.
Improvement
can
be
achieved
through
medicines, surgeries, etc.
Improvement is achieved
through procedures such
as bloodletting to bring
fluids back into balance.
One needs to change
temperature of the body
and to bring fluids into
balance in order to
achieve health.
People
should
be
educated having them
discover god-given truths.
One needs to exercise
articulators to promote
better speech (and health)
References
Aristotle (1957 translation). Problems, Section XI Loeb edition, translator W. S. Hett.
Cambridge, MA.: Harvard University Press.
n.
Coxe, John (1846) Hippocrates, The Writings of Hippocrates and Galen
http://oll.libertyfund.org/?option=com_staticxt&staticfile=show.php%3Ftitle=1988&c
hapter=128122&layout=html&Itemid=27. Retrieved on January 5, 2010.
Duchan, Judith (2004). Frame work in language and literacy: How theory informs practice. NY: The
Guilford Press.
Finney Gretchen L. (1966) Medical theories of vocal exercise and health. Bulletin of the History
of Medicine 40, 395-406.
Lorenz, Hendrik (2009) Ancient theories of soul. In Edward N. Zalta (Ed) The Stanford
Encyclopedia
of
Philosophy.
540
http://plato.stanford.edu/archives/sum2009/entries/ancient-soul.
Retrieved
December 23, 2009.
Plato (1892) The dialogues of Plato (translated by Benjamin Jowett, 1892).
http://books.google.com/books?id=IHJiAAAAMAAJ. Retrieved on December 3, 2009.
Plato
(380
BCE)
Meno.
Translated
by
Benjamin
Jowett.
http://classics.mit.edu/Plato/meno.html. Retrieved January 5, 2010.
Plutarch
(75
CE).
Demosthenes.
Translated
by
John
Dryden.
http://classics.mit.edu/Plutarch/demosthe.html Retrieved January 2, 2010.
541
FP02.5
EVALUATING STUDENTS LEARNING IN ADULT NEUROLOGY SETTINGS
USING AN INTENSIVE CLINICAL EDUCATION APPROACH
Claire Farrington Douglas
Madeline Cruice
Homerton University Hospital NHS Foundation Trust, London UK
Department of Language and Communication Science, City University London, UK
Introduction: Speech and language therapy (SLT) as a profession has not had
the benefit of the long history of educational research and scholarship that exists
within the medical and nursing professions, which has investigated how students are
taught and learn their clinical and communication skills. Aspects of medicine and
nursing education that are common practice, such as clinical skills labs, objective
structured clinical examinations (OSCEs), and standardized or simulated patient
programmes have only been recently introduced into SLT (Hill, Davidson, &
Theodorus, 2009; Zraick et al., 2003). Transferring relevant clinical education models
from these disciplines to SLT will move the profession forward in its understanding
of student learning and achievement of competency. This presentation reports on a 5day intensive programme of clinical education, situated within the workplace
(rehabilitation unit), which used a range of learning activities and an OSCE to
motivate and evaluate student learning and achievement.
Rationale for intensive programme: Communication skills are core for
healthcare, and SLT students need both communication skills (information and
interaction) as well as clinical skills (modifying their language etc and supporting the
communication needs of patients/clients with compromised language and cognitive
abilities). It is difficult for students to focus on both at the same time, and in the past,
the latter has been developed at the expense of the former. Homerton Hospital
Regional Neurorehabilitation Unit SLT Department and the Department of Language
and Communication Science at City University London developed a clinical and
communication skills 5-day intensive programme for SLT students (offered
optionally in 2009-10) which targets both essential aspects of skills learning for
students. The programme was a response to significant student anxiety regarding
lack of their exposure, skills and confidence in working with adult clients, before
commencing their final clinical placement, which is typically in adult neurology
settings.
Content of intensive programme: The programme targets 5 competencies in
information gathering, information giving, interaction, informal assessment, and self
and peer appraisal with adults with communication impairments, their family
members and friends, and multidisciplinary team staff and students in a hospital
setting. Developing a reliable OSCE adds credibility to this skills programme and
addresses the core concern of clinicians that was raised during consultation, that
some form of evaluation of clinical performance is needed (i.e. experience and
participation without competency monitoring is not sufficient).
The 5-day programme targets:
1. basic effective interaction skills with adult clients with communication
impairments, family members, and MDT staff
542
2. information gathering (i.e. observation, case history taking, interviewing,

eliciting patient priorities and preferences) from adult clients, family
members, MDT staff, and written notes (e.g. medical files, other professions
reports and notes)
3. information giving (i.e. requesting informed consent for assessment or any
procedure,
explaining
assessment,
giving
information
about
diagnosis/difficulties/communication or swallowing needs, services, or
advice; giving feedback on assessment results) to adult clients, family
members, and MDT staff
4. knowledge (of content and purpose) and skills in carrying out formal and
informal assessments of communication and swallowing with adult clients in
hospital context
5. goal setting with adult clients with impairments (including how different
from goal setting for paediatric practice, integrating client-centredness and
SMART principles, and impact of brain injury on persons ability to set goals)
6. self and peer appraisal of these skills/competencies
7. understanding the role of MDT staff and appreciating the relevance to the
SLT caseload
8. understanding the written documentation that supports SLT students to
learn, i.e. writing a session plan for any of the information gathering, giving,
assessment of goal setting activities that are undertaken with adult clients,
family members, and MDT staff
The programme also includes (1) a pre-programme reading list of
recommended sources (articles and texts) and (2) some preliminary workbook
activities which will require students to read the various sources.
Method: The programme has run once (January 2010 with 10 second year
postgraduate students) and is scheduled to run again in April 2010 (for a further 10
students). Funding was gained from Homerton Hospital to implement the first cycle
of this intensive programme. Funding for the second cycle (April 2010) and the
development of an OSCE were successfully gained from the Centre for Excellence in
Teaching and Learning Clinical and Communication Skills (City University London
& Queen Mary University of London www.cetl.org.uk ). This second round of
funding also enables us to disseminate the programme to other clinicians throughout
London, thereby increasing interest in clinical education generally.
Evaluation of intensive programme: A number of different measures of
change are planned for evaluation (subjective and objective) in this initiative:
Measures of change
Students will report their ability in the key skills/ competency areas pre and
post the intensive programme (subjective self report)
Students will also report their confidence in these areas pre and post the
intensive programme (subjective self report)
OSCE of interaction, information and assessment competencies pre and post the
intensive programme (objective)
543
Measures of success and effectiveness
Feedback from other team members at Homerton Hospital involved in the

programme
Feedback from user group
Feedback from students participating in the initiative
Research ethics was not sought for the first cycle (January 2010) however research
ethics
approval
is
being
sought
from
both
City
University
(http://www.city.ac.uk/research/ethics/research_ethics.html)
and
Homerton
Hospital Trust for the second cycle.
Planned analysis: Statistical comparison of students pre and post skills and
confidence questionnaires will reveal the students perception of the value of this
programme to their learning and professional attitude and interest in adult practice.
Questionnaires that have been developed over the last 3 years within the SLT
department at City University will be used as a basis for good practice in
questionnaire formulation for this project.
The pre and post programme OSCE comparison of students results will
reveal both where students enter in terms of skills level, and how much change is
generated through a 5-day programme. Students performance on the pre and post
OSCEs will be videoed, and later assessed by the project investigators and 5 invited
SLT consultants. The guidelines for assessment of interaction, information and
assessment competencies, will be developed through this second pilot and
sufficiently detailed to be able to identify both component skills and gestalt skills
change as a result of the programme. Information regarding the performance of
students, the demands made on hospital staff, and the overall perception of the
project, will be collected via open feedback sessions held with staff and users.
Students feedback will be requested through written feedback questionnaire.
Intended desirable outcomes and outputs of this intensive programme are:
All students achieving the key competencies
Increased student confidence, interest and motivation in working with adult
clients
Materials and resources about interaction, information and assessment skills
with adult clients (learning outcomes, workbooks, videos, OSCE, and
guidelines for assessment)
Increased knowledge and skills in small group of users with communication
impairments for ongoing involvement in student education
References:
Hill, A., Davidson, B., & Theodorus, D. (online iFirst). A review of standardized patients in
clinical education: Implications for speech-language pathology programs.
International Journal of Speech-Language Pathology.
Zraick, R., Allen, R., & Johnson, S. (2003). The use of standardized patients to teach and test
interpersonal and communication skills with students in speech-language
pathology. Advances in Health Sciences Education, 8(3), 237-248.
544
SSY01.1
SUPERVISED PRACTICE IN SLP EDUCATION A BRAZILIAN
EXPERIENCE
Fernanda Dreux M. Fernandes
Debora M. Befi-Lopes
Hayde F. Wertzner
Suelly C. O. Limongi
Claudia R. F. de Andrade
Department of Physiotherapy, Communication Sciences and Disorders and
Occupational Therapy
School of Medicine. University of Sao Paulo
Introduction
There is still a live discussion in the academic settings about the most efficient
ways to provide practice training to the Speech and Language Therapist/Pathologist.
Supervised practice should not be considered a complementary part of the SLT/SLP
formation. It must be included as a fundamental step in the construction of the future
professional. Broad notions about the reality in which the professional will perform
his/her practice should provide the framework for the educational goals. The
complete undergraduate education is even more important in countries with few
practice controls. It is fundamental to point out that complete formation doesnt
mean finished or concluded. The complete professional is able to continuously
exercise self-awareness and search for the adequate continued education. These
abilities, along with the adequate and updated tools for the clinical practice will
provide the necessary conditions to face the working demands in different situations.
The purpose of this symposium is to discuss the specific experience
developed in the Speech and Language Pathology-Audiology course of the School of
Medicine of the University of Sao Paulo. The presentations will focus mainly in the
area of childs speech and language. The first one will describe the structure and
alternatives provided to the undergraduate student to build individualized practice
training in this great area. The second presentation specifically discusses the
pedagogical proposal based in active methodologies where students of different
levels share experiences and cooperate in problem solving activities. The third
presentation reports the experience with undergraduate students when the focus is
directed to evidence-based practice.
Supervised Practice in SLP Education the area of childs speech and
language
The education of Speech and Language Pathologists and Audiologists in
Brazil began in University of So Paulo, School of Medicine (FMUSP) just over 50
years and, unlike the professional training in other countries, already started with
the concern in clinical practice. The inclusion of undergraduate training in both
observation and clinical practice was possible due to the experiences of professionals
that had already had the opportunity to study or work in other countries that offered
training in speech therapy. As a matter of fact some of these professionals were
responsible for deploying Speech and Language Pathology and Audiology courses in
our country.
545
Speech and Language Pathology and Audiology formation is regulated by

Brazilian laws and guidelines which indicate the requirement of clinical practice
even though there are some differences between the courses offered by Brazilian
universities especially concerning the hourly grid designated to training practice
accomplishment.
The philosophy that rules the Speech and Language Pathology and
Audiology course at FMUSP aims to train the future speech, language and audiology
pathologist in clinical practice. The supply and implementation of supervised
practice in different areas of speech, language and audiology meet the goal of
providing students with a complete, comprehensive and individualized training.
Supervised training contributes to professional practice in an integrated health
system that serves population needs of all age groups from different social, economic
and cultural situations. Thus the professional role adapted to these needs is fulfilled.
To achieve this goal undergraduate students have a total of 4605 hours
divided into nine groups of formal supervised practice. Supervised training allocated
into groups (modules): Diagnosis in Human Communication, Intervention in Human
Communication Disorders and Primary Health Attention represent 1710 hours (37% of
the total hourly grid).
The areas offered for supervised training are: Auditory Evoked Potential,
Child Language and Cognition, Fluency, Language Development and Specific
Language Impairment, Auditory Processing, Autistic Spectrum Disorders,
Phonological Disorder, Educational Audiology, Neurological Disorders in Adult and
Elderly, Reading and Writing, Health Promotion, Voice, Human Hearing,
Syndromes and Sensorimotor Disorders. Note that seven of the 14 general areas are
related to language and speech in children.
In FMUSPs Speech and Language Pathology and Audiology course
undergraduate students dedicate near 990 hours (58% of supervised practice) to child
language and speech studying areas especially the most common manifestations
related to primary health care attention. Elective experiences are also possible and
students may choose some of them among specific speech and language pathology
areas according to their interest.
From a clinical point of view, there is a great demand for Speech and
Language Pathologists and Audiologists, especially considering the infantile
population. Therefore it is intended to train students in skills both related to typical
development in childhood as well as to childhood disorders. It is important to say
that due to some specific childrens characteristics, students in their clinical practice
must have the opportunity to work in complementary areas of clinical treatment
such as school, family and other health and education professionals. These aspects
support an integrated knowledge in different areas of child development and enable
the future professionals to be fully prepared to perform their work.
Mainstreaming and supervised practice in SLP education

Teaching and training objectives must project the different levels of
competence intended. Learning conditions must take into account cognitive,
psychomotor and affective attitudes and attributes that are essential features of the
complete professional. It is frequently mentioned that the complete professional SLP
is ethical, expert, scientific, reflexive, has practical experience, acts based in evidences
and respects differences. Therefore, teaching strategies should provide opportunities
of development for each one of these qualities. Mainstreaming is a pedagogical
proposal that is favored by clinical and hospital environments because of their
546
inherent comprehensive contexts. These situations present many opportunities of

integration, facilitation, diversity of options, self-monitoring and individualized
outcomes. The close and non-hierarchic team-work including under-graduation
students, of the second to the eighth semesters, graduate and post-graduate students
allow opportunities of Integration, since students of different levels present different
demands facilitating practice pedagogical training while scientific initiation, teaching
exercises and social-affective support are constant opportunities that each student
will take and use in different intensities in different moments. The Facilitation is
possible through multiple experiences, shared solutions, group work, shared
language codes and experiences of cooperation, collaboration and leadership. The
Diversity of Options is inherent to variable contexts and lead to individualized
learning and training opportunities, improving the number of alternatives and
allowing changes of course when needed. These strategies and opportunities
demand constant Self-Monitoring and self-evaluation based on individual goals and
achievements allowing the use of the different support alternatives and the
development of self-consciousness and autonomy. This way, the results are
individualized and based on specific focus of interest and personality characteristics
while also taking advantage of other prior or concomitant experiences.
Based in this proposal some of the supervised practices offered to the
undergraduate students are organized in order to make the better use of learning
opportunities. Depending on the students level, there are opportunities for clinical
observation and/or clinical practice. In each one of these alternatives there are
different levels of activities and demands there are dependent on the students
previous experiences and choices.
This way, the students may be involved, alternatively, in activities such as:
neutral observation, observations report, therapeutic planning, assisted-therapeutic
practice, specific abilities assessment, planning and performing research (scientific
initiation), critical literature review, assessing (initial) interviews, supervised
language assessment and therapy, family orientation, contacts with schools,
institutions and other professionals and interdisciplinary meetings. All these
activities are closely accompanied by the supervising teacher and by more
experienced students (usually post-graduate). It allows the immediate discussions
about clinical events and/or therapists performance. The teaching process in
complemented by programmed activities that include: formal weekly supervising
sessions, programmed seminars and case discussions, study groups. It is expected
that, by the end of the learning process, the students have produced a paper to be
presented in a national and/or regional convention.
This way we expect to facilitate experiences that allow the formation of an
SLT/SLP that is, at one time, attuned and aware of the national reality and able to
perform a good practice in different environments, maintaining continued education
actions. This complete professional is, therefore, ethical, expert, scientific, reflexive,
has practical experience, acts based in evidences and respects differences.
Evidence-Based Practice experience with undergraduate students

The practical experience of students should be safekeeping for both patient
and student. Some unlucky experiences with some disorders or patients - could
determine the future professional options of students. The understanding of
evidence-based practice (EBP) will provide an objective way to see the clinical life.
EBP is an instrumental to promote the best possible outcome for the patient.
Furthermore, with this instrumental the student feel secure to live his/her best
547
opportunity for learning how to be a therapist. EBP involves the integration of three
principles: the current best available research; the clinicians experience and
expertise; and the patients values and preferences. The learning promotion of EBP
offers a great opportunity for the students once they have to: search for the current
best theoretical evidence concerning the disorder; chase for evidences choosing and
applying objective tests; and make treatment decisions. In our undergraduate course,
all students are initiated on their practical experience on the second semester. On the
second, third and fourth semesters, the students ground their practice on the search
for the current best theoretical evidence concerning the disorders. On the fifth and
sixth semesters, students chase for evidences selecting and applying objective tests
based on methodologically designed protocols. On the seventh and eighth semesters,
the students experience the therapist practice by applying treatments selected on the
literature that are identified as the most supported by evidence. In this phase, the
initiation and acquisition of experience on reality and values of patients and their
families are substantiated. The EBP on the Communication Disorders still has a small
reliable theoretical and methodological support when considering the necessary and
provided methodology. The systematic reviews that serve as a baseline for evidencebased clinical practice guidelines, such with regard formal assessment of the body of
scientific evidence related to a clinical question, as with regard the description of the
extent to which various diagnostic and treatment approaches are supported by
evidence, are still insufficient. The majority of studies published on Communication
Disorders still contain limitations on study design and inadequate subject sampling.
The future for an efficient application of EBP on the educational setting is still
dependent on the inclusion of clinical trials once very few studies reach the
excellence level necessary for the Robeys five-phase model. Phase I - pilot stage:
demonstration of an intervention effect in a small number of subjects (treatment
safety and help further develop hypotheses). Phase II - larger group of patients:
verification of whether the demonstrated treatment effect testing sufficiently
warrants additional testing. Phase III - efficacy: study should be implemented to
determine whether the treatment is effective under controlled conditions
(randomized control trial). Phase IV: verification of treatment effectiveness in a less
controlled situation (real setting, with typical patients). Phase V: verification of
treatment efficiency in patient sub-populations. The educational formation of a
golden standard student with the desirable abilities is a goal that evolves
together with science progress.
548
P095
CD-ROM AS A TOOL FOR CONTINUING EDUCATION OF ELEMENTARY
SCHOOL TEACHERS IN WRITTEN LANGUAGE
Thas dos Santos Gonalves
Patrcia Abreu Pinheiro Crenitte
University of So Paulo, Bauru, Brazil
Introduction
Despite the many expectations of teacher educators around the world, there
has been little attention to development of a curriculum for educating teacher
educators, or to local and larger policies that might support the development of what
teacher educators need to know and do in order to meet the complex demands of
preparing teachers for the 21st century (Cochran-Smith, 2003).
The professional formation of any field of work is always an ongoing process,
however educational initiatives are necessary to implement the continuing education
(Marin, 2000).
Diniz (2007) reported that the Distance Education (DE) enables the student
improve and upgrade themselves, respecting their own pace, being at home or in
your workplace. Thus, the DE may represent an effective democratization of
education (Zanette, 2006).
The DE recourses is promising in teacher formation in a country with
continental dimensions like Brazil, that presents a large contingent of teachers with
multiple urges and shortcomings in their conceptual repertoires (Pesce, 2002).
The continuing education courses must have real meaning for teachers work,
and need to allow applicability of what is proposed (Rett, 2008). The DE is
appropriate for realizing the potential for constructive, creative and reflexive
learning, without unduly privileging the informational and instructive aspects used
in the empirical approach to education (Linhares, 2004). Studies about distance
education in the teacher education showed that teachers have used the technologies
in creative ways, calling the attention to the importance of this teachers' abilities as a
basic skill to facing the challenges of the knowledge society (Oliveira-Bueno and
Oliveira, 2008).
Knowledge of acquisition and development of written language aspects is
extremely important for teachers from elementary school, because they deal daily
with this activity of teaching, and is important that these professionals detect early
the presence of written language disorders (Fernandes and Crenitte, 2008). Distance
education seeks to fill the limited access to information presents in certain regions,
allowing the enrichment teacher practice in classrooms and also the work together
between teachers and speech therapists.
This article describes the preparation of a distance education material, which
aims to provide to primary school teachers an interactive course for the acquisition of
knowledge related to the acquisition and development of written language.
Method
Choice of the Distance Education Material
549
The proposal of this material is being applied in different locations, and there
are teachers in some regions of Brazil with difficult to access the Internet, and
therefore among the interactivity tools that do not need the internet, are the DVD
and CD-ROM. Both allow the simultaneous use of visual media (text, animation,
images, videos) and auditory (sound, voice, music), and have large storage capacity,
conducive to learning because the large amount of information presented, and can
even be transported. The CD-ROM can be used on any computer that has a CD-ROM
drive (or reader), which is still found on most computers, when compared to the
DVD player.
CD-ROM Setup
To prepare the CD-ROM, originally a script was drawn with themes related
to the Acquisition and Development of Written Language, witch contented relevant
questions that are commonly encountered by teachers in their school practice.
Thus, the script was constituted as follows:
1. HOME / TITLE - Acquisition and development of written language and its
Disorders: electronic manual for teachers
2. PRESENTATION / CREDITS
3. INTRODUCTION
a. Speech therapist's role in schools
b. Importance of partnership between teacher and speech therapist
4. REQUIREMENTS FOR ACQUISITION OF READING AND WRITING
a. In relation to children
b. In relation to teacher
c. In relation to school
5. THE ACQUISITION AND DEVELOPMENT OF READING AND

WRITTEN
PROCESS
6. READING PROCESS
7. WRITTEN LANGUAGE DISORDERS
a. School Difficulties
b. Learning Disabilities
c. Dislexia
d. Attention deficit and hyperactivity
550
The technical part in the preparation of the CD-ROM was made by LTIA
(Technological Laboratory of Applied Information), which is a group of research and
extension of the Department of Computer Science Faculty at UNESP, dedicated to
convergence technologies and digital technology in education, which currently
brings undergraduate and graduate of the following courses: Information Systems,
Computer Science and Design, which turned the written material in language
multimedia.
Results
The script presented refers to the titles of each contents, available on buttons
and links. The files can be viewed in a sequence, allowing the teacher to start
learning when they want and also leads to the wanted topic (Figures 1 and 2). We
included videos that show in practice some concepts available in text.
Figure 1. Content about the Speech Therapists Role in schools.
551
Figure 2. Content about the Acquisition of Written Language.

In both figures, in the lower left corner, tools can be found responsible for an
increase or decrease of the font size in the selected text, according to the comfort of
the learner, and can also be viewed another tool, responsible for dragging the text up
or down, replacing the scroll bar, located on the right side. This tool was include
because the possibility of the teacher who will conduct the course have some motor
difficulty, which is a way to manipulate the text without requiring much the fine
motor coordination. At the end of each content was presented the option to print the
text. The bottom "Help" (Ajuda) can be seen in both figures, and this tool can be
accessed by the teacher in cases of doubts in the handling of the CD.
The material provided information about normal processes of acquisition and
development of written language, and its disorders, for the teachers be alert when
students do not properly follow these procedures, making possible identification of
alterations, because the teachers will know what processes are expected, facilitating
the diagnosis and early interventions in the disorders of written language. In
addition, the course aims to provoke reflection on the relationship of the various
factors that influence the learning process.
Discussion
The Distance Education offers an individualized study, adjusted to the pace
of the learner, with this pick when and where the study will be conducted, with a
fast and efficient way to train and qualify professionals (Padallino and Peres, 2007).
The choice of technological resources should not be initiated by the
sophistication and complexity, but for usability, ease, and adequacy requirements of
the public. There are simpler and less expensive technologies, but very effective for
learning (Azevedo, 2003). Therefore, the aim in the development of this material was
the contribution to the needs and interests of teachers to acquire such skills, and was
adapted to the socioeconomic reality of the country, presented a low cost in the
material preparation. A pedagogical preparation is very necessary for the "online"
environment and required training or specific skills in this type of education.
The development of teaching materials has required form the educational
institutions the formation of interdisciplinary groups (academic team should be
incorporate with computer professionals, particularly the web designers, capable of
providing the material produced in electronic media), and promoting discussions
about the kind of language to be adopted in the production of this material
(Belisario, 2003). So, in the development of this material, there was a partnership
with LTIA (Technological Laboratory of Applied Information), UNESP, to make the
production of electronic media.
The teacher often has no awareness of its role as mediator in the knowledge
construction of students. Is very important the orientation about the following
aspects: development of written language, strategies to optimize it, situations that
encourage the development of narrative skills, spelling and its relationship with
552
speech (Zorzi, 2003). Most often, teachers do not have the idea that the learning
process depends on many factors, and than, not depends only of the student. And
this fact can occur because the teachers not have such knowledge during your
graduation. Porting because of the importance and necessity of this theme, this
course was addressed to the acquisition and development of written language, and
than, the teacher will learn with a reflectively way the content available, and that
learning of their students also depend of your methodology, your posture and your
relationship with students.
The continuing education is important for the teacher to constantly update
and development of the skills necessary in their practice (Gasque and Costa, 2003). In
general, it is assumed that is spending more public resources in continuing education
than in teachers formation in regular undergraduate courses (degree) in public
institutions (Gatti, 2008).
Conclusion
Brazil is a developing country, and the use of technologies for education
reduces cultural isolation of the education professionals. The teaching materials in
distance education need to consider the reality of the learners, to provide the
effective learning. And for the purposes of distance education be achieved, a
multidisciplinary team is essential in preparing the material, since in addition to
specific knowledge to be taught, is necessary the experience of teaching and
technology areas.
So after all these considerations, the development of a educational material
for distance education about the Acquisition and Development of Written Language
and its Disorders seems not only appropriate but warranted by supply teachers who
need flexibility of time and/or live away from academic centers, the opportunity for
growth and information professional.
References
AZEVEDO, W. (2003). Como detonar com um projeto de educao online. En: SILVA, M.
(Org.). Educao online: teorias, prticas, legislao e formao corporativa. (pp. 155-158).
So Paulo: Loyola.
BELISRIO, A. (2003). O material didtico na educao a distncia e a constituio de
propostas interativas. Em: SILVA, M. (Org.). Educao online: teorias, prticas, legislao
e formao corporativa (135-46). So Paulo: Loyola.
COCHRAN-SMITH M. (2003).Learning and unlearning: The education of teacher educators.
Teaching and Teacher Education, 19 (1), 5-28.
DINIZ, D. D. (2007). A interao no ensino distncia sob a tica dos estilos de aprendizagem.
Master Dissertation, Universidade de So Paulo, So Carlos.
FERNANDES, G. B. E CRENITTE, P. A. P (2008). O conhecimento de professores de 1 a 4
srie quanto aos distrbios da leitura e escrita. CEFAC, So Paulo, 10(2), 182-90.
GASQUE K. C. G., COSTA, S. M. S. (2003). Comportamento dos professores da educao
bsica na busca da informao para formao continuada. Ci. Inf., 32(3), 54-61.
GATTI, B. A. (2008). Anlise das polticas pblicas para formao continuada no Brasil, na
ltima dcada. Rev. Bras. Educ., 13 (37), 57-70.
LINHARES, M. P.; PARONETO, G. M.; SILVA, S. M.; RIBEIRO, O. (2004). Spinning the Web
of Continuing Education: Perspectives and Challenges of Using Education at a
Distance Technology in University Level Teacher Education Courses. In R. Ferdig et
al. (Eds.), Proceedings of Society for Information Technology & Teacher Education
International Conference, 2551-2554.
553
MARIN, A. J. (2000). Educao Continuada: reflexos e alternativas. Campinas: Papirus.

OLIVEIRA-BUENO B; OLIVEIRA, A.S. (2008).. Distance Education in Another Register: Uses
and Appropriation of Technologies in Teacher Education. Universitas Psychologica,
7(3), 823-836.
PADALLINO, Y. E PERES, H. H. C. (2007) E-learning: a comparative study for knowledge
apprehension among nurses. Latino-Am. Enfermagem, 15 (3), 397-403.
PESCE, L. (2002). Educao a Distncia: novas perspectivas formao de educadores. Em: Moraes,
M. C. (Org.). Educao a distncia: fundamentos e prticas. Campinas:
UNICAMP/NIED.
RETT, S. B. T. (2008) Formao Continuada de Professores por meio da Educao a Distncia (EAD):
influncias do Curso TV na Escola e os Desafios de Hoje. Master Dissertation.
Universidade Catlica de Campinas, Campinas.
ZANETTE, E. N., NICOLEIT, E. R. E GIACOMAZZO G. F (2006). A produo do material
didtico no contexto cooperativo e colaborativo da disciplina de Clculo Diferencial e
Integral I, na modalidade de Educao a Distncia na Graduao. Novas Tecnologias na
Educao, 4, 1-9.
ZORZI, J. L. (2003). O que devemos saber a respeito da linguagem escrita e seus distrbios:
indo alm da clnica. En: ANDRADE, C. R. F.; MARCONDES, E. Fonoaudiologia em
Pediatria (130-32). So Paulo: Sarvier.
554
SE08.1
CENTER OF EXCELLENCE IN EARLY INTERVENTION
Higdon CW., Ivy L. , Vaughan L. , Moore L.
University of Mississippi1
The purpose of this proposal is explain how to establish a Center of

Excellence in Early Intervention. This proposal, for a Center of Excellence in Early
Intervention in the state of Mississippi, USA was funded by national stimulus funds
directed through the Mississippi Department of Health and awarded November 1,
2009. This Center proposal consists of a comprehensive system of personnel
development, based on best practices and evidence based research for the Early
Intervention population and professionals serving the Early Intervention population.
Four guiding principles that reflect the current consensus of best practices for
providing early and effective communication interventions for infants and toddlers
(birth to age 3 years) serve as a foundation for the design and provision of this
proposal. Specifically these principles are that services are (a) family-centered and
culturally responsive; (b) developmentally supportive and promote children's
participation in their natural environments; (c) comprehensive, coordinated, and
team-based; and (d) based on the highest quality internal and external evidence that
is available.
The purpose of this proposal is to establish a model center for other states
and countries interested in developing an efficient EI program to provide services.
(Note: In the following discussion, team members, defined as therapists, include
speech-language pathologists, audiologists, psychologists, physical therapists,
occupational therapists, and special instructors/teachers). The presentation of this
center for excellence concept will be carried through the first year of this planning
and development.
(1) The first step proposed will discuss how to develop a comprehensive profile
of current training needs by identifying critical gaps in current knowledge
regarding personnel preparation for Early Intervention professionals and
how to gather data about the current and projected supply and demand for
personnel in Early Intervention services.
(2) Quarterly trainings and continuing education per identified needs
(development of documentation for increased funding of services, arena
assessment, creative parent training methods), will be explained. Electronic
opportunities such as webinar and podcasting will be explained and included
during the trainings.
The primary focus of this grant is personnel preparation and personnel
development to implement cutting edge team service models in natural settings.
Practices nationally and internationally in the past have adopted familiar clinic-based
or fragmented service delivery models. Best practices services need to be
implemented in settings that minimize stress for the family, are developmentally
appropriate, and are supported with training and technical assistance is essential to
meet both the spirit and the letter of the law and mandates.
Using best practices and national standards, and recommendations from the
Division of Early Childhood (DEC) and the National Association for the Education of
Young Children (NAEYC), data was collected to identify the needs and gaps in
personnel preparation as well as current and projected supply and demand for
555
trained personnel. Specific effective training was then designed to be delivered in

the quarterly meeting format requested in the regional workshop. Topics included
were training in the transdisciplinary team model, play-based approaches, preliteracy activities, ways to stay current with specific discipline needs, more training
in family centered approaches, as well as helping providers identify their gaps in
their own knowledge and skills. Training included creating professional work
environments that allowed for change based upon new research and practice
consistent with this training model.
Additional steps completed in this grant, and available to be discussed
included:
(a) Development of a distance learning and teaching component to include
training for team members, teletherapy for families and teams who need
support but are geographically too far to come to the Center, and possible
training for students in university programs around the state.
(b) Development of a resource/ lending library and laboratory for parent and
physician education (individual and small group), on site play based
assessments and treatment, and specific training in areas of autism spectrum
disorders, hearing impairments and other at risk issues for the zero to three
population.
The purpose of this Center is based on the following knowledge and
guidelines about Early Intervention discussed in the following sections. Data
collection, identification of training needs and the actual trainings were developed
around the seven primary needs listed and will be explained in this presentation.
They
include
prevention,
screening/evaluation/assessment,
planning/implementing/monitoring, consultation with and education of team
members including families and other professionals (physicians as one possibility),
service coordination/transition planning, and advocacy.
The grant facilitated the following:
(a) services that were family-centered and culturally responsive
(b) services that were developmentally supportive and promoted children's
participation in their natural environments
(c) comprehensive, coordinated, and team-based services.
(d) services based on the highest quality internal and external
evidence available.
The first primary function of the Center is Prevention.
The goal of prevention activities is to reduce the risk or mitigate the effects of
risk factors on a child's development so as to prevent future problems and promote
the
necessary conditions for healthy development and to achieve typical
developmental milestones. Therapists/teachers can assist in the early detection of
delays or deficits by participating in child-find and screening programs, thereby
mitigating or eliminating the effects of a disorder
(secondary prevention). Finally, they can help remediate an existing
problem by
providing early intervention services, thereby preventing future difficulties
(tertiary prevention).
The second primary function of the Center is Screening, Evaluation, and Assessment.
556
Screening for communication needs in infants and toddlers is a process of

identifying young children at risk so that evaluation can be used to establish
eligibility, and more in-depth assessment can be provided to guide the
development
of an intervention program.
The third primary functionof the Center is Planning, Implementing, and Monitoring
Intervention.
Once it is determined that a child is at risk for or has a deficit, the members of
the early intervention team (e.g., family, pediatrician, early childhood special
educator, audiologist, physical therapist, occupational therapist, home trainer, child
care provider) develop a plan for services and supports that includes intervention
outcomes, approaches, methods, and settings.
Service delivery models. The purpose of early intervention is to maximize the
child's ability to communicate, learn, and move effectively, and to enhance the
family's ability to support their child's development. Service delivery models in early
intervention vary along the dimensions of location and types, both of which
influence the roles of team members in the provision of services. Recent United
States legislation requires that early intervention services and supports be provided
to the maximum extent appropriate in natural environments, including the home
and community settings in which children without disabilities participate.
Types of service delivery models (to be discussed in the presentation as part
of this grant) in early intervention range from the traditional, one-to-one, direct
clinical model (i.e., pull-out) to more indirect collaborative approaches.
Organization of the ever-expanding research base on effective intervention
approaches and strategies in early intervention is challenging for a variety of reasons.
The focus of intervention may be the parent or caregiver, the child, the dyadic
interaction, the environment, or combinations of these factors. The agent of the
intervention may be a team member, a family member or peer, or varying
combinations. The intervention may be in small or large groups, individual or
massed, or distributed opportunities throughout the day.
Strategies with promising evidence fall into one of three groups: responsive
interaction, directive interaction, and blended. Responsive approaches include
following the child's lead, responding to the child's verbal and nonverbal initiations
with natural consequences, providing meaningful feedback, and expanding the
child's utterances with models slightly in advance of the child's current ability within
typical and developmentally appropriate routines and activities.
Directive interaction strategies include a compendium of teaching strategies
that include behavioral principles and the systematic use of logically occurring
antecedents and consequences within the teaching paradigm. Blended approaches,
subsumed under the rubric of naturalistic, contemporary behavioral, blended,
combination, or hybrid intervention approaches, have evolved from the observation
that didactic strategies, while effective in developing new behaviors in structured
settings, frequently fail to generalize to more functional and interactive
environments.
Monitoring intervention. Because young children often change very rapidly,
and families respond differently to their children at various periods in development,
systematic plans for periodic assessment of progress are needed. The three broad
purposes of monitoring are to (a) validate the conclusions from the initial
557
evaluation/assessment, (b) develop a record of progress over time, and (c) determine
whether and how to modify or revise intervention plans.
The fourth primary function of the Center is Consultation With and Education of Team
Members, Including Families and Other Professional.s
In delivering early intervention services and supports, team members
assume important collaboration and consultant functions with other team members,
including the family and other caregivers, and other agencies and professionals.
The fifth primary function of the Center is Service Coordination.
Service coordination is defined as an active, ongoing process that assists and
enables families to access services and ensures their rights and procedural
safeguards.
The sixth primary function: Transition Planning
A major goal of early intervention service is to ensure a seamless transition
process for families moving from one program to another as well as timely access to
appropriate services.
The seventh primary function: Advocacy
Advocacy activities and products that raise awareness about the importance
of early intervention are essential, and therapists/teachers have a responsibility to
play a part in this process.
Awareness and Advancement of the Knowledge Base in Early
Intervention supports the development of this Center of Excellence in Early Intervention
Continued experimental and clinical research is needed to obtain information
and insight into several areas, including identification of risk factors, clarification of
the interactions between risk and resilience factors that affect the likelihood or
severity of early communication difficulties, development and refinement of
identification methods to increase the accuracy of detecting children in need of
services, development and refinement of interventions to prevent and treat
developmental communication difficulties, and scientifically sound studies to
demonstrate the efficacy and effectiveness of current intervention approaches and
collaborative models of service delivery. Further, all those invested in enhancing the
early intervention services delivered to young children and their families have a
responsibility to be aware of and advance the knowledge base in early intervention.
These stakeholders include preservice programs and higher education faculty,
students, in-service providers, practicing clinicians, researchers, policy makers, and
consumers.
The literature review for these guidelines was drawn from sources provided
by individual committee members in their respective areas of expertise as well as
sources such as the (a) DEC Recommended Practices Research Review (B. J. Smith et
al., 2002), (b) ASHA National Center for Evidence-Based Practice in Communication
Disorders (N-CEP), and (c) Research and Training Center on Early Childhood
Development (RTCECD; www.researchtopractice.info/index.php). The DEC
Recommended Practices Research Review includes a thorough review of the
literature on children from birth to 8 years of age that appeared in peer-reviewed
journals through 1999. N-CEP conducted a literature search for this Committee to
identify empirical treatment studies or systematic literature reviews on speech,
language, and/or communication in early intervention. Finally, the RTCECD and the
558
What Works Clearinghouse were used to ensure that a comprehensive literature

search was conducted.
A list of electronic databases used, search criteria, and search terms is
available upon request but were too lengthy to be included in this word limit of the
proposal. The following outline of material will be discuss and available upon
request.
1.
Center for Excellence in Early Intervention

Introduction to the Centers Scope
2. Review of planning year (2009-2010) to include results and data

3. Mission Statement
4. Vision Statement
5. Budget and Financial Analysis
6. Strategic Plan with a plan for sustainability
7. Assessment plan for yearly evaluation
8. Goals and Projected Outcomes with a timeline
9. Operational Needs
10. Physical Plan Development
11. Organizational chart and administrative structure
12. Process for affiliating faculty and researchers
13. Three to five year time line
14. Technology plan
15. Oversight and accountability
16. Summary
17. Acknowledgements
559
FP02.3
Comparison of the IALPs educational directives with the current programs in
Europe the effect of the Bologna Declaration
G. Kalomoiris1, A. Frangouli2, A. Lambrinou3, C. Athanasiadi4
1 Hellenic-American Educational Foundation, Psychico College, Spiros Doxiadis
Diagnostic and Therapeutic Unit for Children
2, 3, 4 Mental Health Institute for Children and Adults, Kallithea, Athens, Greece
1. An Interpretation of the Current Situation
The natural habitat of the speech and language therapist (SLT) is the
interdisciplinary team. Within this context, the SLT has an important role to play in
the prevention, screening, assessment, differential diagnosis and research of
communication disorders. The SLT identifies and puts together all those elements
that make up the profile of communication difficulties and goes into great length to
ensure that the therapy offered is tailored to the needs of the individual client and
their family.
However, the deep changes that have swept across Europe and affect
everybodys life changes in working conditions/hours and pay, in social security,
in the national health system have radically changed all that we used to take for
granted. Education has not survived unscathed. The need for mutual recognition of
degrees and for the free movement of professionals within the EU (the Bologna
Declaration and the directives that followed, 89/48 &2005/36) have changed the
educational landscape. University education has had to become competitive in order
to attract funding that will ensure its survival.
Taken at face value, all these do not necessarily sound bad. But it seems that,
at a deeper level, education is moving towards a superficial, managerial attitude
which takes into account numbers but fails to realize that i.e. preparing someone for
a clinical profession, like the one we are fortunate to practice, one must think in
human terms not only in financial terms. Put in other words, we must make sure that
our profession and the educational course that leads into practicing our profession
will not break into numerous little bits that will be easy game for others to pray upon
i.e. doctors telling SLTs what to do in therapy abolishing, thus, our autonomy and
reducing us to workers in need of their guidance. Nor should we let our clinical
profession become fragmented into clear-cut specialties which will make us see i.e.
a larynx instead of the composite picture of the patient in front of us. We are not
afraid of change that follows the needs of those in need but we should be cautious
of change that depends on measurability. Quality is not measurable in the sense
that politicians want it to be measurable. This whole process of reconceptualising our
education (entry requirements, course duration, ratio of students to teachers,
available space), our clinical training and our clinical services must remain focused
on human needs not on profit making and upon building an even more uneven
society.
2. The Need for a Common Educational Thread
560
What are we? Logopedists? Speech Therapists? Speech and Language

Therapists? Speech Pathologists? Speech and Language Pathologists? Orthophonists?
What does the choice of a name signify? Is the choice we make unbiased? Why do
many of us choose pathologist? Is a speech pathologist more of a scientist when
compared to a mere logopedist? Why is it so important for many of us to come
closer to a medical profile and be pathologists? Because medicine is considered
to be hard science?
Deep down we all have a lot in common if, that is, we ever get the chance to
talk to each other and get to know each other, not only across nationalities but also
within the same nationality! However, no matter how many similarities we share, we
share as many differences. Diversity, of course, within a healthy context, equals
richness and beauty. If not, it is our mentality that forms the stumbling block.
Therefore, we do need a common thread that runs through the spine of the
training courses across the globe or, at least, the EU. Such a common thread is
provided by the educational guidelines set out by i.e IALP, CPLO-LCSTL, ASHA,
RCSLT, PAL/PSL (amongst others), which share the same philosophy and objectives
in order to maintain a high level of theoretical and clinical training that will ensure
that SLTs/ logopedists offer best quality clinical services to the public.
At a more official level it is the Bologna Declaration that carries the
momentum of educational reform in the EU for bad or for worse. It merits some
expanding since it affects the educational reality of all EU member-states:
a. It was signed by 29 countries which undertake to attain the Declarations
objectives and to that end engage in coordinating [their] policies.
b. It is a commitment freely taken by each signatory country to reform its own
higher education system or systems in order to create overall convergence at
European level.
c. The Declaration reflects a search for a common European answer to common
European problems (i.e employability of graduates, the shortage of skills in
key areas, the expansion of private and transnational education, mutual
recognition, free movement of professionals, compatible systems)
d. The Bologna Process aims at creating convergence. It is a path toward
harmonization not standardization. The fundamental principle of
autonomy and diversity are respected.
The action program set out is based on:
a. A clearly defined common goal: to create a European space for higher
education in order to enhance the employability and mobility of citizens and
to increase the international competitiveness of European higher education.
b. A deadline: the European space for higher education should be completed by
2010!
c. A set of specified objectives:
- the adoption of a common framework of readable and comparable degrees
- the introduction of undergraduate and postgraduate levels in all countries
with first degrees no shorter than 3 years and relevant to the labour market
d. ECTS-European Credit Transfer Systems: a compatible credit system also
covering life-long learning activities.
e. A European dimension in quality assurance with comparable criteria and
methods.
f. The elimination of remaining obstacles to the free mobility of students (as well
as trainees and graduates) and teachers (as well as researchers and higher
education administrators).
561
3. A Comparison of Guidelines: IALP, ASHA, CPLOL-LCSTL, PAL/PSL

The Bologna Declaration sets out a general framework. The principles laid
down by IALP, ASHA and CPLOL-LCSTL are more specific. They refer to
professional profiles, education and working practices, continuous professional
development, ethical issues.
In the USA there was an early need for both educational and professional
guidelines in order to accredit educational programs and to certify persons who
should work with communication disorders. The following guidelines were
proposed by ASHA in 1986 and were later adopted as minimum standards for
professionals in SLT/ logopedics:
The American Speech-Language-Hearing Association (ASHA) issues
Certificate of Clinical Competence to individuals who present satisfactory evidence
of their ability to provide independent clinical services to persons who have
disorders of communication (speech, language and/or hearing). An individual who
meets these requirements may be awarded a certificate in speech-language
pathology or in audiology depending on the emphasis of preparation: a person who
meets the requirements for both areas of practice may be awarded both certificates.
Today it is of utmost importance to impose minimal standards all over the
EU.
IALP states that the profession for which students are being prepared is an
identifiable profession and is not one whose practitioners are seen as educational/
medical/social assistants.
CPLOL-LCSTL states that the speech and language therapist/ logopedist is
the professional responsible for the prevention, assessment, treatment and scientific
study of human communication and related disorders. In this context, human
communication encompasses all those processes associated with the comprehension
and production of oral and written language as well as appropriate forms of nonverbal communication.
PAL/PSL - since it was founded in1982 has focused mainly on the
populations needs, on standardizing assessment tools in Greek, on channeling vast
amounts of energy into building a course on speech and language pathology and
therapy at university level. The strong point was that we brought together the
training experience that we had accumulated from a variety of countries that served
as our educational origin before coming back to Greece i.e. the United Kingdom,
France, Russia, Bulgaria, Romania, the USA, Argentina, Italy.
In the statements made by the three aforementioned associations, emphasis is
given to the scientific element of the professional profile. All associations highlight
the importance of research in order to provide adequate treatment and appropriate
services as well as to contribute to the advancement of knowledge about
communication disorders and the improvement of methods of intervention.
Another point of agreement among the three associations is that the course
curriculum should contain core subjects in language sciences (linguistics and
phonetics), behavioral sciences (psychology, education), biomedical sciences
(anatomy, physiology, neuroanatomy, audiology, ENT) and communication
disorders (developmental and neurogenic speech and language disorders, fluency,
voice, hering loss, swallowing and feeding disorders). They also agree that courses
should contain research methodology and statistics as well as writing scientific
papers/ thesis and that the teaching of SLP/logopedics should be taught by
qualified SLTs/ logopedists who maintain active involvement with clinical work.
562
It must be remembered that the course content must contain all these
elements if we are to achieve and retain our autonomy as clinicians and researchers.
Back in 1983, Kenneth Moll in his paper Training Programs in Logopedics argued
that SLTs/ logopedists fall into three categories. The first category are trained for
working in special education primarily for teaching in schools. The second category
are trained to work in a medical auxiliary field under the direction of physicians.
The third category are trained to function rather independently in clinical settings
with evaluation and treatment of speech, voice and language disorders.
Most of us have witnessed a gradual tendency to devalue and diminish the
SLT expertise. Other professions are trying to penetrate in the SLT profession and
field practice.
4. Conclusion
We still have a long way to go in Greece. The approach that emerges as the
most appropriate is that of cooperation between the professional bodies and the
Technological Educational Institutes-TEI. This joint effort should aim at the
theoretical and clinical improvement of the existing course contents and at the
consolidation of continuous professional development-CPD in accordance with the
guidelines set out by IALP and CPLOL-LCSTL.
Members of the professional associations can contribute to this effort. These
members must have the appropriate theoretical/ clinical/ supervisory experience as
well as the appropriate mental attitude if this enterprise is to be fruitful.
If we are to protect the status of the profession worldwide and in Greece
especially and offer optimal services to the public, the initial education should be
strengthened both the scientific knowledge and the clinical competence
component. CPD (i.e seminars offered by the professional associations, mainly)
should not function as initial education fillers. Instead, it should become our ethical
responsibility if we are to maintain our competence to practice.
Today, through the international IALP Congress we whould declare our
persistence to the development of the profession and the creation of a common
forum for the mutual support of the common educational thread and the everyday
practice.
REFERENCES
www.ialp.info
www.cplol.eu
www.asha.org
www.selle.gr
www.let.uu.nl
www.logopedists.gr
Publications of PAL/PSL in Greek:
563
Study on the establishment of a University SLT degree, Athens 1985,

1989, 1996
Prevention, Diagnosis, Intervention of Communication Disorders.

Training of SLT, Athens, Ellinika Grammata, 1999.
Guidelines on Continuing Education, Athens, 2000.
564
P032
THE EFFECTIVENESS OF A REMEDIAL READING TRAINING PROGRAM
WITH THE USE OF A METRONOME (RHYTHM) FOR THE TREATMENT OF
DYSLEXIA
P. Katsigri, P. Van de Craen, I. Vakirtzidellis
Vrije Universiteit Brussel, Brussels, Belgium
Athens Neurolinguistics Center, Athens, Greece
Objectives
The treatment of dyslexia is currently approached through a number of
different strategies such as pedagogical and psychological. There is however only a
limited amount of research on rhythm and dyslexia treatment. In the past decades,
rhythm research in speech and language has been evolving. Rhythm has been
studied from the four following perspectives a) symbolic representation, b)
production, c) perception d) communicative function (Kohler, 2008). To our
knowledge, no specific study has been published yet on the effectiveness of rhythm
as a tool for speech therapy in the area of learning disabilities and dyslexia. As
Cummins suggests the role of temporal structure within speech is continuous with
our understanding of rhythm in nature. Rhythm organizes, coordinates, and unifies
disparate systems (2008).
Reading, with specific frequency rhythms, with the use of a metronome,
enables dyslexic children to overcome reading and learning disorders. Reading
disability is strongly related to lack of phonemic skills. Dyslexic children usually
have great difficulty in manipulating phonemes which are the basic sounds of a
language independently of meaning. Therefore, phonemic awareness training (lettersound relationships word recognition and spelling) is highly recommended for
treating dyslexic students. The research question was designed to determine
whether a Remedial Reading Training Program (RRTP) based on phonemic
awareness specific training with the use of a metronome would be an appropriate
tool for the treatment of dyslexia
Methodology
Eight dyslexic subjects aged 8-10, consisting of six male and two female, were
used in this study. All participants were considered by their teachers to be deficient
in reading and learning. Dyslexia classification was based on teacher referral to the
Alouette reading test score and on a parent - teacher interview.
Pre and Post testing of reading was conducted by the investigators with the
Alouette test (Lefavrais, 1967) as all participants were French speaking. In this test
children have to read a text aloud. The evaluation and final score of the test, takes
into account both accuracy and speed.
After they were addressed the Alouette reading test, the children upon their
parents consent, agreed to follow a RRTP with the use of the metronome.
Participants were seen individually once a week for a period of 35-40 weeks.
Prearranged appointments with the parents were scheduled after the child had
completed the 8th, 16th, 24th, 32nd and the 40th session of the reading program.
In the pre test, the reading skills of all subjects were at least 20 months below
their chronological age. Participants did not suffer from neurological disease, hearing
565
loss, social behavioral problems, nor had poor educational opportunities. They had
not been enrolled in any speech therapy program before or during this study.
Subjects underwent a remedial reading training program with the use of a
metronome which took 35 to 40 one hour individual sessions over an 11 month
period. During each session the subject is administered specialized reading material
and is asked to read aloud syllables or words after the tone of the metronome. All
given material is printed. The one hour session is divided in 3 periods of twenty
minutes. The goal is to make the child read and be concentrated for sixty minutes.
This is achieved since the child follows the tone of the metronome. If the child is tired
a pause is introduced at the end of the first and/or the second period. During the
pause the child is introduced to a creative task. This task lasts for five minutes and
consists of creative building games such as tangram, blocks, bricks and cube
constructions. The RRTP is divided into 5 different chapters with 7 sessions
corresponding to each chapter (total of 35 sessions). In particular cases, when a child
is unable to perform a session successfully, the child is asked to repeat the session.
The exact program for each session and session goals are described in a training
guide. Once all 8 subjects had accomplished the 35 or 40 hours RRTP, the Alouette
reading test was re-administered to each participant, two weeks after the completion
of the RRTP with the use of a metronome.
Results
In order to investigate the effects of a RRTP with the use of a metronome on
the subjects reading skills, the researchers compared the reading age of the subjects
before and after the training using the Alouette reading test. All eight subjects
demonstrated a significant reading age increase, when the pre-test and post-test
results were compared. On the following two tables, the physical age, the Alouette
score, the reading age and the reading delay of each student is demonstrated.
On table 1, it is indicated that all participants suffered from a significant
reading delay varying from 20 months up to 26 months. More specifically,
participant 7, had 20 months delay in reading, participant 3, had 22, participants 1,5
and 8, had 23, participants 2 and 4, had 24 and participant 6, had 26 months of
reading delay.
As it can be observed on table 2 the reading delay of all 8 participants has
decreased significantly. Participants 2,4 and 6 now have a reading delay of 5
months, participants 7 and 8, a delay of only 2 months, participant 1, has a reading
delay of 1 month, whereas participants 3 and 5 have no reading delay. Researchers
believe that participants 2, 4 and 6 will be able to reduce or even completely remove
their reading delay, if they follow additional sessions of RRTP.
Table 3, indicates the reading progress of each participant. Initial and final
delay measurements of the Alouette test show a significant reduction in reading
delay.
566
Table 1 indicates the reading delay of the participants, as it was initially measured by
the Alouette reading test, prior to RPTP.
Participants
Physical age
Alouette Score
Reading age
1
2
3
4
5
6
7
8
9,6
10
9
11
10
9,6
9
11
240
245
225
240
265
225
230
230
9,5
9,7
9,1
10,7
10,1
9,1
9,2
10,10
Reading delay
in months
1
5
No delay
5
No delay
5
2
2
Table 2 indicates the reading delay of the participants as it was re-measured by the
Alouette reading test after they underwent 10 month RRTP with the use of a
metronome.
Participants
Physical age
Alouette Score
Reading age
1
2
3
4
5
6
7
8
8,5
9
8
10
9
8,5
8
10
35
85
9
150
90
10
11
155
6,6
7
6,2
8
7,1
6,3
6,4
8,1
Reading delay
in months
23
24
22
24
23
26
20
23
Table 3 indicates the reading delay of each participant before and after RRTP.
Participants
1
2
3
4
5
6
7
8
Reading delay in months

before the RRTP with the
use of a metronome
23
24
22
24
23
26
20
23
Reading delay in months

after the RRTP with the
use of a metronome
1
5
No delay
5
No delay
5
2
2
567
Conclusions
Our results give clear evidence on the progress of the reading skills (lettersound relationships, word decoding and spelling) from which all participants
benefitted after having received the RRTP with the use of the metronome. It is our
assumption that the reading improvement is due, partly to the RRTP which is based
on phonemic awareness specific training, but also to the use of the metronome. Since
the child is asked to read to a specific frequency given by the metronome, the reading
process is elaborated differently as it is guided by the sound of the metronome. It is
our belief that this new process of reading allows the children to perform better in all
school activities by increasing attention and improving processing ability.
Based on these results, a RRTP with the use of a metronome can be an
appropriate tool for the treatment of dyslexia. Due to the limited number of subjects
participating in this study it is early to prepare a statistical analysis. A need for an
additional research with a larger number of participants is suggested. A larger study
could compare the reading age of a dyslexic group with a time interval of 11 months,
receiving a RRTP with the use of a metronome with another group not receiving any
help. All the subjects in the current study were considered dyslexic. There is an
indication that children suffering from attention deficit disorder, learning or reading
difficulties could also benefit from RRTP with the use of a metronome. Therefore
further research towards this direction is strongly encouraged.
BIBLIOGRAPHY
Bakker, Dirk J. 2007. Cognitive brain potentials in Kindergarten children with subtyped risks
or reading retardation The International Dyslexia Association (on-line)
Available:http://findarticles.com/p/articles/mi_qa3809/is_200706/ai_n19433800/prin
Catts, H. W. 1989 a. Defining dyslexia as a developmental language disorder, Annals of
Dyslexia, XXXIX :50-64.
Catts, H.W. 1989 b. Speech production deficits in developmental dyslexia, Journal of Speech
and Hearing Disorders, 54: 422-428.
Critchley, M. 1970. The dyslexic child. London: Heinemann
Cummins, F. 2009. Rhythm as an Affordance for the Entrainment of Movement. Phonetica,
66:1-128.
Davis,
D.R.
1992.
37
Common
characteristics
of
dyslexia
(on-line)
Available:http://www.ohdyslexia.com/Pages/Common.htm
DeFries, J. C. 1991. Genetics and Dyslexia: An overview. In M. Snowling & M. Thomson
(Eds.), Dyslexia: Integrating Theory and practice pp. 3-20. Whurr Publishers: London.
Dollaghan, C. 1984. Fast mapping in normal and language-impaired children Proceedings
from the fifth Wisconsin Symposium on research in child language disorders, Madison, WI.
Galaburda, A. M., Sherman, G. F., Rosen, G.D., Aboitiz, F., & Geschwind, N. 1985.
Developmental Dyslexia: Four consecutive patients with cortical anomalies. Annals
of Neurology, 18: 222-223.
Griffith, P.L. & Olson, M.W. 1992. Phonemic awareness helps beginning readers break the
code. The Reading Teacher, 45, 7, 516-523.
Hus, Y. 2001. Early reading for Low-SES minority language children: An attempt to catch
them before they fall. Folia Phoniatrica et Logopaedica, 51:173-182
Kamhi, A., Lee, R., Nelson, L. 1985. Word, syllable and sound awareness in languagedisordered children Journal of speech and hearing disorder,. 50: 207-213.
Karpathiou, Ch., Dalla, V., Marra, M., Katsigri, P. 1998. Methode neuropsychologique en
logotherapie neurolinguistique sur la therapie de la dyslexie Proceedings 24th
Congress International Association of Logopedics and Phoniatrics. ,Vol 2 :808-810.
Karpathiou, Ch., Dalla, V., Marra, M., Katsigri, P., Vakirtzidellis, I., Charalambus, D.,
Kapetanios, V. 1998. Diagnose de la dyslexie par letude du fonctionnement cerebral
568
par lelectroencephalogramme mapping et la classification de la dyslexie en 5 types

differents Proceedings 24th Congress International Association of Logopedics and
Phoniatrics. ,Vol 2 :811-813.
Karpathiou, Ch., Dalla, V., Vakirtzidellis, I., Katsigri, P. 1998. Techniques diagnostiques en
logotherapie neurolinguistique Proceedings 24th Congress International Association of
Logopedics and Phoniatrics. ,Vol 2 :818-819.
Karpathiou, Ch., Dalla, Katsigri, P. 1999. Therapy of learning disabilities, dyslexia and nonfocal epilepsy European journal of neurology official journal of the European federation of
neurological societies Abstracts of the 4th congress of the E.F.N.S. Vol 6/ Sup 3 :119.
Karpathiou, Ch., Dalla, Katsigri, P., Charalambus, D., Kapetanios, V., Vakirtzidellis, I. 1999.
Diagnosis and classification of learning disabilities, dyslexia, through the results of
electroencephalogram mapping European journal of neurology official journal of the
European federation of neurological societies Abstracts of the 4th congress of the E.F.N.S.
Vol 6/ Sup 3:119.
Karpathiou, C., Dalla V., Marra M., Katsigri, P. and Vakirtzidelli, I. 1998. Dyslexie: Methode
therapeutique XEK. Fasc 1-12. Ion Publishing Group. Athens, Greece.
Kohler, K.J. 2009. Rhythm in speech and language a new research paradigm Phonetica,
66:29-45.
Korkman, M., Kirk, U., Kemp, S. 1998. A Developmental Neuropsychological Assessment.
The Psychological Corporation. USA.
Lefavrais, P. 1967. Test de l Alouette: Test d analyse de la lecture et de la dyslexie. Les
editions du Centre de Psychologie Appliquee. Paris.
Leonard, L., Nippold, M., Kail, R., Hale, C. 1983. Picture naming in language impaired
children Journal of speech and hearing research, 26 : 609-616.
Springer, S. & Deutsch, G. 1997. Left brain right brain (fourth edition). New York: W.H.
Freeman and Company.
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P161
COMPARATIVE ANALYSIS OF THE MATURITY LEVEL OF SPEECHLANGUAGE CAPACITY WITH PRIMARY (RETARDED SPEECH) AND
SECONDARY (DELAYED PSCYCHOLOGICAL DEVELOPMENT) SPEECH
PATHOLOGY
O.A.Bezrukova, E.V.Khoroshavina
Moscow City Pedagogical University, Moscow, the Russian Federation
One of the topical problems that teachers of specialized preschools face today
is a development of models, methods and techniques of work with the children the
speech impairments of which bear features of systematic character (the systematic
speech impairments). These are the impairments which are examined in the
structurally-semantic impairments group under the clinical-andpedagogical
classification of speech impairments whereas under the psychological-andpedagogical classification they are examined in the group of the means of
communication impairments.
Due to their prevalence and polymorphous manifestations the systematic
speech impairments draw more and more attention of the specialists whose activities
relate to teaching language (native as well as foreign) and to speech
development/correction of preschool and primary school children: logopedists,
preschool teachers, school teachers et alias. The systematic speech impairments are
mostly the main cause of poor progress at school, in the first place in the Native
Language. It is known that children with the systematic speech impairments are not
able to learn the native language as means of communication without specialized
logopedic assistance.
The systematic speech impairments may have primary nature, for example
retarded speech (RS). And they may be secondary defect in relation to the main form
of general mental dysontogenesis, for example at mental retardation (MR), mental
deficiency (oligophrenia), epilepsy, genetic diseases and etc.
In preschool and primary school children the systematic speech impairments
often manifest themselves either as primary form of retarded speech (RS) or as
secondary defect at MR. Quite often children with RS and MR go into one group of
preschool on basis of the generality of external speech language manifestations.
System of logopedic assistance to children with RS has a long history in our
country. There are logopedic groups with special programs in preschools and
logopedic posts in schools. Unfortunately speech-language rehabilitation of children
with MR is a bit worse. At present kindergartens for children with MR have
correction work programs, in which there are detailed sections dedicated to the
acquaintance with the visual environment, fiction, to the preparation for grammar
learning, to the development of elementary maths notions, to the sensor
development (Shevchenko S.G., the author). However the part of the program,
dedicated to the development (correction) of speech of a child with MR requires
improvement. Particularly the section dedicated to the native language teaching as
the main part of communicative capacity and social adaptation of children with MR
requires special attention. In practice the logopedists working with children with this
form of speech pathology often use the technologies developed for children with
570
speech pathology of primary nature. Such approach cannot satisfy the present
progress level of defectolgy.
Undoubtedly there is a lot of common in speech-language defect in children
with RS and MR. However the efficiency of logopedic work will obviously increase if
in the program content and, which is no less important, in the development of
private methods and technologies of logopedic work speech ethiopathogenese and
specific character of speech-language difficulties in children with RS and MR are
taken into account.
At present a lot of empirical material is accumulated indicating that speech of
a child with MR has its own specific peculiarities provided by the leading (primary)
defect of common mental development (R.D.Triger, 1971, 1981; E.S.Slepovitch, 1978;
N.U.Boyrkova, 1983; U.V.Ulenkova, 1990; R.I.Lalaeva, 1991 et alias).
The traditional approach to the diagnostics and correction of the speech
impairments in children with MR (it can be called properly linguistic) doesnt allow
to solve the problem of overcoming of speech difficulties in the given category of
children efficiently, for at such approach the main method is the analysis of form
without due attention to the analysis of content. And in children with MR
meaningful (notional) part of speech suffer in the first place. Difficulties with
handling notional information presented in verbal form are negatively reflected on
communication (abilities to understand and to pass information to others), that in its
turn causes social-cultural maladjustment.
Present level of the logopaedics science allows looking at the study and
correction of speech of children with the systematic speech impairments on basis of
the interdisciplinary approach that shifts accents in methods from pure linguistic to
psycho-linguistic and neuropsychological. It is at that approach that the meaningful
aspect of speech directly connected with the profound process of speech production
becomes the focus of attention of a logopedist working with a child with the
systematic speech impairments. It is that approach that the most representatives of
the logopaedics science acknowledge as the most perspective, for from the up-to-date
scientific point of view it allows to solve the most pressing problems that the practice
faces (Halilova L.B., Lalaeva R.I., Sobotovitch et alias).
There is a contradiction between an acknowledgment of speech defect as a
leading ethiopathogenetic factor at the systematic speech impairments by the most
specialists in the sphere of speech pathology and the traditional logopedics practice
at which there is no due attention is paid to teaching language to preschool children
on systematic basis taking into account the specificity of mastering native language
by children of this age.
Widely spread research data used in logopedics practice do not allow
conducting diagnostics and then correction of child speech if one strictly adheres to
age criteria, taking into account the specificity of speech-language defect of a
particular child which is of course negatively reflected on the quality of correctingdeveloping work on the whole.
With the view of study the specific peculiarities of speech-language defects in
children of 4-5, 5-6 and 6-7 years old with primary (RS) and secondary (MR) speech
pathology we have studied the speech of the children of the special kindergartens of
compensating type.
The studies were conducted in the state educational preschools 1153,
1703 of South District of Moscow. 66 children took part in the experiment. There
were 33 children from the preschool for children with RS and 33 children from the
preschool for children with MR. 11 children were taken into each age group. While
experimental data processing the study results for 17 children were excluded, for the
571
facts from the medical documentation had been revealed which from our point of
view could have negatively influenced the purity of the experiment. On the whole 83
children were examined.
The study of the speech-language development specificity of children with
MR and RS was conducted in accordance with the methodology of O.A.Bezrukova
O.N.Kalenkova (Bezrukova O.A., Kalenkova O.N. The Methodology for
Identification of the Level of Speech Development in Preschool Children, M., 2008)
as the most relevant to the goals of our experimental study. In accordance with this
methodology to define the speech development level in preschool children the
speech of a preschool child was estimated by the following parameters
maturity of a lexical system (the volume of a dictionary, a systematic set-up of a
dictionary);
maturity of grammar capacity (word formation, inflexion, syntaxes);
maturity of phonological capacity (phonematics, prosodics, sound analysis and
synthesis, sound pronunciation).
The following parameters were taken as additional:
familiarity with the visual environment;
status of verbal memory, of verbal-logical thinking and verbal attention.
In the given method the diagnostic material (lexical, grammar, phonological)
was distributed on basis of age criteria: 4-5 years old, 5-6 years old and 6-7 years old.
Besides, this method allows taking into account and estimating different types of
speech activity: productive speaking as well as reproductive listening
comprehension.
The aggregates of the common speech development level indicate that the age
aspect is a meaningful one when comparing speech-language development of
children with RS and MR (Graphic 1).
572
Graphic 1
Thus for example at the age of 4-5 the common level of speech development
of a child with RS does not practically differ from the speech development level of a
child with MR (odds make 3 %). However with the age the situation changes: at the
age of 5-6 the odds make 10 % to the benefit of RS, and at 6-7- 20 %. With respect to
the norm the speech development of a child of 4-5-years old with RS as well as with
MR does not reach even half 46% and 43% accordingly. At the age of 5-6 in a child
with RS 46% and in a child with MR 53%. In the preschool period, 6-7 years old,
the speech development of a child with RS 77% (practically 2/3) and of a child with
MR a bit more than a half 57%.
One doesnt have to forget that these are the children with whom a planned
purposeful work in special schools is conducted.
The data which allows analyzing the condition of the following parameters
are more demonstrative: lexicon status, maturity of grammar and phonological
capacity; familiarity with the visual environment; status of verbal memory, of verballogical thinking and verbal attention.
The aggregates of the childrens speech examination in accordance with these
parameters are graphically presented on the graphics (Graphics 2, 3, 4).
573
Graphics 2
T he R es ults of the E x amination of the S peec h of the 4-5 yers

old C hildren with R S and MR
120%
100%
80%
60%
40%
20%
0%
familiarity with
the vis ual
lex ic on s tatus
grammar
c apac ity
phonologic al
c apac ity
ps yc hologic al
s peec h bas is
MR
50%
48%
37%
35%
47%
RS
50%
53%
41%
32%
53%
100%
100%
100%
100%
100%
Norm
Graphics 3
574
Graphics 4
A data analysis allows to estimate speech of a child with RS and MR taking

into account the quality aspect and to follow the dynamic of the speech development
with certain parameters.
Thus for example the maturity level of lexical system on the whole in a child
of 4-5 years old with RS makes 53% with respect to the norm whereas in a child with
MR it makes 48% (the odds are 5 %); in a child of 5-6 years old with RS 65%, with
MR 57% (the odds are 8%), and at the age of 6-7 the odds reach 17% (70% - at RS,
53% - at MR).
Similarly one can analyze the grammar aspect of speech. Thus in the children
of 4-5 years old with RS as well as with MR the maturity level of grammar capacity
is approximately the same (RS -41%, MR 37%; the odds are 3 % to the benefit of
RS). At the age period from 5 to 6 the maturity level of grammar capacity differs by
10% (RS -62%, MR 52%) and by the age of 6-7 the odds by this parameter make 21%
(RS 79%, MR 58%).
The study results of phonological capacity of the children from the discussed
category are no less demonstrative. Thus at the age of 4-5 the maturity level of
phonological capacity in the children with MR proved to be a bit higher than in the
children with RS (RS- 32%, MR 35%), by the age of 5-6 the maturity level of
575
phonological capacity in the children with MR makes 56% against 71% in the
children with RS (the odds are 15 % to the benefit of RS), and by the age of 6-7 the
odds reach 23% (86% at RS, 63% at MR).
Thus the conducted experiment showed that:
vocabulary, grammar capacity and psychological speech basis mostly suffer

in childrens speech with MR;
total amount of impaired sounds in children with MR are less than in
children with RS. But the process of their automation training takes more time than
in children with RS;
the overall result of the speech-language development is much lower than
norm in the children with RS and MR of 4-5 years old that indicates the importance
of the earliest correcting-developing process.
The presented conclusions are open ended and require further work namely
consideration of the results of the childrens speech examination in structural
components of the presented parameters.
Further perspectives of the development of the experiment we see in the
following:
1. an increase of the quantity of children under the experiment;
2. approbation of the differential diagnostic method for the purpose of
identification of the specificity of speech-language defect in preschool children with
MR and RS;
3. elaboration and approbation of the express-examination of speech that
allows differentiating children with primary (RS) and secondary (MR) speech
pathology.
576
P097
AUTISM SPECTRUM DISORDERS (ASD): SOCIAL SKILLS IN THE SCHOOL
CONTEXT
D.V.M. Abramides1, D.A.C. Lamnica1, L.H.Z. Santos2
of So Paulo (USP), Bauru, Brasil
2University of So Paulo State (UNESP),Bauru,Brasil
1University
I Introduction
The autism spectrum disorders (ASD) is characterized by a behavioral
syndrome that compromises the childs development and presents multiples
etiologies. Among the deficits in SS, missing skills include: lack of social orientation
to a stimulus, misuse of visual contact, problems starting social interactions,
difficulty of interpretation, verbal and non-verbal responses, and inappropriate
social and emotional signs and lack of empathy with the other1.
Many interventions focused on behavioral theory and communication is
being developed. However, there are still many treatments that have not been
explored, including environmental and development intervention of SS programs. It
is necessary to consider the individual needs and abilities of each child and adult
with ASD for the selection of the appropriate treatment2.
Often, it is necessary to teach children with ASD, how to start and maintain a
conversation, the perception of other people, and the nuances of social interaction,
such as personal space, demonstration of empathy, and reading the body language.
However, many early intervention programs continue to focus solely on academic
skills that prepare these students to integrate in regular education3.
This is a field that needs further investigation, because few skills training
programs are designed specifically for social individuals of ASD4.
II Aim
The aim of this study was to examine what circumstances in school context,
social skills are more favored.
III Methods
Eighteen students with ASD participated in the study at program of a special
education school, for both sexes between the ages of 05 to 17. SS and behavioral
problems were evaluated by Child Behavior Checklist (CBCL)5 and Social Skills
Rating System6,7.
Analyses by SSRS showed the greatest number of issuing SS by participants
was communicative and positive sentiment expression; but empathy was the
only one that had no participant. Table 1 shows the characterization of survey and
includes the summary of results in those instruments.
577
Table 1: Characterization of survey

Participant
Sex
Age
SEL
Time
Program
(years)
SSRS
P
(SS)
SSRS
T
(SS)
SSRS
P
(BP)
SSRS
T
(BP)
CBCL
SCP
AP
P1
Low
Low
Low
High
High
P2
Low
Low
Low
High
Average
P3
Low
Low
Low
Low
High
P4
Low
Low
Low
Average
High
P5
Low
Low
Low
Average
High
P6
Low
Low
Low
Average
Average
P7
11
Media
Low
Low
Average
High
P8
14
Media
Low
Low
Average
High
P9
11
Low
Low
Low
Average
High
P10
16
Low
Avera
ge
Average
Average
Average
P11
14
Low
Low
Average
Average
Average
P12
14
Media
Low
Low
Average
Average
P13
13
Low
Low
Low
High
Average
P14
15
Low
Low
Low
High
Average
P15
17
Low
Low
Low
Mdio
Average
P16
14
Low
Low
Low
High
High
P17
17
Low
Low
Low
High
High
P18
12
Low
Low
Low
High
High
578
Legend: SEL: social economic level: SSRS P: version parents; SSRS T: version teacher; SS: social skills repertoire; BP: behavior problems;
SCP: social contact problem; AP: attention problem; ( + ): present/clinical; ( -): absent/non-clinical; B: borderline level.
Materials
Students were filmed in accordance with the protocol to make a record
of the following detailed SS subcategories:
1. Social skills communication
1.a. use of non-verbal signals to communicate.
1.b. ability to identify non-verbal signals.
1.c. social orientation: such as call by name, or non-verbal presentation of an
object.
1.d. show/point objects.
1.e. establish visual contact.
1.f. make/answer questions.
1.g. meeting requests.
1.h. follow instructions of other persons to achieve a goal.
1.i. interact with each other.
1.j. start interaction.
2.Social skills of Civility
2.a. Greetings.
3. Social skills coping assertion
3.a. make/refuse requests.
3.b. express displeasure.
4. Social skills empathy
4.a. offer comfort: verbal action or non-verbal to comfort a person in distress.
4.b. ability to identify emotions in other person: verbal or non-verbal actions.
4.c. express help: verbal or nonverbal action to help someone else.
5. Social skills of positive feeling expression
5.a. social smile.
5.b. accept touch, hug, kiss.
5.c. play, hug and kiss.
5.d. playing with the other or peers.
6 Social skills of self-control
579
6.a. appropriate action emotional response.

6.b. emotional control in front of a situation of conflict.
Students were filmed in different activities, focusing on student- teacher and
student-peers interactions. Filmed context/activities have not been the same for all
students, because there are distinct classes, and each class has a different routine.
Each activity was filmed in two sessions with an verage time of 25 minutes.
Table 2 - Class and filmed activities in contexts school

Class
1
Participants
P1, P2, P3, P4, P5, P6
P7,P8,P9
P10, P11, P12, P13
P14, P15, P16, P17, P18
Filmed activities
Classroom, playground, creative space, playroom,
dream house, music classes, walking, and sensory
space integration.
Classroom, canteen, sensory space integration,
walking, music classes, walking, aviary, and
playground.
Classroom, canteen.
Classroom, canteen, creative space, music classes,
playground, and walking.
IV Results
Table 3 shows the occurrence record and SS frequency positive
observed in classroom 1 and 2.
Table 3: Data SS in classroom 1 and 2

SS
1.a
1.c
1.e
1.h
1.i
1.j
2.a
3.a (make)
3.a
(refuse)
3.b
5.a
5.b
5.c
5.d
6.a
Activities classroom 1
1
2
3
4
5
6
2
0
0
0
0
0
7
0
Total
2
0
0
0
1
0
0
0
0
0
0
0
1
0
0
0
0
0
0
2
1
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
2
0
0
0
0
1
0
0
0
0
0
1
0
0
3
0
1
1
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
4
0
0
0
0
0
0
0
7
0
0
3
4
0
11
0
1
2 3 4 5 6
2
1 - - 0
7
0
8
1
9
0
10
3
11
0
Total
7
10
1
3
0
2
1
0
1
1
1
1
2
14
1
15
7
5
2
2
1
1
3
2
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0
0 0 0 0
0 0 0 0
0
0
0
0
0
0
0
0
0
0
0 0 0 0 0
0 1 0 2 1
0
0
0
3
1
0
0
0 0 0 0
2
0
1
1
1
1
1
1
0
2
4
3
0
0
1
0
1
1
2
1
3
0
0 0 0
0 0 0
0
0
1
7
13
11
1
1
Legend: ( - ) : activities no offers; (1)classroom; (2)playground; (3)criative space; (4)playroom; (5)dreamroom; (6)walking;
(7)sensory integration space; (8)music classes; (9)canteen ; (10) aviary; (11)court.
580
In table 3 the activities that obtained the largest number of frequency of

Sensory integration space were observed during playing with other. And in
Music classes being the ability to following instructions the most often noted.
Table 4 shows the occurrence recorded and SS frequency in students
classroom 3 and 4.
Table 4: Data SS in classroom in classroom 3 and 4

SS
Total
1.a
1.b
1.c
1.d
1.e
1.f answer
1.h
1.i
2.a
5.a
5.b
5.c
5.d
1
0
0
2 3 4 5
- - - - - - -
6
-
7
-
8
0
0
0
0
0
4
12
0
0
0
0
0
0
0
0
1
0
1
15
5
0
0
1
0
Total
0
0
1
8
0
2
0
0
3
0
0
4
-
5
-
6
0
0
7
0
0
8
2
2
9
0
0
10
-
11
-
10
2
0
0
1
4
13
15
0
0
0
0
0
0
0
0
1
5
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
2
0
1
1
9
1
0
1
0
0
0
1
0
0
0
15
5
8
0
5
5
0
0
0
0
0
1
0
1
0
6
2
0
3
0
1
1
30
7
9
2
11
7
3
Legend: (1)classroom; (2)playground; (3)criative space; (4)playroom; (5)dreamroom; (6)walking; (7)sensory integration space; (8) music classes; (9)canteen;
(10) aviary; (11)court.
The classroom 3 has a routine and differs from other classes; most activities
are carried out in the classroom, where similar content is learned to regular
education. In this class it has been possible to verify that music in the classroom
encouraged more skills than could be observed in other classes. The skill that has
most often been observed is interaction with other. Classroom 4 that obtained the
largest number of skill frequency was in Music classes (follow instructions).
IV Discussion
Analysis of the results obtained by filming showed that in the most contexts
the SS were most often seen in Music classes and Sensory integration space.
According to the literature, individuals with ASD have a lot of interest in music, and
several studies have been conducted to investigate the benefits of music therapy in
ASD cases.
This may suggest that the most interesting situations for more participants
can be facilitated for SS through music classes. The benefits of Sensory integration
space have also been studied in the cases of ASD, and sensory integration is already
part of some early intervention programmers in these cases. And the incidents of
higher frequencies occurred during mutual interaction between others/peers while
playing that encouraged skills responding to instructions in these cases. While
show or point skills and SS empathy, and emotional control were not identified
in any film.
This data can confirm the difficulty that individuals with ASD have to react to
a response issued by another person. That may be explained by problems to be in
someone elses shoes or to recognize what the other person thinks or feels.
V Conclusions
581
- The Music classes and the Sensory integration space facilitate a greater
number of responses related to the repertoire of pro active SS.
- This study suggests that these activities must be part of the program of early
intervention for ASD.
- The vigorous analysis of ASD behavioral patterns provides guidelines for
intervention in a supportive environmental context.
VI References
1 WEISS, MJ, HARRIS, SL (2001). Teaching social skills to people with autism. Behavior Modification, 25(5), 785802.
2 SEIDA, JK, OSPINA, MO, KARKHANEH, M, HARTLING, L, SMITH, V, CLARK, V. (2009). Systematic reviews of
psychosocial interventions for autism:an umbrella review. Developmental Medicine & Child Neurology, 51:
95104
3 SCATTONE, D. (2007).Social Skills Interventions For Children With Autism. Psychology in the Schools, Vol. 44(7).
4 RAO, PA, BEIDEL, DC, MURRAY, MJ (2007). Social Skills Interventions for Children with Aspergers Syndrome or
High-Functioning Autism: A Review and Recommendations. J AutismDev Disord., 38(2), 353-361.
5 ACHENBACH, T M, RESCORLA, L. A. (2001). Manual for the ASEBA School-Age Forms & Profiles. An integrated
system
of
multi-informant assessment.
6 GRESHAM, F. ELLIOTT, S. (1990). Social Skills Rating System: Manual. USA: Americam Guidance Service.
7 BANDEIRA, M, DEL PRETTE, Z.PA, DEL PRETTE, A , MAGALHES, T. (s.d) Escala de Avaliao das Habilidades
Sociais de estudantes do Ensino Fundamental, SSRS-BR: Validao transcultural para o Brasil. Artigo encaminhado
para a publicao.
582
SY09B.1
ADVANCED EDUCATION AND SPECIALIZATION IN LOGOPEDICS /
SPEECH AND LANGUAGE THERAPY
M. Lehtihalmes
University of Oulu, Logopedics, Finland
Background
The Education Committee of IALP has just updated the guidelines for initial
education in speech-language pathology for global purposes. This is important as
many countries around the world are still lacking the own education of professionals
working with clients with various types of communication disorders. It is common
that when starting the program foreign teachers are needed in theoretical and
practical studies. A good example is the Makerere University in Kampala, Uganda
where a group of British volunteer speech and language therapists (SLT) were
establishing a program of Bachelor of arts in SLP (Merkley, 2010). Similarly, the
Department of Logopedics at the University of Oulu is starting a project to initiate a
SLT program especially for autism in Bangladesh.
In Europe, CPLOL has prepared the minimum standards for education in
SLT (2007, 2009) just like Royal College of Speech and Language Therapists (2005) in
Britain. There has been rapid increase of SLT professionals in Europe. Still, in 2008
the SLT/inhabitants ratio was varying from 1/900 (Belgium) to 1/30400 (Bulgaria)
with a mean of 1/5645 in 28 European countries where the information was available
(CPLOL, 2008). Bologna declaration in Europe has had a major influence in
harmonizing the basic education in universities during this decade. Not many years
ago, there were still many countries in Europe without university degree education
in SLT. The situation has changed rapidly after Bologna declaration. Today, in most
European countries the minimum requirement for the profession has been upgraded
to the academic degree and at least to the bachelor level. However, upgrading the
education globally or even at the European level to the Masters degree still seems to
be far away.
Why doctoral education?

If even the Masters degree is difficult to organize in many countries, why am
I worried about doctoral education? Seriously, the speech and language therapy is a
scientific profession. Clinical practice will not develop without research. We can ask
if any profession can reach the scientific independence without possibility to have
doctoral education in its own science, in our case SLT. Despite the current
multidisciplinary approach in research, it is not possible to make clinical or scientific
innovations in communication disorders without researchers with SLT background.
For the successful and continuous development of our field it is necessary that a
certain amount of speech and language therapists have PhD degree and are involved
in research. The European Council set a goal of increasing the investment on research
and development to 3% of GDP in 2010. This should help to keep the amount of new
PhD holders at least at the current level. Another question is how these investments
will help the young students holding Masters degree to make decisions for starting
doctoral studies in SLT. In some countries, almost all doctoral students have funding.
In fact, they may be not able to start doctoral studies without the decision of funding.
Still, many students around the world are struggling with their studies without any
long-time funding.
583
It will take years from the initiation of the basic education in SLT to the own
researchbased program. For example, in Finland, the education of Logopedics started
in 1947 as a clinical branch of Phonetics. It took 36 years until the first full professor
in Logopedics was established at the University of Oulu in 1983. After that it took
another 15 years to have a second full professor to the University of Helsinki in 1998.
However, when the local research in Logopedics was really started, the progress was
much quicker, as six new positions for full professors were opened between the years
1998 and 2006 in five universities having SLT program. At the moment, we have
almost 30 SLTs with PhD in Finland. However, according the recommendation of
OECD, we should have about 50 as we have just over 1000 certificated SLTs in the
country. In Europe, there are about 350 SLTs having PhD degree out of about 68.000
practicing SLTs (CPLOL, 2008, responses of 24 countries).
Research doctorate or clinical doctorate?

