Iranian Rehabilitation...

Iranian Rehabilitation Journal The official Journal of the University of Social Welfare and Rehabilitation Sciences

Chairperson: Dr. Shahrbanoo Nakhaei

Editor-in-Chief

Hamid Reza Khorram Khorshid, MD, MPH, PhD, Associate Professor University of Social Welfare and Rehabilitation sciences Tehran, Iran [email protected]

Executive Manager

Dr. Reza Seyednour [email protected]

EDITORIAL BOARD Dadkhah Asghar, PhD, Professor

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran Harizuka Susumu, PhD, Professor

Kyushu University, Fukuoka, Japan Helander Einar, PhD, President

Community Based Rehabilitation Organization, Lisbon, Portugal Hosseiny Seyed Ali, PhD, Assistant Professor

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran Kamali Mohammad, PhD, Associate Professor

Iran University of Medical Sciences, Tehran, Iran Kumar Surender, PhD, Professor

Chikushi Jogakuen University, Japan Lotfi Younes, MD, Associate Professor

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran McConkey Roy, PhD, Professor

University of Ulster, Northern Ireland Mirzamani Seyed Mahmood, PhD, Associate Professor

Baqiyatallah University of Medical Science, Tehran, Iran NajmAbadi Hossein, PhD, Professor

University of Social Welfare and Rehabilitation Sciences , Tehran, Iran Nillipour Reza, PhD, Professor

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran Reife Carol, PhD, Associate Professor

Leiden University, Leiden, The Netherlands

EDITORIAL Staff Coordinator: Masoumeh Ganji, BSc

Web Master: Kamran Najafzadeh, BSc

Graphics and Design: Arash Fekri

Journal Citation Reports®: ISC (Islamic world Science Citation); IMEMR (Index Medicus for WHO); Magiran; Iran Medex, DAOJ, Index Copernicus

Editorial Contact

Iranian Rehabilitation Journal (IRJ) [email protected] University of Social Welfare and Rehabilitation Sciences [email protected] Evin, Kudakyar Ave., Tehran - 1985713831, Iran www.rehabj.ir Tel/Fax: +98-21-2218-0082 http://irjrehab.com

CONTENTS

Original Articles

Comparing the Results of Developmental Screening of 4-60 Months Old Children in Tehran Using 3

ASQ & PDQ Soheila Shahshahani, Roshanak Vameghi, Nadia Azari, Firoozeh Sajedi, Anooshirvan Kazemnejad

The Role of non-Linguistic Variables in Production of Complex Linguistic Structures by Hearing- 8

Impaired Children Robab Teymouri, Shahin Nematzadeh, Masoud Gharib, Naeimeh Daneshmandan

The Effect of Swedish Massage on Glycohemoglobin in Children with Diabetes Mellitus 16 Zahra Kashaninia, Akram Abedinipoor, Samaneh Hosainzadeh, Firoozeh Sajedi

Cerebral Palsy: Motor Types, Gross Motor Function and Associated Disorders 21 Farin Soleimani, Roshanak Vameghi, Mehdi Rassafiani, Nazila Akbar Fahimi, Zahra Nobakht

The Relationship Among Personality Factors, Motivational Strategies and Achievement Goals 32

Orientation in Predicting Academic Achievement of the Students with Intellectual Disability Masoume Pourmohamadreza Tajrishi, Mohamad Ashoori, Seyede Somaye Jalil-Abkenar, Jamal Ashoori,

Outcomes of Receiving a Master‟s Degree in “Rehabilitation Management” on Graduates‟ 39 Professional Lives Nikta Hatamizadeh, Seyed Majid Mirkhani, Ahmad Fotoohi, Asghar Makarem, Azar Petrami, Roshanak Vameghi

Persian Cued Speech: The Effect on the Perception of Persian Language Phonemes and 49 Monosyllabic Words with and without Sound in Hearing Impaired Children Guita Movallali

Prevalence of Feeding Problems in Children with Intellectual Disability 56 Mohammad Rezaei, Vahid Rashedi, Masoud Gharib, Gohar Lotfi

The Prevalence of Ear Disease in Sensorineural Hearing Impaired Children Below 18 Years -Old in 60

Deaf Welfare Clinic of Molavi Rehabilitation Center Naeimeh Daneshmandan, Samaneh Hosseinzadeh, Robab Teymouri

Co-Morbidity of Attention Deficit Hyperactivity Disorder (ADHD) and Tourette Syndrome in Child 63

Referral Psychiatry Clinic in IRAN Sahel Hemmati, Nasrin Amiri, Robab Teymouri, Masoud Garib

Review

Hypertonicity in Children with Cerebral Palsy: a New Perspective 66 Mehdi Rassafiani, Robab Sahaf

Case Report

A Case Report of Bilateral Upper Extremities Arthrogryposis 75 Amin Shahrokhi,Masoud Gharib, Vahid Rashedi, Mohammad Reza Kooshesh

2 Vol. 9 - Special Issue - Child NeuroRehabilitation

Iranian Rehabilitation Journal, Vol. 9, December 2011

Original Article

Comparing the Results of Developmental Screening of 4-60 Months

Old Children in Tehran Using ASQ & PDQ Soheila Shahshahani, MD; Roshanak Vameghi, MD; Nadia Azari, MD; Firoozeh Sajedi*, MD

Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation

Sciences,

Tehran, Iran

Anooshirvan Kazemnejad, PhD University of Tarbiat Modaress, Tehran, Iran

Objectives: This research was performed to compare the results of two parental-based developmental questionnaires.

Methods: In this study the developmental status of 196, 4-60 months old children were screened using

Ages and Stages Questionnaires (ASQ) and prescreening developmental Questionnaire (PDQ) in 4 primary health care clinics in Tehran. Convenient sampling was used. Data was analyzed by SPSS software.

Results: Using ASQ 18% of children were detected as having developmental disorders. Developmental

screening with PDQ showed that developmental delay or doubtful condition was seen in 20% and 19% of

children respectively. The estimated consistency coefficient between PDQ II and ASQ for fine and gross

motor domains was 0.05 and 0.24, and for language and personal-social issues were 0.18 and 0.06,

respectively. Based on two different categorizing possibilities for questionable scores of PDQ-II, that is,

"delayed" or "normal", the total agreement coefficient between two questionnaires were determined 0.30

and 0.20, respectively

Discussion: The process of developmental screening was changed in recent years and performing a correct

and useful developmental screening is easier today. Several screening tools are available now. Recent studies

showed that parental information about their child‟s development have good accuracy. For selecting a suitable

tool we must consider the validity, reliability, sensitivity, specificity and all other positive and negative points

about the tool of the test.

Conclusion: This study showed that the results of developmental screening of 4-60 months old children in

Tehran using ASQ and PDQ lead to different results. This is necessary that the results of screening are compared

with a diagnostic gold standard test.

Key Words: Developmental screening, ASQ, PDQ

Introduction

The importance of early detection of developmental

disorders in the well-being of children and their

families is approved (1). Nowadays there is an

increasing effort for detection of developmental

disorders at an earlier age because intervention

services are cost effective and when provided in early

childhood, have greater efficacy (2). These services

improve the developmental prognosis and have short

and long term benefits (3-6). The process of

developmental screening was changed in recent years

and today it is easier to perform a correct and useful

developmental screening. In order to detect

*All correspondence to: E-mail: [email protected]

Iranian Rehabilitation Journal

developmental disorders at an early age, the American

Academy of Pediatrics (AAP) has recommended that

pediatricians use developmental screening tools at 9, 18,

24 (or 30) months‟ child health visits (1).

In recent years the focus of pediatric medicine in

developed countries has changed from breast

feeding and child health topics to child‟s well being

and preventive medicine. In those societies early

detection and intervention of developmental disorders

are integrated in routine health care services. In

moderate to low income countries developmental

disorders occur in early childhood and are an

important morbidity factor for whole life because

3

still in these areas the priority of health services are

preventing iron deficiency anemia, improving

mother-child relationship and increasing social-

emotional stimuli (7, 8). Health system is the first

and in some countries the only situation that is

available for service providing to children. Thus

some references recommended that developmental

screening be administrated to children in outpatient

clinics or even for inpatient children that are

hospitalized for any other reasons (9-11).

Several screening tools are available now but their

approaches are different. There is no unique tool that

could be useful for all population or age-ranges (1).

It was suspected that, using parental report about an

screening tool is incorrect but several studies

showed that parental information about their child‟s

abilities is very worthy for predicting developmental

disorders (6, 12). On the other hand, it is possible

that during a routine child health care visit, the child

be ill, messy, hungry, sleepy or fearful and we know

that these circumstances are not suitable for showing

his/her abilities. Thus for preventing this problem,

developmental screening tools that use parental

reports are useful (13-16). Also standard objective

tools are time consuming, need more payment and

their providers need to have knowledge and

expertise for performing them. Thus parental-based

questionnaires are suitable option for developmental

screening because recent studies showed that

parents, regardless of their socioeconomic status,

child rearing experiments or their own health status,

have correct information about their child‟s

development (2, 12, 13, 15) and their opinions have

high validity and will lead to increasing rates of

early detection and intervention of developmental

disorders (9, 17, 18). The only barrier in this way is

inability to read or understand the questionnaires.

This problem can be easily relieved by orally

presenting or translating them (19).

This study was performed from February 2008 to

January 2009 in Tehran, Iran to compare the results

of two parental-based developmental questionnaires

Ages and Stages Questionnaires (ASQ) and

Prescreening Developmental Questionnaire-II (PDQ

II).

Materials and methods

PDQ-II is a developmental prescreening tool that is

derived from Denver Developmental Screening

Test-II (DDST-II). Ninety seven of 105 items of

DDST-II are changed to questions that can be answered by “YES” or “NO” by the care-giver.

4

They are categorized into 4 questionnaires for 0-9

month, 9-24 month, 2-4 year and 4-6 year old

children. The 75th and 95

th percentiles for each

question and also the developmental domain to

which it belongs are shown in front of it (20).

Caregivers must continue answering questions until

they arrive at 3 “NO” answers (it is not necessary

that the NO answers be consecutive). The answer to

each question can be: normal (which means the child

is able to do the task), delayed (which means the

child is not able to do the task that 90% of his/her

age-matched children can do) and caution (which

means the child is not able to do the task that 75% of

his/her age matched children can do). For

interpretation of the results, if the child has ≤1 delay

or ≤2 cautions (considered as suspicious),

developmental advices are given to parents and the

child must return for retesting by the PDQ-II one

month later. If the child is still in a „suspicious‟

condition in the second visit then he/she should be

referred for screening by the DDST-II. If in the first

prescreening visit child has ≥2 delays or ≥3 cautions

(considered as delayed), he/she should be screened

by the DDST-II as soon as possible (20). Research

has shown that using PDQ-II decreases the use of

Denver Developmental Screening Test-II (DDST-II)

that needs more time, expense and expertise to

administer, by 69% (21).

The ASQ are a series of 19 questionnaires designed

to be completed by parents when their infant/child is

4 to 60 months of age with a developmental quotient

range of 75-100. Each questionnaire contains 30

simply-worded items written at a 4th to 6

th grade

reading level, equally divided across the areas of

communication, fine motor, gross motor, personal-

social, and problem solving skills (22). The answers

to questions can be "yes," "sometimes," and "not

yet." Questionnaires are scored by comparing each

domain score with the screening cutoff score for that

domain. If the child's score falls at or below the

established cutoff score in one or more domains, it is

recommended that the child be referred for further

assessment. Test-retest reliability, at a two-week

interval, was found to be 94%. Interobserver

reliability was also 94%. Sensitivity ranged from

51% for the 4-month ASQ to 90% for the 36-month

ASQ, with a 75% overall sensitivity rate. Specificity

ranged from 81% for the 16-month ASQ, to 92% for

the 36-month ASQ, with an overall specificity rate of

86% (23). It is used in different studies worldwide and

in Iran as well (23-26).

Vol. 9 - Special Issue - Child Neuro Rehabilitation

For performing the study, 8 examiners (with a BSc

degree in occupational therapy or clinical

psychology) were trained in a 1 day workshop.

Convenient sampling was used and 196 children

aged 4-60 months, were tested in 4 primary health

care centers situated in south, north, east and

western regions of Tehran. The study was approved

by the Research Committee and thereafter by the

Ethical Committee of the University of Social

Welfare and Rehabilitation Sciences. Parents were

informed about the importance of developmental

screening and how the test was performed. Then

their written consent was acquired. The parents

whose children had developmental problems were

informed, guided and referred for additional

evaluations and interventions. The inclusions criteria

were: 1- age between 4 to 60 months 2- parental

cooperation. Exclusion criteria were: 1- having

obvious developmental delay or disability 2-

parental refusal to attend in the study.

Results

In the present study 196 children consisting of 90

(46%) girls and 106 (54%) boys aged 4-60 months

were screened using PDQ and ASQ. Maternal

education of 84% of children was at high school

level or higher. Ninety-six percent of cases were

born term (for preterm children up to 2 years we

calculated and considered corrected age). In

prescreening by PDQ the 'normal', 'delayed' and

'suspect' cases were 61%, 19% and 20%

respectively. In screening by ASQ 82% of children

were normal and 18% of them were detected as

delayed. The results of the two tests are shown in

Table 1.

Table 1: Comparing the results of PDQ-II and ASQ

PDQ-II ASQ results: No. (%)

results Delayed Normal Total No. (%)

Delayed 16 (8.2) 23 (11.7) 39 (19.9)

Normal 13 (6.6) 107 (54.6) 120 (61.2)

Suspect 6 (3) 31 (15.8) 37 (18.8)

Total 35 (17.8) 161 (82.2) 196 (100)

Using the PDQ-II, the number of children falling in

the categories of “delayed” was higher in the gross

motor and language domains, whereas with ASQ,

“delays” were higher in the fine and gross motor

domains.

To determine the measure of agreement between

PDQ and ASQ results, considering the fact that for

cross tabulating two tests, they must have similar

number of answer choices, we first considered the

“suspect cases” of the PDQ as “normal” and the next

time, as “delayed”. When suspect cases were

considered as delayed, the kappa measure of

agreement was 0.20 (P<0.001) and when considered as

normal, it was 0.30 (P<0.001). The estimated

consistency coefficient between PDQ II and ASQ

for fine and gross motor domains was 0.05 and 0.24,

for language 0.18 and for personal-social 0.06

respectively.

Discussion

In the present study there was no relationship

between the presence of developmental delays and

factors such as sex, place of residence and maternal

education. A study in an urban area of India showed


that due to the low educational level of mothers in

that area, PDQ could not evaluate the developmental

status of children correctly (11). A study in Tehran

(Iran) showed that PDQ had a good content validity

and reliability and moderate sensitivity and

specificity (27).

By another research team in Iran, ASQ was translated to Farsi, was standardized on 11000

Iranian children and the cut-off points for Iranian

children were determined. Their results have not

been published yet, but the general report exists and we

have used their translated forms (26).

The present study showed that there is a relatively

weak correlation between results of PDQ and ASQ

in 4-60 months old children of Tehran. Another

native study showed that regardless of considering

suspect cases as normal or delayed, the agreement

coefficients of PDQ and DDST-II were weak and

the 2-4 year- old questionnaire had greatest

agreement with DDST-II (27). Also a study in

Tehran showed that children passed the ASQ (88%)

more than DDST-II (65%) and consistency

coefficient of two tests is poor (0.21) (28). A

research conducted in order to determine the

5

agreement coefficient of PDQ, its modified version

(M-PDQ) and another questionnaire named Alpern-

Boil Developmental Profile-II, with DDST showed

that all tools had good agreement with DDST (29).

Another study in India showed that the 2-4 year-old

questionnaire of PDQ had no good relationship with

DDST (11). In a research, term and very low birth

weight infants were screened by PDQ and the

Grifffiths developmental scale at 12 months of age

and researcher concluded that these two developmental

screening tools had good agreement (23). Another

study performed by Scices et al showed that

questionnaires completed by parents, may not have

good agreement with each other. They concluded

that PEDS and ASQ developmental screening tests

may not identify the same children (30).

This study has some limitations such as limitation of

time and resources for re-evaluating those children

who were detected as cautious or delayed. On the

other hand we know that developmental screening

tools are not diagnostic and their results must be

followed by a more intensive evaluation. The results

of developmental screening must be determined by

comparison of the test results with a gold standard

developmental diagnostic test. Because there was no

standardized diagnostic test in Iran, we compared

References: 1. American Academy of Pediatrics, Council on Children

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2. Rydz D, Srour M, Oskoui M, Marget N, Shiller M, Birnbaum R, et al. Screening for developmental delay in the setting of a community pediatric clinic: a prospective assessment of parent-report questionnaires. Pediatrics. 2006;118(4):e1178.

3. Wagner J, Jenkins B, Smith JC. Nurses' utilization of parent questionnaires for developmental screening. Pediatric nursing. 2006;32(5):409-12.

4. Mayson TA, Harris SR, Bachman CL. Gross motor development of Asian and European children on four motor assessments: a literature review. Pediatric Physical Therapy. 2007;19(2):148.

5. Vameghi R, Hatamizadeh N, Sajedi F, Shahshahanipoor S, Kazemnejad A. Production of a native developmental screening test: the Iranian experience. Child: Care, Health and Development.36(3):340-5.

6. Levine DA. Guiding Parents Through Behavioral Issues Affecting Their Child's Health: The Primary Care Provider's Role. Ethnicity and Disease. 2006;16(2):3.

7. Ertem IO, Dogan DG, Gok CG, Kizilates SU, Caliskan A, Atay G, et al. A guide for monitoring child development in

6

two screening tools, the PDQ-II and ASQ. `

Early detection and intervention in developmental

problems can reduce their impacts on the well-being

and functioning of child and his/her family and is

an important issue in Pediatrics medicine (19). AAP

recommended that pediatricians use standardized

developmental screening test regularly at the 9, 18

and 30 (or 24) month visits (1). It has been proved

that the results of screening tools are most useful

when they are repeated periodically (19, 20, 31),

they are not diagnostic (32), their results should not

be interpreted alone and decision should be made by

considering the child's total function and

environmental factors.

Different studies in Iran were made to choose a

suitable tool for developmental screening in Iranian

children (5, 27, 28, 33). It is suggested that the

results of each of the used screening tests are

compared with a standard diagnostic test in future

studies.

Acknowledgements

This research was supported by a grant from

Pediatric Neurorehabilitation Research Center of

University of Social Welfare and Rehabilitation

Sciences.

low-and middle-income countries. Pediatrics. 2008;121(3):e581.

8. Schor EL. The future pediatrician: promoting children's health and development. The Journal of Pediatrics. 2007;151(5):S11-S6.

9. Glascoe FP, Shapiro HL. Introduction to developmental and behavioral screening. 2010.

10. Ertem IO, Atay G, Bingoler BE, Dogan DG, Bayhan A, Sarica D. Promoting child development at sick-child visits: a controlled trial. Pediatrics. 2006;118(1):e124. 11. Awasthu S. Validation of revised prescreening Denver Questionnaire in preschool children of urban slums. Indian pediatrics. 1997;34:919-22. 12. Glascoe F. Evidence-based approach to developmental and behavioural surveillance using parents‟ concerns. Child: Care, Health and Development. 2000;26(2):137-49. 13. Glascoe FP. Early detection of developmental and behavioral problems. Pediatrics in Review. 2000;21(8):272. 14. Al-Ansari S, Bella H. Translation and adaptation of the revised Denver pre-screening developmental questionnaire for Madinah children, Saudi Arabia. Annals of Saudi medicine. 1998;18(1):42.

15. Glascoe F. The value of parents‟ concerns to detect and address developmental and behavioural problems. Journal of paediatrics and child health. 1999;35(1):1-8. 16. FP G. Developmental Screening and Surveillance. In: Kliegman RM BR, Jenson HB, Stanton BM., ed. Nelson Textbook of Pediatrics. 18th ed. Philadelphia: Saunders

2008:74-81. 17. Ahsan S, Murphy G, Kealy S, Sharif F. Current developmental surveillance: is it time for change? Irish


medical journal. 2008;101(4):110. 18. Williams J, Holmes CA. Improving the early detection of

children with subtle developmental problems. Journal of Child Health Care. 2004;8(1):34.

19. Sandler AD, Brazdzuinas D, Cooley W, Gonzalez de Pijem L, Hirsh D, Kastner T, et al. Developmental surveillance and screening of infants and young children. Pediatrics. 2001;108(1):192-6.

20. Frankenburg WK. Developmental surveillance and screening of infants and young children. Pediatrics. 2002;109(1):144.

21. Frankenburg WK, van Doorninck WJ, Liddell TN, Dick NP. The Denver prescreening developmental questionnaire (PDQ). Pediatrics. 1976;57(5):744.

22. McCrae JS, Cahalane H, Fusco RA. Directions for developmental screening in child welfare based on the Ages and Stages Questionnaires. Children and Youth Services Review. 2011.

23. Janson H, Squires J. Parent-completed developmental screening in a Norwegian population sample: a comparison with US normative data. Acta Paediatrica. 2004;93 (11): 1525-9.

24. Marks K, Hix-Small H, Clark K, Newman J. Lowering developmental screening thresholds and raising quality improvement for preterm children. Pediatrics. 2009;123(6):1516.

25. Jee SH, Conn AM, Szilagyi PG, Blumkin A, Baldwin CD, Szilagyi MA. Identification of social emotional problems among young children in foster care. Journal of Child Psychology and Psychiatry.

26. Vameghi R SF, Habibolahi A, Lornezhad H, Tolouie A, Kraskian Mojembari A, Delavar B. . [Standardization of Ages & Stages Questionnaires (ASQ) in Iranian Children (in Persian)] The University of Welfare & Rehabilitation,


Special Education Organization, Family and Public Health Office of Ministry of Health and Medical Education,

Research Institute of Exceptional Children, Unicef, ; 2009. 27. Shahshahani S, Sajedi F, Vameghi R, Kazemnejad A,

Tonekaboni SH. Evaluating the Validity and Reliability of PDQ-II and Comparison with DDST-II for Two Step Developmental Screening. Iranian Journal of Pediatrics.21(3).

28. Shahshahani S, Vameghi R, Azari N, Sajedi F, Kazemnejad A. Validity and Reliability Determination of Denver Developmental Screening Test-II in 0-6 Year-Olds in Tehran. Iranian Journal of Pediatrics. 2010;20(3):313-22. 29.

Burgess DB. Parent report as a means of administering the Prescreening Developmental Questionnaire: An evaluation study. Journal of developmental and behavioral pediatrics. 1984.

30. Sices L, Stancin T, Kirchner HL, Bauchner H. PEDS and ASQ developmental screening tests may not identify the same children. Pediatrics. 2009;124(4):e640.

31. 31. Dworkin PH. 2003 C. Anderson Aldrich Award Lecture: Enhancing Developmental Services in Child Health Supervision—An Idea Whose Time Has Truly Arrived. Pediatrics. 2004;114(3):827.

32. Stein MT, Lukasik MK. Chapter 79 - Developmental screening and assessment: infants, toddlers, and preschoolers. In: William BC, Md, Allen CC, William LC, Ellen Roy E, Heidi M. Feldman MDP, eds. Developmental- Behavioral Pediatrics (Fourth Edition). Philadelphia: W.B. Saunders 2009:785-96.

33. Sajedi F, Vameghi R, Mohseni Bandpey M, Alizad V, Hemati Gorgani S, Shahshahanipour S. Motor developmental delay in 7500 iranian infants: Prevalence and risk factors. Iranian Journal of Child Neurology (IJCN). 2009;3(3):43-50.

7


Original Article

The Role of non-Linguistic Variables in Production of Complex

Linguistic Structures by Hearing-Impaired Children

Robab Teymouri, PhD Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences,

Tehran-Iran

Department of Linguistics, Science and Research Branch, Islamic Azad University, Tehran, Iran

Shahin Nematzadeh, PhD Department of Linguistics, Al-Zahra University, Tehran, Iran

Masoud Gharib, MSc Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences,

Tehran, Iran

Naeimeh Daneshmandan*, MD Pediatric Neurorehabilitation Research Center, Clinical Sciences Department, University of Social Welfare

and Rehabilitation Sciences, Tehran, Iran

Objectives: Language development is often very slower in hearing impaired children compared with their

normal peers. Hearing impairment during childhood affects all aspects of speech production and language

acquisition. It seems that hearing impaired people suffer from language and speech impairments such as

production of complex linguistic structures. The purpose of this study is to determine the role of non-

linguistic variables in production of the complex linguistic sentences in children with hearing impairment.

Method: Twenty normal children, aged 6-7 years and twenty children with severe to profound hearing

impairment, aged 8-12 years were selected in a simple random sampling from normal kindergartens and

schools, and exceptional schools for hearing impaired people. This research was a case-control research.

The confirmation of the audiologist in the exceptional schools for hearing impaired people and the

information recorded in the history of these students were considered in order to determine the kind and

degree of hearing loss, and other non-linguistic variables. The production of complex sentences was

tested by Elicitation Test. The content validity of the production test was determined and then the

reliability was confirmed with Cronbach Alpha Test. Data collected were analyzed by statistical tests such

as Pearson‟s Correlation, Independent Samples T-Test and Mann-Whitney U Test and using SPSS

software.

Results: The results of this study showed that there was no correlation between the non-linguistic

variables such as early detection and early intervention, and production of complex linguistic structures in hearing

impaired children.

Conclusion: In the first months of life, children have to deal with natural language to create the

foundations for linguistic health and complete development of syntax. If language input is not rich and

available during the critical period for learning a first language, the syntactic competence cannot grow

naturally. Therefore, two non-linguistic variables, early identification and early intervention will be the main

predictors for production of complex linguistic structures.

Key words: Hearing Impairment, Non-linguistic Variables, Complex Linguistic Structures, Production

Introduction

It seems that the deviations in hearing-impaired

children‟s communication result from insufficient

language input in an appropriate development age.

They use innate linguistic capability of rule production

*All correspondences to: E-mail:[email protected]

8

to hear things. Therefore, they create functional but

deviational strategies, for which provide the

possibility of the production and comprehension of

complex linguistic constructions. In face to face

communication, they can choose their own


strategies; and basic and effective language

exchanges can occur (1).

If auditory system does not receive the necessary

inputs from the inner ear, it will not grow enough. In

infancy, the auditory system, which is flexible and

evolvable, can change and grow by receiving

different stimulations from the environment.

Inadequate stimulations prevent the full

development of the auditory nerves, because afferent

and efferent nerves of the brain cortex impose a

bilateral control on each other.

From physiological aspects, the auditory system of

children is flexible and is affected by not only the

anatomical changes, but also changes in the received

auditory stimulations. According to Ruben & Rapin

(2), peripheral and central auditory systems have

mutual control on each other. When the inner ear is

matured, its inputs are essential for development of

at least a part of auditory nerves. When the

peripheral auditory system is fully developed, its

inputs appear to be essential for neural maturation

and development of parts of the central auditory

system. Therefore, since the beginning of the

activity of the inner ear and the eighth cranial nerve

until the maturity of central nervous system (that is

almost from the fifth month of fetal life to the age of

18 to 22 months), environmental sounds have the

greatest impact on formation of hearing ability (3, 4).

