.......Tomatis Topics

W illard was referred to the Spectrum Center for an Tomatis therapy evaluation to determine if he has an underlying sensory integration/listening disorder. According to Willard's mother, Willard presents with difficulties with motor planning and, fine motor skills, He also has poor body awareness and poor motor coordination. Past evaluations suggest that Willard has possible sensory regulatory difficulties. Willard has been receiving occupational therapy and occupational therapy for sensory integration disorder. Willard also has speech and language delays. As a result of his age, it is unclear whether these delays are due to auditory processing difficulties or language difficulties. It should be noted that Willards teacher reports that he is easily distracted by noise, requires multiple cues to follow instructions and has difficulty remembering what is said. Willard has been receiving speech therapy since 2.9 years. Medical history is essentially unremarkable.



A. Behavior During Testing

Willard was very compliant and accommodating during the evaluation. He responded to verbal directives and demonstration.

B. Auditory Listening Functions

It was observed today that Willard needed to have instructions repeated and was overwhelmed by background noise. In general, it was noted that Willard needs more time to process information and that his processing skills seemed to be very inconsistent. These difficulties and characteristics are seen in children with auditory processing disorders. It appears that Willards auditory system does not perceive information accurately and therefore is unable to analyze, discriminate, and sequence sounds appropriately for consistent and efficient language skills.

2) Screening Test for Auditory Processing Skills (SCAN)

The next test administered was the Screening Test for Auditory Processing Skills (SCAN). The SCAN test consists of four subtests.

a) Filtered Words

This subtest consists of one syllable words that are filtered to pass through information in frequencies of 1000 Hz and below. These words are presented to one ear at a time under headphones. This task requires the listener to use auditory closure skills in order to complete a word. Poor functioning of this skill could result, for example, in difficulty understanding a teacher who is speaking with his or her back to the class when writing on the chalkboard, especially when the child is seated towards the back of the room. It could also result in difficulty understanding someone who has an accent or speaks too rapidly. Willards performance on this test revealed a raw score of XX, placing him/her in the Xth percentile, indicating that he has difficulty with auditory closure skills.

b) Auditory Figure Ground

This subtest consists of one-syllable words presented to one ear with a competing background of people talking. Willards raw score was XX, which places him/her in the Xth percentile. Quantitatively Willards scores are below normal limits, demonstrating that Willard has difficulty focusing on the primary message when background noise is present, especially if lengthy verbal communication is required.

c) Competing Words

The third subtest is a dichotic listening test that consists of one syllable words presented to the left ear and the right ear at the same time. This task required Willard to repeat different words that were said simultaneously to each ear. Willard could repeat only one of the words and more often his/her response was a blend of the two words he had heard. Willards raw score was XX, which places him/her in the Xth percentile. This task requires good interhemispheric communication between ears and is considered a higher order processing task. It should be noted that this skill develops at around 5 to 6 years of age.

d) Competing Sentences

This is also a dichotic listening test that requires good communication between ears and lateralization. In the right ear task, the child is expected to repeat the sentences heard only in the right ear. In the left ear task, the child is expected to repeat the sentences heard in the left ear. Willards raw score of X placed him/her in the Xth percentile for this subtest, which is below normal limits and indicates a breakdown in interhemispheric communication between ears.

Auditory processing skills specific to phonemic decoding.

This task requires the child to recognize sounds and combine (synthesize) them with the most recently heard ones. In other words, this test assesses the ability to synthesize separate phonemes into a word. Phonemic decoding is an important skill, as it underlies not only speech and language development, but is closely related to reading and spelling as well. Those who have poor phonemic decoding have classroom difficulties understanding what is said, making verbal associations, and with verbal recall. We administered the picture version of this test because Willard appeared overwhelmed when he attempted the nonpicture version that has no visual cues. Willard clearly lacks the ability to synthesize sounds, an important prerequisite for phonetic reading. It was also observed that most of his/her errors were on the XXXXX sound rather than XXX and XXX sounds.


S ensory Integration Testing

The next tests administered were measures of sensory integration function. They include measures of vestibular function, postural control, bilateral integration, motor planning (praxis), and visual motor functions. These tests are administered to determine if an underlying sensory integration disorder is impacting higher level listening functions.