Besides the classical PhD education, there has been growing interest on
degree of Clinical Doctorate (Kent, 2009). It is not always clear if the target is to
specialize or to go deeper as a generalist. To my knowledge, there are no countries
where at least at the moment the entry level to profession in SLT would be
upgraded to the Clinical Doctorate. However, many practicing SLTs might be
interested in completing the Professional or Clinical Doctorate rather than traditional
research doctorate. When asking the students of seven universities in United States,
the vast majority, 90.7% thought that Professional Doctorate would be good option
for post-certificate studies in SLT (Lass et al. 1996). In Finland, we have at the
moment less than 40 active SLT doctoral students in five universities. However,
when asking the interest on four-year Specialization Program as an academic degree,
about 160 practicing SLTs expressed that they are interested. The Council of the
Rectors of Finnish Universities rejected recently the proposal to initiate programs of
Professional Doctorate in some social and health sciences and decided that the only
doctoral degree in Finland will stay as a traditional research doctorate.
Why specialization?
With increasing practical knowledge as well as research on the nature and
rehabilitation of communication disorders we will meet more challenging clients. We
will need deeper understanding of disorders, i.e. special skills. In many special
clinics, there is a need for special SLT to work in a multidisciplinary team, as
mentioned in recommendation of the members of Voice Clinic by the British Voice
Association (RCSLT, 2005). In addition, due to the competition between the
professions in allied health, there is an increasing need for a proper specialty
education in SLT as many closely related professions will start programs heading to
specialization or to the degree of clinical or professional doctorate (Kent, 2009). My
opinion is that each speech and language therapist should be educated as generalist
in the first place. Specialization should be possible only after the educational level
required to practice with clients with various types of communication disorders.
In United States, the ASHA initiated in 1995 a specialty recognizing program.
Within that program, it is possible to achieve the status of specialized SLT in three
areas: swallowing and swallowing disorders, child language, and fluency disorders.
However, no consensus has been achieved internationally concerning the
educational or professional standards of specialization. Thanks to the international
co-operation, doctoral degrees between the universities are quite well comparable.
However, due to very different entry level to profession in speech-language
pathology, the paths to specialization in our field show enormous variation. At the
584
moment, the paths to achieve officially recognized or nonofficial specialization vary

from short courses for normal lifelong learning, specialty board decisions, and
university Masters programs of specific areas to university degree programmes in
specialization or degrees for Professional or Clinical Doctorate. According to CPLOL
report (2008), there are some officially recognized post qualification education
programs for specialization in SLT in 15 countries in Europe. Ranges of duration of
these programs vary from few days (Sic!) to four years.
International co-operation is very welcome when establishing specialization
programs. In Europe, two international programs for specialization or continuous
education, depending the official regulations in each country, has been initiated
during the last years and funded by the European Union. The European Clinical
Specialization in Fluency Disorders is on its second round at the moment. This is a 20
ECTS credit program operating by nine European universities. The European
Clinical Specialisation in Motor Speech Disorders program with 30 ECTS credits will
start in September 2010 in co-operation with eight different institutions.
Summary
The education in SLT has become more harmonized after the work of
international scientific and professional committees like IALP and CPOL and official
statements like Bologna declaration. International evaluation will help to compare
the level of doctoral degrees between the universities. However, due to lack of
consensus concerning the specialization in SLP, these programmes show enormous
variation.
References
CPLOL (2007). Revision of the minimum standards for education. Completed by the
Education Commission.
http://www.cplol.eu/eng/Revised_Min_Standards_2007_la.pdf
CPLOL (2008). Annual statistics of SLT education data in Europe as 31 December 2008.
Comit Permanent de Liaison des Orthophonistes/Logopdes de l'Union Europenne
/Standing Liaison Committee of E.U. Speech and Language Therapists and
Logopedists. http://www.cplol.eu/eng/Annual_Statistics_Summary_2008.pdf
CPLOL (2009). Position statement on practice education during initial speech and
language therapy education programmes. http://www.cplol.eu/eng/practice-educ_pos_stat.pdf
Kent, R. D. (2009). Clinical doctorate in allied health: Lessons for speech-language pathology.
Paper presented at ASHA Convention in 2009.
http://www.eshow2000.com/asha/2009/download_handouts.cfm
Lass, N.J., Woodford, C.M., Pannbacker, M.D., Schmitt, J.F., Scheuerle, J.F., Kahn, A.R.,
Irwin, D.L., Saniga, R.D., & Novocin, T.L. (1996). Students opinions on a professional
doctorate in speech-language pathology. National Student Speech Language Hearing
Association Journal, 23, 5558.
Merkley, C. C. (2010). Speech-language pathology in Uganda. ASHA Leader, 15 (4), 2.
Patel, R. (2010). Inspiring the next generation of teacher-scholars. ASHA Leader, 15 (4), 32.
RCSLT (2005). Royal College of Speech and Language Therapists. Clinical guidelines.
London: RCSLT.
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P096
PRODUCTION OF AUDIOVISUAL ABOUT DEAFNESS AND SIGN
LANGUAGE:
IMPACT ON DEAF CHILDRENS HEARING PARENTS
G.M. Moura1, I. Lichtig1
1 Department of Physiotherapy, Speech Therapy and Occupational Therapy - University of
So Paulo Medical School, So Paulo, Brazil
Introduction and aims of the study: In Brazil, the Brazilian Sign Language
(Libras) started to be investigated in the decade of 80 and its acquisition process in
the 90s. Nowadays, based on linguistic and neurological studies, SL has a recognized
value regarding their benefits for the linguistic, cognitive and emotional
development of deaf children. However, despite being a right constituted in many
countries in Brazil there is a Federal Law n 10.436, from 24/04/02 and a Decree n.
5.626, from 22/12/05 that recognize Brazilian Sign Language as a real language
there isnt in our reality a real effort in order to assure the right to SL for all deaf
people. The use of SL is still poor at home, at schools, or at speech-language clinics.
Results of a study carried out with Brazilian speech-language therapists enrolled in
specialization courses Knowledge of speech-language therapists enrolled in
specialization courses about the Brazilian Sign language (Marcondes & Lichtig,
2004), aiming at knowing these professionals views about Libras, their interaction
with this language and with their deaf patients, evidenced the participants lack of
information, the presence of pre-concept or incorrect ideas that among other factors,
culminate in the attitude of not providing the deaf a contact with this language. Such
findings drew attention to the information aspect and its importance. Information,
therefore, as a process or as knowledge is a valuable instrument that can contribute
for changing the actual reality of the deaf. Because of its acoustic and visual
characteristics, which makes it an accessible source of information for deaf and
hearing people, the audiovisual was chosen to mediate the performance of this
study, once it is a way potentially capable of bringing information to deaf and
hearing people equally, being therefore a democratic way of information. The
important role of the video as a working tool for the Speech-language pathologist is
emphasized use of audiovisual as a mediator of the clinical/ pedagogical practice.
We propose the role of the Speech-language pathologist as a film maker which we
will demonstrate throughout this paper. The purposes of this study were to develop
an informative educative video (DVD format) for hearing and deaf people with
information regarding SL, concepts of deafness and deaf people, language modalities
available for deaf people (Bilingualism, Oralism), legislation and Speech-language
pathology roles; and to present it to a group of hearing families of deaf children of
So Paulo city, observing the impact of the DVD upon subjects through an
evaluation of their personal opinions about it.
Methods: This study was approved by the Ethics Committee of the Medical
School of University of So Paulo (FMUSP) CAPPesq, protocol n. 876/06. Subjects
signed the Informed Consent Term according to the resolution 196/96, authorizing
the performance of procedures and the publication of results. The method described
in this study comprises two different and complementary stages: The first stage
comprised the process in which the researcher created, produced and edited an
586
informative educative audiovisual resource (DVD) lasting 15 minutes with basic

topics regarding deafness and SL. The video produced was entitled Deafness and
Sign Language Video 1 and has the participation of a foam character, a 60 cm high
articulated puppet named Gabi that acts with the researcher in the presentation of
the mentioned topics. The second stage of this study comprised the presentation of
the video to 28 hearing families of deaf children of So Paulo city and the observation
of the impact produced by the material upon subjects. Concerning the family
relations with the deaf children, the participants were characterized as follows:
mother: 23 (82,1%); father: 02 (7,1%); grandmother: 02 (7,1%) and aunt: 01 (3,6%)
ranging in age from 23 to 54 years old. The research and its purposes were explained
to the participants and the printed material (Informed Consent Term, Identification
form and Questionnaire) was firstly read out loud once, although all participants
were literate some of them did not seem confident for an individual reading (with
comprehension), requesting clarification of doubts. This stage was called preintervention. The presentation of the video to families was called intervention
stage. Data collecting was performed through Extensive Direct Observation
Questionnaire, and it was called post-intervention stage. In this stage, a
questionnaire with 15 questions (14 closed questions 12 specifically about the DVD,
and 01 open question comments, critics and/or suggestions about the video) was
applied. Next, data were tabulated in order to evaluate the impact of the material
upon care givers opinion and to verify whether the audiovisual resource fulfilled its
role of a good informative tool according to the participants views. The analysis of
the 12 closed questions (quantitative-descriptive study - program assessment section)
aiming to evaluate the efficiency of the program (DVD evaluation) was performed
using the Sign Test which verifies if there is predominance of a tendency in a
dichotomic situation (positives x negatives). The Sign Test verifies if there is
significantly more positive aspects than negative ones (or more negative than
positive) or if there is no difference between them. Regarding question 15 (open),
care givers were not obligated to respond it; they were invited to freely register their
critics and/or suggestions.
Results: Concerning the production process of the audiovisual resource: 1)
Concerning the idea/theme: The idea of an audiovisual emerged from the
characteristics of the material (image and sound) that may reach hearing and deaf
people; from the vast use of this resource in education and in some health areas (such
as Public Health, for instance); and from the awareness that alike materials are
scarce, especially in the Educational Audiology field, to be used as an educative and
informative material with groups of hearing parents and even with deaf patients that
would benefit from images. In this stage, the character Gabi - a 60 cm high
articulated foam puppet that interacts with the presenter was built, playing the role
of the expectator, asking some doubts as new information is presented. 2)
Concerning the research about the reality to be filmed: It was in this stage that the
scientific investigation process about the chosen theme was conducted.
Bibliographic and filmic reviews, the field work (raising of doubts brought from
Parents Support Group of the Educational Audiology Laboratory EAL of
University of So Paulo Medical School), discussions about the family quotidian and
the professionals involved, the challenges faced by the triad hearing family deaf
child health professional (carried out during Parents Group and during the EAL
team meeting) and the definition of topics to be considered in the video were carried
out. The 30-year experience in the area of Deafness and the 10-year of the Parents
Support Group existence in the EAL evidenced the need to not only indicate existing
informative materials such as books, magazines, dictionary, Libras CD-ROM,
587
documentaries, but also to produce other more specific informative materials to meet
the doubts brought by deaf and hearing people during all these years. 3) Concerning
the script elaboration: It was from the clinical experience, from the direct contact
with deaf people, from the reflections and conclusions originated by the doubts
brought by hearing families and from data collected in the pilot study with speech
pathologists enrolled in specialization courses that the researcher developed the
Script Argument _the videos soul with all topics to be considered, as well as the
language to be used. The script is the key document where professionals involved in
the elaboration of an audiovisual material base their work. 4) Concerning the script
performance: In this stage, the actions defined by the script argument were carried
out. The researcher and volunteer collaborators performed the first technical stage:
collecting images, interviews, developing the puppet manipulation, recording voices,
writing and singing the original sound track, etc. 5) Concerning the edition of images
and sounds: The researcher defined which images would be part of the video, their
presentation order and supervised the images and sounds treatment in order to
make the final result correspondent to the initial idea, to the research and to the
script argument. That is the finalization of the film. Regarding the families opinions
about the DVD (results concerning the use of the Audiovisual Resource) it was
verified that: 75% of the participants considered the video great, 25% good; 100% of
the participants would like to watch it again; 100% considered it a good way to
clarify doubts; 92,86% affirmed that if they had watched it by the time they received
the diagnostic of deafness of their children it would have contributed to diminish
their anguish, 3,57% affirmed it wouldnt have made any difference and 3,57% (01
subject) didnt know how to answer. The topics of the video were considered enough
by 92,86% of the participants, 3,57% considered it insufficient and 3,57% didnt know
how to answer. The video was considered very easy to understand by 53,57% of
the participants, easy to understand by 42,86% and hard by 3,57%. The image
was considered of great quality by 60,71% of the participants and of good
quality by 39,29%; the sound quality was considered great by 67,86% and good
by 32,14% of the participants. Concerning the duration of the video, 64,29% of the
participants considered it adequate and 35,71% considered it short. The
character Gabi was approved by 100% of the participants. The desire to watch the
video again having the opportunity to interact with it was mentioned by 92,86% of
the participants, 7,14% didnt show such interest. The same 7,14% affirmed that the
interactivity would not have contributed to increase the benefits of the information,
differently than the 92,86% of the participants who responded positively to this
question. These results demonstrated that 11 of the 12 questions were significantly
more incident concerning the positive aspect (p<0,001). In the open question
(Question 15), where participants could freely express their comments and register
their critics and/or suggestions, 09 subjects answered and all comments were
constructive: 04 subjects registered compliments to the initiative of creating this
kind of material; 04 subjects suggested that other videos should be produced in
order to intensify the theme; 01 subject suggested that more time should be given
for reading subtitles and titles.
Conclusions: The first stage of the study described the researchers
experiences as a Speech-language pathologist film maker face the challenges of a new
possibility in the area. The research and its results emphasized the important role of
the video as a working tool for the Speech-language pathologist the use of the
audiovisual as a mediator in its clinical and teaching practice and invite other
professionals to do their own audiovisual projects, since the conclusion of the first
stage of this study demonstrate that it is possible; The Speech-language pahologist
588
may activelly contribute (Speech-language pathologist film maker) for the

developemnt (creation, production, edition) of audiovisual material that inform,
educate about themes of the Speech-language rea, in this case, a vdeo about
deafness and SL; The bibliographic review carried out in three important data bases
of Brazilian and international scientific production indicates that there is a lack of
informative educative material specifically in the Educational Audiology area about
deafness and SL; Concerning the second stage of the study, most of the statistical
analyses (Signal Test) were significant and more incident towards the positive
aspects, except for the 11th question where 18 subjects considered the duration of the
video short, and the test was not significant. Such results demonstrated the absolute
acceptance of the video by these subjects of this study, indicating that the video fulfill
its role as informative educative material in health producing a positive impact upon
this groups opinion; The language and topics presented in the video seemed to be
adequate for reaching a varied public, of different socio-cultural levels; Facing the
great interest of hearing families to receive information about deafness and SL
through audiovisual resources, we suggest the development of other videos like the
one presented here, as well as new uses for the methodology applied in the second
stage of this study, with new researches that enhance the discussion about
information, memory, learning and knowledge mediated by audiovisual resources.
589
P033
PROSODIC ASPECTS OF READING IN STUDENTS WITH DYSLEXIA
L.M. Alves1,2, C. Reis2, A. Pinheiro2, S. Capellini3, M. Lalain4, A. Ghio1
1LPL
(Laboratoire Parole et Langage) - CNRS, Aix en Provence, France

(Universidade Federal de Minas Gerais), Belo Horizonte, Brasil
3UNESP (Universidade Estadual Paulista Jlio de Mesquita Filho), Marlia, Brasil
4Gipsa-lab, DPC (Dpartement Parole et Cognition) CNRS, Grenoble, France
2UFMG
Introduction
Dyslexia has been thoroughly investigated for more than a century through
the lens of the most widely-known fields. Issues of neurology, genetics, psychology,
pedagogy and linguistics have been raised and important discoveries and
observations have been made in recent years. However, when dyslexia is considered
from a linguistic perspective, there are few studies in the field of prosody. In an
effort to address this gap, the objective of this project is to understand the function of
prosody in reading out loud for children with dyslexia.
Methods
Two groups were studied in order to verify the effect of dyslexia on the
temporal prosodic aspects of reading for students with this condition. The first group
was comprised of 10 members who had been diagnosed with phonological dyslexia
(D) and the other had 30 members without this diagnosis and with no evidence of
other language or learning difficulties - control group (C). Both groups were
comprised of students between the ages of nine and 14 years.
The methodology consisted of recording the reading of a text, followed by a
retelling exercise and an objective test for text interpretation. The data were analyzed
through perceptive and acoustic means. In the acoustic analysis, the WinPitch
program was used. The temporal and melodic prosodic aspects of the oral reading
and the retelling exercise were correlated with the data obtained from the objective
interpretation tests.

Our first observations of the prosody in reading for the dyslexic group
studied made through phonological analysis and prior to conducting an acoustic
analysis allowed us to identify a lack of rhythmic regularity when these subjects
were reading. Their difficulty with delimiting tone groups, marking feet, and
producing stresses caused problems for the dyslexic students in their phonological
organization of intonation.
The following table illustrates the primary results obtained for the temporal
acoustic measurements of the reading. The measurements of articulation rate and
articulation time were proposed by Grosjean; Deschamps (1975) and Grosjean;
Collins (1979), but they did not take pauses into consideration.
590
Variable
Total elocution time (sec)
Articulation time (sec)
Elocution rate (syl/sec)
Articulation rate (syl/sec)
Number of syllables
Number of pauses
Duration of pauses (ms)
Means ( Standard Deviation)

Dyslexics
Control
162.3 (135.90)
46.94 (9.48)
91.70 (66.20)
35.07 (5.367)
1.72 (0.85)
3.69 (0.556)
3.11 (1.79)
4.86 (0.610)
213.6 (62.5)
167.67 (6.61)
97.80 (64.70)
22.83 (5.079)
86.00 (87.70)
11.53 (3.719)
F Test (P-value)
12.52 (0.00)*
8.71 (0.00)*
49.69 (0.00)*
8.83 (0.03)*
7.34 (0.00)*
26.69 (0.00)*
12.84 (0.00)*
TABLE 1: temporal acoustic measurements of reading

According to our observations, we obtained values that were statistically
significant for all of the temporal variables studied, with weaker performance in the
abilities of the dyslexic subjects. Consistent with the results of the research by
Fawcett; Nicolson (2002), we particularly noted lower values in the articulation rate
of the dyslexic subjects, demonstrating that the speed of producing each articulatory
gesture is slower in children with a reading disability.
In the retelling exercise, however, we only obtained statistical differences
when comparing the following variables: total elocution time (the dyslexic subjects
required more time), and duration of pauses (longer for the dyslexic subjects).
With respect to the prosodic aspects of fundamental frequency (F0), our
principal findings are presented in table 2:
Variable
Initial F0
Minimal F0
Maximal F0
Final F0
Pitch Range
Mean in Hz
(C / D)
239.92 / 190.53
183.84 / 148.25
309.63 / 234.48
211.51 / 180.81
128.28 / 91.25
D.P.
53.19 / 56.04
46.98 / 48.97
68.42 / 73.05
98.78 / 56.59
67.66 / 52.58
0.00
0.00
0.00
0.00
0.00
TABLE 2: F0 measurements in reading

- Initial, final, maximal and minimal F0 values: all of the measured values
were lower for the dyslexic subjects. The analysis of these same values for different
types of phrases (interrogative, exclamatory and declarative) indicates that the
dyslexic subjects did not mark the differences between phrase types (or they made
little differentiation).
- In order to objectively verify the melodic variation of these subjects while
reading, we measured the pitch range, which is the variation between the maximal
and minimal values obtained from the overall configuration of the F0 curve. The
subjects in the control group had vocal pitch range values that were significantly
higher than those of the dyslexics.
- Another aspect to be observed, particularly in the comparison between the
initial and final F0 values, is declination, which is considered to be a time-related
phenomenon where there is a gradual decline in the F0 curve during an utterance
(COHEN; t HART, 1967; LADD, 1984). This phenomenon can be linked to
physiological issues (LIEBERMAN, 1967; COLLIER, 1975), how grammar was
learned (GUSSENHOVEN, 2004) and can even be under the control of the speaker (t
HART; COLLIER; COHEN, 1990). In this project we did not attempt to specifically
591
measure the line of declination because it would have required a specific

methodology and a very detailed analysis of all of the points of melodic
configuration for each utterance. Through observing the initial and final F0 points,
we perceived this phenomenon in very simple terms. After analyzing the graphs for
the dyslexic subjects, we observed this tendency was quite subtle, with an almost flat
line drawn between the initial and final F0 values.
For the retelling exercise, the same tendencies were observed in both groups.
However, we noted the need to conduct research with spontaneous speech. We can
confirm that the dyslexic subjects are not able to produce melodic variations in
reading activities (reading as an activity itself and reporting on text that has been
read).
Following is the analysis of the localized aspects observed in the prominent
stressed and pre-stressed vowels for each tonal group:
- Duration: the values obtained for the production of the prominent stressed
vowel were not particularly different between the groups, fluctuating between 0.17
and 0.19 seconds, a difference which was not statistically significant. Upon
analyzing the values for the duration of pre-stressed vowels, we observed that the
dyslexic individuals took significantly longer to produce these segments. We know
that the vowel in the prominent stressed syllable is the most important element in
prosodic studies because it holds the key characteristics for melodic movement.
However, when we compared the results of our measurements of duration, we
perceived that there was a difference in behavior between the groups, only related to
the duration of the vowel in pre-stressed syllables. Specifically, we noticed that the
dyslexic subjects produced these vowels with a significantly longer duration (0.13
sec) than the control group (0.08 sec). This explains the difficulty we observed in
their identification of the prominent stress in some cases, since the dyslexic subjects
held the stressed vowel with only a slightly longer duration than the pre-stressed,
making the pre-stressed vowels longer than usual. This difficulty can be related to
their perception of rhythmic alternation between stressed and non-stressed segments
while reading. In the retelling exercise, however, there was no significant difference
in the behavior of the groups. Therefore, in the processing of oral language, this
perception seems to be accurate.
- Melodic amplitude: this variable refers to how much each of the melodic
curve segments, understood as the prominent stressed and pre-stressed vowels of
each utterance, changed from the initial point to the final, that is, the melodic
interval. We noticed that the subjects in the control group presented significantly
higher values in the prominent stresses vowels, with an average of 50.19 Hz, when
compared with the dyslexics (29.73 Hz). In other words, the dyslexic subjects
presented a lower amplitude of melodic variation in the prominent stressed vowel.
These results are consistent with the lower values of pitch range observed in the
overall configuration of the melodic curve for dyslexic subjects. These observations
reaffirm the limitations of dyslexic subjects in their ability to make specific melodic
movements when reading. In the retelling exercise, the amplitude values did not
differ between the studied groups.
Speed of melodic change: to obtain this rate, we divided the value of the
melodic interval by the duration of this interval, measured in Hz/sec, as proposed
by t Hart et al. (1990). Through the values presented in table 3, it can be observed
that, in the control group, we obtained a mean value of 0.30 Hz/sec for the
prominent stressed vowel, which is significantly higher than that of the dyslexics
(0.14 Hz/sec). We can therefore certify that, besides having a lower melodic
variation, the dyslexic subjects had less ability to make melodic changes. In other
592
words, they spent more time to change the melody of the nuclear stress. It is
interesting to note that this could also be applied to pre-stressed elements for
dyslexic subjects since their weak definition of the stressed element resulted in the
pre-stressed element having almost equal importance.
Prominent stressed vowel
Mean
(in Hz/sec)
Group
0.30 / 0.14
C/D
Standard Deviation
0.30 / 0.14
Pre-stressed vowel
P
Mean
(in Hz/sec)
Standard Deviation
0.00
0.22 / 0.13
0.33 / 0.16
0.01
Table 3: Speed of melodic change in Hertz per second

In the retelling exercise, however, when we compared the prominent stressed
and pre-stressed vowels between the two groups, we did not obtain significant
values for this change in melodic movement. In other words, in relating a read text,
both groups had similar speed changes in melodic movement.
- Intensity: the results obtained from reading and retelling were analyzed,
considering both local measurements, that is, the intensity of the stressed and prestressed vowels, as well as enunciation overall, measuring the peak signal of
intensity for each uttered syllable. In both analyses, the dyslexic subjects
presented lower levels of intensity in their reading.
We know, then, that F0 and intensity are independent but related parameters,
which was also proven by the studies of Alku; Vintturi; Vilkman (2001). According
to the authors, the production of a higher voice frequency leads the speaker to
increase the number of glottal stops per second, increasing the vibration of the wave
of speech pressure, which in turn, elevates vocal intensity. An opposing rationale
could be applied to our results which demonstrated that a lower intensity is related
to lower F0 values, thus identifying the interrelationship between F0 and intensity.
We can relate these two aspects to the profile of the dyslexic subjects portrayed
during the reading activity: minor melodic variation, usage of lower F0 and lower
intensity, making these factors closely related.
- Correlation between the studied variables and text comprehension: in order
to verify the factors related to the number of correct answers, we used the Gompit
logistical regression. Through the logistical regression, we obtained a set of variables
that explain part of the variation in the number of correct answers. Using this model,
we correlated all of the studied prosodic variables to the relative data on
comprehension and we found that the rate of elocution and duration of pauses were
significant (p<0.05), indicating that a shorter duration of pauses and a higher rate of
elocution would be associated with higher levels of text interpretation. The study of
the other prosodic variables presented less conclusive results which suggests the
need for a larger sample size in order to obtain more reliable observations.
Conclusion
Without attempting to consider all of the possible variables involved, this
research revealed aspects of the prosodic nature of reading for dyslexic children. It
defined a tendency among these individuals in their intonational and temporal
structure when reading out loud, highlighting unique characteristics such as aspects
related to the variation of fundamental frequency (clearly demonstrating a limitation
in their ability to make melodic changes and to mark phrase type), aspects related to
temporal processing (excessive use of pauses and placement outside their usual
593
location, reduced speeds of reading and articulation) and difficulties in marking

rhythm and prominent stresses, all of which form a profile for the dyslexic subjects in
this study.
References
ALKU, P.; VINTTURI, J.; VILKMAN, E. Measuring the effect of fundamental frequency
raising as a strategy for increasing vocal intensity in soft, normal and loud phonation.
Speech Communication, v. 38, p. 321-334, 2001.
COHEN, A.; t HART, J. On the anatomy of intonation. Lingua, v. 19, p. 177-192, 1967.
COLLIER, R. Physiological correlates of intonation patterns. Journal of the Acoustic Society of
America, v. 58, p. 249-255, 1975.
GROSJEAN, F.; DESCHAMPS, A. Analyse contrastive temporalles de langlais et du franais:
vitesse de parole et variables composantes, phnomnes dhesitastion. Basel:
Phonetica, 1975.
GROSJEAN, F.; COLLINS, M. Breathing, pausing and reading. Phonetica, v. 36, p. 98-114,
1979.
GUSSENHOVEN, C. The phonology of tone and intonation. Cambridge: Cambridge University
Press, 2004.
FAWCETT, A. J.; NICOLSON, R. I. Children with dyslexia are slow to articulate a single
speech gesture. Dyslexia, oct-dec; 8, 4, p. 189-203, 2002.
LADD, R. Declination: a reviewand some hypotheses. Phonology Yearbook, v. 1, p. 53-74, 1984.
LIEBERMAN, P. Intonation, Perception and Language. Cambridge: MIT Press, 1967.
t HART, J., COLLIER, R.; COHEN, A. A perceptual study of intonation: an experimental-phonetic
approach to speech melody. Cambridge: Cambridge University Press, 1990.
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P164
EVALUATION OF MOVIE SUBTITLE READING COMPREHENSION IN

ELEMENTARY SCHOOL CHILDREN
Minucci, MV (Author)* and Crnio, MS (Author)**
*Speech pathologists Master's Degree in Human Communication by Medical School
University of So Paulo (FMUSP).
** 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 So Paulo (FMUSP).
Introduction
Reading is an interactive process that involves different perceptual, auditory,
visual, cognitive and language skills. These skills are interrelated and enable the
reader to develop her abilities from decoding words to reading comprehension (Sola
et al, 2003; Berninger, 2003; Catts, 2009; Murphy and Schochat, 2009) (3-6.
Among the many presentations of written text, video subtitles (mobile text),
disseminated by television and film, are a tool to aid in the development of reading
skills necessary for the individual to be considered a proficient reader (LeppaNen,
Aunola e Nurmi, 2005).
The literature points to the importance of reading mobile texts (film subtitles,
hyperlinks, captions) in the learning process. Studies show the influence of television
and the reading of captions in learning and improving reading comprehension for
readers of all levels (Markham, 1989; Neuman, 1990).
Koolstra, Van der Kamp e Van der Voort (1997) demonstrated that when
video programming is watched along with its subtitles, children have their decoding
skills stimulated. The study of Leppa nen, Aunola and Nurmi (2005) with children
at 1st and 2nd grades of elementary school, also showed that reading habits with
different kinds of texts, beyond school texts, are critical to the development of a
proficient reader.
Linebarger (2001) in her study of the relationship between the use of subtitles
and reading behavior of students in the 2nd grade of elementary education at a
school in Kansas (USA) found that beginning readers recognize more words when
they watch television programs with subtitles. She also reported that captions have
helped children to focus on the central theme and the details of story, and not to be
distracted by the sound and visual effects of the programming being watched.
Kothari et. Al, (2002) studied the impact of subtitles, movies and music in
reading skills in children with learning disabilities. Their results show that the use of
film subtitles is a simple, economical and comprehensive tool with enormous
potential to improve literacy and reading skills of this population.
595
Although fixed text reading is a complex process, it differs from the reading
of mobile texts, especially regarding the timing for the text on screen (Ellis, 1995) and
the syntactic construction of the sentences (Scott, 2009). The assessment of readers for
this kind of text is also different Campbell et al, 2004).
As a result, the use of such media favors the development of reading skills,
especially of rapid recognition and word decoding required for the improvement of
reading proficiency (LeppaNen, Aunola e Nurmi, 2005; Broddason, 2006).
Aim
The main purpose of this research is to compare the movie subtitle reading
comprehension in 2nd and 4th graders of ES in two different situations: when the
movie segment was watched without interruption, and when it was watched with
the option of pausing the movie, thus analyzing the influence of subtitle presentation
speed on reading comprehension.
Methods
This study was approved by the Ethics Committee for Analysis of Research
Projects - CAPPesq, Clinic of the Clinical Hospital and School of Medicine,
University of So Paulo, under the number 1248/06.
60 schoolchildren took part in this research, 30 of those from the 2nd grade
(8.7 years old average) and 30 from the 4th grade (10.6 years old average), paired for
gender.
The criteria used to select students participating in the survey was: being
literate, having never repeated a school grade; having no complaints from the teacher
about learning abilities at school; and no complaints from the teacher and / or family
about sensory and cognitive impairments that could affect its participation in the
research.
Each student watched the movie segment, alone, with subtitles and without
sound in two different days and situations: Situation 1 where the movie segment was
watched without interruption, and Situation 2 where the student had the option of
pausing the movie segment at any time to read the subtitles.
After watching the movie segment, each student told what he understood
and responded to inferential questions.
In situation 2 the time each student spent watching the segment was recorded
to analyze the correlation between this time and reading comprehension.
The reading comprehension performance of each student was compared
through two analysis instruments, one based in reading skills (Castillo, 1999) and
another based in History of Grammar (Carr, 2003).
Pre-suppositions for Castillo (1999) are based on the levels and skills in
developing reading proficiency. Since the criterion of Carr (2003), based on the
Grammar of History concentrates on the analysis of the depth with which the subject
can report the read contents, paying attention to details that are important for the
construction of the story (setting, theme, episodes, climax, sequence), ensuring
greater detail in the retelling.
596
According to Castillo, a student could score at four increasing levels

(decoding, literal comprehension, understanding, independent and critical reading),
and the reading skills of more advanced levels received higher scores than of lower
levels.
The level of decoding had six abilities, the level of literal understanding had
five, the level of independent understanding had six, and critical reading had five.
The sum of the total score of all levels is equivalent to one hundred and eight points.
Reading comprehension was assessed based on the grammar of the story,
based on the criteria of Carr (2003). This analysis is based on the scenario of the story
(introduction, inclusion of the main characters and other characters, time and space),
the Theme (references to the problem to be solved, and the main theme), plot
episodes (number of episodes that has been retelled by the subject), Resolution
(solution of problems / objectives achieved, completion of the story), and the
ordering of events in sequence. In total, the student could reach ten (10) points.

There was no statistical difference between the average time watching the
movie at 2nd and 4th grade in situation 2, like was observed by analyzing the results
of the Mann-Whitney value =0.05 T= 341.50 and p- value= 0.108.
The students in the 4th grade paused to read most of the subtitles, which
could increase the time taken to watch the movie segment. however, these students
had read speeds faster than those of the 2nd grade.
Based on this information, we can surmise that the students of 2nd grade may
have initially tried to read the subtitles, but they then took too long to decode. The
majority of the students in this grade then decided not to proceed pausing the movie.
When analyzing the mean and median of performance in reading abillities
skills, according to Castillo (1999), of the students in 2nd grade we observed that in
situation 2 the group tends to have higher scores when compared to the situation 1, a
fact confirmed by testing the signal: Z statistic = 4.5107, p-value <0.001 and Wilcoxon
test for paired data: statistics T = 13.5, p-value <0.001.
The analysis of the students according to Castillo (1999), by means of the
Wilcoxon statistical tests (T statistic = 12.0 with p-value <0.0001) and test signal
(statistical Z = 4.17 with p-value <0.0001) confirmed the statistical difference between
the performance of students in 4th grade in situation 1 and 2, with a tendency to
higher scores in the situation 2. Despite the statistical difference between the
performance of students in both situations, the reading level did not change.
However, it is important to note that in situation 2 five students had skills of more
advanced level of reading (critical reading), which was not observed in situation 1.
Since there are differences between values of scores obtained in situation 1
and 2, it was decided to calculate the average between them to perform the MannWhitney test, obtaining the statistical W = 180.000, p-value <0.0001 and showing a
statistical difference between the performance of students in 2nd and 4th grades in
the situation 2.
Analyzing the intra-group 2nd grade, according to the protocol of Carr (2003)
we did not observe statistical differences among students in both situations (p-value
= 0.67).
597
In the case of intra-group of students in 4th grade, according to the protocol

of Carr (2003), there was a significant difference when comparing the two situations
by means of Kendall's correlation with the values = 0.314 (p = 0.029). The students
in the 4th grade had better reading comprehension when compared to 2nd grade in
both situations, ruling out the hypothesis of equality between the two groups (p =
0.023) in relation to performance in the situation 2. These findings corroborate the
findings of Sternberg and Grigorenko (2003), emphasizing the existence of a type of
textual and linguistic knowledge needed in each stage of reading development.
Analyzing the performance of students in 2nd and 4th grade, according to
Castillo (1999), we note that the 4th grade students scored very close to the
subsequent reading level (level of self-understanding), achieving, on average, most
of the skills relating to this level (identifying the main ideas, establishing
relationships between main ideas and secondary ones, establishing cause-effect
relationships, making predictions, hypotheses, inferences, drawing conclusions).
This information corroborates the findings of Capovilla and Dias (2007), who
argue that students tend to change the reading strategies used with increasing
education, with a predominance of strategies in spelling and supported greater
proficiency and independence in reading in 4th grade. However, these students were
classified as having a level of understanding of the literal reading, as required by the
assumptions of Castillo (1999), which states that the reader only reaches a reading
level when it has all the skills relating to this level.
These data corroborate results reported by the Evaluation System of Basic
Education in Brazil (SAEB, 2005), which shows that the students do not reach the
most advanced level of reading, ie the critical reading at this age .
When analyzing the groups through the Grammar of History (Carr, 2003), we
observed that there was no significant difference in the performance of students in
2nd grade between situations 1 and 2. According to Pinheiro and Cunha (2008), this
data relates to the fact that the phoneme-grapheme relationship in the beginning
reader is still under development. This reader tends to use the phonological route,
which is slower than the lexical route.
The ability to read with understanding depends on the decoding of words
and on lexical skills, which are mutually reinforcing, developing interactively (Smith,
1999). Since the 4th graders performed better on decoding the words in the movie
subtitles, they also had better scores in reading comprehension, which corroborates
the findings by Protopapas et al (2006) and Roe at al (2003).
The ability to pause the subtitles was more significant for the more
experienced readers, and it suggests that the accuracy of saccadic eye movements,
better developed with increasing age - linked to textual skills - provides a more rapid
and accurate reading (Smith, 1999). Also, the familiarity of the words shown in the
subtitles, as stated by Ellis (1995), potentiated both the decoding and reading
comprehension of the movie subtitles.
The ability to pause the subtitles allowed the 4th graders better results in the
reading comprehension of film subtitles. This supports the findings of Smith (1999)
and Jensema (2000) on the importance of reading speed. The mobile text should
always be presented at a speed which the student can follow, in order not to
discourage it from decoding and comprehending the text satisfactorily.
598
Conclusion
The level of education is an important factor in understanding movie
subtitles. It is also important that people involved in the development of subtitles
take into consideration the speed of the display of subtitles according to intended
school grades. Moreover, it is important that professionals working with learning,
use this type of media while respecting the capabilities of students in each grade.
References
Solan HA, Shelley-Tremblay J, Ficarra A, Silverman M, Larson S. Effect of attention
therapy on reading comprehension. J. Learn Disabil. 2003; 36:556563.
Berninger VW, Abbott RD, Vermeulen K, Fulton CM. Paths to reading
comprehension in at-risk second-grade readers. J. Learn Disabil. 2006;39:334351.
Catts HW. The narrow view of reading promotes a broad view of comprehension.
Lang, Speech, and Hearing Serv in Schools. 2009;40:178183.
Murphy CF, Schochat E. Correlations between reading, phonological awareness and
auditory temporal processing. Pr-Fono R. Atual. Cient. [online] 2009;21:13-18
Leppanen U, Aunola K, Nurmi J. Beginning readers reading performance and
reading habits. J. Res Read. 2005;28:383399
Markham PL. The effects of captioned television videotapes on the listening
comprehension of beginning, intermediate, and advanced ESL students. Educ
Technol. 1989;29:38-41.
Neuman SB, Koskinen P. Captioned television as comprehensible input: Effects of
incidental word learning from context for language minority students. Res Q.
1992;27:95-106.
Koolstra CM, Van der Voort THA, Van der Kamp LJTh. Television's impact on
children's reading comprehension and decoding skills: a 3-year panel study. Res
Q.1997;32(2):128-152.
Linebarger DL. Learning to read from television: the effects of using captions and
narration. J Educ Psychol. 2001;93:288.
Kothari B, Takeda J, Joshi A, Pandey A. Same language subtitling: a butterfly for
literacy? Int J Lifelong Educ. 2002;21:55-66
Ellis AW. The timely recognition of words. In: Ellis AW. Reading, writing and
dyslexia: a cognitive analysis. Porto Alegre: Artes Mdica, 1995.
Scott CM. A case for the sentence in reading comprehension. Lang Speech Hear Serv
Sch. 2009;40:184191.
Broddason T. The instructional value of subtitles. Presented at Informal learning and
digital media: constructions, contexts, consequences.: University of Southern
Denmark; Denmark, 2006 September 21-23; Odense, Denmark p.21-2
Castillo HV. The reading of literary texts vs. scientific texts by incipient readers . In:
Witter GP (ed). Reading texts and research. Campinas:Alnea, 1999 pg. 55-64.
Carr CL. Journaling as a Tool to Improve Story Comprehension for Kindergarten
Students [dissertao]. Tenessee: University of Tennessee; 2003
CAPOVILLA, Alessandra Gotuzo Seabra ; DIAS, N. M. . Development of reading
strategies in elementary school and relationship to school. Psicologia em Revista, v.
13, p. 363-382, 2007.
Brazil. Ministry of Education. Report of the First Results: Mean performance of
students in SAEB/2005 in comparative perspective. 2007.
Pinheiro AMV, Cunha CR, Lucio PS. Task of reading words aloud: a proposal for
error analysis. Rev. Port. de Education. 2008;21:115-138.
599
Smith F. Understanding Reading: A Psycholinguistic Analysis of Reading and

Learning to Read. Porto Alegre: Artes Mdicas, 1999.
Protopapas A, Sideridis GD, Mouzaki A, Simos PG. Development of lexical mediation
in the relationship between reading comprehension and word reading skills in Greek.
Scient Stud Read. 2006;1-17
Roe BD, Smith SH, Burns PC. Teaching Reading in Todays Elementary Schools.
Boston: Houghton Mifflin Company, 2003.
Jensema CJ, Sharkawy S, Danturthi RS, Burch R. Eye Movement Patterns of
Captioned Television viewers. Am Ann Deaf. 2000;145:275-85
600
FP02.2
ASSESSING AND GRADING SPEECH
CONSISTENTLY AND OBJECTIVELY
THERAPY
TRAINEES
L. A. Simoens
University College Ghent, Faculty of Health Care Vesalius, Ghent, Belgium
Correspondence: Luc Simoens, Hogeschool Gent, Faculty of Health Care Vesalius,
Keramiekstraat 80, B-9000 Gent. E-mail: Luc.Simoens@hogent.be.
INTRODUCTION
One of the difficult tasks with high responsibility trainee assessors have to
deal with is determining the mark or grade a trainee gets after accomplishing his
training period. Converting the assessment into a grade is frequently based on the
professional and didactical knowledge, views and background of professionals and
coaches. They observe trainees in authentic situations, go through the students
portfolio and discuss their findings with the trainee. Assessors finally express their
findings in a mark or a grade which, in a number of cases, is affected by the
assessors personal perception of the trainee and his view on the training period. This
method is no longer tenable: trainees want to know what affects their grade and to
what extent whereas coaches feel better when they may rely upon a consistent
system to convert their findings and not having to convert an assessment into a
figure by themselves. In recent years the achievements have to be expressed in terms
of competences.
To deal with these challenges a working method was developed in cooperation with the trainee coaches of the bachelor programme in Speech Therapy of
the University College Ghent, Faculty of Health Care Vesalius. The method is based
on a trainee's observed professional behaviour, the profile of the speech therapy
profession and the expected general and profession specific competences. A software
tool converts the observations into the corresponding competences, calculates a raw
score and proposes a local grade based on the compiled results of previous trainees.
Additionally the international ECTS grade is proposed.
The procedure highly meets the quality criteria published by the ENQA
(2009).
THE METHOD
Before starting students are informed thoroughly about the method.
The method itself consists of two parts worked out in a five step procedure.
In the first part data of the trainees performance are collected in a more strict
procedure compared to earlier methods. The data are collected in an evaluation form.
In the second part the data are transferred in a software tool converting them
in a raw score. The raw scores are used to propose a local and an ECTS grade.
The method combines a norm-referenced assessment based on the
professional profile with a comparative evaluation based on the results of all
601
students of the same subject in a comparable authentic situation and level of study.
The presented method is developed according to the principle only assess what you
observed.
Step one: observing and registering
The speech therapist of the trainee post or the coach observes the trainee
during his representative tasks in an authentic situation. The observations are
registered in one of two sorts of registration forms: an open form wherein the
assessor chronologically and as objective and complete as possible takes note of what
he observes or a form, mostly used by more experienced assessors, wherein the tasks
of the trainee are pre-printed in an easy usable structure. The grouping of the items
in this form corresponds with the structure of the evaluation form described in step
three. The observer only has to take note of how the student affects his tasks.
Step two: feed back
In order to improve the skills of the student and to check the correctness of
the observations or motivation the registered information is discussed with the
student as soon as possible. All conversation with the student may result in
registering of advices or remarks used for feedback. This feedback is crucial as at the
end of it both the assessor and the trainee have to come to an agreement concerning
the trainees performance: assessor and trainee sign the form to avoid any discussion
in the following quantification and classification processes.
A copy of the completed forms is saved in the students portfolio that he
might continuously consult them and if he decides to use them for self grading.
Step three: Summarizing
The coach collects the registration forms of the trainee and transfers the
remarks to an evaluation form. In this evaluation form the tasks of the trainee are
sorted in items. Groups of items form different sections; the sections are grouped in
main categories making it possible to take different weightings into account. Next to
every item all kinds of remarks are sorted in a Likert scale. The coach marks the
sentences applicable for the student to be assessed.
Although the evolution of the students proficiency has been taken into
account in the included descriptions sometimes choices have to be made. These
choices are to be agreed with other coaches in order to make choices consistent. Once
the form has been filled in the assessment is registered and may be quantified.
Since the achievements of trainees more and more have to be expressed in
terms of competences recently a new part is being added to the electronic version of
the evaluation form. This makes it possible to transpose the observed achievements
into corresponding competences.
Step four: Quantification and Classification
The information on the evaluation form is manually keyed in into a
spreadsheet wherein the relative importance of the categories, the sections and all the
items are fixed. The relative values are decided by the group of coaches and practice
lecturers, members of the examination board. The spreadsheet converts the marks
automatically and consistently into a raw score.
Properties of the tool
The calculation results in figures on two levels, one expressing the result of
each section, the other giving the total result in a raw score.
602
At University College Ghent two versions of the spreadsheet tool are

available. One version is password protected. It is intended for the coach and used
by the staff and by that available only within the faculty: figures and relative values
are visible. It has to be filled in at least once for every trainee period of every student.
The second version is the student version. It makes identical calculations but without
visible figures. It is intended to allow self assessment and available on the electronic
learning environment.
Once the spreadsheet has been filled in three printed versions of the report
are available: one for the coach/supervisor, one for the student and one for the
speech therapist of the trainee place. In the reports the achievements on section level
are expressed in two categories: sufficiently (pass) or improvement needed (fail).
The reports are not handed over before all results are available and anyhow after the
meeting of the coaches (see step five).
Preparing scoring and grading
The coach sends the raw scores of all his students to the administrator. The
administrator files the results in a database and a percentile score is generated.
Marks between 0 and 20 are proposed, conformable to the local grade system of the
University College Ghent / Flemish marking system.
The ECTS grade is deduced by filing the raw scores of all students every semester.
Step five: Scoring and Grading
In a meeting preparing the deliberation the coaches may adjust the marks if
needed. This is exceptional and only possible according to earlier made agreements
or when strong evidence makes it necessary.
The coaches confirm and present the students marks to the board of
examiners. Based on the proposed marks the board of examiners deliberates and
awards marks and grades.
FEATURES OF THE METHOD

Consistent
Using a protected spreadsheet makes the link between the observed achievements
and the marks inseparable. It also prevents possible miscalculations. If by incident an
error occurs while entering the marks the error is indicated. The number and level of
the inputs is counted and returned for control reasons.
Additional information due to tasks out of the traineeship cannot be
incorporated without agreement.
Objective
There is a direct link between the level of achievement and the score. It is impossible
for the assessor to influence the calculated result. Grading and scoring may hardly be
affected by the assessors as the calculation of the raw scores the basis for grading
is consistently calculated based on fixed values and weightings.
All students are equally assessed with the same reference: the starting
professional. As the raw scores of trainees with a comparable level of experience are
grouped the system takes their specific acquired level (in consecutive traineeship
periods) into account.
603
Individualized
The individual achievements of the student are expressed in the evaluation form and
the competences profile. In that students may compare their individual level of
performance with the level of the starting professional.
Immediate feedback gives the students the possibility to reply by which false
impressions may be corrected.
Follow up of the forms in consecutive trainee periods reveal to some extent
an evolution of the achievements of the trainee.
Complete
Combined with the theoretical and practical courses of the speech therapy
program, the practical training and the traineeship vade-mecum containing
organizational aspects students have a considerable amount of information at their
disposal. The evaluation form contains all assessed topics and reports clearly the
findings to the assessment partners. If a new task emerges it may easily be added.
The coaches of the program board have to agree concerning topics that have to be
added permanently.
Transparent
The student not only has an overview of the evaluated tasks and
competences; by allowing self assessment and even self grading by means of the tool
published on the e-learning system the student has the possibility to select priorities
in correcting his performances.
For complete transparency the coaches might decide to release the figures
and relative values used to calculate the raw score.
Internationally Applicable
In order to assess international students the procedure and the tool are easily
adaptable by simply translating only the evaluation form and the report. In this way
students and coaches of international partner institutions get a description of the
expected performances during a traineeship. The expectations can of course be
discussed and adapted to specific needs or profiles.
In consequence of the use of a Likert scale the home university receives a
structured description of the trainees work in an authentic situation.
As raw scores are automatically converted into a proposal for an ECTS grade
no extra conversion or decision is needed. In that way adding an ECTS grade is
directly competence based.
Flexible
The spreadsheet makes it easier to add items if necessary, facilitates
simulations and new combinations of tasks and allows computing a variety of
relations between the results.
As the method is based on the registration of observable behaviour the
analysis of this behaviour may lead to more profound discussions concerning for
instance the reasons why it is established.
If wanted the printed reports may present more detailed information
concerning the assessment. All information showing the results of the computation
may be disclosed: the raw score or the proposed total grade of the professional
profile, a grade per group of items, the raw scores of each item and so on.
Supplementary features
604
To a certain extent and not unconditionally the tool makes it possible to

profile the trainee settings, the assessors, the influence of specific authentic situations
and other.
REFERENCES
ENQA - European Network for Quality Assurance in Higher Education (2009), Standards and
Guidelines for Quality Assurance in the European Higher Education Area, 2009,
Helsinki,
3rd
edition.
Retrieved
January
31,
2010
from
http://www.enqa.eu/files/ESG_3edition%20(2).pdf
European commission (2010), ECTS - European Credit Transfer and Accumulation System.
Retrieved January 31, 2010 from http://ec.europa.eu/education/lifelong-learningpolicy/doc48_en.htm
University College Ghent, Faculty of Health Care Vesalius, Speech therapy program.
Stagevademecum (2008-2009). Internally published trainee guide.
Simoens L.(2000). The assessment of vocational skills. In S Lindblom-Ylnne (Ed.),
Innovations in Higher Education. Helsinki: Helsinki University Printing House.
Simoens L.(2005). Assessment van stagecompetenties: andere beoordelaar, zelfde
score in: Delta Tijdschrift voor Hoger Onderwijs, 1, 43-48. Brugge
Simoens L.(2006) Assessing Trainees. How to objectively convert an assessment into an ECTS
grade? In K. Lfgren (Ed.) ECTS Assessment in Higher Education. Ume: Ume
University.
Correspondence: Pyckstraat 6, B-8370 Blankenberge
605
SE04.1
THE UNITED NATIONS CONVENTION

ON THE RIGHTS OF PERSONS WITH DISABILITIES (UN-CRPD):
THE FIRST HUMAN RIGHTS TREATY OF THE 21ST CENTURY AND
ITS RELEVANCE TO SPEECH-LANGUAGE-HEARING PROFESSIONALS
Michelle J. Yee, M.A., CCC-SLP, University of San Francisco and Operations Coordinator for
the American Speech-Language-Hearing Association's (ASHA's) Asian-Pacific Islander (API)
Caucus
Greta Tan, M.A., CCC-SLP, API Caucus Chair of the American-Speech-Language-Hearing
Association (ASHA)
Rhona Galera, M.S., CCC-SLP, Childrens Hospital of Pittsburgh and University of
Pittsburgh
Li-Rong Lilly Cheng, Ph.D., Director of the Confucius Institute at San Diego State University,
Chair of the Asia Desk for the San Diego World Trade Center, and Chair of the Education
Committee for the International Association of Logopedics and Phoniatrics
Kenneth Tom, Ph.D., CCC-SLP, California State University Fullerton
Summary
The United Nations Convention on the Rights of Persons with Disabilities

(UN-CRPD) is the first comprehensive human rights treaty of the 21st century and
the first legally binding international instrument on disability. An overview of the
UN-CRPD will be presented, including the treatys guiding principles, seminal
approach to disability from a social-human rights model, and relevance to speechlanguage-hearing professionals.
Abstract
The United Nations Convention on the Rights of Persons with Disabilities

(UN-CRPD) is the first comprehensive human rights treaty of the 21st century and
the first legally binding international instrument on disability. An overview of the
UN-CRPD will be presented, including the treatys guiding principles, its seminal
approach to disability from a social-human rights model, and the comprehensive
obligations on State Parties that are signatories to the Convention. The UN-CRPDs
relevance to speech and hearing professionals internationally will be highlighted via
two case studies of countries that are signatories to the Convention (Philippines and
Ecuador) where clinical rehabilitative work in cleft palate/ craniofacial disorders is
emergent.
Summary of Proposal
An Overview of the UN-CRPD
The UN-CRPD, which recently entered into force on May 12, 2008, is the first
comprehensive human rights treaty of the 21st century and the first legally binding
606
international instrument on disability. The document breaks new ground by clearly

defining the concept of disability and goes beyond prohibiting discrimination
against persons with disabilities to outlining steps that signatories must take to
create an environment where persons with disabilities can enjoy equality in society.
The UN-CRRD may function as an effective instrument by which speech and hearing
professionals may better advocate for their clients with communicative disorders and
other disabilities.
The UN-CRPD was adopted on Dec. 13, 2006 and opened for signature on March 30,
2007. Out of the 192 member states of the United Nations, 142 countries have become
signatories to the Convention, and 85 countries have ratified the document (United Nations
Enable, 2008). The U.S. recently signed the treaty on July 30, 2009. Countries that have both
signed and ratified the Convention include Argentina, Australia, China, Cuba, Ecuador,
Egypt, India, Italy, Jordan, Mexico, New Zealand, the Philippines, Republic of Korea,
Rwanda, Spain, Sweden, Thailand, the United Kingdom, and Uganda. Signatories to the
Convention include Canada, France, the Czech Republic, Germany, Denmark, and Israel
(United Nations Enable, 2009).
The Convention is seminal because it approaches the conception of disability

using a social-human rights model rather than a medical-social welfare model of
disability (Melish, 2007; United Nations Enable, 2008). The traditional medical-social
welfare model of disability focuses on inability, inherent impairment, and difference
as exceptions to universal human rights. In contrast, the social-human rights model
focuses on ability and inclusion and is consistent with a participatory approach to
disability (Melish, 2007; National Council on Disability, 2002). This rights-based
model regards people with disability as participants in their own self-development
and as consultants in decision-making about their development (National Council on
Disability, 2002). The Convention broadens the scope for persons with disabilities
beyond mere access to the physical environment to equality and non-discrimination
with full participation in health, education, employment, personal development, and
social opportunities (United Nations Enable, 2009). For speech and hearing
professionals, the UN-CRPD is pioneering in Article 2 of the Convention, where clear
definitions of communication, language, and universal design are articulated,
and in Article 26 of the Convention, which articulates the right to habilitation and
rehabilitation.
The UN-CRPD brings to fruition more than five years of advocacy and
drafting work by state parties, non-governmental organizations (NGOs), and
individuals with disabilities. Parties to the Convention are required to eradicate
discriminatory laws and practices against persons with disabilities and to adopt
legislation to protect individuals with disabilities (Crook, 2007). The Convention
consists of fifty articles with eight guiding principles that comprise respect for
inherent dignity, non-discrimination, full participation and inclusion in society,
accessibility, equality of opportunity, equality between men and women, and respect
for the evolving capacities of children with disabilities.
Relevance of the UN-CRPD to Speech-Language-Hearing Professionals: International
Scope and Monitoring of the Convention
The Convention is monitored at the both the international and national levels.
At the national levels, the national monitoring and implementation process of the
CRPD requires the participation of civil society. Article 33 of the convention contains
a singular provision for civil society actors, particularly persons with disabilities and
representative organizations, to full participate in the conventions monitoring
process (General Assembly of the United Nations, 2006; United Nations Human
Rights Office of the High Commissioner for Human Rights, 2008). State parties are
607
also required to establish an independent monitoring system, such as an

independent national human rights institution.
At the international level, both the Conference of States Parties and the
Committee on the Rights of Persons with Disabilities are responsible for international
monitoring. As stipulated in Article 35 of the convention, states parties must submit
reports on measures and progress to implement the obligations of the CRPD to the
Committee within two years after initially becoming a party to the convention and
thereafter at least every four years or upon the request of the Committee (General
Assembly of the United Nations, 2006; United Nations Human Rights OHCHR,
2008). The Committee on the CRPD also considers and receives complaints from
individuals or groups of individuals regarding alleged human rights violations
(United Nations Human Rights OHCHR, 2008). Countries that have already ratified
this convention must submit periodic reports to the Committee on the Rights of
Persons with Disabilities, through the Secretary-General of the United Nations,
regarding how well they are implementing the non-discrimination principles of the
treaty.
Speech and hearing professionals may choose to draw upon the UN-CRPD as
an advocacy tool and resource for their clients if the country in which they are
working has signed and ratified the treaty. Two brief, illustrative case studies of
how to use the UN-CRPD as an advocacy tool on behalf of children with
communicative disorders will be presented in the seminar by highlighting the
emerging habilitative work in two countries that have signed and ratified the UNCRPD: 1) the Philippines and 2) Ecuador. In both countries, habilitation of children
with cleft palate and craniofacial disorders is evolving as more experienced speechlanguage pathologists are invited to join established medical-surgical cleftcraniofacial teams on medical missions.
Selected References
Crook, J. R. E. (2007). Contemporary Practice of the United States Relating to International
Law: International Criminal and Human Rights Law: U.S. Joins Consensus on
Disability Treaty, but Not Expected to Sign. American Journal of International Law,
101(2), 491-492.
General Assembly of the United Nations (2006). Convention on the Rights of Persons with
Disabilities
and
Optional
Protocol.
http://www.un.org/disabilities/documents/convention/convoptprot-e.pdf
Melish, T. J. (2007). The UN Disability Convention: Historic Process, Strong Prospects, and
Why the U.S. Should Ratify. Human Rights Journal, 14(2), 37, 43-47.
National Council on Disability (2008). Finding the Gaps: A Comparative Analysis of
Disability Laws in the United States to the United Nations Convention on the Rights
of Persons with Disabilities (CRPD). Washington, D.C.: National Council on
Disability.
United Nations Enable (2009). Convention on the Rights of Persons with Disabilities.
Retrieved
August
7,
2009
from
http://www.un.org/disabilities/default.asp?navid=12&pid=150
United Nations Human Rights Office of the High Commissioner for Human Rights (2008).
Working with the United Nations Human Rights Programme: A handbook for civil
society. New York: United Nations Human Rights.
608
609
FLUENCY
SY06A.2
WHAT IS NORMAL DYSFLUENCY AND WHY MEASURE IT: BRAZIL
Claudia Regina Furquim de Andrade
Department of Physiotherapy, Communication Sciences and Disorders and
Occupational Therapy
School of Medicine. U of So Paulo
This study is part of a major research titled SPEECH FLUENCY PROFILE in
children, adolescents, adults and elederlies. It was developed during 6 years and
received grant from FAPESP (The State of So Paulo Research Foundation Process
no. 99/11163-9) and CNPq (The National Council for Scientific and Technological
Development Process no. 300379/2004-8), and involved scientific initiation and
technical qualification students.
The aim of this study was to obtain the speech fluency profile of fluent
children, with no stuttering complaints in terms of: speech disruption typology;
speech rate (words and syllables per minute) and frequency of speech disruptions
(number of dysfluencies per minute). The relevance of this study is wide, It reached
satisfactorily its purpose and offered a great contribution, giving a perspective of
what is normal, presenting reference values (of all aspects that contribute to a fluent
speech in children.
The reference values of the speech fluency profile for normally fluent children
are presented per age group. The profiles of each age group are presented as
confidence intervals, i.e. each of the obtained results should be analyzed as either
belonging or not to the pertinent interval. If the result being compared belongs to the
confidence interval appropriate for gender and age, the individual is considered
within the expected parameters for the overall population. If the result does not
belong to the confidence interval, a more refined assessment is indicated. The
confidence interval represents the significance of an isolated measurement in relation
to a representative group.
SPEECH FLUENCY
Speech fluency refers to the continuum and smooth flow of speech
production. In order to produce a fluent speech, two operational neural systems
must be timed together before the generated message reaches the motor cortex.
The first of these two systems is called symbolic. It integrates cognitive,
linguistic and segmental speech components, determining the messages format and
content. This system is responsible for specific phonological segmentation (rhythm
and prosody) and fragmentation (beginning, middle and end). The second system is
called signs. It integrates prosodic and paralinguistic components, determining pitch,
loudness, duration and quality of syllables.
The signs system determines the proportional duration of syllables in a word
and the sequencing order of phonetic gaps. When these two systems segmentation
and organization operate in balance, speech is generated without disruptions.
610
When these systems are unbalanced, speech flow is involuntary and temporary
disrupted, therefore generating speech disruptions.
Theoretically, the process that generates speech disruptions is the same for all
speakers. Fluency levels vary from one individual to the next and depending on the
occasion, on the emotions, on the domain about the theme of conversation, on the
different daily situations, these variations can occur in the same individual.
The absolute continuity of speech is physiologically impossible. The
perception of speech continuity occurs due to the use of prolongations of the audible
speech intervals (acoustic segment) in contrast to breaks and pauses. Fluency can be
seen as a description of oral proficiency (competence, good language command, easy
and efficient language use), i.e. the best use of linguistic knowledge in response to a
specific situation demand.
Fluency is a proficiency element that differentiates itself from other
components (grammar, syntax, vocabulary) because it is automatic, relies primarily
on timing, depends on automaticity. Speech fluency is the effective result of
language production, considering a model performed in real time. It is a highly
automatic function, with a reflex component. This automaticity makes it possible for
the multiple components involved in speech production to work synchronized and
in parallel this is a central condition for fluent uninterrupted speech.
METHOD
In order to elaborate the tables containing the reference values for the speech
fluency profile of fluent children, 200 (100 boys and 100 girls, residents in the city of
So Paulo and So Paulo State were assessed. Procedures for data gathering only
began after informed consent was obtained from all participants or their family
(CAPPesq HCFMUSP no. 791/99). No distinction was made among races and the
cultural level was normalized according to literacy. The socio-economic level was of
middle class.
Participants did not present any personal, family or school complaints about
stuttering or had any associated communication or health deficits. Participants were
grouped according to age, from 2.0 years onwards, and were classified as group of
children (pre-scholars and scholars). Participants who had an SSI score for stuttering
were excluded from the study.
PROCEDURE FOR THE APPLICATION OF THE SPEECH SAMPLE

GATHERING PROTOCOL (PCAF)
Speech fluency assessment is done based on the gathering of a spontaneous
speech sample, containing at least 200 syllables, digitally (Portable Digital High
Precision Recorder Sony MZ-R37) and video recorded (Video Camera Panasonic
NVRJ-28). The estimated time for each speech sample gathering session was between
3 to 6 minutes for children with ages between 4 to 11.11 years. For smaller children
2.0 to 3.11 years the estimated time was of 10 to 20 minutes.
Spontaneous speech is the one that does not require attention to any aspect
involved in its production besides those involved in generating the linguistic
message. It expresses feelings and intentions of the speaker, formulated in a
linguistic code phonological, morphosyntax, semantic and pragmatic with a
communicative intention. Among the possibilities to obtain a spontaneous speech
sample monologue, dialogue, conversation under pressure, conversation based on
an outside stimulus, among others two were selected: elicited through an
interaction with parents (for children with ages between 2.0 and 3.11 years); elicited
611
by a visual stimulus (for children with ages above 4.0 years, adolescents, adults and
elderlies).
In order to obtain a speech sample in an interaction with the parents, parents
were advised to stimulate speech during a play situation with the child in an
interactive way, i.e. aiming at a dialog situation, alternating communicative turns,
introducing new subjects and avoiding directive questions. In order to obtain a
speech sample elicited by a visual stimulus, a picture of a boy playing football was
presented to the participant and the following instruction was given: please look at
this picture and tell me anything you want about it (speech was interrupted, with
questions and comments, only in cases for whom it was necessary to motivate speech
production in order to obtain at least 200 syllables). For those cases were the
collection of at least 200 syllables was not possible, all of the fluent syllables were
analyzed and the sample was normalized according to time.
I Speech Sample Gathering

Speech samples are digitally and video recorded and later transcribed
considering all of the produced syllables (fluent and disfluent), according to
the legend below:
1. Speech disruptions all marked in bold
2. Unintelligible utterances - ~~~~~~~~
3. Interruption of the therapist - //
4. Hesitation - #
5. Pause - ________
6. Blocks - / before the blocked syllable
7. Prolongation - _ after the prolonged utterance (sound or syllable)
8. Intrusion the utterance considered an intrusion comes between / /
II Speech Sample Analysis
A Speech disruption typology:
Typical disfluencies (hesitations, interjections, revisions, broken words, word
repetition, segment repetition, phrase repetition). Less typical disfluencies (sound
repetition, syllable repetition, prolongation, blocks, pauses, intrusion of sound or
segment).
hesitation: short pause (1 to 2 seconds), when the individual is searching for a word
or prolongs an usual vowel sound (e.g. hum).
interjection: inclusion of sounds, words or phrases with no sense or irrelevant to the
message context (e.g. yeah).
revision: change of content or grammatical form of message; change in word
pronunciation (e.g. can she he come here? He saw ate all of the cookies).
612
broken words: word is abandoned, and not finished later in the utterance. Typically,
but not necessarily, is followed by a revision (e.g. I went to Bris during the
weekend).
segment repetition: repetition of at least two complete words of the utterance (e.g
what a what a beautiful day).
phrase repetition: complete repetition of an already uttered phrase.
word repetition: repetition of a whole word, including monosyllables, prepositions
and conjunctions (e.g. I I need a pen / What what time is it?).
syllable repetition: repetition of a whole syllable or of part of an uttered word (e.g. I
want a bababanana / The ambububulance arrived soon).
sound repetition: repetition of a phoneme or of a diphthong element of an uttered
word (e.g. is th th this mine? Do you want some j j j juice?).
prolongation: inappropriate duration of a phoneme or of a diphthong element. May
or may not represent speech qualitative characteristics (e.g. isssss this mine? The
boooooy went home).
blocks: inappropriate time to begin a phoneme or to release a static articulatory
position (mouth opens prior to an utterance; facial tremors prior to an utterance).
pause: temporal interruption of a speech sequence (more than 3 seconds to connect
elements). May or may not be associated to speech qualitative characteristics.
intrusion: production of sounds that are not appropriate to the inter or intra word
context.
B Speech rate:
a) number of words per minute (measures the index of information production)
time the total duration of the speech sample, count the total number of fluent words,
apply the rule for normalizing the sample size for one minute;
b) number syllables per minute (measures the index of articulation rate) time the
total duration of the speech sample, count the total number o fluent syllables, apply
the rule for normalizing the sample size for one minute.
C- Frequency of speech disruptions
a) percentage of speech discontinuity (measures the index of speech disruptions in
the discourse) count the total number of speech disruptions in the speech sample,
typical and less typical, calculate the percentage in relation to the total number of
produced fluent syllables;
b) percentage of stuttered syllables (measures the index of less typical speech
disruptions) count the total number of less typical speech disruptions in the speech
sample, calculate the percentage in relation to the total number of produced fluent
syllables.
Results
The data were submitted to statistical analysis in order to verify the
significance and the possibility of generalization of the results. We conclude that
there were no statistical significant difference between either gender and age
regarding the fluency profile. We found some isolated significance: boys with
betwwen 4:0 and 4:11 years old presented more dysfluencies than girls and children
7:0 years old and over presented less frequency of speech disruptions than preschool children.
References
613
CURLEE, R. F.; YAIRI, E. Early intervention with early childhood stuttering: a critical
examination of the data. American Journal of Speech-Language Pathology, v. 6, n. 2, p. 818, 1997.
PERKINS, W. H. Stuttering Prevented. San Diego: Singular, 1992
ROSEMBECK, J. C. Stuttering secondary to nervous system damage. In: CURLEE, R. F.;
PERKINS, W. H. Nature and Treatment of Stuttering: new directions. San Diego: CollegeHill, 1984. p. 31-48.
YAIRI, E.; AMBROSE, N. A longitudinal study of stuttering in children: a preliminary report.
Journal of Speech, Language and Hearing Research, v. 35, p. 755-760, 1992.
YAIRI, E.; AMBROSE, N. Onset of stuttering in preschool children. Journal of Speech, Language
and Hearing Research, v. 35, p. 782-788, 1992.
YAIRI, E.; AMBROSE, N.; NIERMANN, R. The early months of stuttering: a developmental
study. Journal of Speech, Language and Hearing Disorders, v. 48, p. 394-402, 1993.
YAIRI, E.; AMBROSE, N.; PADEN, E.; THRONEBURG, R. Predictive factors of persistence
and recovery: pathways of childhood stuttering. Journal of Communication Disorders, v.
29, p. 51-77, 1996.
614
FP08.2
THE SPEECH SITUATION CHECKLIST: NORMATIVE AND COMPARATIVE
STUDY OF ITALIAN CWS AND CWNS
1
S. Bernardini, L. Cocco, C. Zmarich, M. Vanryckeghem, G. Brutten

1 Centro Medico di Foniatria, Padova, Italy
2 Azienda Sanitaria Locale ASL TO4, Chivasso, Italy
3 Istituto di Scienze e Tecnologie della Cognizione del C.N.R, sede di Padova, Italy
4University
of Central Florida, United States
Introduction and aims of the study: It has been commonly accepted by

clinicians that those who stutter experience more than just dysfluency. In accord with
Brutten and Janssen (1980), Brutten and Vanryckeghem (2003, 2007), Bakker (1995), it
is also our position that stutterers attitudes about their speech, their emotional
reactions and speech disruption in certain speech situations, and the behaviours
they use to avoid or escape stuttering are important elements of the multidimensional problem they are faced with. The Speech Situation Checklist (SSC)
(Brutten, 1973; Brutten & Vanryckeghem, 2003, 2007) informs the clinician about an
individuals emotional reaction to and extent of fluency failures in particular speech
situations. The SSC is a self-report checklist which is contained in the Behavior
Assessment Battery (BAB) (Brutten & Vanryckeghem, 2003, 2007). The BAB is a
multi-dimensional set of inter-related, evidence-based, self-report tests that provide
normative data for children who do and do not stutter. These self-report test
procedures provide the fluency therapist with a multi-modal view of how a child is
affected, reacts to, and thinks about his or her speech. The BAB is useful as an aid in
differential diagnostic decision making and provides a road map of the treatment
targets. This battery of tests serves to shape therapy and provides the therapist with
clear-cut indications of a child's speech-associated strengths and weaknesses and his
or her particular therapeutic needs. The SSC was designed to be a state test of
speech-related anxiety and speech breakdown, and, its construction rests on the
observation that negative emotion and dysfluency reported by stutterers varies from
one situation to the next. The aim of this study was two-fold: to obtain local norms
on the Italian version of the Speech Situation Checklist (SSC) for children, as well as
to determine if the amount of negative emotional reaction (concern, worry, anxiety)
to particular speech situations and the amount of speech disruption reported by
children who stutter (CWS) are significantly higher compared to children who do not
stutter (CWNS). Past research has indicated that CWS score significantly higher than
CWNS on the both sections of the SSC (Brutten & Vanryckeghem, 2003, 2007).
The SSC has two components. The first one (Emotional Reaction: ER) assesses
speech specific negative emotional reaction to interpersonal speech settings and to
specific sounds \ words. The second section (Speech Disruption: SD) evaluates a
persons report of speech disruption in the same situations. The SSC for children lists
55 speech situations. The childrens reactions are measured on a 5 point scale. In the
ER section, children are to indicate the extent of their emotional reaction, ranging
from not afraid to very much afraid. The 5-point scale for the SD section ranges
from no trouble to very much trouble talking. The SSC has shown to have a high
internal reliability and validity (Brutten & Vanryckeghem, 2003, 2007)
615
Methods:
The Italian translation of the SSC was administered to 68 CWS (20 girls and
48 boys) and 137 CWNS (67 girls and 70 boys) aged from 8 to 14. A more specific
breakdown in terms of age and gender can be found in Table 1.
Both the CWS and CWNS who served in this study were recruited from a
National Health Service and referred to either the Centro Medico di Foniatria in
Padua or the one in Turin, which is situated in the North-West and North-East areas
of Italy. None of the CWS had previously received fluency treatment or were in
therapy at the time of this study. The determination that the participants of this
investigation stuttered was made by a fluency specialist during the initial fluency
assessment using the Systematic Disfluency Analysis (SDA) of Campbell & Hill
(1987, 1993). The CWS did not exhibit any other speech and/or language difficulty as
determined by means of a speech and language evaluation, employing standardized
tests. The CWNS had no history of any form of speech and/or language disorder
and had not previously been or were not currently in therapy. This was confirmed by
their educational records and teacher reports. The CWS were administered the
Italian form of the SSC by the fluency specialist in Padua or in Turin (the first and
second author of this article). The very same researchers administered the SSC to the
CWNS. Each of the test administrators carefully followed the tests administrative
protocol. The SSC was individually administered to both the CWS and the CWNS in
a private setting. In accord with the SSCs protocol, the tests instructions were read
aloud as the children followed along silently.
Age
CWS
N
M
F
6
1
Mean
St.Dev
CWNS
N
M
F
8 15
Mean
St.Dev
ER 114.0
20.5
ER 59.4
2.5
SD 115.3
27.3
SD 56.4
1.9
9
11
4
ER 115.8
34.6
13 10
ER 60.1
2.3
SD 113.7
29.4
SD 56.3
1.2
10
4
7
ER 117.3
20.8
12 13
ER 62.0
3.3
SD 122.8
25.6
SD 56.2
1.4
11
10
1
ER 107.8
30.4
11 11
ER 69.7
5.6
SD 111.5
26.9
SD 58.7
7.0
12
8
3
ER 109.6
23.4
11 8
ER 68.6
3.4
SD 110.4
26.9
SD 57.7
1.3
13
7
2
ER 127.9
25.8
10 9
ER 69.4
1.8
SD 125.6
31.0
SD 57.3
1.3
14
2
2
ER 126.0
31.0
5
1
ER 67.9
1.3
SD 125.6
29.8
SD 63.2
6.6
Table 1. Emotional Reaction (ER) and Speech Disruption (SD) scores' measures of central
tendency and variation for 68 Children who Stutter (CWS) and 137 Children who Do Not
Stutter (CWNS) between the ages of 8 and 14
Results:
Table 1 reports the means and standard deviations for the ER and SD sections
of the SSC and are stratified for group and age. As it relates to the ER portion of the
test, the CWS had a mean score of 115.76 and a standard deviation of 27.15 (range
from 66 to 179). The CWSs median score was 111.00, whereas that of the CWNS was
64.00. The CWNS had a mean score of 64.69 and a standard deviation of 5.48 (range
from 56 to 92). Since the two samples are not equally distributed (their variances are
616
not equal), non parametric statistics were employed to test for significance. The
difference between CWS and CWNS was highly significant (Mann-Whitney U test
statistic = 9459.5, p <.000). Relative to gender, the male CWS had a mean score of
113.87 (St. Dev. 26.87) whereas the female CWS had a mean score of 121.50 (St. Dev.
27.66). The difference proved not to be significant (t =1.13, df = 66, p = 0.26). The
male CWNS had a mean score of 65.00 (St. Dev. 5.94) and the female CWNS had a
mean score of 64.37 (St. Dev. 4.99). It is clear that these scores are not significantly
different (t =-0.67, df = 135, p = 0.51). As to age factor, it can be seen from table 1 that
the scores generally increase with age for both groups. Relative to CWS, this
difference was shown not to be significant (One-way Anova, F = 0.63, df = 6, p =
0.70). For the CWNS, however, a significant age effect was present (One-way Anova,
F = 39.53, df = 6, p < .000)
As it relates to the SSC-SD, CWS had a mean score of 116.71 and a standard
deviation of 27.39 (range: from 57 to 179). The median score for CWS and CWNS was
117.00 and 57.00, respectively. The CWNS scored, on average, 57.33 with a standard
deviation of 3.62 (range: from 55 to 89). Because of uneven distribution of the two
samples, non-parametric statistics were used for significance determination. The
difference between CWS and CWNS was determined to be highly significant (MannWhitney U test statistic = 9235.5, p <.000). Relative to gender, the male CWS had a
mean score of 113.10 (St. Dev. 27.28) and the female CWS mean score was 125.35 (St.
Dev. 26.33). The difference proved not to be significant (t =1.70, df = 66, p = 0.09).
The male CWNS had a mean score of 57.81 (St. Dev. 4.80). The female CWNS mean
score was 56.82 (St. Dev. 1.57). Once again, this difference was not significant (t = 1.62, df = 135, p = 0.22). As it relates to age, it can be seen from table1 that the scores
typically increase with age for both groups. Relative to CWS, this difference proved
not to be significant (One-way Anova, F = 0.49, df = 6, p = 0.81). Similar to the SSCER, as far as CWNS are concerned, a significant difference was observed (One-way
Anova, F = 4.75, df = 6, p < .000).
Conclusions:
The SSC (Brutten,1973; Brutten & Vanryckeghem, 2003, 2007) informs the
clinician about an individuals negative emotional reaction (Emotional Reaction
section) and fluency failures (Speech Disruption section) in particular speech
situations. As has been demonstrated in several cross-cultural investigations, CWS
score significantly higher than CWNS on the SSC (Brutten & Vanryckeghem 2003,
2007). In the current investigation, it was found that also Italian CWS score
significantly higher than CWNS on the two sections of the SSC. Age was significant
only for CWNS. Gender did not have an effect on the scores.
References
Bakker, K (1995). Two supplemental scoring procedures for diagnostic evaluations with the Speech
Situation Checklist. Journal of Fluency Disorders, 20, 117-126.
Brutten, G. (1973). Behavior assessment and the strategy of therapy. In Y. Lebrun & R. Hoops
(Eds.), Neurolinguistic approaches to stuttering (pp. 8-17). The Hague, Holland:
Mouton.
Brutten, G. & Janssen, P. (1980) A normative and factorial analysis study of the responses of Dutch
and American stutterers to the Speech Situation Checklist. Paper presented at the annual
meeting of the International Association of Logopedics and Phoniatrics, Washington,
D.C.
Brutten, G., & Vanryckeghem, M. (2003). Behavior Assessment Battery: A multi-dimensional and
evidence-based approach to diagnostic and therapeutic decision making for children who stutter.
Belgium: Stichting Integratie Gehandicapten & Acco Publishers.
617
Brutten, G., & Vanryckeghem, M. (2007). Behavior Assessment Battery for school-age children who
stutter. San Diego, CA: Plural Publishing, Inc.
Campbell, J.H. & Hill, D. (1987). Systematic disfluency analysis: Accountability for differential
evaluation and treatment. Miniseminar, American Speech-Language and Hearing
Association convention, New Orleans.
Campbell, J.H. & Hill, D. (1993). Application of a weighted scoring system to systematic disfluency
analysis. Poster session presented at the Annual Convention of the American SpeechLanguage and Hearing Association, Anaheim, CA.
618
FP08.4
A TRAINING TO SUPPORT ADOLESCENTS WHO STUTTER IN
THEIR COMMUNICATION AT SCHOOL: AN EVALUATION OF
EFFECTIVENESS.
E.Capparelli1, P.Falcone2, D.Tomaiuoli2
1 CRC
Balbuzie, Rome, Italy

degli Studi di Roma La Sapienza; CRC Balbuzie - Rome, Italy
2 Universit

Multifactorial models on stuttering (see among others Stournaras et al., 1980;
Starkweather, 1987; 1997; Starkweather and Givens-Ackerman, 1997; Smith, 1999;
Bouwen, 2006) acknowledge the complex nature of this disorder and recognize the
influence of social (or socio-dynamic) factors (Stein et al., 1996; Furnham and Davis,
2004). Certain communicative and interactive situations (Andrews et al., 1983; Van
Riper, 1992) can influence the symptoms frequency and severity and can also induce
some non verbal voluntary or involuntary movements (Mulligan et al., 2001; RivaPosse et al., 2008), thus arousing worries and, eventually, inducing an avoidance
reaction (Van Riper, 1992; Stein et al., 1996).
During adolescence, interpersonal relationships and the consequent social
acceptance are fundamental in the construction of personal identity (Coleman and
Hendry, 1999).
In school context, teens (Kidger et al., 2009) daily cope with their teachers
authority and judgement, as well as with a learning to get and share, and with a peer
group of class-mates (not chosen, unlike friends) to be socially accepted from. This
context can contribute to worsen the symptom management (Fraser and Perkins,
1987; Schwartz, 2002), because of both the induced communicative pressure and the
greater reluctance people who stutter can have in participate verbally (Furnham
and Davis, 2004, p.7) to social dynamics.
For these reasons, we propose a study focused on the way teens who stutter
communicate in school context, by observing the acquisition and the use of effective
symptom management strategies in class and, particularly, in oral testing situations.
Our study has two aims:
a. to find out the way communication in school context (oral tests, request for
explanations, and so on) is perceived by teens who stutter, the reasons behind
their attitude and how they manage them, through the verbal and non-verbal
aspects of their communication;
b. to analyze the effectiveness of an integration between stuttering rehabilitation
treatment and a specific training (Menzies et al., 2009), intended to foster their
communication in school context, specially with regard to oral tests.
The following variables have been chosen to reach these goals: verbal fluency,
quality of exposition during oral tests, individual attitudes towards them and both
voluntary and involuntary movements.
619
Methods
a. participants
The study was carried out between 2007 and 2009 and involved a sample
consisting of 27 stuttering adolescents aged 15-18 (18 males and 9 females). All
participants attended secondary school: 8 of them attended the second year; 8 the
third; 7 the fourth and 4 the fifth year. For what concerns the kind of disorder, 14
sample adolescents were suffering from tonic-clonic stuttering, 8, from tonic
stuttering and 5, from clonic stuttering.
Students from first year were excluded from the sample: being in a brand
new context would have made them less experienced and aware than other
participants to the study.
b. the training
In order to reach the goals above-mentioned, besides speech therapy,
participants underwent a specific treatment aimed at improving communication
within the classroom context, through the learning of appropriate techniques and
tools.
The program consisted of eight 2-hours sessions.
The first four sessions were aimed at testing whether or not patients used the
verbal facilitation techniques, whether they used to feel worried during oral tests
and, if so, why and what provoked such a discomfort in oral verbal production.
Analysis concerned both verbal and non-verbal communication, and, in the
first part of the training, it allowed to provide patients with many different verbal
and non-verbal strategies, useful to successfully tackle the situations of verbalization.
In the following four sessions, patients underwent tests and role-plays
simulating oral tests first before a group-therapy class-mate, then before the
logopedist and finally an interlocutor unfamiliar to them.
Later, the therapist analysed each performance, together with the participant
involved, availing him/herself of the feedback provided by the interlocutor and the
group which had attended the performance.
c. tests
Before and after the training, participants to the study underwent some
evaluation tests, both directly and indirectly (through questionnaires administered to
the teachers), for a longitudinal analysis.
At the beginning of the program, the following tests were administered:
to the participants:
o S.D.A. test (Systematic Disfluency Analysis; Campbell and Hill, 1987)
for the evaluation of verbal fluency;
o School and oral tests questionnaire on opinions and attitudes
towards school context and subjects, with special regard to oral tests
in relation to stuttering;
to their teachers:
o a control grid concerning participants reactions to oral tests,
regarding the way they manage and react to the situations of
verbalization in class. It was administered to teachers of both the most
and the less appreciated subjects, according to participants
statements. Teachers were not informed about the training on oral
620
exams their students were attending, in order to keep their evaluation

uninfluenced.
At the end of the experimental program, students were tested again through S.D.A.
and, at the same time, they were indirectly checked through a second administration
of the control grid to teachers.
Outcomes
As shown by results of the administration of the SDA test (table 1),
participants initially found main difficulties in monologue and conversation. In fact,
in those areas they reported higher values of the ratio produced
disfluencies/pronounced words (pd/pw) than in reading. From the first (a1) to the
second (a2) test administration the mean of the mentioned ratios has radically
decreased (from 0.46 to 0.25). In monologue and conversation also the standard
deviation was higher than in reading, and in these areas it decreased in the second
test administration. These positive results are due to both the logopedic treatment
and the training (specifically focused on monologue and conversation).
Table 1: Results of the SDA test administrations.
Indicators
a1
A2
mean pd/pw (reading)
0,33
0,18
mean pd/pw (monologue)
0,54
0,29
mean pd/pw (conversation)

mean pd/pw (total)
st. dev pd/pw (reading)
st. dev pd/pw (monologue)
st. dev pd/pw (conversation)
0,52
0,46
0,07
0,17
0,2
0,27
0,25
0,08
0,13
0,15
st.dev pd/pw (total)
0,11
0,10
As observed by teachers through their control grids, before the training tested
adolescents were not very used to intervene in class discussions (see graph 1).
This was more evident in the less appreciated subjects; in fact, in most cases
(17 out of 27) teachers observed participants never used to intervene.
After the training in the a2 administration, as revealed by teachers, class
intervention frequency increased for all participants; many of them started seldom or
even usually to intervene in class.
621
Graph 1 How often participants to the study intervene in class.

60
50
13
40
31
usually
16
30
seldom
20
10
18
25
19
general a1
general a2
13
17
10
11
never
0
most
most
appreciated appreciated
subject a1 subject a2
less
less
subject a1 subject a2
As shown by graph 2, before the training (in the a1 administration of the

control grid to teachers) tested adolescents were not used to orally intervene
spontaneously, but used to do it only if they were asked to, under a direct request by
the teacher. On the contrary, after the training (in the a2 administration) the
frequency of their spontaneous oral interventions radically increased. This was in
both the most and the less appreciated subject, with a higher score in the first one.
Graph 2: How do participants to the study intervene in class.

45
40
35
30
25
20
only if asked to
15
spontaneously
10
5
0
tot a1
tot a2
most
appreciated
subject a1
most
appreciated
subject a2
less
appreciated
subject a1
less
appreciated
subject a2
622
As table 2 shows, not only the frequency and type of class participation
increased after the training, but also the quality of communication.
Table 2 Some indications about the quality of participants class communication.

total
absolute
frequency
a1
total
absolute
frequency
a2
most
appreciated
subject
a1
most
appreciated
subject
a2
less
appreciated
subject
a1
Less
appreciated
subject
a2
- similar between oral and written tests
12
36
10
21
15
- written tests performance is higher
34
15
11
23
11
- oral tests performance is higher
- yes
27
43
19
23
20
- no
28
11
20
27
19
His/her performance is:
His/her communication is made of

precise words, with an appropriated
language:
During the oral test he/she usually

stutter:
- a lot
- on average
22
19
15
14
- not much
29
20
27
39
13
22
14
17
35
16
24
11
15
12
18
He/she usually stutters during the oral

test:
- yes, always
- no, more when he/she intervenes

9
spontaneously
- no, more when he/she is asked to
intervene
18
He/she keeps to the point:
- yes, always
18
- not always, sometimes he/she

13
wanders off the point
- no, he/she often wanders off the
point
23
In fact, from the a1 to the a2 administration, tested adolescents showed to

align their performances in oral tests to the written ones; during oral tests their
language appeared to be more appropriated, their stuttering frequency reduced (this
data confirms the SDA results in table 1) and they better kept to the point.
Positive results concerning fluency, as obtained from the SDA test
administration and the teachers feedback through the control grids revealed
participants acquisition and generalization of verbal facilitation techniques.
Teachers observation conducted through the control grids also dealt with
non-verbal cues.
As they observed (table 3), all the participants to the study showed some
(voluntary or involuntary) movements and/or neurovegetative reactions during
their oral tests. The average number of different shown movements or
neurovegetative reactions per person was 3.76 in the a1 administration.
623
Table 3: Types of non-verbal cues (movements and neurovegetative reactions)

shown by participants during interventions and oral tests.
types of non-verbal cues
most
appreciated
subject a1
most
appreciated
subject a2
less
less
subject a1
subject a2
touches his/her hair
10
makes a wry face
closes his/her eyes
blinks his/her eyes
widens his/her eyes
lifts up his/her eyebrows
looks up
looks down
looks sideways
avoids eye contact
13
23
wrinkles his/her nose
sweats
blushes
17
14
laughs
10
continuously moves
19
21
st. dev
5,24
1,94
6,88
3,42
Other indicators
mean of different non-verbal
cues identified per person (a1)
3,76
mean of different non-verbal
cues identified per person (a2)
1,80
gap of non-verbal cues in the
most appreciated subject from
a1 to a2
-63%
gap of non-verbal cues in the
less appreciated subject from a1
to a2
-45%
average gap of non-verbal cues
from a1 to a2
-54%
The most occurred non-verbal reactions were continuously movements, the

avoidance of eye contact, the blush or nervous laughs. Their frequency appeared to
be higher in the less appreciated subjects than in the most ones, in a ratio of 1.5-2
times more.
The frequency of movements radically decreased from the a1 to the a2
administration. The average number of different non-verbal cues per person in the a2
administration was 1.80.
The gap was -63% in the oral tests in the most appreciated subject and -45% in
the less one, with an average total reduction of -54%.
The standard deviation of the frequency distributions also radically reduced
between the administrations, from 5.24 to 1.94 in the most appreciated subject and
from 6.88 to 3.42 in the less one.
624
Several complementary evidences were observed from the tested adolescents

self-evaluation carried on through the School and oral exams questionnaire.
The study confirmed that school is a peculiar social context; 15/27
participants (55.6%) perceive their communication difficulties there higher than in
other contexts (e.g. home, street and so on); 8 (29.6%) perceive them the same as in
other contexts and 4 (14.8%) lower. In the a2 questionnaire administration 9/27
considered such difficulties at school higher than in other contexts, 10 consider them
equal and 8 lower. This is the final result of some individual changes in attitudes and
opinions after the training: 13 reduced the intensity of perceived difficulties, 9
confirmed their first evaluation and 5 perceived them higher.
As in a1 administration most tested adolescents said they preferred written
test to oral ones (17 did vs.10 who stated to prefer oral tests), in the a2 sample
preferences got more homogeneous (14 vs.13).
An other interesting result from the study concerned participants avoidance
reactions to oral tests.
They confirmed that oral tests put them on a crossroads: to cope with the
problem, facing the test and its unpredictable consequences, or to avoid it.
Avoidance reactions appeared to be diffused among the participants: most of
them declared to put them into action sometimes or even often. In the a2
questionnaire administration all of them except one declared they had reduced their
frequency of avoidance reactions. Some declared they were not triggering this
behaviour anymore.
Graph 3 Frequency of avoidance reactions to oral tests triggered by participants
in the last two months.
100%
90%
80%
70%
60%
never
often
50%
sometimes
40%
30%
20%
10%
0%
a1
a2
In fact, comparing the a1 and a2 administrations, the number of participants

who undergo an oral test anytime it is necessary, radically increases (+114%) after
the training (graph 4).
Totally 16/27 participants increased the frequency of their oral tests; it is
interesting to observe that 5 of them had in a1 declared to undergo an oral test as
little as possible, and now declare to do it anytime it is needed.
This data confirm the indication of a higher frequency given by the control
grid compiled by their teachers (see graph 1).
625
Graph 4 Frequency of undergoing oral tests declared by participants.

16
15
14
12
12
10
8
8
anytime it is necessary
sometimes
as little as possible
6
4
4
2
0
a1
a2
Some interesting indications also emerged about self perceived quality of

own communication during oral tests. Most participants (14/27) perceived that in
such situation their stuttering got worst than in other verbal situations; 8 perceived it
did not change (the same as in other situations) and 5 felt they stutter less.
Some patients declared that a successful use of strategies for managing their
disorder is undermined by time pressure.
After the training, in the a2 administration, 15 participants perceived their
fluency during oral tests improved, as shown by graph 5.
Graph 5 Stuttering during oral tests: a self-evaluation.