Beside linguistic variables, non-linguistic ones are

likely to affect linguistic production of hearing

impaired children and subsequently their

communication. These factors include severity of

hearing impairment (5), age of hearing impairment

onset, or time of detection of hearing problem (6),

and enrollment in early intervention (7), use of

cochlear implants and/or other hearing aids (8, 9),

duration of the using conventional devices (9, 10),

use of sign language or cued speech or other

communication approaches (11), family background

and history and so on.

Some studies have attempted to explain whether

there is a relationship between the linguistic

competences achieved by the hearing impaired

person and non-linguistic factors. However, how

these factors interact with each other and have

impact on language development is still under

debate.

It is important to note that many hearing losses in

children are preventable, but it will be possible only

when it is identified as soon as possible (7, 12, 13),

and their therapeutic services are implemented.

Obviously, if early diagnosis of hearing loss does


not occur, the reduction of the difference created in

the child's language development will be more

difficult than normal people (14). The hearing

impairment which has occurred during the first three

years of life, has a strong deterrent effect on

individual‟s acquired linguistic skills, regardless of

the type (congenital, acquired, transitional, or

sensorineural), which will later affect his/her

psychological, social, educational, and occupational

aspects. Therefore, reducing the harmful effects of

hearing loss on language acquisition, especially

during the first three years of life, is of special

importance (7, 15, 16). This goal can be achieved

when there is early diagnosis of the impairment,

early medical intervention and rehabilitation, and its

follow-up (using a suitable audio-amplifier and

continuous verbal stimulation program) (8, 17-19).

The first 36 months of life are considered as the

critical period of language learning, so that language

is not possible to acquire with that speed at any other

time (20). Therefore, to minimize the negative

effects of hearing loss, professionals rely on early

identification and follow-up of rehabilitation

services at an early age, which this goal is possible to

achieve by performing the controlled newborn

screening programs (21, 22).

Reports (23) indicate that language development in

children with hearing impairment depends on the

age of beginning rehabilitation services. In a study

in Lexington Deaf School, children who were

adopted before the age of 16 months in this center,

were compared with children who had registered

there between the ages of 16 to 24 months. Children

who had been adopted before the age of 16 months,

showed statistically, at the age of 40 months (3.4

years), higher scores in speech and language

comprehension and social communications. Mother-

child relationship in the children who were adopted

at lower age was higher-the factor which may have

had more impact on achieving this success (7,15,24).

Many recent studies have shown that if comprehensive

programs of early intervention are provided until the

age of six months, some English-speaking hearing

impaired children can acquire receptive and

expressive language skills compared to normal peers

(6, 25, 26).

Moeller (7) studied the relationship between age of

enrollment in intervention program, and language

ability (vocabulary skills) in a 112-member group of

pre-linguistic hearing impaired children aged five

years with mild to profound sensorineural hearing

loss. The researcher found a significant negative

9

relationship between the two variables above, which

means that the children who were under early

intervention programs showed better language

scores at the age of five years, compared with

children who were enrolled later (for example, after

the age of 11 months). Their level of vocabulary

growth was comparable to that of their normal peers.

Participation and cooperation of families and

enrollment age in intervention programs significantly

justify the huge differences and changes in the

language ability at the age of five.

About 43% of children receiving cochlear implants at

the age of 2 years, are able to develop language up to

age of 8-9 years, while only 16% of children with

cochlear implants before the age of 4 years successes to

achieve a good language ability (19, 27, 28).

Nicholas & Geers (29) and Ledeberg & Spencer (30)

believe that there is a critical and vital period for the

effectiveness of cochlear implants. The cochlear

implant which is performed before the age of 2, can

be effective in the development of language

(including syntax) with intonation and severity of

more natural changes, unlike the cochlear implant

received after it (31).

Although it is generally accepted and indisputable

that hearing impairment can retard the development

of natural abilities of language (32), the degree of

hearing loss in the language acquisition has an

unclear and ambiguous role.

Several studies that have examined the relationship

between the degree of hearing loss and speech

production and comprehension skills in different

languages, have not yet seen the correlation between

these two factors (8, 33-39).

To investigate relationships among speech perception,

production, language, hearing loss, and age in children

with impaired hearing, Blamey et al. (8) studied the

language ability and speech comprehension in an 87-

member group of children with moderate, severe or

profound hearing impairment. Result of this research

suggests that the degree of hearing loss was only

correlated with speech comprehension. However, the

assumption that greater hearing loss is associated with

more severe language and educational deficits is not

supported by the present data.

Norbury et al. (34, 37) also presented similar results

in English-speaking children with mild to moderate

hearing loss. In the first research, degree of hearing

loss or age of receiving hearing aids was not directly

related to performance, but other language measures

were. The subset was also significantly younger than

the rest of the SNH group, suggesting that

10

acquisition of finite verb morphology may be

delayed in children with hearing impairments (37). In

the second research, children with SLI did poorly on

tests assessing knowledge of Binding principles and

in assigning thematic roles in passive sentences

whereas hearing-impaired children performed close to

control levels, indicating that poor speech

perception cannot account for this pattern of deficit.

However, the pattern of errors on syntactic tasks and

the relatively weak correlation between different

indicators of syntactic deficit seemed incompatible

with a modular hypothesis (34).

Tuller & Jakubowicz (38) studied the comprehension

and production skills of French-speaking hearing

impaired children with 37 to 64 dB of hearing

impairment. In this study, different features and

aspects of French grammar, including the use of

articles, morphemic pronouns and verb conjugations;

and many differences were observed between the

performances of subjects. In people with hearing

impairment who were tested, some features were

few, incomplete and inadequate, and others were

less or were not damaged at all. But these

phenomena were not correlated with the degree of

hearing loss, the age of hearing loss diagnosis and

the age of beginning the use of hearing aid. The

effect of age was only taken into consideration when

younger children have shown more problems than older

children in learning and mastering their language.

Sztermann and Friedmann (33) studied the

comprehension and production of sentences derived

by syntactic movement, in orally trained school-age

Hebrew-speaking children with moderate to

profound hearing impairment, aged 7.8-9.9 years.

The results showed that hearing impaired children

are unable to comprehend the topical sentences and

object-relative clauses. Similarly, in other research,

the same researchers (33) found that individual

performance was strongly correlated with the age of

intervention: only children who received hearing

aids before the age of 8 months performed well in

the comprehension tasks. Type of hearing aid,

duration of cochlear implant, and degree of hearing

loss did not correlate with syntactic comprehension.

Materials and Methods

In this case-control study, twenty normal children,

aged 6-7 years and twenty children with severe to

profound hearing impairment, aged 8-12 years were

selected in a simple random sampling from normal

schools, and exceptional schools for hearing

impaired people. Subjects in both groups spoke one


language. The normal children were matched with

the hearing impaired children on the basis of

linguistic age. Also among 20 children in the control

group, 10 were male, and 10 were female. Their

average age was 6.5 years; 50 percent were studying

in pre-school level and 50 percent were in the first

grade.

Average age of hearing-impaired students was 10.5

years, 65% of the hearing-impaired group were

boys, and 35% were girls. The children did not have

any confirmed diseases or neurological disorders,

except hearing loss in students with hearing

impairment.

To determine historical variables, such as age of onset of

hearing loss or initiation of early intervention, kind and

degree of hearing loss and so on, the information was

obtained by the principals of the exceptional schools

for hearing-impaired people from children medical

history. Type of hearing impairment among all

hearing-impaired children was sensorineural. Hearing

impairment of all hearing-impaired children was detected

up to three years.

All these children suffered hearing loss in both ears.

They used behind the ear hearing aid. 25% began

using hearing aids at the age of eight, 20% in six

years old, and the rest at lower age.

Each child was tested individually in three to five

sessions. There was no time limit on any of the tests;

and the tester repeated several times each part, as the

subject wanted.

Production of non-canonical sentences was tested by

using a researcher-made task called Eliciting. The

subject hears a sentence that is read by the native

Persian-speaking tester, afterwards the tester asks

the subject “Which child/girl/boy do you like (the

most)?”. Then, he/she sees two pictures on one page:

one on top and another on bottom of the page. While

answering the question, s/he produces a sentence.

Type of constructions of the production task of

eliciting, is classified in terms of word order in two

general groups:

1- Sentences with canonical word order (subject

clefts, object-subject relative)

2- Sentences with non-canonical word order (object

clefts, subject-object relative)

To analyze the data, Independent T-Test, Mann-

Whitney U test, Pearson‟s Correlation and the

software SPSS were used. To determine the

difference between deaf and normal-hearing children

in producing the complex sentences, independent t-

test was used for those scores that had normal

distribution and Mann-Whitney U test was used for

those series of scores that were not normally

distributed. To assess the correlation between

variables, the Pearson‟s Correlation was used.

Results

To identify the non-linguistic factors which are

correlated with the ability to produce the non-

canonical constructions by the hearing impaired

children, we considered the mean of scores of the

subjects in the production tasks of the subject and

object relative clauses and the subject and object

clefts. Then we discussed its correlation with these

variables: age of hearing loss detection, age of

beginning intervention and the use of behind the ear

(BTE) hearing aid, type of hearing impairment and

the degree of hearing impairment.

As shown in Table 1, the calculated t-value (3.18) is

significant at the alpha '0.05' level; so there is a

significant difference between the mean of kind of

hearing loss and the total score of production in

hearing impaired children.

More exactly, it can be said that the children whose

hearing were impaired before the age of language

learning, were more successful in gaining total score

of production, compared to children with congenital

hearing loss.

Table 1: Mean of total score of production and type of hearing loss based on Independent T-Test

Index

total score of

comprehension

Type of

hearing loss

before the

age of

language

acquisition

Congenital

standard Total mean

deviation

9 13.33 5.96

11 8.73 7.47

Degree of freedom t-value

18 3.18

level of Result

significance

The

0.005 difference is

significant

Iranian Rehabilitation Journal 11


Table 2 shows that the correlation between the

degree of hearing loss of both ears of hearing

impaired children and the total score of production of

the non-canonical sentences is significant at the

alpha '0.05' level.

Considering that the correlation is negative, there is

a significant inverse relationship between increased

levels of hearing impairment and reduced production

of the complex sentences. In other words, reducing/

increasing the degree of hearing loss (dB increase in

hearing loss) results in the production of the non-

canonical sentences by the hearing impaired children to

be increased/ reduced.

Table 2: Correlation between the degree of hearing impairment and the total score of production

Index total score of production

level of hearing loss in left ear level of correlation -0.50

level of significance 0.02

Total 20

level of correlation -0.52

level of hearing loss in right ear level of significance 0.02

Total 20

As is evident from the data in Table 3, the

correlation level (0.032) at the alpha '0.05' level is

not significant in this case. Therefore, no

relationship can be considered between the duration

of the use of behind the ear (BTE) hearing aid and

total score of production. So, it can be said that the

duration of the use of behind the ear (BTE) hearing

aid has no effect on the production in children with

hearing problems.

Table 3: Correlation between the duration of the behind the ear (BTE) hearing aid usage and the total score of production

Index Total score of

production

duration of the use of level of correlation 0.032

behind the ear (BTE) level of significance 0.89 hearing aid Total 20

mentioned variables (age of hearing loss detection

As is shown in Table 4, the correlation between the

age of hearing loss detection and the total score of

production (-0.05) and also between the age of

intervention onset with the total score of production (-0.08) is not statistically significant. Therefore, the

and age of intervention onset) have no impact on the

level of the development of skills of the non-

canonical sentences in hearing impaired children.

Table 4: Correlation between total score of production and age of hearing loss

detection/age of intervention onset

Index Total score of production

age of hearing loss level of correlation -0.05

detection level of significance 0.84

Total 20

age of intervention onset level of correlation -0.08

level of significance 0.73

Total 20

12 Vol. 9 - Special Issue - Child Neuro Rehabilitation

Discussion

In general, according to results of similar studies on

Hebrew language (39) English (40, 41), and French

(42), the performance of normal and hearing

impaired children concerning the non-canonical

sentences was clearly different. Obviously, what is

important is to identify the non-linguistic variables

which are correlated with the ability to produce the

complex linguistic constructions by the hearing

impaired children.

Some results of treatment of non-canonical constructions

in other populations such as individuals with

agrammatic aphasia (43-46) and Specific Language

Impairment (47-49) suggest the production skill of

the non-canonical constructions can be improved

through the simple trainings.

The results of this study showed that the hearing

impaired children whose hearing was impaired

before the age of language acquisition, their

production was better and more in the area of

complex linguistic structures, compared to children

with congenital hearing loss. Therefore, the findings

of the study suggest that the type of hearing

impairment can be associated with syntactic

performance.

We found that degree of hearing loss was inversely

correlated to linguistic production. If the degree of

hearing loss was higher, production of the complex

constructions would also be subject to defects and

disorders; and if the hearing loss was reduced,

production of the mentioned constructions would

also increase. But some previous researchers have

reported a lack of relationship between degree of

hearing loss and expressive oral communication skill

(7, 50-52). It seems that the degree of hearing loss in

the language acquisition has an unclear and

ambiguous role and this does not mean that hearing

loss itself does not influence linguistic

achievements.

In contrast, the age of hearing impairment detection,

the age of beginning intervention services or the age

of the use of behind the ear (BTE) hearing aid, and

duration of use of this tool were not correlated with

the production of complex linguistic structures. Lack

of the relationship between these variables is due to

the fact that hearing impairment in many of these

children has been detected after the critical age of

language acquisition, and intervention services have

been also delayed. Hence, there was no correlation

between many non-linguistic variables and

production skill. Therefore, considering late diagnosis

of hearing impairment and late intervention of


rehabilitation and treatment of these children, the

results of this study are consistent with findings

published by Calderon & Naidu (53). They indicate

that the performance of children whose hearing

impairment was diagnosed from birth to the age of

one year was significantly better in the tasks of

receptive and expressive language than children

whose hearing impairment was diagnosed between

the ages of 13 and 36 months.

Similarly, the findings of Yoshinaga-Itano (13) and

Yoshinaga-Itano and A puzzo (25) suggest that

intervention before the age of 6 months is a strong

predictor for several measures of language

development.

Also, according to studies published by Yoshinaga-

Itano et al. (6) and Moeller (7), the children having

normal cognitive skills who are identified as deaf or

hard hearing before the age of 6 months improve

their language skills to the natural levels at an early

age, in case of timely and appropriate intervention;

and their cognitive skills would be commensurate

with their language skills. Regardless of the degree

of hearing impairment, gender, race, socio-economic

conditions, age at time of problem detection , or type

of communication method, these children can

acquire language skills appropriate to the age from

12 to 36 months (6).

However, according to the same studies, abilities of

receptive and expressive language in children who

are identified later, standard deviation is lower than

children who have been identified in a timely

manner. In other words, if the children with normal

cognitive skills are identified later, they will acquire

score 60 out of 100 during the early years of life, for

general language quotient. If early and appropriate

intervention is made after diagnosis of hearing loss,

hearing impaired children who are identified at ages

6-30 months, will use the same language quotient.

But, language skills of these children are

significantly lower compared to the children who

have been identified before the age of 6 months in a

separate study (54).

Conclusion

In the first months of life, children have to deal with

natural language to create the foundations for

linguistic health and complete development of

syntax. If language input is not rich and available

during the critical period for learning a first

language, the syntactic competence cannot grow

naturally. Therefore, two non-linguistic variables,

early identification and early intervention will be the

13

main predictors for production of complex linguistic

structures and, the role of other non-linguistic

factors has not been certified by the other research.

Acknowledgments

Author and her colleagues in this paper express their

appreciation and thanks to respected authorities in

Tehran Province Education Organization, Tehran

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15


Original Article

The Effect of Swedish Massage on Glycohemoglobin in Children with

Diabetes Mellitus

Zahra Kashaninia, MSc Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Akram Abedinipoor, MSc Nursing Department, University of Qom, Qom, Iran

Samaneh Hosainzadeh, PhD Tarbiat Modarres University, Tehran, Iran

Firoozeh Sajedi*, MD Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences,

Tehran, Iran

Objectives: Diabetes mellitus (DM) is the most common endocrine disease in children. Massage therapy can

improve glucose metabolism in DM. This study was conducted to determine the effect of Swedish massage on

the Glycohemoglobin (HbA1c) in children with DM.

Methods: This study was an semi-experimental (clinical trial) conducted on thirty-six children, 6-12 years

old with (DM), recruited from a clinic of the Qom City, Iran. They were randomly assigned to intervention

and control groups (18 patients in each group). Swedish massage was performed for fifteen minutes, three times

weekly, for three months in intervention group. The HbA1c was evaluated before and after intervention in the

two groups.

Results: The average ages of children in the intervention and control groups were 9.05 (±1.55) and 9.83 (±2.03) years respectively. There was statistically no significant difference in Glycohemoglobin before intervention between two groups (P = 0.491), but the Glycohemoglobin was lower significantly in intervention group in comparison with control group after intervention (P < 0.0001).

Conclusion: Massage therapy can be an assisted treatment in children with DM; reducing the drug consumption by patients for the control of DM.

Key words: Diabetes Mellitus, Swedish massage, Glycohemoglobin (HbA1c), Children.

Introduction

Regarding changes in epidemiological trend of

diseases in developing and developed countries and

increase in life expectancy, stresses of modern urban

life, less mobility and change in diet, the prevalence

of Diabetes Mellitus (DM) has been increased (1).

DM type I is rising in rate of 3% in children and

adolescents and is being estimated that 700,000 of

children under 15 are affected annually. Diabetes

type II that is considered as adult disease, is also

increasing in children and adolescents dramatically.

Due to high prevalence of cardiovascular and

ophthalmic complications in diabetic patients, the

prevention, management and control in these

patients is so important and necessary (2).

*All correspondences to: E-mail: [email protected]

16

Nowadays in addition of medical and surgical

treatments in DM, non-organic treatments such as

weight control, tension reduction and change in

lifestyle are also used (3). Sokolow & Cheitlin (1999)

believe that general criteria such as diet, exercises,

weight loss in overweight people, relaxation

techniques, life equilibrium and consideration of

other risk factors can not be ignored in diabetic

patients‟ care (4).

Relaxation is one of the most efficient treatment

modality in anxiety (5). Relaxation can decrease

muscle tension (6) and increase parasympathetic

nervous system activity via hypothalamus (7).

According to Selye‟s stress theory, the limbic

system links emotions and feelings with somatic and


psychological behaviors and replace emotions like

stress, anxiety, anger, depression with relaxation and

good feelings and regulates somatic behaviours of

feelings via neuroendocrine, autonomic nervous

and ambulatory systems (8). Stress, anxiety, anger,

depression and emotional distress often increase

muscle tone. Relaxation and happy feelings decrease

muscle tone in reverse. The limbic system effects on

muscle tone via hypothalamus. Increased anterior

hypothalamus activity raises sympathetic, ambulatory

systems and cortex activity, while increasing posterior

hypothalamus activity elevates parasympathetic system

activity and decreases muscle tone (9). Massage as

an enjoyable experience decreases anxiety and

creates relaxation via muscle tone reduction (10).

Swedish massage is one of the prevalent methods in

stress reduction and was used by Henrik ling in 1830

for the first time and spread in Europe gradually.

This is a type of systematic massage that involves

almost all muscles (11) and causes relaxation via

hormones that is effective in raising insulin absorption

and increases circulation that leads to decreased

blood glucose level (10). It is the most common

complementary therapies in nursing that the

implementation is easy, safe, non invasive and

relatively cheap (12). Nurses are usually qualified in

massage (13) and have applied massage techniques

for a long time (14).

Hence, we decided to evaluate the effectiveness of

Swedish massage as a relaxing method on

Glycohemoglobin (HbA1c) level, as an important

indicator of DM control.

Method and Materials

This was a semi-experimental study. Following

ethical approval from the Ethics Committee of the


Sciences (USWRS), a prospective, randomized,

controlled trial study was conducted in 2009, at the

Clinic of Kamkar-Arabnia Hospital, Qom City, Iran.

Samples were 36 Iranian children (aged 6-12 years)

with clinical diagnosis of diabetes (based on medical

files). They were assigned into intervention and

control groups randomly (18 patients in each group).

Inclusion criteria were age between 6-12 years and,

patients with DM type II. Exclusion criteria were

unwillingness to cooperation, obvious movement

disorder and complete bed rest order, skin disorder,

skeletal disorder, history of spine malignancy, and

any other drug consumption (except routine

medications for DM) that affects on blood glucose

level.


Measurements were scale, tape-measure and

demographic questionnaire. Individuals‟ heights

were measured by tape-measure and weights by

standard scale. The heights were measured as the

patients stood in front of a wall without shoes and

their heel, shoulders and buttock touched the wall

and the highest area of the head level was signed on

the wall. All measurement instruments were

assessed to reassure proper operation continuously.

Demographic questionnaire includes 13 questions

about age, gender, height, weight, children and their

parents‟ educations, the parents‟ job, duration of

diabetes and diabetes medications (Insuline‟s type

and dose), and family history of diabetes.

A nurse was trained Swedish massage by a

physiotherapy professor at the University of Social

Welfare and Rehabilitation Sciences. First she

implemented Swedish massage on a mannequin then

she had been trained on some patients in a clinic

under supervision of the physiotherapist.

The parents of two groups were asked not to change

their children‟s daily routines such as: exercise, diet

and medications.

Next, massage was implemented in quiet rooms with

appropriate temperature, light at 8 am; the time that

children and their parents were comfort for

cooperation. The child took off his clothes and was

positioned in supine position. He/she was massaged

from arms, neck and head and continued to the toes

then in prone position on legs, hip and back [15].

The child received massage for 15 minutes in each

session. Each child in intervention group received

36 sessions and totally 540 minutes massage during

3 months. The children in control group did not

receive any intervention. HbA1c were measured

before and after massage in both groups.

Chi-square test was used to assess variables

homogeneity in two groups, Kolmogrov-Smirnov to

assess variable distribution normality, and

independent t-test, Mann-Whitney tests, to compare

mean and standard deviation of variables in two

groups. Also Paired t-test was used to assess HbA1c.

Independent t-test was used to compare quantitative

demographic variables in two groups. Chi-square

and fisher‟s exact test were used to compare the

categorical demographic variables in two groups. K-

S test was used to assessing normality of variables.

SPSS version 16 was used to statistical analysis of

data. A p-value ≤ 0.05 was considered statistically

significant.

17

Results

Background variables: A total of 36 children were

enrolled in this study (n=18 in each group). There

were 7 (38.9%) males and 11 (61.1%) females in

control and intervention groups respectively (p=

0.182).

Table 1 shows the demographic characteristics of

two groups. There were no significant differences in

age, weight, height, DM duration, medication

duration, and insulin doses (NPH & regular)

between two groups.

There were also no significant differences in jobs of

mothers (p= 0.104) and fathers (p= o.97), educations

of mothers (p= 1), fathers (p=1) and patients (p=1),

and family history of DM (p=1) between 2 groups by

fishers' exact test.

As it is shown in table 2, there was no significant

difference in HbA1c between before and after

intervention in control group (p= 0.592), but there

was significant difference in HbA1c between

before and after intervention in intervention group

(p< 0.0001).

There was also no significant difference in HbA1c

before intervention between two groups (p= 0.491),

but there was significant difference in HbA1c after

intervention between two groups (p< 0.0001).

Discussion

The results of this study demonstrated that Swedish

massage is effective on HbA1c reduction in diabetic

children.

Hernandez, field et al (2000) assessed massage

effect on blood pressure, stress hormones secreted

from salivary glands and depression, demonstrated

that massage reduces blood pressure (p<0.05),

anxiety (p<0.001), depression ( p<0.01) and stress

hormones secreted from salivary glands (p<0.05).

This research confirms that massage results in

relaxation and stress hormones reduction (16).

Preliminary data were available from one small

randomized trial comparing people with type II

diabetes receiving 45-min, full-body massage three

times a week for 12 weeks (n = 6) to similar patients

on a waiting list for massage (n = 2). Researchers

found that of the six patients receiving massage,

HbA1c decreased in three patients from a baseline of

7.9, 8.3, and 9.8% to 7.3, 8.1, and 8.6%,

respectively. In the other three patients receiving

massage, HbA1c increased from a baseline of 7.4,

8.2, and 8.0% to 7.9%, 10.0%, and 8.5%,

respectively. These patients, whose glycemic control deteriorated while receiving massage, were obese,

18

injecting insulin, or both. None of the group whose

glycemic control improved with massage had either of

these characteristics. In the waiting list control

group, HbA1c level also declined from 7.3 and 8.6% to

6.9 and 8.4%, respectively (15).

In other study, the effects of massage therapy had

been determined on Vital Signs (blood pressure,

heart rate, skin temperature, O2 saturation), anxiety /

depression; and Hemoglobin (HbA1c), Cortisol, and

Insulin. Effleurage (gliding/stroking), Petrissage

(kneading) and Tapotement (cupping / hanking /

pincing), and Vibration Friction of the neck,

extremities, back/torso were used and hand pressure

provided 20 minutes of massage. Immediate effects

of massage were lower heart rate and skin

temperature. Intermediate-long term effects appear

to be higher resting heart rate and blood pressure,

increased blood flow, higher cortisol and a trend

toward improved wellbeing. HbA1c increased 22%.

They concluded that randomized controlled studies

are needed to assess whether there are significant

health benefits (17). In another study by Surwit and his colleagues, patients with type II diabetes were randomized to undergo a five-session diabetes group education program with or without stress management training. They followed the patients for a year, testing their serum for HbA [sub]1c, a marker for long-term glycemic control, and evaluating psychological

parameters with patient questionnaires. They reported

stress management training was associated with a

small (0.5%) but significant reduction in HbA [sub]1c.

Therefore group oriented stress management training programs can produce small but significant improvements in long-term glycemic control in type II diabetics, but highly anxious patients with type II diabetes did not gain more benefits from stress management training than other, less anxious patients (18). Any randomized trial should provide intervention for at least 3 months. This would permit changes to become evident in the HbA1c. Trials measuring HbA1c should also have a 2-month lead-in period during which values are measured but no intervention is given in order to obtain valid baseline measures. Changes in HbA1c may demonstrate whether massage may, in fact, be able to alter disease outcome. The sample size for a large, randomized controlled trial, therefore, should be calculated based on a clinically important change in HbA1c. A 1% decrease in HbA1c reflects a 30 mg/dl decrease in blood glucose (15).


Conclusion

Swedish massage as an alternative treatment

accompanied with medication is an effective clinical

intervention in reducing glycosylated hemoglobin as

an important indicator of DM control in diabetic

children. Therefore regarding cheapness, easiness

and accessibility of this method, it is suggested that

Swedish massage to be thought to parents and other

caregivers.

