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how I

how I I use therapeutic listening Dilys Treharne is a speech and language therapist at the
I use therapeutic listening Dilys Treharne is a speech and language therapist at the Department of
I use
therapeutic
listening
Dilys Treharne is a speech and
language therapist at the
Department of Human
Communication, University of
Sheffield. She is a trainer for
The Listening Program,
www.advancedbrain.com.
Dr Colin Lane, the founder of
A.R.R.O.W., is based at The
A.R.R.O.W. Centre, Bridgwater
College Campus, College Way,
Bridgwater, Somerset TA6 4PZ,
e-mail
arrowcentre@bridgwater.ac.uk,
tel / fax 01278 441249.
Karen O’Connor is a speech and
language therapist who runs
her own private practice in
Galway, Ireland. Karen also
co-trains with Sheila Frick
internationally in Therapeutic
Listening™, www.vitallinks.net.
What do we do when clients are
making slow or no progress?
When they have a variety of
difficulties which interfere with their
learning communication and social
skills? When it can be hard to put
your finger on where things are
going wrong?
There is unfortunately no magic
wand in speech and language
therapy but is our understandable
suspicion of therapeutic listening
programmes which do things very
differently making us deaf to their
potential benefits?
So listen up and hear why our three
contributors wouldn’t be without
their CDs and headphones
Practical points: therapeutic listening
1.
Be an objective sceptic - give things a try.
Read this
2.
Attend a structured and comprehensive training programme.
if you
• believe listening has a
major impact on language
and learning
• feel some clients are
underachieving
• want evidence for therapy
approaches
3.
‘Prime the system’ by activating repressed or undeveloped listening abilities.
4.
Use the self-voice as a platform for improving other learning skills.
5.
Enhance outcomes by working closely with other professionals.
6.
Do not underestimate the power of therapeutic listening!

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002

how I Results from her research were so encouraging that Dilys Treharne now uses The Listening

how I

how I Results from her research were so encouraging that Dilys Treharne now uses The Listening

Results from her research were so encouraging that Dilys Treharne now uses The Listening Program as the first step for young people with auditory processing difficulties ‘priming the system’ for more

specific therapy programmes

  • I work with children and young people with auditory processing difficulties. Usually between 6 and 17 years of age when referred, they are underachieving

or complain of not being able to hear prop-

erly in school but on pure tone testing have

From sceptic to convert the objective way

the programme). Nature sounds are added and the whole is presented dichotically. This has the effect of the sound appearing to move around

the room and to be near or distant.

  • I purchased the CDs but ask parents to provide the CD player and high

quality headphones if possible. The children’s pleased expressions at being expected to sit down and listen to CDs twice a day fade a little

when told it is based on classical music. Some have grown to like it while others still only like the “duck bits”.

  • I discuss the listening diary by telephone and the parents collect and

return CDs to the clinic each week, so several children can work with a single set. I am also able to lend a full or half set for eight or four weeks to children who live further away.

Beyond expectations

In the evaluation study the children were reassessed at the end of the programme and then left for eight weeks before being reassessed once more. The results were beyond my expectations: all showed an improvement greater than one would expect from maturation. The pattern of change was interesting. Parents noticed an improve- ment in general attention and attention to sounds within three weeks. All reported a greater responsiveness to conversation. One child who did not initiate conversation even at home began offering opinions and became quite a chatterbox; another noticed the church bells for the first time in his eight years. Awareness of sound and attention span had not been assessed in the pre-trial period so I was unable to objectively mea- sure the amount of improvement in these areas. In the sixth or seventh week of the programme many children exhibited a deterioration in behaviour, becoming disagreeable or aggressive. Fortunately this lasted only a few days to a week, and settled as they moved on to the next CD. This occurred at a point where the gating (acoustic modification) is markedly increased and I believe this, together with the child’s increased sensitivity to sounds in the environment, was the cause and a sign that the programme was being effective. The greatest change was in selective attention (auditory figure- ground). All made an appreciable improvement and the overall change for the group was significant. Those with the severest difficulties made the greatest improvement. In some this change was dramatic moving from below the first centile to the 7th, 9th and in one case 16th centile in just eight weeks. Remember, these children’s scores had remained sta- tic for the previous eight weeks. Many also showed change in auditory memory but perhaps this was due to their improved attention levels. The measured changes were small immediately after the programme and in many cases the greatest change occurred within two months after completion. These improvements were good in themselves but more importantly they were maintained and opened the door for other activities such as Earobics to become effective. Progress did not stop after two months, and even those without direct intervention continued to make gains. The length of this extended progress period varied. When progress stopped or a slight regression was noticed the child took another course of The Listening Program. Progress was also evident in fields not direct- ly targeted. Joe, who had been very slow to make any progress in

