treatment of acquired and developmental...
TRANSCRIPT
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Tim Conway, Ph.D.
The Morris Center, Inc. University of Florida
Gainesville, Florida [email protected]
Lorie Richards, Ph.D., OTR/L University of Florida
Gainesville, Florida
www.TheMorrisCenter.com
Transdisciplinary Assessment and Treatment of Language-based Learning Disabilities:
The Theoretical Importance of Sensory Processing
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Neurons - How the Brain Works
How many neurons In the brain? ~ 100 Billion
How many connections exist in the neural networks formed in the brain? ~ 100 Trillion
How many “connections” from one neuron? ~ 40,000
The brain is specifically designed for learning and behaviors. It is ready and willing to create neural networks.
Learning to drive?
Driving to Ft. Lauderdale…..
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STG (bilateral)
acoustic-phonetic
speech codes pMTG (left)
sound-meaning interface
Area Spt (left)
auditory-motor interface pIFG/dPM (left)
articulatory-based
speech codes
Hickok & Poeppel (2000), Trends in Cognitive Sciences
Hickok & Poeppel (2004), Cognition
STS phoneme
representations
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UNIQUE AND OVERLAPPING NETWORKS
SENTENCE/SYNTACTIC, SEMANTIC, PHONOLOGICAL
VIGNEAU et al., 2006
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How does the brain develop these
distributed networks of sensory and
cognitive abilities?
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UNIVERSAL SPEECH PERCEPTION: 0-6 MONTHS
Time (months) 6 5 4 3 2 1 0 Production
Perception
SENSORY LEARNING
INFANTS PRODUCE
VOWEL-LIKE SOUNDS
INFANTS PRODUCE
NON-SPEECH SOUNDS
INFANTS DISCRIMINATE PHONETIC
CONTRASTS OF ALL LANGUAGES
STATISTICAL LEARNING
(DISTRIBUTIONAL
FREQUENCIES)
LANGUAGE-SPECIFIC
PERCEPTION FOR
VOWELS
UNIVERSAL SPEECH PRODUCTION: 0-6 MONTHS
(Kuhl, 2004)
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UNIVERSAL SPEECH PERCEPTION: 6-12 MONTHS Sensory Learning
TIME
(MONTHS) 12 11 10 9 8 7 6
PRODUCTION
PERCEPTION
CANONICAL BABBLING
STATISTICAL LEARNING
(DISTRIBUTIONAL
FREQUENCIES)
LANGUAGE-SPECIFIC
PERCEPTION FOR
VOWELS
Sensory-Motor Learning
Language Specific Speech Production
LANGUAGE SPECIFIC SPEECH PRODUCTION
FIRST WORDS PRODUCTION
DETECTION OF TYPICAL
STRESS PATTERNS IN WORDS
DECLINE IN FOREIGN-
LANGUAGE CONSONANT
PERCEPTION
INCREASE IN NATIVE-LANGUAGE
CONSONANT PERCEPTION
Language-specific speech perception
(Kuhl, 2004)
STATISTICAL LEARNING
(TRANSITIONAL
PROBABILITIES)
RECOGNITION OF
LANGUAGE-SPECIFIC
SOUND PRODUCTION
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Multisensory = any senses?
To promote language development, does it matter
what sensory systems or how the sensory systems
are engaged/experienced?
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Sensory Systems & Speech Perception
(Kuhl et al., 2003)
Live intervention Machine intervention Live monolingual
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Sensory Systems & Language
Why did live / invivo experience with a parent improve 2nd language discrimination when TV and Headphone experience didn’t?
What sensory systems are engaged by live experience and NOT by recorded experiences?
What do you do when you teach a baby a new word and he/she has trouble saying all the word’s sounds, e.g. “ba” versus ball?
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Early Language Development
Brain is tuned to parents’ language What systems do newborn’s integrate for speech?
Oral-facial movements – visual Speech sounds – phonology Speech/babble – oral motor tactile kinesthetic Social-emotional – (non verbal tones & gestures) – pragmatics
Newborns speech perception is affected by multisensory experiences during language development.
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Sensory Systems & Language Development
Is an adult’s well-developed speech perception affected by multisensory experiences?
http://www.youtube.com/watch?v=eQoYKuNcCpU&feature=fvwrel
Spell pseudo words
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How does the brain develop these distributed
networks of sensory and cognitive abilities?
Sensory and motor systems that fire together
wire together to form functional neural networks
in a typically developing brain.
Which sensory systems are firing during
development of speech perception?