100%
90%
80%
70%
60%
better than other verbal situations
worst than other verbal situations
50%
as in any other verbal situations
40%
30%
20%
10%
0%
a1
a2
This self-perceived fluency improvement is confirmed by the positive

evaluation given by teachers and above described (see table 2).
626
From the a1 to the a2 questionnaire administration also a change in the way

tested adolescents managed words avoidance reactions emerged. In the a1
administration 17 participants said they used to avoid some words during oral tests,
while in a2 12 did.
This data show a higher attention paid by tested adolescents to their
communication and can be related to what teachers said about the increased quality
of their communication and the appropriateness of their language.
After the training, in the a2 administration, more participants declared they
adopted strategies to reduce their worries in facing oral tests: 18 tested adolescents
vs. 12 of the a1 administration. This data is supported by the feedback teachers gave
regarding the general improvement of their communication, their fluency and the
reduction of their movements during the tests.
After the training participants also acknowledged their communication was
less influenced by such factors as teachers severity, the way they were prepared for
it, the preference for the subject, as the presence of the classmates listening to their
test.
The chance to be unable to sustain an oral test, by the effect of worries or fear,
in the a2 administration appeared to be less frequent. In fact, in a2 all the participants
to the study except two stated the frequency of this unpleasant event had decreased.
At last, after the training 10 participants declared their worries concerning
oral tests had reduced; 4 of them declared they increased and for 13 they remained
unchanged.
Results of the analysis showed the effectiveness of this training aimed at
school communication and oral tests, an area which is so relevant to the target of
adolescents who stutter. Tested adolescents have shown to have developed a higher
control ability of the feared situation (also in the less appreciated subjects), the
reduction of avoidance reactions, an improved ability to manage their
communication, in both the verbal (fluency and language) and the non-verbal cues.
Tested adolescents self-evaluation aligns itself with the one given by their
teachers; this reveals their awareness.
Besides, the teachers feedback lets us verify that the tested adolescents have
both learnt and generalized verbal facilitation techniques.
Conclusions
The results of this study confirm the advantages of an integrated intervention
on patients who stutter. This can consist of a mix of logopedic treatment (to let them
learn how to use verbal facilitation techniques) with specific trainings, as the one we
proposed, supporting them to successfully manage specific verbal situations.
References
Andrews G., Hoddinott S., Craig A., Howie P., Feyer A.M., Neilson M. (1983). Stuttering. A
review of Research Findings and Theories circa 1982. Journal of Speech and Hearing
Disorders. 48: 226-246.
Bouwen J. (2006). The Erasmus Models for the Diagnosis and Treatment of Stuttering, paper
presented at the 5th World Congress on Fluency Disorders, held in Dublin, Ireland 2528th July 2006
Fraser J. and Perkins W. (1987).(eds.). Do you stutter? A guide for Teens. The Speech
Foundation of America, No.21.
Coleman, J. C., & Hendry, L. B. (1999). The nature of adolescence (3rd ed.). New York:
Routledge.
Furnham A., Davis S. (2004). Involvement of social factors in stuttering: a review and
assessment of current methodology. Stammering Research. July 1; 1 (2): 112-122.
627
Kidger J., Donovan J.L., Biddle L., Campbell R., Gunnell D. (2009). Suporting adolescent
emotional health in schools: a mixed methods study of student and staff views in
England. BMC Public Health, 9: 403-421.
Menzies R.G., Onslow M., Packman A., OBrian S. (2009). Cognitive behaviour therapy for
adults who stutter: a tutorial for speech-language pathologists. J.Fluency Disorders,
Sep; 34(3): 187-200.
Mulligan H.F., Anderson T.J., Jones R.D., Williams M.J., Donaldson I.M. (2001). Disfluency
and involuntary movements: a new look at developmental stuttering. International
Journal of Neuroscience. July; 109 (1-2): 23-46.
Riva-Posse P., Busto-Marolt L., Schteinschnaider A., Martinez-Echenique L., Cammarota A.,
Merello M. (2008). Phenomenology of abnormal movements in stuttering.
Parkinsonism and Related Disorders; 14 (5): 415-9.
Schwartz H.D. (2002). Adolescents who stutter. Journal of Fluency Disorders 18 (2-3): 289-302.
Smith, A. and Kelly, E. (1997). Stuttering: A dynamic, multifactorial model. In R. F. Curlee &
G. M. Siegel (Eds.), Nature and treatment of stuttering: New directions, 2nd ed. Boston:
Allyn and Bacon.
Starkweather, C. W. (1987). Fluency and Stuttering. Englewood Cliffs, NJ: Prentice-Hall.
Starkweather, C. W. , Givens-Ackerman, J. (1997) Stuttering. Austin, Texas: Pro-ed.
Stein M.B., Baird A., Walker J.R. (1996). Social phobia in adults with stuttering. Am J.
Psychiatry, Feb; 153 (2): 278-80
Stournaras E. F., Bazen M., Bezemer M., & Van Borselen W. (1980). Stotteren bij kinderen. In
C.H. Waar (Ed.), Stem., Spraak- en Taalstoornissenbij kinderen (pp. 65-95). Alphen
a/d Rijn: Stafleus Wetenschappelijke Uitgeversmaatschappij.
Van Riper, C. (1982). The nature of stuttering (2 ed.). Englewood Cliffs, NJ: Prentice Hall.
628
FP08.3
BEHAVIOR ASSESSMENT BATTERY (BAB): EVIDENCE- BASED APPROACH
TO THE ASSESSMENT AND TREATMENT OF CHILDREN WHO STUTTER .
NORMATIVE AND COMPARATIVE STUDY OF ITALIAN CWS AND CWNS
1
L. Cocco , S. Bernardini, , C. Zmarich, M. Vanryckeghem, G. Brutten

1 Azienda Sanitaria Locale ASL TO4, Chivasso, Italy
2 Centro Medico di Foniatria, Padova, Italy
3 Istituto di Scienze e Tecnologie della Cognizione del C.N.R, sede di Padova, Italy
4University
of Central Florida, United States
Introduction and aims of the study: The self-report measures that make up
the Behavior Assessment Battery (BAB) for children have been internationally
investigated and have shown to be reliable and valid test procedures. For each test,
the cross-cultural data are in overwhelming agreement. The scores on each of the
BAB test procedures differentiate children who stutter (CWS) from children who do
not stutter (CWNS). The need for standardized assessment and treatment tools that
incorporate a CWS's affective, cognitive and behavioural accounts, has been
recognized in recent years. However, until present, no evaluation procedures are
available in Italy that incorporate the viewpoint of the person who stutters. The
purpose of the current study is to obtain normative data for Italian CWS and CWNS
and to determine if Italian CWS and CWNS can be differentiated based on their
situation-specific emotional reaction and speech disruptions, speech associated
attitude and coping behaviours. It follows from this that the aim of the study is to
determine if the BAB can serve as a differential diagnostic standardized assessment
tool for the Italian population of CWS.
Methods: The BAB for children (ages 6 to 16), which has been translated from
English (Brutten & Vanryckeghem, 2003, 2007), and used in this study to obtain
normative data for Italian CWS and CWNS is composed of the Communication
Attitude Test (CAT), the Behavior Checklist (BCL) and the Speech Situation Checklist
(SSC) Emotional Reaction (ER) and Speech Disruption section (SD). The complete
battery was administered to CWS and CWNS. All subjects were recruited by the
National Health Service and tested in either the Centro Medico di Foniatria in
Padua or in Turin, Italy. None of the CWS had previously received fluency treatment
or were in therapy at the time of this study. The children in the final pool of
participants did not exhibit any other speech and/or language difficulty as
determined by means of a speech and language evaluation and standardized tests.
The children in the control group, had no history of any form of speech and/or
language disorder and had not previously been or were not currently in therapy.
This was confirmed by their educational records and teacher reports. Both the CWS
and CWNS were individually administered the BAB in a private setting. In accord
with the BABs protocol, the tests instructions were read aloud as the children
followed along silently.
CAT: this test investigates a child's speech-associated attitude from the age of
6 when attitude starts to play an important role in both the instatement and
maintenance of fluency. In addition, evidence exists that a CWS' negative attitude
towards speech increases the likelihood of relapse. The Italian translation of CAT
was administered by a fluency specialist to 149 CWS and 148 CWNS between the
ages of 6 and 14. The CWS group was composed of 116 males and 33 females. There
were 87 males and 61 females in the CWNS sample. The Italian CAT is made up of 35
629
statements to which the children are to respond by circling 'true' or 'false' relative to
whether or not each statement describes what they think about their speech. A group
x age x gender factorial design and an analysis of variance were used to determine if
there was a between-group difference in the attitude that CWS and CWNS held
about their speech and if it was differentially affected by age and gender.( Bernardini
et ali 2009)
BCL: the BCL provides information about a client's speech-associated coping
behaviours that are specific to sounds\words and situations. The form lists 50
behaviours that might be associated with or are exhibited during the act of speaking
to avoid negatively charged sounds\words or speech situations. The child is asked to
indicate whether or not he or she uses some of these behaviours to help sounds or
words come out, indicating 'yes' or 'no' for each behaviour that is described. The
total score on the BCL reflects the number of different coping behaviours that
children who stutter have reported to use. It was administered to 58 CWS (46 males
and 12 females) and 79 CWNS (41 males and 38 females).
SSC: the SSC has two components. The first one (Emotional Reaction: ER)
assesses speech-specific negative emotional reaction in interpersonal speech settings
and to specific sounds \ words, on a 5point scale ranging from 'not afraid' to 'very
much afraid'. The second section (Speech Disruption: SD) evaluates the amount of
speech disruption, on a 5point scale ranging from 'no trouble' to 'very much trouble
talking'. The SSC lists 55 speech situations. The Italian translation of the SSC was
administered to 68 CWS (20 girls and 48 boys) and 137 CWNS (67 girls and 70 boys).
Results: the distribution of CAT scores for the CWS ranged from 7 to 35.
Their modal score was 25 and their median score was 21. In contrast, the CWNS
scored from a low of 1 to a high of 16. The modal and median scores of the CWNS
were 6 and 7, respectively. The mean CAT score for the CWS was 20.21 (SD=6.25)
and that of the CWNS was 6.93 (SD=3.23). The main effect difference, which was
statistically significant F (1,296) =390.31, p=.000), indicates that the CWS and CWNS
sampled were representative of two clinically different populations, with a very large
difference between the two groups. Age effect: the mean CAT scores of the CWS was
statistically significantly higher than that of the CWNS at each of the nine age levels
studied. In addition, the effect size was very large at each age level and the effect of
group membership on attitude remained relatively the same from age six to 14. As
expected, no statistically significant group by age interaction was found (F
(1,16)=1.23, p=.244). Gender effect: as far as the between-group effect of gender is
concerned, the mean CAT score of the male CWS was 19.89 (SD=6.17). It was 7.15
(SD=3.19) for the male CWNS. This difference proved to be statistically significant (F
(1,1)=309.17, p=.000). The mean score of the female CWS was 21.36 (SD=6.51) and
6.62 (SD=3.30) for the female CWNS. This difference was also found to be
statistically significant (F(1,1)=212.77, p=.000). Relative to gender, a within-group
statistical analysis revealed that the speech-associated attitude of the male (19.89)
and female (21.36) CWS did not differ significantly (F(1,1)=1.44, p=.233). Similarly,
the mean CAT scores of the male (7.15) and female (6.62) CWNS did not differ
significantly (F (1,1)=.95, p=.331).To an extent that was much the same, the attitude
of the CWS, regardless of gender, was more negative than that of the CWNS. It
follows from these data that the interaction between group and gender was not
significant (F (1,2)= .21, p=.809).
BCL: the mean score of the CWS was 13.19 (SD=4.78) and that of the CWNS
was 6.05 (SD= 3.96). The data indicate that the average CWS scores fall close to two
standard deviations above that of the average CWNS( Bernardini et ali 2006). Since
the subjects were not uniformly distributed across the age ranges studied, a new
630
classification was created by dividing the subjects into two groups: a younger (age 7
to 10) and an older (age 11 to 14) group. In order to test the statistical significance of
the difference in scores between CWS and CWNS, and the influence of age and
gender, a 3-way ANOVA analysis was performed, in which the scores were the
dependent measures and group (CWS, CWNS), gender (male, female) and age
(younger, older) were the between factors. A significant between-group effect was
found, (F (1,129) = 68.139, p < .000), with CWS scoring higher (13.19); St.Dev = 4.78
than CWNS (6.05); St.Dev = 3.96. In addition, a significant age effect was found to
exist (F (1,129) = 19.872, p < .000), with the older subjects scoring significantly higher
(11.058) than the younger ones (7.578). Gender and interactions among the variables
were not found to be significant. The results of this study provide information
relative to the number of behaviours children use to help their speech. As was
anticipated, CWS use coping behaviours to a significantly greater degree compared
to CWNS. This information not only provides insight relative to the extent to which
children develop concomitant behaviours, it makes a case for including behaviours
that are secondary to stuttering in the treatment of children and points to the
importance of dealing with them early on.
SSC: As it relates to the ER portion of the test, the CWS had a mean score of
115.76 (St. Dev.: 27.15; range from 66 to 179). The CWNS had a mean score of 64.69
(St. Dev.: 5.48; range from 56 to 92). The CWSs median score was 111.00, whereas
that of the CWNS was 64.00. Since the two samples are not equally distributed (their
variances are not equal), we tested for significance by using non-parametric statistics.
The difference between CWS and CWNS was highly significant (Mann-Whitney U
test statistic = 9459.5, p <.000). Relative to gender, the male CWS had a mean score of
113.87 (St. Dev. 26.87) and the female CWS mean score was 121.50 (St. Dev. 27.66).
The difference proved not to be significant (t =1.13, df = 66, p = 0.26). The male
CWNS had a mean score of 65.00 (St. Dev. 5.94) and the female CWNS mean score
was 64.37 (St. Dev. 4.99). These scores are essentially identical (t =-0.67, df = 135, p =
0.51). As to Age factor, the scores typically increased with age for both groups.
Relative to CWS, this difference proved not to be significant (One-way Anova, F =
0.63, df = 6, p = 0.70). Relative to CWNS, the difference was significant (One-way
Anova, F = 39.53, df = 6, p < .000).
SSC-SD: For the SD section, CWS had a mean score of 116.71 (St. Dev.: 27.39,
range: from 57 to 179). The median score for CWS and CWNS was 117.00 and 57.00,
respectively. The CWNS scored, on average 57.33 (St. Dev: 3.62, range: from 55 to 89).
Because of an uneven distribution of the two samples, non-parametric statistics were
used for significance determination. The difference between CWS and CWNS was
determined to be highly significant (Mann-Whitney U test statistic = 9235.5, p <.000).
Relative to gender, the male CWS had a mean score of 113.10 (St. Dev. 27.28) and the
female CWS mean score was 125.35 (St. Dev. 26.33). The difference proved not to be
significant (t =1.70, df = 66, p = 0.09). The male CWNS had a mean score of 57.81 (St.
Dev. 4.80) and the female CWNS mean score was 56.82 (St. Dev. 1.57). The difference
proved not to be significant (t = -1.62, df = 135, p = 0.22). As to the Age factor, the
scores typically increase with age for both groups. Relative to CWS, this difference
proved not to be significant (One-way Anova, F = 0.49, df = 6, p = 0.81). Relative to
CWNS, the difference was significant (One-way Anova, F = 4.75, df = 6, p < .000).
Conclusion: the BAB has been subject to international investigations. The
current normative data on Italian CWS and CWNS are in considerable agreement
with the findings of previous cross-cultural studies of the BABs test procedures.
They indicate that, these two groups respond in discriminatively different ways.
631
References:
Bernardini, S., Zmarich, C. & Cocco, L. (2006).The Behavior Checklist Normative Study of the
Italian CWS and CWNS. Proceedings of 5th World Congress on Fluency Disorders, July
25-28, 2006, Dublin (Ireland). International Fluency Association, 2006, 205-208.
Bernardini, S., Vanryckeghem, M., Brutten. G., Cocco, L. & Zmarich, C. (2009). Communication
attitude of Italian children who do and do not stutter. Journal of Communications
Disorders, 42, 155-161.
Brutten, G., & Vanryckeghem, M. (2003). Behavior Assessment Battery: A multi-dimensional and
evidence-based approach to diagnostic and therapeutic decision making for children who stutter.
Belgium: Stichting Integratie Gehandicapten & Acco Publishers.
Brutten, G., & Vanryckeghem, M. (2007). Behavior Assessment Battery for school-age children
who stutter. San Diego, CA: Plural Publishing, Inc.
632
SY06B.3
WHAT CAN WE LEARN ABOUT PRIMARY INTERVENTION DECISIONMAKING FROM TWIN STUDIES
Steen Fibiger
Corrado Fagnani
Axel Skytthe
Objectives
Based on our twin studies, presented at this IALP Congress (Fibiger et al.
2010), and biometric models on heritability and environmental factors we like to
discuss the decision-making for intervention and therapy in children with fluency
disorders and childhood speech-language disorders.
Methods
Using nationwide questionnaire answers from 34,944 Danish twins, biometric
analyses were performed in order to estimate heritability of the traits and genetic
correlation between childhood speech-language disorders, stuttering and cluttering.
Results
The probandwise concordance rates were always substantially higher for
monozygotic compared to dizygotic pairs, suggesting genetic influence. Multivariate
biometric analyses showed that additive genetic and unique (unshared)
environmental factors best explained the observed concordance patterns. Heritability
estimates were 0.71-0.87 for childhood speech-language disorders, 0.78-0.80 for
stuttering, and 0.53-0.65 for cluttering. For each trait, the same genes were suggested
to affect liability in males and females. Furthermore, high genetic correlations
between the traits were obtained. Substantial unique environmental correlations
between the traits were also found in both genders, and the environmental factors
affecting development of stuttering were unique and unshared. Only few common
(shared) environmental factors seem to be involved.
On this background we will recommend primary intervention for stuttering
in families who have experienced stuttering, but also specific language impairment
and cluttering. The strongest recommendation will be for children in families where
both the mother and father have traits with stuttering, cluttering, childhood speech
disorders, language disorders or reading disorders. Since common (shared)
environmental factors only seem to be very little involved we do not support the
recommendations given in accordance with Johnsons diagnosogenic and
633
semantogenic hypothesis (Johnson, 1959). But because unique and unshared

environmental factors best explain the environmental influences we recommend
strongly observation for intervention where family factors are combined with
injuries, accidents and illness with neurological consequences, such as pre-, peri- and
postnatal incidences, or low Apgar score. Accidents, illness and fewer in childhood
may also be taken into account in combination with family factors when we
recommend primary intervention for prevention of stuttering development.
Older studies have described some connections with the onset of stuttering,
such as sequellae
of acute infectious disease to an inflammatory process in the speech center
(Maas, 1903)
of postencephalitic condition after the Spanish flu (Gerstman & Schilder,
1921)
of organic damage (Szondi, 1932)
of encephalitis, epilepsy and convulsions (Berry, 1938)
of attacks of infectious diseases (Gutzmann, 1939)
of instrument births (Boland, 1951)
of falling into a river (Baba, 1952)
of cerebral lesions (Gllnitz, 1955)
of rhesus incompatibility influence on the brain stem, including chorea
(Schilling, 1956)
of spinal meningitis (Goda, 1961)
of illnesses affecting the brain in 27.5% (Katsovskaia, 1962)
of infections [11 cases], falls or being beaten [18 cases] (Hirscberg, 1965)
of falling through an opening from a hayloft onto a metal container (Hastings,
1966)
of collision with a motorized bicycle (Schachter, 1967)
of cerebral lesions, related to prenatal, perinatal, or childhood adverse events
(Bhme, 1968)
of combination of premature birth and forceps delivery (Bhme, 1977)
of concussion (Bhme, 1977)
of mild closed head injury (Yeoh, et al., 2006)
but those studies have for a long period of time been overruled by Johnson
(1959) and Andrews & Harris (1964). Johnson found no significant differences in the
number of illnesses as reported by parents of stuttering and nonstuttering children
fairly soon after onset. Today, we know that Johnson had no data which could
support his diagnosogenic and semantogenic theory (Goldfarb, 2006). Andrews &
Harris also reported that their 80 pairs of stuttering and nonstuttering children
showed almost identical histories of illness. But recently Alm & Risberg (2007) are
supporting the importance of early neurological incidents in some cases of stuttering.
Zebrowski (2010) more generally stress that there is no core factor(s) necessary for
stuttering to emerge or persist in young children. Rather, stuttering results from the
complex interaction of a number of risk factors, such as speech motor skills,
temperament, genetics, language abilities, cognitive abilities, verbal environment,
time pressure, more than three within-word speech disfluencies per 100 words of
conversational speech, parental expectations, and parents reaction and response to
stuttering. According to the Stuttering Foundation of America (2010) the major
factors that place some children more at risk for continuing to stutter include:
634
Risk Factor Chart

Risk Factor
More
likely
in
beginning stuttering
Family history of A parent, sibling, or
stuttering
other family member
who still stutters
Other
speech- Speech sound errors,
language concerns trouble
being
understood,
difficulty following
directions
Gender
Male
Age at onset
Time since onset
After age 3.5 years

Stuttering
6-12
months or longer
Family history. Almost half of all children who stutter have a family member
who stutters. The risk that your child is actually stuttering instead of just having
normal disfluencies increases if that family member is still stuttering.
Other speech and language factors. A child who makes frequent speech errors such as
substituting one sound for another or leaving sounds out of words may be at greater
risk.
Gender. Girls are more likely than boys to outgrow stuttering. In fact, three to
four boys continue to stutter for every girl who stutters.
Age at onset. Children who begin stuttering before age 3 1/2 are more likely to
outgrow stuttering.
Time since onset. Between 75 percent and 80 percent of all children who begin
stuttering will stop within 12 to 24 months without speech therapy. In most children,
stuttering tends to decrease after the first six months. If your child has been
stuttering longer than this, it may be wise to have his speech screened.
Dysarthria after acquired brain injury in children has been reviewed by
Morgan & Vogel (2009).
The environmental influences on cluttering development have not been
studied in details, and very little knowledge is available about the gene-environment
interaction in childhood speech disorders, stuttering and cluttering.
Discussion
According to Howell (2010) the ratio of whole-word repetitions to part-word
repetitions, prolongations and broken words appear to be an important risk factor
for subsequent recovery from stuttering. A high rate of part-word repetitions,
prolongations and broken words is an important risk factor for persisting stuttering,
and a high relative rate of whole-word repetition is associated with recovery from
stuttering.
635
Guitar (1998) suggested that stuttering children who present with a

behaviorally inhibited profile may be at increased risk for persistent stuttering.
Recovery predictors are according to Yairi et al. (1992, 1996): onset before age
3; female; measurable decrease in sound/syllable, word repetitions, and sound
prolongations over time, observed relatively soon post-onset; no family history of
stuttering or a family history of recovery; and no coexisting phonological problems.
Self-reported data might be prone to recall bias, especially when old twins are
asked about their communication problems in childhood, and the recollections of the
twins might have been influenced by what they remembered of their behavior,
relative to that of their co-twins. In biometric modeling, we also made a number of
simplifying assumptions that were not tested. One such assumption is that there are
only additive effects of genes and environment on the phenotypic variance.
However, in practice, there may be interactive effects. These interactive effects
become incorporated into the estimates of genetic liability (for interactions between
common environmental and genetic risk) or unique environmental estimates (for
interactions between unique environmental and genetic risk). Consequently, the
estimates of genetic and environmental variance may include these types of genes by
environment interaction variance.
Conclusions
When decide about early intervention we recommend taking into account the
liability of communication disorders in the families and unique and unshared
environmental factors, affecting the brain function.
References
Alm, P.A. & Risberg, J. (2007). Stuttering in adults: the acoustic startle response,
temperamental traits, and biological factors. Journal of Communication Disorders, 40,
1-41.
Andrews, G. & Harris, M. (1964). The syndrome of stuttering. London: Heinemann.
Baba, K. (1952). A cured case of infantile stuttering. Japanese Journal of Otology, 55, 51-52.
Berry, M.F. (1938). Developmental history of stuttering children. Journal of Pediatrics, 12, 209217.
Bhme, G (1968). Stammering and cerebral lesions in early childhood. Examinations of 802
children and adults with cerebral lesions. Folia Phoniatrica, 20, 239-249.
Bhme, G. (1977). Das Stotter-Syndrom. Bern: Verlag Hans Huber.
Boland, J. L. (1951). Type of birth as related to stuttering. Journal of Speech and Hearing
Disorders, 16, 40-43.
Fibiger, S., Fagnani, C., Skytthe, A. & Hjelmborg, J. (2010). Genetic and environmental risk
factors for development of stuttering, cluttering and childhood speech-language
disorders. Proceedings from the 28th World Congress of the International Association
of Logopedics and Phoniatrics. 22nd - 26th August 2010, Athenaeum Intercontinental
Hotel, Athens, Greece.
Gerstman, J. & Schilder, P. (1921). Studien ber Bewegungstrungen. V. ber die Typen
extrapyramidaler Spannungen und ber die extrapyramidale Pseudobulbrparalyse.
Zeitschrift fr Neurologie und Psychiatrie, 70, 35-54.
Goda, S. (1961). Stuttering manifestations following spinal menigitis. Journal of Speech and
Hearing Disorders, 26, 392-393.
Goldfarb, R., Ed. (2006). Ethics. A case study from Fluency. San Diego,California: Plural
Publishing.
Gllnitz, G. (1955). Zusammenhnge zwischen Stottern und frhkindlichen Hirnschdigung.
Medizinische Klinik, 50, 685-689.
Guitar, B. (1998). Stuttering: an integrated approach to its nature and treatment, (2nd ed.).
Baltimore: Williams and Wilkins.
636
Gutzmann, H. (1939).Erbbiologische, soziologische und organische Faktoren die

Sprachstrungen begunstigen. Archive fr Stimmheilkunde, 3, 133-136.
Hastings, I. (1966). A case of stammer and tongue thrusting. In: Speech pathology. Diagnosis:
Theory and practice. Report of the National Conference of the College of Speech
Therapists (London) in Glasgow, 1966. British Journal of Disorders of
Communication, 1, Supplement.
Hirschberg, J. (1965). [Stuttering]. Orvosi Hetilap (Budapest), 106, 780-784.
Howel, P. (2010). Recovery from stuttering. Keynote presented at the European Symposium
on Fluency Disorders 2010, Lessius University College, Antwerp, Belgium. April 2324, 2010.
Johnson, W. (1959). The onset of stuttering. Minneapolis: University of Minnesota Press.
Katsovskaia, I.I.K. (1962). The problem of childrens stuttering. Deafness, Speech and Hearing
Abstracts, 2, 296.
Maas, O. (1903). Einige Bemerkungen ber dass Stottern. Deutsche Zeitschrift fr
Nervenheilkunde, 24, 390.
Morgan, A.T. & Vogel, A.P. (2009). A Cochrane review of treatment for dysarthria following
acquired brain injury in children and adolescents. European Journal of Physical and
Rehabilitation Medicine, 45, 197-204.
Schachter, M. (1967). Aphmie suivie de bgaiement dorigine psychodramatique chez une
fillette de quatre ans. Acta Paedopsychiatrica, 34, 1-32.
Schilling, A. (1956). Stottern bei Rhesus-bedingter Stamhirnschdigung. Archiv fr Ohren-,
Nasen- und Kehlkopfheilkunde, 169, 501-505.
Stuttering
Foundation
of
America
(2010).
http://www.stutteringhelp.org/Default.aspx?tabid=555
Accessed May 28, 2010.
Szondi, L. (1932). Konstitutionsanalyse von 1000 Stotterern. Wien Medizinische Monatschrift,
82, 922-928.
Yairi, E. & Ambrose, N. (1992). A longitudinal study of stuttering in children: A preliminary
report. Journal of Speech and Hearing Research, 35, 755-760.
Yairi, E., Ambrose, N.G., Paden, E.P. & Throneburg, R.N. (1996). Predictive factors of
persistence and recovery: pathways of childhood stuttering. Journal of
Communication Disorders, 29, 51-77.
Yeoh, H.K., Lind, C.R. & Law, A.J. (2006). Acute transient cerebellar dysfunction and
stuttering following mild closed head injury. Child's Nervous System, 22, 310-313.
Zebrowski, P. (2010). Subtypes and risk factors in childhood stuttering. Videoconference
presented at the European Symposium on Fluency Disorders 2010, Lessius University
College, Antwerp, Belgium. April 23-24, 2010.
637
SS04.1
GENETIC
AND
ENVIRONMENTAL
RISK
FACTORS
FOR
DEVELOPMENT OF STUTTERING, CLUTTERING, AND CHILDHOOD
SPEECH-LANGUAGE DISORDERS
Steen Fibiger
Corrado Fagnani
Axel Skytthe
INTRODUCTION
Speech-language Disorders
Seeman (1937) was the first to be convinced that genetic factors are often
responsible for various delays in language development. Heritability estimates for
speech-language disorders have been inconsistent, with monozygotic (MZ)
probandwise concordance rates between 0.36 and 0.96, and dizygotic (DZ) rates
between 0.20 and 0.69.
Stuttering
The genetic contributions to stuttering have been mentioned in twin studies
also since 1937 by Berry. Later Yairi (2005) and co-workers have concluded that both
genetic and environmental factors contribute to stuttering.
Cluttering
Colombat (1830) reported the first differentiation between cluttering and
stuttering. Still, the classification status of cluttering is open to much debate, but
Weiss (1964) and Arnold (1965) concluded that heredity plays a prominent role in
most cases of cluttered speech.
Comorbidity of speech-language disorders, stuttering, and cluttering

Simultaneous
occurrence
of
combinations
of
speech-language
disorders, stuttering and cluttering have been claimed and described through clinical
communications since Treitel (1892).
Aims of the study
638
1. to examine the role of genetic and environmental factors in the

development of childhood speech-language disorders, stuttering and
cluttering.
2. to investigate the coexisting of stuttering, cluttering and childhood
speech disorders.
3. to establish to what extent the coexisting can be explained by
overlapping genetic factors or environmental influences shared by the
three communication disorders or traits.
MATERIALS AND METHODS
Subjects and Questionnaire
A paper and pencil questionnaire was sent to a population-wide cohort of
46,418 twins, who had participated in earlier questionnaire studies and were born
between 1931 and 1982 in Denmark. 35,312 returned a filled questionnaire, and it is a
response rate of 76 percent. The questions relevant to this study are:
Did you have problems with your speech and language in your
childhood?
Do you stutter or have you stuttered?
Is it, or has it been a problem, that you speak so fast, that you stumble
over the words and omit syllables (cluttering)?
Prevalence rates
Table 1 shows, separately for monozygotic(MZ) and same gender dizygotic
(SSDZ) pairs, and for males and females, the numbers of complete twin pairs, and
the numbers of concordant and discordant pairs, along with lifetime prevalence
rates, probandwise concordance rates, and tetrachoric correlations for childhood
speech-language disorders, stuttering, and cluttering.
There are no significant differences between twins from complete pairs and
twins from unmatched pairs regarding the distributions of age, gender and zygosity,
the lifetime prevalence rates for the disorders and the phenotypic correlations for the
traits.
The self-reported lifetime prevalences for speech disorders are within the range of other published data.
The self-reported lifetime prevalences for stuttering, from less than 4 percent for females to more than 8 per cent for
males, are only slightly higher than those previously reported. We assume that the high prevalence of cluttering in
our twins is related to a broader definition, Cluttering Spectrum Behavior (CSB), proposed by Ward (2006) and used
by the general public for those speakers who display some cluttering characteristics.
Probandwise concordance rates

For each trait, probandwise concordance rates and tetrachoric correlations
were estimated separately for monozygotic and same gender dizygotic pairs, and for
males and females. Probandwise concordance is the probability that the trait occurs
in a twin given that it has already occurred in the co-twin, and can be estimated as
2n11/(2n11+nd), where n11 and nd are the numbers of concordant and discordant twin
pairs, respectively. Difference in concordance rate between MZ and DZ pairs
suggests genetic effects.
Our probandwise concordance rates for childhood speech-language disorders
are lower than those found in the age range of five to sixteen years by Lewis &
639
Thomson (1992), Bishop et al. (1995), Tomblin & Buckwalter (1998), and DeThorne et
al. (2006). Here the ranges were 0.86 to 0.96 for MZ and 0.44 to 0.69 for DZ. Recently,
Bishop & Hayiou-Thomas (2008) analyzed data from the Twin Early Development
Study (Hayiou-Thomas, Oliver & Plomin, 2005), and they concluded that in genetic
studies it is more likely to find high concordance rates and heritability if they focus
on cases who have speech difficulties and who have been referred for intervention.
Table 1: Twin cohort data
Trait
Zygosity Numbe
r
of
pairs
Males
ChildSL
Number of
concordant
pairs
Number of
discordant
pairs
Lifetime
prevalence
Probandwise
concordance*
Tetrachoric
correlation*
MZ
649
42
79
0.13
0.52 (0.42,0.61)
0.79 (0.66,0.88)
SSDZ
825
22
125
0.10
0.26 (0.18,0.36)
0.40 (0.18,0.58)
MZ
689
36
48
0.087
0.60 (0.49,0.70)
0.85 (0.71,0.93)
SSDZ
880
123
0.077
0.09 (0.03,0.18)
0.071 (-0.24,0.37)
MZ
684
48
118
0.16
0.45 (0.36,0.53)
0.62 (0.45,0.75)
SSDZ
875
20
160
0.11
0.20 (0.13,0.29)
0.31 (0.08,0.51)
MZ
945
36
49
0.064
0.60 (0.48,0.70)
0.87 (0.76,0.94)
SSDZ
1170
15
114
0.062
0.21 (0.12,0.31)
0.35 (0.12,0.55)
MZ
995
21
36
0.039
0.54 (0.39,0.67)
0.84 (0.67,0.93)
SSDZ
1207
92
0.041
0.08 (0.02,0.19)
0.15 (-0.19,0.46)
MZ
992
65
135
0.13
0.49 (0.41,0.57)
0.70 (0.57,0.80)
SSDZ
1209
33
216
0.12
0.23 (0.17,0.31)
0.32 (0.14,0.49)
D
ChildSL
D
Stutterin
g
Stutterin
g
Clutterin
g
Clutterin
g
Females
ChildSL
D
ChildSL
D
Stutterin
g
Stutterin
g
Clutterin
g
Clutterin
g
ChildSLD = Childhood speech-language disorders
SSDZ = Dizygotic twins from pairs with same sex/gender
*In parentheses are 95% confidence intervals
640
Tetrachoric correlations
Tetrachoric correlation is defined under the so called liability-threshold
model. According to this model, there exists a latent liability to the trait. The liability
is bivariate normally distributed in the population, with a threshold such that the
trait occurs when the individual liability level exceeds the threshold. Tetrachoric
correlation is the correlation in twin liabilities to the trait, and is independent of trait
prevalence. A significantly higher correlation in monozygotic (MZ) compared to
dizygotic (DZ) pairs points to genetic influences on liability to the trait.
For all traits, both probandwise concordance rate and tetrachoric correlation
were significantly higher in monozygotic than in dizygotic pairs, irrespective of
gender. It indicates substantial genetic influence on individual liability to each
disorder. For stuttering, tetrachoric correlations also suggested possible dominant
genetic effects.
Univariate gender-limitation modeling
We have used our data for statistical methods and genetic modeling with the
software Mx (Neale et al., 2006). First, we made a univariate analysis of the three
dichotomous traits separately. The models consist of Additive genetic effects (A),
Common environmental effects (C) [experiences that make children growing up in
the same family similar], Non-additive (dominant or epistatic) genetic effects (D),
and Non-shared (individual-specific) environmental effects (E) [influences that make
children growing up in the same family different: e.g. adequacy of blood supply,
position in the womb, birth complications, different home, infections, traumas]. The
combinations ACE, ADE, AE, CE, and E are possible.
Table 2: The best fitting univariate biometric models for males and females related to
childhood speech-language disorders (ChildSLD), stuttering, and cluttering
A
D
E
Best models
ChildSLD
0,79 - 0,86
AE models
0,21 0.14
AE
Stuttering
0,82 - 0,81
0,02 AE
0,16 0.19
ADE - AE
Cluttering
0,62- 0,69
AE models
0,38 0.31
AE
A=Additive genetic effects, D=Non-additive genetic effects, E=Non-shared environmental

effects, =Men, =Women.
Table 2 shows the best fitting univariate biometric models for males and
females. The environmental influences seem to be individual and non-shared, and
common environmental influences are not seen. So, an excessive parental concern
about imperfect speech, a competitive and perfectionistic parental style, and a family
drive for upward mobility seems not to have an influence. Therefore, the present
study does not give any support for Johnsons diagnosogenic and semantogenic
theory on stuttering etiology (Johnson, 1959).
Trivariate biometric analysis
A Cholesky decomposition was fitted to the three dichotomous traits and
covariances between the traits were modeling to a trivariate scenario. The best fitting
trivariate model provides estimates of genetic and environmental influences for the
traits and of genetic correlations between them.
Table 3 shows the heritabilities and genetic correlations of childhood speechlanguage disorders, stuttering, and cluttering, as estimated under the best-fitting AE
Cholesky decomposition. Substantial heritabilities for the traits were found. The
pattern of these estimates was very similar to that derived from the univariate
analysis based on raw dichotomous data. In the univariate analysis, observations
641
from opposite-gender twin pairs also suggested that the same genes may be
responsible for the effects in males and females in each disorder. But lifetime
prevalences are different between genders.
High genetic correlations between the traits emerged (Table 3). The same
table shows substantial unique environmental correlations between the traits
in both genders.
Table 3: Genetic and environmental proportions of variance and

correlations as estimated, for males and females, under the best-fitting
(AE) Cholesky decomposition for childhood speechlanguage
disorders, stuttering, and cluttering
Additive genetic (A) and unique environmental (E) proportions of
variance*
Males
Speech-language
Stuttering
Cluttering
disorders
A
0.71 (0.61,0.81)
0.78 (0.70,0.86)
0.53 (0.42,0.64)
0.29 (0.19,0.39)
0.22 (0.14,0.30)
0.47 (0.36,0.58)
Stuttering
Cluttering
Females
Speech-language
disorders
A
0.87 (0.81,0.93)
0.80 (0.70,0.90)
0.65 (0.57,0.74)
0.13 (0.07,0.19)
0.20 (0.10,0.30)
0.35 (0.26, 0.43)
Additive genetic (upper triangle) and

unique environmental (lower triangle) correlations*
Males
Speech-language
Stuttering
Cluttering
disorders
Speech-language
disorders
Stuttering
---
0.71 (0.63,0.78)
0.73 (0.60,0.86)
0.92 (0.76,0.99)
---
0.53(0.40,0.68)
Cluttering
0.29 (0.07,0.50)
0.63(0.38,0.85)
---
Stuttering
Cluttering
Females
Speech-language
disorders
Speech-language
disorders
Stuttering
---
0.79 (0.71,0.86)
0.56 (0.47,0.66)
0.86 (0.52,0.99)
---
0.57 (0.45,0.68)
Cluttering
0.79 (0.54,0.95)
0.35 (0.05,0.64)
---
*In parentheses are 95% confidence intervals
642
Despite some limitations, our results may aid to the understanding of the
biological and environmental contributions to the development of childhood speechlanguage disorders, stuttering, and cluttering, as well as their co-occurrence, and
therefore may guide the design of effective interventions and treatments.
REFERENCES
Arnold, G.E. (1965). Cluttering: Tachyphemia. In R. Luchsinger & G.E. Arnold. Voice-SpeechLanguage, 598-622. Belmont, California: Wadsworth.
Berry, M.F. (1937). Twinning in stuttering families. Human Biology, 9, 329-347.
Bishop, D.V.M., & Hayion-Thomas, M.E. (2008). Heritability of specific language impairment
depends on diagnostic criteria. Genes Brain and Behavior, 7, 365-372.
Bishop, D.V.M., North, T., & Donlan, C. (1995). Genetic basis for specific language
impairment: evidence from a twin study. Developmental Medicine & Child Neurology,
37, 56-71.
Brady, P.J. (1993). Treatment of Cluttering. The New England Journal of Medicine 329, 813-814.
Colombat de lIsre, M. (1830). Du Bgaiement et de tous les autres vices de la parole traits par de
nouvelles mthodes. Paris: Mansut fils.
DeThorne, L.S., Hart, S.A., Petrill, S.A., Deater-Deckard, K., Thompson, L.A., Schatschneider,
C., & Davison, M.D. (2006). Childrens history of speech-language difficulties:
Genetic influences and associations with reading related measures. Journal of Speech
Language and Hearing Research, 49, 1280-1293.
Hayiou-Thomas, M.E., Oliver, B., & Plomin, R. (2005). Genetic influences on specific versus
nonspecific language impairment in 4-year old twins. Journal of Learning Disabilities,
38, 222232.
Johnson, W. (1959). The onset of stuttering. Minneapolis, MN: University of Minnisota Press.
Lewis, B.A., & Thompson, L.A. (1992). A study of developmental speech and language
disorders in twins. Journal of Speech, Language, and Hearing Research, 35, 10861094.
Neale, M.C., Boker, S.M., Xie, G., & Maes, H. (2006). Mx: Statistical modelling, 7th ed.
Richmond, Virginia: Department of Psychiatry, Virginia Commonwealth University.
Seeman, M. (1937). Die Bedeutung der Zwillingspathologie fr die Erforschung von
Sprachleiden [The significance of twin pathology for the investigation of speech
disorders]. Archiv fr Sprach- und Stimmheilkunde und angewandte Phonetik, 1, 88-98.
St. Louis, K.O., Raphael, L.J., Myers, F.L., & Bakker, K. (2003, Nov. 18). Cluttering updated.
The ASHA Leader, 4-5, 20-22.
Tomblin, J.B., & Buckwalter, P.R. (1998). Heritability of poor language achievement among
twins. Journal of Speech, Language and Hearing Research, 41, 188199.
Treitel, L. (1892). ber Sprachstrungen und Sprechentwicklungen. Archiv fr Psychiatrie und
Nervenkrankheiten, 24, 578-611.
Yairi, E., & Ambrose, N.G. (2005). Early Childhood Stuttering, Chapter 9: Genetics, 285-311.
Austin, TX: PRO-ED,
Ward, D. (2006). Stuttering and Cluttering. Framework for understanding and treatment. Hove,
East Sussex, UK: Psychology Press.
Weiss, D. (1964). Cluttering. Englewood Cliffs, New Jersey: Prentice-Hall.
Acknowledgement
We acknowledge the financial support provided by The William Demant and
Wife Ida Emilie Foundation (The Oticon Foundation), and associated professor
Kirsten Kyvik, M.D., Ph.D. from the Danish Twin Register.
643
P165
SPEECH AND LANGUAGE THERAPY STRATEGIES FOR CHILDREN WITH
FLUENCY DISORDERS
D. Kairiene, R. Ivoskuviene, D. Gerulaitis, V. Makauskiene
Siauliai university, Siauliai, Lithuania
Introduction and aims of the research. Complicated dynamics of fluency
disorders, different their impact for person communication, social participation,
promote development of individualized methods of therapy, active child and family
participation in speech and language therapy process, professional competencies
researches.
The research is related with the complicated situation of speech and language
therapy (SLT) for children with fluency disorders: variety of theoretical definitions,
uncertainty of criterions for differentiation of stuttering and cluttering, assessment
criterions of these disorders, the issues of choosing therapy strategies and their
adjustment, contradictory results of researches about speech and language therapy
efficiency (Sackett, Straus ir kt., 2000; Thomas, Howell, 2001; Langevin, Kully, 2003;
Finn, 2003; Yaruss, Quesal, 2006).
Definitions of cluttering and stuttering disorders are not clear. There are
many terms, defining fluency, cluttering, stuttering (Starkweather, 1987, Ham, 1990,
Cooper, 1993, Culatta, Goldberg, 1995). Stuttering is defined as: repetitions of sounds,
syllables, blocks during the speech, stress and fear of speaking, irregular breathing
and etc. (Roth, Worthington, 2005; Myers, St. Louis, 1992; Makauskien, 2008).
The main features of cluttering are defined as: fast rate of the speech negatively
influencing various forms of communication, motor activity and behavior. There are
common lack of attention, impulsiveness, difficulties in control and planning of
speech, language, behavior. It is possible, that cluttering is identified not correctly,
because of lack of knowledge about this disorder, small amount of the cases, because
persons are not aware of the problem they have and dont apply for the help to SLT.
Speech therapists competence researches (St. Louis, Durrenberger, 1993;
Manning, 2001; Ivokuvien, Makauskien, Rukus, 2006) show that professionals
have the lack of knowledge of work with fluency disorders more than treatment of
other speech, language and communication disorders. It presents importance of
research seeking to distinguish SLTs awareness about fluency disorders therapy for
finding professional competencies development areas.
The aim of research - to define the features of stuttering and cluttering, which
SLTs are use differentiate these disorders and disclose which strategies are
distinguished as efficient in speech and language therapy for the pupils with fluency
disorders in Lithuania.
Methods of the research. Research is based on interdisciplinary approach,
when SLTs are analyzed through two dimensions: educational (strategies,
experiences), sociological (opinions of participants). The data of research are based
on quantitative and qualitative methods. Quantitative data gathering method
structured questionnaire used for disclosing identification features of disorders,
efficient strategies and semi-structured interview seeking to explore SLTs opinions and
suggestions for the therapy.
644
Sample characteristic is presented in 1 table.

1 table
Features of research respondents (N= 96).
Age
Till 25 years
26-35 years
36-45 years
46-55 years
55< years
Seniority of work
1-10 years
11-15 years
16-25 years
25< years
No answer
Workplace
Preschool-school
Preschool institution
Mainstream school
Health care institution
Special education institution
Pedagogical psychological centre
Private sector
Qualification
SLT
Senior SLT
Supervisor SLT
Expert
No answer
7
21
26
24
15
7,5
22,6
28
25,8
16,1
22
16
27
25
3
24,4
17,8
30
27,8
3,2
2
52
30
8
16
5
5
2,2
55,9
32,3
8,6
17,2
5,4
5,4
14
31
40
5
3
15,6
34,4
44,4
5,6
3,2
Results of the research

Cluttering features, which are distinguished of SLTs in Lithuania. Relating
with the theoretical features of cluttering, professionals define these features, as main
characteristic of cluttering (2 table)
2 table
Cluttering features, which are distinguished of SLTs
Related with theoretical features
Fast rate of the speech
Poor auto-control skills
Lack of pauses between words, sentences
Impulsive, fast motor activity
Shortening of words
Poor grammar
Not appropriate to theoretical features
Omission of syllabics
Omission of words
Enlarged blocks during public speech
Tiredness
Awareness about negotiation of speech difficulties
Slow rate of the speech
Loneliness
Indifference
M
3,59
3,24
3,16
2,97
2,86
2,15
2,78
2,75
2,62
2,25
2,14
1,50
1,87
1,93
645
Speech and language therapists partly distinguishing the features of cluttering

based on theoretical features, but there is different frequency of them. Often
characteristics of cluttering, regarding participants opinion, are rarely appropriate to
cluttering children, than many authors note (Curlee, 2007; Roth, Worthington, 2005;
Myers, St. Louis, 1992).
Stuttering features, which are distinguished of SLTs in Lithuania. Relating
with the theoretical features of stuttering, professionals define these features, as
mostly typical for stuttering (3 table)
3 table
Stuttering features, which are distinguished of SLTs
Related with theoretical features
Lack of fluency and blocks during the speech
Hyper-tension
Enlarged blocks of speech in public discourse
Stress related with reactions of others
Repetitions of sounds, syllables
Avoidance of more complex, difficult situations
Irregular breathing
Not appropriate to theoretical features
Reduced amount of blocks during public speech
Speech is more fluent in complex situations
Omission of words
Substitution of sounds, syllables
M
3,43
3,40
3,38
3,22
3,20
3,18
3,17
3,50
1,56
1,67
1,75
The data shows, that SLTs more precisely define stuttering, than cluttering
features. But there are some contradictory opinions, about children speech in more
difficult situations: it could be explained by the lack of possibilities to observe
children speech in every day life.
Efficient strategies of SLT for cluttering children. SLTs (N=96) were asked to
note the efficient treatment strategies for cluttering children (4 table).
4 table
Efficient strategies of SLT provision for cluttering children
Strategies
Fluent speech techniques oriented
Regulation of speech rate (reducing speech rate)
Regular breathing and speech rhythmic promotion
Fluent narrative skills development
Totally
Person awareness oriented
Promotion of self-control
Personality training
Creation of emotionally safe and quiet environment
Promotion of motivation to negotiate speech difficulties
Totally
Collaboration oriented
Collaboration between all members in speech and language
provision
Totally
Other
Clear recognition of disorder reasons
Frequency
22
13
5
40
16
8
7
3
34
5
5
1
646
SLTs noted as mostly efficient fluent speech techniques (40). They are: reducing
of speech rate, regular breathing, speech rhythmic and narrative skills development.
Regulation of speech rate is use for training of reduced speech rate, through repetitive
speech, slow reading, comparison of fast and slow speech in audio tapes, other.
Regular breathing and speech rhythmic promotion are defined as breathing regulation
exercises, language rhythmic and regular diaphragmatic breathing skills training.
Fluent narrative skills development is used by expressive reading, training of structured
narratives, conversation skills and their planning.
Person awareness (34) oriented strategies are also defined as efficient.
Development of self-control is oriented to language skills training and advices for
children to controle their language. Personality training strategy: attention, willpower,
activity planning. Creation of emotionally safe and quiet environment strategy is used
during therapy, where is stress free atmosphere and applying relaxation exercises.
Also, it is distinguished children self-motivation promotion as necessary factor in
pursuance to negotiate fluency difficulties not just during therapy, but either in other
life situations.
Collaboration strategy (5) between all members in speech and language therapy
is not emphasized very much and shows that there are no skills transfer strategies in
other children activities (school, family).
Clear recognition of disorder causes is useful for detection of speech behavior
and social environment of the child and allows the rise therapy goals.
The pattern of distinguished strategies are appropriate to individual work with the
child, relating with particular speech techniques application and person awareness about
speech difficulties, aiming to promote fluent speech during therapy sessions. But there
are lack of SLTs perception that collaboration strategies useful for the promotion of
fluent speech could be factor of efficiency, seeking fluent children speech in external
environment.
Cluttering intervention strategies are related with the professionals perception about
main features of cluttering: fast rate of the speech, poor auto-control skills, shortening
and omission of words. There is no enough attention to activity and language
planning skills, which are the main causes, determining cluttering.
Efficient strategies of SLT for stuttering children. SLTs (N=96) were asked to
note the efficient strategies for treatment of stuttering children (5 table).
5 table
Efficient strategies of SLT for stuttering children
Strategies
Fluent speech techniques
Regular speech breathing skills training
Rhythmic speech promotion
Promotion of using fluent speech techniques
Reducing speech rate
Application of therapy sequence
Totally
Person awareness oriented
Change of environment and personality training
Self-control promotion
Totally
Collaboration oriented
Teamwork in speech skills training
Doctor support (medical treatment)
Totally
Frequency
31
29
18
8
7
93
46
11
57
8
4
12
647
Other
Therapy individualization
The most efficient strategies are defined as application of fluent speech

techniques oriented (93). Regular speech breathing skills training and rhythmic speech
promotion strategies are related with: breathing regulation exercises, speech rhythmic
promotion and regular diaphragmatic breathing skills training through chant speech,
syllabic speech, singing, motions link with speech, drama and other art activity.
Promotion of using fluent speech techniques: training of fluent pronunciation of syllables,
words, their coupling into sentences, soft articulation of the word, repetitive
language. Application of therapy sequence: planned, sequence therapists activity
through didactical games, more complex exercises.
Efficient person awareness oriented strategies (57) are: change of environment and
personality training, which consist of: relaxation based interactions, creation of
communication rules (communication schedule), child self-confidence promotion,
close relations with children creation and self-control promotion (control of the speech
and blocks, speech rate in various situations).
Collaboration strategies (12) are emphasized as efficient also. Teamwork, training
fluent speech skills SLTs is defined as: multi-professional activity - psychologist,
psychotherapist, doctor treatment, also speech and language therapist conversations
with members of family, friends and teachers.
Individualization of therapy is related with professionals choice of therapy
ways, depending on disorder type and level, child age, child personal characteristics.
The pattern of distinguished strategies is appropriate to individual work with the
child, relating with particular speech techniques application and person self-control
promotion. Mostly strategies are oriented to fluent speech shaping, which shows
dominant fluency shaping approach.
There are no considerable differences between the strategies, which professionals
distinguishing as efficient in cluttering and stuttering negotiation therapy. Most efficient
strategies are oriented to the particular fluent speech techniques application as in the cases of
cluttering either stuttering. SLTs more often distinguish stuttering negotiation strategies
than cluttering, it can be explained that SLTs are more certain about the therapy strategies in
stuttering, that in cases of cluttering therapy.
The importance of theoretical and practical factors, which determine
efficiency of therapy negotiating fluency disorders: professionals approach.
Between theoretical factors (collaboration, environmental, professional awareness,
children personal characteristics, individualization), SLTs were asked to evaluate the
main important factors in practice. Professionals opinion is closely relevant with the
factors, maintained in theory, but the there are three factors, which mostly influence
efficiency of therapy (1 diagram).
648
Child aw areness of
speech control
Child motivation
SLT's personal traits

SLT's professional
aw areness
3,1
3,2
3,3
3,4
Theoretically important factors
3,5
3,6
3,7
3,8
3,9
Important factors in practice
1 diagram. Comparison of theoretical and practically important factors

The data shows, that SLTs opinion about the theoretical factors and their
importance in practice are not the same. Professionals think that SLTs professional
awareness (p=0.0463), SLTs personal traits (p=0.033), child awareness of speech control
(p=0.019) and child motivation (p=0,001) are the mostly important, seeking efficient
therapy. It can be possible, that these differences are related with the professionals
lack of theory analysis and their opinion background, based on self-creativity,
professional practice.
Speech and language therapists suggestions for the fluency disorders
therapy. During interview participants (N=4 experts) were asked to give suggestions
for the work with children with fluency disorders. All suggestions can be grouped in
to:
Methodical suggestions (fluency shaping approach): getting in close relationship
with the child for the motivation to negotiate speech and communication difficulties;
planning of therapy areas and goals, relating with the education curriculum; individual
work with the child, teaching fluent speech and regular breathing techniques creatively
using various equipments; analysis of the causes of disorder seeking to arrange speech and
language therapist work with other professionals (psychotherapist, neurologist) possible
provision and meetings with parents; work with family should be organized inviting
parents to participate in therapy and giving them recommendations for understanding
the peculiarities of therapy and its succession in home environment; involving other
activities: music, rhythmic exercises; implementation of learned skills in real social
situations.
1)
Suggestions for fluency modification: work with other people, which child
interact with (friends, parents, teachers) seeking to perceive child as stuttering,
cluttering; orientation not to disorder negotiation, but promotion of others to
use some strategies, which could reduce speech disfluency, during interactions and
communication.
2)
Suggestions for development of speech and language therapy provision:
creation of emphasized speech therapy provision centres, where could be gathered
human and material resources for the specific work with children with fluency
disorders
3
Level of statistical importance p0,05 p demonstrates statistically important difference of

evaluations between professionals practice factors and theoretical factors in speech and language
therapy
649
Suggestions of experts show that SLT should be oriented to the arrangement

of fluency shaping, fluency modification approaches, but also to take attention to
the collaborative practice with other professionals, parents either as other external
resources invocation.
Conclusions
Research data present, that SLT identification of cluttering features is oriented
to the fast rate of speech, poor self-control skills, impulsive motor activity and poor
grammar. Other distinguished features, such as omission of syllabics, words,
awareness of the problem and enlarged blocks during public speech can be explained
as the difficulties which SLTs meet with identifying disorder, because of the lack
of work experience, small amount of cluttering cases in their practice.
Identification of stuttering are more clear for SLTs. They distinguish the main
features of disorder found in theory: repetitions of sounds and syllables, blocks,
increased tension, fear of public speech, stress, avoidance of more complex, difficult
situations, irregular breathing, etc.
There are no considerable differences between the strategies, which professionals
distinguishing as efficient in cluttering and stuttering treatment therapy. It shows
difficulties of differentiation of work in case of these disorders. In both cases
strategies can be grouped into: fluent speech techniques teaching, person awareness
promotion, collaboration between other professionals and families.
Strategies mostly efficient in cluttering treatment therapy are: regulation of
speech rate, regular breathing and speech rhythmic promotion, self-control
development. Strategies mostly efficient in stuttering therapy: regular speech
breathing skills training, rhythmic speech promotion, fluent speech techniques
teaching, change of environment and personality training.
Research data disclose the factors, which are mostly important in therapy: SLTs
personal traits and professional awareness and child motivation to negotiate
disorder.
Professionals suggestions for the fluency disorders treatment therapy are
related with arrangement of fluency shaping, fluency modification strategies,
during collaborative practice and external recourses appliance.
References
1.
Cooper, E. B. (1993). Chronic perseverative stuttering syndrome: A harmful or helpful

construct? American Journal of Speech-Language Pathology, 2 (3), p. 11-15.
2. Conture, E. G., Curlee, R. F. (2007). Stuttering and Related Disorders of Fluency.
Thieme.
3. Culatta, R., Goldberg, S. A. (1995). Stuttering therapy: An integrated approach to theory
and practice. Needham Heights. MA: Allyn&Becon.
4. Finn, P. (2003). Evidence-based treatment of stuttering: II. Clinical significance of
behavioral stuttering treatments. Journal of Fluency disorders, 28, p. 209-218.
5. Ham, R. E. (1990). Therapy for stuttering: preschool through adolescence. Englewood
Cliffs, NJ: Prentice-Hall.
6. Ivokuvien, R., Makauskien, V., Rukus, J. (2006). Pagalbos mikiojantiems teikimas
Lietuvoje: praktika, metodai, tendencijos. Specialusis ugdymas, Nr. 1(14), psl. 123-137.
7. Yaruss, J. S., Quesal, R. W. (2006). Overall Assessment of the Speakers Expierence of
Stuttering (OASES): Documenting multiple outcomes in stuttering treatment. Journal
of Fluency disorders, 31, p. 90-115.
8. Langevin, M., Kully, D. (2003). Evidence-based treatment of stuttering: III. Evidencebased practice in clinical setting. Journal of Fluency disorders, 28, p. 219-236.
9. Manning, W. H. (2001). Clinical decision making in fluency disorders (2nd ed.). San
Diego: Singular Publishing.
10. Myers, F. L., St. Louis, K.O. (1992). Cluttering: A Clinical Perspective. San Diego.
650
11. Myers, F. L., St. Louis, K.O., Raphael, L. J., Bakker, K., Lwowski, A. (2003). Patterns of
disfluencies in cluttered speech. Anual covention of ASHA, Chicago, IL.
12. Roth, F. P., Worthington, C. K. (2005). Treatment Resource Manual for SpeechLanguage Pathology. Thomson Delmar Learning.
13. Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W., Haynes, R. B. (2000).
Evidence-based medicine: How to practice and trach EBM. Edinburg: Churchill
Livingstone.
14. Starkweather, C. W. (1987). Fluency and stuttering. Englewood Cliffs, NJ: PrenticeHall.
15. St. Louis, K. O., Durrenberger, C. H. (1993). What communication disorders do
experienced clinicians prefer to manage? ASHA, 35, p. 23-31.
16. Thomas, C., Howell, P. (2001). Assessing efficacy of stuttering treatments. Journal of
Fluency Disorders, 26, p. 311-333.
651
P166
LINGUISTIC ANALYSIS OF SPEECH OF EARLY STUTTERED AND NORMAL
DISFLUENT CHILDREN
Miglena Simonska
South-West University, Blagoevgrad, Bulgaria
Introduction and aims of the study: An important part of stuttering
assessment process is linguistic analysis. It gives individual information about loci of
disfluencies and helps us to manage therapy. The main purpose of this paper is a
comparative analysis regarding loci of disfluencies and type of disfluent morphemes
between early stuttered and normal disfluent children.
Methods: To meet the purpose of the study was developed a Linguistic
Analyzing Protocol of Disfluent Speech. This Protocol was divided in two parts:
morphological and syntactical. Each type of disfluencies had to be counted and put
in the gap of type and loci of morpheme and syntagma (see Appendix 1). General
evaluation procedure regarding speech recording, disfluency index, disfluency
analysis, stuttering severity, language and phonological ability, was implicated too.
Results: Eighty preschool children (43 stuttered and 37 normal disfluent)
were involved in the study. Was found significant difference (p=0.02) between early
stuttered and normal disfluent speech regarding number of disfluencies in the
beginning of the words. There was not found significant difference (p>0.05) 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<=0.001); verbs (p<=0.001); adverbs (p<=0.001);
particles (p<=0.001); pronouns (p<=0.01); prepositions (p<=0.001), and conjunctions
(p<=0.001).
4,5
Number of disfluencies
3,5
nouns
2,5
adjectives
verbs
adverbs
particles
1,5
numerals
conjuctions
pronouns
interjections
0,5
prepositions
0
1
Early stuttering
2
Normal disfluency
Figure 1. Average number of disfluencies per linguistic unit.
652
Regarding syntactic level, we found similar as morphological level results.

Was found significant difference between early stuttered and normal disfluent
children concerning number of disfluencies at the beginning (<0.01) and within
(<0.001) the sentences.
Early Stuttering
Average number
Normal Disfluency
0
1
Begining of word
2
Within word
3
End of word
Beggining of setence
Within sentence
Figure 2. Results concerning loci of difluencies.
For both, early stuttered and normal disfluent children, loci of disfluencies is
at the beginning of words and sentences, and within the words and sentences.
Number of
children
40
35
30
25
ND-beginning of word
ES-beginning of word
ND-within the word
ES-within the word
20
15
ND-end of word
ES-end of word
ND-beginning of sentence
ES-beginning of sentence
ND-within the sentence
ES-within the sentence
10
5
0
0
0-5
6-10
11-5
Number of disfluencies
16-20
>20
Figure 3. Average number of disfluencies.
Discussion:
As we can see on Figure 1, loci of disfluencies for early stuttered children is
on nouns, verbs, conjuctions, which frequency is between 3,5-4,5. The same type of
653
morphemes is most frequent for normal disfluent children, also. Despite of early
stuttered children, an average number of disfluencies for them is 1,5-2.
The second group of morphemes (particles, pronouns and prepositions) is
with mean value 1,5 for early stuttered children, and less than 0,5 for normal
disfluent children. It means that the main aim of therapy is to reduce number of
disfluencies complying with individual linguistic features.
Stuttering onset typically occurs between 2-5 years (Bloodstein, 1995; Yairi,
Ambrose, 2005). This is a period of intensive language growth, as well. Whether or
not a causal relationship exists between language development and the progression
of stuttering, it is clear that the fluent production of speech and the development of
language skills interact with each other (Hall, Wagovich, Ratner, 2007). However, for
some of examined children we found they have language delay. By reason of
mention above, during early stuttering assessment, it is important to assess language
skills and to apply linguistic analysis of disfluent speech. From this point of view,
working with children, we should be very careful with selection of linguistic
material. Understanding what kinds of morphemes and syntagmas are disfluent will
help us to manage the therapy process. Appropriate and consecutive application of
morphemes and syntagmas will improve both language development and fluency.
There are many direct and indirect therapy programs and strategies for
children who stutter in which is paid attention to language skills and development.
Some of them, such as Lidcombe Program (Onslow, Packman, Harrison, 2005) and
Extended Length of Utterance (Costello, Ingham, 1999) incorporate operant
conditioning principles. Evidence-based practice data for language improvement by
implementation of Lidcombe Program is given by Hewat, Harris, Harrison (2003).
Other therapy programs considering language abilities are Gradual Increase in
Length and Complexity of Utterance/GILCO (Ryan, 1986), Differential
Evaluation/Differential Therapy (Gregory, Hill, 2003), Systematic Fluency Training
Program for Young Children (Shine, 1988), etc. It is a personal choice what kind of
program the speech therapist will use, but it is important to take into consideration
childs language development and to report for therapy effectiveness.
Conclusions: Generally loci of disfluencies are at initial part of words. They
could be happened at different type of morphemes. Most of them are in the
beginning of nouns, verbs, prepositions, conjunctions. The main difference between
early stuttered and normal disfluent children is an average number of disfluencies.
For early stuttered children this number is bigger. Although, each stuttered child
shows individual features, general conclusion about type of disfluent morphemes
can help speech therapists to arrange a therapy program. They should prepare
speech samples consisting mentioned type of morphemes.
References:
1.
2.
3.
4.
Bloodstein, O. (1995). A Handbook on Stuttering. 5th ed. Singular Publishing Group, Inc.,
108-112
Costello, J., Ingham, R. (1999). Behavioral Treatment of Young Children who Stutter: An
extended length of utterance method. In: Stuttering and Related Disorders of Fluency,
2nd ed., ed. by Curlee R., Thieme Medical Publishers, New York. Stuttgart, 80-109
Gregori, H., Campbell, J., Hill, D. (2003). Differential Evaluation of Stuttering Problems.
In: Stuttering Therapy: Rationale and Procedures, ed. by H. Gregory, Allyn & Bacon,
Boston, 78-141
Hall, N., Wagovich, S., Ratner, N. (2007). Language Consideration in Childhood
Stuttering. In Stuttering and Related Disorders of Fluency, ed. by Conture, E. & Curlee,
R., 3rd edition, Thieme, New York, 153
654
5.
6.
7.
8.
Hewat, S., Harris, V., Harrison, E. (2003). Special Case Studies: Children with Other
Speech and Language Problems. In The Lidcombe Program of Early Stuttering
Intervention. A Clinicians Guide. Pro-Ed, Austin, Texas, 120-123
Onslow, M., Packman, A., Harrison, E. (2003). The Lidcombe Program of Early Stuttering
Intervention. Pro-ed, Austin, Texas
Shine, R. (1988). Systematic Fluency Training Program for Young Chlidren, Pro-ed, Austin,
Texas
Yairi, E., Ambrose, N. (2005). Early Childhood Stuttering: for clinicians by clinicians. Proed, Austin, Texas, 45-82
This study is a part of project 02/33: Evidence-based practice in fluency and voice disorders funded by
Bulgarian National Science Fund, leader of the project - Assoc. Prof. D. Georgieva.
Appendix 1
Linguistic Analyzing Protocol of Disfluent Speech
Name:
Examiner:
Date of birth:
Date of examination:
Morphological level
Morpheme
type
Disfluency
Type
Sound rep
Syllable rep
Cluster rep
Monosyllabic
word rep
Word rep
Phrase rep
Prolongation
Part word interj
Word interj
Phrase interj
Pause
Noun
Adj
Pronoun
Verb
Ad
v
Part
Conj
Nume
al
Inter
j
Word position
Prepos
Initia
l
Unfinished
word
Revision
Dysrhythmic
phonation
Syntactic level
Syntagma
type
Disfluency
Type
Sound rep
Syllable rep
Cluster rep
Monosyllable
word rep
Word rep
Phrase rep
Prolongation
Part word interj
Word interj
Phrase interj
Subject
Predicate
Attribute
Object
Adverbial
Conj word
Sentence position
Initial
Within
655
Within
Pause
Unfinished
word
Unf. phrase
Unf. sentence
Revision
Dysrhythmic
phonation
656
MOTOR SPEECH DISORDERS
FP24.4
NASAL VENTILATION IN ASTHMATIC CHILDREN
DA.Cunha1, E.G.F. Silva1, G.K.B.O. Nascimento1, G.M. Andrade1, K.J.R. Moraes1,
R.A. Cunha1, R.M.F.L. Rgis1, S.R.A. Moraes1, C.M.M.B. Castro1, H.J. Silva1
1Universidade
Federal of Pernambuco, Recife, Brazil

Asthma in childhood is a chronic inflammatory disorder of lower airways,
characterized by obstruction to airflow, variably and spontaneously reversible or
with treatment[1,2], hyperactivity bronchial and inflammation by pollen, mold, animal
dander, tobacco smoke exposure and anxiety[3,4].
The mucosae inflammatory reaction of lower airways leads to clinical features
of disease, such as recurrent episodes of coughing, bronchospasm, mucosae swelling
of lower airways, chest constriction, wheezing and dyspnea[3,5,6].
During an asthma attack, spasm, edema and hypersecretion are responsible
for bronchial obstruction, affecting the two phases of breathing becoming the
inspiration rapid and shallow and an ineffective exhalation, leading to lung
hyperinflation[7]. The symptoms occur, mainly at night, after exercises, changes in
temperature or inhaled substances that are irritants to the airways[5,6].
From the intensity and frequency of symptoms and lung function, asthma can
be classified according to their severity as intermittent, mild persistent, moderate and
severe[5]. Thus, treatments are focused on the symptom and prophylaxis to minimize
symptoms and prevent further exacerbations using for this bronchodilators and antiinflammatory drugs[4].
Literature data show that analyzing a sample random of patients who
participated in the European Community Respiratory Health Survey (HRES),
showed that asthma was associated with rhinitis, even in non-atopic patients[8]. Thus,
if child has difficulty of breathing because of asthma and the lack of airflow or its
reduction due to an upper airway obstruction, the probability of mouth-breathing
becomes greater, causing a jaw draw back by the muscles under this[9]. So, there are
several evaluation forms of nasal function, where the best known is the millimeter
nasal mirror of Altmann[10]. Its often used to encourage the functional use of nose
and measure nasal ventilation[11,12], measuring the exhaled air in patients with
obstruction in upper airways[11]. Several studies mention the use of this mirror
comparing the nasal air flow from the same person before and after an
intervention[10,13].
Most of literature shows changes in lower airways that occur in asthmatics.
However, the aim of this study was to evaluate the expiration of asthmatic children
657
by nasal ventilation because there is a shortage on the behavior nasal airway in

children with asthma.
Methods
This is an observational, descriptive and cross-sectional study, which was
developed in the pediatric allergology ambulatory of the Hospital das Clnicas,
linked to the Universidade Federal of Pernambuco (UFPE) in the period of April to
December 2008.
The population was formed by 2 two groups: a group of asthmatic children,
included with 30 children with diagnosis in handbook of moderate or serious
asthma. The other group, named non-asthmatic, formed for 30 children without
asthma. The age was between 6 and 10 years. In this study, were excluded children
who had neurological impairment, crisis of asthma at the moment of evaluation,
serious cardiopathies, orthodontic device, abnormalities craniofaciais and
hypertrophy of tonsil and/or adenoids.
For the evaluation of nasal ventilation was used millimeter nasal mirror of
Altmann according to the instructions of the product. This mirror set in a metal plate
with a flat side and the other with millimeter markings. The mirror was placed below
the volunteer nose who was sitting with straight head during the evaluation. After
two exhalations, was measured the nasal air escape, scoring with blue hidrocor
pencil the blurry area and was used for recording a special sheet, such as millimeter
mirror. The analysis of nasal ventilation was carried out to check out one or both
sides of the air and the relation of symmetry between the right and left nostril. The
data collection was analyzed by the researches observing the outlines of nasal
ventilation (Figure 1).
This work was approved by the ethics committee in research of Universidade
Federal of Pernambuco with n 224/2006 and had the financial support of the CNPqEdictal Universal Process 476370/2007-8. Initially, the responsible one was clarified
about objectives of research, later informed that this was approved by the committee
of ethics in research of the Universidade Federal of Pernambuco and after was
requested that signed an assent free and clarified term allowing the child
participation in study. Regarding data collection, the volunteers of research were
evaluated in a room in the Department of Allergology of the Hospital of Clnicas,
followed of a responsible and, at least, one of the researchers.
After each evaluation, the mirror Altmann was cleaned using cotton with
Germi-rio, which prevents the buildup of pathogenic organisms in the mirror. After
this process, there was another evaluation. The images were imported into the
computer through the scanner series HP Scanjet 2400. The analysis was performed
using Scion Image software for Windows (Alpha 4.0.3.2). This program was used the
measure of area in accordance with the transformation of scale of 76 pixels per 1cm.
A descriptive analysis was carried through to display the results. The
presentation of variables measured was made through tables having also included
the use of some measures such as minimum and maximum values, average, standard
deviation and variation coefficient. To test the assumption of normality of involved
variable in study the Kolmogorov-Smirnov test was applied. For comparative
analysis of variable between groups, t-student test was applied. For the intragroup
analysis were applied the t-Student paired test. All the conclusions took to a
significance level of 5%. The softwares used for the analysis were the Excel 2000 and
SPSS v 8.0.
Results
658
The results were expressed in cm2 (using minimum and maximum values,
average, standard deviation and variation coefficient) after the conversion of 76
pixels per 1 cm2, using the Scion Image software for Windows (Alpha 4.0.3.2) to
measure the nasal ventilation (total and each nostril area), in asthmatic and nonasthmatic groups.
Table 1 presents the data of measurements of the nasal ventilation level in
asthmatic and non-asthmatic children for the total area of nostrils. So, had no
significant differences.
Table 2 presents the data of nasal ventilation in asthmatic and non-asthmatic
children for the right and left nostrils. Here, had no significant differences too.
Discussion
Studies show that there is an interrelation between the upper and lower
airways in healthy individuals, asthmatics and rhinitis patients[8,14]. Thus, there is a
similarity between the tissue formation and architecture of these airways because the
nasal and bronchial mucosae have the pseudo-stratified epithelium with ciliated
columnar resting on the basement membrane[14].
A study evaluating non-asthmatic patients with respiratory symptoms,
performing a bronchial histamine monitored by flow-volume curve, found that there
was presence of bronchial hyperresponsiveness in 52% of cases, hyperresponsiveness
airway extrathoracic airway (upper airways) in 71% and in 41% despite these
individuals are not asthmatic, showing the interdependence of airways as a whole[15].
Thus, according to findings of this research, to the total area of nostrils, values
of nasal ventilation in asthmatic children were higher than the non-asthmatics. Based
on literature, these findings can be explained because the prolonged use of drugs by
asthmatics are preventative, preventing the onset of asthma attacks by fighting
inflammation of bronchi and upper airways (corticosteroids), as well as the use of
drugs called bronchodilators that will act directly to the symptoms of the disease[4].
Some studies say that these bronchodilators may be fast onset of action to
prevent the sudden symptoms of asthma or slow onset of action that will prevent the
narrowing of airways for long time[4,17-20].
All these studies mentioned above which refer to the interdependence in the
upper and lower airways as well as the action of drugs, according to findings of table
1. In addition, cannot also have the presence of structural constraints in asthmatics
because in most cases the limitations of air flow are variable and spontaneously
reversible or with treatment[1,2,6].
In addition, studies of Degan and Puppin-Rontani[21], evaluating the nasal
ventilation in 20 children with sucking habits like pacifier and bottle, a range of 4 to 5
years, detected a direct connection between sucking habits and nasal ventilation. Its
meaning that children using a pacifier and/or bottle had more impaired nasal
ventilation but removing these factors, their nasal ventilation increased significantly.
Despite the range of this research are upper than others studies[21], the suction factor
may also be a reason why the non-asthmatics had lower nasal ventilation in total
area (table 1), whereas the age evaluated suggests that habit.
The data in Table 2 show that the average values for the right and left nostrils
in the non-asthmatic group had larger differences and smaller values when
compared to the asthmatic group, respectively. So, was verified a greater asymmetry
for nasal ventilation in the non-asthmatic group. These findings are not agree with
the studies of White, Ferrari and Weber[22] which refer to asthma as an inflammatory
disease causing nasal obstruction to airflow, reducing this airflow and becoming
irregular .
659
By contrast, studies analyzing the breathing and its effects on the nutritional
status of children, which were 67 children with mouth breathing secondary to
allergic rhinitis and 134 children with nasal breathing in the non-asthmatic group, in
age 6 to 10 years, showed that had an outlet for exhaled air to nasal breathing (100%
of cases) and 83.1% of cases to the mouth breathing[23]. These findings are agree to the
current research because was verified 100% of the sample to nasal ventilation.
However, in studies of Cunha et al.[23], was not evaluated nasal ventilation in each
nostril which can lead to limitations in respect to the targeted aeration to each nostril
in the populations studied.
The asymmetry found in the non-asthmatic group can be justified by the
diagnosis of asthma that is still controversial. Studies show that most children with
recurrent episodes of wheezing after 5 years, is asthmatics. However, the diagnosis
before that age is still a problem[24]. The literature also points to the diagnosis in this
period of life, as clinical findings, missing diagnostic methods available to clarify
them[25]. So, many children evaluated and screened for the non-asthmatics may
shown episodes of wheezing and fatigue without previous diagnosis of asthma and
use of bronchodilators and corticosteroids.
There is a lack of standardization protocols related to the evaluation of nasal
ventilation[12,23,26], which may be evaluated the absence or presence of haze by the
millimeter mirror[12,26], about the spaces marked on the mirror[21] or computer
program[10,27] resulting in a possible interference in the results[23]. Even than, the
evaluation of nasal ventilation using the method of this mirror is still the most
widely used by the easy use and low cost. However, have some subjectivity by
measuring only the breath, while patients with upper airways obstruction had
difficulties mainly in the inspiratory phase of respiratory cycle[28].
The literature shows the Computerized Rhinomanometry and acoustic
Rhinometry as specific methods for evaluation of nasal function[29], but the
equipment is expensive and non-routine use[28]. Some authors also report that
disorders of upper airways can result in mismatches respiratory dynamics, as mouth
breathing can cause imbalances in the naso-pulmonar reflex[30]. This has been
proposed since the 60's, which would be the involvement of nasal airflow in the
regulation of pulmonary ventilation[31].
This study needs more researches to allow a better elucidation about nasal
ventilation in asthmatic children. The literature data about the commitment and
function are scarce, getting difficult to standardize the data evaluation of nasal
ventilation, interfering directly in quality of life of this population.
Conclusion
Through this study did not identify the signs of changes in the exhalation of
asthmatic children. Maybe this is due to the prolonged use of corticosteroids and
bronchodilators of fast and slow onset of action by asthmatic patients, which these
drugs possibly keep the upper airway and especially the lower airway patent for a
long time, as well as interdependent action between these two airways.
In addition to use of the millimeter mirror, is also necessary an analysis of nasal
function by more specific tests such as Computerized Rhinomanometry and acoustic
Rhinometry. Although expensive, its considered specific methods for evaluation.
There is a need for evaluation of lung function by spirometry, as the changes of
upper airways can affect the general respiratory dynamics emphasized the
connection between the airways.
Acknowledgment
660

Development (CNPq), which had a financial support with Edictal Universal Process
476370/2007-8
References
[1] Bethlem N. Pneumologia. 4h ed. So Paulo: Atheneu, 2000.
[2] Silva JRL, Nascentes R, Campos HS, Martire T. Asma brnquica. In: Aid MA, Cardoso
AP, Rufino R, David F, Carvalho SRS, Lucas VS et al. SOPTERJ/Pneumologia:
aspectos prticos e atuais. Rio de Janeiro: Revinter, 2001;201-10.
[3] Birney MH, Brady CL, Bruchak KT, Carrillo C, Clark SH, Conley YP. Guia profissional
para fisiopatologia. Rio de Janeiro: Guanabara Koogan, 2003.
[4] Wannmacher L. Tratamento medicamentoso da asma em crianas. Uso racional de
medicamentos: temas selecionados 2006;3(9):1-6.
[5] III Consenso Brasileiro de Manejo da Asma. Rev AMRIGS 2002;46(3,4):151-172.
[6] Taketomi EA, Marra SMG, Segundo GRS. Fisioterapia em asma: efeito na funo
pulmonar e em parmetros imunolgicos. Fit Perform J 2005;2:97-100.
[7] Guimares MLLG. Fisioterapia na asma brnquica. Pediat 1983;5:33-37.
[8] Sousa DOC. O sistema estomatogntico no respirador oral: fundamentos bsicos para um
diagnstico precoce [monografia]. CEFAC Sade e Educao, 1999.
[9]Tom MC, Marchiori SC. Estudo eletromiogrfico dos msculos orbiculares superior e
inferior da boca em crianas respiradoras nasais e bucais durante o repouso com e
sem contato labial. J Bras Ortodon Ortop Facial 1998;3:59-66.
[10] Melo FMG, Cunha DA, Silva HJ. Avaliao da aerao nasal pr e ps a realizao de
manobras de massagem e limpeza nasal. Rev CEFAC 2007;9(3):375-382.
[11] Marchesan QI. Avaliao e terapia dos problemas da respirao. In: Marchesan QI.
Fundamentos em fonoaudiologia: aspectos clnicos da motricidade oral. Rio de
Janeiro: Guanabara Koogan, 1998;23-36.
[12] Simon MS, Granato L, Oliveira RBC, Alcntara MPA. Rinoscleroma: relato de caso. Rev
Bras Otorrinolaringol 2006;72(4):568-571.
[13] Calliari DS, Brescovici S, Kruse G. O espelho de Glatzel na avaliao da permeabilidade
nasal antes e aps exerccio fsico em indivduos atletas. Rev Soc Bras Fonoaudiol
2005; Supl. Especial.
[14] Camargos PAM, Rodrigues MESM, Sol D, Scheinmann P. Asma e rinite como expresso
de uma nica doena: um paradigma em construo. J Pediatr 2002;78(supl.2):123128.
[15] Bucca C. Are asthma-like symptoms due to bronchiolar extra-thoracic airway
dysfunction? Lancet 1995;346:791-795.
[17] Kelly WJW, Hudson I, Raven J, Phelan PD, Pain MC, Olinsky A. Childhood asthma and
adult lung function. Am Rev Respir Dis 1988;138(1):26-30.
[18] Sherrill D, Sears MR, Lebowitz MD. The effects of airway hyperresponsiveness,
wheezing, and atopy on longitudinal pulmonary function in children: a 6-year
follow-up study. Pediatr Pulmonol 1992;13:78-85.
[19]Oswald H, Phelan PD, Lanigan A. Childhood asthma and lung function in mild-adult life.
Pediatr Pulmonol 1997;23:14-20.
[20] Peat JK, Woolcock AJ, Cullen K. Rate of decline of lung function in subjects with asthma.
Eur J Respir Dis 1997;70:171-179.
[21] Degan VV, Puppin-Rontani RMP. Aumento da aerao nasal aps remoo de hbitos de
suco e terapia miofuncional. Rev CEFAC 2007;9(1):55-60.
[22] Branco A, Ferrari GF, Weber SA. Alteraes orofaciais em doenas alrgicas de vias
areas. Rev paul pediatr 2007;25(3):266-270
[23] Cunha DA, Silva GAP, Motta MEFA, Silva HJ. A respirao oral em crianas e suas
repercusses no estado nutricional. Rev CEFAC 2007;9(1):47-54.
661
[24] Gina GLOBAL INITIATIVE FOR ASTHMA. Pocket guide for asthma management and
prevention in children. 2006. Available at: http://www.ginasthma.com. [Accessed:
September 11th, 2009].
[25] Fontes MJF, Fonseca MTM, Camargos AM, Affonso AGA, Calazaes GMC. Asmas em
menores de cinco anos: dificuldades no diagnstico e na prescrio de corticoterapia
inalatria. J Bras Pneumol 2005;31(3):244-253.
[26] Penido FA, Noronha RMS, Caetano KI, Jesus MSV, Ninno CQMS, Britto ATBO.
Correlao entre os achados do teste de emisso de ar nasal e da nasofaringoscopia
em pacientes com fissura labiopalatina operada. Rev Soc Bras Fonoaudiol
2007;12(2):126-134.
[27]Bassi IB, Franco LP, Motta AR. Eficcia do emprego do espelho de Glatzel na avaliao da
permeabilidade nasal. Rev Soc Bras Fonoaudiol 2009;14(3):367-371.
[28]Di Francesco RC. Avaliao otorrinolaringolgica da respirao oral. In: Krauler LH, Di
Francesco RC, Marchesan IQ. Respirao oral: abordagem interdisciplinar. So Jos
dos Campos: Pulso, 2003;43-45.
[29] Zancanella E, Anselmo Lima WT. Uso da rinometria acstica como mtodo diagnstico.
Rev bras otorrinolaringol 2004;70(4):500-503.
[30] Ribeiro C, Soares LM. Avaliao espiromtrica de criana portadoras de respirao bucal
antes e aps interveno fisioteraputica. Fisiot bras 2003;4(3):163-167.
[31] Balbani APS, Formigoni GGS, Butugan O. Tratamento da epistaxe. Rev Ass Med Brasil
1999;45(2):189-193.
Figure 1: Sketch of nasal ventilation, where the continuous dash represents the
measurement of nasal ventilation of a patient and the dash dotted represents the
measurement by Scion Image software to determine the area.
662
Total Area (cm2)
Minimum Maximum Average
Standard
Deviation
p-value
30
6,78
34,04
16,35
5,34
Control
30
10,41
36,14
18,18
5,80
0,208
Asmathic
Table 1 - Levels of nasal ventilation, expressed in cm2, for the nostrils total area,
between asthmatic and non-asthmatic children.
Nostril Area (cm2)

Control
Right
Left
Minimum Maximum Average
Standard
p-value
Deviation
30
30
3,58
3,32
2,76
2,91
15,95
18,02
8,55
7,93
0,070
Asmathics
30
4,31
18,66
9,04
2,97
Right
30
3,09
17,52
9,15
3,36
0,806
Left
Table 2 - Levels of nasal ventilation, expressed in cm2, for the right and left nostrils
areas, between asthmatic and non-asthmatic children.
663
FP24.5
FACIAL ANTHROPOMETRY IN ASTHMATIC CHILDREN
D.A. Cunha1, R.A. Cunha1, R.M.F.L. Rgis1, G.K.B.O. Nascimento1, E.G.F. Silva1,
K.J.R. Moraes1, S.R.A. Moraes1, C.M.M.B. Castro1, H.J. Silva1.
1Universidade

Some chronic illnesses, especially the asthma, have been implied as cause of
nutritionals alterations, for being a chronic inflammatory illness of high prevalence
and has been considered a problem of Public Health1. The biggest prevalence occurs
in children2 and, generally, becomes related generally as one of the causes of low
weight and growth retardation, that can be initiated by the loss weight and this
occurs mainly in asthma of moderate and serious degree1.
Although the advances in understanding of its physiopathology and the
increasing offer of medications, diverse studies come demonstrating an increase of
prevalence of morbidity and mortality for asthma in some countries3,4.
Independently of the asthma treatment, it can reverberate on growth,
delaying the pubertal growth and later, occur a recovery in relation to the final
height5. The asthmatic children growth has interested to medicine because this is a
chronic illness and were used drugs that can affect the growth process6.
This illness can affect facial growth promoting alterations in the head and
neck positions, the tongue and jaw positions7,8 beyond that its chronic evolution
reflects in emotional, physical and social life of the child9.
So, its given credit that asthmatic children can have a retardation in their
curve of growth, as well as the facial growth. By the way, the present research had as
objective: To characterize the face standards of anthropometry in asthmatic children;
to identify the presence of facial asymmetry in asthmatic and non-asthmatic children
and to relate orofacial anthropometric measures of asthmatic and non-asthmatic
children.
Methods
The present research was developed in the clinic of allergology of the
Hospital das Clnicas, linked to the Universidade Federal of Pernambuco in the
period of April to December 2008. The population was formed by 2 two groups: a
group of asthmatic children, included with 30 children with diagnosis in handbook
of moderate or serious asthma. The other group, named non-asthmatic, formed for
30 children without asthma. The age was between 6 and 10 years defined according
to World Health Organization10.
In this study were excluded children who had neurological neurologic
impairment, crisis of asthma at the moment of evaluation, serious cardiopathies,
orthodontic device, abnormalities craniofaciais, hypertrophy of tonsil and/or
adenoids.
Federal de Pernambuco with n 224/2006 and had the financial support of the CNPq-
664
Edictal Universal Process 476370/2007-8. Initially, the responsible one was clarified
of ethics in research of the Universidade Federal de Pernambuco and after was
participation in the study. Regarding data collection, the volunteers of research were
evaluated in a room in the Department of Allergology of the Hospital das Clnicas,
followed of a responsible and, at least, one of the researchers.
To make the measurement of anthropometric points, the volunteer seated in a
chair with the head in the plan of Frankfurt. After that, the localization of points for
the anthropometric measures was marked in face using a dermatograph pencil.
Finally, was carried and registered in individual protocol based on Cattoni (2006)11,
the measurement of points: upper third (tr-g); middle third (g-sn); inferior third (sngn); gnathion (sto-gn); filter (sn-ls); upper lip (sn-sto); distance between the right
comissure lip and the corner of right eye (ex-ch) and distance between the left
comissure lip and the corner of left eye (ex-ch) with the external rods of
measurement and depth of a digital caliper JOMARCA Starnieless Hardened and
accuracy of 0,01mm, without pressuring its tips of the volunteer skin.
A descriptive analysis was carried through to display the results. The
presentation of variables measured was made through tables having also included
the use of some measures such as minimum, maximum, average, median, standard
deviation and variation coefficient. To test the assumption of normality of involved
variable in study the test of Kolmogorov-Smirnov was applied. For comparative
analysis of variable between groups, t-student test was applied. For the intragroup
analysis were applied the t-Student paired test or ANOVA for paired data and to test
differences found by the ANOVA was applied the LSD test1. All the conclusions took
to a significance level of 5%.
Results
Data of asthmatic and non-asthmatic measurements like age, upper, middle
and inferior thirds, gnathion, filter, right and left upper lip and comissures had no
significant differences between them, but the non-asthmatic group presented
differences between the face thirds (table 1).
The asthmatics had significant differences for thirds and comissures where
middle third was minor than upper and inferior thirds (p-value=0,009) and left
comissure was minor than right one (p-value=0,035) (table 2).
Discussion
The average of children age evaluated in this study, specifically to nonasthmatic group, that were of 8,38 years, was observed that there is similarities with
the average children age evaluated in research in 2008 that had like objectives to
describe the orofacial anthropometric measures in mouth breathing children and to
verify if had significant statistical difference between the averages of these measures
being this average of 8 years and five months11.
In relation to upper third of face (tr-g), was observed an average of 53,99mm
for non-asthmatic group and 53,83mm for asthmatic group and this numbers are
near to data found in literature where it cited a average of 55,44mm and 55,17mm for
this measure12,13.
The average of the middle third measures of face (g-sn) was of 53,62mm to
non-asthmatic group and 52,38mm to asthmatics and these values found in
publications are near of 51,47mm and 50,80mm12,13.
665
The result for inferior third measures of face (sn-gn) was of 56,74mm to nonasthmatic group and 56,41mm to asthmatic group. These measures dont differ
statistical from the value found in another study that brings the average value of
58,20mm for this measure12.
The anthropometric measure of gnathion (sto-gn) to non-asthmatics
presented an average of 38,34mm and 36,85mm to asthmatic group. These values
bracketed with the literature ones that relate an average of 39,70mm and 39,17mm
for this measure12,13.
In a addition to this, the asthmatic children group presented a discrete less
gnathion in comparison to other group corroborating with the findings of the study
where the craniofacial morphology and head position in a hundred children with
and without asthma, 6 to the 16 years were evaluated cephalometric and was
observed that asthmatic ones had a trend of maxillo-mandibular retrognathism
development, beyond the dentoalveolar relations modified14.
The average for filter measure (sn-ls) was 12,43mm to non-asthmatic group
and 12,46mm to asthmatic group. It can be say that these numbers are in accordance
with average of 13,12mm and 13,05mm found in other studies12,13.
Hence, the anthropometric average of upper lip (sn-sto) was 17,72mm for
non-asthmatics and 17,51mm for the other one and these values are near to others
found in some works that were 18,12mm and 18,03mm12,13.
The average of values found in the right comissure measure (ex-ch) was
65,34mm to non-asthmatic group and 64,58mm to asthmatic group. Comparing it
with the average described in literature, perceive that these values were bigger than
the data of some studies with an average of 62,21mm and 62,68mm for this
measure12,13.
With regard to antropometric measure of left comissure (ex-ch) the average
values found here was 65,12mm to non-asthmatic group and 63,40mm for asthmatic
one. Thus, perceive that the asthmatic presented a discrete form of a less measure
than non-asthmatics. Comparing it with the average described in literature, one more
time perceive that these values were bigger than the findings in this research, being
an average of 61,40mm and 61,89mm for this measure12,13.
In respect to facial asymmetry of both groups cited here, has difference
between thirds of face, being the inferior third significantly bigger than upper and
middle thirds, these data differ from the other one in another study, where the
differences between thirds that werent significant12.
For asthmatic group, significant differences for thirds and comissures were
verified, where middle third was minor than inferior third and left comissure was
minor than the right one. In study that presented as one of its objectives to compare
the average in the distance between external corner of the eye and cheilion in the
right side of face with the average of distance between external corner of the eye and
cheilion in the left side of face in mouth breathing children, verifying if has
significant statistical difference between the averages of these distances. In
accordance with age, the average of left side of children in this research also was
statistical minor than the average of right side12.
Conclusions
Results of this study indicate that there were significant differences only for
age, being asthmatic group, on average, younger than non-asthmatic group and the
other measures evaluated did not differ between groups. The non-asthmatic group
showed differences towards face thirds, being inferior third bigger than upper and
middle thirds, respectively. However, in asthmatic group found that middle third
666
was smaller than inferior third and left commissure was smaller than the right
suggesting more prevalence of facial asymmetry in children with asthma.
Its suggested that further researches with a larger number of non-asthmatic
and asthmatic children evaluated must be developed in order to have an even
broader vision in respect with facial growth in children with and without asthma.
Acknowledgment
The authors thank the National Council of Technological and Scientific Development
(CNPq), which had a financial support with Edictal Universal Process 476370/20078.
References
1. Centers for Disease Control and Prevention (CDC). United States, 1995. Morb Mortal Wkly
Rep. Available at http://www.cdc.gov/.
2. McFadden ER, Gilbert IA. Asthma. N Engl J Med. 1992, 327: 1928-1937.
3. Burney PGJ, Chinn S, Rona RJ. Has the prevalence of asthma increased in children?
Evidence from the national study of health and growth 1973-86. BMJ. 1990, 300(6735):
1306-1310.
4. Chatkin JM, Menna Barreto S, Fonseca NA, Gutierrez CA, Sears MR. Trends in asthma
mortality in young people in southern Brazil. Ann Allergy Asthma Immunol. 1999,
82: 287-292.
5. Preece MA, Law CM, Davies PSW. The growth of children with chronic paediatric disease.
Clin Endocrinol Metabol. 1986, 15: 453-477.
6. Wiesch DG, Samet JM. Epidemiology and natural history of asthma In: Middleton E, Reed
CE, Ellis EE, Adkinson NF, Yunginger JW, Busse WW (eds) Allergy: Principles and
practice. 5th ed. St. Louis: Mosby, 1999.
7. Passali D, Damiani V, Passali FM, Passali GC, Bellussi L (2005). Atomized nasal douche vs
nasal lavage in acute viral rhinitis. Arch Otolaryngol Head Neck Surg. 2005, 131: 788790.
8. Fernandes ALG. Asma: uma doena crnica cujas manifestaes vo alm do desconforto
respiratrio, limitao fsica e reduo da qualidade de vida. J Bras Pneumol. 2009,
35(4): 293-294.
9. Campanha SMA, Freire LMS, Fontes MJF. O impacto da asma, da rinite alrgica e da
respirao oral na qualidade de vida de crianas e adolescentes. Rev CEFAC. 2008,
10(4): 513-519.
10. World Health Organization. Physical Status: The Use And Interpretation of
Anthropometry - Report of a WHO Expert Committee - WHO Technical Report
Series 854, 1995, Geneva.
11. Cattoni DM. O uso do paqumetro na motricidade orofacial: procedimentos de avaliao.
1st ed. Barueri/SP: Pr-fono, 2006. v. 1. 44p.
12. Cattoni DM, Fernandes FDM DI, Francesco RC, Latorre MRDO. Medidas e propores
antropomtricas orofaciais de crianas respiradoras orais. Rev Soc Bras Fonoaudiol.
2008, 13(2): 119-126.
13. Cattoni DM, Fernandes FDM. Medidas e propores faciais em crianas: contribuies
para a avaliao miofuncional orofacial. Pr Fono. 2004, 16(1): 7-18.
14. Wenzel A, Hojensgaard E, Henriksen J. Craniofacial morphology and head posture in
children with asthma and perennial rhinitis. Eur J Orthod. 1985, 7: 83-92.
667
Table 1 Data of asthmatic and control measurements like age, upper, middle and
inferior thirds, gnathion, filter, right and left upper lip and comissures.
Standard Variation
p-value
N Minimum Maximum Average Median
Deviation Coefficient
Age
Non-asthmatic
Asthmatic
30 6
30 6
10
10
8,23
7,67
8,00
8,00
1,36
1,47
16,48
19,17
0,126
Upper Third
Non-asthmatic
Asthmatic
30 44,49
30 43,25
75,71
68,81
53,99
53,83
52,97
53,13
6,15
6,24
11,39
11,58
0,923
Middle Third
Non-asthmatic
Asthmatic
30 40,22
30 46,29
61,75
61,81
53,62
52,38
54,82
52,17
4,87
3,88
9,08
7,41
0,283
Inferior Third
Non-asthmatic
Asthmatic
30 45,90
30 42,29
69,09
74,77
56,74
56,41
57,36
55,47
5,25
6,39
9,25
11,33
0,827
Gnathion
Non-asthmatic
Asthmatic
30 29,83
30 24,97
46,31
52,05
38,34
36,85
38,08
36,43
3,90
5,41
10,18
14,69
0,224
Filter
Non-asthmatic
Asthmatic
30 8,22
30 8,72
18,78
17,43
12,43
12,46
11,86
12,46
2,67
2,20
21,47
17,63
0,960
Upper Lip
Non-asthmatic
Asthmatic
30 12,79
30 11,16
23,17
28,58
17,72
17,51
17,24
16,09
2,92
4,18
16,46
23,90
0,820
Right Comissure
Non-asthmatic
Asthmatic
30 56,07
30 53,39
73,09
77,70
65,34
64,58
65,20
64,07
4,15
4,83
6,36
7,49
0,513
Left Comissure
Non-asthmatic
Asthmatic
30 59,10
30 48,69
71,65
74,88
65,12
63,40
64,84
63,29
3,59
5,63
5,51
8,88
0,163
668
Table 2 Data of thirds and comissures analysis in asthmatic and control children
Standard Variation
p-value
N Minimum Maximum Average Median
Deviation Coefficient
Significance
Non-asthmatic
Thirds
Upper (1)
30 44,49
75,71
53,99
52,97
6,15
11,39
Middle (2)
30 40,22
61,75
53,62
54,82
4,87
9,08
Inferior (3)
30 45,90
69,09
56,74
57,36
5,25
9,25
0,035
Comissures
Right
Left
30 56,07
30 59,10
73,09
71,65
65,34
65,12
65,20
64,84
4,15
3,59
6,36
5,51
0,720
Upper (1)
30 43,25
68,81
53,83
53,13
6,24
11,58
Middle
(2)
30 46,29
61,81
52,38
52,17
3,88
7,41
Inferior (3)
30 42,29
74,77
56,41
55,47
6,39
11,33
0,009
Comissures
Right
Left
30 53,39
30 48,69
77,70
74,88
64,58
63,40
64,07
63,29
4,83
5,63
7,49
8,88
0,035
2x3
Asthmatic
Thirds
2x3
669
P043
MASTICATORY PROCESS ANALYSIS OF ASTHMATIC CHILDREN:
CLINICAL AND ELECTROMYOGRAPHIC ANALYSIS
D.A. Cunha1, G.K.B.O. Nascimento1, E.G.F. Silva1, R.A. Cunha1, R.M.F.L.
Rgis1, S.R.A. Moraes1, C.M.M.B. Castro1, H.J. Silva1
1Universidade