no significant hearing loss. Some have had a dyslexia assessment but only show a borderline pattern. Others have had a significant amount of speech and language therapy focusing pri- marily on phonology and comprehension with some expressive work, and have made limited progress. Many have a history of poor attention and in some cases have had a diagnosis of attention deficit disorder or mild autism. Referrals come from audiology departments, speech and language therapists, teachers and parents. After an in-depth assessment a pattern of difficulty emerges with selective attention or auditory figure-ground tasks (hearing speech in background noise which most people are not aware of, such as the hiss of a gas fire or a clock ticking), maintaining attention, auditory sequen- tial memory, sequencing, dichotic listening tasks, temporal pattern pro- cessing, pitch perception, processing language at normal speed, motor coordination, and motor coordination with speaking. Not all the chil- dren have all the problems. Some have a clear auditory processing dis- order and some will be borderline or at the lower end of the normal range. However, if they are having problems functioning in the class- room they are offered a programme of therapy. Initially I used Earobics to improve listening skills, together with tasks tailored to the individual to teach tolerance of background noise, audi- tory memory, and phonological awareness. I used the relative visual strength to support comprehension of read and spoken sequences through visualising and verbalising. ‘Brain Gym’ style activities (see Dennison & Dennison, 1989) were used to improve coordination and concentration. Progress was slow and used a great deal of clinical time.

Worth a try

  • I was then introduced to The Listening Program (Advanced Brain, 1999),

a type of sound therapy programme based on the work of Tomatis and Samonas (Leeds, 2001). It was different in that it was home-based and required the relatively short two fifteen minute periods each day for five days a week over eight weeks. I was objectively sceptical, but any- thing was worth a try, and it came with good reports. I evaluated it with a limited number of children, selecting the prime problem areas for assessment (Treharne, 2001). In this first cohort were 10 children between the ages of 8 and 16 years with non-verbal intelli- gence scores ranging from the 3rd to the 95th centile. They all had problems with auditory figure-ground and most with auditory sequen- tial memory and attention. Temporal pattern perception, phonological awareness, reading and spelling were also common problems but at a higher stage of processing. Baseline assessments were repeated on the prime areas of auditory figure-ground using the Goldman Fristoe Woodcock (1976) Auditory Skills Selective Attention test, and auditory sequential memory using Gardner’s (1996) Test of Auditory Perceptual Skills (TAPS-R). Temporal pattern perception was tested using my own TraCoL (in preparation). Children who had made no progress over the previous eight weeks were selected. The Listening Program is contained on eight CDs, one for each week. Each contains 12 tracks, three to be used at a 15-minute listening peri- od of which there are two each day. The music is classical, specially recorded and then acoustically treated by filtering out certain frequen- cies (this varies from track to track and increases as you move through

SPEECH & LANGUAGE THERAPY IN PRACTICE

WINTER 2002

how I

how I speech and language and at eight years was still almost unintelligible with really low

speech and language and at eight years was still almost unintelligible with really low self-esteem, became much more relaxed and confident and, two thirds of the way through the second course, his phonological system had improved dramatically without further intervention. We have also tried The Listening Program with students who were finding lectures difficult to follow and some have noticed a change. The results are being analysed. Originally designed as a home programme, it can also be used in school. Four children have completed it at two schools with a special needs classroom assistant. The children listen in a group while the assis- tant does paperwork. They discuss what they have heard and the lis- tening record is written up. The schools are amazed at the results and consider it time well spent. The effect of The Listening Program has prompted me to explore other sound therapy techniques - such as the sound health CDs, also from Advanced Brain - to support and maintain attention and concentration levels after the programme at home and in schools. The Listening Program is now my first step in auditory training as it seems to activate listening skills that have been repressed or never

developed, thus priming the system for more specifically targeted therapy programmes.

