Evaluation of the tm in sweden

The Tomatis Method in Sweden An Evaluation of a Sound Stimulation Training Program

Eva Olkiewicz, Ph.D Mats Westin, Statistical Expert

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Tomatis Nordiska AB The first Tomatis Center in the Nordic countries opened in 1998 in Sollentuna, close to Stockholm, Sweden. At present there are five Certified Tomatis Consultants working at the head office. They receive clients within their respective professional areas: The president and founder of the Center, Maria Lundqvist, holds a degree in Science; Ewa Hermansson and Kristina EdstrĂśm are psychologists; Helena Bowin is a speech and voice therapist and opera singer; Antonia Jacobaeus is a medical doctor. To date seven additional professional have been trained and certified in Sweden and work with with Tomatis Method as licencees.

Tomatis Nordiska AB recently assumed the responsibility to deliver professional training and certify Tomatis Consultants in the Nordic Countries.

The Evaluation Methods From the very beginning Tomatis Nordiska AB has put much effort into developing administrative, technical, and measurement processes in delivering Tomatis training, and to document their work. It is these efforts that has made an evaluation possible. The client documentation encompasses personal characteristics, needs or problem areas, present and previous health situation, as well as data about the training, such as hours of training, number of weeks between the completion of the training and the final evaluation, and a self-rating questionnaire administered once before the training and a second time four to six months after completed training.

For the purpose of analysis, data from the client files were transferred to a form designed by a researcher and a statistical expert in co-operation with the Certified Tomatis Consultants at the Tomatis Nordiska AB. A total of 110 different variables were registered for each client. The forms were then sent to a company for computer scanning, results compiled in a database and finally processed with the SAS statistical analysis software.

In the near future, additional methods will be employed, primarily factor analysis regarding the self-rating questionnaires, cluster analysis regarding problem description, and regression analysis.

The methods employed in this report are descriptive with frequency distributions and indices.

Results Totally, the results for 119 persons – 63 adults and 56 children – have been evaluated. The youngest person was 4 years old and the oldest was 65 when the training started. The age range for the children was from 4 to 18 years, and for the

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adults 18 to 65. The decision weather to register a client as child or adult was built upon who had filled in the self-rating questionnaire. If it was filled in by the parent or guardian the client was registered as a child, and if it was filled in by the client, the person was registered as an adult. For analytical reasons adults and children were treated separately in the evaluation. The results, separate for adults and children, are divided into three blocks: ♦ The Background, including the adults’ or children’s age and sex, problem or problems stated by the adults or the parents of the children, and health issues, ♦ The Training Procedures, including number of hours in training, and time span between completed training and final evaluation, ♦ The Indicators of Effects.

Adults Background of the Adults Age and sex As shown in table 1 below almost one third of the adults were below 30 years of age and half in their forties at the initial contact with the Center. Still around one fifth was 50 years or older. The majority of the adults, 70 percent, were women and 30 percent were men.

Table 1. Age of the Adults at the Initial Contact with the Center Age: 18 – 29 years 30 – 39 years 40 – 49 years 50 – 65 years

Percent: 17 13 48 22

Number:

63

Problems Stated by the Clients At the initial consultation clients expressed what question, need or problem had given rise to the contact with the Center. The problem or problems thus reported have then been turned into maximum four problem variables in the questionnaire – one depicting what was perceived as being the main problem, and maximum three additional problems, all in the following areas: ♦ ♦ ♦ ♦ ♦

Intellectual, Motor skills, Emotional, Speech and voice, and Energy level.

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All 63 clients have reported one or more problems, but for two clients there was no main problem pointed out.

As shown in table 2 the largest problem area was emotional, reported by more than half of the adults - indicating stress and communication/empathy difficulties as the dominating problems. The next largest problem area was intellectual, here totally dominated by problems regarding concentration and attention. The other problem areas were smaller in size.

However, most of the adults reported having more than one problem, not only the main problem. In the last column of table 2 it is therefore shown the percentage of adults having a certain problem. As we can see, the percentage of adults reporting having a certain problem multiplied in many cases – difficulties in concentration and attention, dyslexia, problems in social ability and empathy, anxiety and depression for example.

Table 2.

Percentage of Adults Reporting Having a Certain Problem at Initial Contact with the Center.

Percent of Percent of Problem Areas: Problems within the Clients Clients Area: with this reporting as their this Main Problem: Problem Intellectual: ♦ Learning 5 difficulties ♦ Concentration and 21 51 attention ♦ Reading/writing 2 13 difficulties 8 ♦ Memory Motor Skills: 5 ♦ Motor difficulties 3 3 ♦ Balance/Dizziness Emotional: ♦ Social ability/ empathy/ 16 35 communication 30 37 ♦ Stress 3 6 ♦ Anxiety 2 14 ♦ Depression Speech and Voice: 3 6 ♦ Speech 8 22 ♦ Voice Energy Level: ♦ Wants to increase 11 30 Performance 2 ♦ Passivity Percent: 100 Number: 61 63

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These results were of course rather compelling, if not exactly surprising. Most of us do not encounter only one problem at a time – we rather have sets of different difficulties that seem to belong together.