Asthma is considered an important public health problem, according to data
from the International Study of Asthma and Allergies in Childhood ISAAC1.
Studies show that 24% of school-age children have asthma2. All over the world
asthma showed a considerable growth in recent decades but some studies have
shown stabilization of these indicators3.
Morphological and physiological aspects show similarities and structural
differences between the nasal mucosae and the mechanisms that explain the
influence of asthma, including the influence of mouth breathing secondary of nasal
obstruction. Anatomo-functional changes, not associated with asthma, may influence
the mastication process4.
Mastication is the combination of stomatognathic functional phenomena that
lead to mechanical breakdown of food into tiny pieces, aiding the digestion
/absorption process of nutrients necessary for body metabolism5.
Mastication function depends on a complex composed by muscles, ligaments,
bones and teeth, controlled by the central nervous system. The muscles involved in
mastication do movements and postures that approaching or away from the teeth or
exacerbate the interocclusal pressure6.
To evaluate the activity of masticatory muscles, systems and equipments
have been implemented and allows to measure and analyze the electrical activity of
muscle7. Researches about electromyographic analysis of masticatory muscles in the
literature are derived from a sample of pre-adolescents8, young adults or elderly8, 9, 10
and few studies involving children11.
The high number of asthmatic children is alarming public health3. So, there is
an interest for studies that relate this pathology to functions alterations of the
Stomatognathic System and this study had like an objective to verify the
characteristics of mastication in asthmatic children treated at pediatric allergology
ambulatory of the Hospital das Clnicas of Pernambuco, identifying the side
prevalence of mastication, number of cycles, total time of mastication and electrical
activity of right and left masseter of asthmatic and non-asthmatic children.
Methods
This is a descriptive and cross-sectional study, which was developed in the
pediatric allergology ambulatory of the Hospital das Clnicas, linked to the
Universidade Federal of Pernambuco (UFPE) in the period of April to December
2008.
The population was formed by 2 two groups: a group of asthmatic children,
included with 30 children with diagnosis in handbook of moderate or serious
670
asthma. The other group, named non-asthmatic, formed for 30 children without
asthma. The age was between 6 and 10 years. In this study, were excluded children
who had neurological neurologic impairment, crisis of asthma at the moment of
evaluation, serious cardiopathies, orthodontic device, abnormalities craniofaciais and
hypertrophy of tonsil and/or adenoids.
Federal of Pernambuco with n 224/2006 and had the financial support of the CNPqEdictal Universal Process 476370/2007-8. Initially, the companion one was clarified
of ethics in research of the Universidade Federal of Pernambuco and after was
participation in the study. Regarding data collection, the volunteers of research were
evaluated in a room in the Department of Allergology of the Hospital das Clnicas,
followed of a companion and, at least, one of the researchers.
The protocol for evaluation of mastication12, 13 was adapted by one of the
researchers. Was requested that the child sit comfortably in a chair and eat a French
bread of 25g, normaly. During the mastication process, the child was recorded with a
Sony Digital Hand Cam VCR TRV 130 NTSC, set on a tripod with a distance of five
feet and the data were recorded on 8mm tape. The time of mastication was recorded
with a Casio stopwatch, too.
The masseter and temporalis muscles were assessed in microvolts (V) by
MIOTOOL 200/400 equipment of Miotec, connected to the LG notebook with
Windows Vista Premium operating system, 110GB HD, Intel Pentium Dual-Core
T2330 1.10Ghz.
Were used more equipments of the Miotec company:
Communication Cable USB connection between the computer and
electromyography; Miograph 2.0Software, a system of data acquisition provided the
opportunity to choose from 8 independent gains per channel, which was used to
1000gain; a rechargeable battery of 7.2V NiMH 1700Ma with duration of
approximately 40 hours and its operate in isolation from the utility, 4 sensors
SDS500 connection with the claws; Cable Reference (earth), MEDITRACE draft and
disposable electrodes of surface consist of a material formed by Ag/AgCl immersed
in a conductive gel and responsible for collecting and carrying the sign of the EMG.
This type of electrode has been reported in the literature14.
Before placing the electrodes, the skin of each child was cleaned with 70%
alcohol swab to remove the excess of oily skin that promotes the impedance of the
uptake signal15, 16. After this step, the electrodes were placed bilaterally and arranged
longitudinally to muscle fibers17. To avoid interference in the capture of signal, the
reference electrode was placed at the ulnar styloid process of the right arm.
To evaluate the electrical activity of the right and left masseter muscle were
recorded situations like: mandible from the rest position (5 seconds) occlusion with
maximum voluntary contraction (5 seconds) and mastication of one French bread
(recorded the necessary time to the mastication of all bread). The volunteer had no
access to the computer screen to avoid the visual feedback and the commitment
evaluation. After registration, there was a analysis of electromyographic trace, being
considered specifically to record the mastication, the selection of the duration of the
2nd mastication process and cycles count from the second incision of French bread
until the end of last deglutition this same portion of food, by the volunteer.
Results
671
The data of asthmatic and non-asthmatic children about the mastication

speed, alternate bilateral mastication, simultaneous bilateral mastication, unilateral
mastication, alternate bilateral mastication on the right side and alternate bilateral
mastication on the left had no significant differences (table 1). Was found that if
increases the number of cycles, the time to masticate each piece of bread also
increases (table 1 and table 3).
The masseter muscle of the asthmatic group did not show the electrical
activity equivalent to the average measured in the non-asthmatics when a function
requires an increase in muscle strength (table 4).
Asthmatic group present their right side with an increased electrical activity
at rest, comparing the data of the right masseter with the right temporal (table 5).
Discussion
For the masticatory pattern, was observed that the alternate bilateral
mastication occurred in 66,7% of the non-asthmatic children and 53,3% of asthmatic,
according to another study that aimed to describe the findings of mastication in the
mixed dentition and verified that this pattern occurred in 69% of the individuals
analyzed18. Thus, the literature said that the alternate bilateral mastication makes
distributions of mastication strength, alternating periods of work and rest muscles
and joints, leading to synchrony and muscle and functional balance19, 20, 21.
A study of 26 children with 5 to 7 years old in a private school in Recife
indicates that the masticatory pattern can be related to craniofacial growth pattern
and also can have a direct relation between growth and children's habits of this age.
Was observed that 38,5% of the children had alternate bilateral masticatory pattern,
which is the ideal standard. Then, allows the distribution of masticatory force in a
balanced way, providing the harmonious growth of the face21.
In this study, 13,3% of non-asthmatic children and 10,0% of asthmatic showed
the simultaneous bilateral masticatory pattern, also known as vertical structure. A
research conducted in 2003 with 61 children with mixed dentition, had 23%
predominantly vertical movements during mastication of French bread18.
Was observed that the unilateral mastication was presented in 20% of the
non-asthmatic children and 36,7% of asthmatic. It is known that unilateral
mastication stimulates inappropriately the growth or prevent the stabilization of
stomatognathic structures19. In a study that observed the occurrence of unilateral
mastication in children from 4 to 5 years old with normal occlusion was found that
mastication was predominantly unilateral in 65% of children studied22.
The alternate bilateral pattern predominantly on the right side occurred in
33.3% of non-asthmatic children and in 26,7% of asthmatic. Similar data were found
in a research that has 20 children selected from two private schools, which 35% were
predominant on the left and 30% prevalence of the right side of mastication22.
Regarding the total number of masticatory cycles, was observed that the
average of cycle of the non-asthmatic children was 30 and 26,9 in asthmatic children
and those data are according to the findings of a study that verified the total number
of masticatory cycles where the range was 9 to 60 cycles23.
In the literature there are few studies that relate mastication time in adults
and children. In this study, asthmatic children have a lower mastication time
compared with the non-asthmatic. A study comparing the mastication time in
children with different types of food24 showed the interference of food consistency on
mastication time. However, the study does not list this time with possible changes in
the Stomatognathic System.
672
The hypothesis that asthma interferes in the mastication function cannot be

confirmed because the data of this research show that possibly asthmatic children
tend to masticate in less time. Difficulties in breathing process and this
incoordination found in asthmatic children can be directly related to the reduction of
masticatory time, since these infants may have difficulties in maintaining the
necessary balance breathing during feeding.
In the literature, the electromyographic activity of masticatory muscles
increases at rest in patients with disorders of the Stomatognathic System, indicating
an increase of basal tone, compared to healthy people25, 26. A study shows that any
condition that causes imbalances in the orofacial muscles is a precursor of changes in
tone27. This information corroborates with the results of this research. Thus, it is
suggested that equal or exceed values of asthmatic children compared with values
record of the electrical activity of masseter and temporal muscles of non-asthmatic
children at rest had occurred because the asthmatic presented an incorrect
performance of masticatory function .
During the maximum voluntary contraction and in the function of
mastication these values reversed because the the muscle requires a degree of
coordination to perform functionally orofacial actions of the Stomatognathic System.
These data also concur with those of masticatory time, implying that asthmatic
children have a request from the smaller muscles.
Conclusions
Mastication requires a coordinated action of the orofacial muscles and an
optimized electrical activity for the muscles perform their functions. In this study,
were noticed the data that the mastication time of non-asthmatic children was higher
to the time of asthmatic. The average of electrical activity of anterior temporal and
masseter muscles at rest was higher to the asthmatic group and this result was
reversed during the maximum voluntary contraction and in mastication. However,
these results infer that the electrical activity is directly linked to the function for each
muscle group, whereas non-asthmatic children process longer the food and require
more electrical activity of muscles during mastication.
No significant differences in masticatory process between asthmatic and nonasthmatic children were found but this study infers that the masticatory process of
asthmatic children may have some alterations in the anatomo-functional changes
caused by signals of that disease.
Acknowledgment
Development (CNPq), which had a financial support with Edictal Universal Process
476370/2007-8.
Referncias
1 - Asher MI, Keil U, Anderson HR, Beasley R, Crane J, Martinez F, et al. International study
of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J.
1995; 8: 483-91.
2 - Sole D, Wandalsen GF, Camelo-Nunes IC, Naspitz CK. ISAAC Brazilian Group.
Prevalence of symptoms of asthma, rhinitis, and atopic eczema among Brazilian
children and adolescents identifi ed by the International Study of Asthma and
Allergies in Childhood (ISAAC) Phase 3. J Pediatr (Rio J). 2006; 82: 341-6.
3 - Sly RM. Continuing decreases in asthma mortality in the United States. Ann Allergy
Asthma Immunol 2004; 92: 3138.
673
4 - Simons FER. Allergic rhinobrochitis: the asthma-allergic rhinitis link. J Allergy Clin
Immunol. 1999; 104:534-40
5 - Marchesan IQ. O trabalho fonoaudiolgico nas alteraes do sistema estomatogntico. In:
Tpicos em Fonoaudiologia, So Paulo, Lovise, 1994.p.83-95.
6 Bianchini EMG. Avaliao fonoaudiolgica da motricidade oral: anamnese, exame clnico,
o que e por que avaliar. In: Bianchini, E. M. G., (Org). Articulao
temporomandibular: implicaes, limitaes e possibilidades Fonoaudiolgicas.
Carapicuba: Pr-Fono; 2000.p.191-253
7 Pelez A, Gallego G, Jimnez ID. Comportamiento de la actividad electromiogrfica del
msculo orbicular superior de los labios en nios con y sin labio y paladar hendido.
CES Odontol. 2006;19(2):25-9.
8 Preeti Aggarwal, MDSa, O.P. Kharbanda, MDS, FICD, MNAMSb, Rashmi Mathur, MBBS,
PhDc, Ritu Duggal, MDSd, H. Parkash, MDS, FICD, MNAMS, FACDe. Muscle
response to the Twin-block appliance: An electromyographic study of the masseter
and anterior temporal muscles. American Journal of Orthodontics & Dentofacial
Orthopedics Volume 116, Issue 4, Pages 405-414 (October 1999)
9 FERRARIO, V.F.; et. al The use of surface electromyography as a tool in differentiating
Temporomandibular Disorders from neck disorders. Manual Therapy v.12, p.372-379,
2006.
10 - Goiato MC, Garcia AR, dos Santos DM. Electromyographic activity of the mandible
muscles at the beginning and end of masticatory cycles in patients with complete
dentures. Gerontology. 2008;54(3):138-43.
11 De Rossi M, De Rossi A, Hallak JEC, Vitti M, Regalo SCH. Electromyographic evaluation
in children having rapid maxillary expansion. American Journal of Orthodontics and
Dentofacial Orthopedics. September 2009
12 JUNQUEIRA, P. Avaliao miofuncional. In: MARCHESAN, I. Q. Fundamentos em
Fonoaudiologia: aspectos clnicos da motricidade oral. Rio de Janeiro: Guanabara
Koogan, 1998. cap. 3, p. 13- 21.
13 Marchesan IQ. Atuao fonoaudiolgica nas funes orofaciais: desenvolvimento,
avaliao e tratamento. In: Andrade CRF, Marcondes E. Fonoaudiologia em pediatria.
So Paulo: Sarvier; 2003. p. 3-22.
14 Sakai, E. Avaliao eletromiogrfica de msculos da mastigao em pacientes portadores
de malocluso tratados com Ortopedia Funcional dos Maxilares. 2006. Tese
(Doutorado em Biologia Buco-dental rea de Anatomia) Faculdade de Odontologia
de Piracicaba, Universidade Estadual de Campinas, Piracicaba, 2006.
15 Silva SRD, Goncalves M. Comparao de protocolos para verificacao da fadiga muscular
pela eletromiografia de superficie. Motriz Revista de Educacao Fisica - UNESP, n.
Vol. 9, N. 1, Janeiro/Abril/2003, p. 41-47, 2003.
16 Pedroni CR, Borini CB, Brzin F. Electromyographic examination in temporamandibular
disorders- evaluation protocol. Braz. J. Oral. Sci., 3(10):526-9, 2004.
17 Gillings BRD, Klineberg IJ. Latency and inhibition of human masticatory muscles
following stimuli. J DentRes 1975;54:269- 79.
18 Agostini TM, Santana CAM. Aspects of chewing in children with mixed dentition. Rev
CEFAC 2003 ;5 :259-263
19 BIANCHINI, E.M.G. Mastigao e ATM. Avaliao e Terapia. In: Fundamentos em
Fonoaudiologia. Aspectos Clnicos da Motricidade Oral. Rio de Janeiro: Guanabara
Koogan, 2005. Cap.5, p.45-57.
20 Douglas CR. Tratado de fisiologia aplicada a fonoaudiologia. So Paulo: Robe Editorial;
2002. 774p.
21 Lima RMF. Padro mastigatrio em crianas de 5 a 7 anos: Suas relaes com crescimento
craniofacial e hbitos alimentares. Rev CEFAC, So Paulo, 2006, v.8, n.2, 205-15.
22 Amaral DB. UNILATERAL CHEWING X NORMAL OCLUSION: a study about your
occurrence in children of 4 to 5 years old. Rev CEFAC, So Paulo, 2000, 2 :23-30.
23 Herrmann MA, Ribeiro AG. Relao entre o lado preferencial da mastigao e a
dominncia cerebral. Rev Cefac. 2003;5(1):49-53.
674
24 Melo TM, Arrais RD, Genaro KF . Durao da mastigao de alimentos com diferentes
consistncias. Revista da Sociedade Brasileira de Fonoaudiologia, v. 11, p. 170-174,
2006
25 Liu ZJ, Yamagata K, Kasahara Y, Ito G. Electromyographic examination of jaw muscles in
relation to symptoms and occlusion of patients with temporomandibular joint
disorders. J Oral Rehabil 1999;26:33-47.
26 Pinho JC, Caldas FM, Mora MJ, Santana-Penin U. Electromyographic activity in patients
with temporomandibular disorders. J Oral Rehabil 2000;27:985-90.
27 Harper RP, Bruin H, Burcea I. Muscle activity during mandibular movements in normal
and mandibular retrognathic subjects. J Oral Maxillofac Surg 1997;55:225-33.
Table 1 - Data of asthmatic and non-asthmatic children regarding sex, age,

mastication speed, alternate bilateral mastication, simultaneous bilateral
mastication, unilateral mastication, alternate bilateral mastication on the right
side and alternate bilateral mastication on the left.
NonAsthmatic
asthmatic
Mastication Characteristics
p-value
N
%
N
%
Alternate bilateral mastication
Yes
20
66,7
16
53,3
No
10
33,3
14
46,7
0,430
Simultaneous bilateral mastication
Yes
4
13,3
3
10,0
No
26
86,7
27
90,0
1,000
Unilateral mastication
Yes
6
20,0
11
36,7
No
24
80,0
19
63,3
0,252
Alternate bilateral mastication on the
right side
Yes
10
33,3
8
26,7
No
20
66,7
22
73,3
0,779
Alternate bilateral mastication on the left
Yes
10
33,3
7
23,3
No
20
66,7
23
76,7
0,567
675
Table 2 Data of the total number of masticatory cycles and total time of
mastication in asthmatic non-asthmatic and children.
Standard
Minimu Maximu Averag
N
Deviatio p-value
m
m
e
n
Total number of masticatory cycles
30
10,00
81,00
30,00
15,84
Non-asthmatic
30
10,00
70,00
26,90
13,33
0,415
Asthmatic
Total time of mastication of a
French bread (25g)
Non-asthmatic
30
69,30
955,00
262,25 179,38
0,893
Asthmatic
30
90,04
600,00
256,78 129,92
Table 3 Pearson's correlation coefficient between mastication time of each

piece of bread, number of masticatory cycles on the right side, number of
masticatory cycles on the left, number of masticatory cycles on the right and
left and number of total masticatory cycles.
Mastication time of each
piece of bread
Non-asthmatic Asthmatic
Number of masticatory cycles on the right side
Number of masticatory cycles on the left side
Number of masticatory cycles on the right and left side
Number of total masticatory cycles
p<0,05
0,63
0,45
0,41
0,93
0,27
0,42
0,41
0,87
676
Table 4 Data of the electrical activity of masseter at rest, maximum

contraction and mastication in non-asthmatic and asthmatic children
Standard
N
Minimum Maximum Average Deviation p-value
Right masseter at rest
Non-asthmatic
30
3,90
13,00
6,33
2,14
Asthmatic
30
2,80
18,00
6,61
3,60
0,709
Left masseter at rest
Non-asthmatic
30
4,20
13,80
6,86
2,85
Asthmatic
30
3,30
18,70
6,78
3,46
0,922
Maximum
voluntary
contraction
of
right
masseter
Non-asthmatic
30
19,10
198,50
82,70
39,52
Asthmatic
30
8,90
192,50
81,00
45,60
0,878
Maximum
voluntary
contraction of left masseter
Non-asthmatic
30
23,40
242,50
78,73
43,49
Asthmatic
30
10,10
171,30
74,05
35,86
0,651
Mastication
in
right
masseter
Non-asthmatic
30
17,40
110,50
48,78
23,01
Asthmatic
30
14,00
97,20
43,89
20,17
0,385
Mastication in left masseter
Non-asthmatic
30
19,90
124,60
48,36
24,18
Asthmatic
30
10,30
109,40
43,63
21,40
0,426
677
Table 5 Data of the electrical activity of the ipsilateral anterior temporal at

rest, maximal voluntary contraction and mastication in non-asthmatic and
asthmatic children.
Standard
N
Minimum Maximum Average Deviation p-value
Ipsilateral
anterior
temporal at rest
Non-asthmatic
30
5,30
20,80
11,56
4,58
Asthmatic
30
5,70
117,70
15,80
19,96
0,261
Left
anterior
temporal
anterior at rest
Non-asthmatic
30
5,50
32,50
13,93
6,56
Asthmatic
30
5,40
31,30
12,79
5,74
0,474
Right anterior temporal in
maximal
voluntary
contraction
Non-asthmatic
30
14,70
244,70
110,62 54,26
Asthmatic
30
19,10
242,20
99,84
50,76
0,430
Left anterior temporal in
maximal
voluntary
contraction
Non-asthmatic
30
22,50
261,50
110,24 62,41
Asthmatic
30
22,00
233,90
101,41 47,78
0,541
Right anterior temporal
during mastication
Non-asthmatic
30
5,50
130,80
55,07
25,41
Asthmatic
30
14,20
143,20
53,93
29,41
0,873
Left
anterior
temporal
during mastication
Non-asthmatic
30
28,90
146,00
60,85
28,07
Asthmatic
30
17,70
110,50
59,62
22,98
0,853
678
P175
Development of articulatory gestures coordination
in Speech Sound Disorders of Unknown Origin:
an acoustic study on Italian-speaking children
Patrizia Bonaventura1, Donatella Tomaiuoli2, Eleonora Pasqua2, Manuela
Calanca2, Martina Massini2, Lauren Miller1, Rebecca Owens1, and Matilde
Marulli2
1Department of Communication Sciences, Case Western Reserve University,
Cleveland, OH
2Centro Ricerca e Cura Balbuzie e disturbi della voce e del linguaggio, Rome,
Italy.
Introduction
Speech sound disorders of unknown origin (SSDUO) are considered as an
output disorder, characterized by incorrect articulation of mostly consonantal
speech-sounds; also transitions, however, a nonsegmental parameter, appear
incomplete, suggesting poor control of coarticulation between vocalic and
consonantal gestures. Control of production of consonantal gestures, in fact, in most
speech production and motor control models, is hypothesized to be performed in
coordination with control of vocalic gestures within same syllables or words
(Goldstein 2007; Ziegler; Levelt; Fujimura; Ohman). Also, rhythmic and metrical
factors have been shown to affect correct realization of vocalic and consonantal
gestures in words context (Zigler, Dofgil, Fujimura).
The present study aimed to determine whether, to what extent and in what
aspects, coarticulatory effects between vocalic and consonantal gestures are affected
by SSDUO and deviate from implementation of normal production patterns by TD
children during development; the goal of the study was to identify patterns of speech
production, that might be used as time markers for the development of SSDUO and
to improve our understanding of the causes of SSDUO, in highlighting the deficits in
the underlying mechanisms of speech motor control typical of the disorders.
Development of inter-syllabic CV coarticulation and of cross-sylalbic V-V
coarticulation in Italian SSDUO vs. TD children was observed, by analyzing vocalic
targets in stressed vs. unstressed syllable, and formant transitions, in disyllabic
words containing reduplicated CV syllables, at two age stages, childhood (4-6years)
and school age (7-12years).
In particular, F1 and F2 vocalic targets for vowels [a], [i] [o] and [u] in first
(stressed) and second (unstressed) syllable, and the initial second formant transitions
of the vowels after labial, dental and velar stop consonants ([p, t, k]) were analyzed
and compared in the speech of 8 SSDUO and 8 TD children at the two age stages.
The extent of movement of the tongue body for achievement of vowel targets,
both in the vertical (represented by F1) and in the horizontal dimension (represented
by F2), and the extent and rate of tongue advancement from a preceding consonantal
position to the following vocalic position (as measured by the frequency and slope
index of F2 transitions), were observed, as representative of the adequacy of intervocalic and vocalic -consonantal gestures coordination: such acoustic cues greatly
contribute for intelligibility of the vocalic (Ziegler and von Cramon, 1983; Ferrand,
679
2007) and consonantal components of a syllable (Kent et al. 1989; 1991; Weismer et al.
1992), therefore implications of the results of this study might be used to improve
assessment tools to evaluate intelligibility of the SSDUO children at different ages
and to improve existing treatment methods based on contextual repetition of
incorrect speech sounds.
SSDUO symptoms and characteristics

SSDUO have been defined as a clinically notable difference in speech-sound
acquisition that cannot be explained by significant impairment in cognitive, sensory,
motor, structural, or affective functioning (Shriberg, 1980; 2003). SSDUO are
considered as phonetic in nature, and as disturbances in relatively peripheral
speech motor processes, resulting in sounds that are notably different from norm
productions (Bauman Waengler, 2008). Also, SSDUO are characterized as speech
sound production difficulties which do not impact other areas of language
development such as morphology, syntax and semantics (Baumann-Waengler,
1997a), and show, in general, mild-to-severe, regular, and typically self-limiting
error patterns (Shriberg, Aram and Kwiatowski (1997a).
Some sub-types of SSDUO involve Speech Delay and are characterized by
presence of consonant deletions and substitutions, typical of Ingrams (1976; 1989)
Phonologic Stage III (1;6 years to 4 years), persisting after the age of 4 years, in
particular, deletions and substitutions affecting voiced and unvoiced stops, nasals,
glides and voiceless fricatives (Shriberg, Gruber and Kwiatkowski, 1994; Shriberg,
2003).
Two sub-types of SSDUO with Speech Delay have been characterized: one
determined by early recurrent otitis media with effusion, and one by a deficit in
speech praxis (Shriberg, 2003), called Childhood Apraxia of Speech (Velleman,
2003). In the present study, the selected children who have been diagnosed with
SSDUO, have been tested, but not diagnosed with suspected CAS.
1.1. Speech production patterns in SSDUO with SD
Common articulatory characteristics of delayed speech are articulation errors
(e.g. velar/dental stops substitutions), coarticulation and transitions often
incomplete, use of contextually incorrect allophones. Inadequate realizations of
vocalic and consonantal segments, result in acoustically incorrect or incomplete
transitions and segmental realizations, vowel resonances different from normal and
disrupted formantic patterns, incorrect localization of noise in fricatives, separation
of sound elements, indefinite nature of stop gaps, irregularity and tremor in the
harmonic structure. (Pickett, 1998; Ohde and Sharf, 1992).
Although some of the characteristics typical of articulation in SSDUO
apparently affect realization of single segmental sounds, some also involve changes
due to mutual influence between adjacent sounds, or coarticulation. The processes
underlying coarticulation are still debated, due to unresolved differences about the
nature of motor control of speech (Ohde and Sharf, 1992): however, awareness of
contextual influences exerted on segmental sounds, determines the necessity in
treatment for articulation disorders, of training to produce sounds in context.
1.3.Motor programming aspects of articulatory gestures

Some models assume a gestural structure of speech motor programs and an
abstract, atemporal nature of the articulatory gestures (Zsiga, 2008).
The Zieglers model of speech motor programming assumes gestures as
binary and atemporal in nature, and constituting the building blocks of the word
680
phonetic plans, as part of a more complex architecture, including hierarchical levels

of encoding of sub-syllabic, syllabic, metrical, and lexical organization.
Motor control of articulatory gestures

Independently from different assumptions about the phonetic or
phonological nature of the articulatory gestures, some evidence converges to indicate
implementation of coordinated vocalic and consonantal gestures within syllabic and
words units of motor control, with spatio-temporal parameters playing a role in
patterns of articulatory coordination.
The present study aims at observing the emergence of coordination of vocalic
and consonantal gestures to produce velar, dental and labial stops, hoping to shed
some light on the nature of the developmental errors of stops substitution (especially
velar substituted with dentals) particularly frequent in the SSDUO childrens
articulations.
1. METHODS
The analyses performed to test the abovementioned hypotheses as well as a
description of the subjects, the speech corpora and the data collection procedures, is
reported in the following.
2.1. Subjects and assessment tests

16 Italian-speaking children were selected for this study, and kindly referred,
diagnosed and tested at the Center for Research and Therapy of Stuttering and Voice
and Speech Disorders (Centro ricerca e cura della balbuzie e disturbi della voce e del
linguaggio, or CRC), Rome, Italy.
4 children diagnosed with SSDUO, and 4 children in typical development,
were selected at two age stages: childhood (4-6years) and school age (7-12 years).
Table 1 below summarizes the composition of the children sample selected for the
experiment.
Table 1. Synoptic table showing ages and subject for the experiment
ITALIAN
CHILDREN
Childhood
School-age
SSDUO PS (M) 6;8
P.F.
S.A. (M) G.V.
D.D M.C.
(M)
5;1
child (F) 7;0
4;4
Normal DC (F) 6;11 A.I.
A.M. (F) SM
PFsa B.S. (F)
(F)
6;3
10;11
6;2
Italian children were diagnosed with SSDUO with SD, but no CAS, based on
a battery of tests reported in Table 2: for language assessment, the Peabody receptive
language test for syntactic and lexical components, as well as the Rustioni screening
test, the Boston naming test, and the TVL morpho-syntactic expressive language test
were administered; also, children were assessed for CAS by an articulatory test
(Fussi-Cantagallo) and an oral-motor test (Esame prassie), both including a
diadochokinetic test.
681
CG (M) IE
8;7
ED (M) CJ
8;5
Table 2. Assessment tests administered to Italian children for initial

diagnosis
ASSESSMENT TESTS
Expressive language:
Language tests
1) Morpho-syntactic: TVL: 30 to 71 months (2ys to 6ys)
(Italian standard)
2) Boston naming test (6ys to 11ys)
Receptive language:
1) RUSTIONI (Morphological-syntactic screening
only, normalized, from 3.6 to 8ys)
2) Peabody syntactic lexical (3.6ys to 12ys)
Oral-motor test
Esame Prassie
Articulatory tests
FUSSI (for adults, but applied to children)

(includes DDK Test)
Diadochokinetic test
Esame Prassie2
- FUSSI (see above; includes diadochokinetic Test)
Speech corpora and recordings

Italian-speaking children produced speech samples including both words
and non-words, elicited within different sets of carrier phrases (e.g. Ho cose
________ qui , i.e.I have some ___ things here), selected from a corpus created ad
hoc for the experiment, to include carrier contexts as natural as possible, maintaining
the same syntactic and accent phrasal structure. Assessment tests were administered
to all children in a separate session and were not recorded; the samples analyzed for
the present experiments were recorded during normal therapy sessions.
682
Formants values and transitions have been measured within CV sequences, in

trochaic disyllabic words of CVC(C)V syllable structure, reflecting the most of
frequent syllable types in Italian. In particular symmetric vocalic patterns (where V1
= V2) have been selected for the test words, to control cross-syllabic influences in
V1CV2 sequences, where subsequent vocalic gestures (V2) have been shown to affect
preceding vowel (V1)-to-consonant (C) transitions (Maasen, 2001), and preceding
vocalic gestures (V1) have been shown to affect CV2 transitions (Ohman, 1966).
A CVCV word, syllable and stress structure also allowed to control metric
and rhythmic effects within the word. Sentences were elicited from children by
repetition, so controlling the influence of dialogic and focus factors on utterance
intonation patterns.
Data analyses
Vocalic formants
F1 and F2 values were calculated for the vowels [u, o, i, a], in SSDUO and
normal children speech. The measurement of the center of the formants was
performed based on wideband spectrograms, by Praat software. The filter
bandwidth for the wideband spectrograms, was expressed in Praat by the duration
or time constant of the filter instead of Hz: the time constant selected was 3ms, a
value which seemed to be revealing of all characteristics of the childrens formants.
First and second formant measurements were obtained from three sources: a) from
cursor frequency readouts (via mouse positioning), on the wideband spectrogram
display; b) linear predictive coding (LPC) spectra; c) automatic formant tracking.
Reference values for Italian vowels pronounced by Italian children of age 8 12ys (Zmarich and Bonifacio, 2003), are reported in Table 2.
Fig. 1 F1-F2 spaces for Italian vowels produced by children 8-12ys (from
Zmarich and Bonifacio, 2003)
683
Formant transitions
Transition extent was obtained by measuring on a wideband spectrogram,
the change in frequency (Hz) between the lowest and highest point of the transition
slope. Transition duration (in msec) will be calculated as the difference between the
point of offset and onset of the transitions. Transition rate was obtained by dividing
transition extent (Hz) by transition duration (msec).
Both extent and rate of F2 transitions have been measured; transition extent
was obtained by measuring on a wideband spectrogram, the difference F2c F2v in
(Hz), where F2c indicates the terminal frequency of the formant transition measured
in the neighborhood of the consonantal offset, and F2v indicates the frequency of the
formant as measured in the most stationary part of the vowel. (Ohman, 1965).
Transition rate was obtained by dividing transition extent (Hz) by transition duration
(msec), where transition duration (in msec) was calculated as the difference between
the point of offset and onset of the transitions (Hixon et al. 2008). Onset of the F2
transitions of the vowel is defined as the simultaneous onset of voicing of F1 and F2
formants after the burst of the stop consonant, or onset of F2 transition slope after
other consonants. Offset of the F2 transitions was defined as the first steady portion
of F2 after end of transitional change (approximately 30 ms after beginning of
transitions)
Both transitions extent and rate measures are considered to indicate mobility
of the tongue (Wismer, 2008; Hixon, 2008).
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FP23.3
NEW PERSPECTIVES IN TREATING PEDIATRIC MOTOR SPEECH
DISORDERS
C.M. Fox1, C.A. Boliek2, L.O. Ramig1, 3
1National Center for Voice and Speech, a division of the University of
Colorado, Boulder
2Department of Speech and Hearing Sciences, University of Alberta,
Edmonton
3Department of Speech-Language-Hearing Sciences, University of Colorado,
Boulder
There are few published outcome data on treatment approaches for children
with pediatric motor speech disorders (Yorkston, 1996). Recent advances in theories
of motor development as well as activity dependent neural plasticity offer valuable
insight into elements of treatment protocols that may promote positive treatment
outcomes. The purpose of this seminar is three-fold: (a) discuss historical and
emerging theories of motor development in relation to pediatric motor speech
disorders, with an emphasis on cerebral palsy (CP) (b) describe advances in
neuroscience that have identified key elements of exercise/rehabilitation that drive
activity dependent neural plasticity, and c) discuss the impact of a treatment
program (LSVT LOUD) that is designed to facilitate motor execution (through
intensive treatment, endurance and active practice) and motor learning (through
sensory feedback, repeated practice trials and intensive training) on improved
speech and voice functioning in children with CP and Down syndrome. Outcome
data from this treatment approach highlight how both theories of motor
development and principles of neural plasticity can be embedded into protocols and
tested in a systematic manner.
Motor development: Theories of motor development in typically developing
children are often applied to children with CP in an attempt to understand motor
development in a damaged nervous system. Although these theories have
limitations in explaining both normal and disordered development, they provide a
theoretical framework, from which to explore plausible treatment strategies. The
neural-maturationist theory, which contends that motor development is based on a
gradual unfolding of pre-determined patterns in the central nervous system
(McGraw, 1943), has dominated developmental motor literature for many years.
However, newer theories such as dynamic systems theory have emerged that
challenge many of its concepts (Thelen, 1995). The impact of a dynamic systems
view of speech motor development and treatment protocols will be discussed.
Neural Plasticity: Evidence from studies in limb and gait literature in children
with CP indicate a clear shift in therapeutic methods away from traditional
rehabilitation, to more active, repetitive approaches with the goal of
restoring/habilitating some degree of motor functioning (Damiano, Vaughn, & Able,
1995). These collective data from behavioral and basic science studies challenge the,
widely accepted, long-standing belief that therapy aimed at achieving motor
recovery in these children is an exercise in futility (p.147, Garvey et al, 2007).
685
Several key parameters known to drive neural plasticity have emerged and
will be explored in detail. Whereas these tenants are not altogether new in treatment
literature, only recently have the neurobiological phenomenon underlying such
principles been stringently validated for the positive effects on central nervous
system functioning (Garvey et al, 2007; Kleim et al, 2003). The parameters that will
be discussed include: intensive training, task-specific, repetitive practice approaches,
the use of active practice with increased practice trials, and enhanced sensorimotor
experiences.
Treatment Outcome data: The treatment protocol LSVT LOUD was developed
long before recent neuroscience investigations, however, today we recognize that the
training mode of LSVT is consistent with principles that promote motor learning and
activity-dependent neural plasticity (Fox et al, 2006). Furthermore, this training
mode may be consistent with dynamic systems theory where the goal is to perturb
the speech motor system in children with CP or Down syndrome (increase vocal
effort and loudness), force it into a state of instability (explore extremes of
sensorimotor experience related to increased vocal effort and loudness), and with
repeated practice and intensive training, allow the system to self-organize into an
improved motor pattern for voice and speech functioning (Thelen, 1995). The
treatment protocol of LSVT LOUD was administered in two studies of children with
CP and one study of children with Down syndrome. The results of these studies
revealed that acoustic aspects of the speech signal improved in the children who
received LSVT LOUD. These changes were accompanied by a therapeutic effect as
measured by auditory-perceptual ratings, parent perceptual ratings and child selfreport.
These findings identify potential key treatment concepts to consider in
behavioral treatment for children with pediatric motor speech disorders. The value
of treating the voice/respiratory system as a point of entry into the motor speech
problems of children with CP or Down syndrome will be explored. Questions that
need continued research attention will also be addressed, such as, is it intensity that
is most important, or the target of intensive training?
Practical applications: At the conclusion of this seminar, participants will be
able to 1) discuss theories of motor development and their impact on speech
treatment delivery models, 2) explain what aspects of exercise (e.g. speech exercise)
are important to drive neural plasticity, 3) summarize preliminary speech outcome
data from an intensive voice treatment protocol (LSVT LOUD) in children with
spastic CP and Down syndrome, and 4) apply this information to other pediatric
motor speech disorders in clinical practice.
Damiano, D. L., Vaughan, C. L., Abel, M. F. (1995). Muscle response to heavy resistance
exercise in children with spastic cerebral palsy. Developmental Medicine and Child
Neurology, 37, 731-739.
Fox, C., Ramig, L., Ciucci, M., Sapir, S., McFarland, D., and Farley, B. (2006) The Science and
Practice of LSVT/LOUD: Neural Plasticity-Principled approach to treating
individuals with Parkinson disease and other neurological disorders. Seminars in
Speech and Language. 27(4), 283-299.
Garvey, M.A., Giannetti, M. L., Alter, K.E., & Lum, K.E. (2007). Cerebral palsy: New
approaches to therapy. Current Neurology and Neuroscience Reports, 7, 147-155.
686
Kleim, J.A., Jones, T.A., & Schallert, T. (2003). Motor enrichment and the induction of
plasticity before or after brain injury. Neurochemical Research, 28, 1757-1769.
McGraw, M. B. (1943). The neuromuscular maturation of the human infant. New York:
Morningside Heights.
Thelen, E. (1995). Motor development. A new synthesis. American Psychologist, 50, 79-95.
Yorkston, K. M. (1996). Treatment efficacy: Dysarthria. Journal of Speech and Hearing Research,
39, S46-S57.
687
P108
MOBIUS SYNDROME: SPEECH PATHOLOGY'S MENEGEAMENT
Guedes Z. , Silva R. , Goncalves C.
Universidade federal de Sao Paulo
Introduction: The Mbius Syndrome is characterized by the impairment of VI
and VII cranial nerves with little lateral movement of the eyes and bilateral palsy of
face. We can also see little movement of tongue and soft palate that causes
disturbance in the articulation and resonance of speech. The patients have a
convergent strabismus and dont have any expression of happiness, sadness or other
feelings. Many others pairs (IX, X, XI and XII) may be involved too and disorders of
swallowing, breathing, and speech may be present. They can present some other
problems such as microretrognathia, ogival palate, limb malformations, mental
disturbance and cardiac and urinary malformations. This disease may present hand
and foot malformations such as polidactilia, sindactilia and congenital injury foot.
The hipernasal resonance in the speech is very usual. The anomalies in the other
cranial nerves can make the difficulties in these cases even greater. The facial palsy
involves the voluntary and involuntary activities of the lips and many other
structures of the face. A child born with Mbius Syndrome can have a varying
number of problems in his/her life. The etiology to this disease can be genetic,
vascular or terathogenic. The genetic cause is very rare and the vascular does not
have a known cause. In many studies, we can see absence of the central cerebral
nucleus, destructive degeneration of the central cerebral nucleus and other problems
with the peripheric nerve. In Brazil the most usual etiology is the terathogenic. Many
women take Citotec (misoprostol) during the early months of pregnancy
attempting to interrupt it. When the abortion is not accomplished, the baby may be
born with Mbius Syndrome. We have had a great interest in Mbius Syndrome
since 1989 and have been interested with how the speech language pathologist can
help these children to produce some degree of facial expression and better
communication. Aim: this work intends to find out if the children whose mothers
took misoprostol during pregnancy present manifestations of the disease which are
different from those we find in the literature. Methods: after parents had given their
Free Consent, the 13 children (10 male and 3 female) with ages from 0 to 5 years old
were evaluated with the protocol of the Institution. The protocol has an anamnesis
and an evaluation of breathing, suction, chewing, swallowing, speech and the
muscles of face, one by one, in each expression. The receptive and expressive
language was evaluated by role playing or other situations. Some of these children
are at day nursery, and some questions are made to the nurses to complete the
information about them. Mothers of nine children from this group had taken
Citotec (misoprostol) during the pregnancy and they themselves or other relatives
provided us with this information. Some of them feel guilt, but others abandoned the
child with relatives. In the anamnesis, many questions were made about health,
development, educational abilities, home conditions, and how the children live. At to
the assessment, all the children were evaluated for breathing, suction, chewing,
swallowing, speech and the muscles of the face, one by one, in each expression. The
functions of the stomathognatic system were evaluated with the food being offering
with the correct utensil (nursing bottle, spoon and cup). All the muscles of the face
688
were observed. In the babies, when they were crying or communicating with their
mothers or relatives. Two to 5 year- old children were asked to smile and/or to put
on a frightened and frightening face. The remaining muscles were observed
(Orbicularis Oris, Frontalis, Procerus, Risorius, Depressor anguli oris, Levator anguli
oris and Buccal). Besides, the posture, tonus and mobility of each muscle were
observed too. All the children received therapy at our Institution once a week. The
therapy covers feeding, speech and language and specific training for each muscle of
the face. The exercises need to be done at home, many times a day. Massages and
movements in the muscular direction are made to increase the possibility of mobility.
The stimulation is of the muscles cited above. We have exercises for the forehead, for
eye closure, for the sides of the face, for lips (closure and movement). Each exercise is
made 5 times for 5 seconds each, in a passive way. They have to be done many times
a day, in front of a mirror (in the case of the over 2 children). The exercises are
similar for the babies and the mother or relatives have to do them whenever they
have an interaction with them (bathing, changing clothes, etc).The older children are
asked to perform the exercises in front of a mirror and then to apply the movements
to speech sounds. If necessary, help with fingers is given. An additional support to
language is given with gestures during the therapy and with counselling to the
family. The gestures are a great improvement to these children that do not have
facial expression. The gestures and the change of posture are movements no verbal
that help in the children communication. The movements that are associated to the
speech are normal, but to these children they have to be reinforced. These
movements have a language function and are the substitutes of the facial expression.
Results: the three 0 to 12 month-old baby boys had difficulty sucking and
swallowing. The swallowing was slow and noisy. Sometimes they needed to stop the
feed to breathe. The other children (2 to 5 years) could feed well but with
compensatory strategies. They needed to keep their lips together with their finger to
swallow; they had to help with finger or spoon to put the food from one side of the
mouth to the other to chew it. At far as speech is concerned, they were not capable of
producing the bilabial sounds /p,b,m/ because they could not put their lips
together. Some of them had difficulty with the apical /t,d,l,n/. Two boys produced
/t/ for /p/ (tatai instead of papai which in Portuguese means father) and /n/ for
/m/ (nane instead of mame, which, in Portuguese means mother). None of the
children could smile. Only one boy (4y) presented a little movement in the right side
of the face, to smile, but that was after a year and half of therapy. Some children
showed one side of the face better that the other, in terms of tonus, mobility, or
chewing. It seems that one side of the face may have more ability than the other.
When the therapy goes ahead, this manifestation is clearer. A boy and a girl of this
group, 3 and 2 years old, had a severe language problem. They had difficulty
understanding orders, they did not vocalize when were playing and did not play
well with the objects. The boy was evaluated by other professionals to know if he
had a cognitive problem. The result was negative, but he is a slow boy. Perhaps, he
had more difficulty because his family had recently come from Japan. Now, he is
nearly 4 years old and the first language that he learned is Portuguese, but there he
had a different education in the school. The speech of the girl has improved since her
family was given counselling as to how to speak and play with her. Some of the
children go to day nursery and are capable of following the established program. The
teachers and the nurses, when necessary, receive counselling as how to feed and play
with these children. One girl (NGS, 3 year-old) has a good performance now. She is
assisted by her maternal grandmother and aunt. Her mother took misoprostol and
cocaine during the pregnancy. She does not have some of the fingers. When she
689
arrived, she had great difficulty feeding. Now she is capable of swallowing well and
she expresses many words correctly. She is not able to pronounce /p,b,m/ with her
lips, but she puts her frontal teeth above the inferior lip and produces a similar
acceptable sound. Only this girl has more hand malformations and the difference
was that her mother took cocaine in the pregnancy. This particular mother
abandoned her child who is now looked after by relatives. Some of these children (3)
present seizures/ convulsions sometimes and receive drugs to control them. It was
not clear, if the children whose mothers took misoprostol had a different
performance. Many mothers that took Citotec feel very guilty about bringing the
disease upon their children. We are waiting for some imagery exams to know how
extensive the lesions in the Central Nerve System are and if they differ when the
mother took misoprostol or not. Conclusion: we were not able to conclude whether
the children whose mothers had taken misoprostol had different manifestations from
those whose mothers had not. It is clear that they have the manifestations that we see
in the literature such as facial palsy, little lateral movement of eyes, limb
malformations, swallowing and speech difficulties, Central Nerve System lesions
with convulsions and language disorders. It will be necessary to investigate the
different etiologies to this disease more.
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P176
CORRELATION OF THE SIGNAL ELECTROMYOGRAPHIC THE MASSETER
MUSCLE RIGHT AND LEFT AND RIGHT AND LEFT TEMPORAL IN FEMALE
SUBJECTS DURING MASTICATION
J.H.P. Oliveira1, K.J.R. Moraes1, M.M. Filho1, N.S. Lima1, J.B. Oliveira1, H.J. Silva1
1Federal University of Pernambuco, Recife, Brazil
Among all parameters worked by a speech therapist, during orofacial
therapy, chewing is showed as a difficult task to be treated and corrected[1].
Therefore, it is one of the most important functions of the stomatognathic system.
There is need of coordinated contraction of several muscle groups to have effective
chewing, and the chewing muscles are the most outstanding, although the muscles of
mouth and face are also fundamental, especially, buccinator and orbicularis oris
muscles.
The dicrease in muscle tonus of speech organs, the restriction of mandibular
movements and the change of orofacial praxis, make the chewing movements
incompetent[2]. Many patients arrive at the clinic with changes in chewing, giving to
the speech therapist the responsibility to understand the normal operation of
muscles[3], involving that function of the stomatognathic system in order to work and
adapt the musculature involved to be as close as possible of normal range.
Thus, the muscles related to the jaw participate in a series of motor tasks
including chewing food, swallowing and speech. These activities require muscle
function in different proportions and in different time gaps[4]. Thus, the execution of
jaw movements is closely linked to chewing muscles once when talking about
masseter and temporal, they are referred as jaw elevators. Other studies report about
the morphological and functional fibers that compound the jaw muscles relating
composition/form with muscle actions, which implies in a specific functional
performance for each type of muscle fiber[4].
Some researchers say that there is difference in masseter muscle activity when
both genders are compared[5]. Furthermore, the most current studies which talk
about the development of chewing movements, using pure made from cereals, in
children during 9th, 12th, 18th, 30th months of life, in a diet with approximately 30-45
minutes. It was also suggested that chewing movements involve learning according
to the different foods[6]. Thus, some studies have evaluated the cerebral blood flow
with near infrared spectrosgraphy (NIRS), during chewing in elderly.
Studies verify a significant electric activity of masseter muscle during
chewing and, concomitantly to this, a considerable activity of do prefrontal dorsal
cortex[7], and chewing is influenced by specific characteristics of each food[8], beside
the strong influence of anxiousness, type of dental occlusion, food consistency and
other factors[9]. It is possible to find researches which evaluate electric activity of
chewing muscles, using different foods, in the literature, for example: Keeling et
al.[10] used cheese to study chewing in children; studies which evaluate chewing
efficiency with peanuts[11], and specifically related to masseter[12-15], beside other
foods like carrot[12,14], celery, chewing gum and cheese, to the same muscle group[12].
691
Regarding masseter and temporal muscles, the literature evaluate

electromyographic activity of them with meat[16] and also using bread, lettuce and
peanuts[17]. Thus, this study aim to correlate normalized electromyographic signal
(SN) and median frequency (Fmed) of masseter (right and left) and temporal (right
and left) muscles in females during chewing of different foods.
METHODS:
The study was a descriptive, observational, cross-sectional and
individualized, conducted at the at the laboratory of Orofacial Myology and Clinic of
Pediatric Dentistry, Federal University of Pernambuco (UFPE). Participants were 25
young adult volunteers, healthy, exclusively female students of Speech Pathology
and Dentistry, UFPE, selected from a convenience sample, with ages ranging from 18
to 27 years[18], average age 22 years (SD = + / - 1.8).
Individuals who showed temporomandibular dysfunction, craniomandibular
dysfunction, use of interocclusal plate, using orthodontic or orthopedic braces,
periodontal disease, swallowing disorder, tooth clenching, mouth breathing, cleft lip,
orofacial and cervical myology disorders, speech disorders, distoclusion, sore throat,
finger sucking, biting nails, mandibular dysplasia, lip incompetence and ever doing
therapy with botulinum toxin.
Regarding the general health, making use of tranquilizers, anxiolytics and
antidepressants, have complaints related to arthritis, rheumatism, osteoporosis,
diabetes. Exclusion criteria were adapted from the studied literature[19,20]. We used
electromyography brand Miotool 400, Hardware data acquisition system connected
to notebook with the Miograph 2.0 software configured to the sampling frequency of
1024 points, cut-off frequency of 20Hz - 500Hz; Nothi offline 59Hz-61Hz filter. We
used a method of electrode placement, which was standardized for all volunteers,
and the chewing sign was normalized by maximum voluntary contraction (MVC).
Volunteers initially conducted a MVC supported, and instructed to keep it for
4 seconds, then food chewing was done (bread, apple, filled cookie and peanut,
respectively). After the achievement of the electromyographic signal (Fmed and SN)
of each muscle, data were submitted to correlation with the median frequency and
normalized signal, both during chewing of the foods mentioned.
Statistical analysis through Kolmogorov-Smirnov test was done for testing
the supposition of normality of the variables and the Pearson correlation coefficient
to verify the correlation between the sign median frequency (FFT - Fast Fourier
Transformation) and the normalized signal considering margin of error of 5%. This
study was approved by the Ethics Committee of UFPE and registered with CEP /
CCS / UFPE No. 116/08, Of No. 218/2008; SISNEP 0114.0.172.000-08, funded by the
National Council for Scientific and Technological Development (CNPq) - Universal
15/2009. Notice PIBIC UFPE / CNPq. 2008/2009.
RESULTS:
The normalized electromyographic signal (SN) to the masseter muscle,
during chewing of different foods made by individuals, showed more intensity on
the left (Table 1). The same was observed in the temporal muscle during chewing of
foods by individuals.
In the verified population, the study of the correlation coefficient (Table 2)
between the sign median frequency and the normalized signal shows that peanut
was the food that got a stronger correlation (right masseter muscle - R = 0.28, left
masseter muscle - R = 0.303; right temporal muscle - R = 0.271) only the left temporal
muscle had a stronger correlation to the bread (R = 0.100). The subjects had lower
692
correlation levels for the cookie (right masseter muscle - R = 0.052, right temporal
muscle - R = 0.01) for bread (left masseter muscle - R = 0.003) and peanuts (left
temporal muscle - R = 0.01).
The graphic 1 shows that during the chewing of bread and peanut, the
median values of frequency and normalized signal were close. Already, during
chewing apple values exhibited a greater difference. The graphic 2 shows that during
the chewing of apple, the values of frequency and the median normalized signal
were close. Already, during chewing peanuts values exhibited a greater difference.
The graphic 3 shows that during the chewing of the all the foods the values of
the median frequence and of the normalized signal remained considerably different.
However, the bread and peanut maintained values (Fmed and SN) nearest compared
to apple and biscuit. The graph 4 shows a phenomenon similar to that seen in graph
3, values of median frequency and the normalized signal, remained relatively
different, put bread and peanut maintained values (Fmed and SN) Nearest compared
to apple and biscuit.
DISCUSSION:
Researches mentioning the same comparative analisys among individuals of
both genders and the foods studied in this research were not found, regarding to the
correlation between median frequency and normalized signal of chewing. The study
of these parameters, median frequency and normalized signal, showed different
informations. So, statistic data of correlation between the parameters related show a
positive correlation, although, in all the cases, the value of the correlation was
inferior than 0,6; which shows a weak correlation.
Researchers say that the variation of resistance implicated by the specific
characteristic of each food during usual chewing result in variations for the time of
shutting due the specific ductility of food and will result in the movement/speed of
characteristic food[21]. This can be observed at the present study through the analisys
of normalized signal of masseter and temporal muscles.
The lengthy chewing can reduce chewing efficiency as a result of chewing
muscles fatigue[11]. Fontijin-Tekamp et al.[22], in his study verified that chewing
performance was significantly influenced by dental state, but not by age or gender.
Ueda et al.[5] investigated the fatigue of the masseter muscle and its period of
recovery, during the contraction of the muscle in the situation of bite, in healthy male
and female.
There was a significant difference between both genders for the period of
recovery from fatigue to the masseter muscle. It is suggested that this difference is
related to muscle composition for each gender. And, although the strength is related
to the proportions of muscle fiber types. In usual chewing, the time is a variable that
may depend on the amount of food, while the number of cycles for each side may
depend on factors such as habit, occlusal and / or postural alterations or even TMJ
and muscles disorders. Therefore, it was not considered for this study. It is also
possible that the type of food can influence the preferred chewing side.
CONCLUSION:
Chewing act, in relation to the muscle activity may be influenced by
emotional factor, or dental factor regarding to the presence or absence of teeth, type
of activated muscle fibers, and the preference for the chewing side. These facts will
influence in a prevalent manner the fatigue of these muscles, as well as in their
recovery.
693
Higher prevalence of electrical activity (SN) of masseter and temporal

muscles of the left side during chewing of all foods was showed. The subjects had a
level of correlation (R) between the median frequency and the signal normalized, less
than 0,6. However, the results proved dominant for the chewing of a single food,
peanuts. Other studies with larger sample that can contribute to a better
understanding about the theme are suggested.
REFERENCES
[1] Munz I et al. Anlise dos potenciais eltricos do msculo masseter durante a mastigao
de alimentos com rigidez variada. Rev CEFAC 2004; 6(2):127-34.
[2] Saconato M, Guedes ZCF. Estudo da mastigao e da deglutio em crianas e
adolescentes com sequncia de Mbius. Rev. Soc Bras Fonoaudiol 2009;14(2):165-71.
[3] Rahal A, Goffil-Gomez MVS. Estudo eletromiogrfico do msculo masseter durante o
apertamento dentrio e mastigao habitual em adultos com ocluso dentria
normal. Rev Soc Bras Fonoaudiol 2009;14(2):160-4.
[4] Korfage JAM et al. FiberLtype Composition of the Human Jaw Muscles (Part 1) Origin and
Functional Significance of FiberLtype Diversity. J Dent Res 2005;84(9):774-83.
[5] Ueda HM et al. Differences in the fatigue of masticatory and neck muscles between male
and female. Journal of Oral Rehabilitation 2002; 29(6):575-82.
[6] Green JR, Wilson EM. The development of jaw motion for mastication. Early Human
Development 2009; 85(5):303-11.
[7] Narita N et al. ChewingLrelated prefrontal cortex activation while wearing partial denture
prosthesis: Pilot study. Journal of Prosthodontic Research 2009; 53(3):126-35.
[8] Deguchi T, Kumai T, Garetto L. Statistics of differential Lissajous EMG for normal
occlusion and Class II malocclusion. Am J Orthod dentofac Orthop 1994; 105(1):42-8.
[9] Melo TM, Arrais RD, Genaro KF. Durao da mastigao de alimentos com diferentes
consistncias. Rev. Soc. Bras. Fonoaudiologia 2006; 11(3):170-4.
[10] Keeling S D et al. Analysis of repeatedLmeasure multicycle unilateral mastication in
children. Am J. Orthod Dentofac Orthop 1991; 99(5):402-8.
[11] Tzakis MG, Kiliaridis S, Carlsson G. Effect of chewing training on masticatory efficiency.
Acta Odontol. Scand 1989; 47(6):335-60.
[12] Gibbs C. Electromyographic activity during the motionless period in chewing. The
Journal Phosthetic Dentistry 1975; 34(1):35-40.
[13] Pancherz H. Temporal and masseter muscle activity in children and adults with normal
occlusion: Acta Odontol. Scand 1980; 38(6):343-48.
[14] Byrd KE, Milberg D J, Luschei ES. Human and Macaque Mastication: A Quantitative
Study. Journal of Dental Research 1978; 57(78):834-43.
[15] Panchez H, Anheus M. Masticatory function after activatory treatment. An analysis of
masticatory efficiency, occlusal contact concitions and EMG activity. Acta Odontol.
Scand 1978; 36(5L6):309-16.
[16] Turcio KHL et al. Avaliao eletromiogrfica e eletrovibratogrfica antes e aps o
tratamento da desordem temporomandibular. PGRO - Ps-Grad Rev. Odontol 2002;
5(2):36-43.
[17] Adams SH, Zander HA. Functional tooth contacts in lateral and in centric occlusion.
Journal of the American Dental Association JADA 1964; 69(4):465-73.
[18] Biassoto DA. Estudo eletromiogrfico de msculos do sistema estomatogntico durante a
mastigao de diferentes materiais. Piracicaba 2000. Dissertao (Mestrado) Faculdade de Odontologia de Piracicaba, Universidade Estadual de Campinas, So
Paulo.
[19] Oncins MC, Freire RM, Marchesan IQ. Mastigao: anlise pela eletromiografia e
eletrognatografia. Seu uso na clnica fonoaudiolgica Rev. Distrbios da
Comunicao 2006; 2(18):155-65.
[20] Santana-Mora U et al. Changes in EMG activity during clenching in chronic pain patients
with unilateral temporomandibular disorders. Journal of Electromyography and
Kinesiology 2008; 19(6):1-7.
694
[21] Schindler HJ, Stengel E, Spiess WEL. Feedback control during mastication of solid food
testures L a clinicalLexperimental study. The Journal of Prosthetic DentIstry 1998;
80(3):330-36.
[22] Fontinjin-Tekamp FA et al. Swallowing threshold and masticatory peformance dentate
adults. Physiology & behavior 2004; 83(3):431-36.
MASSETER MUSCLE
Bread
TEMPORAL MUSCLE
Apple Cookie Peanut Bread
Masseter right
Apple Cookie Peanut
Temporal right
Fmed 182,96 175,14
165,74
166,94
199,89 196,97
192,42
191,12
SN
143,70
162,98
121,58 99,62
102,87
112,74
178,22 131,03
Masseter left
Temporal left
Fmed 172,96 167,77
161,92
158,21
205,25 201,01
195,01
192,37
SN
189,90
208,42
129,02 103,81
108,78
121,69
198,29 163,55
Table 1: exposes the data of the electromyographic signal, the masseter and temporal, for the
median frequency (Fmed) and normalized signal (SN) during chewing of food.
BREAD
APPLE
COOKIE
PEANUTS
Fmed
Fmed
Fmed
Fmed
0,167
0,119
0,052
0,28
0,003
0,108
0,055
0,303
0,07
0,224
0,01
0,271
0,1
0,094
0,081
0,01
Masseter R
SN
Masseter L
SN
Temporal R
SN
Temporal L
SN
Table 2: exposes the data correlation between the median frequency (Fmed) and the
normalized signal (SN) for each muscle for each chewing food.
695
200
180
160
140
120
100
Fmed
80
SN
60
40
20
0
Bread
Apple
Cookie
Peanut
Graphic 1: exposes the comparison of the EMG signal of the right

masseter muscle during mastication of foods made over time.
250
200
150
Fmed
100
SN
50
0
Bread
Apple
Cookie
Peanut
Graphic 2: exposes the comparison of the EMG signal of the left

masseter muscle during mastication of foods made over time.
696
250
200
150
Fmed
100
SN
50
0
Bread
Apple
Cookie
Peanut
Graphic 3: exposes the comparison of the EMG signal of the right

temporal muscle during chewing of food over time.
697
250
200
150
Fmed
100
SN
50
0
Bread
Apple
Cookie
Peanut
Graphic 4: exposes the comparison of the EMG signal of the left

temporal muscle during chewing of food over time.
698
P039
ORAL- MOTOR- SENSORY THERAPY OF A MALE ADOLESCENT
SUFFERING FROM FACIO- SCAPULO- HUMERAL MUSCULAR
DYSTROPHY(FSHMD)- LANDOUZY- DEJERINE.
Nikos Litinas
Neurogenic disorders affecting the speech mechanism can be classified as
developmental or acquired, affecting a wide range of population from early infancy
to elderly people. There is also a wide variety of therapeutic techniques that speech/
language pathologists can apply in order to help their patients develop and/ or
acquire their speech.
In the present case study , a male adolescent suffering from Facio- ScapuloHumeral Muscular Dystrophy (FSHMD) will be described. The Neuromascular
Treatments (NMTs) that were selected in treating the patient will also be described.
The effectiveness of the therapy techniques applied will be discussed.
FSHMD is an autosomal dominant form of muscular dystrophy, gene located
at chromosome 4q, that affects the skeletal muscles of the face (facio), scapula
(scapulo), and upper arms (humeral). Prevalence is 7/ 100000 equally occurring in
male and female. Life expectancy is normal. Characteristic of this form of muscular
dystrophy is the progressive weakness of the skeletal muscles. Some non- muscular
symptoms are sensorineural hearing loss and telangectasias. Disease is manifested by
age twenty; symptoms develop in early childhood and include:
Facial muscle weakness (eyelid drooping, inability to whistle, difficulty
with speech).
Shoulder weakness (difficulty working with the arms rose).
Hearing loss.
Abnormal heart rhythm.
Foot drop.
Unequal weakness of the bicepts, tricepts, deltoids and lower arm
muscles.
Muscle tone is defined as the tendency of the muscle to resist passive stretch.
Hypotonicity is characterized by reduced resistance to passive stretch. FSHMD is
characterized by muscle hypotonicity. Hypotonicity is characterized by reduced
resistance to passive stretching.
Neuromuscular Treatments (NMTs) have been used mostly by physical and
occupational therapists but many speech/ language pathologists are using these
techniques as well in treating neuromuscular problems related to the speech
mechanism. There are three categories of NMTs: active exercises, passive exercises
and physical agent modalities. (Clark, 2003). At the patient described we used the
physical agent modalities NMTs, particularly the icing and brushing. Quick icing
and brushing increases tone by eliciting withdrawal reflexes (McCormack, 1996).
Subject: T.F. is a fifteen year old male suffering from FSHD. He has an I.Q.
70-85 and also presents with a mild sensorineural hearing loss in both ears wearing
hearing aids. At the age of five his frenulum was cut. He attends a vocational school
in Athens, Greece and he likes to play soccer and basketball. He came for a speech/
language evaluation because his hypotonic muscles of the mouth (tongue, lips, face)
were causing him difficulty in speech and eating.
699
Method: During therapy emphasis was given at icing and brushing

techniques for strengthening the hypotonic mouth and face muscles and at
transferring in real life activities (straw sipping, whistling, blowing, eating and
drinking) the therapy techniques. Therapy sessions carried out at a rehabilitation
clinic for cerebral palsied children in Athens, Greece. T.F. visited the clinic once a
week for two months for 45 minutes. During therapy sessions emphasis was given
at:
1. Behavioral approach of the patient in order for the speech/ language
pathologist to get the patients full cooperation.
2. Icing and brushing techniques for strengthening the hypotonic mouth
muscles.
3. Transferring in real life activities (straw sipping, whistling, blowing, eating
and drinking) the therapy techniques.
Goal: T.F. will be able to use straw for sipping, whistle, blow, eat and drink
without drooling with 90% accuracy in three consecutive therapy sessions for 5 min/
activity. Icing and brushing techniques imposed on the mouth musculature for 2
minutes with a 3 min interval in between for 6 times during the 45 minute session.
Positive reinforcement was used immediately after an effort was made. (Good job,
very good, good effort).
Results: After twelve weeks of therapy, T.F. was able to use in every day life
situations a whistle while playing soccer with his friends, sip all liquids with a straw,
blow candles, drink from a cup without drooling, and eat food without drooling as
well.
WEEK 1- WEEK 4: straw sipping: no
whistling: no
blowing: no
eating: drooling
cup drinking: drooling
WEEK 5:
straw sipping: 2 min.

whistling: 2 min.
blowing: 1 min.
eating: 3min.
cup drinking: 3 min.
WEEK 6:

whistling: 2 min.
blowing: 2 min.
eating: 3 min.
WEEK 7:

whistling: 4 min.
blowing: 4 min.
WEEK 8:
straw sipping: 4min.

whistling: 4min.
blowing: 4 min.
WEEK 9:
straw sipping: 4min.

whistling: 4min.
blowing: 3 min.
eating: 4 min.
eating: 5min.
cup drinking: 4min.
eating: 5 min.
cup drinking: 4min.
WEEK 10- WEEK 12: straw sipping: 4 min.

whistling: 4 min.
eating: 5 min.
700
blowing: 4 min.
Discussion/ conclusion: Over the twelve week period these therapy sessions
lasted, it was proven that the NMTs therapy techniques imposed helped T.F. use
activities such as blowing, whistling, straw sipping, eating and drinking successfully.
Furthermore, the icing and brushing techniques used proved to maintain the mouth
musculature in a functional condition despite the progressive muscular
degeneration. NMTs as a therapeutic technique is widely used among therapists,
nevertheless it has raised a lot of controversy because it does not provide enough
support for evidence based practice. On the other hand this same technique provides
enough theoretical background so as many clinicians are using it in treating
neurogenic speech disorders and dysphagia.
T.F. seemed to have benefited from the particular technique, because it was
easy for the speech/ language pathologist to teach these techniques, easy for the
patient to learn and to generalize these activities in a short amount of time.
More patients need to be treated in order to establish more accurate results
regarding NMTs .
BIBLIOGRAPHY
Clark, Heather, M. Neuromascular Treatments for Speech and Swallowing: A
Tutorial. American Journal of Speech- Language Pathology. Nov 2003,Vol.
12, pp 400-415.
Dixit etal., Proc Natl Acad Sci USA, Nov 2007,13 104 (46) : 18157- 62.
Drennan, J. C. Neuromuscular Disorders in Morrissey, R. T. ed., Lovell and Winters
Pediatric Orthopaedics, 3rd edition, J B Lippincott: Philadelphia, 1990.
Encyclopedia Entry for Muscular Dystrophy, NIH, Medline Plus, Oct 9, 2006.
FSHD Fact Sheet, MDA, Nov 1, 2001.
Landouzy- Dejerine Syndrome, whonamedit.com, March 11, 2007.
Wikipedia, the free encyclopedia.
701
P109
SPEECH AND OROFACIAL APRAXIA IN ALZHEIMERS DISEASE (AD)
M. L. Cera1, K. Z. Ortiz1, T. S. C. Minett1
1Federal University of So Paulo, So Paulo, Brazil.
INTRODUCTION
The increase in life expectancy of the general population has been
accompanied by an increase in the incidence and prevalence of neurodegenerative
diseases, especially Alzheimers (AD), the most common type of dementia.
The diagnosis of AD is based on clinical examination and elimination of other
causes of dementia by means of laboratory exams, and is confirmed only with
neuropathologic exams. Nevertheless, the clinical diagnostic criteria agree with the
neuropathologic diagnosis in as much as 90% of AD cases (McKahnn et al.,1984).
Thus, the clinical evaluation is crucial for an early diagnosis and, as such, evaluation
of cognitive functions is very important.
It is well known that apraxias are frequently found as manifestations of
dementias (Kareken et al., 1998).
Liepmann (1905) was the first author to study and describe the different types
of apraxia, such as ideomotor and ideatory apraxia (apud Landry and Spaulding,
1999).
In 1969, Darley described verbal apraxia, a type of ideomotor apraxia, as a
disturbance which interferes with the capacity to program the positioning of speech
musculature and the sequencing of muscle movements for volitional production of
phonemes.
Orofacial apraxia is a problem with movements of the face, lips, tongue and
pharynx in response to a verbal command or imitation (Broussolle et al. 1996).
In AD, studies involving large numbers of patients have reported both limb
and ideatory apraxia (Giannakopoulos et al., 1998; Crutch, Rossor and Warrington,
2007). Several cases of verbal and orofacial apraxias have been described, including
the initial stages of the disease (Croot et al., 2000; Gerstner et al., 2007).
Thus, it is clear that speech and orofacial apraxias may be present in AD. The
determination of these apraxias can aid in early evaluation of communication
difficulties, in patient follow up, and in rehabilitation.
Against this background, the objective of the study was to compare the
speech and orofacial performance of patients with AD against a healthy population.
METHODS
This study (#0390/08) was approved by the Research Ethics Committee of the
Federal University of So Paulo. Participants in the study, or their legal guardians,
signed an informed consent based on principles outlined in Resolution Number 196,
10th October 1996, National Council of Health.
This was a transversal study of 90 older individuals with AD; 30 mild, 30
moderate and 30 severe cases of the disease. All patients were from the Outpatient
Unit of the Behavioral Neurology sector of the Department of Neurology and
Neurosurgery of the Federal University of So Paulo.
702
Inclusion criteria were: age greater than or equal to 60 years, probable

diagnosis of AD according to clinical criteria of NINCDS-ADRDA (McKhann et al.,
1984), presence at every session of a carer who could act as informant. Additionally,
patients with mild or moderate AD had to be on treatment with acetyl cholinesterase
inhibitors at therapeutic doses (Birks, 2009), conforming to government regulations
on drug distribution for AD in the public sector (Ministry of Health Secretary of
Health Assistance - Ruling N843, 31 October, 2002).
Exclusion criteria were:
history of alcoholism, or use of illicit drugs;
use of psychoactive drugs; at least once in the last month, with the exception
of atypical neuroleptic;
previous severe neurologic or psychiatric disease (e.g..: epilepsy, carcinoma,
schizophrenia);
visual or hearing impairments which could compromise the performance on
the assessment tasks;
lack of speech or inability to complete the evaluation, as the patient has to be
able to respond to the stimuli presented to allow speech analysis.
Scales:
Clinical Dementia Rating (CDR), adapted by Morris (1993), according to the
Portuguese version validated by Montao and Ramos (2005). Using this instrument,
the stage of disease is classified according to the total score on the test.
Mini Mental State Examination (MMSE) (Folstein, Folstein, McHugh, 1975):
This test screens for cognitive alterations. All patients had a performance on the
MMSE which was lower than the established standards established by Brucki et al.
(2003) for the normal Brazilian population.
Lawton Index (Lawton and Brody, 1969): This evaluates instrument activities
of daily living. Patients with a score of 0 or 1 are considered to be independent while
those with higher scores are dependent persons.
Evaluation of apraxia of speech and orofacial:
The Boston oral agility test was used to evaluate speech and orofacial
apraxias (Goodglass and Kaplan, 1983). Normal scores for the Brazilian population
for nonverbal agility are 8. 72.2, and for verbal agility are 12. 11.9 (Radanovic,
Mansur and Scaff, 2004). Maximum points for nonverbal agility is 12 and for verbal
agility is 14.
Statistical Methods
The ANOVA One Way Test was used to compare the MMSE scores of the
three groups with AD, and further comparisons among groups made using the post
hoc Bonferroni and, for non-parametric values, Kruskal-Wallis and Mann-Whitney
tests, which showed similar results. Assumptions of a normal distribution and
homogeneity of variances were tested by using Komogorov-Smirnovs Test and
Levenes Test. Only the results of the parametric tests are presented.
To compare the scores of the praxis and details published in the literature, we
performed an analysis of the difference between two means, using Students t Test
for a single sample.
703
A p value of less than 0.05 was considered statistically significant. All tests
were bicaudal. The statistical software package SPSS (Statistical Package for the
Social Sciences) version 13.0 was used for data analysis.
RESULTS
Of the 90 individuals, 66 were women. Age varied from 64 to 97 years (mean
80.27.2) and level of education in years ranged from 0 to 12, with a mean of 4.23.5
years. The mean MMSE score for those with mild disease was 20.03.4, with
moderate disease was 14.41.6, and with severe disease was 9.02.9. The mean score
on the Lawton Index for patients with mild AD was 7.04.2, with moderate AD was
14.32.0, and mean score for patients with severe AD was 15.41.0.
The ANOVA Test showed a statistically significant difference in the MMSE
scores among the three stages of AD: (F(2.87)=118.37,p<0.001*).
Table 1. Comparison of MMSE scores among the three AD
stages according to the Bonferroni Test
Diference
among 95%
IC
means
(difference)
P
mildXmoderate
mildXsevere
5.6
11.0
ModerateXsevere 5.4
3.9
9.3
7.4
12.8
<0.001*
<0.001*
3.6
7.1
<0.001*
Table 2 shows the mean scores on tests of praxia in patient groups with AD.
Table 2. Descriptive analysis of scores on verbal and orofacial praxia tasks by study group
N
Mean
SD
Minimum
Maximum
Median
90
90
3.8
9.2
2.6
2.3
0.0
3.0
11.0
13.0
3.5
10.0
30
30
5.6
10.5
2.9
1.7
0.0
5.0
11.0
13.0
6.0
11.0
30
30
3.6
9.6
1.9
1.6
0.0
7.0
8.0
12.0
3.5
10.0
30
30
2.3
7.6
1.8
2.3
0.0
3.0
6.0
12.0
2.0
7.5
AD
NVOA
VOA
MILD
NVOA
VOA
MODERATE
NVAO
VOA
SEVERE
NVOA
VOA
SD: Standard Deviation; NVOA: Non-verbal oral agility;
VOA: Verbal Oral Agility.
Of the 90 patients, 79 had orofacial apraxia and 81verbal apraxia. Of the 11

with normal orofacial praxia, 10 presented the mild AD and one moderate AD. A
704
total of 6 of the 9 patients without verbal apraxia had mild AD and 3 moderate AD.
Only 4 patients out of the group of 90 had normal verbal and orofacial praxias.
Table 3 shows the differences among the means of nonverbal and verbal oral
agility, for mild, moderate and severe AD groups, along with the averages
(Radanovic, Mansur and Scaff, 2004) for the normal population.
Table 3. Comparison using Students t Test for single sample among the means of the
groups with AD, and the literature data on normal populations.
95%
CI
Difference among Means
(difference)
T
P
AD
NVOA
VOA
-4.9
-2.9
-5.4
-3.3
-4.3
-2.4
-17.9
-12.1
p<0.001*
p<0.001*
NVOA
VOA
-3.1
-1.6
-4.2
-2.3
-2.1
-1.0
-5.9
-5.2
p<0.001*
p<0.001*
MODERATE
NVOA
VOA
-5.1
-2.5
-5.8
-3.1
-4.4
-1.9
-14.8
-8.3
p<0.001*
p<0.001*
SEVERE
NVOA
-6.4
-7.1
-5.8
-20.0
p<0.001*
VOA
-4.5
-5.3
-3.6
-10.4
p<0.001*
MILD
DISCUSSION
Patients with AD showed a significantly poorer performance than the normal
population in both verbal and orofacial praxia.
Derouesn et al. (2000), Crutch, Rossor and Warrington (2007) and Edwards
et al. (1991) also found praxis scores to be worse in patients with AD compared to
normal individuals across all evaluated tasks. However, these authors examined
ideatory and limb praxia, and did not include nonverbal and speech evaluations.
Mitsuru and Satoshi (1999) studied 35 patients with progressive primary
apraxia and found 9 had orofacial apraxia, and of these, four also had verbal apraxia.
Three of the five patients in whom autopsy or biopsy was performed had confirmed
AD. Of these, one had both verbal and orofacial apraxias on clinical examination.
However, the above study evaluated patients with apraxia of various etiologies, not
only patients with AD.
Our study contributes to the literature on this subject by showing the
frequent occurrence of verbal apraxia in AD, which has been largely overlooked in
earlier studies. We believe that, in general, other cognitive domains such as language
and memory are more obviously affected in AD than speech apraxia. Consequently,
these other cognitive aspects of AD have been more intensively studied due to their
associated functional compromise. Notwithstanding, evaluation of verbal and oral
apraxias could help toward achieving earlier diagnosis of AD, as we have shown that
these signs are often already present in the mild stages of the disease.
Broussolle et al. (1996) concluded that the reason verbal and orofacial
apraxias occur together is most likely due to the anatomic proximity of the involved
structures, although they are distinct clinical entities.
705
Studies on speech apraxia have also investigated the relationship between

this disturbance and working memory (WM), which is altered in AD (Martins and
Ortiz, 2009; Howard et al., 2000), having found that speech apraxics present
impairments in WM which are more suggestive of phonoarticulatory loop
dysfunction. However, the presence of WM impairment does not predict the
presence of speech apraxia, as studies in older normal adults have shown that
alterations in WM can occur without the occurrence of verbal praxias (Charlton et al.,
2009).
We are aware of cases described with symptoms of verbal and orofacial
apraxias in AD which initially presented focal alterations, and which received a
diagnosis of AD only later in the course of the disease or at post mortem. It should be
noted that in our study, we found verbal and orofacial apraxia from the mild early
stages of the disease. In summary, verbal and orofacial apraxias can be present in
AD, independent of their form of presentation albeit focal or generalized, or of the
stage of the disease. These apraxias may aid in the early diagnosis of this disease.
CONCLUSIONS
Alzheimer patients, in all phases of the disease, have significantly poorer
performance in verbal and orofacial praxis than the normal population.
REFERENCES
Birks J. Cochrane Database Syst Rev. 2009;(3),CD005593.
Brasil.
Available
from:
<http://sna.saude.gov.br/legisla/legisla/informes/SAS_P843_02informes.d
oc>.
Broussolle E et al. J Neurol Sci. 1996;144(1-2):44-58.
Brucki SMD et al. Arq Neuropsiquiatr. 2003;61(3):777-81.
Charlton RA et al. Cortex (2009). In press.
Croot K et al. Brain Lang. 2000;75(2),277-309.
Crutch S, Rossor MN, Warrington EK. Cortex. 2007;43(7):976-86.
Darley FL. Paper presented to Academy of Aphasia meeting; 1969 sept 30; Boston,
Massachusetts.
Derouesn C et al. Neuropsychologia. 2000;38(13):1760-9.
Edwards DF et al. Dement Geriatr Cogn Disord. 1991;2(3):142-9.
Folstein MF, Folstein ME, McHugh PR. J Psychiatr Res. 1975;12: 189-98.
Gerstner E et al. Cogn Behav Neurol. 2007;20(1):15-20.
Giannakopoulos P et al. Arch Neurol. 1998;55(5):689-95.
Goodglas H, Kaplan EF. The Assessment of Aphasia and Related Disorders. 2 ed. Lea
& Febiger, Philadelphia, PA, USA. 1983.
Howard LA et al. Brain Lang. 2000;74(2):269-88.
Kareken DA et al. Arch Neurol. 1998;55(1):107-13.
Landry J, Spaulding S. Can J Occup Ther. 1999;66(1):52-61.
Lawton MP, Brody EM. Gerontologist. 1969;9(3):179-86.
Martins FC, Ortiz KZ. Arq Neuropsiquiatr. 2009. 67(3b):843-8
McKhann G et al. Neurology. 1984;34:939-944.
Mitsuru K, Satoshi M. 1999;19(3):249-58.
Mitsuru K. Jpn J Logop Phoniatr. 2004;45(4):315-20.
Montao MBM, Ramos LR. Rev Saude Publica. 2005;39(6):912-7.
706
Morris JC. Neurology. 1993;43(11):2412-4.

