162001 - alexorl.edu.egalexorl.edu.eg/alexorlfiles/pptorl2007/162001.pdf · Prof. Dr. Abdelzaher...

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Mohammad Ramadan HassanMohammad Ramadan Hassan

Lecturer of Audiology Lecturer of Audiology –– Zagazig Zagazig universityuniversity

MD thesis MD thesis -- 20052005Audiology unit Audiology unit –– Ain Shams universityAin Shams university

Discuusion committee:Discuusion committee:

Prof. Dr. Abdelzaher Tantawy Prof. Dr. Abdelzaher Tantawy

Prof. Dr. Nadia KamalProf. Dr. Nadia KamalProf. Dr. Somaia TawfikProf. Dr. Somaia Tawfik

Supervisors:Supervisors:

Prof. Dr. Somaia Tawfik MohammadProf. Dr. Somaia Tawfik MohammadProf. Dr. Iman Mohammad SadekProf. Dr. Iman Mohammad SadekProf. Dr. Amany Ahmad ShalabyProf. Dr. Amany Ahmad Shalaby

Central auditory processing is an Central auditory processing is an umbrella term for all operations umbrella term for all operations executed on peripheral auditory executed on peripheral auditory inputs, and which are required for inputs, and which are required for the successful generation and the successful generation and identification of auditory percepts.identification of auditory percepts.

(Phillips, 2002)(Phillips, 2002)

Central auditory processing disorder Central auditory processing disorder (CAPD) refers to difficulty in the (CAPD) refers to difficulty in the processing of auditory information in the processing of auditory information in the central auditory nervous system (CANS). central auditory nervous system (CANS). This is demonstrated by poor This is demonstrated by poor performance in one or more the performance in one or more the following auditory behaviors:following auditory behaviors:

��Sound localization and lateralization.Sound localization and lateralization.

��Auditory discrimination and auditory Auditory discrimination and auditory pattern recognition.pattern recognition.

��Temporal auditory processing.Temporal auditory processing.

��Auditory performance with competing Auditory performance with competing acoustic signals.acoustic signals.

��Auditory performance with degraded Auditory performance with degraded acoustic signals.acoustic signals.

Other neuroOther neuro--cognitive mechanisms such as cognitive mechanisms such as ATTENTION and MEMORY ATTENTION and MEMORY are deployed in are deployed in performing these behaviors.performing these behaviors.

(ASHA, 1996)(ASHA, 1996)

ScholasticScholasticUnderUnder--

achievementachievementCAPDCAPD

DeficiencyDeficiencyin languagein languageacquisitionacquisition

CAPD management:CAPD management:

Auditory Auditory remediation remediation ProgramsPrograms

EnvironmentaEnvironmental modificationl modification

CompensatoCompensatory strategiesry strategies

(Bellis, 1996)(Bellis, 1996)

Experience dependant Experience dependant auditory plasticityauditory plasticity

CANS can undergo organizational CANS can undergo organizational changes in response to intensive changes in response to intensive

auditory trainingauditory training

The auditory remediation programs rely on the concept of ………….

The auditory remediation programs rely The auditory remediation programs rely on the concept of on the concept of ……………………..

AuditoryRemediation

programs

Formalprograms

Informalprograms

Informal remediation programs:Informal remediation programs:

�� LanguageLanguage--based auditory tasks with nonbased auditory tasks with non--sophisticated arrangements.sophisticated arrangements.

�� Practicing occurs in the context of meaningful Practicing occurs in the context of meaningful communication.communication.

Powerful means of fostering listening skills.Powerful means of fostering listening skills.�� They tap other central auditory abilities beside the They tap other central auditory abilities beside the

targeted one.targeted one.Helpful in training integrative auditory Helpful in training integrative auditory

functions.functions.�� These programs can be undertaken at home and in These programs can be undertaken at home and in

school.school.They allow for additional practice.They allow for additional practice.

(Musiek et al., 2002)(Musiek et al., 2002)

Musiek (1999) Developed An Informal Musiek (1999) Developed An Informal Remediation Program, Which Proved Remediation Program, Which Proved

To Be Effective In Management Of To Be Effective In Management Of many children with CAPD.many children with CAPD.

Availability Of Such Program In Arabic Availability Of Such Program In Arabic Language Will Be Helpful In Language Will Be Helpful In

Management Of A Lot Of Children Management Of A Lot Of Children With CAPD.With CAPD.

�� To develop an informal auditory To develop an informal auditory remediation program in remediation program in Arabic language.Arabic language.

�� To standardize the program on a sample To standardize the program on a sample of normal Egyptian children.of normal Egyptian children.