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(Miller, 2011)
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Typical LANGUAGE Networks
SPEECH
PRODUCTION
AREA
AUDITORY
PROCESSING
AREA
VISUAL-LANGUAGE
ASSOCIATION AREA
VISUAL /
VERBAL
AREA
LEFT HEMISPHERE
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Typical READING Areas
LEFT HEMISPHERE
WORD ANALYSIS
WORD ANALYSIS
AUTOMATIC
(SIGHT WORD)
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“CHANGES IN SYNAPSES?”
At what chronological age do neurons lose the
ability to make new connections (synapses) or
networks?
Can neural networks make new connections even
after documented brain injury?
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Following a stroke,
can partially
damaged brain
areas be re-
activated by
neurorehabilitation?
YES! New activity
and improved
behaviors occur in
some patients.
(Chang, et al. 2006)
Pre-Treatment
Front
Back
L R
Post-Treatment
L R
Front
Back
Top
Bottom
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Principles Of Neural Plasticity
Neurons that fire together - wire together - Multiple, salient sensorimotor inputs that wire together can
strengthen neural networks
Optimal arousal and attention
Consistent input/learning experiences
Learning experiences drive neural plasticity: 1. SALIENCE – specificity of instruction/experience
2. FREQUENCY - hour(s) per day
3. INTENSITY - days per week practice, practice, practice
(Heilman and Alexander, 2003; Kleim and Jones, 2008)
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Variability in Neural Plasticity?
Why don’t neural networks all form the same for
each person’s brain?
Why do some brains work “differently” than others?
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Visual, auditory & oral sensory systems –
Are they integrated well in dyslexia?
Montgomery, 1981
Articulation Accessing scores of subjs in sample 2
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WHAT DYSLEXIA IS NOT
DYSLEXIA…
.. is NOT A VISUAL PROBLEM
.. is NOT A LACK OF INTELLIGENCE
.. is NOT DUE TO LACK OF EFFORT
.. is NOT RESPONSIVE TO STANDARD READING
INSTRUCTION
.. is NOT UNCOMMON: 5–17.5 % OF POPULATION
.. is NOT A DEVELOPMENTAL LAG
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DYS = trouble LEXIA = words
Dyslexia is…
Neurologic in origin – genetic
Lifelong – but environment may alter course
Reading comprehension > word reading skills
Dyslexia may include accompanying challenges
ADHD 50-70%
Behavioral problems
Sensory motor difficulty
= More challenging to remediate
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STRENGTHS
LEADERSHIP SKILLS THINKING “OUT OF THE BOX”
CHURCHILL
POLITICAL
&
MILITARY
BUSINESS SCIENTISTS &
INVENTORS
THE PICTURE OF DYSLEXIA (ALL STENGTHS DO NOT OCCUR FOR EVERYONE)
JFK TED TURNER
(Alexander & Conway, 2007)
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H.C. ANDERSEN Da VINCI SPEILBERG / FORD
CREATIVITY
WRITERS ARTISTS MUSICIANS ACTORS/DIRECTORS
MOZART
STRENGTHS
THE PICTURE OF DYSLEXIA (ALL STENGTHS DO NOT OCCUR FOR EVERYONE)
(Alexander & Conway, 2006)
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VISUOSPATIAL / MOTOR SKILLS
SURGEONS ATHLETES
NEUROSURGERY MOHAMMAD ALI NOLAN RYAN
THE PICTURE OF DYSLEXIA (ALL STENGTHS DO NOT OCCUR FOR EVERYONE)
STRENGTHS (Alexander & Conway, 2006)
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THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE)
ORAL LANGUAGE
CHALLENGES
LISTENING
Auditory Memory (word sequences, phone numbers,
remembering directions)
Phonological Awareness
Foreign Language
SPEAKING
Word Finding
Multi-syllable Words
Sequencing Ideas
Foreign Language
(Alexander & Conway, 2006)
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WRITTEN LANGUAGE CHALLENGES
READING
Mechanics Comprehension
Speed Mechanics
Speed
SPELLING & WRITING
Expressing Ideas
THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE)
(Alexander & Conway, 2006)
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ACCOMPANYING SENSORIMOTOR CHALLENGES
Up/Down
Left/Right
Oral Motor Messy Eating
Writing/knots Fingers
Eyes
Tired
Words Swim
Lose Place
Spatial Awareness
THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE)
(Alexander & Conway, 2006)
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ACCOMPANYING CHALLENGES (BEHAVIORAL)
Parents with similar challenges
Brain / Behavior
Disorders
Attention & Executive Function
Anxiety
Depression
OCD
Oppositional
Behavior
THE PICTURE OF DYSLEXIA (ALL SYMPTOMS DO NOT OCCUR WITH EVERYONE)
(Alexander & Conway, 2006)
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Dyslexia – really, what is it?