Acknowledgements

This research was supported by the University of

Social Welfare and Rehabilitation Sciences

(USWRS). We would like to acknowledge Elham

Mahmoudi, our patients and their parents for their

sincere cooperation.

Table 1: Demographic characteristics (quantitative) in two groups*

Intervention (n 18) Control (n 18) P

Age (year) 9.0 ± 1.5 9.8 ± 2.0 0.206

Weight (kg) 26.7 ± 5.3 30.7± 6.5 0.052

Height (cm) 129.7± 8.4 126.8 ± 33.0 0.342

DM duration (month) 21.6 ± 13.2 27.7 ± 19.6 0.278

Medication duration (month) 20.8 ±12.2 27.6 ± 19.4 0.225

NPH doses (IU) 30.0 ± 5.8 32.8 ± 7.0 0.198

Regular doses (IU) 14.4 ± 3.2 16.0 ± 4.2 0.226 * values are expressed as mean ±SD

Table 2: Comparison of HbA1c means between before and after intervention in 2 groups.

Group Intervention

Control Before

( n=18) After

Intervention Before

( n=18) After

HbA1c

Mean (SD)

7.93(0.554)

7.95(0.531)

7.7(0.712)

7.01(0.597)

T- Value df P- Value

0.546 17 0.592

7.283 17 <0.0001

Table 3: Comparison of HbA1c means before and after intervention between 2 groups.

HbA1c Before

Mean (SD) After

Control Intervention

( n=18) ( n=18)

7.93 (0.554) 7.7 (0.712)

7.95 (0.532) 7.01 (0.596)

P- Value

0.491 (K-S test)

<0.0001 (T- test)

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pressure in population above 18 age in zabol city [ in Persian)].Tabib shargh. 2003; 4(4): 184.

2- Alemzadeh R, Wyatt DT. Diabetes Mellitus in children,

Chap 590, In: Kliegman RM, Behrman RE, Jenson HB,

Stanton BM; Nelson Textbook of Pediatrics; WB Saunders

Company, Philadelphia,18th edition; 2007: 2404-2431.

3- Mortan JR. Hypertension step-care Management.

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USA: Appleton & Lange Co,1999; 5: 235

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psychosocial status for clients with essential hypertension

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10- Esther M, Chin Pang W. The effects of slow-stroke back

massage on anxiety and shoulder pain in elderly stroke

patients. Complementary Therapies in Nursing & Midwifery. 2004; 10: 209-216.

11- William C. Guide to Alternative Medicine. The American

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(2): 121-126.

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19

14- Mitzel-Wilkinson A. Massage Therapy as a Nursing Practice. Holist Nurs Pract. 2000; 14 (2): 48-56.

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Spectrum. Alexandria. 2001; 14: 218-225. 16- Hernandez- Reif M, Field T, Krasnegor J, Hossain Z,

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17- Edwards B. Effects of massage therapy on African Americans (AA) with Non-Insulin Dependent Diabetes

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35.



Original Article

Cerebral Palsy: Motor Types, Gross Motor Function and Associated

Disorders

Farin Soleimani, MD, Pediatric Neurorehabilitation Research Center,

University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Roshanak Vameghi, MD, MPH Pediatric Neurorehabilitation Research Center, Clinical Science Department,


Mehdi Rassafiani*, PhD Pediatric Neurorehabilitation Research Center, Occupational Therapy Department


Nazila Akbar Fahimi, PhD; Zahra Nobakht, MSc University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Objectives: Cerebral palsy (CP) describes a group of disorders in the development of movement and

posture in the developing brain. The main aim of this study was to determine the distribution of motor

impairment and associated disorders in a population of children with CP.

Method: This study was carried out in 2011 during three months, on 200 CP children. Multiple sources of

ascertainment were used, including medical records of patients who access at the major rehabilitation and

special educational centers in Tehran and examination by rehabilitation team. Children were grouped according

to motor type, topographic pattern according to the Surveillance of Cerebral Palsy in Europe (SCPE)

definitions and classifications, Manual Ability Classification System (MACS) and Gross Motor Function

Classification System (GMFCS) scales. In this study we evaluate impairments such as seizure disorders,

hearing and visual problems, and cognitive issues.

Results: During the study period, 200 CP child (103 males, 97 females) aged 4-12 years were seen, with

a mean (SD) age of 7.7(2.4) years. In this study spastic CP was the most common type (80.5%) and more

specifically, bilateral CP (62.5%) was more common than unilateral (18%). With respect to the MACS

classification, level IV (23%), and to the GMFCS classification also level IV (30.5%) was the most

common.

Conclusion: Bilateral spastic CP was the most frequent type that had the worst motor problem, and

difficult treatment, so it seems that the health care system should pay more attention to perinatal insults for

prevention of CP in our population.

Key words: Cerebral palsy, Associated disorder, Child, MACS/GMFCS/SCPE

Introduction

Cerebral palsy (CP) describes a group of disorders in

the development of movement and posture, causing

activity limitation which is attributed to non-progressive

disturbances that occur in the developing fetal or

infant brain. The motor disorders of CP are often

accompanied by disturbances of sensation,

cognition, communication, perception, and/or

behavior, and/or by a seizure disorder (1).

CP is the most common cause of physical disability

affecting children in most developed countries, with

a prevalence of approximately 2 per 1000 live births



(2). Although these clinical syndromes are often not

pure, recognition of the dominant motor types and

topography has been important for research into

causal pathways and possible prevention, correlation

with brain imaging, and for establishing a prognosis

and setting management goals and strategies. It may

also trigger a search for associated problems such as

epilepsy, cognitive and communication difficulties,

which may significantly impact on the well-being

and development of these children (3-4).

Traditionally, CP has been classified according to motor type, topographical distribution and functional

21

severity (2-3) but as yet there has been no consensus

reached on either the descriptors or the definitions of

motor type and topographical distribution.

The motor type is usually described as spastic,

dyskinetic, ataxic, hypotonic or mixed. Currently in

the USA, under the auspices of the National

Institutes for Health, a taskforce on childhood motor

disorders is working on the important issue of motor

type classifications and some helpful guidelines

have been published (5-7). The Surveillance of CP

in Europe (SCPE) has also gone through a consensus

process to develop standard definitions and classifications

of topography and motor type. However, although

classical presentations are easily recognized, there

are many children with mixed or changing motor

types that are difficult to define (2-8).

Classifications according to topographical distribution

are widely employed. Although hemiplegia, diplegia

and quadriplegia are commonly used terms, monoplegia

and triplegia sometimes exist as separate entities or

may be grouped with hemiplegia and quadriplegia,

respectively (2). Not surprisingly, classifications

based on motor type and topographical distribution

has poor reliability, even when observers are

experienced and undergo special training (2-8).

The most useful development in the classification of

CP in recent years has been the development of the

Gross Motor Function Classification System

(GMFCS) (9). The GMFCS is a five-level ordinal

grading system based on the assessment of self-

initiated movement with emphasis on function

during sitting, standing and walking. Unlike the

classification of motor type and topography, the

GMFCS has been shown to be a valid, reliable,

stable and clinically relevant method for the

classification and prediction of motor function in

children with CP between the ages of 2 and 12 years

(9-10).

Of the many types and subtypes of CP, none have a

known cure. Usually, medical intervention is limited

to the treatment and prevention of complications

arising from CP's effects. A 2003 study put the

economic cost for people with CP in the US at

$921,000 per individual, including lost income (19).

In another study, the incidence in six countries

surveyed was 2.12-2.45 per 1,000 live births, (20)

indicating a slight rise in recent years. Improvements

in neonatology, or the medical specialty which is

involved with treatment of neonates, have helped

reduce the number of babies who develop cerebral

palsy, but the survival of with very low birth weight

neonates has increased, and these babies are more

22

likely to have cerebral palsy (21-22).

Perinatal insults are common causes of cerebral

palsy in Iranian children. Childhood long-term

morbidities and handicaps such as CP are the main

factors of years of life lost (YLL) in Iran. According

to the WHO report 2006 , in Iran " perinatal factors "

cause 10 years of life lost, which is the third most

common cause for lost years in the country (after

ischemic heart disease and road traffic accidents)

(23).

Descriptions of the frequency of CP subtypes in the

population may yield clues regarding etiology, and

studies of functioning can help clinicians and other

service providers develop more coordinated, more

holistic care. The determination of the spectrum of

functional limitation that characterizes the group of

children with CP is essential to enable planning for

resource allocation and to facilitate studies relating to

etiology, prevention or prognosis (2).

The main aim of this study was to determine the

distribution of motor impairment and associated

disorders in a population of children with CP with

respect to the motor type, topographic distribution,

hand abilities and gross motor function according to

the SCPE definitions and classifications, manual

ability classification system (MACS) and GMFCS.


This study was carried out in 2011 during 3 months,

on 200 CP children of 4-12 year old. In order to

detect demographic characteristics, a questionnaire

was completed for each child, including the child,

parents, care givers, and child health- medical status,

with the aid of parents and the child's records. This

questionnaire includes the child and parents' age, sex,

job, level of education, siblings, family income,

hometown, insurance, duration and the start age of

rehabilitation program. In addition, associated

problems were collected and information on MACS

and GMFCS were obtained by occupational therapists

with direct examination and parent reports in any of

the children. The questionnaire evaluated for content

validity and pilot studies had been carried out.

Definition of CP

CP is an umbrella term covering a group of non-

progressive but often changing motor impairment

syndromes secondary to lesions or anomalies of the

brain, occurring at any time during brain

development (24).

Patients with CP may also have other

neurodevelopmental impairments that can affect


adaptive functioning, sensory function, learning,

communication, and behavior, as well as may cause

seizures. Abnormal motor control may be further

impaired by features that are associated with CP.

Resulting limits in movement and posture cause

activity limitation and are often accompanied by

disturbances of sensation, deep perception and other

sight-based perceptual problems, communication

ability, and cognition problems and epilepsy is also

found in 1/3 of cases.

Cerebral palsy is divided into four major classifications

to describe different movement impairments. These

classifications also reflect the areas of the brain that are

damaged. The four major classifications are: spastic,

ataxic, athethoid/dyskinetic and mixed. Secondary

conditions can include seizures, epilepsy, speech and

language or other communication disorders, sensory

impairments, mental retardation, learning disabilities,

urinary or , fecal incontinence and/or behavioral disorders.

Participants

The study was performed on children with CP at

different rehabilitation centers in Tehran between

January 2011 and April 2011.

Ascertainment of cases was based on a standard

definition of CP (25). Multiple sources of

ascertainment were used, including records of

patients who access a variety of services at the main

pediatric rehabilitation and special education centers

in Tehran. The rehabilitation centers were in

different parts of Tehran including: 3 centers in

south, 3 in down town and 2 in north of Tehran (five

non-governmental, one public, and two charities)

and three schools for children with special needs (1

in south and 2 in west) were sources to identify

children with developmental disabilities. The

inclusion criteria were having been diagnosed with

“CP” by a specialist, being in the age range of 4-

12 years, and having accepted participation in the

study. Informed consent was obtained from the

families after they were informed about the study.

All children evaluated by a CP clinician that were 3

senior occupational therapists with an advanced

degree, and good clinical experience, and specially

trained in the assessment of children with CP. In the

absence of excluding conditions such as progressive

disorders and neuromuscular diseases, children were

confirmed as CP cases.

Instruments

CP subtype was determined on the basis of the classification system developed by the Surveillance


of Cerebral Palsy in Europe Collaborative Group

(2).

Children were grouped according to motor type,

topographic pattern, MACS and GMFCS levels.

Motor types were classified as spastic, dyskinetic,

mixed, ataxic and hypotonic, as defined in

Appendix 1(5-7). Spastic patterns were further

classified according to topographical distribution as

unilateral involvement (hemiplegic), bilateral

involvement (diplegia with the lower limbs more

affected than the upper limbs and quadriplegia (with

the upper limbs more or equally involved).

The gross motor function of all patients was

classified according to the GMFCS for CP by the

senior occupational therapists. In this standardized

and validated scale, the severity of motor

impairment of children with CP is classified by age

into five levels. It is based on self-initiated

movement, with particular emphasis on sitting and

walking. Distinctions between the five levels of

motor function are made on functional limitations

and the need for assistive devices. Thus, children

classified as level I have the most independent motor

function, while children at level V have the least

(26). The GMFCS levels of the children were

determined by the same occupational therapists by

means of observation and evaluation of the mobility

of the children.

MACS provide a systematic basis to classify how

children with CP use their hands when handling

objects in daily activities. The MACS is based on

self-initiated manual ability, with particular

emphasis on handling objects in an individual‟s

personal space (the space immediately close to one‟s

body, as distinct from objects that are not within

access). As a general principle, if a child‟s manual

ability fits within a particular level, the child will

probably be classified either at or above that level.

Children who do not perform the functions of a

particular level will almost certainly be classified

below that level. Level I includes children with CP

with, at most, minor limitations compared to

typically developing children, and where the limitations,

if any, barely influence their performance of daily

life tasks. In the MACS, five levels are described.

Distinctions between each pair of levels are also

provided to assist in determining the level that most

closely resembles a child‟s manual abilities. The

scale is ordinal, with no intent that the distances

between levels should be considered equal, or that

children with CP are equally distributed across the

five levels (27). The MACS levels of the children

23

were determined by means of observation and

parents reports.

The GMFCS and the MACS levels were classified

by the same occupational therapist according to the

available manuals for the GMFCS and MACS

(Appendix 2) (26, 27).

Associated impairments

In many individuals with CP, other impairments

interfere with the ability to function in daily life and

may at times produce even greater activity limitation

than the motor impairments that are the hallmark of

CP. In this study we evaluate impairments such as

seizure disorders, hearing and visual problems, and

cognitive issues. These impairments were classified

as present or absent; if present, the extent to which

they interfere with the individual‟s ability to

function or participate in desired activities and roles

were described. The presence or absence of epilepsy

(defined as two or more afebrile, non-neonatal

seizures) was recorded.

The estimated cognitive levels (IQ) of the children

were determined using a form which was filled in by

the families. The form was taken from the

impairment form in the SPARCLE project. The

learning disability was defined as mild in children

with an IQ level of 50 to 70 and severe if the IQ

level was less than 50 (28). The details of the form

are given in Appendix 3. Characteristics and co-

morbidity conditions, such as hearing loss, vision

loss, speech disorders, and seizures, were obtained

from the parents‟ reports and medical records.

The collected data was verified and entered into a

standard database file and analyzed using the

statistical package for social sciences. SPSS 16.0

was used for the statistical analysis.

Results

During the study period, 200 CP children (103

males, 97 females) aged 4-12 years were seen with an

overall male: female ratio of 1.06, with a mean (SD)

age of 7.7(2.4) years. The demographic

characteristics of primary caregivers and children

are shown in table 1. Characteristics and co-

morbidity conditions, such as hearing loss, vision

loss, speech disorders, and seizures are presented in

Table 2, and table 3 shows the frequency and

percentage of associated disorders of cerebral palsy

in this study. The distribution of motor types and

topographical distribution within each GMFCS and

MACS level and each type are shown in Table 4 &

5.

24

One hundred- twenty five children (62.5%) with a

mean age of 7.6 years were bilateral spastic CP, and

36 (18%) children with a mean age of 7.9 years were

unilateral spastic CP, 10 children (5%) with a mean

age of 7.6 years were ataxic, and 14 children (7%)

with a mean age of 8 years were dyskinetic. About

mean age no difference was found among the CP

types.

Level IV in MACS classification (23%) and also

Level IV in GMFCS classification (30.5%) were the

more commons. The remaining cases were

distributed rather equally to other levels, near to (19-

20%) to the MACS classification and (11-24.5%) to

the GMFCS classification per level.

Discussion

In this study spastic CP was the most common

(80.5%) and more specifically, bilateral CP (62.5%)

was more common than unilateral (18%).The other

groups with hypertonia (dyskinetic) accounted for

7% of cases while the remaining motor types

(ataxic) represented 5% of the cases. Level IV of

Both MACS and GMFCS were more common, 23%

and 30.5% respectively.

The information available for providing an adequate

classification of the features of CP in any individual

will vary over the age span and across geographic

regions and settings. The role of aging in changing

the clinical phenomenology of CP has been little

studied, and the possibility of classification changes

over time cannot be completely dismissed. Defining

the presence or degree of associated impairments,

such as cognitive deficits, is age-dependent, and in

infants the type of motor disorder may be hard to

explain. Some young children diagnosed as CP may

in fact have very slowly progressive disorders that

have not yet been clearly identified.

Classification often requires making difficult

decisions about where to draw the boundaries within

ordinal or quantitative measures. Some degree of

arbitrariness is inevitable. Assignment of individuals

with the diagnosis of CP to distinct clinical groups is

not straightforward and will differ depending on the

characteristic(s) chosen as the basis for

classification. No one single approach has emerged

as definitive; depending on the purpose of the

classification, certain characteristics or combinations

of characteristics may be more useful than others.

For example, in assessing the effectiveness of a new

treatment for a specific type of tone abnormality, the

nature of the motor disorder and the level of

functional motor ability are likely to be paramount,


whereas determining service delivery needs will

require the consideration of associated impairments.

No classification system is useful unless it is

reliable. It is, therefore, not enough to specify the

characteristics to be used in classification; they must

be operationally defined so that, in general,

competent examiners will classify the same individual

in the same way given identical information.

However, providing such definitions is beyond the

scope of this document. For example, the term

spastic diplegia is problematic for classification

because its existing definitions are variable and

imprecise, and because we lack evidence that the

term can be used reliably. Some use the term to

describe children with spastic CP whose only motor

deficit is in the legs, whereas others include children

who have arm involvement of lesser severity than

leg involvement. However, determining the relative

severity of arm and leg involvement can be

challenging because they perform very different

functions. By examining CP subtypes, we can gain

information that may improve our understanding of

possible causes, because certain types of CP may be

associated with recognized risk factors. For

example, spastic diplegia is reported to occur more

often in low birth weight (29). Therefore,

examination of changes in the distribution of

subtypes may yield clues to contextual factors that

may affect the risk of CP.

Similar to previous prevalence reports,(30-34,16)

most children in this study had spastic CP (80.5%),

with bilateral being more common than unilateral

spastic CP. The proportions of children with ataxic

CP (5%), and dyskinetic CP (7%) were low, other

reports of the proportions of dyskinetic and ataxic

CP ranged from 1% to 7% of all cases (33-36).

Few researches have performed relevant studies

about the type, associated disorders and functional

level of CP in Iran. In one study in a rehabilitation

center in Tehran on 112 cases, the frequency of

different types of CP were spastic [hemiplegic

(36.6%), diplegia (31.3%), quadriplegia (12.5%)],

atonic & hypotonic (12.5%), dyskinetic (4.5%), and

mixed (1.8%) (39).

In another study on 200 cases the frequency of

different types of CP were spastic diplegia (39.5%),

mixed (28%), spastic quadriplegia (22%), atonic

(4.5%), dyskinetic (4%), and hemiplegic (2%) (40).

Differences in the prevalence of subtypes may result

from definition issues or ascertainment methods.

Further classifications of the spastic subtype according to

limb involvement (i.e., hemiplegia, quadriplegia,


diplegia, triplegia, or monoplegia) have raised the

issues of reliability. However, other CP investigators

also found that the distinction between spastic

diplegia and spastic quadriplegia is particularly

difficult (37-38). Greater confidence was expressed

and more consistent estimates were found when

cases of spastic CP were classified as either unilateral or

bilateral, as proposed by the Collaboration for

Surveillance of CP in Europe, (37) than when the

limb involvement method was used.

The widespread adoption of the definition of CP

proposed by Bax in 1964 has resulted in the

grouping together of large numbers of children with a

wide variety of movement disorders, topographical

distributions and functional abilities under the

„cerebral palsy umbrella‟ (3,45). The marked

variation in functional abilities of children sharing

the common diagnosis of CP has led to repeated

efforts to classify children into meaningful clinical

syndromes. In terms of motor type and

topographical distribution, these efforts have had

limited success, and this makes it difficult to make

meaningful time and geographical comparisons. (2-

3, 8-9) By contrast, the use of the GMFCS now

facilitates a reliable means of classification of the

severity of the motor disorder. The distribution of

children throughout all GMFCS levels confirms the

wide range of function and disability in a typical

population sample of children with CP. GMFCS

level I children are completely independent, they do

not use aids, and usually have mild spastic

hemiplegia. By contrast, children in GMFCS level V

have no independent mobility and often have severe

spastic dyskinesia in a quadriplegic distribution. It is

of note also, that children with spastic hemiplegia

will usually be in levels I and II, and those with

quadriplegia will be in levels III, IV and V.

In this study, within the spastic group, differences in

motor function among the two topography groups

were extremely clear-cut. Compared to children with

unilateral distribution, children with bilateral were

more severe on the GMFCS and MACS scales.

Children with bilateral spastic had the lowest levels

of function, being significantly higher on the

GMFCS and MACS scales than those with

unilateral. In comparison with the total group with

spasticity, children with ataxia appeared to have

higher levels of function on the GMFCS and MACS

scales, but the numbers of children in this group

were too small for a conclusive finding. Children

classified as having a mixed type of motor disorder

were significantly more severe on the GMFCS and

25

MACS scales than children with ataxia.

The SCPE reported the following incidence of

comorbidities in children with CP (the data are from

1980-1990 and included over 4,500 children over

age 4 whose CP was acquired during the prenatal or

neonatal period): mental disadvantage (IQ < 50):

31%, active seizures: 21%, mental disadvantage (IQ <

50) and unable to walking: 20%, and blindness: 11%

(41).

The SCPE noted that the incidence of comorbidities is

difficult to measure accurately, particularly across

centers. For example, the actual rate of an

intellectual impairment may be difficult to

determine, as the physical and communicational

limitations of people with CP would likely lower

their scores on an IQ test if they were not given a

correctly modified version.

Speech and language disorders are common in

people with cerebral palsy. The incidence of

dysarthria is estimated to range from 31% to 88%.

Speech problems are associated with poor

respiratory control, laryngeal and velopharyngeal

dysfunction as well as oral articulation disorders that

are due to restricted movement in the oral-facial

muscles. In this study speech problems were 47 %

which was near to recent study in Iran (41%) (40).

Concurrent seizure with CP in different reports is

between 25-33% and in this study was 17%.

This report of population characteristics of children

with CP, co-morbid disabilities and evaluation of

gross motor and hand functioning by using the

GMFCS and MACS at eight rehabilitation centers

and two special schools makes an important step

forward in expanding our understanding of CP in the

Tehran. Future analyses will examine the

characteristics of children with CP in other cities in

Iran. We need additional research using consistent,

population-based methods over time and in more

communities to provide a more comprehensive

picture of CP among children in the Iran.

The goal of the classifications in the assessment of

children with CP is to assist in the communication

between clinicians, select homogeneous groups of

use of the instruments improves the ability to care

for children with CP.

Conclusion

In this study the most frequent type of CP was

bilateral spastic that had the worst motor status, and

difficult treatment, so it seems that the health care

system should pay more attention to perinatal insults

for prevention of CP in our population.

Significant number of children with CP (59%) had

IQ>70 or educable, therefore through early diagnosis

and detection of those with normal IQ and use of

specialized educational programs (with special

attention to their functional disabilities), they can a

normal life like others and enjoy themselves.

In conclusion, the term „cerebral palsy‟, despite all

its shortcomings, is worth retaining, although it

might be better to use the term „cerebral palsies‟ to

describe a CP phenotype that encompasses the

enormous variability in motor type, topography and

gross motor function. We think that the best way of

classifying children with CP is a combination of

motor type, topography and gross motor function,

according to the GMFCS and MACS scales.

Acknowledgements

We would like to thank Pediatric Neurorehabilitation

Research Center and University of Social Welfare

and Rehabilitation Sciences (USWRS) for financial

supports and children, parents, care givers,

rehabilitation centers and special schools as well for

their active participation in this study.

Appendix 1

Definitions of motor types

Hypertonia in which resistance to

externally imposed movement increases

Spasticity with increasing speed and varies with

direction of movement and/or rises

rapidly above a threshold speed.

Involuntary, sustained or intermittent

Dyskinesia muscle contractions causing twisting children for clinical research trials, facilitate the

development of rating scales to assess improvement

or deterioration with time, and, eventually, to better

match each individual patient with specific therapies

(49). In our opinion, this paper may provide

pediatricians and rehabilitation teams an

introduction in how far the classification of CP has

come. It may be important to try to make it more

relevant to health professionals and expand why the

26

and repetitive movements, abnormal postures or both.

Mixed Clinical features of more than one type,

motor types usually spastic and dyskinetic.

Abnormal pattern of posture and/or

movement with loss of orderly muscle

Ataxia coordination so that movements are

performed with abnormal force, rhythm

or accuracy.


Abnormally low tone, in the trunk and

Hypotonia limbs that must be distinguished from

weakness.

Appendix 2

Summary of the criteria for the GMFCS and MACS

(MACS) in children with cerebral palsy. A

population-based study of 359 children. BMC

Musculoskelet Disord 8:50

Appendix 3

Estimated cognitive level of children with CP

For the cognitive level, you can ask the parents some GMFCS MACS

Level I questions and report “estimated cognitive level”:

Cognitive description/IQ

Walks without

restrictions, limitations in

more advanced gross

motor skills

Level II

Walks without

restrictions, limitations

walking outdoors and in

the community

Level III

Handles objects easily

and successfully

Handles most objects

but with somewhat

reduced quality and/or

speed of achievement

Has your child had an assessment of IQ in the last

year or so?

If yes, what was the result?

1. Do you think your child learns as well as other

children of a similar age?...

...Yes/No

2. Does your child play with and be friends with

children of a similar age?... ............... ..Yes/No

If the answer is Yes to Questions 1 and 2, the IQ is

probably >70. If not,consider the following questions:

Walks with assistive

mobility devices,

limitations walking

outdoors and in

community

Handles objects with

difficulty, needs help to

prepare and/or modify

activities

3. Does you child have severe difficulty with

learning in all aspects of development?

... Yes/No

4. Is your child‟s ability to read and understand

ideas like that of a much younger child, such as

Level IV

Self mobility with

limitations, children are

transported or use power

mobility outdoors and in

the community

Level V

Self mobility is severely

limited, even with use of

assistive technology

Handles a limited

selection of easily

managed objects in

adapted situations

Does not handle objects

and has very limited

ability to perform even

simple actions

one more than half of their age? ... ... Yes/No

If the answer is Yes to Questions 3 and 4, IQ is

probably <50.

Otherwise the child probably falls into IQ 50-70, but

this should be confirmed by expecting the answer

Yes to the questions below:

5. Do you think that your child needs much more

help than other children to learn things like

reading and understanding

ideas?... ......................... .. Yes/No

6. Does your child find it easier to make friends and

play with younger children?... ............ ... Yes/No This table was taken from Carnahan KD, Arner M,

Hنgglund G (2007) Association between gross

motor function (GMFCS) and manual ability

Table 1. Demographics of Primary Caregivers and Children Participating in the Study.