1) Vestibular Function

On tests of vestibular function, today's evaluation indicated some atypical responses within this system. On the post rotary nystagmus test, a classic measure of vestibular function where the child is rotated 10 times in 20 seconds, Willard's responses were depressed. He presented with 3 - 5 seconds of nystagmus when spun in either direction, and the excursion of his nystagmus was non-rhythmic. A depressed nystagmus indicates depressed processing within the vestibular system. [As mentioned previously, Willard exhibited slightly depressed functions and asymmetry in the low frequencies of sound perception on the Listening Test, signs that are often associated with depressed processing within the vestibular system. ]

Another example of depressed vestibular processing was evidenced by Willard's low muscle tone.

2. Postural Control and Muscle Tone

Tests of postural function that assess muscle tone and antigravity postural control proved challenging for Willard. He had significant difficulty with both antigravity prone extension and supine flexion postures. [Willard was unable to maintain an anti-gravity prone extension posture or a supine flexion posture. [He was able to assume both postures with facilitation, but could not maintain them for more than a few seconds.] Difficulty with antigravity postures indicates underlying low muscle tone and depressed vestibular processing.

Cocontraction, which is the ability to maintain muscle tension to stabilize a joint against resistance, was also slightly diminished, again suggesting evidence of depressed vestibular processing.

Low muscle tone was also noted to have an impact on Willard's fine motor skills. Ligament laxity was observed. He tended to use his whole arm when coloring

Willard had significant difficulty with standing balance, both with eyes open and shut. He was able to balance on his left foot for only 3 seconds. He was, however, able to balance for 0 seconds on his right foot. With eyes closed Willard was not able to balance on his left or right feet. This suggests poor processing within the vestibular system and the way in which the body relates to gravity. Individuals with depressed processing within the vestibular system often have greater difficulty on standing balance with eyes closed, as they are unable to use their vision to compensate for their weak vestibular feedback.

3. Bilateral Integration

Willard had significant difficulty with tasks that required smooth coordinated communication between both sides of the body. He had difficulty tapping out rhythms with both his/her hands and his/her feet. He especially had difficulty with tasks that required imitating the evaluator and crossing the midline of the body.

On tasks that required higher integration of motor functions, Willard had particular difficulty on tasks that required smooth and coordinated communication between both sides of the body. Tapping out rhythms with his hands and his/her feet were difficult. This is consistent with the observation noted earlier about Willard's difficulty with dichotic listening tasks. Both conditions indicate that there is poor interhemispheric communication and it is affecting skills on both the motor level and on the level of higher order auditory processing.


M otor Planning (praxis)

Tasks that require motor imitation are a measure of motor planning abilities. Willard had a difficult time imitating gross motor postures. It was also observed that Willard was very slow in his execution when attempting to imitate motor postures. He had to think through each posture cognitively before his body could execute the posture.

Willard also had a difficult time with tasks that required sequencing. When asked to rapidly sequence movements of thumb to alternate fingers, it was observed that Willard had accuracy in finger to thumb opposition. The evaluator had to slow down the demonstration of the sequencing pattern in order for Willard to successfully complete the task. He was eventually able to figure it out with the help of cognitive reasoning. Motor planning abilities under lie sequencing abilities and this appears to be an area with which, once again, Willard was cognitively thinking through each movement and also visually watching his/her thumb touch each finger.

Willard's responses were limited and concrete when asked to initiate the motor plan for a novel behavior. For example, when asked to pretend how he would hammer a nail into a piece of wood, rather than pretend to hold a hammer and a nail, Willard turned his hand into a hammer and pounded it against the table.

5. Visual Motor Processing

It was observed today during fine motor activities that Willard has a right hand dominance.

His grasp pattern was a spread four finger grasp. He had good flexion of his fingers and good wrist extension for the observed adapted grasp. Distal manipulation was obtained through whole arm movements with little or no dissociation at the wrist.

On the Beery Test of Visual Motor Integration, (VMI portion) on a pure quantitative measure, Willard had an age equivalent of 3 years, 10 months. This is significantly below his chronological age. Deficits did not appear to be a perceptual difficulty (as Willard's age equivalent in visual perceptual portion was 6 years, 6 months), but rather a difficulty in motor planning as it is involved in visual motor integration.

When visual eye tracking was assessed, it was observed that Willard was consistently able to following a moving object with his eyes for horizontal, vertical, and diagonal patterns of movement. He lost the tracking in the upper quadrants with his right eye greater than that of his left.

Next Part of Evaluation