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VISUAL /
SIGHT WORDS
LANGUAGE /
VOCABULARY
GRAMMAR
COMPREHENSION
FLUENCY
3 – LEGGED
STOOL
AUDITORY /
SOUNDING
OUT
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If Phonology Is So Important, Then When Does It Begin Developing? At what age do children begin to learn the sounds of their native language?
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Developmental Building Blocks for Language
18 MONTHS
1 MONTH
9 MONTHS
5 YEAR S
9 YEARS
PHONOLOGY (FORM)
PRAGMATICS (FUNCTION)
SEMANTICS
(MEANING)
SYNTAX (FORM)
READING
WRITING
SPELLING
METALINGUISTICS
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STG (bilateral)
acoustic-phonetic
speech codes pMTG (left)
sound-meaning interface
Area Spt (left)
auditory-motor interface pIFG/dPM (left)
articulatory-based
speech codes
Hickok & Poeppel (2000), Trends in Cognitive Sciences
Hickok & Poeppel (2004), Cognition
STS phoneme
representations
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UNIQUE AND OVERLAPPING NETWORKS
SENTENCE/SYNTACTIC, SEMANTIC, PHONOLOGICAL
VIGNEAU et al., 2006
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“OUT OF LINE NEURONS” (ECTOPIAS)
FRONT BACK
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Typical READING Areas
LEFT HEMISPHERE
WORD ANALYSIS
WORD ANALYSIS
AUTOMATIC
(SIGHT WORD)
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Neuronal migration
goes awry in
developmental dyslexia?
www.thebrain.mcgill.ca
NEURONAL
MIGRATION
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Galaburda, 2006
NEURONAL MIGRATION
(Galaburda, et al., 2006)
*transmembrane adhesion molecules and receptors
*downstream targets: change cytoskeletal processes & neuron motility
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Neuronal Ectopia
(Ramus, 2004)
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What effects on brain function might ectopias have? Functional MRI (fMRI)
- same machine as clinical MRI
- additional measure of blood oxygenation levels in brain
- shows brain’s active areas when doing some behavior/task
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STRONG
ACTIVITY
PATTERN
weak activity
pattern
BRAIN ACTIVITY DURING READING
“SIGNATURE” DYSLEXIC BRAIN
Simos, et al 2002
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Decreased activity
in right hemisphere
TREATMENT CHANGES the BRAIN’S ACTIVITY
(Simos, et al., 2002)
left left right right
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Biology (RAMUS, 2004)
Behavior
Cognition
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PHONOLOGY
EXECUTIVE FUNCTION / INTENTION
WORKING MEMORY
HOLD / MANIPULATE
(PERCEPTION & PRODUCTION)
ACOUSTIC VISUAL ORAL MOTOR SOMATOSENSORY
ATTENTION / AROUSAL
PHONEMIC REPRESENTATION
PROSODIC (WORD LEVEL)
(Alexander, 2006)
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READING
EXECUTIVE FUNCTION / INTENTION
WORKING MEMORY
HOLD / MANIPULATE
ATTENTION / AROUSAL
(PERCEPTION / PRODUCTION)
PHONICS RULES
SYNTACTIC
REPRESENTATION
SEMANTIC / LEXICAL
REPRESENTATION
ARTICULATORY
REPRESENTATION
PHONOLOGIC
REPRESENTATION
ORTHOGRAPHIC
REPRESENTATION
MORPHOSYNTACTIC
REPRESENTATION
PROSODIC
REPRESENTATION
DYSLEXIA(Alexander, 2006)
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Theory
Developmental Dyslexia: A Motor-articulatory Feedback Hypothesis (Heilman, Voeller, Alexander, 1996)
“The inability to associate the position of their articulators with speech sounds may impair the development of phonological awareness and the ability to convert graphemes to phonemes. Unawareness of their articulators may be related to programming or feedback deficits.”