Health Issues Twenty of the 63 adults had a medical diagnosis, in most cases a somatic disorder: Somatic diagnoses: ♦ Hearing disorders of different kinds (10 clients) ♦ Epilepsy (2) ♦ Stuttering (1) ♦ Dyslexia (1) ♦ Spasms and breathing disorder (1) ♦ Whiplash (1) ♦ Aspergers syndrome (1) ♦ von Recklinghausens disease (1) Psychological diagnosis: ♦ Stress (1) Psycho-somatic diagnosis: ♦ Fibromyalgia (1) However, given the fact that less than a third of the adults have a medical diagnosis, as well as the great variation between and within the diagnoses, it is likely that this data will have a more limited value for the evaluation, than the problems and problem areas reported by the adults in table 2.

Training Procedure In 70 percent of the cases the adults paid for the training themselves. In most of the remaining cases the employer paid, and in one case the regional social insurance office.

The adults were recommended different amounts of training, depending on the outcome of the initial assessment. As a general rule, the more severe the symptoms the more training was recommended and needed. At least 60 hours of training was always recommended. The vast majority of the adults, 83 percent, received 60 hours of training but some received up to 85 hours. Only one person got less, 52 hours.

Table 3 shows that the time span between end of the training and evaluation has varied between 4 and 72 weeks for adults. For two thirds of the adults the evaluation took place between 4,5 and 8,5 months after the training. A scatter plot, however, showed no correlation tendencies between time span and training effects.

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Table 3.

Number of Weeks between Completed Training and Final Evaluation. Percent of Adults

Number of Weeks: 4–9 10 – 19 20 – 29 30 – 39 40 – 72

Percent: 8 30 33 22 6

Percent: Number:

100 63

Indicators of Effects Four different measures are used as indicators of the effects of the method. One is a tape recording of the voice before and after training, a video recording of the adult’s posture and movements in everyday life before and after, a written document showing the adult’s handwriting before and after training, and a selfrating questionnaire. For practical reasons only the self-rating questionnaire is used as a result variable in this evaluation.

A self-rating questionnaire was administered to the adults at two occasions – before the training, when the adults were tested and interviewed, and after the training had been complete 1 . The questionnaire covered 38 questions for adults (41 questions for children), divided into five different areas, namely: ♦ ♦ ♦ ♦ ♦

Attention, Motor Skills, Expressiveness, Level of Energy Behaviour and Social Adaptation

By calculating the difference between the initial self-ratings and the self-ratings after completed training it is possible to get an estimate of the changes. Therefore, an index was calculated before and after training for each separate area and for the total, and a delta was calculated for the total difference, as well as for the respective areas. It should be pointed out that the higher the value of the index is, the more severe the problems are. The results are shown in table 4.

When the adults had filled in the self-rating forms at the evaluation, indices before and after were calculated and presented in an Excel diagram. The adults were asked if they felt that the changes they had undergone as a result of the training, also were reflected in the diagram, and if not, whether the ratings gave a too negative or too positive a picture of the results of the training.

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For time span between completed training and final evaluation, see table 3.

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However, this procedure, was not systematically employed until May 2001, which means that this information was available for only 42 of the 63 adults. An analysis showed, that 35 of the 42 adults considered the self-ratings giving a fair picture, six adults considered the estimates to be too negative, and one adult too positive.

Table 4 shows the mean differences between the self-ratings before and after training, totally and for each of the five areas. The areas of the greatest progress was Attention and Level of Energy. This was also the areas where the clients had the highest means initially and therefore could be assumed to have their largest problems or needs, whereas the other three areas were somewhat less problemladen. The progress in these areas was also smaller.

Table 4.

Result of Training – Mean Differences in Indices before and after Training According to Self-Ratings Areas in Self-Rating:

Total Change for all five areas: ♦ Attention ♦ Motor Skills ♦ Expressiveness ♦ Level of Energy ♦ Behaviour and Social Adaptation Number:

Before After

Diff.

41 51 35 31 51

27 31 23 20 35

14 20 12 11 16

40

27

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*Differences within groups are significant a the 1% level

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Children Background of the Children Age and sex As shown in table 5 below the majority of the children, 75 percent, were between 7 and 12 years of age. The majority of the children were boys, 79 percent, and 21 percent were girls.

Table 5.