�� To assess the effectiveness of the To assess the effectiveness of the program on a sample of children with program on a sample of children with central auditory processing disorders.central auditory processing disorders.

They were distributed in three groups:They were distributed in three groups:

�� Pilot study group: 42 children.Pilot study group: 42 children.

�� Control group: 60 normal hearing children.Control group: 60 normal hearing children.

�� Study group: 21 children with CAPD.Study group: 21 children with CAPD.

Children included in this study were Children included in this study were of both genders and ranged in age of both genders and ranged in age between 6 between 6 –– 12 years.12 years.

�� Age subAge sub--group I: 6 group I: 6 -- >8 years.>8 years.

�� Age subAge sub--group II: 8 group II: 8 -- >10 years.>10 years.

�� Age subAge sub--group III: 10 group III: 10 -- 12 years.12 years.

These groups were further subdivided These groups were further subdivided into three age subgroups:into three age subgroups:

�� TwoTwo--channel audiometer Madsen, model Orbiter channel audiometer Madsen, model Orbiter 922.922.

�� Immittancemetry Interacoustics model AZ7.Immittancemetry Interacoustics model AZ7.

�� Evoked potentials audiometer Amplaid, model MK Evoked potentials audiometer Amplaid, model MK 12.12.

�� DoubleDouble--wall soundproof room IAC, model 2001.wall soundproof room IAC, model 2001.

�� TwoTwo--channel cassette tape recorder Nasr Sharp, channel cassette tape recorder Nasr Sharp, model GS 500.model GS 500.

�� Arabic central auditory tests recorded on tapes: Arabic central auditory tests recorded on tapes: LPF, SPIN, CST, DPT and memory tests for LPF, SPIN, CST, DPT and memory tests for recognition, content and sequence.recognition, content and sequence.

�� Missing word exercise for auditory closure Missing word exercise for auditory closure training.training.

�� Auditory vigilance exercise for auditory attention Auditory vigilance exercise for auditory attention training.training.

�� Auditory memory exercise for auditory memory Auditory memory exercise for auditory memory training.training.

�� Phonemic awareness exercise for auditory Phonemic awareness exercise for auditory decoding skills.decoding skills.

�� Auditory directives exercise to enhance interAuditory directives exercise to enhance inter--hemispheric transfer of auditory information.hemispheric transfer of auditory information.

PILOT STUDY

�To exclude too easy and too difficult items.

�To select the best approaches to introduce the materials to children.

STANDARDIZATION

To derive age-appropriate normative

data for each stage in all remediation

materials

REMEDIATION

To study the efficacy of the

developed remediation program

� Basic audiological evaluation: pure tone audiometry, speech audiometry and immittancemetry.

� Questionnaire (to thier mothers).

� Arabic central auditory tests for children:�Low pass filtered speech test.�Competing sentences test.�Speech in noise test.�Duration pattern test.�Memory tests for content, sequence and recognition.

� Psychosocial evaluation using Hiskey Nebraska and Good-enough tests.

� P300 testing with active paradigm.

� Testing with marker items to determine the baseline scores in different remediation materials.

standardization

�All items of the developed informal remediation material were presented to the children of the control group in two sessions.

�Scores of those children in the remediation materials were collected to standardize each exercise material for each of the three age subgroups.

8 weeks training period as:

� 2 sessions / week in the audiology unit.

� 2 home-sessions / week by the parents.

Each session lasted 20 – 30 minutes.

REMEDIATION

Post-remediation evaluation:To assess the program efficiency.

3-months post-remediation evaluation.To assess the stability of the program

outcome.

REMEDIATION

All children of the control group revealed normal scores in central auditory tests

and psychosocial measures.

Results

Mean ( ) standard deviation (SD) and 95% confidence Mean ( ) standard deviation (SD) and 95% confidence range of auditory closure material in the control group. range of auditory closure material in the control group.

AuditoryAuditoryclosureclosurestage III stage III

AuditoryAuditoryclosureclosurestage II stage II

AuditoryAuditoryclosureclosurestage Istage I

18.7 (13.8) 18.7 (13.8) 52.7 (24.4) 52.7 (24.4) 98.7 (2.5) 98.7 (2.5) (SD)(SD)AgeAgeSubgroupSubgroup

II 12.212.2 -- 25.125.141.341.3 -- 64.164.197.597.5 -- 99.899.895%95%confidenceconfidencerangerange

54 (18.5) 54 (18.5) 89.5 (9.9) 89.5 (9.9) 99.5 (1.6) 99.5 (1.6) (SD)(SD)AgeAgeSubgroupSubgroup

IIII 45.345.3 -- 545484.984.9 -- 89.589.598.798.7 –– 100#100#95%95%confidenceconfidencerangerange

76.8 (14.4) 76.8 (14.4) 96.2 (5.5) 96.2 (5.5) 100 (0) 100 (0) (SD)(SD)AgeAgeSubgroupSubgroup

IIIIII 70.170.1 -- 83.683.693.693.6 -- 98.898.8100100 –– 10010095%95%confidenceconfidenceRR

X

X

X

X

Results

Mean ( ), standard deviation (SD) and 95% confidence range Mean ( ), standard deviation (SD) and 95% confidence range ofofauditory vigilance material in the control group.auditory vigilance material in the control group.