References

Dennison, P.E. & Dennison, G.E. (1989) Brain Gym. Edu-Kinesthetics Inc. Leeds, J. (2001) The power of sound. Healing Arts Press. Treharne, D. (2001) Efficacy of TLP with children with auditory process- ing problems. Paper presented at TLP conference November 2001 (full version to be posted on www.advancedbrain.com).

Resources

Earobics: Cognitive Concepts www.cogcon.com. Gardner, M.F. (1996) Test of Auditory perceptual Skills - Revised. Ann Arbour Publishers Ltd. Goldman, R., Fristoe, M. & Woodcock, R.W (1976) Auditory Skills Battery Selective Attention Test. American Guidance Service. Treharne, D. (in preparation) Test of Rhythm and Comprehension of Language. The Listening Program (1999) Advanced Brain www.advancedbrain.com. UK contact: F. Mitchell-Roberts, e-mail: twi@pobox.com.

how I speech and language and at eight years was still almost unintelligible with really low

Dr Colin Lane stresses the importance of the self voice to the A R R O W technique for improving listening speech and literacy skills Originally developed for children with hearing impairment its use has extended across the community to include adults with aphasia brain injury and learning disability

A R R O W hits the bull’s ear

how I speech and language and at eight years was still almost unintelligible with really low

ing skills. Students aiming to improve their reading/spelling skills are averaging eight months’ improvement in reading and seven months’ improve- ment in spelling after an eight hour A.R.R.O.W. pro- gramme. Whilst the improvement of listening, speech

A.R.R.O.W. is a multisensory learning programme I first developed in 1975. It is based on the use of the student’s own recorded voice which I termed ‘the self-voice’. A.R.R.O.W. has since been under continuous refinement with students of all ages and abilities including those with reading and spelling problems, dyslexia, hearing impairment, speech and language dis- orders, communication difficulties and visual impairment. Some 800 tutors have been trained and an estimated 30,000 children and adults have been helped. A.R.R.O.W. requires the use of special high fidelity two-track recording equipment either in CD-ROM or audiocassette formats in which tutor and students wear appropriate headsets. A.R.R.O.W. is an acronym for:

• Aural - The student listens to speech through headsets (either a tutor’s spontaneous speech or pre-recorded speech through CD-ROM or audio cassette facility). • Read - The student reads associated text whilst listening to speech. • Respond - The student is required to make a response. • Oral - The student repeats the text. • Write - The student writes down or types the text while listening to the self-voice recording. Whilst any or all of the above components may be stressed during training, the role of the self-voice is essential to A.R.R.O.W.’s effectiveness. Many stu- dents, particularly those of preschool age or those with severe learning/com- munication problems, may not be able to undertake the reading or writing components. However, virtually all students can benefit enormously from the use of the self-voice as a platform for improving other learning skills includ- ing those of listening, cognitive processing and speech. Since its inception, research and practical application of the programme has taken place in schools, colleges and the community. It has been demonstrably proved by A.R.R.O.W. trained tutors that it is possible to make rapid and sus- tained improvements in reading, spelling, short term memory, speech and listen-

and cognitive skills is a central feature of the system, many tutors also report an improvement in a learner’s self-esteem after under- taking it. Initially I developed A.R.R.O.W. as a listen read copy compare model for hear- ing impaired children to improve their speech and listening skills. They were expected to improve by comparing the original teacher recording with their own recorded version played back to them on specially developed equipment. Conventional modelling techniques were used for speech or language improvements before self-voice replay. Tutor and child listened to the master track recording, the child repeated the phrase and had both voices played back as confirmation of progress. It quickly became apparent that severely hearing

impaired students could operate the recorders themselves. Students of all ages and abilities maintain attention for up to 30 minutes when working alone on A.R.R.O.W. During practice sessions I noticed many of the original group of stu-

dents preferred to turn down the tutor voice and only listen to their own replayed voices. I observed them smiling when listening to the self-voice and, in some cases, silently mouthing the replayed speech material. These effects have since been noted elsewhere by other tutors. My later Ph.D. research into the self-voice showed that children preferred their own voices far more than any other voice delivering either a sentence, list of words or single vowel. An early effect of A.R.R.O.W. was a marked improvement in listening skills of the hearing impaired students at my unit. Parents and mainstream teachers commented upon the improvements, including Shirley Manley, the parent of

a nine-year-old severely hearing impaired student: “

his speech has improved

... enormously but also his listening. Before I would call him from upstairs and he

couldn’t hear me, now I call him from upstairs and he responds.”