Age of the Children at the Initial Contact with the Center

Age: 4 – 6 years 7 – 9 years 10 – 12 years 13 – 18 years

Percent: 9 36 39 16

Percent: Number:

100 56

Problems Stated by the Parents of the Children At the initial consultation the parents of the children expressed what question, need or problem had given rise to the contact with the Center. The problem or problems stated were then transferred to the questionnaire as maximum four problem variables in the questionnaire – one describing what was perceived to be the main problem, and three additional problems in the following areas: ♦ ♦ ♦ ♦ ♦

Intellectual, Motor skills, Emotional, Speech and voice, and Energy level.

As shown in table 6 the majority, 70 percent, of the parents reported intellectual difficulties as the main problem for their children. The most dominating problem was difficulties in concentration and attention, a problem that – considering that almost all the children most likely were school children – probably interfered with the school work. Only 16 percent of the parents considered their child’s main problem to be emotional.

As also shown in table 6, the last column, most children were reported having other problems as well, apart from their main problem. As we can see, if instead the amount of children experiencing a certain problem is estimated, the

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percentages multiplied in many cases – for example concentration difficulties, dyslexia, problems in social ability, anxiety and depression seem to be a problem for many more of these children, than those who indicated this as their main problem.

Table 6.

Parents’ Statement of the Problems of their Children at Initial Contact with the Center – Main Problem and other Problems.

Percent.

Percent of Percent of Problem Areas: Problems: Children Children with this reporting as Main this Problem: Problem: Intellectual: ♦ Learning 4 16 difficulties ♦ Concentration and attention 48 71 difficulties ♦ Reading/writing 18 32 difficulties 5 ♦ Memory Motor Skills: ♦ Locomotive 25 problems Emotional: ♦ Social ability/ empathy/ 11 43 communication 2 ♦ Stress 4 9 ♦ Anxiety 2 4 ♦ Depression Speech and Voice: 9 21 ♦ Speech 9 ♦ Voice Energy Level: 2 7 ♦ Passivity 4 18 ♦ Hyper activity Percent: 100 Number: 56 56

These results were not surprising. Most children, as well as adults, do not encounter only one problem at a time – they rather have sets of different difficulties that seem to belong together.

Health Issues Almost half of the children – 42 percent – had medical diagnoses. A majority of the children had rather severe disorders like AD/HD or autism, something that should be kept in mind when the progress of these children is evaluated:

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♦ AD/HD, only (7 children) - -“with dyslexia (1) - -“with Asperger’s syndrome (1) - -“with delayed speech development (2) - -“with XYY syndrome (1) - -“with Noonan’s syndrome (1) ♦ Asperger’s syndrome (1) ♦ Atypical autism with unspecific speech disorder (1) ♦ Infantile autism (1) ♦ Foetal alcohol syndrome (1) ♦ Delayed speech development (3) ♦ Dyslexia (3) ♦ One-sided, sensory neural hearing disorder (1) As mentioned above, thirteen of these children were diagnosed with AD/HD, in half of the cases in connection with another diagnosis. This group is of particular interest, as they have been the subject of a very heated debate in Sweden concerning the aetiology of their severe difficulties, as well as the question of what could be done to help them and their families. So far there seems to be have been few remedies for them, and they will therefore be subject of a special analysis in the near future.

Another interesting finding was that the children seemed to be over represented in certain aspects, compared to the rest of the population, for example: ♦ 13 percent were adopted ♦ 18 percent were more than three weeks pre-mature, and ♦ 32 percent had a history of frequent ear infections.

Training Procedures In 68 percent of the cases the parents paid for the training. In the remaining cases the costs were paid, either by the county through their Child and Youth Psychiatric Centers, or by the municipality through School Authorities.

The children received different amounts of training, depending on the outcome of the initial assessment. As a general rule, the more severe the symptoms the more training was recommended and needed. More than half of the children, 57 percent, received 60 hours of training, and most of the others 75 hours. Only four percent received 90 hours.

Table 7 shows that the time span between end of training and evaluation has varied between 5 and 51 weeks. For almost half of the children the evaluation took place between 4,5 and 6,5 months after the training. A scatter plot, however, showed some correlation tendencies between time span and training effects, which will be explored more deeply in a coming analyses.

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Table 7.

Number of Weeks between Completed Training and Final Evaluation. Percent of Children

Number of Weeks: 5–9 10 – 19 20 – 29 30 – 51

Percent: 4 36 46 14

Percent: Number:

100 56

Indicators of Effects As mentioned above, four different measures are used as indicators of the effects of the method. One is a tape recording of the voice before and after training, a video recording of the children’s posture and movements in everyday life before and after, a written document showing the child’s handwriting before and after training, and a self-rating questionnaire answered by the parents. For practical reasons only the self-rating questionnaire is used as a result variable in this evaluation.

