Professional Documents
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a Department
of Physical Therapy, Speech-Language Pathology and Audiology, and Occupational Therapy, School
of Medicine, Universidade de São Paulo (FMUSP), São Paulo, Brazil; b Universidade Paulista (UNIP), Santos, Brazil
Keywords there were differences between the children’s pre- and post-
Autism · Language · Pragmatics · Cognition · Executive test performance. Significantly different performances were
function observed in the areas of occupation of communication
space, proportion of communicative interactivity, and so-
cial-cognitive performance. Conclusion: The inclusion of ac-
Abstract tivities to stimulate executive function abilities in language
Aims: Identifying effective methods for stimulating lan- intervention for children with ASD warrants further investi-
guage and communication of children with autism spec- gation. © 2017 S. Karger AG, Basel
trum disorder (ASD) is fundamental to the effective use of
available resources to support these children. This pilot
study was designed to explore the potential benefits of a
program of stimulation of executive functions (SEF) on the Introduction
functional aspects of language and communication through
the assessment of the functional communicative profile and Throughout the years, despite variations in diagnostic
social-cognitive performance. Methods: Twenty children, criteria and classification, descriptions of autism spec-
aged 5–12 years, with a diagnosis of ASD participated in the trum disorder (ASD) include impairments in language
study. Two stimulation programs were offered over a 10- to and communication [1]. Identifying effective methods
12-week period as part of the regular services offered to for stimulating language and communication in children
these children through a University’s speech and language with ASD is fundamental to the adequate use of resourc-
therapy outpatient clinic in São Paulo, Brazil. Children either es, such as specialized intervention and education, espe-
received SEF intervention in their home implemented by cially in regions of the world where this population is un-
their parent/s, with close monitoring by the speech-lan- derserved or where geographic distances impede access
guage pathologist (SLP) (group 1), or they received SEF by to appropriate intervention.
the SLP during regular speech-language therapy individual The close association between language development
sessions (group 2). Results: The findings suggested that and executive functions (EFs) has been studied for de-
© 2017 S. Karger AG, Basel Ingrid Ya I. Sun, Department of Physical Therapy, Speech-Language
Pathology and Audiology, and Occupational Therapy
School of Medicine, FMUSP, Rua Cipotânea, 51
E-Mail karger@karger.com
Cidade Universitária, São Paulo, SP 05360-160 (Brazil)
www.karger.com/fpl E-Mail ya.ingrid @ gmail.com
cades regarding specific aspects, such as meta-represen- inability to utilize inner speech to regulate nonroutine be-
tation and syntactic awareness in children with ASD and haviors [7]. Other researchers have found that EF impair-
Asperger syndrome [2–4]. However, it is still not clear if ments are associated with language deficits intrinsic to
there is a causal relationship between them. A recent lit- ASD [6, 7]. In contrast, findings from some studies sug-
erature review [5] indicates that there is evidence of a gest that there is no link between language ability and EFs
moderate association between EFs and academic achieve- [4]. Results that connect EFs with language showed an
ments but little evidence of causality. The authors also association between both verbal and nonverbal abilities
report that there is evidence that EFs can be improved by and direct measures of EFs [25]. The contradictory find-
intervention. ings in the research may well be due to the large variabil-
EFs are understood as the ability to manage the mental ity among individuals with ASD despite the common di-
processes that organize, control, program, and monitor agnosis.
perceptual and motor information already stored in Family dynamics are another important aspect of the
memory. Numerous studies have focused on understand- intervention process with children with autism, especial-
ing the association between EFs and ASD [6–14]. These ly when considering the more direct involvement of par-
abilities enable the individual to define a goal, plan neces- ents in the intervention process. Several studies have
sary actions, execute and monitor goals, adjusting actions identified a high level of parents’ stress, especially regard-
as necessary, and assess the outcome of the actions [15, ing the choice between intervention alternatives and the
16]. Stemmer and Whitaker [17] suggest that EFs include demands involved in providing appropriate treatment
the abilities of self-control, working memory, cognitive and education to their child [26–29]. Parents’ beliefs, lim-
flexibility, and central coherence. Cognitive flexibility is its, and challenges are important factors to consider in the
required in any complex activity where the person needs intervention process, as parents frequently provide the
to consider several kinds of information at the same time. child’s major socialization experiences [30, 31].