Demographics Response Categories Frequency (%)

Gender Male 103 (48.5)

Female 97 (51.5)

4-6 Years 55

6-8Years 41 Preschool 8-10 Years 17

10-12 Years 11


Demographics Response Categories Frequency (%)

Total 124 (62)

4-6 Years -

6-8Years 12 Child‟s Education Elementary 8-10 Years 34

School 10-12 Years 24

Total 70 (35)

4-6 Years -

Middle 6-8Years - School 8-10 Years -

10-12 Years 6

Total 6 (3)

Ordinary School 45 (22.5)

Special School 57 (28.5) Type of School Not Going 98 (49)

North 15 (7.5)

Center 20 (10)

East 28 (14)

West 30 (15) Living place of family South 92 (46)

Margin 13 6.5)

Missing 2 (1)

Completed primary School 70 (35)

Completed high School 84 (42)

Over diploma & BS 42 (21) Mother‟s Education MS & higher 2 (1)

Missing 2 (1)

Completed primary School 71 (35.5)

Completed high School 67 (33.5)

Over diploma & BS 46 (23) Father‟s Education MS & higher 13 (6.5)

Missing 3 (1.5)

Table 2. Characteristics and accompanying co-morbidity conditions of children with cerebral palsy (CP)

Characteristic Value

Ages (years), median (range) 7 (4-15)

Types of cerebral palsy N (%)

Unilateral Spastic 36 (18)

Bilateral Spastic 125 (62.5)

Ataxic 10 (5)

Dyskinetic 14(7)

Unclassified(mixed) 15(7.5)

Co-morbidity conditions N (%)

Hearing problems 15 (7.5)

Vision problems 80 (40)

Speech disorders 94 (47)

Seizures, epilepsy 34 (17)


Table 3. The frequency and percentage of associated disorders in 200 children with

cerebral palsy in Tehran

Associated Disorders Frequency (N) Percent (%)

Estimated Cognitive <50 36 18

Level 70-50 46 23

>70 118 59

with functional limitation 40 20

Visual Problems Having without functional limitation 40 20

Not having 114 57

Not Response 6 3

with functional limitation 7 3.5

without functional limitation 8 4

Hearing Problems Having

Not having 182 91

Not Response 3 1.5


without functional limitation 21 10.5

Speech & Language Having

Disorders Not having 95 47.5

Not Response 11 5.5



Epileptic Disorders Having

Not having 157 78.5

Not Response 9 4.5



Voiding Having

Incontinence Not having 145 72.5

Not Response 11 5.5

with functional limitation 36 18

Deification without functional limitation 9 4.5

Incontinence Having

Not having 143 71.5

Not Response 12 6

Table 4. Motor types and topographical distribution in 200 children with cerebral palsy in Tehran. For each motor type/topographic pattern, the frequency and percentage are shown

within each GMFCS level and each type.

Motor type/topographic pattern

Hypertonia

Spastic

Unilateral In Total/ n (%)

Spastic In Type(%)

Bilateral In Total/ n (%)

Spastic In Type(%)

In Total/ n (%)

GMFCS

I II III

12(33.3) 16(44.6) 0(0)

33.3 44.4 0

4(3.2) 23(18.4) 25(20)

3.2 18.4 20

2(14.3) 2(14.3) 0(0)

Total

IV V n (%)

6(16.7) 2(5.6) 36(18)

16.7 5.6 100

42(33.6) 31(24.8) 125(62.5)

33.6 24.8 100

6(42.9) 4(28.6) 14(7) Dyskinesia

Unclassified

In Type(%) 14.3

In Total/ n (%) 2(9.1)

14.3 0 42.9 28.6 100

3(6.1) 4(12.9) 6(9.8) 0(0) 15(7.5)



In Type(%)

In Total/ n (%)

GMFCS

I II III

13.3 20 26.7

2(9.1) 5(10.2) 2(6.5)

Total

IV V n (%)

40 0 100

1(1.6) 0(0) 10(5) Ataxia

Total /Level

In Type(%) 20

n (%) 38(19)

50 20 10

38(19) 40(20) 46(23)

0 100

38(19) 200 (100)

Table 5. The distribution of motor types and topographical distribution in 200 children with

cerebral palsy in Tehran. For each motor type/topographic pattern, the frequency and percentage

are shown within each MACS level and each type


Unilateral In Total n (%)

Spastic

MACS

I II III

Hypertonia

Spastic

11 7 11

(28.9) (18.4) (27.5)

Total

IV V n (%)

5 2 36

(10.9) (5.3) (18)

Bilateral

Spastic

Dyskinesia

Unclassified

Ataxia

Total

In Type(%)

In Total n (%)

In Type(%)

In Total n (%)

In Type(%)

In Total n (%)

In Type(%)

In Total n (%)

In Type(%)

N (%)

30.6 21

(55.3)

16.8

0(0)

0

2

(5.3)

13.3

4

(10.5)

40

38

(19)

19.4 30.6 13.9

21 (55.3) 22 (55) 31(67.4)

16.8 17.6 24.8

3(7.9) 1 (2.5) 5 (10.9)

21.4 7.1 35.7

2(5.3) 5(12.5) 5 (10.9)

13.3 33.3 33.3

5 (13.2) 1 (2.5) 0 (0)

50 10 0

38 40 46

(19) (20) (23)

5.6 100

30(78.9) 125 (62.5)

24 100

5 (13.2) 14 (7)

35.7 100

1 (2.6) 15 (7.5)

6.7 100

0 (0) 10 (5)

0 100

38 200

(19) (100)

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٣31


Original Article

The Relationship Among Personality Factors, Motivational Strategies

and Achievement Goals Orientation in Predicting Academic

Achievement of the Students with Intellectual Disability

Masoume Pourmohamadreza Tajrishi, PhD Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences,

Tehran, Iran

Mohamad Ashoori*, MSc Department of Educational psychology, Faculty of psychology, Islamic Azad University, Roudehen Branch,

Roudehen, Iran

Seyede Somaye Jalil-Abkenar, MSc University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Jamal Ashoori, MSc Department of Educational psychology, Faculty of Sciences and Research, Islamic Azad University, Sciences

and Research Branch, Esfahan, Iran

Objectives: Some studies have recognized factors that are effective on academic achievement. The aim of the

present study was to determine the relationship among personality factors, motivational strategies and

achievement goals in predicting academic achievement of 2nd grade high school intellectually disabled

students in Tehran Province.

Methods and Materials: In present correlation study, 200 intellectually disabled students (126 females and 74

males) in 2nd grade high school selected randomly by stratified sampling method from Tehran Province.

Subjects completed Big Five Factor Personality Inventory (NEO-FFI), Motivational Strategies for Learning

Questionnaire (MSLQ) and Achievement Goals Questionnaire-Revised (AGQ-R). Data analysis was based

on stepwise regression analysis method.

Results: As personality factors, openness and being conscientiousness were correlated positively. In

motivational strategies, effort regulation, help seeking and self-efficacy correlated positively, also

mastery-approach and performance-avoidance goals in achievement goals orientation showed positive

correlation (p<0.05). Neuroticism, test-anxiety and academic achievement were correlated negatively

(p<0.01). It can be explained that 44% of variations in academic achievement are due to self-efficacy, Being

conscientiousness, mastery-approach goal and neuroticism (p<0.05). Self-efficacy had the most contribution

in predicting academic achievement of students (p<0.01).

Conclusion: Paying attention to the variables such as: personality (being conscientiousness and

neuroticism), motivational (self-efficacy) and achievement goals orientation (mastery-approach goal) have crucial role in predicting academic achievement in students with intellectual disability.

Key words: Personality factors, Motivational Strategies, Achievement Goals Orientation, Academic Achievement, Intellectual disability.

Introduction

Acquaintance with intellectual disabled students is

helpful for recognizing them, also for planning and

providing educational resources (1). These students

are facing more problems in academic setting in

comparison to normal students. To explore these

students and using appropriate strategies will improve

their educational and academic achievement (2, 3).

Many studies have indicated that the relation

between intelligence and academic achievement is


32

unexpected. As far as the role of cognitive variables

reduces in prediction of academic achievement, the

contribution of personality variables will increase

(4). One of the characteristics that affects academic

performance is personality. Personality is a set of

stable and organized traits which distinguishes an

individual from others. Schultz proposed that

personality is consisting of five factors: Neuroticism,

extroversion, openness to experience, agreeableness

and conscientiousness (5, 6).


Previous results are contradictory about the

relationship between personality factors and

academic achievement. Some other studies have

mentioned, a positive and significant relationship

between agreeableness, neuroticism and academic

achievement, but others have showed no significant

correlation between extroversion, conscientiousness,

openness to experience and academic achievement

(7, 8).

Martin reported that there is a negative relationship

between neuroticism and academic achievement,

also positive one between conscientiousness,

openness to experience, extroversion and academic

achievement in intellectual disabled students (9).

Review of literature shows that there is no linear

relation between personality factors and academic

achievement. Some studies have shown that

motivational strategies are determinant factors for

academic achievement. According to Pintrich,

motivational strategies are consisting of three

components such as resources management, self-

efficacy and test-anxiety. Some studies have

indicated positive and significant relationship

between academic achievement and variables like

time management, study environment, effort

regulation, peer learning and help seeking (10, 11).

Also, the other studies revealed no significant relation

between time and place management, effort

regulation, help seeking and academic achievement

(12). However, research on children with intellectual

disability has shown positive and significant

relationship between management strategies and

academic achievement (13-15). In addition, it is

reported that there is positive and significant

relationship between academic achievement and

self-efficacy (15, 16), also negative relation between

test-anxiety and academic achievement in students

with intellectual disability (17, 18, 19, 20, 21, 22,

23).

Achievement goals are considered as one of the

dimensions of motivational strategies. Educational

theorists have mentioned a few goal-oriented

approaches. For example Elliot and Pintrich

introduced goal achievements as a matrix with two

dimensions. Four types of goal approaches can be

recognized based on the matrix as follows: mastery-

approach, mastery-avoidance, performance-approach,

performance-avoidance (24, 25).

Students with mastery-approach goals focus on learning,

task master, learning of new skills, developing or

improving their competencies, concentration on

understanding and insight (26,19,27-28). In contrast,


students with performance-approach goals focus on

avoidance of misunderstanding, no gain control over

the task or profit from wrong criteria (27-31). More

have shown that there is a positive relationship

between mastery-approach and performance-approach

goals with academic achievement and a negative

relationship between performance-avoidance goal

and academic achievement (12, 14, 28, 31-38).

Although many studies have examined the role of

personality factors, motivation strategies and

achievement goals orientation on academic

achievement in normal students, the role of these

variables in students with intellectual disability has

not been known. Additionally, the contribution of

these variables in academic achievement has not

been already studied. In fact, the purpose of present

study is to explain the simultaneous role of

personality factors, motivational strategies and

achievement goals orientation in predictive model

for variations of academic achievement.


The study was approved by Ethics Committee of


Sciences. This was a descriptive-analytical

correlation study. From 272 secondary school

students who were educating in exceptional centers

in Tehran Province, 200 subjects (126 females and

74 males) were selected randomly by stratified

sampling method. They were 16 to 20 years old. All

students completed Neo Big-Five Factor Personality

Inventory (NEO-FFI; Costa and McCrae, 1992),

Motivational Strategies for Learning Questionnaire

(MSLQ; Pintrich) and Achievement Goals

Questionnaire-Revised (AGQ-R; Elliot and

Murayama) (10, 39).

NEO-FFI: this inventory was made by Costa and

McCrae and is a personality test with two short-

forms (60 and 44 items). In present study, a 44-items

form was used which measured five factors such as

neuroticism, extroversion, openness to experience,

agreeableness and conscientiousness. Each item was

scored according to Likert‟s five-degree scale. Its

reliability was reported 0.90, 0.78, 0.76, 0.86, and

0.90 for above-mentioned five factors respectively

(6).

MSLQ: the questionnaire has 32 items which was

made by Pintrich and consisted of resource

management strategies and motivational strategies.

The first section includes time management and

study environment, effort regulation, peer learning

and help seeking; the second one includes self-

33

efficacy and test-anxiety. Each component is scored

according to Likert‟s seven-degree scale. Its

reliability was 0.75, 0.65, 0.65, 0.58, 0.90, and 0.78 for

the above-mentioned components in order (10).

AGQ-R: the questionnaire has 12 items which was

made by Elliot and Murayama and scored based on

Likert‟s seven-degree scale. It is consisted of 4 goals

such as: mastery-approach, mastery-avoidance,

performance-approach, performance-avoidance and

their reliability have reported 0.84, 0.88, 0.92, and

0.94 for each goad respectively.

In present study, the reliability coefficients and of

three questionnaires have calculated by Cronbach's

alpha and shown in table 2.

The mean scores of all students in Science and

Hygiene, Religion and Life, and Mathematics

courses were collected in second semester and it was

considered as a criterion of their academic

achievement. The data that was obtained was

analyzed by using the statistical software SPSS

version 16. Mean, standard deviation, correlation

coefficient, stepwise regression analysis was used.

Results

Two hundred students with intellectual disability

(126 females and 74 males) from exceptional educational centers (aged from 16-20 years old)

participated in the study. They were from middle

socio-economical class. Academic level of their

fathers (73.5%) and mothers (67.5%) were diploma or

higher education. Mean and standard deviation of

variables has been shown in table 1.

Table 1. Mean and standard deviation of variables (n=200)

Variable M SD

neuroticism 3.24 1.62

extroversion 3.95 1.78

agreeableness 3.62 1.45

openness to experience 2.96 1.27

conscientiousness 4.07 0.98

time management & study environment 3.44 1.70

effort regulation 3.56 1.43

peers learning 2.17 1.36

help seeking 5.78 0.87

mastery-approach 6.15 0.96

mastery-avoidance 4.64 1.78

performance-approach 5.80 1.28

performance-avoidance 4.06 1.83

self-efficacy 5.36 1.34

test-anxiety 4.53 1.69

academic achievement 15.36 3.86

In table 2 correlation matrix and variables reliability of research has been determined.

Table 2. Correlation matrix and variables reliability of research (n= 200) Variable

neuroticism

extraversion

Agreeableness

Openness

conscientiousness

Time management and

study environment

1

0/85

-0/26

-

0/43**

-0/09

-

0/40**

-0/07

2 3 4 5

0/80

0/45** 0/76

0/03 0/07 0/79

0/32** 0/38** 0/22* 0/92

0/11 0/13 0/27** 0/09

6 7 8 9 10

0/73

11 12 13 14 15 16


Variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

effort regulation -

0/18** 0/06 0/08 0/12 0/19* 0/26** 0/62

peers Learning

Help seeking

Mastery-

Approach Mastery-

Avoidance

Performance-

Approach Performance-

-0/03 0/32** 0/24** 0/16* 0.06 0/05 0/13 0/76

0/12 0/23** 0/13 0/27** 0/12 -0/04 0/07 0/15* 0/64

-0/17* 0/14 0/06 0/27** 0/22** 0/36** 0/29** 0/10 0/09 0/74

0/07 0/12* 0/05 0/23** 0/04 0/24** 0/20* 0/13* 0/08 0/46** 0/76

0/12* 0/32** 0/12 0/06 0/09 0/18* 0/23** 0/25** 0/32** 0/26** 0/29** 0/69

-

Avoidance

Self- Efficacy

0/11 -0/09 -0/02 0/12 0/14* 0/18* 0/16**

- 0/36** 0/17* 0/39** 0/32** 0/29** 0/36** 0/27**

- -

0/20** -0/07 -0/02 0/53** 0/34** 0/82

- - 0/11 0/08 0/36** 0/05 0/95

0/22** 0/23** - -

Test -Anxiety 0/47** Academic -

Achievement 0/42**

0/27**

0/12

0/11 -0/07 -0/04 0/13**

0/15* 0/08 0/52** 0/09

-0/09 0/16* 0/06 0/52** 0/25**

0/15* 0/05 0/36** 0/42** -0/13

0/22* 0/42** 0/85 0/27**

- 0/15 0/17 0/56

0/34** 0/76 The reliability coefficients are on the major diameter. * P <0 / 05 ** p <0 / 01

As indicated in table 2 the lowest correlation and openness to experience. The highest correlation

coefficient was 0.02 for performance-avoidance and coefficient was 0.56 for openness to experience and

mastery-approach, also for performance-avoidance academic achievement.

Table 3. Summary of stepwise regression analysis

Step Predictive variables

1 Self-efficacy

2 Self- efficacy and conscientiousness

3 Self-efficacy, conscientiousness and mastery-

approach goal

4 Self-efficacy, conscientious, mastery-approach goal

and neuroticism

R R2

0.56 3.13

0.62 0.384

0.65 0.422

0.67 0.448

Change Change

R F

0.313 66.08

0.071 14.87

0.038 9.65

0.26 8.07

Df1 Df2 sig

1 97 0.001

1 96 0.001

1 95 0.002

1 95 0.005

As it is reflected in table 3 in 1st step, self-efficacy

had the greatest role in predicting academic

achievement (r=0.56). In other hands, 31.3% of

academic achievement can be explained by changes in

self-efficacy. In 2nd step, after Self-efficacy,

conscientiousness entered in the equation (r=0.62).

So, these two variables could be explained 38.4% of

variation of academic achievement. In 3rd

step,

besides of conscientiousness and self-efficacy,

mastery-approach goal entered in the regression

equation (r=0.65) which means these three variables

predicted 42.2% of changes in academic

achievement. In 4th

step, Self- efficacy,

conscientiousness, mastery-approach goal and

neuroticism entered in the equation (r=0.67). These

four variables can be predicted 44.8% of changes in

academic achievement.

Table 4. Standard and not standard coefficients and partial and semi partial correlation of variables in the

stepwise model

Model Variable predictive

coefficients regression

Not standardized

correlation

sig

standardized Beta partial semi partial ك

1 self-efficacy 1.75 0.56 0.001 0.56 0.56 0.56

self-efficacy 1.83 0.59 0.001 0.56 0.62 0.62

2 conscientiousness 0.92 0.38 0.001 0.52 0.45 0.42


Model Variable predictive

coefficients regression correlation

Not sig

standardized ك

self-efficacy 1.65

3 conscientiousness 0/98

mastery-approach 0/85

self-efficacy 1.57

4 conscientious 0.85

mastery-approach 0.78

neuroticism -0.74

standardized Beta partial semi partial

0.53 0.001 0.56 0.55 0.52

0/39 0.001 0.52 0.47 0.43

0/34 0.002 0.42 0.37 0.32

0.52 0.001 0.56 0.53 0.51

0.37 0.001 0.52 0.44 0.39

0.31 0.002 0.42 0.34 0.29

-0.21 0.005 -0.42 -0.22 -0.18

With entrance of variables in 4th

step, self-efficacy

had the greatest contribution in predicting changes in

academic achievement with standard beta equals

0.52. Conscientiousness had positive and effective

role in predicting academic achievement with

standard B = 0.37. Then, mastery-approach goal had

positive and effective role with standard B = 0.31.

At last, neuroticism had negative and effective role in

predicting academic achievement with standard (B =

-0.21).

Discussion

The results of the study showed that openness to

experience, conscientiousness, effort regulation, help

seeking, mastery-approach, performance-avoidance

goal, and self-efficacy had positive and significant

relationship with academic achievement. Also,

neuroticism and test-anxiety had negative and

significant relationship with academic achievement.

This finding was consistent with the results of some

studies (12, 15, 16, 19, 20, 22, 24, 39). In a predictive

model, only self-efficacy, conscientiousness, mastery-

approach goal and neuroticism can be explained for

academic achievement. Also self-efficacy had the

greatest contribution among the other variables. This

finding was consistent with some previous studies

(28, 31, 35-37).

Among NEO-FFI factors, only the openness and

conscientiousness had a significant and positive

relation with academic achievement. Also

neuroticism had a significant negative relationship

with academic achievement. These findings are

consistent with a few of studies (8, 9, 10) and

inconsistent with Kardum and Krapic study (7). It

can be explained that positive relationship between

openness to experience and conscientiousness with

academic achievement is due to the mediating the

role of some characters such as: effort, regularity,

36

perseverance, progress and responsibility. Also, the

negative and significant relationship between

neuroticism and academic achievement can be

explained based on anxiety, especially in stressful

situations like tests.

Only effort regulation and help seeking from

resource management strategies had a significant

and positive relationship with academic

achievement, that was in aggreement with some

studies (11, 13, 14, 15) and inconsistent with the

Abedini‟s study (12). This finding is probably

because of students with intellectual disability make

effort to get helping from key people such as

teachers, consultants and managers in comparison to

their normal peers. Finally, the results showed that

self-efficacy has significant and positive relationship

with academic achievement and it was the most

effective variable in prediction of academic

achievement. This was consistent with many studies

which have done in normal students (12, 15, 16, 19,

20, 22, 24, 39).

The results showed that academic achievement in

students with intellectual disability looks like in

normal students and is dependent to many variables.

The present study have examined the relationship

between personality factors, motivational strategies

and achievement goals in predicting academic

achievement of 2nd

grade high school students with

intellectual disability. The results proposed that self-

efficacy, conscientiousness, mastery-approach goal

and neuroticism were the most important predictive

factors in academic achievement. Self-efficacy had

the effective role in predicting of academic

achievement. It also showed that intellectual

disabled students will be successful in acquiring

higher education if: 1) they accept that are more

capable to do their homework, 2) in order to

accelerate their tasks, be more disciplined, 3) in


order to facilitate learning and achieving their

understanding and insight, they should be more

dependent to inner standards instead of compete and

get ahead of other students, 4) experience less

anxiety, tension, impulsivity and depression.

As far as present study used correlation method, the

relations which were shown could not be considered

as a causal factors and it is probable that these

results and relationships are due to the effect of other

variables. Other limitation of this study is the usage

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Original Article

Outcomes of Receiving a Master‟s Degree in “Rehabilitation

Management” on Graduates‟ Professional Lives

Nikta Hatamizadeh, MD, MPH Pediatric Neurorehabilitation Research Center, Department of Rehabilitation Management, University of

Social Welfare and Rehabilitation Sciences, Tehran, Iran

Seyed Majid Mirkhani, PhD candidate, Ahmad Fotoohi, MSc University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Asghar Makarem, MD Department of Rehabilitation management, University of Social Welfare and Rehabilitation Sciences,

Tehran, Iran

Azar Petrami, BA University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Roshanak Vameghi*MD, MPH Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences,

Tehran, Iran

Objectives: The aim of this study was to determine the outcomes of receiving a master‟s degree in “Rehabilitation Management” in Iran on the professional lives of graduates, as reported by them.

Method: A questionnaire consisting of open and close-ended questions was e-mailed to 75 graduates and alumni

of the course, graduated since the beginning of implementation of the course in Iran, from 1997 to 2003. The total

response rate was 52/75.

Results: Results overall indicated that 67% of graduates believed attending the Rehabilitation

Management post-graduate course was worth the costs and 87% mentioned it as „very effective‟ or „relatively effective‟ on their present quality of job performance.

Conclusion: Findings could serve as a baseline for periodic evaluations and revisions of the Rehabilitation Management curriculum in the future and also for comparisons with other management courses.

Key words: Rehabilitation management, Course outcome evaluation, Graduate, Alumni

Introduction

Rehabilitation management is a relatively new field of higher education in Iran. Although still a small field compared with others, it is expected to grow in the near future. Through the years 1997 to 2003, only the University of Social Welfare and Rehabilitation Sciences offered this Master of Science course. Since 2004 "Iran University of Medical Sciences (IUMS)” and from 2007 “Ahvaz University of Medical Sciences” began to offer this course too. This academic program emphasizes on training experts in management of rehabilitation services. Although few in number, this educational course is important in that it reflects the desire to establish rehabilitation management as a separate field due to the fact that it requires knowledge, skills, attitudes and values distinct, at least in part, from those needed in other fields of management.

* All correspondences to: E-mail: [email protected]


As a generally accepted definition, outcomes are the

end results of a program for the people the program

is intended to serve (1). Finding the outcomes of a

graduate professional program from the point of

view of the graduates involves measuring the

perceived effects that the program has had on them,

including how the program may have affected their

careers (1).

In all graduate and post-graduate professional

programs it is important to know what outcomes

were achieved by the students who graduated from

that program (1). This is even more important about a

program that has been recently launched and has not

as yet proven to be reaching its goals. In fact, a

changing environment requires any educational

institution to make assessments and define new ways of

better fulfilling its mission. (2)

39

One of the most familiar ways of doing this is the

taxonomy in which outcomes are categorized as

either cognitive or affective. Cognitive measures

have to do with behavior that requires the use of

high order mental processes such as reasoning and

logic; affective measures deal with behavior that

relates to the student‟s attitudes, feelings, and

personality. Thus affective outcomes include the

development of self-concept, values, and beliefs.

While cognitive outcomes may be effectively

measured during the students‟ academic careers, the

perceptions of alumni are a necessary component of

the assessment of affective outcomes.

Although the importance of assessing the impact of

academic programs has been well established (3, 4,

5, 6, 7, 8, 9), there has been little research on the

impact of university-based, graduate or post-

graduate level programs on their alumni in the

world, and especially in Iran. Unfortunately, those

outcome assessments that have actually been carried

out reveal relatively little about lasting impacts of

the program and must be supplemented with other

data (10). Assessment must focus on tasks where students can

show application of their skills and knowledge in a

business-world context (11). There are examples of

study projects around the world demonstrating that

students were not prepared adequately for

integrating their academic knowledge and skills with

their job responsibilities (12, 13). Student surveys

conducted in academic outcomes assessment most

commonly target three groups of students:

continuing students, graduating students, and alumni

(10).

A rather frequent confusion exists between two

different purposes of academic outcome assessment:

those assessment efforts aimed at assessing

individual student‟s results for the sake of student

feedback and development, versus assessment aimed

at evaluation of the programs or courses themselves

(3). The latter, which is a more contemporary

approach, usually measures student achievement of

designated program learning outcomes as a result of

their exposure to the program (3). In other words, it

demonstrates the extent to which a university course

or program does what it says it intends to do, thus

reflecting accountability of the educational program to

students, faculty professionals, employers who hire

a university‟s graduates (14), and also to

educational policy makers.

The purpose of the present study was to assess the professional outcomes such as the required

40

knowledge, skills and business perspectives, as

perceived by the students, of receiving a master‟s

degree in Rehabilitation Management in Iran, during

the period 2003 to 2007.

Materials & Methods

For this study completed in 2007, graduating students

and alumni of “Rehabilitation Management”

master‟s degree course from the University of Social

Welfare and Rehabilitation Sciences (USWRS) and

Iran University of Medical Sciences (IUMS) were

surveyed. Both universities are public institutions

located in Tehran city and are the first to offer

master‟s degree courses in rehabilitation

management in Iran. They were the only universities

offering the degree at the time the research was

conducted. Both universities used full-time faculty,

and their curricula were nationally recruited.