AuditoryAuditoryvigilancevigilancestage III stage III

AuditoryAuditoryvigilancevigilancestage II stage II

AuditoryAuditoryvigilancevigilancestage Istage I


II 56.456.4 -- 69.369.364.764.7 -- 77.177.19696 -- 99.399.395%95%confidenceconfidencerangerange


IIII 79.879.8 -- 84.484.483.483.4 -- 87.287.299.799.7 -- 100 # 100 # 95%95%confidenceconfidencerangerange

86.4 (6) 86.4 (6) 87.8 (5.4) 87.8 (5.4) 99.95 (0.2) 99.95 (0.2) (SD)(SD)AgeAgeSubgroupSubgroup

IIIIII 83.683.6 -- 89.289.285.385.3 -- 90.390.399.999.9 -- 100 # 100 # 95%95%confidenceconfidenceRR

X

X

X

X

Results

Mean ( ), standard deviation (SD) and 95% confidence range oMean ( ), standard deviation (SD) and 95% confidence range offauditory memory material in the control group.auditory memory material in the control group.

Seq.Seq.memmem

..55--ww

Seq.Seq.memmem

..44--ww

Seq.Seq.memmem

..33--ww

ContCont..

MemMem..

55--ww

ContCont..

MemMem..

44--ww

ContCont..

MemMem..

33--ww

Rec.Rec.MemMem

..33-- ww

Rec.Rec.memmem22--ww

72.872.8(15.3(15.3

))

90.890.8(15.4(15.4

))

96.596.5(10.8(10.8

))

7373(21.8(21.8

))

91.591.5(15.3(15.3

))99.899.8(1.1)(1.1)

8787(14.1(14.1

))9898(5)(5)(SD)(SD)AgeAge

SubgroSubgroup Iup I 65.665.6

-- 808083.583.5-- 9898

91.591.5-- 100100

##

63.163.1--

82.982.9

84.384.3--

98.798.7

99.399.3––

100#100#

80.480.4--

93.693.6

95.795.7-- 100100

##95% C. 95% C. R.R.

9393(9.5)(9.5)

100100(0)(0)

100100(0)(0)

95.395.3(8)(8)

100100(0)(0)

100100(0)(0)

93.893.8(8.4)(8.4)

100100(0)(0)(SD)(SD)AgeAge

SubgroSubgroup IIup II

88.688.6––

97.597.5

100100––

100100100100 ––100100

91.591.5-- 9999

100100––

100100

100100––

100100

89.889.8--

97.897.8100100 --100100

95% C. 95% C. R.R.

9797(5)(5)

100100(0)(0)

100100(0)(0)

100100(0)(0)

100100(0)(0)

100100(0)(0)

9898(8.9)(8.9)

100100(0)(0)(SD)(SD)AgeAge

SubgroSubgroup IIIup III

94.794.7--

99.399.3

100100––

100100100100 ––100100

100100 --100100

100100––

100100

100100––

100100

93.893.8-- 100100

##100100 ––100100

95% C. 95% C. R.R.

X

X

X

X

Results

Mean ( ), standard deviation (SD) and 95% confidence range Mean ( ), standard deviation (SD) and 95% confidence range of phoneme awareness material in the control groupof phoneme awareness material in the control group

PhonemePhonemeblendingblending

PhonemePhonemesegm.segm.stage IIstage II

PhonemePhonemesegm.segm.stage Istage I

PhonemePhonemecomp.comp.stage IIstage II

PhonemePhonemecomp.comp.stage Istage I

64.564.5(17.8)(17.8)

93.593.5(9.2)(9.2)

95.895.8(11.3)(11.3)93.8 (10) 93.8 (10) 98 (5.5) 98 (5.5) (SD)(SD)AgeAge

SubgroSubgroup Iup I 56.256.2 -- 72.972.989.289.2 --

97.897.890.590.5 --100 # 100 #

89.289.2 --98.498.4

95.495.4 -- 100100##

95% C. 95% C. R.R.