Radanovic M, Mansur LL, Scaff M. Braz J Med Biol Res. 2004;37(11):1731-38.
707
SE12.1
EVOLUTION OF EVIDENCE-BASED PRACTICE: LESSONS LEARNED FROM
LSVT LOUD
L.O. Ramig1,2, C.M., Fox2
1Department of Speech-Language-Hearing Sciences, University of Colorado, Boulder
2National Center for Voice and Speech, a division of the University of Colorado, Boulder
Attention to evidence-based practice and treatment efficacy and effectiveness
are at the forefront of clinical practice today. However, there are few speech
treatment protocols that have evolved through the five Phases of evidence described
by Robey and Schultz (1998). While the process for development of pharmaceutical
treatments has been well-established (data suggest that it takes 12 years on average
for an experimental drug to travel from lab to medicine chest, only five in 5,000
compounds that enter preclinical testing make it to human testing, and it costs
including the expense of failed drugs$802 million to take a drug from phase I trials
to approval) these data and the process are not well-established for behavioral
treatment paradigms.
For the first time, the opportunity is at hand to explore the 20+ year
development and research process of a specific speech treatment program, LSVT
LOUD, for people with Parkinson disease (PD). The discussion of the journey from
invention of a program through research and global scale-up will highlight the
practical application of phases of research as well as the clinical discovery that has
improved our understanding of motor speech disorders.
The purpose of this presentation is to: a) describe the phases of development
through efficacy and effectiveness of LSVT LOUD, b) discuss the real-world challenges
and considerations of implementing treatment research, and c) demonstrate that the
journey to establishing treatment efficacy has also provided understanding of both
underlying mechanisms of treatment-related change as well as the speech disorder in
PD.
Background: Nearly ninety percent of the six million individuals with PD
worldwide have a speech or voice disorder.
Neuropharmacological and
neurosurgical treatments for PD do not make a positive or lasting impact on speech
at this time. In 1990, the consensus was that speech treatment did not work for
individuals with Parkinson disease. Today, nearly 20 years later, LSVT LOUD is the
speech treatment for PD with Level 1 evidence (Ramig et al, 2001a; 2001b) and it is
being delivered by speech clinicians in over 40 countries around the world.
Furthermore, given recent neuroscience breakthroughs (e.g., Tillerson, Cohen,
Philhower et al., 2001), there is additional motivation for speech treatment to be a
routine, integral part of disease management in PD.
a) Phases of development: The progression of LSVT LOUD through the classic
Phases of treatment research will be discussed: Phase I studies included initial
experimental manipulations to define the treatment parameters (Ramig et al., 1990).
Phase II studies included a treatment protocol carried out on small groups of
speakers with PD with no control or treatment comparison (Ramig et al., 1994).
Phase III randomized control efficacy studies funded by NIH-NIDCD included
treatment protocols tested in ideal laboratory conditions (Ramig et al., 2001a). Phase
IV effectiveness studies include real world application of LSVT in clinical settings.
708
Today Phase V work is ongoing to determine the feasibility of implementing LSVT as

the global standard of care in routine clinical practice. Technology-enhanced delivery
systems (webcam, software programs) are being evaluated for their role in increasing
real world accessibility.
b) Real world challenges and considerations: The following inherent challenges
and considerations in behavioral speech treatment research will be explored: 1) the
impossibility of using a true placebo treatment in behavioral studies, 2) issues of
clinical equipoise in the development of a contrastive treatment, 3) the issue of
concealment for a double-blind study that cannot occur in behavioral treatment since
a clinician cannot unknowingly administer a treatment, and 4) the financial and
human resource burden of carrying out treatment efficacy research.
c) Co-occurring Clinical Discovery: The evolution in our understanding of why
LSVT LOUD has been successful, as driven by treatment outcome data, will be
discussed. In summary, LSVT LOUD began as a physiologically based treatment
focused on laryngeal function (Smith et al., 1995). Our observations expanded to
include distributed effects of treatment to articulation, facial expression, and
swallowing. Given these distributed effects, together with physiological and imaging
data (Liotti et al., 2003), today we hypothesize that LSVT recruits a wide network of
brain regions including phylogentically old regions and right hemisphere associated
with amplitude scaling, emotive vocalization and prosody. In addition, the
evolution of our work within the greater field of sciences, has led us to the
recognition of the significance of embedded elements of motor learning and neural
plasticity, providing a perspective on the underlying bases for the speech disorder in
PD.
Practical applications: At the conclusion of this seminar, participants will be
able to 1) discuss the five phases of treatment research, 2) explain the progression of
LSVT LOUD through these phases, 3) summarize key challenges and considerations
when conducting behavioral speech treatment research, and 4) review the clinical
discovery that occurred and expansion of our understanding of Parkinson disease
and motor speech disorders as a result of this work.
Liotti M, Ramig LO, Vogel D, New P, Cook CI, Ingham RJ, Ingham JC, Fox PT. Hypophonia
in Parkinsons disease. Neural correlates of voice treatment revealed by PET.
Neurology. 2003;60:432-440.
Ramig, L. and Bonitati, C. (1990) Voice treatment for Parkinson disease. Paper presented at
the Clinical Dysarthria Conference, San Diego.
Ramig, L., Sapir, S., Fox, C., and Countryman, S. (2001a) Changes in Vocal Intensity following
intensive voice treatment (LSVT) in individuals with Parkinson disease: pre- postand six months comparison with untreated patients and age-matched normal
controls. Movement Disorders. 16; 79-83.
Ramig, L., Sapir, S., Countryman, S., Pawlas, A., OBrien, C., Hoehn, M., and Thompson, L.
(2001b) Intensive voice treatment (LSVT) for individuals with Parkinson disease: a
two-year follow-up. J. Neurology, Neurosurgery and Psychiatry. 71: 493-498.
Robey, R. R. & Schultz, M. C. (1998). A model for conducting clinical-outcome research: an
adaptation of the standard protocol for use in aphasiology. Aphasiology, 12, 787-810.
Smith M, Ramig LO, Dromey C, Perez K, Samandari R. Intensive voice treatment in
Parkinsons disease: Laryngostroboscopic findings. J Voice. 1995; 9:453459.
Tillerson JL, Caudle WM, Reveron ME, Miller GW. Exercise induces behavioral recovery and
attenuates neurochemical deficits in rodent models of Parkinsons disease. Neurosci.
2003;119:899-911
709
SE09.1
TREATMENT OF CHILDREN WITH SPEECH ORAL PLACEMENT
DISORDERS (OPDS): A PARADIGM EMERGES (BAHR & ROSENFELDJOHNSON, IN PRESS)
SUMMARY
Diane Bahr, MS, CCC-SLP, NCTMB, CIMI and Sara Rosenfeld-Johnson, MS,
CCC-SLP
Ages and Stages, LLC and TalkTools Therapies
Article Objectives:
1.
Initiate an international clinical exchange of ideas regarding
pediatric motor-speech treatment to facilitate worldwide cohesion in
the field.
2.
Discuss treatment of children with speech oral placement
disorders (OPDs); current types of speech oral placement therapy
(OPT); the relationship of OPT to motor learning theories and oral
motor treatment; and the critical need for appropriately designed,
systematic research on OPT using a collegial approach to fulfill this
need.
Methods:
In an upcoming issue of Communication Disorders Quarterly (a peer-reviewed
journal), the authors (Bahr & Rosenfeld-Johnson, in press) suggest initial ideas for a
motor-speech treatment paradigm to be used in conjunction with the Speech
Disorders Classification System (SDCS; Shriberg, Austin, Lewis, McSweeny, &
Wilson, 1997). The paradigm addresses oral placement disorders (OPDs) and oral
placement therapies (OPTs) for children who cannot imitate or follow specific
instructions to produce targeted speech sounds and sound combinations (concerns
recently expressed by DeThorne, Johnson, Walder, & Mahurin-Smith, 2009).
The authors review the many forms of OPT that use tactile-proprioceptive
input in conjunction with more typical auditory-visual input found in traditional
speech therapy methods. They discuss the relevance of two current motor learning
theories (i.e., dynamic systems theory and schema theory) in relationship to OPT
(Kent, 2008; Maas, Robin, Austermann Hula, Freedman, Wulf, Ballard, & Schmidt,
2008; Schmidt, 2003). The authors clearly differentiate speech OPT from non-speech
oral motor exercise/treatment (NSOME/T). An approach to resolve the crucial need
for properly designed, systematic motor-speech treatment research is also discussed
(Bahr, 2008; Scott, Bahr, & Reardon-Reeves, 2009).
710
Results:
Some Current OPTs (Bahr & Rosenfeld-Johnson, in press)
Therapists
Type of Treatment
Description
Diane Bahr (2001, in Hands-On
Tactile- Therapists
gloved
press)
Proprioceptive
and hand/fingers placed
Bottom-Up
Speech near/on lips and/or
Approaches Combined
under
tongue
base/mouth floor to
facilitate appropriate
speech
oral
movements
while
presenting
speech
production
stimuli
(e.g., pictures, words,
etc.) beginning with
vowels and moving
toward increasingly
complex
speech
sound combinations
(e.g., CV, VC, CVC,
etc.).
Appropriate
props
(e.g.,
bite
blocks
to
attain
graded jaw height)
may also be used.
Samuel Fletcher (2008) Palatometry
Computerized visualauditory
feedback
tool that provides an
online,
dynamic
display
of
the
tongues contact with
the
hard
palate
during speech and
swallowing
functions. (Dorais,
2009)
David W. Hammer Touch
Cues/Visual Combined with sign
(2007)
Prompts
language (e.g., to
prompt the final
sound in the signed
word), touch cues are
used
on
the
therapists structures
as a model or on the
childs
structures
711
Deborah
Hayden
(2004, 2006)
Nancy Kaufman (2005)
Pamela
(2004;
1982)
Marshalla
Rosenwinkel,
Merry Meek (1994)
when needed. Visual

prompts
are
provided to indicate
manner
of
production and to
signal
when
the
vowel or consonant
is added to the
sequence .
PROMPT (Prompts for PROMPT uses tactileRestructuring
Oral kinesthetic input to
Muscular
Phonetic shape or reshape
Targets)
muscle actions and
speech subsystems to
produce speech.
Visual/Tactile Cues
Uses least invasive
tactile-proprioceptive
input only when
child cannot produce
speech target via
visual and auditory
cueing.
Tactileproprioceptive
cueing demonstrated
on therapist before
touching child.
Oral-Motor techniques in Hands-on
and
articulation & phonological hands-off tactiletherapy (2004),
Tactile- proprioceptive
proprioceptive techniques in stimulation added to
articulation therapy (1982) traditional
articulation
and
phonological therapy
for clients who do
not progress with
visual and auditory
stimuli.
Motokinesthetic
Approach Meek
demonstrates
(DVDs)
hands-on,
tactileproprioceptive
manipulation of the
oral structures to
assist the child in
producing
specific
speech
sounds/sound
712
Donna Ridley (2008)
Tactile-kinesthetic
Cues,
Muscular Manipulation,
Ultrasound Imaging
Sara
Rosenfeld- Oral Placement Therapy
Johnson (1999, 2009)
(OPT)
Barbara Sonies (1998); Ultrasound Imaging

Donna
Ridley
(Ridley,
Sonies,
Hamlet, & Cohen,
1990, 1991)
Edythe Strand (Strand, Dynamic Temporal

Stoeckel, & Baas, Tactile Cueing
2006)
and
combinations
(originally developed
by Young and Hawk,
1955).
Hands-on
manipulation
of
childs oral structure
to directly facilitate
speech
sound
production.
See
description
of
ultrasound imaging
below.
Therapist
task
analyzes dissociation,
grading,
and
direction of oral and
respiratory
movements needed
for targeted speech
sound
production
and
applies
appropriate
tool(s)
with
required
number of repetitions
to teach motor plans
similar to standard
speech production.
Movements
and
placements
are
transferred directly
into
speech
production ASAP.
Provides auditory and
visual
feedback
regarding
tongue
shape,
movement,
and
placement
during
speech
production.
When child cannot
produce
speech
target via typical
auditory-visual
imitation,
various
levels
of
cueing
713
systematically added
(e.g., unison, oral
movement without
voice, rate variation,
and tactile/gestural
cues as appropriate).
Based on the work of
Rosenbek, Lemme,
Ahern, Harris, and
Wertz (1973).
Some important OPT research questions are (Bahr & Rosenfeld-Johnson, in
press):
Which tactile-proprioceptive OPT techniques (for speech) are
most effective?
Which combination of treatment approaches work best with
OPT?
For whom is OPT most effective?
Conclusions:
The authors conclude there is a need for:
1.
Refinement and expansion of the SDCS to address treatment.
2.
Speech therapists to understand:
a.
OPT as a form of oral motor treatment that is not
NSOME/T.
b.
The motor learning theories on which current OPTs are
based.
3.
Well-designed
treatment
studies
(i.e.,
meta-analysis,
randomized controlled trials, and epidemiological studies) fulfilling
the requirements of evidence-based practice and publication in peerreviewed journals.
4.
Coordination between academic researchers (with expertise in
the research process) and clinicians (with expertise in OPT and data
collection). This collegial effort could facilitate cohesion among speech
therapists worldwide and promote the International Association of
Logopedics and Phoniatrics goal of the sciences of communication
meeting art and culture.
References:
Bahr, D. (2008, November). The oral motor debate: Where do we go from here? Poster session
presented at the annual meeting of the American Speech-Language-Hearing
Association, Chicago, IL. (http://convention.asha.org/handouts.cfm)
Bahr, D., & Rosenfeld-Johnson, S. (in press). Treatment of children with speech oral placement
disorders (OPDs): A paradigm emerges. Communication Disorders Quarterly.
DeThorne, L. S., Johnson, C. J., Walder, L., & Mahurin-Smith, J. (2009, May). When Simon
Says doesnt work: Alternatives to imitation for facilitating early speech
development. American Journal of Speech-Language Pathology, 18(2), 133-145.
714
Kent, R. D. (2008, July). Theory in the balance. Perspectives on Speech Science and Orofacial
Disorders, 18, 15-21.
Maas, E., Robin, D. A., Austermann Hula, S. N., Freedman, S. E., Wulf, G., Ballard, K., &
Schmidt, R. A. (2008). Principles of motor learning in treatment of motor speech
disorders. American Journal of Speech-Language Pathology, 17(3), 277-298.
Rosenfeld-Johnson, S. (2009). Oral placement therapy for speech clarity and feeding. Tucson, AZ:
Innovative Therapists International.
Schmidt, R. A. (2003). Motor schema theory after 27 years: Reflections and implications for a
new theory. Research Quarterly for Exercise and Sport, 74, 366-375.
Scott, K. S., Bahr, D., & Reardon-Reeves, N. (2009, November). Creating effective and efficient
research teams. Seminar to be presented at the annual meeting of the American
Speech-Language-Hearing Association, New Orleans, LA. (Accepted).
Shriberg, L. D., Austin, D., Lewis, B., McSweeny, J. L., & Wilson, D. L. (1997). The speech
disorders classification system (SDCS): Extensions and lifespan reference data. Journal
of Speech, Language, and Hearing Research, 40, 723-740.
Acknowledgements:
CDQ article feedback obtained and incorporated from colleagues Heather

Clark, PhD; Raymond D. Kent, PhD; Edwin Maas, PhD, and Donna Ridley, MEd.
715
P172
Dysphasia Senzo-motorica
Nikolic S.V.N.
Primary School for Children with Damaged Hearing
Introduction to research the problem

The development period is the period of early childhood from birth to seven,
eight, possibly nine or ten years of life. In extremely rare cases, the age limit for the
period of development can move. Moving boundaries period real development,
leads to a situation that certain conditions are classified differently than usual.In that
period are possible fluctuations in the maturation of certain senzo-motor functions. It
is difficult to set limits when a psycho-motor function to reach its full maturity.
Theoretically, there are norms regarding the abilities that children need to have a
particular environmental age. Regular preventive systematic examination of children
by experts tasked to even variation in the ability of functions notice, record, monitor
and intervent immediately when there are first signs of moving border capabilities.
Any delay in the function is considered as an alarming situation that requires
attention, monitoring and early intervention.
In the period when a developmental problem is manifest in its true form,
defekts professional help, parents often ask when the child demonstrated problems
in speech intelligibility. The presence of other interference is less visible and is
interpreted as less important compared to the corrupted speech. The big problem for
timely assistance in the rehabilitation of the ignorance of parents to help there and
that they are the main drivers of note that disorder, that they must be persistent in
finding solutions to problems. Parents should check that the child grows up. Then it
is a valuable development period for habilitation and rehabilitation state passed the
time a child takes longer trains and run slower.
Research Problem
Condition senzo-motor dysphasia is a condition that the criteria for
classification of 10 ICD revisions diagnosed and treated as such, habilitation and
rehabilitation.
The study sample for this research project, were recorded and summarized as
the possible causes that may lead to the emergence of state senzo motor dysphasia.
As the most common causes of the phenomen recorded the presence of organic
damage to the centers for speech in left and right hemisphere of the brain. Each
center has its own particular speech function and task in the development of speech.
In order to develop speech in the proper form, function centers must be
synchronized.
Of the possible causes of occurrence of status senzo-motor dysphasia, in this
sample, the smaller number of cases recorded as traumatic injuries during
pregnancy. The effect of trauma on the pregnant woman can cause brain injury and
damage to fruit mass centers for speech in the left or right hemisphere of the brain.
For this sample, recorded the occurrence of risk factors on the birth of the
newborn. In the period of early development of babies up to one year of age, the
occurrence of possible status "Shock" as a result of high body temperature. Shock is
essentially a phenomenon of status stroke when the brain mass damage, and as a
716
consequence of this situation comes to the appearance of symptoms senzo-motor

dysphasia.
The majority of the investigated sample, it was concluded that parents were
not adequately trained to monitor the status of the child after the occurrence of
certain incidents in the appearance of high fever (loss of consciousness, the brake
body, the appearance of recoil body parts and body as a whole).
The conclusion regarding the causes senzo-motor dysphasia that the causes
can be like benign conditions appear to very serious injuries that require mandatory
medical intervention, treatment and monitoring for a long time during childhood.
Research Methodology
For purposes of this research project applied the methodology of taking
anamnestic data directly from patients themselves, who are can be able enough to be
able to provide adequate data. In the second part of the investigated sample, the
methodology is applied taking heteroanamnestic from parents, guardians and
companions who were able enough to be realistic to consider the issue and to
emphasize that the problems were noticed in children.
Insight into the findings of the early development of psychomotor ability,
recorded the speech and language disorders and interfere with the functioning
psihomotoric.
Test results
Test results appear senzo-motor dysphasia point to the fact that the diagnosis
must implement pediatrician physician review, review Neurology, fizijatar and
otorinolaringolog with the view of psychologists, surdologist, speech therapist,
teachers and pedagogues. Parent is a valuable assistant in the diagnosis and proper
habitation and rahabilitation condition. Mandatory review of the status hearing,
review the status of organs of speech, mobility, language ("tie-language short Hyoid
shoelace"). Diagnosing the condition is komlet defectologists medical and diagnostic
procedures.
Medical and defektoloist diagnosis may show multiple disability with the
presence of the central brain of organic sequelae (damage).
Neurological, EEG (electroencephalography) findings may be normal. Mental
abilities in most of the investigated sample preserved. If necessary, to cut short the
operation Hypoglossal ties (Debrevisatio frenulum linquae). Sporadic, recorded
more damage to brain nerve function impairment with chewing and swallowing
reflex, salivary salivation can be increased, can occur leftside hemiparezis spastic
type in the presence of paresis on the left of the person or vice versa, the lag in the
physiological development of one side of the body with kifozis and spinal
sinistroscoliozis column (warp of the spine), difficulty using the left / right hand
thumb without opposition, there is apraxia devirant thumb in right / left without the
possibility of movement performance up language above, nedifirent logomotorik.
Sporadic, the problem is complicated when it comes to innate lateralization with left
lateralization trained right, walk with a slightly harsh withdrawal left / right foot,
footprint size of the hand and foot is different (weaker development of one side of
the body).
Findings of magnetic resonance (NMR) of the brain can detect brain damage
to the left or right, which is due to lack of oxygen in the previous period.
Findings scanner (CT) brain can detect the presence of partial (partial)
reduktiv (organic) change right / left.
717
Voice expression is difficult understandable for the wider social environment,

the more difficult to establish contact with people from the environment.
Verbal (speaking) is a short-term memory, poor attention, scattered,
articulated a number of votes is damaged, analysis and synthesis of spoken word
does not exist, motor hand and fingers is neizdiferent.
Conclusion Research
The conclusion derived by applying the methodology of taking anamnestic
data heteroanamnestic is:
The majority of the investigated sample is recorded child's stubbornness,
poor response to the call, the rapture of the game, response in the form of "to be deaf
not to hear." The verbal expression is difficult to perform recording body movement
for the speech, difficulty carrying out movements of language, the impossibility of
moving language in the mouth, the inability of licking the lips, cheeks inability to
move muscles, muscles of the cheeks and face may be difficult to movable or
immovable (paresis oral and bukal.s muscles), manifests itself in the face "mask",
without mime, the child seems to not know how to laugh, and do not know how to
cry,
Development of speech runs very slowly, agrammatic, without attachments,
tedious, monotonous and very difficult to understand. The child wants something to
say but difficult to perform the action of speech, to say, but does not understand
what want. with unintelligible speech, there is disruption to the rhythm of speech,
disturbance in motor functioning and the inability of teaching basic motor functions,
disturbed the social patterns of behavior and with kotakt environment. Evedence the
sporadic occurrence of rigidity of body parts (hand, foot, half of the body).
Speech is the most damaged and most often seek help because of suspicion of
hearing loss. In fact, the speech like the speech of children with hearing impairment,
and parents pay review ear doctor on suspicion that the child does not hear or less
heard. There is dissatisfaction with the child and the parents ... the problem is
deepening as time goes on.
The conclusion regarding the time answering parents' doctor is often too late
parents notice a problem and seek professional help late doctor. Parents often think
that a child is spoiled, it will eventually correct itself and thus the speech and motor
dexterity.
Technical assistance should provide the time. Each state after some excess to
monitor and record changes. Any departure from offten model, in speech, motor
and behavior should be monitored and rehabilitated. You do not need to wait five to
six years, when the child grows.
With preserved mental abilities and with the individualization of instruction
by teachers, the child can be educated in regular education.
It takes a lot of work and patience, both in school and in the family to achieve
success at the level of formal education.
Proposal of measures for improving professional practice
Early habitation and rehabilitation process begins and ends defectolog,
speech therapist, surdolog, psychologist and teacher with the supervision of
specialists. Good, competent and conscientious defectolog will find time with your
child establish social contact and cooperation with child and without delay will
begin the process of training and the establishment of new forms of functions of
damaged skills.
718
Delaying treatment and temporary controls do not solve the problem.

After a short period of adaptation to the new Rehabilitation procedure,
contact between the child-defectolog will prove positive. After that, continue
habilitacion-long rehabilitation process that gives results. In the treatment senzomotor dysphasia, be sure to apply the methods of psychomotor reeducation,
relaxation methods by Schulz, matod of passive and active massage, hydrotherapy,
psychotherapy and social therapy. The work with parents, should be applied a
method meeting teachers, parents and children by Rogers in order to exchange
experiences and active otsselfes problem. Working Group refines and enriches both
the individual and the whole group, and indirectly, has an impact on behavior
change ocure all children from an environment sensor-motor dysphasia.
Persistence and perseverance give good results. We should not stop with
rehabilitation if the results are not seen immediately.
It is recommended the inclusion of every child in the collective, whether or
not the child has problems in speech, in motor, in mental, cognitive. The preschool
treatment group of their peers as preparations for the training and education. The
possibility of education in the regular education system should enable every child. If
a child can not be educated in regular school, you should consider the possibility of
inclusive education under supervision of professional personnel. Make sure the
active involvement of a parent who is most interested in the well child.
You must be persistent, have patience and the results are coming slowly but
surely. Keywords: disfazia, apraxia, hemiparezis, spasm, sequelae.
719
MULTILINGUAL AFFAIRS
FP03.1
INITIAL FIELD TRIAL DEVELOPMENT OF THE COMPREHENSIVE
ASSESSMENT OF SPANISH ARTICULATION-PHONOLOGY (CASA-P):
CULTURAL AND LINGUISTIC VALIDITY.
Alejandro E. Brice, Ph.D., CCC-SLP, University of South Florida St.
Petersburg
Roanne G. Brice, University of Central Florida
Introduction
Five million bilingual preschool children live in the United States. This
comprises almost 60% of all 3-5 year old children (i.e., 59.5%) (U.S. Census Bureau,
2005). Hispanic or Latino children constitute the largest ethnic group in the United
States. It is known that articulation and phonology development in bilingual
children, particularly Spanish-English speaking children, show very distinct
differences in their development when compared to monolingual English or
monolingual Spanish speakers (Goldstein & Cintron, 2001). When children acquire a
second language errors due to articulation or phonological interference often occur
(Goldstein, Fabiano, & Washington, 2005). It is important that speech-language
pathologists in the U.S. know Spanish articulation and phonological patterns and the
influence that these two languages have upon each other.
Studies on Spanish phonology have been restricted to only a few Spanish
dialects, i.e., mainly Mexican Spanish or Puerto-Rican Spanish. For example, the
study by Jimenez (1987) is typically referenced by the American Speech-LanguageHearing Association (ASHA). In the Jimenez (1987) study, 120 Mexican-American
children from south Texas, i.e., ages of 3:0 to 5:7, were the participants. Results
indicated that the preschoolers had acquired 50% of the majority of all Spanish
consonants by four years of age except: /d/, /g/, / /, , /x/, /s/, the trill /R/,
and/or the tap /r/. Children had not mastered the /s/ and trilled /r/ by five years
if age (i.e., at the 90% accuracy level). Martinez (1986) found the following Spanish
deficiencies in her study: tap or trill /r/; consonant sequence reductions; fronting;
deaffrication; stopping; affrication; palatalization; assimilations; sibilant distortions;
metathesis; migration; and vowel deviations. These processes were still evident after
four years of age in the Mexican Spanish-English speaking children. Monolingual
children who speak Mexican Spanish demonstrate the following phonological
processes: consonant sequence reduction; deaffrication; and tap/trill deficiencies
after four years of age (Becker, 1982).
When a child acquires two or more languages in their early development
(simultaneous and sequential bilinguals), then each language has a definite effect on
the other. It is known that rules from L1 (the first language) can positively affect
articulation and phonology productions in L2 (second language) resulting in correct
speech production. However, the languages may interact negatively resulting in
articulation and/or phonological interference.
720
It should be noted that bilingual Spanish-English speakers are different from

monolingual Spanish speakers or monolingual English speakers, i.e., their
articulation and phonology should not be compared to monolingual speakers as their
productions are influenced by their two languages (Grosjean, 1989). In
predominantly monolingual countries where English is the predominant language
(such as the United States), it is inevitable that Spanish will be influenced by English.
The rare possibility of discovering pure monolingual Spanish speakers is highly
unlikely. As a consequence, English influence will have an affect on Spanish
articulation and phonology and also vice versa.
Articulation and phonological development in Spanish, has not been
sufficiently investigated. As a result, limited developmental and normative
information for Spanish-English speakers is relatively sparse. Therefore, the purpose
of this paper is to present initial field trailing results from the Comprehensive
Assessment of Spanish Articulation-Phonology (CASA-P).
Methods
Sixteen bilingual Spanish-English speakers, four to five years of age, enrolled
in a preschool program were the participants for the field trialing development of the
CASA-P. The sample consisted of six females ten males among the eight four year
olds and eight five year olds. The childrens ages ranged from: 3.7 to 5.7 (M=4.8
years of age). The participants Spanish dialects were from the following: (a) Puerto
Rico (n= 9); (b) Nicaragua (n= 2); (c) Cuba (n= 1); (d) Columbia (n= 1); (e) Bolivia (n=
1); (f) Dominican Republic (n= 1); and (g) Argentina (n= 1).
It was reported by the parents that all the children spoke Spanish and English
concurrently at home and English at the preschool. According to the parents, it was
reported that the children were mainly exposed to Spanish. All of the children were
typically developing and had no indication or history of a speech, hearing, or
language disorder. Language screening and speech screenings were administered in
order to verify typical development among the participants. In addition, all
participants passed a hearing screening.
Procedures
A researcher developed test (i.e, the Comprehensive Assessment of Spanish
Articulation-Phonology, CASA-P) initially with 121 items was reduced to an essential
42 items to measure Spanish phonology for the Spanish-English speaking
participants.
CASA-P Development
The CASA-P was developed to assess Spanish articulation and phonology. It
was developed by two university researchers: (1) The first researcher is a high level
proficient Spanish-English speaker with extensive knowledgeable of both Spanish
and English phonology; (2) the second researcher is a proficient English speaker with
extensive knowledge of English phonology.
The CASA-P evaluates all Spanish initial and final consonants, consonant
blends, and vowels. In addition, 10 occurrences for each phonological process are
elicited. Content, cultural, and linguistic validity of the CASA-P was developed by
means of:
1. A comprehensive literature review was performed regarding Spanish
articulation and phonology (Acevedo, 1989; Brice, 1996; Eblen, 1982;
721
Goldstein, Fabiano, & Washington, 2005; Goldstein & Iglesias, 1996a, 1996b;
Jimenez, 1987; Mann & Hodson, 1994; Martinez, 1986; Paulson, 1989; RiveraUmpiere, 1988; Villanueva, 1990). Ten phonological processes were found to
be specific to Spanish which included: (a) Fronting; (b) Stopping; (c) Liquid
simplification; (d) Assimilation; (e) Consonant sequence reduction; (f) Weak
syllable deletion; (g) Pre-vocalic singleton omission; (h) Tap/trill deficiency;
(i) Stridency deficiency. Vowel deviations and English interference were also
added as these may contribute to Spanish phonology productions as a result
of English influence. Therefore, a total of 12 processes are assessed by the
CASA-P. Six native Spanish speakers reviewed the items for Spanish
pronunciation common or standard to all dialects and age appropriateness.
2. The review panel consisted of six native speakers of Mexican Spanish,
Cuban Spanish, Puerto Rican Spanish, Costa Rican Spanish, and Peruvian
Spanish.
3. The CASA-P was initially field trialed on 16 SpanishEnglish speaking
four to five year olds.
4.
Adult fluent and high level bilingual, Spanish-English, speakers
participated in transcribing the test items using narrow and broad
transcription during seven meetings (i.e., approximately one hour each).
Consensus of 100% agreement was achieved for the final form of the CASA-P.
4. The CASA-P includes alternate pronunciations (17/44 = 39% or all items)
that are dialectally acceptable and are considered to be errors. These alternate
Spanish productions involve tap vs. trill differences, post-vocalic singleton
omissions common to a Caribbean Spanish dialect (Goldstein & Iglesias,
1996b), l/r substitutions, /b substitutions, j/ substitutions, and n/
substitutions.
Equipment
A Panasonic video camera (i.e., Super VHS 456 Pro-Line) was used to tape all
sessions and audio record the responses to the test picture stimuli. The cameras
microphone frequency response is the range of 50-20,000 Hz and signal to noise ratio
is greater than 47dB. During all data gathering sessions the camera was placed three
and six feet from the children.
Results and Conclusions

From the field study it was found that: (1) bilingual speakers display different
types of articulation and phonological errors than do monolingual speakers; (2) not
all sounds transfer between languages, accuracy wise and at the same rate; (3) the
frequency of occurrence of a sound in a language can affect production for that
language; (4) the developmental age at which English is acquired can affect English
productions (as compared to Spanish productions); (5) Spanish vs. English voicing,
manner, and place differ and can affect productions in either language; and, (6)
Dialectal variations of Spanish can affect productions in Spanish and English.
Further refinement of the CASA-P has included: (1) inclusion of two more
items to address all Spanish consonant blends, bringing the total to 44 items; (2)
further evaluation by speakers of other Spanish dialects, i.e., Mexican Spanish; (3)
refinement of the phonetic transcriptions of Spanish words; and, (4) additional
alternative pronunciations were added to reflect other Spanish dialects that are
acceptable. The authors expect to continue to field test the CASA-P with additional
722
Spanish-English speaking children, e.g. Spanish-English speaking children with

articulation/phonological disorders and children from other Spanish dialects.
References
Acevedo, M. A. (1989, November) Typical Spanish Misarticulations of MexicanAmerican Preschoolers. Paper presented at the American Speech-Language-Hearing
Association Annual Convention, St. Louis, MO.
Becker, M.C. (1982). Phonological analysis of speech samples of monolingual Mexican 4-year olds.
Unpublished masters thesis, San Diego State University, San Diego, CA.
Brice, A. (1996). Spanish phonology: A review of the literature. The Florida Journal of
Communication Disorders, 16, 14-17.
Eblen, R.E., (1982). Some observations on the phonological assessment of Hispanic-American
children. Journal of the National Student Speech, Language, Hearing Association, 10, 44-54.
Goldstein, B., & Cintron, P. (2001). An investigation of phonological skills in Puerto
Rican Spanish-speaking 2-year-olds. Clinical Linguistics and Phonetics, 15, 343-361.
Goldstein, B., Fabiano, L., & Washington, P. (2005). Phonological skills in
predominantly English, predominantly Spanish, and Spanish-English bilingual
children. Language, Speech, and Hearing Services in Schools, 36, 201-218.
Goldstein, B., & Iglesias, A. (1996a). Phonological patterns in Puerto Rican Spanish-speaking
children with phonological disorders. Journal of Communication Disorders, 29(5), 367387.
Goldstein, B., & Iglesias, A. (1996b). Phonological patterns in normally developing Spanishspeaking 3-and 4-year-olds of Puerto Rican descent. Language, Speech, and Hearing
Services in Schools, 27, 82-89.
Grosjean, F. (1989). Neurolinguists, beware! The bilingual is not two monolinguals in one
person. Brain and Language, 36(1), 30-15.
Jimenez, B.C. (1987). Acquisition of Spanish consonants in children aged 3-5 years,
7 months. Language, Speech, and Hearing Services in Schools, 18, 357-363.
Mann, D., & Hodson, B. (1994). Spanish-speaking children's phonologies: Assessment and
remediation of disorders. Seminars in Speech and Language, 15(2), 137-147.
Martinez, R. (1986). Phonological analysis of Spanish utterances of normally developing MexicanAmerican Spanish speaking 3-year olds. Unpublished masters project, San Diego State
University, San Diego, CA.
Paulson, D. M. (1989). Phonological systems of Spanish-speaking Texas preschoolers.
Unpublished masters thesis, Texas Christian University, Ft. Worth, TX.
Rivera-Umpierre, E. (1988). Phonological analysis of 3- and -4 year old monolingual Puerto-Rican
Spanish-speaking childrens utterances. Unpublished masters thesis, San Diego State
University, San Diego, CA.
U.S. Census Bureau [Homepage of U.S. Census Bureau], [Online]. (Last updated July, 2005).
Available: <http://www.census.gov> [2005, August, 4].
Villanueva, R. (1990). Phonological Analysis of Spanish Utterances of Puerto Rican Children
with Speech Disorders. Unpublished masters thesis, San Diego State University, San
Diego, CA.
723
P044
TEAMING ACROSS CULTURES: PROGRAM DEVELOPMENT FOR
CHILDREN WITH DISABILITIES.
Rosario Roman, Bilingual Multicultural Services, Albuquerque, NM USA
Speech-language pathologists (SLPs) and audiologists are increasingly
interested in providing assistance to persons in countries outside the United States.
Many are offering support in countries that have had little or no contact with
SLPs/audiologists. To provide useful assessments and interventions in other
countries, professionals must understand the values and beliefs about
communication impairments. Furthermore, they need to understand and appreciate
the influence of a variety of environmental factors on communicative functioning if
they are to provide appropriate assessments and interventions with a diverse
population around the world.
To train professionals/paraprofessionals in Bolivia, it is important to
recognize Bolivians attitudes about communication in life experiences. The goal of
intervention is to enable children to be able to function within their families and
communities. Assessment and intervention strategies must be adapted by
considering how language is used in life activities and how impairments or
disabilities are viewed. The degree to which children with impairments are able to
function is influenced by contextual factors (personal factors e.g., culture, language,
race, ethnicity, socioeconomic level; and environmental factors, e.g., access to
technology, natural environmental conditions, attitudes toward disability, social
policies) .
Bolivia at one time was the richest part of the Spanish empire and at its
independence was one of the largest countries of Spanish speaking South America.
Now Bolivia is one of the poorest countries and one of the two landlocked nations.
Six out of eight million Bolivians are of Native lineage. Almost half of the populace
speaks the indigenous language of either Quechua or Aymara as their mother
tongue; many are monolingual speakers, who do not speak Spanish at all
(Stephenson, 2003).
Providing services in Bolivia can be a challenge, as only 5% of the roads are
paved and the terrain is rugged making communication, education, and
transportation within the country difficult. Many Bolivians do not venture far from
their birthplace.
This poster will demonstrate how the International Classification of
Functioning-Youth Version (WHO, 2007) has been used as a culturally sensitive,
multi-dimensional, multidiscipinary framework for assessing and developing
interventions for Bolivian children with multiple impairments..
The ICF uses three main components in evaluating a childs functioning: (1)
impairments in body functioning/body structure; (2) restrictions/limitations in
activities/participation; and (3) the influence of contextual factors on functioning.
Coding of childrens functioning using the ICF framework is done by the teams of
professionals working with the children
724
1a. Body Functioning: This area addresses the functioning of major body
systems, e.g., mental functions (e.g., language, calculation, thought process,
sequencing complex movements); Sensory functions and pain (e.g., seeing, hearing
and vestibular, taste, smell functions); voice and speech functions;
and
neuromusculoskeletal and movement-related functions.
It is important to
understand that cultural groups using the same language may have different views
of what it means to perform these functions appropriately and intelligently; while
cultural groups using different languages may have similar views on what it means
to perform intelligently (Westby, 2008).
1b. Body Structures: This area does not change with culture as it makes
reference to the body structures that are similar across all humans, e.g., structure of
nervous system, of the sensory systems, of the voice and speech mechanisms, or
structures related to movement. In Bolivia, the input from the medical profession
has assisted professionals to transition from providing isolated therapeutic
treatments
by
individual
therapists
to
employing
a
multidisciplinary/transdisciplinary approach to treatment.
2. Activities and participation: Activities refer to an individuals capacity to
perform a behavior or task, while participation refers to an individuals actual
execution of the behavior or tasks within family, school, and community
environments. SLPs typically assess a childs capacity through the use of a variety of
formal tools/tests in structured situations. They have been less likely to assess
childrens participation in the events of daily life. The ultimate goal of any
intervention should be to develop childrens abilities to participate in the activities
and events of their families and communities. To accomplish this, professionals must
understand the families desires or expectations for the ways they want their children
to participate. This requires that professionals develop cultural competency. They
must be aware of their own values, beliefs, behaviors, and communication styles and
recognized how they may need to change speech patterns or body language
(gestures, eye contact) to suit people from a different culture.
3. Contextual factors: The Contextual Factors component of the ICF, which
includes both Environmental and Personal Factors, provides a framework for
clinicians to acknowledge the ways language and cultural factors influence the
manifestation of a persons disability and perception of that disability. Personal
factors can include a persons temperament, socioeconomic level, race, ethnicity,
language, gender, age, educational level, religion, and lifestyle. Environmental
factors can include technology, the natural environment, support and relationships,
attitudes, available services, systems and policies. These contextual factors can serve
either as barriers or facilitators to childrens ability to participate.
The use of the ICF in Bolivia has provided professionals with a way to
acknowledge the multiple aspects of Bolivian families culture (personal factors) and
the role of environmental factors in the development of intervention programs for
their children with disabilities. The role of culture is very
important in
understanding the development of family relationships (Cheng, 2009). Only by
rooting themselves in the concepts of cultural proficiency and competence can
professionals begin to work efficiently with families from diverse backgrounds. In
order to create optimal language and learning environments, professional must
recognize, appreciate, and respect the vital role parents and family members have in
educating their children (Cheng 2009). This involves understanding that families are
defined differently depending on the norms, beliefs, values and rules of their culture.
725
References
Folia Phoniatrica et Logopaedica (2003), International Cross-Culture Issues. S Karger Medical
and Scientific Publishers. 55(6)
Cheng, L. (2009) Creating an optimal Language Learning environment: A focus on family and
culture, Communication Disorders Quarterly, 30(2), 69-76
Earley, C., & Mosakowiaki, E. (2004 October), Cultural Intelligence. Harvard Business
Review; pp. 139-146
Stephenson, S. (2003)
Understanding Spanish-Speaking South Americans: Bridging
Hemispheres. International Press.
Westby, C.E. (2007) Being Smart in a Diverse World. Communication Disorders Quarterly.
(29), pp 7-13
World Health Organization (2007). International Classification of Functioning, Disability, and
Health: Children and Youth version. Switzerland: WHO.
726
FP03.6
PERFORMANCE OF
BACKGROUND ON
PARADIGMS
BILINGUAL CHILDREN FROM MIGRATION

A TEST OF GERMAN MORPHOLOGICAL
W Scharff Rethfeldt1, K Bilda2

1 University of Oldenburg, Oldenburg, Germany
2 Hochschule fuer Gesundheit, Bochum, Germany
Introduction
Although bilingualism in the world today is a frequent phenomenon, specific
procedures for bilingual assessment and for interpretation of the results are still
lacking. Generally it is recommended that bilingual children should be assessed in all
their languages. In addition, studies of language acquisition of bilingual children are
mostly based on children who are typical learners of the languages.
The growing number of multilingual children from different linguistic
backgrounds in Germany in already second and third generation from migration
background confronts speech and language therapists with a diagnostic dilemma.
Next to the fact that there is a lack of systematic, norm-referenced assessment
materials in a number of languages as well as sufficient numbers of qualified
bilingual / bicultural clinicians, there is an even greater concern of even if
assessment in both languages is feasible, it is not clear at all how the results should
be interpreted. The majority of published studies on bilingualism focus on children
acquiring two languages simultaneously from birth on.
As a result, children from different multilingual / multicultural backgrounds
with normal language may be identified as having a language disorder.
Objectives
Research has demonstrated that monolingual children of German with
speech language impairment (SLI) show specific errors on the regularities of the
German noun plural forms due to difficulties with irregular inflections (Schler /
Kany, 1989); which is similar to findings from other studies which have
demonstrated that children with SLI are impaired at producing irregular as well as
regular inflections (Bishop, 1994; Ullman / Gopnik, 1994). As a result, morphological
paradigms focusing on plural assignment are often used for standardised tests of
language competence. Since plurals are, on the whole, learned late, plural
assignment is considered as a suitable part of a whole test battery in order to
differentiate and identify possible language disorders (Schler / Lindner, 1990)
especially in elementary school aged children. In order to provide the explanation of
morphological acquisition as well as strategies used, the theories of MacWhinney
(1978) and Pinker (1991) are taken into account.
However, languages differ greatly from one another in their morphological
structure. That is, different languages mark morphosyntactic features in different
ways. German is associated as being a language with a great morphological
complexity. While i.e. the English plural rules are mainly phonetically motivated, in
727
German it is necessary to select the correct form of some grammatical class to go with
the gender of the noun being used. Recently, the research of Jackson and Dussias
(2009) revealed, that L2 speakers utilized native-like processing strategies in sentence
processing, while other research suggests that even high proficient speakers may
never attain native-like competence in their L2 (White, 2003).
With regards to children from different linguistic backgrounds, the question
arises whether or not children acquiring German as a morphologically complex
language will show similar strategies when performing on problem solving
morphological tasks or transfer strategies and / or knowledge from their first
languages. Therefore the question at hand will be how and by means of which
strategies children from different linguistic and migration backgrounds solve
problems of morphological paradigms regarding German plural markers.
Participants and Methods

Extracts of findings from research on twenty-five children with different
linguistic backgrounds from migration background for which German is a second
language which is gradually being acquired before six years of age in different
natural contexts (Scharff Rethfeldt, 2010) will be presented. Six of the bilingual
children were a priori confirmed special needs, whereas nineteen of them were
assumed normal language development. In addition three monolingual children
with special needs were tested. All twenty-eight subjects were tested during their
first and second year of elementary school with a standardised test evaluating
language related skills including language processing strategies in German. As
regards the standardised subtest Plural-Singular-Bildung (morphological
paradigms of plural and singular) of the H-S-E-T was used, by means mainly nonwords in order to ensure that possible correct plural forms were not learned by rote.
Supplementary data on their socio-cultural background including language
use within their families were assessed by questionnaires.

The results of the present study provide further evidence that morphological
paradigms is an area of weakness in children with suspected SLI, especially when it
comes to children from different linguistic backgrounds acquiring a second language
with great morphological complexity such as German. Monolingual children with
suspected SLI performed significantly worse than bilingual children from different
linguistic backgrounds, whereas there was no significant difference between the
results of the two bilingual groups. Furthermore, when examining the performance
considering possible cross linguistic influences, problem-solving strategies need to be
discussed in relation to grammatical gender regarding specific influences from
heritage grammar. The results provide directions for the use of language measures as
part of a complete assessment that can potentially differentiate lack of knowledge
from language disorders. Moreover the discussion will lead to the suggestion that as
long as separate norms for bilingual children are lacking, certain existing extensive
monolingual measures with full theoretical foundation may instead be useable when
they incorporate a complete view which takes into account the childs knowledge
and structure of his or her languages next to his or her socio-cultural background.
This can be a tenable basis for the SLTs interpretation of assessment and
intervention with bilingual children.
728
\
References
Bishop, D. V. M. (1994): Grammatical errors in specific language impairment. J Child
Psychology and Psychiatry, 33: 1-64.
Jackson, C. N. / Dussias, P. E. (2009): Cross-linguistic differences and their impact on L2
sentence processing. Bilingualism: Language and Cognition 12: 65-82.
MacWhinney, B. (1978): Processing a first language: the acquisition of morphophonology.
Monographs of the Society for Research in Child Development 43, 174.
Pinker, S. (1991): Rules of language. Science, 253: 530-535.
Scharff Rethfeldt, W. (2010): Sonderpdagogische Feststellung der Sprachkompetenz mehrsprachiger
Kinder vor dem Hintergrund ihrer persnlichen Lebenssituation und der schulischen
Anforderung. Idstein: Schulz-Kirchner.
Schler, H. / Kany, W. (1989): Lernprozesse beim Erwerb von Flexionsmorphemen: Ein
Vergleich sprachbehinderter mit sprachunaufflligen Kindern am Beispiel der
Pluralmarkierung. In Kegel, G. et al. (Ed.): Sprechwissenschaft und Psycholinguistik 3,
Opladen: Westdeutscher Verlag, 123-175.
Schler, H. / Lindner, K. (1990): Zum Lernen morphologischer Strukturen. Der
Deutschunterricht, 42: 60-78.
Ullman, M. / Gopnik, M. (1994): The production of inflectional morphology in hereditary
specific language impairment. In Matthews, J. (Ed.): Linguistic aspects of familial
language impairment. Special Issue of the McGill Working Papers in Linguistics, 10,
Montreal: McGill University.
White, L. (2003): Fossilization in steady state L2 grammars: persistent problems with
inflectional morphology. Bilingualism: Language and Cognition 6: 129-141.
729
P110
DEVELOPING INTERNATIONAL CLINICAL, RESEARCH, AND
TEACHING COLLABORATIONS FOR STUDENTS AND FACULTY IN
THE HEALTH PROFESSIONS
Brian B. Shulman, PhD, CCC-SLP, ASHA Fellow
Theresa E. Bartolotta, PhD, CCC-SLP
Universities across the globe are increasingly exploring international
partnerships for a multitude of reasons. Technology has minimized or often
completely eliminated barriers to successful exchange of ideas, students, faculty,
programs, and core values. Universities see great opportunity for expanding
programmatic offerings across countries, thereby increasing their market reach and
their influence across many lands. With the globalization of economies and
industries, the need for students who have knowledge of the similarities and
differences pertaining to the financial, educational and healthcare systems of other
countries is growing rapidly. The traditional idea of cultural exchange, which was
formerly limited to immersing students in the language and culture of a country for a
brief period, has expanded from a study abroad concept to a transformational
concept where ideas and people move back and forth across borders (Sutton, 2010).
In this new concept, the impact of partnership is rich and lasting.
This expansion is occurring across academia, and most notably in schools of
health and medical professions. Exposure to health systems across the globe is not a
new idea in education of healthcare professionals. Medical schools have long offered
courses in international health for students (Imperato, 1996). The basic premise on
which these courses (which were typically elective courses) were based has evolved
exponentially over time. Previously, students observed and studied a particular
health care system in another country. Their experiences may have included
opportunities to observe delivery of health care, participation in service delivery, and
interaction with professionals and patients to understand roles of providers and
values of a culture related to education and healthcare. Faculty who participated in
these exchanges may have taught a lecture or a course, or engaged with colleagues in
a short-term exchange of knowledge or collaboration on a research project. These
transactional experiences (Sutton, 2010) were based on a clearly defined exchange of
resources with defined, product-oriented outcomes. Though highly valuable, these
experiences were usually limiting in that the effects of the relationship were usually
restricted to the individuals who actually participated in the exchange. The effect on
the universities or facilities involved, or the host country, was not lasting or
transformational in any way.
Universities and governments have come to recognize that in order to be
successful and compete in both the American and global economies, students must
have a full and complete understanding of other countries, which cannot be limited
to didactic experiences in the classroom (Loveland, 2010). There is now growing
engagement by university faculty in global initiatives, especially in healthcare
(Pechak & Thompson, 2009). Students and faculty are exploring an increasingly
diverse range of experiences, including didactic teaching experiences, clinical
exchange, service-learning projects, and research collaborations. This is driven by
forces at the university level and also by external accrediting bodies who oversee
education of allied health professionals in the US and abroad. These accreditors are
increasingly looking to universities to produce healthcare professionals who are
730
prepared for autonomous and collaborative practice in all settings and are involved
in global health initiatives (Pechak & Thompson, 2009). The potential to make a
significant impact on global health through partnerships across the globe is
becoming increasingly evident to researchers. For example, it now becomes possible
for universities and academic health centers to partner in large-scale clinical trials
across the world (Wartman et.al., 2009). This sharing of research expertise, patient
databases, and outcomes could address global health issues in the developing world
as well as in industrialized nations.
To address these issues, the School of Health and Medical Sciences (SHMS) at
Seton Hall University developed a plan to establish global collaborations in the areas
of teaching, research and clinical education for students and faculty. The goal was to
provide students and faculty with transformational experiences in global health
while remaining true to the Schools mission to teach students to learn the art and
science of caring using a research-to-practice model of education. SHMS is a
professional school within the University structure that prepares healthcare
professionals to assume leadership roles in the healthcare arena. The School offers a
variety of unique and innovative degree-granting educational programs using a
multi-institutional and integrated approach to graduate education. The School
consists of two distinct educational divisions:
The Division of Health Sciences provides on-campus graduate education
programs within six academic departments: athletic training, occupational therapy,
physician assistant, physical therapy, speech-language pathology, and health
sciences (post-professional only). Although these are campus-based programs, the
students receive hands-on clinical education at off-campus sites. Currently, the
School of Health and Medical Sciences has clinical affiliation agreements with more
than 500 clinical sites in the New York/New Jersey metropolitan area in addition to
sites across the United States and internationally.
The Division of Medical Residencies and Fellowships offers 22 off-campus
post-medical school programs for physicians, dentists and pharmacists at five
affiliated hospitals Saint Michael's Medical Center in Newark; St. Joseph's Regional
Medical Center in Paterson; Trinitas Regional Medical Center in Elizabeth; John F.
Kennedy Medical Center in Edison and St. Francis Medical Center in Trenton. The
hospitals and the University jointly attest to the successful completion of` the
residency training through the issuance of a certificate. The University currently
enrolls more than 200 medical residents and fellows in programs in A.O.A.
(American Osteopathic Association) Emergency Medicine, A.O.A. Internal Medicine,
A.O.A. Internship, Dentistry, General Surgery, Internal Medicine, Neurology, Oral &
Maxillofacial Surgery, Orthopedic Surgery, Podiatry, and Psychiatry, among other
medical specialty areas.
This poster presentation will highlight the transformational relationships that
SHMS has established with universities in Denmark, Belgium, The Philippines,
Brazil, Ireland and Scotland. These relationships, which encompass clinical exchange,
research collaboration, and/or planned teaching experiences, will be described from
inception to actualization. The specific goals and objectives of each unique type of
experience will be highlighted. The first agreement that was established was a
student clinical exchange partnership with Metropolitan University College in
Copenhagen, Denmark for students in physical therapy and occupational therapy.
Over a two-year period, multiple conversations and meetings were held which
culminated in a formal meeting between administrators and faculty from both
universities to sign a collaborative agreement that allowed for bi-directional student
clinical exchange. Specific issues related to academic objectives, prerequisite
731
knowledge and skills for clinical education, delivery of knowledge on healthcare

systems, insurance and safety for students, education of clinical supervisors,
oversight by university faculty, travel and housing considerations, financial issues,
and accreditation concerns will be highlighted and solutions discussed.
Development of transformational research collaborations will be highlighted using
partnerships established with Ghent University in Belgium as well as Palacky
University and Charles University in The Czech Republic. For all partnerships,
impact on students, faculty, administrators and the School(s) will be described. For
example, students involved in clinical exchanges were surveyed before traveling to
their host country, and again upon return. As part of the requirements for successful
completion of the clinical exchange, SHMS students studying clinical education in
Denmark posted blogs about their experiences while abroad. Likewise, students
from Denmark participating in clinical education in New Jersey were interviewed at
the start and at the end of their experiences, and asked to reflect on the similarities
and differences between the healthcare and educational systems of the countries.
Faculty involved in these exchanges were also asked to reflect on their growth and
development in terms of teaching and supervision of students from different
cultures.
New partnerships, which have expanded to include students in speechlanguage pathology and faculty in physical therapy, athletic training and movement
science will also be described. Challenges to collaboration, especially acute in the
current global economic crisis, will be noted. The Schools plans for expanding the
current partnerships to include more students and faculty will be described.
REFERENCES
Imperato, P.J. (1996). A third world international health elective for U.S. medical students.
The
16-year experience of the State University of New York, Health Science Center at Brooklyn.
Journal of Community Health,21(4), 241-268.
Loveland, E. (2010). A renewed commitment to international education. International Educator,
19(1), 18-21.
Pechak, C.M., Thompson, M. (2009). A conceptual model of optimal international servicelearning and its application to global health initiatives in rehabilitation. Physical Therapy,
89(11), 1192-1204.
Sutton, S. B. (2010). Transforming internationalization through partnerships. International
Educator,19(1), 60-63.
Wartman, S.A., Hillhouse, E.W., Gunning-Schepers, L., & Wong, J.E.L. (2009). Aninternational
association of academic health centres. The Lancet, 374(9699), 1402-1403.
732
FP03.2
LINGUISTIC ETHNOGRAPHY APPROACHES
DISABILITY IN MULTILINGUAL FAMILIES
TO
COMMUNICATION
Deirdre Martin and Jane Stokes

University of Birmingham and University of Greenwich, UK
This paper will present the potential application of concepts developed in the
field of linguistic ethnography to the study of communication disability in
multilingual families. In the field of multilingual language disabilities, linguistic
ethnographic approaches offer the researcher opportunities to observe and record
interactions while remaining cognisant of the cultural and socio-cultural contexts,
including the participant-researcher role. It affords the researcher opportunities for
close observation of special moments with an emphasis not so much on prescriptions
of what to see, as directions along which to look (Blumer 1969).
o.
As speech and language therapists in practice we have felt limited by the
expectations on normative comparisons and the diagnostic focus. By employing
linguistic ethnographic approaches there is greater scope for making sense of the
complex intricacies of situated everyday activity and the systemic communication
activity around the child with communication difficulty. Ochs et al ( 2002) has used
linguistic anthropological approaches in examining autism and her work is
underpinned by the central premise that language acquisition and language
socialisation are integrated. But this perspective is largely unknown to speech and
language therapists who we believe unwittingly are applying aspects of this
approach in their daily practice. Analytical concepts developed in linguistic
anthropology and ethnographies describe relationships evident in language
socialisation but are concepts and terms that are rarely applied in the field of
language disability.
p.
Studies on developmental language disabilities have implications for
communication and quality of living throughout life. A perspective on the relevance
of researching language socialisation can be seen through two claims:
the process of acquiring language is deeply affected by the process of
becoming a competent member of a society;
the process of becoming a competent member of society is realized to a large
extent through language, by acquiring knowledge of its functions, social distribution,
and interpretations in and across socially defined situations, i.e. through the
exchanges of language in particular social situations (Ochs and Schieffelin
1984/2001;264).
q.
These claims are highly relevant for people with language disabilities in light
of increasing evidence on the depressed expectations and quality of life for this
group in childhood and adulthood (eg Markham 2009). Furthermore, those with
multilingual language disabilities and their families are additionally excluded since
733
language disability is an under-researched aspect of sociolinguistics and language in

use.
An anthropological perspective on disability is under-researched and offers
potential for a new and different perspective from that offered by the perspectives of
biomedical and social models of disabilities. It offers insights into what it means to
be disabled within specific cultures, how these meanings are differently negotiated,
and how the experience of being disabled is a complex product of socio-cultural and
biological factors (Klotz 2003; 6).
An anthropological perspective on language
socialisation of children with language disabilities in multilingual families has the
potential to offer insights into different ways of being in the world, which up to
now have not been examined.
r.
Given then that anthropology is the study of culture, linguistic anthropology
is the study of language as a cultural resource and speaking as a cultural practice
(Duranti 2001; 33). According to Duranti:
[l]anguage socialisation is the study of the development of communicative
competence and communities. It looks at the impact of cultural expectations and
social interaction on the development of language as well as at the role of language
in producing competent and productive members of the society (Duranti 2001;32).
Ground-breaking research in language socialisation by Ochs and Schieffelin
(1984/2001) among Malagasy families and communities shows the interrelationship
between cultural practices and language development in interactions between family
members and children. They illustrate how language is an important site for the
processes of socialisation.
the primary concern of caregivers is to ensure that their children are able
to display and understand behaviours appropriate to social situations. Therefore we
must examine the language of caregivers primarily for its socialising functions ,
rather than for only its strict grammatical input function..What a child says, and
how he or she says it, will be influenced by local cultural processes in addition to
biological and social processes that have universal scope. (Ochs and Schieffelin
1984/2001; 263)
Furthermore, language socialisation does not end with the acquisition of
grammatical competence but continues throughout life (Duranti 2001; 259). Parents
of children with language disorders may undergo a process of socialisation into this
identity as their child grows up but research on this area of socialisation is lacking.
Linguistic ethnographic approaches allow us to examine the construction and
blurring of conventional identities those of researcher, professional, bilingual child
are identities that are imposed without reflection or appraisal. Linguistic
ethnography consciously examines the representation of the child and familys
perspectives on language socialisation.
Culture is often interpreted as the nurturing environment within which
language and other aspects of childhood develop. A more pertinent understanding
for our purposes is that culture is the manner in which communication is performed.
That is, culture is produced through historical and social activity which shapes how
734
language is developed and used. From this perspective language development as

language socialisation in multilingual multicultural families requires research
practices that examine languages in use in different cultures. The characteristics of
ethnographic research include a focus on culture where the researcher looks for
patterns in everyday practice, while remaining aware that there are limitations in
representing this.
Ethnographic research examines the interplay between the strange and the
familiar, looking beyond the immediate information presented at the interactions
between different levels of socio cultural organisation. There is an emphasis on the
researcher as participant and the reflections of the researcher are integral to the
produce of the research.
Ethnography aims to help the researchers (the outsiders) to understand
the groups values, culture and social activities and aims to help the group
(the insiders) understand themselves and their way of life better
(Aubrey et al, 2000 p 112)
Personal subjectivity throughout the research process adheres to systematic
field strategies, to accountable, analytic procedures and expects researchers to face
up to the partiality of their interpretations (Hymes [1978] 1996:13). But the
researchers own cultural and interpretive capacities are crucial in making sense of
the complex intricacies of situated everyday activity among the people being studied
(Blommaert 2001:2) and tuning into these takes time and close involvement.
Monolingual researchers work with bilingual colleagues to create bilingual teams to
interpret, reflect on and understand language in use.
Linguistic research tends to isolate and abstract, looking for recurrent
structures and patterns, employing well established descriptions and analyses of
these patterns. Analyses seek to find generalisations and consensus. It benefits from
the use of relatively technical vocabularies, and empirical procedures. It uses a wide
range of well-established procedures for isolating and identifying these structures.
These technical vocabularies can make a valuable contribution to our understanding
of the highly intricate processes involved when people talk, sign, read, write or
otherwise communicate.
Linguistic ethnography offers an approach to examine the traditional
separation between language acquisition and language socialisation. A familiar
criticism of ethnography is that it is too open and of linguistic analysis that it is too
rooted by its established descriptions. One perspective interprets linguistic
ethnography as benefiting from where linguistics ties ethnography down, and
ethnography opens linguistics up (Rampton et al 2004). Developments in applied
conversation analysis and critical discourse analysis offer more potential for
reflexivity and critical perspectives. This research approach affords social and
personal processes that may bring the researcher to the level of understanding where
s/he could start to formulate linguistic rules that are not included in the established
descriptions required by new scenarios of the development of multilingual language
disability.
s.
Expectations of normative comparisons and a diagnostic focus place
constraints on speech and language therapists in practice. In research practice
735
linguistic ethnographic approaches afford greater scope for making sense of the
complex intricacies of situated everyday activity and the systemic communication
activity around the child with communication difficulty. But this perspective is
largely unknown to speech and language therapists who we believe/suggest
unwittingly are applying aspects of this approach in their daily practice. Terms such
as intersubjectivity, indexicality, entextualisation, contextualisation cues, describe
relationships evident in language socialisation but are concepts that are rarely
applied by practitioners in the field of language disability.
Important work has been done by Ochs and her colleagues during the 1990s
on the language socialisation of children with autism, through linguistic
anthropology. (Differences between linguistic ethnography and linguistic
anthropology are not explored here.) An important contribution to anthropological
and ethnographic methodologies is the under-researched childrens perspective of
the process of development of language, knowledge and expertise among
participants, such as families and professionals. She looked at language socialisation
around autism as a troublesome site of cultural language learning. Multilingualism
is included (Kremer-Sadlik, 2005) and further research is invited.
Ochs et al (2002) have used linguistic anthropological approaches in
examining autism and their work is underpinned by the central premise that
language acquisition and language socialisation are integrated. For example, in one
study Ochs and her colleagues identified that in comparison with other sociocultural ways of communicating, Euro-American Child Directed Communication
(CDC) practices may compound rather than minimise the communicative difficulties
associated with severely autistic childrens impairments; that is, they are ill-adapted
for autistic children (Ochs et al 2005).
Language socialization studies are not often associated with learning theories
but some linguistic ethnography studies in classrooms have drawn on Vygotskian
and neo-Vygotskian theories of learning through language mediation (Maybin 2003).
Some have focused on childrens language learning as a way of revealing what and
how children learn curriculum knowledge (e.g. Mercer 2000), while others have
focused on childrens language as a tool in social and emotional learning in
friendships (Maybin 2006). Ochs (2002) also draws on a particular neo-Vygotskian
theory of social group learning, Activity Theory, which she uses to interpret
language development in social contexts. She indicates that the use of language
informs not only the childs psychological and emotional states, it also precipitates a
response (learning) from others. Within the dyad or group identities are coconstructed. Her study demonstrates the co-construction of identities and language
around children with and without autism. Further research could explore the coconstruction of language disabilities in language development in multilingual
families
We argue that a language socialisation approach offers a way of re
conceptualising language disabilities and linguistic ethnography offers research and
practice frameworks for speech and language therapists working with multilingual
populations.
t.
References
736
Aubrey, C., David, T., Godfrey, R. and Thompson, L. (2000) Early Childhood Educational
Research: Issues in methodology and ethics, London Routledge/Falmer Press
Baquedano-Lopez, P. (2001) Creating social identities through Doctrinanarratives, in A.
Duranti (Ed) (2001) Linguistic Anthropology: A Reader,(pp343-358), Oxford:
Blackwell
Benedict, R. (1934) Anthropology and the Abnormal, The Journal of General Psychiatry 10:
59-80
Blommaert J. (2001) Reflections on ethnography; At www.ling-ethnog.org.uk/Leicester 2001
Overseas reflections (cited in UKLEF 2004)
Blumer H (1969) Symbolic interactionism, Berkeley: University of California Press
Duranti, A. (Ed) (2001) Linguistic anthropology: history, ideas and issues, in A. Duranti (Ed)
(2001) Linguistic Anthropology: A Reader,Oxford: Blackwells (pp1-38)
Hymes D (1996) Ethnography, Linguistics, Narrative Inequality, London:Taylor & Francis
Klotz, J. (2003) The Culture Concept:Anthropology, disability studies
and intellectual disability. Paper Presented to Disability Studies andResearch Institute
(DSaRI) Symposium, "Disability at the Cutting Edge: A
colloquium to examine the impact on theory, research and professional practice" University
of Technology, Sydney,12 Sept 2003
Kremer-Sadlik, T. (2005) To be or not to be Bilingual: Autistic Children from Multilingual
Families, in ISB4: Proceedings 4th International Symposium on Bilingualism, eds. J.
Cohen, K.T. McAlister, K. Rolstad, J.
MacSwan pp1225-1234.Somerville, MA: Cascadilla Press.
Markham, C., van Laar, D. Gibbard, D. and Dean, T(2009) Children with speech, language
and communication needs: their perceptions of their quality of life, International
Journal of Language & Communication Disorders 44, 5, 748-768
Maybin, J. (2006) Children's Voices: talk, knowledge and identity, Basingstoke: Palgrave
Maybin, J. (2003) The potential contribution of Linguistic Ethnography to Vygotskian studies
of talk and learning in school. Paper presented at the UKLEF Colloquium at BAAL
Annual Meeting, 4-6 September 2003,University of Leeds: Linguistic Ethnography at
the Interface with Education
Mercer, N. (2000) Words and Minds: how we use language to think together
London : Routledge
Ochs and Schieffelin (1984/2001) Language acquisition and socialisation: three
developmental stories and their implications, in A. Duranti (Ed)(2001) Linguistic
Anthropology: A Reader, Oxford: Blackwells (pp263-301)
Ochs, E. (2002) Becoming a speaker of culture, in C. Kramsch (Ed)Language Acquisition and
Language Socialisation, (pp99-120), London:Continuum
Ochs, E., Solomon,O. and Sterponi, L. (2005) Limitations and transformations of habitus in
Child-Directed Communication, Discourse Studies 7, 4-5, 547-583
Rampton, B., K. Tusting, J. Maybin, R. Barwell, A. Creese and V. Lytra(2004), UK Linguistic
Ethnography: A Discussion Paper. Paper published at www.ling-ethnog.org.uk
737
PHONIATRICS
FP45.4
TREATMENT OF VOCAL FOLD PARALYSIS AFTER THYROIDECTOMY
Natalia Konoiko, Zhanna Romanova
National Theoretical and Practical Otorhinolaryngologic Center
Belarusian Medical Academy of Postgraduate Education
Minsk, Belarus
Key words: thyroidectomy, vocal cord paralysis, rehabilitation
Abstract. Injury of recurrent nerve during thyroid surgery is a dangerous
complication. Even the light hoarseness and dyspnea make difficulties for
communication abilities, result in social disadaptation, sometimes in disability. In a
voice expert it can lead to the professional impropriety or the necessity of changing a
occupation. The article is concerning urgent topicality of this problem - the causes of
nervus laryngeus recurrens injury during surgery. The course of rehabilitation for
the patients with vocal fold paralysis is suggested.
Background. The acute problem of postoperative management of vocal fold
paralysis is connected with the consistently increasing thyroid disease morbidity in
European countries over the last few decades. Moreover, most of thyroid disease
require surgery [1;9].
According to all up-to-date available data, laryngeal nerve injury complicates 3 to
15% thyroid surgeries [1]. It should be noted that lesion of superior laryngeal nerve
branch despite the common view occurs quite often; though, due to poor and
transient clinical symptoms usually remains underdiagnosed [3,4,5].
The likelyhood of vocal fold paralysis after surgery depends on:
the form of thyroid disease;
the extent of surgical intervention;
the number of previous operations.
N.recurrens is the most frequently injured during the operation which is far
dangerous. The nerve originates from vagus nerve, rounds the subclavian artery on
the right, from behind and below, and on the left it rounds the aortic arch, and
ascendes to neck in the space between trachea and esophagus. Its terminal branches
penetrate into inferior constrictor muscle of pharynx and approach the larynx, where
innervate mucous membrane below the fissure of glottis and all the muscles except
the cricothyroid muscle [3,5,7,10].
The terminal branch innervating the larynx is called the inferior laryngeal nerve. The
right nerve compared to the left one is (anatomically) more superficially and
anteriorly [7,10].
Relatively to the thyroid gland the nervus recurrens can be located:
extracapsularly;
adjacent to the capsule of the thyroid gland;
intracapsularly.
All these variantions are normal and individual to every patient, though in
intracapsular location of n.recurrens the frequency of iatrogenic injury is increasing.
738
In many pathologic processes nerve is involved and adheres into the tissue of the
thyroid gland. This becomes possible when, for example, the nerve appears between
growing back and inside nodes of big, fast growing goiter. In such cases even the
most perfect surgical techniques cannot guarantee its safety [1,6,8].
Injury of recurrent nerve during surgery can happen in different ways:
blunt nerve injury;
acute injury transection;
compression by hematoma in early postoperative period;
soft tissues edema in postoperative period.
After thyroid surgery the injury of recurrent nerve can be easily diagnosed, even
without laryngoscopy. A patient has got a vocal dysfunction in the form of voice
hoarseness (dysphonia) and breathlessness (of different extent) [2,4,6,7].
The diagnosis can be confirmed by indirect laryngoscopy. If postoperative vocal fold
paralysis is caused by not a direct trauma but nerve overdistension, rehabilitation
period can last for some months. In the case of the obvious nerve injury during the
surgery, perspectives for complete functional recovery are poor [7,8,9].
In paralysis all three larynx functions protective, phonic and respiratory are
impared. The clinical picture depends on either the paralysis is unilateral or bilateral,
as well as on the level of vocal fold fixation.
In the unilateral paralysis patients experience voice timbre change, voice intensity
derangements, paradoxical breathing, dyspnea which is increasing with speaking or
physical activity, choking by fluids [8,9].
In the bilateral paralysis main symptom becomes dyspnea, the voice is resounding,
as a rule.
Recurrent nerve injury during the thyroid gland surgery is a dangerous
complication; the quality of persons life is getting worse. Even slight hoarseness and
breathlessness make difficulties for communication abilities, result in social
disadaptation, sometimes in disability. In voice expert it can lead to the professional
impropriety or the necessity of changing an occupation [7,8].
Objective: Create a common comprehensive approach in vocal fold paralysis
management including the rehabilitation of vocal function as well as the correction of
larynx respiratory function.
Patients and Methods: 140 patients (2007) and 161 patients (2008) with postoperative
paralysis were included. 34 patients (2007) and 38 patients (2008) were admitted to
the hospital. All patients were suggested to have the course of medical treatment
under the following scheme:
Adjustment of adequate individual substitutive hormonotherapy (by the
endocrinologist);
Drugs which stimulate and reestablish neuromuscular transmission:
Neuromidine 5 mg bid IM or Neuromidine 15 mg once a day IM for 10 days;
then 20 mg bid PO for 3 weeks. The course can be repeated in 1-2 months.
Medications which relieve the psychoemotional stress, anxiety and have a
nootropic effect: Phenibutum 250-500 mg tid for 4-6-weeks
Group B vitamins IM or PO for 1 month
Anti-edematous medications: calcium gluconate 10% - 10 ml IM and ascorbic
acid 5% - 2 ml IM for 10 days
Physiotherapeutic procedure (magnetotherapy on the larynx, magnetic-laser
therapy on the postoperative scar at the neck 8-10 procedures, HIVAMATtherapy).
739
In satisfactory condition of postoperative suture and if it is not

contraindicated, hyperbaric oxygenation in acute postoperative period is
actively prescribed. The course of hyperbaric oxygenation treatment includes
8-10 procedures.
Psychologist and psychotherapeutist consultation and the course of
psychosomatic correction
Speech correction
Neuromuscular electrophonopedic stimulation
Aim of treatment is not only health preservation or resumption but also

rehabilitation of patients personal and social status. Treatment in vocal folds
paralysis should be initiated as soon as possible.
Results: results of therapy are estimated by clinical improvement of voice,
dyspnea and laryngoscopic (laryngostroboscopic) picture. After the treatment all
patients reported voice and breathing improvement. We observe extension of
dynamic sound range, increase of voice intensity, emergence of stamina, tone
stain, full-blown respiration, disappearance of talking dyspnea. Maximum
phonation time (MPT) has been increased from 3-4 seconds to 20 and more
seconds.Vocal folds mobility has been completely reestablished in 27 patients.
Moreover, 18 patients which were ranked to mild disability previously, were
acknowlegded as healthy after the treatment. All the patients with unilateral
paralysis at working age continued to work on their speciality. In case of bilateral
injury of recurrent nerve when dyspnea is increasing we were obliged to use
surgical methods to restore larynx lumen.
Conclusion:
1. Patients with postoperative vocal fold paralysis should have a complete
course of rehabilitation
2. The course of rehabilitation treatment should be started earlier.
3. Multidisciplinar approach should be used, including endocrinologist,
phoniatrist, psychotherapeutist (psychologist), logopedist (phonopedist).
References:
1. Kirasirova E.A., Tarasenkova N.N., Lafutkina N.V. The rehabilitation of
patients with bilateral vocal fold paralysis in aspect of time. Herald of the
otorhinolaryngology 2007; 3: 44-47.
2. Shilenkova V.V., Karelina I. B. Speech and voice disturbances at children,
teenages, adults. Yaroslavl, 2005; 106-107.
3. Krylov B.S., Felberbaum R.A., Ekimova G.M. Physiology of laryngeal
neuromuscular apparatus. L., 1984; 216.
4. Maksimov I. Phoniatrics. M., 1987; 283.
5. Soldatov I.B. A guide to otorhinolaryngology. M.: Medicine, 1997; 608.
6. Romanenko S.G., Tokarev O.P., Vassilenko Y.S. Herald of the
otorhinolaryngology 2001; 3: 52-54.
7. Vassilenko Y.S. Voice. Phoniatric aspects. M., 2002;481.
740
8. Kitsmanyuk Z.D., Balatskaya L.N., Balatskaya S.Y. Medical rehabilitation of

vocal fold paralysis after surgery on thyroid gland. Live issues of theoretical
and clinical oncology 1996; 73.
9. Yagudin R.K., Demenkov V.R., Yagudin K.F. On the issue of larynx state after
the injury of nervus laryngeus recurrens. Herald of the otorhinolaryngology
2008; 6: 59-63.
10. Yamada M.L., Hirano M., Ohkubo H. J Auris Nasus Larynx 1983; 10: Suppl:
1-15.
741
Ss13.3
VOICE QUALITY ASSESSMENT AMONG VOICE PROFESSIONALS
E.V Osipenko, A.V Mesherkin A.V.
Federal centre of ENT of Russia1
Moscow State Humanitarian University named after M.A. Sholokhov2
Nowadays there is a large number of professions connected with considerable
voice load. These are not only singers and teachers as it had considered before.
For today for the objective description of a voice the method
of an estimation of spectral structure of a voice. This is voice acoustic analysis. The
essence
of the given method consists in simultaneous registration of the basic tone and
intensity of a voice on all range on both forte and piano, definition both frequency
and
a
dynamic
range
of a voice, an estimation overtone and formant sound structure.
The purpose of making our model of an acoustic analysis among voice
professionals consists of providing the regular approach in the examination of the
different patients. An attempt will be made to teach attendees how to elicit various
problems with their own voices.
The based thought consists of our obliged considering character of voice load at
the record of a voice and carrying out those or other tests.
The majority of phoniatrician and speech pathologists understand the necessity of
use of the acoustic voice analysis during the medical examination and carry it out.
But are the results of our research always correct?
Carried out in a right way the procedure of voice record is the guarantee of the
correct voice assessment. It allows to carry out the objective comparison of
phonograms recorded at different times. During our seminar we will try to explain
what leads to the wrong voice analysis, to attempt the main positions leading to
incorrect acoustic voice analysis.
We would like to familiarize listeners with our model of a voice recording in
the laboratory of vocal and scenic voice of Federal Research Clinical Centre of
otorhinolaryngology of Russian Federation Ministry of public health.
In our opinion researcher must be a professional at acoustics principles for
carrying out this computer analysis of the voice. Also he has to understand the
specification of voice recording among professionals of the voice, vocalists, people
with different larynx pathologies and people with health glottis. Computer Acoustic
voice analysis allows finding ways of voice disorder correction taking into account
the received acoustic parametres and work specification. lot of examples will be
illustrated by sound samples.
The conclusion: the application of our model of the analysis of the voice allows
to reveal thin changes of the vocal function and then defines the differentiated
methods of the correction of vocal frustrations taking into account the received
acoustic parameters and the features of professional work. It helps to achieve the
steady positive results in the complex rehabilitation of the vocal function.
We have analyzed the indications for the medical treatment and research of
professionals and non-professionals of the voice having voice disorders and also for
healthy.
742
Indication of this method at voice professional users is:

1) Within the limits of prophylactic medical examination
2) At students of vocal branches
a. in the beginning and the end of academic year for ascertaining of
dynamics of training
b. as screening on revealing of formation of a pathology voice
production
3) Computer acoustic analysis of the voice allows to diagnose objectively both
rough and delicate" changes in the voice and carry out the comparative
analysis of these changes during treatment, training
4) Presence of the changes in the voice defined by ear;
5) Presence of complaints of hoarseness, fatigue, a "weak", "high", "low" voice.
These changes are not defined by ear;
6) Preoperative preparation;
7) During the postoperative period, before the beginning
of the rehabilitation stage;
8) In the dynamics during the rehabilitation stage.
Also we have determined the difficulties arising at record:
1) Absence or bad development in investigated ear for music and inability to
repeat the tone set on a piano that tightens research;
2) Nonability phonation more than 3 seconds
at patients with benign tumor, larynx paresis;
3) Restriction of possibility or absolute impossibility
to generate a voice is very silent or loud
a. At serious change of a patients structure vocal fold
in general can have very narrow dynamic range.
4) Presence of the expressed noise in a voice.
And will discuss the characteristics of the voice, definition of the speaking
voice quality and singing voice quality. We have developed the technique of voice
recording and its subsequent computer analysis depending on the professional
group, the algorithm of the definition of the voice type.
The conclusion: the application of our model of the analysis of the voice allows
to reveal thin changes of the vocal function and then defines the differentiated
methods of the correction of vocal frustrations taking into account the received
acoustic parameters and the features of professional work. It helps to achieve the
steady positive results in the complex rehabilitation of the vocal function.
743
P113
INFLUENCE OF REHEARSING NEW VOCAL MATERIAL ON LARYNX
CONDITION
L.B. Rudin
Alexandrovs Academic Ensemble of Song and Dance of the Russian Army
Research and Clinical Center of Otolaryngology at the Russian Federal
Medical and Biological Agency
Russian Public Academy of Voice
Tematic area: phoniatrics.
Voice hygiene is a separate branch of otolaryngology and phoniatrics that
includes the whole spectrum of preventive measures for preserving and
strengthening vocal function. Thus, it is essentially a lifestyle handbook for singers
and actors. However, a few things should be marked out. First, given a highly
intensified voice load for such individuals in the nowadays social environment, a
number of preventive principles become problematic for them to follow. Second, the
reason for neglecting the basic rules in most cases is nothing but ignorance. Third,
many of the principles have not been properly researched. Forth, therapists pay little
attention to the subject when working with patients and they do not facilitate the
spread of the important knowledge. Therefore, there has been an increase in the
number of voice pathology cases.
Rehearsing new material is an integral part of any singers creative life; it can
be anything from separate parties, arias or programs. For a drama actor this means
rehearsing new parts especially with singing involved which is a very common case
in the modern theatre.
The research of the issue was initiated based on observations we made from
our medical practice, directly related to rehearsing. Vocal apparatus pathology often
occurred when the voice load intensity was low and featured refractory course. Our
observations proved a necessity of certain preventive principles when rehearsing
new vocal material. The analysis of available literature on the subject revealed that
the principles of voice hygiene had not been developed. Survey of professional
singers including teachers showed that the issue was either understated or
considered unimportant altogether that resulted in incorrect distribution on voice
load and permanent vocal pathology.
The voice-training per se or learning technical aspects of vocalization allows
for acquiring correct vocalization skills and master resonator singing technique that
is an essential part of singers work and guarantee of a long professional life. This is
the foundation for further singing skills mastering, broadening the repertoire,
reaching new technical heights.
Rehearsing any vocal piece means memorizing numerous muscular
movements necessary to form different pitch intervals, dynamic tones etc. It involves
a complex process of interaction of available vocal stereotypes with new muscle
movements and the singers intellectual and emotional state. This is a process of
developing a certain dynamic stereotype of vocalization consisting from a gradual,
744
finely coordinated chain of muscular movements (reflexes) performed by the vocal

apparatus. In the process of rehearsing and thus a dynamic stereotype development,
metabolic cost is much higher and nervous system experiences a lot of stress. It is
associated with constant self-control and excessive attention a singer pays to the
process that provides the fine coordination in the work of all vocal apparatus
components. This leads to increased fatigability of both larynx and the singer both
physically and emotionally. All this highly increases vocal pathology risk.
Purpose of research: The purpose of the research is to study the influence of
new vocal material rehearsing on larynx condition.
Task of research: Task of the research is to study:
the structure of laryngeal changes when rehearsing new vocal material
a possibility of occurrence of a persistent dysphonia when rehearsing new
vocal repertoire
a degree of laryngeal changes depending on the complexity and volume of
rehearsed vocal material.
From 2003 to 2010 we observed 60 patients. 18 of them were students at the
Faculty of Music Theatre at Russian Academy of Theatre Arts, 15 were soloists at the
Gelikon-Opera Moscow music theatre, 27 were soloists at Evgeny Kolobovs New
Opera Moscow music theatre. During the 7 years those singers picked up and
rehearsed new material 135 times which means 1 to 3 occasions per each of them.
The rehearsing included taking up new opera parts, new vocal programs (3 songs
and more), and separate vocal pieces (up to 2). In all cases they kept their regular
voice load. For example, the students still had singing classes with old repertoire
and prepared to test concerts, and rehearsed in the student theatre. The opera
singers continued to perform in regular performances and concerts, had training
classes with teachers and concertmaster, self-study sessions etc.
Their complaints were of a similar type and came to singing discomfort,
especially during high pitch singing, tunelessness of voice tonality and occasional
harsh feel in the larynx. Often their general condition was also affected: they
experienced weakness, melancholy, sleeping disorders.
It is very important to mention that the singers very seldom linked the change
in their condition with rehearsing new vocal material. As a rule, such working
situation is considered quite normal therefore, when answering a question about the
current voice load, they most often said as usual. Rehearing new material was
acknowledged only if they were asked about it specifically despite that in several
cases it took an extreme form (a few hours of work during the day, a concert or a
performance in the evening, more rehearsing at home or in the theatre the next day).
The patients complaints were proportioned in the following way.
Per 67 episodes of rehearsing a new opera piece there were acute complaints
made in 54 cases (80,6% 4,8%). Per 38 episodes of rehearsing new vocal programs
(from 4 to 6 pieces) there were complaints made in 24 cases (63% 7,8%). Per 30
episodes of rehearsing new separate vocal pieces (from 1 to 3) there were complaints
made in 15 cases (50% 5,5%). The rehearsed pieces were both technically and
semantically complex. In cases when no complaints were made, the rehearsed pieces
were reported as relatively simple.
Differences between the first and the second, the first and the third, the
second and the third groups proved to be reliable ( < 0,05), which manifests a
dependency between pathological changes in the larynx (and subsequent
complaints) with the volume of rehearsed vocal material and its complexity.
745
Singers with corresponding rehearsal episodes were divided into two groups
by complaint/no complaint factor.
In the group where complaints were made during rehearsing, the following
pathological laryngeal changes were found in 100% cases (93 episodes): in 36 cases
(38,7%) rehearsing resulted in hypotonic dysphonia, in 28 cases (30,1%) in
hypotonic disphonia combined with soft nodules, in 15 cases (16,1%) in hypotonic
dysphonia combined with marginal chorditis, in 9 cases (9,7%) in acute laryngitis,
in 4 cases (4,3%) to vasomotor monochorditis, in one case vasomotor monochorditis
was combined with marginal chorditis (1,1%).
In the second group (42 rehearsing episodes with no complaints made) the
larynx condition was nevertheless not ideal in 34 cases (81%): we observed rounding
of the free edge of the vocal folds, accumulation of mucus in nodular zones during
vocalization, slight injectedness of the zones, formation of a mucus bridge,
stroboscopic vibratory cycle with minimal changes. It should be noted that during
the episodes relatively short and simple opera pieces or other vocal material were
rehearsed.
Thus, per 135 rehearsing episodes combined with regular voice load
laryngeal changes were found in 94% 2% cases.
We compared the receive data with two test groups.
The first test group consisted of 20 student singers with 20 rehearsing
episodes with no additional voice load. All of them were rehearsing a graduate
program that consisted from 6 pieces different in the form, style and content. They
were allowed to pick up 2-3 old pieces, while the rest had to be new. Thus, the test
group worked on 3-4 new vocal pieces from the beginning of the academic year.
12 people made acute complaints on an increased voice fatigue, laryngeal
discomfort, and sometimes straining feelings in the neck. In 10 cases an objective
examination revealed a hypotonic dysphonia, in 3 cases a hypotonic dysphonia
combined with soft nodules, in 1 case an acute laryngitis. The other 8 people had
no complaints at all. Laryngeal changes were observed in 6 of them. The changes
were represented with injectedness, sponginess, vocal folds tonus depression,
accumulation of mucus in nodular zones, and sometimes roughness of the vocal
folds edge.
Thus, in this particular test group, laryngoscopy revealed changes in 90%
6,7% of cases: hypotonic dysphonia was found in 13 patients (75%), hypotonic
dysphonia with soft nodules in 4 patients (20%), acute laryngitis in 1 patient (5%).
There were no differences between the observed and the fist test groups. ( >
0,05).
These observations were made in the very beginning of rehearsing new
material during 2 to 4 months. Each illness episode lasted from 5 to 10 days under
condition of voice rest and medicated treatment. Then reactive laryngeal changes
became increasingly less frequent, less intense and less persistent. In patients with
no complaints there were no laryngeal changes observed and the recurring
pathology resulted from neglecting hygienic rules like singing during a viral
infection, overload with additional work etc.
Second test group consisted from 10 soloists of the Gelikon-Opera Moscow
music theatre who were observed during rehearsing a familiar leading piece in an
upcoming performance without additional rehearsing of new vocal material. The
condition of no additional voice load during the rehearsal period was also met (or
the load added was so insignificant that it could be neglectd). Every soloist was
observed during the period of rehearsing of two different pieces with different time
746
interval which comprises to 20 observations. Under the given conditions the only
laryngeal changes were those that correspond to a natural reaction to voice load.
Differences between the observed group and second test group are reliable (
< 0,05).
The differences between two test groups are also reliable ( < 0,05).
Thus, the given information leads to a conclusion that rehearsing new vocal
material contributes considerably to both functional and statical laryngeal pathology
and additional voice load increases the level of statical changes.
Under a standard treatment, hypotonic dysphonia remained for up to 10-14
days and soft nodules for up to 14-30 days which is approximately 5 to 15 days
more than standard treatment duration for such disorders. Changes in vocal folds in
a form of sponginess with accumulation of mucus during vocalization remained for
up to one month.
Finding out the factors of rehearsing new vocal material has a fundamental
meaning for a correct diagnosis making and determining further treatment. In our
practice we often come across situations when patients with asthenic conditions were
sent by otolaryngologists and voice therapists to neurologist as those specialists did
not find out the true reason for their condition. Certainly, neurological treatment is
advisable, but only after the true reason for the singers condition is defined. On one
hand, such situations show inadequacy of diagnostics by voice therapists, on the
other hand, they record nonspecific changes in the central and peripheral nervous
systems as a result of the developed fatigue. It is the fatigue that forms the basis for
the pathogenetic mechanism described above, but its adequate elimination is
possible only through the voice load optimization. A singers condition improved
quickly after they were explained the reasons for their condition and balance their
work-rest routine.
Conclusion:
Rehearsing new vocal material produce a considerable influence on laryngeal
condition and requires following certain preventive measures aimed at optimization
of the work-rest routine in the period of rehearsing.
Laryngeal changes occurring in response to rehearsing new vocal material
are nonspecific.
Vocal load additional to rehearsing new material increases the level of statical
changes in larynx.
The intensity of laryngeal changes specifically depends on the volume and
complexity of the rehearsed vocal material.
Laryngeal changes occurred during rehearsing new vocal material are more
persistent and their elimination, as compared with elimination of the same pathology
developed under different circumstances, requires 5-10 days.
747
VOICE
P124
HIGH LEVELS OF NOISE IN CHILDREN EDUCATION INSTITUTIONS
AND ITS IMPACT ON THE EDUCATORS VOICE
M. L. Bitar1, M. Simes Zenari1, K. Nemr1
1Department of Physiotherapy, Communication Science and Disorders, Occupational
Therapy, University of So Paulo Medical School, Brazil
Key-Words: occupational noise, effects of noise, voice disorders
INTRODUCTION
The teachers voice has been the focus of several surveys that search to
prevent or to minimize occupational risks. Aspects concerning the institutions
physical environment, related to the lack of preparation on teachers part for the
adequate use of voice, have stand out as facts that may favor the occurrence and
maintenance of voice disorders. Voice problems on teachers generate difficulties on
the professional exercise and, on most of cases, a negative impact on these persons
quality of life. Environment noise is detached as an important factor to be
considered.
OBJECTIVE
The purpose of this paper was analyzing the relation between the
environmental noise measurement at the children education centers and aspects of
the educators vocal evaluation on these very centers.
METHOD
This transversal observational paper was accomplished at three children
education centers associated with the Mayor Hall of a Brazilian city, managed by a
same social institution and the Crche Program of Speech Therapy Investigation
Laboratory on Health Promotion assists them.
At first, it was done a measurement of noise levels at all the spaces on which
children and educators do their daily routine activities, that is to say, classrooms,
cafeterias, ateliers, parks and courtyards. For so, it was used a decibelmeter of Center
trademark, model 322, following norms established by the Brazilian association that
rules technical norms (ABNT). There were considered minimal, medium and
maximum values of the different spaces and the medias were classified according to
what was commended by World Health Organization for comfort, discomfort and
auditory injury: up to 50 dB=comfort limit; from 50 to 54dB=discomfort 1, the
organism starts feeling the impact; 55 to 65dB=discomfort 2, the person remains in a
constant alert state, he/she doesnt relax; 66 to 70dB=injury 1, the organism reacts,
undermining its defenses; above 70 dB=injury 2, the organism is liable to
degenerative stress, with possible shock to mental health. After the noise
measurement at every space described it was done a voice assessment of all the
748
educators from the three institutions: a vocal self-assessment, a perceptive-auditory

assessment and an acoustics of voice one.
For the vocal self-assessment it was used a visual analogical scale with 10 cm
(3.9 in.) of length, where 0 (zero) represented lack of vocal alteration and 10 the
maximum vocal alteration. The educators should mark with a trace which local on
this scale would have the power to represent how was her voice on the last days.
From the numbers obtained it was done a self-assessment classification on: voice
without alteration (zero), voice with a light alteration (values among 0,1 and 3,4),
voice with a moderate alteration (values among 3,5 and 6,7) and voice with a severe
alteration (values among 6,8 and 10). After that, it was done an individual recording
of speech samples sustained emission of vowel /a/ and numbers counting from 1
to 10. This recording took place at the very institutions, in more distant rooms, and it
was used the PRAAT acoustic analysis program and a professional microphone of
AKG trademark. The PRAAT program was previously installed and tested, and the
rooms were quite noiseless at the recordings moment. With this sample, later on, it
was possible doing the perceptive-auditory assessment of the educators vocal
quality, making use of GRBASI scale. This evaluation was done by a sole speech
therapist, expert on voice and with a large experience on this kind of procedure.
Based on this evaluation the educators were divided into two groups: educators with
an adequate voice, when the G of GRBASI scale was equal to 0 (zero) and educators
with modified voice when the G of GRBASI scale was different from 0 (zero). For the
analysis of data concerning this scale, it wasnt possible considering the alteration
grade in view of the reduced number of sample subjects. Consequently, this
classification was used only on the descriptive analysis.
The acoustics analysis was also done with the PRAAT acoustics analysis
program, making use of each participants sustained emission, from which it was
removed the initial and final portion, as they were more irregular. There were
extracted the automatic measurements of interest for this paper: fundamental
frequency, jitter, shimmer and harmonic-noise proportion. It was done, yet, a
qualitative analysis of the spectrographic tracing of the same emission, considering:
tracing global characteristic, the harmonics visibility, presence of noise among
harmonics, harmonics replacement for noise, graphic regularity, presence of the
harmonics interruptions and bifurcations and definition (on which were considered
two variables as a whole: number of harmonics and frequency up to where
harmonics are defined). Afterwards, it was done a classification of these values in
adequate or altered, according to reference data from literature.
For data analysis it was used the statistic program SPSS. All the findings were
analyzed by means of descriptive statistic and from the application of Friedman nonparametric test and Shi-Square test. Due to the reduced size of the sample, 10% was
considered a significance level.
RESULTS
All the 27 educators from the three institutions participated on the work. Their ages
varied between 21 and 56 years, with analysis average of 30 years.
The general average of environmental noise on the different spaces of the
three institutions was 72,7dB, considered level 2 injury. The average of minimal
values was 56,1 dB, or, level 2 discomfort; and the average of maximum values 94,1
dB, level 2 injury. It was not possible analyzing separately data concerning noise
obtained at the three institutions due to the reduced size of the sample.
The educators self-vocal assessment exhibited an analysis average of 5,1 on
the visual analogic scale, representing a moderate alteration.
749
On the vocal perceptive-auditory evaluation, only 26% of the educators were

considered having an adequate voice and 74% presented vocal alteration. Hoarseness
was the main modified aspect, followed of breathiness. Most of them (52%) were
considered with altered voice in light degree and 6 (22%) altered voice in moderate
degree. In spite of not being foreseen at first, during the contact with the educators,
the orofacial motricity alterations presence has attracted the evaluator attention,
who, on her turn, registered these observations. More than half of the educators have
presented an alteration of this kind, with oral breathing and open bite standing out
among them.
On the acoustics assessment most the professionals have presented F0 below
the expected one, being the general average of 197,7 Hz. The averages of jitter,
shimmer and harmonic-noise proportion were also altered, as well as the
spectrographic tracing. It was observed the presence of noise among the harmonics,
irregularity and interruptions on the tracing of most of the voices, as well as
alteration on the harmonics definition, with a reduced number of harmonics and a
low frequency till the point on which the harmonics are defined.
When observing all the aspects related to the presence of vocal alteration, it
was verified an association between adequate spectrographic tracing and adequate
voice and presence of noise among harmonics and altered voice. The noise levels and
all the other variables have not presented association with dysphonia.
DISCUSSION
The main finding on this work refers to the high noise levels observed, what
configures the presence of environments of risk for professionals and children in
several aspects, and that this should be modified. Various current papers corroborate
the relation between high noise and alterations on peoples health. The interference
of this noise on these children teaching and learning process should be substantially
considered and followed by actions designed for modifications on this aspect. These
data are already being discussed next to the institutions, with the aim of defining
jointly actions for improving these conditions.
Besides, it is necessary considering the constant situations of sonorous
competition provoked by noise, that lead to the difficulty on the use of voice mainly
on the educators part, who would require average vocal intensities around 90 dB in
order to supplant in 15 dB the relation signal/noise of the observed spaces.
Most the educators, on their turn, present altered voice, though in a great part
it is in a light degree. It is known that these professionals are not previously prepared
for the adequate vocal use of voice at work and that they consider presenting vocal
alterations as part of the teaching career. Added to this, were observed several
myofunctional oral alterations on most of the participant educators, what comes to
make even more difficult the adequate projection vocal during the professional vocal
use. This lack of projection can be clearly observed on the acoustics analysis, which
indicated most of the voices without brightness and without projection, with few
resources for the daily professional vocal task they have. Probably this sensation of
not projecting well the voice is an important factor considered on the educators
vocal self-perception, leading them to judge voice as worse that it is on reality. On
this work it was observed that the majority of them regards their voice with
moderate alteration, when, in fact, most of them has the vocal quality with light
alteration. This shows that the light vocal alterations cant be disregarded when it is a
matter of professional voice, since they can be related to important difficulties and
have a negative impact.
750
Data found on this work reinforce the results of other researchers who have
indicated the necessity of multisectorial measures for the adequate use of voice on
the work place on the educators part. Measures concerning the reduction and
control of the noise levels, the adjustment of the educators oral myofunctional
conditions and work aiming improving the vocal behavior and quality of voice are
being discussed next to the institutions.
CONCLUSION
Noise levels observed on the three analyzed institutions are beyond the limits
considered comfortable by World Health Organization, what urges the necessity of
effective actions on a short-term. Most of the educators from these institutions
presented altered voice in a light degree, but on the evaluation it was found that they
presented moderate altered voice, what should be considered. Their voices presented
with a few resources for the vocal projection required in their daily work. Besides, it
is necessary considering the oral myofunctional alterations found.
751
P055
The person with dysphonia: comparative analysis pre and post
voice therapy program
Ira Bittante de Oliveira
Pontifcia Universidade Catlica de Campinas
Introduction
Dysphonias may be didactically classified in two categories: primary, due to
incorrect use of voice, lack of voice knowledge or a vocal deficient model; and
secondary due to not vocal adaptation, anatomical or functional (Behlau, 2009).
The main purpose of a speech therapist, when facing a voice disorder,
is to identify its nature, defining goals and techniques to solve that problem. There
are a great number of procedures to be chosen and vocal therapy programs based on
cognitive conceptions that might provide better understanding of the optimal
communication standards.
The objective of this study is to evaluate the efficacy of one voice
therapy program based in cognitive conceptions, idealized for adults with functional
voice disorders, stablishing results comparisons through different assessment
instruments between pre and post- therapy.
Materials and Methods