First, the total list of Rehabilitation Management

graduating students and alumni of both universities

was acquired. This resulted in a list 75 graduating

students and alumni: 63 from USWRS, and 12 from

IUMS. Of the total 75 people, 6 were inaccessible

because of changes in address and phone number. A

survey questionnaire and cover letter were sent by e-

mail after explaining the study to each participant by

telephone. For those who did not respond at the

expected time, a second e-mail (and then a third one

if necessary) was sent one and tw0 months after the

first. Finally, a total of 52 responses were received,

resulting in an overall response rate of 69.3%.

The questionnaire which was designed by the

researcher asked about graduates‟ perceptions

regarding the extent to which their rehabilitation

master‟s degree had resulted in different outcomes.

The questionnaire consisted of 27 questions

categorized into three parts: 1- demographic

questions, present and previous job titles; 2- open-

ended questions inquiring about the graduates‟

expectations for studying “rehabilitation management”

and about their perceptions of the outcomes of

completing the course, and 3- likert-type questions

on the effects of the course on their competency in

their jobs. At the end of the questionnaire they were

asked if they thought attending the course was

worthwhile overall.

In order to verify the validity for the instrument, a

total number of four experts who were the founders

and pioneers in the field of rehabilitation management

education were asked to review the questionnaire.

The purpose of the review was to ascertain that the

content of the questionnaire appeared to cover the


major outcomes expected for graduates of the

rehabilitation management master‟s degree course

and whether there was any other important issue

missing in the content. The experts were in general

agreement that the outcomes being measured were

appropriate for graduates of rehabilitation

management master‟s degree program. A few

changes were made based on their suggestions.

Internal consistency for part 3 of the questionnaire

was determined using Cronbach‟s coefficient alpha,

which was determined to be 0.79.

Results

Description of respondents A total number of 52 graduates completed and sent

back the questionnaire. The age range of the

respondents was 25-46 (34.5±6.4) at the time of the

survey. The male/female ratio was 31/21.

Job situation before and after education As it can be seen in Table 1 the graduates were classified

into 4 groups, according to their job situation; 1- Manager

(Top manager, Middle manager, Manager-consultant,

vice-manager), 2- Staff in a related organization (Welfare

Organization, Red Crescent Organization, Veterans'

Organization), 3- Therapist and 4- unemployed.

Table 1: Job situation of graduates before and after attending master‟s course of rehabilitation management

Job situation

Manager

Staff in a related organization

Therapist

Unemployed

Total

Time

Public

*Non public

Total manager

Public

Non public

Total staff

Public

Non public

**Community service

Total Therapist

Before attending the After attending the

course (%) course (%)

Number % Number %

7 15

2 2

9 17% 17 33%

12 18

- -

12 23% 18 35%

22 9

3 7

4 -

29 56% 16 31%

2 1

52 52 *Non public: Means private or NGO.

**Community service: The Iranian Law mandates all people who graduate from public universities, in which education is free of

charge, to work for a certain period of time in places in the country determined by the government where their services are

needed, with a predetermined amount of salary.

It can be seen that 50 of 52 respondents were

employed before attending the course and after

graduation this rose to 51. The total number of

alumni who had a managerial position rose from 9 to

17 and of those who had a staff position in related

departments increased from 12 to 18. With a more

precise look we can see that the increase in number

of people in managerial and staff positions is totally

limited to public centers. On the other hand, in the

non-public sector we can see a rise in the total

number of people who have occupied a therapist

position. It must be noted that of those 6 people who

were either in community service or unemployed

before attending the course; 4 were employed in a

therapist position in a non public center, 1 remained


unemployed and 1 was employed in a managerial

position in a public center. Only 2 graduates had a

managerial position in the non public sector. These

were the same people who were employed in those

positions before starting the course.

Expected and Perceived Achievement of Skills (answers to the open-ended questions) Figure 1 shows students‟ expected and perceived

achievement of skills from completing the course.

As it can be seen, two of the most stated skills which

the graduates had expected to achieve were “skills

for management of rehabilitation centers" and

"planning skills" (mentioned by 43 and 15 of 52

respondents, respectively). Results showed that 12

41

of 43 (28%) graduates who had expected to achieve

rehabilitation management skills believed that they

had achieved the skill, and 3 of 15 (20%) who had

expected to achieve planning skills stated that they

had achieved the skill.

The highest ratio in terms of expected skills to

achieved skills belonged to "the ability of planning

and conducting research projects” which was about

57% (4 out of 7). In this regard the graduates‟

opinions about the course effectiveness in improving

their research skills and its utilization at their work

place were also asked irrespective of their

expectations, using a close-ended likert-type

question. The results showed that overall 43 out of

52 graduates (83%) evaluated their research skills

achievement as acceptable or desirable.

It must be stated that only skills which were

mentioned by at least 2 graduates as their expected

skill outcome have been demonstrated in figure 1.

Other skill expectations, each of which had been

mentioned by only one respondent, and none of

which were stated as achieved, were: strategic

planning skills, crisis management skills,

rehabilitation services, policy making skills,

evaluation skills, consultation skills and finally

official correspondence skills.

Figure 1:Skills improvement Expectations and

Achievements as preceieved by graduates of

Ms degree in rehabilitation management

50

45

40

35

30

25

20

15

10

5

0

42

31

12 12 3

3 4 4 3 3 1

Stated skills

not achieved

3 2


Expected and Achieved Career Outcomes (answers to the open-ended questions) As it can be seen in Figure 2, twelve respondents

replied that they had no career expectations, so

comparison of expectations and outcomes was not

possible.

The remaining 40 graduates each mentioned one or

more career expectations, which were categorized

into 11 main items. Among all graduates who had

responded to this question, only 10 stated that they

had achieved one of their expectations. Only 1

graduate mentioned achievement of 2 expectations.

So, an overall 12 expected career outcomes were

achieved. It is noteworthy to state that all 12

expectations were achieved by alumni who were

either employed in the State Welfare Organization or

the University of Social Welfare and Rehabilitation

Sciences, or were in a managerial position in a

private center, before attending the course

Figure 2: Career outcome expectations and achievements as precieved by graduates

13 12 11 10 9 8

7 6

5 4 3 2 1 0 0

7

3

2

4

6 6 5 2

3 3 1 1 0 1 0 1 0 0 1 0 1

Indicated Career Outcomes

achieved not achieved not applecable


Perceived effects of the course on the graduates‟ professional lives (answers to an open-ended question) The graduates‟ opinions were asked about the effects

of the course on their professional lives. As can be

seen in table 3, 33 graduates (63.45%) perceived

positive effects of the course on their professional

lives including such effects as improvement of job

performance, improvement of job position,

broadening of job-related perspectives and outlooks,

and receiving different job offers. On the other hand,

17 graduates (33%) believed that the course did not

affect their professional lives.

Finally, 2 graduates (11%) replied that attending the

course had some negative effects on their

professional lives, pointing to such issues as: a sense of

being rejected at the work place, slogging for

nothing, and lag from life.

Table 3: Perceived outcomes of Rehabilitation Management course on the professional lives of graduates

Overall Effect perceived effect (Number of respondents who mentioned to it)

Positive effect

33 (63.45%) Broadening of job-related perspectives and outlook (5)

Improved insight about disabled people; achievement of a holistic view towards disabled patients; improvement of communication and provision of services for the disabled and their families (4) Improvement in quality of work (9)

Improvement in ability to analyze different situations at the work place; acquiring a better understanding of the work place; acquiring a better understanding of rehabilitation in the country (2)

Increased dignity and prestige at the work place (4)

Positive impact on career progress and job positions (6)

Being hired by the government more easily (1)

Increased Salary (1) Positive effect in general (5)

a sense of being rejected at the work place,

Negative effects slogging for nothing,

2(4%) lag from life (2)

No effects

17 (33%)

Total number of *

respondents

52 (100%) * Some graduates mentioned more than one effect.

Perceived compatibility of course „skill outcomes‟ with the actual requirements of current job (answers to the close-ended questions)

In answering the close-ended question: “how

compatible is your acquired skills with your current

job?”, as is demonstrated in Table 4, 11 graduates

44

among the 17 who held managerial positions after

graduation (65%), 7 graduates among the 18 who

held staff positions (39%), and only 3 out of 16 who

held therapist positions (19%) considered high or

very high compatibility with their current job

requirements.


Table 4: Perceived compatibility of course „skill outcomes‟ with job requirements after graduation

Job position

Compatibility of

acquired skills with

current job requirements

Very high

high

Moderate

low

Very low

Not applicable

Total

Manager Staff Therapist

No % No % No %

4 41 2 11 - -

5 24 5 28 3 19

- 29 9 50 6 38

1 - 2 11 3 19

- 6 - - 4 25

17 - - - - -

7 100 18 100 16 100

Unempl Total

oyed

No No %

- 9 17

- 12 23

- 20 38

- 5 10

- 5 10

1 1 10

1 52 100

Changes in job positions following graduation from Rehabilitation Management course After inquiring about their job positions before and

after attending the course, the graduates were

classified into six groups considering the size and

direction of change in their job positions. As

demonstrated in table 5, 32 (61%) graduates had no

changes in job positions, 18 (35%) graduates had at

least a single-level improvement and 2 (4%) had a

decline in their job positions after attending the

course.

Table 5: Changes occurring in graduates‟ job positions at work, after attending the Rehabilitation

Management course

Size and direction of change

One level decline in job position

No change in job position

A Single level promotion in job position

Two-level promotion in job

position

Three-level promotion in job

situation

Type of change Number (%) of

graduates

1-decline from therapist position to an 2 (4%)

unemployed position, or

2- decline from a managerial position to a staff

position

32 (61%)

1-advancement from an unemployed position to 12 (23%)

therapist position, or

2- improvement from a therapist position to a

staff position, or

3- improvement from a staff position to a

managerial position

Therapist position to managerial position 5 (10%)

Unemployed position to a managerial position 1 (2%)

Perceived efficiency of attending the Rehabilitation Management course (answers to close-ended question) The graduates were asked whether what they

acquired by attending the Rehabilitation

Management course was worth the costs (such as

costs in time, energy, stress, financial and other

types of-expenses), The results are shown in Table

6. Among 52 graduates, 35 (67%) stated that the


cost-benefit ratio was good or satisfactory.

Meanwhile, 12 graduates believed that the benefits

were not worth the costs, noting that ten of these

graduates either did not experience any changes or

had declines in their job positions after graduation.

It should be stated that 5 (28%) of those whose job

positions had improved after graduation mentioned

that the course was not worth the costs, while 23

(68%) of those who had no improvement in their job

45

positions answered that the course was worth its

costs.

Table 6: Perceived efficiency of the Rehabilitation Management course, in terms

of graduates‟ current job positions

Current job

position

Efficiency

Optimal

Good

Poor

Total

Manager Staff

No % No %

3 33 - -

3 33 9 75

3 33 3 25

9 100 12 100

Unem Total

Therapist ploye

d

No % % No %

7 24 - 10 19

12 41 1 25 48

10 35 1 17 33

29 100 2 52 100

Graduates‟ perceptions about the effect of attending the Rehabilitation Management course on their present quality of job performance (answers to close-ended questions)

Table 7 demonstrates the graduates‟ perception

about the effect of attending the Rehabilitation

Management course on their present quality of job

performance. As can be seen, 45 of the 52 graduates

(87%) have considered it as „very effective‟ or

„relatively effective‟. For those who currently held

managerial positions the figure is as high as 95%,

and for those who didn‟t, it is 69% (all of whom

have considered it as „relatively effective‟).

Table 7: Graduates‟ perceptions about the effect of attending the course on their present quality of job performance, in terms of their current job positions

Current job

position

course

effects on

job performance

Very effective

Relatively effective

Non-effective

Manager Staff

No % No

7 41 1

9 54 16

1 6 1

Une

Therapist mplo Total

yed

% No % No No %

6 - - - 8 15

88 11 69 1 37 71

6 5 31 - 7 13

Total 17 100 18 100 16 100 1 52 100

Discussion

All improvements of study programs, teaching and

support services in educational institutions are based

on the voice of the customer, which in this case are

the students. So measuring the students‟ perception

of the “product” or “service” they receive and their

satisfaction is the cornerstone of every educational

promotion plan (15).

This article aimed at providing an image of

professional life consequences of graduating from

rehabilitation management master‟s degree course in

Iran, as experienced by the alumni of the first eight

courses ever conducted in the country. Being aware

46

of the perspectives of graduating from a course and

of what would be accomplished after graduation is

of great value for those who have to make decisions

about their path for post graduate education. It can

also provide educational policy makers and

managers with good clues for curriculum revision.

Alumni-based outcome assessment is important for

at least three reasons:1- it provides the opportunity

for “detached objectivity”; that is, their measurement

of outcomes is often more reflective, given their

distance from the college setting, both

geographically and temporally; 2- As Robert Pace

and Peter Ewel assert, there is a positive correlation


between a graduate‟s perception and actual levels of

achievement (16, 17); and 3- alumni-based research

provides an appropriate context within which to

measure long-term objectives, in contrast to

assessments based on current student perceptions,

since alumni have had some reasonable time to live

with the results of their education and reflect upon it.

Especially when „affective outcomes‟ are to be

measured, the matured and detached perspective of

alumni is preferred over the perspective of current

students (16).

One important result of the present study was that

63.45% of graduates perceived positive effects of

the course on their professional lives. Also, overall

67% of graduates believed that the efficiency of

attending the rehabilitation management post-

graduate course was optimal or good, or in other

words it was worth the costs and 87% have

considered it as „very effective‟ or „relatively

effective‟ on their present quality of job

performance. However, this did not mean that they

were satisfied with all course outcomes. For

example, 70% and 72% of graduates declared they

had not reached their career expectations and

expected managerial skills, respectively. It seems

that in each professional education program a

tension is inherent between teaching practical skills

and providing theoretical background (1). Eskilden

et al, have shown that unsatisfied expectations do

not make students lower their expectations. Instead,

it results in a lower evaluation of image as well as

low evaluations for the quality of human and non-

human elements in an educational institution. This is

important since image is the variable with the single

largest impact on student loyalty (15). Therefore,

considering the importance of fulfillment of student

expectations, this result may infer a need for

curriculum revision in the post-graduate

rehabilitation management course in Iran. In case of

such a reform, the results of the present study can be

utilized as basic information and used as a scale for

comparing to future studies.

The results also demonstrated a high employment

rate in graduates, but as most of the have already

employed, the high percentage of graduates‟

References 1. Fletcher KM. The Impact of Receiving a Master‟s Degree

in Nonprofit Management on Graduates‟ Professional Lives. Nonprofit and Voluntary Sector Quarterly 2005; 34: 433.


employments might not be attributed to getting the

degree. However, a significantly higher proportion

of graduates have been employed in higher

managerial positions after graduating the course. So,

acquiring higher professional managerial positions

after graduation was the result that could be

generalized only to future graduates who have

already been employed in the rehabilitation sector.

It seems that having had previous experience in the

professional workplace may play a rather important

role in acquiring managerial positions in that field,

after graduation.

Our results are concordant with the results of a study

performed by Fletcher, in which some respondents

found that their past experience was more important

to prospective employers than their degree. Others

said the degree was no help in getting a job without

relevant experience. According to Fletcher KM, if

some alumni find that their degree is not an asset in

seeking employment, then more work needs to be

done to publicize these degrees and the skills they

impart to graduates, thus making this type of degree

more attractive to employers and the nonprofit

community in general. Thus as Fletcher suggests,

universities should consider having practice or

internship opportunities for students who have little

or no professional or career background so that they

can gain experience while enrolled in the program

(1).

We should also emphasize that since passing the

course seems to have been more effective and

efficient for those who had already held job

positions in rehabilitation or other relevant

organizations or institutions; it is rational to

recommend this course especially for those people

interested in management who are already working in

the rehabilitation sector.

Conclusion

Results of this study could be helpful by future

studies for periodic evaluations and revisions of the

Rehabilitation Management curriculum in Iran and

also as an instrument to compare the perceived

outcomes for graduates of other specialized degree

programs that offer courses in management.

2. McClain CJ. Planning: Using Student Outcome Measures to Plan for the Future. Descriptive Report 141, 1987; Northeast Missouri State University, Kirksville.

3. Roberson MT, Carnes LW, Vice JP. Defining and Measuring Student Competencies: A Content Validation

47

Approach for Business Program Outcome Assessment. The Delta Pi Epsilon Journal 2002; 44(1): 13-24.

4. Association of American Colleges. Integrity in the college curriculum: A report to the academic community. Project on Redefining the Meaning and Purpose of Baccalaureate Degrees 1990; Washington, D.C.: Author.

5. Braathen S, Robles M. The importance of assessment in business education. In: J. Rucker (Ed.), Assessment in business education national business education yearbook 2000; 38: 11-24. Reston, VA: National Business Education Association.

6. Hatfield SR, Gorman KL. Assessment in education-the past, present, and future. In: J Rucker (Ed.), Assessment in business education national business education yearbook 2000; 38: 1-10. Reston, VA: National Business Education Association.

7. Mundrake GA. The evolution of assessment, testing, and evaluation. In: J Rucker (Ed.), Assessment in business education national business education yearbook 2000; 38: 39-47. Reston, VA: National Business Education Association.

8. National Institute of Education (U.S.) Study Group on the Conditions of Excellence in American Higher Education. Involvement in learning: Realizing the potential of American higher education 1984; Washington, D.C.: Department of Education.

9. Nichols JO. A practitioner‟s handbook for institutional effectiveness and student outcomes assessment implementation 1991; New York: Agathon Press.

10. Palomba CA, Banta TW. Assessment essentials: Planning,

48

implementing, and improving assessment in higher education 1999; San Francisco: Jossey-Bass, Inc.

11. Chandler JW. The why, what, and who of assessment: The college prospective. Assessing the outcomes of higher education. Proceedings of the 1986 ETS Invitational

Conference 1986; pp.11-18. Princeton, NJ: Educational Testing Services.

12. National Business Education Association. National standards for business education: What America‟s students should know and be able to do in business 1995; Reston, VA: Author. 13. Secretary‟s commission on Achieving Necessary Skills. A SCANS Report for America 2000, 1991; The workforce skills website. Washington, D.C.: U.S. Department of Labor. 14. Henninger E. Outcomes assessment: The role of business school and program accrediting agencies. Journal of Education for Business 1994; 69: 296-298. 15. Eskildsen JK, Martensen A, Gronholdt L, Kristensen K. Benchmarking Student Satisfaction in Higher Education Based on the ECSI Methodology 2000; The Aarhus School of Business. 16. Pace R. Measuring Quality of Effort: A New Dimension for Understanding Student Learning and Development. Laboratory for Research on Higher Education, University of California 1979. 17. Ewell P. Information on Student Outcomes: How to Get It and How to Use It. National Center for Higher Education Management Systems 1983.



Original Article

Persian Cued Speech: The Effect on the Perception of Persian

Language Phonemes and Monosyllabic Words with and without

Sound in Hearing Impaired Children

Guita Movallali*, PhD Pediatric Neurorehabilitation Research Center,


Objectives: This paper studies the effect of Persian Cued Speech on the perception of Persian language

phonemes and monosyllabic words with and without sound in hearing impaired children. Cued Speech is a

sound based mode of communication for hearing impaired people that is comprised of a limited series of hand

complements and the normal pattern of speech. And it is shown that it effectively can improve speech skills of

hearing impaired children and adults. Cued Speech has recently been adapted to Persian language (1) and our

knowledge about its efficiency is very limited.

Methods: Two groups of profoundly hearing impaired children participated in the study. They were

matched with each other. The experimental group received an intensive Persian Cued Speech training

program for several months. Prior to and following training and also three weeks after the sample‟s

perception of Persian language phonemes and monosyllabic words were evaluated. Mixed Repeated

Measurement was used to analyze the results.

Results: Findings indicated that experimental group‟s scores in both phonemes and monosyllabic words with

and without sound were significantly difference between pre-test and post-test and follow up as a function of

Cued Speech training (p<0.0001).

Conclusions: The results support the use of Persian Cued Speech for improving perception of Persian hearing impaired children to promote their communication performance.

Key words: Hearing impaired, Cued Speech, Monosyllabic words, Phonemes, Perception.

Introduction

Traditionally speech perception has been associated

almost exclusively with audition. Mc Gurk and Mac

Donald (1976) showed that this assumption was

wrong, as sight does contribute to speech perception.

Their findings have important implications for

hearing impaired people, because visual speech

constitutes the main speech modality (2). Hearing

impaired children who have been orally educated

typically rely heavily on lip-reading. On the other

hand lip-reading has many limitations because

without hearing the sounds, many syllables remain

ambiguous due to their similar articulatory

movements. For example labial consonants in /ma/,

/pa/ and /ba/ or the lip rounding of vowels in /tu/ and

/to/ cannot be differentiated. Only 40 to 60% of the

vowels are recognized by the lip-reading system for

a given language (American English). Thus

understanding spoken language is difficult for many

hearing impaired individuals (3, 4).

* All correspondences to: Email: [email protected]


To overcome these deficiencies, several systems

have been created aimed at disambiguating lip-

reading by adding visual information carried out by

the hands. The most current of them is Cued Speech.

Cued Speech is a simple sound-based system of

manual cues, cued in conjunction with spoken words

which makes all the sounds of spoken language,

fully comprehensible for hearing impaired people.

When Dr. Cornett (1967) first invented Cued

Speech, he set out to create a system, based on English phonemes (5, 6). Ever since then many

people have worked to adapt Cued Speech (CS) to

approximately 60 other languages and dialects

which illustrates how useful Cued Speech is. Persian

Cued Speech (1) is an example of Cued Speech

being recently adapted to a language. Persian Cued

Speech is not well known and Persian speaking

communities are required to increase awareness of

it, as well. Persian Cued Speech consists of nine

hand shapes in three hand placements. Placements of

49

the hand code vowels whereas hand shapes (or

configurations) distinguish among the consonants.

Fig .1 shows the adaptation of Cued Speech for

Persian language.

A large amount of work has been devoted to the

effectiveness of Cued Speech. Cued Speech allows

access to complete phonological representations of

speech (5) and language (7 & 8) and improves

reading and writing performances in hearing

impaired children, exactly like hearing children.

Cued Speech has significant effect on perception of

phonemes both with and without sound, so it

improves lip-reading as well (10). Nichols and Ling

(1982) presented 18 profoundly hearing impaired

children, with English syllables in seven conditions

with auditory, lip-reading and cues presentations

combined together. Under audition (A) alone,

subjects correctly identify 2.3% syllables whereas

scores in lip-reading (L), audition + lip-reading

(AL), cues alone (C) and audition + cues (AC)

reached 30-39% without significant differences. The

scores with lip-reading + cues (LC) and audition +

lip-reading + cues (ALC) reached 83.5% and 80.4%,

respectively Mean scores for keywords were more

than 90% in LC and ALC conditions (11). Kaplan

(1974) studied the effect of Cued Speech on speech-

reading performance of the prelingually hearing

impaired individuals. The results showed that the

presence of manual cues improved speech-reading

scores for all types of materials (12). Chilson (1979)

also showed that learning of Cued Speech

significantly improved the speech reading skills of

normal-hearing college students enrolled in

phonetics courses (13). Uchanski et al., (1994)

confirmed the effectiveness of Cued Speech for the

identification of sentences with high or low predict

performance. Subjects obtained mean scores varying

from 78%to 97% with Cued Speech against 21% to

62% with lip-reading alone. French researchers

showed that the subjects exposed early and

intensively to Cued Speech were better lip-readers

for the identification of words and pseudo words

(14).

Cornett (1985), Kipila (1985), Hage, Alegria and

Perier (1989) reported the effectiveness of Cued

Speech on word perception. Several other studies

indicate the efficiency of Cued Speech in several

languages (15, 16, 17), but there is no evidence that

shows Persian Cued Speech can have the same

effect, because Persian phonetic differs from those

languages; So the purpose of this study was to

examine the effect of Persian Cued Speech on

50

perception of Persian phonemes and monosyllabic

words with and without sound (CS + lipreading vs

CS + Audition + lipreading) in hearing impaired

Iranian children. The goals were to examine whether

Persian Cued Speech improves auditory perception

and lip-reading of the nonsense syllables and mono-

syllabic words or not and whether this effect sustains

after the training.


Participants: Sixteen profoundly prelingually hearing

impaired children (eight boys and eight girls), ages

9-12 years old were recruited in this study.

Audiograms showed a pure tone average hearing

loss of 90 dB or more for the better ear, according to

the most recent available medical records. All

participants studied in special schools for the hearing

impaired in Tehran city. All were native speakers of

Persian (Farsi) language and preferred an oral

communication mode and had no other disabilities.

The participants were matched with each other in

IQ, age and sex so that we had two matched pair

groups. Each group consists of eight children (four

girls and four boys).

Instruments: Two tests were elaborated to achieve

the goals of the study. The purpose of the materials

selected was to ensure that the participants'

responses were exclusively due to perception that is

they were not deduced from the context. For this

reason two tests were administered: Speech

Discrimination Score Test (SDS) and Sara test

(No.2). Both of the tests were administered

individually for each participant.

SDS is one of the current routine tests in clinical

audiology. We used one of SDS lists which consist

of 25 monosyllabic words (the Persian version, 18).

In order to examine the lip-reading performance of

the participants, for monosyllabic words, the test

was administered without sound. A female examiner

read each word from the list without sound and

without any exaggeration in lip patterns for each

child. The child should then write whatever he/she

understood on an experimental test page. The

scoring was phonemic-the percent of correct

phonemes not the whole word.

Sara test (19) is a lip-reading test which uses all the

phonemes of Persian language in a simple A-

phoneme-A context, so that the lip-reading

performance of nonsense syllables can be examined.

Errors are not simply counted rather the errors types

are important. In fact groups of phonemes will be

examined not just as a single consonant. For


example if a child mistakes /apa/ with /aba/ or /ama/,

he/she will obtain 50% of the score. Because /p/, /b/

and /m/ are all bilabial and cannot be distinguished

with lip-reading alone. The correct answer will

obtain 100% of the score and 0% means the entirely

incorrect answer.

Procedure: In this study we used a true experimental

design, in which we had pre-test, post-test and

follow-up with control group. Both of the

experimental and control groups were tested three

times, once before and twice after training. The

groups were matched, so they were assumed equal.

The dependent variables were examined in the same

time and the same condition for both groups. Our

study was administered in several stages.

Pre-test stage:

All of the participants, the experimental and the

control group underwent the examination through

both tests.