A self-rating questionnaire was administered to the parents of the children at two occasions – before the training, when the children were assessed, and children and parents interviewed, and after the training had been completed 2 . The questionnaire covered 41 questions for the children (38 questions for the adults), divided into five different areas, namely: ♦ ♦ ♦ ♦ ♦

Attention, Motor Skills, Expressiveness, Level of Energy Behaviour and Social Adaptation

By calculating the difference between the initial self-ratings and the self-ratings after completed training it is possible to get an estimate of the changes. Therefore, an index was calculated before and after training for each separate area and for the total, and a delta was calculated for the total difference as well as for the respective areas. It should be pointed out that the higher the value of the index is, the more severe the problems are. The results are shown in table 8.

When the parents had filled in the self-rating forms at the evaluation, indices before and after training were calculated and presented in an Excel diagram.

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For time span between completed training and final evaluation, see table 7.

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The parents were asked if they felt that changes their children had undergone as a result of the training, also were reflected in the diagram, and if not, whether the ratings gave a too negative or too positive a picture of the results of the training.

However, this procedure, was not systematically employed until May 2001, which means that this information is available for only 42 of the 56 children. An analysis showed, that 28 of the 42 parents considered the self-ratings giving a fair picture, and 14 parents – one third of the parents asked – considered the estimates to be too negative compared to the results of the training. No parent considered the estimates to be too positive.

Table 8 shows the mean differences between the self-ratings before and after training, totally as well as for each of the five areas. The area of the greatest progress was Attention. This was also the area where the children had the highest mean initially and therefore could be assumed to have their largest problems or needs, whereas the other four areas were somewhat less problem-laden. The progress in these areas was also smaller.

Table 8.

Result of Training – Mean Differences Before and After Training According to Self-Ratings by the Parents of the Children Areas in Self-Rating:

Total Change for all five areas: ♦ Attention: ♦ Motor Skills ♦ Expressiveness ♦ Level of Energy ♦ Behaviour and Social Adaptation Number:

Before After

Diff.

45 59 37 38 47

32 39 25 28 36

13 20 12 10 11

46

34

12

56

*Differences within groups are significant a the 1% level

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Discussion From the very beginning Tomatis Nordiska AB has put much effort into developing systematic measurement processes, and to document their work. It is these efforts that have made an evaluation possible.

Data regarding the background, problem areas and health issues of the adults and the children have been collected, as well as facts about the training. A self-rating questionnaire, covering five different areas – Attention, Motor Skills, Expressiveness, Energy Level, and Behaviour and Social Adaptation – was also administered both to the adults, and to the parents of the children at two occasions, before and after the training.

Ideally, to measure the efficiency of the training, control groups should be employed. Unfortunately, in reality it is hardly ever possible in situations like this.

Instead, the procedure that is available is before-and-after measurements.

The self-rating questionnaire, used in this evaluation, was designed by Tomatis Nordiska AB, based on decades of experience of other Tomatis Centers, as described in the book When Listening Comes Alive by Paul Madaule.

Self-ratings are easy to administer and simple to use. In other areas, for example language proficiency, they have also proven to be highly correlated to direct tests of language ability and to estimates of outside judges3 (Grosjean, 1982:233). The self-rating instrument in this evaluation is not validated, and should not be rated as such.

The evaluation encompasses data from 119 persons – 63 adults and 56 children – between the age of 4 and 65 years of age, who had completed training and final evaluation at the Center since the start in 1998.

The results show, that the problems reported by the adults and the parents of the children, were remarkably similar. A major part of both adults and children had problems concerning attention and concentration, as well as behaviour and social adaptation. For adult clients, stress was also a common problem.

In the self-rating instrument before the training, attention difficulties was the most common problem area for both adults and children, and it was also the area that had undergone the most substantial changes for both groups as measured in the self-ratings after the training had been completed.

Almost half of the children (42 percent) had one or more medical diagnoses, and the majority of those had either very serious conditions as for example autism or Aspergers syndrome, or disorders as AD/HD, which seem to be difficult to remedy. In spite of these very serious conditions, the results indicated that there has been a substantial progress for the children as a result of the training.

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Grosjean, F. 1982. Life with Two Languages. Massachusetts: Harvard University Press.

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One conclusion that can be drawn, is that the training appears to have beneficial effects on concentration and attention difficulties, as well as on social adaptation and behaviour, in both adults and children, even in severe cases.

This report is, however, only the very first step in the evaluation, carried out very shortly after data had become available. In the next step more advanced statistical analyses will be employed, i.e. cluster analysis, factor analysis and regression analysis, which will allow us to go deeper into the analysis of the data.

This evaluation is, however, not a goal in itself. It should instead be seen as a necessary starting point for more systematic evaluation and research, using among other things control groups, physiological data and validated tests.

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