Marked and sustained

I undertook higher degree research with children in special schools for those with moderate or severe learning difficulty and in hearing impaired units in Somerset. The research showed that 15 minutes daily A.R.R.O.W.

SPEECH & LANGUAGE THERAPY IN PRACTICE

WINTER 2002

training for five weeks caused marked and sustained improvements in lis- tening and speech tasks. These improvements were statistically superior to those being achieved from non-A.R.R.O.W. work being undertaken at each site. The improvements covered identifying sounds of the environment, sentence understanding, working short term memory for digits and words, consonant discrimination and vocalisation skills. After extensive use in Somerset schools, the A.R.R.O.W. programme was tried with adults. A teacher of lip-reading, herself severely hearing impaired, agreed to undertake A.R.R.O.W. training at home. She practised using the special recorder linked to a neck loop attachment. Material was based on various pre-recorded poems. After two weeks’ practice for a maximum of 15 minutes each day, she reported a considerable improvement in her abili- ty to distinguish sounds of the environment and to hold conversation in less than ideal acoustic conditions. We have since developed an A.R.R.O.W. Accelerated Concentration Programme. I had the idea of asking students to listen to their voice against varying levels of background noise using the two-track facility available on the A.R.R.O.W. recorder. Using carefully graded stages of listening, including easily attainable and extremely difficult tasks, I found it was possible to min- imise the time taken to train listening skills to a period of 40 minutes or in some cases even less. I initially used the system with hearing impaired adults and found marked improvements on pre-post test measures. Adults also reported improvements in environmental listening and ability to hold con- versations. Work with children followed and we showed it is possible to improve listening skills with hearing impaired children inside a total of one hour’s training. We have since found that the training is appropriate for both normally hearing and hearing-impaired children / adults whilst the CD- ROM format offers exciting new possibilities for self-help attention training. In late August 2002 a small group of normally hearing students (n=6) were given a background noise listening test. Five of the students were re-tested without receiving any A.R.R.O.W. listening training. Mean scores on the

training for five weeks caused marked and sustained improvements in lis- tening and speech tasks. These

how I

initial test averaged 60.6 words correct from 20 sentences containing 100 words. Re-test scores averaged 65.2, an improvement of 9 per cent. A sixth student was tested but was then given A.R.R.O.W. listening training. On re-test his score rose from a pre-training 51 to 81 correct after A.R.R.O.W. - an improvement of 58.8 per cent. He comments, “After completing the A.R.R.O.W. Listening Enhancement Programme that took approximately 25 minutes I experienced a mental clarity, I had a feeling of heightened awareness, found it easier to focus on the voice and differentiate and ”

exclude background noise

...

(Gallagher, 2002).

A.R.R.O.W. self-voice methods hold considerable application for children and adults within the community. Through the auspices of Bridgwater College, a community-based initiative featuring the self-voice has been most successfully implemented. Members on the A.R.R.O.W. community course include adults with aphasia as a result of stroke, adults with brain injury as a result of accidents or surgery, and adults with learning problems for whom Further Education at Colleges is not a realistic option.

Note

It is essential that practitioners receive a structured training programme to competently assess and deliver A.R.R.O.W. Costs are currently set at £426.00 plus VAT for a four day Advanced BTEC Award for A.R.R.O.W. Tutors. These courses cover both the CD-ROM and audio cassette format - equipment costs p.o.a. and are organised on a regional basis according to demand.