It involves the assessment of the situation and the pro- Previous studies have considered the inclusion of par-
posal of strategies and alternatives regarding different sit- ents and caretakers in language therapy processes with
uations and everyday demands [18]. Inhibitory control children with autism. Fernandes et al. [32] studied a
refers to the ability to hold impulsive answers, to avoid group of 36 children between 3 and 12 years and verified
distractions, or even to interrupt an action to achieve a the results of a 20-week period of language therapy with
goal. This ability is of importance because it increases the different proposals: individual therapy, dyad with anoth-
effectivity of mental operations and minimizes the de- er child, and dyad with the mother. Comparing the results
mand for information processing [19, 20]. Central coher- of the functional communicative profile (FCP) and the
ence involves the ability to gather and process dispersed social-cognitive performance (SCP), these researchers
information in order to understand the whole in a coher- observed that the therapies with participation of the
ent and integrated fashion [21]. mothers produced the best results. Reagon and Higbee
Working memory refers to a system of temporary stor- [33] studied daily language intervention with 3 children,
age that enables the manipulation of information and im- aged 2, 3, and 6 years, conducted by their mothers during
proves the learning and thinking abilities, facilitating the 2 weeks and reported better results when including the
integration of environmental sensorial elements and in- caretakers and the familiar environment in the interven-
formation from the long-term memory [22]. Working tion process. Fernandes et al. [34] also reported positive
memory is represented by two brain systems; one is in- results after a short period of group mentoring sessions
volved in selective attention towards behaviorally rele- with 26 mothers and their children with ASD aged be-
vant information, and the other is implemented by main- tween 5 and 11 years where the focus was placed on their
ly left hemispheric premotor and parietal brain regions experience with the children and not on the child’s symp-
which underlie language functions and may also be in- toms.
volved in the recovery and maintenance of verbal repre- The data from the international survey (see this issue
sentations during preparation for switching tasks [23]. [35]), involving responses from 1,114 speech-language
The abilities of goal identification, planning, executing pathologists (SLPs) from 35 countries, suggested that col-
goal-directed plans, and effective performance are com- laborative intervention practices involving parents of
ponents of EFs [24]. EF deficits have been found in chil- children with ASD should be carefully studied, especially
dren with ASD, and these impairments are suggested to because parents frequently report the desire of a more di-
be associated with their language difficulties, such as the rect involvement in the process [35]. The aim of this study
Participants
A convenience sample was used. There were 24 students with
ASD enrolled in an outpatient language service, but 4 children did Table 2. Average number of areas with progress per participant in
not complete the intervention, so the data presented are for 20 FCP and SCP
children who completed the planned intervention. The children
had received a diagnosis of ASD by a neurologist or psychiatrist n FCP SCP Average per Average per
and were aged between 5 and 12 years. They received language subject in FCP subject in SCP
therapy for at least 6 months before the onset of this study and were
able to engage in cooperative play activities. Their parents were Group 1 6 15 12 2.5 2
able and willing to participate in the intervention and maintained Group 2 14 48 17 3.4 2.1
regular contact with the SLP by phone or digital means.
Since each participant was his/her own control, the inclusion cri- FCP, functional communicative profile; SCP, social-cognitive
teria were defined so as to be as broad as possible. A score above 70% performance.
in the SCP assessment was required to obtain some homogeneity
among the participants. In addition, the child’s behavior in play ac-
tivities during the semester prior to the study was observed. Verbal
and nonverbal children were included. The same criteria were used
with both groups. The study did not change the routine of therapeu- The SCP assessment identified the child’s best performance in
tic intervention procedures at the service where it was conducted. 7 different areas: gestural communicative intent, vocal communi-
cative intent, gestural imitation, vocal imitation, tool use, combi-
Procedures natory play, and symbolic play.
All participants were assessed regarding the FCP and the SCP The children attending the outpatient clinic formed 2 groups.
[36] in the pre- and postintervention periods implemented. In the In group 1, 6 children received stimulation of executive functions
FCP, 15-min samples of child and SLP interactive play sessions (SEF) exclusively conducted by their parents, at home, over a 10-
were video recorded and transcribed to specific protocols. The week period. During this period, parents and therapists made sys-
SLP’s transcription and marking were checked by another exam- tematic contact (by phone, WhatsApp, or Skype) to report the chil-
iner, and any differences in the transcription were resolved through dren’s progress, solve problems, or discuss necessary small chang-
discussion and repeated listening to the video recordings. es in the activities proposed. In group 2, 14 children received SEF
The data used in this study referred to: during individual weekly language therapy sessions with the SLP
• the number of communicative acts expressed per minute, for a 12-week period. Parents were asked to engage in follow-up
• occupation of the communicative space (identified by the pro- activities demonstrated by the SLP at home.
portion of communication initiated by each participant of the The SEF program involved the use of game activities to facili-
interaction), tate the child’s cognitive flexibility, operational memory, inhibi-
• percentage of interactivity (determined by the proportion of tory control, and central coherence. These therapeutic activities
communicative acts with interactive functions), and could be managed at home by the parents in low-stress situations.
• the use of different communicative means (verbal, vocal, or Table 1 presents examples of the activities proposed and their
gestural) [37]. goals.
AM, communicative acts per minute; OCS, occupation of communicative space; % inter, proportion of
interactivity; SCP, social-cognitive performance.
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