Cued Speech Training: Training sessions for

Persian Cued Speech were held for the experimental

group. The experimental group was trained in a five-

month training course, in individual sessions. The

training course last five months and each of the

children were taught 1-2 hours per day. In first

sessions we reviewed the Persian phonemes to

assure that the children know enough about the

sounds that make up words. Because Cued Speech is

a phonemic system, Cueing is relatively easy to

learn; it requires about twenty hours to memorize the

system at which point anything that can be spoken

can be cued, albeit slowly. It is best to learn from an

instructor in a face-to-face setting. Classes were

offered in a room in the children's schools. It is

much easier to follow a demonstration than read a

wordy explanation, so we designed colorful cards

each of them for a given hand shape. Learning to cue

is like learning to take shorthand or to type. After the

basic system is learned, regular practice is required

to develop speed and fluency. One must, over time,

develop the performance to automatically translate

his/her internal representations for words as sounds

into manual patterns. Surprisingly, the hardest part is

identifying the sounds one actually produces when

he speaks. Because we're more accustomed to

dividing words into letters for spelling than into

phonemes and this often leads us astray. Afterwards

each hand shape was taught in several sessions so

they became familiar with all of the hand shapes. In

Persian language there are thirty two consonants,

however only nine hand shapes are necessary to

make each consonant visually distinct. We started


with hand shape No.9 which represents for /gh/

which is a phoneme sound like /r/ in French

language. We used it with vowels /a/ and /i/ which

are produced in side placement-beside the face.

Then hand shapes No.5, No 3, No.2.....were taught.

Then the hand placements (vowels) were practiced.

In the last month, two syllabic words and then multi-

syllabic words and sentences were introduced to the

children.

Figure 1: Persian Cued Speech (Movallali, 2009)

Post-test Stage: Immediately after the completion

of Cued Speech training, all of the participants, both

experimental and control group were examined with

SDS and Sara tests, in Cued Speech plus lip-reading

condition.

Follow-up: One month later, both tests were

repeated with and without sound for all of the

children, with Cued Speech.

For statistical analysis, descriptive statistics were

examined at first. Then to answer the study

questions, we used mixed repeated measurements so

that the effect of Cued Speech on phoneme and

monosyllabic word perception of experimental and

control group in pre-test, post-test and follow-up can

be studied.

51

Results

In this study, we examined the effect of Persian

Cued Speech on phoneme and monosyllabic words

in Iranian profoundly hearing impaired children. The

results are presented in two parts. In the first, we

examined the results of the effect of Persian Cued

Speech on the perception of Persian language

phonemes (nonsense syllables) with and without

sound. And secondly, we presented the effect of

Persian Cued Speech on the perception of

monosyllabic words.

A: Persian language phonemes (nonsense syllables), Sara Test

The results of within-subjects effects of Cued

Speech on perception of phonemes showed that the

amount of the obtained F (516.90) in perception of

phonemes without sound and F (748.01) in

perception of phonemes with sound in two groups

(experimental and control group) was significant (α

=0.01). It is obvious that there was significant

difference in perception of phonemes both with and

without sound in pre-test, post-test and follow-up

stages between experimental and control group.

The between subject effects of Cued Speech on

perception of phonemes results were F (3427.02)

with sound and F (34830.18 ) without sound in two

groups (experimental and control group). Therefore

we can indicate that there is a significant difference

(α =0.01) between perception of phonemes with and

without sound in experimental and control groups.

Therefore mean scores of the perception of

phonemes with and without sound are higher than

control group in post-test and follow-up. That is

Cued Speech had improved the perception of

phonemes with and without sound in experimental

group. The effect size was 0.99 for phoneme

perception with sound and 0.97 without sound that

shows how great the effect of Cued Speech on

phoneme perception is.

52

B. Perception of Monosyllabic Words (SDS Test)

The results of within-subjects effects of Cued

Speech on perception of monosyllabic words with

and without sound showed that the amount of the

calculated F in monosyllabic words perception with

sound (F=121.79) and without sound (F=87.81) in

two groups (experimental and control group) were

significant (P =0.01) and showed that there was

significant difference in the perception of

monosyllabic words with and without sound in pre-

test, post-test and follow-up stages between

experimental and control group.

The results of the between-subject effects of Cued

Speech on perception of monosyllabic words

showed that regarding the amount of calculated F

with sound (F=9047.52) and with sound

(F=8667.18) in perception of monosyllabic words in

two groups (experimental and control group), it

could be concluded that there was a significant

difference (P =0.01) between perception of

monosyllabic words with and without sound of the

experimental and control group. Mean scores of

perception of monosyllabic words with and without

sound in experimental group were higher than

control group, in post-test and follow-up. The Cued

Speech had improved perception of experimental

group for monosyllabic words both with and without

sound. The effect size amount for monosyllabic

perception with sound was 0.96 and monosyllabic

perception without sound at 0.95, that showed the

remarkable effect of Persian Cued Speech on

perception of monosyllabic words.

Figure 2 shows the phoneme and monosyllabic word

perception in four (1-Lipreading, 2-Lipreading +

Audition 3-Cued Speech and Lipreading and 4-

Audition + Cued Speech + Lipreading) in hearing

impaired children. As it is shown Cued Speech

improves the phoneme and monosyllabic word

perception of the cases both with sound (audition)

and without sound (lipreading)


Figure 2: Phoneme and monosyllabic word perception in four conditions in hearing impaired

children: 1-L (Lipreading), 2-L + A (Lipreading + Audition) 3-CS + L (Cued Speech and Lipreading) and 4- CS + L + A (Cued Speech + Lipreading + Audition)

The effects of Cued Speech on lip-reading

performances were not related to the chronological

age of hearing impaired children and there was no

significant difference between boys and girls in lip-

reading performance.

Discussion

These results regarding the effects of Cued Speech

on deaf children‟s perception can be summarized in

two points. First, and in consistency with some

previous studies (11, 18), this study provides further

empirical support for the notion that Cued Speech

does enhance lip-reading performance (using speech

materials without sound) effectively. Although most

educators use the term lip-reading to mean the

understanding of spoken language through its visible

manifestations, and despite the importance of lip-

reading for hearing impaired pupils, even with

extensive training, most hearing impaired persons

are inferior to the average hearing persons in ability

to lip-reading without sound (5).

Second, we examined the effect of Cued Speech on

speech perception of hearing impaired children in

two areas, phonemes and monosyllabic words, and


the effect was very astonishing: phonemes and

monosyllabic words perception with and without

sound was almost completed with cues.

The mean score obtained for the perception of

phonemes (without sound) in experimental group

increased from 19 (pre-test) to 99.52 ( post-test ) and

99.62 ( follow-up) and for perception of phonemes

with sound the mean score increased from 21.12

(pre-test) to 99.25 (post-test) and 99.62 (for follow-

up). But the difference of mean scores in control

group was not significant. So mean scores of

phoneme perception with and without sound in

experimental and control groups were significantly

different. These results indicate that using Cued

Speech, phoneme perception is almost completed.

Previous studies gained such results too (20, 21).

The results pertaining the effect of Cued Speech on

perception of monosyllabic words showed that there

was a significant difference between word

perception in experimental and control group both

with and without sound in pre-test, post-test and

follow-up. Assessments while the mean scores of

control group remained almost the same from pre-

test to post-test and follow-up, there was a

53

significant difference between mean scores of

experimental group in pre-test (44.75), post-test

(98.25) and follow-up (98.75) for monosyllabic

words without sound and an increase from 46.37

(pre-test) to 97.87 (post-test) and 98.62 (follow-up)

for monosyllabic words perception with sound.

These findings again showed the strong effect of

Cued Speech on perception of monosyllabic words

in Persian language, which was in congruence with

previous studies (12, 20). The results also indicate

the great effect of Persian Cued Speech on

lipreading and perception of phonemes and

monosyllabic words do not show significant

differences with and without sound. In the other

word even if there is no sound, the perception is

completed (because of lipreading). One possible

explanation for the excessive improvement effect of

Persian Cued Speech on lip-reading performance

might be related to the Persian phonetics. We have

no diphthongs and have only six vowels in Persian

language so we use only three hand placements,

each representing two vowels, thus Persian Cued

Speech is much more easier to learn than Cued

Speech in some other languages.

References 1. Movallali G. Developing the Persian version of Cued speech

and evaluation of its impact on speech perception of hearing impaired school age children .Unpublished Ph.D thesis, Faculty of Psychology, Tehran University, Tehran, IRAN,2009, [Persian].

2. McGurk H & MacDonald J. Hearing lips and seeing voices.

Nature.1976; 264, 746-748. 3. LaSasso CJ, Crain KL, Leybaert J. Cued Speech and cued

language for deaf and hard of hearing children , San Diego:Plural Publishing,Inc.2010.

4. Portolano M. Cued American English: a variety in the visual mode. Word Englishes.2008; 27, 2, 196-216.

5. Cornett RO and Daisey M. The Cued Speech resource book for parents of hearing impaired children (2nd ed.).Cleveland, OH: National Cued Speech Association. 2001.

6. Alegria J, Leybaert J, Charlier B, Hage C. On the origin of phonological representations in the hearing impaired: Hearing lips and hands .In: Alegria J, Holender D, Morais JJD, Radeau M.(Eds), 1992.Analytic Approaches to Human Cognition.Elsevier Science Publishers,Amsterdam,pp.107- 132.

7. La Sasso C and Metzger M. An alternate route for preparing hearing impaired children for BiBi program: The home language as L.I. and Cued speech for conveying traditionally-spoken language. Journal of Hearing impaired Studies and Hearing impaired Education.1998;3,264-289.

8. Torres S, Moreno-Torres I, Sontana R. Quantitative and qualitative evaluation on linguistic input support to a prelingually deaf child with cued speech. A case study .J Deaf Stu Deaf Educ.2006;11(4):438-448.

9. Leybaert J. La lecture chez l'enfant sourd:l'apport du Langage Parle' Complete.Revue Francaise de Linguistique Appliquee. .,1996 ;1,81-94.

10. Neef NA and Iwata BA. The development of generative

54

One of the study's limitations was that we could not

examine long term effects of Persian Cued Speech

on children's performances, because Persian Cued

Speech is a very newly-introduced system in our

country. Although lip-reading skill is desperately

important to a hearing impaired person, yet it

appears that only a few of them tend to become very

good lip-readers. Prior knowledge of spoken

language is probably the single important factor in

becoming able to lip-read well. The prime function

of Cued Speech during the early years is language

development through easy and clear communication,

therefore it seems reasonable to assume that

children, who grow up on Cued Speech in the home,

will often be skillful in speech perception and lip-

reading (5, 22).

Conclusion

In sum, we can conclude that Persian Cued Speech

strongly contributes to skill in lip-reading. It does

improve the perception of phonemes and

monosyllabic words and so can improve the hearing

impaired children‟s overall language skills. Further

researches are needed to examine long term effects.

lipreading skills in hearing impaired persons using Cued Speech training, Analysis and Intervention in Developmental Disperformance, 1985; 5 , 4 , 289-305.

11. Nichols G, Ling D. Cued Speech and the Reception of Spoken Language, Journal of Speech and Hearing Research,1982;25,262-269. 12. Kaplan H. The Effect of Cued Speech on the Speech reading Performance of the Hearing impaired. Dissertation Abstracts International.1974.36, 2, 645B. 13. Chilson RF. Effects of Cued Speech on Lip-reading Performance. Unpublished master's thesis, University of Rhode Island. 1979. 14. Alegria J, Charlier B, Mattys S. The Effect of lip-reading and Cued Speech in the Processing of Phonological Information in French-educated Hearing impaired Children,European .Journal of Cognitive Psychology.

1999;11,4,451-472. 15. Cornett RO. Diagnostic factors bearing on the use of cued speech with hearing impaired children, Ear and Hearing, .1985;6,1,33-5. 16. Kipila B. Analysis of an oral language sample from prelingually deaf child's cued speech. Cued speech annual, 1985; 1, 46-59. 17. Hage C, Alegria J, Perier O. Cued Speech and language acquisition: The case of grammatical gender morpho- phonology. In Martin D (Ed.), Advances in cognition,

education and hearing impairedness. Washington, DC:Gallaudet University Press. 1990.

18. Delfi M. Evaluation of speech discrimination scores (SDS) in normal hearing and noise induced high frequency hearing impaired workers of fulad company in Khuzestan ,Unpublished Master's dissertation .Iran Medical University. Tehran, IRAN, 2009, [Persian]. 19. Movallali G, Biglarian A. Designing Sara Lipreading test (No2) and implementing it in a group of hearing adults, J


Reh 2003;4(13):53-58 [Persian] 20. Nicholls G. Cued Speech and the reception of spoken English. Unpublished Ph.D. Thesis , McGill University,

Montreal , Canada. 1979, 21. Perrier O, Charlier B, Hage C, Alegria J. "Evaluation of the effects of prolonged cued Speech practice upon the perception of spoken language".1989. In I.G Taylor (Ed) "The education of hearing impaired: Current


perspectives",1985;1, International Congress on education of the hearing impaired. Beckenham, Kent, UK: Croom

Helm Ltd. (Reprinted in Cued Speech Journal, 1990; 4). 22. Montgomery AA, Jackson PL. Physical Characteristics of the Lips Underlying Vowel Lip-reading Performance, Journal of the Acoustical Society of America .1983;

73,6,2134-2144.

55


Original Article

Prevalence of Feeding Problems in Children with Intellectual

Disability

Mohammad Rezaei, MSc; Vahid Rashedi, MSc Faculty of Rehabilitation Sciences, Hamedan University of

Medical Sciences & Health Services, Hamedan, Iran

Masoud Gharib*, MSc Pediatric Neurorehabilitation Research Center, University of

Social Welfare & Rehabilitation Sciences, Tehran, Iran

Gohar Lotfi, MSc University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Objectives: Feeding is an essential function which affects quality of life of the intellectually disabled (ID) persons. Approximately 80% of the severe and profound mentally retarded population have some feeding difficulties. This study aimed to determine the prevalence of feeding problems in children with ID.

Methods: In this cross-sectional descriptive study, 144 individuals with Intellectual Disability referred to speech

and language pathology clinic were included using random sampling. To gather the data, Screening Tool

of feeding Problems (STEP) was used. ِData analysis was done through SPSS.

Results: The findings of the study indicated that all subjects were somehow involved with feeding

problems. The results also show that mean score of problem in feeding skills (2.41) are most prevalent and

aspiration risks (0.37) are of less prevalence among the subjects. Analyses revealed that gender and level of ID

severity are effective factors in feeding problems.

Conclusion: Our study indicates that in children with ID, eating problems are more prevalent than

previously reported. The importance of these data is further underscored by the fact that the majority of these

feeding problems had not been previously identified.

Key words: Feeding problems, Intellectual disability, Screening Tool of feeding Problems

Introduction

Feeding, an essential adaptive function that affects

quality of life of the intellectual disabled persons

(ID), is a complex sensorimotor process that

involves integration between the nervous system and

the muscles and is affected by environmental factors

(1). Feeding enables the child to grow up, learn, and

develop relationships with others (2) and is

associated with the development of social and

communicational skills (3). Any deficit in structure

and/or function can lead to difficulties in performing

feeding activities such as chewing, swallowing, and

drinking (4). These feeding problems have been

linked to various disorders, including ID (5), and

shown to affect physical, mental, social and

educational development (6, 7).

Feeding disorders are common in early childhood;

the incidence of minor feeding problems has been


56

ranged between 25% and 35% in normal children

(8). Palmer, Thompson, and Linscheid reported that

approximately 1/3 of individuals with developmental

disabilities have some feeding problems,

furthermore approximately 80% of the severe and

profound mentally retarded people have some

feeding difficulties (9).

There are numerous types of feeding problems in the

developmentally disabled people, and assessment

and treatment should be tailored to address each

specific one. Sisson and Van Hasselt suggested that

feeding problems could be divided into four

categories; (1) lack of independent skills, (2)

disruptive behavior, (3) eating so much or little, and

(4) selectivity (by type and texture) (10). Though

these categories do account for many feeding

problems, they are not comprehensive. Other

feeding problems presented among the mentally


retarded population that are not included in this

model are rumination, vomiting, pica, food stealing

(during and/or outside of meal times), and other

areas of selectivity (i.e., setting, temperature, and

feeder). Fredericks, Carr, and Williams found that

6-10% of developmentally disabled persons living

in institutional settings engage in rumination

(behaviors that repeatedly bring food past one‟s

airway) (11). Unfortunately, risks associated with

rumination are aspiration, suffocation and/or

pneumonia which can be fatal. According to

Konarski, Favell, and Favell rumination is estimated

to be the cause of death in 5-10% of those who

ruminate (12). Pica is another serious behavior that

occurs in 9-25% of mentally retarded individuals in

institutional settings (13). Individuals who ingest

inedible objects (i.e., pica) such as paint chips and

cigarette butts are at great risk of poisoning and

intestinal obstruction (14). Individuals who are food

refusal or food selective, either by type (e.g., eat

only cheeseburgers), texture (e.g., eat only pureed

foods), temperature (e.g., eat only foods of room

temperature), feeder (e.g., will only eat if fed by

their mother), location (e.g., will only eat alone), or

a combination of these, are at risk of malnutrition,

and possibly the need for a feeding tube if they do

not take in enough food or lack a well balanced diet.

Many feeding difficulties pose serious health risks,

including aspiration, the need for feeding tubes,

poisoning, and malnutrition (15). O‟Brien, Repp,

Williams and Christophersen discussed the lack of

feeding skills that can result being maintained on a

developmentally inappropriate diet/food texture

(16). An inappropriate diet for the individual‟s

developmental level can result in delayed

development of chewing and sucking. Systematic

and effective identification of feeding problems and

problematic mealtime behaviors is essential in order

to inform the physicians and therapists (i.e., psychologists, nutritionists, speech therapists and

occupational therapists) who can be involved with

evaluation and treatment (17). However, only slight

evidence exists whether how people on the various

levels of ID differ in amount and type of their

feeding problems. According to the aforementioned

issues, the prevalence of feeding problems in ID

children has been targeted in the present study.


Participants In this cross-sectional descriptive study, 144

individuals with intellectual disability (mild, moderate and


profound percentiles were 4.8%, 14.2% and 72%

respectively) referred to speech and language

pathology clinic of University of Social Welfare and

Rehabilitation Sciences were recruited using random

sampling. Diagnoses of intellectual disability were

previously made by individually administered

intelligence tests (e.g., Stanford-Binet IV).

Materials To gather the data, feeding problem questionnaire

was used as well as demographic questionnaire

which contains gender, age, height, weight, BMI,

IQ, type of disability, mothers' age and education.

To detect feeding problems in participants, we

applied the Screening Tool of feeding Problems

(STEP). The STEP is a 23-item feeding problem

screening instrument for persons with intellectual

disability. The contents of screening instrument were

instructed to respond the items in terms of two

dimensions, frequency and severity. Each dimension

can be rated on a 3-point Likert-type scale. On the

frequency dimension, “0” indicates no occurrence of

the behavior in the last month, “1” indicates the

behavior occurred once to 10 times, and “2”

indicates the behavior has occurred more than 10

times. For the severity dimension, “0” suggests that

the behavior does not cause any harm or problems,

“1” presents the behavior causes some problems

and/or results in harm, and “2” shows that the

behavior causes serious problems and/or injury. The

general categories of feeding problems included:

aspiration risk, selectivity, feeding skills, food

refusal related behavior problems, and nutrition

related behavior problems.

Data analysis The obtained data from the questionnaires were initially analyzed by descriptive statistics.

Continuous variables are presented in terms of mean

value, SD and range. Data analysis was conducted

using the statistical package for the social sciences

(SPSS) version 12. Simple percentages were

obtained, Independent t-test and Univariate analysis

of variance (ANOVA) were used and correlation

analyses were also performed to assess the

association between variables. P< 0.05 level was

considered for statistical significance.

Results

The number of participants was 144 (96 male, 48

female) ranging from 3 to 13 years old with standard

deviation of 2.125. Distribution of these children

was as follow: 30 down syndrome (20.8%), 30

autistic (20.8%), 46 cerebral palsy (31.94), and 36

57

other disabilities (26.38) with IQ scores of 32 for

mild (22.22%), 80 moderate (55.55%), and 32 cases

severe with ID (22.22%).

Mothers' minimal and maximum ages were 26 and

55 respectively with the SD of 6.47 whose academic

levels included; 10 under diploma (6.94%), 88

diploma (61.11%), 2 associate diploma (1.38%), 40

BSc (27.77%) and 4 MSc (2.77%). Other

Table 3

Variable

Feeding

Problems

Table 4

N = 144

Sever Moderate Mild

Mean SD Mean SD Mean SD

13.81 8.45 6.37 3.15 3.62 1.50

N = 144

SS df MS

P value

< 0.001

F demographic information is presented in table 1. Between Groups 927.93 2 463.96 21.40 Total feeding difficulties for individuals were Within Groups 1495.56 141 21.67

measured by the sum of responses to the 23- STEP Total 2423.50 143

items (with scores ranging from 0 to 46). The

findings of the study indicated that all subjects were

somehow involved with feeding problems. Mean

score for total STEP was 7.41 with a SD of 2.84.

Results showed that among the all participants 42

(29.16%) were at aspiration risk, 106 (73.61%) had

disability of selectivity, 114 (79.16%) showed

feeding skills disorders, 92 (63.88%) suffered from food refusal related behavior problems and 96

(66.66%) with nutrition related behavior problems.

The other results indicate that mean scores of

problem in feeding skills (2.41) are most prevalent

and aspiration risks (0.37) are of less prevalence

among the subjects.

Analyses were also implemented to determine the

mean score in STEP depending on the participants'

gender and level of ID. Independent t-test was used

for comparison between the male and female and

among the mild, moderate and severe levels of ID

group. Severity of feeding difficulty was observed to be

greatest in male participants (table 2). As seen in

tables 3 and 4, the severity of feeding problem was

also greatest for those with severe ID compared to

the mild and moderate level of ID group.

Table 1

N = 144

Discussion

Proper eating/feeding behaviors are important to

have a healthy lifestyle (18). Feeding problems are

serious clinical problems that complicate the

management of children with intellectual disabilities

(19). The results of the current study show a high

prevalence of feeding problems in children with ID.

Other studies report feeding problems in about 80%

of children with intellectual disabilities (9). The

present results suggest a higher prevalence of

feeding problems in children with ID. This is

consistent with the study of Matson (13). Similar to

other problem behaviors in ID, the etiologies of

feeding problems are usually discussed as either

medical or environmental (e.g., esophageal reflux

and food refusing as medical and environmental,

respectively). The most prevalent feeding problems found in this study were in the area of feeding skills, including, inability to feed him/herself independently, requiring special equipment for feeding, and requiring special positioning during feeding. This finding is similar to Matson (13). Feeding skill disorders include items which are motor oriented, may derive from sensory motor difficulties affected by sensory modulation, muscle tone, coordination and endurance that

Variable

Height*

Weight**

BMI * Meter ** Kilogram

Table 2

Variable

Feeding

Problems

58

Min Max Mean

0.75 1.60 1.20

8.00 52.00 28.13

10.20 32.00 18.57

N = 144

Female Male

Mean SD Mean SD

6.12 3.04 8.06 6.76

influence ability in timing and accuracy of the SD 0.21 mouth movements, or from sensory-motor

11.54 disabilities that affect control of the food in the 4.16 mouth. Indeed, the literature suggests that children

with ID often present difficulties in their motor skills that are affected by their general severe brain damage, lack of motivation to develop motor learning, and decreased heart activity (19). The lack of motor experiences may also result in further

P value motor limitations (20). In this instance, being male and more severely intellectually disabled further

0.004 increases the ID person‟s risk for feeding problems. This result should be taken into account in the planning of clinical services, particularly with respect to feeding issues.


Conclusion

To conclude, our study indicates that in children

with ID, eating problems are more prevalent than

previously reported. The importance of these data is

better underscored by the fact that the majority of

these feeding problems had not been previously

identified. This study may therefore have great

implications for the places where clinicians can

direct efforts and preventative care. It is of

importance that all children with ID will be assessed

for feeding problems, and these problems will be

treated using suitable and proper methods.

References 1. Eynat G, Reem HN, Batya EY. The relationship between the severity of eating problems and intellectual developmental deficit level. Research in Developmental Disabilities. 2011; 32 (5): 1464-1469. 2. Morris SE, Klein MD. Pre-feeding skills: A comprehensive

resource for feeding development. 2nd ed. USA: Academic Pr. 2001.

3. American Occupational Therapy Association. Problems with eating: Interventions for children and adults with developmental disabilities. USA: The American

Occupational Therapy Association.1996. 4. Case-Smith J. Intervention strategies for promoting feeding skills in infants with sensory deficits. Occupational Therapy in Health Care. 1989; 6 (2-3): 129-141. 5. Chatoor I. Diagnosis and treatment of feeding disorders in infants, toddlers and young children. USA: Zero to three. 2009. 6. Gravestock S. Diagnosis and classification of eating disorders in adults with intellectual disability: The diagnostic criteria for psychiatric disorders for use with adults with learning disabilities/mental retardation (DC-LD). Journal of Intellectual Disability Research. 2003; 47 (1): 72- 83. 7. Laud RB, Girolami PA, Boscoe JH, Gulotta CS. Treatment outcomes for severe feeding problems in children with autism spectrum disorder. Behavior Modification. 2009; 33 (5): 520-536. 8. Colin DR, Dana TL. Feeding disorders in infants and children. Pediatric Gastroenterology and Nutrition. 2002; 49 (1): 97-112. 9. Palmer S, Thompson RJ, Linscheid TR. Applied behavior analysis in the treatment of childhood feeding problems. Developmental Medicine and Child Neurology. 1975; 17 (3): 333-339. 10. Sisson KA. Van Hasselt VB. Feeding disorders. In Luiselli JK. Behavioral Medicine and Developmental Disabilities. USA: Springer-Verlag. 1989.


Intervention services may not only affect the quality

of life of those with ID, but may also have potential

to prevent further eating problems, and direct impact

on the physical and emotional wellness of children

with ID.

Acknowledgement

We are so grateful to Amir Rahmani Rasa for

reviewing the original article. The authors thank the

children and their families for good cooperation in

the study.

11. Fredericks DW, Carr JE, Williams WL. Overview of the treatment of rumination disorder for adults in a residential setting. Journal of Behavior Therapy and Experimental Psychiatry. 1998; 29 (1): 31-40. 12. Konarski EA, Favell JE, Favell JE. Manual for the assessment and treatment of the behavior disorders of people with mental retardation. USA: Western Carolina Center Foundation. 1992. 13. Matson JL, Fodstad JC, Boisjoli JA. Cutoff scores, norms and patterns of feeding problems for the Screening Tool of feeding Problems (STEP) for adults with intellectual

disabilities. Research in Developmental Disabilities. 2008; 29 (4): 363-372.