90.5 (7.6) 90.5 (7.6) 99.399.3(1.8)(1.8)100 (0) 100 (0) 100 (0) 100 (0) 99.5 (1.5) 99.5 (1.5) (SD)(SD)AgeAge

SubgroSubgroup IIup II 8787-- 94.194.198.498.4 --

100 # 100 # 100100 –– 100100100100 –– 10010098.898.8 -- 100100##

95% C. 95% C. R.R.

97.5 (4.1) 97.5 (4.1) 99.899.8(1.1)(1.1)100 (0) 100 (0) 100 (0) 100 (0) 100 (0) 100 (0) (SD)(SD)AgeAge

SubgroSubgroup IIIup III 95.695.6 -- 99.499.499.299.2 --

100 # 100 # 100100 –– 100100100100 –– 100100100100 –– 10010095% C. 95% C. R.R.

X

X

X

X

Results

Mean ( ), standard deviation (SD) and 95% confidence range of Mean ( ), standard deviation (SD) and 95% confidence range of auditory directives material in the control group.auditory directives material in the control group.

AuditoryAuditorydirectivesdirectivesstage III stage III

AuditoryAuditorydirectivesdirectives

stage II stage II

AuditoryAuditorydirectivesdirectives

stage Istage I

90.8 (9.4) 90.8 (9.4) 95.5 (7.9) 95.5 (7.9) 100 (0) 100 (0) (SD)(SD)AgeAge

Subgroup ISubgroup I 86.486.4 -- 95.295.291.891.8 -- 99.299.2100100 –– 10010095% confidence 95% confidence rangerange

98.4 (3.9) 98.4 (3.9) 100 (0) 100 (0) 100 (0) 100 (0) (SD)(SD)AgeAge

Subgroup IISubgroup II 96.596.5 -- 100 # 100 # 100100 –– 100100100100 –– 10010095% confidence 95% confidence rangerange

99.6 (1.2) 99.6 (1.2) 100 (0) 100 (0) 100 (0) 100 (0) (SD)(SD)AgeAge

Subgroup IIISubgroup III 99.199.1 -- 100 # 100 # 100100 –– 100100100100 –– 10010095% confidence 95% confidence RangeRange

X

X

X

X

Results

All of the developed material scores revealedAll of the developed material scores revealed

Deceasing value withDeceasing value with

increasing the levelincreasing the level

Increasing performanceIncreasing performance

with increasing the agewith increasing the age

Auditory closure I Auditory closure I 0.060.06

Auditory closure II Auditory closure II 0.000*** (b a a)0.000*** (b a a)

Auditory closure IIIAuditory closure III0.000*** (c b a)0.000*** (c b a)

Auditory vigilance Auditory vigilance II

0.001** (b a a)0.001** (b a a)Auditory vigilance Auditory vigilance

IIII0.000***0.000*** ((b a a)b a a)

Auditory vigilance Auditory vigilance IIIIII

0.000*** (b a a)0.000*** (b a a)

R M 2R M 2--words stage words stage 0.05* (b a a) 0.05* (b a a)

R M 3R M 3--words stage words stage 0.008** (b ab a) 0.008** (b ab a)

C M 3C M 3--words stage words stage 0.40.4

C M 4C M 4--words stage words stage 0.004** (b a a) 0.004** (b a a)

C M 5C M 5--words stage words stage 0.000*** (b a a) 0.000*** (b a a)

S M 3S M 3--words stage words stage 0.10.1

S M 4S M 4--words stage words stage 0.002** (b a a)0.002** (b a a)

S M 5S M 5--words stage words stage 0.000*** (b a a)0.000*** (b a a)

Phoneme comparison Phoneme comparison ––II0.20.2

Phoneme comparison Phoneme comparison ––IIII0.001** (b a a) 0.001** (b a a)

Phoneme segmentation Phoneme segmentation ––II0.090.09

Phoneme segmentation Phoneme segmentation --IIII0.0002*** (b a a) 0.0002*** (b a a)

Phoneme blending Phoneme blending 0.000*** (b a a)0.000*** (b a a)

Auditory directives I Auditory directives I 0.10.1

Auditory directives II Auditory directives II 0.003** (b a a)0.003** (b a a)

Auditory directives III Auditory directives III 0.000*** (b a a) 0.000*** (b a a)

Effect of age on the remediation material Effect of age on the remediation material scores using onescores using one--way ANOVA test.way ANOVA test.