Took part in this study ten adults, one male and nine females, aged
from 26 to 74 years old, that were on a waiting list for vocal treatment at one
university school-clinic from Campinas city, Brazil. They had been referred by
otolaryngologists and their laryngeal examinations indicated that five patients
presented vocal fold nodules, three presented functional dysphonia (glottal chink)
and two with indication of differential diagnosis of small cyst with contralateral
nodule reaction on the opposed vocal fold or vocal fold nodules. The subjects were
separated in two groups equally and submitted to eight voice therapy sessions; after
a voice evaluation session. Therefore, the study was comprised by three stages: pretherapy evaluation, therapeutic program development and post-therapy evaluation.
Group A was underwent to a cognitive voice therapy program and group B received
traditional voice therapy. Group A received a voice therapy program consisting in:
instructions directed followed by logical explanations about the adverse effects of an
effective standard of communication (Behlau, 2001), addressing the physiological
aspects of voice production, all necessary information for better understanding of
ideal standards of communication as respiratory training, orientation of correct body
posture, auditory training of different types of voice, visual support for better
understanding of the voice therapy steps (such as DVD, pictures and illustrative
handouts). They also received a CD for voice training at home (resonance and vocal
fold vibration exercises, accompanied by explanations from the therapist). Group B
received, as already explained, traditional voice therapy consisting in: respiratory
752
training, orientation of proper posture when speaking, vocal health habits, vocal fold
vibration, and resonance and articulation exercises.
To compare the results of the program, a set of assessment measures
were applied, in the beginning and at the end of the voice therapy sessions, that was
composed by: vocal and laryngopharyngeal symptoms prevalence protocol,
auditory-perceptive analysis (using adapted GRBAS scale), acoustic analysis
(VOXMETRIA software CTS Program), otolaryngology evaluation, quality of life
and voice protocols, Voice-Related Quality of Life VR-QOL, Voice Activity and
Participation Profile (VAPP) and Voice Handicap Index (VHI). For the auditoryperceptive analysis samples of the subjects voices were collected pre and post
treatment (sustained vowels /a/, /i/ e /u/, counting numbers 20 to 0, and speaking
months of the year). Such samples were numerically organized and randomly
distributed and reproduced in a CD numerically controlled and presented to three
speech pathologists judges that were not informed before the analysis whether the
subjects sample was pre or post-therapy.
Results
Both groups showed improvement rates in all the evaluated aspects,
when pre and post voice therapy moments were compared. No relevant differences
were detected between the groups referring to the vocal symptoms prevalence
results (both groups had decreased vocal symptoms), and measures of life quality in
voice. The otolaryngology evaluation demonstrated improvement for both groups,
with no difference between them, showing normal results for the majority of the
participants (eight people) and at least significant improvement for the others,
regarding the previous exam. The auditory perceptive analysis showed, however,
better results for group A, regarding the global classification of voice deviation
classified by: normal, light, moderate and intense levels, which can be seen below.
Fig.1. Auditory- Perceptive Analysis: Global Classification of Voice Deviation

at the Pre and Post Therapy Moments
753
The acoustic analysis showed better results in spectrographic analysis,

values of jitter, shimmer and irregularity in favor of the group A that received
cognitive therapy. The acoustic analysis showed normal diagram of phonatory
deviation for all subjects in group A, at the post therapy moment, as shown below.
Fig.2. Acoustic Analysis: Diagram of Phonatory Deviation Indicating

Normality for all Subjects in Group A
754
Discussion
The voice therapy program based on cognitive conceptions, had had as its
goal the education of participants (Berhman, 2005; Behlau et al 2005;
Gomes,Schrochio, 2001) including different resources in order to facilitate the
comprehension of the subjects on a effective standard of communication (Behlau,
2005).
The voice therapy resulted in positive effects for both groups, no differences
were found concerning the reduction of vocal symptoms and laryngopharyngeal
sensations, laryngeal examinations results and results of life quality in voice
protocols.
Despite the small sample it is important to consider the fact that the
subjects of the Group A showed better results at the moment post-therapy in
auditory perceptive analysis and acoustic analysis, especially concerning the
indexes of the voice irregularity, diagram of phonatory deviation and
spectrographic analysis that showed better results regarding harmonics and
regularity.
Possibly the audio visual resources of the cognitive voice therapy program,
especially the CD containing templates for vocal exercises at home, have
facilitated the comprehension and performance of subjects in group A. Future
studies are suggested to verify these results.
Conclusion
The voice therapy showed itself effective for both groups, without
distinction regarding the applied program. The therapy program based on
cognitive conceptions may seem to have helped the subjects to improve their voice
harmonics, in frequency as in quality.
Acknowledgment
The author wish to thank Dr Maria Beatriz N. Pascoal, Dr Jos Francisco S.
Chagas e Dr Flvio A. Sakae for the laryngeal examinations
References
Behlau, M.; Madazio G; Feij D.; Azevedo, R.; Gielow,I; Rehder, MI.
Aperfeioamento Vocal e Tratamento Fonoaudiolgico das Disfonias. In
Behlau, M (org). Voz, O livro do especialista Volume II, So Paulo, Revinter,
2005, p.409 - 519.
Behlau, M. Tcnicas Vocais. In Fernandes FDM; Mendes BCA; Navas, ALPG. Tratado
de Fonoaudiologia, So Paulo, Roca, 2009 p.734-745, 2ed.
Berhman, A. Common Practices of Voice Therapists in the Evaluation of Patients,
Journal of Voice, Vol.19, No 3, 2005, pp 454-469.
Gomes,MJC; Scrochio, EF. Terapia da Gagueira em Grupo: experincia a partir de
um grupo de apoio ao gago. Rev. Bras. Ter Compor Cogn. Vol.3,N2, 2001.
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756
P051
CHOIR SINGING IMPROVES DEPRESSIVE SYMPTOMS AND VOCAL
QUALITY IN THE ELDERLY
Cassol M.1, Bs A. J. G.2
1 Federal
University of Heath Sciences of Porto Alegre - Brazil

Catholic University of Rio Grande do Sul Brazil
2 Pontifical
Introduction and aims of the study: The objective of this research is therefore
to observe the relationship between choir singing and the possible changes in vocal
quality and in the prevalence of depressive symptoms in healthy elders. The
depression disturbance displays characteristic phonoarticulatory changes, such as
low, clear or breathy voice, sometimes hoarse with vocal fry; limited pitch range;
unvaried, downward intonation; hypophonia; lack of volume and strength; slow,
halting and hesitant speed; slow speech; little expressiveness1. Larynx changes,
associated with the normal aging process - presbyphonia -, have been mentioned by
several authors, who describe the changes that occur as the laryngeal musculature
ages. An individual with trained voice, who knows and follows proper vocal hygiene
guidelines, may show presbyphonia characteristics in a more subtle way, which will
not significantly interfere in voice activities2. Choir activities involve not only
learning to sing, which improves vocal quality, but also the development of new
social relations within that context3.
Methods: The study was carried out at the Catholic University of Rio Grande
do Sul (PUCRS), Brazil, between 2001 and 2002. Elderly people, 60 years old or over,
who volunteered for the Its Never Too Late to Start Singing project, were invited
to take part in this study. The project comprised 2-hour weekly choir rehearsals. The
meetings, organized by an experienced conductor, consisted of relaxing exercises,
posture guidelines, vocal technique, social reintegration, and self-esteem and
motivation retrieving. The beginning of this study coincided with the beginning of
the choir activities, but they were not linked. All members of the choir were assured
that no harm to the choir participation would result from not taking part in the
study. All members of the choir, participating or not in the study, received the same
vocal training. Participants with presence of previous neurological diseases, such as
Parkinsons disease or previous stroke or had a history of brain or neck surgery were
excluded from the study. Data from Individuals who later withdraw from the study
or the choir activity were not analyzed. The individuals were not questioned about
psychological or psychiatric treatments, or the use of antidepressant medication.
They were observed for two years with a three-month vacation intermission.
Depressive symptoms were evaluated through the Yesavage geriatric scale for
depression, which consists of 15 questions with simple answers (yes/no). Each
depressive answer is graded 1 point. Individuals with 10 or more depressing
answers are considered very depressive, while between 5 and 10 they are considered
mild depressive, or bearers of a mild depression . The depression scale was applied
in four evaluations: the first evaluation took place before the beginning of the choir
activity; the second evaluation, 8 months later; the third evaluation, after a 3-month
vacation period; and the fourth evaluation, after 21 months of choir singing. The data
used to evaluate the perceptive-auditory performance of the voice resulted from the
757
voicing of vowels [a], [e], [i], [u]. Then, the subject was asked to count from one to
twenty and sing Happy Birthday to you. The auditory data were evaluated by a
group of five speech specialists. The voices were randomly presented and the
assessment of each voice was individually made. Voice samples were later evaluated
as to the presence and intensity of roughness, hoarseness and breathiness. To
compare the changes in voice problems during the study, a scale of vocal quality was
created, where each problem evaluated was assigned scores from zero (normal) to
three (severe). Thus, the vocal quality scale ranges from zero (no changes) to nine
(severe roughness, severe hoarseness and severe breathiness). In this assessment,
lower the grade means better vocal quality. The averages of the number of
depressive symptoms and of the results from the vocal quality scale were calculated
in each step of the evaluation. An Analysis of Variance (ANOVA) of double factor
was used to test statistical differences among the averages of the four evaluations,
adjusting for individual variation. When the comparison of the groups resulted in a
significant ANOVA (p<0.05), the results of the second, third and fourth evaluations
were compared with the ones of the first through the Students t test for paired
samples. Likewise, a value of p<0.05 was considered significant.As noted above, a
scale of vocal quality was calculated from the presence and intensity of hoarseness,
roughness, and breathiness. To observe whether improvements in this scale or in
each factor were associated with improvements in the depression scale, correlation
rates were estimated. Specifically, Pearson correlation was calculated between
improvement in depression and each of the following: improvement in the vocal
quality scale, improvement in hoarseness, improvement in roughness and
improvement in breathiness. Improvements were measured between the beginning
of the program and eight weeks afterwards, between eight and 12 weeks from the
beginning and between 12 and 21 weeks. Improvements were coded as +1 for
positive improvements, -1 for negative changes and 0 for no changes.Following the
statistical analysis, a qualitative analysis of the behavior changes observed through
the answers given to depression questions, we tried to understand the effect of choir
singing over these symptoms.
Results: At initial evaluation the mean number of depressive symptoms was
2.57 ( 3.216) and a vocal quality scale was 2.18 (1.529). The second evaluation, at
eight months of activity, the mean number of depressive symptoms was 1.30 (
1.983) and the vocal quality was 1.61 ( 1.125). The third evaluation was done after a
three-month vacation of the choir, with 1.05 ( 1.120) depressive symptoms and the
vocal quality 1.59 (1.148). Finally, the last evaluation took place after 21 months of
choir singing with 1.48 ( 1.577) depressive symptoms and a mean vocal quality of
1.11 ( 0.689). The ANOVA was significant for the distribution of the depressive
symptoms among the four assessments (p<0.001). The average depressive symptoms
at initial evaluation was significantly higher in than each other evaluation when
tested by paired Students t tests (p<0.05). There was no significant difference on
mean depressive symptoms between the second and third evaluations, or between
the latter and the fourth evaluation. At the initial evaluation, two elders (4.5%)
scored 10 or more points in this scale (severed depressed level); seven (16%) scored
between 5 and 9 (mild depressed level), adding up to nine people (21%) suffering
from depression disorders. At the end of the study, no participant scored 10 or over
points, and five people (11%) had mild depression. Figure 1 also shows a gradual
and significant (ANOVA p<0.01) improvement in vocal quality in connection with
choir singing. Scores for vocal quality at first evaluation were significantly higher
than each of the other evaluations when tested by paired Students t tests (p<0.01).
The paired Students t test was significant in the comparison between the second and
758
the last (p<0.01), but not the third evaluation, which was significant higher than the
last evaluation (p<0.001). Among vocal parameters only hoarseness was significantly
correlated with depression (r = 0.29, p<0.05). Notice that, given the methodology of
this study, it is not possible to specify whether improvements in hoarseness caused
the improvement in depression, or whether the causation runs the other way around.
Since the other correlation coefficients were not significant, they are not being
presented here. In the initial evaluation, 86% of the elderly stated they were satisfied
with their lives. As the evaluations progressed, the rate gradually increased until the
end of the study when all participants seemed to be satisfied with their lives. An
important initial decrease in the number of elderly who had given up activities and
interests was observed, with a mild increase as the study progressed. Also observed
was an important initial decrease in the number of elders who felt their lives were
empty, showing little variance later. The complaint about often feeling upset,
reported by 18% of the elders, displayed a decline during their choir practice, then an
increase after the vacation follow a decline after 21 months. The number of elders
who were lively most of the time increased at the beginning of the activities and
remained the same throughout the study. It was possible to observe that the choir
singing had a positive effect on their feeling that something bad might happen to
them, since in the beginning of activities, 24% of the elders were afraid something
bad might happen to them, and in the final evaluation, only 19% experienced that
fear.In regards to happiness, in the beginning of the choir singing activities, 90% of
the elders said they were happy most of the time, and this feeling remained the same
until the final evaluation. The number of elders who felt deserted came down to a
half after eight months of choir singing. In the initial evaluation, 24% mentioned this
feeling. In the final evaluation, only 14% felt deserted. When asked if they preferred
to stay home instead of going out and doing new things, 35% of the elders answered
yes. In the final evaluations (third and fourth), only 12% said they would rather stay
home than go out and do something new. As to memory problems, 31% complained
about having more memory problems than others have before joining the choir
singing, and after the fourth, at the end, 17% had this complaint. The elders were
questioned about their desire to be alive now. In the first as well as in the second
evaluation, 94% answered yes. In the third and fourth evaluations, 100% said they
were happy to be alive now. The study showed that the elders embarrassment
decreased as evaluations progressed. In the beginning of the activities, 6% were
ashamed of who they were. During the final evaluations, this number was cut down
to 2%. In the beginning of the activities, 78% said they were full of energy, and at the
end, 98% gave an affirmative answer. In regards to hope, the study showed that in
the beginning as well as after 8 months of choir singing, 6% felt helpless. However,
during the fourth evaluation, the number of elders who felt helpless increased to 7%.
When questioned whether they thought most people had better lives than theirs, 14%
answered yes in the beginning of the activities. During the final evaluations - third
and fourth -, no elderly thought most people had better lives. In relation to all
depressive symptoms evaluated by the Yesavage scale, had an initial improvement,
but after the vacation hiatus, some individuals started to experience depressive
symptoms again.
Conclusion: In the shadow of the weakness of this study, by been a nonexperimental using non-depressive subjects, the results corroborate our hypothesis
that choir singing would improve depressive symptoms, the study showed a gradual
reduction of the symptoms initially detected during the choir singing activities. The
elders began to enjoy their lives better, experiencing a decline in boredom, fears over
the future, feelings of desertion and helplessness, embarrassment and inferiority.
759
They said they felt more lively, full of energy and happy with their lives, and made
their activities and interests a priority. There was also an improvement in their
physical and mental health in regards to memory. Also observed was a gradual
improvement in their vocal quality in connection with choir singing, which reduced
alterations caused by voice aging. This improvement; however, had no direct
connection with the improvement of depressive symptoms. Therefore, one can
assume that choir singing is not just about learning how to sing, but also about
developing new social relations within the context of that activity. Music can
develop, improve and reestablish social relations. So, music can be used to treat
emotional problems associated with affective relations, helping solve conflicts and
being responsible for behavior changes. A case-control study with depressive
participants can easily confirm these hypotheses.
References
1.KUNY, S. & STASSEN, H.H. (1993). Speaking behavior and voice sound characteristics in
depressive patients during recovery. J Psychiat. Rev., 27(3)289-307.
2.Brown WS Jr, Morris RJ, Hicks DM, Howell E. Phonational profiles of female professional
singers and nonsingers. J Voice. 1993 Sep;7(3):219-26.
3. BRUSCIA, K. E. Defining music therapy. Rio de Janeiro: Enelivros. 2000
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P052
STUDY ON COMMUNICATION AND PSYCHOLOGICAL CHARACTERISTICS
IN A GROUP OF INDIVIDUALS WITH OBSESSIVE-COMPULSIVE DISORDER
Cassol M.1, Reppold C.2,Ferro Y.3,Almada C.4, Gurgel L.5
1Federal
University of Heath Sciences of Porto Alegre - Brazil

University of Heath Sciences of Porto Alegre Brazil
3 Methodist University of Porto Alegre Brazil
4 Federal University of Heath Sciences of Porto Alegre - Brazil
5Federal University of Heath Sciences of Porto Alegre - Brazil
2Federal
Introduction and aims of the study: Assess the auditory and acoustic aspects
of the voice of individuals with Obsessive-Compulsive Disorder (OCD) and analyze
the psychological aspects involved in the voice questions assessed, characterizing the
voice self-assessment. The voice is one of the main links in human relationship, and
is an integral part of an individuals body and personality. Though the voice, one
displays emotions, sensations and intentions. According to authors, the voice is
responsible for most of the information broadcast by message, revealing ones
personal characteristics1. The vocal self-image is part of the vocal psychodynamics
assessment, which has the individual get acquainted with the elements of ones vocal
quality2. The phonoaudiological assessment of the voice involves the perceptive
auditory assessment and the computerized acoustic analysis3. The perceptive
auditory assessment describes the way an individual uses the voice and determines
the laryngeal vocal capacity and the characteristics of the vocal tract and its
articulators. This method is the only way to determine the acceptability of a certain
voice in its environment4. The acoustic analysis consists of collecting and quantifying
the vocal sign through objective tools. This assessment provides indirect
measurements of the vibratory pattern of the vocal folds, the vocal tract adjustments
and its changes through time5. OCD is a mental disturbance that the Diagnostic and
Statistical Manual of Mental Disorders of the American Psychiatric Association
(DSM-IV)6 describes as an anxiety disorder. It manifests itself in changes in behavior
(rituals or compulsions, repetitions, avoidance), in thinking (obsessions such as
doubts, excessive worrying), and in emotions (fear, discomfort, affliction, guilt,
depression). Its main characteristic is the presence of obsessions (thoughts, images or
impulses that take over the mind, and are followed by anxiety or discomfort), and
compulsions or rituals (voluntary and repeated behavior or mental activity in which
an individual engages in order to reduce the affliction that comes with obsessions.
Among the most common obsessions are the excessive concern about neatness
(followed by repeated cleaning - compulsion), or even doubt-obsessions (followed by
constant checkings - compulsion)7.The direct interference of compulsive-obsessive
symptoms or the indirect interference of correlated symptoms may be connected to
distorted perceptions of the overall self-image, including the vocal self-image. Oral
communication disorders in psychiatric illnesses can involve complex manifestations
that result in deviations in the voice, speech articulation, fluency and language.
761
Methods: This cross-sectional study investigated 17 individuals with OCD

that participate in the Brazilian Consortium of Research and Treatment of ObsessiveCompulsive Disorders and 18 individuals without psychiatric or voice diagnosis
(control group), randomly selected through convenience sampling. All participants
signed the informed consent term, approved by the Research Ethics Committee of
the IPA. Ages ranged from 16 to 74 years. For inclusion in the clinical group, the
individual had to: present OCD diagnosis criteria proposed by DSM-IV-TR, be at
least 16 years old, present minimum score of 16 in the Yale-Brown ObsessiveCompulsive Symptom (YBOCS) for the presence of obsessions and compulsions and
10 for the presence of either obsessions or compulsions. For the control group, the
inclusion criteria were non-diagnosis of psychiatric diseases and be at least 16 years
old. The study employed the following research protocols: Beck Depression Scale,
Beck Anxiety Scale, questionnaire of voice psychodynamic assessment focused on
voice self-assessment. The voice perceptive-auditory assessment and acoustic
analysis were also made, as procedures to measure the individuals voice
parameters.The voice self-assessment was made with the application of a protocol
divided into three parts. In the first part, the participant was requested to attribute
his/her voice a score, from 1 to 10. The second part involved the description of eight
pairs of voice description terms, where each pair was composed of two opposite
adjectives and the participant had to select one in each pair of adjectives with an x.
The pairs were presented in the following order: ugly/beautiful; bad/good;
weak/strong; thin/chesty; sad/happy; in tune/out of tune; slow/fast; old/young.
The third part consisted in answering whether they were well understood by other
people. In the perceptive-auditory analysis of voice quality, the measurement
involved the sustained emission of vowel /a/, count from 1 to 20 and reading of The
art of loving, by Manuel Bandeira. The following aspects were evaluated: voice
quality and alteration degree, type of resonance, loudness, pitch, articulation, speed
of speech, voice modulation and intonation. The acoustic analysis of voice was
performed using Doctor Speech 3.0 of TRS, and the study opted for the assessment of
parameters related to fundamental frequency (f0) and its short- and long-term
perturbation indexes, such as jitter (PPQ - Period Perturbation Quotient), shimmer
(APQ - Amplitude Perturbation Quotient) and tremor frequency. The measurement
was made with the sustained emission of vowel //, as it was the vowel accepted by
the software used in this study. The voices were presented randomly and
individually and four voice experts performed the auditory analysis of the voices,
whose origin was unknown to them. The relative measurements of jitter (PPQ) are
presented in percentage and the normality value limit is 0.5%, values valid for
Doctor Speech 3.0. The Fischers Exact Test was used to assess the perceptiveauditory and voice self-assessment data. The t test of independent samples was used
in the acoustic analysis of voice, after the normal distribution control through the
Kolmogorov-Smirnov test. The level of statistical significance was 5%.
Results:
The voice quality analysis of individuals with OCD showed predominance of
hoarse voice, with mild alteration degree and the control cases showed
predominance of adapted or functional voice. The voice alteration may be the result
of the effect caused by the continuous use of anti-obsessive drugs, which cause
alterations to the vocal tract. In the assessment of resonance type, 94.1% of the
individuals with OCD presented alterations (p=0.002), with predominance of
laryngeal (35.3%) and laryngeal-pharyngeal (29.4%) focuses.
762
Pitch was altered in 64.7% and loudness was adequate in 52.9% of the
individuals with OCD. Habitual elevated pitch suggests characteristics of
restlessness, while habitual low pitch and slow speech suggest strong signs of
depression. The speed of speech, in around half of the individuals with OCD (52.9%)
is adequate. Depressive individuals presented slower voice and anxious individuals
presented faster voice (p=0.05). Voice modulation and intonation in most individuals
with OCD was monotonous, while adequate in all individuals of the control group.
To control the confounding effect of severity of depressive or anxious
symptoms, we compared the scores of Beck depression and anxiety scales of both
groups. In the depression scale, the OCD group presented mean of 9.42 (sd = 7.83)
and the control group 6.23 (sd = 3.14) (t=1.32; p=0.21), while in the anxiety scale, the
OCD group presented mean of 7.33 (sd = 3.77) and the control group 7.31 (sd = 4.97)
(t=0.014; p=0.99).
The voice acoustic analysis of the showed significant differences in the values
of jitter (PPQ) (p=0.04), with 0.38% of the individuals with OCD and 0.21% in the
control group. This finding can be associated with the voice hoarseness found in the
individuals with OCD, a characteristic not observed in the control group. Patterns of
elevated pitch and hoarse voice may indicate stress in the communication and
tension in the vocal tract. The acoustic assessment presented shimmer (APQ) of
3.43% in the OCD group and 2.45% in the control group. The value found in the
OCD group can be related to the reduced glottal resistance and voice emission noise.
The mean value of tremor frequency in the OCD group was 1.8 Hz and 1.5 Hz in the
control group. The fundamental frequency values characterized the voice of male
individuals with mean of 130.94 Hz in individuals with OCD and 137.27 Hz in the
control cases, and the voice of female individuals with mean of 177.43 Hz in women
with OCD and 189.11 Hz in women without such diagnosis.
Conclusions: The statistically significant aspect described by the clinical
group was the voice emission attributed as sad and bad. It could be a result of
the depressive symptoms secondary to OCD and not necessarily a direct
consequence of the obsessive-compulsive symptoms, but, as the groups did not
present statistical differences regarding the intensity of depressive symptoms using
the Beck scale, a study with more adequate designs and more significant sample
sizes will be required to explain this aspect. Although we recognize the sample size
limitation, initial results indicate a population to be investigated, in the perspective
of speech therapy. In the attempt to understand the OCD patients perception of
his/her own voice and voice emission deviations, the speech therapist may obtain
information to improve the quality of life of these individuals, their communication
and self-esteem, helping them in the treatment of these cases.
References:
1.BEHLAU, M.; PONTES, P. Higiene vocal: cuidando da voz. 2 ed. Rio de Janeiro: Revinter,
1999.
2.BEHLAU, M.; REHNDER, M.I.; AZEVEDO, R.; BORTOLOTTI, E.L. Disfonias psiquitricas.
In: BELHAU, M. Voz: O livro do especialista II. Rio de Janeiro: Revinter, 2005. v. 2, cap.
8, p. 79-100.
3.FERREIRA, L.P.; ALGODOAL, M.J.; ANDRADA e SILVA, M.; Avaliao da voz na viso (e
no ouvido) do fonoaudilogo: saber e que se preocupa para entender o que se acha.
In: MARCHESAN, I.Q.; ZORZI, J.L.; GOMES, I.C.D. Tpicos em fonoaudiologia
1997/1998. So Paulo: Lovise, 1998.
4.BARROS, A.P.B.; CARRARA DE ANGELIS, E. Anlise acstica da voz. In: BARROS, A.P.B.;
DEDIVITIS, R.A. Mtodos de avaliao e diagnstico de laringe e voz. So Paulo: Lovise,
2002. cap. 14 e 15. p. 185-221.
763
5.CARRARA DE ANGELIS, E.; CERVANTES, O.; ABRAHO, M. Necessidades de medidas

objetivas da funo vocal. In: FERREIRA, L.P.; COSTA, H.O. Voz ativa falando sobre a
clnica fonoaudiolgica. So Paulo: Roca, 2001. p. 53-72.
6.DSM VI Manual diagnstico e estatstico de transtorno mentais. Trad. Dayse Batista, 4
ed. Porto Alegre: Artes Mdicas, 1995.
7.CORDIOLI, ARISTIDES. http://www.ufrgs.br/toc/oque_toc.htm. 2000.
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P123
QUALITY OF LIFE AND VOICE IN INDIVIDUALS INTERVIEWED BY THE
CALL CENTER VIVAVOZ - PILOT STUDY
T.Campos Moreira1, H.M.T. Barros2, S.Fernandes3, M. Ferigolo4, M.Cassol5
1.Federal University of Heath Sciences of Porto Alegre - Brazil
4.Federal University of Heath Sciences of Porto Alegre Brazil
Introduction and aims of the study: Investigate the quality of life and voice,
as well as describe the profile of users and non- psychoactive substances users which
have called to an health service, National guidance and information on prevention of
drug -VIVAVOZ .The concept of lifes quality refers to an idea inside human and
biological sciences, that it has to do with raising values on more broad parameters
than in the symptoms controlling, as well as in the decrease of mortality or life
expectation increase.The term life quality deals with a variety of conditions that
can affect ones perception, feelings and behavior related to the daily activities.To the
World Health Organization, lifes quality should be considered on the local
development context, as well on human needs.It is and subjective evaluation, from
the situation of someone or a group of people affected by several topics, such as
health determinants, happiness (including environment comfort and satisfactory
occupation), intellectual and social education, freedom of action and justice.This
concept is measure by the physic and social well-being for each individual or group.
Voice problems also interfere on this individuals lives. Voice disturbs act in 3 to 9%
of the general population and deeply affect lifes quality this individuals. Many
uncomfortable voice problems such as fatigue, and lost of voice due the excessive
and inadequate use, lead to the gradual decrease its use on a daily basis.Clinic
experience on patient with vocal problems showed that there are frequent as physic
disturbs, emotional or social are not easily measured by traditional clinic parameters.
Besides, the importance of voice for a patient is related to many professional and
personal issues, which, most of the time act a fundamental role. Vocal pathologies
can put at risk the quality of communication, and well as the social relations,
therefore, it can affect ones quality of life. It is essential took in consideration the
patients perception towards and vocal change or impact in social life, when it comes
to vocal problems. This aspect can make the difference on motivation and
phonoaudiologic treatment. In Brazil, the concern on quality of life for patients with
voice disturbs is something recent and new, especially in users of psychoactive
substances, licit or not. Nowadays, the number of people that use psychoactive
substances is increasing in the country, even though there are national campaigns for
prevention of unreliable use.The application of questionnaires by telephone has
being useful, and active on many different health areas. This resource helps to reach
a bigger sample of the population due the easy access, comfort and low cost. The
telephone use allows to investigate therapeutic processes relating the patient with his
problem, since they meet the capable professionals. Methods: It was realized a broad
study on the call Center VIVAVOZ since December, 2009 to January, 2010. All the
765
clients which call VIVAVOZ were invited to join a research, after reading the given
consent term.The participants answered the Voice-Related Quality of Life (VRQL)
that investigates the relations between the self-evaluation of voice and the
instrument scores.This instrument was translated and transformed according to the
Brazilian conditions, and it has being useful to measure the quality of life related to
voice with emotional and functional domain. First of all, the patients answered
questions about socio-economic data and psychoactive substances consume (licit and
illicit), where the annual, monthly or daily consume were evaluated, besides abused
or addition of drugs. Individuals that use any psychoactive substances associated or
not, with age between 18 and 60,that call to the call center VivaVoz with the objective
of stop the consumption, were included. People that showed being incapable to
answer the protocol, did not have the cognitive conditions to answer or appeared to
be under the effect of drugs were excluded.The telephone help and application of the
questionnaire were made by academics in graduated levels on health areas. All of
them were trained for the application of instruments, including the telephone
service. They also had a specific training for VRQL, with 2 hours of study on the
theoretical and practical exposures, including discussion of clinic cases. Classes and
discussions were made, also a training session, where the academics could work
with a partner.Concerning the VRQL, the higher scores presents less impact on voice,
therefore lead to a better quality of life. This instrument is build by ten questions that
involve aspects of physic domain (questions 1,2,3,6,7,9) and socio-emotional domain
(questions 4,5,8,10). They were answered in a scale of 1 to 5 to the level of impact
caused by voice in ones life, when higher the scores, more impact on the physic or
emotional of the patient. To analyze statistic, there were made descriptive univariate
analysis, and after bivariate analysis with the Mann-Whitney-Wilcoxon test,
considering P < 0,05 significant. The project was approved by the ethical board on of
Federal University Health Sciences. Results: In this pilot study, 12 subjects data were
evaluated, being 5 (42%) psychoactive substances users, which 4 of them ( 80%) men,
2 (40%) with incomplete elementary school,1 (20%) with element school completed,
1(20%) high school completed, 1(20%) incomplete under graduation, 4 (80%)
married, 1 (20%) divorced, 3 (60%) earning 1 to 5 basic income, 1 (20%) earning 5 to
10 basic income, 1(20%) earning more than 10 basic income, with and average of 36
years old, 1(20%) self employed, 3(60%) professional of different areas, 5(42%)
addicted on substances that they use. The non-users sample, showed 6 (86%) women,
4 (57%) married, 2(30%)single, 1(14%)widow, earning 1 to 5 basic income, 1(14%)
earning more than 10 basic income, 2(30%) completed high school, 1(14%)incomplete
under graduation, 1(14%) undergraduated, with an age average of 27 years old.
1(14%) housewife, 1(14%) student, 4 (57%) professionals of different areas. In 4 (80%)
use alcohol, 4(80%) cocaine, 3(60%) cark, 3(60%)marijuana, 2(40%) tobacco; also, the
same client could not use more than one substance.The average of the global domain
of VRQL was 83,75 in both groups; to the social-emotional on the users group the
average was 12,5 and on the non-users group the average was 25,0; the physic
domain on users the average was 50,0, and on non-users 58,0. Conclusion: In both
evaluated groups, on impact of vocal changes, the domain was the socio-emotional
was higher than the physic domain. Given the fact that when closer to 100 points,
better the quality of life of individuals, relating socio-emotional and physic domain,
with a prominence of the substances users. Since this is a pilot study, the sample was
smaller, therefore, was not possible to observe the significant statistics between users
and non-users. The sample will be collected with the purpose to differ the quality of
life of user and non-users, and it is expected 350 participants from the whole country
of Brazil, in both groups. Studies that evaluate the vocal alterations that interfere in
766
lifes quality of population concerning users of psychoactive substances are import to

investigate risk factors and impact on the lives. Information like these are generated
from a complete study and can help important strategies of promotion, prevention
and treatment of vocal disturbs on users of abuse drugs. Besides, the data can
contribute to phonoaudiology , since quimical dependence on that area is recent.
Scientific literature about the subject is needed, given the fact that voice disturbs is an
example of health problem, being related to the abusive consumption of
substances.Future Contributions: This study will contribute to the knowledge of
vocal problems that affect quality of life of users of drug abuse in Brazil.
References:
Barros, H.M.T et al. Neuroscience education for health profession undergraduates in a callcenter for drug abuse prevention. Drug and alcohol dependence, 2008, 98, 270-274.
Behlau, M. et al. Quality of Life and Voice: Study of a Brazilian Population
O livro do especialista. Volume I. Reimpresso 2008. Livraria e editora Revinter, 2008.
Fleck M.P.A., et al. Aplicao da verso em portugus do instrumento WHOQOL-bref. Rev
Saude Publica 2000;34(2):178-83.
Fleck, M.P.A, et al. Development of the Portuguese version of the OMS evaluation instrument
of quality of life WHOQOL-100. Revista Brasileira de psiquiatria, 1999, 21(1):19-28.
Gasparini G; Behlau M. Quality of Life: Validation of the Brazilian version of the voice-related
quality of life (V-RQOL) Measure. Journal of Voice, 2007.
Penteado, R. Z; Bicudo-Pereira, I. M. T. Avaliao do impacto da voz na qualidade de vida de
professores. Rev. Soc. Bras. de Fonoaudiologia, 2003, So Paulo, ano 8 n. 2, p. 19-28.
Thibeault et al. Occupational Risk Factors Associated with Voice Disorders among Teachers.
Ann Epidemiol 2004;14:786792
Voice-Related Quality of Life Measure. Folia Phoniatr Logop, 2007;59:286296.
767
P181
VARIATION IN THE TEMPORAL CHARACTERISTICS OF PROFESSIONAL
SPEAKING STYLES
L. Castro, B. Serridge, J. Moraes, M. Freitas
Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
Introduction
In everyday conversation, speech is for the most part spontaneous and
natural; but in numerous professional activities in which oral language is transmitted
by different media such as television and radio, speech exhibits quite distinct
dynamics. In previous studies using the same corpus, listeners were able to
distinguish between professional speaking styles based on prosodic cues alone
(Castro et al., 2010a). Presumably, listeners ability to distinguish speaking styles
derives in part from perceived differences in the prosodic characteristics of the
different speaking styles. If so, it should be possible to define metrics that quantify
these differences, and furthermore, show that the measured differences vary in a
statistically significant way across speaking styles. However, an analysis of metrics
that characterize the fundamental frequency contour had limited success in
identifying statistically significant differences between the speaking styles (Castro et
al., 2010b). The objective of this study is to perform a similar analysis on metrics that
quantify the temporal characteristics of speech, to determine whether, even when
taking into consideration the variation between individual speakers, there is still
sufficient variation between classes of speakers (speaking styles) to explain the
ability of listeners to distinguish among the classes.
Methodology
The data used in these experiments consist of one minute of speech of twenty
Brazilian professionals: five TV news anchors, five Catholic priests, five politicians,
and five interview subjects. The speakers, all male and native speakers of Brazilian
Portuguese with no apparent communication disorders, range in age from 35 to 78.
All recordings were captured directly from regularly televised programs on Brazilian
television, and each recording consists of one minute of speech sampled from normal
use situations: the TV news anchors and the interview subjects in the television
studio, the politicians on the senate floor during debate, and the Catholic priests in
the church, from which mass is broadcast live on television.
u. Corpus
The speech data were collected by a portable computer coupled to an external
sound card, in turn linked to the digital decoder supplied by the cable TV company.
768
Figure 1: Diagram of the setup used to capture speech from television.

The audio signal was sampled at 22 kHz / 16 bits and stored in PCM (.wav)
format for later processing by the acoustic analysis software Praat (Boersma &
Weenink, 2008). Transcription of the speech was performed in stages, and by using
Praat it was possible to partially automate the transcription process. A total of 20
minutes of speech were analyzed, containing 2780 words and 5861 syllables.
v. Metrics
As a starting point for the metrics described below, the data were analyzed
based on the segmentation of the corpus into phonetic sequences and pauses
(Delgado-Martins & Freitas, 1993). Pauses are further classified as one of two types:
silent pauses and filled pauses. Zellner (1994) defines silent pauses as those that
correspond to a silent region in the speech signal, produced in conjunction with
taking a breath, swallowing, laryngeal-phonatory reflex, or silent exhalation. Filled
pauses, on the other hand, correspond to vocalized breaks in the speech signal,
including repetitions of a part of the utterance and false starts. As per Howell &
Kadi-Hanifi (1991), any silence in the speech signal not coincident with a consonantal
occlusion and reaching a length of at least 100ms is considered a pause. The metrics
used to quantify the temporal characteristics of speech are based on metrics
proposed by Freitas (1992) and by Goldman et al. (2008). Table 1 shows the full set of
metrics evaluated in this study.
Table 1: Metrics that quantify the temporal characteristics of a speaking style.
Metric
Description
silent pauses per minute
the number of silent pauses divided by the total speech duration

in minutes
average pause duration
the sum of the durations of all silent pauses, divided by the

number of silent pauses
total pause time
the sum of the durations of all silent pauses, divided by the total
speech duration, expressed as a percentage (%)
filled pauses per minute
the number of filled pauses divided by the total speech duration

in minutes
769
average phonetic sequence the sum of the durations of all phonetic sequences, divided by the
duration
number of phonetic sequences
syllables
sequence
per
phonetic the total number of syllables, divided by the number of phonetic

sequences
speaking rate
the total number of syllables, divided by the total speech

duration
articulation rate
the total number of syllables, divided by the sum of the durations

of all phonetic sequences
Each of the metrics listed in Table 1 was calculated for each of the 20 oneminute recordings in the corpus. One way analysis of variance, in which the
speaking styles correspond to treatments, was then performed on each metric. In
the context of this study, a result is considered statistically significant if the null
hypothesis, that a single mean value can account for the observed values without
taking speaking style into consideration, is rejected (p < 0.05).
Results
The results of the ANOVA analysis on the data from this corpus show that
the only metric that does not vary significantly across the four speaking styles is the
average number of pauses per minute. However, the differences in average pause
duration are significant (p < 0.01), with the political and religious speaking styles
characterized by significantly longer pauses than TV news and interview speech.
Table 2 shows the values obtained for each metric, along with the p-value result of
the ANOVA analysis.
Table 2: Observed values and ANOVA p-value for duration metrics defined in Table 1.
Speaking
Style
silent
pauses
/
minute
Average
pause
duration
(ms)
Average
Total
syllables
phonetic
pause
/
Speaking Articulation
sequence
time
phonetic rate
Rate
duration
(%)
sequence
(ms)
filled
pauses
/
minute
ANOVA
p-value
0.079
0.009
0.0004 0.013
0.0006
0.000001
0.00004
N/A
Interview
21.7
387
14
2216
15.8
6.1
7.1
3.8
TV news
19.8
327
11
2306
15.7
6.0
6.8
0.0
Political
23.1
823
32
1706
10.0
4.0
5.9
1.0
Religious
27.3
707
32
1436
6.9
3.2
4.8
0.0
The total pause time, which is the product of the number of pauses per
minute and their average duration, is also statistically significant (p < 0.001). The
religious and political speaking styles exhibit much greater total pause time (about a
third of the total speaking time) than the TV news and interview speaking styles.
These results corroborate those of Braga and Marques (2004), who in their analysis of
European Portuguese political speech, found that politicians appear to utilize silence
770
deliberately for several purposes: to build suspense, to give the speech rhythm, and
to suggest ideas that are not stated all of which help hold the audience's attention.
The TV news speaking style includes phonetic sequences longer than any
other speaking style, being the only one with a phonetic sequence lasting more than
7500 ms, whereas in the religious speaking style there are no phonetic sequences
longer than 4000 ms. A comparison of the number of syllables per phonetic sequence
shows that the TV news and interview speaking styles have the most number of
syllables between pauses, followed by the political and religious speaking styles.
These measurements reflect both the speed of articulation and the average length of
phonetic sequences, and in both cases the differences between speaking styles are
statistically significant (p < 0.001).
To measure the rate of speech, two separate metrics are considered: the
speaking rate, which measures the overall number of syllables per second, and the
articulation rate, which considers only the speech within phonetic sequences (i.e. not
including pauses). Note that the styles that have a slower speaking rate (political and
religious) also have a lower articulation rate. That is, not only do these speaking
styles have a higher total pause time, but they also exhibit a slower rate of
articulation of speech sounds between pauses. Both measures of speech velocity are
highly statistically significant per the ANOVA analysis (p < 0.001). As a reference
point, for Portuguese spoken in Sao Paulo, according to Behlau (2001), the average
speaking rate is 140 words per minute, with a range from 130 to 180 words per
minute (4.6 6.3 syllables / second for this corpus).
Finally, another factor that distinguishes the speaking styles is the presence or
absence of filled pauses. The data analyzed in this study have an average of 3.8 filled
pauses for every minute of interview speech and one filled pause per minute of
political speech, while filled pauses are not present at all in the TV news and
religious speaking styles. These results support the hypothesis of Goldman-Eisler
(1968) that filled pauses are markers of information processing and the planning of
speech organized in real time, the interview speaking style being the one that most
closely resembles spontaneous speech.
Conclusion
In summary, the results of the analysis presented here show that, with the
exception of the number of pauses per minute, all of the temporal metrics considered
in this study average pause duration, total pause time, average phonetic sequence
duration, number of syllables per phonetic sequence, speaking rate, and articulation
rate exhibit behavior that varies in a statistically significant way across speaking
styles. Furthermore, the data suggest a division of speaking styles into two groups,
with the informational speaking styles (TV news and interview speech) exhibiting
temporal characteristics quite distinct from those of the more dramatic or
persuasive political and religious speaking styles. For every temporal metric
evaluated in this study, a value can be given that divides the samples in this corpus
into one of these two groups. Note that these results are in sharp contrast to those of
a similar study performed on metrics that characterize the fundamental frequency
contour (Castro et al., 2010b), in which most of the metrics proposed in the literature
were shown not to vary in a statistically significant manner across speaking styles.
Future research will be needed to quantify the relative importance of temporal and
frequency characteristics of speech in listeners ability to identify professional
speaking styles.
771
References
Behlau, Mara. Voz: o livro do especialista. Volume I. Rio de Janeiro: Revinter, 2001.
Boersma, P. & Weenink, D. Praat: doing phonetics by computer, 2008. Computer program
available at http://www.praat.org/.
Braga, D. & Marques, M. A. The pragmatics of prosodic features in the political debate. In:
Proceeding of Speech Prosody, Nara, p. 321-324, 2004.
Castro, Luciana; Freitas, Myrian; Moraes, Joo; Serridge, Ben. Listeners Ability to Identify
Professional Speaking Styles Based on Prosodic Cues. In: Proceeding of Speech Prosody,
Chicago, 2010.
Castro, Luciana; Serridge, Ben; Moraes, Joo; Freitas, Myrian. Characterizing Variation in
Fundamental Frequency Contours of Professional Speaking Styles. In: Proceeding of
Speech Prosody, Chicago, 2010.
Delgado-Martins, M. R. & Freitas, M. J. Temporal structures of speech: reading news on TV.
In: Proceedings of The ESCA Workshop of Speaking Styles, Barcelona, v. 19, p. 1-5, 1991.
Goldman Eisler, Frida. Psycholinguistics: experiments in spontaneous speech. London: Academic
Press, 1968.
Howell, Peter & Kadi-Hanifi, Karima. Comparison of prosodic properties between read and
spontaneous speech material. Speech Communication, v. 10, p. 163-169, 1991.
Freitas, Maria Joo. Contributo para o estudo de padres de estruturao temporal da fala no
portugus europeu. In: Pereira, I. et al. (orgs.) Estudos em prosdia. Lisbon: Colibri,
1992. p. 74-103.
Goldman, J.-Ph., Auchlin, A., Avanzi, M., Simon, A.C. ProsoReport: an automatic tool for
prosodic description. Application to a radio style. In: Proceedings of Speech Prosody,
Campinas, p. 701-704, 2008.
Zellner, B. Pauses and the temporal structure of speech. In: Keller, Eric. (org.) Fundamentals of
speech synthesis and speech recognition: basic concepts. State of the art and future challenges.
Chichester: John Wiley, 1994. p. 41-62.
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FP36.6
EMOTION AND VOICE: ACOUSTICS AND ELECTROGLOTTOGRAPHIC
CHARACTERISTICS
L.A. Cecconello1, M.E. Dajer2, N. Golub1, M. Becerra1
1Fundacin Iberoamericana de voz cantada y hablada (F.I.V.C.H.), Crdoba, Argentina
2Universidade de So Paulo- Escola de Engenharia de So Carlos, USP-EESC,So CarlosSP- Brasil
Key words: Voice- Emotion- acoustic parameters- EGG Parameters
Introduction
In every day experiences, the same word pronounced under sad or happy
emotional circumstances sounds different. Obviously, oral communication includes
verbal and nonverbal components that express the real emotional state of the
speaker.
In a Scherer et al. (2001) study, they found that different emotional spoken
phrases can be correctly identified by a listener even in an unknown language. Other
studies (Protopapas and Lieberman, 1997) and (Sobin and Alpert, 1999) also showed
that specific emotions are expressed acoustically. And, according to (Shackman and
Pollak, 2005) vocal affect remains a primary channel of emotional expression during
development and throughout our lives. Therefore, scientists from different areas
have been interested to identify important relationships between a number of
acoustic parameters and the speakers emotions; and from different points of view
they tried to better understand how the acoustic characteristics of emotional speech
are determined by underlying emotional and physiological changes.
The aims of the study is provide an acoustic and electroglottographic
characterization of seven emotional voices Neutral, Happiness, Surprise, Sadness,
Anger, Fear and Disgust and find out whether there are acoustic features
distinguishing different vocal emotional states.
Method
Participants
The participants were eight professional actors (5 females and 3 males),
between the ages of 20 and 37 years old (mean age 25 year old); without vocal
disorders from Crdoba, Argentina. All participants were native Spanish speakers.
Procedure:
Participants were asked to emit a sustained vowel /a/ in spontaneous
frequency and were asked to read the phonetically balanced sentence La abuela de
Lola le da un helado de limn al nene (Lolas grandmother gives lemon ice-cream to the
baby) with seven different emotional states: (1) neutral, (2) happiness, (3) surprise, (4)
sadness, (5) anger, (6) fear and (7) disgust.
Acoustic recordings were made with the actors seated, in a room without
acoustic treatment but with no excessive noise. A Beyerdynamic TGX-58 dynamic
773
microphone placed at 45 degrees and 10 cm from the mouth was used for data
recording. Tiger Electroglottograph EGG-PC3 was used to assess the EGG signal. The
electrodes were placed on the wings of the thyroid cartilage at vocal folds level.
Signals were digitalized at 16 bits/ 44KHz.
Measures:
Three software programs were used to extract the acoustic and EGG
parameters correlated to different emotions.
With Dr. Speech 4, vocal Assessment module were extracted: Mean F0, Standard
Deviation of F0 (SD F0), Jitter PPQ, Shimmer APQ, Normalized Noise energy (NNE),
Harmonic-To-Noise-Ratio (HNR), Signal-To-Noise-Ratio (SNR), F0 Tremor, Amp
Tremor and Ratio from the vowel /a/ audio signal. Seventeen parameters from EGG
signals were assessed: EGG-Mean F0, EGG-SD F0, EGG-Jitter PPQ, EGG-Shimmer
APQ, EGG-NNE, EGG-HNR, EGG-SNR, EGG-F0 Tremor, EGG-Amp Tremor, Contac
Quotient (CQ), Contac Index (CI), Contac Quotient Perturbation (CQP), Contac Index
Perturbation (CIP), Closing Rate (CR), Opening Rate (OR), Presence of the Knee in
the opening phase and Predominant phase of the glottal cycle. The last parameter
was categorized in three classes: Predominance of the Close Phase (PCP),
Predominance of the Open Phase (POP) and Phases of Similar Duration (PSD).
We calculated Mean F0, Habitual F0, Ratio and duration from the sentence,
audio signal.
For vowel /a/ analysis Anagraf was used to assess the Actors Formant with
wide-band spectrogram (64 pt FFT) classified into present, absent and inconsistent.
Frequency (F), Bandwidth (B) and Energy (E) values of the first four formants were
measured with Linear Predictive Coding (LPC) at a midpoint of the wave where
energy is high and formants are more constant. Nasality was considered under three
conditions: 1) presence of nasal extra formant between 250 and 350 Hz, 2) high
values of the first formant bandwidth and 3) low values of the first formant (F1).
For the sentence, we calculated Frequency (F) and Energy (E) values of the
first four peaks from the Long Term Average Spectrum (LTAS).
The Vocal Range (VR) of the sentence was assessed by means of Fonetograma
ATR.
For statistical analysis One-Way ANOVA was performed and statistical
significance was set at the level of 0.05.
Results:
To examine the effect of the emotional voice on acoustic and
electroglottalgraphic parameters, we first analyzed the recorded vowel /a/, and then
test sentence data was analyzed. Quantitative parameters were also statistically
analysed with One-way ANOVA.
The results for our data showed that the seven emotional inflections can be
characterized by specific acoustic profiles, differentiating one emotional meaning
from all others.
Sustained vowel /a/
For sustained vowel /a/ statistical difference was significant, for Mean F0, SD
F0, Ratio and F1. Surprise showed the higher values of Mean F0 (359,14 Hz) and the
lowest values were for neutral voice (187,89 Hz), surprise presented the higher
values of SD F0 (20,83 Hz) and the lowest values were for neutral (2,02 Hz), anger
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showed the higher values of Ratio (38,12 %) and the lowest values were for neutral
voice (31,5 %), happiness showed the higher values of F1 (1006 Hz) and the lowest
values were for sadness (710 Hz). The other parameters presented different mean
values that were not statistically significant. All mean values and level of significance
(P) for acoustic analysis for the seven emotions are shown in table I.
TABLE I. Mean acoustic values for seven Emotions of 8 actors

Parameter
Neutral Happiness Sadness Anger
Fear
Disgust Surprise P
Mean F0
187,89
265,91
214,77
211,25
226,01
188,11
359,14
0,0103**
Mean F0 female
229,48
339,88
268,27
255,67
282,18
227,77
451,32
2,88985 e-005***
Mean F0 male
118,59
142,62
125,62
137,21
132,4
122
205,51
0,0072**
SD F0
2,02
7,88
3,39
5,36
5,53
5,17
20,83
0,0003***
SD F0 female
2,24
11,11
4,45
6,91
6,89
5,22
23,18
0,0146**
Sd F0 male
1,67
2,5
1,64
2,78
3,27
5,1
16,92
0,0837
Jitter PPQ
0,28
0,17
0,2
0,17
0,23
0,23
0,2
0,5186
Shimmer APR
1,97
1,76
1,67
1,69
2,06
2,43
2,22
0,7003
NNE
-15,21
-16,96
-13,95
-19
-16
-14,66
-17,65
0,3606
HNR
24,51
23,71
25,74
24,64
24,06
21,43
22,5
0,2484
SNR
23,25
22,56
24,35
23,49
23,07
20,55
21,8
0,4466
F0 tremor
3,2
2,94
3,21
2,35
4,99
5,05
0,3531
Amp tremor
2,83
2,67
3,31
3,56
2,13
4,56
5,93
0,2329
Ratio
31,5
35,62
32
38,12
32,87
36
36,25
0,0312*
F1
755
1006
710
946
777
883
888
0,0124*
F2
1477
1629
1393
1508
1453
1548
1566
0,0577 (*)
F3
2912
3010
2916
2851
2882
2800
2836
0,8372
F4
4061
4202
4096
3986
3986
3961
3963
0,8357
B1
196
157
192
234
209
240
170
0,6922
B2
185
174
236
223
215
306
145
0,4919
B3
205
380
234
197
442
371
227
0,545
B4
359
424
459
520
447
563
419
0,7213
E1
22,57
23,55
22,96
23,11
22,45
21,85
21,49
0,9176
E2
21,9
24,19
21,32
25,68
22,3
20,87
24,54
0,3978
E3
17,82
15,84
16,36
19,6
13,77
17,44
17,77
0,603
E4
12,24
11
10,77
13,51
11,09
10,45
12,2
0,9016
Notes: Asterisks indicate the significance level: *P>0.05, **P>0.01, ***P>0.001 and (*) for values slightly
higher than the first level of significance. The significance is an overall significance, indicating that the
respective parameter distinguishes at least one emotion from other emotions. It does not indicate that all
possible single pairs of emotions differ significantly.
For EGG analysis, qualitative parameters Predominance of phase, Presence

of the Knee of the opening phase and Actors Formant were analysed by percentage.
For Neutral voice Predominant of phase presented: PCP 37,5%; POP 25%;
PSD 37,5%; for happiness: PCP 37,5%; POP 37,5%; PSD 25%; for sadness: PCP 50%;
POP 25%; PSD 25%; for anger: PCP 75%; POP 12,5%; PSD 12,5%; for fear: PCP 75%;
POP 0%; PSD 25%; for disgust inflexions: PCP: 87,5%; POP: 12,5%; PSD: 0% and for
surprise: PCP: 25%; POP: 37,5%; PSD: 37,5%.
Percentage for the Presence of the Knee of the opening phase were: neutral
(87,5%), anger, fear and disgust (75%), happiness (37,5%), sadness and surprise
(25%).
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The Actors Formant percentages were: in neutral and sadness (12,5%),

disgust and surprise (25%), happiness and anger (37,5%) and (0%) for fear which
only yielded an inconsistent formant (12,5%).
Nasality was present in happiness (25%), surprise (37,5%); neutral, angry and
fear (50%), disgust (62,5%) and sadness (87,5%).
EGG-Mean F0 and EGG-SD F0 presented statistical significance, Surprise
showed the higher values of EGG-Mean F0 (360,07 Hz) and the lowest values were
for disgust voice (188 Hz), surprise presented the higher values of EGG-SD F0 (25,5
Hz) and the lowest values were for neutral (3,79 Hz). However, CI, CR and OR were
not significant, they presented a slightly higher level of significance than P>0.05. The
other parameters were not statistically significant.
All mean values and level of significance (P) for EGG analysis are presented
in table II.
TABLE II. Mean EGG values for seven Emotions of 8 actors
Parameter
Neutral Happiness Sadness
Anger
Fear
Disgust
Surprise
EGG-Mean F0
188,38
266,49
215,73
211,79
226,36
188
360,07
0,0107*
EGG-SD F0
3,79
10,6
4,96
6,39
6,66
7,21
25,5
0,0002**
EGG-Jitter PPQ
0,95
1,35
0,93
0,82
0,75
1,03
1,28
0,8784
EGG-Shimmer APQ
3,34
4,44
3,9
3,52
2,61
4,11
4,73
0,9305
EGG-NNE
-21,39
-18,68
-22,59
-20,66
-23,88
-20,45
-17,25
0,7767
EGG-HNR
24,24
21,34
25,35
23,74
26,67
23,55
19,98
0,7803
EGG-SNR
23,16
20,45
24,35
22,43
25,65
22,22
19,02
0,7769
EGG-F0 tremor
6,14
7,17
6,46
4,41
4,12
4,1
6,06
0,5873
EGG-Amp tremor
3,25
7,98
4,17
6,12
3,64
4,78
6,32
0,2372
CQ
53,35
53,58
54,93
57,81
55,86
57,77
54,37
0,6692
CI
-0,41
-0,38
-0,41
-0,52
-0,42
-0,44
-0,23
0,0592 (*)
CQP
2,05
3,95
3,32
1,61
1,81
2,44
3,64
0,6458
CIP
14,49
22,09
16,13
5,99
61,46
16,98
85,1
0,3394
CR
29,43
30,82
29,29
23,85
28,82
28,05
38,55
0,0593 (*)
70,48
69,09
70,61
76,06
71,09
71,86
61,36
0,0594 (*)
OR
Sentence test
The mean values of the sentence test with statistical significance were F0
mean and Vocal Range. Surprise showed the higher values of Mean F0 (316,68 Hz)
and the lowest values were for neutral voice (187,57 Hz), disgust showed a high
value for vocal range (17,12 ST) and the lowest values for sadness (8,25 ST). The
shorter duration was (2,61 seconds) for anger and the longest (3,36 seconds) for
disgust, the differences were not statistically significant but were slightly higher than
P<0.05. Other parameters were not statistically significant.
The sentence mean values and significance of acoustic parameters are shown
in Table III.
Figure 1 present three examples of emotion, happiness, sadness and anger in
a sentence; this image shows that the F0 curve is higher in happiness and lower in
sadness, the duration is longest for sadness and shorter for anger. CQ is higher in
anger and lower in happiness.
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Figure 1. Dr Speech program screen. Image shows the differences for

three emotions (happiness, sadness and anger) in a spoken sentence.
TABLE III. Mean Acoustic values for seven Emotions of 8 actors

Parameter
Neutral
Happiness
Sadness
Anger
Fear
Disgust
Surprise
Mean F0
187,57
272,82
208,66
241,81
233,92
215,12
316,68
0,0417*
Habitual F0
177,14
258,21
199,09
247,13
238,64
197,44
285,51
0,1249
Ratio
37,38
39,38
35,63
39,25
37,13
38,25
37,5
0,3372
Duration
3,13
3,28
2,61
2,99
3,36
3,11
0,0641 (*)
Vocal Range
8,75
13
8,25
12,375
10,875
17,125
16,5
0,0004*
F1
-15,21
-16,96
-13,95
-19
-16
-14,66
-17,65
0,2776
F2
24,51
23,71
25,74
24,64
24,06
21,43
22,5
0,9981
F3
23,25
22,56
24,35
23,49
23,07
20,55
21,8
0,8999
F4
3,2
2,94
3,21
2,35
4,99
5,05
0,3624
E1
2,83
2,67
3,31
3,56
2,13
4,56
5,93
0,0823
E2
31,5
35,62
32
38,12
32,87
36
36,25
0,3007
E3
188,38
266,49
215,73
211,79
226,36
188
360,07
0,4321
E4
3,79
10,6
4,96
6,39
6,66
7,21
25,5
0,7218
Conclusion:
This study was an approach toward better understanding of how acoustic
characteristics are linked to different emotional speech. Therefore, we focused on the
acoustic and electroglottographic manifestation of seven emotional voices.
Results demonstrated that for sustained vowel /a/, Mean F0, DS F0, Ratio, F1
and nasality are voice parameters influenced by the emotion. EGG-Mean F0, EGG-SD
F0, Knee of the opening phase and Predominant phase were distinguishing
parameters for EGG analysis. F0 Mean and Vocal Range were the parameters that
showed statistical significance in differentiating the emotions in a test sentence.
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In summary, the present results suggest that by analyzing adequate

parameters, different emotional states can be characterized by a specific acoustic
profile. In this study seven emotional inflections could be distinguished by analyzing
seven acoustical parameters and four EGG parameters.
However, individual variability in the data set was large; further studies
should address this question and provide a clearer interpretation of the effects of
emotion on voice quality.
References:
Scherer KR, Banse R, Wallbott HG. Emotion inferences from vocal expression correlate across
languages and cultures. J Cross-Cult Psychol. 2001;32:7692.
Protopapas A, Lieberman P. Fundamental frequency of phonation and perceived emotional
stress. J Acoust Soc Am. 1997;101:22672277.
Sobin C, Alpert M. Emotion in speech: the acoustic attributes of fear, anger, sadness, and joy.
J Psycholinguist
Res. 1999;28:347365.
Shackman, J.E., Pollak, S.D.. Experiential influences on multimodal perception of emotion.
Child Development. 2005; 76, 111626
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FP29.3
QUALITATIVE
AND
QUANTITATIVE
ASPECTS
OF
THE
ELECTROGLOTTOGRAPHY IN SINGERS WITH DIFFERENT GLOTTIC
CONTACT PATTERNS
L.A. Cecconello1
1Sanatorio del Salvador, Crdoba, Argentina
Key words: Qualitative parameters-Quantitative parameters-ElectroglottographySingers-Glottic contact patterns
Introduction:
The electroglottography (EGG) uses the movement induced by variations in
the electric impedance and supplies information about the vibratory patterns of the
vocal folds in a non-invasive way, what is highly useful since it permits the
evaluation of the patient in phonation physiological conditions. The usefulness of
this technique is worldwide acknowledged both in vocal clinic and in research. It is
being recently applied in education, especially in the sung voice (Miller, 2008). The
qualitative assessment of the EGG wave is considered more useful than the
quantitative one. The Voice Committee of the International Association of
Logopedics and Phoniatrics (IALP) determines that the numerical measurements that
depend on the opening and closure times derived from the electroglottograms must be
considered of questionable validity, depending on future investigations (Behlau et al, 2004).
For this reason, in order to analyze the utility of the quantitative parameters of the
EGG, it is necessary to investigate the use of this technique on other tests that study
the acoustic and mechanical vibratory patterns.
The aim of this work is to analyze the efficiency of qualitative and
quantitative parameters of the EGG in order to differentiate among singers with
different glottic contact patterns.
Method:
In this work participated 59 singers from the city of Crdoba, Argentina,
without vocal complaint. Among the 59 subjects, 53 were non-classical singers and 6
were opera singers, aged between 18 and 36. Transnasal videostroboscopy
examination was performed, by means of a flexible fibroscope model HSW and a
stroboscope model Strobo Light. The singers were requested to emit the vowel /e/
for a prolonged period of time (3 seconds as a minimum) in a comfortable frequency
of the modal register and at medium intensity. The modal register was selected
because the contact time patterns vary according to the vocal register used. The 59
singers did not present organic alterations in the vocal folds. A speech and language
pathologist specialized in voice, analyzed the phases of the glottic cycle, separating
the singers into two groups: the first was formed by the singers who presented open
phase predominance (OPP) and the second, by the singers who presented both,
closed phase predominance (CPP) as well as phases of similar duration (PSD). CPP
and PSD were included in the same group because these are the two expected
patterns in the normal phonation of the modal register. The result obtained was 30
singers (10 male and 20 female) with OPP, who constituted the group I, and of the
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other 29 singers (14 male and 15 female), 25 presented CPP and 4 PSD, constituting
group II. Later, electroglottography and acoustic analyses were performed by means
of the Tiger Electroglottograph EGG-PC3, developed by Tiger DRS. Electrodes were
placed on the wings of the thyroid cartilage, at the level of the vocal folds. For the
acoustic signal it was used a condenser microphone Shure Beta 87A, which was
placed at 10 cm from the mouth, in an angulation degree of 45. The singers were
requested to emit the vowel /e/ with the same instructions given in the transnasal
videostroboscopy examination. The signals were digitalized in 16 bits/44 KHz. The
recordings were performed in a room without any special acoustic treatment but not
excessively noisy. The singers remained seated during the recording and they were
controlled so that they did not move their necks during the test. In the same way,
prior to the recording of the EGG signal, it was verified that the electrodes had been
placed in optimum position by means of a pre test in which the electrodes were
moved around till the best EGG signal was engaged.
By means of the Dr Speech version 4 program, Vocal Assessment module, the
following qualitative aspects of the EGG were assessed: Predominant phase of the
glottal cycle (Closed, open or similar duration), frequency regularity, amplitude
regularity, Presence of the knee of opening phase. The quantitative parameters of the
EGG assessed were: Fundamental frequency mean (EGG-Mean F0), Standard
deviation of frequency (EGG-DE F0), Contact quotient (CQ), Contact index (CI),
Contact quotient perturbation (CQP), Contact index perturbation (CIP), Closure rate
(CR), which is an indicator of the speed of closing of the vocal folds, Opening rate
(OR), which is an indicator of the speed of opening of the vocal folds, Normalized
noise energy (EGG-NNE), Harmonics-to-noise ratio (EGG-HNR), Signal-to-noise
Ratio (EGG-SNR), EGG-Jitter PPQ (Period perturbation quotient), EGG-Shimmer
APQ (Amplitude perturbation quotient), Glottic closure time and Vocal fold
regularity. Besides, Jitter PPQ, Shimmer APQ, NNE, HNR, SNR and Ratio were
analyzed from the acoustic signal.
When it was necessary, the Students t-test was performed and Stadistical
significance level was established in alpha 0, 05.
Results:
In the analyses performed on the qualitative parameters, it was found out
that the predominant phase in group I was the open phase in 100 % of the cases and
in group II, the closed phase with the 69 % of the cases, 27,6% presented phases of
similar duration and 3,4% predominant of the open phase. The EGG wave resulted
more frequently irregular both in frequency as well as in amplitude in group I (46, 7
% and 60 % respectively) with respect to the group II (24, 1 % and 41, 4 %). The knee
of opening phase appeared less frequently in group I (43, 3 %) than in group II (69%).
In the analysis of the quantitative patterns, it was found out that the CQ was
inferior in group I (43,3 %) with respect to the group II (55,3 %), with highly
significant differences (P<0.0001), The OR value was inferior in group I (66,1%) with
respect to the group II (70,7%), with significant differences (P: 0.0018). CQP value
was significantly higher in group I (2, 84 %) with respect to the group II (1, 61 %) (P:
0.0174), the same happened with CIP (group I: 13, 21 %; group II: 7,84 %; P: 0.0478).
CI was higher in group I (-0,32) with respect to group II (-0,41%), with significant
differences (P: 0.0021), the same happened with CR (group I: 33,8 %; group II: 29,21
%; P: 0.0018). The glottic closure time was decreased in 16 % of the cases in group I,
while in group II, was normal in 100 % of the cases. Although this parameter showed
in group I a small percentage with a reduction of the closure time, it did not appear
with the expected frequency previously obtained with other qualitative and
780
quantitative parameters as the predominant phase of the glottal cycle and the CQ.
The vocal fold regularity proved to be irregular in group I in 50 % of the cases (Slight
Irregularity:10 %, moderated Irregularity 10 % and severe Irregularity 30 %) and in
group II it appeared irregular in 24,1% of the cases (Slight Irregularity : 3,4 %,
Moderate Irregularity 6,9 % and Severe Irregularity 13,8 %).
The noise measurements of the EGG signal did not prove to be statistically
significant but the significance value obtained was near the established one. The
EGG-NNE value was higher in group I (-21,5 dB) indicating a higher amount of
muscle noise than in group II (-24,9 dB) (P: 0.0554), the EGG-HNR and the EGG-SNR
values were lower in group I (24,7 dB and 23,3 dB) than in group II (28,06 dB and
26,6 dB) (P: 0.554 and P: 0.534). The EGG-Jitter PPQ and EGG-Shimmer APQ values
were higher in group I (0,64 % and 2,91 %) with respect to group II (0,47 % and 2,2
%), the differences were not significant.
In the acoustic signal only two parameters presented significant differences:
NNE, being higher in group I (-12,5dB) with respect to group II (-15,4dB) (P: 0.0025)
and Ratio which turned out to be lower in group I (38, 7%) than in group II (40, 6%)
(P: 0.0482).
Figure 1 shows the EGG wave in a singer of the group I (left) and in a singer
of the group II (right). The singer of group I showed open phase predominance, the
singer of group II showed closed phase predominance. The knee of opening phase
was observed only in the singer of group II. CQ was higher in group II (58,03%). The
red lines show the point of maximum glottal closure, which allows to observe that
the speed of closing is lower in the singer of the group I, this is corroborated by
higher value of CR.
Figure 1. EGG wave in a singer of the group I (left) and in a singer of the group II
(right)
Conclusion:
The results show the usefulness of both, the qualitative and the quantitative
aspects of the EGG to differentiate the vocal function altered by the reduction of the
glottic contact time in singers, from the normal vocal function.
All the qualitative parameters studied proved to be useful to tell differences.
The quantitative parameters with higher significance to differentiate the two study
groups were CQ, CI, CQP, CIP, CR and OR, which provide information with respect
to the glottic contact, the vibratory regularity, the vibration symmetry and the speed
of closing and opening of the vocal folds. The Vocal Fold Regularity and the noise
measures of the EGG signal (EGG-NNE, EGG-HNR y EGG-SNR) were also very
useful.
781
-Relating the data obtained with the videostroboscopy examination, the

electroglottography and the acoustic analysis, in group I was obtained predominance
of the open phase, with a low CQ and lower glottic contact speed (high CR) with
respect to group II, what results in a low level of energy in the region of the Singing
formant. It is for this reason that a low Ratio value was obtained, which studies the
energy region of the 2 to 4 KHz. On the other hand, in group II, in most cases it was
obtained the predominance of the closed phase, with a high CQ, higher glottic
contact speed and a higher Ratio value.
References:
Behlau, M., Madazio, G., Feij, D., Pontes, P.: Avaliao de voz. In: Voz O Livro do Especialista.
Volume I. Ed. Revinter, pp 85-245. Rio de Janeiro, 2004.
Miller, D.: Resonance in Singing. Voice Building through. Acoustic Feedback. Inside View
Press. Unites States of America, 2008.
782
FP22.3
TAPE
AUTHENTICATION
AND
VOICE
A CASE STUDY IN FORENSIC ACOUSTIC PHONETICS
Paul
Corthals1,2
John
Van
IDENTIFICATION:
,
Borsel2,
Kristiane Van Lierde2
Faculty of Health Care Vesalius, University College Ghent, Belgium
Faculty of Medicine and Health Sciences, Ghent University, Belgium
Classic voice and speech pathology metrics can be relevant in the realm of
forensic science. This report is about a case of threatening telephone calls. Tape
authentication was done by visual and statistical analysis of pitch and loudness
contours. Voice identification was done by means of a voice line-up (judging
differences and similarities in a series of matched voices). The first formant and its
relative position vs. the fundamental and the second formant have some potential as
speaker-specific features for voice identification.
Introduction and aims of the study.
Forensic phonetics has no definitive set of target parameters and no
universally accepted protocol to underpin speaker identification or tape
authentication procedures. Experts have to adapt their methods to the available
material in each case. The purpose of this paper is to explore the potential of acoustic
analysis of the voice fundamental and formant structure as speaker-specific features
and to document the feasibility of a voice line-up protocol in a case study on
threatening telephone calls.
Audio tapes are often used as evidence in courtrooms. In this type of cases,
voice identification is crucial (i.e. asserting that the defendants voice is, or is not
identical to a recorded voice). Involvement in a crime can be proven by a recording
of compromising statements only if there is no doubt that the recorded voice is
indeed the defendants voice. Furthermore, there are situations where possible
tampering can bring doubt on an audio recording unless proper authentication has
been conducted. This report is about a case of threatening telephone calls. The
authors were asked to authenticate a recording (i.e. asserting that essential features
of two recordings are identical) and to identify a voice on it.
A police copy of an original exhibit tape was authenticated by detailed visual
and statistical comparisons of the pitch and loudness contours from the recorded
utterances with those from a copy of this original analogue tape made by the authors
themselves. Voice identification was done by means of a voice line-up, i.e. judging
the similarity between three acoustic-phonetic features in a series of voices
(including the defendants voice) on the one hand and the voice on the exhibit
recording on the other hand.
783
Methods.
Methods for tape authentication
In order to examine the authenticity of the digitized police copy of a tape, a
new digitized copy of the original recording was made (44 kHz sampling rate wave
files were created using Praat software version 4.3 on a personal Dell Latitude D800
computer). Subsequently, pitch (fig. 1a and 2b) and loudness (fig. 2a and 2b)
contours were drawn and superimposed for visual inspection. Pitch and loudness
contours were produced using standard Praat algorithms. Visual inspection by
super-positioning the contours was used to identify non-coinciding intervals due to
possible
tampering.
12
10
0
30
50
75
100
125
150
175
Fo in Hz
200
225
250
275
0
30
300
50
75
100
125
150
175
Fo in Hz
200
225
250
275
300
200
175
175
150
150
130
125
100
100
75
75
fragment 15 seconden
19 % stemhebbend
fragment 13 seconden
50e percentiel 130 Hz

gemiddelde 191 Hz
132
125
29 % stemhebbend

gemiddelde 139 Hz
Fig.
1a
(left)
and
1b
(right).
Pitch contours of the authors copy (1a) and police copy (1b) of the original tape.
86.69
48.64
0
11.7276
Time (s)
83.32
47.34
0
10.1068
Time (s)
Fig.
2a
(top)
and
2b
(bottom).
Intensity contours of the authors copy (2a) and police copy (2b) of the original tape.
784
After visual inspection of pitch and intensity contours, listings of

instantaneous sound pressure levels of corresponding fragments from both the
authors copy and the police copy were produced. Since the output signals of tape
recorders can be damaged by noise, interference and distortion and because of the
bandwidth of telephone lines that limit voice frequencies to between 300 to 3500
hertz, not all fragments of the recordings could be used. Eight fragments, containing
11 words, and corresponding to 7 seconds in total (i.e. 50 % of the total message
duration) were selected for analysis. These fragments were chosen because they were
relatively intense and had a good signal-to-noise ratio. A Pearson product moment
correlation was calculated for each of the 11 sets of corresponding intensity values
using SPSS 10.1.
Methods for voice identification A sample of the defendants speech was
recorded in a sound treated room in wave sound file format using a Computerized
Speech Lab CSL4300 with a 44 kHz sampling rate. To that purpose, the language
content of the usual testing protocol for new speech pathology clients was adapted to
include specific words that were also used in the court exhibit tape (declarations to
inflict harm on a person). The defendant was given a reading assignment, in which
the target words appeared in a neutral context. The same assignment was given to
three other speakers, matched in age and gender to the defendant. The recording
sessions resulted in 4 samples each containing the target words. From these target
words 9 vowels were drawn, which differed phonetically in height and tongue
position. They were compared with the equivalent passages in the exhibit recording
(fig. 3) using a t-test in SPSS 10.1. These comparisons were done for three specific
acoustic phonetic vowel features, all relating to the first formant. These were (a)
absolute value of the first formant, (b) relative position of the first formant and the
fundamental, (c) relative position of the first formant and the second formant. F1related features were chosen, because F1 is a function of the dimensions of the vocal
tract and it is the most salient formant when it comes to energy. For each of the three
features, data were collected on total 63 points on the time axis. They were compared
with the equivalent passages in the exhibit recording (fig. 3).
785
DEFENDANT
speech
sample
Comparison
D
MATCH1
speech
sample
Comparison
C
EXHIBIT
speech
sample
MATCH3
speech
sample
Comparison
A
MATCH2
speech
sample
Comparison
B
Fig.
Voice line-up protocol.
3.
The core acoustic feature here is the first formant (F1). This is a deliberate
choice, since F1 values are a function of the dimensions of the vocal tract and since it
is the most salient formant when it comes to energy. Under the hypothesis that the
defendant is NOT the speaker in the exhibit recording, all comparisons should yield
significant differences. Alternatively, if the defendant is in fact the speaker in the
exhibit recording, A-type comparisons should yield NO significant differences, while
the other types of comparisons should all yield significant differences.
Results.
Tape authentication
Visual inspection of the super-positioned pitch and intensity contours
revealed no clearly differing stretches. The correlations between the sound pressure
level listings of corresponding utterances were all significant (p < .001), yielding
correlation coefficients between 0.804 en 0.987. Based on these results, the authors
concluded that the police copy was essentially identical to the original exhibit
recording and that it therefore was not tampered with.
Voice identification
Table 1 is an overview of the statistical results. If the defendant is in fact the
speaker in the exhibit recording, A-type comparisons should yield NO significant
differences, while the other types of comparisons should all yield significant
differences. The cells in bold text and the significant results marked with a double
asterisk (**) (i.e. 10 on a total of 12 tests) corroborate the view that the speaker in the
exhibit recording and the defendant are the same person. The chance of obtaining 10
hits in 12 trials is less than 5% (the exact binomial probability is 1.6%).
Comparison A
(defendants
voice exhibit
recording)
Comparison B
(matched voice
#2
exhibit
recording)
Comparison C
(matched voice
#3
exhibit
recording)
Comparison D
(matched voice
#1 exhibit
recording)
786
Absolute value NO significant

difference
1st formant
p=0.300 **
Relative position NO significant
1st formant and difference
p=0.851 **
fundamental
Relative position NO significant
1st formant and difference
p=0.131 **
2nd formant
Significant
difference
p<0.001 **
Significant
difference
p<0.001 **
Significant
difference
p<0.001 **
Significant
difference
p<0.001 **
Significant
difference
p<0.001 **
NO
significant
difference
p=0.112
Significant
verschil p<0.005
**
Significant
verschil p<0.005
**
NO significant
difference
p=0.076
Table 1.
Differences of the voices recorded in the lab with the voice on the exhibit
tape. Results marked with a double asterisk (**) are in line with the hypothesis that
the speaker in the exhibit recording and the defendant are the same person. See also
fig. 3 for legend of A, B, C and D labels.
Conclusions
Classic voice and speech pathology metrics can be relevant in the realm of
forensic science. Analysis of suprasegmental features can help in tape
authentications. In this case, visual inspection of pitch and vocal intensity contours
and correlation of instantaneous speech sound pressure values for equivalent
stretches in two recordings (ours and a police copy) did not reveal major differences.
Therefore the police tape could be authenticated. As for voice identification, the first
formant and its relative position vs. the fundamental and the second formant have
some potential as speaker-specific features. In this case, verifying differences and
similarities in the defendants speech and the exhibit recording for these three
selected acoustic-phonetic vowel features yielded 10 results on a possible total of 12,
which lead to the conclusion that the speaker in the exhibit recording and the
defendant are the same person.
787
FP41.4
QUALITATIVE AND QUANTITATIVE ANALYSIS OF VOCAL DYNAMIC
VISUAL PATTERS
M.E. Dajer1, F.A. Andrade Sobrinho1, J.C. Pereira1
1 Electrical Engineering Department -School of Engineering of So Carlos (EESC)
University of So Paulo (USP), So Carlos, So Paulo, Brasil
Voice production is a complex and multidimensional process; consequently
one of the most important factors for a successful therapy is to assess the different
aspects of voice production. Perceptual evaluation, aerodynamic parameters and
acoustic analysis are some of the typical voice assessment tools. The combination of
different methods furnishes important morphological and functional information
about the vocal folds and the glottal waveform. Recent advances in signal processing
area suggest that nonlinear dynamic methods provide complementary and more
accurate information to the existing analysis methods. The purpose of this paper is to
assess and characterize normal and nodules voices using qualitative and quantitative
analysis of Vocal Dynamic Visual Pattern (VDVP), acoustic perturbation measures
and perceptual analysis. VDVP analysis is based on nonlinear techniques Phase
Space Reconstruction and Poincar Section and describes the underlying dynamic
of the vocal system. Methods: Ten voice signals from healthy people (4 females and 6
males) and ten voice signals from patients with vocal nodules (6 females and 4 men)
were analyzed. Sustained vowels /a/ from Brazilian Portuguese were recorded at
22,050 Hz sampling rate and analyzed in order to obtain qualitative and quantitative
measures of VDVP, perturbation measures jitter and shimmer and perceptual
characteristics. One-way ANOVA test was performed for mean values of
perturbation analysis and quantitative measures of VDVP. Probability values below
0.05 were considered significant. Results: The three evaluation techniques showed
consistent differences between the groups. Acoustic analysis and quantitative
measures of VDVP showed statistical difference. The results suggest that tools based
on nonlinear models seem to be a suitable techniques for voice analysis, due to the
nonlinear component of the human voice. Conclusions: However qualitative and
quantitative analyzes of VDVP do not replace the existing techniques, they improve
and complement the assessment tools available for phoniatrics and speech therapist.
Introduction:
Voice production is a complex and multidimensional process and the effect of
voice pathologies causes many physiological modifications that result in an
unhealthy pattern of vocal folds vibration. Consequently pathological voice
assessment should search the different aspects of voice production.
One of the most regular pathologies in voice clinic is the vocal nodules. They
are benign lesions of the vocal folds and usually interfere with vocal fold closure.
They typically occur as bilateral lesions and often result in a perceptual quality of
hoarseness during phonation and aperiodic acoustic waveforms.
Nodules voice quality is usually evaluated through a perceptual analysis
(PA), however it may present certain disagreement due to the subjectivity involved
in this process (Kreiman and Gerratt, 1998), (Bergan and Titze, 2001),(Oates, 2009). In
order to complement the perceptual analysis, Acoustic Analysis (AA) methods
788
provide noninvasive and objective perturbation measures such as jitter, shimmer.