14. Matson JL, Bamburg JW. A descriptive study of pica behavior in persons with mental retardation. Journal of Developmental and Physical Disabilities. 1999; 11 (4): 353- 361. 15. Matson JL, Kuhn DE. Identifying feeding problems in mentally retarded persons: development and reliability of the Screening Tool of feeding Problems (STEP). Research in Developmental Disabilities. 2001; 22 (2): 165-172. 16. O‟Brien S, Repp AC, Williams GE, Christophersen ER. Pediatric feeding disorders. Behavior Modification. 1991; 15 (3): 394-418. 17. Matson JL, Smiroldo BB. The Validity of the mania subscale of the Diagnostic Assessment for the Severely Handicapped-II (DASH-II). Research in Developmental

Disabilities. 1997; 18 (3): 221-225. 18. Rurangirwa J, Van Naarden Braun K, Schendel D & Yeargin-Allsopp M. Healthy behaviors and lifestyles in young adults with a history of developmental disabilities. Research in Developmental Disabilities. 2006; 27: 381-399. 19. Schwarz MS. Feeding disorder in children with developmental disabilities. Infants and Young Children. 2003; 16 (4): 317-330. 20. Antero M, Pauli R & Ulla L. Physical performance of individuals with intellectual disability: A 30-year follow-up. Adapted Physical Activity Quarterly. 2007; 24 (2): 125-143.

59


Original Article

The Prevalence of Ear Disease in Sensorineural Hearing Impaired

Children Below 18 Years-Old in Deaf Welfare Clinic of Molavi

Rehabilitation Center

Naeimeh Daneshmandan, MD; Samaneh Hosseinzadeh, MSc; Robab Teymouri*, PhD Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation

Sciences, Tehran, Iran

Objectives: Hearing impairment in children is considered as an important public health problem.

Auditory function in these children is poor and depends on their hearing aids efficacy and also their ears‟ status.

Hearing aids are very expensive and ear disease deteriorates its performance. Therefore detecting the ear

disease and offering proper treatment is necessary. The aim of this study is to highlight the prevalence of

ear disease in children with SNHL to justify the efforts made to insure diagnosis and adequate treatment.

Method: Eighty children with bilateral sensorineural hearing loss were selected in our study from deaf

Welfare Clinic affiliated to Welfare Organization. Otological examination and tympanometry were

performed for all these children.

Results: The most pathologic finding was ear wax and observed in 37 children (48.7%). Ear discharge was

seen in 7 (8.7%) children. Normal TM in 63 (81.8%), abnormal TM in 14 (18.2%) and perforated TM in 3

cases were detected.

Conclusion: The most common disorder was wax which deteriorates hearing aids performance by clogged ear molds. Middle ear disease which aggravates the degree of hearing loss in one forth of

children was observed. The high prevalence of external and middle ear disease highlights the need of regular otological examination in hearing impaired children.

Key words: Prevalence, Ear disease, Deafness, Children, Wax

Introduction

Hearing loss in early childhood can affect the

development of speech and language, social and

behavioral status, attention and academic achievement of

children (1). External and middle ear diseases can

affect auditory performance (2). Ear disease is

common in a general population in any part of the

world. External ear disease is the most common

cause of visits in the district hospital of Ear, Nose

and Throat departments (3). Acute otitis media in

children is one of the most frequent reasons for

concerned parents to take their child for medical

services (4, 5). Many studies performed to determine

the prevalence of ear disease in normal and hearing

impaired children. Jacob et al. in an investigation

showed that, most of children with hearing

impairment had associated middle ear disease (6). A

study in the first year school children showed that

the most common disorder was wax and in

consequence was middle ear disease. The prevalence


60

of inactive ear disease in these children was the third

common disorder (7). The other study in students of

deaf school performed and ear examination findings

showed that impacted wax was the most common

pathology and the second prevalent disease was

middle ear disease (8). Sensorineural Hearing Loss

(SNHL) children are not sensitive to changes in their

hearing threshold, so there is a need for regular

otological examination in this group to detect and

diagnose any extra or deteriorating conductive

hearing loss (9). On the other hand, hearing aids are

an important resource for the rehabilitation of

hearing impaired children and additional conductive

hearing loss may affect their hearing aids‟ efficacy

(10, 11).

The aim of this study was to determine the

prevalence of ear disease in hearing impaired

children in order to enhance the role of regular

otological examination in deaf rehabilitation centers.


Materials & Methods

A cross-sectional study was designed. The study

population comprised of 80 SNHL children below

18 years-old from rehabilitation center (Molavi)

affiliated to Social Welfare Organization in 2010-

2011. All cases were examined by otolaryngologist

to determine the ear disease among them.

Tympanometry was performed to confirm our

clinical evaluation of middle ear and tympanic

membrane status. Tymponometry was not performed

in perforated TM. In calculating the individual ear‟s

hearing loss, we used the average of 500, 1000, and

2000 HZ SNHL in better ear. The deafness was

classified as slight hearing loss if the threshold level

was between 10-25 , and mild if it was between 25-

50, moderate if it was between 51-70 , severe if it

was between 71-90, and profound if it was between

91-110 dB.

Results

The range of age was 2-18 with mean 10 years. There were 49 boys (61%) and 31 girls (39%). In external ear examination, wax was present in 37 children (48.7%) of whom 27 children had bilateral wax. Ear discharge was seen in 7 children (8.7%). The most of children had Tympanogram type A (81.8%). Abnormal tympanogram was seen in 14 (18.2%) children. Among the 8 cases with type B, four cases had inactive chronic ear disease and four cases had middle ear effusion. In the last group, three cases respond to medical treatment and one case has been operated. Three children had perforated TM (table 1). The most frequent degree of hearing loss was severe to profound (46.3%). Four cases had serious otitis media, of whom three cases responded to medical treatment, and in one myringotomy with grommet insertion was performed (table 2).

Table 1: distribution of tympanometry types in deaf

children

Tympanometry type No. of case (%)

normal (Type A) 63 (81.8)

Abnormal (Type B, C,…) 14 (18.2)

Table 2: distribution of degree of hearing loss in

deaf children

Degree of hearing loss No. of case (%)

Severe to profound hearing loss 37 (46.25)

Severe hearing loss 17 (21.25)

Moderate hearing loss 18 (22.5)

Mild hearing loss 4 (5)

Slight hearing loss 4 (5) Iranian Rehabilitation Journal

Discussion

Ear disease in general population is very common

(12). On the other hand, external and middle ear

disease can affect auditory performance. Auditory

function in hearing impaired children is poor and

dependent on their hearing aids‟ efficacy and their

ears‟ status too. Ear disease can affect the hearing

threshold but SNHL children are not sensitive to

these changes. Many studies investigated this

problem and showed the high prevalence of ear

disease in hearing impaired children.

Our study showed that wax in SNHL children was a

common disorder (49%) but its prevalence in other

studies such as Swart (1995), Karatas and Egeli

(2003) was 7%, 23% and 39% respectively (7, 8, 13). So,

this comparison indicated that, wax problem was more

frequent in deaf children in our studied group.

We also investigated the middle ear disease in

SNHL children. Eighteen percent of them had

abnormal TM that was less than abnormal TM in

Egeli‟s report (22%) (7). It was compared with

Kartasl and Oztruk studies, (8%) (10, 13) which

showed lower frequency than ours. In our findings 3

children (3.7%) had perforated TM which it was

compatible with the study of Kamal-Eldin et al that

reported 25% middle ear problem and 5% perforated

TM (14).

Roser in 2004 discussed about the aided speech

threshold changes from 40 dB to 90 dB because of

the clogged ear molds by ear wax (11). As we

showed 49% of our NSHL children had wax which

was a few more than other studies.

Most of investigated children (90%) in the present

study had hearing loss with degree of moderate to

profound. The degree of hearing loss in other

studies showed that more than 90% were moderate

to profound too (8-14). We indicated that prevalence

of some of ear diseases in sensorineural hearing

impaired children is high and regular otological

examination is needed and tympanometry as a part

of the screening protocol to diagnose middle ear

disease is essential.

Acknowledgements

This study was supported by the Deputy of Research

and Technology grant from University of Social

Welfare and Rehabilitation Sciences.

I would like to thank Mrs. Malihe Sahami, the head

manager of Molavi Rehabilitation Center, Mrs.

Maryam Panahi, the head of Audiology Department

and finally the hearing impaired children and their

families for their good cooperation in this study.

61

References 1. Storbeck C and Calvert-Evans J. Towards Integrated

Practice in early detection of and Intervention for Deaf and

Hard of Hearing Children, American Annals of the Deaf,

2008. 153(3): p. 314-321.

2. Behrman RE, Kliegman RM and Jenson HB. Nelson text

book of pediatrics, ed. 16. 2000: W.B Saunders Company.

3. Paparela, et al. Otolaryngology, ed.3, 1991: W. B. Sanders

Company.

4. Hayes D, and Northern JL. Infants and Hearing, 1996:

Singular publishing group.

5. Northern JL and Downs MP. Hearing on children, ed. 5.

2002: Lippincott Williams and Wilkins. 6. Jacob A et al. Hearing impairment and otitis media in a rural

primary school in south India. Int J Pediatr Otorhinolaryngol, 1997. 39(2): p. 133-8.

7. Swart S et al. A survey of ear and hearing disorders amongst

a representative sample of grade 1 schoolchildren in

Swaziland, Int J Pediatr Otorhinolaryngol, 1995. 32(1): p. 23-34.

8. Egeli E, Ciçekçi G, and Oztürk O. ear examination findings

62

at the Yeditepe School for the Deaf. Int J Pediatr Otorhinolaryngol, 2003. 67(8): p. 905-10.

9. Elango S, Htun Y, and Raza H. Additional conductive hearing loss in children from a school for the deaf in

Malaysia. Int J Pediatr Otorhinolaryngol, 1994. 28(2-3): p.

125-8.

10. Ozturk O et al. Evaluation of deaf children in a large series

in Turkey, Int J Pediatr Otorhinolaryngol, 2005. 69(3): p. 367-73.

11. Roser RJ and Downs MP. Audiotry disorders in school

children. 2004 New York: Thieme.

12. Berzon D. Ear Disease in a group general practice. A review

of world communities. J Laryngol Otol, 1983. 97(9): p. 817- 24.

13. Karatas E, Kanlikama M and Mumbuc S. Auditory functions in children at schools for the deaf, J Natl Med Assoc, 2006.

98(2): p. 204-10.

14. Abou-Elhamd K-EA, Moussa A-E and Soltan MA-E,

Prevalence of middle ear pathologies in children with

bilateral sensorineural hearing loss, International journal of

Pediatric Otorhinolaryngology, 2006. 70: p. 1081-1084.



Original Article

Co-Morbidity of Attention Deficit Hyperactivity Disorder (ADHD)

and Tourette Syndrome in Child Referral Psychiatry Clinic in IRAN

Sahel Hemmati* MD; Nasrin Amiri, MD; Robab Teymouri, PhD; Masoud Garib, MSc;

Pediatric Neurorehabilitation Research Center, University of Social

Welfare and Rehabilitation Sciences, Tehran, Iran

Objectives: Tourette syndrome is a disorder with motor and vocal tics, which has many psychiatric

comorbidities. Attention Deficit Hyperactivity Disorder (ADHD) is one of co-morbid features of this

syndrome. The aim of this research is studying Tourette and co morbidity ADHD in school age children. One

of our purposes is to identify the range of ADHD in Iranian Tourette patients.

Methods: Thirty children with Tourette syndrome attended in an adolescence psychiatry disorders clinic

studied during one year using a descriptive, cross sectional method. Control group selected from students of

Tehran schools matched to first group in age and sex. K-SADS questionnaire used to investigate the presence

of ADHD in both groups. Results analyzed with SPSS.

Results: A clear pattern of co-morbidity was demonstrated with ADHD. Seventy percent of Tourette

group had ADHD; this co-morbidity in both sexes was different (20% of girls and 80% of boys).

Conclusions: Although the frequency of ADHD co-morbidity with Tourette is high, but in our study was

higher (50-60% versus 70%). Hence every Tourette patients must be studied for co-morbidity.

Regarding to small size of studied people, similar studies must be performed with larger sample size.

Key words: Attention Deficit Hyperactivity Disorder (ADHD), Tourette syndrome of childhood, Comorbidity, K-SADS.

Introduction

Tourette disorder is a chronic, potentially disabling,

neuropsychiatric disorder of childhood (1). Its

symptoms are involuntary multiple motor and phonic tics, not necessarily concurrent (2). Tics

show waxing and waning patterns in childhood, (2-

3) with a tendency of decline in late childhood (3).

The prevalence of Tourette disorder is ranging from

3-5 per 10,000 (3-4), it is estimated that milder

cases were not counted (5). The co-morbidity of

Tourette disorder was widely discussed (3-4).

Attention-Deficit Hyperactivity Disorder is more

than any other mental disorders co morbid with

Tourette (6-7). Data from clinical studies indicate

that ADHD symptoms occur in half or all of

Tourette patients. In some studies Tourette

diagnosis, has been diagnosed after ADHD (8).

Material and Methods

This study performed in Rozbeh Child and

Adolescence Psychiatry Clinic of Tehran for one



year. Thirty patients in range of 7-18 years were

recruited in the study. All of 30 children with a

clinical diagnosis of Tourette disorder were

examined individually by the first authors, also

visited by other members of the team. Sampling

methods were simple descriptive-analytical method

and cross sectional method. Parents were

interviewed in accordance with structured DSM-IV-

TR. All children in two groups had IQ test, numbers

lower than 84 were failed for research. This was an

exclusion criterion. There were 5 girls and 25 boys

in our group. We asked to keep on their medications.

At the same time 30 cases were chosen that study in

primary and high school in Tehran. This group was

matched with our patients group in sex and ages, as

well. They were chosen by chance with numbers

from primary and high schools in Tehran. Two

groups were studied with (K-SADS) for psychiatric

disorders. K-SADS (K-SADS is a Kiddy Schedule

for Affective Disorder & Schizophrenia for children)

was used to investigate the presence of ADHD in

63

both groups. It is a standard scale, which is being

used since 1380.

All data were analyzed by SPSS software and

statistical tests (CHI-square, fisher exact test,

Mental Hanzal, Cochran, Paint test, PAIR t-TEST).

Results

In this study thirty children with Tourette disorder (5

girls and 25 boys) investigated (16.7 % were girls

and 83.3% were boys). Their average age was 13.73

(SD=2.06). Majority of them (63.3%) were in 10-15

years old range. While 80% of boys with Tourette

had ADHD, in girls this co-morbidity was 20%

(Table 1). Average age of Tourette patients with

ADHD co-morbidity was slightly less than Tourette

itself. This finding was not statistically significant.

Twenty percent of them (6 patients) had been

referred for evaluation by school health officers,

40% by pediatricians (12 patients) 23.3% (7

patients) by neurologists, 10% (3 patients) by

general practitioners and 6.7% (2 patients) by their

parents (Table 2).

In recruited patients, 53.3% (16 patients) received no

medication and 46.7 % (14 patients) received

neuroleptic for their tics prior the study. Twenty-

four patients (80%) of Tourette patients had motor

tics as a disturbing problem and vocal tics as a

problem found in 17 patients (56.7%). In Tourette

group, 1 girl and 20 boys (70%) had Attention

Deficit Hyperactivity Disorder. In control group, no

one had ADHD (Table 3). There was a significant

difference (p<0.05).

Table 1: Absolute and relative frequency distribution

based on ADHD co- morbidity situation and sex

Co- + - total morbidity

Table 3: Absolute and relative frequency distribution of

Tourette disorder patients based on ADHD co-morbidity

situation Affection + - total

situation/Group number % number % number %

control 0 0 30 100

study 21 70 9 30 30 100

total 21 70 9 30 60 100

Discussion

In this study boys to girls ratio was 5 to 1, similar to a

study in Sweden (their ratio was 6 to 1) (9), but

other studies reported higher ratios (10). Some

researches show this ratio is lower, approximately, 3 to

1 (11). This study has showed, 73.3% of children with

Tourette disorder referred to the other clinics. Base

on some studies from every 6 or 7 of patients, only

one patient referred for checkup (12-13) in the present

study. Among patients 63.1% of them were treated by

relative and appropriate medicine for their co-morbid

psychiatric disorders.

In this study boys with Tourette have higher co-

morbidity with ADHD and average ages in co-

morbid Tourette group was slightly lower than

Tourette patients. These findings are significant and

show that, at first all Tourette children must be

examined for ADHD and other co-morbidities.

Therefore every Tourette patient must be examined

for psychiatry co-morbid especially ADHD by

structural or semi structural interview. We showed

70% of our patients had Attention Deficit

Hyperactivity Disorder. In another study two thirds

of the Tourette, group met the clinical criteria of

ADHD. The degree of clinical impairment is more

strongly correlated with the attention deficits than

with the tic symptoms per se (14). Spencer showed

this result, as well (4). Clinically the findings

confirm other research results, indicating the

/Sex

Boy

Girl

number % number % number %

20 5 20 25 100

1 4 5 100

importance of ADHD in understanding the

behavioral problems that often associated with

Tourette syndrome. Additional ADHD co- total 21 70 9 30 30 100

Table 2: Source of referral in clinical cases of Tourette disorder

Source of referral number %

pediatrician 12 40

neurologist 7 23.3

School health officer 6 20

General practitioner 3 10

Parent without prior

morbidities should be considered in diagnosis,

management, training (15) and accurate prognostic

prediction in the course of illness or acquired

improvement (16), which may affect the patients‟

treatment process (17).

Limitation and Suggestions

Although present study performed in child referral

psychiatry clinic lasted one year, the sample size of consultation 2 6.7

present study was rather small, so there is a need for performing similar research in large groups in different clinics of Iran. The small sample size makes our findings‟ generalization less reliable.


References 1. Scahill L, Leckman JF. Tic disorders. In: Sadock BJ, Sadock VA. Comprehensive textbook of psychiatry, 18th Ed,

Philadelphia, Lippincott Williams & Wilkins; 2005, Vol .4, p: 3228-3235

2. Haerlet T. Children with Tourette syndrome: A parent's guide, 1st ed., Rockville, Woodbine; 2003, p: 16- 25 3. Tanner C, Goldman S. Epidemiology of Tourette syndrome, Neuro Clin 1997; 15:395-402 4. Spencer T, Biederman J, Coffey B, Geller D, Faraone S, and Wilens T. Tourette disorder and ADHD, Adv Neural, 2001; 85:57 5. Biederman J, Coffey BJ, Geller D. Distinguishing illness severity from tic severity in children and adolescents with Tourette disorder, Am Academic Child Adolescent Psychiatry, 2000, May; 39 (5): 556-61 6. Comings DE, C0mings BG: a controlled study of Tourette syndrome in; attention deficit disorder, Learning disorders, and school problems. AmJHumGenet 1987; 41:701-741 7. Kerbershian J, Burd L. Case study: co morbidity among Tourette syndrome, autistic disorder, and bipolar disorder, J Am Aca Child Adolesc Psychiatry 1996; 35:681 - 685 8. Kaplan & Sadock: Tourette disorder, 10th Ed, Synopsis of psychiatry, Philadelphia; Wolters Kluwer, Lippincott, Williams& Wilkins, 2007; p: 1235-1240 9. Larsson B, Frisk M. Social competence and emotional/behavior problems in 6-12 year old Swedish


school children. Eur child Adolescent psychiatry 1999; 8:24- 33

10. Comings DE, Himes J. comings: an epidemiological study of Tourette syndrome in school district; Clin psychiatry 1990; 51:463-465 11. Burd L, kerbeshian J, WikenheiserM, fisher W: Prevalence study of Gilles de la Tourette syndrome in North Dakota school - age children; Am academy child psychiatry 1986; 25:552-3 12. Leckman JF, Peterson BS,Anderson GM, Arnsten AFT, Pauls DL, Cohen DJ. Pathogenesis of Tourette syndrome; Child Psycho Psychiatry 1997;38:119-142 13. Leckman JF, Zhang H, Vitale A. Course of Tic severity in Tourette syndrome: the first two decades. Pediatrics 1998; 14-19 14. Kadesjo B, Gillberg C. Tourett,s Disorder: Epidemiology and Comorbidity in primary school Children, J Am Acad Child Adolesc Psychiatry, 39:5, May 2000.P:548-549 15. Freeman RD. Tic disorders and ADHD: Answers from a world-wide clinical Database on Tourette syndrome. Eurppean child and adolescents psychiatry J, Vol 16.Sup1 15-23 DOI:10-1007/s00787-007-1003-7 16. Swain JE, Leckman JF. Tourette syndrome and tic disorders: Overview and practical guide to diagnosis and treatment, Psychiatry J, 2005, Jul;2(7):28-36 17. Coffey B, Park K. behavioral and emotional aspects of Tourette syndrome, Neuro clin, 1997; 15:277-289

18.

65


Review

Hypertonicity in Children with Cerebral Palsy: a New Perspective

Mehdi Rassafiani, PhD Pediatric Neurorehabilitation Research Center, Department of Occupational Therapy, University of Social

Welfare and Rehabilitation Sciences, Tehran, Iran

Robab Sahaf*; MD, PhD Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Objectives: Hypertonicity is a major problem in children with cerebral palsy that has not been explained

effectively to address clinical decision making. Therefore, this article aims to provide a theoretical framework about hypertonicity for clinicians, rehabilitation and medical practitioners to be used in their practice.

Methods: Literature was reviewed to examine the new perspectives towards the hypertonicity and its

signs and symptoms. Then, these symptoms were scrutinized to identify various aspects of the

phenomena.

Results: The results of this review revealed various components of hypertonicity, including neural and

biomechanical. Neural component was also classified into positive and negative symptoms. These

components altogether influence gross and fine motor function and consequently disturb children in their daily

activities.

Conclusion: Using term “spasticity” is not definitively enough to explain various aspects of the affected

persons. Therefore, the term “hypertonicity” appears to be much appropriate to be used by professions in their

daily practices. Furthermore, to have a very effective intervention, practitioners should consider all various signs

and symptoms of hypertonicity that are explained in this review.

Key words: Hypertonicity, Cerebral palsy, Children

Introduction

As individuals with cerebral palsy (CP) present a large

group of clients visited by occupational therapists,

understanding clinical decision making in this context is

very important. Moreover, the literature suggests that

both pathology and diagnosis can influence clinicians‟

data collection and clinical reasoning, therefore it is

necessary to understand these children in depth.

Hypertonicity is the most prevalent type of CP (85%)

and, therefore, clinical decision making occurs more

frequently for this type of diagnosis. Various factors may

influence clinical decision making including individual

(e.g., range of movement, amount of spasticity), familial

(e.g., family income) (1), and contextual factors (e.g.,

work place, hospital or school) (2). Research involving

therapists with various level of expertise demonstrated

that hypertonicity is the most important influential factor

on their decision making (3-5). Therefore, this review

aims to investigate the most prevalent type of CP - the

hypertonic (spastic) -including its neural and

biomechanical components. Prior to this review, CP will be

explained and its classification will be discussed.


66

Cerebral Palsy Cerebral palsy is the most common cause of

movement disorders in children (6-8). As such,

people with CP constitute a major client group for

occupational therapists as both outpatients and those

receiving short and long term rehabilitation services

(9). CP is an umbrella term, used to describe a group

of non-progressive, but often changing, motor

impairment syndromes secondary to lesions or

anomalies of the brain, arising in the early stages of

its development (10). CP is a lifelong condition (11),

usually associated with various other disabling

abnormalities including: seizures, learning

disabilities, communication and intellectual

impairments, behavioural problems, feeding, visual,

speech and hearing difficulties, as well as sensory

impairments (6, 12-15). The severity of CP varies

from person to person and constitutes a continuum.

At one end of the continuum all muscles and body

movements are severely affected (16), making the

person functionally dependent. At the other end, the

influence of the disorder is minimal and only mild

neurological signs are evident.


Classification of children with CP Cerebral palsy is most commonly classified

according to: (1) central control and area of brain

involvement; (2) functional motor abilities; (3)

nature and typology of motor disorder; and (4)

anatomic distribution (17). The area of central

control involves selective and automatic processes

(18). Selective control refers to the pyramidal tracts

in the central nervous system (CNS) that control

selective movements and its lesions causes spasticity.

Automatic control is ruled by extrapyramidal tracts and

their lesions results in athetosis and ataxia. Damage to

both tracts can cause a mixed presentation.

Classification on the basis of functional motor

abilities aims to address the importance of evaluating the

functional consequences of disabilities emphasised

by the World Health Organization International

Classification of Functioning, Disability and Health

(ICF) (19). Two scales of objective function for

upper and lower limb have been recently developed:

the Manual Ability Classification System (MACS)

and the Gross Motor Function Classification System

(GMFCS). MACS aims to classify children with CP

on the basis of how to use their hands when

manipulating objects in daily activities and rank

them into five levels on the basis of proficiency (20).

The GMFCS is based on the concepts of abilities

and limitations in gross motor functions. This

classification is a reliable and valid system and

similar to MACS classifies children with CP based

on their age specific gross motor activity into five

levels (21).

Involuntary movement disorders and tonality

abnormalities provide the third concept for

classification of CP (22). Tone is described as

spastic (hypertonic), hypotonic, ataxic, athetoid,

and/or mixed. Involuntary movement disorder is

defined as any involuntary and uncontrolled

movement that appears in the affected part of body.

Muscle tone refers to the amount of resistance felt

against passive movement, while an individual is

attempting to be relaxed (23). This resistance is

produced by neural and biomechanical mechanisms

(24). Neural factors refer to the amount of

contraction that is present naturally in the muscles as

a result of tonic stretch reflex (24, 25).

Biomechanical factors include physical inertia of the

extremity as well as the elastic properties of tissues,

joints, blood vessels, muscles etc (25, 26). Any

resistance present in a relaxed person is mostly

biomechanical and only some is related to neural

factors (26).


The last classification of CP is based on anatomic

distribution (22) that is traditionally called

topography. This refers to the pattern and extent of

motor involvement (27) regarding different anatomic

areas including all body regions (i.e., trunk and

limbs) (22). Such a classification can therefore be

referred to as monoplegia in which one limb is

affected (usually one arm); hemiplegia when one side of the body is affected (left or right side);

diplegia where both upper and lower limbs are

affected, but lower limbs are affected more severely

than upper limbs; and quadriplegia where all limbs

are affected (27).

Both the nature and typology of motor disorder and its

anatomic distribution are usually employed to

describe a person with CP, however, there is

disagreement in sub-classifications, for example,

between those used in Europe and Sweden. The

European classification (28) was introduced by

different teams from European countries in which

CP was classified into three types: spastic, ataxic,

and dyskinetic. Although this classification tries to

distinguish and define different types of CP based on

affected areas, it does not completely addresses the

impact of CP in terms the number of limbs involved

or the extent to which they are affected (i.e., diplegic

versus quadriplegia).

Hypertonicity Hypertonicity (spasticity) is the most prevalent

estimated as high as 85% of CPcases, in Europe and

Australia, and 94% in Northern Ireland (6, 29, 30).