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Transdisciplinary Team for Assessment & Treatment
Disciplines:
Neuropsychology
Psychiatry
Nursing/Nurse Practitioner
Clinical Psychology
Occupational Therapy
Speech-Language Pathology
Education
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Multidisciplinary vs Transdisciplinary
Multidisciplinary – more than one discipline individually evaluates and treats Each discipline retains its methodologies and assumptions,
without change or development from other disciplines
Cooperation may be mutual and cumulative, but is not interactive
Transdisciplinary – several disciplines evaluate and treat together Each discipline is trained in some tenets of the other disciplines
Shared theoretical models that integrate perspectives from several disciplines
Blends the practices and assumptions of each discipline involved
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Case Study
High school student
History of dyslexia since elementary school
Parent is a school teacher
Years of school-based academic intervention and specialized tutoring at franchised centers…
Starting athlete with scholarship potential, but he has body function and academic deficits in…
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Case Study - Assessment Findings
Attention
ADHD-Inattentive
Language Phonological
Reading
Writing
Spelling
Written comprehension
Expression
Sensory Processing Disorder
Visual vigilance
Visual tracking
Vestibular
Visual perceptual
“Low Registration” on Sensory Profile
Poor balance with eyes closed
Poor supine flexion
Deficits in:
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Case Study: Transdisciplinary Treatments
Psychology:
Individual therapy
Therapy with mother
Speech-Language:
Phonological Awareness (LiPS Program®)
Mental Imagery
(Visualizing & Verbalizing®)
Written Composition
(Visual-Kinesthetic Sentence Structure)
OT w/ SI focus
Sensory modulation & processing - esp. vestibular
Oculomotor skills
Joint stability
Visual perceptual skills
Balance
Movement perception
Sequencing
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Case Study: Transdisciplinary Treatment of Dyslexia
Treatment Schedule:
Daily
4-6 hours treatment per day
~1 hour of OT-SI
~3-5 hours language
5 days per week
~12 weeks
Treatment Hours:
Phonological/Cognitive: ~150
(neurodevelopmental LiPS®)
Semantic/Memory (V/V®): ~50
Syntax/Cognitive (VKSS): ~50
Physical Medicine (OT-SI): ~45.
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Sensory Processing Disorder (SPD)
“…difficulty taking in and interpreting sensory information so that an appropriate response can be generated.” (Bialer & Miller, 2011, pg 20)
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Treatment of SPD
“So, to be able to design and implement helpful treatment activities for kids with sensory challenges, it is important on a behavioral level to have some understanding about how sensory input either supports or challenges a child.” (Bialer & Miller,
2011, pg.20)
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0
20
40
60
80
100
120
Visual-Motor Integration Motor Coordination
Pre Post
Body Functions: Visual-Motor Integration (VMI)
IQ=101
Sta
nd
ard
score
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Body Functions: Test of Visual Processing Skills-3
0246810121416 Pre Post
IQ=101
Sca
led
sco
re
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Body Functions: Comprehensive Test of Phonological Processing (CTOPP)
0
20
40
60
80
100
120
Phonological Awareness Alternate PhonologicalAwareness
Pre
PostIQ=101
Sta
nd
ard
score
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Improved Body Functions Sensory Processing – “Low registration” was improved with OT-SI, medication
and arousal strategies for use at home and school.
Processing/ Modulation of Vestibular Information - R & L LE balance
without vision = 4 and 7 secs, improved to 21 and 18 secs; impaired supine flexion
improved to 90 seconds while counting (without holding shoulders); depressed post
rotary nystagmus was improved
Oculomotor Skills - losing his place during reading and poor visual endurance
(blinked excessively during visual tasks/testing), both visual tracking and endurance
were improved and excessive blinking was markedly decreased
Visual Perception -TVPS=83 SS (below average) to TVPS=110 (high average)
Graphomotor Skills - VMI Motor Coordination = 75 SS improved to 89
Oral Motor Skills - trouble with his oral-motor “feeling” was improved
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Academic Functions: WECHSLER INDIVIDUAL ACHIEVEMENT TEST (WIAT-II)
0
20
40
60
80
100
PseudowordDecoding
Word Reading ReadingComprehension
WrittenExpression
Pre Post
Sta
nd
ard
score
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Conclusions and Future Directions
Participant01 Demonstrated:
Improved Body Functions,
Improved Academic Functions
Improved School Performance
passed high school proficiency tests (including written exam)
earned a standard high school diploma
Follow-up report: He has completed his first year of college
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Future Directions:
More “Single-Subject Research Design” and
RCT studies need to be published to
document the specific impact of OT-SI
treatment on body functions and academic
functions for children with LD’s.
OT is an essential part of an
Transdisciplinary assessment and treatment
for children and young adults with LD’s, but
more empirical data is needed.
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Future Perspectives: TransdisciplinaryTreatment
Language
Sensory processing/integration
Interpersonal relationships
Social engagement
Auditory processing
Cognitive behavioral strategies
Regulating mood/affect
Executive functioning
Academic performance
Parent & client education/training
(adapted from Doreit & Miller, 2011) Complimentary Interventions
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Thank You
Questions & Comments
Tim Conway, Ph.D.
The Morris Center, Inc.
Gainesville, Florida
www.TheMorrisCenter.com
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Human Sensory Systems
Visual Gustatory Olfactory Auditory Tactile Also: Vestibular – movement of the head in relation to gravity Proprioception – pressure in the muscles and joints Interoception – awareness of body organs, hunger, thirst…
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L R
Back
Pre-treatment 3D
L R
Back
Post-treatment 3D
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Reading Pseudo words
Front