References

Bellamy, H. & Long, L. (1994) In: Lane, C.H. A.R.R.O.W. Links 2, 1 (3); 5-9. Crewdson, D. (1996) The Sound of One’s Voice. Bulletin, Royal College of Speech and Language Therapists 533; 8-9. Gallagher, J. (2002) Personal Comunication. Harvey, B.M. (1995) An Arrow Experience. Dyslexia Contact 14; 2. Lane, C.H. (1997) With One Voice. Special Children, May; 17-20.

training for five weeks caused marked and sustained improvements in lis- tening and speech tasks. These
A s a speech and language therapist with a keen interest and growing knowledge in the
A s a speech and language
therapist with a keen
interest and growing
knowledge in the area of
sensory integration, I was fascinated
to hear
of
a
three
day
course

With satisfied clients Karen O’Connor needs no further convincing of the benefits of occupational therapist Sheila Frick’s Therapeutic Listening™ in helping children achieve their potential

Enthusiasm knowledge and a set of headphones

‘Listening with the whole body’, given by Sheila Frick. This well-known American occupational therapist lec- tures worldwide in the area of sensory integration, on topics such as clini- cal neurology, respiration, the vestibular-auditory system and auditory intervention techniques such as therapeutic listening. Occupational thera- pists, physiotherapists, speech and language therapists, audiologists, psy- chologists and other educators were there. I returned with a new found enthusiasm in my heart, knowledge in my head and a set of headphones in each hand! Parents also hoped this technique could help their children where more traditional therapy had not succeeded. Those same parents, having seen some very encouraging results, urged me to write this article so others can benefit. From my per- spective, it has opened up a new world where clients can now achieve their potential in a more functional and effective way. “Therapeutic Listening uses sound stimulation in combination with sensory integrative techniques to stimulate brain processing. It combines a variety of electronically altered compact discs based on the ideas and technology created by Alfred Tomatis, Guy Berard and Ingo Steinbach, within a sensory integrative framework,” (Frick, 2001.) This approach highlights the importance of close collaboration and joint work between therapists, as activities are often based on “postural activation,

organisation, oral motor and respiratory strategies” (Frick, 1991). CDs vary in level of musical complexity and enhancement.

Individualised programme

Each client is assessed with the view to developing an individualised therapeutic listening programme, which can be school and/or home rather than clinic-based. Each programme should be supported by a strong sensory-diet of activities (Wilbarger & Wilbarger, 1991). ‘Sensory- diet’ is a concept which proposes that each individual requires a certain amount of activity and sensation to be at their most alert, adaptable and skilful. These activities are tailored to the individual’s needs and

scheduled throughout their day. The development of listening techniques began with the work of Alfred Tomatis - a French Ear, Nose and Throat Consultant - in the 1940s. “He researched the role of the ear and its profound effect on listening,

language and learning

he seeks to explain how humans function

... through the focal point of the auditory system,” (Madaule, 1994.) Tomatis is renowned for developing the first auditory training device, using progressively filtered sounds - Mozart’s music, Gregorian chant and mother’s voice - to cause change.

SPEECH & LANGUAGE THERAPY IN PRACTICE

WINTER 2002

how I

how I A French doctor, Guy Berard, felt the Tomatis method was too lengthy and developed

A French doctor, Guy Berard, felt the Tomatis method was too lengthy and developed his own method of filtering sound. This Auditory Integration Training (modulating sound frequencies at random intervals for random periods of time) was developed to treat people with audi- tory processing problems. Ingo Steinbach, a German sound engineer, developed the Samonas method. “He found that by heightening his attention to the structural elements contained in all natural sounds, and capturing them in his recordings, immediate listening was achieved, even in unfiltered music. He developed special technology to capture music as sound in space and combined his spectral activation process with Tomatis’ method of filter- ing” (Frick et al, 1997). The benefits of a therapeutic listening programme are extensive and varied. When I introduce the areas in which families should expect to see change, they are understandably surprised. Having used therapeutic listening programmes with approximately three hundred children, I have witnessed and recorded change in all the areas in figure 1. The case studies in figure 2 give some indication as to how ‘therapeu- tic listening’ can be used with quite different client groups. I now use this technique with most of my clients, in combination with other approaches, and I endeavour to work closely with occupational thera- pists and physiotherapists to enhance the benefits.

‘Listening with the Whole Body’ - courses

• Karen O’Connor (Ireland) e-mail

speechtherapyservices1@eircom.net.

• Sandra deWet (UK),

tel.

01892

513659 (also supplies

the

‘Listening with the whole body’ book in the UK for £37 inc p+p).

Further information

www.vitallinks.net - includes

case studies www.samonas.com - Samonas CDs, developed by Ingo Steinbach.

References

Ayres, A.J. (1979) Sensory Integration and the Child. Los Angeles: Western Psychological

Services. Ayres, A.J., & Mailloux, Z. (1981) Influences of sensory integration procedures on language develop- ment. American Journal of Occupational Therapy 35 (6); 383-

390.