For the purpose of this article the term

„hypertonicity‟ will be used, because it is an

umbrella term which subsumes a number of signs

and symptoms consistent with central nervous

system (CNS) lesions. These signs and symptoms

usually occur together and seem to influence each

other during task performance, for example when a

person with hemiplegia wants to reach out to grasp a

glass of water, she/he may experience resistance

against the initial starting movement caused by

spastic dystonia affecting the upper limb in a flexor

pattern. When the movement starts, the agonist

muscles trigger antagonist stretch reflexes and

therefore, spasticity develops (e.g., elbow extension

triggers stretch reflex in elbow flexors causing

spasticity). Associated reactions may also occur in

the other affected limbs. The clasp knife phenomenon

(i.e., sudden muscle relaxation following initial

resistance to movement in spastic muscles)

manifests during movement usually at the end range.

67

Reciprocal inhibition may cause increased tone in

finger muscles and prevent finger extension. These

signs and symptoms cannot all be covered and

defined by the term „spasticity‟, thus requires a more

comprehensive term such as „hypertonicity‟.

Furthermore, the term hypertonicity promotes a

more accurate assessment and observation covering

all known signs and symptoms.

A wide variety CNS lesions may cause

Hypertonicity- from proximal to distal - including:

the motor or premotor cortex, the periventricular

white matter, internal capsule, midbrain or pons, and

the descending spinal tract (31, 32). Lesions to the

central white matter are the most common cause of

hypertonicity in CP (33). Lesions or any injury to

the spinal cord do not come under the umbrella term

of CP.

Following a CNS lesion a person usually moves

through three phases: shock, a transition phase, and

hypertonic state (26, 34). During shock, the spinal

reflexes (e.g., stretch reflex and flexor reflex) are

suppressed and flaccid muscle tone occurs for a

period of time (26, 31, 34). This phase is followed

by a transition stage, when reflexes gradually return.

An increase in the excitability of tendon reflexes and

in muscle tone is then observed. The third hypertonic

phase is characterized by hyperexcitability of

reflexes (stretch reflexes), increased muscle tone,

exaggerated tendon reflexes and muscle spasm (34).

These phases can be observed in some children with

CP when hypertonicity becomes exaggerated in the

first year of life (9, 27). Hypertonicity can occur in

various distributions including monoplegia, hemiplegia,

diplegia, and quadriplegia.

Components of Hypertonicity

As previously mentioned, hypertonicity has two

main components, neural and biomechanical. (see

Table 1) (25). The neural component consists of two

types of symptoms which can be classified as

positive and negative. Positive symptoms comprise

those features that are not normally present, for

example, spasticity, flexor spasms, clasp knife

phenomenon, clonus, associated reactions, spastic

dystonia, and pathological co-contractions (8, 26,

35-37). Negative symptoms comprise features that

have been lost and result in muscle weakness;

problems in making selected or isolated movements

(dexterity), and fatigability (8, 26, 36, 37). Positive

symptoms are mostly caused by the release of more

or less intact motor subsystems from precise

proximal control (32). Spinal reflex activities are

normally controlled and inhibited by the upper

centres of CNS. When this inhibition is lost

following injury, the balance is destroyed and

excitation can be seen (26). Most negative

symptoms are direct results of disconnecting lower

motor centres from higher ones (32). In other words,

positive symptoms are present in the lower motor

centres and are controlled by higher motor centres,

while negative symptoms are caused directly by

damage to the higher motor centres and loss of

connections to lower motor centres (32). It seems

that negative symptoms (e.g., weakness) are more

contributed to motor dysfunction, than positive

symptoms (e.g., spasticity) (38-40).

Table Error! No text of specified style in document.. Clinical Features of Hypertonicity

Neural Components: Positive symptoms: Spasticity

Flexor spasm Clasp knife phenomenon Clonus Associated reaction Spastic dystonia Pathological co-contraction

Negative symptoms: Weakness

Loss of selective control of muscles and limb segment Fatigability Biomechanical Components:

Muscle shortness Muscle contracture Fibrosis

Atrophy


Based on Barens, 2001; Burke, 1988; Katz &Rymer,

1989; Mayer, 1997; O‟Dwyer et al., 1996; Sanger,

2003b; Sheean, 2002; Young, 1989.

The biomechanical components of hypertonicity

include shortness occurring in soft tissues, muscles,

joints, and blood vessels as well as contractures

causing limitation in passive range of motion (26,

36). There is also restriction of passive and active

range of motion. The inertia of the limb that

produces resistance in normal muscle tone does not

change in hypertonicity(25). The different

components (i.e., neural and biomechanical) of hypertonicity will now be addressed.

Spasticity is defined as a problem in muscle tone

due to a velocity-dependent increase in tonic stretch

reflexes. Velocity-dependence refers to the speed of

the stretch impacting on resistance resulting in

greater stretch reflex activity. The tonic stretch

reflex is a sustained muscle stretch, and has a long-

term response, rather than a phasic one, similar to a

tendon reflex (26). Spasticity is mediated by Ia

afferent fibres situated in muscle spindles. Any

stretch to Ia causes muscle contraction via the spinal

cord. Spasticity is also length-dependent which

means that the excitability of the tonic stretch reflex

depends on the length of the muscle which is being

stretched (26), The shorter the muscle, the greater

the resistance.

Flexor spasm is another type of positive symptoms

resulting from the dis-inhibited normal “flexor

withdrawal reflex” that shows itself in a flexor

pattern (26). Flexor withdrawal reflex is a

nociceptive reflex normally elicited in response to a

painful stimulus and resulting in a withdrawal

reaction. This reaction helps a person to protect

his/her body against harmful situations such as a

sharp object. In the presence of an upper motor

neuron lesion, this reflex becomes exaggerated

resulting in a flexor pattern in upper limb (26).

Clasp knife phenomenon accompanies spasticity

and is characterized by sudden muscle relaxation

following initial resistance to passive movement

around a joint. The underlying mechanism is

different from spasticity. Because spasticity is

length-dependent, in stretching the spastic muscle,

the tonic stretch reflex is greater when the muscle is

short. As the stretch is continued and the muscle

lengthens, the excitability of the tonic stretch reflex

reduces. At the same time, the resistance to the

stretch slows movement, and it reduces the spasticity

due to the velocity-dependent mechanism. The


combination of velocity-dependent and length-

dependent mechanisms lead to a point where the

stretch is so slow and the muscle so long that it

results in a reduction of the excitability of the tonic

stretch reflex to such an extent that resistance

suddenly disappears (26).

Spastic dystonia is a sustained (tonic) flexor posture

that can affect elbow, fingers and wrist flexors and

leg extensors. Hemiplegic posture is one example of

spastic dystonia in which the person stands or walks

while her/his arm is in high flexion and leg in

increased extension. The mechanism underlying

spastic dystonia is not clear. It seems to come from a

supraspinal drive to the alpha motor neurones (26).

The dis-inhibition of vestibulospinal tract may cause

spastic dystonia, because one of the responsibilities

of the vestibulospinal tract is the maintenance of

antigravity muscles (i.e., the extensor muscle group

in the lower limb and flexor muscle group in the

upper limb) (41).

Associated reactions occur when there is an

increase in spasticity in involved areas when a

person with hypertonicity attempts to do a task

(voluntary movement). The greater the effort, the

more exaggeration of the response of the associated

reaction (26). It may manifest in an exaggerated

flexor pattern in the left affected arm and extensor

pattern in the left affected leg, for example, when the

person tries to comb his/her hair with the sound right

hand. Associated reactions are not due to any stretch

or nociceptive reflex, but appear to be the result of

tonic efferent drive to the alpha motor neurons of

muscles (26).

Pathological reciprocal inhibition: Reciprocal

inhibition occurs normally in groups of muscles in

two ways. First, when agonist muscles contract, their

antagonist muscles relax simultaneously to allow a

smooth movement to occur (26) (for example, in

reaching out elbow extensors contract and inhibit

elbow flexors). Second, in some circumstances, both

flexor and extensor muscles work together to fix the

joint for a movement (26), such as, fixing elbow and

wrist during writing.

Reciprocal inhibition may be disordered in two

ways. It may be reduced leading to inappropriate co-

contraction. For example, during elbow extension,

flexors are not inhibited and oppose the movement.

This may be explained by two mechanisms: the

triggering of the tonic stretch reflex and/or out-of-

phase activation of antagonists (in the previous

example, elbow flexors) (26, 36). Excessive

69

reciprocal inhibition is the second type of disorder in

which weakness of antagonists may occur, e.g., excessive inhibition of muscle elbow extensors by

the elbow flexors may cause weakness in the

extensors (36).

Negative symptoms caused by upper motor neuron

(UMN) lesions in hypertonicity may include

weakness that is characterized by an inability to

generate force adequately, and slow movement (8,

26, 36). Two problems in the motor units may

contribute to weakness. First, an inability to recruit

sufficient motor units and difficulties sustaining

their discharge rate (Hoefer, & Putnam, 1940 cited

in Mayer, 1997). Secondly, an inability to orderly

recruit and modulate motoneurons within a given

motoneuron pool can lead to insufficient muscle

activation (25). Another negative sign is impairment in

making selected or isolated movements across

specific joints (36). Clients with hypertonicity

usually show stereotypic whole limb movements in

which they demonstrate mass flexor or extensor

patterns. The last negative symptom is fatigability

(32, 42) resulting from inefficient muscle activation

due to loss of orderly recruitment and rate

modulation of motoneurons (25).

Biomechanical changes in muscles may be largely

responsible for hypertonicity (25) and may

contribute to resistance to passive movements more

than tonic stretch reflexes (37). Biomechanical

changes involve muscle contracture and shortening

in soft tissue. Contracture is defined as an increased

resistance to passive stretch due to shortening of

muscle length resulting from a decrease in the

number of sarcomeres in series along the myofibrils

(43). Contractures in children with hypertonicity

may happen over time through three mechanisms.

Firstly, a cerebral lesion, associated with paresis,

causes a transformation of motor units resulting

most probably in shortening of muscle fibres leading

to contracture (44). Muscle and soft tissue changes

compensate for the loss of supraspinal drive and

contribute essentially to hypertonicity in both active

and passive movements (45). Secondly, the limited

and stereotypical movements as well as weakness

typical for most people with hypertonicity tends to

result in shortening of muscle fibres, a reduced range

of movement, and the onset of contractures, as they

get older (26, 36, 46). Thirdly, when a CNS lesion

70

occurs in childhood, the race between bone and

muscle growth in the child may accelerate

development of more contractures and deformities

(47). The presence of soft tissue changes apart from

contractures is controversial, requiring further

research. While some believe that degenerative

changes (fibrosis) and muscle atrophy may also

occur following hypertonicity (25, 36), others argue

that it results from shortening in muscle fibres rather

than atrophy and fibrosis (48).

The development of contractures in CP appears to

progress through three stages. First, deformities are

flexible and reversible. This occurs typically in the

younger child with hypertonicity. In the second

stage, contractures become fixed and may require

surgical intervention. In the third stage, in addition

to contractures, there are changes in the structure of

bones and joints (7).

In the assessment of a client with recent onset of

hypertonicity (before the onset of shortness and

contracture), the abnormal resistance against passive

movement is the result of reflexes and neural

activities. However, in chronic hypertonicity, both

neural and biomechanical components may provide

resistance against passive movement. In other

words, resistance felt by clinicians is generated by

reflex activity and abnormal properties of muscle

and other soft tissues (36). In active movements,

nevertheless, it is very difficult to distinguish

clinically between the contribution of abnormal

neuronal and biomechanical components (36).

Electromyographic (EMG) and biomechanical

recordings show that overall muscle activity is

reduced during functional movements in muscles

with hypertonicity (45). Therefore, the influence of

the signs and symptoms of hypertonicity on active

and passive movements differs requiring more

investigation for effective treatment.

Biomechanical components as well as positive and

negative symptoms may affect the movement

activities (movement dysfunction) of a person with

hypertonicity (26, 36, 39, 46), resulting in

limitations in occupational performance (i.e., activities of daily living, work and school activities,

play, and recreational activities). Figure 1 illustrates

the interactions between positive and negative

symptoms, and biomechanical components

contributing to occupational performance.


Upper Motor Neuron

Lesion

Non-CNS factors (e.g.

Hypertonicity

Neural component Altered muscle function (e.g.,

prolonged shortening)

Positive Symptoms:

Dynamic: Negative symptoms:

Spasm Weakness

Co-contraction Lack of selective control

Clonus of muscles

Associated reaction Fatigability

Flexor withdrawal

Static:

Spasticity

Spastic dystonia

Movement dysfunction

Limitation in occupational performance

areas including self-care (activities of daily

living), work, play and recreational activities

immobilization)

Biomechanical component:

altered passive mechanical

properties, shortness in soft

tissue, blood vessels,

contracture

Figure 1. Interaction and relationship among positive and negative neural

symptoms, and biomechanical components.


Clinical Manifestations of Hypertonicity

When hypertonicity occurs, there are accompanying

abnormalities in patterns of motor behaviour

observed throughout the body in both gross and fine

movements. Persistent and exaggerated postural

reflexes such as tonic neck reflexes, asymmetrical

and symmetrical tonic neck reflexes cause the

development of abnormal movement patterns

resulting in difficulties in maintaining the body in

space, and restricting active and passive movements

(17). Righting and equilibrium reactions might also

be poor in people with hypertonicity and limit active

movement patterns and upright positions.

Consequently, movement and function of the upper

limbs are affected and can impact on the

performance of everyday tasks.

Gross movement in children with hypertonicity and

CP might be affected in two ways. First,

hypertonicity may cause delays in the attainment of

gross movement milestones compared with normal

children. The rate of delay depends on the severity

of hypertonicity, the more severe, the greater the

delay. Secondly, presence of abnormal patterns of

movement and posture in people with hypertonicity

can make this problem worse. Abnormal patterns of

movement and posture manifest in all developmental

milestones such as rolling over, creeping, crawling,

sitting, standing up, and walking.

Postural reflexes such as asymmetrical and

symmetrical tonic neck reflexes, and tonic

labyrinthine reflexes (supine and prone) are essential

to normal child development (49). For example, the

asymmetrical tonic neck reflex normally helps a

child to develop eye-hand coordination by bringing

the hand towards the midline. However, these

reflexes in a child with hypertonicity may be

exaggerated thereby hampering developmental

progress (49). In this situation, the asymmetrical

tonic neck reflex may cause asymmetry in the body,

prevent arms coming to midline, and restrict

movement such as rolling from supine to prone. In

another example, the tonic labyrinthine reflex may

increase extensor tone in the trunk during sitting up

from the supine position and provide excessive

resistance against flexion. Exaggerated postural

reflexes may also impede the maintenance of the

body in space. In an upright position such as sitting,

the tonic labyrinthine reflex may decrease balance

and stability. Therefore, as the child moves his/her

head, this reflex is activated resulting in loss of

72

balance. All problems in gross movements and

maintaining position interfere with a child‟s ability to

carry out activities of daily living, playing and

school work.

Upper limb function is also affected by

hypertonicity. The upper limbs are important for the

performance of daily tasks. With the help of hands

and arms, a person is able to reach out, grasp,

manipulate, transfer and release objects. People

accomplish activities of daily living such as

dressing, feeding, toilet, and showering by using

their arms and hands. Moreover, hands provide the

means whereby human beings manipulate their

environment. Hands have a main role in every

aspects of motor, social, language, and cognitive

development (50). The contribution of the hands to

development starts even before birth, e.g. , by

grasping and releasing the umbilical cord, and

sucking the thumb (Milani-Comparetti, 1980 cited in

Erhardt) and continues after birth.

Hypertonicity imposes abnormal patterns on the

upper limbs, causing limitation in range of

movement and speed and resulting in excessive

efforts in the performance of tasks (50). Different

patterns may be observed in the upper limbs of

people with hypertonicity, but the most prevalent

one is the antigravity pattern (51), that is, scapular

protraction and depression, shoulder adduction and

internal rotation, elbow flexion, forearm pronation,

wrist flexion and ulnar deviation, thumb adduction

and flexion, and finger flexion.

Impaired upper limb function also interferes with

gross motor development and impacts on actions

such as rolling over, creeping, and crawling. For

example, because children with hypertonicity have

limited hand function (e.g., by holding walking aide)

they are not able to facilitate standing and walking.

These limitations result in a delay in attaining

developmental milestones.

Conclusion

Hypertonicity includes two neural and

biomechanical components resulting in abnormal

movement patterns in both gross motor function and

manual abilities in the children with CP;

consequently, these children experience problems in

their all activities of daily living. Focusing on all

aspects of the hypertonicity will surely help to

decide better for these children and have better

results.


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Case Report

A Case Report of Bilateral Upper Extremities Arthrogryposis

Amin Shahrokhi, MD; Masoud Gharib*, MSc Pediatric Neurorehabilitation Research Center, University of Social Welfare & Rehabilitation Sciences,

Tehran, Iran

Vahid Rashedi, MSc Faculty of Rehabilitation Sciences, Hamedan University of Medical Sciences & Health Services

Mohammad Reza Kooshesh, MSc Pediatric Neurorehabilitation Research Center, University of Social Welfare & Rehabilitation Sciences,

Tehran, Iran

Arthrogriposis is a disorder in which two or more joints in more than one limb of body, place in a stable

position and malformation status that usually is the result of joints' immobilization during fetal period.

Problems resulting from this congenital deficit can occur in difference places, in upper and lower limbs,

trunk, and even in face. It occurs in 3 of 1000 births, in two-third of these patients, all four limbs suffer

and one-third of patients suffer in lower limbs and it rarely occurs in upper limbs. In this case affected

children and their parents try different treatment such as surgical and non-surgical treatments which are of

argument and controversial even among specialists of these treatments. In this paper, a 3-year old boy has

been introduced who suffers from congenital deficit with developmental disorder in upper extremity

bones and the absence of flexor muscles group and extensor of wrist. The boy was sent to Bahar

Rehabilitation Center for occupational therapy and rehabilitation services by physician of rehabilitation

clinic in Tehran.

Key words: Arthrogryposis, Upper extremity, Rehabilitation

Introduction

Arthrogryposis Multiple Congenital is one of the

congenital defects that has been observed during

birth, the exact cause of this has not been still known

but variety of causes like decrease of foetus

movement, damage to anterior horn of spinal cord,

genetic reasons, lack of amniotic liquid, unnatural

growth of connective tissue, viral or bacterial

infections and endocrine disorders etc. can be

effective in this disorder (1, 2).

Usually the joints are involved bilaterally. In

general, this disorder can be divided into two

groups: neurological and non-neurological. First

group includes central and peripheral nervous

system disorders and the second group includes

rheumatologic disorders and movement limitations

(2).

Classic arthrogryposis or amyopalsia was first

suggested by Shlordane in 1932. This disorder is due

to lack of muscles groups and occurs because of

muscles replacement which happens by fibrous or

fat tissue. The most prevail type of this disorder

involves both lower and upper limb joints and rarely *All correspondences to: E-mail: [email protected]


involves upper extremity isolatedly; it occurs 1 to 5

in l0000 births (3).

Clinical manifestations in upper extremity has more

affected by elbow joint that could be in flexion and

extension positions. In the first case because of

flexion in child‟s elbow joint, he/she can use his/her

hand to reach his/her mouth and face for hygiene or

eating, but in the second case which is more

important, elbow extends, arm bone and forearm

rotate internally and wrist is inflexed which is called

"waiter's hand" (4, 5) .

The only advantage of this shape of the hand is in

hygiene of genital area. In this case the child is

unable to bend elbow joint to eat or brush his teeth.

These children usually have delayed movement

growth such as crawling, and getting up from ground

and walking. Usually they move from one place to

another place with the help of upper extremity when

their buttock is on the ground, because in this

condition their dorsal of the hand is on the ground,

the extent of motion increases and also increases the

lumbar lordosis. Usually in these children upper

extremity is shorter than should be in normal case.

Treatment of these children depends on the present

75

circumstances including the range of motion,

situation and the power of upper extremity muscles.

The final goal in treatment of these patients is to

help them being able to eat and do their face and

genital area hygiene (8-9).

The main current surgical option for these children

is elbow capsulotomy and triceps release. This

operation is usually for bending elbow joint in a

passive way and if we want to bend the elbow in an

active way, we must transfer one of the triceps,

pectoralis major, wrist and fingers flexors and

latisimus dorsi in addition to what has been

mentioned. In order to transfer of each of the

mentioned parts, there are different ideas among

muscle surgeons. Such transfers also depend on rang

of motions of the shoulder and elbow and wrist and

the most crucial item is the power of the muscle

which has been transferred (9-11).

In treatment of these children, it is necessary to

know that treatment of each person is unique and is

based on the extent of limitation of upper extremity

and the level of independence in basic activities that is

vital for the person.

All rehabilitation team members including

physicians, therapists, orthopedic surgeons,

psychologists and so on must be well informed

about their crucial role in patient management and

counseling and explaining the treatment options and

each option advantages or disadvantages.

The involved team including psychologist,

occupational therapist, physiotherapist, orthopedic

surgeons, technical orthopedic must work together

and explain to parents the ways of treatment.

Rehabilitation team has a key role before and after

the surgery.

In order to improve the range of motion and muscle

reinforcement, occupational therapist and

physiotherapist should use support traction exercise,

manipulation, warming, serial casting and

hydrotherapy prior to surgery. To increase function

and maintain the range of motion, technical

orthopedics should make suitable splint or orthosis

considering the patient conditions as well.

Occupational therapist can also have a very

important role in designing and using equipments to

make daily activity of patients independent. After

the operation, rehabilitations are very important.

Orthosis-prothesis prescriptions must be

accompanied with a complete assessment and should

be continued to six months after operation. By

active/passive movement of uncasted joints we must

stop the stiffness of joints during non-movement

76

period. Muscle exercise should be the priority of

rehabilitation exercises, if muscle transfer happens

(12-13).

Because this disease is rare and therapists have little

information about it, such patients have many

problems (in addition to psychosomatic and physical

disorders) the different kinds of treatment for these

patients, cause stress and confusion for their parents.

Rehabilitation treatment is a crucial and effective

part of treatment both before and after the surgery.

Thus, knowing the disease and the role of therapists

are the most important factors in the treatment of

affected persons.

Case report

The patient was a 3-year old boy whom was

recognized as having the bilateral upper extremity

due to arthrogryposis. To improve the range of

motion and to reinforce the daily activity training by

therapist recommendation, he came to Bahar

Rehabilitation Clinic in Tehran. The parents were

not related and they did not have any history of such

disease in their family. Mother was 38 years old

when she got pregnant and the child was born

through cesarean section. The birth time weighed

and height was 3/5 kg and 50 cm, respectively and

head circumference was normal. Radiography

showed severe mal-development on elbow and wrist

joints, arm bone and forearm, when he was 2.5 years

old. Because the wrist of infant was bent, steps of

motion development like grasping things had very

slow development but other steps of motion were

almost in time, as the parents explained, he could

control his head and neck when he was 4 months

old, he could sit when he was7 months old, he was

able to move by sitting on his buttock when he was 9

months old, and he could stand up straight from

sitting when he was 13 months. Other steps of

motion development like crawling were not done

because of disorder in toddler. Because the toddler

was able to bring up his hand from his shoulder and

had good muscle strength, all of the rehabilitation

treatments were related to increase range of elbow

flexibility. Although the wrist flexibility would help

him eat by himself, but for holding things he needs

to bring up his wrist. Therapist should not forget to

straighten his wrist. The child was able to put the

pieces of food in his mouth with the assist of the

other hand, when he was 3\5 years old and with the

increase of range of motions of elbow of his right

hand, was able to do most of his personal activities

when he was 4. Some surgeons believed that


operation must be done in younger ages and some

others recommended postponing the surgery. After

bone growth and joint plates completed, some

believed that one hand should be bent and fixed and

then operation can be done on them, and some

believed that one hand should be bent and not

moved. Therefore one hand performs the needs of

upper half, and the other hand stays straight to do the

needs of the lower half of the body, and also in the

References 1. Taricco LD, Aoki SS. Rehabilitation of an adult patient with

arthrogryposis multiplex congenita treated with an external fixator. Am J Phys Med Rehabil. May 2009;88(5):431-4.

2. Darin N, Kimber E, Kroksmark AK, Tulinius M. Multiple

congenital contractures: birth prevalence, etiology, and

outcome. J Pediatr. Jan 2002;140(1):61-7.

3. Bamshad M, Van Heest AE, Pleasure D. Arthrogryposis: a

review and update. J Bone Joint Surg Am. Jul 2009;91 Suppl 4:40-6.

4. Alves PV, Zhao L, Patel PK, Bolognese AM. Arthrogryposis:

diagnosis and therapeutic planning for patients seeking

orthodontic treatment or orthognathic surgery. J Craniofac

Surg. Jul 2007;18(4):838-43.

5. Axt MW, Niethard FU, Doderlein L. Principles of treatment of the upper extremity in arthrogryposis multiplex congenita

type I. J Pediatr Orthop B. Jul 1997;6(3):179-85.

6. Bayne LG. Hand assessment and management of arthrogryposis multiplex congenita. Clin

Orthop. Apr 1985;(194):68-73.


case of muscle surgery, some suggest pectoralis

major muscle and some others surgeons suggest

triceps release. But rehabilitation treatment have

been done with emphasis on practices of muscles to

improve their strength, improvement of range of

motion, prevention of joints deformation, the

mental support of parents and infant, and teaching

the parents to teach their infant how to be

independent.

7. Kroksmark AK, Kimber E, Jerre R, Beckung E, Tulinius

M. Muscle involvement and motor function in

amyoplasia. Am J Med Genet Part A. Aug

15 2006;140(16):1757-67.

8. Bennett JB, Hansen PE, Granberry WM. Surgical

management of arthrogryposis in the upper extremity, J

Pediatr Orthop. May-Jun 1985;5(3):281-6.

9. Lahoti O and Bell MJ. Transfer of pectoralis major in arthrogryposis to restore elbow flexion: Deteriorating results

in the long term, J Bone Joint Surg Br, June 1, 2005; 87-

B(6): 858 - 860.

10. Palmer PM, MacEwen GD, Bowen JR, Mathews PA. Passive

motion therapy for infants with arthrogryposis. Clin Orthop Relat Res. Apr 1985;(194):54-9.

11. Williams PF. Management of upper limb problems in

arthrogryposis. Clin Orthop Relat Res. Apr 1985;(194):60-7.

12. Thompson GH, Bilenker RM. Comprehensive management

of arthrogryposis multiplex congenita. Clin Orthop Apr 1985;(194):6-14.

13. Mennen U, van Heest A, Ezaki MB, Tonkin M, Gericke

G. Arthrogryposis multiplex congenita. J Hand Surg

[Br]. Oct 2005;30(5):468-74

77

Author Guidelines

Manuscripts for Iranian Rehabilitation Journal should follow the following instructions:

1. MANUSCRIPT TYPES ACCEPTED

The editorial policy of the Iranian Rehabilitation Journal (IRJ) is to encourage the publication of evidence-based research articles related to rehabilitation. IRJ publishes articles within the more basis aspects of rehabilitation in following forms:

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issues such as timeliness, general interest and balanced treatment of controversies, as well as on scientific accuracy.

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Iranian Rehabilitation Journal, University of social welfare and rehabilitation sciences

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