As observed from LSD values,As observed from LSD values,the significant differencethe significant difference………………

Plateau in maturation of these skills Plateau in maturation of these skills

No effect were found for gender or No effect were found for gender or psychosocial levels (within its normal psychosocial levels (within its normal range) on the performance in these range) on the performance in these

materialsmaterials

9293949596979899

100

Control Per-rem. Post-rem. Post rem. (3 m.)

L.P.F. test

0102030405060708090


75

80

85

90

95

100


SPIN test

Duration pattern test

0

20

40

60

80

100


CST

0

2

4

6

8

10

12


Memory tests

0

20

40

60

80

100

Per-rem. Post-rem. Post-rem. (3 m.)

Questionnaire

0

2

4

6

8

10

12

Per-rem. Post-rem. Post rem. (3 m.)

P300 amplitude

050

100150200250300350400

Per-rem. Post-rem. Post rem. (3 m.)

P300 latency

0

20

40

60

80

100


Auditory vigilance

0

20

40

60

80

100

Auditory closure

Control Per-rem. Post-rem. Post-rem. (3 m.)

0

20

40

60

80

100


Auditory memory

0

20

40

60

80

100

Control Per-rem. Post-rem. Post-rem. (3 m.)

Auditory directives

0102030405060708090

100


Phonemic awareness

SPIN right ear

76.3

96.3

1 2 3

Scor

e %

SPIN left ear

74.4

94.4

1 2 3

Scor

e %

Memory for recognition test

5.51 2 3

Memory for content test

2.561 2 3

Memory for sequence test

2.131 2 3

P 300 amplitude right

5.181 2 3

P 300 amplitude left

4.651 2 3

P 300 amplitude binaural

5.831 2 3

Recognition memory

8.8

28.8

48.8

68.8

88.8

1 2 3

Scor

e %

Content memory

3.8

23.8

43.8

63.8

1 2 3

Scor

e %

Sequence memory

1.3

21.3

41.3

61.3

81.3

1 2 3

Scor

e %

Phoneme segmentation I

10

30

50

70

90

1 2 3

Scor

e %

Phoneme segmentation II

10

30

50

70

90

1 2 3

Scor

e %

Questionnaire

56.1

76.1

1 2 3

Scor

e %

LPF right ear

94.51 2 3

Scor

e %

LPF left ear

93.51 2 3

Scor

e %

DPT right ear

13.3

33.3

53.3

73.3

1 2 3

Scor

e %

DPT left ear

15

35

55

75

1 2 3

Scor

e %

CST right ear

55.4

75.4

95.4

1 2 3

Scor

e %

CST left ear

54.6

74.6

94.6

1 2 3

Scor

e %

Auditory vigilance stage I

43.1

63.1

83.1

1 2 3

Scor

e %

Auditory Closure

55

65

75

85

95

1 2 3

Scor

e %

Auditory vigilance stage II

24.5

44.5

64.5

84.5

1 2 3

Scor

e %

Auditory vigilance stage III

21.6

41.6

61.6

81.6

1 2 3

Scor

e %

Phoneme comparison I

37.5

57.5

77.5

97.5

1 2 3

Scor

e %

Phoneme comparison II

30

50

70

90

1 2 3

Scor

e %

Phoneme blending

25

45

65

85

1 2 3

Scor

e %

Auditory directives

0

20

40

60

80

100

1 2 3

Scor

e %

P 300 latency right

340

360

380

400

1 2 3

P 300 latency left

358

378

398

418

1 2 3

P 300 latency binaural

340

360

380

400

1 2 3

1) An informal remediation program in Arabic language for auditory processing disorders was developed.

2) The remediation program was standardized on a sample of normal school children.

3) The developed program proved to be efficient in the remediation of children with central auditory processing disorders and reflected the presence of auditory plasticity in 6-12 years aged children.

4) There was a significant effect of age on the degree of improvement of children

5) The number of sessions needed to achieve age-appropriate normal levels was variable among age groups. Younger children achieved normal levels in memory materials more rapidly, while older children achieve normal levels in phonemic awareness material more rapidly.

6) Psychophysical tests and P300 amplitude could be considered objective indicators of improvement in central auditory abilities.

7) The developed marker items were useful in the process of evaluation before and after

1)1) To use the developed remediation To use the developed remediation program in rehabilitation of children program in rehabilitation of children with CAPD.with CAPD.

2)2) To study outcome stability over a longer To study outcome stability over a longer period of time.period of time.

3)3) To compare between the outcome of To compare between the outcome of informal remediation programs and the informal remediation programs and the outcome of formal programs.outcome of formal programs.

4)4) To study the applicability of marker To study the applicability of marker items as an informal screening tool for items as an informal screening tool for CAPD in school children.CAPD in school children.

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