Frick, S. & Hacker, C. (2001) Listening with the Whole Body. Vital Links, Madison, WI. Madaule, P. (1994) When listening comes alive. Norval, ONT., Canada:

Moulin Publishing. Semel, E., Wiig, E.H. & Secord, W. (2000) Clinical Evaluation of Language Fundamentals - Third Edition (UK). The Psychological

Corporation. Tomatis, A.A. (1996) The Ear and Language. Norval, ONT., Canada; Moulin Publishing. Stark, R.E. & Tallal, P. (1981) Selection of children with specific language deficits. Journal of Speech and Hearing Disorders 46 (2); 114 -122.

how I A French doctor, Guy Berard, felt the Tomatis method was too lengthy and developed
how I A French doctor, Guy Berard, felt the Tomatis method was too lengthy and developed
how I A French doctor, Guy Berard, felt the Tomatis method was too lengthy and developed

Figure 1 Areas potentially affected by therapeutic listening

Arousal, attention and focus Receptive and expressive language

Increased speed of motor and language processing Balance and coordination Praxic skill - ideation, planning and execution Affect; facial expression and responsiveness • Motivation

Awareness of the environment

Gravitational security Modulation of ability to stay calm while receiving sensations • Organisation

Self-initiation of play and work behaviors, and verbal instruction Social and emotional development Eye contact and tracking Decrease in self-stimulating behaviours • Independence

Feeding skills

Eating and sleeping patterns

Improved awareness and regulation of hunger and thirst patterns (Frick et al, 1997)

Figure 2 Case studies

Eoin has Asperger’s Syndrome. I worked with his family three years ago when the primary concerns were concentration, auditory processing and pragmatics, in particular topic maintenance. We had utilised many approaches with limited generalisation. Mum was eager for me to reassess Eoin as she felt his auditory processing difficulties were directly related to his auditory distractibility. He became my first client to use Therapeutic Listening - and he loved it! We started Eoin on EASE 1 and blended in a Samonas CD within a fortnight. Mum reported he would lie down on a chair and listen attentively to the music. She noticed improvements in his ability to concentrate within the first three weeks. Over the past year we have focused on his ability to filter out important auditory information from background noise, auditory processing skills, sentence formulation and pragmatic language. Eoin’s standard scores on the Clinical Evaluation of Language Fundamentals (Semel et al, 2000) have increased by approximately three standard deviations in both receptive and expressive language. More importantly, Eoin is doing better at school and making more friends.

Peter, a twin whose general milestones were achieved as expected, was referred aged 3;4 years by his local GP. Mum became worried when Peter was much slower than his twin to put words together. He had a significant history of ear infections and grommets were inserted following his initial assessment. Peter was constantly moving from one activity to another and generally did not respond to questions, but chatted away to himself. He tended not to look at you when asked a question. Peter attended regularly for eight months with the focus on:

* attention and listening skills * auditory processing skills * auditory memory * sentence formulation skills * vocabulary-building * phonological development. Limited improvements were noted and mum agreed to try Therapeutic Listening. We started Peter on Disc EASE and gradually introduced Carulli (Classic Quality Version) on week 3. Within the first three weeks mum noticed Peter was much “calmer, less active and generally listening more attentively”. Improvements continue to be seen in the areas of expressive language and vocabulary building. Peter is also following a language programme, which consolidates and enhances development of the emerging linguistic skills. His skills are approaching age appropriate in all targeted areas.

Nigel (10), who has spina bifida, had been attending regularly for eighteen months. Formal and informal assessments indicated attention and listening difficulties, auditory processing and sentence formulation deficits. His teacher reported he was “quite distracted in class, finding it difficult to concentrate” and he was functioning approximately three years behind the rest of his class. Rigorous direct and indirect work showed limited improvement so we introduced Therapeutic Listening. After three weeks, Mum reported Nigel seemed “much more ‘tuned-in’, able to become involved in conversations and beginning to follow and talk about story-lines from television programmes, which he hadn’t done previously”. Nigel continues on a listening programme and is responding more effectively to other language programmes to further develop and consolidate his skills.

SPEECH & LANGUAGE THERAPY IN PRACTICE

WINTER 2002