However, Titze (1995) suggested that perturbation analysis might not be applicable
to aperiodic signals, as patients voices with benign mass lesions of the vocal fold.
In recent years, diverse techniques based on nonlinear dynamic models as
phase space reconstruction and Poincar Section - have been applied to investigate
the dynamic behavior of biomedical systems, including voice signals (Pitsikalis,B
2003); (Jiang,JJ et all 2009); (Scalassara, PR et al. 2009).
The purpose of this paper is to assess and characterize normal and nodules
voices using qualitative and quantitative analysis of Vocal Dynamic Visual Pattern
(VDVP), acoustic perturbation measures and perceptual analysis.
METHODS:
Data base
Twenty voice signals divided in two equal groups were analyze by means of
perceptual analysis, perturbation measures and qualitative and quantitative
measures of Vocal Dynamic Visual Patterns. The first group includes 10 acoustic
signals of healthy people (4 females and 6 males) ranging from 19 to 39 years old,
with no voice complaints and no laryngeal pathology. The second group includes
voice signals from people (6 females and 4 men) ranging from 21 to 40 years old with
vocal fold nodules in different stages of disease evolution.
All signals were from voice database of the Group of Bioengineering of the
School of Engineering of So Carlos of the University of So Paulo, Brazil. The
subjects were asked to produce a sustained vowel /a/ at a comfortable pitch and
loudness level for about 5 seconds. The microphone was placed at 45 degrees and 5
cm from the persons mouth. Consecutive trials were performed, selecting the signal
with less voice variability.
For data analyzes the beginning and ending of the signal were discarded; and
the amplitude of the signal was normalized according to its absolute maximum
value. All voices samples were quantized in amplitude with 16 bits and recorded in
mono-channel WAV format to preserve the fidelity of the signal. The sampling
frequency was 22,050 Hz.
For statistical analyzes we applied the one-way analysis of variance
(ANOVA) on perturbation measures and on quantitative measures of VDVP.
Statistical significance level was set at p = 0.05.
Perceptual voice analysis
In order to describe the vocal quality of the samples five specific parameter R
(Roughness); H (Harshness); B (Breathiness); A (Asthenia), and S (Strained quality)
were scored on a four-point scale: 0 for normal, 1 for slight deviance, 2 for moderate
deviance, and 3 for severe deviance. Results are denoted with capital letters for the
parameter and subscript number for the rate, as R1H1B1A0S0. These parameters and
scale were based on the GRBAS scale (Hirano, 1981)
A voice specialist performed the perceptual assessments with 30% of repetition
in order to assurance the jury reliability. The specialist scored 89% of consistency.
Perturbation measures
Traditional acoustic parameters of jitter and shimmer were analyzed for
normal and nodule voices. Voice recordings and voice analysis were performed
using Analise de Voz 6.0 (Montagnoli, 1998). Jitter percent was estimated from the
frequency perturbation measurements and shimmer percent from amplitude
perturbation measurements, using residue inverse filtering technique (Davis, 1976).
789
Vocal Dynamic Visual Patterns (VDVP)

Vocal Dynamic Visual Pattern (VDVP) analysis is run in Matlab 7.0 and
provides qualitative and quantitative measures for normal and pathological signals.
It was developed from space reconstruction technique with time delay technique
(Fraser, AM; Swinney, 1986) and Poincar Section (Kantz and Scheiber, 1997).
According to the embedding theorem (Abarbanel, 1996), the reconstructed
space can be formed by samples of the original signal delayed by multiples of a
constant time delay and defines a motion in a reconstructed multidimensional space
that has many common aspects with the original phase space. Figure 1 shows
examples of one cycle and 10 cycles wave and VDPV of the same sustained /a/.
Figure 1- Example of one cycle and 10 cycle waves and the VDVP.
Qualitative measures
VDVP describes the nonlinear dynamic characteristics of voice signal in two
or three dimensional plots. Therefore qualitative and quantitative measures from
these VDVP can be extracted. For qualitative analyzes we observed three
characteristics: number of loops (NL), trajectory regularity degree (TRD) and
convergence degree (CD).
These characteristics were scored on a five-point scale. For NL a decreasing
scale form 4 to 0 describes the VDVP configurations. VDPD with more than loops
are scored with 4 degree; 3 loops= degree 3; 2 loops= 2; 1 loop= 1, and 0= non
defined configuration.
Regularity of the trajectories was classified from 4 to 0. Where the highest
degree 4 corresponds to completely regular trajectories and the lowest degree 0 is for
completely irregular trajectories. Middle scores 3, 2 and 1 are different degrees for
combine behavior of regularity.
For trajectory convergence scores are: 4= trajectories with high degree of
convergence and 0= the lowest convergence; scores 3, 2 and 1 are different degrees of
convergence.
790
Quantitative measures
In order to quantify the behavior of the trajectory lines we performed and
algorithm based on Pointcar section to calculate the dispersion of points in one or
more sections in the VDVP. The number of points is not always accurate because it
depends on the jitter of the signal. Previous tests showed that this error is about 2
points.
To determine the Pointcar Section we first select a tangent line in a trajectory
segment. Then we select three points that determine the region for Poincar section
or cut region, and two other points for establish the perpendicular line to the
Poincar plan. Figure 2 shows the selected points and graphically describes these
procedures.
Figure 2- Example of Poincar section. P1-P2 is the tangent line; P3, P4 and P7 are
delimitating points; and P5, P6 and P7 are the orientation points for determine the
perpendicular line to Poincar section.
The next step is to calculate the dot product (see Figure 3A) between
the perpendicular line to Poincar plan and the lines formed by the midpoint
of the cut region with the other points of the cut region. Dot product near zero
guarantees that points belong to Poincar Section.
Subsequent to this procedure, a 3D rotation of the points is performed
using the perpendicular line to the plane. Next, all points will be parallel to
the x axis; then, all points are projected in the x=0 plane. In order to avoid the
correlation of the points we extract the principal components. Finally,
Poincar section is achieved. (Figure 3B).
791
Figure 3A- Determination of dot product. 3B Example of Poincar section.
In order to quantify the dispersion of the points, two parameters were

established using the traditional statistical methods:
DSD: Dispersion Standard Deviation - deviation from the midpoint of
the
section.
ASD: Axis standard deviation related the coordinate axes.
RESULTS
Perceptual voice analysis
Perceptual evaluation for all healthy voices showed that the five parameters
were classified with grade 0 or 1. Seven voice were classified with R1 and three
samples with R0 (Roughness); nine voices with H0 and 1 voice H1 (Harshness); nine
with B0 and one sample with B1 (Breathiness); all samples with A0 (Asthenia) and for
Strained quality five voices with S0 and 5 with S1.
Nodules voices presented 3 samples with R1 and 7 with R0 (Roughness); three
voices with H0 and 4 voice H1 and 3 H2 (Harshness); 3 with B0, 6 samples with B1 and
1 voice B2 (Breathiness); 9 samples were classified with A0 and 1 voice with A1
(Asthenia) and for Strained quality seven voices with S0 and 3 with S1.
Perturbation measures
Mean values, standard deviation and statistical significance level for jitter and
shimmer for both groups are shown in table I.
Table I: Results for perturbation measures jitter and shimmer
Healthy
Nodules
Mean
SD
Mean SD
p
Jitter %
0,509 (0,33)
1,65 (0,99)
0.0027
Shimmer
%
3,09 (1,21)
7,20 (2,06)
3,67 e-005
Qualitative measures
Generally healthy voices (Figure 4A) showed various loops configuration,
regular trajectory lines and a high degree of convergence while nodule voices (Figure
4B) showed minor loops configuration, irregular trajectory lines and lower
convergence degree. Figures 4A and figure 4B show two typical examples of healthy
and nodules VDVP.
792
Figure. 4A. VDVP of a healthy voice. 4B VDVP from a patient with vocal nodule
Results of qualitative analysis for loops, Regularity and Convergence

behavior for both groups are presented in table II.
Table II: Results for qualitative analyzes of VDVP
Loops
L4
L3
Healthy
8
2
_
_
Nodules Regularity Healthy

_
8
R4
3
2
R3
1
_
R2
6
_
R1
Nodules Convergence Healthy

_
7
C4
2
3
C3
4
_
C2
_
_
C1
L2
L1
L0
1
7
R0
C0
Nodules
_
1
Quantitative measures
VDVP of healthy and nodule voices were analyzed by means of ten Poincar
Section. Figure 5 shows an example of 10 Poincar Section in a healthy VDVP. The
Mean values of Axis Standard Deviation ASD and Dispersion Standard Deviation
showed statistical difference.
Figure. 5. VDVP of a healthy voice with ten Poincar sections.
Mean values, standard deviation and statistical significance level for Axis
Standard Deviation ASD and Dispersion Standard Deviation are shown in table III.
793
Table III: Results ASD and DSD of the Poincar Section Points.
ASD
DSD
Healthy
Mean
SD
0,197
(0,02)
0,0143
(0,004)
Nodules
Mean
SD
0,298
(0,05)
0,136
(0,029)
p
3,49 e-005
0,0004
Conclusion:
This paper shows that tools based on nonlinear dynamical methods, as phase
space reconstruction and Poincar section seem to be suitable techniques for voice
signals analysis, because of the chaotic component of the human voice.
Vocal Dynamic Visual Pattern qualitative analysis has shown a potential value
to describe normal and nodules voices. The standard healthy VDVP of vowel /a/
showed complex configuration and nearly periodic behavior, while nodules voices
presented simpler loops configuration, irregular trajectory lines and lower
convergence degree.
Our results also suggest that parameters as jitter and shimmer, as well as,
perceptual can be correlated to the VDVP quantitative and qualitative analysis. We
observed that voice signals with higher shimmer are separated and disperse among
themselves and presented higher values of Standard Deviation ASD and Dispersion
Standard Deviation in the Poincar Section.
We consider that traditional perturbation analysis and perceptive evaluation
associated with quantitative and qualitative analysis of the VDVP provide more
information and represent a non-invasive and helpful tools to describe objectively
the vocal folds dynamic.
References:
Titze IR: Workshop on Acoustic Voice Analysis: Summary Statement. Denver, National
Center for Voice and Speech, 1995.
Kreimana, J. Gerratt R. .Validity of rating scale measures of voice quality J. Acoust. Soc. Am.,
Vol. 104, No. 3, Pt. 1, September 1998
Bergan CC; Titze IR Perception of Pitch and Roughness in Vocal Signals with Subharmonics
Journal of Voice, Vol. 15, No. 2, 2001
Oates, J Auditory-Perceptual Evaluation of Disordered Voice Quality. Folia Phoniatr
Logop;61:4950 56. 2009
Pitsikalis,B; Kokkinos,I; Maragos, P. Nonlinear Analysis of Speech Signals: Generalized
Dimensions and Lyapunov Exponents. Proc. European Conf. on Speech
Communication and Technology - Eurospeech Geneva, Switzerland , 2003
Jiang,JJ, Zhang,Y; MacCallum, J; Sprecher, A; Zhou, L. Objective Acoustic Analysis of
Pathological Voices from Patients with Vocal Nodules and PolypsFolia Phoniatr
Logop;61:342349. 2009
Scalassara, PR; Dajer,ME; Maciel, CD; Guido, CR; Pereira, JC Relative entropy measures
applied to healthy and pathological voice characterization. Applied Mathematics and
Computation 207 95108 (2009)
Hirano M. Clinical examination of the voice. New York: Springer Verlag,1981:81-84.
Davis S B. Acoustic characteristics of normal and pathological voices. Academic Press Inc,
Santa Barbara, CA, 1976.
Montagnoli, A. N. Anlise Residual do sinal de voz. So Carlos Dissertao de estrado
Dissertao de Mestrado Universidade de So Paulo Campus de So Carlos, 1998.
Fraser, AM; Swinney, HL. Independent coordinates for strange attractors from mutual
information. Phys. Rev. Lett. 1986, vol. 33, pp. 1
Kantz H; Schreiber, T. Nonlinear Time Series Analysis. Cambridge University Press,
Cambridge (1997).
Abarbanel, H. D.I. Analysis of Observed Chaotic Data, Springer-Verlag, NewYork, 1996
794
795
FP18.1
A VOICE CASE STUDY:
WHEN THE DOCTORS SAID THERE
WAS NOTHING MORE THEY COULD DO
D.S. Davis
The Davis Center, Succasunna, NJ. USA
Client VS1 after a thyroidectomy lost her ability to speak well and articulate
clearly. A vocal cord injury was reported secondary to the thyroidectomy. After
numerous physicians and tests, she was told there was nothing more they could do.
She reported that she had made little progress since her surgery. Dysarthria,
inability to be heard, vocal fatigue, hoarseness, and poor articulation were described
when she initially came for services. VS1 sought out The Davis Model of Sound
Intervention in August 2007. As VS1 presented with yet untreated considerations
with The Davis Model, a Case Study was undertaken to determine if positive change
was possible with this unique approach.
The Diagnostic Evaluation for Therapy Protocol (DETP) was administered
initially to determine the appropriate sound-based therapies needed to accomplish
the possibility of positive change. The Davis Model of Sound Intervention was
initiated and three sound-based therapies were administered: Auditory Integration
Training, a Listening Training Program, and BioAcoustics. Continuation programs
were administered when follow-up testing indicated the need. A videotape of VS1
before starting the sound-based therapy protocol was taken. Subsequent videotape
footage was captured after two years of therapy. Voice recordings were taken pre,
mid and post therapy intervention.
After 2 years of following the suggested sound-based therapy protocol,
defined by the Diagnostic Evaluation for Therapy Protocol (DETP), VS1s speech is
clearly articulated and understood, hoarseness has disappeared, and vocal fatigue is
gone. A breathy quality has remained.The Davis Model of Sound Intervention is a
possible viable approach to support positive change for vocal cord injuries, vocal
fatigue, articulation issues, and hoarseness. Additional case studies can be initiated
in order to determine if a larger study should be conducted.
Client History
VS1 was 49 years old when she first came to The Davis Center for services.
She was referred by her violin instructor, who had researched the concepts of The
Davis Model of Sound Intervention. At age 48, she was diagnosed with bilateral
thyroid nodules which were growing rapidly with the left greater than the right. Her
vocal cords were both mobile. A total thyroidectomy was done. She had a history of
chronic sinusitis.
A vocal cord injury secondary to the thyroid surgery was noted. The tumors
had to be pulled off of two nerves during surgery. The surgeon indicated that the
right nerve was not severed during surgery. The left vocal cord was clear and
mobile. The right cord was mobile but not moving as well. Trauma to the recurrent
laryngeal nerve was reported. On her one month post surgery visit, a right paralytic
cord was reported. Four months after surgery, the right cord was moving very well
with no paralysis. Her voice was fatiguing easily; her voice would get soft after
talking for awhile. She was hoarse and her voice was off.
796
Six months after surgery, she saw an ENT physician. His report suggests that
she was complaining of dysarthria and the inability to be heard and understood. She
had a halting speech pattern, and although her voice got better, the articulation did
not. Her voice was characterized by hoarseness, vocal fatigue, and volume
disturbances.
His report suggests that there is reduced diadochokinesis and loss of
articulation of the plosives as well as consonants. Her transition from consonants to
sustained vowel is poor and lacking precision. There was no obvious tongue motion
abnormality, however evidence of tongue fasciculation was present. Laryngeal
examination showed good vocal fold motion with only a slight, subtle right paresis.
There was reduced diadochokinesis to the right and left vocal folds as well. In the
physicians impressions, he suggested that VS1 appeared to have suffered dysarthria
and dysphonia with subtle findings of palatal incompetence as well as laryngeal
tongue involvement. There is evidence of tongue fasciculations. As a result, the
evidence pointed to a central neurological disorder and not a peripheral laryngeal
nerve disorder. Subsequent MRI testing was normal.
Initial Intake Information
VS1 contacted The Davis Center seven months after surgery as she reported
that no change was significantly made in the 7 months. All clients utilizing The
Davis Model of Sound Intervention must initially received The Diagnostic
Evaluation for Therapy Protocol (DETP), a diagnostic evaluation that determines if,
when, how long, and in what order any or all of the many different sound-based
therapies can be appropriately applied. A sound-based therapy uses the vibrational
energy of sound with special equipment, specific programs, modified music and/or
specific tones/beats, the need for which is identified with appropriate testing. VS1
received the DETP on 8/20/07.
Initial Intake information also revealed that VS1 had always been affected by
allergies, and had been prone to sinus infections. She had four surgeries over time to
remove nasal polyps. She was prone to migraine headaches often triggered by light
flashes. She was more sensitive on the right side. Prior to her surgery, she was
sensitive to loud sound and thought movie theaters were too loud to attend. She also
reported both mental and physical abuse by her mother. Her mother would hit her a
lot on her face, often more on the right side than left, until age 30. She also yelled
and screamed at her a lot. She had not spoken with her mother in over ten years and
her sister for longer than that. She had been married for 9 years on the initial
testing date.
Her voice quality was so soft that it was difficult to hear her speak. She used many
w/r substitutions and sounded like a little child learning to speak. She speech
patterns were also not rhythmical.
Background on The Davis Model of Sound Intervention
The Davis Model of Sound Intervention is a unique approach blending 3 tenets4:
1. There is a connection between the voice, the ear, and the brain. Five laws
support this connection. Three were identified by Dr. Alfred Tomatis and
were presented to the French Academie of Science in 1957. They became
known as The Tomatis Effect and in summary suggest that the voice
produces what the ear hears and when the correcting sound is reintroduced
to the ear, the voice regains coherence. The remaining two laws were
4
For more information, visit http://www.thedaviscenter.com/davis_model.html.
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identified by D. Davis and presented to the Acoustical Society of America in

2004. They became known as The Davis Addendum to the Tomatis Effect and
in summary suggest that the ear also emits the same stressed frequencies as
the voice and when the correcting frequency is introduced to the body, the
voice regains coherence.
2. Every cell in the body is a resonating entity, both emitting and receiving
sound frequencies. As such, every part of the body responds to its correlating
sound frequency. By reintroducing the correcting/balancing frequency, the
body regains stability.
3. The ear is our bodys global sensory processor, not just a hearing mechanism.
Because of the way the body responds to sound wave vibrations, all of the
sensory information of the body can be stimulated through the ear.
In addition to the 3 tenets, all sound-based therapies are not the same. The
Tree of Sound Enhancement Therapy was created to provide a developmental flow
chart for the correct administration of any sound-based therapy. The DETP is based
upon this flow chart, and offers an assessment testing ones sense of hearing, sound
processing skills, auditory processing skills, otoacoustic emissions, and a
measurement of the persons vocal frequencies. The interpretation of the results
formatted the protocol for change.
Sound Protocol for VS1
The results of VS1s DETP identified many issues associated with the
connection between the voice, the ear, and the brain.
She demonstrated
hypersensitivities to sound in three different ways. She demonstrated sound
processing issues within vestibular, language, and attention/focus skills, as well as
processing sound patterns more quickly through bone conduction vibration. She
had difficulty identifying differences between pitches. Her voiceprint demonstrated
many irregular patterns. These results demonstrated that sound-based therapies
could make foundational change for her.
The protocol established followed in this order:
1. The first therapy suggested was Auditory Integration Training, which
repatterns the acoustic reflex muscle in the middle ear cavity. There are 3
possible therapies at this level. VS1 used Berard Auditory Integration
Training. This therapy is associated with the Root System of The Tree of
Sound Enhancement Therapy.
2. In order to address VS1s specific wellness challenges brought about not only
from the surgery, but overall wellness, BioAcoustics was suggested to be
implemented at the same time as Auditory Integration Training.
3. Once Auditory Integration Training was finished, a Listening Training
Program was suggested, which represents the Trunk of The Tree analogy.
This program is modeled after the work of Dr. Alfred Tomatis and while
there are a few programs to choose from, the Tomatis Method was used
with VS1. This program supports how the body processes sound through the
reception of sound by the air canal of the ear and the bone response of the
entire body. Then the work is supported by introducing the voice of the
person so that they can self-modulate their vocalizations.
After the therapies, VS1 reported the following changes:
1. After Auditory Integration Training:
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a.
b.
c.
d.
e.
f.
g.
h.
The quality of her voice improved a lot

Speech became easier to produce
She could converse more easily without tiring
She felt others could understand her speech more easily
Her articulation improved
She became less shy
She had fewer allergic reactions.
She was able to listen to music at a higher volume and no longer wore
ear plugs.
2. After BioAcoustics (This science uses the Frequency Equivalents of body
irregularities and by reintroducing the irregular frequencies to the ear, the body
works towards stability.):
a. The muscles of the tongue and its supporting nutrients were stimulated,
and
enhanced and as a result, articulation was clearer.
The orbicularis oris muscle of the mouth provided better support for
articulation.
c. The leukotrienes associated with her allergies decreased and her allergic
responses were fewer.
3. After the Tomatis Method:
a. She could hear her own voice better
b. Others said that her voice was stronger.
c. She felt she had fewer problems communicating her thoughts.
d. New concepts came more quickly to her.
e. She was better able to memorize music
f. Her vocal range improved.
g. Her articulation was much clearer.
b.
Over time, her friends and family all report that they can finally understand
her again. The initial changes occurred within 3 months. Her therapy now comes in
maintenance sessions only to help her maintain and support her progress. On her
last visit, all articulation was clear and precise. Her voice was only slightly breathy.
She reports that she is a happier person, can do more for herself and is looking ahead
to her 50s being the best decade of her life. She restarted playing the violin, began
painting more, and reports feeling free.
Summary
VS1 was helped with The Davis Model of Sound Intervention to regain her
use of her voice after a thyroidectomy appears to have affected initially her vocal
cords and other nerve/muscle innervations needed to speak. Three specific
therapies based upon The Tree of Sound Enhancement Therapy were used: Berard
Auditory Integration Training, the Tomatis Method, and BioAcoustics. VS1
improved her voice quality, articulation, vocal range, and strength of her voice, in
addition to supporting her tongue and mouth muscles and nerves, her musical skills,
and her communication skills. The combination of the therapies defined by the
DETP provided the correct foundational sequence for the changes to occur.
Dorinne Davis can be contacted at ddavis@thedaviscenter.com
Or c/o The Davis Center, 19 State Rt 10 E., Ste 25, Succasunna, NJ 07876
Trademarks
799
Tomatis assigned to TOMATIS: N 3291182

DETP, The Tree of Sound Enhancement Therapy assigned to The Davis Center.
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SY02A.1
FROM VOCAL FOLD VIBRATION TO VOICE ACOUSTICS
D. D. Deliyski
University of South Carolina, Columbia, South Carolina, USA
The vibration of the vocal folds during phonation is a leading causal factor in
producing sound pressure changes, i.e. acoustic energy, termed voice. Acoustic
measures characterize objectively the voice characteristics, but there is insufficient
evidence regarding their physiological validity. Little direct data about the
correspondence of the acoustic features to the actual biomechanical vibration of the
vocal folds has been reported. The technological advancement in high-speed
videoendoscopy (HSV) allowed for capturing unprecedented details about the
biomechanics of laryngeal sound production, allowing for imaging with high
temporal resolution and precise synchronization of the vocal fold vibration to the
acoustic signal. The purpose of this lecture is to summarize our recent progress
through several studies addressing this relationship. (1) HSV was used to validate an
acoustic-electroglottographic measure of vocal attack time. (2) Another HSV-based
study found that acoustic jitter is not proportional (as thought) to the variations of
the glottal period and that it is better explained by the fluctuation of intra-cycle
features. (3) It was also found that the jitter in the acoustic voice signal does not
relate to vocal fold vibratory asymmetry but rather to its variation. (4) Respectively,
acoustic shimmer is best explained with the HSV-based variations of the open
quotient. (5) Recent findings cautioned us that the inherent delay between the vocal
fold vibration and the resulting acoustic waveform may vary to become significantly
greater than the commonly-accepted estimates based on the distance from the larynx
to the microphone divided by the speed of sound. These initial results warrant
further research to better understand and re-evaluate the use acoustic analysis for
functional voice assessment.
801
FP32.1
Voice Problem and Its Symptoms in Elementary School

Teachers
Faham M*5, Jalilevand N6, Torabi Nejad7
1 * Shyraz University of Medical Sciences (S.U.M.S), Department of speech-language pathology
2 Iran University of Medical Sciences (I.U.M.S), Department of speech-language pathology
3 Iran University of Medical Sciences (I.U.M.S), Department of speech-language pathology
Introduction:
The teachers usually speaks with loudness higher than normal for continues
times of teaching in the class. This long time using of the voice with high intensity
will cause some negative effects on voice characteristics as like as glottal closure
pattern, changes in feature of vocal cords.
The voice that has some abnormality may bother the audiences and may be
distracting their attention. For a teacher in this situation it is a negative factor in
teaching affair so that the students cannot concentrate on his utterances. Thus an
incorrect cycle will be creating when Teachers try to compensate this deficiency by
adding more force to their voice.
Rogerson & Doddt (2004) studied the effect on disordered voice of a teacher
on students verbal processing. It was shown that children's' uptake from reader with
normal voice were clearly more than one with voice difficulties (6).
Prevalence of voice disorders among teachers is high. It was reported that
51.4% of 504 Italian teachers experience voice disorders across their lifetime (1). But
unfortunately they rarely refer to voice clinic. May be they do not know where they
should go or what they should do. Most of them think that this is normal in their jobs
(7).
The aim of this study is to determine the prevalence of voice disorders and
frequent symptoms of voice disorders among elementary school teachers.
Method:
This is a descriptive study. In this study we evaluated 398 teachers (373
Female-25 Male) with an age ranging between 22 and 58 years, randomly choice in
schools of Tehran.
We gather the data in a silent room with 40-45 SPL by using:

1. An interview
At first the examiner do an interview that contains: Age, work experience (in
year), any feeling of voice problems.
Then the examiner explains about 9 symptoms of voice problem that they are a
below:
802
1) Hoarseness 2) pitch break 3) pain in the throat 4)breathiness 5) aphonia

6)strain and struggle 7)vocal fatigue 8) reduced vocal range 9) tremor(4)
2. A voice sampling during reading a standard Persian passage, sustained
vowel /a/, and counting 1-20:
The teachers must read a passage by their normal voice with regards to the
examiner explanations. After that they produce a sustained vowel/a/ and at the
end count from 1 to 20 slowly. All the voice samples of a teacher recorded to will
be analyses by Dr.Speech software and assess by the voice therapists for
perceptual analyses.
3. A perceptual assessment by 3 expert voice therapist:
Three expert voice therapists have been candidate for assessing the voice
samples. For this step the therapists should listen to the voice samples one by one
and fill the prepared forms. They should mark that the voice sample seem
normal or with voice problem; if the voice sample has a significant signs they
write in the appropriate field in the forms.
4. An instrumental assessment by Dr.speech software:
After finishing the sampling, we transfer the voice samples to speech
laboratory so that the sample will be analyzed by the software. It is an
original version of Dr.Speech software that exists in Iran University of
Medical Sciences. The software gives us a chart that shows the severity of 3
voice problem's signs as: Hoarseness, Breathiness, and Harshness. Then the
charts should be interpreted in the basis of the scores of each voice sample.
For example if a unique voice sample get 0 in breathiness it means that there
wasnt any diagnosed breathiness.
0= no sign 1= mild 2= moderate 3= sever
We analyze the data by discarepative statistics (mean and standard deviation)

and T-test.
Results:
The results from interviews show that teachers with self-reported voice
problems have more work experience (in year) than those who didnt report any
voice problem as shown in Table 1. The differences was significant (P<0.05).
Table 1: the mean of work experience (in year)
Female
Work experience(in Male
year)
With
voice 21.4
problem
Healthy voice
17.5
Work experience(in
year)
With
voice 23
problem
Healthy voice
19.8
24.37% of teachers (97 of 398) had self-reported voice problems. 95 of them

were female and 2 of them were male. Other 301 teachers in response to this question
that Do you feel any voice problem? Say NO but in the final stage of interview
they express that they had experience some of the symptoms that interviewer explain
803
about them. Only 34.22% (103 of 398) said "NO" in response to the question and
hadnt experience any symptoms.
By analyses the responses of the interview it is declared that hoarseness is the
most frequent complaints of the teachers.219 of teachers experienced this symptom.
104 of teachers (103 without self-reported voice problems and 1 with self-reported
voice problem) had experience none of the 9 symptoms.4 of the teachers had
experienced 8 of 9 symptoms (Table 2).
Table 2: the citation of symptoms by teachers
Symptoms
Hoarseness
Number
citation
219
Vocal fatigue
Pitch break
Aphonia
184
124
115
Breathiness
78
of Symptoms
Number
citation
and 75
of
Strain
struggle
Laryngeal pain
40
Tremor
24
Reduced
vocal 17
range
According to perceptual assessment 53.27%of teachers (212 teachers) were

diagnosed as having voice problems. 61 of 212 teachers had self-reported voice
disorders. On the other hand there were 36 teachers who had self-reported voice
problems but in perceptual assessment they diagnosed as healthy voices (Table 3).
Table 3: percentage of self-reported voice problems ( basis on perceptual assessment)
Voice
problems
Yes
Percentage
61
151
212
62.89%
50.17%
53.27%
No
Percentage Toral
Total
percentage
37.11%
49.83%
46.73%
100%
100%
100%
Self-reported
V.P
Yes
No
Total
36
150
186
97
301
398
The interesting item is that 151 of those 301 teachers who hadnt self-reported
voice problems in perceptual assessment diagnose as having voice problems.
In instrumental assessment we can utilize 341 of the voice samples because
the device couldnt analyze the remain voice samples because of some technical
errors. So we could analyze 341 voice samples.
The Dr.Speech software diagnosed voice problems in 68.09% (271 teachers) of
voice samples. In this group that had been diagnosed as having voice problems 252
of the samples were female (92.9%) and 19 of them were male (7.01%). In fact all the
male teachers had diagnosed as having voice problems. Among these 271 teachers
only 71 teachers had self-reported voice problems.
The software give the top score (=3) in all 3 voice disorder index to 66 of voice
samples. These situations called sever voice problems. On the other hand only 22 of
voice samples get the lowest score (=0) in all 3 voice disorder signs.
In Table 4 it was shown in detail.
804
Table 4: the number of voice samples in each voice disorder signs (basis on instrumental assessment)
Hoarseness
Signs
Teachers
Female
Male
Total
Harshness
40
133
83
66
165
23
64
70
36
40
35
211
15
15
18
40
148 *
36
40
36
229*
85
Breathiness
68
180*
24
65
72
The frequent scores in hoarseness were 1, in breathiness were 3 and in

harshness were 0.
Conclusion:
Among this group of teachers 24.37% of teachers had self-reported voice
problems. The frequent chief complaints of teachers were hoarseness (219 teachers),
vocal fatigue (184 teachers) and pitch break (124 teachers).
Simberg (2005) reported that 49% of their teacher's samples had experienced
1 or 2 symptoms of voice problems. The most frequent symptoms were: throat
clearing (29%), vocal fatigue (19%) pain in larynx(14%) and hoarseness(14%) (7)
According to perceptual assessment 53.27% (include 212 teachers,16 male
&196 female) had voice problems. 151 of these teachers with voice problems didnt
reported any voice problems. In fact, they didnt alert enough about their voices; or
maybe they get accustomed with their voice problems. In this case, it will be logic
that they rarely refer to voice clinic.
De Alvear RM et.al (2010) reported that 62.7% of the teachers were
experiencing voice disorders. They assess 282 teachers in a randomly selection
manner. He concluded that this voice disorders have an impact on psychological
work conditions (5).
Angelino M, et.al (2009) found that prevalence of voice disorders in teachers
is higher than other occupations (51.4% vs. 25.9%) across the life time. Women in
compare to men had a higher prevalence than men. They concluded that voice
problem in teachers in are in a higher rate that other occupation and this a treat for
their jobs (1).
Instrumental assessment declared that 68.09% of teachers had voice
problems. In this group of teachers 229 teachers with sever breathiness (=3), 72
teachers with severe harshness and 68 teacher with sever hoarseness were exist.
In Table 1 we can see that work experience (in year) in teachers with voice
problems is higher than in teachers with healthy voice. This can be logic. As increase
in years the teachers get old and because of hormonal change the larynx changes (8).
Plus this hormonal changes risk factors of voice problems in a classroom cause more
effort on teachers voice that worse the voice by passing years.
According to this finding it is clear that voice misuse and abuse are high in
teachers. But obviously these problems can be preventable. If teacher train to how to
use their voice appropriately in a noisy classroom decrease side effect of voice
overusing (3). Voice training in Iranian teachers should be considered as a preventive
factor.
805
References:
1.
2.
3.
4.
5.
6.
7.
8.
Error! Hyperlink reference not valid., Error! Hyperlink reference not valid., Error!
Hyperlink reference not valid., Error! Hyperlink reference not valid., Error!
Hyperlink reference not valid.. Prevalence of occupational voice disorders in
teachers. Prev Med Hyg. 2009 Mar; 50(1):26-32.
Atarzade A. Voice disorders because of vocal overusing. Iran rehabilitation
faculty.Tehran,Iran, 2000
Hyperlink reference not valid., Error! Hyperlink reference not valid., Error!
Hyperlink reference not valid.. Risk Factors and Effects of Voice Problems for
Teachers. J Voice. 2009 May 27
Colton RH, Casper JK & Leonard R. Understanding Voice Problems, Physiological
Perspective for Diagnose and Treatment. Philadelphia ,NewYork, LIPPINCOTT
WILLIAMS & WILKINS;2006
Hyperlink reference not valid., Error! Hyperlink reference not valid.. An
interdisciplinary approach to teachers' voice disorders and psychosocial working
conditions. Folia Phoniatr Logop. 2010; 62(1-2):24-34. Epub 2010 Jan 8.
Roggerson J& Doddt B. Is there Effect of Dysphonic Teachers Voice on Childrens
Proccessing of Spoken Language?, J Speech Lang Hear Res :47(3) pages:542-551;Jan
2004
Simberg S, Sale E& Lain A. changes in the Prevalence of Vocal Symptoms among
Teachers during 12 Years period. Journal of voice, volume 19,Issue 1, Pages :95-102,
March, 2005
Torabi Nejad F, Clinical Voice Assessment. Iran rehabilitation faculty. Tehran,Iran
2002.
806
SS12.2
FUNCTIONAL DYSPHONIA AND (C)APD: CLINICAL APPLICATIONS
I.Gielow
CEV - Centro de Estudos da Voz, So Paulo, Brazil
From the fifth month before a child is born, he or her auditory system is able
to be hearing, starting hearing sounds like his or her mothers heart beat. As the child
is born, the voice comes as the first way of communication: the cry.
There is a close correlation between the development of phonation and the
verbal perception ability of the child, mainly during his/her first year of life1. From
the first months of his/her life, the child is capable of distinguishing the differences
in plosive voice onset times, as well as identifying both the pauses that delimit the
syntactical elements of a phrase, and the modulations imposed by prosody on verbal
sounds 2. Babbling starts with specific patterns, which change with time, as a
function of the characteristics of the sounds of the language that the child hears in
his/her environment. As the child improves babbling relative to his/her mother
language, he/she also specializes his/her perceptive system as a function of the
verbal sounds present in the environment1.
However, at the same time, the child experiences a reduction both in the
capacity to identify and to produce the sounds not used in his/her mother language.
For this reason, there is usually an accent when one speaks non-native languages.
But, this is the way by which the child specializes his/her auditory processing and
the phonatory system.
Functional Magnetic Resonance images suggest that there are specific areas
engaged in the processing of emotions perceived in voice. Vocal perception ability
includes the perception of identity and emotional status of the speaker3; thus, babies
recognize their parents voice even when they do not yet recognize speech.
From the early infancy, the children follow vocal models and imitate vocal
patterns4. Some of them, during his or her development, may develop voice
disorders. Others may develop voice problems in the adulthood, related to voice
abuse or misuse. Some of these children and adults, however, may not be aware
about his/her voice problem. An important question, in those cases, is if the subject
has condition to be aware of his/her problem, that is, how is his or her auditory
feedback, or how is the possibility to a given subject to monitor his or her own
production.
Classical authors of voice therapy for children4,5, include in their
rehabilitation program suggestions for auditory training, such as monitoring the
childs own production, aware of the differences in voices, and hearing the voices of
others and the childs own voice.
The voice quality is directly related to the auditory monitoring abilities. In a
noisy environment, one unconsciously increases pitch and loudness. Individuals
with artificial pitch increase in their auditory feedback tend to adjust the pitch of
their voices6,7. A recent published study concluded that children with cochlear
implants who have better speech sound perception ability have lower degrees of
vocal auditory-perceptual deviations8.The auditory monitoring or feedback is one of
the processes that occurs in the central auditory nervous system, and it includes the
voice production self-monitoring.
807
A study9 applying the sound source localization test, the memory for verbal
and non-verbal sounds test, the speech-in-noise and verbal and non-verbal dichotic
tests in children with and without organo-functional dysphonia, concluded that the
group of children with dysphonia presented a tendency of CAPD.
Thus, one may suggest that it might be important, for management
considerations, to alert the voice specialists to investigate if the functional dysphonic
patient has some of the characteristics related to (C)APD, such as difficulties to hear
in noisy environments, to match the pitch or to perceive rhythms, to repeat melodies
or labeling sequences of sounds as high and low, according to their frequencies.
Some of the (C)APD manifestations may be screened by simple tasks, such as:
the sound source localization in five directions;
the verbal and non-verbal memory tests with 3 or 4 syllables, asking he/she
to repeat the model;
the ability to perceive temporal and frequency patterns - as short or long,
high or low sounds.
If the subject fails in one or more tests, she/he should be referred to a specific
CAP evaluation. However, even when the subject does not fail, it might be possible
to find some auditory processing disorder.
It is possible to find in the literature, since 196710, references about the
relationship between voice and (C)APD. Patients with poor hearing abilities, subjects
that do not have a good perception of what they are doing with their larynx, as well
as patients that present difficulties with the discrimination of frequency patterns and
with tonal memory would get benefits of auditory training. Even so, the assessment
of the (central) auditory processes is not a routine in the field of voice disorders
management.
It is known that primary functional dysphonias may occur due to the
incorrect use or misuse of the voice. This means that the use of the voice itself is the
main cause of the vocal alterations. These dysphonias have two main causes: lack of
vocal knowledge and deficient vocal model11.
A BJM Editorial in 199512 was dedicated to the doubts concerning etiology
and treatment of Functional Dysphonia. It commented about historical and modern
conventional treatment in speech therapy, referring that voice therapy is far from
standardised.In patients who fail to respond to conventional voice therapy,
additional support may be advocated, as the psychological cognitive behavioural
approach or the laryngeal electromyelographic biofeedback technique. Good results
were also claimed for massage of the laryngopharyngeal area. None of the
approaches, however, has been compared with a placebo or with no treatment12.
There are few references to auditory processing or monitoring abilities related
to dysphonia. One of them13 investigated the correlation between the vocal output
and the central auditory functions in relation to the frequency patterns and duration
patterns. 40 individuals, divided in a group of 20 subjects with complaints and/or
vocal disorders, and a control group with no voice complaints went through an
auditory evaluation as well as the PPS (Pitch Pattern Sequence) and the DPS
(Duration Pattern Sequence) tests14, which assess the ability to differentiate and
reproduce sequences of tones in different combinations of low/high and short/long
tones. The results indicated that G1 had statistically significant difficulties in
reproducing and naming the patterns of duration and frequency, indicating an
important relation between alterations in the vocal output and impaired central
auditory functions, as far as the perception of frequency and duration are concerned.
The results of the PPS and DPS tests may contribute to the enabling and the
therapeutic intervention programs for vocal disorders.
808
An auditory training consists of intensive experiences to improve the

auditory abilities. The processes and skills involved become stronger with the
repetitive practice.
A vocal training protocol based on the literature may consist of relaxation,
vocal warming up, articulation training, resonance, frequency, intensity and speech
rate control training, and melodic and prosody aspects of speech training. On the
other hand, an auditory training may consist of strategies to improve the following
aspects15,16:
i) The perception of the voice/hearing relationship;
ii) The auditory attention;
iii) The perception of the frequency patterns of vocal and non-vocal sounds:
perceiving and discriminating sounds regarding frequency, duration and intensity,
using a keyboard or special softwares and programs;
iv) The localization of the sound source;
v) The perception and the emission of high and low pitch sounds, soft and
loud sounds, the timbre discrimination, the perception by the patient of the voices of
the other ones and voice self perception and the resonance perception. The
perception and the production of different prosodic aspects, such as happiness,
sadness, frightness and tiredness might be explored.
vi) The perception and the reproduction of melodic patterns by humming or
labeling. It might be useful to practice how to match the pitch offering a visual clue
to help the patients perception.
vii) Rhythmic perception and production
viii) Listening and controlling voice intensity in noisy environments.
Despite the lack of studies designed to verify the efficiency and the efficacy of
the auditory training as a tool for voice therapy, when indicated, the clinical practice
reinforces that mixing some auditory training strategies to the voice exercises might
be a very good blend. The auditory training may help the patients with primary
functional dysphonia for the auditory monitoring of their voices and to improve the
perception of what they are doing with their larynx. At least, a specific auditory
training should be considered as an initial step of the vocal rehabilitation for these
cases.
809
P122
CAN THE PARALYZED VOCAL FOLD RESTORE VOCAL FOLD
VIBRATION
FOR
VOICE
IMPROVEMENT
IN
UNILATERAL
RECURRENT NERVE PARALYSIS?

Yoshihiro Iwata. Seiji Horibe. Tadao Hattori. Kazuo Sakurai. Kensei Naito. Hitosi
Toda.1
1
Fujita Health University School of Medicine Department of Otolaryngology, Toyoake City
Aichi prefecture , Japan
(*) Introduction and aims of the study

Patients with unilateral recurrent nerve paralysis present a symptom of weak
voice and difficulties in continuous long vocalizations because of their incomplete
glottal closure for phonation. For voice improvement, thyroplasty developed by
Isshiki has contributed to restore voice quality1). In this technique, the paralyzed
vocal fold is pressed from the outside of the laryngeal framework and the shape of
the vocal fold is changed to achieve long and loud phonation. However, vibration of
the paralyzed vocal fold is not taken into consideration in this method.
Here, we present our newly devised thyroplasty which enables the paralyzed
vocal fold to vibrate in patients with recurrent nerve paralysis and the post-operative
examination of phonation.
(*) Methods
Unique thyroplasty was performed in 9 patients with unilateral recurrent
nerve paralysis (composed of 8 males and 1 female with the age ranged from 33 to 77
years). Thyroplasty was performed under local anesthesia as described below. An
opening (6 10 mm) was created in the thyroid cartilage from the outside nearly at
the middle of the paralyzed vocal fold. A Gore-Tex sheet with a thickness of 0.3 mm
was cut into 6 mm wide strips and the strip was rotated and winded from the edge
to prepare a roll. The roll was inserted from the opening like a corkscrew and fixed
at the depth where phonation was improved. The paralyzed vocal fold was
expanded in front and in the rear by this roll. As a result, this vocal fold thinned and
gained muscle tonus.(fig. 1)
810
Phonation and vibration of the vocal fold were examined by the following
methods and the pre- and post-operative results were compared. Using the
phonatory function analyzer PS-77 and PIS2000 (Nagashima Medical Instruments
Co. Ltd, Japan), the maximum phonation time (MPT) (sec), strength of the sound
(dBspl), basic wave number of the sound (Hz), and the airflow rate (ml/sec) were
obtained. Using Visi-Pitch II, a sound analyzer obtained from KayPENTAX, pitch
perturbation quotient (PPQ), amplitude perturbation quotient (APQ), and noise-toharmonic ratio (NHR) were examined.
The vocal folds were photographed by a high speed camera at 3000 frame per
second.
Kay's image processing software (KIPS) from KayPENTAX was used for
image analysis.
Student's t-test was used to evaluate the significance of the observed
differences.
(*) Results
Immediate pre-operative results were compared to 4 and 6 months postoperative results. The results from 9 cases were the following.
In the patients' post-operative vocal self-evaluation, marked improvement in
phonation was observed for all cases.
The mean maximum phonation time was increased from 2.6 seconds (ranged
from 2.0 to 4.0 seconds) at the pre-operation to 11.5 seconds (ranged from 4.0 to 16.0
seconds) at the post-operation (p < 0.01).
Strength of the sound measured at 20 cm from the mouth was increased from
the pre-operative mean of 69.8 dBspl (ranged from 65.0 to 73.0 dBspl) to the postoperative mean of 76.8 dBspl (ranged from 66 to 81.0 dBspl) (p < 0.01).
The airflow rate was decreased from the pre-operative mean of 1078 mL/sec
(ranged from 380 to 1700 mL/sec) to the post-operative mean of 266 mL/sec (ranged
from 120 to 560 dBspl) (p < 0.01).
The results of sound analysis were as the following.
PPQ was decreased from the pre-perative mean of 4.08 (ranged from 2.40 to
6.53) to the post-operative mean of 0.95 (ranged from 0.42 to 3.0.0) (p < 0.01). The
pre-operative mean APQ was 8.72 (ranged from 2.26 to 13.25) and the post-operative
811
mean APQ was 3.66 (ranged from 1.55 to 4.375) (p < 0.01). NHR was decreased from
the pre-operative mean of 0.41 (ranged 0.28 to 0.458) to the post-operative mean of
0.19 (ranged from 0.07 to 0.20).
Laryngeal fiberscope examination revealed that the paralyzed vocal fold was
expanded in front and the rear and the border of the vocal fold thinned.
Observation of the vocal fold using a high-speed camera confirmed that the
paralyzed vocal fold vibrated in the middle. Although the vibration cycles of the
post-operative vocal fold were the same as those of normal vocal folds, the postoperative vocal fold tended to exhibit delayed phase.
(fig. 2 : case 71years old man left vocal fold paralyzed )
(fig 3 High-speed camera image: post-operation Point & Area FFT Analysis )
(*) Conclusions
812
Our thyroplasty markedly improved phonation of the patients. The voice

quality was improved in particular and the patients recognized that their voices were
almost completely restored.
The conventional thyroplasty improves glottal closure by pressing the entire
paralyzed vocal fold.
In this method, we suspected that the pressure applied on the vocal fold
might restrict vibration of the paralyzed vocal fold.
In our thyroplasty, the thyroarytenoid muscle of the paralyzed vocal fold
appears to be expanded by pressing a small part of the vocal fold by a Goro-Tex roll.
It is suggested that the membranous portion of the paralyzed vocal fold gains muscle
tonus as a result of the expansion. This muscle tonus seems to be effective for
vibration of the membranous portion, giving rise to vibration of the previouslyparalyzed vocal fold with the same vibratory cycle as the healthy vocal folds.
(*) Acknowledgments
I would like to express my sincere appreciation and gratitude to my
colleagues, my family and late Prof Shigenobu Iwata.
(*) References
1) Issiki, N. Morita, H.,Okamura, H,. and Hiramoto, M.: Thyroplasty as a
new phonosurgical technique : Acta Otolaryng 78: 451-457, 1974.
813
P182
ELECTROMYOGRAPHIC EVALUATION OF MANEUVERS OF SUPRAHYOID

AND
INFRAHYOID
MUSCLES
CONTRACTION
FOR
SIGNAL
NORMALIZATION
P.M.M. Balata1,2, G.K.B.O. Nascimento1, E.G.F. Silva1, S.R.A. Moraes1, R.A. Cunha1,
H.J. Silva1
1 Federal University of Pernambuco, Recife, Brazil
2 Institute of Human Resources of Pernambuco, Recife, Brazil

The surface electromyography (SEMG) is a non-invasive procediment
improve in diagnostic and follow-up therapy, being most common in studies of
chewing and deglutition functions, in evaluation and treatment of stuttering and,
less significantly, in voice area1,2. In this area, there are few studies investigating the
electrical activity (EA) of the extrinsic suprahyoid (SH) and infrahyoid (IH) muscles,
during various physiological manifestations of voice and dyphonia 3,4.
The studies that involve the vocal function are scarce and difficult
comparison because they vary in: muscle groups, technical inspection of cervical
muscles during phonation and sample size. The signal normalization of EA of these
muscle groups through maximal voluntary isometric contraction (MVIC) seems to be
controversial. Studies in voice are parsimonious in describing this aspect5-7.
Considering that the functional and organic-functional dysphonia can be
related to vocal hyperfunction and to extrinsic contraction, its important to have
more objectivity to evaluation of this region, which exam takes place through visual
and manual inspection8.
Therefore, the aim of this paper is to investigate the EA of IH and SH in
maneuvers of muscle contraction for signal normalization, by the SEMG.
Methods
Were evaluated 12 individuals of both sexes, aged between 18 and 45 years
without dysphonia, hearing loss and musculoskeletal cervical disorders. To collect
the electrical potential of the IH and SH muscles, measured in microvolts (V), were
used MIOTOOL 200 electromyography, provided the possibility of selecting eight
independent gains per channel, using a gain of 1000. Three sensors were used are:
SDS500 with plugin claws; reference cable; calibrator; Software Miograph 2.0, USB
814
communication cable, all Miotec mark, and MEDTRACE electrodes disposable

surface.
After cleaning the area with gauze and 70% alcohol, two electrodes were
placed on submandibular region, along the fibers of the anterior belly of digastric
muscle and two electrodes bilaterally to the larynx, between 1 and 1.5cm from the
thyroid notch, according to other previous studies for evaluation of this muscle
group4,9. The SEMG equipment was connected to the LG notebook and Windows
Vista Premium. To avoid interferences, a reference electrode was placed on the right
arm of elbow of individuals, distant from the muscles evaluated.
Were tested 06 types of maneuvers: dry deglutition (DD), tongue against the
palate with effort with mouth open (TAPOM) and closed (TAPCM); tongue retracted
with open mouth (TROM) and closed (TRCM), and pushing the wall (P). The rest (R)
was considered basal activity for comparison.
The maneuvers were selected according to the classification of vocal training
approaches proposed by Behlau et al10, adapting some techniques which sounds
could be excluded because was not evaluate the EA of intrinsic muscles. So, the DD
with effort has been adapted from sonorized incomplete deglutition technique,
which produces laryngeal closure and forced adduction of the vocal folds. For this
study, the vocal sounds was excluded, adapting the effort in the contraction to the
DD to test its response in the IH and SH muscles.
The TAPOM and TAPCM were selected to promote pression on mouth
muscles11. TROM and TRCM maneuvers are adaptations of the posterior
displacement of tongue technique that promotes the lower laryngeal and the
activation of IH group to be tested. Finally, the Pushing the wall is from the
providing laryngeal closure.
Each maneuver was performed three times with maximum sustained
contraction for five to seven seconds, then 10 seconds rest between each one for the
average extraction of EA. Among the testing of each maneuver, was requested that
the subject relax, stretching the neck and body as a whole in order to undo the setting
contraction generated in each room, avoiding the selection bias. This activity took
five minutes. Then, was applied other task.
The AE signal was converted using the root media square (RMS) in
microvolts (V) and were extracted the average of three executions of maneuver and
calculated the final average, to be compared with the maximum value in each
channel. Were subtracted the average of each maneuver by the average value of rest,
considered like basal activity.
For the characterization of each individual, was calculated the middle of three
measurements of maneuvers, subtracted from the resting potential (R), considered as
basal activity. For the characterization of each maneuver, were considered the mean
and standard error mean of 12 individuals, express the values in V.
For comparison between maneuvers, utilizes the Students t-test for
differences of middles in significance level of 0.05, considering the most appropriate
maneuvers that provide lower coefficient of variation and higher agreement of the
confidence interval between SH and IH right side (IHR) and left (IHL).
For chose of maneuver that could be used for signal normalization, was used
the mean differences test in significance level of 0.05. The maneuver more
appropriate was the one which associated higher EA to the easy execution by
individual in the technical conditions suitable for capturing the potential.
The measurements were converted into percentage of resting potential,
receiving the same statistical treatment of values expressed in microvolts.
815
Results
In Table 1 the data expressed in microvolts indicate the TROM maneuver that
has more AE joint SH and IHD and IHE. Although the DD and TAPs had high
values of EA, the values between IH and SH groups were discrepant. The maneuver
P was negligible.
Table 1 - Average potential difference of maneuvers of muscle groups in microvolts
Manuevers
Muscle
Group
DD
46,49,4
27,26,8
31,98,7
SH
IHR
IHL
TAPOM
43,87,9
31,617,4
29,118,7
TAPCM
49,010,7
29,414,1
28,315,2
TROM
37,812,4
40,012,6
36,910,7
TRCM
34,58,4
41,214,5
42,413,4
P
14,73,5
21,87,8
20,47,9
The graph 1 shows that the TROM and TRCM maneuvers had greater
homogeneity among the groups evaluated and submitted to the mean differences
test, which had no significant differences between muscle groups (SH: p=0.547; IHR:
p=0.825; IHL: p=0.187).
1600
1400
1200
1000
SH
IHR
IHL
800
600
400
200
0
DD
TAPOM
TAPCM
TROM
TRCM
Graph 1: average percentage variation from the rest to the maximum contraction during the
different maneuvers
Discussion
This study allows some important considerations about the use of SEMG in
the voice area, although the number of subjects may seem limited.
The larynx external evaluation is performed through tactile and visual,
manipulating this structure to investigate the neck position and movement10, as the
reaction to the touch. It also evaluated the touch, tension, symmetry and volume.
These items are marked qualitative on protocols, describing the findings. This
classification may difficult the comparison between before, during and after voice
therapy because the tactile and visual references may dissipate over time when they
are unregistered.
From the anatomical point of view, these muscles are covered by the quad
muscle, subcutaneous tissue and superficial of neck, the platysma muscle, which
involves much of the anterior area with the origin of the pectoral fascia and inserts
on the inferior border of mandible, allowing the tension skin of neck, shifting the
816
angles of mouth down and help in mandible lower. In the side of neck are mainly the
sternocleidomastoid muscle (SCM) and scalene, which also have been investigated in
studies of voice disorders 1,4.
This muscular architecture of head and neck may limit the reliability research
of SH and IH muscles because the signal received through EMG may occur the
crosstalk, which would be interference by a signal of adjacent muscles. However, this
type of occurrence is predictable and can be minimized. How SEMG evaluates a pool
of motor units and the human body works in synergy, it is possible that crosstalk is
negligible when amplification of signal interest, having some care like the distance
between the electrodes and the direction of position them in the muscle fiber.
The use of SEMG requires that the examiner had knowledge of the
instrumentation on acquisition and signal analysis. The choice and electrodes
placement positioning and the task to be performed are determinant criterious in the
quality of exam. The SEMG has been widely used in Neurology, Orthopedics,
Physical Therapy and Physical Education and the evaluation of muscles or muscle
groups of interest in these areas follow the recommendations of Surface EMG for the
Non-Invasive Assessment of Muscles (SENIAM) that integrates the basic research
and enable the exchange of data and experience 12. On the recommendation of
SENIAM about the electrodes placement positioning include the shoulders and neck
muscles but there are no references to SH and IH.
Concerning the SH muscles, propose the electrodes placement in the direction
of anterior fibers of digastric muscle and studies in orofacial motricity area have been
used this place to capture the SEMG signal2,13.
As the IH muscles, can consider some points. These are thin and straight
muscles, extending from the hyoid bone to the sternum bone. They may have
overlapping SCM, depending on the anatomy of each individual. Thus, in order to
reduce crosstalk and have greater reliability in signal normalization was important
for the present study show that the action of TROM has strong EA, because the
larynx lowers through the contraction of both groups. The placement of electrodes
between 1 and 1.5cm from the thyroid notch, also can reduces crosstalk. In case of
more bulky necks by adiposity, the maneuver may not be effective and can propose
more studies considering these anatomical differences.
The SEMG signal is dependent on impedance and a possible limitation of
exam can be presented in cases of edema or sagging neck skin to evaluate the SH and
IH, being the signal amplification is an important alternative for such frameworks,
improving the signal x noise and the quality of signal. The gravity action on the
electrodes display can be circumvented by placing adhesive tape on sensors.
Is consensus in SEMG studies that normalization reduces the variable
between individuals because the functionality of a system differs among people and,
by analogy, as in voice, also. Thus, the individual is own reference which will be
evaluate the percentage of difference in EA of SH and IH muscle between tasks.
The EMGS evaluation protocols propose that the signal from muscle rest is
captured as a reference for basal activity, which for vocal assessment has already
been proposed in other studies. Can noted that the rest should be performed after the
maximum voluntary action (MVA) to guarantee that the individual to be examined
not in a tense situation when starts the exam picking up the EA signal at rest.
The MVIC is an isometric task which serves as a reference for normalization
of increased electrical activity of muscle. Should be performed by static load which
the muscle should not vary in length14. However, in larynx, the synergy of the
phonatory apparatus does not seem to allow this measure to be drawn by the
plasticity of system and because they are small muscle groups, even in situations of
817
stress or intentionally. The MVA cannot be used as a parameter for normalization as

in chewing, for example. By reason of similarity, the present study proposes the
TROM and TRCM maneuvers used as feasible maneuvers for normalization of EA
signal through the SEMG, being considered not like MVIC but MVA, since the load
of effort applied is unknown.
The SEMG is a procedure that will provide objective information to vocal
evaluation even though has limitations and requires technical care in selecting the
sites of electrodes, capture and signal analysis. However, this is a procedure that
provides objective information to vocal evaluation by the standards of reliability in
normalization signal of muscle groups of interest, as intended this study.
Conclusions
The TROM and TRCM maneuvers showed greater homogeneity in EA and
the TROM had a higher EA for signal normalization of SH and IH muscles. This
maneuver must be considered like MVA to evaluation of these muscle groups.
Thus, adapting the principles recommended to use of SEMG for clinical voice
is feasible provided that the correlation with clinical history of individuals and the
vocal pathophysiology disorders are considered and followed in therapeutic
intervention.
Acknowledgment
Development (CNPq), which had a financial support with Edictal MCT/CNPq
14/2009 - Universal / Edictal MCT/CNPq 14/2009 - Universal - Faixa B Process: 476412/2009.
References
1. Guirro RRJ et al. Transcutaneous electrical nerve stimulation in disphonic women. Profono. 2008;20(3):189-94.
2. Andrade CRF, Sassi FC, Juste FS, Ercolin B. Modelamento da fluncia com o uso da
eletromiografia de superfcie: estudo piloto. Pr-Fono. 2008;20(2):129-32.
3. Hocevar-Boltezar I, Janko M, Zargi M. Role of surface EMG in diagnostics and treatment of
muscle tension dysphonia. Acta Otolaryngol. 1998;118(5):739-43.
4.Silvrio KCA. Atividade eltrica dos msculos esternocleidomastideo e trapzio fibras
superiores em indivduos normais e disfnicos. (dissertation). Universidade
Estadual de Campinas, 1999. 148p.
5.Pettersen V, Westgaard R. The Activity Patterns of Neck Muscles in Professional Classical
Singing . J. Voice. 2004;19(2):238-51.
6.Sapir S, Baker Kk, Sa, Larson Cr, Ramig LO. Short-latency changes in voice F0 and neck
surface EMG induced by mechanical perturbations of the larynx during sustaneid
vowel phonation. J Speech Lang Hear Res. 2000;43:268-76.
7. Redenbaugh MA, Reich AR. Surface EMG and related measures in normal and vocally
hyperfunctional speakers. J Speech Hear Disorders. 1989;54:68-73.
818
8. Stager S, Bielamowicz Sa, Regnell Jr, Gupta A, Barkmeier JM. Supraglottic activity:
evidence of vocal hyperfunction or laryngeal articulation? J Speech Lang Hear Res.
2000;43:229-38.
9. Warnes E, Allen KD. Bioffedback treatment of paradoxical vocal fold motion and
respiratory distress in adolescent girl. J Apll Behav Anal. 2005;38:529-32.
10. Behlau M, Madazio G, Feij D, Azevedo R, Gielow I, Rehder MI. Aperfeioamento vocal e
tratamento fonoaudiolgico das disfonias. In: BEHLAU M. (org). Voz. O livro de
especialista. v. 2. So Paulo: Revinter; 2001. p.410-564.
11. Palmer PM. et al. Quantitative Contributions of the Muscles of the Tongue, Floor-ofMouth, Jaw, and Velum to Tongue-to-Palate Pressure Generation. J Speech Lang
Hear Res. 2008;51:828-35.
12. Surface ElectroMyoGraphy for the Non-Invasive Assessment of Muscles SENIAM
project. [cited in 2009 Nov 20th]. Available from: http://www.seniam.org.
13. Ding R, Larson CR, Logemann JA, Rademaker AW. Surface electromyographic and
electroglottographic studies in normal subjects under two swallow conditions:
normal and during the Mendelsohn manuever. Dysphagia, 2002;17(1):1-12.
14. Masuda K, Masuda T, Sadoyama T, Inaki M, Katsuta S. Changes in surface EMG
parameters during static and dynamic fatiguing contractions. J.Electromyogr
Kinesiol. 1999;9(1):39-46.
819
FP46.3
THE RELIGIOUS ORATORY : CASE STUDY
Leite, C.M.B 1 ;Barja, P.R2
1-2 Universidade do Vale do Paraba, So Jos dos Campos/SP, Brazil
Introduction: The interest on developing this study came from the
questioning on searching understanding the charismatic oratory notability that
modified the leader in a national identity, that drag clouds of people with more
rent and education than other catholic media.Describes the influent strategist from
the oral speech of the Catholic Charismatic Renovation religious leader, on
composing the messenger senses.
Methods: The work corpus is an available shatter in audio and VHS, from
public dominium. In a descriptive approach with Aristoteles: the aspect of speech
and the digression.By means of an evaluation perceptive-visual-acoustics was
valuated expressiveness oral and corporal. For the measurement of intermissions
duration was used the Praat Program, in audio archive converted in WAV.
According with the speech division, on the preface is accomplish the auditorium
memory composed by faithful on the end of a religious meeting about the subject
Radical change; which is metaphorically recovered on the narration and oratory,
on trial session, present numberless arguments, in defence of his thesis, inclusive of
experiencing form, in a gradual way, emphatic and dramatically causing commotion
and exaltation from believers; the conclusion is from reflexive life. Between
strategies used for conviction are used numberless evasion and speech forms. The
more used speech of evasion are: metaphors, anaphors, gradations and reiteration.
The arguments are frequent, break and recover the transact theme.
Results: The oral expression is symbolically compatible: push on the diction
tax and realize quick gestures from the hand and body; long breaks are followed by
corporal statically. The usual voice is by adjusting the high larynx and blowing, with
discreet nasality. On temporary adjusts shows blowing voice with week intensity or
voice with strong intensity. The acute pitch and medium loudness. Shows
regionalism, speech over articulated, increase of saliva on the oral cavity and
repeated movements of lingual protrusion. The orator moves a bit on stage, however
in phrenitis movements, on balancing and beats his closed fist against is chest.
Number of breaks are frequent (1/3 of the speech), being that narrative occur a break
each 2,11 seconds of speech, changing the durability from 134 to 3174 MS, with
multiple functions. There are successive dramatically and emphatically breaks, that
besides being speech marks, maintain the emotional exalted tone of the speech. The
long breaks are for planning the speech and give dramatization. There are break of
influence associated to fast speech and panning.
Conclusions: The speaker presents different marks than usually is pointed in
literature as better for the good speaker. There are lot of variety of oral strategies
that come up on the speech as pure instruments of logic, the combines values and
reasons exposed by the speaker making immediate tunning with the believers.
820
FP35.3
DISEASES IN PROFESSIONAL VOICE USERS VOICE

PROBLEMS AND ASSOCIATED
Renata
Markowska,
Agata
Szkielkowska,
Joanna
Ratynska
Elzbieta
Wlodarczyk, H.Skarzynski.
Phoniatric Clinic of the Institute of Physiology and Pathology of Hearing in
Warsaw, International Center of hearing and Speech
Renata Markowska, Agata Szkielkowska, Joanna Ratynska
Voice problems and associated diseases in professional voice users
Logopedics Phoniatrics Vocology (LPV)
Introduction and aims of the study: Voice professionals often report voice
problems, the number of which increases with time of professional activity. The
number of chronic diseases also increases with age. Some of those diseases may have
direct effect on voice. Also medicines taken by the patient may affect voice. The aim
of this report was to assess frequency of occurrence of the chronic diseases affecting
voice quality in randomly selected group of patients professionally using their voice.
Methods: 100 professional voice users were randomly selected. The patients
appointed specialist-phoniatrician due to voice disorders. There were 77 females in
the age ranging from 20 to 60 years old (the mean age was 48 years) and 33 males in
the age 24-64 (the mean age was 51 years). Based on the specialists interview and
otolaryngological, videofiberoscopy and stroboscope examinations the dysfunction
of voice apparatus was found.
Results: In the assessed group 46 hyperfunctional dysphonias, 23 mixed
dysphonias, and 12 hypofunctional dysphonias were found. In 19 patients organic
lesions were observed on the vocal folds. The most often disease is reflux (33%), next
the thyroid gland diseases, and as the third are allergies of the upper respiratory
pathways (26%).
821
Hormonal disorders were found in 18% of patients, hypertension was

observed in 18%, moderate and medium hearing loss was occurring in 15% of
patients, chronic rhinitis and sinusitis in 7%, asthma 4%, neurosis was treated in
2% of patients and actinomycosis in 1%. Only in 10% of all revised cases there were
no associated diseases.
Conclusions: The research showed that diseases of accompanying voice
disorders in professional voice users occur more often than incidence of chronic
diseases in human population. That means that chronic diseases of people
professionally using their voice may significantly affect voice disorders, which in this
particular group is overloaded. Therefore admitting the occupational disease it is
important to consider influence of the other diseases on mentioned by the patients
ailments of the voice apparatus.
Key words:
Voice disorders, chronic diseases, professional voice users
Introduction
People professionally using their voice (teachers, salesmen, lecturers, priests,
lawyers, singers, actors, journalists and others) more often visit phoniatricians with
their voice disorders [1]. It is commonly known that the number of chronic diseases
increases with age. Some of those diseases may directly affect voice quality or
indirectly influence voice through medicines applied for treatment. Among the
chronic diseases affecting voice there are gastroesophageal reflux, thyroid gland
diseases, allergy, hormonal disorders, hypertension, hearing loss, chronic rhinitis,
chronic sinusitis, asthma and other lung disorders, neurological diseases and others,
being reported.
Aim
The aim of this report was to assess frequency of occurrence of the chronic
diseases affecting voice quality in randomly selected group of patients professionally
using their voice.
Material and Method

100 professional voice users were randomly selected. The patients appointed
specialist-phoniatrician due to voice disorders. There were 77 females in the age
ranging from 20 to 60 years old (the mean age was 48 years) and 33 males in the age
24-64 (the mean age was 51 years). Based on the specialists interview and
otolaryngological, videofiberoscopy and stroboscope examinations the dysfunction
of voice apparatus was found.
Results
In the assessed group 46 hyperfunctional dysphonias, 23 mixed dysphonias,
and 12 hypofunctional dysphonias were found. In 19 patients organic lesions such as
nodule vocals, cysts and polyps were observed on the vocal folds.
822
In the Figure 1 frequency of occurrence of chronic diseases coexisting with

voice disorders is presented. The most often disease is reflux (33%), next the thyroid
gland diseases, and as the third are allergies of the upper respiratory pathways
(26%).
Hormonal disorders were found in 18% of patients, hypertension was
observed in 18%, moderate and medium hearing loss was occurring in 15% of
patients, chronic rhinitis and sinusitis in 7%, asthma 4%, neurosis was treated in
2% of patients and actinomycosis in 1%. Only in 10% of all revised cases there were
no associated diseases.
Frequency of occurrence of 1, 2, 3 and more chronic diseases coexisting with
voice disorders is presented in Figure 2. 36% of patients from the group suffered
from voice disorders with one coexisting chronic disease, in 28% of patients 2 chronic
diseases accompanied voice disorders and in 26% of cases there were more than 2
accompanying diseases.
Fig 1. Frequency of occurrence of diseases accompanying voice disorders

Diseases coexisting with voice disorders
w. Percentage[%]
Gastroesophageal reflux
33
Thyroid gland disease
30
Upper respiratory tract allergy
26
Hormonal disorders
18
Hypertension
18
Hearing loss
15
Chronic rhinitis
Chronic sinusitis
Asthma
Neurosis
Actinomycosis
823
Fig 2. Frequency of occurrence of 1, 2, 3 or more chronic diseases in patients

with voice disorders
Number of coexisting diseases with voice Percentage
disorders
of patients
[%]
1
36
2
28
3 and more
26
Fig 1. Frequency of occurrence of diseases accompanying voice disorders
Discussion
People professionally using their voice like the other part of population are
exposed to chronic diseases of systems that may affect voice quality. Chronic disease
means long-term exposition to medicines, which beside the curative effect have also
side effects.
Allergic patients, for example, suffer from acute and chronic laryngitis or
pharyngitis as an effect of allergen influence on tissues in these areas. According to
the medical data 5 to 20 % of population suffers from allergy, including pollen
allergy 20%, bronchial asthma 5-8% [2]. There were 26% of them in our research
group. The patients often complained to have itching, tickling and thick secretion
remaining in the throat or larynx. They have often timbre of voice changed, they are
hoarse, clear their throat and have feeling of foreign body in throat. Cough, voice
fatigability, and impairment of voice strength may occur.
In acute conditions reddening, vocal folds oedema, epiglottiditis are observed
during physical examination. In the chronic conditions this state is accompanied by
large quantity of saliva in the area of pyriform recesses [Jacksons syndrome] and
pale-livid oedema of the epiglottis, arytenoepiglottic folds and the area of arytenoid
[3,4]. Antihistamine medicines commonly used in case of allergy have also side
effects. They stop secretion of the mucous glands located in the mucosa of the
respiratory pathways [5]. This is a cause of drying mucosa of the upper respiratory
pathways, which additionally, especially in case of speakers gets drier because of
breathing by mouth. The fact of inappropriate moistening mucosa may results in dry
cough, especially in case of prolonged speaking.
The biggest number of patients 33%, was suffering from reflux. Scientific
data from the literature shows that 10% of population suffers from reflux [6].
Presence of the bottom - gastroesophageal reflux (GERD) as well as
laryngopharyngeal reflux (LPR) may significantly affect voice quality [6]. Patients
usually suffer from: morning hoarseness, burning in the sternum area, feeling the
824
foreign body in the larynx or pharynx, they have to clear their throat and larynx or
experience night coughs. Examination of the larynx shows inflammatory state of the
posterior parts of the larynx, arytenoid oedema, posterior commissure, reddening of
vocal folds in the intracartilagineous area [7,4]. In case of long lasting disease contact
ulcers in the posterior parts of vocal folds may appear. A few month application of
H2 blockers of stomach receptors, medicines like scopolamine or atropine which are
included in the medicines decreasing tension of the smooth muscles may also
decrease secretion of the mucosa glands and as a result lead to laryngo- and
pharyngoxerosis [7,5].
Many authors [8,9,7,10,4] describe how hormonal disorders of the thyroid
gland affect voice quality. Hypothyreosis may cause similar disorders as ageing
process of the voice apparatus. Patients with hypothyreosis complain about change
in voice timbre hoarseness, low-pitched voice, fatigability of voice, low power of
voice, disorders in voice modulation, slow speech, feeling a foreign body in larynx,
xerostomia, pharyngoxerosis and laryngoxerosis. Larynx examination shows
thickened vocal folds and in advanced cases significant edema of the vocal folds
called myxomatous edema with increased mass of the folds. Decreased vibrations of
the vocal folds as well as paresis of vocal fold or folds are observed [4]. Incompetence
of glottis, which may be caused by paresis of the intrinsic thyroarytenoid inner
muscle or its atrophy, is observed. Sometimes hyponasality may occur [10].
Hypothyreosis may lead to the following disorders in the voice apparatus:
harsh voice, quick fatigability of voice, evening hoarsens or hoarseness after long
term voice effort, short phonation time. Disorders of vocal folds mobility are
observed during the larynx assessment [9]. Stroboscopic examination shows
hyperfunctional dysphonia [9]. Insufficiency of the intercartilagineous may occur
[10].
It is worth mentioning that laryngeal nerves recurrent and superior are
located near the thyroid gland, they affect the mobility of vocal folds. Therefore
enlarged thyroid gland (goiter and tumors), depending on its magnitude, may press
the upper mentioned nerves. Such a phenomena may cause laryngeal nerves
dysfunctions such as paresis of the nerves, what in effect is observed as limitation of
the vocal folds mobility or their total fixation. Increased mass of the thyroid gland
may affect the vertical mobility of larynx. Similar problems may occur during the
surgery procedures on the thyroid gland.
Hypertension was found in 18% of the subjects. It is assessed that
hypertension occurs in 11-14% of polish population [11]. Regularly used medicines
affect voice of these patients. Almost all available medicines regulating hypertension
have parasympatycomimetic side effect [5,4]. It causes dryness of the mucosa,
sometimes they are diuretic, which results in dehydration and intensify the effect of
the mucosa mucosal xerosis. Proper humidity of mucosa, especially glottis, during
the phonation time helps to decrease friction between vocal folds [12]. Increase if the
friction may cause disorders in vibration synchronization during phonation,
fatigability of voice and mechanical disorders of vocal folds as well as attack of the
ineffective, dry cough.
10% of human population use sex hormones, in the case of our research there
were 18% of subjects took such hormones [10]. Sex hormones influence voice quality,
they accumulate liquids in the fragile structures of the vocal folds and change the
larynx structure by thickening and shortening vocal folds, lowering the larynx and
causing overgrowth of the mucosa [13]. These changes are reversible only if a subject
stops taking hormones.
825
These patients mainly complain about the change in timbre of their voice, the
Fo value. Fatigability of voice and synchronization disorders of vocal folds vibrations
may appear. In the menopause period, to maintain parameters of voice, especially in
case of professional singers alternative hormonal therapy based on estrogens is
applied [4].
4% of the examined patients were taking inhalatory steroids because of
asthma. It is evaluated that 5-8% of human population suffers from asthma [2].
Asthma limits the lung efficiency, affects lung capacity. The phonation time is
shorted. Long talking causes fatigability of voice.
Inhalatory steroids have also side effects such as dryness of the mucosa
(mucosal xerosis). Long use of the steroids may lead to inflammation of larynx by
anascogenic yeasts and dysphonia [4].
There were 7% of patients with chronic sinusitis and rhinitis in the examined
group. Also these diseases may cause changes in voice quality. As in case of chronic
rhinitis hyponasality may occur. Thick secretion mucus going down from the
nasopharynx may remain in the pharynx stuck to the vocal folds and causing an
obstacle, which changes timbre of voice and disorders in folds vibrations. It forces
patients to clear their throat often.
In the mentioned diseases pharmacological measures such as drops, aerosols
facilitating blood vessels decongestion, reducing edema and limiting secretion of the
mucous gland of the upper respiratory pathway are being used. Chronic application
of upper mentioned pharmacological measures may result in reverse than primary
curative effect; repeatedly they might cause chronic inflammation.
Upper mentioned cases show that chronic disease of various systems, as well
as pharmaceutics used chronically for treatment of the diseases might adversely
affect voice organ, especially in professional voice users.
The research showed that diseases of accompanying voice disorders in
professional voice users occur more often than incidence of chronic diseases in
human population. That means that chronic diseases of people professionally using
their voice may significantly affect voice disorders, which in this particular group is
overloaded. Therefore admitting the occupational disease it is important to consider
influence of the other diseases on mentioned by the patients ailments of the voice
apparatus.
Conclusions
People professionally using their voice often suffer from other chronic
diseases, which may affect the voice organ.
Admitting the occupational disease it is important to consider influence of the
other diseases on mentioned by the patients ailments of the voice apparatus
Bibliography
o-Spychalska T, Fiszer M, liwiska Kowalska M, Ocena czstotliwoci
wystpowania chorb narzdu gosu u nauczycieli. Ot.Ryn.Lar. Przeg. Klin. 2002;
1(1): 39-44.
Sopel R, Mincewicz G, Wybrane pojcia z alergologii. Encyklopedia Bada
Medycznych. Wydawnictwo Medyczne MAKmed, Gdask, 1996.
Buczyko K, Alergia w praktyce otolaryngologicznej Cz 1 i 2. Problemy
Laryngologiczne w Codziennej Praktyce, 2002; 31: 2-15.
826
Sataloff RT, Professional Voice The Science and Art of Clinical Care. Sin. Pub.
Group, Inc. San Diego. London, 1997.
Martin FG, Drugs and Vocal Function. J. of Voice. 1988; 2(4): 338-344.
Markowska R, Szkiekowska A, Ratyska J, Dolegliwoci laryngologiczne w
chorobie refluksowej przeyku. Audiofon.2004; XXIV: 103-109.
Kaufman JA, Isaacson G, Voice Disorders. Otol. Clin. N. A. 1991; 24(5): 375381.
Dabikiewicz-Wicko D, Problemy laryngologiczne w codziennej praktyce.
Problemy Laryngologiczne w Codziennej Praktyce. 2002; 29: 2-7.
Domeracka-Koodziej A, Maniecka-Aleksandrowicz B, Zaburzenia gosu w
chorobach tarczycy. Mag. Otorynolaryngol. 2002; I(2): 33-41.
Pruszewicz A, Obrbowski A, Hormonalnie uwarunkowane zaburzenia
gosu i mowy. (in) Foniatria kliniczna. Pruszewicz A (red.) PZWL, Warszawa, 1992:
158-171.
Bednarkiewicz Z, Epidemiologia chorb ukadu krenia. Polskie
Towarzystwo-Kardiologiczne, 2004; www.nowy.ptkardio.pl
Titze IR, Current Topics in Voice Production Mechanisms. Acta. Otolaryngol.
(Stockh.) 1993; 113: 421-427.
Damste PH, Virilization of the voice due to anabolic steroids. Fol. Phoniat.
1964; 16: 10-18.
827
FP41.5
"SINGING
LIFE"
GALAS CHORAL LARYNGECTOMIZED SUPPORT GROUP
Martins, VB.; Santana, MG.; Santos, JB..; Brito, ES.; Sehn, FC.; Gadenz, SD.; Sbaraini,
L.; Macedo, TL.; Sperb, D., Fontana, C.
Santa Rita Hospital / Womens League Against Cancer/RS
Introduction - The Gala Laryngectomized Supporting Group, which aims at global
rehabilitation of these patients, has used the group singing (Choral) as a way of
training to acquire these individuals new voice. We should remember that singing is
not only one of the oldest expressions of the human being, but also can cure many
ailments. Singing generates psychic harmony and strengthens the immune system.
You can give the music both the ability to achieve the man fully, as the ability to act
as a bridge between psyche and body, due to its intense inherent possibility to
communicate and express emotions, making clear its therapeutic potential.
Objective: Through the singing improve not only verbal and global communication,
but also the self-esteem of GALAs Laryngectomized participants.
Material and Methods - Ten patients of the Laryngectomized Supporting Group
took part of the Choral. Initially the idea was to make the task of training the
acquisition of esophageal speech or adaptation of electrolarynx more enjoyable by
singing. After several days of training without sound instrument to improve the
maximum phonation and articulation, has come the idea of Choral to show the
results of this work. A musician was invited to follow them on a guitar with lower
speed.
Results - Patients showed themselves happy, relaxed in the choral moments. Some
referred to the thrill of hearing themseves singing, the shining eyes of colleagues.
The maximum phonation time increased slightly and it was observed the
improvement of coordination and dissociation of pulmonary air.
Conclusion - The singing is good for the laryngectomized, both pleasurable way to
exercise the production of esophageal voice and the improvement of their selfesteem, showing they can do various things they thought they would never do again.
828
P180
AN INTERDISCIPLINARY VISION OF GALA LARYNGECTOMIZED SUPPORT GROUP
Hospital Santa Rita / Liga Feminina de Combate ao Cncer/RS
Introduction:
Cancer is a disease witch brings around emotional and social impact to
patients and their relatives. It is hard to cope with all the information about
the disease and elaborate on painful emerging feelings, such as, fear, anger,
denial, guilt, depression and anxiety. Larynx cancer, one of the commonest in
head and neck, often requires total laryngectomy causing definitive
tracheostomy and loss of laryngeal voice. GALA (support group to the
laryngectomized) is an open homogeneous somatic operative group fostering
mutual help. The group is coordinated by speech pathologists; psychologists,
physiotherapists, nutritionists, and head neck surgeons.
Objective: to demonstrate the importance of support groups,
interdisciplinary work and their influence in general rehabilitation.
Methodology:
Initially, orientation is given and doubts are cleared out concerning medical
treatment and physical rehabilitation with the performance of Physiotherapy
(rehabilitation of posture and respiratory functions) and Speech Pathologist
(rehabilitation of voice and speech). Nutrition promotes nutritional status
monitoration and nutritional guidelines to prevent and treat. Doctors answer
questions about the general treatment. Psychology permeates the group
evolvement by turning meetings into instances of exchange, learning, growth,
support and less suffering.
Results:
Through observation highlight the improvement of communication, posture,
breathing and eating habits and nutritional status.
As for emotional state, level of stress, anxiety and depression have been
considerably diminished as attested in patients reports.
Conclusions:
GALA is a support group differing from others due to its interdisciplinary
configuration and its global view of the patient. It takes not only physical
aspects into consideration but also social, emotional and spiritual aspects aims
at rehabilitation of patients overall
829
P183
QUALITY OF LIFE AND VOICE PROTOCOL FOR GALAS PATIENTS LARYNGECTOMIZED SUPPORT GROUP
Santa Rita Hospital / Liga Feminina de Combate ao Cncer/RS
Santana, MG.; Martins VB.;
Introduction - On Total Laryngectomy the removal of the larynx besides being a
physical mutilation is also a psychic mutilation, since losing the voice involves losing
one's identity, the ability to communicate, to express their desires, feelings, their
individual characteristics. This leads the patient to retract, not wanting to expose
because peoples difficulty to understand them, they become embarrassed by their
condition and that directly interfere with their quality of life and communication.
Objective - To assess the life quality of laryngectomized patients supporting group GALA for the voice.
Material and Methods - Cross-sectional qualitative study with content analysis. The
study included 11 patients (7 men and 4 women) of GALA. Data were collected
through the questionnaire Measurement of Quality of Life and Voice (V-) of
Hogikyan and Sethuraman (1999) translated and adapted by Behlau (2001), which
are assessed two areas: socio-emotional and physical functioning. Eight patients
using electrolarynx, three, esophageal speech.
Results - six patients were 65 years or more and five were under 65 years. The
subjects aged over 65 had better physical functioning (63.19%) than those aged less
than or equal to 65 years, but had a lower percentage in relation to socio-emotional
(53.13%). Patients who did not use electrolarynx had better quality with a higher
percentage (75.83%) than those who used it. Men had a higher percentage than
women in all aspects showing a better quality of life.
Conclusion - males aged over 65 had a better percentage of quality of life related to
voice, however, it became apparent the difficulty of oral communication (voice) in
this group can be considered a moderate problem, because in the areas assessed by
this questionnaire (socio-emotional and physical) the rates were around 40% and
60%, which leads us to think that difficulties are being worked on and overcome.
830
P185
ANY WAY OF LOVE IS WORTH IT...
SEXUALITY IN PATIENTS WITH HEAD AND NECK CANCER
Martins, VB.; Santana, MG.; Santos, JB..; Brito, ES.; Sehn, FC.; Gadenz, SD.;
Sbaraini, L.; Macedo, TL.; Sperb, D., Fontana, C.
Introduction The laryngectomized experience periods lack of sexual
interest. To return to normal life it becomes difficult the resumption of sexual
activity, often for lack of information or communication. In total
laryngectomy, there is the loss of laryngeal voice and the change of the breath
path which now occurs through a hole in the neck (tracheostomy). Physical
changes, the air coming out the neck and the possible presence of secretion,
severe pain in the region of the tracheostomy, and the very sound of breath,
difficult sexual activity. Therefore, it is desirable that laryngectomized
patients receive guidance on this subject, so that their sexual life takes over
because the sexuality along with open communication are very important to
improve the patients quality of life and well-being.
Objective - To understand the challenges related to sexuality in patients of
Laryngectomized
Supporting
Group
(GALA).
Methods - 20 patients were individually interviewed about changes in sexual
life after treatment. Following attended a lecture on sexuality and from this
could expose their doubts.
Results - Patients received guidance on the importance of the couple looking
for ways to woo and adaptation forms aiming to intimacy. The dialogue
between the partners was encouraged. Was passed a few practical tips and
ways to disguise the traqueostomy, and possible odors coming from that,
using loose scarf, collar or turtleneck sweater and fragrances.
Conclusion - This action of challenging the GALAs patients with such
subject enabled them to speak more about sexuality. Is therefore necessary
that patients receive guidance on the subject, they often have to start develop
and adapt new ways to give and receive sexual pleasure. The reconstruction
of the emotional-sexual intimacy of the patient is gradual and any particular,
any way of love is worth it!
831
P186
Laryngectomy:
Securing tracheostomy with style
Introduction: Total laryngectomy is a surgical procedure that involves removing all
of the larynx, causing loss of speech and breath air path change. The individual starts
to breathe through a hole in the neck, This hole should be protected to prevent entry
of dirt and to avoid secretion output by tracheostomy, which can lead to
embarrassment of the patient or partner. Many patients are ashamed or refuse to use
the protectors, because they believe that they attract much people attention. Thus, in
a meeting of the GALA Group (Laryngectomized Supporting Group), which aims at
rehabilitation of patients overall, there was performed a workshop on the use of
accessories; protecting tracheostomy with style.
Objective: To present the laryngectomized patient alternatives to protect their
tracheostoma without losing the elegance, showing alternatives and thereby regain
their self-esteem and socialization of the patient.
Material and Methods: We performed a workshop in which the guest speaker took a
few accessories, scarves, collars, ties, hair bands, etc.. and gave several tips and
guidance to patients.
Results: The positive reaction of patients to the work met expectations. Everybody
participated actively in the meeting, including giving tips, reviews and presenting
alternatives, which ranged from the use of protective crochet matching the clothes
colors, to a transformation of t-shirts, hair accessories, and more.
Conclusion: In this days when appearance is highly valued, this workshop was very
positive because ever since many of them started to cope better with their
tracheostomy, which is no longer an obstacle to the resumption of their social life.
832
FP36.4
ACOUSTIC
ANALYSIS
OF
SUBSTITUTION
VOICES :
DIFFERENTIATION BETWEEN TRACHEO-ESOPHAGEAL VOICES
AND VOICING WITH A VOICE-PRODUCING ELEMENT
M.Moerman1,2, L.Wiersma1, J.P.Martens3, P.H.Dejonckere1
1 Institute of Phoniatrics, Utrecht University, the Netherlands
2 AZ Maria Middelares and Jan Palfijn, Ghent, Belgium
3 Electronics and Information Systems Department, Ghent University, Belgium
COST action 2130 Advanced Voice Function Assessment
Introduction and aims of the study: Tack et al developed a sound-generating

prosthetic device, called a voice-producing element (VPE). This VPE is based on two
vibrating membranes placed parallel to each other inside a circular housing. Whilst
expiring there is a constant vibration and subsequent voicing. Next to an in vitro
study (1), an in vivo (2) study evaluated speech in female laryngectomised patients.
Objective measurements revealed a higher fundamental frequency and a more
tensed voice production in VPE patients when compared with the traditional voice
prosthesis. The authors also performed a perceptual evaluation, by the patient
herself and by a speech pathologist. Although only 3 patients out of 17 rated their
voice quality with the VPE device as substantially better, Tack et al concluded that
VPE is suitable for laryngectomised patients with a hypotonic tracheo-esophageal
segment, who thus can benefit from a more melodic and louder voice production (2).
The Auditory Model Based Pitch Extractor (AMPEX) developed by Van
Immerseel and Martens (3) has been proven superior to the ordinary acoustic
analysis programs (f.i.
Kay Elemetrics) in severe pathological voicing such as substitution voicing
and spasmodic dysphonia (4, 5, 6, 7, 8). AMPEX outstands other pitch extractors in
analysing samples with low frequency components (< 100 Hz) and extracts in a valid
way periodicity in irregular signals with background noise. Furthermore, it is
designed to analyse running speech, which is a more natural representation.
We subdued the voice samples collected by Tack et al to an acoustical
analysis with AMPEX. It is hypothesized that if the VPE is correctly functioning and
rightfully adds to the voice quality, AMPEX would demonstrate an increase in the
voicing related parameters and a decrease in the perturbation related parameters.
Methods: The sound samples from Tacks 17 laryngectomised female patients
(mean age 65years) were used, both whilst producing regular TE voice and VPEvoice. The pharyngo-esophageal segment tonicity was esteemed by a physician and a
speech pathologist, using visual and perceptual cues, on a 4 point-scale, ranging
from atonic through severely hypotonic, slightly hypotonic and normotonic.
Laryngectomised patients with a hypertonic voice were excluded.
833
The recordings from Tack et al. comprised the first paragraph of the Dutch
prose De Vijvervrouw, a phonetically rich text. All files were converted to 44.1 kHz
and wav. files before analysing them with the AMPEX model.
The program generates voicing related parameters and perturbation related
parameters:
PVF/PVS: while PVF is the proportion of voiced frames and depends on the
pauses appearing in speech, PVS is the proportion of voiced speech frames is
computed, considering only frames that are classified as speech in the first step of the
analysis. Since pauses and weak sounds are typically unvoiced, PVS will typically be
larger than PVF. For vowels it should be expected that PVS = 100 %: the better the
voice, the higher the percentages.
AVE: the average voicing evidence. The more regular (periodic) the voiced
frames are, the higher AVE will be, with a maximum of 1.0.
VL90: the 90th percentile of the voicing length distribution as a robust
estimate of the maximum time voicing can be maintained by the speaker. The
voicing length is defined as the number of consecutive voiced frames found by the
AMPEX analysis in the data. Phonatory breaks reduce this parameter. The higher the
VL90, the better the voice.
Jitter: Period to period variability. Jitter is a measure for the degree of
aperiodicity. Qualitatively better voices show lower jitter values.
Corrected jitter (Jc): The correction means that only frames with a reliable
fundamental frequency (F0) are taken into account; a reliable F0 is one that deviates
less than 25% from the mean over all voiced frames.
PFU: The percentage of frames with unreliable F0 is considered as a separate
F0-instability factor. Frequency shifts make F0 unreliable. The lower the PFU, the
better the voice.
In the present study, the group (17 laryngectomees) was divided into two
subgroups based on their pharyngo-esophageal (PE) tonicity because of the expected
difference regarding the AMPEX-parameter values. Subgroup 1 contains patients
with a severely hypotonic or atonic PE segment; in subgroup 2 the PE segment is
slightly hypotonic or normotonic.
Results: Table 1 lists the results of the AMPEX analysis in all subjects. Care
must be taken for correct interpretation of these results. As the first step in the
AMPEX analysis divides the voice sample into voiced and unvoiced frames, the PVF
value is of utmost importance. In subjects 1, 3, 8, 9, 10 and 13 for instance, PFU can
not be reliably analysed because the number of voiced frames is too low (less than
5% of the frames). Further statistical analysis to compare the TE and VPE group is
performed after exclusion of these subjects.
Table 2 shows the averaged AMPEX parameter values for the different
groups. Table 3 demonstrates the group differences after Wilcoxon signed pair rank
test in SPSS 17.0.
Discussion: For TE-voicing, subgroup 1 has lower voicing parameters than
subgroup 2 (Table 2). This was to be expected: low or absent tonicity results in less
vibration at the PE segment and therefore in lower voicing evidence. In general, the
VPE group has the highest values for the voicing parameters (PVF/PVS,
AVE/VL90), followed by subgroup 2; the lowest values are found in subgroup 1.
This is logical: the VPE device contains a constantly vibrating membrane and
subgroup 2 has more PE-tonicity than subgroup 1. For the perturbation related
parameters, it was expected that the TE group would have the highest amount of
perturbation (Jitter, Jc, PFU) and subgroup 1 even more than subgroup 2. The results
concur with the fact that VPE produces more regular voicing (lowest perturbation
834
parameter values). However, the values indicate less perturbation for subgroup 1
compared to subgroup 2. This can be explained by the fact that subgroup 1 contains
more exclusions. Precisely these subjects with low voicing evidence (low PVF) were
withdrawn from further calculations.
Table 3 clearly demonstrates a significant change for PVS between TE-voicing
and VPE- voicing, in favor of the last. Jitter values are higher in the TE group,
although not significantly different. Subjects in subgroup 1 with an atonic or severely
hypotonic PE segment were expected to have a significant change, whilst the subjects
in subgroup 2 who have a slightly hypotonic or normotonic PE segment only have
moderate changes.
A side effect from the VPE device was the occurrence of diplophonia. This
can be explained by sound generation at two levels: on the one hand the VPE device
itself and on the other hand vibration at the PE segment. Evaluation by means of
perception and spectrography showed that diplophonia occurred in 8 subjects, 4
from subgroup 1 and 4 from subgroup 2. AMPEX generates lower values for voicingrelated parameters in the subjects with diplophonia compared to those without. F0perturbation values were higher for subjects with diplophonia.
Comparing subjects individually (Table 1), it was expected that the voicing
parameters would increase and that the F0-related parameters would decrease in the
VPE condition. This is obvious for the voicing related parameters. The F0-related
parameters reflect a decrease in 7 subjects; 4 subjects however show an increase of
F0-perturbation in the VPE condition. The latter could be caused by diplophonia. As
table 3 demonstrates perturbation increases as a result of diplophonia.
Conclusion
AMPEX, able to analyse running speech, is reliable in demonstrating a
difference in these two groups of substitution voices. The values suggest an
improvement in voice quality applying a VPE device in subjects with poor TE
voicing. However, diplophonia eventually troubles the outcome. As ever, selfevaluation by the patient him- or herself will be decisive.
References
- 1) Tack, J.W., Rakhorst, G.J., van der Houwen, E.B., Mahieu, H.F., Verkerke, G.J.
-
(2007) In vitro evaluation of a double-membrane-based voice-producing element for

laryngectomized patients Head & Neck pp.665- 674
2) Tack, J.W., Qui, Q., Schutte, H.K., Kooijman, P.G.C., Meeuwis, C.A., Van der
Houwen, E.B., Mahieu, H.F., Verkerke, G.J. (2008) Clinical evaluation of a membranebased voice-producing element for laryngectomized women Head & Neck, DOI: 10,
1002/hed
3) Van Immerseel, L.M. & Martens, J.P. (1992) Pitch and voiced/unvoiced
determination with an auditory model J. Acoust. Soc. Am. 91 (6)
4) Moerman, M., Pieters, G. Martens, J.P., Van der Borgt, M.J., Dejonckere, P. (2004)
Objective evaluation of the quality of substitution voices Eur. Arch.
Otorhinolaryngoloy, 261: pp. 541-547
5) Moerman, M., Martens, J.P., Crevier-Buchman, L, de Haan, E., Grand, S., Tessier,
C., Woisard V., Dejonckere, P. (2006) The INFVo perceptual rating scale for
substitution voicing: development and reliability Eur. Arch. Otorhinolaryngology, 263,
pp. 435-439
6) Siemons-Luhring, D.I., Moerman, M., Martens, J.P., Deuster, D., Mller, F.,
Dejocnkere, P. (2009) Spasmodic Dysphonia, perceptual and acoustic analysis:
presenting new diagnostic tools Eur Arch Otorhinolaryngol, 266: pp.1915-1922
835
7) Dejonckere P.H., J.P. Martens, M. Moerman (2009) Long term follow- up of

patients with spasmodic dysphonia repeatedly treated with botulinum toxin
injections Proceedings 6th international workshop Models and Analysis of Vocal
Emissions for Biomedical Applications
8) Moerman, M.B.J. Martens, J.P., Chevalier, D., Friedrich, G., Hess, M., Lawson, G.,
Licht, A.K., Ogut, F., Reckenzaun, E. Remacle, M., Woisard, V., Dejonckere P.H.
(2007) Towards a basic protocol for functional assessment of substitution voices:
preliminary results of an international trial, proceedings 5th international workshop
Models and Analysis of Vocal Emissions for Biomedical Applications, pp.201-204
Tables and figures

Parameter
Subject
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
PVF
TE
VPE
PVS
TE
VPE
AVE
TE
VL90
TE
VPE
Jitter
TE
3.308
25.973
4.994
44.956
40.652
7.619
11.455
1.643
0.054
4.371
49.836
71.206
58.811
55.044
53.637
70.629
75.128
51.920
81.672
25.788
62.582
41.330
3.657
28.646
5.238
56.111
48.097
10.825
12.175
2.935
0.107
4.496
61.853
77.195
69.261
63.441
59.290
84.179
82.673
67.827
90.301
57.186
71.056
53.057
0.675
0.587
0.000
0.840
13.788 15.609
0.312
0.230
0.632
0.630
0.120
0.050
0.420
0.200
0.461
0.608
0.234
0.273
0.443
0.289
0.233
0.537
0.418
0.617
0.632
0.538
0.680
0.437
0.627
0.379
0.210
0.160
0.110
0.060
0.080
0.000
0.070
0.210
13.624
3.117
42.971
44.086
16.105
22.283
57.386
81.266
59.920
54.027
81.304
70.342
15.510
3.473
46.790
66.250
28.054
31.523
60.903
82.519
66.927
64.277
80.973
75.179
0.335
0.321
0.600
0.660
0.517
0.501
0.397
0.347
0.437
0.492
0.536
0.580
VPE
VPE
PFU
TE
VPE
6.005
10.027
7.407
9.707
32.060 7.065
6.106 11.786
12.318
6.106
5.701
7.349
38.462
0.000
1.308
3.384
0.206
0.600
0.570
0.530
0.680
0.210
0.180
0.270
18.546
10.789
25.284
40.676
18.024
50.000
9.278
12.483
11.309
9.925
12.227
14.819
5.629
50.000
9.278
9.530
13.852
10.022
10.476
10.681
6.354
9.328
11.013
7.497
16.543
1.923
32.099
58.475
17.241
50.000
0.000
2.198
31.945
8.123
12.722
3.571
3.206
10.105
12.914
14.751
0.080
0.050
0.310
0.550
27.524 18.126
8.162
8.365
13.936 10.569
8.162
7.292
34.031 12.914
0.000
2.177
0.230
0.240
0.080
0.110
0.180
0.310
0.410
0.270
27.940 17.258
26.036 33.672
17.103 16.866
30.266 9.556
13.772 9.090
12.317 13.138
11.956 10.845
10.815 6.838
19.737 7.973
38.230 47.547
11.230 11.464
28.870 1.628
VPE
24.566
14.056
18.071
12.383
9.668
15.298
18.819
21.596
Jc
TE
Table 1: AMPEX values for all subjects with TE versus VPE speech. Excluded
values are bold. Subject 11 (marked in italics) perceptually showed a large
discrepancy in amplitude between vibration of the PE-segment and the
superposed VPE, in which the oesophageal folds oscillation outperforms the
VPE vibration. AMPEX therefore probably only detects the vibration of the
PE- segment.
Paramete
r
TE-voice
N=11
PVF
PVS
AVE
VL90
Jitter
Jc
PFU
29.1
35.2
0.42
0.15
26.2
11.7
25.5
TE-voice
Subgroup 1
N =5
27.4
29.9
0.40
0.15
23.7
10.1
21.6
TE-voice
Subgroup 2
N=6
30.5
39.6
0.42
0.15
28.3
13.0
28.8
VPE- voice
N=15
69.9
77.0
0.61
0.43
13.6
8.3
8.6
Table 2: averaged AMPEX values per group
836
Parameter
Number of Positive
Cases
ranks
TE-group compared to VPE-group
PVS
17
15
Jitter
11
4
TE Subgroup 1
PVS
5
5
Jitter
5
2
TE Subgroup 2
PVS
5
4
Jitter
5
1
VPE with diplophonia
PVS
7
6
Jitter
7
2
VPE without diplophonia
PVS
3
3
Jitter
3
1
Negative
ranks
Z-score
Asympt. Sig. (2-tailed)
2
7
-3.432a
-1,511b
0.001c
0.131
0
3
-2.023a
-1.214a
0.043
0.225
1
4
-1.753a
-1.483b
0.080
0.138
1
5
-2.197a
-1.690b
0.028
0.091
0
2
-1.604a
-0.535b
0.109
0.593
Table 3: Wilcoxon signed rank test for parameters PVS and Jitter for TE and
VPE-subjects and per subgroup; a = based on negative ranks b = based on
positive ranks c = significant
837
FP26.4
SELF-ASSESSMENT PROTOCOLS FOR MODERN AND CLASSICAL SINGING
VOICE: BRAZILIAN VERSIONS OF MSHI AND CSHI
F. Moreti1, M.E.B. vila1, C. Rocha1, M.C.M. Borrego1, G. Oliveira1,2, M. Behlau1,2
1CEV,
So Paulo, Brazil
So Paulo, Brazil
2UNIFESP,
Introduction
The relationship between voice disorder and quality of life in professional
voice is complex. For some professionals, i.e. teachers, a vocal deviation may restrict
their professional activity, whereas other professionals, i.e. singers, a small voice
change may cause a great impact on personal aspects (physical, mental, social,
emotional and communication) as well as professional and financial (Sataloff 2005,
Wingat et al 2007, Franic et al 2005). Voice problems can be either in the speaking or
singing voice. Even though any voice deviation for a singer may represent a major
problem, because of their vocal demand and requirements, the perception they have
about their voice-related handicap can vary a lot, since they have a wide range of
voice use in the different singing styles, they have work for long and crazy periods
and also they are very alert to their voice changes (Rosen et al 2000).
In the voice area, the VHI Voice Handicap Index (Jacobson et al 1997;
Grbel et al 2007) is one of the most used voice-related quality of life self-rating
protocol that was developed originally in the US (Jacobson et al 1997) and have been
validated in almost 20 countries (Verdonck-de Leeuw et al 2008), including Brazil
(Behlau et al 2010). Usually this questionnaire is administered to adults with vocal
complaint (Zur et al 2007) and it assesses 3 different aspects of quality of life:
impairment, handicap and disability. Although the VHI validity and reliability are
not questionable, its sensitivity to evaluate singers is poor, since some specific
aspects of singing voice are not addressed in it (Rosen et al 2000, Behrman et al 2004,
Cohen et al 2007, 2008).
In order to address this population, VHI adaptations for assessing singing
voice were proposed (Cohen et al 2007, Morsomme et al 2007). An Italian
phoniatrician, called Franco Fussi, proposed two versions after analyzing more than
400 singers: the Modern Singing Handicap Index MSHI, for popular singers and
the Classical Singing Handicap Index CSHI, for classical singers (Fussi et al 2008).
Purpose
The purpose is to compare MSHI and CSHI scores of popular and classical
singers, with and without vocal complaints.
Methods
A total number of 229 singers participated by answering the respective
protocol according to their singing style, classical or modern. The group of modern
singers was composed of 170 individuals (32 tenors, 48 basses, 49 sopranos and 41
contraltos), 58 with voice complaint MSWC and 112 without voice complaint
MSWoC and age ranging from 16 to 66 years. The group of classical singers had 59
individuals (22 sopranos, 10 mezzo-sopranos, 1 contralto, 13 tenors, 10 baritones and
3 basses), 17 with voice complaint CSWC and 42 without voice complaint CSWoC
838
and age ranging from 20 to 75 years. These participants belonged respectively to

choirs of Brazilian popular music and classical choirs from Sao Paulo city. All
participants usually perform vocal warm-up for approximately 20 to 30 minutes
before rehearsal and presentations.
Both protocols had been translated and culturally adapted for the Brazilian
Portuguese (Moreti et al 2009, vila et al 2010). The adapted versions were
administered individually to their respective population. The protocols have 30 items
distributed into 3 subscales: disability, handicap and impairment, which correspond
respectively to the functional domain, emotional domain and organic domain.
The answers were rated according to the frequency of the item on a 5-point
Likert type scale, ranging from 0 - never to 4 - always. Both protocols produce 4
scores: disability (functional), handicap (emotional), impairment (organic) and total.
Total score may vary from 0 to 120, with 0 indicating no voice-related handicap and
120 high voice-related handicap, the other individual scores range up to 40.
Therefore, the higher the score, the bigger the handicap is perceived.
Descriptive statistical analyses were used for clinical and demographic
subject characterization (mean confidence interval and Spearman Correlation). In
addition, the Mann-Whitney test, the Kruskal-Wallis test, the Friedman test and the
Wilcoxon test were used for non-parametrical variables. The level of significance
adopted was 5% (0.050).
Singers are professional voice users that develop a great sensitive in
perceiving their voice. It is plausible that any voice deviation may play an important
role on these professional lives; thus the assessment of voice-relate quality of life is
essential for composing the vocal evaluation of such individuals. Treatment outcome
instruments have to be specific, regarding disease, population, culture to provide
adequate and accurate results. In order to address these professionals population,
some singing voice-related self-assessment protocols were created, such as the two
protocols used for these research.
MSHI scores of popular singers indicated that there was not a statistically
difference concerning singing voice classification and sex. CSHI scores of classical
singers also indicated that there was not a statistically difference regarding singing
voice classification and sex, except from the disability subscale scores of both sexes
(p=0.044). Women had higher scores than men.
The comparison of MSHI and CSHI mean subscales and total scores between
the groups with and without vocal complaint showed significant differences for all
scores. The results indicated that the impairment subscale that corresponds to the
organic domain exhibited the greatest deviations for both the modern and classical
singers. Aspects of technical skills, high vocal demand and singing experience may
explain this result (Jotz et al 2002) and consequently, reflects a potential risk for
singers to developing a voice problem (Cohen et al 2007).
In addition, the groups with vocal complaint both for popular and classical
styles had higher scores compared to the groups without vocal complaint (Table 1).
Thus, vocal complaint was the factor that differentiated the individuals studied
(Murry et al 2009).
Although classical singers with vocal complaint did not have a voice disorder
diagnosis, they perceived some singing voice handicap, as the slightly reduced CSHI
scores demonstrate. Perhaps, training and practicing help them to develop a detailed
perception of their voice production. The CSHI results suggested that the greatest
impact of a voice problem is found in the functional and organic domains, so they
839
may experience varied degree of performance, vocal fatigue during or after

presentations, however these limitations do not play a negative emotional role for
them.
Table 1: Mean subscales and total scores of MSHI and CSHI

Subscales
Mean
N
Disability
7.88
58
Handicap
5.05
58
MSWC Group
Impairment
13.98
58
Total
26.91
58
Disability
4.66
112
Handicap
3.16
112
MSWoC Group
Impairment
8.79
112
Total
16.61
112
Disability
11.71
17
Handicap
7.59
17
CSWC Group
Impairment
11.94
17
Total
31.24
17
Disability
2.83
42
Handicap
1.62
42
CSWoC Group
Impairment
4.14
42
Total
8.6
42
Statistical tests: Friedman, Kruskal-Wallis and Wilcoxon
* statistically significant
p
<0.001*
<0.001*
<0.001*
<0.001*
In order to determine accurately subscale differences of both protocols, they were

compared in pairs. All subscales scores were statistically different, except from the
impairment and disability (Table 2).
Table 2: Significance of MSHI and CSHI subscales scores comparison between
the groups
Subscales
Disability
Handicap
Handicap
0.001*
MSWC Group
Impairment
<0.001*
<0.001*
Handicap
<0.001*
MSWoC Group
Impairment
<0.001*
<0.001*
Handicap
<0.001*
CSWC Group
Impairment
0.391
<0.001*
Handicap
<0.001*
CSWoC Group
Impairment
0.590
<0.001*
Statistical test: Wilcoxon
* statistically significant
Results showed that both groups of singers (modern and classical) perceive
their vocal handicap in a different manner. Classical singers presented with the
highest scores, no matter they had vocal complaint or not. In order to have a better
idea of the magnitude of scores, following mean values are presented in a crescent
order: CSWoC < MSWoC < MSWC < CSWC. As far as the domains are concerned,
840
the organic domain (impairment subscale) showed the highest deviations, no matter
singing style or presence of vocal complaint. Mean values of subscales are presented
in a decreasing order: impairment > disability > handicap.
Conclusions
Voice complaint was decisive for differentiating the groups both for the
MSHI and CSHI. Classical singers with voice complaint perceived a higher impact on
quality of life due to their problem, reflecting a greater sensitivity. The organic
aspects showed the greatest deviations for the popular singers. The classical singers
with and without vocal complaint had greater deviations on both the organic and
functional aspects. Both protocols proved to be a useful tool for helping SLP, singing
teachers and conductors to map voice problems of popular and classical singers.
Therefore, modern and classical singers deserve to be evaluated with specific
protocols.
Referncias
vila MEB, Oliveira G, Behlau M. ndice de Desvantagem Vocal no Canto Clssico (IDCC)
em cantores eruditos. Pr-Fono Revista de Atualizao Cientfica. No prelo 2010.
Behrman A, Sulica L, He T. Factors predicting patient perception of dysphonia caused by
benign vocal fold lesions. Laryngoscope 2004; 114:1693-700.
Cohen SM, Jacobson BH, Garrett CG, Noordzij JP, Stewart MG, Attia A, et al. Creation and
validation of the Singing Voice Handicap Index. Ann Oto Rhino Laryngol 2007;
116(6):402-406.
Cohen SM, Noordzij JP, Garrett CG, Ossoff Robert. Factors associated with perception of
singing voice handicap. Otolaryngology Head and Neck Surgery. 2008, 138, 430434.
Franic DM, Bramlett RE, Bothe AC. Psychometric Evaluation of Disease Specific Quality of
Life Instruments in Voice Disorders. J Voice 2005; 19(2):300-315.
Fussi F, Fuschini T. Foniatria artistica: la presa in carico foniatrico-logopedica del cantante
classico e moderno. Audiologia & Foniatria 2008: 13(1-2):4-28.
Grbel E, Hoppe U, Rosanowski F. Grading of the Voice Handicap Index. HNO In press 2007.
Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS, et al. The
Voice Handicap Index (VHI): Development and Validation. Am J of Speech-Lang
Pathol 1997; 6:66-70.
Jotz GP, Bramati O, Schimidt VB, Dornelles S, Gigante LP. Aplicao do Voice Handicap
Index em Coralistas. Arq Otorrinolaringol 2002; 6(4) p.260-64.
Moreti F, Rocha C, Borrego MCM, Behlau M. Desvantagem vocal no canto: anlise do
protocolo ndice de Desvantagem para o Canto Moderno IDCM. Rev Soc Bras
Fonoaudiol. No prelo, 2010.
Morsomme D, Gaspar M, Jamart J, Remacle M, Verduyckt I. Adaptation du Voice Handicap
Index la voix chante. Rev Laryngol Otol Rhinol. 2007; 128(5):305-314.
Murry T, Zschommler A, Prokop J. Voice Handicap in Singers. J Voice 2009: 23(3):376-379.
Rosen CA, Murry T. Voice Handicap Index in Singers. J Voice 2000; 14(3):370-377.
Behlau M, Santos LMA, Oliveira G. Cross-Cultural Adaptation and Validation of the Voice
Handicap Index Into Brazilian Portuguese. J Voice, 2010, in press.
Sataloff RT. Voice Impairment, Disability, Handicap, and Medical-Legal Evaluation. In:
Sataloff RT (ed). Professional Voice: The Science and the Art of Clinical Care, ed 2.
San Diego, Singular, 2005, p.1433-41.
Verdonck-de Leeuw IM, Kuik DJ, De Bodt M, Guimaraes I, Holmberg EB, Nawka T, et al.
Validation of the voice handicap index by assessing equivalence of European
translations. Folia Phoniatr Logop. 2008;60(4):173-8. Epub 2008 Apr 24.
Wingate JM, Brown WS, Shrivastav R, Davenport P, Sapienza CM. Treatment outcomes for
professional voice users. J Voice 2007; 21(4):433-449.
841
Zur KB, Cotton S, Kelchner L, Baker S, Weinrich B, Lee L. Pediatric Voice Handicap Index
(pVHI): a new tool for evaluating pediatric dysphonia. Int J Pediatr Otorhinolaryngol
2007; 71(1):77-82.
842
FP26.5
RELATIONSHIPS BETWEEN VOICE ERGONOMIC RISK FACTORS,
VOICE SYMPTOMS AND ACOUSTIC PARAMETERS
A STUDY MADE IN CLASSROOM ENVIRONMENT
Rantala L1, Sala E2, Hakala S1
1Department
of Speech Communication and Voice Research, University of
Tampere, Tampere. leena.m.rantala@uta.fi

Finland
2Department
of Otorhinolaryngology-Head and Neck Surgery. Turku
University Hospital. Turku. eeva.sala@tyks.fi

Finland
Introduction
The risks for voice disorders are partly related to the work environment
(Simberg et al., 2009). Hence the work environment must be taken into consideration
when a voice is assessed and treated during voice care. This applies especially to
voice professionals such as teachers. For a teacher, a good voice production
environment is of the utmost importance. However, there are many factors that
threaten voice in a classroom. Noise is one of the best known risk factors (Pekkarinen
& Viljanen, 1991; Sala et al., 2002; Sdersten et al., 2005). Poor acoustics and long
reverberation times of a classroom (Pekkarinen & Viljanen,1990; Pekkarinen &
Viljanen,1991; Sala et al., 2002, Yang & Bradley, 2009) as well as equipment and the
activity culture (Sdersten et al., 2005) cause noise. Noise impairs speech
discrimination (Pekkarinen et al., 1990) and reception (Stuart, 2008), and distracts
childrens attention (Matheson et al., 2003) which may, for its part, increase noise. In
addition, the vocal tract may be loaded by poor air quality, dry air, bad working
postures and unfavorable working culture although the relationship between the
factors is not linear (Ilomki et al., 2009).
The purpose of voice ergonomics is to take into account all the risk factors in
voice production. The recently published Voice Ergonomic Screening in Work
Environment - Handbook and Checklist (Sala et al., 2009. Sala et al., 2010) has been
constructed for this. It provides a tool to systematically assess and measure voice
ergonomic factors in working environments, especially schools. The Handbook and
Checklist is intended for the use of occupational health service experts and work
safety personnel.
843
This is a preliminary study the purpose of which was to study relationships

between voice ergonomic risk factors in teachers working environment and
teachers voice symptoms. Connections between risk factors and acoustic features of
teachers voices were also investigated. The risk factors were assessed and measured
according to the Voice Ergonomic Screening in Work Environment - Handbook and
Checklist.
Methods
The study subjects were nine female and one male teacher. One of them had
worked less than 5 years, three 5 10 years, two 5 10 years and four over 20 years
as teachers.
Information on the teacher schools is presented in Table 1.
Table 1. Information on the schools where voice ergonomic risk factors were
screened
School Number
of Year
Year
Acoustic
Other
1
pupils/teache built
renovate treatments considerations
rs
d
in the school
A
200/16
1898
1991-93
No2
A railway and a
road with heavy
traffic go past the
school.
B
678/55
1939
2001
Done 2001 Extensions have
been built.
C
300/30
2009
---Done
Special attention
when built paid
to
functionality and
the latest teaching
aids
1 Sound-absorbing treatments in the classrooms
2 The school is protected by the National Board of Antiquities
For the classrooms, the voice ergonomic factors screened were 1) noise, 2)
indoor air quality, 3) working posture, 4) working culture and 5) aids. The teachers
voice ergonomic risk condition was quantified by scoring the risk factors. For a more
accurate description of the screening see the Voice Ergonomic Screening Handbook
and Checklist in this publication (Sala et al.).
Teachers voice symptoms were rated by a questionnaire (7 statements with a
five- point-scale 0 = never; 4= very often). For a voice sample, teachers recorded a
text reading (82 words without sibilants) before and after a day at work. The samples
were recorded with a portable DAT recorder (Zoom H-2) and a headset microphone
(AEG C555L) located 3 cm from the lips. Fundamental frequency (F0), sound
pressure level (SPL) and alpha ratio ([(SL 15 kHz) SL (50 Hz 1 kHz)]) were
measured using Praat software. SPL was calibrated with a sound generator (BOSS
TU-120) and a sound level meter (Brel & Kjr 2206).
844
Statistical analyses for voice changes were calculated with Wilcoxon signedrank test for paired samples. The connections between voice ergonomic risk factors
and voice symptoms as well as the connections of risk factors and acoustic features of
voice were analyzed with Spearmans Correlation Coefficient. Statistical package of
SPSS for Windows 16.0 was used.
Results
Teachers voice symptoms, vocal behavior and voice ergonomic risk scores
The average number of voice symptom scores for the subjects was 13 (SD 6.5;
maximum scores 28). Mean F0 for the female teachers was180 Hz (SD14.8 Hz) and
for the male teacher 89 Hz measured in the morning. Mean SPL for all the subjects
was 75.7 dB (SD 3.5 dB) and alpha ratio -16.6 dB (3.4 dB). F0 and alpha ratio rose
significantly during the days work; see Table 2 for the changes. The interpretation of
the apha ratio change is that teachers voices have turned in the direction of strained
voice
Table 2. Changes in voice acoustic parameters during teachers workday, N=

10.
F0
SPL
Alpha ratio
Change during a + 8.9 Hz
+2.6 dB
+2.05 dB
work day (SD)
(8.7 Hz)
(2.5 dB)
(2 dB)
p-value (Z-value)
0.007 (2.7)
No significance 0.014 (-2.45)
Table 3 shows the voice ergonomic risk scores for the subjects. Working
culture most often caused problems for the teachers voices. Working culture
included loud and continuous talking and long talking distances, all of which the
teachers admitted to having. During breaks, the subjects also reported using their
voices a lot.
Table 3. Voice ergonomic risk scores for the teachers, N = 10. Max =
maximum scores
Noise
Indoor
air Working
Working
Stress
(max 18) quality
posture (max culture
(max 4)
(max 7)
4)
(max 8)
Mean
3.9
3.2
1.2
4.6
1.9
(range)
(1 7)
(2 4)
(0 5)
(3 6)
(1 3)
%
22
46
11
58
47
Relationships between voice ergonomic risk factors. voice symptoms and acoustic
parameters
Teachers voice symptoms and the variable working culture of voice
ergonomic risk factors had a significant connection (r = 84; p = 0.003). No other
relationships were found between the variables. No acoustic parameter correlated
with voice ergonomic risk factors, either.
845
Discussion
The results showed that the teachers had voice problems and their voices
reacted to teaching in a way that can be interpreted to express voice loading (e.g.
Rantala et al. 2002). Moreover, several voice ergonomic risk factors were found to
threaten teachers voices. Interestingly, only one of the voice risk factors assessed,
working culture, had a linear relationship with the teachers voice symptoms. This
cannot, however, be interpreted to mean that ergonomic risk factors do not affect
voice. The connection may be more complicated than linear. The result can be also
explained by the fact that some assessments of the risk factors were elicited from the
teachers themselves. This is seen in the finding that the researchers perception on
the risk factor differed from that made by the teachers (Hakala et al., forthcoming).
Indeed, only 55 % of the two observers assessments of the factors were in
agreement.
One explanation for the results may also be that one school (C) was brand
new. The teachers in that school had not worked there long thus their voice
symptoms may have begun in their previous school building. Furthermore, an
interesting observation was made in school C: because the school was new, the
teachers did not notice the high sound levels of equipment in their classrooms. It
seemed that the teachers assumed that the latest technology of a modern building
could not have any flaws.
Acknowledgements
The project was supported by grants from The Finnish Work Environment
Fund.
References
Hakala S, Rantala L & Sala E. Relationships between a researchers and a teachers
evaluations of voice ergonomic risk factors. Forthcoming.
Ilomki I, Leppnen K, Kleemola L, Tyrmi J, Laukkanen AM & Vilkman E. (2009).
Relationships between self-evaluations of voice and working conditions, background
factors. and phoniatric findings in female teachers. Log Phon Vocol, 34: 20-31.
Matheson MP, Stansfeld SA & Haines MM. (2003).The effects of chronic aircraft noise
exposure on children's cognition and health: 3 field studies. Noise Healt,. 5:31-40.
Pekkarinen (Sala) E & Viljanen V. (1990). The effect of sound-absorbing treatment on speech
discrimination in rooms. Audiol, 29: 219-227.
Pekkarinen (Sala) E & Viljanen V. (1991). Acoustic conditions for speech communication in
classrooms. Scand Audiol, 20: 257-263.
Rantala L, Vilkman E & Bloigu R. (2002). Voice changes during work: subjective complaints
and objective measurements for female primary and secondary schoolteachers. J Voice,
16: 344-55
Sala E, Airo E, Olkinuora P, Simberg S, Strm U, Laine A et al. (2002). Vocal loading among
day care center teachers. Log Phon Vocol, 27: 21-8.
Sala E, Hellgren U, Ketola R, Laine A, Olkinuora P. et al. (2009). Voice Ergonomic Screening
in Work Environment - Handbook and Checklist. [in Finnish]. Helsinki: The Finnish
Institute of Occupational Health
Sala E, Rantala R & Hakala S. (2010). Voice Ergonomic Screening in Work Environment Handbook and Checklist. In this publication.
Simberg S, Santtila P, Soveri A, Sala E & Sandnabba NK. (2009). Exploring genetic and
environmental effects in dysphonia: a twin study. JSHR, 52:153-163.
Stuart A. (2008). Reception thresholds for sentences in quiet. continuous noise. and
interrupted noise in school-age children. J Am Acad Audiol, 19: 135-46.
846
Sdersten M. Ternstrm S. Bohman M. (2005). Loud speech in realistic environmental noise:

phonetogram data. perceptual voice quality. subjective ratings. and gender differences
in healthy speakers. J Voice. 19: 29-46.
Yang W & Bradley JS. (2009).Effects of room acoustics on the intelligibility of speech in
classrooms for young children. J Acoust Soc Am, 125: 922-33.
847
SE17.1
VOICE ERGONOMIC SCREENING IN WORK ENVIRONMENT
- HANDBOOK AND CHECKLIST
E. Sala1, L. Rantala2, S. Hakala2
1Department of Otorhinolaryngology-Head and Neck Surgery. Turku
University Hospital. Turku. eeva.sala@tyks.fi
2Department of Speech Communication and Voice Research, University of
Tampere, Tampere. leena.m.rantala@uta.fi
Finland
Introduction
Speaking and listening are an essential part of the job descriptions of many
professions. As the voice is an occupational tool, its condition has to be taken care of
in professions such as those of schoolteachers and kindergarten teachers who are
demonstrably at high risk for voice disorders (e.g. Sala et al. 2002, Ilomki et al. 2005,
Sliwinska-Kowalska et al. 2006). There are also other professions, such as those in
information services and physical education, whose working environment loads the
voice. Because the risks for voice disorders are partly related to environment
(Simberg et al. 2007), the demands of voice ergonomics ought to be taken into
consideration when the work environment is planned and assessed.
Although occupational health care conducts general workplace surveys to
collect detailed information on work and working conditions for purposes of
detecting health hazards, these surveys do not include any assessment of voice
ergonomics. Consequently there has been little information available on voice
ergonomics, and advice for assessing voice ergonomics has not been available at all
prior to this publication. The Voice Ergonomic Screening in Work Environment Handbook and Checklist helps workers in occupational health care to establish the
assessment of voice ergonomics as a part of their operations. Reference to the
screening handbook will make it possible to systematically individualize, observe,
measure and document the voice ergonomic factors of the work environment.
The Voice Ergonomic Screening Handbook has been constructed with most
typical work environments in mind: schools and kindergartens, offices and open
plan offices. The instructions in the handbook can also be applied in the working
environments of other professionals - lawyers, physical education instructors,
priests, cantors, domestic science teachers, nurses, interpreters, theatrical prompters
or people in information services.
The Voice Ergonomic Screening Handbook is specifically intended for the use of
occupational health service experts and work safety personnel. In the forms included
in the handbook, parts have also been marked that are suitable for employees and
workers if they want to assess their own voice ergonomic situation if their voice is
showing symptoms of disorder. Using voice ergonomic screening, a professional
voice user can identify risk factors that threaten her/his voice and thereby adopt new
and safer voice use habits.
Each chapter of The Voice Ergonomic Screening Handbook includes a short
introduction to the voice ergonomic risk factor it is intended to measure. It also
contains forms to assist in making observations, solving problems and planning
further operations. The screening handbook proceeds from one voice ergonomic
848
factor to another; the factors are the following: 1 Noise, 2 Indoor air quality, 3
Working posture, 4 Working culture and 5 Aids. The order of the forms is arranged
in the same sequence as the screening process.
For employee instruction an information card is provided with information
on what a good work environment and culture are like from the perspective of voice
and how an employee can relax her/his voice independently. This Information Card of
Voice Ergonomics (written in Finnish) can be purchased from the publisher and seller
of the The Voice Ergonomic Screening in Work Environment - Handbook and Checklist,
Tyterveyslaitos (the Finnish Institute of Occupational Health), or electronically from
http://www.ttl.fi/Internet/Suomi/Aihesivut/Ergonomia/Tyokalut/aaniergonomia
.htm
A preliminary study on the use of the Voice Ergonomic Screening in Work
Environment - Handbook and Checklist has been carried out in ten classrooms. The aim
was to find out how the checklist works and what kind of voice risk factors exist in
classrooms. The results are presented here. The project is ongoing and is scheduled
to cover forty classrooms in ten school buildings.
Methods
Voice ergonomic screening was conducted with ten teachers in their
classrooms in spring 2010 according to the Voice Ergonomic Screening in Work
Environment - Handbook and Checklist. The classrooms were situated in three different
schools: one (school A) in a city of 200,000 inhabitants and the others (schools B and
C) in municipalities with 20,000 inhabitants each (more information on the schools in
Table 1). The study subjects were nine female and one male teacher. One of them had
worked less than 5 years, three 5 10 years, two 5 10 years and four over 20 years
as a teacher.
During the voice ergonomic screening, only the researcher and the teacher
were in the classroom. The researcher made observations and measurements of the
risk factors related to the classroom and the teacher. Some risk factors were elicited
from the teacher. Noise was measured from equipment (like computers and
projectors), ventilation, adjacent rooms and traffic. Reverberation was also estimated.
The indoor air quality evaluation included assessing the temperature, dustiness,
odors, draftiness and humidity of the classroom. Working postures were rated by
asking the teacher to show her/his most typical positions when teaching. For
example, turning head or body or hunching shoulders while speaking were deemed
harmful. The assessment of the working culture included questions on voice
loudness, communication distances and opportunities to rest the voice. Stress level
was also elicited in one question. The last question concerned an amplifier: did the
school have one and did the teachers need it (aids). During the screening, ways and
means of improving voice ergonomics in the classroom were discussed with the
teacher and information was provided on the effects of the risk factors.
849
Table 1. Information on
screened
School Number
of
pupils/teach
ers
in the school
A
200/16
the schools where voice ergonomic risk factors were
B
C
Year Year
buil renovate
t
d
Acoustic
treatment
s*
Other considerations
1898 1991-93
No**
678/55
1939 2001
300/30
2009 ----
Done
2001
Done
when
built
A railway and a road

with heavy traffic go
past the school.
Extensions have been
built.
Special attention paid
to functionality and
the newest teaching
aids
* Sound-absorbing treatments in the classrooms

**The school is protected by the National Board of Antiquities
The teachers voice ergonomic risk condition was quantified by scoring the
risk factors. If the finding regarding a certain voice ergonomic risk factor was
according to the recommendation, the finding was scored 0 (no risk to voice); if the
finding deviated from the recommendation, a value of 1 was given (risk of voice
disorder). Tables 2 and 3 show the maximum risk scores to each risk factor.
Results and conclusions

Every school and every classroom was found to have voice ergonomic risk
factors and this was not dependent on the year in which the school was built (Table
2). However, there were differences between classrooms, especially regarding noise.
The best classroom was scored 1 and the worst 7 (maximum risk score 18).
Interestingly, the quietest classroom was located in the largest school (school B).
Indoor air was also found to be unsatisfactory. Indeed, it was threatened by
relatively more risk factors than noise. The air was considered to be dry in many
classrooms (8/10 of the classrooms). No teacher had access to an amplifier but none
of them felt a need for it.
850
Table 2. Voice ergonomic risk factors in the classrooms tested. Maximum risk
scores (max) in parentheses. The greater the number, the more voice
ergonomic risk factors in the classroom.
School
identification
Classroom
identification
Number of voice ergonomic risk factors

Noise
Indoor
air Total
(max 18)
quality (max 7)
(max 25)
7
4
11
5
28 %
3
3.3
47 %
4
8.3
33 %
7
2.5
14 %
5
3.5
50 %
3
7
28 %
8
4.6
25 %
3.9
22 %
2.7
39 %
3.2
46 %
7.3
28%
8.1
32 %
Mean
B
Mean
C
Mean
Mean total
Table 3 shows the risk factors related to the teachers. Risks including in
working culture were found for all teachers (e.g. using loud voice, long talking
distances and durations, lack of voice rest). On the other hand, teachers working
postures were mostly acceptable. All the teachers felt that they used their voice a lot
and continuously. The teachers in school C, the newest one, reported most stress.
851
Table 3. Risk scores for working postures, working culture and stress in
teachers. Maximum risk scores in parentheses. The greater the number, the
more voice ergonomic risk factors.
Number of voice ergonomic risk factors
School
identificatio
n
Gender
Working posture
(max 11)
Working
culture
(max 8)
Stress1
(max 4)
Total
(max 19)
11
Mean
scores
of
school
8
Mean total
1.2
4.6
1.9
7.6
11 %
58 %
47 %
40 %
F = female; M = male; 1Stress: 1 = little, 2 = some; 3 = quite a lot; 4 = very much
Because only a few schools and classrooms were included in the study, no
statistical analysis was made, but it seems that
7. voice ergonomic screening works well using the handbook
8. every school and every classroom was found to have voice ergonomic
risk factors
9. several voice ergonomic risk factors could be found in one classroom.
10. voice ergonomic risk factors may even be present in a new school
building and classroom.
Acknowledgements
The project was supported by grants from The Finnish Work Environment
Fund.
References
Ilomki, I., Mki, E. & Laukkanen, A-M. 2005. Vocal symptoms among teachers with and
without voice education. Logopedics Phoniatrics Vocology, 30: 17174.
Sala E, Airo E, Olkinuora P, Simberg S, Strm U, Laine A, Pentti J, Suonp J. 2002.
Vocal loading among day care center teachers. Logoped Phoniatr Vocol. : 27:21-8.
Sala, E., Hellgren, U., Ketola, R., Laine, A., Olkinuora, P., Rantala, L. Sihvo, M. (2009). Voice
Ergonomic Screening in Work Environment - Handbook and Checklist. [in Finnish].
Helsinki: The Finnish Institute of Occupational Health
852
Simberg S, Santtila P, Soveri A, Varjonen M, Sala E, Sandnabba NK. 2009 Exploring genetic
and environmental effects in dysphonia: a twin study. J Speech Lang Hear Res. 52:15363.
Sliwinska-Kowalska, M., Neibudek-Bogusz, E., Fiszer, M., Los-Spychalska, T., Kotylo, P.,
Sznurowska-Przygoka, B. & Modrzewska, M. 2006. The prevalence and risk factors for
occupational voice disorders in teachers. Folia Phoniatrica et Logopaedica, 58: 85101.
853
P120
COMMUNICATIVE SKILLS AFTER ADMISSION IN PERFORMING
ARTS AND THE USE OF VOCAL EFFORT ON STAGE
Paula Belini Baravieira1, Ldia Cristina da Silva Teles2,
1
Speech Pathologist, graduated at University of So Paulo, Bauru, Brazil.
Departament of Speech Pathology and Audiology Faculty de Odontologia de Bauru - University of So Paulo
(USP), Bauru, Brazil
1. INTRODUCTION
In the scenic arts, the domination of communication skills is crucial, since the
actor must give life and meaning to the handled text. For each character, the actor
must compose a new speech pattern, which means breaking created patterns all the
time, in an imaginative arrangement of those.
Actors must have plain control of their bodies and voices, for they are in
constant dialog while constituting their characters, which is also associated to the
manipulation of emotions and the dramatic diversity of the handled scripts. To
possess plain domination of the voice means being able to use widely intonation
parameters, once they provide the richness of vocal expressivity. The intonation
parameters include pauses, which are responsible for rhythm of speech and scilence3;
intensity variations, which develop an important role in the actors voice projection,
in addition of contributing for expressivity, being for that reason target of many
studies4,5; and the melodies, which are the result of the association between intensity
variations, frequency and speech velocity, by which the public recognizes the
characters emotions.
The actor who wishes to widely use these parameters needs a good quality of
voice, since a healthy voice is much more flexible and shapeable by the actor. To
understand the actors vocal behavior is primal, so they can be assisted to take better
care of their voices6,7,8. It is known that the scenic arts require great vocal demand
from the actor, who needs to use maximum voice projection and intensity to be
clearly heard by the audience, with minimum vocal effort, which is a great challenge.
Taking this into consideration, the first task that should be developed with actors is
their awareness of vocal habits and vocal function practice9,10, such as the harm
caused by alcohol smoking for the voice11,12, or the importance of hydration for its
health13. Adding this too many health and vocal improvement, programs are being
developed by speech-language pathologists with actors, showing them the benefits
of these efforts for their professional performance1,14,15. To identify theatrical actors
acquire greater skill in their social communication, which intonation parameter are
most used by actors during a scene, and also what are the care and habits harmful to
their voice.
2. METHODS
854
Thirty eight actors, being 22 of the female gender and 16 of the male gender
with age average of 24 years and 7 months ( 3 years) participated in this study.
From the 38 actors, 20 (53%) are professionals with average time of theater acting of 9
years, and 18 actors (47%) remain studying scenic arts, with average time of
experience in theater acting of 8 years.
The evaluation process consisted in the use of a questionnaire, developed for
this study, which 20 questions related to: period of scenic acting (2 questions);
communication abilities prior to and after enrolling in scenic arts (4 questions); use of
the intonation parameters during a scene (3 questions); vocal warm up and cool
down (4 questions); and vocal hygiene (5 questions).
The Fishaer Test was used for the analysis, using significance level of 5%.
3. RESULTS
The results presented the percentages do not add to 100% because the
participants had the option to write in the questionnaire more than one alternative.
The results regarding in Figures 1 to 6.
Communicative skills before and after admission in
P< 0,05
P< 0,05
Figure 1 Percentage of the actors communication abilities before and after enrolling in the
scenic arts.
855
Parameters of intonation of the voice used in scene
Figure 2 Percentage of vocal resources usage while playing characters, and of the
difficulties using these resources by the actors.
Vocal Resources for the voice to reach audience
Scream
2,50%
Speak up with effort
18%
26%
Speak up without effort
29%
Speak more mouth

opening
61%
Talk with respiratory

support
63%
Speak the words with

greater accuracy
82%
Talk with vocal projection

0%
20%
40%
60%
80%
100%
Figure 3 Percentage of vocal resources usage, so that the voice can reach the audience.
Vocal warm up and cool down, showed that all (100%) perform vocal
warm up and 21% (n=8) vocal cool down (Figure 4).
856
Average period of execution of vocal warm up and cool down by the actors
who perform them
21%
100%
Figure 4 Percentage of the average period of execution of vocal warm up and cool down by
the actors who perform them.
857
Frequency of the alcoholic

beverages consumption
Tobacco consumption
Figure 5 Percentage of actors who are smokers, consume alcoholic beverages, and the
frequency of the alcohol consumption.
Percentage of actors regarding daily consume of water
Figure 6 Percentage of actors of the present study regarding daily consume of water.
858
Figure 7 Percentage of the actors answers regarding vocal perception after a theatrical
performance.
The results also show that 95% (n=36) of the actors received attention to
maintain a good vocal health and 84% (n=32) reported to want professional help for
a better performance, and 8% (n=3) declared to receive speech-language pathology
assistance to build their characters expressivity.
4. DISCUSSION and CONCLUSION

The concept of intrinsic relation between the theater and communication have
been discussed for a very long time. Without it the theater would not exist, since it is
the immediate communication with the audience16,17. In the theater the individuals
are constantly exposed to the public and their criticism, whether positive or not. It is
possible that this constant challenge prepare them to face best these situations,
guaranteeing greater security in communication. Another apprenticeship that occurs
in the theater is the corporal, vocal, and speech expressivity training.
Considering the use of intonation parameters by actors while acting this data
emphasizes the importance of these resources in the expressivity of the scenic
communication. Some actors indicated negative vocal behaviors and for the
education of actors, reminding that 8% of the actors reported speech-language
pathology assistance for building the characters expressivity. This attendance can
maximize the use of these vocal resources, in an adequate way, with minimum
abrasion of the phonation apparatus, contributing for the actors vocal heath, in
short, medium and long terms. The benefits of vocal improvement and prevention
programs with actors were revealed in many studies1,14,15.
The amount of water drunk daily by the actors, the index of actors that
consume alcoholic drinks and that are smokers were approached. In this research
most actors (66%;n=25) referred to consume between 1 and 2 liters of water per day
and 15,75% (n=6) more than 2 liters. The literature refers that 2 liters of water per
day is enough to guarantee the replacement of losses by urine and perspiration, and
for the maintenance of a good body hydration18. It is known that corporal hydration
allows the mucus that overlay the respiratory tract to be more fluid, which reduces
friction during phonation. This way, the vibration of the vocal folds occur in a more
loose and flexible way, allowing better quality of voice.
859
As for the consumption of alcoholic drinks, the results showed that 13% of
the actors consume alcohol every day, and their daily consume can be a sign of
addiction according to the World Health Organization (WHO). This index is close to
the number of Brazilian alcoholics, which is 12%19. Specifically for vocal health it is
known that alcohol provokes irritation on the mucosa of the respiratory tract and,
concurrently, causes anesthetic effect on this region, which propitiates vocal abuse20.
Referring to smoking, the harm that cigarettes can cause in the vocal
apparatus are decrease in the fundamental frequency, greater vocal instability,
irritation in the respiratory tract, Reinkes edema, chronic laryngitis and cancer11,12.
For a voice professional such as the actor, vocal heath is essential for a good vocal
and professional performance.
A great part of this researchs actors (79%;n=30) reported some vocal
alteration after theatrical presentations. Vocal fatigue, ardor and soreness in the
throat and hoarseness are among the most cited signs. These data indicate poor use
of the phonation apparatus during the theatrical presentations, so much as for the
use of intonation parameters, as for vocal projection resources. In addition, the lack
of vocal cool down by most of them and the insufficient period of vocal warm up of
40% (n=15) of the actors and the smoking and drinking habits sustained by some of
them are harmful for the voice. The emphasize that 84% of the actors showed interest
on professional help for a better performance, which matches the literature14.
To conclude, this study Identified that theatrical actors have gained greater
skill in their media, with a decrease of shyness (p<0.05) and increase communicative
expressiveness (p<0.05).
The parameters of intonation most used in scene were increase of intensity,
frequent use of pauses, increase and decrease the speed of speech and increase and
decrease vocal frequency.
As for vocal care, most actors: performs 15 to 20 minutes of voice warm up;
drink between 1 and 2 liters of water/day, do not consume alcohol daily; do not
smoke.
The harmful habits often found were the lack of vocal cooling, consumption of
alcoholic beverages regularly (weekends).
REFERNCIAS BIBLIOGRFICAS
1- Scharama ELS. The Instrumental Phase of the voice Program at the Utrecht School of
Acting. Folia Phoniatr Logop. 2008 Nov;6(60):291-3.
2- Gayotto LHC, Silva TPP. A voz do ator de teatro. In: Oliveira IB, Almeida AAF, Raize, T.
(Org.). Voz profissional: produo cientfica da fonoaudiologia brasileira. 3 ed. So
Paulo: Rev. soc. bras. Fonoaudiol. Suplemento, 2008. CD-ROM.
3 Sprintzer M. O ator e o rdio. In: NP06 Teorias da comunicao do Encontro dos
Ncleos
de
pesquisa
da
Intercom,
IV,
2004.
Avaible
in:
<
http://www6.ufrgs.br/estudiodeaudio/textos/ator_radio.pdf > Acessado em:
25/11/2009.
4- Emerich KA et al. Vocal Range and Intensity in Actors: A Studio Versus Stage Comparison.
Journal of Voice. 2005 Mar;1(19):78-3.
5- Pinczoer R, Oates J. Vocal Projection in Actors: The Long-Term Average Spectral Features
That Distinguish Comfortable Acting Voice From Voicing With Maximal Projection
in Male Actors. Journal of Voice, 2005 Sep;3(19):440-53.
6- Aydos B, Hanayma EM. Tcnicas de aquecimento vocal utilizadas por professores de
teatro. Rev CEFAC, 2004 Jan-Mar;1(6):83-8.
7- Ueda KH, Santos LZ, Oliveira IB. 25 anos de cuidados com a voz profissional: avaliando
aes. Rev CEFAC. 2008 Out-Dez;4(10);557-65.
860
8- Rehder MIBC, Behlau MS. Perfil vocal de regentes de coral do estado de So Paulo. Rev
CEFAC. 2008 Apr-Jun;2(10):206-17.
9- Lopes FTA. Hbitos vocais de profissionais de rdio. Pr-Fono R. Atual. Cient. 1999
Mar;1(11):100-5.
10- Zeine L, Waltar KL. The voice and its care: survey findings from actors' perspectives.
Journal of Voice. 2002 Jun;2(16);22943.
11- Awan SN, Morrow DL. Videostroboscopic Characteristics of Young Adult Female
Smokers vs. Nonsmokers. Journal of Voice. 2007 Out;2(21):211-23.
12- Guimares I, Abberton E. Health and voice quality in smokers: na exploratory
investigation. Logoped. Phoniatr. Vocol. 2005 Nov;3-4(30):185-91.
13- Fujita R, Ferreira AE, Sarkovas C. Avaliao videoquimogrfica da vibrao de pregas
vocais no pr e ps hidratao. Rev. Bras. Otorrinolaringol. 2004 Nov-Dec;6(70).
14- Padovani M, Baruzzi MB, Madazio G. Treinamento vocal em atores amadores. Fono atual,
2005 Apr-Jun;32(8):4-12.
15- Walzak P. et al. Acoustic Changes in Student Actors Voices After 12 Months of Training.
Journal of Voice. 2008 Mai;3(22):300-13.
16- Alves MA. O teatro como um sistema de comunicao. Trans/Form/Ao, 2001;1(24).
17- Bulik L. Comunicao e teatro: por uma semitica do Odin Teatret. 1 ed. So Paulo: Arte
e Cincia; 2001.
18- Behlau M, Pontes P. Higiende vocal: cuidando da voz. 3 ed. Rio de Janeiro: Revinter;
2001.
19- USP Universidade de So Paulo. So Paulo, 2009. Avaible in:
<http://www4.usp.br/index.php/saude/18028-encontro-discute-politicas-publicase-aspectos-clinicos-do-uso-de-drogas-e-alcool >. Acesso em: 27 novembro 2009.
20- Almeida APC. Trabalhando a voz do professor: Prevenir, Orientar e Conscientizar
[monografia curso de especializao]. So Paulo: CEFAC; 2000.
861
P179
ACOUSTIC ANALYSIS OF VOICE
Characteristics of Male Vocal Development in Adolescence
Ldia Cristina da Silva Teles2, Cristiane Ferraz de Oliveira1
1 Departament of Speech Pathology and Audiology Faculty de Odontologia de Bauru - University of So Paulo (USP),
Bauru, Brazil
2Postgraduation Program Interunits in Bioengineering Escola de Engenharia de So Carlos / Faculdade de Medicina de
Ribeiro Preto / Instituto de Qumica de So Carlos - University of So Paulo (USP), So Carlos, Brazil
INTRODUCTION
The voice development follows physical, psychological and social

developments of an individual. The most notable changes of male vocal
development occur during puberty when, because of hormonal changes, the larynx,
childlike before, develops and gets the proportions of an adult larynx. (Behlau,
Azevedo & Pontes 2001). For this reason its necessary a vocal adaptation to the new
anatomical conditions of vocal tract, that leads to a period of unbalance called vocal
mutation, characterized by muscular lack of control during voice production,
instability and accentuated decrease of fundamental frequency (Fuchs et al. 2006).
The necessity of vocal evaluations that provide objective data has made the
acoustic analysis of voice widely used. Among the various types of acoustic
evaluations we find the measurement of the fundamental frequency (F0) of voice,
parameter that suffers less external influences during its analysis (Behlau et al. 2001),
and the phonetography, which evaluates the relation of the frequency and intensity
(Schutte & Seidner 1983). The phonetography is capable to plot in a graphic, called
phonetogram, the maximum and minimum intensities that an individual is able to
produce for each note of the vocal range. This way, the phonetography is a very
useful tool in the evaluation of vocal potential and the voice development from
childhood to old age (Schutte & Seidner 1983). Thus, the objective of this study is to
identify the characteristics of vocal development in adolescence on male individuals
by phonetography and habitual F0 of voice measurements.
2 Materials and methods

Fifty-two male individuals were evaluated, ages 9-18 ( X =14 2.87), divided
into 4 groups according to vocal development stage: vocal premutation (group I)
with 8 individuals from 9-11 ( X =100.76) years; vocal mutation (group II) with 9
individuals from 11-15 ( X =121.50) years; end of vocal mutation (group III) with 19
individuals from 12-18 ( X =161.39) years and vocal postmutation (group IV) with 16
individuals from 14-18 ( X =161.48) years. The group division was done by 3
specialists in voice, by the perceptual evaluation of a spontaneous speech sample.
Individuals with low vocal pitch and vocal instability were classified in the
development stage called here end of vocal mutation (group III). The evaluations
862
were performed with the individuals seated and at a recording studio with acoustic
treatment.
2.1
Measurement of Habitual F0
A sample of spontaneous speech was recorded using the software Sound

Forge 7.0 (Sony Pictures Digital Inc.) and a unidirectional head-set microphone, AKG
C444, 3cm from labial commissure and connected to a stereo pre-amplifier (KAY
Elemetrics Corporation) to control the entrance signal gain.
The F0 of speech was extracted by the software Multidimensional Voice
Program (MDVP) by KAY Elemetrics Corporation, model 5105, version 2.5.2.
2.2
Computerized Phonetography
The software Voice Range Profile (VRP) by KAY Elemetrics Corporation,

model 4326/-1/-2, version 2.5.2, was used.
To perform the exam the individuals emitted the sustained vowel /a/ in the
strongest (excluding screaming) and the weakest intensities possible over the vocal
range (excluding vocal fry). The exam was started in note C4 - 261,63Hz (American
Notation) following the presentation of the C, E, G and A notes in rising and falling
scales. The minimum and maximum intensities produced by the individual were
registered by VRP (Figure 1).
Figure 1: Phonetogram visualized after phonetography using the software VRP (KAY Elemetrics).
The measurements obtained by phonetography were:

Minimum (FMIN) and maximum (FMAX) frequencies: expressed by musical notes
with average in Hertz (Hz), are respectively the lowest and highest notes produced;
Vocal range (VR): expressed by number of semitones (st), is the total number
of musical notes produced, from low to high. It was calculated by the software
FonetoBD (Magalhes 2004) by the difference between the semitone of the highest
and the lowest notes the individual was able to produce;
Minimum (IMIN) and maximum (IMAX) intensities: expressed in decibel (dB), are
obtained, respectively, from the lowest point of the lower curve and the highest point
of the upper curve of the phonetogram;
Maximum Dynamic Range (MDR): expressed in dB, is the greatest difference in
intensity between the upper and lower curves of the phonetogram in the same
frequency. It was calculated by FonetoBD;
Phonetogram area: expressed in cm2, is the resulting area of the connection
between the points of the lower and upper curves in relation to the vocal range. It
was calculated by FonetoBD.
2.3
Statistic Analysis of the Results
863
The statistics comparison of the results of the 4 groups was done using
ANOVA one way and the Tukey Test and to verify the correlation among the
variables the Spearmans correlation (rs) was used. The results with p>0.05 were
considered insignificant.
RESULTS
Were presented in figures that show maximum and minimum values, mean
( X ) and standard deviation. The results of ANOVA and Tukey Test, when
statistically significant, were indicated in the figures by letters of the alphabet.
3.1
Measurement of F0 (Figure 2)
A strong negative correlation between the habitual X F0 of spontaneous

speech and the vocal development stages was found (rs=-0.76;p<0.01).
3.2
Computerized Phonetography (Figures 3-7)
There was a medium to strong negative correlation between the

phonetography of FMIN and the phases of vocal development (rs=-0.70;p<0.01) and
medium negative correlation between the FMAX and the vocal development (rs=0.59;p<0.01).
DISCUSSION AND CONCLUSION
Although the mean age among groups I, II and III presented statistically
significant differences, the 11 to 18 years-old participants were found in, at least, 2
groups.
F0 of Speech (Hz)
320
310
285
a(*)
272
(27.6)
250
244
b(*)
215
216
(38.1)
230
180
206
158
c(*)
145
110
119
75
c(*)
132
(24.6)
II
119
(16.4)
97
97
III
IV
Groups
Figure 2: Fundamental frequency of speech for the

studied groups. (*) different letters indicate significant difference among groups (p<0,01).
Minimum Frequency
Maximum Frequency
( )
( )
X =88Hz (F2) b *
C#2
A4
A#2
( )
C#2
X =95Hz (F#2) b *
X =732Hz (F#5) b *
F#4
E3
( )
X =1002Hz (B6) a *
F5
( )
C2
Groups:
F#3
C3
G5
C4
II
F6
( )
X =1070Hz (C6) a *
X =168Hz (E3) a *
C#6
( )
X =155Hz (D#3) a *
F2
G3
D#3
D6
( )
X =749Hz (F#5) b *
C5
III
E6
C6
IV
864
Vocal Range (no. of st)
Figure 3: Minimum and maximum frequencies of phonetography for the studied groups. (*) different
letters indicate significant difference among groups (p<0.01).
46
50
42
45
40
32
30
25
37
36
35
28 (2.6)
(5.5)
(3.2)
27
20
37
35
32
(4.6)
29
22
15
II
III
IV
Groups
Figure 4: Vocal range of phonetography for the
studied groups.
Minimum Intensity (dB)
Maximum Intensity (dB)
The results of F0 of speech confirmed the significant decrease of F0 of

approximately one octave between the initial and final stages of vocal development
(Behlau, Azevedo & Pontes 2001, Gutirrez 2003). Fuchs et al. (2006) evaluated the
voices of 21 male singers, 9-12 years old, and found that 6 months before vocal
mutation there was a decrease of F0 to 226 Hz, value close to the X F0 of group II of
the present study. In group IV was found X F0 close to the value of 110 Hz,
mentioned by Gutirrez (2003) for individuals after the mutational vocal change, and
close to 113 Hz, value found by Behlau, Tosi & Pontes (1985) for adult Brazilian men.
This clearly observed decrease of F0 was due to the growth of the vocal tract,
principally of the larynx and the vocal folds during puberty (Kahane 1996).
125
122
122
120
115
114
(7,4)
110
118
(2,7)
95
117
(2,6)
116
(4,7)
114
112
105
100
122
123
108
101
85
80
75
70
75
65
60
74
69
69
64
66
(2,0)
62
59
55
66
(3,1)
65
(4,5)
II
64
(2,9)
59
III
IV
Groups
Figure 5: Maximum and minimum intensities of
phonetography for the studied groups.

65
MDR (dB)
60
55
50
40
38
47
45
(6.2)
(7.1)
35
30
53
48
45
45
59
56
54
(5.8)
37
41
(3.8)
31
25
II
III
Groups
IV
Figure
6:
Maximum
dynamic
range
of
phonetography for the studied groups.
865
Phonetogram Area (cm)
80
70
60
58
57
51
50
45
40
30
77
71
(9.6)
42
56
51
(6.0)
(11.3)
(9.8)
39
32
32
20
II
Groups
III
IV
Figure 6: Phonetogram area for the studied groups.
With regard to the phonetography was possible to compare the results of

groups I and II with the findings of McAllister et al. (1994) that performed the
manual phonetography in 10-year-old children with normal and dysphonic voices
and found 6 boys in vocal mutation. The results obtained for the boys in vocal
mutation ( X FMIN=196Hz, X FMAX=1047Hz, X VR=29st and X MDR=22.8dB) presented
lower values than group II of the present study. The boys with normal voice
obtained X FMIN=208Hz higher and X FMAX=880Hz, X VR=25st and X MDR=21.4dB
lower in relation to group I of the present study.
The significant decrease of 11st of FMIN of the phonetography and of 6st of the
FMAX of the present study showed that the phonetogram has moved to lower
frequencies during vocal mutation.
In relation to the VR, all groups presented X VR higher than 20st, value
considered by Behlau et al. (2001) as the minimum for individuals with healthy vocal
folds. It was possible to observe the non-significant increase of the VR with the voice
development. Although Fuchs et al. (2006) had declared that during vocal mutation
the VR is restricted, in this study a reduction of the VR in group II was not observed.
Neuschafer-Rube, ram & Klajman (1997) found, in men from 29-63 years with vocal
training, X VR=37st, equal to the one in group IV of the present study. Mean
VR=38st, similar to the one found in group IV of the present study, was described by
Montojo, Garmendia & Cobeta (2006) after performing the computerized
phonetography of singers of both sex from 21-53 years and by Sulter, Schutte &
Miller (1995) after computerized phonetography in male singers men without vocal
training from 17-75 years.
The parameters of intensity (IMIN, IMAX and MDR) did not present significant
differences with vocal development. None of the studied works presented
phonetogram area values. In the present study was observed an increase (not
statistically significant) of the phonetogram area with vocal development that can be
justified by the increase of the VR.
The use of the computerized phonetography has made this test much simpler
and less difficult in relation to the manual phonetography. The automatic record
(real time) of the phonetogram, during the test, on the computer screen helps the
patient with difficulty in distinguishing different tones to produce the notes
presented by the appraiser.
With the present study it is concluded that, with voice development, there
was a significant decrease of the F0, approximately one octave, of speech. With
regard to the phonetography, the frequency parameters showed a statistically
significant decrease of minimum and maximum frequencies and an increase, not
significant, of vocal range and of the phonetogram area. There was no significant
modification in the intensity parameters (minimum and maximum intensities and
maximum dynamic range).
866
REFERENCES
Behlau, M, Azevedo, R & Pontes, P 2001, Conceito de voz normal e classificao das
disfonias, in: Voz: o livro do especialista, vol.1, ed. M Behlau, Revinter, Rio de Janeiro, pp.5384.
Behlau, M, Madazio, G, Feij, D & Pontes, P 2001, Avaliao de voz, in: Voz: o livro do
especialista, vol.1, ed. M Behlau, Revinter, Rio de Janeiro, pp.85-245.
Fuchs, M, Frehlich, M, Hentschel, B, Stuermer, IW, Kruse, E & Knauft, D 2006, Predicting
mutational change in the speaking voice of boys, Journal of Voice, in press.
Gutirrez, CA 2003, Evolucin de la voz desde el nacimiento hasta la senectud, Acta de
Otorrinolaringologa e Ciruga de Cabeza y Cuelo, vol.31, no.2.
McAllister, A, Sederholm, E, Sundberg, J & Gramming, P 1994, Relations between voice
range profiles and physiological and perceptual voice characteristics in ten-year-old
children Journal of Voice, vol.8, no.3, p.230-239.
Montojo, J, Garmendia, G & Cobeta, I 2006, Comparacin entre los resultados del
fonetograma manual y el fonetograma automtico, Acta Otorrinolaringologica Espaola,
vol.57, pp.313-318.
Neuschafer-Rube, C, ram, F & Klajman, S 1997, Tree-dimensional phonetographic
assessment of voice performance in professional and non-professional speakers, Folia
Phoniatrica et Logopaedica, vol.49, pp.96-104.
Schutte, HK & Seidner, W 1983, Recommendation by the union of european phoniatricians
(UEP): standardizing voice area measurement/phonetography, Folia Phoniatrica, vol.35,
pp. 286-288.
Sulter, AM, Schutte, HK & Miller, DG 1995, Differences in phonetogram features between
male and female subjects with and without vocal training, Journal of Voice, vol.9, no.4,
pp.363-377.
Magalhes, MK 2004, Banco de dados sobre fonetografia e elaborao digital do fonetograma,
Dissertation, So Carlos.
Kahane, JC 1996, Lifespan changes in the larynx: an anatomical perspective, in Organic voice
disorders: assessment and treatment, eds. WS Brown, BP Vinson & MA Crary, Singular, San
Diego, pp.89-110.
Behlau, MS, Tosi, O & Pontes, PAL 1985, Determinao da freqncia fundamental e suas
variaes em altura (jitter) e intensidade (shimmer), para falantes do portugus
brasileiro, Acta AWHO, vol.4, pp.5-10.
867
P187
LISTENERSIDENTIFICATION
OF
TARGET
SOUNDS
IN
CLEFT
PALATE SPEECH
JCR Dutka 1, LC Teles 2, VCC Marino 3, MI Pegoraro-Krook 4
1Speech-Language
Pathologist at the Experimental Phonetics Laboratory at the Hospital for Research

and Rehabilitation of Craniofacial Anomalies.
2,4 Departament of Speech Pathology and Audiology - University of So Paulo (USP), Bauru, Brazil
3 Departament of Speech Pathology and Audiology - University Estadual Pulista (USP), Bauru, Brazil
INTRODUCTION
Individuals with cleft palate and/or velopharyngeal dysfunction (VPD) may
have difficulty articulating consonants that require relatively high air pressures such
as stops, fricatives and affricates. These difficulties can lead to the use of
compensatory articulations (CAs) which are articulatory errors in which manner is
generally maintained, but place of articulation is typically posteriorized to the
pharynx or larynx. Speech-language pathologists (SLPs) who work with individuals
with cleft palate and/or VPD need to be able to identify the use of atypical place of
sound production (CAs) to treat this typo of articulatory errors and improve speech
intelligibility. While identification of these productions is important from a clinical
perspective, it may not be an easy task, especially for inexperienced listeners
(Quinzer, 1997). Some studies that have specifically addressed the difficulties
involved in the perceptual rating of CAs suggesting that listener training and
experience are both critical factors for the successful management of CAs
(Santelmann, Sussman & Chapman, 1999; Quinzer, 1997). No previous study,
however, has compared listeners agreement during identification of target sounds
before and after therapy for elimination of CAs, which is the objective of this study.
METHOD
Ten students at a Speech-Language Pathology program with no history of
speech, language or hearing disorders, as self-reported, were selected to participate
in this study. The listeners ranged in ages from 21 to 40 years old. Each listener
participated in one listening session involving the auditory-perceptual ratings of the
samples recorded for this study.
The speech samples analyzed in this study were obtained from a 25 year-old
male patient with VPD. Before speech therapy this speaker presented with severely
unintelligible speech characterized by the use of compensatory articulations (CAs),
nasal air emission (NAE) and hypernasality. Prior to the management of his VPI,
this patient participated in a 8-week intensive speech therapy program for the
elimination of CAs and establishment of oral place of production for the sounds /p/,
/t/, /k/, /d/, /g/, & /s/. Speech therapy was provided while the patient waited
for the prosthetic management of his severe VPI condition.
The speech samples used in this study were recorded before and after an 8week intensive speech therapy program for the elimination of CAs and for
establishment of oral place of production for sounds /p/, /t/, /k/, /d/, /g/, and
868
/s/. The speaker repeated a word list incorporating the 6 oral target sounds in the
initial, medial, and word final positions. The pre- and post-therapy samples were
recorded with a Sony DCD-D8 Digital Audio tape (DAT) recorder with a Sony PCM1 electret microphone firmly attached to the subjects shirt collar. The audio
recordings obtained with the DAT were sampled onto a Pentium PC (Gateway 2000)
with the use of a Sound Blaster 16-bit A/D card. The software Dr. Speech for
Windows (Tiger Electronics, INC, 3.0, 1995) was employed for the editing of a
listening sample that randomly presented the speech stimuli recorded before and
after elimination of CAs.
Rating Task
The audio playback for this study consisted of a total of 96 words organized
according to each of the 6 target sounds. For each target sound the samples were
edited to randomly display: syllable repetition, 3 word positions (target sound in
initial, medial, and final positions), and two therapy conditions (pre- and posttreatment). This yielded a total sample of 96 tokens to be played to 10 different
listeners for a total of 960 perceptual judgments.
Prior to the identification task a brief training session was provided to
prepare the 10 listeners. Samples of words with the oral target sounds and samples
of words with the CAs were used to demonstrate either the presence or absence of
the targets. The samples were played to the listeners directly from a Dell Inspiron
3200 laptop computer over external speakers with a pre-amplifier. A sound pressure
meter was employed to assure a consistent intensity level across all listeners during
the rating task.
RESULTS
A standard rating of all samples, indicating presence or absence of the target
sounds for all rated samples, was obtained from a SLP with more than 5 years
experience in rating cleft palate speech. This sample was used as base for
comparison with the listeners ratings. Listeners' group means percentage agreement
before and after therapy were calculated for each target under each position. The
/p/ was not identified (by the group of 10 listeners) in 50%(20/40) of the samples
before therapy, when it was co-articulated with glottal stop CAs, but it was identified
in 68.5% (27/40) of the samples recorded after elimination of glottal stop CAs. The
/t/ was not identified in 52.5% (21/40) of the samples recorded before therapy,
when it was substituted by pharyngeal stop CAs, but it was identified in 62.5%
(25/40) of the samples recorded after elimination of pharyngeal stop CAs. The /d/
was not identified in 70% (28/40) of the samples recorded before therapy, when it
was substituted by glottal stop CAs, but it was identified in 15% (6/40) of the
samples recorded after elimination of glottal stop CAs. The /k/ was not identified in
75% (30/40) of the samples recorded before therapy, when it was substituted by
glottal stop CAs, but it was identified in 100% (40/40) of the samples recorded after
elimination of glottal stop CAs. The /g/ was not identified in 57.5% (23/40) of the
samples recorded before therapy, when it was substituted by glottal stop CAs, but it
was identified in 40% (16/40) of the samples recorded after elimination of glottal
stop CAs. The /s/ was not identified in 10% (4/40) of the samples recorded before
therapy, when it was substituted by pharyngeal fricative CAs, but it was identified in
80% (32/40) of the samples recorded in the post-therapy condition after elimination
of pharyngeal fricative CAs.
869
Overall mean percentage agreement for all 10 listeners before therapy was
52.5%, with a range between 10% and 75% agreement, and after therapy it was 61%,
with a range between 15% and 100% agreement. While listeners' identification of the
target sounds /p/, /t/ and /k/ increased after elimination of CAs, the identification
of the target sounds /d/, /g/, and /s/ decreased after elimination of the CAs.
Intrajudge Reliability
All recorded samples were rated twice by each of the 10 listeners. Intrajudge
reliability measures were obtained for each listener by calculating the percentage of
agreement between the two ratings of each stimulus. For the group, a mean
intrajudge reliability measure of 92% was found with a range between 83% and 98%.
DISCUSSION
The overall findings of this study revealed low group mean listeners'
agreement during identification of target sounds before and after speech therapy.
For the ratings obtained before therapy it was anticipated that there would be high
listeners' agreements regarding absence of target sounds. However, the presence of
obstruction, although produced at unusual places in the vocal tract appeared to
confound listeners in almost half of the combined ratings. Approximately 48% of the
samples in which the target sounds were not produced at the oral place of
articulation, obstruction elsewhere in the tract seemed to have provided enough
clues for listeners to "guess" the presence of these non-existing sounds.
After speech therapy, when all samples involved the use of oral place of
production (as verified by the experienced SLP's standard ratings), listeners failed to
correctly discriminate the presence of oral targets in almost 40% of the time. A
possible explanation for these findings may be the presence of the so-called
"obligatory errors" associated with VPD (hypernasality, weak oral air pressure
consonants, and nasal air emission).
Interestingly, whereas the presence of the target sound /d/ was identified
least (15%), its voiceless cognate /t/ was heard 62% of the time. The same "trend"
was observed for the velar cognates. While the sound /g/ was identified only 40%
of the time its voiceless cognate /k/ was identified 100% of the time. Although these
results are limited to the identification of specific patterns, the existence of a trend
towards lower listeners agreement during production of voiced plosives calls for
further investigation. While facing such a variability of findings the need for
increased sample sizes become apparent if hypothesis testing or estimation
procedures are warranted.
The results from this study suggest that the lack of specific training on the
identification of CAs could be the explanation for the lower listeners' agreement
found among the listeners. One could also question that the training session prior to
this study should have included a practice trial so less reliable listeners could have
been eliminated. Although such a pre-experimental trial was not available, it is
important to note that, the intra-judge reliability measures obtained were quite good.
The lack of standard guidelines for use across clinical settings have been
pointed as an important variable for improving listeners agreement during
auditory-perceptual tasks, particularly for cleft palate speech (Henningsson, 2008;
Lohmander & Olsson, 2004). SLPs will benefit from protocols that are consistent and
reliable and provide a complete clinical portrait of speech disorders.
870
To date, research has only investigated listeners ability to transcribe

compensatory articulation errors (Trost, 1981, Quinzer, 1997; Santelmann et al., 1999).
Although these researchers advocate the need for better knowledge and description
of speech errors related to VPI, many clinicians continue to rely on the perception of
target sounds in an attempt to assess progress in therapy. Furthermore, many
clinicians are under trained, or not trained at all in this area. Finally, university
programs and national professional organizations need to promote and support
specialized training and further research in the reliable diagnosis and effective
speech therapy for the elimination of compensatory articulation related to VPI.
REFERENCES
Bzoch KR. Introduction to the study of communicative disorders in cleft palate and related
craniofacial anomalies. In: Bzoch KR. ed. Communicative Disorders Related to Cleft Lip
and Palate. Austin, TX: Pro-Ed Publishers; 2004:3-66.
Henningsson G, Kuehn DP, Sell D, Sweeney T, Trost-Cardamone JE, Whitehill TL. Universal
Parameters for Reporting Speech Outcomes in Individuals With Cleft Palate. The Cleft
Palate-Craniofacial Journal, 2008;45: 1-17
Kent RD. Hearing and believing: Some limits to theauditory-perceptual assessment of speech
and voice disorders. Am J of SLP, 1996;5;7-23.
Lohmander A, Olsson M. Methodology for Perceptual Assessment of Speech in Patients With
Cleft Palate: A Critical Review of the Literature.The Cleft Palate-Craniofacial Journal,
2004;41:64-70.
Quinzer J. Reliability of listener judgments of compensatoryarticulations. Cleveland,OH:Case
Western Reserve University, Dissertation, 1997.
Santelmann L, Sussman J, Chapman K. Perception of middorsum palatal stops from the
speech of three children with repaired cleft palate. Cleft Palate J. 1999;36:233-242.
Trost-Cardamone JE. Diagnosis of specific cleft palate speech error patterns for planning
therapy or physical management needs. In: Bzoch KR. ed. Communicative Disorders
Related to Cleft Lip and Palate. Austin, TX: Pro-Ed Publishers; 2004:463-492
871
FP32.2
COMPARATIVE STUDY OF INTENTION OF TV REPORTERS VOICES
IN READING TWO NEWS TEXTS WITH DIFFERENT INTENTIONS
Maria Lucia Torres,1 SLP, MSc, voice and language specialist. Associate Teacher at UnB NESPROM/CEAM. Associate Researcher at the Centro de Estudos da Voz - CEV. IALP
member, Speech Language Pathologist at Rede Globo Braslia. Director at Torres Clinic. Areas
of interest: voice and professional communication.
Mara Behlau, SLP, PhD, voice specialist, coordinator of the specialization course at the
Centro de Estudos da Voz - CEV, adviser professor at the Graduate Program at UNIFESP,
So Paulo, Brazil. IALP member. Main interests are clinical voice, professional voice, low cost
softwares for clinical purposes and team work with otorhinolaryngologists.
Institution UnB University of Braslia: NESPROM/CEAM, CEV
INTRODUCTION - Reporters should transmit news with the credibility

required of the text and its style. This study was proposed to certify the intent of
journalists and reception of listeners the objective being to verify the percentage of
correct identification of reporters transmission of news, independent of semantic
content of the text: sports or editorial news and through acoustic analysis, to
recognize which acoustic parameters are responsible for the correct identification of
the styles researched.
MATERIAL AND METHOD Ten male and seventeen female reporters,
between twenty-four and forty-one years old, participated. Participants had, on
average, eleven years of experience in television journalism and were part of a
speech training program.
The news stories used were informative texts that may or may not use
television images. Texts were selected from national news. The editorials covered
their subjects seriously, while sports covered a commemorative date. In this study,
we refer to news as editorial and sports text.
Each text was read four times each time with two distinct intentions: (1) to
transmit an editorial and (2) to transmit sports. Recordings were made of the
reporters reading of the sports text with two distinct intentions as well: to transmit
sports and to transmit editorial news.
Four combinations of content-intention were observed:

Situation 1: Editorial-Content read with Editorial-Intention
Situation 2: Sports-Content read with Sports-Intention
Situation 3: Editorial-Content read with Sports-Intention
Situation 4: Sports-Content read with Editorial-Intention
The second phrases of each sample (6 seconds) were analyzed and then
edited and organized in random order. These recordings were given to twenty-one
872
speech therapists, specialized in voice, and to twenty naive listeners, who analyzed
each recording on a response sheet. Participants doing the analysis were not
journalists. They were to note journalist intent in their transmission of the news
without considering content. A total of 108 recordings were evaluated.
RESULTS The study analyzed concordance between reporter intent and
identification of intent by specialists and naive listeners, according to the four
combinations of content-intention listed above. In addition, the study attempted to
gather information regarding acoustic evaluation of recordings.
COMMENTS Findings indicate that data used to identify vocal intent are
as important as acoustic data raised by the study. The correspondence between
acoustic analysis and perceptive-auditory analysis indicates that acoustic parameters
of F0, pauses, and speech, change, thereby defining acoustic units that are perceived
in both analyses.
84% of listeners accurately identified reporter intent. When content and intent
were the same, concordance was over 90%. When content differed from intent,
concordance decreased, but remained above 70%.
Table I - Distribution of results identifying the communicative intent of reporter in

accordance with combination of content-intention by the group of experts (N=27).
Content-Intention Combination
C EdI Ed
C EsI Sp
C EdI Sp
C SpI Ed
Total
Identificao
Int-Rep=Id-Int
Int-RepId-Int
27
0
100
0
25
2
92,6
7,4
19
8
70,4
29,6
20
7
74,1
25,9
91
17
84,3
15,7
Total
27
100
27
100
27
100
27
100
108
100
Legend:
Rep-Id = Int-Int - intention of communicating the same reporter to identify the intention
Id-RepInt-Int - announced intention of the reporter than the identification of intention
C-Sp - sport content
I-Sp - intention sport
C-Ed - editorial content
E-I - editorial intent
Of the voices evaluated, considering the content and intention of the reporter in
transmitting sports text and the identification of intent as that of a voice for sports,
92.6% agreement was obtained. When the content was editorial news and the intent
was sports, 70.4% agreement was obtained. In recordings of sports content with an
intention to transmit an editorial text and which the text was identified as an
editorial, 74.1% agreement was obtained. Considering content and spoken intent of
editorial news and which was identified as editorial news, 100% concordance was
obtained. Thus, we believe that reporter intent in transmitting the editorial text is
873
more efficiently executed than transmitting the same text with the voice of sports
text.
In analysis of content of editorial and sports news, the concordance between
reporter intent and identification of intention was significant: the result of k in
reference to the editorial content news (k=0.704) was higher than that of sports
(k=0.667).
In relation to editorial content news and identification of intent, 50% of the
recordings were perceived as editorial news. Of the recordings of editorial content
read with intention of sports, 35.2% were perceived as sports, whereas 14.8% of
readings with intent of sports news were identified as editorial.
Regarding sports news, 37% of results presented editorial intention and were
recognized as such. There was 3.7% discordance in identifying the parts of editorial
news read with sports intent. 46.3% of recordings containing sports content read
with intention of sports were correctly identified and 13% were perceived as
editorials. There was a relevant concordance between reporter intention and
identification of intention. The concordance was higher (k=0.926) when the content
matched intention and lower (k=0.444) when content differed from intention.
Editorial content spoken with same intention had a higher concordance in
identifying intent (k=0.704) than sports content with sports intent (k=0.667).
Table II - Distribution of correlation between intention of reporter in different contents and
identification of intention by specialists (N = 27).
Report's intention
Editorial
Sport
Total
Intention's Identification
Editorial
Sport
N
%
N
27
50,0
0
8
14,8
19
35
64,8
19
%
0,0
35,2
35,2
Editorial
Sport
Total
20
2
22
37,0
3,7
40,7
7
25
32
13,0
46,3
59,3
k=0,667
p<0,001*
Editorial
Content=intent Sport
Total
27
2
29
50,0
3,7
53,7
0
25
25
0,0
46,3
46,3
k=0,926
p<0,001*
Editorial
Contentintent Sport
Total
20
8
28
37,0
14,8
51,9
7
19
26
13,0
35,2
48,1
k=0,444
p<0,001*
Content
Editorial
Sport
Kappa
k=0,704
p<0,001*
Considering gender-specific findings, results demonstrate that for female

reporters, identification of reporter intent was accurate 86.8% of the time and
80% for male reporters.
874
When content and intention were the same, concordance between intention of
the reporter and identification of intention, by both specialists evaluation and that of
nave listeners, was over 88%. In the case of male reporters, when the situations of
combination content and intention were the same, concordance reached 100%.
Regarding editorial content in relation to identification of intent, there was
concordance between the reporters intent and identification of intent, results for
female reporters were higher (k=0.765) than were those for male reporters (k=0.600).
Regarding sports content, the concordance between intention and identification of
intention was significant (p<0.001); the results for women being higher (k=0.706)
than for men (k=0.600). When content was the same as intention, male reporters
obtained higher results in evaluation (k=1.000), but when content was different,
females obtained better results (k=0.588).
When content and intention were different, concordance was over 76% in the
evaluation of women and over 60% for men. These data suggest that males seem to
have more facility in transmitting news of semantic content that matches the
intention necessary for interpretation.
It is the prosody that defines reporter intent in transmitting news. Results
indicate that the transmission of news containing content that is the same as
intention of editorial news is always identified as such in the case of males as well as
females. The reporter should interpret news using resources: emphasis, pauses, facial
expressions, variations in intensity and velocity of speech, depending on semantic
content of the report and the profile of program.
Sports or editorial news are perceived beforehand through non-verbal aspects
of communication, which include frequency, time, loudness, tone, accent and
intonation, and are directly related to the structure of information. This can explain
why intention of what is spoken by reporters in reporting news with an editorial
intention is executed more efficiently than what is spoken with sports intent. Even
though reporters do not have the same level of awareness in relation to vocal
expressivity nor the awareness of ones own voice and the care one should take of it,
reporters seem to follow a model of professional voice characterized by low
frequency, average loudness, balanced resonance, sufficient articulation and
appropriate velocity of speech in relation to the news.
This study also attempts to verify acoustic parameters responsible for
accurately identifying reporter intent in the reading of two texts containing diverse
content a sports and editorial news.
Data referring to F0 demonstrate that among four situations and between
genders, sports news was most variable in intonation. When the intention was to
transmit sports, the result of F0 was higher pitched, and in all situations female
reporters presented better results. Intention to produce sports voice presented a
higher F0 in relation to the intention of editorial news.
Recordings with concordance in identifying intent and acoustic analysis of F0
demonstrated that the voice of highest F0 indicates that use of specific frequency is
directly related to discourse intent in such a way that a positive environment is
875
transmitted through high tones, associated to wider tonal range, marked emphasis
and higher velocity of speech.
Both male and female genders obtained concordance between reporter intent
and identification of intention. Males raised F0 more to transmit editorial news with
sports intent and also spoke at higher frequency when transmitting sports news with
sports intent. There was also a difference between genders in relation to averages of
minimum F0, but there was no difference between situations of combination of
content-intention. Females had higher responses than males in relation to averages of
minimum F0 and average of maximum F0.
Results indicate that a tendency exists for both genders to reduce F0 in
emission with the intention of editorial news, independent of content.
In relation to intensity, there was no difference between situations of
combination content-intention or between the four situations or between genders;
however, males raised intensity for sports intent.
It was also observed that sports content news stories presented a higher
standard deviation than did editorial. Also, there was a difference in the comparison
between the four situations, but no difference was identified between genders. The
situation of content-editorial and intention-sports had lower results, followed by
results of the situation of content-intention editorial. The situations of content-sports
and intention-editorial and content-intention of sports have higher results.
Results indicate extension of larger F0 in both genders when intention of
reporters speech was to transmit sports with editorial content, i.e., sports were more
variable in regards to intonation. When reporter intent was to transmit editorial news
with matching content, extension of F0 was less in both genders. In all situations,
women presented a larger extension of F0, except in situation of combination contentintention sports-sports, in which males presented a wider variation.
Regarding the minimum F0, there was no difference among the four
situations of combination content-intention; however, a difference between genders
was observed. In relation to maximum F0, there was no difference between situations
of combination content-intention for genders, although there was a difference
between the four situations of combination content-intention. Results of maximum F0
were larger between situations, genders and interaction, when intention was to
transmit sports news. Females produced better results than did males. In relation to
semitones, there was no difference between situations of combination contentintention. This result indicates that there was no variation in vocal extension of either
gender to transmit news with sports or editorial intent. In relation to time taken to
read, there was a difference among situations but not between genders.
Comparatively, speech of content and intention sports-sports was the most rapid,
and editorial intention was the slowest.
CONCLUSIONS The intention of television communication reporter in
transmitting editorial and sports news, independent of spoken content, was
identified by speech pathologists and nave listeners through prosody and
intonation.
876
Some acoustic parameters such as standard deviation of intensity and F0

determine the sex of the speaker. Males have a strong inclination to transmit news
with sports intent with a higher F0; women did not elevate F0 in this task. To transmit
editorial news, both genders reduced F0 and the standard deviation of F0. The
acoustic parameter of intensity does not identify whether a voice transmits sports or
editorial news.
There is no variation in results of semitones or measurements of extension of
F0 for transmitting editorial or sports news according to gender. Transmission of
sports content news causes reporters to speak more quickly even when intent is to
transmit editorial news.
877
FP32.3
REHABILITATION
LARINGECTOMYS
OF
VOICE
AND
SPEECH
AT
THE
1.Vasiljevic Snezana , 1.Pantelic Natasa , 1.Filipovic Verica , 2. Savic Mirjana , 3.

Nikolic Slavka , 4. Petrovic Jelena, 5. Savic Marija, 5. Savic Vesna (student anglistike
Faculty, Novi Sad, Serbia)
1.General Hospital Sabac, Serbia
2.Specialist surdology General Hospital Sabac, Sabac, Serbia
3.M.A. Primary School for Children with Damaged Hearing Zemun, Belgrade, Serbia
4.Specialist surdology DZ, Sabac, Sabac, Serbia
5. student anglistike Faculty, Novi Sad, Serbia
INTRODUCTION TO THE TEORY OF THE PROBLEM

The contents of this research project is the problem of voice and life of people
with laryngeal operation.
If the speech high humans traits, then removal of the larynx affects high
humans part of his personality. It is therefore understandable that all efforts aimed
at finding ways after laryngectomys, re-establish a speech that was as natural and
normal speech closer.
Larynx/Larinx, is sensitive and the least change, and thus any changes
immediately hear or feel. This often leads to early detection and treatment of
disease. Common symptoms of larynx cancer include hoarseness, constant cough,
sore throat or pain in the ear. If the tumor is too large or re-emerged after radiation
and chemotherapy, will probably have to be removed surgically. In thar case, the
patient must be operate by the method of total laryngectomy. Such a patient is called
laringeal patient.
Since the introduction of total laryngectomys is considered to mitigate the
vocal trauma after the surgery. All Onko-Surgical procedures on the generator to
vote more or less aggressive and damaging the vocal function. Must respect the rule
that applies to all areas of practical medicine, to treat, if at all possible to effectively
remove the cause and consequence of disease in all its forms. Precisely for that
reason today laringektomy of implement treatment experts and institutions of
different profiles. Team technical cooperation should include Onko-Surgeon,
Foniatricy and fonopedy.
Since the laryngectomy lost human traits HIGH HUMANS SPEECH, lost
part of his personality. In this case, all efforts so that after laryngectomy patient reestablish a speech and must become as human been.
I
RESERCH OF THE METHODOLOGY
The contents of this research project is the problem of voice and life of people
with laryngeal operation
the patient must operate by the method of total laryngectomy. such a patient is called
laringektomiran
research methodology
in order to obtain adequate data for the purposes of this itrazivackog project, applied
the methodology of taking data anamnestickih patients pretiranih operational
878
way. the same sample, after a laryngectomy operation was subjected to a special
voice and speech rehabilitation. Data obtained are presented chronologically

in relation to the method of rehabilitation.
II
CONCLUSION OF THE TEST RESULTS
What is speech of the laringeal patients?
Summing the results of examination of patients with laryngeal operation,
during the rehabilitation of voice, they obtained different results. Results of
examination of speech laringeal, show that patients can apply:
1.independ vocal therapy (developed ezofageal speech)
2.hirurgical installation of the voice or the vocal prostheses
3.helps prosthesis, elektolarinx.
First, to indicate the status of the patient who has no speech.
This is such a patient who:
1.must always carry with you paper and pencil,
2.only way communication is in writing,
3.must have patience with other people and
4.inpossible use the phone.
What is speech of the laringeal patients with elektrolarinx?
After adding up the results of testing the patient's condition without speech,
to indicate the results of patient speech that use elektrolarinx. Speech of the
patients with elektrolarinx is:
1.visible for the environment,
2.non achieves the intensity of installing braces and ezofageal speech
3.give a monotonous and tedious sound and
4.laringeal speech depends on the correctness of prostheses.
What is speech of the laringeal patients with ezofageal speech?
In patients who have a good condition, preserved health, mental ability and
psychological stability, a good rehabilitation can enable the patient to develop
esophageal speech. Esophageal speech is a good method that works well in
many patients, but it has its bad side. Bad factors of the ezofageal method for
the formation of speech are:
1.insuffitient motivation of the patient,
2.his intellectual abilities,
3.long duration of rehabilitation,
4.onsuffitient of professional staff to implement rehabilitation in smaller
places where living laringektomys.
If the patient fails to master all the techniques, at any time can be used in a
speech that his hands are free.
What is TE/Tracheo-esiphageal speech?
Finally, adding up the results sheet speech laringektomirah patients, and
display the results of testing the patient's condition is no speech, language
condition laringektomiranih patients with elektrolarinksom and state
laringektomiranih using esophageal speech, it is necessary to show the results
of patients who have developed a method using a built-in speech vocal
prosthesis.
879
TE / traheo-esophageal speech of the laringeal patients is a method of speech

with a built-in vocal prosthesis, which has its advantages and disadvantages.
The main advantages of voice technology are:
1. his new voice of the patient can get pretty quickly after surgery and
2.quality voice is closest to the natural voice,
III
RECOMMENDATION
FOR
BETTER
CLINICAL
WORK
Successful solution of speech after total laryngectomy has a social-economic
importance for society and especially for the individual and a great psychological
effect
on
the
patient,
his
family
and
close
environment.
Key words: laryngectomy, ezofaguss speech, vocal prosthesis, elektrolarinx.
Seron, 1979 apud Jakubovicz; Cupello Testagens das afasias. In: ______.
Introduo afasia: elementos para diagnstico e terapia. Rio de Janeiro: Revinter,
1996c. cap. 13, p. 153-195.
Pracharitpukdee, N.; Phanthumchinda, K.; Huber, W.; Willmes, K. The Thai version of
Aachen aphasia test (THAI-AAT). Journal of the Medical Association of Thailand, Bangkok,
v. 83, n.6, p. 601-610, jun. 2000.
1 Seron, 1979 apud Jakubovicz; Cupello Testagens das afasias. In: ______. Introduo afasia:
elementos para diagnstico e terapia. Rio de Janeiro: Revinter, 1996c. cap. 13, p. 153-195.
1 Pracharitpukdee, N.; Phanthumchinda, K.; Huber, W.; Willmes, K. The Thai version of
Aachen aphasia test (THAI-AAT). Journal of the Medical Association of Thailand, Bangkok,
v. 83, n.6, p. 601-610, jun. 2000.
1 Mansur, L.L.; Radanovic, M.; Regg, D.; Mendona, L.I.Z.; Scaff, M. Descriptive study of 192
adults with speech and language disturbances. So Paulo Medical Journal / Revista Paulista
de Medicina, So Paulo, v.120, n.6, p.170-174, 2002.
6 Junqueira, A.M.S. Adaptao do exame de afasia M1-Alpha ao portugus. 1983. 131f.
Dissertao (Mestrado em Letras) Pontifcia Universidade Catlica de Campinas, Campinas,
1983.
7 Lecours, A.R.; et al. Illiteracy and brain damage: 1. Aphasia testing in culturally contrasted
populations (control subjects). Qubec, Canad: Centre de recherche du Centre Hospitalier
Cote-des-Nieges, 1985. 42p.
8 Ortiz, K.Z.; Osborn, E.; Chiari, B.M. O teste M1-Alpha como instrumento de avaliao da
afasia. Pr-fono Revista de Atualizao Cientifica, Barueri, v. 5, n.1, p. 23-29, mar. 1993.
1
Goodglass, H.; Kaplan, E. La naturaleza de las perturbaciones del lenguaje. In: _______.
Evaluacin de la afasia y de trastornos similares. Buenos Aires, Argentina: Panamericana,
1974a. cap. 2, p. 16-25.
10 Pea-Casanova, J. Diguez-Vide, F.; Pamies, M.P. Explorao de base da linguagem para
orientao teraputica. In: Pea-Casanova, J.; Pamies, M.P. Reabilitao da afasia e
transtornos associados. 2. ed. Barcelona, Espanha: Masson, 2005b. cap. 2, p. 27-63.
9
880
881

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WELCOME ADDRESS

Mara Behlau, PhD

Ilias Papathanasiou, PhD

MESSAGE OF THE PRESIDENT OF THE PANHELLENIC ASSOCIATION OF LOGOPEDISTS

Konstandinos Rogas, President,

ALTERNATIVE AND AUGMENTATIVE COMMUNICATION

Besides the Lisinas definition, I have chosen two other theories:

Direction of sight ( where is child looking)

The direction of hearing

Touching and feeling using hands, foots, face / mouth, body

Which are the expression forms of the child

Things to do are as follows:

Create symbols to structure the day, week etc

Organize the materials according the subjects, e.g. biology etc

Continue with trainings of teachers regarding AAC

Work with concrete and real tools

Prepare the passport for communication of the child

The booklet Gate Book which is wider than the passport

Creation of everyday situations where signs are needed

Creation of tables and books for communication

Changing the symbols according to the childs progress

Results and Discussion

RESULTS AND DISCUSSION

Possible implications for intervention

Possible implications for intervention

Participants and Procedures

Music Speech, Language - Movement

The abilities under training were:

DISCUSSION AND CONCLUSIONS

Introduction and aims of the study:

graduating phonological and morphological variability,

graduating syntactical variability,

To a minimum extent, items will determine the response of a patient.

The whole stimulation process will not require any visualisation.

Czech aphasiologic material

Qualification of clinical logopedists

Regulations of aphasiologic care

kodov, E. Jedlika, I. 2003. Klinick logopedie. Praha: Portl.

cases. Arq. de Neuro-Psiquiatria 2008, 66, 3

Assessment and Intervention of Communication Skills

Assessment and Intervention of Communication Effectiveness

Assessment and Intervention of Communication Opportunities

The following research questions were defined:

1. Numerical Sequence (3 subtasks, C1, C2, C3)

Time post onset (in months)

112 RBD individuals

Full description (lesion + site) of lesion site in the

With the same stimuli, participants repeat the sentences

Participants indicate the presence or absence of semantic relationship

Verbal fluency free

Participants say as many words as possible starting by the letter p in 2 minutes

Demographic and lesion datas

Performance for each MEC communication task (z-score)

To explore the functional weight assigned by eight Greek-speaking Brocas aphasic

SVO word-order condition

(7) Giati pro fevgi gia pada stin Ameriki.

Null pronoun condition

(6b) Giati ton Niko ton filai o Giorgos toso lipimena?

OclVS word-order condition

Null pronoun condition

Experiment 1: Production task

(2) Agrammatic [item: enter walk]